A global overview of gender-based violence

International Journal of Gynecology and Obstetrics 78 Suppl. 1 (2002) S5–S14 A global overview of gender-based violence L. Heise*, M. Ellsberg, M. Gottmoeller Program for Appropriate Technology in Health (PATH), Washington, DC, USA Abstract This paper provides an overview of the extent and nature of gender-based violence and its health consequences, particularly on sexual and reproductive health. ᮊ 2002 International Federation of Gynecology and Obstetrics. Published by Elsevier Science Ireland Ltd. All rights reserved. Keywords: Violence; Women; Gender; Health Violence against women is the most pervasive obscure and deny abuse. The same acts that would yet least recognized human rights violation in the be punished if directed at an employer, a neighbor, world. It also is a profound health problem, sap- or an acquaintance often go unchallenged when ping women’s energy, compromising their physical men direct them at women, especially within the health, and eroding their self-esteem. In addition family. to causing injury, violence increases women’s long-term risk of a number of other health prob- For over two decades women’s advocacy groups lems, including chronic pain, physical disability, around the world have been working to draw more drug and alcohol abuse and depression. Women attention to the physical, psychological, and sexual with a history of physical or sexual abuse are also abuse of women and to stress the need for action. at increased risk for unintended pregnancy, sexu- They have provided abused women with shelter, ally transmitted infections (STIs), and adverse lobbied for legal reforms, and challenged the pregnancy outcomes. widespread attitudes and beliefs that support vio- lent behavior against women w1x. Despite its high costs, almost every society in the world has social institutions that legitimize, Increasingly, these efforts are having results. Today, international institutions are speaking out *Corresponding author. Tel.: q1-202-822-0033; fax: q1- against gender-based violence. Surveys and studies 202-457-1466. are collecting more information about the preva- lence and nature of abuse. More organizations, E-mail address: [email protected] (L. Heise), service providers, and policy-makers are recogniz- [email protected] (M. Ellsberg). ing that violence against women has serious 0020-7292/02/$ - see front matter ᮊ 2002 International Federation of Gynecology and Obstetrics. Published by Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 0 2 0 - 7 2 9 2 Ž 0 2 . 0 0 0 3 8 - 3

S6 L. Heise et al. / International Journal of Gynecology and Obstetrics 78 Suppl. 1 (2002) S5–S14 adverse consequences for women’s health and for 3. Sexual coercion and abuse society. 1. Extent and nature of the problem Sexual coercion and abuse also emerge as defin- ing features of the female experience for many Gender-based violence includes a host of harm- women and girls. Forced sexual contact can take ful behaviors that are directed at women and girls place at any time in a woman’s life and includes because of their sex, including wife abuse, sexual a range of behaviors, from forcible rape to non- assault, dowry-related murder, marital rape, selec- physical forms of pressure that compel girls and tive malnourishment of female children, forced women to engage in sex against their will. The prostitution, female genital mutilation, and sexual touchstone of coercion is that a woman lacks abuse of female children. Specifically, violence choice and faces severe physical or social conse- against women includes any act of verbal or quences if she resists sexual advances. physical force, coercion or life-threatening depri- vation, directed at an individual woman or girl Studies indicate that the majority of nonconsen- that causes physical or psychological harm, humil- sual sex takes place among individuals known to iation or arbitrary deprivation of liberty and that each other—spouses, family members, courtship perpetuates female subordination (2). partners, or acquaintances w7,8x. Ironically, much nonconsensual sex takes place within consensual 2. Intimate partner violence unions. For example, in a 15-country qualitative study of women’s HIV risk, women related pro- The most pervasive form of gender violence is foundly troubling experiences of forced sex within abuse of women by intimate male partners. A marriage. Respondents frequently mentioned being recent review of 50 population-based studies car- physically forced to have sex andyor to engage in ried out in 36 countries indicates that between 10 types of sexual activity that they found degrading and 60% of women who have ever been married and humiliating w9x. or partnered have experienced at least one incident of physical violence from a current or former Regrettably, much sexual coercion takes place intimate partner w2x. Although women can also be against children or adolescents in both industrial violent and abuse exists in some same-sex rela- and developing countries. Between one-third and tionships, the vast majority of partner abuse is two-thirds of known sexual assault victims are age perpetrated by men against their female partners. 