Violence against women: the hidden health burden Lori HeisetJ
Introduction The health consequences of violence against women may be a serious problem worldwide, as gender violence is a significant cause of female morbidity and mortality, and represents a hidden obstacle to economic and social development. By sapping women's energy and confidence, gender violence can can deprive society of their full participation. As the United Nations Fund for Women (UNIFEM) recently observed, "women cannot lend their labour or creative ideas fully if they are burdened with the physical and psychological scars of abuse" (1). In recent years, the world community has taken some tentative, yet important, steps toward urging greater attention to the issue of gender-based abuse. Various United Nations bodies, including the Commission on the Status of Women, the Economic and Social Council, and the Committee on Crime Prevention and Control, have passed resolutions recognizing violence against women as an issue of grave concern. Negotiations are underway through the Organization of American States to draft a Pan American treaty against violence against women. This international attention comes on the heels of over two decades of organizing by women's groups around the world to combat gender-based abuse. Women have started crisis centres, have had laws passed, and have worked to change the cultural beliefs and attitudes that undergird male violence. A recent directory published by the Santiago-based ISIS International, lists 379 separate organizations working against gender violence in Latin America alone (2). These grassroots efforts need to be supported and amplified by strong governmental commitments to prevent violence and assist survivors of abuse. Some argue that to date, few governments have taken violence against women seriously, failing to recognize either the extent of the problem or its implications for health and development. In part, this reflects active denial; but it is a denial facilitated by the lack of solid data documenting the pervasiveness and health consequences of abuse. Furthermore, ignorance is often an excuse for inaction.
In order to draw attention to and marshall greater support for violence-related programmes, this article will seek to: (i) summarize the existing information on gender-based abuse; (ii) identify data gaps and priority areas for research; and (iii) . discuss methodological issues related to the study of the health consequences of gender violence.
Definition of gender violence In September 1992, the United Nations Commi~ sion on the Status of Women convened a special working group to prepare a draft declaration against violence against women. This declaration to be voted on by the Commission in the autumn of 1993 - includes for the first time a proposed definition of gender-based abuse. This draft definition of "violence against women" includes "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 (3)". Among the specific acts listed in the declaration are: Physical, sexual and psychological violence occurring in the family and in the community, induding battering, sexual abuse of female children, dowryrelated violence, marital rape, female genital mutilation and other traditional practices harmful to women, non-spousal violence, violence related to exploitation, sexual harassment and intimidation at work, in educational institutions and elsewhere, trafficking in women, forced prostitution, and violence perpetrated or condoned by the State.
This article accepts the Commission's definition as a point of departure; for the sake of brevity, it explores only a subset of the above-mentioned abuses.
Wife abuse The most endemic form of violence against women is abuse of women by intimate male partners. Studies have documented severe and ongoing abuse of women in almost every culture, save for a handful of small-scale societies where wife beating occurs only rarely. Levinson's analysis of ethnographic data from 90 peasant and small-scale societies indicates that in 86% of these, there is violence against wives by husbands. Only 16 of the societies studied "can be described as essentially free or untroubled by family violence" (4). In an analysis of ethnographic research on 14 cultures by female anthroRapp. trimest. statist sanit. mond., 46 (1993)
a
Lecturer, The State University of New Jersey, Centre for Women's Global Leadership, New Brunswick, New Jersey
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pologists using female informants, Counts et al. identified only one society, the Wape of Papua New Guinea, that have little or no woman abuse (5). In the United States of America, for example, experts estimate that 2-4 million women are battered each year (6). Similarly, between one-third and one-half (or more) of women surveyed in many developing countries report being beaten by their partner (Box 1).
The health consequences of such violence are considerable. In the United States, wife abuse is the leading cause of injury among women of reproductive age (See, for example, 7,8,b); moreover, between 22 and 35% of women who visit emergency rooms are there for symptoms related to abuse (6). Wife abuse also provides the primary context for many other health problems. Battered women are 4-5 times more likely to require psychiatric treatment and 5 times more likely to attempt suicide than are other women. c•d They are also. at increased risk of alcohol abuse, drug dependence, chronic pain, and depression (9,10). IIi one study of health care utilitation in the United States, a history of rape and/or assault was a stronger predictor of physician visits and outpatient costs than a woman's age or other health risks, such as smoking (11): : Similar data are beginning to emerge from the developing world. A United Nations case study on 'Wife ab~ In China reports that domestic violence causes 6% of serious injUries and death in Shanghai. d In Papua New Guinea, 18% of all urban wives sUlveyed had received hospital treatment for jnjuries inflicted by their husbands (12).
