Gender-based Violence and Public Health: International Perspectives on Budgets and Policies [1 ed.] 0415504929, 9780415504928

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Table of contents :
List of illustrations
List of contributors
List of abbreviations
1 Introduction • Keerty Nakray
Part I: Conceptual framework
2 Gender-based violence: a framework for public health budgets and policies • Keerty Nakray
3 Gender budgets and public health approach: addressing gender-based violence in India • Vibhuti Patel
4 Gender-based violence as a public health issue and the legal perspective: a critical overview • Ronagh McQuigg
5 Gender, gender-based violence and HIV/AIDS: review of evidence and policy • Rachel Jewkes
6 Measuring gender-based violence: issues of impact and prevalence • Emma Williamson
7 Gender-based violence in Australia: a State-based joined-up approach • Deborah Western and Robyn Mason
Part II: Risks, impacts and responses to gender-based violence
8 Gender-based violence in post-disaster recovery situations: an emerging public health issue • Margaret Alston
9 Gender, use and abuse: sexually abused women in alcohol and drug treatment • Jan Breckenridge and Michael Salter
10 The impact of intimate partner violence on the mental health of Latin American immigrant women in the U.S. • Blanca M. Ramos
11 Legal response to domestic violence in Tajikistan • Dilbar Turakhanova
12 Sexual violence within intimate contexts of marriage: integrating human rights and public health approach for gender-sensitive interventions • Nishi Mitra
13 Gender-based violence and reproductive health in five Indian states • Ernestina Coast, Tiziana Leone and Alankar Malviya
14 Rethinking gender-based violence and public health policies in India: insights from Dilaasa, Mumbai, India • Padma Bhate-Deosthali and Ravi Duggal
15 Contributing to the prevention of domestic violence-related homicide: a multi-systemic practice response framework • Jan Breckenridge and Kerrie James
16 Sexual violence and culture of silence in India: a critical appraisal of the role of the health services • Nishi Mitra
17 Conclusion • Keerty Nakray
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Gender-based Violence and Public Health

Gender-based violence is a multi-faceted public health problem with numerous consequences for an individual’s physical and mental health and wellbeing. This collection develops a comprehensive public health approach for working with gender-based violence, paying specific attention to international budgets, policies and practice and drawing on a wide selection of empirical studies. Divided into two parts, the text looks at how public health budgets and policies can be used to influence a range of risk factors and outcomes, and then outlines a theoretical and conceptual framework. The second section draws on empirical studies to illustrate ways of managing the risks and impacts of, and responses to, the problem. It concludes by summarising those risk factors that can be effectively addressed through appropriately budgeted public health programmes globally. Highlighting ways of bolstering protective and resilience factors and identifying early interventions, it demonstrates the importance of inter-agency interventions through coordinated effort from a wide range of sectors including social services, education, religious organisations, judiciary, police, media and business. This inter-disciplinary volume will interest students and researchers working on gender-based violence, gender budgeting and public health policy from a range of backgrounds, including public health, sociology, social work, public policy, gender studies, development studies and economics. Keerty Nakray is an Assistant Professor and Assistant Director of the Centre for Women, Law and Social Change at the Jindal Global Law School, OP Jindal Global University, India.

Routledge Studies in Public Health

Available titles include: Planning in Health Promotion Work Roar Amdam

Health and Health Promotion in Prisons Michael Ross

Alcohol, Tobacco and Obesity Morality, mortality and the new public health Edited by Kirsten Bell, Amy Salmon and Darlene McNaughton

Global Health Disputes and Disparities A critical appraisal of international law and population health Dru Bhattacharya

Population Mental Health Evidence, policy, and public health practice Edited by Neal Cohen and Sandro Galea

Gender-based Violence and Public Health International perspectives on budgets and policies Edited by Keerty Nakray

International Perspectives on Public Health and Palliative Care Edited by Libby Sallnow, Suresh Kumar and Allan Kellehear Organisational Capacity Building in Health Systems Niyi Awofeso

Forthcoming titles: Health Rights in Global Context Edited by Alex Mold and David Reubi Globalization, Environmental Health and Social Justice R. Scott Frey

Gender-based Violence and Public Health International perspectives on budgets and policies

Edited by Keerty Nakray

First published 2013 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Simultaneously published in the USA and Canada by Routledge 711 Third Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2013 selection and editorial material, Keerty Nakray; individual chapters, the contributors The right of the editor to be identified as the author of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Gender-based violence and public health : international perspectives on budgets and policies / edited by Keerty Nakray. p. ; cm. — (Routledge studies in public health) Includes bibliographical references and index. I. Nakray, Keerty. II. Series: Routledge studies in public health. [DNLM: 1. Battered Women. 2. Health Policy—economics. 3. International Cooperation. 4. Violence—prevention & control. 5. Women’s Health—economics. WA 309.1] 362.1—dc23 2012023855 ISBN: 978-0-415-50492-8 (hbk) ISBN: 978-0-203-07734-4 (ebk) Typeset in Baskerville by Keystroke, Station Road, Codsall, Wolverhampton

Dedicated to all the women and girls who toil each day silently to make this world a better place


List of illustrations List of contributors Acknowledgements List of abbreviations 1 Introduction

ix xi xv xvii 1



Conceptual framework 2 Gender-based violence: a framework for public health budgets and policies

13 15


3 Gender budgets and public health approach: addressing gender-based violence in India



4 Gender-based violence as a public health issue and the legal perspective: a critical overview



5 Gender, gender-based violence and HIV/AIDS: review of evidence and policy



6 Measuring gender-based violence: issues of impact and prevalence



7 Gender-based violence in Australia: a State-based joined-up approach D EB OR A H W E STE RN AND RO B YN MASO N


viii Contents PART II

Risks, impacts and responses to gender-based violence 8 Gender-based violence in post-disaster recovery situations: an emerging public health issue




9 Gender, use and abuse: sexually abused women in alcohol and drug treatment



10 The impact of intimate partner violence on the mental health of Latin American immigrant women in the U.S.



11 Legal response to domestic violence in Tajikistan



12 Sexual violence within intimate contexts of marriage: integrating human rights and public health approach for gender-sensitive interventions



13 Gender-based violence and reproductive health in five Indian states



14 Rethinking gender-based violence and public health policies in India: insights from Dilaasa, Mumbai, India



15 Contributing to the prevention of domestic violence-related homicide: a multi-systemic practice response framework



16 Sexual violence and culture of silence in India: a critical appraisal of the role of the health services



17 Conclusion






Figures 2.1 Framework for public health budgets and policies 15.1 Conceptualising a multi-systemic approach

17 202

Tables 1.1 Gender violence throughout the life cycle phase: type of violence present 1.2 Brief overview of the economic costs of gender-based violence 7.1 The Risk Assessment and Risk Management Framework 13.1 Sample characteristics (percentage distribution) 13.2 Reported experience of sexual violence in our sample (percentage distribution) 13.3 Reports of non-sexual violence in the preceding 12 months (percentage distribution) 13.4 Gendered differences in responses to forced sex (percentage distribution) 13.5 Gendered differences in attitudes towards violence (percentage distribution) 13.6 Logistic regression of factors associated with violence and health outcomes 14.1 Number of women (minimum) facing domestic violence 14.2 Selected crimes against women 14.3 Budget allocations for selected programs of Ministry of WCD, GoI 2009–2012 (Rs. crores) 14.4 States that have planned scheme for Protection of Women from Domestic Violence Act (Indian Rupees in lakhs) 14.5 Estimating the costs of a Dilaasa Crisis Centre per year (Indian Rupees)

4 7 86 168 169 170 172 173 175 185 186 190 191 193


Keerty Nakray is an Assistant Professor and Assistant Director of the Centre for Women, Law and Social Change at the Jindal Global Law School, OP Jindal Global University, India. She has completed her PhD from Queen’s University Belfast (Northern Ireland). Prior to her PhD she completed an M Phil in Planning and Development (Indian Institute of Technology, Bombay), a Masters in Social Work (Mumbai University) and a BA Sociology (Honours) (St Xavier’s College, Mumbai, India). Margaret Alston OAM is Professor of Social Work and Head of Department at Monash University, Melbourne, Australia where she has established the Gender, Leadership and Social Sustainability (GLASS) research unit. Padma Bhate-Deosthali has been working as a researcher and trainer with CEHAT for the past 12 years. She coordinated the establishment of Dilaasa, a public hospital crisis centre set up for responding to survivors of domestic violence. She has worked on various aspects of health services research including standards of care in private health sector and its unregulated growth, women’s work and health, domestic violence and its impact on health. She is a member of the Steering Group of the Guidelines Development group of the WHO that is developing guidelines for responding to intimate partner violence and sexual assault for health sectors in low- and middle-income countries. She is a trustee of Samyak, an organisation that works with men on gender and violence issues. Jan Breckenridge is a Senior Lecturer in the School of Social Sciences at the University of New South Wales (UNSW), Sydney, Australia. She is the Director of the Centre for Gender-Related Violence Studies (CGRVS) at UNSW and has undertaken a substantial number of funded research projects in the areas of child and adult sexual, domestic and family violence. She prioritises projects which specifically focus on engagement with ‘communities’, service providers and service users in gender-related violence contexts. Ernestina Coast is a Senior Lecturer in Population Studies in the Department of Social Policy, LSE and is a Deputy Director of LSE Health. Her research focuses on the inter-relationships between social context and demographic

xii Contributors behaviour, including reproductive health, using a combination of quantitative and qualitative methods. Ravi Duggal has an academic background in sociology and has worked for over three decades in the area of public health, especially health systems and financing and has written several books, research reports and papers. In the past he has worked at the Foundation for Research in Community Health, Swissaid, the Ministry of Health and the Centre for Enquiry into Health and Allied Themes. Presently he works with the International Budget Partnership. Kerrie James BSW, MSW, MLitt. (Gender Studies) is a social worker and family therapist who now teaches counselling, trauma studies and family therapy in social work undergraduate and postgraduate programs. Before joining the School of Social Sciences, University of NSW in 2005, she was the Clinical Director at Relationships Australia NSW for 20 years. She now convenes the Masters of Counselling Social Work and teaches in the Masters of Couple and Family Therapy. She is an associate of the Centre for Gender-Related Violence (UNSW) and is involved in research on domestic violence in relation to prevention of homicide and in relation to disasters. She is also involved in refugee projects in India through the Centre for Refugee Research (UNSW) and has written about counselling training for refugee communities. Throughout her career, she has published extensively on gender and domestic violence and on practice issues in couple and family therapy. In 1999 Kerrie was awarded the Australian and New Zealand Journal of Family Therapy Special Award for Distinguished Contributions to Family Therapy. Rachel Jewkes is the Director of the Medical Research Council’s Gender and Health Research Unit and Secretary of the Sexual Violence Research Initiative. A public health physician, she has spent nearly 20 years undertaking research on the intersections of gender, gender-based violence and health in South Africa. Tiziana Leone is a Lecturer in Demography in the Department of Social Policy, LSE and a Senior Research Fellow, LSE Health. Her area of expertise is reproductive and maternal health in low-income countries, focusing on Brazil and India. She uses quantitative methods and works on demographic and statistical modelling of mortality and health outcomes. Alankar Malviya is the UNAIDS Adviser in Monitoring and Evaluation for Nepal and Bhutan, and has previously worked with the Government of Madhya Pradesh (India) and UNDP. He was the National Project Coordinator of CHARCA, a nine UN agency joint initiative, working in six states of India to reduce gender-based vulnerabilities to HIV/AIDS. Robyn Mason is a teacher and social worker with practice experience in rural Australia. She has worked in several fields, including sexual assault, aged care and community development. Her doctoral research reported on a national study of feminist support services in rural Australia and her continuing research

Contributors xiii interests include women’s policy, women’s services and feminist practice. She has also researched practice issues for rural workers and is committed to including knowledge about rural and remote practice in the social work curriculum. She has taught social work and welfare at urban and rural universities in Australia. Ronagh McQuigg holds an LLB with First Class Honours; an LLM in Human Rights Law with Distinction; and a PhD, all awarded by Queen’s University Belfast. She qualified as a solicitor in 2008 and joined the School of Law, Queen’s University Belfast as a lecturer in 2009. Her research interests lie in the area of international human rights law, with a particular focus on how human rights law can be used in relation to violence against women. Nishi Mitra is presently an Associate Professor and Chairperson of the Centre for Women’s Studies at a premier social science institute in India, the Tata Institute of Social Sciences. She has been involved in several national and international researches on violence against women. She has published a pioneering report on domestic violence intervention in India, Domestic Violence as a Public Issue: A Review of Responses, and has been involved in teaching, research and police training programs on the issue of violence against women. In recent years she has been involved in formulating and launching one of the few Women’s Studies MA Programs in India. Presently she is engaged in teaching several courses of this new Women’s Studies MA Program, developed in partnership with universities in UK. Vibhuti Patel has a Doctorate in Economics and is the Head of Economics Department at the SNDT Women’s University Mumbai. She has made contributions in Women’s Studies and Gender Economics. She has authored one book, Women’s Challenges of the New Millennium (2002), and co-authored two more, Indian Women: Change and Challenge (1985) and Reaching for Half the Sky (1985). She co-edited Macro Economic Policies and the Millennium Development Goals (2006), a series of 15 volumes on Empowering Women Worldwide (2008), and edited the books Discourse on Women and Empowerment (2009) and Girls and Girlhoods: At the Threshold of Youth and Gender (2010). Blanca M. Ramos, MSW, Ph.D is an Associate Professor at the University at Albany, State University of New York. Her teaching and scholarly experience centers on mental health, immigrants, multiculturalism and domestic violence with a focus on US Latinas. She is an experienced community organizer and has served in professional, private, and governmental boards and commissions at the local, national, and international levels. She is past Vice President of the US National Association of Social Workers and served on the Institute for the Advancement of Social Work Research Board. Her international experience includes research, teaching, and partnership building with the Peruvian national association of social workers and with universities and community organizations in Mexico, Costa Rica, Peru, and Spain.

xiv Contributors Michael Salter is a Lecturer in Criminology at the University of Western Sydney, Australia. His research is focused on gendered violence across the lifespan and policy responses, particularly in relation to child sexual abuse and domestic violence. He has been a Research Associate at the Centre for Gender Related Violence Studies (CGRVS) since 2007 where he has worked in a range of areas, including projects on the experiences of sexual abuse survivors in alcohol and drug treatment, gendered violence prevention and the management of highrisk domestic violence offenders. His forthcoming book Organised Child Sexual Abuse (Routledge) is the first qualitative study of multi-perpetrator child sexual abuse, and he has forthcoming papers in the British Journal of Criminology, Violence Against Women and Child Abuse Review. Dilbar Turakhanova received her LLM in Law and Governance in the Queen’s University of Belfast. She has worked in Tajikistan with several international organisations including the United Nations and managed projects aimed at elimination of the violence against women, establishment of gender equality, protection of children from child labour, and anti-corruption. Previously, she was a public servant and worked in the Supreme Economic Court of Tajikistan. Since 2008 she has been a freelance consultant researching Tajik law governing maternity protection, labour administration, public administration, family law, and the compliance of Tajik law with international obligations on human rights. Deborah Western is a social worker with practice experience in the fields of child and family welfare, education, sexual assault and family violence, and has worked in rural, regional and metropolitan areas in Australia. Through her work in a state-wide peak body for family violence services, she developed an appreciation of the role of advocacy and social policy. Her doctoral thesis explored the area of women and depression with emphasis on women’s use of personal journals and consciousness-raising. Her research interests include women and mental health, feminist practice, and violence against women. Emma Williamson BA (Hons), PGDip., PhD, is a Senior Research Fellow in Gender-Based Violence at the University of Bristol. She has over 15 years of research experience working in the area of gender-based violence which has included research on health, law, social policy, and service interventions. She previously worked as the Domestic Violence Information and Membership Manager for Women’s Aid, the National Domestic Violence charity in the UK, and continues to provide training to the National Domestic Violence Helpline. She is currently working on a number of different research projects including the PROVIDE domestic violence and health project.


I am deeply indebted to: •

• • • •

all the contributors who worked tirelessly and displayed high levels of commitment towards the completion of the book in spite of their gruelling schedules; Grace McInnes and James Watson (Routledge, London) for their support and patience; the publishing team at Keystroke for meticulous editing; OP Jindal Global University for opening new avenues and possibilities; my family and friends for their unflinching support.



Abuse Assessment Scale Acquired Immune Deficiency Syndrome alcohol and/or other drug azidothymidine, also known as zidovudine British Crime Survey Composite Abuse Scale Centre against Sexual Assault Convention against Torture and Other Cruel, Inhuman and Degrading Treatment or Punishment Convention on the Elimination of All Forms of Discrimination against Women Committee on Economic, Social and Cultural Rights Commonwealth of Independent States Comparing Love and Domestic Violence in Heterosexual and Same Sex Relationships Study Conflict Tactics Scale Demographic and Health Surveys deliberate self-harm emotional abuse European Union Department of Families, Housing, Community Services and Indigenous Affairs female genital mutilation family violence reform gender-based violence Gross Domestic Product hurts, insults, threatens, and screams human immunodeficiency virus infection/acquired immunodeficiency syndrome Herpes simplex virus International Covenant on Civil and Political Rights International Covenant on Economic, Social and Cultural Rights


International Conference on Population Development International Institute for Population Sciences United Nations Intergovernmental Panel on Climate Chang intimate partner violence Index of Spouse Abuse Millennium Development Goals Mahatma Gandhi National Rural Employment Guarantee Act Mental Health Coordinating Council National Crime Records Bureau National Family Health Survey Organisation for Security and Cooperation in Europe Ongoing Violence Assessment Tool physical abuse post-exposure prophylaxis Programme of Research on Violence in Diverse domestic Environments post-traumatic stress disorder partner violence screening The Protection of Women from Domestic Violence Act Relationships Australia, South Australia Sexual Assault Reform Strategy severe combined abuse sexual violence Thohoyandou Victim Empowerment Project Universal Declaration of Human Rights United Nations Joint United Nations Programmeon HIV/AIDS United Nations Development Programme United Nations Educational, Scientific and Cultural Organisation United Nations Population Fund United Nations Fund for Empowerment of Women United States United States Dollars Value Added Taxes Violence Against Women Act Violence Against Women Survey woman abuse screening tool Women’s Evaluation of Abuse and Violence Care in General Practice: A Randomised Controlled Trial women’s experience with battering World Health Organization


Introduction Keerty Nakray

This book encapsulates some of the recent debates on the theoretical and empirical advances in the understanding of gender-based violence as a public health issue. Each chapter in the book systematically presents how gender-based violence undermines the well-being of females across the world and thwarts the development of nations. It requires priority attention from policy-makers across the world, through dedicated financial budgets supporting various interventions which aim to prevent the occurrence of gender-based violence and also provide remedial services to individual victims. The chapters reflect on how gender-based violence remains the primary means to maintain and perpetuate women’s exclusion from social, economic and political participation. A public health approach to genderbased violence is based on explicit recognition of the health consequences of violence to women and the enormous costs to society. It also recognises the vital role that health and social care professionals play in the early recognition of violence, and initiating interventions. However, the approach is less understood and requires serious consideration from policy-makers in developing countries where public health systems are still evolving to respond effectively to gender-based violence. This decade is marked by several challenges that the global financial crisis has unleashed on several developed economies which have had adverse impacts on health and social services. Economic growth in some developing economies is also marked by a deepening of the existing social exclusion. In this difficult and challenging context feminists need to pointedly articulate the need to address gender-based violence as a serious problem which not only affects individual women but also impacts the overall development of nations. Therefore, it is necessary that commitment to gender equality and the elimination of all forms of violence should not be foregone. As nations march together towards the achievement of the Millennium Development Goals (2015) (United Nations, 2010) it is vital to address genderbased violence, and direct financial and human resources to policies and programmes that will be effective.

2 Keerty Nakray

Gender-based violence: key developments in the international policy arena The early advances in addressing gender-based violence as a public health issue include the United Nations Commission on the Status of Women special working group which, in the fall of 1993, drafted a declaration on violence against women which offered the first definition of gender-based violence (Heise et al., 1994). According to Article 1 of the declaration, violence against women includes: 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 deprivations of liberty, whether occurring in public or private life. (United Nations General Assembly, 1993) The definition was further amended in Article 2 to include: a Physical, sexual and psychological violence that occurs in the family, including battering; sexual abuse of female children in the household; dowry-related violence; marital rape; female genital mutilation and other traditional practices harmful to women; non-spousal violence; and violence related to exploitation; b Physical, sexual and psychological violence that occurs within the general community, including rape; sexual abuse; sexual harassment and intimidation at work, in educational institutions and elsewhere; trafficking in women; and forced prostitution; c Physical, sexual and psychological violence perpetrated or condoned by the State, wherever it occurs. (United Nations General Assembly, 1993) The United Nations Population Fund (1998) further expanded the definition as follows: Gender-based violence is violence involving men and women, in which the female is usually the victim and which is derived from unequal power relationships between men and women. Violence is directed specifically against a woman because she is a woman, or affects women disproportionately. It includes, but is not limited to, physical, sexual and psychological harm (including intimidation, suffering, coercion, and/or deprivation of liberty within the family or within the general community). It also includes that violence which is perpetrated or condoned by the State. (United Nations Population Fund, 1998) The Convention on Elimination of All Forms of Discrimination against Women (CEDAW) was adopted by the United Nations General Assembly in 1979 (Division

Introduction 3 for the Advancement of Women, Department of Economic and Social Affairs, 1979). It is described as the international bill of rights for women and recognised the need for State Parties to eliminate discrimination against women in public life and also recognised a wide range of rights including the right to protection of health and to safety whilst in employment; and the right to choose a spouse and enter into marriage through free and full consent. The World Conference on Human Rights held in 1993 in Vienna also recognised that gender-based violence and all forms of sexual harassment should be eliminated by legal measures and through national action and international cooperation (Office of the United Nations High Commissioner for Human Rights, 1993). The International Conference on Population Development, Cairo (United Nations, 1994), in their fourth guiding principle, recognised the importance of ‘gender equality and equity and the empowerment of women and elimination of all kinds of violence against women and ensuring women’s ability to control their own fertility as a cornerstone for development’. It also encouraged national policies to prioritise population and development strategies and budget programmes to improve access to information, and high quality health. The Beijing Platform for Action of 1995 has been ratified by 189 states and complements the CEDAW. It recognised that financial and human resources have been insufficient for the advancement of women, and that the key to increased budgetary allocations is rooted in the political commitment of national governments (Beijing Declaration, Ch. IV, para. 345; UN Women, 1995). It also strongly recommended research, data collection and statistical analysis related to the prevalence of different forms of violence against and also analysis of the causes, nature, seriousness and consequences of violence against women, and the effectiveness of measures implemented to prevent and redress it. The absence of data – specifically victimisation surveys and standardised data – is a hindrance to institutional change and evaluation of policy effects (Day et al., 2005). Most recently the Millennium Development Goals (2015) agreed by all members of the UN emphasised the need to address violence against women as being central to women’s empowerment and equality (GarciaMoreno and Watts, 2011). Heise et al. (1994) made one of the most important advances in the understanding of the health burdens associated with gender-based violence. They developed the life-cycle approach to include the various practices manifested in communities: female foeticide and infanticide, female genital mutilation (FGM), forced marriages, honour killings, payment of dowry and related harassment, forced pregnancies and abortions, physical beatings and emotional abuse in natal and affinal homes, rape, sexual abuse, prostitution, exclusion from education, employment and property, harassment at the workplace, trafficking and slavery for domestic labour and sex work. In spite of the diversity of contexts and practices in which gender-based violence occurs, one overarching explanation for genderbased violence is rooted in the patriarchal organisation of societies. Since the first inception of the key definitions on gender-based violence significant changes have occurred across the world which have further deepened and shaped the contemporary practices and contexts in which violence against

4 Keerty Nakray Table 1.1 Gender violence throughout the life cycle phase: type of violence present Pre-birth

Sex-selective abortion; battering during pregnancy (emotional and physical effects of the women; effects on birth outcomes); coerced pregnancy (for example, mass rapes in war).


Female infanticide; emotional and physical abuse; differential access to food and medical care for girl infants


Child marriage; genital mutilation; sexual abuse by family members and strangers; differential access to food and medical care; child prostitution


Dating and courtship violence (for example, acid throwing in Bangladesh, date rape in the United States); economically coerced sex; sexual abuse in the work place; rape; sexual harassment; forced prostitution, trafficking in women

Reproductive age

Abuse of women by intimate male partners; marital rape; dowry abuse and murders; pattern homicide; psychological abuse; sexual abuse in the workplace; sexual harassment; rape; abuse of women with disabilities


Abuse of widows, elder abuse (in the United States, the only country where data is currently available, elder abuse affects mostly women)

Source: Heise et al., 1994

women occurs such as natural disasters and ‘man- made catastrophes’ related to climate change and environmental degradation; globalisation of labour force with increasing masculinisation of cities and feminisation of villages; disruption of social relationships; prevalence of extreme forms of sexual violence and cannibalism in severely conflict-affected societies; and interactions between gender-based violence and vulnerability to HIV/AIDS or adverse health outcomes amongst female victims of violence. This requires a nuanced public health approach which can systematically address these challenges through effective policies and budgets at international, national, sub-national and community-based levels of intervention.

Theoretical and methodological debates: measurement of prevalence and incidence of violence One of the main hindrances to an effective response to gender-based violence is the misconception that the parity or symmetry of violence that is perpetrated by males against females is the same as violence perpetrated by females against males (Schwartz, 2005). These perceptions are related to the exaggerated stances that are undertaken by politicians, journalists and the groups claiming greater rights for men (Schwartz, 2005). This flawed assumption of ‘gender symmetry’ has led to increased incarceration of females for assaulting partners (Das Dasgupta, 2002; Osthoff, 2002). It also has implications for the judiciary and child protection services as they need to understand that women are trying to protect their children from abuse and the circumstances in which this violence occurs should be taken into consideration (Downs et al., 2007).

Introduction 5 ‘Gender symmetry’ is a fallacious assumption and it should not impede the development of a policy response to gender-based violence. First, the health outcomes for women and men in violent relationships are distinctly gendered as women are more likely to suffer from adverse health outcomes as compared to men. Men can use physical strength to hurt women and cause injuries, and can also emotionally control women due to their higher social status (Gordon, 2000). Secondly, the premise that women are as violent as men contradicts the fact that in every other arena of society male violence is dominant (Downs et al., 2007). The differences in contexts are influenced by a wide range of factors, such as sociohistorical factors, including the historical use of violence to resolve conflict and power differentials based on gender, culture, economic and physiology (Das Dasgupta, 1999; Das Dasgupta, 2002). Third, it has implications for research and policy development in the field of gender-based violence. One of the common criticisms of the Conflict Tactics Scales (CTS) which is commonly used to measure the incidence and prevalence of gender-based violence leads to specious inferences about gender symmetry in relationships (Walby, 2005; see Williamson in this volume). The Conflict Tactics Scales (CTS) are widely applied across countries to study the prevalence of violence through the Demographic Health Surveys (International Institute for Population Sciences, 2007). The measurement of violence is affected by several limitations (see Williamson; Jewkes; and Coast et al. in this volume). The scale is restricted to measuring domestic violence and omits some important forms of violence such as sexual assault and stalking (Walby, 2005). Sexual violence is in itself a distinct area of study and research in the field is fraught with methodological problems; as a result, the estimates of prevalence and incidence of sexual violence within marriages is not known (Mahoney and Williams, 2007).

Economic costs of gender-based violence: private woes to public troubles Since the publication of the Commission on Social Determinants of Health report on social determinants of health (2008) increased attention has been drawn to the role of structural factors that shape health inequalities within and between countries. The term ‘social determinants’ denotes a wide range of social, political, economic, environmental and cultural factors that affect the health status of people (Commission on Social Determinants of Health, 2008). One of the paramount concerns within the social determinants of illness is to address gender differences in health outcomes as not merely an outcome of biological differentials but also as a result of social marginalisation and the iniquitous distribution of resources such as employment, property, health care or education between females and males (Sen and Östlin, 2007). Research has clearly illustrated that gender-based violence has deleterious impacts on women’s health, covering physical, reproductive and psychological morbidities such as burns, miscarriages, HIV/AIDS, chronic pains and injuries, depression, anxiety and poor self-esteem (Abramsky et al., 2011; GarciaMoreno et al., 2005). It requires serious attention from international and national

6 Keerty Nakray governmental and non-governmental organisations both in terms of clear policy focus and budgetary expenditure. One of the overriding factors that has led to the development of a public health approach is related to the economic costs of health outcomes resulting from genderbased violence on individuals, families, communities, societies and as nations as a whole (Gold et al., 2011). Since the 1980s researchers have started documenting the economic costs of various types of violence against females (Helweg-Larsen et al., 2010). Most of this research has indicated that costs are incurred not only by individual women but by the whole of the society, and societies need to identify appropriate policies and programmes which can systematically address genderbased violence in the long run (Day et al., 2005; McFarlane et al., 2000). At an individual level, women with a history of violence are more likely to have higher healthcare utilisation and costs (Ling Chan and Yin-Nei Cho, 2010). One of the notable studies documenting economic costs was undertaken by Walby (2004) in the United Kingdom; she concluded that domestic violence costs the criminal justice system £1 billion and the National Health Service £1.2 billion in a single year. There are variations in the methodologies or data sources used for the estimation of economic costs. Generally, the economic costs could include direct and indirect costs, and tangible and intangible costs, for example, costs of financing shelters, or lower earning, or estimating opportunity costs rather than actual expenditures (Day et al., 2005; Rivara et al., 2007). It is important to clarify that the rationale of economic costs has often been used to justify public services for protecting women against violence. It might be viewed critically by few as undermining feminist cause of articulating gender-based violence as a fundamental human rights issue. However, both the approaches can mutually strengthen each other (see Nakray; McQuigg; Mitra (a) in this volume). A public health approach is of strategic value to feminists as it not only improves an argument in favour for greater financial allocations for public health services for females but also can improve the evidence base for policy formulation and responses. A human rights approach does not specify how an individual victim will access justice. A public health approach provides means for creating enabling conditions through which individuals can reach optimum human functioning.

Overview of the book This book provides enriching insights from an array of first-hand experiences, perspectives and theoretical debates from authors based across the world. Each chapter provides an overview of the key difficulties and challenges that are faced in developing an effective policy approach to gender-based violence. One of the underlying themes emerging from all the chapters is that a public health approach is effective in addressing gender-based violence, however, policies and programmes have to be further fine-tuned to the structural realities of women’s lives. It requires sustained efforts from various organisations, both governmental and nongovernmental, to develop systems that are continually evolving to respond to the needs of women.

Higher levels of alcohol and drug abuse in the family; Child abuse and neglect; Poor school performance and drop-outs;

Higher levels of out-of-pocket expenditure on health care services; Impacts on physical, reproductive child health and mental health


Inter- and intragenerational impact; Impacts on school performance; Poor employment prospects; Adverse health impacts

Loss of self-esteem and impacts on subjective wellbeing; Community participation

Loss of productivity and contribution to the household and the economy

Loss of income; adverse impacts on education, health and well-being

Transport expenses (for example, travelling from police station or the court)


Time consumption of the police station; Costs of salaries or professionals such as the police, judges; Costs of imprisonment and court fees; Costs of shelter homes and number of stays; Referrals to emergency departments; Increased incarceration







Table 1.2 Brief overview of the economic costs of gender-based violence

Adverse impacts on inter-personal relationships

Emotional impacts and stress


continued overleaf

Economic and social costs

Social exclusion and deepening of deprivation.


Loss of personal income; loss of working days due to health or judicial visits; increased indebtedness

Loss of income and concomitant impacts on livelihoods; food and health security

Loss of disposable Loss of self-esteem income due to linked to paid work direct and indirect spending on seeking health or judicial approaches; Increased absenteeism at the workplace; Decrease in labour market participation; Reduced productivity; Lower earnings, investment and savings and lower generational productivity

Source: Compiled from Helweg-Larsen et al., 2010; Day et al., 2005; Morrison and Orlando, 2004


Children likely to suffer from recurrent coughing, severe respiratory infections, severe diarrhoea and high fever; impacts children’s nutritional status







Table 1.2 Continued

Seriously affects the family’s access to food security, health resources and also recreation


Increased poverty, social exclusion and ill-health in the society; Reduced quality of life and reduced participation in the democratic process; Loss of tax revenues;


Introduction 9 One of the strengths of the book is that it provides a conceptual roadmap for a policy response based on a public health approach to a wide range of issues that could be defined as gender-based violence (even though it does not cover all the issues, for example, violence against women in post-conflict societies). It also articulates the need for a public health agenda in developing countries and strengthening or sustaining the approach in developed countries. The learning outcomes of the whole of the government approach in Australia (Chapter 7) or Dilaasa, Mumbai India (Chapter 14) provide vital insights for a public health policy approach on gender-based violence. This is specifically important as budgetary allocations by governments or other organisations are largely motivated by ‘success stories’. Each chapter has been carefully selected and presented to provide the readers with a broad overview of the key debates underpinning a public health approach to gender-based violence. The book is divided into two main parts: (I) Conceptual Framework, and (II) Risks, Impacts and Responses to Gender-based Violence. This will enable the reader to develop broad inter-linkages between theoretical debates (such as Jewkes’s chapter (Chapter 5) on gender-based violence and HIV/AIDS in South Africa) and its relevance to specific issues (such as Alston’s chapter on climate change (Chapter 8) or Coast, Leone and Malviya’s chapter on genderbased violence and reproductive health outcomes in India (Chapter 13). Part I consists of chapters explaining the relevant theoretical concepts, and also critically reviewing existing approaches to address gender-based violence, such as human-rights-based or public health. Chapter 1 introduces the book. Chapter 2 provides an overview to the public health approach and budgets and policies which could serve as a basic roadmap to a reader who might not be aware of this approach. Chapter 3 highlights that in India gender budgets have been accepted as a strategic way to address gender inequality. However, budgets should be more synchronised to address gender-based violence both on a long-term and a shortterm basis. Chapter 4 addresses the legal dimensions of gender-based violence as a public health issue. Chapter 5 reviews the evidence and advancements on gender, gender-based violence and HIV/AIDS and its implications for policy in South Africa. Chapter 6 addresses questions related to the measurement of violence and its implications for policy. This will resonate with the chapters from Jewkes (5), Mitra (12) or Bhate-Deosthali and Duggal (14) which also highlight that the evidence base in developing economies does not accurately measure violence and there is scope for further development. Chapter 7 critically reviews a state-based joined-up approach to address gender-based violence in Australia. It provides an excellent illustration of how a multi-sectoral public health approach can effectively work. Part II engages with some of the risk factors, impacts and responses related to gender-based violence in various geographical, social and economic contexts. Chapter 8 is based on empirical data collected in the three geographically distinct locations of Australia, Bangladesh and Pacific Islands, and highlights the gendered impacts of climate change and the dire need for policy commitment for resources to address gender related vulnerability. Chapter 9, also based on empirical data, addresses the questions of abuse amongst women undergoing alcohol and drug

10 Keerty Nakray treatment in Australia and provides policy insights for effectively addressing this issue. Chapter 10 addresses the double oppression and interactions with intimate partner violence amongst Latinas in America and how social work professionals can easily address this issue. Chapter 11 addresses the difficulty of passing and implementing laws in Tajikistan relating to social problems such as domestic violence. Chapter 12 addresses the need to address sexual violence in Indian marriages from both a human rights and a public health approach. Chapter 13, based on a detailed survey, highlights issues of violence and reproductive health in five Indian states. Chapter 14 provides a first-hand account of the Dilaasa project which is a pioneering effort to initiate a public health response to gender-based violence in India. Chapter 15 proposes a practice framework for counselling for women who might be at risk of homicide. Chapter 16 addresses the difficulty of addressing sexual violence in intimate contexts in public health settings in India and the need for a new approach for interventions. Chapter 17 provides a conclusion highlighting the need for addressing gender-based violence on a priority basis at the international and national policy arena in terms of financial resources.

References Abramsky, T., Watts, C., Garcia-Moreno, C., Devries, K., Kiss, L., Ellsberg, M., Jansen, H., and Heise, L., 2011. What factors are associated with recent intimate partner violence? Findings from the WHO multi-country study on women’s health and domestic violence. BMC Medical Journal, 11, p. 109. Commission on Social Determinants of Health, World Health Organization, 2008. Closing the gap in a generation health equity through action on the social determinants of health, Geneva, Switzerland: World Health Organization. Das Dasgupta, S., 1999. Towards an understanding of women’s use of non-lethal violence in intimate heterosexual relationships, Harrisburg, PA: National Resource Center on Domestic Violence. Das Dasgupta, S., 2002. A framework for understanding women’s use of nonlethal violence in intimate heterosexual relationships. Violence Against Women, 8(11), pp. 1364–1389. Day, T., McKenna, K,. and Bowlus, A., 2005. The economic costs of violence against women: An evaluation of the literature, New York: United Nations. Division for the Advancement of Women, Department of Economic and Social Affairs, 1979. Convention on the Elimination of All Forms of Discrimination Against Women, New York: United Nations. Downs, W., Rindels, B., and Atkinson, C., 2007. Women’s use of physical and nonphysical self-defence strategies during incidents of partner violence. Violence Against Women, 13(1), pp. 28–45. Garcia-Moreno, C., Jansen, H., Ellsberg, M., Heise, L., and Watts, C., 2005. WHO multicountry study on women’s health and domestic violence against women: Initial results on prevalence, health outcomes and women’s responses, Geneva: World Health Organization. Garcia-Moreno, C., and Watts, C., 2011. Violence against women: An urgent public health priority. Bulletin of the World Health Organization, 89, p. 2. Gold, L., Normal, R., Devine, A., Feder, G., Taft, A., and Hegarty, K., 2011. Costeffectiveness of health care interventions to address intimate partner violence: What do we know and what else should we look for?. Violence Against Women, 17(3), pp. 389–403. Gordon, M., 2000. Definitional issues in violence against women: Surveillance and research from a violence research perspective. Violence Against Women, 6(7), pp. 747–783.

Introduction 11 Heise, L., Pitanguy, J. ,and Germain, A., 1994. Violence against women: The hidden health burden, Washington DC: World Bank Discussion Papers. Helweg-Larsen, K., Kruse, M., Sorensen, J., and Bronnum-Hansen, H., 2010. The cost of violence: Economic and personal dimensions of violence against women in Denmark, Copenhagen: Statens Institut for Folkesundhed, Syddansk Universitet. International Institute for Population Sciences and Macro International, 2007. National Family Health Survey 3, Mumbai: International Institute for Population Sciences. Ling Chan, K., and Yin-Nei Cho, E., 2010. A review of cost measure for the economic impact of domestic violence. Trauma, Violence and Abuse, 11(3), pp. 129–143. Mahoney, P., and Williams, L., 2007. Sexual assault in marriage: Prevalence, consequences and treatment of wife rape. NNFR Partner Violence: A 20 Year Literature Review and Synthesis, pp. 1–43. University of New Hampshire, NH: Family Research Laboratory, McFarlane, J., Soeken, K., and Wiist, W., 2000. An evaluation of interventions to decrease intimate partner violence to pregnant women. Public Health Nursing, 17(6), pp. 443–451. Morrison, A., and Orlando, M., 2004. The costs and impacts of gender-based violence in developing countries: Methodological considerations and new evidence, Washington DC: World Bank. Office of the United Nations High Commissioner for Human Rights, 1993. Vienna Declaration and Programme of Action adopted by the World Conference on Human Rights in Vienna on 25 June 1993. [Online] Available at: english/law/vienna.htm [Accessed 29 May 2012]. Osthoff, S., 2002. But Gertrude, I beg to differ, a hit is not a hit is not a hit: When battered women are arrested for assaulting their partners. Violence Against Women, 8(12), pp. 1521–1544. Rivara, F., Anderson, M,. Fishman, P., Bonomic, A., Reid, R., Carrell, D., and Thompson, R., 2007. Healthcare utilisation and costs for women with a history of intimate partner violence. American Journal of Preventive Medicine, 32(2), pp. 89–96. Schwartz, M., 2005. The past and the future of violence against women. Journal of Interpersonal Violence, 20(1), pp. 7–11. Sen, G., and Östlin, P., 2007. Unequal, unfair, ineffective and inefficient gender inequity in health: Why it exists and how we can change it. Geneva: World Health Organization. UN Women, 1995. Fourth World Conference on Women. [Online] Available at: [Accessed 24 May 2012]. United Nations, 1994. International Conference on Population and Development ICPD. [Online] Available at: [Accessed 29 May 2012]. United Nations, 2010. We Can End Poverty 2015: Millennium development goals. [Online] Available at: [Accessed 29 May 2012]. United Nations General Assembly, 1993. Declaration on the Elimination of Violence Against Women, New York: United Nations General Assembly. United Nations Population Fund, 1998. UNFPA gender theme group, Geneva: United Nations Population Fund. Walby, S., 2004. The cost of domestic violence, Leeds: Women and Equality Unit, National Statistics. Walby, S., 2005. Improving the statistics on violence against women, Geneva, Switzerland: UN Division for the Advancement of Women.

Part I

Conceptual framework


Gender-based violence A framework for public health budgets and policies Keerty Nakray

Introduction Increasing evidence in the last two decades has highlighted that gender-based violence (GBV henceforth) is not only a serious social problem, but also a multifaceted public health problem. GBV results in high levels of morbidity and mortality amongst women and also has long-lasting impacts on their physical, reproductive and mental health, such as physical bruises and disfigurement, gastrointestinal disorders, traumatic brain injury, Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) and other sexually transmitted infections, maternal and infant mortality, fear, anxiety, depression, post-traumatic stress disorder, substance abuse and addiction, suicide and re-victimisation (Solomon et al. 2009; Plichta 2007; Dunkle et al. 2004; Campbell 2002). The emphasis on a public health approach is also based on the strategic importance of health care workers in identifying and preventing the occurrence of gender-based violence and providing remedial services to victims. It also takes into consideration the role of institutions in the health sector, judiciary, education, governmental and non-governmental organisations, private sector and civil society movements (World Health Organization (WHO) 2005). In spite of recent evidence and legislation which recognise a wide range of practices, such as female foeticide, female genital mutilation, or sexual and physical abuse of girls and women, as human rights violations, GBV continues unabated all over the world, cutting across lines of nations, ethnicity, race and class (WHO 2010). One of the growing criticisms is that inadequate budgetary allocations for effective implementation of laws pose a serious impediment in addressing GBV (Jhamb 2011; Vives-Cases et al. 2010; Patel 2009; Luciano et al. 2005). This chapter will address one of the critical gaps related to the allocation of budgetary resources to address GBV from a public health approach. It will further highlight the key risk factors which shape women’s vulnerability to GBV and the myriad health, social and economic impacts of violence on individual women and wider society. Based on these debates the chapter presents a framework to facilitate gender-sensitive budgeting of integrated health, social and economic services for primarily preventing new incidences of violence and rehabilitation of victims.

16 Keerty Nakray

Gender-based violence and public health budgets and policies: advances in policy thinking Several developments in the international arena have emphasised GBV as a public health concern and the need for dedicated resources to address this problem and its manifold consequences (as discussed in the introduction). The WHO’s MultiCountry Study on Women’s Health and Domestic Violence against Women (2005) highlighted that a public health approach to GBV has a potential to make an impact on women. However, currently few doctors, nurses or other health professionals have the awareness and training to identify violence as an underlying cause of women’s health problems and provide assistance in accessing relevant services in absence of care and protection services (Garcia-Moreno et al. 2005). The WHO (2005) recommended a threefold prevention strategy: 1 Primary prevention: This includes improving public awareness to change attitudes and beliefs that promote social acceptance of violence, and combating sexual abuse of girls and boys through well-coordinated public health programmes, along with reforms in the judiciary, education and social services. It also includes improvements in the physical safety of women and girls by increased lighting and vigilance; involving the education sector and utilising the reproductive health services as an entry point to identify and support women who are being victimised and provide referral services; it also includes provision of mental health services. 2 Secondary prevention: This includes immediate responses to violence such as pre-hospital care, emergency services, or treatment of sexually transmitted infections following rape or sexual assault. 3 Tertiary prevention: This includes long-term care for victims of violence in terms of provision of rehabilitation and reintegration into the society.