15 or younger, according to information from justice systems statistics and rape crisis centers in Representative sample surveys indicate that Chile, Peru, Malaysia, Mexico, Panama, Papua physical violence in intimate relationships is New Guinea and the United States w10x. almost always accompanied by psychological abuse and, in one-third to over one-half of cases, Sexual exploitation of children is widespread in by sexual abuse w3–5x. Most women who suffer virtually all societies. Child sexual abuse refers to any physical aggression generally experience mul- any sexual act that occurs between an adult or tiple acts over time. However, measuring ‘acts’ of immediate family member and a child, and any violence does not describe the atmosphere of terror nonconsensual sexual contact between a child and that often permeates abusive relationships. For a peer. Laws generally consider the issue of con- example, in Canada’s 1993 national violence sur- sent to be irrelevant in cases of sexual contact by vey one-third of women who were abused physi- an adult with a child, defined variously as someone cally in a relationship said they had feared for under 13, 14, 15, or 16 years of age. their lives at some time w6x. Women often say that the psychological abuse and degradation are even Because of the taboo nature of the topic, it is more difficult to endure than the physical abuse difficult to collect reliable figures on the preva- itself. lence of sexual abuse in childhood. Nonetheless, the few representative sample surveys provide cause for concern. A recent review of 17 studies worldwide indicate that anywhere from 11 to 32% of women report behavior constituting sexual

L. Heise et al. / International Journal of Gynecology and Obstetrics 78 Suppl. 1 (2002) S5–S14 S7 abuse in childhood. Although both girls and boys New Guinea—where domestic violence is virtually can be victims of sexual abuse, most studies report absent w20,21x. This reality stands as testament to that the prevalence of abuse among girls is at least the fact that social relations can be organized in 1.5 to 3 times that among boys w11x. Abuse among such a way to minimize abuse. boys may be underreported compared with abuse among girls, however. Why is violence more widespread in some places than in others? Increasingly, researchers are Studies consistently show that, regardless of the using an ‘ecological framework’ to understand the sex of the victim, the vast majority of perpetrators interplay of personal, situational, and sociocultural are male and are known to the victim w12–14x. factors that combine to cause abuse w22x. In this Many perpetrators were themselves sexually model, violence against women results from the abused in childhood, although most boys who are interaction of factors at different levels of the sexually abused do not grow up to abuse others social environment. w15x. The model can best be visualized as four con- Although for some children the effects of sexual centric circles. The innermost circle represents the abuse are severe and long-term, not all will expe- biological and personal history that each individual rience consequences that persist into later life brings to his or her behavior in relationships. The w16,17x. Sexual abuse is most likely to cause long- second circle represents the immediate context in term harm when it extends over a long period, is which abuse takes place: frequently the family or by a father or father figure, involves penetration, other intimate or acquaintance relationship. The or uses force or violence w16,18,19x. third circle represents the institutions and social structures, both formal and informal, in which 4. Explaining gender-based violence relationships are embedded in neighborhoods, the workplace, social networks, and peer groups. The While violence against women is widespread, it fourth, outermost circle is the economic and social is not universal. Anthropologists have documented environment, including cultural norms. small-scale societies—such as the Wape of Papua

S8 L. Heise et al. / International Journal of Gynecology and Obstetrics 78 Suppl. 1 (2002) S5–S14 A wide range of studies agree on several factors women who challenge that right—even by asking at each of these levels that increase the likelihood for household money or by expressing the needs that a man will abuse his partner: of the children—may be punished. In countries as different as Bangladesh, Cambodia, India, Mexico, (1) At the individual level these include being Nigeria, Pakistan, Papua New Guinea, Nicaragua, abused as a child or witnessing marital violence Tanzania, and Zimbabwe, studies find that violence in the home w23x, having an absent or rejecting is frequently viewed as physical chastisement— father w24x, and frequent use of alcohol w25x. the husband’s right to ‘correct’ an erring wife w2x. As one husband said in a focus-group discussion (2) At the level of the family and relationship, in Tamil Nadu, India, ‘If it is a great mistake, then cross-cultural studies