Amatter ollife and. death ' Since it often results in forced suicide and murder, gender violence. is an important caq.se of femal~ mortality. After reviewing evidence from the United States, Stark & Flitcraft conclude that "abuse may be the single most important precipitant fOr female suicide attempts yet identified" (10). One out of every four suicide ~ttempts by women is preceded by abuse, as are half of all attempts by African American women (10). Starkb reports that 26% of all female suicide attempts presenting to Yale University Hospital in 1979 were associated with abuse as were 50% of attempts made by Mo-
can American women. The battered women also accounted for 42% of all traumatic attemptS and were significantly more likely to attempt suicide more than once (20% vs. 8%). A cross-culfural survey of suicide by Counts draws the same conclusiQn, citing evidence from Africa, Peru, Papua New Guinea and several Melanesian islands (lJ). The relationship between domestic violence and homicide may be even stronger. In Canada, 62% of women murdered in 1987 died as a result of domestic violence (14), and in Papua New Guinea, almost three-fourths of women murdered were killed by their husbands (12). In India, ~ creaSed commercialization of dowry has led to a dramatic rise in dowry-related murders and suicides. Increasingly, dowry is being seen as a "getrich-quick" scheme by prospective husbands, with young brides sufferirig severe abuse if ongoing demands for money or goods ;ue not met. A frequent subterfuge is to set the woman alight with kerosene and then claim she died in a kitchen accident - this crime is known as bride-burning. In 1990, the pOlice officially recorded 4 835 dowry deaths in all of India, but the Ahmedabad Women's Action Group estimates that 1 000 women may be burned alive annually in Gujurat State alone (15). In both urban Mahara:shtra and greater Bombay, lout of every 5 deaths among women aged 15-44 year is due to "accidenta.t:. burns". For the younger age group, 15-24, the proportion is 1 out of 4 (16). This suggests that 'a si~,ificant number of homicides and suicides are being. recorded as "accidents" instead of intentional injuriesr Violence may also be responsible for a sizeable, although yet unrecognized, portion of maternal deaths; especially among young unwed mothers. Fauveau & Blanchet report that in Matlab Thana, Bangladesh, homicide and suicide - motivated by stigma over unwed pregnancy, or resulting from beatings or related to dowry - accounted for 6% 'of all maternal deaths between 1976 and 1986.e The figure rises to 22% if one includes deaths due to botched abortions, many of which are also related to shame over pregnancies out of wedlock.
Rape and sexual abUSB . .
.
b
Stark, E. The battering syndrome: social knowledge, social therapy and the abuse of women. Ph.D dissertation. Department of Sociology, Suny-Binghamton. 1984. Observation about psychiatric treatment from: Koop. C.E. Violence against women: a global problem. Address by Surgeon-GeneraJ Koop at the Pan American Health Organization. Washington, DC, May 22,1989. Wu, H. Proceedings of the Expert Group meeting on violence in the family with a special emphasis on its effects on women. United Nations Case Study of China. Vienna. Austria. UN Doc. BAW/EGM/86/CS.15.1986.
In recent years, it has become increasingly recognized that rape and sexual abuse are far more common than was thought earlier. An island-wide. sUIVey of women in Barbados revealed that 1 in 3 women had been sexually abused as children.f In e The World Health Organization (WHO) defines maternal mortality as a death during pregnancy or within 42 days afterward, from causes related to or aggravated by the pregnancy or its management. f
C
d
Handwerker, W.P. Gender power difference may be STD risk factors for the next generation. Paper presented at the 90th Annual Meeting of the American Anthropological Association, Chicago, Illinois, 1991.