The above approach emphasises on primary prevention that is focus on preventing the occurrence of gender based violence and not merely focus on the consequences (see also Western and Mason; Bhate-Deosthali and Duggal in this volume). Against the backdrop of these advances in the international policy arena, 115 countries have adopted or revised legislations on violence against women which include laws, legal codes or legal reforms in the constitution, and Spain (2004), the United States (2005), Brazil (2006), Venezuela (2006) and Mexico (2007) have drawn up laws that include sectors of health, education, social services, legal, police, media and also women’s groups (Vives-Cases et al. 2010). Although the European Union (EU) has not included domestic violence legislation as a formal criterion for its member states to join it has recognised it as a part of formation of a collective identity (Krizsan and Popa 2010). In South Africa the Criminal Law Amendment Bill introduced in 2003 included a wide range of measures to sensitise the police and judges, provide victims with emergency contraception and STD and HIV prophylaxis, and introduce a system of forensic nurses who are authorised to provide evidence (an authority earlier restricted to district judges) (Bott 2010). In India,

Public health budgets and policies 17 the Domestic Violence Act – known as the Protection of Women from Domestic Violence Act – came into effect in 2005, recognising physical, sexual, verbal, emotional or economic abuse as domestic violence and also rape within marriage as an offence (Babu and Kar 2009). Several impediments have been identified in the effective implementation of these laws which include limited governmental expenditure, or lack of understanding of the social contexts of violence; strategies such as provision of legal advice or health services and protection remain a problem (Vives-Cases et al. 2010; Patel 2009). In Latin America, most campaigns focused on the content of the law have overlooked the details of implementation that includes estimated resources required to implement the laws, which is primarily due to the lack of budget advocacy skills on the part of non-governmental organisations (Luciano et al. 2005; see Patel; Bhate-Deosthali and Duggal in this volume). Gender mainstreaming and budgeting

Mainstreaming gender-based violence in existing programmes

National policy on gender-based violence

Contexts: Conflict and post-conflict societies; climate change and environmental disasters; community and family-based violence; workplace

Practices: sex-selective abortions; female genital mutilation; homicides; reproductive child health; acid throwing, bride burning; homicides

Physical impacts:

Physical and environmental factors:

Bruises, abrasions, cuts, and bites, injuries to the eyes and ears, fractures or broken teeth, headaches and premature mortality

Reproductive child health impacts: HIV/AIDS; STIs; depression, anxiety, pre-and post-natal depression; suicides

Economic risk factors:

Social impacts: Social exclusion

(Climate change, migration and refugees)

(Poverty; lack of poverty and educational entitlements) Individual and relationship factors alcohol abuse; marital discord Cultural factors:

Social risk factors: Lack of education and economic entitlements; support; race; ethnicity; class; caste; disabilities

Economic impacts: Poverty

Prevailing notions of masculine and feminine behaviour

Lack of Judicial and Health System Response Primary prevention: Public health message; Human resource development: Training health and social care professionals, police and judiciary, teachers; Education – research and policy development

Secondary prevention: Emergency Services or treatment of sexually transmitted diseases or HIV/AIDS; mental health interventions; Interventions by judiciary and police (female professionals); help lines

Tertiary prevention: rehabilitation and reintegration of victims

Figure 2.1 Framework for public health budgets and policies

18 Keerty Nakray The reduction in government expenditures and democratic backwardness to address gender inequalities are explicitly recognised as factors related to deaths due to GBV (Palma-Solis et al. 2008).

Gender-based violence: interactions between risks and impacts Figure 2.1 draws attention to the various risks that underpin women’s vulnerability to GBV and the health consequences that can further deepen women’s inequalities and social exclusion. According to the WHO (2009a: page V) risk is defined as ‘a factor that raises the probability of adverse health outcomes’. This definition indicates that a detailed study of risk has specific implications for the development of preventive and curative strategies to avert diseases. It explains the causal interrelationships between the wide ranges of individual, social, economic, environmental and community determinants to a health problem. It further highlights a vital need to effectively address the risk factors through public health programmes. The gender differences in health risks are shaped by the biological (sex), as are entitlements to economic resources and autonomy in the household, community and national governance, prevailing cultural notions of masculinity and femininity and access to health services and good nutrition, education and paid employment (Östlin et al. 2006: p. 26; see Jewkes in this volume). Individual and relationship risk factors Individual risk factors intersect with other gradients of social marginalisation. Girls who have been victims of sexual assault as children are at an increased risk of physical or sexual violence (Dunkle et al. 2004). Similarly, women who have been witness to violence at home as children are also vulnerable to lifetime experience of violence (Arnold et al. 2008). Women’s religious affiliation, ethnicity, indigenousness and marital status are also predictors of their vulnerability to GBV (Illiyasu et al. 2011); and women with disabilities suffer from both gender and disability-based violence (Manjoo 2011). Certain relationship factors also shape GBV, such as violence that is largely concentrated in current or recently severed relationships, or by a person known to the woman (Hearn and McKie 2008). Often for women in relationships sexual jealousy on the part of the male partner may trigger violence (Parish et al. 2004). Alcohol abuse often disinhibits a male partner from engaging in violent behaviour (Abramsky et al. 2011). Physical and environmental risk factors Although violence against women is a universal phenomenon it is further exacerbated in certain social contexts. Migration is one of these, as women constitute a large proportion of migrants globally and constitute more than half the refugee population in the world (Berman et al. 2009). Often these women are fleeing from conflict, environmental disasters, poverty and impacts of gender equality such as

Public health budgets and policies 19 oppression, forced marriage or inheritance loss, and often these women who lack the familial or social support networks are more likely to fall victims to smugglers, traffickers, detention facility personnel or border guards; women with children are specifically vulnerable (Zimmerman et al. 2009; see Alston in this volume). We know that women living in conflict situations or as refugees suffer higher rates of physical and sexual assault by intimate partners (Cottingham et al. 2008). They may not have access to family planning methods, may suffer from unwanted pregnancy, and have no access to antenatal care or emergency obstetric care; most health providers are also not trained in the clinical management of rape survivors (Cottingham et al. 2008). Lack of economic entitlements Poverty is a major risk marker for violence (Heise et al. 1994). Women have fewer entitlements to education, secure and paid employment and property (Krishnan et al. 2010; Patel et al. 2006; Panda and Agarwal 2005). The intersection between poverty and violence is expressed in terms of stress, that is, poorer men have fewer resources to cope with stress (Jewkes 2002). Economic independence is a protective factor though not in all circumstances, especially if the woman is working and her partner is not (Jewkes 2002). Poverty and violence are also related to depression during pregnancy, as pregnancy poses additional social and biological pressures that further exacerbate pre-existing vulnerabilities (Lovisi et al. 2005) Cultural ethos In most societies of the world women are expected to be submissive and sexually available for their husbands and it is considered a male right and obligation to use violence to chastise women to conform to societal norms (World Health Organization 2010; see Ramos in this volume). For instance, unlike in the West where it is usually lone men involved in beating lone women, in Asian contexts it is often the husband’s family, including the female members, who perpetrate various forms of violence against women (Fernandez 1997). In the Indian subcontinent, in particular, the practice of ‘dowry’ has often resulted in continued harassment of women (Shidhaye and Patel 2010) and has often culminated in bride burning (Kumar and Kanth 2004). Similarly, the practice of husbands or spurned lovers throwing acid on ‘their’ women continues unabated in the Indian subcontinent (Chowdhury 2005). Social risk factors Societies are often stratified on grounds of gender, where male power and control is privileged and disadvantages are placed on women in seeking the same rights (Manjoo 2011). The lack of education and capability to earn a secure income increase women’s risks of violence (Ntaganira et al. 2008; Bates et al. 2004), and post-school education is more likely to be a protective factor for women (Jewkes

20 Keerty Nakray 2002). Women with husbands with lower levels of education are more likely to suffer from violence (Jeyaseelan et al. 2007). If both partners have completed their secondary education it has a reductive effect on violence whereas primary education by itself fails to have the same impact (Abramsky et al. 2011). Lack of legal rights In spite of the advancements in law in recognition of GBV, the effective implementation thereof to improve women’s legal protection remains a significant impediment. The majority of countries have no laws against marital violence (World Health Organization 2009b; see Mitra (a); Patel; McQuigg; and Turkhanova in this volume). Legally, women have human rights recognised by most international and national conventions, but these rights are mediated by a wide range of social institutions such as their community, education, health, the judiciary and the family (Nakray 2010; see McQuigg in this volume). Cultural contexts in which violence against women occurs also impede women’s access to justice, and a weak judiciary sustains and deepens violence against women. Therefore, progressive legislation has to be considered along with the criminal justice systems and judges and police; medical and social service professionals and how they respond to cases of violence; and the transformation of public perceptions of the social acceptance of violence against women is also vital. Health care system The health sector has a pivotal role in the early identification of abuse to lessen the impact on individual women and also on social costs (Rodriguez et al. 1999). Even though the victims of violence are more likely to use health care services more often than others, they are more likely to face barriers such as feelings of shame, fear of abusers finding out, lack of recognition that they are being abused, fear of being judged by the health care provider, increased anxiety about the future, and finding intervention protocols cumbersome (Plichta 2007). Training and support programmes targeted at primary care clinicians can improve referral to specialised domestic violence agencies (Feder et al. 2011; see Breckenridge and James; BhateDeosthali and Duggal; Mitra (b) in this volume).

Impacts of gender-based violence As stated before, GBV has manifold impacts on women’s health and also on the wider society. This adverse impact further deepens women’s social exclusion and denies them opportunities to improve their individual well-being and also their economic and social participation.

Public health budgets and policies 21 Physical impact Women who are physically abused are likely to suffer from bruises, abrasions, cuts, and bites, more serious injuries to their eyes and ears, fractures or broken teeth, facial injuries, sprains and genitourinary symptoms, and will also suffer from chronic pain such as headaches, back pain or recurring central nervous system complaints including fainting and seizures, fibromyalgia, functional limitation and disability, and premature mortality (World Bank 2009; World Health Organization 2005; Parish et al. 2004; Campbell 2002). For survivors of bride burning and acid burns, the consequences include lifelong physical disfigurement, especially if they lack resources for corrective surgeries (Avon Global Centre for Women and Justice at Cornell Law School and the New York City Bar Association 2011). Reproductive health impacts Research studies have clearly established that sexual violence in ‘paid’ and ‘marital’ contexts play an important role in deepening women’s vulnerability to HIV/AIDS; the violence also worsens after the illness is diagnosed (Silverman 2010; Jewkes et al. 2010). Female genital mutilation is also associated with obstetric morbidity and an increased risk of stillbirth and early neonatal death (Glasier et al. 2006). Violence against pregnant women poses a serious public health concern (Nasir and Hyder 2003) as it results in obstetric and perinatal complications and depressive symptomatology (Bacchus et al. 2003). It is also associated with miscarriage and maternal mortality (Fonck et al. 2005). Pregnant women who are abused are likely to suffer from bleeding and poor maternal weight gain, as well as lack of access to health care (Rose et al. 2010). Violence against women is also related to anaemia and malnourishment, possibly due to the withholding of food as a means of abuse and the impact of stress on the nutritional status of women (Ackerson and Subramanian 2008). Psychologically abused women also experience pre- and postnatal depression (Tiwari et al. 2009; Patel et al. 1999). Abused women report higher levels of anxiety and depression, which also adversely impacts post-partum breastfeeding (Sarkar 2008). Addressing violence is an integral part of improving morbidity and mortality rates; therefore, screening pregnant women for GBV is vital (Alio et al. 2009). Children born to abused women are at greater risk of dying before the age of five, and GBV is also associated with low birth weight gain, preterm delivery and foetal growth retardation (Rose et al. 2010). Family violence against women is also associated with diarrhoeal and acute respiratory tract infections amongst infants (Åsling-Monemi et al. 2009). Gynaecologists and other healthcare workers have a vital role in identifying abused women based on their presenting symptoms, and also to self-report these women and make appropriate referrals to health and social services (Rose et al. 2010; Sarkar 2008).

22 Keerty Nakray Mental health impacts There is a strong association between GBV and poor mental health amongst women, especially poor women (Kumar et al. 2005). Abused women can suffer from depression, stress-related syndromes, chemical dependency and substance abuse, post-traumatic stress disorder, phobias, anxiety, panic disorders and suicide (Rose et al. 2010). Harassment by in-laws for dowry is associated with poor mental health and suicides amongst women (Shidhaye and Patel 2010). Women reporting the highest risk of post-natal depression experience physical or sexual violence along with psychological violence (Ludermir et al. 2010). The mental health problems are also associated with the stigmatisation that women undergo in society, as they are labelled as home wreckers and thus do not leave their abusive partners (Enander 2010). Economic impacts The analysis of economic costs and impacts provide the necessary foundation for policy-makers to take decisions related to prioritising allocations of budgets and also scarce human resources to address GBV effectively (Chan and Cho 2010). In Uganda, the average out-of-pocket expenditure related to an incident of violence for an individual woman was estimated to be 11,337 UGS (Ugandan Shilling), or $5, with the highest expenditure being on police intervention, at 17,904 UGS, or $10 (International Center for Research on Women 2009). Globally, violence results in increased usage of reproductive health services, and loss of employment and educational opportunities and also result in poor educational outcomes amongst children who are witness to violence (Morrison and Orlando 2004). Walby (2004) studied three main types of costs associated with government-funded services (such as the criminal justice system, health care, social services, housing, civil and legal); economic output losses (sustained by employers and employees); and human and economic costs borne by the individual victim of GBV. The research concluded that domestic violence costs the police alone £1 billion a year and the National Health Service £1.2 billion. In 2009, Walby (2009) elaborated that there had been a decrease in domestic violence due to the development and increased utilisation of public services. The decrease in the rate of domestic violence has not resulted in decrease in the costs related to the provision of public services. Investment in public services is cost effective as it prevents both economic losses and human costs.

Gender-based violence: a framework for international public health budgets and policies Figure 2.1 depicts the various risks and impacts of GBV on individuals and society. As evident from the discussions in the previous sections a public health approach is indicated, as it facilitates the prevention of violence and also enables health and social care professionals to make referrals to appropriate remedial services. The WHO (2005; 2010) has emphasised that primary prevention should be at the centre

Public health budgets and policies 23 of a public health approach to gender-based violence. Therefore, activities related to primary prevention should be recognised as a priority for public health budgets. These include: developing human resource capabilities in health and social services to facilitate early identification of risks and impacts of gender-based violence, and promote multi-sectoral collaborations; and public health campaigns in the media to create a public opinion against violence and promote pro-women stances in the judiciary, health and community. Primary prevention activities should also aim to improve women’s entitlements to income, employment, education and property rights. Secondary prevention includes provision of emergency or treatment services to individual women who have been victims of violence. Establishment of helplines can also enable individual women to access immediate help and support. Tertiary prevention includes addressing the needs of victims of violence to be reintegrated into society especially if they have suffered from long-term disabilities (WHO 2010). Mainstreaming gender-based violence in public health budgets and policies It is pivotal to draw out the inter-linkages between the many risk determinants that shape women’s vulnerability to GBV and public health programmes. This requires mainstreaming GBV at two levels: 1 Mainstreaming gender-based violence within existing programmes: For example, the National Rural and Urban Health Mission in India (see Patel in this volume) aims to upscale universal health care to all citizens. Such programmes can provide entry points to health workers to women who are at risk of violence or are already suffering from violence. 2 National policy on gender-based violence: All governments should have a national policy on gender-based violence which takes into consideration the various practices of violence and the specific contexts in which violence occurs. Such a policy has a vital role to play in shaping the response of the health and social services to gender-based violence. Multi-sectoral collaboration Several organisations are involved in funding and providing services for women at the grassroots. However, GBV does not appear in the frontline agenda of these organisations. It is therefore necessary to develop a common understanding within these organisations of GBV as a public health risk. Transnational organisations such as the United Nations, the European Union and national governments have a vital role in shaping funding priorities for this issue and also developing capabilities across varied institutions, non-governmental organisations and civil society movements to respond to this challenge.

24 Keerty Nakray Human resource training A public health approach to GBV largely depends on how professionals associated with the health, social and judiciary systems respond to individual victims’ needs and also how they work in collaboration to facilitate the prevention of violence (see Bhate-Deosthali and Duggal; Mitra (b) in this volume). A pro-woman stance within these institutions has the potential to act as a deterrent to perpetrators of violence. Establishment of specialist gender-based violence health units Major hospitals in any country need to have GBV specialist units to provide the necessary medical-legal interventions (see Western and Mason; Bhate-Deosthali and Duggal in this volume). These specialist units could also develop programmes to address associated risk factors such as alcohol or drug abuse in the communities, conflict resolution in marital relationships, etc. (see Breckenridge and Salter in this volume). Promoting behaviour change through public health campaigns This can include innovative use of a wide range of mass communication channels such as television advertisements, radio programmes, street theatre, documentary films, music videos and endorsements of the issue of celebrities or youth icons. These activities should aim at creating a strong public opinion against violence against women and also encouraging the community to stand up against violence. Judicial reforms Progressive legislations have been developed in various countries to address GBV. Judges, police and other officials have to be trained to implement these laws effectively. These professionals can intervene effectively only if these laws are embedded in a wide spectrum of health and social protection interventions (see Mitra (b) in this volume). Strengthening the response of the health system Health and social care professionals have a significant role in identifying victims and potential victims of GBV. It is vital to budget for training these professionals to be able to address these challenges in terms of participation in public health campaigns to prevent violence and also to provide remedial services to women. New or existing public health programmes in developing economies (such as India’s National Rural and Urban Health Mission) that aim at scaling up universal health care have ignored GBV as a critical risk factor for women’s health. This gap should be addressed through additional funding for awareness campaigns, screening of women for violence and also education programmes. Along with specialist health care professionals such as general practitioners, obstetricians, paediatricians, gynaecologists, psychiatrists and psychologists in both the public and private health

Public health budgets and policies 25 sectors should be able to make referrals to specialist gender-based violence units and appropriate social protection support. Education system It is necessary to finance programmes at primary, secondary and tertiary education sector which question the prevailing stereotypes of masculine and feminine behaviour and also address issues around violence. Social protection/policy interventions Income and employment support for women regardless of their marital status can enable them to walk out of abusive marriages or workplace. Setting up a national helpline for women can also provide them with the immediate support to address abuse. Improving women’s access to micro-credit is also recognised as an important step towards empowerment (see Patel; Jewkes in this volume). Research and policy development Research shapes and informs policies and also health and social services to respond to public health challenges. It is necessary to develop existing capacities in academic institutions to undertake cutting edge research embodying quantitative and qualitative approaches which could inform future policy thinking in the field. In conclusion, GBV in various contexts and forms remains a challenge for most communities across the globe. Critical advances have been made to address GBV as a public health problem. However, budgetary commitment from international, national and local organisations remains a gap in addressing this issue. These organisations need to focus on financing many more activities to prevent the occurrence of violence and also to provide remedial services to victims of violence.

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Gender budgets and public health approach Addressing gender-based violence in India Vibhuti Patel

Introduction Gender budgets have increasingly become popular in several developing economies of the world as a strategy to address deep-rooted gender inequalities. Unlike the previous approaches to address inequality, gender budgets are unique. They primarily focus on state institutions and critically analyse hindrances to the effective functioning of the development programmes. Some of these issues include inadequate financial allocations, lack of allocations for human resource development or other social, economic and cultural issues. Gender budgets critique mainstream economic policies which create or hinder the achievement of gender equality. It requires the redressal of such macro-economic policies and also the development of appropriate social policies which address the exclusion of women. Gender budgeting mark a departure from a project- or programme-based approach to gender equality and development. It takes into consideration structural impediments to the achievement of social justice. Gender mainstreaming is the process of incorporating strategies to achieve ‘gender equality’ in existing governmental programmes or to also initiate policies for women’s concerns which have been previously unaddressed. Gender budgeting specifically addresses the application of gender mainstreaming in the budgetary processes (Daly, 2005; Walby, 2005). It entails the application of gender-based assessment of the budget at all levels of the budgetary process and the restructuring of revenues and expenditures in order to promote gender equality (Schmitz, 2003–2004). Gender-responsive budgeting requires a participatory and transparent process, an equitable base and a non-discriminatory rationale. It also requires that women are not regarded as a vulnerable group who are the beneficiaries of government assistance but rather as right holders, whose government are under obligation to empower and protect them (Elson, 2006). According to the World Bank (2011) gender-based violence includes but is not limited to: (1) domestic violence (DV) by an intra-family member, and intimate partner violence (IPV), which includes physical, sexual or psychological harm by a current or former partner or spouse; (2) sexual violence (SV), which includes rape, sexual abuse, forced pregnancies and prostitution; (3) traditional harmful practices, which includes female genital mutilation (FGM), honour killings and dowry-related

Addressing gender-based violence in India 31 violence; and (4) human trafficking. These have a wide range of impacts on women’s health, including increased risk of HIV and other sexually transmitted infections, minor injuries (bruises, abrasions, cuts, punctures and bites), and in some settings, more serious injuries (broken bones, injuries to ears and eyes). This further adversely affects their mental health problems, emotional distress and suicidal behaviour, which are common among women who have suffered partner violence (Garcia-Moreno et al., 2005). A gender-sensitive approach to public health is rooted in the recognition of differences between women and men. The risks, experiences and outcomes are different for women and men, boys and girls (World Health Organization (WHO), 2007). Therefore mainstreaming gender in public health policies implies addressing the social, cultural, and biological risk determinants that impact distinct health outcomes for women and men (Sen and Östlin, 2007; WHO, 2007). As Nakray (in this volume) has illustrated, gender-based violence has manifold outcomes for women and also for societies as a whole. In spite of the legislative advancements made in several countries across the world, including India, gender-based violence remains rampant (see Bhate-Deosthali and Duggal; Mitra (a) in this volume). The significant barriers to addressing violence that have been recognised include immunity for perpetrators, inadequate services to victims or survivors, attitudes and behaviours that perpetuate negative stereotypes and violence against women, and an overall scarcity of resources for implementation of existing measures. These remain persistent barriers to prevention and ending of violence against women (Division for the Advancement of Women, 1995). This requires rethinking the existing strategies to address the gender-based violence and effectively direct financial and human resources to address this issue in the society.

Understanding gender budgets: approaches and methods The earliest gender budget initiatives were introduced in Australia in 1984 at federal level, under the Labour Party (Sawer, 2003). The Beijing Platform for Action in 1995 emphasised that greater political commitment is needed to support women’s equality through financing development programmes (Division for the Advancement of Women, 1995). At the same time, the International Conference on Population Development also emphasised that governments should prioritise investment in population development strategies and budgets (United Nations, 1994). Most recently, the Millennium Development Goals (2015) has resulted in 192 countries make a strong commitment to several goals related to gender equality, such as Goal 3, which is related to gender equality and women’s empowerment, Goal 5, which is related to improving maternal health, and Goal 6, which is related to combating HIV/AIDS (World Bank Gender and Development Group, 2003). Gender budgeting has gained momentum as an approach in many developing economies: India, South Africa, the Philippines, Botswana, and Tanzania, to name a few (Sawer, 2003; Botlhale, 2011). In developing economies, the United Nations Fund for Empowerment of Women (now United Nations Women), along

32 Vibhuti Patel with several governmental and non-governmental organisations, has played a pivotal role in advocating gender budgets. There are three main types of expenditure in government budgets. The first is gender-specific expenditure, which includes budgetary allocations specifically targeting women, men, boys, or girls; second, expenditures that promote gender equality within the public services: these include allocations for equal employment opportunities; the third is, general and mainstream expenditure: this includes Gender Impact Analysis, focusing on the differential impact of sectoral allocations on women and men, boys and girls. This analysis is challenging, as 99 per cent of government expenditure is in this sector (Elson, 1998; 2000). Elson (1998; 2000) has developed specific gender budgeting tools which are discussed below. Analytical tools for gender-sensitive budgets (GSB) Gender-aware sectoral policy evaluations This involves asking, “In what ways are the policies and their associated resource allocation likely to reduce or increase gender inequality?” It involves a gendered analysis of the impact of policies by using desk reviews, surveys, and cost-benefit analyses. Gender-disaggregated benefit incidence analysis of public expenditure This examines the extent to which women/men and girls/boys benefit from the expenditure on public services. The method here is to use household surveys in order to calculate the unit cost of services, followed by a calculation of the number of units utilised by various categories of beneficiaries. Cross-checking of official data sources concerning beneficiary lists is also carried out. Elson (1998) highlights that data is required on the amount spent at national, regional and local levels on the provision of a particular service collected from the relevant public service providers. The decentralisation of expenditure to lower tiers of government tends to make it more difficult. Gender-disaggregated beneficiary assessments These are done to examine the priorities of potential/actual beneficiaries regarding public services and spending, through opinion polls, group discussions, qualitative interviews, etc. ‘It is particularly important to assess whether measures which are supposed to improve effectiveness actually do improve the quality of service from a beneficiary’s perspective’ (Elson, 1998: p. 932). Gender-disaggregated revenue incidence analysis This calculates the relative amount of direct and indirect taxes and user fees. In many countries, the incidence of income tax falls more directly on men than on

Addressing gender-based violence in India 33 women, whereas indirect taxation (such as Value Added Taxes) on basic household goods would fall more directly on women (Elson, 1998). Gender-disaggregated analysis of impact of budget on time use This makes visible the relationship between national budgets and the care economy. The methods used include household time-use surveys; calculation of time spent on paid and unpaid work, and gross household product; and mapping of changes in private and public services and expenditures. Gender-aware budget schemes These would systematically compare the implications for men and women, and analyse the extent to which the budget is gender-balanced. On the expenditure side, this could be done by including in the budget statement a series of genderaware indicators, such as women’s priority public services to enhance their access to education and health; gender focal points in ministries; women’s priority income transfers like child benefits or women’s pension; or gender balance in business contracts. Gender-responsive medium-term macroeconomic policy framework This disaggregates existing variables by gender, introduces new variables, and constructs new models incorporating both national and household income accounts reflecting unpaid work. Since 2005, the gender budget statement has become an integral part of the annual national financial budget in India. However, it has only contained information on gender-specific expenditure. The incorporation of gender budgets was largely an outcome of advocacy efforts of several individuals and agencies such as the Ministry of Women and Child Development, the United Nations Fund for Women, women’s groups such as Women Power Connect and gender experts in the academia (Sharma and Kanchi, 2007). This was a milestone for the women’s movement in India as it displayed a commitment on the part of the national government to address gender equality within the institutional mechanisms of the state. Gender budgets have evolved considerably since then, and include programmes which have a pro-women allocation (Mishra and Jhamb, 2007). Gender budgets, in spite of being endorsed by the Government of India, have not resulted in any tangible gains for the women of the country (Mishra and Sinha, 2012). Several shortcomings have been noted in the annual gender budgets of the Ministry of Finance, Government of India. For instance, the presentation of the annual financial statement of expenditure on women has little implications for service delivery, which is carried out by state and local governments (Sharma and Kanchi, 2007). The focus is on women as beneficiaries and not as participants (Goyal, 2006). There is also a lack of a systemic and analytical approach to address issues related to education, employment or industrial policy and its impacts on

34 Vibhuti Patel women (Senapathy, 2000). There is very little coordination between the budgetary resources and the legal measures or economic measures necessary to improve the status of women.

Gender-based violence: key issues for gender-sensitive budgeting in India India remains one of the most gender unequal countries of the world. The Census of India (Ministry of Home Affairs, Government of India, 2001) indicated that child gender ratios (zero to six years) declined from 945 females per 1,000 males in 1991 to 927 females per 1,000 males in 2001. The recent census has confirmed this trend of declining child gender ratios from 917 females to 1,000 males ( Jha et al., 2011)). The gender differentials are also visible in the under-five mortality rates (79 girls out of 1,000 compared to 70 boys). The maternal mortality (MMR) continues to be one of the highest in the world at 301 per 100,000 per births (2001–2003) despite a decline from 397 in 1999–2001. An estimated 2.47 million adults are living with HIV: 0.36 per cent of men and 0.22 per cent of women. Women (one in four) lag behind men (two in five) in knowledge about transmission and prevention (International Institute for Population Sciences (IIPS), 2007: p. xiii). Pertinent threats to women’s health include morbidity due to anaemia, excessive work load and violence-related injuries (two out of five women in India experience spousal violence) (IIPS, 2007: p. xiii). The health status of women is particularly poor and this is attributed to inter- and intra-household discrimination in the distribution of food, health care issues such as lack of accessibility due to inadequate transport facilities, non-availability of female health care providers, costs incurred on treatment, and lack of clean drinking water and sanitation (IIPS, 2007: p. 210). Several developmental initiatives in the form of programmes and policies have been initiated for women. There are also legislative advancements aimed at improving women’s status in the society, especially in the context of widespread gender-based violence in Indian society. However, one of the major stumbling blocks for many of these legislations, policies and programmes is inadequate allocation of budgetary funds (Patel, 2009; Jhamb, 2011; see Bhate-Deosthali and Duggal in this volume). Some of the notable legislative advancements include: Pre-Natal Diagnostic Treatment (Prevention of Misuse and Regulation) Act 1994 This Act was amended in 2002 to tighten its enforcement. Gender-selective abortions are peculiar to India. The gender ratios have declined from 927 females to 1,000 males (Census 2001) to 917 females to 1,000 males (Jha et al., 2011). The easy availability of low cost prenatal medical technologies has resulted in many abortions of healthy female foetuses (Lemoine and Tanagho, 2007–2008). The PreNatal Diagnostic Techniques (Regulation and Prevention of Misuse) Act provides for the prohibition of gender selection for the regulation of prenatal diagnostic techniques, and prevention of gender determination leading to female foeticide.

Addressing gender-based violence in India 35 Unlike the Medical Termination of Pregnancy (MTP) Act, it allows for termination of certain pregnancies by registered medical practitioners. It limits the woman’s rights to abortion only in specific circumstances as explained in the MTP Act. The Prevention of Misuse and Regulation Act covers all the reproductive technologies and also strengthens the roles of supervisory boards and advisory committees at various levels (Subramanian and Selvaraj, 2009). The Protection of Women from Domestic Violence Act This Act is considered as a landmark, as for the first time issues of marital violence were addressed; it also defined the role of the service providers such as the hospitals, law and order machinery, protection officers, counsellors and the shelter homes. It comes against the backdrop of the feminist movements which advocate benefits for women. However, the lack of adequate budgetary support renders this progressive legislation ineffective. India comprises several federal states which are governed by the provincial governments. The lack of institutional mechanisms at the level of the provincial governments severely limits the application of the act (see Mitra (a); Bhate-Deosthali and Duggal in this volume). It is necessary that government provides details of expenditures under the different heads of counselling, food, shelter, medical check-up, medicine, clothes and education/vocational training (Ministry of Women and Child Development, Government of India, 2007). Sexual harassment in the workplace The Supreme Court of India in 1997 recognised that sexual harassment in the workplace is a serious violation of human rights. The landmark Vishaka judgement outlined a set of guidelines on how to handle sexual harassment in the workplace (Chaudhuri, 2007) As defined in the Supreme Court guidelines (Vishaka versus State of Rajasthan, August 1997), sexual harassment includes such unwelcome sexually determined behaviour as: physical contact; a demand or request for sexual favours; sexually coloured remarks; showing pornography; any other unwelcome physical, verbal or non-verbal conduct of a sexual nature for example, leering, telling dirty jokes, or making sexual remarks about a person’s body, etc. (Patel, 2005). There is lack of evidence on the extent and nature of sexual violence in the workplace (Chaudhuri, 2007; Rufus and Beulah, 2009). To obtain an understanding of women’s experiences of sexual harassment in the health sector, an exploratory study was undertaken in 2005–2006 among 135 women health workers, including doctors, nurses, health care attendants, administrative and other non-medical staff working in two government and two private hospitals in Kolkata, West Bengal, India. Four types of experiences were reported by the 77 women who had experienced 128 incidents of sexual harassment: verbal harassment (41), psychological harassment (45), sexual gestures and exposure (15), and unwanted touch (27) (Chaudhuri, 2007). Without cultural and social change it is difficult to address these issues (Dasgupta, 2002).

36 Vibhuti Patel

Key issues of gender budgets and gender-based violence in India It is difficult to address issues of gender-based violence unless one takes into consideration the structural contexts in which such violence occurs and is also sustained. Culture plays a vital role in justifying violence against women. Unless intervention efforts directly issues related to women’s empowerment and existing initiatives are less likely to have optimum outcomes (see Jewkes in this volume). Therefore, it is necessary to create clear linkages between various policies and their implications for women’s empowerment and gender-based violence. Some of the sectors where gender-based violence should be mainstreamed include the health sector and social security programmes. Health sector The health sector plays a vital role in the early identification of violence and in averting the pernicious health outcomes suffered by individual women and society as a whole (see Nakray in this volume). Several programmes such as the National Rural and Urban Health Mission or Janani Suraksha Yojana (Hindi for ‘protection of motherhood’) have been initiated by the Government of India. The National Rural Health Mission aims to improve health services in rural areas. It focuses on the delivery of nutrition, a reproductive and primary health package, and better sanitation and water supply in the rural areas of eighteen poorly performing states. It aimed to limit maternal mortality (to 1/100,000 live births) and infant mortality (to 30/1,000 live births) by 2010 (Sharma and Kanchi, 2007). Janani Suraksha Yojana aims to improve health facilities for all pregnant women and also creates awareness about the care of mothers during pregnancy, promotes safe deliveries and provides care or transport facilities to take women to maternity clinics (National Institute of Public Cooperation and Child Development, 2010). Violence is a common cause of injury amongst women, therefore health workers are strategically placed to identify women who are vulnerable to or victims of violence especially during antenatal care, other obstetric or gynaecological consultation, primary health care and mental health services (Garcia-Moreno, 2002). This requires considerable sensitisation of health workers and also development of service protocols which will facilitate identification and screening of vulnerable women (Garcia-Moreno, 2002) (see also Mitra (b); Bhate-Deosthali and Duggal in this volume). It also requires that vulnerable women be supported through a wide range of social security measures that will enable them to move out of abusive homes. Social security programmes There are a wide range of social security measures in India. However, the role of these measures in improving women’s status has not been distinctly realised. Some of these schemes include: Indira Awas Yojana (a scheme for housing the poor); the Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA)

Addressing gender-based violence in India 37 (which aims to provide universal employment and has few provisions for women); and the National Pension Scheme. Even though women have been included in the schemes, cultural and institutional barriers persist. In the case of MGNREGA there is no official provision for different types of work to be allocated to pregnant women or women who have recently given birth (Holmes et al., 2010). The violence against older women remains an unaddressed issue in the Indian context. Old women live in the margins of the society with limited opportunities for social interaction or limited earning possibilities and also suffer from severe medical complications, emotional isolation (in many cases even from their own children), very limited knowledge or awareness of their legal rights and natural reluctance to seek justice (Agewell Foundation, 2011).These problems can be acute for widows or single women living alone. In February 2009, funding of a national widow’s pension was debated in the cabinet and the proposal was made that Rs.200 (US$ 4.08) be available to all below- poverty-line widows aged 40 to-64; the central government funding was charged by the Finance Ministry with making the pension ‘open ended’ (Vera-Sanso, 2010). It is necessary to link various social security programmes with women to improve their status in the society in order to reduce the occurrence of violence (see Jewkes in this volume).

Implications for policy and conclusion A gender budget analysis of the existing approaches and schemes to address genderbased violence indicates severe lacunas most importantly the lack of budgetary support for key legislations and schemes. Gender-based violence poses a serious problem for women’s health and well-being. However, it has not been addressed systematically in the national policies and programmes. It is necessary to develop a multi-sectoral approach to address gender-based violence in India. This initiative should receive necessary support from the national and state governments. Unless the overall entitlements of women to income, employment and property ownership are not significantly improved it is difficult to address gender-based violence in the long run. It is necessary to implement the existing schemes for women and also initiate schemes which systematically address gender inequality. It is necessary that respective ministries prepare a critical appraisal of the outcomes of existing legislation and social development programmes and schemes for women. They also address the lacunae in the existing policies and programmes. Certain groups of women – such as disabled women or women belonging to scheduled castes, tribes or other ‘backward’ castes or ethnic minority communities such as Muslims – are largely invisible in the national policies. The budget is one of the key instruments to actually realise affirmative action and social justice. It provides direct financial resources which can facilitate the process of development and change. Gender budgets or child-sensitive budgets or green budgets or disability-sensitive budgets are a form of self-audit on the part of the government. As it brings into the fold the most excluded categories of people, it also facilitates the effective targeting of policies and programmes. Therefore, it creates long-lasting impacts on development programmes which are more worthwhile. To conclude, gender budgets strengthens

38 Vibhuti Patel state mechanisms for development by creating an enabling environment for women’s participation. This is noteworthy in a deeply divided Indian society where discrimination against women continues to be rampant and is largely unaddressed.

References Agewell Foundation, 2011. Agewell study on human rights and status of older women in India, New Delhi: Agewell Foundation. Botlhale, E., 2011. Gender-responsive budgeting: The case for Botswana. Development Southern Africa, 28(1), pp. 61–74. Chaudhuri, P., 2007. Experiences of sexual harassment of women health workers in four hospitals in Kolkatta India. Reproductive Health Matters, 15(30), pp. 221–229. Daly, M., 2005. Gender mainstreaming in theory and practice. Social Politics: International Studies in Gender, State and Society, 12(3), pp. 433–450. Dasgupta, M., 2002. Social action for women? Public interest litigation in India’s Supreme Court. Law, Justice and Global Development, 1. Available at (accessed 11 July 2012). Division for the Advancement of Women, 1995. Fourth world conference on women: Beijing declaration, New York: Department of Economic and Social Affairs, United Nations. Elson, D., 1998. Policy arena: Integrating gender issues into national budgetary policies and procedures: Some policy options. Journal of International Development, 10, pp. 929–941. Elson, D., 2000. Progress of the world’s women, New York: United Nations Development Fund for Women. Elson, D., 2006. Budgeting for women’s rights monitoring government budgets for compliance with CEDAW. New York: UNIFEM. Garcia-Moreno, C., 2002. Dilemmas and opportunities for an appropriate health-service response to violence against women. The Lancet, 359(9316), pp. 1509–1514. Garcia-Moreno, C., Jansen, H., Watts, C., Ellsberg, M., and Heise, L., 2005. WHO multicountry study on women’s health and domestic violence against women: Initial results on prevalence, health outcomes and women’s responses, Geneva: World Health Organization. Goyal, A., 2006. Women’s empowerment through gender budgeting: A review in the Indian context, New Delhi: Department of Women and Child Development, Government of India. Holmes, R., Sadana, N., and Rath, S., 2010. Gendered risks, poverty and vulnerability in India: Case study of the Indian Mahatma Gandhi National Rural Employment Guarantee Act (Madhya Pradesh), London: Overseas Development Institute.International Institute for Population Sciences and Macro International, 2007. National Family Health Survey 3, Mumbai: International Institute for Population Sciences. Jha, P., Kesler, M., Kumar, R., Ram, F., Ram, U., Aleksandrowicz, L., Bassani, D., Chandra, S., and Banthia, J., 2011. Trends in selective abortions of girls in India: Analysis of nationally representative birth histories from 1990 to 2005 and census data from 1991 to 2011. The Lancet, 377(9781), pp. 1921–1928. Jhamb, B., 2011. The missing link in the Domestic Violence Act. Economic and Political Weekly, 46(33), pp. 45–50. Lemoine, K. and Tanagho, J., 2007–2008. Gender discrimination fuels sex selective abortion: The impact of the Indian Supreme Court on the implementation and enforcement of the PNDT Act. University of Miami International and Comparative Law Review, 203, pp. 203–254. Ministry of Home Affairs, Government of India, 2001. Census of India. [Online] Available at: [Accessed 30 April 2012].

Addressing gender-based violence in India 39 Ministry of Women and Child Development, Government of India (2007) Ujjawala: A comprehensive scheme for prevention of trafficking and rescue, rehabilitation and reintegration of victims of trafficking for commercial sexual exploitation. [Online] Available at [Accessed 30 July 2012]. Mishra, Y. and Jhamb, B., 2007. What does Budget 2007–08 offer women?. Economic and Political Weekly, 42(16), pp. 1423–1428. Mishra, Y. and Sinha, N., 2012. Gender responsive budgeting in India: What has gone wrong?. Economic and Political Weekly, 47(17), pp. 50–57. National Institute of Public Cooperation and Child Development, 2010. Statistics on women in India, New Delhi: National Institute of Public Cooperation and Child Development. Patel, V., 2005. A brief history of the battle against sexual harassment. [Online] Available at: [Accessed 19 April 2012]. Patel, V., 2009. Debate reply. Policy and Politics, 37(4), pp. 615–617. Rufus, D. and Beulah, D., 2009. A noiseless crime: Sexual harassment against women employees at private hospitals in Tirunelveli City, an empirical analysis. The Indian Police Journal, 1, pp. 51–55. Sawer, M., 2003. Australia: The Mandarin approach to gender budgets. In: D. Budlender and G. Hewitt, ed. Gender Budgets make more cents: Country studies and good practice. London: Commonwealth Secretariat, pp. 43–65. Schmitz, C., 2003–2004. Gender responsive budgeting in the Nordic countries: The Scandinavian experience: Barriers, results and opportunities, Copenhagen: The Nordic Council of Ministers. Sen, G. and Östlin, P., 2007. Unequal, unfair, ineffective and inefficient gender inequity in health: Why it exists and how we can change it, Geneva: WHO Commission on Social Determinants of Health. Senapathy, M., 2000. Government of India Budget 2000–2001, London: Commonwealth Secretariat. Sharma, B. and Kanchi, A., 2007. Integrating gender responsive budgeting into the aid effectiveness agenda, New York: UNIFEM. Subramanian, S. and Selvaraj, S., 2009. Social analysis of sex imbalance in India: Before and after the implementation of the Pre-Natal Diagnostic Techniques (PNDT) Act. Journal of Epidemiology and Community Health, 63, pp. 245–252. United Nations, 1994. International Conference on Population and Development, Cairo, Egypt, September. [Online] Available at: [accessed 19 November 2011]. Vera-Sanso, P., 2010. Gender, urban poverty and ageing in India: Conceptual and policy issues. In: S. Chant, ed. The international handbook of gender and poverty concepts, research and policy. London: Edward Elgar, pp. 220–225. Walby, S., 2005. Gender mainstreaming: Productive tensions in theory and practice. Social politics: International studies in gender, state and society, 12(3), pp. 321–343. World Bank, 2011. Gender-based violence, health and the role of the health sector. [Online] Available at: HEALTHNUTRITIONANDPOPULATION/EXTPHAAG/0,,contentMDK:22421 973~pagePK:64229817~piPK:64229743~theSitePK:672263,00.html [Accessed 12 March 2012]. World Bank Gender and Development Group, 2003. Gender equality and the millennium development goals. Washington DC: World Bank. World Health Organization, 2007. What is a gender-based approach to public health?. [Online] Available at: [Accessed 17 April 2012].


Gender-based violence as a public health issue and the legal perspective A critical overview Ronagh McQuigg

Introduction The responses of the majority of states around the globe to gender-based violence tend to be heavily dependent on their criminal justice systems. However, given the complex nature of the factors causing and sustaining gender-based violence, it is clear that responses based solely on criminal justice are insufficient. Pro-arrest and pro-prosecution policies have been adopted in many states; however such policies are in themselves inadequate to support victims. This chapter will briefly discuss the substantial difficulties involved in fitting the issue of gender-based violence into the criminal justice system, and will propose that a new strategy is needed, such as the adoption of a public health approach. The focus of the chapter will be on domestic violence, one of the most common forms of gender-based violence. The chapter will proceed to examine the development of the right to health in intenational human rights law, and the budgetary implications of this development. It will then analyse the potential held by the use of a human rights framework as regards the issue of gender-based violence, with a particular focus on the right to health.

