Gender and Health Unit Pan-American Health Organization Regional Office of the World Health...

Gender and Health UnitPan-American Health Organization Regional Office of the World Health Organization

Violence against Women: The Health Sector Responds

• Published May 2003

• Result of 10 years of work

• Collaborative effort between PAHO, PATH, CDC and WHO

• Funding from SIDA and NORAD

Violence against Women: The Health Sector Responds

Background

GBV is one of the most widespread human rights GBV is one of the most widespread human rights abuses and public health problems in the world todayabuses and public health problems in the world today

GBV is devastating, affecting women and girls’ long-GBV is devastating, affecting women and girls’ long-term physical and mental well-beingterm physical and mental well-being

The ripple effects of GBV compromise the well-being The ripple effects of GBV compromise the well-being of families, communities and societiesof families, communities and societies

A strategy to address the problem is needed - for A strategy to address the problem is needed - for health workers, decision-makers and communitieshealth workers, decision-makers and communities

The Health Sector Responds to GBV

• Over the last decade, GBV has been widely recognized Over the last decade, GBV has been widely recognized as a public health and human rights problemas a public health and human rights problem

• Several conventions and declarations (CEDAW, Several conventions and declarations (CEDAW, DEVAW, Belem do Para) have established DEVAW, Belem do Para) have established international/governmental commitment to addressing international/governmental commitment to addressing and eliminating GBVand eliminating GBV

• GHU has played a pivotal role in these developments GHU has played a pivotal role in these developments within the Americaswithin the Americas

• Our primary emphasis has been on the involvement, Our primary emphasis has been on the involvement, not only of the health sector, but of women themselves, not only of the health sector, but of women themselves, their families and communitiestheir families and communities


VAW is “…any act of gender based violence that VAW is “…any act of gender based violence that results in, or is likely to result in, physical, sexual results in, or is likely to result in, physical, sexual or psychological harm or suffering to women…”or psychological harm or suffering to women…”

Chapter I -Chapter I - Gender-Based Violence: A Public Health and Human Gender-Based Violence: A Public Health and Human Rights Problem….Rights Problem….

SOCIETYSOCIETY COMMUNITYCOMMUNITY RELATIONSHIPRELATIONSHIPINDIVIDUALINDIVIDUAL

PERPETRATORPERPETRATOR

- Being male - Witnessing marital violence as a child - Absent or rejecting father - Being abused as a child - Alcohol use

- Marital conflict - Male control of wealth and decision-making in the family

- Poverty, low socioeconomic status, unemployment - Associating with delinquent peers - Isolation of women and family

- Norms granting men control over female behaviour - Acceptance of violence as a way to resolve conflict - Notion of masculinity linked to dominance, honour or aggression - Rigid gender roles

ECOLOGICAL MODEL OF FACTORS ASSOCIATED WITH INTIMATE PARTNER VIOLENCE

The Health Sector Responds to GBVChapter I -Chapter I - Gender-Based Violence: A Public Health and Human Gender-Based Violence: A Public Health and Human

Rights Problem….Rights Problem….

• 10-50% of women have been victims of intimate-partner violence10-50% of women have been victims of intimate-partner violence

• Women are at greatest risk of violence from men they already knowWomen are at greatest risk of violence from men they already know

• Violence is a complex problem - cannot be attributed to one causeViolence is a complex problem - cannot be attributed to one cause

Nature and ExtentNature and Extent

ConsequencesConsequences

• Increased risk of physical/reproductive and mental health problemsIncreased risk of physical/reproductive and mental health problems

• Increased exposure to STIs and HIVIncreased exposure to STIs and HIV

• Increase in negative health behaviours (drug-use/sexual risk-taking)Increase in negative health behaviours (drug-use/sexual risk-taking)

• Homicide, suicide, maternal mortality, miscarriageHomicide, suicide, maternal mortality, miscarriage


In response to this reality, PAHO’s Gender and Health Unit...In response to this reality, PAHO’s Gender and Health Unit...

Chapter II -Chapter II - The “Critical Path”: From Research to Action….The “Critical Path”: From Research to Action….