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Box 1 Prevalence of wife abuse, studies in selected countries Country Barbados (Handwerker, 1991) Sample size 264 women and 243 men aged 20-45 years Sample type Island-wide national probability sample Findings 30% of women battered as adults Remarks 50% of women and men report their mother being beaten 50% of women and men report their mother being beaten Taken from contraceptive prevalence survey Almost perfect agreement between % of women who claim to have been beaten and % of men who admit to abuse
Antigua (Handwerker, 1993)
97 women aged 20-45 years
Random subset of national probability sample District-wide cluster sample
30% of women battered as adults
Kenya (Raikes, 1990)
733 women from Kissi District
40% "beaten regularly"
Papua New Guinea (Toft,1987)
Rural: 736 men and 715 women Urban low income: 368 men and 298 women Urban high income: 178 men and 99 women 200 mixed ethnic, lowincome women from Colombo 109 men and 109 women from a village in Juliundur District, Punjab
Rural survey in 19 villages in all regions and provinces Urban survey with oversample of elites
60% rural women "beaten"" 56% urban lowincome women "beaten" 62% urban elite women "beaten"
Sri Lanka (Sonali,1990)
Random sample from low-income neighbourhood 50% sample of all scheduled caste households and 50% of non-scheduled caste households National random probability sample of Peninsular Malaysia conducted by a large market research firm in South-East Asia National probability sample
60% had been beaten
51 % of women said husbands used weapons 75% of scheduledcaste wives report being beaten "frequently"
India (Mahajan, 1990
75% of scheduled caste men admit to beating their wives; 22% of higher caste men admit to beatings 39% of women reported having been "physically beaten" by a partner in the last year
Malaysia (Raj-Hashim, 1993)
713 women and 508 men over 15 years of age
Annual figure; 15% of adults consider wife beating acceptable (22% among Malays)
Colombia (Profamilia, 1992)
3 272 urban women 2 118 rural women
20% physically abused; 33% psychologically abused; 10% raped by husband 50% reported being physically abused
Part of Colombia's DHS survey
Costa Rica (Chacon et aI., 1990)
1388 women
Random sample of women attending child welfare clinics Random probability sample of urban women
Sponsored by UNICEF/PAHO
Costa Rica (1990)
1 312 women aged 15-49 years
51 % reported being beaten up to several times per year; 35% reported being hit "regularly" 49% abused; 74% by an intimate male partner Includes physical, emotional and sexual abuse in adulthood; study sponsored by UNICEF/PAHO
Guatemala (Coy, 1990)
1000 women
Random probability sample of women in Sacatepequez
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Mexico (Jalisco) (Ramirez & Vasquez, 1993)
1 163 rural women and 427 urban women in Jalisco State
Random household survey of women on DIF register
56.7% of urban wom.en and 44.2% of rural women reported physical abuse 33% had lived in a "violent relationship"
Experienced some form of "interpersonal violence"
Mexico (Valdez Santiago & Cox, 1990)
342 women from Nezahualcoyotl
Random, probability sample of women from city adjacent to Mexico City Random convenience sample of Quito barrio
Ecuador (CEPLAES, 1992)
200 low-income women
60% had been "beaten" by a partner
37% of those beaten were assaulted every day up to once a month 70% of those abused are abused more than once a year
Chile (Larrain, 1993)
1 000 women in Santiago, aged 22 to 55 years, involved in a relationship of 2 years or more
Stratified random probability sample with a maximum sampling error of 3%
60% have been abused by a male intimate; 26.2% have been physically abused (more severe than pushes, slaps or having object thrown at you) 25% had been phYSically or sexually abused by a male partner
Norway (Schei & Bakketeig, 1989)
150 women aged 20 to 49 years in Trandheim
Random sample selected from census data
Does not include less severe forms of violence like pushing, slapping or shoving
New Zealand (Mullen et al. 1988)
2 000 women sent questionnaire; stratified random sample of 349 women selected for interview
Random probability sample selected from electoral rolls of five contiguous parliamentary constituencies
20.1% report being "hit and physically abused" by a male partner; 58% of these women (>10% of sample) were battered more than 3 times 28% report at least one episode of physical violence
United States of America (Straus &Gelles, 1986) United States of America (Grant, Preda & Martin, 1991)
2 143 married or cohabiting couples
National random probability sample
6 000 women statewide from Texas
State-wide random probability sample
39% have been abused by male partner after age 18; 31 % have been phYSically abused 40.2% have been abused after age 18; 31 % have been physically abused
>12% have been sexually abused by male partner after age 18
United States of America (Teske & Parker, 1983)
3000 rural women in Texas
Random probability sample of communities with 50 000 people or less
22% abused within the last 12 months
Sources Barragan Alvarado, L. el al. Proyeeto edueativo sobre violeneia de genero en la relaeion domestica de pareja. Centro de Planificati6n y Estudios Sociales. CEPLAES. Quito, Ecuador 1992. Chacon, K. 81 al. Caracteristicas de la muier agredida entendida en el patronato nacional de la infancia (PANI). In: Batres Gioconda & Claramunt, Cecilia. La violencia contra Ia mujer en la familia costarricense: un problema de salud pUblica. San Jose, Costa Rica: ILANUD 1990. Coy, Frederico. Study cited in: Castillo, Delia et al. 1992 Violencia hacia la mujer en Guatemala. Report prepared for the F irst Central American Seminar on Violence Against Women as a Public Health Problem, Managua, Nicaragua, March 11-13, 1990 Granl, Robert el al. Domestic violence in Texas: a study of statewide and rural spouse abuse. Wichita Falls, Texas: Bureau of Business and Government Research , Midwestern State University, 1989. Handwerker, Penn. Genderpowerditference may be STD risk factors for the next generation. Paper presented althe 90th Annual Meeting of the American Anthropological Association , Chicago, Illinois, 1991. Handwerker, Penn. Power, gender violence, and high risk sexual behaviour: AIDS/STD risk factors need to be defined more broadly. Private communication, Department of Anthropology. Humboldt State University, Arcata California, February 10, 1993.