Gender-based violence: inadequacies with legal and judicial responses There are certainly substantial problems with fitting the issue of domestic violence into the criminal justice system. Freedman (2003: 588) comments that, ‘the criminal justice system is best at dealing with relatively straightforward examples and easily categorised domestic violence, with recognisable story lines and sympathetic victims’. In cases of domestic violence, the concept of ‘good’ and ‘bad’ victims seems to come into play, as vividly illustrated by the cases of R v Ahluwalia1 and R v Thornton.2 These cases, which both took place in the United Kingdom, concerned women who had been victims of domestic violence and who had killed their abusive husbands. As Rollinson (2000: 114–115) discusses, the characters of the defendants were subject to much comment during their respective trials (see Western and Mason in this volume). In Ahluwalia the defendant was depicted as a dutiful wife and a good mother. By contrast, in Thornton the defendant was portrayed as a calculating woman who drank and used drugs. Nicolson (2000: 172) comments

GBV: the legal perspective 41 that, the treatment of these women depended ‘on a judgment, not so much of their actions, but of their character and the extent to which it accords with social constructions of appropriate femininity’. Similarly, if a victim of domestic violence shows ambivalence about pursuing a case against her abuser, she may be defined as a ‘bad’ victim, and thus receive a far lesser degree of assistance from the police and other actors in the criminal justice system (Merry 2003: 354–355). In addition, in many instances of domestic violence the imposition of criminal law measures is inappropriate. For example, some victims are faced with a degree of coercion that has not yet reached the level at which the criminal law can be applied. Many victims of domestic violence simply do not trust the criminal justice system. Others may want to continue the relationship, while the involvement of the criminal law assumes that the relationship has come to an end. Essentially, the criminal justice system does not take account of the many complexities and variations at work in the issue of domestic violence. As Freedman (2003: 590–591) remarks, The criminal justice system concentrates its resources on the most serious, urgent and unambiguous cases, then labels one or both parties as deviant, and administers simple and easy to understand remedies, thereby providing a safe social distance between ‘normal’ families and those afflicted with domestic violence. An excessive reliance on criminal justice measures to deal with domestic violence has also led to difficulties for victims from ethnic minorities. These communities may have had experiences of police brutality and such victims may therefore be extremely reluctant to enmesh themselves in the criminal justice system (Maguigan 2003: 431; see Ramos in this volume). There may also be social, economic and cultural barriers which impede the access of ethnic minority groups to the criminal justice system. Women from such groups may be particularly marginalised as compared to the rest of the population. If a criminal law strategy is relied upon to the exclusion of other methods of combating domestic violence, victims from ethnic minorities may well be left with no protection whatsoever. There is also a more fundamental argument made against the use of the criminal law in cases of domestic violence. It has been claimed that the law is largely patriarchal and therefore it simply cannot be used to improve the condition of women (Thomas 1999: 230–231). The advocates of this viewpoint have much in common with the early supporters of the battered women’s movement. According to this argument, appropriate responses to the domestic violence issue lie in the provision of refuges and resources to victims, and in the implementation of social measures to prevent violence from taking place. It has thus been accepted by many commentators that legal responses to domestic violence are inadequate in themselves. As Schneider comments, ‘Legal intervention may provide women certain protection from battering, but it does not provide women housing, support, child care, employment, community acceptance, or love. It also does not deal with the economic realities of life’ (Schneider 2000:

42 Ronagh McQuigg 52). Criminal justice responses can only be part of a comprehensive strategy to deal with such a complex problem as domestic violence (Randall 2004: 144). It is clear that victims need more than the criminal justice system. It is therefore proposed that a different strategy is needed, such as the adoption of a public health approach (see also Nakray in this volume). A potential legal framework for this can be found in international human rights law, in particular, the right to health.

The right to health in international human rights law and its implications for budgets The area of health was first addressed by international human rights standards in the Universal Declaration of Human Rights (UDHR), which was adopted by the General Assembly of the United Nations in 1948. Article 25(1) of the Declaration states that, ‘Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including . . . medical care . . .’. The standards of the UDHR were expanded upon and transformed into provisions of international law binding upon states by two treaties, the International Covenant on Civil and Political Rights (ICCPR) and the International Covenant on Economic, Social and Cultural Rights (ICESCR), which were both opened for signature in 1966. Article 12(1) of the ICESCR contains ‘the right of everyone to the enjoyment of the highest attainable standard of physical and mental health’. In 2000 the Committee on Economic, Social and Cultural Rights (CESCR), the body responsible for overseeing the implementation of the ICESCR, issued its General Comment 14. In this document the Committee elaborated upon its interpretation of article 12. In paragraph 8 of General Comment 14, the Committee stated, crucially, that the right to health is not to be viewed as a right to be healthy. Clearly a right to be healthy would simply be unrealistic and unattainable. Rather, The right to health contains both freedoms and entitlements. The freedoms include the right to control one’s health and body . . . and the right to be free from interference . . . By contrast, the entitlements include the right to a system of health protection which provides equality of opportunity for people to enjoy the highest attainable level of health.3 In paragraph 21 of the General Comment, the Committee stated that, To eliminate discrimination against women, there is a need to develop and implement a comprehensive national strategy for promoting women’s right to health throughout their life span . . . A major health goal should be reducing women’s health risks, particularly lowering rates of maternal mortality and protecting women from domestic violence. In paragraph 30, the Committee emphasised that states must ensure that the right to health is exercised without discrimination of any kind. Paragraph 51 of the General Comment explicitly links gender-based violence and the right to health,

GBV: the legal perspective 43 stating that a failure to protect women against violence or to prosecute perpetrators would constitute a violation of the obligation to protect the right to health. Article 2 of the ICESCR places an obligation on the state ‘to take steps . . . to the maximum of its available resources, with a view to achieving progressively the full realization of the rights recognized in the present Covenant’. The principle of progressive realisation of economic, social and cultural rights constitutes a realistic recognition of the fact that the resources available to governments are limited. Nevertheless, as the Committee stated in its General Comment 3, this principle ‘should not be misinterpreted as depriving the obligation of all meaningful content’.4 Instead, the phrase must be read in the light of the overall objective . . . of the Covenant which is to establish clear obligations for States parties in respect of the full realization of the rights in question. It thus imposes an obligation to move as expeditiously and effectively as possible towards that goal.5 The principle of progressive realisation cannot therefore be used as a generic excuse by governments for failing to allocate sufficient budgetary resources to the implementation of economic and social rights, including the right to health. Indeed, under article 2(2) of the ICESCR, states ‘guarantee that the rights enunciated in the present Covenant will be exercised without discrimination of any kind as to . . . sex’. This obligation is of immediate effect. Therefore, in taking steps to realise the right to health, as contained in the ICESCR, states must ensure that in so doing they respect the principle of gender equality. Hence, women’s health issues must be given sufficient budgetary consideration in the allocation of resources to health care. As the CESCR stated in its General Comment 14, the Covenant proscribes any discrimination in access to health care and underlying determinants of health, as well as to means and entitlements for their procurement, on the grounds of . . . sex . . . which has the intention or effect of nullifying or impairing the equal enjoyment or exercise of the right to health. The Committee stresses that many measures, such as most strategies and programmes designed to eliminate health-related discrimination, can be pursued with minimum resource implications.6 Indeed, in its General Comment 3, the Committee stated that ‘even in times of severe resources constraints whether caused by a process of adjustment, of economic recession, or by other factors, the vulnerable members of society can and indeed must be protected by the adoption of relatively low-cost targeted programmes’.7 It can certainly be argued that women suffering from gender-based violence fall within the category of ‘vulnerable members of society’. The area of health was also addressed in subsequent UN human rights treaties. For example, article 12(1) of the Convention on the Elimination of All Forms of Discrimination against Women 1979 (CEDAW) places a duty on states to ‘take all appropriate measures to eliminate discrimination against women in the field of

44 Ronagh McQuigg health care in order to ensure, on a basis of equality of men and women, access to health care services, including those related to family planning’. In 1999 the Committee on the Elimination of Discrimination against Women (CEDAW Committee), which is responsible for overseeing the implementation of the treaty, issued its General Recommendation 24. The purpose of this document was to set out the Committee’s views on the obligations entailed by article 12. Paragraph 13 of the General Recommendation states that article 12 implies an obligation to respect, protect and fulfil women’s rights to health care. Paragraph 15 states that the duty to protect rights relating to women’s health requires states to take action to prevent and impose sanctions for violations of rights by private persons and organisations. The Committee then proceeded explicitly to link the area of health to gender-based violence, commenting that, Since gender-based violence is a critical health issue for women, States parties should ensure: (a) The enactment and effective enforcement of laws and the formulation of policies, including health care protocols and hospital procedures to address violence against women and abuse of girl children and the provision of appropriate health services; (b) Gender-sensitive training to enable health care workers to detect and manage the health consequences of gender-based violence; (c) Fair and protective procedures for hearing complaints and imposing appropriate sanctions on health care professionals guilty of sexual abuse of women patients; (d) The enactment and effective enforcement of laws that prohibit female genital mutilation and marriage of girl children.8 These statements have clear budgetary implications for governments. In paragraph 30 of the General Recommendation the Committee asserted that, ‘States parties should allocate adequate budgetary, human and administrative resources to ensure that women’s health receives a share of the overall health budget comparable with that for men’s health, taking into account their different health needs’. This paragraph emphasises the need for governments to provide sufficient financial support for the area of women’s health and to ensure that funding practices are non-discriminatory. Likewise, paragraph 17 of this document states that, ‘The duty to fulfil rights places an obligation on States parties to take appropriate . . . budgetary . . . measures to the maximum extent of their available resources to ensure that women realize their rights to health care’. It is therefore abundantly clear that states parties to CEDAW are under a duty to ensure that they take account of their obligations in this area in formulating budgets. As Elson (2006: 13) comments, ‘where the failure of the State to allocate appropriate resources is frustrating effective implementation of the Convention, it has failed to comply’. It is noteworthy that the right to health is also found in a number of regional human rights instruments, such as the Revised European Social Charter of 1996,

GBV: the legal perspective 45 article 11 of which comprises a right to the protection of health. Likewise, article 16(1) of the African Charter on Human and People’s Rights 1981 states that, ‘Every individual shall have the right to enjoy the best attainable state of physical and mental health’. Similarly, article 10(1) of the Additional Protocol to the American Convention on Human Rights in the area of Economic, Social and Cultural Rights, which was adopted in 1988, states that, ‘Everyone shall have the right to health, understood to mean the enjoyment of the highest level of physical, mental and social well-being’. It can be seen therefore that the right to health is a well-established part of international human rights standards, and can be found in many of the main human rights treaties. It is important to note that the right to health has been explicitly linked to the area of gender-based violence by international bodies such as the Committee on Economic, Social and Cultural Rights and the Committee on the Elimination of Discrimination against Women. In addition, it is very clear that the obligations of states under international human rights law must be taken into account by governments in formulating national budgets. The international bodies have also recognised that gender-based violence constitutes a public health problem, and they have increasingly called on governments to collaborate with health services as regards this issue. For example, in 1990 the UN General Assembly urged Member States ‘to begin or continue to explore, develop and implement multidisciplinary policies, measures and strategies . . . with respect to domestic violence in all its facets, including . . . health-related . . . aspects’.9 In 1995 the Beijing Platform for Action, which arose from the Fourth World Conference on Women, stated that HIV/AIDS and other sexually transmitted diseases, the transmission of which is sometimes a consequence of sexual violence, are having a devastating effect on women’s health, particularly the health of adolescent girls and young women . . . Sexual and gender-based violence, including physical and psychological abuse . . . place girls and women at high risk of physical and mental trauma . . . Such situations often deter women from using health and other services.10 Likewise, it has been recognised at an international level that there is a pressing need to ensure that health care professionals receive appropriate training in relation to the issue of gender-based violence. For example, in 2002 the UN Special Rapporteur on violence against women, its causes and consequences commented that ‘States should train all public officials in the administration of justice, education and health sectors to be sensitive and energetic with regard to issues relating to violence against women’.11 Likewise, in 2001, the UN Commission on Human Rights called upon states, To create, improve or develop, as appropriate, and fund training programmes, taking into account, inter alia, sex-disaggregated data on the causes and effects of violence against women, for . . . medical . . . personnel, in order to avoid

46 Ronagh McQuigg the abuse of power leading to violence against women and to sensitize such personnel to the nature of gender-based acts and threats of violence so that fair treatment of female victims can be ensured.12 In 2004, the Commission again called upon states to ensure that health care personnel are appropriately trained with regards to gender-based violence.13

What potential does the use of a human rights framework hold as regards gender-based violence? Prior to analysing the potential held by the use of the right to health as regards gender-based violence, it is first necessary to examine the wider issue of the benefit afforded by the application of a human rights framework more generally to this issue. International human rights law certainly constitutes a powerful force within the modern world. Cassel (2001: 122) comments that, ‘International articulation of rights norms has reshaped domestic dialogues in law, politics, academia, public consciousness, civil society, and the press’. Likewise, Robinson (2003: 1) states that, Starting with the Universal Declaration and carried forward in the body of international law that has been painstakingly developed over half a century, the world has expressed through human rights its shared commitment to the values of dignity, equality, and human security for all people. Nevertheless, there has been some debate amongst feminist commentators regarding the merits of using a human rights framework to further their claims. For example, one argument is that although framing claims in the language of rights can help to mobilise support, it can also have the opposite effect and generate hostility, as rights claims may be viewed in some quarters as being individualistic. Also, the language of rights may oversimplify complex power relations. Essentially, legal rights tend to treat the people involved only as adversaries. For example, a victim of domestic violence may have the legal right to apply for an injunction to have her abuser removed from the family home; however there may be a multitude of reasons why she may choose not to do so. Linked to this argument is the difficulty that conferral of legal rights may suggest that a wrong has been remedied, when in fact this is not the case. For example, the fact that a victim of domestic violence has the right to apply for an injunction does not mean that the problem has been solved (Smart 1989: 144). Another difficulty is found in the way in which rights themselves were formulated. Essentially, the concept of human rights evolved to protect the rights of the individual from encroachment by the state. As Thomas and Beasley (1995: 1121) remark, ‘States are bound by international law to respect the individual rights of each and every person and are thus accountable for abuses of those rights’. However, at the inception of the human rights movement, the state was required only to refrain from violating the rights in question and was not required to protect the rights of the individual from violation by another private party. Essentially, rights were developed in such a manner as to create a public/private dichotomy

GBV: the legal perspective 47 whereby human rights norms were upheld in the public sphere where the state was involved, but were not applied in the private sphere. Ewing (1995: 753) states that, ‘The public/private distinction in international law . . . places many forms of violence against women beyond the protective scope of human rights instruments’. Many forms of gender-based violence, such as domestic violence, female genital mutilation, dowry killing and sati, take place in the private sphere. Nevertheless, human rights law has developed in such a manner as to create a range of ways in which it may now enter into the private sphere. In particular, a concept of state responsibility has been developed, under which positive obligations can be placed directly on the state to ensure that human rights standards are upheld in situations involving only private individuals. For example, the UN human rights bodies often refer to the state’s duties to respect, protect, promote and fulfil rights. It is certainly true that there may well be difficulties regarding the use of a human rights framework as a vehicle for the advancement of feminist arguments regarding issues such as gender-based violence. However it is also the case that the adoption of such an approach carries very significant advantages. The use of the language of rights is undeniably empowering. As Smart (1989: 143) comments, ‘To couch a claim in terms of rights is a major step towards a recognition of a social wrong’. In addition, the language of rights has political currency. Essentially it puts the issue into a political language through which the interests in question can be advanced. Very importantly, rights language can be used to give the claim legitimacy, thus helping to mobilise support. Rights claims tend to focus on the protection of the weak against the strong, a concept which carries weight in terms of public opinion. The language of rights carries substantial symbolic importance. Smart (1989: 143) remarks that, ‘It is almost as hard to be against rights as it is to be against virtue’. As Palmer (2002: 115) comments, ‘Law and its language can be a critical frontier for feminist change’. Therefore, it seems that the very substantial benefits afforded by the use of a human rights framework as regards issues such as gender-based violence certainly outweigh the difficulties which may be involved. Indeed, the public/private dichotomy, which in the past has been arguably the most fundamental problem with such an approach, has now been eroded to a great extent by the development of the concept of state responsibility. Human rights law has been instrumental in holding states accountable in relation to a multitude of issues and the application of a human rights framework to the area of gender-based violence certainly has the potential to advance greatly feminist claims in this area.

Gender-based violence as an issue in human rights law: key considerations One of the most significant achievements of recent years as regards the area of gender-based violence has been the recognition by the United Nations and a growing number of governments that violence against women constitutes a human rights issue. For example, the UN Declaration on the Elimination of Violence against Women recognises that,

48 Ronagh McQuigg Violence against women is a manifestation of historically unequal power relations between men and women, which have led to domination over and discrimination against women by men and to the prevention of the full advancement of women, and that violence against women is one of the crucial social mechanisms by which women are forced into a subordinate position compared with men.14 The UN human rights bodies, such as the CEDAW Committee, have made an extensive range of statements on the issue of violence against women in recent years.15 These statements have certainly proved to be extremely influential. For example, in the context of the European Union, the European Commission has used these standards in documents it has produced on violence against women.16 The European Court of Human Rights has also used the concept of state responsibility, or positive obligations, in a particularly effective manner in a recent series of cases involving the issue of domestic violence, one of the most common forms of gender-based violence. The first of these cases was Kontrova v Slovakia,17 which was heard in 2007. The applicant in this case had been subjected to domestic violence by her husband. The Slovakian police had known of her husband’s abusive behaviour, and the applicant alleged that they had failed to take appropriate action to protect the right to life of her children under article 2 of the European Convention on Human Rights. She also argued that the police had failed to protect her own right to private and family life under article 8 of the Convention. The applicant’s husband had threatened to kill himself and their two children and he had in fact carried out this threat. In holding that there had been a breach of the children’s right to life, the Court stated that article 2 enjoins the State not only to refrain from the intentional and unlawful taking of life, but also to take appropriate steps to safeguard the lives of those within its jurisdiction . . . It also extends in appropriate circumstances to a positive obligation on the authorities to take preventive operational measures to protect an individual whose life is at risk from the criminal acts of another individual.18 The Court held that in the light of the finding of a violation of article 2, it was not necessary to also examine the case under article 8. In Bevacqua and S v Bulgaria19 the applicants were a victim of domestic violence and her young son. It was argued that there had been a violation of article 8 of the Convention and also a breach of article 3, which contains the right to be free from torture and inhuman or degrading treatment, due to the failure of the authorities to protect the first applicant against the violent behaviour of her former husband and to take the necessary measures to secure respect for the family life of both applicants. The Court examined the complaints under article 8, but not under article 3. In holding that there had been a breach of article 8, the Court stated that, the authorities’ failure to impose sanctions or otherwise enforce (the perpetrator’s) obligation to refrain from unlawful acts was critical in the circumstances

GBV: the legal perspective 49 of this case, as it amounted to a refusal to provide the immediate assistance the applicants needed. The authorities’ view that no such assistance was due as the dispute concerned a ‘private matter’ was incompatible with their positive obligations to secure the enjoyment of the applicants’ Article 8 rights.20 In Opuz v Turkey21 the applicant alleged that the authorities had failed to protect herself and her mother from domestic violence, which had resulted in the death of her mother and her own ill-treatment. She complained that the authorities had failed to safeguard the article 2 right to life of her mother, who had been killed by the applicant’s husband, an argument which was upheld by the Court. The applicant also alleged that she had been subjected to violence, injury and death threats but that the authorities were negligent towards her situation, which caused her pain and fear in violation of article 3. The Court concluded that there had been a breach of article 3 ‘as a result of the State authorities’ failure to take protective measures in the form of effective deterrence against serious breaches of the applicant’s personal integrity by her husband’.22 In addition, the applicant claimed that there had been a breach of article 14 of the Convention, the right to nondiscrimination, an argument which was also upheld by the Court. It was stated that, ‘Bearing in mind . . . that the general and discriminatory judicial passivity in Turkey, albeit unintentional, mainly affected women, the Court considers that the violence suffered by the applicant and her mother may be regarded as genderbased violence which is a form of discrimination against women’.23 In A v Croatia24 the applicant was again arguing that the state had failed to protect her sufficiently from domestic violence on the part of her former husband. Although the Croatian courts had ordered measures such as periods of detention and fines, many of these had not been enforced. It was held that the authorities’ failure to implement these measures had resulted in a breach of the applicant’s article 8 rights. In E. S. and Others v Slovakia25 the applicants were a mother and her three children. All four applicants had suffered abuse from the first applicant’s husband. The Court held that the article 3 and article 8 rights of all four applicants had been violated due to the failure of the authorities to protect them in an appropriate manner from the treatment to which they had been subjected. Finally, in Hajduova v Slovakia26 the applicant’s former husband had been convicted after he had attacked her and repeatedly threatened to kill her and also several other persons. The national court had ordered that he be detained for psychiatric treatment. However, the treatment was not carried out. He was released and he subsequently renewed his threats against the applicant. It was alleged that the state had failed to fulfil its positive obligation to protect the applicant from her former husband, in violation of article 8, an argument which was upheld by the Court. Overall, it can be seen from these cases that states clearly have positive obligations to ensure that their criminal justice systems are of a sufficient standard in dealing with domestic violence. The fact that the European Court has now directly addressed the problem of domestic violence is an extremely important development in itself, as it underlines the fact that it is a human rights issue. It is only relatively recently that domestic violence has been recognised as such, as

50 Ronagh McQuigg evidenced by the fact that it took until 2007 for a domestic violence case to come before the European Court. Although international human rights law was originally developed in such a manner as to create a public/private dichotomy, which had the effect of putting many forms of gender-based violence beyond its scope, the concept of state responsibility has now been developed in such a manner as to greatly increase the potential of human rights law to be used in this area.

Gender-based violence and right to health: potentials It can be seen therefore that there have been crucial developments in recent years as regards the application of a human rights framework to gender-based violence. However, to date the right to health has been under-utilised in this regard. In relation to the case law of the European Court of Human Rights, this situation can be explained by the fact that the European Convention on Human Rights does not contain a right to health. The Convention is concerned primarily with civil and political rights, such as the right to life and the right to be free from torture and inhuman and degrading treatment, as opposed to social and economic rights, such as the right to health or the right to work. The European Convention dates from 1950 and is therefore one of the earliest human rights instruments. Its focus on civil and political rights is reflective of the situation that for many years this category of rights was viewed as being superior to that of social and economic rights by the human rights community. The focus on civil and political rights is reflected in the fact that the judgements in the cases of the European Court cited above focus on the responses of the criminal justice systems of the states in question to the issue of domestic violence. Essentially, the Court has placed positive obligations on states to ensure that police and prosecutors respond in an effective manner to cases involving domestic violence; however, it has not placed positive obligations on states as regards the provision of social support measures, such as refuge accommodation, housing and health care provision, to victims. This is problematic as it has been argued that the most pressing needs of victims of domestic violence are for social support measures (Schneider 2000: 52). There are essentially two main ways in which human rights law can be utilised. The first is through a litigation approach. From a United Kingdom perspective, this essentially means using the Human Rights Act 1998 and the case law of the European Court of Human Rights. The rights incorporated into UK law by the Human Rights Act are the majority of the rights contained in the European Convention and therefore do not include the right to health. However, the second way in which human rights law can be utilised is by using the statements made by the international human rights bodies to place pressure on governments to take steps in relation to the issues involved. The primary difficulty with such a strategy relates to the issue of enforcement. Problems with implementation affect all of the UN human rights treaties. As Byrnes (1994: 191–192) comments, ‘The limitations of international law generally when it comes to enforcement of binding standards are well known, and international human rights law is no exception in that regard’. Essentially, the UN has no real method of forcing states to alter their policies.

GBV: the legal perspective 51 Schopp-Schilling (2007: 204) remarks that ‘many States Parties have often not addressed issues of legal reform or programmes to improve the material situation of women to enable and empower them to claim, exercise and enjoy their human rights, even if they ratified the CEDAW 15 or 20 years ago.’ For example, in a study of the responses to domestic violence of the Member States of the Association of Southeast Asian Nations (ASEAN), it was found that the majority of the laws on domestic violence found in the ASEAN area do not conform to international standards, as they are formulated in a gender-neutral manner. (UN Women 2011: 15) Nevertheless, a strategy of using the statements made by the international human rights bodies to place pressure on governments to take further steps in relation to gender-based violence could be better utilised than is currently the case. It is a greatly under-publicised fact that states have duties under international human rights law to take measures to combat gender-based violence. If NonGovernmental Organisations and women’s groups were to publicise more extensively the fact that governments are not fulfilling their international duties in this area, this would serve to place more pressure on the governments concerned to make greater efforts to address this issue. Both the UN Committee on the Elimination of Discrimination against Women and the UN Committee on Economic, Social and Cultural Rights have explicitly linked the right to health to the issue of gender-based violence. These bodies have also clearly stated that the obligations of states under international human rights law must be taken into account by governments in formulating national budgets. These factors should be strongly emphasised as part of such a strategy.

Conclusion In conclusion therefore, it is clear that international human rights law has been instrumental in holding states accountable in relation to a multitude of issues. It seems that the application of a human rights framework to the area of gender-based violence certainly has the potential to accord substantial benefits. Indeed, there have been crucial developments in recent years as regards the use of human rights law in this area. The right to health is a well-established part of international human rights law; however, to date this right has been under-utilised in relation to genderbased violence. This is despite the fact that the right to health has been explicitly linked to the issue of gender-based violence by international bodies such as the UN Committee on Economic, Social and Cultural Rights and the UN Committee on the Elimination of Discrimination against Women. It is also very clear that governments must take into account their duties under international human rights law in formulating national budgets. It seems that the right to health certainly has the potential to be used effectively by Non-Governmental Organisations to place further pressure on governments to make greater efforts to address the issue of gender-based violence.

52 Ronagh McQuigg

Notes 1 [1992] 4 All ER 889. 2 [1992] 1 All ER 306. 3 UN Committee on Economic, Social and Cultural Rights, General Comment 14 (2000), paragraph 8. 4 UN Committee on Economic, Social and Cultural Rights, General Comment 3 (1990), paragraph 9. 5 Ibid. 6 UN Committee on Economic, Social and Cultural Rights, General Comment 14 (2000), paragraph 18. 7 UN Committee on Economic, Social and Cultural Rights, General Comment 3 (1990), paragraph 12. 8 UN Committee on the Elimination of Discrimination against Women, General Recommendation 24 (1999), paragraph 15. 9 Resolution 45/114 (1990) at para. 1. 10 Beijing Platform for Action, UNB Doc.A/CONF.177/20 (1995) at paras. 98–99. 11 Report of the Special Rapporteur on violence against women, its causes and consequences, E/CN.4/2002/83, 31 January 2002, at para. 128. 12 UN Commission on Human Rights Resolution 2001/49, at para. 10(f). 13 UN Commission on Human Rights Resolution 2004/46, at para. 15(g). 14 UN General Assembly, Declaration on the Elimination of Violence against Women (1993), preamble. 15 For discussion of the statements made by the UN human rights bodies on the issue of domestic violence, see McQuigg (2011: 78–98). 16 For example, Resolution on the need to establish a European Union wide campaign for zero tolerance of violence against women, Resolution A4-0250/1997. For discussion of European Union responses to domestic violence, see Krizsan and Popa (2010). 17 Application No. 7510/04, 24 September 2007. 18 At para. 49. 19 Application No. 71127/01, 12 September 2008. 20 At para. 83. 21 Application No. 33401/02, 9 September 2009. 22 At para. 176. 23 At para. 200. 24 Application No. 55164/08, 14 October 2010. 25 Application No. 8227/04, 15 December 2009. 26 Application No. 2660/03, 30 November 2010.

References Byrnes, A. (1994) ‘Enforcement through international law and procedures’, in R. Cook (ed) Human rights of women: National and international perspectives, Philadelphia: University of Pennsylvania Press. Cassel, D. (2001) ‘Does international human rights law make a difference?’, Chicago Journal of International Law, 2: 121–35. Elson, D. (2006) Budgeting for women’s rights: Monitoring government budgets for compliance with CEDAW, New York: UNIFEM. Ewing, A. P. (1995) ‘Establishing state responsibility for private acts of violence against women under the American Convention on Human Rights’, Columbia Human Rights Law Review, 6: 751–800.

GBV: the legal perspective 53 Freedman, A. E. (2003) ‘Symposium: Fact-finding in civil domestic violence cases: Secondary traumatic stress and the need for compassionate witnesses’, American University Journal of Gender, Social Policy and the Law, 11: 567–656. Krizsan, A. and Popa, R. (2010) ‘Europeanization in making policies against domestic violence in Central and Eastern Europe’, Social Politics, 17: 379–406. McQuigg, R. (2011) International human rights law and domestic violence, London: RoutledgeCavendish. Maguigan, H. (2003) ‘Wading into Professor Schneider’s ‘murky middle ground’ between acceptance and rejection of criminal justice responses to domestic violence’, American University Journal of Gender, Social Policy and the Law, 11: 427–45. Merry, S. E. (2003) ‘Rights talk and the experience of law: Implementing women’s human rights to protection from violence’, Human Rights Quarterly, 25: 343–81. Nicolson, D. (2000) ‘What the law giveth, it also taketh away: Female-specific defences to criminal liability’, in D. Nicolson and L. Bibbings (eds) Feminist perspectives on criminal law, London: Cavendish. Palmer, S. (2002) ‘Feminism and the power of human rights: Possibilities and paradoxes’, in S. James and S. Palmer (eds) Visible women: Essays on feminist legal theory and political philosophy, Oxford: Hart Publishing. Randall, M. (2004) ‘Symposium: Domestic violence and the law: Theory, policy, and practice: Domestic violence and the construction of “ideal victims”: Assaulted women’s “image problems” in law’, Saint Louis University Public Law Review, 23: 107–54. Robinson, M. (2003) ‘Making human rights matter: Eleanor Roosevelt’s time has come’, Harvard Human Rights Journal, 16: 1–11. Rollinson, M. (2000) ‘Re-reading criminal law: Gendering the mental element’, in D. Nicolson and L. Bibbings (eds) Feminist perspectives on criminal law, London: Cavendish. Schneider, E. M. (2000) Battered women and feminist lawmaking, New Haven: Yale University Press. Schopp-Schilling, H. B. (2007) ‘Treaty body reform: The case of the Committee on the Elimination of Discrimination Against Women’, Human Rights Law Review, 7: 201–224. Smart, C. (1989) Feminism and the power of law, London: Routledge. Thomas, C. (1999) ‘Domestic violence’, in K. D. Askin and D. M. Koenig (eds) Women and international human rights law, Vol. 1, New York: Transnational Publishers, Inc. Thomas, D. Q. and Beasley, M. E. (1995) ‘Symposium on reconceptualizing violence against women by intimate partners’, Albany Law Review, 58: 1119–47. UN Women (2011) Domestic violence legislation and its implementation, Bangkok: UN Women.


Gender, gender-based violence and HIV/AIDS Review of evidence and policy Rachel Jewkes

Introduction The importance of gender inequity and gender-based violence in women’s vulnerability to HIV has been recognised by researchers and activists since the 1980s. As the epidemic and responses have evolved, the focus has broadened from recognising barriers to women’s condom use, to encompass understandings of gender ideals as barriers to men’s protective practices, as well as women’s. Quite recently research on the contribution of gender inequity and violence to HIV incidence has solidified the evidence base, yet questions are still raised about whether the relationship pertains in all settings, and some cross-sectional research has contrary findings. This chapter discusses the evidence of how gender inequity, violence and HIV interface, considers the implications for policy and programming and discusses the costs of inaction.

Gender inequity, violence and HIV: the evidence for links There is substantial evidence of the importance of gender inequity and genderbased violence exposure in women’s risk of acquiring HIV (Jewkes, 2010). Near two decades of observations from work in the field, qualitative research and crosssectional studies, have recently been supplemented by longitudinal research showing that uninfected women have a greater chance of acquiring HIV if they are in very unequal relationships or have experienced partner physical or sexual violence ( Jewkes, 2010; Jewkes et al., 2010a). Research shows that nearly one in seven new HIV infections could be prevented if women were not subjected to physical or sexual abuse and a similar proportion if women did not experience the greatest relationship power inequalities ( Jewkes et al., 2010a). Furthermore young women who have experienced sexual abuse in childhood are also at two-thirds greater risk of incident HIV infections ( Jewkes et al., 2010b). Jewkes et al. (2010a) argue that the evidence points to four key dimensions to the interface between gender inequity, violence and HIV. First, women may become directly infected with HIV through rape. This is biologically inarguable and has been seen in clinical practice, yet population-based

Gender, gender-based violence and HIV/AIDS 55 research suggests that the risks of HIV acquisition from rape are not great ( Jewkes et al., 2010a; Dunkle et al., 2004). This is because the act is usually a single act of intercourse and the risks entailed in this are not very great. Further fears that rapists may be more likely than other men to have HIV have, at least in South Africa, have been shown to be unfounded (Jewkes et al., 2011). Nonetheless there is the potential for HIV acquisition during rape; in high prevalence Sub-Saharan African countries many men who rape will be infected, and so it is vitally important that the violation of the rape is not compounded by preventable infection with HIV. Second, women who experience more gender inequity and violence are less able to protect themselves from HIV, for example they have sex more frequently and use condoms less often. The former may reflect a lesser ability to gain respect for their right not to have sex when they don’t want it, but in some settings it may also reflect a practice of taking another partner for an emotionally more fulfilling relationship when trapped with a violent partner. Women who have more equitable relationships are much more able to use condoms consistently with their partner (Jama Shai et al., 2010). This may be explained by women’s inability to negotiate in such situations, but qualitative research points strongly to the acquiescence of women to male dominance in relationships and suggests that women who submit to unequal relationships are more likely to submit to an agenda of male control, and so their own wants are not even considered (Jewkes and Morrell, 2011). Third, childhood sexual abuse increases the risk of a range of risky sexual practices, including having multiple and concurrent partners, transactional sex and substance abuse. All of these increase the risk of HIV acquisition as well as rendering women vulnerabile to further partner violence or rape. Women who have experienced sexual abuse thus have a sustained elevated risk of HIV (Jewkes et al., 2010b). The mechanisms of increased risk are partly though the long-term mental health impact of child sexual abuse and often co-occurring emotional neglect, including and increased risk of post-traumatic stress disorder (PTSD) and substance abuse, as well as insecure adult attachment which is associated with increased rate of partner change and greater difficulties in emotional relationships. In this way abuse risks intersect with cycles of risk of violence and HIV. Fourth, ideals of marked gender hierarchy generally legitimate the use of violence in making and sustaining it, and often co-occur with ideals of masculinity that emphasise heterosexual performance, particularly toughness, strength and having many partners (Jewkes and Morrell, 2010). As a consequence men who are violent towards women often engage in a range of sexually risky practices and some research has shown that they are more likely to be HIV-infected (Jewkes et al., 2011; Decker et al., 2009). If these research findings pertain more broadly, women partners of violent men are at higher risk of HIV acquisition per sexual act. Generalising across settings There have been recent attempts to examine the generalisability of connections between gender-based violence and HIV through meta-analyses of Demographic and Health Surveys (DHS) (Harling et al., 2010). These have been published with

56 Rachel Jewkes considerable confusion following in their wake, chiefly because the limitations of the data source and analysis did not enable this to be satisfactorily explored (see also Mitra (a); Williamson in this volume). The first problem has been the measurement of exposure. The evidence of association between GBV and HIV point to the importance of lifetime GBV exposure, with strong association for more severe exposure – whether both physical and sexual violence or more incidents. The DHS measure of violence asks about ‘current or most recent partner’ and so women who have experienced violence from a previous partner will be categorised with ‘never abused’ women. This is particularly important as violence often leads to relationship breakdown. The analyses did not take into account severity of violence. Both of these problems result in estimate bias towards the null – i.e. to lessen any effect of the exposure. Gender power inequity was not examined in the DHS analyses. A further problem is that the analysis was performed for ‘ever married’ women and so does not examine risks among unmarried women. In South Africa, this is a substantial group of the adult female population and their HIV prevalence is higher than that of married women. In any setting with considerable extra-marital sexual activity and a later age of marriage the DHS sample would be unrepresentative of women overall. There was also a problem in the dataset as the response rate to the HIV and IPV questions in the DHS was low (less than half), raising important questions of bias. These were compounded as Harling et al. (2010) did not use the DHS sample weights in their analyses. Analyses done by others, who have used these weights, have shown higher estimates of association (Silverman et al., 2008), ones that are certainly more reliable. Thus the meta-analysis of DHS data thus far performed is not helpful in understanding the generalisability of connections between gender inequity, violence and HIV. It serves however to highlight important issues that need to be taken into account in future studies and analyses that seek to explore the GBV–HIV interface in different settings. It’s important to recognise that globally HIV epidemics are diverse. Some are concentrated in population sub-groups such as men who have sex with men, women in prostitution, their clients and clients’ wives, or ethnic minority groups, whereas other epidemics, especially in Sub-Saharan Africa, are generalised. The prevalence and circumstances in which intimate partner violence occurs within relationships differs between cultural contexts and the relative importance of experience of violence versus experience of gender inequity may also differ. For example: in a very patriarchal society a woman may avoid exposure to violence by never challenging her husband, yet her subordinate position gives her absolutely no power to protect herself from HIV. If the HIV epidemic is not generalised in her country, or is generalised but with very low prevalence, her risk of acquiring HIV may be extremely small. Logically her risk is heightened by her subordinate status, but whether or not this is realised in incident infections will depend on her husband’s behaviour. Where women are subordinate and men engage sexually just with one wife, gender inequity and violence are likely to be poor predictors of HIV risk, but if men have other sexual partners, gender inequity and violence are likely to be important predictors. Thus the contribution of gender inequity and violence to HIV incidence should be expected to vary between countries and population

Gender, gender-based violence and HIV/AIDS 57 sub-groups. The evidence that it does vary is still rather limited as there is only one study of the impact of physical and sexual IPV on HIV incidence, which shows elevated risk ( Jewkes et al., 2010a; Decker et al., 2009). UNAIDS promotes the maxim ‘know your epidemic’, and this should be applied to reflection on gender-based violence, gender inequity and the circumstances in which they contribute to HIV infections in women. This may result in differences between settings in programming on gender inequity and gender-based violence and HIV within national AIDS responses.

Understanding the key challenges There are a number of key challenges in prevention programming around gender and HIV. These are to reduce direct transmission to women from acts of rape; to empower women to enable them to demand non-violent and respectful men; to work with men to promote gender equity and reduce the use of violence by them against women; and to prevent abuse in childhood, strengthen the capacity of mental health services to treat the mental health consequences of gender-based violence, and to change social norms around transactional sex and multiple concurrent partners. Preventing HIV acquisition in rape by giving survivors post-exposure prophylaxis (PEP) with anti-retroviral medication is theoretically the easiest intervention. The marginal costs of providing it in post-rape care is relatively low as the drug cost is not great and, even in high-rape-prevalence countries, the number of survivors needing treatment is not terribly large. Yet experience of services is increasingly showing that providing PEP is not as easy as was previously imagined. It has to be taken by HIV-negative women within seventy-two hours of the rape, and so post-rape care services need to be widely distributed and accessible around the clock. In many countries in Sub-Saharan Africa, post-rape care has been rather scantily provided and of notoriously poor quality. Thus services are hard to reach, not available or lack basic tests, drugs and equipment, and appropriately trained service providers. When PEP is given to survivors, it must be taken daily without missing doses for twenty-eight days. Although there is considerable concern in a country like South Africa about acquiring HIV after rape, most survivors find it very difficult to complete their tablets. Part of the problem is the drugs’ side-effects, which can be considerable and lead to missing doses or giving up the tablets. Side-effects are particularly bad with zidovudine (AZT)–based regimens and are exacerbated by a recent practice of prescribing three drugs, i.e. Kalentra in addition to AZT and 3TC. There is no evidence that any anti-retrovirals are better than any others as PEP, and the World Health Organization recommends that PEP regimens use a country’s first-line treatment regimen drugs. In most countries these are now regimens including tenofovir because of its lower side-effect profile, yet there has been reluctance in Sub-Saharan Africa to move to tenofovir-based PEP regimens. This has quite serious consequences for adult rape survivors as it means that their PEP regimens entail unnecessary drug side-effects.