• Developed and implemented the “Critical Path that Women Developed and implemented the “Critical Path that Women Follow when Affected by Family Violence” in 16 communities Follow when Affected by Family Violence” in 16 communities of 10 countries of 10 countries

RESPONSE FACTORS- Availability/Quality of services- Social representations of service providers- Obtained results

MOTIVATING FACTORS- Information/Knowledge- Perceptions/Attitudes- Previous experiences- Support from close people

DECISIONS AND ACTIONS TAKEN

The Health Sector Responds to VAW

The study found that...The study found that...

Chapter II -Chapter II - The “Critical Path”: From Research to Action….The “Critical Path”: From Research to Action….

• All women interviewed were victims of physical and/or All women interviewed were victims of physical and/or psychological, sexual and economic violencepsychological, sexual and economic violence

• Women were generally unaware of their rightsWomen were generally unaware of their rights• Even when they took steps to resolving their situation, the Even when they took steps to resolving their situation, the

women met with frustrating resultswomen met with frustrating results• For the majority of women, violence started following co-For the majority of women, violence started following co-

habitation or marriage, and was exacerbated by pregnancyhabitation or marriage, and was exacerbated by pregnancy• Women tolerated abuse out of fear, social pressure or lack of Women tolerated abuse out of fear, social pressure or lack of

financial resourcesfinancial resources• Women identified the negative attitudes of service providers Women identified the negative attitudes of service providers

as primary obstaclesas primary obstacles


Out of the “Critical Path” study grew the Integrated Out of the “Critical Path” study grew the Integrated Model for Addressing GBV...Model for Addressing GBV...

Chapter III -Chapter III - Joining Forces to Address GBV….Joining Forces to Address GBV….

NATIONAL COALITIONS

SECTORS

COMMUNITIES

Advocate for improved policies and legislation

Build capacity, develop instruments and systems

Form networks, organize campaigns and self-help and support groups

GENDER

EQUITY

PARTICIPATION

PARTERSHIPS

CROSS-CUTTINGVALUES

OPERATIONAL LEVELS INTERVENTIONS OF THE INTEGRATED MODEL

DETECTIONFirst step towards breaking the

cycle of violence

ATTENTION AND CAREImperative that providers have

the necessary policies, materials, protocols and procedures

PROMOTION ANDPREVENTION

Raising awareness about GBV is key to preventing it


At the regional level...At the regional level... Symposium 2001: Gender-Based Violence, Health Symposium 2001: Gender-Based Violence, Health

and Rights in the Americasand Rights in the Americas Technical exchanges between Central American and Technical exchanges between Central American and

Caribbean countriesCaribbean countries Political commitment to address GBVPolitical commitment to address GBV

Chapter III -Chapter III - Joining Forces to Address VAW….Joining Forces to Address VAW….

What has the Integrated Model achieved?What has the Integrated Model achieved?

At the national level...At the national level... Inter-sectoral coalitions formed in 10 countriesInter-sectoral coalitions formed in 10 countries GBV legislation passed in 10 countriesGBV legislation passed in 10 countries ““Critical Path” results published in 10 countriesCritical Path” results published in 10 countries GBV prevention campiagns in 10 countriesGBV prevention campiagns in 10 countries GBV detection, prevention and care incorporated in GBV detection, prevention and care incorporated in

health-sector reform policies in 5 countrieshealth-sector reform policies in 5 countries

At the sector level...At the sector level... Instruments and systems developed and implementedInstruments and systems developed and implemented

Norms and protocols in 10 countriesNorms and protocols in 10 countries Surveillance systems in 5 countriesSurveillance systems in 5 countries Training modules in 10 countriesTraining modules in 10 countries

At the community level...At the community level... Formation of more than 150 community networksFormation of more than 150 community networks Support groups for men and women formed in 5 countriesSupport groups for men and women formed in 5 countries Self-help groups formed in 8 countriesSelf-help groups formed in 8 countries Zero tolerance campaigns and other non-violence Zero tolerance campaigns and other non-violence

activities promoted in numerous communitiesactivities promoted in numerous communities

Lessons Learned from Central America

July/August 2001 - Participatory evaluation of the July/August 2001 - Participatory evaluation of the Integrated model project to determine...Integrated model project to determine...

