Violence against women : intimate partner violence and sexual violence

VIOLENCE AGAINST WOMEN INTIMATE PARTNER VIOLENCE AND SEXUAL VIOLENCE KEY FACTS • PREVALENCE: Evidence shows that nearly one quarter (24.6%) of women in low- and middle-income countries in the Region have faced violence by an intimate partner (1). When taking into account sexual violence by a non-partner, this figure rises to 27.9% (1). Between 13% and 68% of women (who have ever been married or had a partner) have experienced at least one incident of physical violence from an intimate partner (2-7). • HEALTH CONSEQUENCES: Intimate partner and sexual violence are major public health issues. Such violence may result in physical, mental, sexual, reproductive and other health problems (8). Violence against women may also increase vulnerability to sexually transmitted infections, including HIV, and act as a precursor to several noncommunicable diseases. These consequences are among the top 10 leading causes of death and disability for women in the Region. • CAUSES: Violence against women is rooted in gender inequality and constitutes a human right violation. The unequal position of women relative to men and the normative use of violence to resolve conflicts are strongly associated with both intimate partner violence and sexual violence by any perpetrator (8). DEFINITIONS (9) Intimate partner violence: behaviour by an intimate partner or ex-partner that causes physical, sexual or psychological harm, including physical aggression, sexual coercion, psychological abuse and controlling behaviours. Sexual violence: any sexual act, attempt to obtain a sexual act, or other act directed against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting. It includes rape defined as the physically forced or otherwise coerced penetration of the vulva or anus with a penis, other body parts or object. Figure 1: Prevalence estimates of lifetime exposure to intimate partner violence of women 15-49 years old*, 2000-2010, selected countries, Western Pacific Region MEASUREMENT OF PREVALENCE Population-based surveys using a standardized methodology (developed for the WHO Multi-country Study on Women’s Health and Domestic Violence against Women) have produced comparable information on the prevalence, causes, contributing factors and consequences of violence against women. According to these studies conducted in the Region, 13% to 68% of women reported experiencing physical and/or sexual violence by an intimate partner at some point in their lives (2- 7). These surveys and studies estimate a lifetime prevalence of such violence between 9% and 68% in selected countries in the Region (10-13). In developing countries, women are twice as likely as men to experience violence (2). In the Region, 27.9% of women have experienced such violence at some point in their lives (1). Evidence shows that a woman is more likely to be assaulted, injured, raped, or killed by a current or former intimate partner than by any other person (14). Variation in the prevalence of violence against women across countries and communities shows that such violence is preventable. Samoa 46% Tonga 40% New Zealand (North Waikato) 42% Solomon Islands 64% Fiji 64% Kiribati 68% Vanuatu 60% Australia 27%Japan (Yokohama) 15% Philippines 18% Viet Nam 34% New Zealand (Auckland) 34% Hong Kong 9% Cambodia 14% *Except Japan and New Zealand where women 18-49 were surveyed and Viet Nam where women 18-60 were surveyed 1 CAUSES AND RISK FACTORS Intimate partner and sexual violence against girls and women is mostly perpetrated by men (2). Worldwide, approximately 20% of women and 5% to 10% of men report being victims of sexual violence as children (15). Experiencing gender inequality in childhood influences the potential of victimization or perpetration of violence against women in later life (9). Population-based studies suggest that relationship violence affects a substantial proportion of young people (1, 15). Cultural norms of gender inequality and violence against women increase the susceptibility of facing or perpetrating intimate partner and sexual violence (16). PERPETRATION BY MEN VICTIMIZATION OF WOMEN Table 1: Risk factors for both intimate partner violence and sexual violence (16) INDIVIDUAL LEVEL Demographics •Low income •Low education •Young age •Low education •Separated/ divorced marital status Exposure to child maltreatment •Sexual abuse •Intra-parental violence •Intra-parental violence Mental disorder •Antisocial personality •Depression Substance use •Harmful use of alcohol •Illicit drug use •Acceptance of violence •Harmful use of alcohol •Illicit drug use •Acceptance of violence RELATIONSHIP LEVEL •Multiple partners/ infidelity •Low resistance to peer pressure COMMUNITY LEVEL •Weak community sanctions •Poverty •Weak community sanctions •Poverty SOCIETAL LEVEL •Traditional gender norms and social norms supportive of violence •Traditional gender norms and social norms supportive of violence * Factors that have the strongest reported effect or are consistently reported across studies are highlighted in bold. In studies from the Region, 21% to 75% of women who have ever had a partner reported one or more controlling behaviours by their intimate partner (2). In the Solomon Islands, the most common (36%) reason for never leaving a relationship was that the violence was considered “normal” or “not serious” (4). Gender inequalities and norms sanctioning the use of violence to resolve conflicts are strongly associated with the risk of perpetration of intimate partner and sexual violence (16). Table 1 summarizes the risk factors identified in the evidence for the perpetration (by men) and the experiencing (by women) of both intimate partner and sexual violence. 