58 Rachel Jewkes The problem does not entirely lie with side-effects. Rape usually has a profound psychological and social impact and, in the aftermath, adhering to a strenuous regime of twice-daily pill taking can be difficult. Survivors respond in diverse ways to trauma. Some turn inward and shut themselves off from their social networks, others drown their sorrows in alcohol, some find the rape and reporting to the police precipitates a chain of reactions that lead them to move from their neighbourhood, whilst others try to carry on as before with varying degrees of success. Many of these responses cause disruption that makes PEP course completion difficult (Abrahams et al., 2010). A further complication is that a recognised reaction to trauma is to resist reminders of it. Unfortunately PEP drugs are often viewed as a twice-daily reminder of the rape. In South Africa, there are examples of excellent services where PEP completion levels have been shown in research to be very high (around 90 per cent). This is achieved by the Thohoyandou Victim Empowerment Project (TVEP), which is an NGO that supports a Government rape service in a very remote part of the country. They use volunteers to very actively support rape survivors and motivate PEP completion as well as providing food supplements to ensure that pills need not be taken on an empty stomach. Few other parts of the county can equal that. Indeed generally research has shown that services achieve 30 to 50 per cent completion rates and in other areas these have been relatively resistant to being increased by even quite complex interventions with social support and reminders. Thus, providing PEP in a manner that is accessible after rape, and ensuring that the highest possible proportion of eligible survivors receive it and complete their course are important programming goals. Service experience suggests that providing PEP in the context of comprehensive post-rape care by trained service providers who meet other mental and physical health needs sensitively and appropriately is critical (Abrahams et al., 2010). Establishing and maintaining such services requires political will. The budgeting and policy implications of providing post-rape care properly with appropriately trained health care professionals are much greater than when just providing PEP as a marginal addition to existing services. Yet rape is a fundamental and lingering violation of the human rights of victims. Governments should exert all efforts to protect potential victims from rape and when these efforts fail, they should provide victims with high quality services to ensure that they do not experience the most severe consequences. Given the abundant evidence that rape is most common in rape-supportive settings, i.e. those that exonerate the perpetrator, it is necessary and justified that adequate budget is provided for post-rape care services as additionally this communicates a view about the severity and non-acceptability of rape. Empowering women Interventions that seek to empower women address both the psychological and material dependence of women on violent and controlling male partners. Some abused women are dependent on their partners for survival. They are trapped and have no opportunity to assert their needs in the relationship, either for condom use

Gender, gender-based violence and HIV/AIDS 59 or for their partner not to have sex with other women. Research with men who have relationships with women that they perceive as predicated on adopting a provider role (rather than being primarily based on something more mutual such as emotional engagement) show that they are much more likely to be violent towards women than men having mutually respectful relationships (Jewkes et al., 2012). Mark Hunter described some of these relationships in his ethnography of a South African informal settlement, particularly describing unemployed women partnering low-income men in order to be supported (Hunter, 2010). Poignantly one woman informant who was in prostitution drew a parallel to women in these dependent relationships and mentioned how much more power she had because she was able to earn. Programming on HIV risk reduction and gender-based violence prevention addressing women in these circumstances needs to focus on enabling women to become financially independent. The irony of the assertion of Hunter’s informant is that women who are in prostitution are highly vulnerable to both HIV and sexual and physical violence from men. As are women who have transactional sex with men of a more casual nature, for example to get clothes or toiletries or cell phone air time. South African research shows that most men who seek sex in these circumstances are much more violent and controlling than other men. In Tanzania, Wamoyi et al. (2010) describe how the HIV risk for girls having transactional sex is heightened as the amount received from a male partner is greatest the first time they have sex, thus incentivising partner change. Although women and girls having transactional sex may not be dependent on it for survival, it is unlikely that social norms around transactional sex will be substantially changed in Sub-Saharan Africa without providing other ways of earning money. Even in circumstances of poverty, the emotional ties that women have to violent and controlling partners are often much stronger than the material bonds. These are very complex and are very intimately connected to cultural models of successful womanhood. Thus many women perceive that their value is shown by their ability to attract and keep a man. They perceive that they should strive to build a home for their children and a home should have a father in it. Further women often perceive that as good women they should submit to their partner, look for guidance and accept punishment from him and obey him (Jewkes and Morrell, 2011). All of these ideas trap women in violent and controlling relationships and they may also lead to women acquiescing to and even justifying the violence. Unless women are able to demand respect and have the ability to leave a relationship they are in a very weak position. This awareness raising and efforts to transform women’s ideas of successful womanhood must form a key theoretical component of violence and HIV prevention interventions. The Image intervention research in South Africa revealed many of the complexities of the interplay between emotional and economic dependence. This combined an intervention on gender to improve women’s economic status through revolving credit micro-loans. The researchers targeted particularly poor women in villages for the study. Not only was the intervention shown to be effective two years after the start in reducing women’s exposure to

60 Rachel Jewkes violence, but the full intervention was effective in this regard whilst an intervention of only giving micro-loans to women was not (Pronyk et al., 2006). Thus the authors concluded that the gender intervention was critical. The micro-loans raised women’s financial power at home and enabled them to meet needs, cover crises and build assets, but they were only able to understand their right to translate this into respect and altered relations with their partner through the consciousness raising intervention. This finding is particularly important as micro-loans are not appropriate as an economic intervention for all women and need considerable expertise to establish successful schemes. It is likely that any intervention that economically empowers women, when combined with a gender intervention has a chance of having the same effect on women’s exposure to violence and gender inequity and thus will have a long-term impact on HIV risk. Understanding of this area is still largely based on one study from South Africa and so more research is needed in conjunction with rolling out best practice programming. Transforming men Theorising around the contribution of men to violence and HIV-risky practices has been considerably influenced by the theoretical work of Raewyn Connell (Connell, 1987) on masculinities. Within an overarching patriarchal system, this provides a framework for understanding masculinities within a given context as multiple, dynamic (i.e. not fixed in content) and open to change. Further, it enables understanding of the interconnections between ideals of manhood which operate in different social groups and sub-groups, and men’s gendered practices which flow from these. In South Africa, for example, there is a marked gender hierarchy, and the ideal of African manhood is based on an expectation that men will dominate and control women, and display toughness and strength in all areas of their lives. Further it is strongly heterosexual and valorises demonstrations of heterosexual process. This does not necessarily entail the use of violence against women, but physical and sexual violence are often used as a way of establishing gender hierarchy and punishing transgressions. Displays of heterosexual process characteristically involve having multiple sexual partners, whereas the need to be tough and strong is translated into a fearlessness in the face of risks (including of HIV) and reluctance to admit vulnerability to illness (Jewkes and Morrell, 2010). Masculinity provides a unifying theoretical construct for understanding the interconnectedness of men’s violence, controlling practices, multiple partnering and non-condom use – a set of behaviours that otherwise are commonly viewed in isolation. Considerable research has established their interconnectedness, noting for example that men who rape are more likely to have multiple partners and transactional sex and be physically violent towards women, just as men who have transactional sex are more likely to also do all these other practices than men who don’t. The critical test of a theory like this is intervention. In other words – can an intervention that seeks to build a more respectful and less gender inequitable masculinity impact on other male behaviours? This is what was examined in the

Gender, gender-based violence and HIV/AIDS 61 randomised controlled trial of the Stepping Stones HIV prevention methodology in South Africa ( Jewkes et al., 2008). In response to the intervention, men significantly changed their sexual behaviour, achieving a one-third reduction in Herpes Simplex Virus (HSV2) incidence and a 38 per cent reduction in the perpetration of intimate partner violence two years after the intervention (Jewkes et al., 2008). They also reduced their number of partners, transactional sex with a casual partner and problem drinking after a year. This points to the importance of interventions to address masculinity in prevention of men’s use of violence and reduction ultimately in the HIV risk of both men and women. Stepping Stones is one example of an intervention that seeks to do this, and it has been used very widely across settings particularly in diverse parts of Africa and Asia (Welbourn, 1995). It is an HIV prevention programme that aims to improve sexual health through building stronger, more gender-equitable relationships, using critical reflection, drama and other participatory learning approaches to equip participants to build better, safer more gender equitable relationships. It situates HIV within the broader context of sexual and reproductive health and has a substantial emphasis on skills building. There are several other interventions that seek to build more respectful and gender-equitable masculinities; the research base for many of these has been reviewed by Barker and colleagues (Barker et al., 2007). There has been considerable debate among feminists about the role of interventions with men in gender work overall and an opinion is that this is simply recentring men. However the counter to this stems from recognition that one impact of patriarchies is the disempowerment and subordination of women and this makes change difficult for women and potentially very costly. Just as for men, performing ‘successful manhood’ is socially valued and rewarded, for women, social status is generally attached to displaying ‘good womanhood’ even at the expense of considerable personal sacrifice. Put differently, women often have considerable investments in their own subordination, that are hard and frightening to relinquish. If gender is understood relationally, it follows that interventions with men will greatly assist women and that those expecting women to change without change in the relational context within which their gendered practices are performed will generate friction and potentially more violence and discord. Interventions with men that build more gender-equitable and respectful masculinities create social space for women to change without bearing the full (social) costs of empowerment themselves. Mental health interventions The fourth major area in which intervention is theoretically needed has been relatively little researched. There is considerable research evidence of the impact of child abuse and prior trauma exposure on women’s sexual risk taking behaviour, but it is not clear what types of interventions that can change this behaviour in the population of abuse-exposed women, and how and in what circumstances this can feasibly be delivered in low and middle income countries. Further it is not clear which interventions are effective in reducing transactional sex and multiple concurrent partnering among abuse-exposed women in the general population –

62 Rachel Jewkes or indeed whether there is any benefit at all in identifying them as a separate subgroup for intervention. It is possible that part of the links between child abuse and sexual risk taking behaviour are explained by a shared risk context, or a risk context that developed subsequent to the abuse but then are perpetuated by independent factors (such as peer norms supporting heavy drinking or transactional sex) and that interventions are needed to address this rather than the specific psychological impact of abuse. This is an important area for further research.

What are the costs of inaction? The critical question seems not to be whether gender inequity and violence place women at risk of HIV, but how the interface with HIV operates in different settings. Research in South Africa most strongly suggests that without programming to reduce gender-based violence and build gender equity, efforts to promote behavioural responses to HIV risk will fail. This applies equally to men and women. Recently there has been a substantial emphasis on testing and treatment and yet it has been powerfully argued that the reason men are much less likely to test than women is because a diagnosis of HIV challenges their masculine self-image, particularly ideas of bodily strength. Yet unless early HIV infections can be detected in men and services can provide men with appropriate psychological support, potential for HIV prevention through treatment-induced broad-based viral load reduction will fall far short of goals. Furthermore, medical male circumcision may yet result in continuing HIV risk for women if the gendered nature of men’s sexual practices is not addressed. Medical male circumcision only provides partial protection. It’s salient to remember that the area of South Africa where the HIV and IPV incidence research has been done is one with a very high population prevalence of male circumcision yet the incidence of HIV in adolescent women in the study was 6 per cent (Jewkes et al., 2008). There are simply not enough resources to continue responding to HIV through treatment without making substantial headways into prevention; the costs of inaction on gender issues are very very high (see also Nakray in this volume).

Conclusion We have an imperative to act on gender inequities and violence as key drivers of the HIV epidemic. This will benefit both women and men. Policies should be based on the maxim ‘know your epidemic’, and this requires a far better evidence base from which to understand the HIV–GBV interface in different settings. In the short term, policy must draw on a gender analysis of existing data on the interface of GBV and HIV. We cannot treat ourselves out of the HIV epidemic so interventions to transform the fabric of sexual risk and remove gender-based barriers to early entry into treatment and care are essential. The World Health Organization has published a review of interventions working at the interface of HIV and GBV (2010). Programming needs to draw on the existing evidence-base, whilst promoting research to expand knowledge of best practice.

Gender, gender-based violence and HIV/AIDS 63

References Abrahams, N., Jewkes, R., Lombard, C., Mathews, S., Campbell, J. & Meel, B. (2010) Impact of telephonic psycho-social support on adherence to post exposure prophylaxis (PEP) after rape: A randomised controlled trial. AIDS Care, 16, 1–9. Barker, G., Ricardo, C. & Nascimento, M. (2007) Engaging men and boys to transform gender-based health inequities: Is there evidence of impact?. Geneva/Rio de Janeiro, World Health Organization/Institute Promundo. Connell, R. (1987) Gender and power: Society, the person and sexual politics. Palo Alta, Calif., University of California Press. Decker, M. R., Seage, G. R. 3rd, Hemenway, D., Raj, A., Saggurti, N., Balaiah, D. & Silverman, J. (2009) Intimate partner violence functions as both a risk marker and risk factor for women’s HIV infection: Findings from Indian husband–wife dyads. Journal of Acquired Immune Deficiency Syndromes, 51, 593–600. Dunkle, K. L., Jewkes, R. K., Brown, H. C., Gray, G. E., Mcintyre, J. A. & Harlow, S. D. (2004) Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. The Lancet, 363, 1415–21. Harling, G., Msisha, W. & Subramanian, S. (2010) No association between HIV and intimate partner violence in women in 10 developing countries. PloS One, 5, E14257. Hunter, M. (2010) Love in the time of AIDS: Inequality, gender and right in South Africa. Pietermaritzburg, University of Kwazulu-Natal Press. Jama Shai, N., Jewkes, R., Levin, J., Dunkle, K. & Nduna, M. (2010) Factors associated with consistent condom use among rural young women in South Africa. AIDS Care, 22, 1379–85. Jewkes, R. (2010) Gender inequities must be addressed in HIV prevention. Science, 329, 145–7. Jewkes, R., Dunkle, K., Nduna, M. & Shai, N. (2010a) Intimate partner violence, relationship gender power inequity, and incidence of HIV infection in young women in South Africa: A cohort study. The Lancet, 367, 41–48. Jewkes, R., Dunkle, K., Nduna, M., Jama, N. & Puren, A. (2010b) Associations between childhood adversity and depression, substance abuse & HIV & HSV2 in rural South African youth. Child Abuse and Neglect, 34, 833–41. Jewkes, R. & Morrell, R. (2010) Gender and sexuality: Emerging perspectives from the heterosexual epidemic in South Africa and implications for HIV risk and prevention. Journal of the International AIDS Society, 13 (9 February). Jewkes, R. & Morrell, R. (2011) Sexuality and the limits of agency among South African teenage women: Theorising femininities and their connections to HIV risk practices. Social Science and Medicine, 74(11), 1729–37. Jewkes, R., Morrell, R., Sikweyiya, Y., Dunkle, K. & Penn-Kekana, L. (2012s) Transactional relationships and sex with a woman in prostitution: Prevalence and patterns in a representative sample of South African men. BMC Public Health, 12, 325; doi:10.1186/1471-2458-12-325. Jewkes, R., Nduna, M., Levin, J., Jama, N., Dunkle, K., Puren, A. & Duvvury, N. (2008) Impact of stepping stones on HIV, HSV-2 and sexual behaviour in rural South Africa: Cluster randomised controlled trial. British Medical Journal 337, A506. Jewkes, R., Sikweyiya, Y., Morrell, R. & Dunkle, K. (2011) The relationship between intimate partner violence, rape and HIV amongst South African men: A cross-sectional study. PloS One, 6, E24256. Pronyk, P., Hargreaves, J. R., Kim, J. C. & Al, E. (2006) Effect of a structural intervention for the prevention of intimate partner violence and HIV in rural South Africa: A cluster randomised trial. The Lancet, 368, 1973–83.

64 Rachel Jewkes Silverman, J., Decker, M. R., Saggurti, N., Balaiah, D. & Raj, A. (2008) Intimate partner violence and HIV infection among married Indian women. JAMA, 300, 703–710. Wamoyi, J., Wight, D., Plummer, M., Mshana, G. & Ross, D. (2010) Transactional sex among young people in in rural northern Tanzania: An ethnography of young women’s motivations and negotiation. Reproductive Health 7, 2. Welbourn, A. (1995) Stepping stones. Oxford, Strategies For Hope. World Health Organization (2010) Addressing violence against women and HIV/AIDS: What works? Geneva, World Health Organization.


Measuring gender-based violence Issues of impact and prevalence Emma Williamson

Introduction This chapter is concerned with the ways in which we currently measure gendered violence, particularly in relation to health and well-being. Current debates about the prevalence and impact of domestic violence in particular have raised questions about how we define abuse and identify appropriate outcomes to measure. Measuring gendered violence and abuse in society is an important indicator of inequality between men and women, on both an individual and a social level. Of particular concern are the ways in which assumptions are made in relation to the impact of ‘potentially abusive incidents’ with little or no evidence about how different people experience abuse and as a result are impacted by it. This is problematic for a number of reasons. First, if we do not adequately measure the impact of abuse then we know very little about the services which might be appropriate for either victims or perpetrators. Second, inadequate consideration of impact results in data which treats the prevalence of incidents out of context. And finally, examining data which seeks merely to establish a quantifiable measure of the frequency (or prevalence) of abusive behaviour, if not placed in the context of the impact or meanings attached to the behaviours being measured, affects the ways in which we theorise the issue of domestic violence in relation to different populations, particularly in relation to gender and sexuality, which may not be helpful. This chapter will examine these debates by first considering what is being measured while conducting research into domestic violence and its impacts on policy. Second, the issue of prevalence and incidents will be considered using examples from recent research. Third, this chapter will consider how developments in the measurement of impact can assist in assuring that assumptions about what prevalence data can provide further information on experience and thus service provision. Finally, this chapter will give examples of research where these methodological dilemmas have been considered and addressed.

66 Emma Williamson

Defining and measuring domestic violence and abuse: prevalence and policy Within a UK context the issue of defining domestic violence/abuse was raised during a proliferation of multi-agency forums in the 1990s (Hague and Malos, 1996). (These forums, often based on the community-based intervention models from Duluth, Minnesota, in the U.S., sought to bring different government and nongovernmental organisations together to provide a more holistic service to victims, and sometimes perpetrators, of domestic violence through the development of both policy and practice.) In 1995 the British government released an interagency circular that provided explicit guidance for health commissioners on how to address domestic violence (Home Office, 1995). Many local health authorities, in conjunction with local multi-agency forums, took up the challenge of defining the problem. These forums would meet regularly at a community level to discuss local provisions for abused women. Similar bodies of service providers, called coordinating councils, also began meeting in the United States at the same time. Frustration and conflict often hampered the process because agencies brought differing and in some cases competing definitions of abuse, from differing ideological perspectives, to the table. For example, groups from the specialist voluntary sector (nongovernmental organisations) defined domestic violence in its broadest sense, whereas the police were more concerned with acts that fell within the boundaries of criminal law. Despite these differences, and for the sake of pragmatism, most local authorities in England and Wales, developed a working definition of domestic violence that (1) included physical, psychological, sexual, and emotional abuse; (2) recognised that financial abuse and controls could be part of this pattern; (3) identified the majority of victims as female; and (4) emphasised the criminal and unacceptable nature of any domestic violence. Whilst each agency definition of domestic violence often differed according to their focus, whether criminal focus of the police, or focus on children from social services, these principles eventually led to a government Home Office definition of abuse which most government and non-government agencies adopted. Although a consensus emerged on these points, at the root of many of the ideological differences between agencies about how to define domestic violence was the contrast between the emphasis placed on discrete incidents of abuse by the criminal justice system and on outcomes or impact, as in health. Within the UK, the most reliable source of data relating to population level data on domestic violence and abuse is found within the British Crime Survey (BCS) (Smith et al., 2010). Using a module specifically focused on interpersonal violence, the BCS uses a representative population-based sample to measure the frequency, and some impacts, of domestic and sexual violence. Whilst the headline figures of frequency of abuse suffer from the same criticisms which will be explored later in this chapter, the use of measures of impact are important in placing the prevalence data into context. For example, the BCS looks at whether incidents of violence and abuse resulted in physical and/or emotional/mental problems; impacts on trust in relationships; whether victims were impacted in a way which resulted in them

Measuring gender-based violence 67 attempting suicide; and whether they sought medical attention for the impacts of the abuse they experienced. The BCS (Smith et al., 2010) also analyses repeat incidents of victimisation which would be indicative of a pattern of abusive and/or coercive relationship behaviour. These measures of impact enable the prevalence (frequency) figures to be understood within context. In relation to the development of policy and practice, the ways in which we measure the frequency or prevalence of domestic violence and abuse is crucial. Within the UK, policy decisions about how best to respond to incidents of domestic violence are driven by the research evidence we have. If that evidence is primarily focused on discrete incidents of abuse, rather than patterns of coercive control, then the services developed to address these issues inevitably focus on specific incidents rather than the long-term patterns and impacts of it. For example, within the UK there has been a proliferation in recent years of IDVAs (Independent Domestic Violence Advocates) whose role is to support those victims who are at the greatest risk of abuse. These victims are identified primarily through their contact with the police or the courts in relation to specific incidents of abuse. Similarly, health practitioners within primary care are encouraged to address the issue of domestic violence reactively by learning how to respond to abuse if it is presented to them. Both of these examples illustrate how the longer term impacts of abuse, and the subsequent service needs associated with them, are lost if the way we measure abuse (discussed shortly) does not include consideration of impact.

Importance of understanding cultural contexts There has been a growing realisation within the research literature that population data, predominantly collected by governments through National Surveys of the general population, do not match the reality of police, health providers, and refuge or shelter workers’ experience of service users, which has prompted a major reconsideration of what we mean by domestic violence in policy and practice (Stark, 2007; see Bhate-Deosthali and Duggal in this volume). Before looking at the prevalence data and what that might tell us, it is important to consider cultural differences which might exist in relation to the experience of abuse. The theories of intimate terrorism and coercive control which will be addressed shortly are focused primarily on research data which has been collected within the US, Australia, the UK and some European countries. Stark (2007) argues in his thesis of coercive control that this type of control is necessary in Western countries because in those contexts women have different freedoms related to economic independence, and some protection through legal sanctions. This is not the case for women in many different places in the world. However, that is not to say that women in all countries are not experiencing coercive control, but that in some contexts the mechanisms of control need not be subtle but are explicit and sanctioned through state apparatus (Aghtaie, 2011; see Mitra (a) in this volume). It is important to bear in mind therefore that the ways in which we measure prevalence of abuse, and how we define it, will itself be culturally and geographically specific. Within the West the key question which affects the ways we measure

68 Emma Williamson domestic or gendered violence is, if, in some countries, it is suggested that men and women hit one another in similar numbers, why are the outcomes so much more serious for women? The World Health Organization utilises the United Nations definition of ‘violence against women’ which defines intimate partner violence as “behaviour in an intimate relationship that causes physical, sexual or psychological harm, including physical aggression, sexual coercion, psychological abuse and controlling behaviours” (WHO, 2011). This definition is intentionally broad in order that it can encompass the differing legal definitions of abuse in different countries around the world. This definition, whilst including controlling behaviours, does not explicitly include a gendered dimension, nor does it differentiate between discrete incidents of abusive behaviour and pattern of coercion and control. This is explored in the following discussion.

Theoretical debates: intimate terrorism and coercive control To explain why women’s experience of abuse is so different to men’s, Johnson (1995) has identified a type of violence he calls “intimate terrorism,” in which an individual is violent and controlling to their non-abusing partner. In Johnson’s theory, intimate terrorism is one of four types of abuse, which also includes “violent resistance” in which an individual is violent but not controlling, in response to a controlling violent partner; “situational couple violence” in which an individual is violent but neither is controlling; and, finally, “mutual violent control” in which both partners are both violent and controlling. Johnson argues that in relation to policy and practice, we need to be clear about the types of abuse we are referring to. He believes that general surveys, which will be considered shortly, that examine prevalence are measuring “situational couple violence” and not these other types of abuse, which are more common in clinical samples from agencies. He also argues that, while men and women may engage in situational couple violence in similar numbers and with similar motives, intimate terrorism is committed largely by male partners, a fact not picked up by population surveys, which typically ask only about the use of force. Violent resistance mainly involves women responding with force to control by male partners, and “mutual violent control” is relatively rare. If this typology proves valid, it could explain differences in impact as well as offer useful information on which to base service provision and need. Marianne Hester (2009), in her work entitled Who Does What to Whom?, considers the different types and experiences of abuse through the use of data from police and court records. By tracking individual cases from police report to final police or court outcome, she was able to compare those cases with a single male perpetrator, those with a single female perpetrator, and those cases where both the male and female partner were recorded as perpetrators within the police data. From this research Hester found that gender resulted in significant differences between perpetrators with the proportion of either sole or dual male perpetrators outweighing female perpetrators. Hester found that the violence of male per-

Measuring gender-based violence 69 petrators was more severe and more likely to result in arrest. Concurring with Stark’s thesis on coercive control, Hester found that the ways in which men and women experienced violent or abusive behaviour differed, with fear and control more likely in cases of male perpetrators, these cases were also more likely to involve repeat incidents or a pattern of abuse (Hester, 2009: 19). Johnson’s typology, and Hester’s research, helps explain why prevalence studies do not reflect practice. But it also raises a more fundamental question about what is and is not abusive within intimate relationships. For instance, if the typical forms of partner abuse by men, but not by women, include a range of control tactics in addition to assault, the consequences of these tactics might well be missed by narrow definition focused only on violent incidents or injurious outcomes. This is particularly important when considering the wider (mental) health impacts of abuse over time. Johnson’s notion of a more complex definition of abuse is linked to a growing body of work on the dynamics of coercion and control in partner relationships, including researchers who looked at these dynamics in lesbian relationships (Hart, 1986; Renzetti, 1992; Ristock, 2002). This body of work defines the experience and significance of abuse in terms of its impact on an individual and/or group as well as the behaviours of the abusive partner. The idea that the measures of prevalence used in population studies largely identify behaviours that are neither as serious nor as far-reaching in their effects of what most people consider domestic violence challenges us to reconsider prevailing definitions. Evan Stark (2007) argues that failure to reach a consensus on a definition of abuse that corresponds to victim experience has confounded attempts to accurately measure or understand the problem as it is seen by practitioners. He writes: Researchers have yet to provide satisfactory answers to such basic questions as to whether abuse by male and female partners is similar, how many victims require assistance, why abusive relationships last as long as they do, or why so many battered women—but not men assaulted by female partners—develop medical, psychosocial, and behavioural problems that compromise their physical and mental health. (Stark, 2007: 8) Returning to definitional issues in the domestic violence field can sometimes seem like a backward step, particularly for those who may have spent years arguing for the definitions we now have. But it may be necessary because defining behaviour as abusive has significant legal, moral, cultural, and individual consequences. If we limit our study to incidents of physical violence, as do the prevalence studies, rather than examining the meaning of ‘potentially abusive’ behaviour on the basis of its context and impact, we risk missing whole classes of victims and failing to consider how gendered violence ultimately impacts on health and well-being.

70 Emma Williamson

Defining domestic violence: the health context Stark’s (2007) thesis on coercion and control defines domestic violence as a gendered ‘liberty’ crime which has the effect of preventing women from attaining what we might define as full human rights (see McQuigg in this volume). It is this, he argues which has the greatest impact on those experiencing abuse. From a health perspective, domestic violence can be better understood as a chronic syndrome characterised not only by episodes of physical violence but also by the emotional and psychological abuse experienced as part of a pattern of controlling behaviours. Perpetrators use these different types of abuse to maintain control over their predominantly female partners with often damaging psychological consequences. “Most women experiencing partner abuse report that the physical violence is the least damaging suffered: it is the relentless psychological abuse that cripples and isolates the woman” (Sassetti, 1993: 297). My own work looking at the health impacts of domestic violence showed how health practitioners were well equipped to deal with the physical injuries which victims present with but were less comfortable dealing with the non-physical injuries women sustained as a result of domestic violence (Abbott and Williamson, 1999; Williamson, 2000). If we include the ideas of coercion and control as forms of psychological abuse which women suffer in our understanding then we can begin to see the ways in which the health and wellbeing of victims is impacted by abuse and can provide more appropriate responses (Williamson, 2010). From a health perspective it is unfortunate that the World Health Organization predominantly uses the United Nations definition of intimate partner violence (outlined and described above) as although this allows its use across different legislative jurisdictions it does not explicitly place its definition within a gendered context of a pattern of controlling behaviour.

Identifying appropriate outcome measures As has already been alluded to in the discussions above, identifying what it is we are measuring when we research gendered violence is complex and ideologically influenced. Research within the health context has traditionally prioritised quantitative data over that which is qualitatively produced and looks to find concrete statistically verifiable measures of intervention success. This is not that easy within the domestic violence field. Even identifying the outcomes which would determine a successful intervention are problematic. For example, research which has attempted to measure the effectiveness of domestic violence perpetrator programmes (either court-mandated or voluntary programmes intended to assist abusive men in changing their behaviour), in both the UK and the US often struggle to determine whether an increase in reported incidents of abuse to the police, relating to the men on the programmes, is a positive or negative outcome (Gondolf, 2004; Feder et al., 2008). For some, the fact that reporting increases, and potentially increases the safety of the female partners of men within the programme, is seen as a positive outcome. However, for those who are looking to measure

Measuring gender-based violence 71 whether incidents of abusive behaviour are reduced by the programme intervention the increase is evidence that the programme has not worked. This is an excellent example of how identifying outcome measures within this area are fraught with difficulty.

Measuring prevalence The definition debates which were outlined above have primarily been concerned with the ways in which definitions used in the measurement of abuse have resulted in theoretical assumptions about gender. Based on self-reported prevalence data, a number of studies (Archer, 2002) have suggested that heterosexual men and women experience domestic violence in similar, if not equal, measure. Similarly, prevalence data has been presented which suggests that those in same-sex relationships experience abuse to the same extent as heterosexual couples. Such assertions, and the premise on which they are based, have been challenged on a number of different grounds in relation to both gender (Hester, 2009) and sexuality (Hester, 2010). The measures used to argue symmetry in prevalence generally focus on incidents of abusive behaviours with little or no consideration of the impact of those behaviours on the reported victim. For example, they may ask if someone has been slapped by a partner in the last year but do not ask in what context this occurred nor the seriousness of the consequences of the action. Second, there are concerns about the samples used in this population research, particularly in relation to samesex couples where there may be little or no population data about these groups (Hester et al., 2010). Bearing in mind the methodological issues raised above, there are some representative studies which have looked to consider the prevalence of domestic violence and abuse experienced by male and female victims and which have done so within a context of impact. These prevalence figures come from a range of methodologically rigorous and representative studies and also consider issues of impact. Smith et al. (2010) report 16 per cent male compared to 28 per cent female respondents; Tjaden and Thoennes (2000) report 7.3 per cent male and 21.7 per cent female respondents; Grande et al. (2003) report 12.1 per cent male and 22.9 per cent female respondents; Slashinski et al. (2003) report 2.4 per cent male and 8.3 per cent female respondents; Williams and Frieze (2005) report 14.8 per cent and 21.9 per cent female respondents; Watson and Parsons (2005) report 6 per cent male and 15 per cent female respondents; and finally, Hoare and Jansson (2008) report 18 per cent male and 28 per cent female respondents reporting that they have experienced domestic violence since the age of 16. This data shows that when measuring prevalence, both men and women report experiencing domestic violence and abuse and that the extent of that abuse differs depending on the methods of the study, the questions it asks, and the way in which that data is analysed and presented. From the evidence above it is clear that women are still more likely to report experiencing domestic abuse during their lifetimes when compared to men. However, without considering ‘impact’ even these figures, from methodologically rigorous studies, are limited.

72 Emma Williamson

Measuring impact If we believe that measuring the prevalence of incidents of abuse is not enough to help us understand the impact of domestic violence, then it is necessary to look at the different ways in which we can measure impact. The first consideration is whether the instruments we use are capturing data related to discrete incidents of abuse or patterns of abuse and coercive control. It is helpful in order to examine the latter to consider how long abusive relationships have lasted. The British Crime Survey found that men were more likely than women to experience short periods of partner abuse, with 55 per cent experiencing abuse for less than one month (Hoare and Jansson, 2008). In an update of the British Crime Survey 2008/09, it was found that 14 per cent of female victims had experienced partner abuse for six or more years compared to 4 per cent of male victims. For nearly half (48 per cent) of the male respondents who had experienced abuse this lasted for one month or less, compared with 29 per cent of female victims. This suggests that there are differences in the duration of abuse, which are likely to affect the ways in which that abuse would impact on the victim/survivor, within the headline prevalence figures being presented in the section above. If these differences are gendered, as this data seems to suggest they are, then this raises questions about the conclusions which can be drawn from prevalence data in relation to the delivery of services. The British Crime Survey reported that, on the basis of men and women’s reports of a range of different impacts, fewer men than women were affected by the abuse they reported experiencing in a negative way or sought help for the consequences. Men were less likely (45 per cent) than women (59 per cent) to have experienced injuries or emotional effects as a result of the abuse (Smith et al., 2010). These findings suggest therefore that in the process of measuring ‘potentially abusive’ experiences respondents should also be asked if these experiences were experienced as abusive; have short- or long-term negative impacts on their wellbeing; and from the political context, whether behaviours resulted in future coercion and control. The following section examines those measures of abuse which include these questions in order to ascertain a greater understanding of the impact of abuse and therefore service and intervention requirements.

Clinical measures Not all measures are designed for research. Within the health context there have been numerous attempts to design practical screening tools for use with individual patients. This raises other questions about the role of screening which have been discussed elsewhere. Phelan (2007) reviews the issue of screening and screening tools and identifies a number of measures intended for use in clinical health contexts. These include: the Abuse Assessment Scale (McFarlane et al., 2000); HITS – Hurts, Insults, Threatens, and Screams (Sherin et al., 1998); PVS – Partner Violence Screening (Feldhaus et al., 1997); WEB – Women’s Experience with

Measuring gender-based violence 73 Battering (Coker et al., 2002); VAWS – Violence Against Women Survey (Kataoka et al., 2004); WAST – Woman Abuse Screening Tool (Brown et al., 1996); OVAT – Ongoing Violence Assessment Tool (Ernst et al., 2004); and finally, the ISA – Index of Spouse Abuse (Hudson and McIntosh, 1981). As with the research measures outlined below, many of these measures start from the premise that the Conflict Tactics Scale (Straus, 1979) is the ‘gold standard’ of measurement in relation to domestic abuse and as such, many of these measures are limited to physical incidents of abuse rather than including wider ongoing patterns of all forms of abuse. This is an important omission as we know from the testimony of victims and survivors of abuse, illustrated in the discussions above that it is often the emotional and psychological abuse that women experience which is particularly difficult to deal with and which therefore has the most impact. The Conflict Tactics Scale is a validated measure of domestic violence and abuse which has been utilised extensively in a wide range of countries around the world. As such it is often the first choice of researchers who wish to produce validated prevalence data about domestic violence which can then be compared with other samples. Unfortunately however, this desire to create the same verifiable data also reproduces the limitations of the measure particularly in relation to a lack of questions about patterns of abuse, coercion and control, and sexual violence.

Research measures Despite the concerns raised above in relation to measures which fail to adequately address issues of impact, the Conflict Tactics Scale (CTS) is the most commonly used standardised measure of domestic abuse (Straus, 1979). Debates about the CTS have been ongoing since it was first introduced 30 years ago. This chapter will not address those debates but suffice to say that the main criticism of the CTS measure is its failure to adequately measure impact, and specific emotional impacts in particular. The CTS revised version (Straus et al., 1996) addresses some of the concerns raised in relation to the original version but still fails to address issues of emotional abuse, or what we might now consider to be aspects of coercion and control. As Hegarty et al. (1999) identify, the revised scale still fails to consider social isolation and harassment. Composite Abuse Scale (CAS) The Composite Abuse Scale (CAS) was developed in order to address some of the concerns raised above in relation to the CTS and revised CTS2. The CAS also sought to ensure that the emotional elements of abuse which may constitute coercion and control were also included within the measure in order that it was able to detect ongoing ‘minor’ levels of abuse that form patterns rather than incidents. The CAS contains items related to: Severe Combined Abuse (SCA), Emotional Abuse (EA), Physical Abuse (PA), and Harassment (H). The measure authors tested the reliability and validity of the measure against the CTS2 (Hegarty et al., 1999) and found it scored highly on both. In addition, they believe that the

74 Emma Williamson inclusion of emotional abuse and harassment makes the measure more sensitive to the different types of abuse outlined by theorists such as Johnson (1995) and Stark (2007). The authors state: This preliminary factor analysis of the Composite Abuse Scale items supports the view that there may be a difference between emotional acts used as part of conflict tactics in relationships (e.g., the verbal aggression items from the Conflict Tactics Scale) and emotional acts that are part of abuse tactics used in relationships (e.g., those actions that dominate and isolate women). It could be hypothesised from this research that violence that occurs in intimate relationships is not a unitary phenomenon. (Hegarty et al., 1999: 413) Since the initial validation of the measure CAS has been used widely in Australia to measure domestic violence and abuse most recently in the WEAVE project (Women’s Evaluation of Abuse and Violence care in general practice: A randomised controlled trial; Hegarty et al., 2010). Comparing love and domestic violence in heterosexual and same sex relationships (COHSAR Study) The COHSAR study (Hester and Donovan, 2009; Hester et al., 2010) sought to develop a measure of abuse which was sensitive to gender, sexuality, and experience of abuse. This measure included questions about whether an individual had experienced ‘potentially abusive’ behaviours as a victim or perpetrator. As with the CAS study the authors looked at the validity of the measure and found it has good internal consistency reliability (Cronbach’s alpha: 0.83). The COHSAR measure is particularly useful as it includes items which might be specific to people in same sex relationships and was developed following in-depth qualitative work to ascertain the ways in which abuse might manifest itself in a range of different relationships. This measure does not make assumptions about the ways in which individuals might experience potentially abusive behaviours and as such includes detailed questions about how victims/survivors experience the impact of their experiences. Programme of Research On Violence in Diverse domestic Environments (PROVIDE) Building on the COHSAR measure, the PROVIDE study looked to develop a measure of how abuse might impact on health and well-being. This study was primarily concerned with men as victims and/or perpetrators and included heterosexual men and men who have sex with men. Recruitment to the survey took place in general practitioners’ practices and sexual health clinics. The analysis of the PROVIDE survey data is currently ongoing, but it is useful to consider how the research team approached the questions and items they included.

Measuring gender-based violence 75 The PROVIDE survey was divided into two parts. The first part included sections on: demographic details; health and well-being, including the Hospital Anxiety and Depression Scale (HADS); relationships (which will be discussed shortly); alcohol use; drug use; view on health practitioners asking about potential abuse; and finally, use of services. Whilst we would have liked all respondents to answer very detailed questions about the types of behaviours they may have experienced or perpetrated in the past, it quickly became apparent that this would not be feasible in the context of limited time available for participants of the research to complete the survey. As such, four screening questions for use with all respondents in part one of the survey were developed, which were: 1) As an adult, have you ever felt frightened of the behaviour of a partner? 2) Have you ever needed to ask your partner’s permission to work, go shopping, visit relatives, or visit friends? (Beyond the usual being considerate to and checking with your partner); 3) As an adult, have you ever been hit, slapped, kicked or otherwise physically hurt by a partner? And 4) As an adult, has a partner ever forced you to have sex or made you engage in any sexual activity when you did not want to? These four questions arose from the development of the COHSAR survey, discussed above, as well as through consideration of the Composite Abuse Scales (Hegarty et al., 2010). Whilst the questions in part two of the survey ask if specific behaviours have occurred in the past twelve months or ever, and ask about the frequency of such behaviours (never, sometimes, often), the four screening questions simply ask whether the respondent has ever experienced them, ‘yes’ or ‘no’. If there was a positive response then further questions were asked. These follow-up questions were included to clarify who the perpetrator was/is; whether this was an isolated incident or part of a pattern of abuse/controlling behaviour; whether it had got worse over time; and the impact this had on daily life. We also asked if the respondent had told anyone about these experiences. All of these questions were then repeated in relation to perpetration of potentially abusive behaviours. Part two of the PROVIDE survey contained a much more detailed measure of abuse containing a range of items relating to potentially abusive behaviour. For some items in the scale there were only minor differences between the wording of the COHSAR survey, the CAS and the PROVIDE items. This will enable an analysis of the validity and reliability of the PROVIDE measure. The survey includes the types of behaviours which are normally included when considering the potentially abusive behaviours experienced by women, as well as additional questions such as those relating to driving (driving too fast while you are in the car, and drink-driving while you are in the car) and work (stopped you from working). We also included questions from the COHSAR survey, which would relate specifically to gay men and these questions were added to the bottom of the scale under the header, “If you have had a male partner, please answer the following”. For example: “Accused you of not being a real gay man”; “threatened to out you”; and “threatened to out you so that you lose your children”. The survey contained items relating to potentially abusive physical behaviours, emotional behaviours, and sexual behaviours which respondents might have

76 Emma Williamson experienced as either victims or perpetrators. Those completing the survey were asked to tell us whether they had experienced each item ‘never, sometimes or often’, both in the last twelve months or ever as an adult. Unlike other surveys which only look at measuring these items, where respondents had had an experience they were asked to give more information about who the perpetrator or victim was, and whether the experience had an impact. Impact included both physical and wider impacts such as having a negative impact on daily activities. The PROVIDE survey was successfully used with 1,431 male patients in GP practices, and 1,133 men attending sexual health clinics. The survey findings are currently being analysed by the research team. (For information about the PROVIDE findings see:

Conclusion This chapter has considered the theoretical debates which have influenced the ways in which we currently measure domestic violence and abuse in all its forms. By introducing the concepts of intimate terrorism and coercive control, this chapter has suggested that the Conflict Tactics Scales and the revised Conflict Tactics Scales 2 are limited in their measurement of discrete incidents of physical violence. I have argued that in the case of measuring abuse it is the measurement itself which has led our understanding over recent years and that a re-thinking of the aims of measurement, both for clinical and research purposes, is needed. Only by challenging and removing some of the assumptions which our measures imply can we really understand the ways in which potentially abusive behaviours have an impact on victims’ health and well-being. Ergo, only by using more sophisticated measures which include measures of impact can we use this data to make decisions about health policy and practice. This chapter has considered those measures which seek to replace the CTS tool by including questions about all aspects of potentially abusive behaviours, alongside impact. The Composite Abuse Scale, the COHSAR measure and, developed from both of these, the PROVIDE measure attempt to address this issue so that health care policy reflects the needs of survivors of abuse. I am fortunate to be part of a dynamic research group many of whom are concerned with the overall well-being of those who experience domestic violence. From this perspective comes an underlying concern that as the medical profession moves to identify and quantify domestic violence in the abstract, it must not lose sight of the broad range of health needs of (in)direct victims, survivors, and perpetrators.

Acknowledgement I would like to thank all of my colleagues from the PROVIDE project for their contribution to my thinking on the issue of domestic violence and measuring abuse, in particular Professor Marianne Hester and Dr Sue J. Jones.

Measuring gender-based violence 77

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Gender-based violence in Australia A State-based joined-up approach Deborah Western and Robyn Mason

Introduction Violence against women is a major policy, crime and public health challenge in Australia. It is often referred to as one of the so-called “wicked” problems confronting society, along with drug dependency, terrorism and poverty (State Services Authority 2007). These complex problems require sophisticated responses involving attitude and behaviour change across levels of government and communities. Family violence reform (FVR) in the State of Victoria, Australia, provides a useful case study of how a whole-of-government or joined-up approach was applied as a response to a complex public health and public policy problem. In this chapter we present a summary of the reforms and consider implications for public health agencies and practitioners, in the light of relevant literature about a whole-of-government approach. Our analysis is also informed by a public health approach to violence against women, employing the three strands of primary, secondary and tertiary prevention as noted in Nakray’s chapter with a generic understanding of “prevention, the social determinants of health and equity principles” (Public Health Association of Australia 2010: 3). Whilst the reforms brought long-needed change, integration, collaboration across sectors and organisations and a greater awareness of the needs of women and their children affected by violence, caution must be taken when examining the merits of a public health preventative approach to violence against women and of categorising reforms as one type of prevention rather than another. Despite the many benefits of the reforms, statistics in late 2011 from Victoria Police showed clearly that the number of reports of family violence had increased by 25 per cent over the year. Typically, as with these types of statistics, it has not been possible to determine whether this increase was due to more women making reports to the police as they feel more confident to do so in a society that is increasingly intolerant of violence against women, or due to an increase in the actual incidents of violence against women and their children. What was evident, however, was that the demand for services such as information, housing, counselling, legal advice and financial assistance had grown exponentially and organisations providing services to women and their children were working to capacity. Such a situation highlights the importance of policy-makers and governments remembering that ‘traditional’ (or secondary and

80 Deborah Western and Robyn Mason tertiary prevention) family violence responses such as crisis response, refuge accommodation, outreach and specialised counselling remain crucial in enabling women to be safe within their own communities and to make decisions about where and how they wish to live. Primary prevention responses are, of course, also crucial, but should not be considered an alternative to secondary and tertiary prevention when violence against women clearly remains an enormous problem. Further, the notion of gender mainstreaming, also noted in Nakray’s chapter as a component of a framework for public health budgets and policies, enables violence against women to be placed on the public agenda and highlighted for community action and responsibility: a primary prevention response. However, retaining an awareness of the importance of gender analysis, and the gender-informed and specialised, skilled responses to women and their children that have long been a part of family violence and sexual assault organisations (that is, secondary and tertiary prevention responses), is vital. There is a risk that these understandings and responses can be lost when the primary prevention response is implemented in isolation from an overall response to violence against women. As Reed et al. (2010: 349) note, “the erasure of gender from the theoretical frameworks that guide public health efforts may have serious consequences, namely the development of misguided and ineffective prevention and intervention programs to address (violence against women)”. Underpinning these arguments and our further analysis in this chapter is a feminist perspective that acknowledges women’s inequality relative to most men, the driving force of power and entitlement in much of the violence perpetrated by men against women, the consistent research throughout the world that shows that women are most likely to be subject to violence from a male they know and the need for broad cultural and social change in order to address the problem. To illustrate the way that reforms impacted on practice, we review two of the products of the reform process. We conclude by offering some implications for public health agencies.

The Australian and Victorian context In Australia, one in three women has experienced physical violence since the age of 15; one in five has experienced sexual violence; and women in Australia are more than three times as likely to be victims of intimate partner violence as men (Australian Bureau of Statistics 2006). Indigenous women in Australia are thought to be 40 times more likely to be victims of family violence (Aboriginal Affairs Victoria 2008), and women with disabilities are at much greater risk of violence than women without disabilities (Healey et al. 2008). In Victoria, Australia’s second most populous State with a population of 5.55 million in 2010 (Department of Planning and Community Development 2011), violence against women is equally prevalent. In 2006–7 in Victoria, there were thirteen people killed by a partner – eleven were women. The cost to the community of violence against women in Victoria has been estimated at A$3.4 billion, rising to A$3.9 billion by 2021 (Office of Women’s Policy 2010b).

Gender-based violence in Australia 81 The response to violence against women in Victoria since the 1970s has seen an ebb and flow of policy interest. The service system, established and maintained by women volunteers in the 1970s, at first comprised a small number of sexual assault support services and women’s refuge services. In the sexual assault field, a paradigm shift occurred in the late 1980s, with the foundation of the first Centre Against Sexual Assault (CASA) auspiced by the Royal Women’s Hospital but located separately in a nearby house. The practice model employed by CASA House was founded on a rights/advocacy model for women victim/survivors of sexual violence. Workers in the sector are known as counsellor/advocates, and the approach is underpinned by a feminist analysis that acknowledges men’s power over women (Gilmore 1994; Weeks 1994; Orr 1997). There are now thirteen CASAs throughout the state of Victoria. The women’s refuge and family violence sector developed separately in Victoria, mainly funded under the housing budget. Workers were less well paid than their sexual assault counterparts and they were generally less qualified. An unfortunate by-product of the separate development of these two sectors was a fragmented service system that responded to a woman differently depending on which agency she approached and how the problem was defined. At the same time, the police were notoriously negligent in their lack of response to “domestics” and offered little support to women reporting violence.

A whole-of-government approach Before considering the reform process in Victoria, we review in brief what is meant by a whole-of-government approach. The State Services Authority attributes the term “joined-up government” to the Blair government in the UK, where the concept was introduced “to improve the government’s response to ‘wicked’ problems” (State Services Authority 2007: 3). In Canada the term “horizontal management” was employed. The authors argue that many public policy matters cut across departments and levels of government, and therefore require collaboration across levels and sectors. In addition, they argue, citizens are demanding coordinated services that meet complex individual needs, a view supported by anti-violence practitioners in health and crime prevention, for example, who call for co-ordinated and multi-sectoral service delivery (O’Donnell 2005; Shaw and Andrew 2005; Rees and Silove 2011). The following definition of joined up government is offered: “Working collaboratively across departments, portfolios or levels of government to address complex issues which cross individual agency boundaries” (State Services Authority 2007: vii). The approach includes new ways of working, new types of organizations, new accountabilities and new ways of delivering services (State Services Authority 2007: 4). At the time of publication of this overview in 2007, there had been 39 joined up initiatives in Victoria, including 22 projects with a focus on social issues. The project entitled Changing Lives: A New Approach to Family Violence was one of these.