A review of project and country documentsA review of project and country documents Interviews with informants (PAHO consultants, MOH staff, Interviews with informants (PAHO consultants, MOH staff,

etc…) carried out in each countryetc…) carried out in each country Focus group discussions with stakeholdersFocus group discussions with stakeholders

Whether health providers changed the way they thought Whether health providers changed the way they thought about and addressed violenceabout and addressed violence

Whether women’s “Critical Path” had become less Whether women’s “Critical Path” had become less complicatedcomplicated

What lessons were learned through the implmentation of the What lessons were learned through the implmentation of the projectproject

Components...Components...


Increasing international and national recognition of Increasing international and national recognition of GBV as a public health and human rights problemGBV as a public health and human rights problem

Chapter IV -Chapter IV - Policy and Legal Reforms….Policy and Legal Reforms….

Creation of National Plans on preventing violence against Creation of National Plans on preventing violence against women in several countries (for e.g. PLANOVI in Costa women in several countries (for e.g. PLANOVI in Costa Rica, Mesa Nacional in Peru)Rica, Mesa Nacional in Peru)

Legislative reform throughout Central America - for Legislative reform throughout Central America - for example:example: Establishment of protective measuresEstablishment of protective measures Expanding the concept of injuryExpanding the concept of injury Establishing family ties as an aggravating circumstanceEstablishing family ties as an aggravating circumstance Changing the status of sex crimes/spousal violence to Changing the status of sex crimes/spousal violence to

public offensespublic offenses

Lessons Learned from Central AmericaChapter IV -Chapter IV - Policy and Legal Reforms….Policy and Legal Reforms….

Putting the laws into effect...Putting the laws into effect... Interpretation of laws may be biased by culture or other Interpretation of laws may be biased by culture or other

factorsfactors Little coordination between family and criminal justice courtsLittle coordination between family and criminal justice courts Contradictions between family law and domestic violence Contradictions between family law and domestic violence

lawlaw Allowing offenders “curative treatment” instead of prison Allowing offenders “curative treatment” instead of prison

timetime Mediation is neither forgiveness nor reconciliationMediation is neither forgiveness nor reconciliation Mandatory reporting dicourages providers from asking Mandatory reporting dicourages providers from asking

questionsquestions Legal proof may be required fron forensic physicians (very Legal proof may be required fron forensic physicians (very

few)few)


Why is GBV invisible in the health sector?Why is GBV invisible in the health sector?

Chapter V -Chapter V - Building an integrated approach….Building an integrated approach….

““There’s simply no time to talk There’s simply no time to talk or perform special exams for or perform special exams for women reporting violence”women reporting violence”

““I thought that there were just I thought that there were just a few people living like this a few people living like this and that it was something and that it was something shameful…”shameful…”

““Women do not speak for fear Women do not speak for fear that the husband will be put in that the husband will be put in jail and then no money will come jail and then no money will come into the household”into the household”

““People think that our People think that our indigenous costumes make us indigenous costumes make us stupid…In the health centre stupid…In the health centre we have to wait longer”we have to wait longer”

““When someone isn’t sensitized When someone isn’t sensitized he can get annoyed and think…he can get annoyed and think…`Now how am I going to get rid of `Now how am I going to get rid of her?’”her?’”

““I wanted to get things off my I wanted to get things off my chest but I felt rejected by the chest but I felt rejected by the other health workers”other health workers”

““Health workers - doctors, Health workers - doctors, nurses, health inspectors - are nurses, health inspectors - are men first before they are men first before they are health workers. ”health workers. ”

Statements from health workers

Lessons Learned from Central AmericaChapter V -Chapter V - Building an integrated approach….Building an integrated approach….

