Gender-based Violence: Prevalence and Health Consequences C. Garcia-Moreno, Coordinator, Gender and Women's Health World Health Organization The Development Implications of Gender-Based Violence, World Bank Washington, D.C.

What this talk is about To provide an understanding of how common violence against women is, and how it affects the health of women and children: GBV: definitions, prevalence and patterns Health consequences

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

Types of gender-based violence Intimate partner violence (physical, sexual, psychological, economic) Forced sexual initiation Childhood sexual abuse Rape and other forms of sexual coercion Trafficking Rape/sexual abuse in conflict situations Acid throwing Female Genital Mutilation Killings in the name of honour Dowry deaths

Prevalence of physical and/or sexual partner violence (WHO, 2004)

Types of physical violence according to severity (WHO, 2004) * In all countries but Japan, more severe violence than “moderate”. Ethiopia and Peru, particularly serious.

Overlap lifetime physical and sexual violence PERU - CAP THAILAND - CAP 29% 20% 3% 11% 12% 18% phys viol sex viol phys viol sex viol NAMIBIA 19% 11% 5% physical viol sexual viol

Prevalence of non-partner sexual violence

Sexual abuse in childhood is common (WHO , 2003)

Prevalence of forced first sex (WHO, 2004)

Female adolescents forced sexual initiation, as % of those reporting having had sex. (Population-based surveys, 1993-1999)

Global prevalence of violence against women Around the world, at least one out of three women is beaten, coerced into sex or otherwise abused by a partner during her lifetime Women are most at risk at home and from men they know, usually a family member or spouse A growing number of studies indicate that the first sexual experience is often forced, particularly for young females Rough estimates suggest that 700,000 to 2 million women and girls are trafficked across international borders every year.

Violence is a risk factor affecting women’s health and wellbeing

A major cause of disability and death One reason the health sector should address GBV is that it is a major cause of morbidity and mortality among women. The data in this slide are estimates of the disability and death worldwide caused by GBV (specifically, rape and domestic violence), relative to other common conditions. These estimates were developed by the World Bank in 1993, in an attempt to quantify the global burden of ill health due to different causes. The World Bank counted every year lost due to premature death as a “disability-adjusted life year” (DALY), and every year spent sick or incapacitated as a fraction of a DALY, depending on the severity of the disability. (World Bank, 1993, cited in Heise et al. 1994.) The World Bank estimated that among women of reproductive age, the burden of disability and death due to rape and domestic violence is higher than that due to malaria and cancer, and only slightly lower than tuberculosis and cardiovascular disease. These estimates probably underestimate the burden caused by gender-based violence, given that in 1993, the current extent of the HIV/AIDS pandemic had not been fully recognized. More recent estimates of the burden due to AIDS is approximately 3 times as high as the 1993 estimate and, both rape and domestic violence play a role in the spread of HIV. Moreover, DALYs give less weight to years of lost health and life among women older than 25, discounting health in most of the reproductive years, and they use a fairly narrow definition of disability. Source: World Bank, 1993, cited in Heise et al., 1994

Violence increases risk for … Fatal Outcomes homicide suicide maternal deaths AIDS related deaths Non-fatal outcomes physical mental reproductive and sexual injurious health behaviors For example: unwanted pregnancy chronic pain injury depression alcohol/drug use STIs/HIV Irritable bowel gynecological disorders

Intimate partner violence is a risk factor for femicide

Violence is a risk factor for health problems Compared to non-abused women, women who have been victimized have: more physical symptoms, reduced physical functioning, worse subjective health, more life-time diagnoses, higher health care utilization Severity of abuse correlates with severity of symptoms

Proportion of women reporting poor health and association with reported violence % women who report their current health status as “poor” or “very poor” All women were asked early on in the questionnaire (before we asked about the partner and about violence) questions on general and reproductive health. The respondents had to indicate on a scale of 5 how they generally describe their health: Excellent, good, fair, poor, very poor. In all countries and sites we see that abused women report worse perceived health and this is statistically significant.

Violence and suicidal ideation % of women who have ever thought of suicide With regards to the association between violence and suicide ideation we found that in every site women who have experienced physical or sexual abuse by a partner were more likely to have ever thought of suicide.

Violence and use of health services in Managua, Nicaragua (IDB, 1999)

Prevalence of injury among women ever physically abused by a partner

Women who are physically or sexually abused by their partner are more likely to report: Problems with walking Difficulties with daily activities Recent pain Problems with memory Recent dizziness Vaginal discharge Source: WHO, 2004

Violence contributes to adolescent pregnancy and sexually transmitted infections Greater likelihood of teen pregnancy, STIs Childhood sexual abuse Increased “risk” behaviors such as sex with many partners, unprotected sex Younger age at first intercourse

Percentage of women whose last pregnancy was unwanted (ever pregnant women)

Violence increases women’s vulnerability to HIV/AIDS VAW, particularly sexual violence, increases women’s risk of HIV/AIDS directly and indirectly Violence can prevent women from accessing HIV/AIDS information, treatment and care Fear of violence is a barrier to HIV testing and disclosure Violence affects women’s ability to mitigate the impact of HIV/AIDS on themselves and their children

Violence increases risk for other gynecological problems A history of sexual violence has been associated with: vaginal bleeding vaginal discharge painful menstruation sexual dysfunction pelvic inflammatory disease chronic pelvic pain

Many women experience physical violence in pregnancy (ever pregnant women) The results on physical violence in pregnancy show that between 4 and 28 percent of women report having been beaten or kicked in pregnancy. One third to one half of these women reported to have been punched or kicked in the stomach

Physical violence during pregnancy (ever pregnant women) % women who report violence during a pregnancy

Violence leads to negative pregnancy outcomes increased smoking and substance use vaginal and cervical infections premature labor miscarriages/abortions bleeding during pregnancy low birth weight late entry into prenatal care

Partner Violence and abortions % ever pregnant women who report 1 or more abortions *

Conclusions About one in three women around the world have been beaten or sexually abused by an intimate partner Physical and sexual abuse is a major cause of ill-health and disability among women Most women do not receive the support they need

I had no one... “…If I had had help I would have left my ex husband earlier. I would not have put up with him five years because I could not find anywhere to hold on to and I had no one who could tell me what I could do." Ana Cristina, a young woman from Nicaragua (in Ellsberg, 1998) Por ejemplo, Ana Cristina cuenta que... “…Si yo hubiera tenido una ayuda, creo que me hubiera apartado antes de mi ex-marido. No le hubiera aguantado cinco años porque yo no hallaba por donde agarrar, y no tenía a nadie quien me dijera que podía hacer. “

Health sector response can: Help change attitudes in society Educate providers and managers to respond sensitively and prevent providers from causing harm Improve quality of care for women and children Research the epidemiology of GBV Design and evaluate prevention and intervention strategies Carry out community-based education Educate professionals in all sectors Advocate to change laws and their application Collaborate with organizations from other sectors (legal, rights, social services, etc.)

What can we do? The health care setting is an opportunity for intervention… …and presently it is a lost opportunity (Heise, Ellsberg and Gottemuller, 1999)