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qua'!., 46 (1993)
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Larra rn, Soledad. "Estudio de Irecuencia de 13 violenc;a Intratamillar y ta cOndiciOn de la mujer en Chile ,," Santiago, Chile: Pan American Health Organization, 1993 Mahalan, A. "Instigators of wife batterlng",ln: V/olence against women, pp. 1010. Sushma Sood, ed Janipur, India: Arihant Publishers PROFAM llIA. Encuestra de prevalenc/a, demografla y salud (OHS) Bogota ' Colombia, 1990. Ral·Hashlm, Rita. "Summary of a Survey Research Malaysia (SRM) study on women and girlfriend battery". Asia·Pacific Resource and Research Centre for Women, Kuala Lumpur, Malaysia, 1993. Ra ikes. Alanagh, Pregnancy, birthing and family planmng in Kenya ' changing patterns of behaviour: a health utilization study in Kissi District Copenhagen: Centre for Development Research, 1990. Ramirez Rodriguez, J.C. & Uribe Vasquez, G. "Mujer y violencia: un hecho cotidiano" .Salud Publica de Mexico. Cuernavaca: Inst~uto nacional de salud publica. (In press). SChB i, 8, & Bakkeleig, l.S. "Gynecological Impact of sexual and physical abuse by spouse: a study of a random sample of Norwegian women". British journal of obstelflcs and gynecology 96:1379-1383. 1989, Sonall, Deranlyagala. "An Investigation into the incidence and causes of domestic violence in Sri Lanka". Women in need (WIN), Colombo, Sri lanka. 1990. Shrader COl. E. & ValdezSantiago, R. "Lavlolencia hacia la mujerMexlcana como problema de salud publica:.la incidencia de la violencla domestica en una microregi6n de Cludad Nexahualcoyotl". Mexico City: CE COVID. 1992. Straus, M,A. & Gelles, R_ J. "Societal changes andchange In lamllyvlolence from 1975 to 1985 as revealed by two national surveys". Journal of marriage and the family, 48:465-479. 1986. Teske, R. Jr. & Parker, M. · Spouse abuse in Texas: a study of women's attitudes and experiences·. Austin, Texas Department of Human Resources. 1983. Tort. S. (ed). Domestic violence in Papua New Guinea. Law Reform Commission Occasional Paper No. 19, Port Moresby, Papua New Guinea. 1986.
