Violence against Women: The Health Sector Responds

Chapter One - Gender-Based Violence: A Public Health and Human Rights Problem

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In León, Nicaragua, among 188 women who were physically abused by their partners, only five were not abused sexually, psychologically, or both. (Ellsberg et al. 2000)

Gender-based violence, or "violence against women," includes many kinds of harmful physical, emotional, and sexual behaviors against women and girls that are most often carried out by family members, but also at times by strangers. The United Nations Declaration on the Elimination of Violence against Women includes a widely accepted definition of violence against women as:

. . . any act of gender-based violence that results in, or is likely to result in, physical, sexual, or psychological harm or suffering to women, including threats of such acts, coercion, or arbitrary deprivations of liberty, whether occurring in public or private life.
(United Nations General Assembly, 1993)

This definition places violence against women within the context of gender inequity as acts that women suffer because of their subordinate social status with regard to men.

There is much debate about a universally agreed-upon GBV terminology. In Latin American countries most laws and policies use the term "family violence" when referring mostly to violence against women by an intimate partner. PAHO initially used the term "family violence" in the early days of its work in this area, but has since shifted to the use of "gender-based violence" or "violence against women" to refer to the broader range of acts that women and girls commonly suffer from intimate partners and family members, as well as individuals outside the family. Thus, both these terms will be used interchangeably throughout the book. The term "family violence" will only be used when referring to the titles of formal laws or programs.

Gender-Based Violence: How Prevalent? How Complex?

According to a recent review of 50 studies from around the world, between 10% to 50% of women have experienced some act of physical violence by an intimate partner at some point in their lives (Heise, Ellsberg, and Gottemoeller 1999). This and an earlier World Bank review (Heise, Pitanguy, and Germain 1994) highlight some of the characteristics that often accompany violence in intimate relationships:

• The great majority of perpetrators of violence are men; women are at the greatest risk from men they know;
• Physical violence is almost always accompanied by psychological abuse and in many cases by sexual abuse;
• Most women who suffer any physical aggression by a partner generally experience multiple acts over time;
• Violence against women cuts across socioeconomic class and religious and ethnic lines;
• Men who batter their partners exhibit profound controlling behavior.

These studies show that gender-based violence is a complex problem that can not be attributed to a single cause. There are risk factors, such as alcohol and drug abuse, poverty, and childhood witnessing of or experiencing violence, that contribute to the incidence and severity of violence against women. Overall, however, it is a multicausal problem, influenced by social, economic, psychological, legal, cultural, and biological factors, as illustrated in the figure below:

Figure 1-1    ECOLOGICAL MODEL OF FACTORS ASSOCIATED WITH INTIMATE PARTNER VIOLENCE

From: Heise, Ellsberg, and Gottemoeller 1999

Why is Gender-Based Violence a Health Problem?

As time goes on, there is increasing evidence and awareness among health providers and policymakers of the negative health outcomes of gender-based violence. It has been associated with reproductive health risks and problems, chronic ailments, psychological consequences, injury, and death (Figure 1-2.).

Figure 1-2    HEALTH OUTCOMES OF VIOLENCE AGAINST WOMEN

From: Heise, Ellsberg, and Gottemoeller 1999

Physical and sexual abuse affect women's reproductive health, either directly through the risks incurred by forced sex or fear, or indirectly through the psychological effects that lead to risk-taking behaviors. Children may also suffer the consequences, either during the mother's pregnancy, or during their own childhood due to neglect or the psychological and developmental effects of living with or experiencing abuse (Heise, Ellsberg, and Gottemoeller 1999). The table below summarizes how violence undermines women's control over their own reproductive health, as well as the health of their children.

However severe the physical consequences of violence, most women find the psychological consequences to be even more long-term and devastating (Sagot 2001). A recent World Health Report titled Mental Health: New Understanding, New Hope points to the disproportionate rates of depression among women and recognizes that GBV may contribute to these high rates (WHO 2001). Recurrent abuse can erode women's resilience and places them at risk of other psychological problems as well, such as post-traumatic stress disorder, suicide, and alcohol and drug use.

Health care providers can play a crucial role in detecting, referring, and caring for women living with violence. Abused women often seek health care, even when they do not disclose the violent event. While women tend to seek health services more than men throughout their lifespan, studies show that abused women seek services even more for ailments related to their abuse (García-Moreno 2002). Thus, interventions by health providers can potentially mitigate both the short- and long-term health effects of gender-based violence on women and their families. In Section II of this book, we will see the effects of these life-transforming and, at times, even life-saving interventions on the lives of women and their families affected by violence.