Around the world at least one woman in every three has been beaten, coerced into sex or otherwise abused in her lifetime, according to a new report from the School of Public Health and the Center for Health and Gender Equity. Based on the most comprehensive overview to date, the report calls on the world's health care community to respond to physical and sexual abuse as "a major public health concern and a violation of human rights."
"What is striking is how similar the problem is around the world," says Lori Heise, co-director of CHANGE and lead author of the Population Reports issue "Ending Violence Against Women," published by the Johns Hopkins Population Information Program. "Without exception, women's greatest risk of violence comes not from 'stranger danger' but from men they know, often male family members or husbands."
More than 50 population-based surveys indicate that 10 percent to more than 50 percent of adult women have been assaulted physically by an intimate male partner. Psychological abuse almost always accompanies physical abuse. One-third to more than one-half of cases also involve sexual abuse. Most women who suffer any physical aggression are abused repeatedly.
In countries as different as Bangladesh, Cambodia, Mexico and Zimbabwe, many people see wife beating as justified--a husband's right to "correct" an erring wife. According to Heise and co-authors Mary Ellsberg and Megan Gottemoeller, women often share this notion. "For example," Heise says, "in rural Egypt, up to 81 percent of women say that wife beating is justified under certain circumstances."
Among findings culled from more than 500 studies of domestic abuse:
Many women conceal their plight. In surveys, 22 percent to almost 70 percent of abused women said that before being asked in the interview they had never told anyone about their abuse.
Rates of abuse can vary greatly in neighboring areas. Differences among regions, towns or villages in the same country can be greater than differences among countries.
Beyond immediate injury, violence often leads to serious long-term health problems, including chronic pain, physical disability, drug and alcohol abuse, depression and suicide attempts.
The physical and psychological impact of different types of abuse and multiple episodes over time appears to be cumulative and can persist long after the violence has stopped.
Children of battered women face a greater risk of low birth rate, malnutrition, behavioral problems and infant death in some settings.
Gender-based violence and fear of physical and sexual abuse also has an enormous impact on women's reproductive health. Such violence has been linked to gynecological disorders, unsafe abortion, pregnancy complications, miscarriage, low birth weight and pelvic inflammatory disease. In addition, women living in abusive relationships often have difficulty refusing unwanted sex, negotiating condom use or using many other types of family-planning methods. Thus they risk unwanted pregnancy and sexually transmitted diseases including HIV/AIDS.
Health workers must address violence against women, say the authors, because in most countries, the health care system is the only institution that interacts with almost every woman at some point in her life. With training and institutional support, the authors say, health workers can identify abuse victims, offer empathy and support, provide medical care and refer clients to legal assistance and support services.
"Although health workers should be part of the solution, at this point they are often part of the problem," co-author Ellsberg notes. "They often violate confidentiality, trivialize the abuse or blame the victim." Bureaucratic delays and indifference add to the problem. "Frequently, women feel re-victimized by the very system that is supposed to help them."
To make health systems more responsive, activists have begun pilot programs in Brazil, Canada, Ireland, Malaysia, Mexico, Nicaragua and the United States to train health workers and reform institutional policy. "We are heartened by the efforts of activists and committed health care providers to make the health system sensitive and attentive to the needs of abuse victims," Heise says. "Many developing countries are taking up this challenge far quicker than Western countries did."
Training programs for health workers, regardless of their primary focus, should cover gender, sexuality, healthy relationships and abuse, the authors say. The Population Reports issue includes a four-page pullout to help health workers in training or on the job, suggesting how to ask women about violence, how to spot symptoms of violence and how to help women develop a personal safety plan.
While health workers can help, ending violence against women requires strategies and communication that reach across society, according to the report. "An agenda for change must include empowering women and girls, raising the cost of abusive behavior, providing for the needs of victims, coordinating institutional and individual responses, involving youth, reaching out to men and changing norms," the report concludes.
The full text of "Ending Violence Against Women" can be found on the Center for Communication Programs' Web site at: http://www.jhuccp.org.