82 Deborah Western and Robyn Mason Joined-up government sounds desirable but there are challenges inherent in the approach. In an analysis of a UK program in two local authorities Davies (2009) argues that there is little clarity about the concept, and that there has been too much attention paid to its managerialist and technical aspects, neglecting to examine the politics that invariably include value conflict among stakeholders. He concludes that joined up government “will remain elusive unless partners can also articulate, debate and resolve value conflicts” (Davies 2009: 90). Research on the FVR experience in Victoria found that establishing a common philosophy was difficult, because “[f]amily violence services lack the kind of central ideology that characterises more established service areas like health” (Ross et al. 2011: 137). There are also accountability and resourcing challenges when multiple organisations and departments are involved, as well as the risk that arrangements will be so complex as to be unworkable (Ross et al. 2011).

The Victorian experience The decision to engage in reform for the family violence sector was a result of recognition of the fragmented response, high demand and limited service integration in the sector. The sequence of events is reported in an innovation case study, where relevant departments and police were recognised for their achievements in public policy innovation (Department of Premier and Cabinet 2010) and in an analysis of the reforms as an example of integrated social policy (McClelland 2009). A key driver for change was the appointment of Christine Nixon as Victoria’s first woman Chief Commissioner of Police who announced a new focus on violence against women for Victoria Police in 2001. A State-wide Steering Committee was subsequently tasked with developing an integrated service system for family violence. At the same time the Victorian Government’s Women’s Safety Strategy was launched and action was taken to tackle violence in Indigenous communities. A Code of Practice for the Investigation of Family Violence was released by Victoria Police in 2004 and the Victorian Health Promotion Foundation published a report on the health costs of violence (VicHealth 2004). The State-wide Steering Committee reported in 2005 with recommendations about reforming the service system, and funds were allocated in the State budget for the reform strategy, as well as specialist family violence courts in two locations. Reform proceeded at an astonishing pace in the following two years: initiatives included the establishment of Regional Integration Committees involving 20 partnerships and more than 70 organisations; the development of a new Family Violence Protection Act; a Code of Practice for Specialist Family Violence Services; a Risk Assessment and Management Framework; research funding; and establishment of referral pathways. Further reforms included funding for Indigenous family violence and prevention, and an Indigenous family violence ten-year plan: Strong Culture, Strong People, Strong Families (Aboriginal Affairs Victoria 2008). A sexual assault reform strategy was funded in 2006/7, with the objective of improving the functioning of the criminal justice system and the experience of sexual assault victim/survivors (Success Works 2011). All of these reforms implied and required

Gender-based violence in Australia 83 a new way of working, including a commitment from different work areas to treat the problem as prevalent and serious, working towards integrated and consultative practice, and securing funding to assist. The reforms aimed to ensure more accountability for perpetrators, more reporting by victims of violence and that no matter where a woman presented, “the first door is the right door”. A key next step was the decision to focus on primary prevention of violence against women. The Victorian Health Promotion Foundation (VicHealth) was commissioned to review the evidence on prevention and produce a conceptual framework that could be used to develop policy. VicHealth published a disturbing report about community attitudes to violence (VicHealth 2006), and the publication of Preventing Violence Before It Occurs (VicHealth 2007) articulated the underlying causes of violence against women – gender inequality, gender stereotyping – and suggested change at many levels: individual, community, organisational and society. The prevention strategy suggested change and action in five key settings: education and training; local government, health and community services; workplaces; sport and recreation; media, arts and popular culture. The vision for Victoria became: “Victorian communities, cultures and organisations are non-violent and gender equitable. Relationships are respectful and non-discriminatory.” The prevention agenda was launched as a ten-year plan called A Right to Respect (Office of Women’s Policy 2009), and a similar plan the following year, A Right to Safety and Justice: Strategic framework to guide continuing family violence reform in Victoria 2010–2020, addressed how the reforms in justice and safety were to be continued (Office of Women’s Policy 2010b). A policy statement about violence against women brought all the reform strands together and connected them to the broader Victorian context that included the Charter of Human Rights and Responsibilities (Office of Women’s Policy 2010a). Soon after, in late 2010, the State Labor Government was defeated after eleven years in office, and the Minister for Women’s Affairs lost her marginal seat after a bitter campaign that included a sustained attack by anti-abortion campaigners. Strong leadership and governance arrangements were central to the reform process. Five Ministers with responsibility for family violence drove the reforms,1 with leadership from the Chief Commissioner of Police. The structures that operationalised the reform included an interdepartmental committee, a state-wide advisory committee, regional advisory committees, the Indigenous partnership forum and a whole-of-government budget proposal to support the reform (Department of Premier and Cabinet 2010). Practitioners and policy-makers involved in the reforms have reported to us their view that the presence and commitment of senior Ministers, leadership from Victoria Police and the consistency and longevity of membership of key committees were success factors. This view is supported by McClelland in her analysis (2009), who also comments that the structure allowed for the bringing together of different perspectives about family violence and the building of strong relationships across and outside government. Research findings suggest that the processes used to negotiate values and goals were successful in building shared understanding and addressing differences (Ross et al. 2011: 138). Importantly, practitioners and managers from the service sector were

84 Deborah Western and Robyn Mason included, so that decisions were made about reform based on practice experience. Those involved in the reform reported that they were part of a “genuinely transformative process of change in the company of others who also exhibited a strong and sustained commitment” (Ross et al. 2011: 139).

An exploration of two outcomes from the family violence reforms in Victoria In the light of the discussion above about a whole-of-government approach, the three strands of prevention responses and the Victorian experience, we offer a brief analysis of two practice outcomes of the reform process. The Family Violence Risk Assessment and Risk Management Framework The Framework (known as the CRAF – the Common Risk Assessment Framework) was introduced in 2007 and reflected the major features of the reforms noted above and largely sits within the secondary prevention strand. However, because there was an educative component within the Framework documentation itself and in accompanying training sessions, there was also an element of primary prevention within this specific reform. The CRAF was developed to assist organisations to provide a holistic, consistent and integrated response to women experiencing family violence with a strong focus on the rights, needs and safety of women and their children and the accountability of perpetrators for their violence. The assumption was that if all organisations worked from a common risk assessment and risk management framework, all women would receive a sound, coordinated and consistent response no matter where they entered the service system. The Framework also aimed to provide a “focus on the needs of victims from Aboriginal and other culturally and linguistically diverse backgrounds and other vulnerable groups” (Department for Victorian Communities 2007: 19) such as women with disabilities, older women and women in rural areas. Six key components underpin the Framework. The first three guide the effective identification of victims of family violence (risk assessment) and the last three guide the response to them (risk management): 1 2 3 4 5 6

A shared understanding of risk and family violence across all service providers. A standardised approach to recognising and assessing risk. Appropriate referral pathways and information sharing. Risk management strategies that include ongoing assessment and case management. Consistent data collection and analysis to ensure the system is able to respond to changing priorities. Quality assurance strategies and measures that underpin a philosophy of continuous improvement.

Gender-based violence in Australia 85 The CRAF was designed to be used by family violence specialist services, legal and statutory services and mainstream services such as health, education and disability services; this reflected the integrated service system of the reforms and could be described as a form of gender mainstreaming in which increased professional and community understandings resulted in more informed responses to violence against women. Consequently the CRAF comprises three separate frameworks for use depending upon a worker’s position within the service system. The first framework provides information about identifying family violence and is developed for use by mainstream professionals who have contact with women they believe have experienced, or are experiencing, family violence. The second framework assists professionals to undertake a preliminary risk assessment and is aimed at practitioners who work with women experiencing family violence although this is not their core field of work. These practitioners could include relationship counsellors (see Breckenridge and James in this volume), police and court staff and members of community legal centres and community health centres. The third framework was designed for use by specialist family violence service workers whose work is primarily with women and their children experiencing family violence. It was expected that these workers would “have a common understanding of family violence, its impact on family members, the role it plays in traumatising the individuals and relationships within families, and be familiar with all appropriate referral pathways” (Department for Victorian Communities 2007: 65). See Table 7.1. When undertaking risk assessments, including the level of risk, workers need to have regard to three main guiding factors: 1 2 3

the victim’s own assessment of their level of risk evidence-based risk indicators the practitioner’s professional judgement.

The development and use of the CRAF have been successful for a number of reasons. First, the three guiding factors of effective risk assessment introduced a concise yet comprehensive framework in which either initial or extensive assessments could be undertaken. There is a recognition that women are often the best predictors of future risk regarding family violence; including women in any assessment, discussion and decision-making enables vital information to be incorporated into a risk assessment as well as providing women with a sense of inclusion in the process and agency in making future plans. Second, across the three frameworks of assessment the CRAF manual offers workers detailed information about various topics such as how to introduce and structure questions about family violence and safety, how to recognise and assess risk indicators as well as possible protective factors, how to determine whether other services are or have been involved, and how to ensure that action is taken based on the outcomes of the assessment. Third, a comprehensive state-wide cross-sector training program accompanied the release of the CRAF. In 2008/09, 2,491 workers from targeted sectors including maternal and child health nurses, court registrars, family violence and sexual assault workers,

To assist professionals who work with victims of family violence but for whom it is not their only core business, including: • police and court staff • members of community legal centres • members of community health centres, including counselors • disability and housing services workers.

To assist mainstream professionals who may encounter women they believe to be victims of family violence. This Guide presents a consistent set of possible indicators of family violence and clear advice about how to identify family violence, including a set of questions that should be asked. Mainstream professionals may include: • maternal and child health nurses • general practitioners • teachers • other health care providers.

Adapted from Department for Victorian Communities (2007: 8)

** Should only be used when family violence situation has been established.

Practice Guide 2: Preliminary Assessment

Practice Guide 1: Identifying Family Violence

** Should only be used when family violence situation has been established.

To assist specialist family violence professionals working with women and children who are victims of family violence. Comprehensive assessment requires enhanced client engagement skills and detailed safety planning and case management responses. Such professionals will generally be qualified in: – welfare – social work – psychology – counselling or family therapy – have significant experience in the family violence field including expertise in conducting complex assessments.

Practice Guide 3: Comprehensive Assessment

Women access an organisation and, depending upon the nature of the organisation and the role of the worker, one of three possible risk assessments will be undertaken. A Practice Guide for each level of assessment provides suggested questions for workers, information about responding and developing safety plans, and an aide memoire of risk factors needing assessment. Such factors include mental health concerns, drug and alcohol use, presence of weapons and use of threats, violent behaviours and pregnancy.

Table 7.1 The Risk Assessment and Risk Management Framework

Gender-based violence in Australia 87 child protection, family services, housing and homelessness services, disability, counselling and mediation, men’s behaviour change programs, and in some regions, family violence specific Indigenous services were trained in the use of the CRAF (Office of Women’s Policy 2010c). Participants demonstrated significant and long-term changes in their practice including using the CRAF, asking questions about family violence, referring clients to other organisations, undertaking risk assessments and working with women on safety plans. Finally, the CRAF integrates well with different legislation, codes of practice and practice guidelines demonstrating the coordinated and integrated nature of the overall FV reforms in Victoria. However, other than these evaluations with workers undertaken during and after the CRAF training sessions, no outcome evaluations exploring the experiences of clients appear to have been conducted. Shortcomings have included the time lag between the release of the CRAF and the development and release of the Risk Management component. Risk management is noted as vital follow up after a risk assessment; however, four years after the release of the CRAF, detailed guidelines, explanations or frameworks for risk management within the CRAF have not been issued. Second, whilst attention has been given to the important role that context may play in people’s understanding and experience of family violence, Australian Indigenous people have found that the CRAF does not provide sufficient space, focus or flexibility to enable the identification, assessment and planning for the differences that they experience. Similarly, women with disabilities have noted the limited possibility of a detailed assessment being undertaken when the CRAF is employed as a sole risk assessment tool that clearly identifies and communicates their needs such as the presence of a carer (who would need to accompany a woman into crisis accommodation for instance) or the need for existing financial support that can follow her across regions, thereby contributing to her overall safety (Austin 2011). Finally, reports from workers in the field have indicated concerns that the CRAF does not provide sufficient flexibility and information to allow for a comprehensive enough assessment of children. As with all reform, strengths and limitations have been discovered as the process has evolved. Systematic evaluation is crucial to ensure the framework is as relevant as possible to practitioners and therefore is used in the ways anticipated in order to keep women and their children safe from violence. Sexual Offences and Child Abuse Investigation Teams (SOCITs) and Multidisciplinary Centres (MDCs): 2 improving responses to victims of sexual assault A second example of reform constitutes part of the Victorian Sexual Assault Reform Strategy (SARS). The Strategy resulted from findings of the Victorian Law Reform Commission Inquiry completed in 2004, suggesting that whilst Victorian law was sound in relation to sexual assault, there were concerns with the way it might be implemented given low reporting rates, falling conviction rates, poor access to the criminal justice system for Indigenous women and women from culturally and linguistically diverse backgrounds and a “lack of consistency in police decisions

88 Deborah Western and Robyn Mason about whether or not to authorise briefs of evidence for sexual offences” (Success Works 2011: 9). There were also concerns that the (existing) service model suffered from fragmented, inadequate and inconsistent service delivery that exacerbated victim stress because victims had to repeat their account to numerous service providers. The report also emphasised the prevalence of poor police attitudes toward sexual assault investigation (Powell and Wright 2009). In response the Victorian government allocated A$6m in 2006–2007 over four years to Victoria Police to establish two pilot multidisciplinary centres in order to improve the multisystem response that victim/survivors of sexual assault were offered. The Mallee Sexual Assault Centre in rural Mildura, already offering a combined specialist sexual assault and family violence response, was one pilot site; the other was Peninsula Sexual Assault Centre based in an outer southern suburb of Melbourne. A third centre in Geelong, a regional city west of Melbourne, has also been funded. The multidisciplinary centres co-located existing specialist sexual assault organisations (CASAs) with police SOCITs (Sexual Offences and Child Abuse Investigation Teams) with the aim of providing “a more victim-centred response to victims of sexual assault” (Office of Women’s Policy 2010a). The MDCs were located separately from police stations. Whilst CASAs and police have worked closely together for many years, the two sectors have not always approached victim/survivors of sexual assault with the same aims or with consistent responses (for example Mason 2001). Co-location has enabled workers from different sectors with different training and sometimes different philosophies to work more closely together, to communicate more clearly, to learn about how and why each sector works the way it does and to provide a more consistent, responsive, coordinated and supported response to victim/ survivors. Victim/survivors have reported satisfaction with the new “one-stop shop” model and have described feeling listened to and treated with respect. Co-location, increased communication with sexual assault workers and specific training for SOCIT members in responding to sexual assault has seen a cultural shift in police attitudes to victim/survivors demonstrated by their “belief” in accounts of sexual assault and their understanding of the impacts of sexual assault as a crime (Success Works 2011). Clients experience more privacy and anonymity and the number of service providers has been reduced with clients being able to see the same police member from the time of reporting through to the authorisation of briefs. These factors have all contributed to better access to services for victim/survivors. Police members, sexual assault workers and other stakeholders have also been very positive about the reforms (Powell and Wright 2009; Success Works 2011). Police are able to focus on the specific sexual assault cases rather than be involved in a range of police duties that come about when located in a police station. Police and CASA workers are more likely to consult in relation to women’s options about reporting, progress of cases through the police and justice system and outcomes of particular choices available to women. This means that women are able to receive accurate and timely information and do not have to visit different locations. The

Gender-based violence in Australia 89 MDCs are comfortable and private; the centres are not obviously identifiable. Powell and Wright (2009: 8) summarised four elements that demonstrated strengths of this aspect of the reforms and that enabled much closer cooperation and collaboration between police and CASA workers. These elements were the colocation of key services, the adoption of a neutral independent service facility, increased specialisation of police and strong organisational commitment and support. Outcomes of the reform have included improved collaboration, more victim/ survivor satisfaction, increased reporting rates, more referrals between professionals (as happened with the CRAF reform), reduced response and investigation times, better quality briefs, and higher prosecution and conviction rates. These were all areas where the Victorian Law Reform Inquiry had highlighted need for improvement. The reform continues to evolve and whilst there have been very positive responses there have been some concerns about police workforce capacity. There are questions about coverage of the MDCs and future staff needs given increasing administrative requirements. Other challenges noted by Powell and Wright (2009) include the need for: formalised processes to facilitate inter-agency collaboration; improved training in investigative interviewing; an ongoing built-in evaluation system; and a review of current procedures for managing work-related stress. Another consideration is how the two components of sexual assault and family violence reforms can be combined, as recommended in the evaluation of the SARS (Success Works 2011). This is an area where continued discussion and sharing of ideas needs to continue given that many women experience sexual assault as well as family violence. These two examples illustrate how the whole-of-government commitment to collaboration has been mirrored in practice. Evaluation of reform components so far, although limited and not always accessible to the public, suggests that workers across sectors are more informed about violence against women as a compelling health, social, economic and cultural community challenge, and that more women are experiencing better quality services, in a timely and accessible way. The sustainability of the reforms, however, will depend on leadership, funding and workforce planning. Further research will provide us with more evidence about the success and long-term sustainability of the various reform components.

Implications and conclusion The Victorian whole-of-government approach to FVR has seen a concerted effort to reframe and redesign the response of the state and the community to this “wicked” problem. A significant development from a public health perspective, and a catalyst for a new discourse about violence, has been the emphasis on prevention. It would have been inconceivable a decade ago to see domestic and family violence and sexual assault services engaging widely in prevention programs; now they are proliferating in Victoria and across Australia. The evidence base documenting the impacts of violence against women has facilitated new ways of framing

90 Deborah Western and Robyn Mason the response, based on recognition of women’s inequality and gender stereotyping as the underlying causes (see Nakray in this volume). This is the important conceptual addition to a public health approach that has made a difference in Victoria. The gendered perspective has also been incorporated by the national Labor government in a National Plan to Reduce Violence Against Women and Their Children, seen to be an international first (FaHCSIA 2009). All States and Territories have signed on to the Plan and commitments will be monitored by a national women’s issues Select Council with a brief to implement the plan and to pursue gender equality (FaHCSIA 2011). What does this mean for public health agencies? The lessons from Victoria suggest that a prevention approach, based on recognition of gender inequality and gender stereotyping as the main causes of men’s violence against women, coupled with strong leadership and governance arrangements, along with adequate resourcing and funding, will give public health agencies and practitioners the best opportunity to tackle this complex and challenging problem. At the same time, the service response to women experiencing violence must not be neglected at the expense of more fashionable prevention programs. It may be more interesting to run media campaigns with celebrities, (for example, aspects of the current White Ribbon campaign in Australia; see Bhate-Deosthali and Duggal in this volume), but the hard work of supporting women to access justice, for example, needs to continue. Most importantly we argue that a gendered analysis is fundamental to success (see also Jewkes in this volume). The new Victorian government has been in office for just over a year as we write and little has been forthcoming about their intentions. A recent Government publication about homelessness commits to continue the whole-of-government approach. The language is, however, de-gendered: men are not mentioned at all (only “adults”); women are linked with families and referred to as “vulnerable” women (Department of Human Services 2011). It would be a backward step to revert to a view of women as passive victims of violence needing to be rescued, because we know that how the problem is framed will affect the way the state and community respond (Bacchi 1999; Nixon and Humphreys 2010). If nothing else, the successes of the FVR need to be made known to the community at every opportunity, not least because the electorate deserves to know how public money is being spent, but also because those successes need to be shared and owned by all if we are to see lasting change.

Notes 1 The five Ministers represented the following portfolios: Women’s Affairs and Early Childhood Development (lead Minister); Attorney-General; Community Services; Police and Emergency Services; Aboriginal Affairs, Housing and Local Government. 2 The authors acknowledge and thank Professor Martine Powell and Dr Rebecca Wright from Deakin University Geelong, Victoria and Detective Superintendent Rod Jouning of Victoria Police for access to the 2009 evaluations of the SOCIT and MDC model.

Gender-based violence in Australia 91

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92 Deborah Western and Robyn Mason Office of Women’s Policy (2010b) A right to safety and justice: Strategic framework to guide continuing family violence reform in Victoria 2010–2020, Melbourne: Department of Planning and Community Development, State of Victoria. Office of Women’s Policy (2010c) The Victorian family violence risk assessment and risk management framework: Summary of the evaluation report of the statewide training program, Melbourne: Department of Planning and Community Development, State of Victoria. Orr, L. (1997) The development of services against sexual assault in the state of Victoria 1970–1990, unpublished MA thesis, La Trobe University, Melbourne. Powell, M. and Wright, R. (2009) Stakeholders’perceptions of the new SOCIT and MDC model adopted by Victoria Police, Geelong: Deakin University. Public Health Association of Australia (2010) Submission of the PHAA on national plan to reduce violence against women and their children (2010–2020), Canberra: Public Health Association of Australia. Reed, E., Raj, A., Miller, E. and Silverman, J. (2010) Losing the ‘gender’ in gender-based violence: The missteps of research on dating and intimate partner violence, Violence Against Women 16(3): 348–354. Rees, S. and Silove, D. (2011) Gender-based violence and the threat to women’s mental health: A sustained and coordinated multisectoral approach is vital, Medical Journal of Australia 195(8): 434–435. Ross, S., Frere, M., Healey, L. and Humphreys, C. (2011) A whole of government strategy for family violence reform, The Australian Journal of Public Administration 70(2): 131–142. Shaw, M. and Andrew, C. (2005) Engendering crime prevention: International developments and the Canadian experience, Canadian Journal of Criminology and Criminal Justice 47(2): 293–316. State Services Authority (2007) Victorian approaches to joined up government: An overview, Melbourne: State Services Authority, State Government Victoria. Success Works (2011) Sexual assault reform strategy: Final evaluation report, Melbourne: Department of Justice. VicHealth (2004) The health costs of violence: Measuring the burden of disease caused by intimate partner violence, Melbourne: Department of Human Services, State of Victoria. VicHealth (2006) Two steps forward, one step back: Community attitudes to violence against women. Progress and challenges in creating safe and healthy environments for Victorian women. A summary of findings, Melbourne: Victorian Health Promotion Foundation. VicHealth (2007) Preventing violence before it occurs: A framework and background paper to guide the primary prevention of violence against women in Victoria, Melbourne: Victorian Health Promotion Foundation. Weeks, W. (ed.) (1994) Women working together: Lessons from feminist women’s services, Melbourne: Longman Cheshire. White Ribbon (n.d.) Homepage of White Ribbon: Australia’s campaign to stop violence against women, retrieved 4 March 2012 from

Part II

Risks, impacts and responses to gender-based violence


Gender-based violence in post-disaster recovery situations An emerging public health issue Margaret Alston

Introduction This chapter links two extraordinarily vexing global challenges – climate change related disasters and gender-based violence. Many will note that making this link in a short chapter risks both conflating varied and complex post-disaster situations and also portraying women in particular as unitary, subordinate, vulnerable victims who lack agency, power and influence. These risks are worth taking to alert the reader to the ample emerging evidence from across the globe that women’s vulnerability to violence increases significantly during and after major climate events regardless of cultural context. That this is not limited by place and circumstances reinforces that gender is a significant factor in post-disaster vulnerability. Acknowledging gender-based violence as a factor in climate change responses and providing strategies and actions to support women and to reduce violence is critical to women’s ongoing health and well-being. One of the significant factors that reduce attention to gender-based violence is that the development of climate change policy using a scientific or technological framework results in an absence of people and communities in climate change discourse and a consequent lack of attention to gendered vulnerabilities in climaterelated post-disaster planning and responses. Without a gender lens and a failure to mainstream gender across government policy portfolios, gender-based violence remains a minor or largely absent issue in policy and planning responses. This chapter addresses gender-based violence in climate-related post-disaster recovery situations. It will focus on both incremental (drought and desertification) and catastrophic climate events (typhoons, cyclones and flooding) and argue that violence is exacerbated in these situations. The chapter draws on primary research in three research studies undertaken through the Gender, Leadership and Social Sustainability (GLASS) Research Unit. GLASS has quickly established itself as a leading facility on gender research in the global south. In the three years since establishment we now have two post-doctoral fellows, sixteen PhD students and a number of academics studying and researching under GLASS. The first of the three studies discussed here was conducted in Australia in the Murray-Darling Basin area where a ten-year drought has led to major social upheaval in farming communities; the second in the Pacific Islands where sea level rises and storm surges

96 Margaret Alston are eroding coastal communities and causing significant social dislocation; and the third is Bangladesh where typhoons and sea water inundation have led to high mortality and morbidity rates and extensive family and community disruption. Ethics clearance has been received from Monash University’s ethics committee and qualitative interviews and focus groups have been undertaken in each of these sites. Data emerging from these projects demonstrate that climate change events exacerbate the incidence of gender-based violence (Alston and Whittenbury 2010; Alston and Vize 2010; Alston et al. in press) and these findings are corroborated by research from other disaster areas such as those affected by Hurricane Katrina in New Orleans in 2005 (Enarson 2005), the 2010 Haitian earthquake (Bayard 2010), the Christchurch earthquake in 2010 (New Zealand Press Association 2010) and a diverse range of other disaster sites (Enarson and Meyreles 2004). Women affected by climate change disasters as well as service providers and program directors working in climate affected areas report exacerbation of gender-based violence, sex trafficking, increased vulnerability for women and girls and higher numbers of women seeking assistance for violence-related health and welfare issues.

Gender-based violence, climate change and health outcomes Gender refers to the different ways women and men operate within socially constructed, sanctioned roles that subsequently shape the ways individuals respond to circumstances and events. Gender is not static or ahistorical but emerges from constant negotiation and renegotiation between women and men at the intimate level of the family (or what Connell (1995) refers to as the gender regime level) and at wider societal levels (the gender order (Connell 1995)). Gender is not what one ‘is’ but what one ‘does’ (Pini 2004) and thus women and men are ‘made’ in response to cultural cues and validated experiences (Liepins 2000). Hegemonic masculinity describes the way men, their issues and concerns are prioritised in the gender order and this hegemonic position ensures that men’s dominance over women continues (Connell and Messerschmidt 2006). This preeminence is so normalised that it is rarely questioned or challenged and all other relationships adjust. Gender-based violence is recognised as a significant problem at transnational and national levels. The 1993 United Nations Declaration on the Elimination of all Forms of Violence Against Women defines gender-based violence as any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivations of liberty, whether occurring in public or in private life. (UNFPA 2005) Gender-based violence has taken a terrible toll across the globe, affecting as many as one in three women, and resulting in significant hardship and cost to women and ultimately to nations (UNFPA 2005; see Nakray in this volume).

GBV in post-disaster recovery situations 97 Our research reveals that gender-based violence has increased in the three diverse geographical areas being investigated as a result of climate events and that women are more vulnerable during disasters and post-disaster recovery periods. Gender-based violence in post-disaster situations includes physical, emotional and sexual assaults, suggestions of trafficking and violence in disaster recovery facilities, women of low caste being shut out of shelters, and women and girls being vulnerable to ongoing attack. In post-disaster situations women are increasingly vulnerable to violence and abuse. Dankelman (2011) also notes the increase in domestic and sexual violence following disasters; that young girls drop out of school following disasters to reduce household costs and also to provide assistance in the household; that young girls are often married off early to older men in post-disaster situations; and that many women are forced to sell sex for money in order to survive. There is increasing recognition that climate change disasters have gendered impacts (Food and Agricultural Organisation 2007; Alber 2011) for diverse reasons, including that women are more likely to be rescuing children, that their dress limits their movements, that they may be culturally compelled to stay within the household unless accompanied by a male relative and because shelters designed to protect people do not attend to the needs of women for safety and privacy. They are also vulnerable because they do not own assets such as land and thus have reduced levels of power (Dankelman 2011). Women are up to fourteen times more likely to die in a catastrophic climate event (Neumayer and Pluemper 2007), and, particularly poor rural women, are more likely to be severely impacted by disasters and post-disaster circumstances (Alber 2011). Women’s lack of access to resources makes them more vulnerable in preparing for, and recovering from, disasters. Many women have significantly increased workloads as a result of a lack of energy sources, clean water, sanitation and health issues. Thus when a disaster strikes their workload increases still further, especially as it is often the case that men will migrate for work leaving women in charge of households and livelihood strategies. Women have less decision making power and therefore less ability to influence the way resources are distributed; their access to information is often tenuous and reliant on others. Their ability to relocate, to find work and to adapt to changed circumstances is reduced, further increasing their vulnerability (Dankelman 2011). Despite the evident gendered issues associated with climate change these are overshadowed by the scientific debate about the veracity of evidence, a debate that sets people in opposition to each other as either sceptics or true believers. While there is very evident cause for concern about climate change impacts, debate has tended to centre on the science and on whether changes in weather patterns are caused by humans or are the result of a long slow period of global warming. As a result climate change has become a highly contested and complex area polarising the community around very divergent positions (see for example Hamilton 2007; Plimer 2009). There is no doubt that climate change is one of the most pressing issues of our time and occupies significant political and policy attention at both national and

98 Margaret Alston international levels. Climate change refers to the build-up of greenhouse gas emissions that are causing melting of the polar ice caps, sea level and rises in air temperature. Climate change related events include both slow onset change like drought and desertification and catastrophic disasters like floods, storm surges, mud slides, hurricanes and extreme bushfires. These have resulted in significant climate events and consequent health impacts including higher levels of morbidity and mortality (Inter-Governmental Panel on Climate Change 2007). There is little doubt that climate change will have a significant impact on human health across the globe, a factor that will be exacerbated by anticipated population growth from the current six billion to over nine billion by 2050. These changes will result from obvious direct impacts from events such as heat waves, floods and bushfires, but also from malnourishment and hunger resulting from drought periods, from air- and water-borne diseases, from altered disease patterns, from changes in ecosystems and from increasing pressure on arable land to produce enough food for the growing population (Pachauri and Reisinger 2007). Health impacts will also result from conflict over resources and predicted high levels of population displacement (World Health Organization 2011a). Climate change affects food and water security and creates critical concern about global social sustainability, as evidenced by the devastating drought in the Sudan in 2011 that resulted in the deaths of many thousands of people, and also by widespread food riots occurring across the globe (Adams 2008). Adding to the precarious nature of food production and the rapidly rising global population, is the co-option of food-producing areas for biofuel production, the rise in corporate agriculture, the increasing inequities between those in the North and the South, and the decline in political influence of farmers. All of these factors add to growing concerns about health. Speaking to the World Business Summit on Climate Change in Copenhagen in 2009, the United Nations Secretary General Ban Ki-moon referred to his concerns about health impacts: Climate change affects every aspect of society, from the health of the global economy to the health of our children. It is about the water in our wells and in our taps. It is about the food on the table and at the core of nearly all the major challenges we face today. (Ki-moon 2009) Climate change is having both direct gendered impacts on physical and reproductive health and indirect impacts because of women’s social roles in the household, society and community. Their need to access water is often compromised during and after disasters and their lack of access to reproductive health care and sanitation places women and their families at risk. Gender has a significant impact on health outcomes; essentially this is because a vast majority of the world’s poor are women, and cultural prescriptions about gender roles often create the circumstances where women are more vulnerable to disease, malnutrition and infections such as HIV/AIDS. The feminisation of

GBV in post-disaster recovery situations 99 poverty results in women being more food insecure (Beaumier and Ford 2010) and their experiences of violence impacts significantly on their health. In a study undertaken in Papua New Guinea, Hinton and Earnest (2010) discovered that barriers to women’s better health outcomes included violence, heavy workload and a lack of access to services. Health impacts from slow onset weather events such as drought and desertification include heat-wave related mortality, and malnourishment and disease from food and water insecurity in drought areas. These factors have significant gender impacts, particularly as women are usually responsible for collecting fuel and water and may have to walk much further in drought-affected areas. Additionally women are more likely to absorb the impacts of reduced food within their family by eating less themselves (Lambrou and Nelson 2010). In catastrophic events, gender impacts post-disaster include: higher work burdens for women in caring for the sick and injured; malnutrition as they prioritise food for husbands and children; mental health factors associated with trauma; loss of income; inadequate support for female-headed households; increase in maternal and infant mortality; genderinsensitive reconstructive policies; an increase in women’s workloads; deterioration of women’s working conditions more than men’s; slower economic recovery for women; and differential migration patterns (Alber 2011; Lambrou and Piana 2006; Lambrou and Nelson 2010). These impacts for women raise concerns about public health responses to climate disasters and the physical infrastructure built in post-disaster situations. Shelters are often constructed in isolated and unlit areas and require women and girls to walk in unsafe conditions to facilities, services and markets. Our research also reveals that access to family planning advice and support often breaks down in disasters leaving women at risk of unsafe sexual practices and unwanted pregnancies. In our three studies we also note that gender-based violence increases where families are suffering financial stress and when mental and emotional health is eroded. Regardless of its causes or oppositional debates, the United Nations Intergovernmental Panel on Climate Change (IPCC) has released a series of reports over a number of years warning that the build-up of greenhouse gases appears to be accelerating and that, unless global action is taken, consequences will be catastrophic (IPCC 2007). Yet the focus on the scientific veracity of the evidence for climate change has infiltrated the language of responses. This has resulted in global and national attention being focused on the technological aspects of postdisaster preparedness rather than social and community impacts. The MurrayDarling Basin in Australia is a good example, where drought has resulted in limited water for irrigation farming and resulted in national policy attention to water efficiencies, to buying back water licences and to exiting farm families from agriculture. Far less emphasis has been placed on supporting families emotionally through this major period of social upheaval and almost none at a policy level on resulting increases in gender-based violence.

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Gender mainstreaming and climate change policy Social policy refers to the processes established by governments to provide social protection and support the welfare of citizens (Spicker 2008). It is innately valueladen and, as a result, social policies are often condemned by feminists as strongly supportive of patriarchy and reinforcing the subordinate status of women (see for example Pascal 2001). Social policy development is very much shaped by the cultural context of society and therefore differs amongst nation states. Post-disaster response policies necessarily focus on keeping transport and communications services operating and ensuring access to food, water and shelter. In a crisis situation these issues are paramount. However our research and that of others demonstrates there is a need for gender sensitivity in the way these factors are addressed. The global community must be sensitised to the fact that climate change policy must be gender sensitive and must be assessed for gender discrimination and inequitable resource distribution. The Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) was adopted by the United Nations General Assembly in 1979. It sets out a platform for nations to remove discrimination. At the fourth World Congress on Women in Beijing in 1995, the Beijing Declaration and Platform for Action declared that women-focused initiatives had done little to advance gender equality and that what was needed was gender mainstreaming. Gender mainstreaming has been supported globally as a way to ensure that gender is a sensitising feature of policy development. The United Nations defines gender mainstreaming in the following way: Mainstreaming a gender perspective is the process of assessing the implications for women and men of any planned action, including legislation, policies or programmes, in all areas and at all levels. It is a strategy for making women’s as well as men’s concerns and experiences an integral dimension of the design, implementation, monitoring and evaluation of policies and programmes in all political, economic and societal spheres so that women and men benefit equally and inequality is not perpetuated. The ultimate goal is to achieve gender equality. (United Nations Economic and Social Council 1997) UN WomenWatch (2011) notes that climate change is not gender neutral and that the international community must ensure gender sensitivity. One way to achieve this through ensuring gender-disaggregated data is collected in all climate disaster situations. The World Health Organization (WHO 2011b) suggests that genderdisaggregated data is essential for measuring the vulnerability of communities and undertaking capacity assessments. Another is through scrutinising climate budgets to determine whether climate budgets and other resources are equally distributed. Gender budgeting has also been widely supported although has not been widely taken up by nation states (see Patel in this volume). The Council of Europe defines gender budgeting as: ‘A way of linking gender equality policy to macroeconomic

GBV in post-disaster recovery situations 101 policy . . . based on the premise that budgets are not gender-neutral . . . and as a way of expediting gender mainstreaming’ (Quinn 2009). Gender mainstreaming and gender budgeting are not without their problems. There is general resistance to the scrutiny of budgets and to power being shared; those in power fear a loss of authority and there is a lack of support from middle management for gender mainstreaming of policy and gender budgeting processes (Skard 2002; Hannan 2002; Alston 2006). Yet, if applied thoroughly and with the intent of improving gender equality and the empowerment of women, gender mainstreaming and gender budgeting can ensure that women’s vulnerability in post-disaster situations can be acknowledged and addressed. Given our findings, it is particularly crucial that differential gender vulnerabilities in health and welfare are assessed, that shelters and reconstruction sites are gender-sensitive, that differential health outcomes are monitored, that family planning support is maintained and that women are protected from violence and abuse. As a consequence of this lack of attention to gender impacts, climate change policy at national levels tends to devolve resources and personnel to technological solutions such as early warning systems, green energy projects and environmental protection measures – issues of significant importance to managing climate change events. Arguably, however, there is more limited attention to the health and welfare consequences of climate change, and gender is not mainstreamed in climate change policy. There is no doubt that this neglect is facilitated in many nations by the separation of policy portfolio areas. Furthermore, there is limited integration of policy across these government portfolios with reduced attention to the way climate change, health and other household and community issues are interlinked. Nongovernment organisations (NGOs) working in affected areas are more likely to attend to the gendered social and community issues because of their direct experiences in the field with people in post-disaster crisis situations. However they have less influence and ability to address these in national government policies and actions. The siloed nature of policy portfolios and the singling out of climate change for special policy attention has resulted in a disconnect between the scientific or technological attention to climate change risks and causes and the socio-cultural aspects that emerge from climate events. In Australia, for example, gender-based violence is addressed mainly by the Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA) but also by the Department of Health and Ageing and the Department of Education. Australia has also released a National Women’s Health Policy (Australian Government Department of Health and Ageing 2010) that establishes gender-based violence as one of the critical issues facing Australian women. Yet a new Department of Climate Change and the Environment appears to have a more scientific/technological focus and does not encompass social and gendered impacts for detailed analysis. The result is that policy-makers may ignore or dismiss gender-based violence in the context of climate events, or view it as a women’s issue to be addressed by other portfolio areas, resulting in a lack of integration of climate change and gender-based violence policy. Whether gender should be mainstreamed in climate change policy or climate

102 Margaret Alston change mainstreamed into gender portfolios is a matter for debate. It would appear sensible to do both.

Research findings Three studies in areas affected by climate events have been the subject of research undertaken from 2009 to 2011. The first was undertaken in the Murray-Darling Basin area of Australia, otherwise known as the nation’s food bowl as much of Australia’s food is grown in its rich agricultural areas (Alston and Whittenbury 2010). The area has been affected by a decade-long drought that has resulted in limited water available for irrigation farmers and water being redirected to urban areas and the environment. Water allocation has been subject to targeted government policy to buy water licences back from irrigators and exit them from farming. This policy has proved to be extremely divisive and has resulted in uncertainty and complexity for farming families deciding whether their futures lie elsewhere. Fifty-five women and men were interviewed and three focus groups undertaken with women during 2009–10. Because the issues of family breakdown and violence emerged as a significant but unforeseen issue in this research further research was undertaken in 2011 with service providers working in the area of women’s health and safety. Service providers have reported the following issues: violence against women increased significantly during severe drought years, evidenced by a rise in numbers of women seeking help; violence is exacerbated by financial pressures, evidenced by the cyclical nature of reporting which has tended to coincide with three-monthly bill cycles and with water policy announcements; increased male drug and alcohol use during this crisis period has led to increased violence, evidenced by reports from women interviewees; emotional and financial control/abuse affecting women increased during drought years, as described by women interviewees; and women are more isolated because they limit their time away from the farm because of the cost of petrol, a situation noted by both women and service providers. Service providers note that reporting of domestic violence incidents to police increased markedly during the drought, particularly during the period when water was being withdrawn from irrigators. Providers also note that more women are seeking help for relationship difficulties and that many are reluctant to admit to being victims of violence: Most of the time you just observe it [women’s experiences of violence]. It’s very rarely raised [with service providers]. (Service provider) You find a lot of that . . . it’s not always that easy to see – mental [abuse]. I go to farms quite a lot, and the man will do all the talking, and the wife won’t say anything. And a lot of the time I pick up from that she’s not game to say anything basically. When that happens, I usually try to make another appointment to make sure he’s not there. (Service provider)

GBV in post-disaster recovery situations 103 There has been a major focus in Australia on the depression experienced by men during the drought period, a much-needed focus that has brought this issue into sharp relief. Government resources have been directed to men’s help lines and other services. Beyond Blue, a high profile national organisation funded by government and other private sources, to address depression and other mental illnesses in Australia, has provided excellent support services, particularly for men experiencing mental health issues during the drought. There is much less of a focus on the experiences of rural women during the drought and very little if any focus on their experiences of gender-based violence. The focus on men’s mental health issues and the lack of attention to gender-based violence is disturbing as it demonstrates hegemonic masculinity extending to the cooption of drought experiences as peculiarly male. Women are absent from the imagery and representations of drought and this appears to have led to a lack of resourcing and support for women. Our second study was undertaken in the Pacific area in 2010 funded by the United Nations Educational, Scientific and Cultural Organization (UNESCO). Six key informants from non-government and government organisations were interviewed and a detailed systematic review of secondary data was undertaken resulting in the release of a report on gender and climate change in the Pacific (Alston and Vize 2010). The Pacific Islands have experienced both slow onset events such as drought, sea level and temperature rises as well as catastrophic events such as cyclone and storm surges. Health impacts include a rise in water-borne diseases and an increase in infant mortality. Violence against women is a significant problem in the Island nations regardless of climate events and is widely viewed by policymakers and others of influence as culturally grounded, a claim disputed by women’s organisations. This reference to culture allows policy-makers to distance themselves from the need for attention to gender-based violence in disaster situations. Our analysis reveals that gender-based violence is exacerbated in areas affected by climate events, that women’s poverty exacerbates their vulnerability, that men tend to migrate away for work following disasters and that in some instances they have brought the HIV/AIDS virus back, infecting their wives. Gender inequality and gender-based violence appears to have increased markedly in nations such as Papua New Guinea. Informants spoke of non-governmental organisations facilitating microcredit to assist women to develop their own income, but that women were being attacked and raped on the way to markets to sell their products. One key informant, Robyn, from a women’s international non-government organisation, noted there was some concern that women were so poverty-stricken they may be trying to sell their children. There is no doubt that gender-based violence has increased in the Island nations as a result of climate events. Following one cyclone we were informed that over 150 people died in Samoa; that women in this region were exposed to unsafe conditions in shelters and that reconstruction areas have poor lighting and require women and girls to walk further to school and markets. Existing women’s organisations have been working in post-disaster sites but receive limited resourcing for this additional work. The third study in Bangladesh is currently underway (2011–13) and includes key informant interviews and detailed case study site investigation across three

104 Margaret Alston divergent areas experiencing both slow onset and catastrophic climate events. Preliminary findings are indicating significant hardship experienced by women in the villages that form part of the research and an increase in gender-based violence as a result of catastrophic cyclones experienced in these areas. Women report violence is widespread regardless of climate events but that following cyclones and other extreme weather events they are at risk walking to shelters, while in shelters, and in post-disaster construction sites. Cultural constraints make it more difficult for women to walk alone and many do not go to the shelters for this reason. Some women of lower status were shut out of shelters during the cyclone. Women also report that there were no female toilets in the shelters and that therefore remaining in shelters for long periods of time is not possible under these circumstances. Women also report that their access to family planning services was interrupted and that this left them vulnerable to unwanted pregnancies. Young women interviewed report that climate events including river erosion has led to early marriage for women as young as ten or eleven because at this age the dowry is cheaper. These women report that they are exposed to violence if dowry is not paid (and many families are unable to pay following catastrophic climate events) and that many describe their experiences as ‘torture’. We are continuing to analyse the data from this study but data indicates that climate events in this region have increased gender-based violence, and in some areas close to borders, the trafficking of young girls. Women report they expect violence in their relationships and are powerless to change this. Climate events break down community and family supports, and increase significantly women’s vulnerability to violence and the constraints and sanctions against men. Under conditions of extreme stress, usual normative customs that minimise and condemn violence are not evident and this results in violence escalating within families. This breakdown of customary constraints and sanctions extends to shelters where women and girls are vulnerable to violence.

