| | Protection of sexual and reproductive health rights: Addressing violence against women published online 29 June 2009. Abstract Violence against women is recognized as a global public health and human rights problem in need of urgent attention. It affects women's health, including their sexual and reproductive health, and their human rights. While progress has been made in the last 15 years, there is still a long way to go. International human rights law and public health provide tools to governments and non-governmental actors to ensure women a life free from violence and its consequences. Health policies and services need to address violence more systematically and health providers must take action. At a minimum, they should be informed and able to respond appropriately to violence, providing appropriate care and referral to other services. Equally, if not more important, is to provide support to interventions that prevent violence against women from happening in the first place. 1. Introduction  Violence against women is one of the most widespread human rights violations as well as a public health problem in need of urgent attention. It is sometimes called gender-based violence as it is both maintained by, and in turn perpetuates, gender inequality that puts women and girls in subordinate positions. This violence has many devastating consequences for women's lives and their health, including their sexual and reproductive health, and their human rights. Violence against women can take many forms: physical, sexual, and emotional. It can take place in the home, the community, and state institutions, and be perpetrated by intimate male partners, acquaintances, or strangers. In certain settings, such as those in conflict or involving displacement or in prisons, women may be at increased risk, particularly of sexual violence by both State and non State actors. Most of the data on the impact of violence on health comes from studies of either intimate partner violence or sexual violence. While recognizing that other forms of violence are important also, this article predominantly addresses these two forms. It provides an overview of the prevalence of this violence, its impact on women's sexual and reproductive health, and on their human rights. It considers the implications of this for health care provision and makes some recommendations for action. 2. Violence against women: Prevalence, risk factors, and health consequences The World Health Organization defines violence as: “The intentional use of physical force or power, threatened or actual… that results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.” The inclusion of the word “power” broadens “the conventional understanding of violence to include those acts that result from a power relationship, including threats and intimidation” [1]. Intimate male partners are most often the main perpetrators of violence against women, a form of violence known as intimate partner violence, “domestic” violence or “spousal (or wife) abuse.” Intimate partner violence and sexual violence, whether by partners, acquaintances or strangers, are common worldwide and disproportionately affect women, although are not exclusive to them. Other forms of violence such as trafficking also affect women and children more often. In situations of conflict, sexual violence against civilians, including men, is increasingly being documented. Globally, studies have shown that: •between 10% and 69% of women report that an intimate partner has physically abused them at least once in their lifetime [2], [3]; •between 6% and 59% of women report attempted or completed forced sex by an intimate partner in their lifetime [2]; •between 1% and 28% of women report they have been physically abused during pregnancy by an intimate partner [2], [4]; •between 7% and 48% of adolescent girls and between 0.2% and 32% of adolescent boys report that their first experience of sexual intercourse was forced [1]; •approximately 20% of women and 5%–10% of men report having been sexually abused as children [5]; •between 0.3% and 12% of women report sexual violence by a non-partner [2]; •it is estimated that 2.5 million people are trafficked every year [6], the majority of them women and children. 2.1. Risk factors for intimate partner violence (and sexual violence) Violence against women is a complex phenomenon driven by factors at the level of the individual woman, the perpetrator, the relationship and family, the community, and the society. Research has identified the following as common “risk factors” for intimate partner violence [7]: being young; witnessing or suffering family violence as a child; suffering sexual abuse as a child; alcohol and substance abuse; relationships characterized by inequality and power imbalance; poverty, economic stress, and unemployment; gender inequality; lack of institutional support or sanctions; and social norms that support traditional gender norms, condone violence, or promote models of masculinity based on abuse of power and aggressiveness. The majority of research on risk and protective factors has until recently been conducted in high-income countries and therefore needs to be tested for its relevance to middle- and low-income countries. Some factors may operate differently in different contexts, as has been shown for example with women's education levels and status disparities within couples [8]. In high-income settings women's education is usually protective, whereas in low-income settings it may be a risk factor, particularly when it is the exception and there are disparities of education status within the couple. 