Seoul, Republic of Korea, 17% of women surveyed reported being a victim of an attempted or completed rape.g In the United States, 78 adult women - and at least as many girls and adolescents - are raped each hour (17). Contrary to popular perception, the majority of rape survivors know their assailants, a reality confirmed by studies in Malaysia, Mexico, Panama, Peru and the United States (Table 1). A large percentage of rapes (36-58%) is perpetrated against girls 15 years or younger, with a substantial propor-
tion against girls under 9 years, Rape survivors exhibit a variety of trauma-induced symptoms, including sleep and eating disturbances, depression, feelings of humiliation, anger and self blame , nightmares, fear of sex, and inability to concentrate,h Survivors also risk becoming pregnant or contracting sexually transmitted diseases (STDs) , including HIVI AIDS. A rape crisis centre in Bangkok, Thailand reports that 10% of their clients contract STDs an d 1~1 8% become pregnant as a result of rape, a figure consistent with data from Mexico and
Table 1 Statistics on sexual crimes, selected countriesa Tableau 1 Statistiques des agressions sexuelles. echantillons de paysa Percentage of perpetrators known to victim Pourcentage d'agresseurs connus de la victime Percentage of survivors 15 years and underPourcentage de survivants de 15 ans et moins Percentage of survivors 10 years and ul)Jler Pourcentage de survivants de lOans et moins
Lima, Peru - Lima, Perou Malaysia - Malaisie Mexico City - Mexico Panama City Papua New Guinea e - PapouasieNouvelle-Guineee United States of AmericaEtats-Unis d'Amerique
60 68 67d 63 78
58 36 40 47
18b 18c
23 13f
29
a Studies include rape and sexual assaults such as attempted rape and molestation except for United States data which includes only completed rapes . - Les ~tudes ont port~ sur les viols et agressions sexuelles telles que tentative de viol et attentat ~ la pudeur sauf aux Etats-Unis d' Am~rique ou seuls ont ~t~ pris en compte les viols effectlfs, b Percentage of survivors age 9 and you nger, - Pourcentage de survlvants de 9 ans et moins. C Percentage of survivors age 6 and younger. - Pourcentage de survivants de 6 ans et moins. d Data Irom Carpets basica. 1991 , Mexico City: Procurador de Justlcia del Dislric:lo Federal de Mexico. - Donn~es lournies par Carpeta basica. 1991, Mexico City: Procu rador de Justicla del Distrlcto Federal de Mexico. I Bradley, C. WlJy male violence against women is a deve/opmenl Issue: Rellections 'rom Papua New Guinea. Paper for United Nations Fund for Women (UNIFEM), 1990. I Percentage Of survivors age 7 and younger. - Pourcentage de survlvants de 7 ans et mains. g Percentage of survivors age 17 and younger. - Pourcentage de survlvants de 17 ans el mains. Sources: Malaysia - Malaisie (20), Panama City (21), Peru - P6rou (22), Mexico City (23), United States - Etats-Unis (17).
g
Shim, V-H. Sexual violence against women in Korea: a victimization survey of Seoul women, Paper presented in St, Petersburg, Russia at the Conference on "International Perspectives: Crime, Justice and Public Order", June 21-27, 1992.
h
Kilpatrick, D. Testimony before the house selel=tcommittee on children, youth and families. Washington, DC, March 28, 1990.
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Rapp. trimest. statist. sanit. mond., 46 (1993)
Korea.iJ,k In countries where abortion is illegal in case of rape, victims often resort to illegal abortions, greatly increasing their chance of future infertility or even risking death.
Response of the health sector Violence against women has only recently begun to be recognized as a health problem by the medical and public health establishment. In the United States, the American Medical Association (AMA) launched a major campaign in 1991 to educate the public and physicians about family violence (18). Similarly. the Joint Commission on Hospital Accreditation issued new standards requiring all hospitals to develop protocols and provide training to their staff on how to respond to different forms of abuse. Mter training and protocols were introduced, the percentage of women found to be battered rose from -5.6% to 30% at the emergency department of the Medical College of Pennsylvania (19). Once identified, the women can be referred to shelters, counselling and other poterttially lifesaving services. On the international front, violence is slowly becoming recognized as an obstacle to women's health and development. In 1991, the Pan American Health Organization (PAHO) sponsored a conference in Managua, entitled "Violence against women: a problem of public health". The Ministry of Health of Colombia issued an action agenda on women's health which included a programme -on the "prevention of abuse and attention to victims of violence." In 1992, the United Nations Fund for _ Women (UNIFEM) published Battered dreams: violence against women as an obstacle to development (1).
was the case with abortion, once researchers have created a safe space for discussion, women have proved willing to discuss abwe. Indeed, it is important for researchers to consider the sensitive nature of violence when designing research strategies. Perhaps most important is ensuring the physical and emotional safety of the women being interviewed. Not only for the woman's safety, but also for the sake of accuracy, it is essential for women to be interviewed away from their partners or other family memben who may be perpetrators. Also, prior to initiating research, there is an ethical obligation to investigate the psychological and legal resources available locally to support women who disclose having suffered abuse or violence.