Lessons from the field Because gender is so significant in shaping experiences for women and men regardless of cultural context, it is no surprise that climate change has particular gendered impacts. As Nakray notes (in this volume) there are intersections between individual risk factors and other social and cultural factors that in combination create significant risk for women and girls. We have noted that gender-based violence following disasters has been identified in a number of sites across the world. Our research supports this claim and adds significant understanding to the evidence base. That gender-based violence is reported by women in a wide variety of cultural consequences during and after climate events suggests the need for gender sensitivity to be a critical factor in research, policy and planning surrounding climate change responses and planning and in public health spending. Our research in Australia, the Pacific Islands and Bangladesh indicates that women’s vulnerability to gender-based violence is not bound by culture but is a factor of vulnerability following catastrophic events.

GBV in post-disaster recovery situations 105 If we are to address the public health factors associated with climate change, we must go way beyond an analysis of air- and water-borne diseases and focus attention on gender-based violence, providing safe shelters for women and children, providing reproductive health services along with family planning support in the immediate crisis period, ensuring that girls are safe from rape and trafficking and that women’s access to food and water is not compromised by their altruistic need to support their family and put themselves last. We must also ensure that, in focusing on mental health aspects of disaster such as the Australian drought, we also note that women’s mental health is severely compromised and that resources must be provided to women as well as men. Women might be in need of legal counsel as well in situations where they have to establish rights over property especially if their husbands or parents have died. Existing literature from other disaster sites and our own work reveals an identified need for gender-disaggregated data in any assessment of climate change events, for gender sensitivity in all postdisaster responses and service implementation, and particularly in climate change policy initiatives. The health consequences of climate events are well documented. It is not so clear that these health consequences are gendered. In the context of climate events, health policy should be responsive to women’s needs for safety, for family planning access, for crisis interventions and for ongoing counselling and support following major trauma. Health responses must address immediate needs as well as medium- and long-term issues that result from climate events and the post-disaster situation. This should include addressing cultural factors such as early marriage and dowry and the particularly precarious situation of young girls in postdisaster situations in the medium and long term as well as the crisis period. We must also guard against any acceptance of gender-based violence as somehow culturally appropriate and therefore not open for scrutiny. It is clear from our research there is a lack of gender sensitivity in policy and planning around climate-induced disasters across the world. The key learning from our research is that climate change policy lacks a gendered lens and that this lack of attention leaves women particularly vulnerable. It is necessary to undertake gender mainstreaming of policy, planning and services to deal with the particular needs of both women and men during times of extreme crisis and gender budgeting of climate and disaster budgets to ensure that gender equality is an inherent part of post-disaster responses. A critical requirement would also be to incorporate more women into decisionmaking relating to climate events and ensuring that women’s views are collated and considered. The technological or scientific focus of climate change attention to date appears to have overshadowed the gendering of climate change experiences and more integration of policy is required. Incorporating public health, climate change and gender-based violence policy will help to address the consequences of climate events particularly for women. It is time to re-imagine climate change as a social issue with significant gendered consequences.

106 Margaret Alston

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Gender, use and abuse Sexually abused women in alcohol and drug treatment Jan Breckenridge and Michael Salter

Introduction The high rates of childhood sexual abuse and other forms of gendered violence in the lives of women in alcohol and/or other drug (AOD) treatment is now well documented (Najavits et al., 1997; Simpson and Miller, 2002; Wechsberg et al., 1998). Their treatment is typically complicated by psychiatric co-morbidities and underlying issues related to repeated physical and sexual victimisation from childhood to adulthood. However, the harms of sexual abuse and violence against women do not occur in a vacuum but rather take shape within the gendered inequities of health systems and social policies that fail to address the needs of this particular group. In the absence of protective or effective interventions, sexually abused girls and women frequently turn to AOD, but this response is both stigmatised and criminalised. Further, a new cycle of victimisation can be initiated whereby AOD-using women are subject to a range of punitive, disciplinary interventions by health, welfare and justice services. Service models do exist that specifically address the needs of sexually abused women with AOD problems (Greenfield et al., 2007; Grella, 2008; Messina et al., 2010), although public investment in such initiatives is limited. This chapter draws from a qualitative study of clients and former clients of alcohol and drug services with a history of sexual abuse in New South Wales, Australia.1 Alcohol and drug workers were interviewed as a separate cohort about their experiences of working with this client group. The study gathered provocative reflections from workers and sexually abused clients on the relationship between past sexual abuse and AOD abuse, and the ways in which treatment paradigms and contexts can facilitate or complicate recovery from substance abuse and trauma. After a brief review of the relevant literature, this chapter will focus on the reflections of client and AOD worker participants whose interviews suggest that AOD use can be understood as a mechanism for establishing a baseline of emotional regulation and control of the untreated, intrusive trauma symptoms common reported amongst sexually abused women. Clients and workers alike suggested that dominant understandings of ‘addiction’ in the AOD sector did not acknowledge the use of AOD as a coping strategy by sexual abuse survivors. This chapter will examine responses by the AOD sector to

Gender, use and abuse 109 the needs of sexually abused women from the perspective of clients and workers before discussing select policy and practice recommendations.

The perfect (gender) storm: abuse, illness and inequality In a global review of health risks, the World Health Organization found that child sexual abuse is responsible for between 7 to 8 per cent of the burden of disease amongst women due to its associations with depression and alcohol and drug abuse (Andrews et al., 2004). One third of the burden of post-traumatic stress disorder (PTSD) amongst women was attributed to child sexual abuse, as was 13 per cent of the burden of panic disorder. Child sexual abuse is linked to lower physical as well as mental health outcomes since it is a driver of lifestyle risk behaviours such as smoking and obesity (Draper et al., 2008). Despite sporadic resistance to research findings demonstrating the harmfulness of child sexual abuse (e.g. Malón, 2010), it is widely accepted that child sexual abuse has a significant impact upon the mental and physical health of girls and women in the community. However the ways in which these linkages unfold across the lives of sexually abused women are not fully captured by statistical measures, regardless of how useful and illuminating they may be. The impact of child sexual abuse upon the victim is shaped, to a significant degree, by experiential factors such as the relationship between the child and the perpetrator and whether the subjective experience of abuse is attended by emotions such as betrayal, helplessness or fear (Freyd, 1996). For girls and women, child sexual abuse has a social and political dimension in that it can signal to the victim that the thoughts, feelings and needs of girls and women are subordinate to those of men (Salter, 2011). The emotional and cognitive changes associated with child sexual abuse increase the vulnerability of girls and women to later abuse by coercive or violent men, and hence child sexual abuse survivors are over-represented amongst rape and domestic violence victims (Coid et al., 2001). The cumulative impact of multiple sexual and physical victimisations is further compounded by gendered inequities in health systems (Sen and Östlin, 2008). Health systems rarely allocate sufficient funds to address the health problems associated with gendered violence, and victims often use AOD as a coping strategy in the absence of accessible, affordable and effective health interventions (Briere and Jordan, 2009; Brown and Stewart, 2008; Leeies et al., 2010). This can intensify the cycle of re-victimisation since many of the contexts associated with alcohol and drug abuse (and illicit drug use in particular), are also associated with violence against women, e.g. criminal economies, street-based sex work. Women’s substance abuse commonly involves an intimate partner and AOD abuse is a well-recognised risk factor for domestic violence (Follansbee et al., 2006; Stuart et al., 2008). Moreover, Brady and Randall suggest that AOD-related health problems can be more acute for women than for men (see Brady and Randall, 1999). Paradoxically, AOD abuse can be understood both as a means by which victims respond to the repercussions of gendered violence as well as posing a significant risk of revictimisation and other AOD-related health problems.

110 Jan Breckenridge and Michael Salter Studies of sexually abused women in AOD treatment emphasise the gender differences in the aetiology of AOD abuse and in particular, the relationship between abuse, psychiatric illness and AOD use in women (Brady and Randall, 1999; Simpson and McNulty, 2008). There are a range of studies that suggest that drug treatment outcomes for clients with histories of child abuse improve when the client is provided with support in relation to broader abuse-related problems (Boles et al., 2005; Chiavaoli, 1992; Simpson and McNulty, 2008). When abuse is ignored as an aetiological factor, AOD treatment can prove harmful to clients where abstinence triggers the return of trauma memories and/or symptoms (Jarvis and Copeland, 1997) or where a disclosure of abuse is met with an inappropriate response (Copeland et al., 1993). However it would seem that, outside of the services that are specifically badged as gender-specific or gender-responsive, AOD treatment frequently ignores the relationship between abuse, mental illness and AOD use. Given the potential impact of this on relapse and treatment failure, documenting the experiences and perceptions of AOD clients with histories of sexual abuse is an important step in identifying potential shortfalls in AOD service provision. However, the voices of clients are often absent from the treatment literature, and even less is known about the experiences of the professionals who are intervening with these clients.

The research project This chapter is based on the findings of a qualitative research project undertaken by the Centre for Gender-Related Violence Studies at the University of New South Wales (UNSW), Sydney, Australia. Two groups of research participants were recruited and interviewed as part of the project. The first group comprised 16 adults (13 women and three men) with histories of child sexual abuse who had accessed alcohol and drug services in New South Wales in the five years prior to interview. Client participants were recruited from a range of health-funded AOD rehabilitation and generic counselling services as well as community self-help organizations. The second group comprised 15 workers and managers (14 women and one man) from a selection of health-funded AOD services who volunteered to be interviewed in-depth, about their experiences of working with this client population. The worker participants represented a range of professional backgrounds (including psychology and social work) as well as those who nominated their expertise as coming from their own experience of AOD recovery and general welfare work. Interviews were semi-structured and aimed to elicit and explore the perceptions and experiences of both workers and clients regarding AOD treatment. Data analysis was based on the principles of grounded theory, defined by Strauss and Corbin (1990) as the breaking down, naming, comparing and categorising of data, in which hypotheses, theories or best practice strategies are generated directly from the data, rather than through a priori assumptions or existing theoretical frameworks. All qualitative data from both cohorts of participants are presented in italics to demonstrate the authenticity of participants’ voices. Approval was successfully sought from UNSW’s Human Research Ethics Committee (HREC) Approval

Gender, use and abuse 111 Number 08205 as well as the Ethics Review Committee (RPAH Zone) of the Sydney South West Area Health Service Approval Number X08-0280.

Identifying, naming and claiming the links between abuse and AOD use The workers interviewed as part of this project were a self-selected group who reported considerable interest and understanding of the overlap between sexual abuse, mental illness and substance abuse. As such they do not represent the majority of either AOD or mental health workers who maintain a separate and specific focus on either AOD treatment or mental health issues. As a group they were already sensitized to these issues and keen to discuss their understanding of ways that these issues complicated the treatment pathways of clients. Most worker participants were currently employed in services in which routine screening for trauma and abuse was not used in intake procedures but they were all cognisant of the high rates of sexual abuse amongst female clients. Those workers who did take a trauma history from clients suggested that rates of disclosure were likely to be lower than actual rates of abuse: In asking everyone [women] at screening, I’d say around 70–80% have experienced childhood abuse and 40–50% have experienced rape as adults. That’s of the women who disclose, and not all do. (Service worker) It was common for workers to suggest that some services were better placed to address abuse-related issues with clients than others. The focus on the immediate medical needs of clients at detoxification services, for example, as well as the physical working environment meant that there was neither the opportunity nor the space to engage clients regarding more complex issues: Ninety per cent of child abuse histories would not be picked up in a detox setting as the clients come in high, they’re often homeless. Many are out of it so an assessment or history taking would never take place. There is no opportunity to refer on as we aren’t aware of their [past abuse] issues. Often the assessment, as far as it goes, took place in the open plan office with others present, so it wasn’t private enough. (Service worker) Clients also emphasised the importance of addressing abuse-related issues in a timely and appropriate manner. Some participants lamented the failure of healthcare providers to make the links between sexual abuse and substance use earlier in their lives, indicating that without this knowledge they had internalised the shame and stigma associated with substance abuse: If only a psychiatrist or psychologist had been able to say to me, ‘You know that twitching you have when you speak of molestation? That’s because of not being safe at home’. Instead

112 Jan Breckenridge and Michael Salter they said, ‘It’ll be better in long-term rehab, get a bit of distance and learn life skills’. I thought because I was bad, I was being sent away. (Female service user) In their research interview, a selection of client participants were able to retrospectively map the way in which their AOD and mental health difficulties developed, often explicitly linking patterns of AOD behaviour with the ways in which they self-medicated to cope with the ongoing effects of the abuse experienced in their childhood and the pain caused by these experiences in adulthood: At this programme the pennies are now dropping. In the past [in other rehabs] we just studied the NA [Narcotics Anonymous] book. Now I’m looking at trauma, the cycle of violence. Now I see I was in the cycle with my mum and in other relationships. I always thought it was me, that I attracted [abusive] people like that. (Female service user) It seemed that, when workers were able to make the link between past sexual abuse and adult AOD use, participants directly utilised this information to develop increased insight into both their AOD use and their experiences of sexual abuse. However participants indicated that there were systemic barriers in the AOD sector to providing this information. Not only were some services considered poorly equipped to deal with such sensitive topics, but workers suggested that culture of the AOD sector tended to discourage or even prevent clients from putting their AOD use in the context of their life history. Client participants similarly expressed the fear that in some services a woman who linked her AOD use to past abuse would likely be viewed by many AOD workers as ‘denying responsibility for their own addiction’, ‘making themselves out to be a victim’ and ‘using their past to excuse their drug-taking behaviour’. The exclusive focus on AOD use functions to minimise or exclude considerations of past trauma and even current mental health concerns, effectively limiting the provision of appropriate and integrated treatment for women survivors of childhood abuse with AOD concerns.

Conceptualising AOD use as ‘self-medication’ or ‘self-soothing’ AOD use is typically framed in the AOD sector in terms of ‘addiction’, understood as a biological state of dependency which induces craving and compulsion. However moral and political judgements are apparent alongside the medicalisation of substance abuse, in which the ‘addict’ is envisioned not simply as ‘sick’ but also as irresponsible and self-indulgent, even criminal. Ubiquitous labels such as ‘addict’ construct the stigma associated with AOD use and provide yet another burden for clients with a history of childhood sexual trauma. In interviews, clients described powerful feelings of pain and shame arising from their experiences of child sexual abuse and other abuse:

Gender, use and abuse 113 The abuse is one thing, but it is every day after that you have to contend with. I had sexual, physical and emotional abuse . . . by my mother and father. Looking back when I used alcohol hard it was to numb the pain – socially, the loneliness, ‘I’m a piece of shit and to blame for everything.’ (Male service user) I started smoking and drinking at the age of 15 after having repressed memories surface. Within the family, the situation had been difficult at the time and I couldn’t talk to them. Alcohol was a means of repressing the pain. (Female service user) For the most part, worker participants demonstrated considerable insight into the lived experiences of adults with histories of sexual abuse and AOD use. Their appreciation of the negative emotional consequences of sexual abuse fitted with clients’ experiences of their own lives and is typified in the following comment: It is the case that they self-medicate because when the abuse happened there was no opportunity for the child to be validated or supported. Few have had a good response from caregivers. So for some it’s about the child not being given support and so they had to seek other ways to cope. They choose AODs ’cos they work; opiates in particular make you feel comfortable in your own skin. (Service worker) Both client and worker participants strongly contested the moral and medical simplicity of the ‘addiction’ model, and routinely framed AOD use as a dys/ functional method of ‘self-medication’ aimed at emotional regulation and the management of out-of-control feelings and memories: I don’t see the links between child sexual abuse and drugs and alcohol as causal, but more likely that abuse will lead to problems with self-esteem. Many other skills such as regulation of emotions are missed, they aren’t able to tolerate distress or to self soothe. So while sexual abuse it is not causal, it is more likely to lead to alcohol and drug problems. Substance abuse can be a substitute for coping and to regulate emotions, a way of coping with stress, ironing things out. Alcohol and drugs can be used to fill the void. (Service worker) Some workers and clients were able to link AOD use with attempts to suppress the intrusive symptoms of PTSD disorder that are difficult to treat even with psychopharmacotherapy (see Raskind, 2009): AOD use is such an important tool to manage nightmares, flashbacks, being unable to speak, relationship problems, and if this affects daily living then it is important to work with. (Service worker)

114 Jan Breckenridge and Michael Salter Workers highlighted a treatment paradox in which the cessation of AOD use could precipitate the re-emergence of debilitating trauma symptoms in the lives of clients with histories of child abuse, which accords with research and clinical literature ( Jarvis and Copeland, 1997). Although they acknowledged the negative health and social consequences of AOD use for clients, workers indicated that AOD use could equally be perceived as ‘self-soothing’ and had an important role to play in stabilising otherwise intolerable trauma symptoms: Drugs help numb the feelings, produces positive feelings that override the negative emotions. Some have been abused to such a degree that it is to obliterate having any feelings at all. For some, the secondary trauma of life since then, struggles with relationships and life on the streets, their inability to cope with daily life, is what then perpetuates the using. (Service worker) For clients giving up drugs is scary as they know symptoms will come up and it is hard to think of effective replacements, of finding coping mechanisms as effective as drugs. (Service worker) The notion that AOD use is a functional form of self-medication for trauma survivors has tentatively circulated throughout the literature on trauma and abuse for some time (Najavits et al., 1997; Roesler and Dafler, 1993; Rohsenow et al., 1988). However it represents a radical departure from the entrenched moralism that characterises much AOD policy and practice. Emerging from this has been a rigid insistence on abstinence which workers in this study indicated was not only unachievable for many clients with histories of abuse, but potentially dangerous: Depending on the intervention context the importance of the links between self-medication, symptom control and past abuse can be missed. This is particularly concerning because treatment insistence on total abstinence can result in a massive increase in negative feelings and memories that exacerbate mental health conditions such as depression and suicide ideation which in turn can trigger a relapse in alcohol or drug use. (Service worker) There is a sense that if they get their drugs and alcohol recovery addressed all the other issues will go away as well. However, they stop using, and feelings and memories regarding the abuse become more apparent. (Service worker) Worker or service insistence on unrealistic treatment goals such as total abstinence is indicative of the rigidity of many AOD treatment paradigms and the compartmentalisation of service provision. Many client participants reported that the efficacy of treatment seemed to depend on ‘luck’ – finding the right worker, at the right time, often in unlikely places. Receiving effective treatment addressing both

Gender, use and abuse 115 AOD and mental health issues pertaining to child abuse was seen as ‘serendipitous’ rather than an integrated, comprehensive therapeutic offering consistently available in an either AOD or mental health services.

Women as AOD users and mothers: treatment implications Women with AOD problems are likely to have dependent children and this has a range of implications for treatment and recovery. Sexually abused women can feel particularly vulnerable and uncertain throughout pregnancy and as mothers (Breckenridge et al., 2008; Kim et al., 2010; Stojadinovic, 2003) and these difficulties are compounded for women with AOD problems by the stigmatisation of mothers with AOD problems (Finkelstein, 1994). Again, a seeming paradox emerged from the narratives of client and worker participants whereby a woman who selfmedicated with AOD, to better manage their lives including the care of their children, could compromise their parenting and trigger the involvement of statutory child protection involvement whereby children were removed and/or AOD treatment was mandated. The complexity of the pressures experienced by this group of women in relation to their parenting was mostly ignored or minimised in AOD treatment contexts. In the study, it became apparent that AOD services did not attend well to issues of parenting and the needs of children, even when funded to do so. In interview, a number of worker participants spoke of their concerns about the approach of many AOD services to clients with children. They suggested that AOD staff found it difficult to take family relationships into account, and were at times dismissive of the relationship between parents who are drug affected and their children – even at services claiming to offer a service for women and their children: Even in a residential facility for woman and children like ours, it is not child focused. The mother is the client and the children come too. In fact although we have the capacity, we don’t even have as many women and children stay here as we could, which is interesting. (Service worker) They say they’re child friendly but it’s not. Mothers here are more stressed. There is nothing for them [the kids], no TV, they’re stuck in the house unless they go to school. There’s no programme for them. They go into a playroom when the mothers are in groups but they’re bored. They put pressure on mothers to keep the kids occupied and be a good parent, while the parent is sick and that’s why she’s here. It is really unfair for parents and children. Others are not allowed to give help ‘cos it’s their responsibility. Parents are really stressing and others are upset by it. (Service user) Some workers (particularly those with children) were concerned that the lack of skill and/or interest in family intervention in some services acted to negate the mother–child bond. This was then justified by the prevailing treatment philosophy that the parent ‘has to straighten themselves out first’:

116 Jan Breckenridge and Michael Salter Many workers are not parents themselves. No one is in tune with the dynamics and family relationships. They see it only in terms of recovery, perhaps at all costs. (Service worker) The comment ‘perhaps at all costs’ speaks to a very particular and rigid treatment regime often described by participants as emanating from AOD services following the 12-step AOD Programme whereby abstinence is the total and only goal of treatment and requires the ‘addict’ to take responsibility for their recovery often to the exclusion of other life factors – such as being a parent: In our service the woman is our client and her recovery is our focus. This can mean she forsakes her children if the obligations or worry regarding her children seem to compromise her recovery. Making decisions regarding care of children, for example ‘putting up with’ a poor relationship, accepting financial support, even fighting to get children back, can be framed as ‘selfish’ and not in keeping with recovery. In one case recently it was thought that doing these things to care for a grown child was not in her interests, that is, in the interests of her recovery. (Service worker) The common treatment expectation that women should separate their recovery needs from their ongoing relationship with their children increases the stress experienced by AOD users and can prompt clients to leave treatment and/or use AODs to self-soothe and reduce their distress: I miss my kids. I don’t know if I can handle being in here without my daughter. I feel like leaving. (Service user) But him [son] being taken away enabled me to use more. (Service user) Workers also clearly identified their dilemmas in knowing how best to respond to the often serious child protection concerns associated with an AOD abusing parent/s. While the sympathies of many worker participants were with their adult clients, they described their difficulties in managing the contradictions between the best interests of their clients and their children: We develop an alliance with the mother – you develop compassion and sensitivity for the mother, knowing her childhood, knowing that she doesn’t have the capacity to care for herself, let alone anyone else. So I suppose that is hard – having that compassion for the mother, and yet still having such deep feeling for the child. And realising that sometimes separation is the best thing for the child, and on one level – yes, it’s the best thing for the child – yes on one level, but not really on another. That push and pull, emotionally, is the hardest thing to cope with in this work. (Service worker)

Gender, use and abuse 117 The lack of attention paid to parenting in AOD treatment means parents may leave treatment somewhat recovered but with no greater parenting ability or attunement to their children. Even at services that were said to be for parents and children, many clients did not feel well supported in their parenting: I have a son and they didn’t give me any help, no counselling or welfare. I couldn’t stop using, and we went to court and he was taken out of my care. All I was told was ‘stop using’ but I couldn’t. I had a DoCS worker [Department of Community Services – State based (New South Wales) statutory child protection body], but no counsellor. I was told to stop using or they’d take my son out of my care. They wanted me to go to parenting classes but the parenting wasn’t related to drug use. They said do A, B, C, then I did that and there was more to do. I just ended up using. (Female service user) All of the clients interviewed in the study reported significant sexual, emotional and physical abuse and neglect throughout their childhoods, although almost none had had any intervention by statutory bodies or counselling to address their own abuse. The description of ‘missed opportunities’ poignantly describes the way many AOD clients described lack of appropriate interventions offered at the time of their childhood trauma and then later in life for its effects. Some identified the intergenerational links, and a certain helplessness about breaking the cycle without someone (outside the family) showing them how: I thought he was better off without me. I suffered at mum’s hand and I didn’t want that for him. (Female service user) I didn’t get pointed in any directions. It was all about dirty urines and court. Not all mothers that use are bad mothers. They need guidance unless the child is in immediate threat of harm. If a service had worked with me I’d have been really willing to break the cycle then. I pretty much gave up hope. It was a really big opportunity missed. (Female service user) It was very clear that services for parents and children that focus on the needs of all family members, the family as a whole, and the special issues raised as a result of intergenerational abuse and AOD use are almost non-existent. This is despite the fact that the majority of people with a chronic AOD problem will at some point become parents, and in the face of the social and financial cost of the foster system. This is a highly significant service gap, and one that has significant social and community implications. Workers who are employed in services catering for families have very mixed experiences; allowing families to seek treatment together does not necessarily mean that they will receive care from trained family workers, or that parents will emerge from AOD treatment with greater attunement to the needs of their children.

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Treatment implications The simplistic treatment notion that people “choose to use” alcohol or drugs fails to acknowledge the limited and constrained choices that face many women who have experienced violence and abuse as children and adolescents. As a result, AOD services may punish women for their coping mechanisms rather than supporting them to work towards developing healthier responses. Clients with a trauma background who self-medicate with AOD as a genuine attempt to manage their trauma symptoms may require a staged approach to drug withdrawal and parameters within which they can still seek treatment without being compromised psychologically. It was clear from the research that in order to best respond professionally to the intersections between child abuse, AOD and mental health, the provision of specialist training, supervision and support of workers is a first, and fundamental, step in constructing effective and comprehensive AOD services. In this study, four key practice issues emerged as crucial to constructing effective and comprehensive AOD services. Providing counselling and therapy The availability of counselling for survivors of childhood abuse is limited generally, not just for those with AOD issues. However, client and worker participants consistently emphasised the importance of professional and ongoing counselling being available – either within AOD services or externally brokered. Group programmes While 12-step groups are the ‘backbone’ of the AOD sector in many regards, client and worker feedback on the helpfulness of group work for abuse survivors with AOD problems was mixed. Client participants agreed on the usefulness of the information/education component of group work however almost all retained a strong preference for individualised care and intervention. Parenting programmes It was very common for client participants in this study to have disclosed difficulties with their parenting and in most cases they reported involuntary contact with child protection agencies. Despite explicit evidence of problems with parenting, clients and workers all suggested that AOD services do not attend well to issues of parenting and the needs of children, even when funded to do so. To address this gap requires investment in worker training and re-conceptualising how AOD intervention may better address the needs of children and help rebuild the mother–child relationship.

Gender, use and abuse 119 Gender-specific and gender-responsive programming In this study, both clients and workers were unanimous that gender-specific services are crucial in the treatment of adults with histories of child abuse and AOD problems. It is common for female AOD users to express a preference for a womenonly environment, and those women with histories of abuse and trauma are a group for whom such an environment is particularly attractive (Copeland and Hall, 1992; Nelson-Zlupko et al., 1996). Common practices in the AOD sector, such as group programmes, peer support and the recruitment of former clients as service staff, appear to have evolved (at least in part) because they are relatively inexpensive. However this study emphasised the complexity of the needs of sexually abused clients and hence the need for more comprehensive and integrated service provision by staff with the training to appreciate the sensitivities of this work. Unfortunately the dearth of resources and referral options for this client group within the AOD sector, and in the health system more generally, only perpetuated their experiences of abuse and neglect.

Conclusion Women frequently present at alcohol and drug services with histories of abuse and violence that go unacknowledged in prevailing service models, which can penalise clients whose complex needs and life circumstances fall outside a ‘one size fits all’ approach. In this study, both client and worker participants framed AOD use as a frequently misunderstood coping strategy used by adult survivors. The experiences of workers and clients participating in this research underscore the need for a fundamental change in AOD organisational culture in relation to adult survivors of child abuse, as well as the development of new capacities and services in the sector. The data demonstrates that where service contexts are characterised by linear, mono-modal approaches to treatment, they can fail to accommodate complex clients and may inadvertently function to compromise survivors’ chances of AOD recovery. Client participants described compelling histories of ongoing cycles of seeking help from AOD and other welfare services until the links between their AOD use and their childhood trauma were made. This should be seen in the context of research which finds that women with histories of child sexual abuse present more frequently in a range of health care settings than other women, resulting in increased health costs to the women, insurers and the public purse (Finestone et al., 2000; Hulme, 2000; Walker et al., 1999). The needs of adults with histories of child abuse and AOD problems call for a general reassessment of the prevailing punitive and moralistic view of AOD use, and a more complex understanding of the role that AOD use can play in people’s lives as a coping mechanism and in particular as a form of self-soothing. The persistence of AOD use for some adult survivors, despite repeat contacts with AOD services, may not be evidence of their lack of readiness or commitment to treatment as much as the failure of services to recognise and address the complex role that AOD use plays in their lives.

120 Jan Breckenridge and Michael Salter

Note 1 This project was funded by the Mental Health Coordinating Council (MHCC) of New South Wales, Australia, under the Non-Government Organisation Mental Health and Drug and Alcohol Research Grants Programme. For the full research report, see Breckenridge, Salter and Shaw (2010).

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122 Jan Breckenridge and Michael Salter Simpson, T. L., and Miller, W. R. (2002). Concomitance between childhood sexual and physical abuse and substance use problems: A review. Clinical Psychology Review, 22(1), 27–77. Stojadinovic, T. (2003). For the first time somebody wants to hear: The effects of CSA on women’s experiences of pregnancy, birth and mothering. Adelaide: Women’s Statewide Health. Online. Available at: (accessed 31 March 2012). Strauss, A. L., and Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park, CA: Sage. Stuart, G. L., Temple, J. R., Follansbee, K. W., Bucossi, M. M., Hellmuth, J. C., and Moore, T. M. (2008). The role of drug use in a conceptual model of intimate partner violence in men and women arrested for domestic violence. Psychology of Addictive Behaviors, 22(1), 12–24. Walker, E. A., Unutzer, J., Rutter, C., Gelfand, A., Saunders, K., VonKorff, M. and Katon, W. (1999). Costs of health care use by women HMO members with a history of childhood abuse and neglect. Archives of General Psychiatry, 56(7), 609–13. Wechsberg, W. M., Craddock, S. G., and Hubbard, R. L. (1998). How are women who enter substance abuse treatment different than men? A gender comparison from the Drug Abuse Treatment Outcome Study (DATOS). Drugs and Society, 13(1–2), 97–115.

10 The impact of intimate partner violence on the mental health of Latin American immigrant women in the U.S. Blanca M. Ramos Introduction Intimate partner violence (IPV) against women is an insidious global public health problem and a fundamental violation of human rights. IPV is the most common form of violence against women and includes psychologically, sexually, and physically coercive acts by a current or former male husband, boyfriend, or male partner (United Nations, 2011). The pain and suffering physical and psychological violence inflicts upon victims have multiple consequences including an adverse effect on the emotional well-being of victimised women and their families, particularly children. For immigrant women, xenophobia, oppression, and undocumented status in the receiving countries can further increase their risk for IPV and curtail options to end abusive relationships, obtain informal help, and access formal services. As women increasingly cross international borders due to migration and related social transformations globally, public health social work to prevent mental health breakdown and support and protect the mental health of IPV victimised immigrant women worldwide is crucial. This chapter provides a comprehensive overview of the potential adverse mental health consequences of IPV among immigrant women from Latin American countries in the United States (US). The chapter begins with a brief portrayal of the intimate partner violence against Latinas in United States. Information on their incidence of IPV and risk and protective factors is provided. The potential impact of IPV on emotional well-being is discussed drawing from stress-coping models of mental distress. Strategies for effective public health social work responses to address IPV and support victimised immigrant women are offered. Latina women migrants in United States: prevalence of intimate partner violence In the US, as in other parts of the world, IPV against women is a significant public health problem. According to US government statistics, in 2007 about 554,000 violent crimes against women were committed by an intimate partner and 40 to 50 per cent of all murders of women were IPV-related in 2002 (VPC, 2007). It is estimated that each year about 1.5 million women are raped or physically assaulted

124 Blanca M. Ramos and over 1 million are stalked by intimate partners (U.S. Department of Justice, 2000). Comparative studies examining IPV prevalence differences across ethnic groups in the US have yielded inconclusive results. For Latinos, some found higher (Straus and Smith, 1990), lower (Tjaden and Thoennes, 1998) and similar (Kantor et al., 1994) rates compared to non-Latinos. Data from the US Department of Justice indicate that Latinas experience about the same level of physical assaults and stalking as do non-Latina women, but report a 2.2 per cent higher level of rape (Violence Prevention Coalition, 2007). The prevalence rates of IPV against Latina immigrants are difficult to ascertain. Most available data are presented as an aggregate for the Latina ethnic subgroup and do not distinguish between immigrants and non-immigrant Latinas. These data indicate rates of 21 per cent to 35 per cent for lifetime IPV and 4 per cent to 33 per cent for IPV in the last one to three years (Bauer et al., 2000; Bonomi et al., 2009; Dearwater et al., 1998; Fedovskiy et al., 2008; Wu et al., 2003). The US Department of Justice estimates that about 21.2 per cent of Latinas will be physically assaulted, 7.9 per cent will be raped, and 4.8 per cent will be stalked by an intimate partner during their lifetime (Violence Prevention Coalition, 2007). In a study conducted by the Immigrant Women’s Task Force of the Northern California Coalition for Immigrant Rights 34 per cent of Latinas reported IPV experiences either in their nation of origin, in the US, or in both (Lee and MorelloRosch, 1991). In a sample of 309 primarily immigrant Latinas from Mexico, 70 per cent reported violent victimisation in the previous year (Murdaugh et al., 2004). Conversely, some research suggests that IPV may be less prevalent among Latina immigrants compared to non-immigrant populations. For example, in a review of the relevant literature Klevens and colleagues (2007) concluded that data on the incidence of IPV in immigrant communities is far from conclusive. Latina women migrants in the United States and intimate partner violence: double oppression In 2010, there were 25 million Latinas in the U.S. (U.S. Bureau of the Census, 2010a). However, this number could be considerably higher because it does not include Latinas who were not enumerated because they preferred not to be counted, lacked proper immigration documents, or were simply missed by census workers. According to the American Community Survey, approximately eight million Latinas over the age of 18 were foreign-born (U.S. Bureau of the Census, 2010c). Latina immigrants are diverse primarily because they trace their ancestral backgrounds to a range of Latin American nations (see Figure 10.1). Additional differences include immigration history and status, socio-demographic characteristics, acculturation levels, length of stay, and geographic distribution in the U.S. Latina immigrants also share some commonalities including the Spanish language, cultural traits, and the social disadvantages that accompany Latino ethnic minority group affiliation. In the U.S., where people from many national origins and diverse cultures coexist, ethnic groups are placed in stratified positions where opportunities and

Latin American immigrant women in the U.S. 125 privileges are unequally distributed (Pearlin et al., 1990; Schaefer, 1996). Certain ethnic groups, including Latinos, are ascribed minority status, which signifies differential treatment, social disadvantage, disempowerment, and collective discrimination (Aguirre and Turner, 1995; Parrillo, 2000). For example, educational attainment is low for most Latinas; only 63.3 per cent of those 25 years and older have completed high school or its equivalent, or higher. Most Latinas are employed in low-paying jobs with fewer holding professional-managerial positions. The median income of female-headed households is just under $25,000 a year, with the median earnings of full-time, year-round workers at just below $27,000. The overall poverty rate for female-headed households in 2010 was 38.8 per cent. The poverty rate for Latinas, compared to 25.2 per cent for White women, is 40.7 per cent. These rates are substantially higher across the board for those households who have related children under 18 years old (U.S. Bureau of the Census, 2010b). Also, for decades Latinas have been exploited in the labour force, where they have been confined largely to low-level jobs that capitalise on their gender-specific skills and are unattractive to men. Latinas have been employed under deplorable working conditions, long hours, very low pay, and few or no medical and retirement benefits, primarily in factories and sweatshops, and as domestic and migrant farm workers (Hesse-Biber and Carter, 2004). Despite their significant contributions to the U.S. economy over time, Latinas occupy one of the most underprivileged positions in today’s society. Latinas experience oppression not only due to their ethnicity but also because of their gender. The social inequalities they face, due to ethnic prejudice and discrimination, are compounded by those stemming from the ideology of sexism which predicates male superiority and, thus, a subordinate status for women. One of these prescriptions clearly places work and family responsibilities in two distinct separate spheres, ascribing to women the family roles of primary nurturers, kin keepers, and uncompensated caregivers. Despite recent changes in gender family roles, women continue fulfilling the roles of mothers, wives, daughters, and daughters-in-law and, as a result, provide the vast majority of family care across the life span (Hooyman and Gonyea, 1995; Ramos, 2001). Some relate to cultural patterns espoused in their societies of origin and others to the opportunities, challenges, and social conditions they encounter in the new home country. First, hierarchical, patriarchal structures are at the core of traditional Latin American societies. Here, the man is regarded as the head of the household and the woman is expected to defer to him in a submissive, obedient manner (Malley-Morrison and Hines, 2004). Similarly, certain key cultural values and religious beliefs such as familism, marianism, and fatalism operate together to reinforce a patriarchal family structure. Familism ascribes central importance to the family and prescribes strong loyalty to the family, affiliation over confrontation, and interdependence over independence. This value also expects family members to place the needs of the family above their own and to keep the family together (Ramos and Carlson, 2004). A closely related value stemming from the religious belief in the Virgin Mary is marianism, which idealises characteristics of femininity and motherhood such as

126 Blanca M. Ramos humility, acceptance of fate, and self-sacrifice. Fatalistic beliefs entail acceptance of an unkind fate, passive endurance, and external locus of control (Ramos, Jones, and Toseland, 2005). Second, Latin American women usually migrate to the U.S. seeking safety, freedom of choice, employment, and better economic and social conditions. More recently, an increasing number are migrating to escape IPV in their home countries. Yet, once they reach their “dream” destination, many come to the harsh realisation that their reception is not favourable and their opportunities for employment, housing, education, and rights to health and healthcare are limited. Contemporary immigrant Latinas are forced to endure the social disadvantage, marginality, and disempowerment resulting from social exclusion, differential treatment, and unequal distribution of resources that have long been accorded to Latino ethnic group members as well as to other indigenous people in the U.S. (Ramos, Carlson, and Kulkarni, 2010). Risks and protective factors against intimate partner violence among Latinas A number of socioeconomic, ethnic, and cultural factors may place many at high risk. As with women in general, youth, low socioeconomic status, and psychosocial stress tend to increase their risk for IPV (Cunradi et al., 2002; Klevens, 2007; Lown and Vega, 2001; Perilla et al., 1994). Several factors specific to Latina immigrants not only heighten their vulnerability for IPV but also limit their options to get help and/or leave abusive relationships. These factors, which interact with each other, include those associated with (1) migration and resettlement, (2) cultural values and norms, (3) immigration status, and (4) Latino ethnic group affiliation. The migration and resettlement processes bring about many changes and challenges including new linguistic and often conflicting cultural expectations, psychosocial stressors, the loss of previously established social networks, and the need to navigate a new, unfamiliar environment. These predicaments can have adverse consequences for women already in abusive relationships or in relationships where marital conflict can potentially erupt. For example, women can become socially isolated, unaware of their legal rights and formal resources for help, and left with no choice but to stay in peril with the batterer in the face of the unknown. Data have linked social isolation and lack of social support to IPV among Latina immigrants (Lie and Lowery, 2003). Research has shown that changes in cultural practices and psychosocial stress stemming from migration and resettlement can affect the power dynamics in marital relationships, which if not successfully negotiated can lead to IPV against the female partner (Raj and Silverman, 2002). Although culture per se does not explain or cause IPV, a hierarchical, patriarchal family structure and some cultural values and religious beliefs that interact as part of a complex web can influence how IPV manifests itself and the ways in which Latina immigrants experience victimisation. For instance, gender roles prescribed by familism may become maladaptive when male partners adhere rigidly to them and misuse their privileged position in the family to deliberately dis-

Latin American immigrant women in the U.S. 127 empower, hurt, and abuse their female partners. The literature identifies traditional gender roles as a risk factor for IPV among immigrant women, including Latinas (Bui and Morash, 1999; Morash et al., 2000; Perilla, 1999; Tran and Des Jardins, 2000). Familism practices can also preclude victimised women from seeking help, disclosing, or reporting the abuse as doing so would entail breaking up the family they are charged to keep intact (Raj and Silverman, 2002). Marianism and fatalism may encourage women to self-sacrifice and accept the violence believing they have little or no control over it. A woman who deviates or does not adhere to marianist prescriptions might be at great risk of IPV as her male partner can use it as an excuse and justification to perpetrate abusive behaviours (Ramos and Carlson, 2004; Vasquez, 1994). Oppression and racism due to Latino ethnic group affiliation, particularly in the job market, can directly or indirectly increase the risk for IPV against women. For example, a male partner who is unemployed or underemployed because of prejudicial attitudes and discriminatory behaviours, feeling demoralised and/or unable to fulfil the role of economic provider, may turn to alcohol abuse. Alcohol consumption by male partners has been associated with IPV against female partners in research with Latino populations (Caetano et al., 2000; Schafer et al., 2004; Van Hightower et al., 2000). On the other hand, if it is the female partner who finds employment, albeit with menial pay and under oppressive working conditions, the male partner may become resentful and unable to deal with this gender role reversal which affects the power dynamics in their relationship, channelling his anger and frustration through IPV. Latina immigrants usually bring readily transferable gender-specific, homemaking skills that make them highly sought out in the labour market (Ramos and Carlson, 2004; Vega, 1995). Immigration status is perhaps the most salient concerning factor for unauthorised immigrant Latinas with a male partner who is a U.S. citizen or an authorised immigrant. A batterer can use threats of deportation, which often entails leaving her children behind, as a means to exert power through abusive behaviour and perpetuate the cycle of violence (Anderson, 1993; Ramos et al., 2009). Foreignborn Latinas in relationships arranged through international brokers or dating services are often expected to be passive and subservient and may find themselves at the total mercy of a male partner’s power and control in a new, unknown environment (Runner et al., 2009). When the batterer is an unauthorised immigrant, he can use fear of his own deportation to justify his abusive behaviour. He can further manipulate to his advantage his victim’s beliefs in endurance, self-sacrifice, and forgiveness, deeply ingrained through the values of familism and marianism. Hence, the batterer knows with certainty she would not jeopardise his immigration status and even expects her to tolerate the abuse, forgive him, and self-sacrifice for the benefit of her children, if any, and that of the rest of the extended family. Much remains to be learned with regard to protective factors against IPV among immigrant Latinas. As members of an oppressed group, Latinas have historically relied on their own cultural traditions and ethnic community for survival and continuity under adverse environmental conditions (Ramos et al., 2010b). Yet, when it comes to IPV, as these mechanisms intersect with socio-political and socio-

128 Blanca M. Ramos historical contexts, they may not necessarily serve to protect victimised Latina immigrants, but rather to make their already vulnerable situation even more dire. Some Latino communities may espouse beliefs and attitudes that condone, minimise, or ignore IPV against women, blame the victim, do not support victimised women, and prefer not to get involved in a domestic dispute particularly if it entails involving the police (Ramos et al., 2010a). A study on public opinions about domestic violence in a Latino community found an awareness of the potential causes and consequences of IPV and the recognition that it is a social problem (Klevens et al., 2007).