2.1.1. Health consequences Violence is associated with a wide range of negative health outcomes for women. These range from mild to severe injuries including fractures and permanent damage to ears and eyes [9], chronic pain syndromes including chronic pelvic pain [10], depression, anxiety disorders, eating disorders and many other mental health problems [11], and sexual and reproductive health problems. Whether directly increasing the risk of sexually transmitted infections (STIs) including HIV/AIDS, and unwanted or mistimed pregnancies through rape and sexual assault, or indirectly through inability to request or negotiate the use of condoms because of actual violence, coercion/intimidation or fear of violence (Fig. 1), violence contributes to women's increased risk of unwanted pregnancies—which may lead to unsafe abortion and gynecological problems [12]. This association has been documented in many countries [13]. Intimate partner violence during pregnancy is not uncommon. In the WHO multicountry study between 1% and 28% of women reported being physically abused by a partner in at least one of their pregnancies, with between 4% and 12% reporting this in the majority of the sites [2]. This frequently involved blows or kicks to the abdomen. This is consistent with findings in other studies where the range in low-income countries was between 4% and 32% [4]. It must be noted however that the studies in this review use different measures of violence and some also include sexual and emotional violence. There is clearly some cultural variation in the level of protection to violence that pregnancy may confer to women and in most places violence appears to reduce during pregnancy, but there is a group of women for whom the pregnancy may be what triggers the violence or for whom the violence gets worse during pregnancy [14]. Violence during pregnancy has been found to be associated with pre-term labor [15], miscarriage, stillbirth [16], abortion [17], low birth weight [18], lower levels of breastfeeding [19], and higher rates of smoking and drinking during pregnancy [20]. Recent studies also document an association of intimate partner violence with infant and child mortality [21]. Half to two-thirds of femicide or the murder of women is perpetrated by an intimate partner [22]. In situations of conflict, such as we have seen recently in many countries in Africa and elsewhere, sexual violence against women has increasingly become part of war tactics and has taken egregious forms [23]. While precise numbers are hard to come by, estimates range in the hundreds of thousands [23]. 3. Violence against women in the international agenda: Right to a life free of violence Long recognized by women's health and rights advocates as a critical issue in the lives of many women, violence against women was firmly placed on the international agenda in the early 1990s; the Human Rights Conference in Vienna (1993), the International Conference on Population and Development in Cairo (1994), and the Fourth World Conference on Women in Beijing (1995) all recognized and highlighted violence against women and made specific recommendations for governments to respond to it. In 1996, the World Health Assembly recognized the prevention of violence, including violence against women, as a public health priority requiring urgent action with resolution 49.25, and in 2002 the WHO published the first ever world report on violence and health [1], which included chapters on intimate partner violence and sexual violence. In 1997, the International Federation of Gynecology Obstetrics (FIGO) initiated a pre-congress workshop and a declaration on violence against women, outlining the role that FIGO and its country affiliates could play to address violence against women. More recently, the United Nations Security Council passed resolution SCR 1820 and thereby recognized rape during war as a crime against humanity and a threat to global security. The resolution demands that all parties to armed conflict immediately take appropriate measures to protect civilians from all forms of sexual violence. It also calls on governments to ensure that all victims of sexual violence, particularly women and girls, have equal protection and access to justice, and it requires governments to strengthen services to respond to the needs of women who have been raped. 3.1. The right to the highest attainable standard of health Violence against women is a serious public health problem, as noted above. It clearly impacts people's ability to achieve the highest attainable standard of physical and mental health [24]. It also impinges on many other human rights, not least women's reproductive rights as defined at the International Conference on Population and Development [25]. These include the right of women to make decisions about reproduction, free of discrimination, coercion or violence. Specifically, sexual violence and intimate partner violence against women, whether physical, sexual or emotional, impinge on women's ability to decide freely if and when to get pregnant and to protect themselves from STIs, including HIV/AIDS. Other human rights that are potentially affected are the right to life, the right to bodily integrity, and the right to nondiscrimination, among others. 3.2. Right to nondiscrimination Much of the violence that women experience is condoned and at times exacerbated by gender inequality. Laws that discriminate against women with regard to age of marriage, divorce, right to own property and to inherit, for example, can contribute to violence and make it difficult for women to leave abusive relationships. In addition, the violence itself can be considered a form of discrimination. Some have gone further and argued that extreme forms of domestic violence constitute private torture and invoke the Convention Against Torture as a form of protection states' responsibilities [26]. 