have cited male control of the husband is justified in beating his wife. Why wealth and decision-making within the family w21x not? A cow will not be obedient without beatings’ and marital conflict as strong predictors of abuse w28x. w23x. Worldwide, studies identify a consistent list of (3) At the community level women’s isolation events that are said to ‘trigger’ violence. These and lack of social support, together with male peer include: not obeying her husband, talking back, groups that condone and legitimize men’s violence, not having food ready on time, failing to care predict higher rates of violence w26,27x. adequately for the children or home, questioning him about money or girlfriends, going somewhere (4) At the societal level studies around the without his permission, refusing him sex, or world have found that violence against women is expressing suspicions of infidelity. All of these most common where gender roles are rigidly represent transgression of dominant gender norms. defined and enforced and where the concept of masculinity is linked to toughness, male honor, or 5. The impact of violence on women’s repro- dominance w22x. Other cultural norms associated ductive health with abuse include tolerance of physical punish- ment of women and children, acceptance of vio- A growing number of studies document the lence as a means to settle interpersonal disputes, ways in which coercion and violence undermine and the perception that men have ‘ownership’ of women’s sexual and reproductive autonomy and women w21,22x. jeopardize their physical and mental health (see Table 1). Although violence can have direct health By combining individual-level risk factors with consequences, it also increases women’s risk of findings of cross-cultural studies, the ecological future ill health. Physical violence and sexual model contributes to understanding why some abuse can put women at risk of infection and societies and some individuals are more violent unwanted pregnancies directly, if women are than others and why women, especially wives, are forced to have sex, for example, or fear using so consistently the victims of abuse. contraception or condoms because of their part- ners’ potentially violent reaction. A history of Other factors combine to protect some women. sexual abuse in childhood also can lead to unwant- For example, when women have authority and ed pregnancies and STDs indirectly by increasing power outside the family, rates of abuse in intimate sexual risk-taking in adolescence and adulthood. partnerships are lower w21x. Likewise, prompt Therefore, like tobacco or alcohol use, victimiza- intervention by family members and friends tion can best be conceptualized as a risk factor for appears to reduce the likelihood of domestic vio- a variety of diseases and conditions w2x. lence. By contrast, where the family is considered ‘private’ and outside public scrutiny, rates of wife 5.1. Reduced sexual autonomy leads to unwanted abuse are higher w21x. pregnancies and STIsyHIV Justifications for violence frequently evolve In many parts of the world marriage is inter- from gender norms—that is, social norms about preted as granting men the right to unconditional the proper roles and responsibilities of men and women. Many cultures hold that men have the right to control their wives’ behavior and that

L. Heise et al. / International Journal of Gynecology and Obstetrics 78 Suppl. 1 (2002) S5–S14 S9 Table 1 unwanted pregnancies unless he agrees to do Health outcome of violence against women something? Once when I gathered the courage and told him I wanted to avoid sex with him, he said Partner abuse, sexual assault, child sexual abuse what else have I married you for? He beats me for the smallest reasons and has sex whenever he Fatal outcomes wants’ w29x. Homicide Many women are afraid to raise the issue of Suicide contraception for fear that their partners might Maternal mortality respond violently w30–36x. In some cultures hus- AIDS-related bands may react negatively because they think that protection against pregnancy would encourage Nonfatal outcomes Injury their wives to be unfaithful. Where having many Physical health Functional impairment children is a sign of male virility, a wife’s desire Physical symptoms to use family planning may be interpreted as an Chronic conditions Poor subjective health affront to her husband’s masculinity w30x. Mental health Permanent disability Severe obesity For women living with men who are violent, Negative health behaviors the fear of a negative reaction is often enough to Reproductive health Chronic pain syndromes cut off discussion of contraception. As one woman Irritable bowel syndrome said of her husband, ‘Whenever he hears people Gastrointestinal disorders discussing family planning over the radio, he Somatic complaints fumes and shouts« If he can threaten a wireless, Fibromyalgia what would he do to me if I open the topic?’ w33x. Post-traumatic stress Violence influences the risk of HIV and other Depression STIs directly when it interferes with women’s Anxiety ability to negotiate condom use. For many women, Phobiasypanic disorder asking for condoms can be even more difficult Eating disorders than discussing other contraceptives because con- Sexual dysfunction doms are often associated with promiscuity, infi- Low self-esteem delity, and prostitution. Substance abuse Raising the issue of condom use within marriage Smoking or other primary partnerships is especially difficult Alcohol and drug abuse w37x. As a 46-year respondent in Brazil said, ‘‘If I Sexual risk-taking ask my husband to use a condom now, he is going Physical inactivity to ask ‘why?’ He is going to think I am fooling Overeating around or that I am accusing him of fooling around, two things that shouldn’t be happening’’ Unwanted pregnancy w38x. STIsyHIV Gynecological disorders Sexual victimization in childhood appears to Unsafe abortion place young women at increased risk of pregnancy Pregnancy complications during their teenage years. In the early 1990s Miscarriageylow birth weight studies began to find a consistent association Pelvic inflammatory disease between sexual abuse in childhood and adolescent pregnancy w39–41x. The studies also found a clear sexual access to their wives and the power to and consistent link between early sexual victimi- enforce this access through force if necessary. zation and a variety of risk-taking behaviors, Women who lack sexual autonomy often are pow- including early sexual debut, drug and alcohol use, erless to refuse unwanted sex or to use contracep- more sexual partners, and less contraceptive use. tion and thus are at risk of unwanted pregnancies. As a 40-year-old woman in Uttar Pradesh said, ‘What can I do to protect myself from these

S10 L. Heise et al. / International Journal of Gynecology and Obstetrics 78 Suppl. 1 (2002) S5–S14 Childhood abuse has also been linked to unin- ogy. A variety of studies have found that women tended pregnancies among adult women. A study suffering from CPP are consistently more likely to of 1200 women in the US found that women who have a history of childhood sexual abuse w64x, reported being psychologically, sexually andyor sexual assault w63,66–69x, or physical and sexual physically abused, or whose mother was beaten by abuse by their partners w70,71x. a partner, had higher rates of unintended first pregnancies than women who did not experience Past trauma may lead to CPP via unidentified abuse. The likelihood of an unintended first preg- injuries, by stress, or by somatization—the expres- nancy increased with both the number of different sion of psychological distress through physical types of abuse women experienced, and its fre- symptoms w63x. Also, sexual abuse in childhood quency w42x. has been linked to increased sexual risk-taking, and thus to STIs, which can lead to CPP, often In a 1999 speech, Peter Piot, the Executive due to pelvic inflammatory disease. Director of UNAIDS, noted that violence against women has many links to HIVyAIDS. ‘Violence Other gynecological disorders associated with against women is not just a cause of the AIDS sexual violence include irregular vaginal bleeding epidemic,’ he noted, ‘it can also be a consequence w72x, vaginal discharge, painful menstruation of it.’ Sexual abuse in childhood appears to w68,73x, pelvic inflammatory disease w74x, and increase the incidence of STIs among adults, large- sexual dysfunction (difficulty in orgasms, lack of ly through its effect on high-risk sexual behavior desire and conflicts over frequency of sex) (w43–50x). Several studies have linked a history w71,73,74x. Sexual assault also increases risk for of sexual abuse to higher risk of selling sex for premenstrual distress, a condition that affects 8 to money or drugs w39,50–53x. Abuse in childhood 10% of menstruating women and causes physical, also increases the risk of HIVyAIDS through its mood, and behavioral symptoms w75x. The number effect on drug use. Sexually abused or assaulted of gynecological symptoms appears to be related women often turn to drugs as a coping mechanism, to the severity of abuse suffered, whether there in addition to such unhealthy behavior as having was both physical and sexual assault, whether the unprotected sex and trading sex for money or victim knew the offender, and whether there were drugs w54–61x. multiple offenders w76,77x. In some places, fear of men’s reaction has also 5.3. Violence leads to adverse pregnancy outcomes hindered efforts to encourage voluntary HIVy AIDS counseling and testing among women w62x. Around the world, as many as one woman in This has implications both for controlling sexual every four is physically or sexually abused during transmission of the virus and for efforts to reduce pregnancy, usually by her partner w78–87x. Esti- mother to child transmission. mates vary widely, however. Within the US, for example, estimates of abuse during pregnancy 5.2. Violence increases risks for other gynecolog- range from 3 to 11% among adult women and up ical problems to 38% among teenage mothers w80x. Some of this variation is likely due to differences in how the Sexual and physical violence appears to increase questions were asked, how