Intimate partner violence and mental health among Latina immigrants This section uses a stress-coping framework (Lazarus and Folkman, 1984) to explore how when the psychosocial realities of a victimised Latina immigrant intertwine with the dynamics of IPV she could be at an even greater jeopardy for adverse mental health consequences. From this perspective, IPV can be viewed as a monumental stressor or a person–environment relationship that a victimised woman appraises as taxing or exceeding available resources and endangering her wellbeing. Victimised Latina immigrants are not only forced to endure the massive stress generated by IPV but simultaneously face the overwhelming stress associated with factors specific to them. These stressors include those stemming from little or no knowledge of the English language, cultural conflict, immigration status, financial strains, racism and xenophobia, and those that come along with the challenging task of navigating a new and different environment – lack of social support networks such as friends and family. Thus, dealing with the cumulative stress and personal sense of lack of control that ensues from IPV and the alluded risk factors can become heavily burdensome for victimised Latina immigrants. Evidence suggests that the accumulation of stress from multiple sources and a lack of personal control over a situation can result in greater vulnerability for emotional distress (Thoits, 1995). Coping, a woman’s cognitive and behavioural efforts to manage specific stressful situations (Lazarus and Folkman, 1984), can buffer the negative impact of stress on a victimised woman’s mental health (Arriaga and Capezza, 2005; Yoshihama, 2002). Ideally, a woman should be able to draw upon a wide range of resources in order to cope with the multiple demands of daily living. Yet, for a victimised Latina immigrant coping responses are contingent on the severely limited psychosocial resources she has available and the multiple constraints that preclude her from using them effectively. These resources and constrains can derive from personal as well as environmental sources. Personal resources may include psychological characteristics such as healthy levels of selfesteem and self-efficacy, which for a victimised Latina immigrant are likely to be seriously eroded. The batterer, and mainstream society through xenophobia and racism, are continuously undermining, belittling, and telling her that she is of lesser value and worth than others. Research with Latinas indicates that IPV can negatively affect the self-esteem and self-efficacy of victimised Latinas as well as of

Latin American immigrant women in the U.S. 129 Latinas who experience prejudice and discrimination (Ramos and Carlson, 2011; Ramos, Li, and Do, 2012). Cultural values and beliefs that sanction some types of behaviour or feelings can also serve as powerful psychological coping resources (Ramos, 2004). For example, the resignation and acceptance prescribed by marianismo could build the strength and endurance crucial to a victim’s efforts to cope with the overwhelming stress they experience and survive (Runner et al., 2009). At the same time, internalised fatalistic beliefs that place the locus of control and mastery externally can constrain the use of coping resources effectively (Ramos, 2001). Such deterministic beliefs may discourage a victimised Latina immigrant from seeking help because she views her situation as hopeless, and there is nothing that can be done to change it. In addition, the ensuing feelings of powerlessness and entrapment can further jeopardise her mental health. This illustrates the clear interrelatedness of these cultural factors which may operate as stressors and constraints to coping simultaneously (Ramos, 2001). Social support is perhaps the most widely recognised and studied environmental coping resource. A strong social network composed of supportive family, friends, community members, and professionals can play an important role mediating the stress–mental health relationship (Choi and Wodarski, 1996). Unfortunately, for an immigrant Latina victim of IPV, the notion of such a strong social network is not consistent with her psychosocial realities. The dynamics of IPV, migration, and resettlement bring about loneliness, isolation, and emotional, physical, and even geographic distancing from family, friends, and other social network members. Similarly, environmental resources such as professional mental health, legal, and social services as well as opportunities for recreation and relaxation are rarely available or accessible to them. Poverty and economic marginality, prejudicial and discriminatory structural factors, and the batterer’s possessive and controlling behaviours vastly curtail these valuable resources for coping. Overall, the number, frequency, and intensity of stressful situations in an immigrant Latina victim’s life may far outweigh her options and resources for coping, placing her at high risk for mental health problems. At the same time, the stress-coping–mental distress dynamic appears to be more complex for victimised women, one that researchers have just began to examine (Meyer et al., 2010). Studies documenting this coping pattern found that initially women use passive, emotion-focused strategies which become increasingly active, problem-solving efforts as the violence becomes more intense (Goodman et al., 2003; Shannon et al., 2006). Other factors related to IPV that could influence a woman’s choice of coping strategies include the frequency and severity of the abuse, the length of the relationship with her partner, her history of abuse, and the relative effectiveness of her previous coping efforts (Meyer et al., 2010; Waldrop and Resick, 2004). Above all, victimised women are embedded within ecological contexts that severely constrain their options for coping. To survive and continue functioning, their coping efforts may need to conform to these limitations (Kocot and Goodman, 2003; Meyer et al., 2010).

130 Blanca M. Ramos

Addressing IPV against immigrant Latinas and Support the Victim As Dutton (2000) so poignantly states, women victims of IPV unequivocally want to avoid, escape, and stop the victimisation and actively seek to prevent, confront, endure, and end it once and for all. Clearly, these are monumental tasks that, despite her determination and countless efforts, a victimised Latina immigrant may not be able to successfully carry on alone. Social work responses to support and protect the victim’s emotional well-being and eradicate IPV against women must take place at the individual, community, and societal levels. Responses at the individual level Social workers can play a pivotal role supporting and assisting victims in their efforts to leave an abusive relationship and to cope in their quest for survival. Yet, research has consistently shown that Latinas tend to underutilise formal services, particularly IPV services, because they are linguistically and culturally dissonant (Ingram, 2007) or due to their own help seeking preferences, uncertain immigration status, and institutional racism (Ramos and Carlson, 2004). An immigrant Latina may prefer to seek help only from family and fictive kin to preserve the pride and dignity of her family, which could be compromised if she reaches out to an outsider, fearing loss of face and stigmatisation for her family and the broader Latino community (Ramos et al., 2010a). Thus, when a Latina immigrant opts to seek help because she is ready to disclose the abuse, a social worker must be prepared to offer linguistic and culturally responsive services that take into account her complex ecological context and to promote personal change through social action and empowerment (Ramos et al., 2010a; see also Western and Mason in this volume). The worker has to acknowledge and respect a woman’s wishes to ignore or deny her own needs, to ensure family preservation and unity, and her reluctance to seek outside support, as prescribed by familism norms (Vasquez, 1994). Despite these culturally prescribed behaviours, she is still in need of help and protection (Kanuha, 1994). A family-centred approach that expands services beyond the victim to other affected family members, such as children and the perpetrator, would be consistent with a Latina immigrant’s ethno-cultural realities. For example, culturally responsive couple-therapy focused on the victim’s safety and the perpetrator’s accountability could help reduce further violence. Caution should be exercised when introducing the notions of leaving the abusive partner or removing him from the victim’s life through incarceration, particularly if she is not ready to consider discussing them (Ramos et al., 2010a) (see Breckenridge and James in this volume). Workers should be familiar with current immigration laws and recognise migration, resettlement, and acculturation issues that may exert a powerful impact on the daily experiences of victimised Latina immigrants.

Latin American immigrant women in the U.S. 131 Responses at the community and societal levels At the community level, social workers could join emerging grassroots movements, or organise new ones, that mobilise Latinas and their communities to collectively address IPV as a social problem of concern to all members. They could build coalitions with government health and social service agencies, universities, legal experts, non-profit and professional organisations, businesses, civil leaders, consumers, grassroots activists, policy-makers, and, whenever possible, victimised women. Acting in tandem with members of such coalitions, social workers could take an active role advocating for change in the service delivery and criminal justice systems, providing community education, and promoting culturally responsive specialised services (Kanuha, 1994). For example, together, they could call attention to the bureaucratic, rigid nature of the service delivery system and advocate for measures that address inherent long-standing ethnocentric beliefs, prejudices, stereotypes, and institutional racism (see Western and Mason; Mitra (b) in this volume). Offering services in geographic locations with heavy Latino concentrations would facilitate access to victims who do not have transportation or do not know how to navigate an unfamiliar environment (Ramos, Jurkowski, Gonzalez, and Lawrence, 2010). Also, advocacy for radical fundamental changes in the criminal justice system historically known for its racist attitudes and behaviours toward Latinos, particularly police brutality, is crucial. A Latina immigrant victim often prefers to endure the abuse rather than have her partner involved with the criminal justice system where he is likely to be maltreated and injured (Ramos et al., 2010a). Social workers could design and implement community education activities to challenge public opinions that may lead to harmful, unsupportive community responses for victims. This is critical for prevention and intervention because Latina immigrants tend to disclose the IPV first to trusted members of their community. The ways in which her community reacts play a crucial role in setting the course for a successful or an unsuccessful resolution of the abusive situation (Dutton, 2000). As part of the coalition, social workers could promote a coordinated community response to IPV through an integrated, comprehensive service delivery system that provides health, mental health, social, and legal services. For example, Latina immigrant victims may need services for co-occurring health and mental health conditions that result from IPV including chronic diseases, psychological distress, and the use of drugs and alcohol for coping. Women may also require assistance finding a job, housing, financial resources, and schools for their children. Legal services could provide information about their rights as victims and the implications of immigrant status for the victim and the abusive partner. Ideally, the design and implementation of this coordinated delivery system would incorporate members of the Latino immigrant community such as advocates, leaders, and faith-based and grassroots organisations. It is imperative that these community representatives do not endorse victim-blaming ideologies or represent a risk to the victims’ safety but rather demonstrate a genuine interest in their well-being (Ramos et al., 2010a). Runner and colleagues (2009) underscore the effectiveness of political activism, primarily through strong grassroots lobbying efforts, in helping women victims of

132 Blanca M. Ramos IPV become more ‘visible’ in the public arena. Its success is evidenced by the enactment of the Immigration Act of 1990 and the Violence Against Women Act (VAWA) of 1994. These laws provided an immigrant victim with legal recourses such as the right to self-petition for residency status and a waiver exempting them from fulfilling all the standard requirements for permanent residency. The VAWA was reauthorised in 2000 and 2005 with provisions that broadened the criteria for women to be eligible for relief, relaxed the evidentiary requirements, and expanded access to public benefits and services. Policy recommendations Several recommendations for policy and program development that are specific to immigrant Latinas and other immigrant women who are victims of IPV by a male partner can be drawn from the discussion in this chapter and the literature. Some of these build on those carefully crafted in the Handbook for National Action Plans on Violence against Women prepared by the United Nations Women (United Nations, 2011). First, separate national epidemiological data on the incidence of IPV and risk and protective factors among Latina immigrants are sorely needed. Existing and future IPV data on the US population should be disaggregated by ethnic group and foreign- and native-born status as migration and other related forces may differentially shape an abusive situation. Second, government funding should support research that examines the consequences, particularly the health effects and especially the mental health effects, of IPV for Latinas and other immigrant women. It is important to gain a better understanding of the ways in which the migration and resettlement processes impact their coping patterns and, thus, the stress-coping–mental health relationship. This research could also identify evidence-based strategies for IPV prevention and intervention with immigrant women to inform policy and program development and implementation. Third, public resources should be made available to build and support coalitions seeking to address IPV in Latino communities. Fourth, policy recommendations should be fully actualised to address the health and healthcare needs of the Latino immigrant population. These include policies to ensure healthcare for unauthorised immigrants, most of whom pay taxes but are not eligible for many services (Acevedo et al., 2007; Ramos et al., 2010a). Fifth, public policy should include provisions for linguistic and culturally responsive programs that offer services to inform and support IPV victims regardless of their immigration status. These should provide basic information on IPV signs, causes, and consequences; the victims’ rights; and how to navigate the service delivery system effectively. Provisions to address previously identified individual and systemic barriers to services should be clearly stated. More effective anti-discrimination and equality laws could help address the multiple social disadvantages they face as these intersect with IPV and its adverse mental health consequences.

Latin American immigrant women in the U.S. 133

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11 Legal response to domestic violence in Tajikistan Dilbar Turakhanova

Introduction Upon consideration of the combined initial, second and third periodic report of Tajikistan, the Committee on the Elimination of Discrimination against Women (CEDAW) recommended to Tajikistan to adopt promptly the existing draft law on social and legal protection against domestic violence that will ensure criminalisation of the violence against women and girls, access of victims to relevant social services and protection mechanisms such as protection orders and prosecution of abusers (CEDAW, 2007:2). Similarly, in her mission report after visiting Tajikistan in 2008, Yakin Erturk, the Special Rapporteur on violence against women, its causes and consequences, recommended the following: [to] ‘Adopt Bill on Social and Legal Protection against Domestic Violence, including provisions for protection and restraining orders, and provide adequate funding and instructions to relevant State bodies for its implementation’ (UN Human Rights Council, 2009:25). Indeed, the draft law on social and legal protection against domestic violence has been in place since 2003 when women’s civil society organisations took the initiative to study similar laws and experiences in other countries and developed on this basis a draft law. The draft law had undergone several reviews by international experts in the area to ensure its better compliance with similar legislation, relevant best practices and international standards. It was submitted for consideration to the Government of Tajikistan and the lower chamber of the Tajik Parliament. Nevertheless, it was not adopted due to the following two arguments. The first argument is that the necessary legal norms already exist in the current criminal legislation and those legal mechanisms necessary for prosecution of domestic violence and protection of victims of domestic violence are already embedded in the system. The second reason is economic. The Government argued that due to budgetary constraints, adoption and proper implementation of this draft law will require a substantial allocation from the national budget that is not possible given current budget deficits (see Bhate-Deosthali and Duggal in this volume). This chapter in this respect will be limited to assessing the first argument of the Government, to challenge the view that legislation is in place already to protect women from domestic violence. The discussion starts with a short overview of the social, economic and cultural context in which domestic violence occurs in Tajikistan, and current responses to it. This overview will be followed by a

138 Dilbar Turakhanova description of the legal framework of Tajikistan that arguably enables prosecution of domestic violence and protection of victims of domestic violence. Hereafter the chapter will continue with discussion of the draft law on domestic violence. The chapter will conclude with the summary of arguments for the need to adopt the draft law to ensure proper protection against domestic violence in Tajikistan.

Tajikistan: a summary of country context The Republic of Tajikistan is one of the Central Asian republics (Central Asia comprises Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan) that gained its independence in 1991 upon the dissolution of the Soviet Union. It borders Afghanistan, China, Kyrgyzstan and Uzbekistan. Breakdown of former economic affiliations with the centre in Moscow and devastating civil war after the declaration of independence (in 1992–1997) brought political, economic and social crisis in the country. Amongst the consequences of the civil war are human losses estimated at 60,000 deaths, 25,000 widows and 55,000 orphans; financial losses of seven billion United States Dollars (USD) that was equivalent to 18 years’ Gross Domestic Product (GDP) in 1996; and changes in demographic situation resulting in one million people displaced by war (more than 250,000 fled the country entirely and 700,000 were displaced internally) (UNDP, 1996:16–19 cited in Kuvatova, 2001:128). It also resulted in disintegration of social relations on the ground of religion and politics. The power struggle started by the civil war was ended by the reconciliation and peace-building. Though there are no official figures assessing the impact of civil war on the moral and psychological state of people, the United Nations Development Programme (UNDP) in its Tajikistan Human Development report in 1996 argued that in the aftermath of the civil war there was a growth of criminality and violence that impacted moral and psychological state of population (UNDP, 1996:16–19 cited in Kuvatova, 2001:128; Foroughi, 2010:516). In 2010 the total population of Tajikistan was 7.6 million compared to 6.78 million in 2005 (State Statistics Agency, 2011). The majority of the population resides in rural areas (about 70 per cent) and women constitute 49.8 per cent of the total population (State Statistics Agency, 2010:23). During the Soviet period Tajikistan was amongst the poorest Soviet republics with a poor record of economic and social development. With the lowest GDP per capita among the countries of the Commonwealth of Independent States (CIS) Tajikistan occupies the one hundred and twenty-seventh place in the UNDP ranking of human development.1 In this regard, it is included in the group of medium development countries (UNDP, 2009:169) and ranks the lowest in the Central Asian region. Though there was a steady growth of GDP from 2003 until the financial crisis (between 2003 and 2010 annual GDP growth fell from 10.2 to 3.9 per cent), approximately 47 per cent of the population still remains poor (World Bank, 2011). There is a steady trend of feminisation of poverty. The public sector is characterised by systemic corruption (The Centre for Strategic Studies under the President of Tajikistan, 2010:67), but the health and education sectors are perceived by the population as the most corrupt (The Centre for Strategic Studies under the President of Tajikistan,

Legal response in Tajikistan 139 2010:28). Tajikistan, traditionally a country with labour force surplus, suffers from high unemployment. Men and, more recently, women opt to travel abroad in search of jobs mostly to Russian Federation. According to some sources, about 1.5 million of the population, as young as 18 years of age, are engaged in labour migration. Remittances from labour migrants constituted 42 per cent of the country’s GDP in 2010 (World Bank, 2011). As for public sector services and social security systems, both were eroded due to troubles caused by the civil war and the inability by the public institutions of the independent state to accelerate planned economic, social and political reforms. These adverse socio-political and economic changes have affected every part of life in the country in general and that of women in particular. Despite the fact that women’s rights and gender equality were on the agenda of the government after independence, the gender gap is widening in the economic, social and political spheres. During the Soviet times due to the discourse of the ‘woman question’2 Tajik women were encouraged to take employment in the public sector, and engage more actively in political life. Besides, in Soviet Tajikistan the ‘woman question’ was also used to challenge feudal traditions and patriarchal treatment of women as well as suppress Islamic practices (Kasymova, 2007:65; Kennedy-Pipe, 2004:92; Richters, 2001:154; Tadjbakhsh, 1998). Mostly, urban women or women residing in district centres and employed by the public sector benefited from this discourse, as compared to rural women employed in agriculture (Kasymova, 2007:65–66; Richters, 2001:155–156; Harris, 2000). The discourse of the ‘woman question’ resulted in achieving gender equality in employment, education and political participation. By contrast their traditional role in the private sphere was not substantially affected. Women had to bear the double burden of combining traditional roles of mother and housewife and the role of employee or worker in the public sphere (Harris, 2000; Kasymova, 2007:125; Richters, 2001:154–155). After independence, due to the resurgence of patriarchal values and the prevalence of popular Islam that supports subordination of women, as well as the failure by the government to challenge both phenomena, previous achievements by women were lost. Discrimination against women regarding access to income generation, education, political life and health is persistent (Kasymova, 2007; Richters, 2001:155). The social and economic difficulties described above impact gender relations. For instance, male labour migration forces women to take over the new role of a breadwinner and assume full responsibility of children and family. Factors like traditions and religion seriously affected the role of women in society, practices of marriage, and access of women to education, employment and public life. It is common now in Tajikistan to enter into marital relations without state registration, for children to be born out of wedlock, and for polygamous marriages to be illegally contracted by a religious ceremony (Khegai, 2002), as the preferred way of establishing relationships is through the religious ceremony of nikah. These phenomena are potential sources of violation of women’s rights since marital relationships that are not registered in state bodies do not establish any legal obligations for members of these unions. After the religious divorce ceremony women are left without any financial support and property. Besides, this change in

140 Dilbar Turakhanova gender relations and the more vulnerable position of women in terms of establishment of the family and sustaining the family relations leads to an escalation of domestic violence, since women have to tolerate domestic violence in the fear of loss of property, economic dependence on their husbands and the stigma women face upon divorce. The problem is aggravated by poor state response through political, legal and social protection systems supposed to prevent domestic violence, and protect and support women who have suffered. There is no data available about the prevalence of gender-based violence in Soviet Tajikistan. This may be due to strong control over the private life of women by the state during Soviet times. For instance, Kasymova (2007:146–147), in her inquiry into the transformation of gender order in Tajik society, argues that the state and its social policy towards women performed a masculine role and protected a woman in the case of violation of her rights by family and non-family members. Similarly, in cases of domestic violence an abused woman had an opportunity to complain to the Communist Party (that acted as a state representative) about her husband, father or other member of the family. There is no official data on the prevalence of violence against women during the civil war. Harris (2000:192–193) believes that the escalation of domestic violence in the present Tajikistan is inter alia a result of the massive violence that people experienced during the civil war. The following examples of violence against women are cited by Harris (2000:193): . . . raping with bottles and other objects, some of them large and/or sharp enough to cause very serious physical damage indeed; shooting in the pelvis or the abdominal area, burning them alive; taking them captive and subjecting them to humiliation and violence over long periods. In the post-conflict phase, there was no effort to establish a system to collect statistics on violence against women and domestic violence, in particular, in Tajikistan. The data available on the prevalence of violence after the war is provided by the survey of the World Health Organization (WHO) carried out in 1999 through interviews of 900 women and girls over 14 years of age. It points tellingly to the prevalence of physical, sexual or psychological violence directly experienced by women (WHO, 2000:26). According to the study during womanhood (age 15+), approximately 50 per cent of women experienced physical, psychological or sexual violence by a family member while 47 per cent of women experienced sexual abuse by their husbands (WHO, 2000:26). As to the impact of violence on the health of women this study states that about 28 per cent of women reported a causal link between violence and their health. Among these women 77 per cent reported experience of physical violence as adults and 77 per cent reported sexual violence by their husbands (WHO, 2000:26). Domestic violence, as this study demonstrates, is quite prevalent. Similarly, the survey of domestic violence in Khatlon province (in the south of Tajikistan) among 600 women confirmed that domestic violence is a common phenomenon in Tajik families. Thus, one-third of surveyed women experienced physical violence by their husbands. Moreover, in the family setting women experience violence inflicted on them by their mothers-in-law. The same

Legal response in Tajikistan 141 survey pointed out that 75 per cent of women reporting beating by their mothersin-law were also beaten by their husbands (Haar, 2005). Amongst the consequences of domestic violence and family conflicts (especially with mothers-in-law) is suicide (see also Nakray in this volume). According to the Committee on Women’s and Family Affairs under the Government of Tajikistan in 2010, 703 cases of suicide were registered in Tajikistan. About 50 per cent of suicides were committed by women and girls due to various reasons including domestic violence and other family conflicts (Khasanova and Rafieva, 2011; The Advocates for Human Rights, 2008:15–16). Among other negative consequences of domestic violence on the health of women are physical injuries of various degrees starting from bruises, fractures, and traumas to severe brain injuries, unwanted pregnancies, miscarriages, and sexually transmitted diseases (State Statistics Agency, 2010:97). According to information collected by the Coalition of Public Associations “From Equality De-Jure to Equality De-Facto” among women who applied for assistance to crisis and women’s resource centres in Tajikistan, women reported that in 70.5 per cent of cases psychological and emotional frustrations resulted from domestic violence (State Statistics Agency, 2010:97).

Current system of response to domestic violence Tajikistan has ratified a number of international human rights treaties calling for protection of women from violence. Amongst them are the International Covenant on Civil and Political Rights (ICCPR), 1966 (ratified in 1999), the International Covenant on Economic, Social and Cultural Rights (ICESCR), 1966 (ratified in 1999), the Convention Against Torture and Other Cruel, Inhuman and Degrading Treatment or Punishment (CAT), 1984 (ratified in 1995), Convention on the Rights of a Child, 1989 (ratified in 1993) and, finally, the Convention on Elimination of All Forms of Discrimination of Women (CEDAW), 1979 (ratified in 1993). The Committee on Elimination of Discrimination Against Women (the Committee) in its General Recommendation No. 19 stressed that Family violence is one of the most insidious forms of violence against women. It is prevalent in all societies. Within family relationships women of all ages are subjected to violence of all kinds, including battering, rape, other forms of sexual assault, mental and other forms of violence, which are perpetuated by traditional attitudes. Lack of economic independence forces many women to stay in violent relationships. The abrogation of their family responsibilities by men can be a form of violence, and coercion. These forms of violence put women’s health at risk and impair their ability to participate in family life and public life on a basis of equality. (The Committee on Elimination of Discrimination Against Women, 1992: 213) Furthermore, the Committee developed a framework necessary to defeat domestic violence. It encompasses measures such as adoption of criminal as well as civil

142 Dilbar Turakhanova remedies in case of domestic violence; establishment of services aimed at the safety and security of victims of family violence, counselling and rehabilitation programmes; availability of rehabilitation programmes for perpetrators of domestic violence; and establishment of support services for families where incest or sexual abuse has occurred (The Committee on Elimination of Discrimination Against Women, 1994: 213). Thus, Tajikistan as a country that took an obligation under the CEDAW is responsible for establishment of the national framework as outlined in the General Recommendation No. 19 mentioned above. Yet, in Tajikistan domestic violence is still treated as a family/private matter by the law, governmental agencies and society at large. Due to the perception of the subordinate role of women domestic violence is tolerated by the society and not perceived as a problem requiring legal response (Amnesty International, 2009:21; Dairiam, 2002:27; Ranjbar, 2012:32; The Advocates for Human Rights, 2008:20; see McQuigg in this volume). Women themselves rarely take domestic violence problems to public bodies due to a range of factors such as the desire to preserve the family, economic dependence, vulnerable status resulting from polygamous and unregistered marriages, absence of personal property, resistance of law enforcement bodies to handling these cases, and last, but not the least, stigmatisation of women initiating prosecution of their husbands (The Advocates for Human Rights, 2008:20–24; Amnesty International, 2009:21). The general perception is that a wife should please her husband and in case of misbehaviour punishment is a logical consequence (Dairiam, 2002:27). So far, the efforts to confront domestic violence in Tajikistan are fragmented and not sustainable. They are not bound by any law, policy and programmatic paper of the government that establish an approach to confronting domestic violence in Tajikistan. In addition to normative requirements to the response established in the CEDAW, another reference for development of the conceptual framework to confront domestic violence could be the public health approach to domestic violence promoted by the World Health Organization (WHO). This approach calls for the following steps: 1 2

3 4

To define the problem through the systematic collection of information about the magnitude, scope, characteristics and consequences of violence; To establish why violence occurs using research to determine the causes and correlates of violence, the factors that increase or decrease the risk for violence, and the factors that could be modified through interventions; To find out what works to prevent violence by designing, implementing and evaluating interventions; To implement effective and promising interventions in a wide range of settings. The effects of these interventions on risk factors and the target outcome should be monitored, and their impact and cost-effectiveness should be evaluated.

In Tajikistan so far, the approach to addressing domestic violence has not followed the public health approach. As mentioned, there are no statistics on the prevalence of violence, the types of violence that occur, or the impact of violence

Legal response in Tajikistan 143 on health and lives of women. The research on violence against women, in general, and domestic violence, in particular, is mostly non-existent. Predominantly, existing efforts are the result of activism by international and Tajik non-governmental organisations. Subsequently, public services for women who have suffered violence, such as crisis centres, shelters, social support services and psychological advice, are barely available. Women’s resource centres, crisis centres, women’s support centres, free legal aid bureaus, and community outreach programmes are run by nongovernmental organisations that suffer from lack of funding, lack of possibilities to improve quality of services and competent personnel. As to the public support services, the Committee on Women’s and Family Affairs under the Government of Tajikistan established a women’s support centre in the capital, but it is sustained by external funding. One women’s support centre established in 2009 (fully operational since 2010) by the Mayor of Dushanbe city (the capital of the country) is fully funded by the municipal budget. It provides a range of services for women (legal advice, seeking employment, health care and psychological assistance) and for women who experienced domestic violence. This initiative by a municipality is rather an exception than a rule. Some attempt has been made to train health care personnel on domestic violence, and the screening of women who suffered from domestic violence and referral. This topic is not included in the curricula of educational institutions training health and care personnel (see Bhate-Deosthali and Duggal; Mitra (b) in this volume). Therefore, this training initiative is not sustainable. However, police as well as students at the police academy under the Ministry of Internal Affairs (MIA) were trained on domestic violence and intervention strategies. In 2010 Ministry of Internal Affairs introduced special positions – police inspectors – responsible for combating domestic violence. In practice, only a few special police stations were opened in the capital city. Nevertheless, law enforcement bodies are reluctant to respond to women’s requests to intervene in domestic violence case, since women frequently decide to stop the investigation due to reconciliation with the abuser, and the general encouragement that women resolve the issues privately with the abuser (Ranjbar, 2012:33–34). In this respect, none of the services mentioned were able to establish a comprehensive model involving all possible actors, both governmental and non-governmental, to respond to domestic violence effectively and enjoy government funding. This situation is a result of the legal response embedded in Tajik legislation which does not criminalise domestic violence against women and, thus, does not include domestic violence in the list of punishable crimes. Neither has it included provisions establishing an institutional response to domestic violence such as guarantees of protection and necessary support services for women who suffered violence as well as prevention programmes aimed at the establishment of zero tolerance of domestic violence in the society. Thus, a comprehensive national framework aimed at the protection of women from domestic violence as well as the prevention of domestic violence and the support of victims that comply both with normative requirements and a public health approach has not been established by the law. There is no separate law on domestic violence in Tajikistan.

144 Dilbar Turakhanova

The Draft Law on social and legal protection against domestic violence In 2002 the Organisation on Security and Cooperation in Europe (OSCE) commissioned a review of national legislation to assess its compliance with the CEDAW. This review recommended inter alia enactment of the law on domestic violence to ensure that women are protected from this crime (Dairiam, 2002:27, 42). It further emphasised the existence of negative traditional stereotypes and cultural practices that tolerate domestic violence against women by husbands and mothers-in-law and called for adoption of the law on domestic violence combining criminal and civil remedies (Dairiam, 2002:44). Upon consideration of the combined initial, second and third periodic report of Tajikistan the Committee on the Elimination of Discrimination against Women recommended to Tajikistan to adopt promptly the existing draft law on social and legal protection against domestic violence, in order to ensure the criminalisation of violence against women and girls, and the ability for victims to access relevant social services and protection mechanisms such as protection orders and prosecution of abusers (The Committee on Elimination of Discrimination against Women, 2007:2). Indeed, the draft law on social and legal protection against domestic violence has been in place since 2003 when women’s civil society organisations took the initiative, based on the review commissioned by the OSCE, to study similar laws and experiences of other countries and developed on this basis a draft law. As previously discussed, the draft law was rejected on two grounds, one legal and one economic. This chapter is only focusing on the legal grounds for rejection, i.e. existence of legal norms protecting women from domestic violence. In Tajikistan it is argued that in order to punish an abuser who has committed domestic violence, the current Criminal Code may be invoked; however, in practice there are very few cases of this kind (Dairiam, 2002:27, 42). The Criminal Code does not include a crime called ‘domestic violence’. However, several articles in the current Criminal Code punish such crimes as driving to suicide (article 109), intentional major bodily injury (110), intentional minor bodily injury (111), intentional bodily injury of lesser degree (112), assault (116), torture (117), rape (138), forcible actions of sexual character (139), sexual intercourse and other actions of sexual character with an individual under 16 years (141), debauched actions, in relation to a minor under 16 (142), and hooliganism (237). These articles are, generally, referred to as those that provide protection of women against domestic violence as well as prosecution of abusers (Amnesty International, 2009:36). As Amnesty International (2009:36) notes in its review of situation with wife abuse in Tajikistan: None of the articles, with the exception of Article 109 (Suicide) and 117 (Torture), differentiates between strangers and partners as perpetrators. While there is no explicit prohibition of marital rape, a husband or intimate partner can be prosecuted under the articles listed . . . . According to non-governmental legal aid bureaus there are two most frequently invoked articles in cases of domestic violence. These are article 112, which crimi-

Legal response in Tajikistan 145 nalises intentional bodily injury of lesser degree, and article 116, which criminalises assault (Human Rights Centre, 2010:53). However, it is virtually impossible to open criminal cases under these articles due to the special criminal procedure assigned for these crimes. The criminal case can be opened and closed exclusively upon the decision of the victims of these crimes, but not the public prosecutor. Besides, current criminal procedural legislation does not provide a clear procedure for opening criminal cases and investigation of these crimes. In order to open the criminal case the victim must file a complaint in the court, which has to rule an order to start investigation of this case by the police. However, there is no special procedure in place allowing the police to conduct an investigation under this special category of crimes where no public prosecution is involved (Criminal Procedural Code, 2009: articles 354–355). Thus, these gaps in the legislation are one of the obstacles for women to get protection from violent abusers. Moreover, these provisions of the criminal law that can theoretically be invoked to protect women from domestic violence carry a punishment of either a fine or compulsory public works. The fine assigned if the case is prosecuted and resolved by the court will inflict additional damage on the family via the family budget. In this respect, the family is bearing a double burden: suffering from the domestic violence and from the financial losses associated with the punishment of abuser. In this respect, the argument of availability of protection under the current legislation of Tajikistan is not substantiated. Regulation of domestic violence by the criminal law, and the punishments assigned for committing domestic violence, are not effective in view of their impact on the family. In most cases, if these articles are invoked, law enforcement bodies prefer to close the case through reconciliation, without giving any assessment of the actual situation of a woman and her children, or the behaviour of the man (Human Rights Centre, 2010:53). Thus, women are not practically provided with effective protection against domestic violence, especially that committed by mothers-in-law. Besides, as it was mentioned, domestic violence is a phenomenon in Tajikistan that is sustained by the traditional and patriarchal view of society about the role of women and is thus tolerated. This same stereotype as well as the treatment of domestic violence as a family or private matter prevents law enforcement bodies from handling domestic violence properly and ensuring women and children suffering from domestic violence are effectively protected. As was mentioned, no proper public services funded by the government are available to run the support services for women or for abusers, as prescribed by the Committee. There is also no proper legislation in Tajikistan that provides proper legal guarantees for protection of women from domestic violence, nor a comprehensive institutional framework aimed at support for women, prevention programmes, and training and education of public officials involved in addressing domestic violence results. In this respect, the current legal response brings no benefit to women, but, on the contrary, facilitates the prevalence of domestic violence and creates a sense of impunity for committing this human rights violation (see McQuigg in this volume). In her mission report, after visiting Tajikistan in 2008 Yakin Erturk, the Special Rapporteur on violence against women, its causes and consequences, recom-

146 Dilbar Turakhanova mended the following: ‘Adopt Bill on Social and Legal Protection against Domestic Violence, including provisions for protection and restraining orders, and provide adequate funding and instructions to relevant State bodies for its implementation’ (UN Human Rights Council, 2009:25). These recommendations served as a basis for the civil society organisations to once again open discussion on the adoption of the draft law. In 2010 a working group on the study of the draft law and its finalisation was established in the lower chamber of the Tajik Parliament. The working group included several deputies of the lower chambers of the Parliament, officials of the Committee on Women’s and Family Affairs, Executive office of the President as well as several representatives of non-governmental organisations and international organisations. To date, the working group is still working on finalisation of the draft law and drafting of proposals necessary for amendments to other relevant laws. So far, the weaknesses of the draft law are the following: it does not establish any coordination mechanism between institutions involved in protection of women from domestic violence; exhaustive state intervention is planned for the prevention and protection against domestic violence instead of the provision of a set of instruments and measures available for victims of domestic violence to select; the idea of the family and of those who are given the protection of this draft law is based on the registered marriage; the definition of the victim of domestic violence includes only the person who directly suffered sexual, physical, and/or psychological violence, thus excluding other members of the family, for instance, children who observed abuse; it does not provide support other than medical and psychological support to the victims of domestic violence, for instance, access to jobs; there is an excessive referral to existing civil, criminal and administrative remedies that (as was mentioned) do not establish a crime or action of ‘domestic violence’; proposed measures aimed at the prevention of domestic violence do not establish a clear prevention strategy or clearly defined bodies in charge of undertaking preventive measures; though the draft law provides for the application of restraining orders it is not at all clear what the procedure will be of deciding on its application, which protection measures it includes, and in which situation this order can be imposed by the court; no role of non-governmental organisations providing services for women suffering from domestic violence is acknowledged in this draft law, thus there is no discussion of how their activities can be coordinated with law enforcement and other public bodies in assisting victims of domestic violence (Tisheva, 2011). These weaknesses of the draft law do not offer much optimism about the actual benefit it may bring to women suffering from domestic violence. However, it is obvious that the current legal framework calls for adoption of the separate law on domestic violence in compliance with criteria established by the General Recommendation No. 19 and steps outlined in the public health approach to ensure the end of impunity.

Legal response in Tajikistan 147

Conclusions During the last ten years civil society organisations as well as international organisations have called for the adoption of a separate law on domestic violence that combines criminal and civil remedies necessary for protection of women against domestic violence. However, since 2003 the government of Tajikistan has not adopted the draft law on social and legal protection against domestic violence despite explicit calls to do so by both the Committee on Elimination of all Forms of Discrimination Against Women and the UN Special Rapporteur on Violence against Women, its Causes and Consequences. The proposed draft law was dismissed by the Parliament on the grounds that legislation already existed protecting women from domestic violence, and that there were a lack of the financial resources required for the law’s implementation. The argument that there is already appropriate legislation is an inconsistent one. Current criminal legislation is not effective since it does not establish a crime called ‘domestic violence’. Even using other articles from the current legislation that criminalise rape, intentional bodily injuries, or assault, charges are difficult to bring against family members, an intimate partner or a relative. Besides, there are procedural difficulties to opening a criminal case on frequently invoked crimes such as assault and intentional bodily injuries of lesser degree due to the absence of an obligation on the public prosecutor to open the case and conduct the investigation. This situation results in a feeling of impunity for abusers and the continuing prevalence of this human rights violation. Moreover, the current legislation is weak on the establishment of preventive and supportive measures on domestic violence; this is in violation of the obligations of Tajikistan under the CEDAW and as the public health approach directs us. In addition to a lack of statistics and research, existing efforts, though fragmented, are not bound by activities aimed at monitoring and evaluation of these interventions and do not feed policy and strategies development. Thus, the current legal framework does not offer proper protection against domestic violence in Tajikistan. This situation calls for the adoption of an essentially different law that proclaims domestic violence as a crime; establishes civil and criminal remedies for women against domestic violence; sets up an institutional framework for the prevention and rehabilitation measures necessary to address domestic violence; explicitly binds public institutions and public officials to respond to complaints by women and provide support; establishes coordination arrangements; and promotes the public health approach to confront domestic violence. At this stage, the draft law that is being finalised by the working group under the Parliament fails to comply with these set objectives, but it does offer an opportunity to end the impunity of the abusers.

Notes 1 Human development is measured using the Human Development Index, which is a composite measure of three dimensions of human development: living a long and healthy life (measured by life expectancy), being educated (measured by adult literacy and

148 Dilbar Turakhanova enrolment at the primary, secondary and tertiary level) and having a decent standard of living (measured by purchasing power parity (PPP) and income) (UNDP, 2009:210). 2 The ‘woman question’ was a policy of the Soviet Communist Party that included involvement of women in public production and political life, state regulation of family, establishment and changes of official discourses interpreting femininity and masculinity. This policy was guided by the theoretical Marxist approach of class struggle (Kasymova, 2007:32–33).

References The Advocates for Human Rights (2008) Domestic violence in Tajikistan, Minneapolis: The Advocates for Human Rights. Amnesty International (2009) Violence is not just a family affair: Women face abuse in Tajikistan, Amnesty International Publications, Index: EUR 60/001/2009. Centre for Strategic Research Studies under the President of the Republic of Tajikistan (2010) Corruption in Tajikistan: Public Opinion, Dushanbe, available at: files/undpeng.pdf (last accessed on March 1, 2012). Committee on the Elimination of Discrimination against Women (1992) General Recommendation 19, Violence against women (Eleventh session, 1992). Committee on the Elimination of Discrimination against Women (1994) Compilation of general comments and general recommendations adopted by human rights treaty bodies, U.N. Doc. HRI/GEN/1/Rev.1 at 84. Committee on the Elimination of Discrimination against Women (2007) Concluding observations of CEDAW on the first, second and third combined report of Tajikistan, UN Doc. CEDAW/C/TJK/CO/3, 2 February. Criminal Code of the Republic of Tajikistan (1998) Available from: legislation/legislation-base/codecs/ (accessed on February 23, 2012). Criminal Procedural Code of the Republic of Tajikistan (2009) Available from http:// (accessed on February 23, 2012). Dairiam, S. (2002) Report on the compliance of the Law of the Republic of Tajikistan with the UN Convention on Elimination of All Forms of Discrimination Against Women (CEDAW), OSCE Project, OSCE. Available from: publications/articles.htm (accessed on July 16, 2012). Foroughi, P. (2010) Tajikistan, in Mootz, L. (eds.), Nations in Transit 2010: Democratization from Central Europe to Eurasia, New York: Freedom House, pp. 511–528. Kasymova, S. (2007) Transformatsiya Gendernogo Poryadka v Tadzhikskom Obshestve [Transformation of gender order in Tajik society], Dushanbe: Irfon. Kennedy-Pipe, C. (2004) Whose security? State-building and the ‘emancipation’ of women in Central Asia, International Relations, 18(1): 91–107. Khasanova, M., and Rafieva, M. (2011) Suicid v Tadzhikistane Nabiraet Oboroti [Incidence of suicides in Tajikistan increasing], (accessed on February 2, 2012). Khegai, M. (2002) Issledovanie Yavleniya Mnogozhenstva v Tadzhikistane (Study of the Phenomenon of Polygamy in Tajikistan), Dushanbe: LLC Visa Print. Kuvatova, A. (2001) Gender issues in Tajikistan: The consequences and impact of the civil war. In Graduate Institute of Development Studies, Hommes Armes: Femmes Aguerries, 127–136. Available at: docs/2888_Actes2001/11-kuvatova.pdf (last accessed on February 23, 2012).

Legal response in Tajikistan 149 Haar, R. N. (2005) Violence against women in marriage: A general population study in Khatlon Oblast, Tajikistan, Dushanbe: Swiss Cooperation Office Tajikistan. Harris, C. (2000) Control and subversion: Gender, Islam, and socialism in Tajikistan. Thesis, University of Amsterdam. Human Rights Centre, Tajikistan (2010) Study of the legislation governing family relationships in Tajikistan: Analysis and recommendations, unpublished document.[now UN Human Rights Council] Ranjbar, A. (2012) Informal justice in Tajikistan: The role of informal leaders in providing and preventing access to justice, Dushanbe: Eurasia Foundation. Richters, A. (2001) Gender violence, health and healing in situations of ethno-national conflicts: The cases of the former Yugoslavia and Tajikistan, In Graduate Institute of Development Studies, Hommes Armes: Femmes Aguerries, 127–136. Available at: http:// (last accessed on February 23, 2012). State Statistics Agency under the President of Tajikistan (2010) Jenshini I Mujchini Respubliki Tadzhikistan [(Women and men in the Republic of Tajikistan], Dushanbe: State Statistics Agency.. State Statistics Agency under the President of Tajikistan (2011) Macro-economic indicators, (last accessed March 1, 2012). Tadjbakhsh, S. (1998) Between Lenin and Allah: Women and ideology in Tajikistan, in H. L. Bodman and N. Tohidi (eds.) Women in Muslim societies: Diversity within unity, 163–187. Boulder, Col.: Lynne Rienner Publishers. Tisheva, G. (2011) Comments on the Law of the Republic of Tajikistan on prevention of domestic violence, Unpublished paper. UNDP (2009) Human Development Report 2009, Overcoming Barriers: Human Mobility and Development, New York: Palgrave Macmillan. Available at: en/media/HDR_2009_EN_Complete.pdf (last accessed March 1, 2012). UN Human Rights Council (2009) Report of the Special Rapporteur on Violence against Women, its Causes and Consequences, Yakin Ertürk: addendum: 15 years of the United Nations SR on violence against women, its causes and consequences (1994–2009): a critical review, 27 May, A/HRC/ 11/6/Add.5, available at: (accessed July 16, 2012). World Bank (2011) Tajikistan: Country brief 2011 Available at: http://go.worldbank. org/JI1AOY9RZ0 (last accessed March 1, 2012). World Health Organization (2000) Violence against women: Report on the 1999 WHO pilot survey in Tajikistan. Copenhagen: WHO, Family and Reproductive Health Unit.

12 Sexual violence within intimate contexts of marriage Integrating human rights and public health approach for gender-sensitive interventions Nishi Mitra Introduction Sexual violence within marriages is a less studied phenomenon in India (Acharya et al. 2012; Santhya et al. 2011; Pande et al. 2011; Santhya et al. 2007). Recent estimates indicated that 37 per cent of ever-married women have experienced spousal physical or sexual violence and 16 per cent have experienced emotional violence; in comparison, only 1 per cent of married women have initiated violence against their husbands (International Institute for Population Sciences 2007). Research conducted amongst young women has suggested that one in four experienced forced sex in marriages and often the first sexual intercourse itself was forced (International Institute for Population Sciences (IIPS) and Macro International 2010). Even though population-based surveys such as the National Family Health Survey have included sexual violence in their remit, information on the nature of the violence and the impacts on women’s health outcomes remains relatively sparse (International Institute for Population Sciences 2007; see Williamson; Jewkes in this volume). Jeejeebhoy and Bott (2003) highlighted the methodological difficulties in eliciting responses from young people on sensitive subjects like sexual relations due to fear and stigma. The Domestic Violence Act 2005 for the first time included the concept of rape within marriage however its application is restricted in society due to prevailing cultural ethos; inadequate social protection and inadequate budgets for the implications of the provisions of the Act (see Bhate-Deosthali and Duggal; Nakray; McQuigg in this volume). The inter-linkages between sexual violence and health outcomes are well established (Garcia-Moreno and Watts 2011; Nakray in this volume). Sexual violence in marriages results in adverse outcomes such as women’s inability to negotiate condom use or contraception, and their higher vulnerability to HIV/ AIDS and other sexually transmitted infections (Silverman 2010; Chan and Martin 2009; Stephenson et al. 2006). Abusive men are more likely to engage in extramarital sex, contract sexually transmitted diseases, and put their wives at risk through forced sex (Jejeebhoy and Koenig 2003; Verma and Collumbien 2003; Martin et al. 1999). Sexual violence is also interlinked with poor access to prenatal care, still births, and attempted suicides (Chowdhary and Patel 2008; Kishor and

Sexual violence within marriage 151 Johnson 2006; Stephenson et al. 2006). Puri et al. (2011) indicated that women also suffer from backache, headache, lower abdominal pain, vaginal bleeding and thoughts of suicide as a result of sexual violence. A public health approach is widely endorsed by the World Health Organization (2010; Garcia-Moreno et al. 2005); however, this approach has its own strengths and limitations. The strengths include the creation of a solid evidence base which provides insights into the risk determinants that underlie violence and informs policies better. However, people have a right to life without violence not only because it impacts their health but for its implications for overall well-being (Heath 2002). Therefore, recognising gender-based violence as a public health issue should not undermine it as a human rights issue. Both the approaches should strengthen each other and work in tandem towards eradicating the malaise of gender-based violence (Phinney and De Hovre 2003). A public health approach can promote educational activities which question the existing gender stereotypes, especially amongst the youth. It can also promote early identification of violence in families and initiate appropriate interventions in terms of referrals to appropriate agencies. Feminist approaches to public health also place human rights abuse or health disadvantages of women in wider social contexts, such as skewed distribution of power, or the organisation of health services or training and gender as a central axis of disadvantage (Rogers 2006). None of these approaches can eradicate gender based violence from society. However, they do extend the available knowledge base and also help in finding solutions.