3.3. Human rights and healthcare provision All individuals are entitled to the protection of, and respect for, their human rights by healthcare providers. In terms of service provision, survivors of domestic violence, rape, and other forms of sexual abuse have a right to receive good quality health services, including reproductive health care to manage the physical and psychological consequences of the violence and to prevent and manage pregnancy and STIs. Health providers should ensure they do not in any way “re-victimize” women, force them to have any examination against their will, or take away their agency and decision-making. All patients need to be treated with respect, be given the information they need to make decisions, and have their privacy and the confidentiality of their health records guaranteed. Governments have a legal obligation to take all appropriate measures to prevent violence against women and to ensure that quality health services are available that can respond to the needs of survivors. The Convention on the Elimination of All forms of Discrimination against Women (CEDAW) and other human rights treaties can be used to invoke states' responsibilities to ensure women's protection and access to services [27], [28]. 4. Action Both public health and international human rights law provide tools for responding in a more systematic way to women's right to be free from violence and its consequences. Governments and non government actors, including the international community, have a responsibility and must be accountable to do what is within their sphere. Addressing violence requires action at multiple levels. Countries must abide by the human rights agreements and treaties that they have signed and ratified and ensure they are translated into national law and that these laws are implemented. For example, they need to ensure that laws do not discriminate against women, by providing them the same right as men to divorce, own and inherit property, and to ensure that laws are in place that recognize marital rape as a crime. Laws need to be enforced and prosecution and conviction should be commensurate to the crime and not place the burden of proof on women. In terms of protection it is important to train police, prosecutors, and judges to implement the law in nondiscriminatory ways, ensure the protection of victims from further abuse, and to guarantee the availability of a female officer at police stations, special family courts, or other special measures as appropriate. In terms of service provision, it is important that women living with abuse are able to access the services they need: medical, psychological, legal, housing, and other support services as needed. As regards health care, providers should as a minimum be informed and aware of the possibility of violence as an underlying factor in women's ill health. This is particularly important in relation to obstetric and gynecologic care as this is one of the most common points of contact with the health service for women. This is particularly the case in resource-poor settings, where women are most likely to use family planning, prenatal care, delivery, and at times postnatal care. All of these offer potential opportunities for identification of women experiencing abuse, providing appropriate interventions and, if necessary, referral to other services. Equally, if not more important, are interventions to prevent violence against women from happening in the first place through increased awareness among the general public and actions targeted at specific groups. Campaigns that break the silence and shroud of privacy about these issues and advocate for no tolerance have been shown to be effective in modifying social norms around the acceptability of violence, as has work with men and young boys to challenge notions of masculinity [7] and interventions to empower women economically and otherwise [29]. Programs that focus on prevention of childhood abuse and neglect, including sexual abuse, and those that target children who witness partner violence, are also important for prevention of violence later in life [30]. Policies and programs for sexual and reproductive health, maternal and newborn health, adolescent health, and HIV/AIDS prevention should include issues of violence, sexuality, and power dynamics in gender relations as key elements. 5. Conclusion Violence against women operates as a risk factor for a wide range of women's health problems, as well as being a potential cause of neonatal, infant, and child health problems. It affects women's well-being, their productivity, and their ability to support their children and families. The human and economic costs of this makes it imperative that both public health and healthcare providers educate themselves on the problem and implement relevant prevention and response strategies. Violence is also a violation of women's human rights and a human rights framework is essential in guiding public health policy and action. 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a Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland b Department of Social Policy and Social Work, University of Oxford, Oxford, UK  Corresponding author.
PII: S0020-7292(09)00148-9 doi:10.1016/j.ijgo.2009.03.053 © 2009 Published by Elsevier Inc. | |
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