Priority data needs on violence against women • Better definitions of rape, child sexual buse, wife abuse, apd other forms of gender Violence to facilitate measurement and comparison across populations. Better data on the incigence and prevalence of gender-related violence in representative populations of women. Data'o n the percentage of women presenting in different contexts (e.g. emergency roollls,family planning clinics; et<;. ) who have been .raped and/ or abused. (This will help convince.health care providers of the prevalence of apuSe aswell as help defme the potential of using different settings as points of identification and referral for victims.) .. Data on health Care and social costs of domestic violence and sexual assal.1lt/abuse. Estimates of cost of emergencY services, indirectcosts ~fpro ductivity losses, costs associated with increased utilization of primary care services, etc. , Data on the mental health consequences of violence: relative risk among victimized and non-victimized women for suicide attempts, al~ cohol and drug abuse, depression, somatic health complaints, anxiety, sexual dysfunction, etc. Data on the impact of domestic violence and/ or sexual assault/abuse on birth outcomes: rates of miscarriage, low birth weight, pregnartcy complications, etc. Studies that analyse the relationship between gender violence and other development issues such as Safe Motherhood, child survival, prospects for AIDS prevention, family planning etc. Descriptive profiles of the typical presenting symptoms of rape and abuse victims (location of injuries, somatic comp~.unts, etc.) so as to facUi~ tate identification by health care providers.
•
•
•
Measurement and research issues As with any issue similarly underreported and fraugh~ with problems or measure,"ent, deriving accurate statistics on violence against. women represents a great challenge. However; to assume that women Will not disclose abuse would be a mistake for researchers; it has been observed by most' researchers to date that womert are remarkably willing, indeed eager, to share their experiences. As
•
•
• i
Thai data from "Ban Thanom Rak", a home for rape survivors run by the Friends of Women, Bangkok; Thailand as quoted in Archavanitkui, K. & Pramualratana, A. Factors affecting women's health in Thailand. Paper presented at the workshop on Women's Health in Southeast Asia. Population Council,Jakarta, October 29-!H, 1990. Mexican data from COVAC, 1990. "Evaluacion de proyecto para educacion, capacitacion y atencion a mujeres y menores de edad en materia de violencia sexual, Eneroa Diciembre 1990." Mexico City: Asociacion mexicana contra la violencia a las mujeres; and CAMVAC, 1985. "Carpeta de informacion bisica para la atencion solidaria y feminista a mujeres vio\adas. " Mexico City: Centro de apoyo a mujeres violadas. Korean data from Shim, Y-H., see footnote g.
•
j
Suggestions for the research community While existing data are sufficient to capture the severity of the problem, research is still needed to 83
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Wid hffh $list. quart., 46 (1993)
improve our understanding of gender violence and to help design better interventions, using the list of priority issues for research, above. In addition, the following suggestions could greatly facilitate future work on violence: • WHO and other agencies could sponsor crosscultural research on violence against women. Donors could convene meetings of researchers and women's advocates working on gender violence to begin exploring methodological issues with respect to studying violence against women and girls. (All research efforts can draw on the experience ofNGOs that have worked to combat gender violence and provide services for victims.) • On-going research efforts, such as focus groups and surveys being conducted on sexuality for the purposes of developing HIV/ AIDS prevention programmes, can use these opportunities to explore the role that violence and coercion play in women's sexual and reproductive decision-making. • All crime statistics should be broken down by gender (for both the perpetrator and the victim). Information should be recorded on the relationship between the perpetrator and the victim, to help identify the gender-specific nature of much of violent crime. Governments and the international community should recognize that it is important for women to live free from physical and psychological abuse. Gender violence is damaging, both physically and mentally. A health research agenda that values women can no longer ignore this regrettably frequent reality of women's lives.
ont porte sur I'ampleur et les scMmas de la violence dans differentes cultures ainsi sur les consequences pour la sante . Ces etudes indiquent que la violence contre les femmes est tres repandue et constitue une importante cause de morbidite et mortalite. Ce n'est que recemment que les traumatismes dus a la violence ont ete reconnus comme un important probleme de sante publique. De nouvelles recherches sont donc necessaires pour ameliorer notre comprehension de cette violence et mettre au point de meilleures interventions.