PAHO’s Integrated Approach emphasizes….PAHO’s Integrated Approach emphasizes…. Development of national policies recognizing violence as a Development of national policies recognizing violence as a

public health problempublic health problem Drafting of norms and protocols that define the kind of care Drafting of norms and protocols that define the kind of care

that should be offered to victims of violencethat should be offered to victims of violence A training plan for health personnel on use of the normsA training plan for health personnel on use of the norms Creation of support groups for violence survivorsCreation of support groups for violence survivors Promotion of male involvement in violence preventionPromotion of male involvement in violence prevention Development of an information system to track reports of Development of an information system to track reports of

GBV through the health sectorGBV through the health sector Development of community-level public awarenessDevelopment of community-level public awareness Establishment of community networksEstablishment of community networks

Lessons Learned from Central AmericaChapter V -Chapter V - Building an integrated approach….Building an integrated approach….

Lessons learned from the Integrated Approach….Lessons learned from the Integrated Approach….

Establishment of a specific health sector policy outlining Establishment of a specific health sector policy outlining the role of health providers in addressing violence is a key the role of health providers in addressing violence is a key step towards institutionalizing violence programs and step towards institutionalizing violence programs and raising awareness among personnelraising awareness among personnel

The placement of program coordination for care for GBV The placement of program coordination for care for GBV or family violence in the areas of women’s health and or family violence in the areas of women’s health and reproductive health services facilitates lateral integration reproductive health services facilitates lateral integration into other programs and servicesinto other programs and services

Inter-programmatic coordination is essential for enabling Inter-programmatic coordination is essential for enabling violence programs to become integrated laterally into key violence programs to become integrated laterally into key health programs and for ensuring the sustainability of the health programs and for ensuring the sustainability of the violence programviolence program

Having oficially approved norms and protocols helps to Having oficially approved norms and protocols helps to ensure the quality of care and also facilitates the scaling ensure the quality of care and also facilitates the scaling up of pilot experiencesup of pilot experiences

It is important to train all health personnel on the It is important to train all health personnel on the identification of and basic care for women suffering identification of and basic care for women suffering violence. This creates a favourable environment so that violence. This creates a favourable environment so that individuals may be identified and referred for care.individuals may be identified and referred for care.

Surveillance systems for violence should consider Surveillance systems for violence should consider collecting as a minimum, information identifying the type of collecting as a minimum, information identifying the type of violence (physical, sexual, psychological), the sex and age violence (physical, sexual, psychological), the sex and age of the victim, as well as the age and relationship of the of the victim, as well as the age and relationship of the perpetrator to the victim. perpetrator to the victim.

Information systems are only valid if the data are used to Information systems are only valid if the data are used to improve services. Not only is it a waste of resources, but it improve services. Not only is it a waste of resources, but it is also unethical to collect information or carry out active is also unethical to collect information or carry out active screening for violence with the sole purpose of information-screening for violence with the sole purpose of information-gathering, if no services are offered in returngathering, if no services are offered in return

Lessons Learned from Central AmericaChapter VI -Chapter VI - What Happens at the Clinic?What Happens at the Clinic?

How can health workers support women living with abuse?How can health workers support women living with abuse?

Assess for immediate dangerAssess for immediate danger

Provide appropriate careProvide appropriate care

Document the woman’s conditionDocument the woman’s condition

Develop a safety planDevelop a safety plan

Inform the woman of her rightsInform the woman of her rights

Refer the woman to other Refer the woman to other community resourcescommunity resources

Lessons Learned from Central AmericaChapter VI -Chapter VI - What Happens at the Clinic?What Happens at the Clinic?

