Policy ForumPUBLIC HEALTH

Violence Against Women

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Science  25 Nov 2005:
Vol. 310, Issue 5752, pp. 1282-1283
DOI: 10.1126/science.1121400

The Millennium Development Goals commit the 191 member states of the United Nations to sustainable, human development and recognize that equal rights and opportunities for women and men are critical for social and economic progress (1). This must include addressing violence against women—a concrete manifestation of inequality between the sexes. Policies to prevent this violence should be implemented as part of the agendas for equality, development, public health, and human rights (2). Although statements and international declarations have called for the eradication of violence against women (3, 4), many agencies, governments, and policy-makers view it as a relatively minor social problem.

There is a growing body of evidence from research that suggests that violence against women is highly prevalent, with an estimated one in three women globally experiencing some form of victimization in childhood, adolescence, or adulthood (5-10). This violence has a direct economic impact along with the human and emotional costs. A study in the USA estimated the costs of intimate partner rape, physical assault and stalking as exceeding $5.8 billion each year, nearly $4.1 billion of which is for direct medical and mental health care services (11).

Violence against women also has a substantial impact on health (12-15). In the Australian state of Victoria, violence by intimate partners is calculated to result in more ill health and premature death among women of reproductive age than any other risk factor, including high blood pressure, obesity, and smoking (16). Intimate partner violence is also an important cause of death, accounting for 40 to 60% of female homicides in many countries, and an important portion of maternal mortality in India, Bangladesh, and the United States (17).

The evidence suggests that violence can be prevented. Policies to prevent violence include promoting social awareness to change norms that condone violence against women; equipping young people with skills for healthy relationships; expanding women's access to economic and social resources and to support services; providing training for health services to better identify and support women experiencing violence and to integrate violence prevention into existing programs, including for HIV prevention; and promotion of adolescent health. States must take responsibility for the safety and well-being of their citizens and must tackle the problem with the urgency it requires.

Percentage of ever-partnered women reporting physical or sexual violence, or both, by an intimate partner, by site.

The results from the WHO Study on Women's Health and Domestic Violence against Women released this week (18) greatly extend the geographic range and scope of available data. The results in this report are based on over 24,000 interviews with 15- to 49-year-old women from 15 sites in 10 countries: Bangladesh, Brazil, Ethiopia, Japan, Peru, Namibia, Samoa, Serbia and Montenegro, Thailand, and the United Republic of Tanzania (19). In 13 of the 15 sites studied, between one-third and three-quarters (35 to 76%) of women had been physically or sexually assaulted by someone since the age of 15. In all the settings but one, the majority of this violence was perpetrated by a current or previous partner, rather than by other persons.

Overall, 15 to 71% of women who ever had a partner had been physically or sexually assaulted by an intimate partner (see figure, this page). In most settings, about a half of these respondents reported that the violence (20) was currently ongoing (occurred in the past 12 months preceding the interview). In the majority of settings, too, a greater proportion of women had experienced “severe” physical violence than those suffering “moderate” physical violence (21). Much of the violence reported was hidden: More than one-fifth (21 to 66%) of women reporting physical violence in the study had never told anyone of their partner's violence before the study interview.

The study findings confirm that women around the world are at significant risk of physical and sexual violence from their partner, but also highlight that there is substantial variation both within and between countries. In the WHO study, the lowest prevalence of lifetime and current partner violence was found in urban Japan and Serbia and Montenegro, which suggests that rates of abuse may reflect, in part, different levels of economic development. However, a study in two sites in New Zealand that replicated the WHO methodology found lifetime prevalence of partner violence as high as that found in many WHO developing country sites (22). The rates of current violence were much lower (less than 6% in both sites), which suggests that women in industrialized nations may find it easier to leave abusive relationships.

