An eighteen-year-old woman chronically raped by her father, brother and uncles since she was eight.
A nineteen-year-old girl having chronic pelvic and genital pain secondary to genital mutilation.
A twelve-year-old female child being sold and married off to a forty two year old man in her village.
A twenty-eight-year old woman physically beaten by her husband regularly when he is intoxicated.
A forty–ear old woman who was kidnapped and sold to her former husband when she was nineteen.
These are just examples of women and female children whom I have come into contact with through my clinical practice, outreach work and in my social life. I have found these women in the emergency rooms, in psychiatric facilities, in the genitourinary medicine & contraception clinics. I have found these women not only as a doctor in the corridors of hospitals – I have found these women in the lanes of my life.
All of these women, as you may have guessed by now, have been subject to violence. Violence against women takes place in several forms – physical violence by intimate partners, sexual harassment, sexual violence, female genital mutilation, trafficking, child marriages etc.
Although there is an increased awareness of the violence suffered by women and female children, we still live in a society where violence is horrifically rampant. We live in a world where a third of the countries have NOT outlawed domestic violence. We live in a world where 1 in 7 girls are married in Central and West Africa before they are 15 years of age. We live in a world where 1 in 2 women were killed by their partners and/or families in 2012. We live in a country where up to a third of adolescent women describe their first sexual experience as rape/sexual abuse. We live in a world where thirty-seven countries exempt rape perpetrators from prosecution if they are married or marry the victim after the event1.
The purpose of this article is to educate and discuss the nature of violence experienced by women, to understand the extent of the problem, and finally, what to expect from our health professionals and our governments.
The vast majority of the statistics and information is taken from the World Health Organisation and the United Nations websites, which I implore you to read. All of the factual information, which is present in this article, from the aforementioned institutions is listed at the end.
Background and definitions
Violence against women is a global public health problem and a violation of human rights. The United Nations defines violence against women as “any act of gender-based violence that results in, or is likely to result in, physical, sexual, or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life”2 .
A 2013 analysis conduct by WHO with the London School of Hygiene and Tropical Medicine and the South Africa Medical Research Council, used existing data from over 80 countries and found that worldwide, 1 in 3 women have experienced physical and/or sexual violence by an intimate partner or non-partner sexual violence3.
The risk factors for women experiencing intimate partner violence include low education, exposure to mothers being abused, abuse during childhood, attitudes accepting violence, male privilege and women’s subordinate status.
Equally, men are more likely to perpetrate violence if they have low education, a history of child maltreatments, exposure to domestic violence against their mothers, alcohol dependence, unequal gender norms, attitudes accepting violence and privilege over women.
Factors associated with sexual violence perpetration include beliefs in family honour, sexual purity, ideologies of male sexual entitlement and weak legal sanctions for sexual violence.
Impacts on health, children and socioeconomics
Physical and sexual violence against women has led to physical, mental, reproductive and sexual health issues of victims. Some of these include unwanted pregnancies, sexually transmitted infections and other gynaecological problems. Specifically, in pregnancies, the risks include miscarriage, pre-term labour and the babies being at significant risks related to low birth weight.
Women exposed to partner violence as twice as likely to experience depression; almost twice as likely to have alcohol use disorders; 1.5 times more likely to acquire HIV, syphilis, chlamydia or gonorrhoea and 16% more likely to have a low birth weight baby. Furthermore, 42% of women who have experienced physical/sexual violence at the hands of a partner have experienced further injuries as a result and 38% of all murders of women, globally, were committed by their intimate partners1,3.
Children who witness such violence can display behavioural and emotional disturbances as well as being at risk of being perpetrators of violence themselves. Intimate partner violence has also been linked with higher rates of infant and child morbidity and mortality3.
The social and economic costs include women being at risk of suffering isolation, not being able to work, losing wages, not participating in regular activities and being unable to care for their children.
Prevention and response5
There are a number of guidelines as to how health professionals can train, prepare and respond for issues in violence against women. These include:
- Providing women centred care – professionals offering first-line support when violence is disclosed i.e. empathy, non-judgemental attitude, privacy, confidentiality and access to relevant services.
- Identifying and caring for survivors of intimate partner violence – Professionals should ask about exposure to violence with the aim to improve diagnosis, identification and subsequent care. First line clinical care should include emergency contraception, STI and HIV with relevant follow up.
- Mandatory reporting of intimate partner violence to the police is NOT recommended. Professionals should offer support to report the incident if the woman chooses. It is important to know the legal framework of reporting in each state/country. Usually if an incident is to be reported, the professionals should NOT carry out an intimate examination.
- Training of healthcare providers – Adequate history taking, risk management, investigations and planning management should be done at a pre-qualification level.
- Healthcare policy and provision – Care for women experience violence and sexual assault should be, where possible, integrated into existing health services as opposed to a stand alone service. In the UK, this can include presenting to a General Practice, GUM services and if required, A&E.
Prevention is a powerful tool and evidence base from high-income countries has suggested that advocacy and counselling improve access to services for victims and are effective in reducing violence. In low resource countries, prevention strategies that have shown some effectivity include programs that empower women economically and socially through a combination of microfinance and skills training related to gender equality; that promote communication and relationship skills within couples and communities; transform harmful gender and social norms through education6.
Legislation is another key aspect, which can help achieve change. There is a need to implement policies that promote gender equality by ending discrimination against women in marriage, divorce and custody laws; ending discrimination in inheritance laws; improving women’s access to employment and developing national policies to address violence against women5,6.
References and further reading
1. United Nations. Declaration on the elimination of violence against women. New York : UN, 1993.
2. United Nations. Fact and figures: Ending violence against women. http://www.unwomen.org/en/what-we-do/ending-violence-against-women/facts-and-figures
3. World Health Organisation. Global and regional estimates of violence against women. Prevalence and health effects of intimate partner violence and non-partner sexual violence. http://www.who.int/reproductivehealth/publications/violence/9789241564625/en/
4. World Health Organisation. Violence against women and children: facts. http://www.who.int/news-room/fact-sheets/detail/violence-against-women
5. World Health Organisation. Primary prevention of intimate-partner violence and sexual violence: Background paper for WHO expert meeting May 2–3, 2007
6. World Health Organisation. Infographics: Violence against women infographic. http://www.who.int/reproductivehealth/publications/violence/VAW_infographic.pdf
Written by: Dr Huma R Khan