Healthy Dialogues: November 2010


Last month, the CSIS Global Health Policy Center (GHPC) launched our first monthly blog – Healthy Dialogues. The Healthy Dialogues blog strives to create a dynamic space for conversations about current topics in health. We pick experts, from both inside and outside CSIS, to provide a range of views on a single topic. We hope that by stringing our experts’ responses together, an interesting and complex picture of the topic will be created. An integral component of this blog is you! If you have a topic you'd like us to address in the future, tell us. If you have a question you'd like us to answer next, ask it. We want to hear what's on your mind.

With the International Day to Eliminate Violence Against Women approaching at the end of the month – November 25th – we decided to make the theme of this month’s blog gender based violence (GBV.) According to the United Nations Population Fund, “Gender-based violence both reflects and reinforces inequities between men and women and compromises the health, dignity, security and autonomy of its victims. It encompasses a wide range of human rights violations, including sexual abuse of children, rape, domestic violence, sexual assault and harassment, trafficking of women and girls and several harmful traditional practices. Any one of these abuses can leave deep psychological scars, damage the health of women and girls in general, including their reproductive and sexual health, and in some instances, results in death.  Violence against women has been called 'the most pervasive yet least recognized human rights abuse in the world.'"

This month the Global Health Policy Center is excited to have an impressive group of contributing writers answer questions about gender based violence. November’s writers include:

Katherine Bliss, Deputy Director and Senior Fellow, Global Health Policy Center and Senior Fellow, Americas Program
Mary Ellsberg, Vice President of Research and Programs at the International Center for Research on Women,
Janet Fleischman, Senior Associate, Global Health Policy Center, CSIS
Jennifer Redner, U.S. Policy Consultant for the International Women’s Health Coalition,
Kiersten Stewart, Director of Public Policy for the Family Violence Prevention Fund,
Melanne Verveer, Ambassador-at-large for Global Women’s Issue

**Also listen to a podcast with Michele Moloney-Kitts, Assistant Coordinator in the Office of the U.S. Global AIDS Coordinator, where she answers many of the questions below.**

Week 4

Question: November 25th is the International Day for the Elimination of Violence against Women.  What lessons have we learned about policies and programs that have sought to reduce gender based violence globally?

Katherine Bliss

In previous posts I have focused on the challenge of gender-based violence in Latin America and the Caribbean, noting the high percentage of women in the region reporting some form of psychological, physical, or sexual abuse by spouses or intimate partners.  I also highlighted the importance of programs that empower girls and women through education and income-generating activities; raise family and community awareness about gender-based violence; encourage police and social services agencies to both enforce laws against gender-based violence and protect and support victims of abuse; and inform policy makers about the negative social, political, and economic implications of gender-based violence in the region.  These educational, legal, and policy approaches can have a direct and positive impact on the lives of women and girls in Latin America and the Caribbean – and beyond.

Today I want to highlight what might seem to be an indirect approach to preventing gender-based violence, but which has proven to be extraordinarily important in a variety of settings: ensuring access to drinking water and sanitation facilities. 

In many developing countries, girls and women bear the burden of fetching water for household use.  They travel great distances to wells or boreholes, wait in long lines for their turn to collect water, and then lug heavy buckets or jerry cans several miles back to their communities.  Beyond the educational and occupational opportunities lost to lengthy hours spent walking and waiting, girls and women face violence and sexual abuse while visiting water sources, as well.  One study at a Sudanese refugee camp in northern Uganda revealed that when girls had to wait long hours at a distant borehole to fill their water cans, they became vulnerable to rape and were often rejected by their families following an attack.   When there are no sanitation facilities within a camp or community, women may decide to wait until nightfall to travel some distance away from the camp to relieve themselves in private; however, this, too, leaves them vulnerable to violence...

Click here to read the rest of Katherine's blog.

Mary Ellsberg

We’ve learned many lessons over two decades of sustained effort to draw international attention to gender-based violence as a serious human rights, public health and development issue. But perhaps the most important one is that, although transforming restrictive and discriminatory laws and policies is essential to provide women and girls access to justice and protection from gender based violence, it is only a first step in reducing gender-based violence globally. 

Since 1995, when the Beijing Platform of Action urged governments to address violence against women and girls, most countries have adopted new laws criminalizing different forms of gender based violence, and provided protection and services for survivors of violence.  However, according to research carried out by ICRW and others,  women are just as likely to be beaten or sexually abused by an intimate partner today as they were two decades ago. In order to achieve tangible improvements in the lives of women and girls, we need to effectively implement and monitor laws. We need much greater investments, both in developing and testing innovative approaches for preventing violence. And we need to scale up programs which have been proven to work.

Experience has shown that individual “awareness raising” workshops or campaigns are rarely effective in changing people’s attitudes or behavior. Social change requires long-term, systematic engagement of communities, institutions, and decision-makers. Although GBV prevention is still an emerging field, there are many innovative programs that have shown promising results in changing social norms.  One such program developed by the Uganda-based organization Raising Voices, is called SASA!SASA! is a community mobilization strategy for preventing violence and HIV which is being implemented in at least 10 African countries.  Rather than discussing punitive responses to violence, SASA! emphasizes prevention by focusing on the benefits of non-violence and gender equity to both men and women. It also supports a deeper analysis of the impact of violence, and the underlying causes of gender inequality. The overall process of social change generated by SASA! is designed to stimulate local activism and advocacy...

Click here to read the rest of Mary's blog.