Structural contexts of sexual violence against married women in intimate contexts: a review of evidence The structural prevalence of sexual violence in Indian marriages can be explained through the predominant patriarchal ethos and the patri-local nature of the residence of married couples, which shape everyday ‘gender relations’ in families (Santhya and Jejeebhoy 2005). Marriage and family are institutions embedded in patriarchal norms, which are primarily characterised by a male-headed household with violence as the primary mode of social control exercised on women. The process of socialisation plays a pivotal role in structuring relationships between women and men in marriages. From childhood, cultural restrictions are placed on women on expressing their sexual desires; they often grow up thinking that sex is a dirty and sinful activity, and also that first intercourse is unpleasant (Khan et al. 2002; George and Jaswal 1995). On the other hand, masculinity plays a vital role in shaping sexual relationships as it is often associated with control of the female body (Khan et al. 2002). Most marriages in India are arranged and little ‘love’ or emotional bonding exists between the couple. These unions happen against the backdrop of societal expectations of male and female behaviour, roles and obligations of social reproduction that necessitate early consummation and procreation within marriages (Maitra and Schensul 2004; 2002). In most Indian families the new couple not only need to adjust and respond to the expectations of each other but also to address the economic, social and spatial pressures of living and sharing (housing) space in a joint family (Maitra and Schensul 2004). As indicated earlier,

152 Nishi Mitra socialisation, on one hand, is the core process by which women and men are prepared for their roles of social reproduction, based on gendered norms of men as breadwinners and females as homemakers. However, it also incorporates a negative approach to sex, and both women and men might view it rather as a site of the perpetuation of existing gender relations than as a way of establishing a reciprocal relationship of emotional bonding and ‘love’. Specifically, sexual violence intersects with varied forms of physical and emotional violence, and also with various other factors such as economic dependence of women, poverty, alcohol consumption by husbands, lack of knowledge, social stigma and lack of supportive familial and social environment (Puri et al. 2011). Forced sex is also related to practices such as dowry, as women who bring an adequate dowry or whose husbands do not care about it are less likely to suffer from forced sex (Acharya et al. 2012). Economic independence by itself is an inadequate protective mechanism against forced sex unless supported by progressive cultural norms and so on (Dalal 2011). Often men devalue women’s economic empowerment through coercion and violence (Maitra and Schensul 2002). Sexual violence in marriages reflects the poor quality of marital relationships. It is also related to poor communication between the married couple, and also incongruence between men’s and women’s expectations from sexual relationships. The lack of privacy is also an important issue amongst couples in deprived communities (Maitra and Schensul 2004; George and Jaswal 1995). Inadequate sex education in schools and the reluctance of families to discuss these issues also ill prepares young people for sexual relationships. Pande et al. (2011) have highlighted the importance of sex education amongst young women before marriage to enhance their sexual agency and communication. The lack of social support for couples and also excessive stressors such as inadequate income, housing, health care and social protection are all risk factors for sexual violence. Forced sex is less likely if women knew their husbands fairly well before marriage, if they support their husbands in conflicts with other family members, or if they are from economically better off backgrounds (Santhya et al. 2007). Women are likely to have better experiences if they are better aware of sex and sexual pleasure, an understanding of their rights, and better skills to articulate and achieve their sexual desires (Santhya et al. 2007). It is vital to educate young women and men about sexuality and also the responsibilities associated with a sexual relationship (George and Jaswal 1995). Even women in poor communities enjoyed sex and often men engaged in sweet talk with their wives to initiate sex although sex is often constrained because of lack of privacy (Maitra and Schensul 2002). Maitra and Schensul (2004) reported one man saying, ‘I tried talking to her nicely but when I touched her she behaved as if she had got an electric shock. It is very insulting for me . . . .’ Similarly, Puri et al. (2011) reported that women often use varied coping strategies to protect themselves from sexual violence such as threatening to scream, suicide threats, waking up young children and feigning menstruation, but that some women also develop greater intimacy with their husbands, communicating sexual desire and participating in decision making related to sex to make it into a mutual experience.

Sexual violence within marriage 153

The study This chapter is based on evidence from one hundred qualitative interviews in the city of Mumbai, India, conducted with women who reported sexual violence and sought counseling in public counseling cells. The in-depth interviews were carried out by the author. Pseudonyms have been used to protect the identities of the participants. The findings of this study and the core themes generated from the interviews are organised into two sub-sections: 1) contexts and nature of sexual violence; (2) forced sex and adverse physical, reproductive and mental health outcomes It draws attention to the severity of experiences of sexual violence along with physical and emotional abuse and also the consequences suffered by individual women. The article draws attention to the nature of sexual violence in Indian marriages and it further highlights: 1. 2.



The need to generate a systematic evidence base to record the occurrence of sexual violence and its impacts on individual women; The need to develop comprehensive primary public health policies which address structural risk determinants, such as the prevailing cultural ethos, which allow sexual violence to continue unabated; The need for secondary interventions which allow the early identification of women who are victims or potential victims of sexual violence, and initiate appropriate health and social protection interventions; The need to facilitate effective implementation of legislation for the protection of women’s rights and to improve their access to resources to enable them to continue their lives outside abusive marriages.

Contexts and nature of sexual violence Women have a secondary position in the Indian society. They suffer from considerable disadvantages from childhood, and after marriage these disadvantages often intensify. Women often have little choice in choosing a marriage partner and are forced into arranged marriages. This is usually related to the socio-economic status of their natal family. Women have little choice in such marriages, as indicated by an excerpt from an interview with Gulzar: My mother was a sex worker and she wanted to protect me from being dragged into this profession. I was married off early. My husband would demand sex several times in one day. I would refuse as I was tired of sex and did not feel any pleasure. I underwent two pregnancies in quick succession. Third time I got pregnant I decided to undergo an abortion. When he learnt of the abortion he abused me and said that he wanted the child. (Gulzar, aged 26, currently unemployed) Women are often married at a young age with little awareness of their sexuality and the expectations from them after marriage, therefore they may be fearful of their first intercourse (Pande et al. 2011). This is especially true in cases where

154 Nishi Mitra women are married to men they hardly know and move into their husband’s house where they are relatively isolated and marginalised. Often forced sex can happen at the very onset of sexual relationship between the couple as shared by Sati: My first sexual experience was extremely unpleasant so I had to visit the doctor. The doctor advised us to refrain from having sex. However, after refusing to have sex with my husband for one month he threatened that he would have sex outside marriage. One night he forced himself on me, tore all my clothes and bruised me. He hit me on my vagina and had sex with me. Month after this happened I got pregnant. He refused to accept that the child was his. I underwent an abortion as a result. (Sati, aged 21, currently unemployed trained nurse) The above narrative indicates that the male partner does not even try to win the confidence of the female partner or engage in appropriate pre-coital behaviours (Maitra and Schensul 2004; 2002). One of the important issues in couples’ sexual relationship is lack of privacy (Maitra and Schensul 2004). The women interviewed live in poor housing conditions and often share the house with other family members. They are left with little time to engage in appropriate pre-coital behaviours and also communicate openly with each other. Communication beyond sex plays a vital role in shaping marital relationships and how couples can respond to each other’s emotional needs as well: We share our house with my in-laws. My husband and I do not have a separate room. There is little privacy. (Reema, aged 24, housewife) Education seems to have little impact on women’s experiences of violence and does not seem to act as a protective factor (Dalal 2011): My husband is a gynecologist and I was a science graduate when we married. I had three daughters but we wanted to have a male child. I conceived a boy after seven abortions. The male child is abnormal so my husband left me. I wish my first child was male, he could have protected me. (Manali, aged 47, pathologist) The lack of social support is an important factor shaping women’s experiences. Even when women might “not” hail from families which might be able to support them financially if they walk out of abusive marriages, the social taboos associated with a married daughter returning to her natal family are considered stigmatising and have negative repercussions. As Mrinal shared: Within a month of my marriage my in-laws and husband started abusing me for dowry. It was unbearable for me to stay with my in-laws. I called up my parents and my parents came to tell my in-laws that they could not give more

Sexual violence within marriage 155 dowry. I was three months pregnant. The torture was unbearable after that I was asked to draw water from the well at 2.00 am in the morning. I was left starving and I could barely walk. My mother’s brother left me back with my parents as he could not see my situation. I stayed with my family for one month and they came with me to leave me again with my in-laws. My father-in-law slapped me in front of them. I was accused of being a liar and dragged into a room and locked there. This is when I was seven months pregnant. (Mrinal, aged 21, housewife) In spite of the severity of the violence undergone by the women some of them continue to be resilient and want to start a new life independent of their husbands. However, it depends on whether there is social and economic support available for these women. Possibly, if they are employed, it might be easier to walk out of abusive marriages. As Kamila and Devi shared: I was too naive. I knew karate and other self-defence techniques. I had no confidence. I had no exposure, no picnics or friends. I started working as a nurse again. I leave my child with my neighbours for child care. People sometimes pass taunts and comment on my character. I do not care anymore. (Kamila, aged 25, nurse) After completing my studies I want to take up a job and start a new life. I would not like to get married again. (Devi, aged 29, works as an assistant in the school) In Indian society, women’s social identity is shaped by their marital and maternal status. Even though they might be economically independent, the social stigma associated with being single or divorced or widowed still clings. This social isolation further deepens their vulnerability to poverty and exclusion. They might not have adequate financial resources to get appropriate interventions to restore their physical or mental well-being. Women who walk out of abusive marriages are further stigmatised as home wreckers (Enander 2010). Women with children are doubly vulnerable as they might not have enough resources to support them. Sexual violence might occur in isolation or might be initiated after physical threats or coupled with physical beatings and emotional abuse. There are no boundaries between different forms of violence. Physical beating might be a way for a man to force a woman into having sex by coercion. As shared by two respondents: My husband is like a shaitan [demon] who comes home and removes my clothes and forces himself on me. If I oppose anything he beats me. (Urvashi, aged 42, landlady) My husband wakes me up at odd hours of the night to have sex and if I refuse I am beaten up brutally. (Bharti, aged 25, housewife)

156 Nishi Mitra This association between physical beating and sexual violence could result in women in developing negative attitudes towards sex. This is also reflective of the lack of negotiating power those women have in their sexual relationships. The sense of disempowerment is quite profound. As Gayatri shared: When a woman does not want sex with her husband she is labelled as a ‘bad woman’. Forced sex within marriage is also rape. I felt angry when he forced himself on me. I could not scream but I did feel extremely dirty. (Gayatri, aged 20, housewife) Woman’s voice does not have legitimacy in the social discourses on ‘feminine’ and ‘masculine’ sexual behaviour. They are likely to be isolated if they talk openly about forced sex in their marriages. They often have to bear it along with physical beatings or emotional abuse. All three forms seem to interact with each other and adversely impact on women’s overall well-being. Forced sex often occurs along with severe forms of beating and emotional abuse, not only by the husband but also other members of the family.

Forced sex and adverse physical, reproductive and mental health outcomes Forced sex has a devastating impact on women’s health and well-being. Forced sex can also restrict contraceptive choices in the marital relationship. As shared by Raksha: I have suffered from three miscarriages. I was very weak but he refused to use condoms during sex. He just said ‘why use condoms with wife?’ Women should not be listened to. (Raksha, aged 43, housewife) Sexual jealousy and fear of infidelity plays a vital role in male attitudes to contraception, as some men think that the use of contraception in the marital relationship would enable the wife to have sexual relationships outside marriage. These beliefs might be completely unfounded and may be largely explained by an excessive need by men to control women. As Malvika and Kavita shared: After I underwent two abortions, after that my husband underwent a vasectomy to avoid unwanted pregnancies. He did so also because he was suspicious that I might have extramarital relationships. (Malvika, aged 42, housewife) I insisted on condom use but I was never listened to. He never physically abused me but he suspected me of sleeping with other men. (Kavita, aged 34, housewife)

Sexual violence within marriage 157 Non-use of appropriate contraception in the marital relationship further exacerbates women’s vulnerability to contracting HIV/AIDS (Jewkes et al. 2010; Silverman 2010; Decker et al. 2009). Women are often married to men who might have contracted HIV/AIDS or engaged in pre-marital sex without any form of contraception. It is also important that couples address safe sexual practices after diagnosis with HIV/AIDS to address any further health threats. However, the social context of sexual relationships, which is largely driven by male power, often undermines the health risks posed. As Raksha and Khurshida shared: I was suffering from a severe vaginal infection so I suspected my husband of having HIV/AIDS. I refused to have sex with him. However, he beat me and also hit on my head and stomach with an iron rod and said that ‘If I get AIDS I will kill you’. (Raksha, aged 43, housewife) I was diagnosed first for HIV/AIDS. My husband had not been diagnosed. I learnt later that he knew about it and yet had sex with me . . . The doctor advised us to use condoms or refrain from sex. But my husband did not stop and he would wear a condom in front of me but remove it before the intercourse. (Khurshida, aged 25, housewife) Forced sex could also result in unwanted pregnancies which women might be forced to abort. The birth of a child could result in additional responsibilities for the father so women might be forced to abort the child by their in-laws. Abortions not only have adverse physical implications for women but are also emotionally traumatising. As Kalindi says: My natal family was poor. My husband and his mother expected a larger dowry but I could not get any more and so my husband wanted to get married for the second time. However, I got pregnant which ruined his plans. I was happy about my pregnancy. My husband and his mother wanted me to have an abortion and they added mala-d (a form of an oral contraceptive pill for women in India) into my food to kill my child. (Kalindi, aged 23 and working as vegetable seller) Women’s vulnerability to forced sex is often deepened during pregnancy. They are more dependent on their husband’s for emotional, economic and physical support. It results in wide-ranging adverse outcomes with long-term implications for individual women. Jyotsna shared: After two years of being humiliated as baanj [Hindi: infertile], I was able to conceive. In spite of which my husband insisted on having sex and I refused to do so he hit and kicked me on my stomach. He threatened to have extramarital relations. I miscarried. (Jyotsna, aged 23, housewife)

158 Nishi Mitra Women need extra care and attention to have normal child-birth. They are also not able to respond to their husband’s sexual demands and are thus often forced to have sex in the third trimester. As Anuja says: I was on the verge of labour pains yet my husband wanted sex and I met his demand. I was in severe pain and suffering from high blood pressure. I wanted the baby to survive. The doctor advised a birth through Caesarean section. My husband refused because it would affect his sex life. I was partly conscious and I signed the papers of consent. (Anuja, aged 35, working in a travel agency) Sexual violence often occurs in the background of other forms of violence such as excessive burden of household chores, deliberate denial of food and medical care, and physical beatings from the husbands and in-laws (Raj et al. 2011). As shared by Mehnaz and Varsha: I was advised complete bed rest. So my husband asked his sister to stay with us. She started abusing me and started saying ‘why did you marry my brother?’ She started beating me and twisted my arm. I fainted. I started staying with my husband separately; he fought with me and in the eighth month of my pregnancy he hit me with a broom till it broke. (Mehnaz, aged 36, housewife) I stayed with my in-laws as my husband worked in Mumbai. When I was pregnant my mother-in-law accused me of having an affair with my neighbour. She started beating and abusing me along with my father and brother-in-law. I gave birth in mother’s house and my husband did not visit me. (Varsha, aged 20, housewife) The forms of violence perpetrated against women are extreme and inevitably have adverse mental health outcomes for the individual women. The mental health impacts of partner victimisation are everlasting (Anderson and Saunders 2003). Neither the intensity nor frequency of assault can predict the impacts on women’s psychological well-being (Heise et al. 1994). Some experiences of violence against women are extreme, as shared by Somti: He would tie me and kick and beat me and also rape me. He would also bite on my chest, breast, vagina and thighs. Once he poured kerosene on me. This continued till I got pregnant. I had visited doctors several times with black marks. I used to fear his coming home and suffered from palpitations. (Somti, aged 28, para-professional social worker) Women undergo these violent experiences in a trusted relationship. Violent men want their women to lose self-confidence and respect and become completely dependent on them. It is hard for women to walk out of abusive relationships as they might not have the necessary economic and social support in place. Emotional

Sexual violence within marriage 159 abuse also results in certain self-defeating patterns of thinking and behaving with a learned helplessness. As shared by Kriti: I was head girl of my school. I was a tennis player and swimmer. My relationship with my husband changed everything. I have lost my self-confidence. (Kriti, aged 24, human resource consultant) Forced sex not only has impacts on individual women but on children, who are often victims of violence or witnesses of abuse being perpetrated against their mother. Reema shared: I have passed my limits of tolerance of abuse. My children are extremely scared of him and live under constant pressure. They tell me, ‘leave this house and you keep us in boarding and you work’. The children do not eat at night as they are afraid of their father. (Reema, aged 25) In the Indian scenario, women are extremely helpless. Once married they are less likely to get emotional or financial support from their parents and walking out of an abusive marriage is not easy. The nature of sexual violence erodes their selfesteem and confidence. In some circumstances suicide might be the only way out for women. As Raksha and Sneha shared: I feel dejected with life and tried to kill myself. It is better to die one day than every day through beatings and humiliation. I tried once to consume poison and another time I tried jump into a well. I was saved both times. I cannot understand my life. (Raksha, aged 43, housewife) I tried to commit suicide as my marriage was falling apart. My husband called me liar and cheat. Even my family members blame me for not making my marriage work. (Sneha, aged 25, early childcare provider) Some women leave abusive relationships yet its impacts reverberate through the rest of their lives. Often threats continue after separation. As Ardhana shared: He threatens to throw acid on my face and break my arms and legs if I ever leave him. I determined to do so and I cannot take abuse any more. (Ardhana, aged 30) Separation is quite traumatic for women. Further, it increases economic and social deprivation. The situation is particularly acute if women leave with their children. They might not be able to secure permanent and well-paid jobs. They might not receive support from their natal family as they have gone against prescribed social norms of ‘making marriages work’ in all conditions. Most importantly, family and

160 Nishi Mitra marriage are supposed to be institutions for protecting women but most violations occur within marriage.

Rethinking gender-based violence interventions from a human rights and public health perspectives One of the major advancements in terms of interventions for sexual violence in India is the Protection of Women from Domestic Violence Act (2005) which recognised violence within marriage as a serious cause of concern. However, as illustrated in the previous sections, the nature of sexual violence undergone by women is very severe and requires urgent attention not only in the form of legislation but also in terms of multi-faceted interventions. Structurally, this form of extreme violence is rooted in the patriarchal ethos of the Indian society where violence against women is tolerated, in the overall marginalisation of women from economic entitlements to employment or property rights, and also in inadequate social networks. Both the human rights perspectives and public health approach are complementary and must function in a manner which will deepen the understanding of gender-based violence and the interventions that are associated with it. Violence undoubtedly impacts women’s right to life; however, women’s access to justice is seriously impeded if they walk out of abusive marriages and initiate criminal proceedings as they might hail from poor families with no social support. Therefore, a public health approach can play a vital role in questioning the existing patriarchal norms in Indian society, through education programmes within mainstream education for the youth and also through specialist education for professionals in the medical and social care or judiciary. A public health approach focuses on the mobilisation and training of human resources who can facilitate access to justice for those women who are often isolated in their affinal families or communities. The lynchpin of a public health approach must clearly be the ideal of protecting women’s human rights. The National Family Health Survey, India (2005–06) (IIPS Macro International 2007) has made significant advances in collecting evidence on sexual violence (see Jewkes; Williamson; Bhate-Deosthali and Duggal). Several other studies (Santhya et al. 2011; Maitra and Schensul 2004) have provided more detailed insights into the causal factors that underlie the occurrence of sexual violence in Indian marriages. Similarly, the study discussed in this chapter also illustrates the severity of sexual violence that women undergo and also how it is related to the patriarchal norms of the Indian society. This requires an approach which is multi-faceted in its nature and addresses the significant barriers to women’s access to justice. This would include primary prevention activities aimed at educating the youth about existing gender stereotypes and the socialisation process by which the ideals of ‘feminine’ and ‘masculine’ behaviour is inculcated in the families, schools and communities. The acceptability of male violence against women should be seriously censured through various education programmes. It is also necessary to undertake a nationwide campaign against any form of genderbased violence through various mediums such as radio, television, folk theatre and

Sexual violence within marriage 161 music. An increased awareness of gender-based violence amongst various professionals who are directly involved with working with women should facilitate referrals to medical, legal and social policy interventions such as income support. Most important would be a wide range of interventions which can support a woman and will promote effective implementation of legalisation that aims to protect women’s rights.

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13 Gender-based violence and reproductive health in five Indian states Ernestina Coast, Tiziana Leone and Alankar Malviya

Introduction Gender-based violence (GBV) is a global public health concern that has only relatively recently received significant research and policy attention (Mayhew and Watts 2002; Campbell 2002). It is one of the most common forms of violence globally and includes physical, sexual, emotional and economic violence. Much more research on GBV is conducted in high income settings rather than middle and lower income countries, although this is changing rapidly (Hackett 2011; Archer 2006; Verma and Collumbien 2003). In India the issue has been highlighted with the Protection of Women from Domestic Violence Act in 2005 (Kaur and Garg 2008). Multi-country analyses by the World Health Organization suggest that at least 15 per cent of women experience sexual or physical intimate partner violence, with levels above 70 per cent in some settings (Heise and Garcia-Moreno 2002). Issues of definition notwithstanding (Burge 1998), GBV remains under-reported and international comparisons are affected by differential attitudes towards violence. It is difficult to measure because in most societies violence is highly stigmatised, with shame for the victim. Data can come from the abused individual, the abuser, or witness(es) to the abuse. Under-reporting, is, however, common and there are differences in reporting by men and women (Jejeebhoy 2002). Most evidence about domestic violence in India is based on reports from married and/or pregnant women. The distribution of studies across India is uneven, with studies from the east least well represented (Babu and Kar 2009). There is much less evidence on sexual and psychological violence compared to physical violence (Babu and Kar 2009). A few studies are based on reports of men about perpetration of sexual violence (Stephenson et al. 2006; Duvvury et al. 2002; Martin et al. 1999). There is also evidence that the mode of data collection can impact on the reported levels of violence (Rathod et al. 2011). Studies from India suggest a relatively high prevalence of gender-based violence and estimates vary widely, from 18 per cent to 70 per cent, reflecting in part a wide variety of methodologies (Jeyaseelan et al. 2007; Stephenson et al. 2006; Hassan et al. 2004; Krishnan 2005; Duvvury et al. 2002; Visaria 2000; Martin et al. 1999). However, it is likely that there are regional variations in violence prevalence, as

164 Ernestina Coast, Tiziana Leone and Alankar Malviya nationally representative surveys – such as the NFHS – suggest considerable variation between states (International Institute for Population Sciences 2007). Data from the International Crime Victimisation survey, cited in the World Report on Violence and Health, reports that 1.9 per cent of women aged 16 and above in Bombay (India) report having been sexually assaulted in the last five years (Morrison and Orlando 2004). Forty per cent of women in India in a six-state study reported physical assault by a male partner (World Health Organization 2005), and the prevalence of lifetime physical IPV in India is estimated to be approximately 40 per cent (Kumar et al. 2005). Recent estimates of lifetime partner violence among ever-married women are 39.7 per cent for all type of violence (emotional, physical or sexual) (Sharma 2010). A study of 2,000 pregnant Indian women found that 30.7 per cent of women who had not wished to have sex had been forced to do so (Chhabra 2008). A separate study, also of pregnant women attending an antenatal clinic, suggests self-reported physical, psychological and sexual violence in the last year at 14 per cent, 15 per cent and 9 per cent, respectively (Varma et al. 2007). A survey of 397 women in rural South India reported that 34 per cent of women had been hit, forced to have sex by their husband, or both (Krishnan 2005). Analysis of the NFHS3 estimated the national prevalence of domestic violence in India and the identified lifetime experience of several incidents of physical violence and sexual violence at 10 per cent and 8 per cent respectively for ever-married women aged 15 to 49 years old (Dalal and Lindqvist 2010). However, trends in levels of gender-based violence in India are conflicting, suggesting that not only are Indian women becoming more liberated but that there is more violence against women, possibly as a male response to increasingly ‘modern’ attitudes among Indian women (Simister and Mehta 2010). Gender-based violence is a product of social context (Boyle et al. 2009), and has been traditionally condoned and culturally sanctioned in India – albeit with regional normative variations (Sharma 2005; WHO 2002; Segal 1999; see Mitra (b); Bhate-Deosthali and Duggal in this volume). Men report that they are justified in physically hurting their spouse under certain circumstances, reflecting relatively high levels of tolerance to violence in general in India (Ravindran and Balasubramanian 2004; Martin et al. 2002; Jejeebhoy, S. J. 1998). This is reflected in women’s attitudes towards violence, which are ingrained and socially reproduced. Analyses of National Family Health Survey data (2005)1 in rural South India show that 96 per cent of women believe that intimate partner violence is acceptable in at least one circumstance (Sturke 2008). More than four out of every five women surveyed in a village in Karnataka reported that they would ‘accept it quietly’ if their husband beat them (Rao 1997). Qualitative studies demonstrate the wide range of impacts of intimate partner violence in India (Panchanadeswaran and Koverola 2005; Rao 1997) The determinants of gender-based violence in India have been studied in a variety of ways. Analyses of the Indian National Family Health Survey suggest social gradients in the reported experience of violence, with women from poorer households, with no education and from marginalised castes more likely to report IPV (Boyle et al. 2009; Ackerson and Subramanian 2008). In general, increased

Reproductive health in five Indian states 165 socio-economic status is associated with lower likelihood of IPV in India, based on analyses of the Male Reproductive Health Survey (Koenig et al. 2006; Martin et al. 2002) and other surveys (Babu and Kar 2009; Panda and Agarwal 2005). Lower dowry levels are associated with significantly higher subsequent risks of violence in India (Rao 1997; Jejeebhoy and Cook 1997). Intergenerational transmission of violence has been described as a ‘systematic’ association with the prediction of a girl subsequently experiencing domestic violence as a woman (Koenig et al. 2006). Indian women who witness their fathers beat their mothers were at increased risk of spousal physical violence (Jeyaseelan et al. 2007). The role played by alcohol consumption, has also been noted in an Indian context (Rao 1997). Women tend not to seek help for the violence they experience, often because they do not know that the services are available (Chibber et al. 2011; Leela 2008; Dutta 2000). Where help is sought, either through the policy or health services, the likelihood is that the service provider will have received little or no specialist training in dealing with cases of IPV (Chibber et al. 2011; Majumdar 2004; Bush 1992). Individual physician attitudes in India affect the reporting or identification of violence (Chibber et al. 2011). What are the health implications? Evidence from India reflects global patterns, and shows implications for murder (Shaha and Mohanthy 2006), suicide (Vizcarra et al.2004; Paltiel 1987), attempted suicide (Chowdhary and Patel 2008), mental illhealth (Chandra et al. 2009; Chowdhary and Patel 2008; Varma et al. 2007; Kumar et al. 2005; Vizcarra et al. 2004), poorer health outcomes for women and their children (Mahapatro et al. 2011; Sudha and Morrison 2011; Ackerson and Subramanian 2008; Chowdhary and Patel 2008; Weiss et al. 2008; Sudha et al. 2007; Stephenson et al. 2006; Martin et al. 1999; Jejeebhoy, S. J. 1998), marital satisfaction (Maitra and Schensul 2002) and HIV risk (Panchanadeswaran et al. 2007; Go et al. 2003). Reproductive tract infections (RTIs) account for a large burden of disease in low income settings because of their role in making HIV transmission more effective and because of their impact on reproductive and child health (Aledort et al. 2006). RTIs refer to three different types of infections: endogenous; iatrogenic; and sexually transmitted. Endogenous infections (e.g. candidiasis and bacterial vaginosis) are the most common RTIs globally and result from an overgrowth of organisms normally present in the vagina. Iatrogenic infections occur due to a medical procedure (e.g. IUD insertion when instruments have not been properly sterilised) introducing the infection. Finally, sexually transmitted infections, of which there are approximately thirty (including HIV) are transmitted through sexual activity with an infected partner (Germain et al. 1992). Diagnosis and treatment of RTIs in low resource settings tends to be delayed or inadequate, leading to higher rates of complications. Evidence suggests that considerable proportions of women in India have RTIs, with between 10 and 60 per cent of women reporting indicative symptoms. Furthermore, domestic violence has substantial social and economic costs that impact at the individual, household, community and national levels (Menon-Sen and Shiva Kumar 2001; Heise et al. 1994). The financial costs of GBV range from direct costs (including health care, judicial and social services) to indirect costs (including lost productivity from paid

166 Ernestina Coast, Tiziana Leone and Alankar Malviya and unpaid work and foregone lifetime earnings from mortality due to GBV) (Morrison and Orlando 2004). Policy options include changing of cultural norms (Ackerson and Subramanian 2008; see Jewkes; Western and Mason in this volume), increased economic and educational opportunities for men and women (Boyle et al. 2009; Ackerson and Subramanian 2008), increased public health and clinical programmes that target intimate partner violence (Chowdhary and Patel 2008), integration of violence prevention efforts within programmes that target women’s empowerment (Sturke 2008), the need to screen for IPV in other clinical settings (Chandra et al. 2009; Chandrasekaran et al. 2007; see also Breckenridge and James in this volume), increased training for service providers (Chibber et al. 2011), the development of services to help women who are victims of intimate partner violence (Jeyaseelan et al. 2007), and community-level interventions that challenge the normative role of violence against women (Koenig et al. 2006). In our study we address three questions. First, what levels of violence – both intimate partner and other forms of gender-based violence – are reported by women and girls? Second, how do men and women perceive differences in sexual rights? Finally, what are the links between socio-demographic characteristics and health-related outcomes (RTIs) for women that report experiencing violence?

Methods We analyse quantitative data collected in 2007, collected in five districts in India (Kanpur, Kishanganj, Bellary, Guntur and Aizawl). A multi-stage random sampling procedure was used to identify and select respondents. Individual households were randomly sampled from a recently completed household list. Households were not interviewed if neither a female aged 13–24 nor a male aged 15–29 were recorded as household members. Strategies to assure the quality of sampling and data collection included the listing of all households in a Primary Sampling Unit (PSU) immediately prior to the fieldwork in order to reduce sampling error and the use of both male and female interviewers. We analysed data collected from 2,363 girls and women aged 13–24 and 1,365 boys and men aged 15–29, and analysed all of the districts together. Limited qualitative data were collected from focus group discussions (n=30) conducted with a range of key informants and community members. For many of the focus group discussions, unfortunately, verbatim transcripts were not produced. Instead, only facilitator summaries were collected. In our analyses below we only include evidence from those focus group discussions where verbatim transcripts were collected. The transcripts were reviewed by two of the authors (EC and AM), and memos made of the key themes that emerged. Transcripts were not coded, and discussion of key themes was based on comparison of thematic description. We include the qualitative evidence here as supplementary to the quantitative data to explore some of the socio-cultural norms and perceptions around gender-based violence.

Reproductive health in five Indian states 167 In order to understand the quality of the data collected in the quantitative survey, the authors interviewed some of the interviewers who had conducted the survey. In particular, we focused on those questions that either the interviewer had been uncomfortable in asking, or the respondents had been uncomfortable to answer. It is worth noting that two questions in particular were identified as being particularly problematic for both the interviewer to ask, and the respondent to answer: How often does your husband/partner have sex with you when you are not willing? If you say no to sexual intercourse what is your husband’s/partner’s reaction? Our conclusions are impressionistic and tentative, but support work from elsewhere that questionnaire-based interviewing about the reporting of such behaviours is likely to result in under-reporting of these topics. The analyses below should be interpreted in the light of this possible under-reporting.

Sample characteristics The socio-demographic characteristics of the quantitative survey are shown in Table 13.1, and includes a range of respondents in terms of marital status, employment, level of education and place of residence (urban vs. rural). Over half (54 per cent) of the women were married and most (89 per cent) were aged over 15. The majority lived in rural areas (78 per cent) and 17 per cent had received no schooling. Most women were either homemakers or students (83 per cent), with 30 per cent having at least one child.

Gender-based violence We asked all women, married and unmarried, whether they had ever (either as a child or as an adult) been forced to have sexual intercourse or perform any other sexual acts against their will. This question was asked in order to try to estimate any experience of sexual violence (Table 13.2); 1.9 per cent (n=45) of respondents refused to answer this question. A supplementary question was asked of women who had reported any experience, and responses suggest that respondents were referring to relatively recent events in their lifetime, with 41 per cent and 28 per cent respectively of currently married and never-married women reporting experiences in the last 12 months. For currently married women the reported perpetrators are overwhelmingly known to the respondents, including current/former husbands and boyfriends and other relatives. Higher levels of stranger as perpetrator are reported by never-married respondents. Focus group discussions with key informants drawn from a range of positions (e.g. village committee members, health service workers, peer group facilitators, etc.) showed perceptions that gender-based violence was perceived to be a problem

168 Ernestina Coast, Tiziana Leone and Alankar Malviya Table 13.1 Sample characteristics (percentage distribution) Female (n=2,363)

Male (n=1,365)

Age group • 3

70.4 11.1 11.2 4.6 2.7

– – – – –

Place of residence • Urban • Rural

22.8 77.2

15.5 84.5

for specific population sub-groups, in particular those identified as being Dalit. This refers to groups traditionally referred to as ‘untouchable’ in the Indian caste system. Whilst discrimination based on the caste system has been abolished under the Indian constitution, although not the caste system itself, prejudice and discrimination against Dalit communities continues to be widespread in India: Here, sexual violence is there in the Dalit colony . . . we can observe such type of violence. Most of the Dalit people are taking alcohol at evening time. (Panchayat chairwoman) These (Dalit) men are used to drinking alcohol and then beating the women but still the women surprisingly are justifying such behaviour due to lack of job of their husbands (male ex-army)

Reproductive health in five Indian states 169 Table 13.2 Reported experience of sexual violence in our sample (percentage distribution) Currently married

Never-married women

Sexual violence Lifetime report (n=2358)



Perpetrator (n=57) • Current husband • Former husband • Current /former boyfriend • Relative • Friend/acquaintance • Family friend • Employer/work colleague • Stranger • Other

38.5 2.6 43.6 10.3 2.6 0 2.6 0 0

0 0 27.8 33.3 0 5.6 0 22.2 11.1

Sexual violence in the last 12 months (n=52)



Ever sought help for sexual violence (n=20)



In many of the key informant focus group discussions, the link between multiple behaviours – sexual violence and alcohol consumption – was attributed to Dalit communities. This is a clear example of the ‘othering’ of stigmatised and taboo behaviour by people in positions of relative power. Interestingly, in focus groups of women, alcohol consumption was discussed as an issue related to violence against women, but was not attributed to specific groups: Women are facing violence more within their home than community . . . drinking habits of husbands is mainly responsible for beating up wives in our community. (female focus group participant, Bellary) In order to more fully understand the prevalence of gender-based violence, we also included questions on non-sexual violence experienced by women and girls (Table 13.3). The level and type of reporting of abuse is remarkably similar between currently married and never-married women, reporting 21 per cent and 22 per cent, respectively. The most commonly reported type of abuse in the last 12 months is pushing. The reported perpetrator of this abuse vary according to whether marital status, with husbands the most frequently reported for married women and siblings for never-married women: She is dumped by her in-laws due to not bringing any dowry . . . now her situation is worse at her natal family, her brother harasses her a lot after the death of her parents. (female focus group discussion participant, Kishanganj)

170 Ernestina Coast, Tiziana Leone and Alankar Malviya Table 13.3 Reports of non-sexual violence in the preceding 12 months (percentage distribution) Currently married

Never-married women



36.9 26.6 17.0 35.4 4.4

41.9 27.5 11.0 36.4 6.8

If reported abuse in the last 12 months, who was involved?* • Mother/mother-in-law • Father/father-in-law • Stepmother • Stepfather • Child/sibling • Boyfriend/husband • Other relative • Teacher/employer • Stranger • Refuse to state

32.0 17.6 1.1 0.4 6.3 51.8 9.9 0.7 7.7 2.6

27.4 12.2 2.5 1.3 40.1 5.0 20.7 0.4 5.1 0.8

If experienced abuse, sought help?



If sought help, from where? • Women’s Group (Mahila Mandals) • CBO/NGO • Peer support group • Women’s Court (Nari Adalat) • Local government (Panchayat Raj) • Police • Health service • Other / not stated

14.9 6.0 29.9 0 32.8 1.5 0 21.5

7.9 5.3 47.4 0 21.1 5.3 0 25.7

Non-sexual violence Report of being mistreated by anyone in the last 12 months? • pushed • punched • kicked • verbal • other abuse


Totals add to more than 100% as multiple responses permitted.

It is possible that reporting of mistreatment by unmarried women includes some reporting of “normal” sibling behaviour – including that of much younger siblings who might push and shove their older siblings – childhood behaviour that does not necessarily constitute ‘mistreatment’. Such reporting issues need to be taken into effect, and the data interpreted cautiously. Both married and never-married women report older women – either mother-in-law or mother – as the second most common category of abuse perpetrator in the preceding twelve months. Minorities of women sought any help for mistreatment, and if they did seek help, married women most frequently reported approaching local government (Panchayat Raj), compared to never-married women, who were more likely to seek peer group support.

Reproductive health in five Indian states 171 The focus group discussions frequently referred to examples where the community knew about cases of gender-based violence, but the victim was unable to act against her perpetrator: A woman in my village was severely beaten by her husband. He kicked and punched her until the wife lost her consciousness and the woman was unconscious for four hours . . . . Other women of the village suggested the woman to file a complaint report of this incident and assured her of their support. But the woman refused them by saying that it is her family matter and that she cannot file a report against her husband. (female shop owner) A further set of questions focused on married men’s and women’s and unmarried men’s responses to questions about the frequency of experience or perpetrating forced sex. The categories of ‘often’ and ‘sometimes’ are deliberately vague and impressionistic, and do not correspond to some specified amount of reported behaviour, e.g. weekly versus monthly. Irrespective of nuances in how people understood the nuances of the differences between ‘often’ and ‘sometimes’, more than one-third (26.7 per cent) of currently married women are reporting forced sex in their current marriage. The responses from currently married women need to be interpreted with caution, as 27.7 per cent of women refused to answer this question, reflecting the issues raised in our interviews of the interviewers, and we suggest that these levels represent an under-reporting of the extent of forced sex within marriage. This is corroborated by married women’s responses to a hypothetical question about what would happen if they did refuse sex, with 36.7 per cent of women reporting that they would be forced to have sex. Mindful of the biases likely to be introduced by men responding to questions about behaviour that is socially aberrant, even if it is socially sanctioned, nearly a quarter of all married men reported that they had had sex with their wife when she was unwilling (Table 13.4) (see also Mitra (a) in this volume). This proportion is likely to be an underreporting of the true levels of non-consensual marital sex. Men and women – both married and unmarried – were asked questions about their perceptions about what women and men should do in marriage (Table 13.5). The distribution of responses by gender and marital status are very similar, with both married women and men saying that a wife should just accept it if her husband is having an affair (14.5 and 14.7 per cent, respectively), with slightly lower proportions for unmarried men and women (11.5 per cent and 10.4 per cent, respectively): When I am not ready for sex with my husband, it does not make any difference for him . . . . He comes home and wants sex . . . sometimes even if I am not feeling well I can’t say no as I am afraid he will beat me up. (female focus group participant, Guntur) A significant minority of both men and women report that they do not think that a woman has the right to refuse sex, although the substantial majority report

Currently married women

7.2 29.5 35.6 27.7 54.5 36.8 5.1 0.8 1.0 1.6 0.3

Forced sex in marriage/relationship

How often does your husband have sex with you when you are not willing? / How often do you have sex with your partner when she is not willing? • Often • Sometimes • Never • Missing answer

If you say no to sex, what is your husband’s / your reaction? • Do not have sex • Forces or blackmail to have sex • No sex but beat up • Beat up and goes to other women • Goes to another woman • He is angry • Missing answer/other

Table 13.4 Gendered differences in responses to forced sex (percentage distribution)

75.5 16.2 0.5 0.8 1.1 – 5.8

1.9 22.4 75.7 0

Currently married men (n=617)

86.3 2.9 0 0 1.0 – 9.8

0 1.4 47.9 50.7

Never married men who are sexually active (n=211)

– 78.9 15.5 5.2 – 0.5

14.5 68.4 14.6 0.5 0.2

– 77.1 14.9 6.9 – 1.1

11.5 67.3 17.3 0.5 0.6

25.8 55.6 12.2 4.8 1.3 0.2

14.7 72.3 7.7 – – 5.3

NB: The questionnaires for men and women included differently scaled Likert scales, so some response categories were not collected for women (–)

Do you think a woman has the right to refuse sex? • Strongly agree • Agree • Somewhat agree • Disagree • Strongly disagree • Do not know

What do you think a wife should do if her husband is having an affair? She should . . . • Accept it • Protest • Seek divorce • Try to understand • Beat him • Other

Currently married (n=621)

Currently married

Never married



Table 13.5 Gendered differences in attitudes towards violence (percentage distribution)

20.6 63.0 10.4 3.6 1.5 0.9

10.4 68.6 15.6 – – 5.4

Never married (n=743)

174 Ernestina Coast, Tiziana Leone and Alankar Malviya that it is acceptable to refuse sex. What is interesting is the spread of responses across different ‘strengths’ of category, with male and female respondents replying that they ‘agree’ or ‘somewhat agree’ that a woman has a right to refuse sex, suggesting that there are scenarios where respondents feel that a woman has less of a right to refuse sex. Male focus group participants were sometimes relatively sanguine about the justification for violence of husbands towards their wives, reflecting strong socially sanctioned behaviours: If the wife is not listening to things or she is doing something which her husband doesn’t like . . . he tells her for many times . . . if she doesn’t listen to him, what is left then? At that situation you can’t blame a husband for beating or scolding his wife. (male focus group participant, Kanpur) When we consider the patterns of forced sex reporting by socio-demographic characteristics, we find that more than three quarters (77 per cent) of women with more than eight years’ schooling report their partner has never had sex with them when they were unwilling compared to just 45 per cent of women with no schooling. We find similar patterns of the normalisation and socialisation of gender-based violence when we consider responses to questions about people’s understandings of the risks of HIV infection. Both men and women think that women are at higher risk of contracting HIV/AIDS (75.5 per cent and 51.9 per cent respectively), and report that coerced sex is a contributing factor (69.34 per cent and 68.6 per cent, respectively). Men and women were asked about their experience of symptoms associated with RTIs. Using logistic regression, we modelled the determinants and risk factors of women who • • •

reported any RTI symptoms; reported having experienced forced sex; reported mistreatment (as defined above)

in the twelve months preceding the survey. Increasing education lowers the risk of reporting RTI symptoms (Table 13.6), as does wealth. Wealth appears to be a protective factor for reporting RTI symptoms, with the risk decreasing as the wealth quintile increases. Being Muslim or belonging to a general caste increases the risk of reporting RTI symptoms. District of residence was significant for the risk of reporting RTI symptoms, with Kishangani reporting the highest risk. The findings for caste (often used as a proxy for socio-economic status) contrast with those for wealth in ways that were unexpected, however, there was no significant interaction between caste and wealth. Age, parity and marital status were not significant predictors for the reporting or RTI symptoms. We constructed a similar model with mistreatment in the preceding twelve months (but not forced sex) as the outcome variable. Results showed that wealthier

.015 .0638871



ref 0.90 1.16

ref .60*** .55*** .77*

ref 3.20*** 1.35

Years of schooling

Number of children

Marital status Married Divorced/widowed/separated Never-married

Caste General Scheduled Caste Scheduled Tribe Other backward caste

Religion Christian Muslim Hindu .870 .291

.104.108 .117

.723 .172

.179 .140 .191


ref 1.25 1.08 1.18

Odds Ratio