Assault by a partner was a direct cause of injuries, with between one in five and one-half of women reporting that they had been injured as a result of physical violence, often more than once. In addition, women who experienced violence by a partner were more likely to report poor general health and greater problems with walking and carrying out daily activities, pain, memory loss, dizziness, and vaginal discharge in the 4 weeks before the interview. The study also found that abused women were more likely to experience emotional distress and to have considered or attempted suicide. An association between recent ill health and lifetime experience of violence suggests that physical and mental effects may last long after the violence has ended.

Although pregnancy is often considered a time when women are more likely to be protected from harm, 1 to 28% of women who had ever been pregnant reported being beaten during pregnancy. More than 90% of these women were abused by the father of the unborn child, and between a quarter and half of them had been kicked or punched in the abdomen. In most cases, the abuse during pregnancy was a continuation of previous violence. However, for some women, the abuse started during pregnancy. Intimate partner violence was also associated with an increased number of induced abortions and, in some settings, with miscarriage. In all sites except urban Thailand and Japan, women who experienced violence were significantly more likely to have more children than other women.

Despite these health associations, over half of physically abused women (55 to 95%) reported that they had never sought help from formal services or from people in positions of authority. Only in Namibia and in both sites in Peru had more than 20% of women contacted the police, and only in Namibia and in urban Tanzania had about 20% sought help from health-care services. Family, friends, and neighbors, rather than more formal services, most often provide the first point of contact for women in violent relationships.

The study also demonstrates the remarkable degree to which women in some settings have internalized social norms that justify abuse. In about half of the sites, 50 to >90% of women agreed that it is acceptable for a man to beat his wife under one or more of the following circumstances: if she disobeys her husband, refuses him sex, does not complete the housework on time, asks about other women, is unfaithful, or is suspected of infidelity. This was higher among women who had experienced abuse than among those who had not, and may indicate either that women experiencing violence learn to “accept” or rationalize this abuse, or that women are at greater risk of violence in communities where a substantial proportion of individuals condone abuse.

The association between the prevalence of partner violence and women's belief that such violence is normal or justified constitutes one of the most salient findings of the WHO study. The data also highlight the degree to which women in some settings feel that it is unacceptable for women to refuse sex with her husband, even in circumstances where it could put them at risk. In three of the rural provincial sites, as many as 44 to 51% of women believe that a woman is not justified in refusing her husband sex if he mistreats her. The fact that the association is particularly marked in rural and more traditional societies reinforces the hypothesis that traditional gender norms are a key factor in the prevalence of abuse and that transforming gender relations should be an important focus of prevention efforts.

Violence against women is a complex social problem, and our knowledge on how to address it is evolving. Tackling the problem requires coordinated action that engages communities and many different sectors—including health, education, and justice—to challenge the inequities and social norms that give rise to violence and to provide emotional and physical support for victims. Early intervention, particularly targeting children who witness violence or are abused, is a promising yet underdeveloped area for action. Developing curricula for children and young people to learn emotional and social skills, including nonviolent methods of conflict resolution, could be an important contribution to violence prevention. Support services for abused women and programs to sensitize legal systems are also needed.

Health providers need to be trained to identify women experiencing violence and to respond appropriately to those who disclose abuse. Health services that women are most likely to use, such as those for family planning, prenatal care, or post-abortion care, offer potential entry points for providing care, support, and referral to other services. Existing programs, particularly those involved in prevention of HIV, promotion of adolescent health, and reduction of teenage pregnancy, need to address women's and girl's vulnerability to abuse.

Many local and national organizations exist to combat violence against women and to promote gender equality, and these vital efforts deserve increased support. At the international level, the WHO Global Campaign for the Prevention of Violence aims to increase awareness about the impact of violence on public health and the role of public health in its prevention, and seeks to support governments in their efforts to prevent violence and to develop policies and programs for this (23).

There is nothing “natural” or inevitable about men's violence toward women. Attitudes can and must change; the status of women can and must be improved; men and women can and must be convinced that violence is not an acceptable part of human relationships.

Supporting Online Material

www.sciencemag.org/cgi/content/full/310/5752/1282/DC1

References and Notes

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