2 VIOLENCE AGAINST WOMEN HEALTH CONSEQUENCES Intimate partner and sexual violence against women has serious short- and long-term consequences. These include physical trauma, psychological trauma and stress and poor sexual and reproductive health (1, 2). Violence against women leads to poor overall health outcomes for victims, and can increase a women’s risk of future ill health by impacting access to care. Violence and sexual abuse often result in sexual and reproductive health issues including limited sexual and reproductive control, lack of contraception, gynaecological problems, induced abortions and sexually transmitted infections (1). Intimate partner violence in pregnancy increases the likelihood of miscarriage, stillbirth, preterm delivery and low birth weight. Psychological consequences of abuse can be more serious than its physical effects. Women who experience intimate partner violence are more likely to report poor or very poor health and emotional distress (1). Experiencing abuse erodes women’s self-confidence and puts them at greater risk of various mental health problems, including depression, post-traumatic stress, eating disorders, substance abuse and suicide attempts (1, 16). Intimate partner violence harms the health and well-being of the victims’ children as well. Such children tend to have poorer health and educational outcomes, as well as suffer from a range of behavioural and emotional disturbances (16). Children from households where there is intimate partner violence are more likely to become perpetrators or to experience violence later in life (16). In the most severe outcomes, intimate partner violence and sexual violence can lead to disability and/or death. Female homicides are often perpetrated by a partner. In the Region, intimate partner homicides account for 19% of all female homicides (2). PREVENTION Violence against women is preventable. Effective prevention takes good quality intervention programmes, policy change and judicial enforcement (18). A multisectoral approach is important to ensure effective implementation and to promote a culture of zero-tolerance for violence. Key sectors needed for prevention include health, social development, police and justice. Lasting change will require laws and policies that protect women, address discrimination and promote gender equality and a culture of zero-tolerance for violence against women. Primary prevention efforts aim to stop violence against women from happening in the first place. Among primary prevention strategies, the strongest evidence on effectiveness points to school-based programmes that focus on prevention of violence in dating relationships (16). However, less is known about their effectiveness in resource-poor settings. Evidence is emerging on the effectiveness of several other primary prevention strategies, including combining microfinance with gender equality training; promoting communication and relationship skills; reducing access to and the harmful use of alcohol; and changing cultural and gender norms (16). Secondary prevention efforts focus on immediate responses to violence, such as emergency services and treatment for sexually transmitted infections following a rape (16). In addition tertiary prevention measures focus on long-term care for women exposed to violence; such as rehabilitation and reintegration, and attempt to lessen trauma or reduce long-term disability associated with violence (16). The health sector can play an important role in the prevention of violence. Sensitization and education of health and other service providers is an important strategy. More resources are needed to strengthen the effectiveness of current interventions. Better awareness of violence against women among health workers can save more lives and protect health. Psychological consequences of abuse can be more serious than its physical effects. 3 VIOLENCE AGAINST WOMEN WHO RESPONSE WHO is committed to ending violence against women by: • building the evidence base by supporting countries’ efforts to document and measure the extent, nature and consequences of violence against women; • developing technical guidance on evidence-based strategies and interventions to prevent intimate partner and sexual violence and to strengthen the health sector’s clinical and policy response; • disseminating information and supporting national capacity and efforts to advance women’s rights, and prevent and respond to violence against women; • strengthening research and research capacity to assess interventions to address intimate partner violence and sexual violence against women; and • strengthening partnerships and collaboration among stakeholders to end violence against women. References: 1. World Health Organization, London School of Hygiene and Tropical Medicine, South African Medical Research Council. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: WHO; 2013. 2. Garcia Moreno C. et al. WHO Multi-country study on women’s health and domestic violence against women: initial results on prevalence, health outcomes and women’s responses. Geneva: WHO; 2005. 