77605 Addressing Violence against Women in Middle and Low-Income Countries: A Multi-Sectoral Approach We must become tireless in our efforts not only to attain peace, justice and prosperity for countries, but also for communities and members of the same family. We must address the roots of violence. Nelson Mandela, World Report on Violence and Health, 2002. *** During the last decade, violence against women and girls also referred to as “violence against women,� has gained international recognition as a grave social and human rights concern affecting virtually all societies. Epidemiological research has demonstrated that violence against women (VAW) is a major cause of ill health among women and girls. The impact of VAW can be seen directly through death and disability due to injuries, as well as indirectly through increased vulnerability to a host of physical and mental health problems. Violence and the fear of violence severely limit women’s contribution to social and economic development, thereby hindering the achievement of important national and international development goals, such as the Millennium Development Goals (MDGs) of eradicating extreme poverty and hunger and improving maternal and child health. Scope, Magnitude, Consequences and Causes of Violence against Women VAW includes, but is not limited to: ‰ physical violence, such as slapping, kicking, hitting, or use of weapons; ‰ emotional violence, such as systematic humiliation, controlling behavior, degrading treatment, and threats; ‰ sexual violence, including coerced sex, or being forced into sexual activities that are considered degrading or humiliating; and ‰ economic violence, such as restricting access to financial or other resources with the purpose of controlling or subjugating a person. Both men and women can be victims or perpetrators of violence, but the characteristics of violence commonly committed against women and men differ. Women are more likely to be physically assaulted or murdered by someone they know, often a family member or intimate partner. They are also at much greater risk of being sexually assaulted or exploited, in childhood, adolescence or as adults. Prevalence estimates for intimate partner violence vary widely among countries, and sometimes even between studies in the same countries. A study of 10 countries found that between 13 and 62 percent of women have experienced physical violence by a partner over the course of their lifetime and between 3 and 29 percent of women reported violence within the past year (Bott, Morrison and Ellsberg, 2005). Internationally, eight- 26 percent of women and girls report having been sexually abused as children or adults. An estimated one of every three women globally is beaten, raped or otherwise abused 1 Prepared for the Gender and Development Group, PREM during her lifetime (Heise, Ellsberg, et al, 1999). A recent study in South Africa found that a woman is murdered by an intimate partner every six hours in South Africa (Matthews, Abrahams). Women are subjected to different types of violence throughout their lives (see Figure 1). FIGURE 1: The Life Cycle of Violence against Women VAW has serious consequences for women’s health and well-being, ranging from fatal outcomes, such as homicide, suicide, and AIDS-related deaths to non-fatal outcomes such as physical injuries, chronic pain syndrome, gastrointestinal disorders, gynecological problems, unwanted pregnancy, miscarriage, low birth-weight of children, and sexual dysfunction. Sexual abuse in childhood and adolescence is associated with higher risk of subsequent victimization, early sexual activity, substance abuse, and multiple sexual partners. Researchers have also documented negative outcomes among children of women who experience violence, including increased levels of child mortality and emotional and behavioral problems. VAW causes significant economic costs, due to lower worker productivity and incomes, disability, lost years of life, and lower rates of accumulation of human and social capital. And it generates other forms of violence now and in the future. VAW is a complex phenomenon, shaped by forces operating at the individual, relationship, community and societal levels. Key risk factors include witnessing or suffering abuse as a child, exposure to violence as a child, male control of household decision-making and wealth, cultural norms that support violence as a way of resolving conflicts or that support male dominance over women, low educational levels of men and 2 Prepared for the Gender and Development Group, PREM women, and policies and laws that discriminate against women. Male abuse of alcohol is an important trigger. Figure 2 presents an ecological framework used by the World Health Organization and others that shows risk factors for violence at difference levels. FIGURE 2: An Ecological Framework for Explaining Violence against Women ƒ Norms and laws ƒ Isolation of ƒ Marital conflict ƒ Witnessing granting men control women and ƒ Male control of abuse ƒ Violence accepted for family wealth and ƒ Absent or resolving conflict ƒ Delinquent peer decision making rejecting ƒ Masculinity linked to groups in the family father dominance, honor or ƒ Low socio- ƒ Poverty ƒ Being abused aggression economic status ƒ Unemployment as a child ƒ Impunity ƒ Inequality ƒ Alcohol and/or ƒ Problems with police drug use Promising Practices: National Commissions and Integrated Local Services Improving coordination between sector-specific approaches, civil society initiatives, and government institutions is a critical part of an effective strategy for addressing VAW. A study by PAHO in ten Central American and Andean countries found that poor coordination across agencies and institutions meant that women had to negotiate through complex and sometimes contradictory information and requirements when seeking care and support. Many governments, particularly in Latin America, have established national commissions to improve inter-sectoral coordination and monitor progress in developing national plans and policies on violence. Although there are no rigorous evaluations of these programs, qualitative reports suggest that the existence of a national plan on violence against women creates commitment and political space for dialogue between civil society and the state. Services for survivors of VAW provided through multi-sectoral initiatives include telephone hotlines, emergency shelters, police intervention, legal assistance, psychological and other counseling, psychological care, support groups, income- 3 Prepared for the Gender and Development Group, PREM generation programs, and programs for batterers, women police stations and child welfare services. Much research has evaluated women’s police stations, primarily by gathering data on the number, nature and outcomes of cases reported, and by exploring perspectives of police, judges, NGO staff, lawyers, prosecutors, judges, detectives, and survivors (WHO, 2002). Special police stations generally appear to increase reporting as well as the likelihood that women will receive services such as forensic exams, counseling, emergency contraception and sexually-transmitted infection (STI) prophylaxis. Support groups for survivors appear effective and low-cost in reaching large numbers of women. Research has documented the impact of comprehensive services on the proportion of women who know about services and who seek help, but not yet on whether these services reduce the probability of revictimization. A relatively new approach is to develop community-based networks for coordinating services to survivors of VAW, improving access to justice and promoting violence prevention. Some networks comprise only governmental agencies such as the criminal justice sector, social welfare and education. Others coordinate the civil society response to violence. A third type integrates public and private agencies addressing VAW. These networks can significantly enhance the quality of care provided to survivors and help to mobilize public support for survivors; they can also decrease the tolerance for violent behavior. Community-based educational activities can increase women’s knowledge of legal and social rights and empower them to seek help for abuse. They can also challenge the underlying beliefs that justify women’s subordination and the use of violence for settling conflicts. Changing attitudes, however, is easier than changing behaviors. Promoting non-violent and equitable relationships between men and women is the key to preventing future violence. Further Reading Bott, Sarah, Andrew Morrison and Mary Ellsberg, Preventing and Responding to Violence against women in Middle-and Low-Income Countries: A Global Review and Analysis, World Bank Policy Research Working Paper 3618, the World Bank, Washington, DC, June, 2005 Morrison, Andrew, Mary Ellsberg and Sarah Bott, Addressing Violence against women in the Latin American and Caribbean Region: A Critical Review of Interventions, World Bank Policy Research Working Paper 3438, The World Bank, Latin America and the Caribbean Region, Poverty Sector Unit, October 2004 Heise, Lori, Mary Ellsberg and Megan Gottemoeller, 1999, “Ending Violence against Women�, Population Reports, Vol. XXVII, Number 4, Series L, Number 11, (available at www.infoforhealth.org.pr/111/violence.pdf) UNIFEM, Not a Minute More: Ending Violence against Women, UNIFEM, New York, 2003. 4 Prepared for the Gender and Development Group, PREM