Lessons learned from the Integrated Approach….Lessons learned from the Integrated Approach…. It is not enough to simply wait for women to disclose It is not enough to simply wait for women to disclose

violence on their own. Experience has shown that many violence on their own. Experience has shown that many women are willing to talk about violence, but it isw usually women are willing to talk about violence, but it isw usually necessary for health personnel to take the initiative and necessary for health personnel to take the initiative and open the discussionopen the discussion

Encouraging health personnel to screen women for Encouraging health personnel to screen women for violence in their regular practice can be an excellent violence in their regular practice can be an excellent exercise for raising general awareness and helping exercise for raising general awareness and helping personnel to become more confident in treating cases of personnel to become more confident in treating cases of violence. Ideally the screening tool should include violence. Ideally the screening tool should include questions on physical, emotional and sexual violence, as questions on physical, emotional and sexual violence, as well as violence during pregnancy well as violence during pregnancy

It is not necessary to have specialized personnel in mental It is not necessary to have specialized personnel in mental health to provide quality care for victims. What is essential health to provide quality care for victims. What is essential is to motivate and train staff and to organize services so is to motivate and train staff and to organize services so that women that need support receive treatment with a that women that need support receive treatment with a human quality and in a timely mannerhuman quality and in a timely manner

Emotional support is essential for health providers who Emotional support is essential for health providers who care for survivors of violence. Activities to ensure support care for survivors of violence. Activities to ensure support for personnel should be included in norms and for personnel should be included in norms and implemented at the local levelimplemented at the local level

Lessons Learned from Central AmericaLessons Learned from Central AmericaChapter VII -Chapter VII - Beyond the Clinic….Beyond the Clinic….

Community healh leaders have a crucial role to play in Community healh leaders have a crucial role to play in violence prevention, through the promotion of nonviolent violence prevention, through the promotion of nonviolent relationships, and by informing the community about their relationships, and by informing the community about their legal and social rights - and providing information and legal and social rights - and providing information and appropriate referrals to abused women.appropriate referrals to abused women.

Lessons learned from the Integrated Approach….Lessons learned from the Integrated Approach….

The establishmet of community networks can greatly help The establishmet of community networks can greatly help in coordinating services form victims of violence and in in coordinating services form victims of violence and in developing joint programs for violence preventiondeveloping joint programs for violence prevention

Abusers’ treatment groups should not be confused with Abusers’ treatment groups should not be confused with men’s refelction groups. The purpose of the reflection men’s refelction groups. The purpose of the reflection groups is to encourage men to challenge prevailing cultural groups is to encourage men to challenge prevailing cultural views on masculinity and to become more sensitive to views on masculinity and to become more sensitive to gender-equitable norms. Men’s groups can be an effective gender-equitable norms. Men’s groups can be an effective way to involve both adults and young men in violence way to involve both adults and young men in violence prevention activitiesprevention activities

Support groups can be a very effective technique for Support groups can be a very effective technique for helping violence survivors. Nevertheless, health providers helping violence survivors. Nevertheless, health providers do need training and ongoing support to be effective do need training and ongoing support to be effective facilitatorsfacilitators

Lessons Learned from Central AmericaChapter VIII -Chapter VIII - Global Implications of the Integrated Approach….Global Implications of the Integrated Approach….

Expanding the model beyond Central America….Expanding the model beyond Central America….

The approach is flexible and non-prescriptiveThe approach is flexible and non-prescriptive The approach calls for action at several levelsThe approach calls for action at several levels A multi-sectoral approach achieves the best resultsA multi-sectoral approach achieves the best results Partnerships and networks provide the necessary Partnerships and networks provide the necessary

underpinningunderpinning The health sector has a fundamental role to play in The health sector has a fundamental role to play in

violence-prevention and caring for victims of violenceviolence-prevention and caring for victims of violence Training is critical to developing and sustaining the health Training is critical to developing and sustaining the health

sector’s role in violence prevention and caresector’s role in violence prevention and care The health sector should be pro-active in raising The health sector should be pro-active in raising

community awareness about GBVcommunity awareness about GBV

Lessons Learned from Central AmericaChapter VIII -Chapter VIII - Global Implications of the Integrated Approach….Global Implications of the Integrated Approach….

The most important lesson we have learned is that...The most important lesson we have learned is that...

““Violence can be prevented…In our own countries Violence can be prevented…In our own countries and around the world we have shining examples of and around the world we have shining examples of how violence has been countered. Governments, how violence has been countered. Governments,

communities and individuals can make a communities and individuals can make a difference” difference”

Nelson MandelaNelson Mandela

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