References - References 1. Canillo, R. Battered dreams: viclenceagainst women as an obstacle todrueWjJment. New York, UNIFEM, 1992. 2. VlOlencia enrontra tk la mujer en America latina 'J EI Caribe: dir~ctorio tk programas. ISIS internacional, Santiago, Chile, (1990). 3. United Nations. &port of the wurlting group on violence against women. Economic and social council, Vienna, United Nations, E/CN.6/WG.2/1992/ L.3, 1992. 4. Levinson, D. Violence in cross-cultuml pers~ctive. Newbury Park, Sage Publications, 1989. 5. Counts, D. et aL Sanctions and sanctuary: culturalpers~ctives on the beating ofwives. Boulder, Colorado, Westview Press, 1992. 6. Council on Scientific Affairs. Violence against women: relevance for medical practitioners. Journal of the Ammcan medical association, 267(23): 3184-3189 (1992). [Citing three studies: Journal of the Ammcan medical association, 51: 3259-3264 (1987) ; AnnualEmergm" MMicim, 18: 651-653 (1987); WIfe abuse in the medical setting: An introduction for health personnel. Office of Domestic Violence, Washington, D.C., monograph No.7, 1981.] 7. Grisso,J. etal. A population-based studyofinjuriesofinntercity women. Ammcan Journal of Epidemiology, IM(l): 59-68 (1991) . [Study based on a surveillance programme of68 103 people in 17 Census tracts in Western Philadelphia.] 8. National Committee for Injury Prevention and Control. Injury prroention: meeting the challenge. New York, Oxford University Press, 1989. 9. Plitcha, S. The effects of woman abuse on health care utilization and health status: a literature review. Women ' s health, 2(3): 154-161. 10. Stark, E.lIe F1itc:raft, A. Spouse abuse. In: Rosenberg M. lie Finley,A.,eds. ViolenceinAmmca:apublichealthapproach.New York, Oxford University Press, 1991. 11. Koss, M. etal. Deleterious effects ofcriminal victimization on women's health and medical utilization. ArchivesoJinternal ~icine, 151: 342-347 (1991). 12. Bradley, C. The problem of domestic violence in Papua New Guinea. In: Guitklinesforpolicetrainingagainstwomenandchild sexual abuse. London, Commonwealth Secretariat, Women and Development Programme, 1988. 13. Counts, D. Female suicide and wife abuse: a cross cultural perspective. Su.icitk and lif~ threatening behavior, 17 (3) : 194205 (1987). 14. Homicitk in Canada 1987: a statistical perspective. Department ofSupply and Services, Canadian Centre forJustice Statistics, Ottawa, 1988. 15. Kelkar, G. Stopping the violence against women: issues and perspective from India. In: Margaret Schuler, ed. Freedum from Violence: Women 's straUgi~ from around the world, OEF International, Washington, DC, 1991 [available through UNlFEM, New York]. 16. Karkal, M. How the other half dies in Bombay. Economic and political W«kly, 14.24 (1985) . 17. Kilpatrick, D. Rape in Ammca: a report to the nation. Arlington, VA, The National Victim Center, 1992. 18. Perrone,J. AMA sounds call for coalition of doctors to fight family violence. Ammcan medical mws, Jan. 6, 1992.
Summary Violence against women is a major health problem around the world . It often goes unnoticed and undocumented partly due to its taboo nature. A number of recent studies have explored the extent and patterns as well as the health consequence of violence in different cultures. The studies cited indicate that violence against women is widespread and an important cause of morbidity and mortality among women . Injuries due to violence have only recently been recognized as an important public health problem. More research is needed to improve our understanding of gender violence, and to design better interventions.
Resume La violence contre les femmes: un probleme de sante cache La violence contre les femmes est un probleme majeur de sante dans Ie monde entier, mais elle est souvent inaperyue et inobservee, en partie parce qu 'elle constitue un tabou . Recemment, un certain nombre d'etudes
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Rapp. trimest. statist. sanff. mond., 46 (1993)
19. McCleerS.V.BcAmnr,R.Astudyofwomenpresentinginan emergency department. American j/JUrnal ofpublic heallh, 79: 65-67 (1989). 20. Rape in Malaysia. Consumer's Association of Penang, Penang, Malaysia, 1988. 21. perez Marquez A. Aprt»eimat:i6n cliagn6stica a las violacion&J de mujem en los dishitos de Panamd, San Migtulito. Universidad de Panama, Centro para el Desarrollo de 1a mujer, 1990.
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