often, and by whom women’s risk for many common gynecological w81,88x. disorders, some of which can be debilitating. An example is chronic pelvic pain (CPP), which in Violence before and during pregnancy can have many countries accounts for as many as 10% of serious health consequences for women and their all gynecological visits and one-quarter of all children. Pregnant women who have experienced hysterectomies w63–65x. violence are more likely to delay seeking prenatal care w80,89–94x and to gain insufficient weight Although CPP is commonly caused by adhe- w80,95x. They are also more likely to have a history sions, endometriosis, or infections, about half the of STIs w96x, unwanted or mistimed pregnancies cases of CPP do not have any identifiable pathol- w81,94,97x, vaginal and cervical infections

L. Heise et al. / International Journal of Gynecology and Obstetrics 78 Suppl. 1 (2002) S5–S14 S11 w80,90,91x, kidney infections w97x, and bleeding in refer their clients to legal assistance and support pregnancy w80,90x. services. Violence may also have a serious impact on Reproductive health professionals have a partic- pregnancy outcomes. Violence has been linked ular responsibility to help because: with increased risk of miscarriages and abortions w83,98x, premature labor w97x, and fetal distress ● Abuse has a major—although little recog- w97x. Several studies also have focused on the nized—impact on women’s reproductive health relationship between violence in pregnancy and and sexual well-being; low birth weight, a leading contributor to infant deaths in the developing world w80,90,93,94,97– ● Providers cannot do their jobs well unless they 103x. Although the findings are inconclusive, sev- understand how violence and powerlessness eral studies suggest that violence during pregnancy affect women’s reproductive health and deci- contributes substantially to low birth weight, at sion-making ability; least in some settings. In one study at the regional hospital in Leon, Nicaragua, for example, research- ● Reproductive health care providers are strategi- ers found that after controlling for other risk cally placed to help identify victims of violence factors, violence against pregnant women was and connect them with other community support associated with a threefold increase in the inci- services. dence of low birth weight w94x. Providers can reassure women that violence is How violence puts pregnancies at above-average unacceptable and that no woman deserves to be risk is unclear, but several explanations have been beaten, sexually abused, or made to suffer emo- suggested w82,88x. Blunt abdominal trauma can tionally. As one client said, ‘Compassion is going lead to fetal death or low birth weight by provok- to open up the door. And when we feel safe and ing preterm delivery. Extreme stress and anxiety are able to trust, that makes a lot of difference’ provoked by violence may also lead to preterm w104x. delivery or fetal growth retardation by increasing stress hormone levels or immunological changes. References Finally, violence may affect pregnancy outcome indirectly by increasing women’s likelihood of w1x Heise L. Violence against women: global organizing for engaging in such harmful health behaviors as change. In: Edleson JL, Eisikovits ZC, editors. Future smoking and alcohol and drug abuse, all of which interventions with battered women and their families. have been linked to low birth weight. Thousand Oaks, California: Sage Publications, 1996. p. 7 –33. 6. The role of reproductive health professionals w2x Heise L, Ellsberg M, Gottemoeller M. Ending violence Health professionals can do much to help their against women. Population Reports. Baltimore: Johns clients who are victims of gender-based violence. Hopkins University, 1999. Yet providers often miss opportunities to help by being unaware, indifferent or judgmental. With w3x Ellsberg M, Pen˜ a R, Herrera A, Liljestrand J, Winkvist training and support from health care systems, A. Candies in hell: women’s experiences of violence in providers can do more to respond to the physical, Nicaragua. Soc. Sci. Med. 2000;51:1595 –1610. emotional and security needs of abused women and girls. First, health care providers can learn w4x Koss MP, Goodman LA, Browne A, Fitzgerald LF, how to ask women about violence in ways that Keita GP, Russo NF. No safe haven: male violence their clients find helpful. They can give women against women at home, at work, and in the community. empathy and support. They can provide medical Washington DC: American Psychological Association, treatment, offer counseling, document injuries and 1994. w5x Yoshihama M, Sorenson SB. Physical, sexual, and emotional abuse by male intimates: experiences of women in Japan. Violence Victims 1994;9:63 –77. w6x Rodgers K. Wife assault: the findings of a national survey. Juristat Serv. Bull. Can. Centre Justice Statistics 1994;14:1 –22. w7x Heise L, Moore K, Toubia N. Sexual coercion and women’s reproductive health: a focus on research. New York: Population Council, 1995. p. 59

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