3. National Study on Domestic Violence against Women in Tonga. Nuku’alofa: Ma`a Fafine mo e Famili; 2012 (http://www.pacificwomen.org/resources/research/national-study-on-domestic-violence-on-women-in- tonga/, accessed 20 January 2014). 4. Secretariat of the Pacific Community for the Ministry of Women, Youth & Children’s Affairs. Solomon Islands Family Health and Safety Study: A study on violence against women and children. Noumea: Secretariat of the Pacific Community; 2009 (http://www.spc.int/hdp/index.php?option=com_docman&task=cat_view&gid=39&Itemid=44, accessed 16 January 2014). 5. General Statistics Office (Viet Nam) with technical assistance from the World Health Organization. ‘Keeping silent is dying’ Results from the National Study on Domestic Violence against Women in Viet Nam. Hanoi: General Statistics Office; 2010 (http://www.gso.gov.vn/default_en.aspx?tabid=487&ItemID=10693, accessed on 20 January 2014). 6. The Vanuatu National Survey on Women’s Lives and Family Relationships. Port Vila: Vanuatu Women’s Centre; 2011 (http://www.pacificwomen.org/resources/reports/vanuatu-womens-centre-overview-on-vaw/, accessed on 20 January 2014). 7. Secretariat of the Pacific Community for Ministry of Internal and Social Affairs. Kiribati Family Health and Support Study: A study on violence against women and children. South Tarawa: Ministry of Internal and Social Affairs; 2010 (http://www.spc.int/hdp/index.php?option=com_docman&task=cat_view&gid=89&Itemid=44, accessed on 20 January 2014) 8. Information sheet: Understanding and addressing violence against women: Intimate partner violence. Geneva: WHO; 2012 (http://www.who.int/reproductivehealth/publications/violence/en/, accessed 16 January 2014). 9. Fact Sheet: Violence against women; Intimate partner and sexual violence against women. Geneva: WHO; 2013 (http://www.who.int/mediacentre/factsheets/fs239/en/, accessed 14 January 2014). 10. Johnson H, Ollus N, and Nevala S. Violence Against Women: An International Perspective. New York: Springer; 2008. 11. Research on Women’s Health and Life Experiences in Fiji (2010/2011): A survey exploring the prevalence, incidence and attitudes to intimate partner violence in Fiji. Suva: Fiji Women’s Crisis Centre; 2003 (http://www.fijiwomen.com/index.php?option=com_content&view=article&id=222&Itemid=124, accessed on 20 January 2014). 12. Cambodia Demographic and Health Survey 2005. Phnom Penh and Maryland: National Institute of Public Health, National Institute of Statistics (Cambodia) and ORC Macro; 2006 (http://www.measuredhs. com/pubs/pdf/FR185/FR185%5BApril-27-2011%5D.pdf , accessed 16 January 2014). 13. Philippines Demographic and Health Survey 2008. Manila and Calverton: National Statistics Office (Philippines) and ICF Macro; 2009 (http://www.measuredhs.com/pubs/pdf/SR175/SR175.pdf, accessed 16 January 2014). 14. Heise L, Garcia Moreno C. Violence by intimate partners. In: Krug EG et al., eds. World report on violence and health. Geneva, World Health Organization, 2002:87–121. 15. World Report on Violence and Health. Geneva: WHO; 2002. 16. World Health Organization and London School of Hygiene and Tropical Medicine. Preventing intimate partner and sexual violence against women: taking action and generating evidence. Geneva, WHO, 2010 (http:// www.who.int/reproductivehealth/publications/violence/9789241564007/en/index.html?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+ungen+(UN+gender+equality+news+feed), accessed 20 January 2014) 17. Stöckl H et.al. The global prevalence of intimate partner homicide: a systematic review. The Lancet. 2013; 382:859-65. 18. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: World Health Organization; 2013. Health-care service providers play an important role in responding to intimate partner and sexual violence against women through clinical interventions and emotional support. Health providers can provide women-centred emergency and first-line care to those who disclose sexual assault, and address reproductive and sexual health needs (18). An appropriate and adequate response by the health sector can also prevent violence from recurring or escalating through the identification of women in danger. The health sector is crucial in providing assistance through referral to specific services for survivors. This includes assistance in accessing help services, protection and aid that women may require at a later date, such as social welfare and legal aid. WHO recommends the training for health service providers and the integration of intimate partner violence and sexual violence into existing health services to strengthen the health sector response to violence against women (16, 18). HEALTH SECTOR RESPONSE Like prevention strategies, response strategies need to be multisectoral. Strengthening the capacity of all sectors in communication, awareness, advocacy and support is critical. Victims and survivors are the immediate beneficiaries of such collaboration. The health sector in particular has a key role to play in responding to violence against women. Women who face violence often seek care for their injuries, even if they do not disclose the associated abuse or violence. Evidence shows that abused women use health services more than non-abused women (18). They also identify health-care providers as the professionals they would most trust with disclosure of abuse (18). A health-care provider is, thus, likely to be the first professional contact for survivors of intimate partner violence or sexual assault. 4 VIOLENCE AGAINST WOMEN