Jennifer Redner

Inspired and effective programs to eliminate the gender inequalities that that lead to violence against women and girls serves as a guidepost for policies and programs that work. Sustainable, locally-driven efforts provide lessons we can build from as we know that a cookie-cutter approach to preventing violence against women will not succeed. Because gender norms, traditions and politics vary from community to community, the involvement of local leaders in the design, planning, and implementation of policies and programs is essential.

Engagement of communities – Community leaders, as well as individuals affected by and responsible for violence against women must be involved in the design, planning, and implementation phases. The involvement of women and young people in these processes is critical, and special attention must be paid to reaching women and young people in rural areas rather than solely in national capitals.

Working with young people – By educating and empowering the largest-ever generation of young people, we can achieve gender equality in this and future generations. Comprehensive sexuality education provides young people with the information, skills, and access to health services they need to make healthy and informed decisions about their lives and relationships. This includes understanding the right to consent, and that they do not have the right to be violent with others.

Coordinated response –Responding to and preventing future incidents of violence requires multiple interventions that need to be coordinated, linked, or integrated. For example, when a survivor of violence enters a health facility, not only should she be provided with the necessary medical care, including post-exposure prophylaxis and emergency contraception if sexual violence was involved, but she should receive information about social and legal resources, as well as information on protecting her rights.

At the policy level, scale-up of proven interventions are needed now to capitalize on the political will that exists in the United States and elsewhere in the world to once and for all eliminate violence against women and girls. This includes robust funding for community-based programs that empower women and girls, as well as human rights protections.

The women and girls of our world cannot wait. Only when nations address violence against women in a comprehensive way can we secure a just and healthy life for every woman and girl.

Kiersten Stewart

There are three great lessons that we’ve learned- neither are necessarily new ideas but unfortunately they aren’t put into practice that often. First, listen to and involve the women most affected. And no this doesn’t mean ask a few women who happen to speak your language and are easy to reach. Listening to women involves finding them and involving them at the earliest stages of your planning and then being willing to change what you’re doing based on the feedback you get. While this can often be frustrating for those who’ve been doing this work for decades and have the benefits of research and experience, it remains essential because the women in the community are still the greatest experts on their lives and most importantly they are the ones who will bear the consequences if we’re wrong.  We must promote their leadership and listen to their guidance – the sustainability and success of any program begins with their insights.

Secondly,  involve the men. Generally the single biggest ask that comes from the women is to “fix the men.” While this request often leads to both heartbreaking and at times humorous conversations (particularly over what it means to “fix” the men), the gist of what women want is for the  men to stop being violent, not to go to jail or go away. Programs need to find ways to engage with and motivate men to be involved in solving the problem as well as changing their ways if they have or continue to use violence.  In every place there are good men who also want the violence to stop. We must help them too.

Finally, programs have to be holistic and multi-sectoral. This is not new to many who do work on gender-based violence but it is the thing that often gets lost under the ever-present challenge of limited funding. We are always being asked to focus in on the one thing that has the biggest effect, if you were able to do just one thing what would it be.  The truth is violence against women and girls will never be solved by a vaccine or a device – there is no one simple thing.  It takes a coordinated approach. For instance changing laws matters tremendously,  but if we are not also changing the culture, the laws will be worth no more than the paper they’re printed on. Similarly, one could empower girls all day long but if we are not also working with her in-laws, her teachers, the boys in her community, the local “law enforcement”  and government leaders, our efforts will fall flat. It must be this holistic approach. While it sounds complicated it is worth the effort. Why? Because when we do this well, so much else gets solved along the way. Girls are far more likely to get educated. They don’t get married off at 12 or 13 and die in childbirth or get HIV/AIDS from the husband who believes his manhood is dependent on his use of physical or sexual violence. Boys grow up with male role models and community members who understand that strength and violence are not the same thing – that their power in the world doesn’t just come from doing damage to others. So many of our human rights and development and even security challenges get addressed as we solve this scourge. It is worth the investment for all of these reasons and it is also worth the investment for the simplest reason of all: no girl or woman (or man) deserves to be beaten or raped. Period. Not here, not anywhere.

Week 3

Question: What is the Obama administration doing to tackle the link between gender based violence and global health?

Jennifer Redner

Unprecedented support exists within the highest levels of the U.S. government to tackle the gross human rights violations that women and girls face daily, including lack of access to the information and services needed to live healthy and productive lives free from discrimination, violence and coercion. Individuals, families, communities, and nations cannot prosper as long as violence against women and girls continues. President Obama has acknowledged that he learned from his mother (who was herself a development professional) that, “the best indicator of how a country is going to develop is how it treats its women and whether it educates its girls”.

Since the launch of the GHI in 2009, the importance of women, girls, and gender equality have been central in creating a comprehensive and effective framework to tackle the world’s greatest global health challenges. Recognition of the need to address violence against women to achieve gender equality and better health outcomes for all is a critical step forward in U.S. development policy, and is indicated not only by the Women, Girls, and Gender Equality Principle of the GHI, but also by work on violence underway through PEPFAR’s Sexual and Gender-Based Violence (SGBV) Initiative and strong U.S. leadership at the United Nations.

But more needs to be done to eliminate violence against women. Solutions must involve partnerships with multiple stakeholders, including multilateral partners such as UNAIDS and UNFPA, as well as other bilateral and private donors. Engaging civil society, particularly women and young people, in the planning and implementation of policies and programs is also critical to our success.

One promising collaboration that the US should pursue further is working with UNAIDS to implement the UNAIDS Agenda for Accelerated Country Action on Women, Girls, and Gender Equality, which can be used to make national AIDS policies and programs more responsive to the needs and rights of women and girls. Not only should PEPFAR use this as a guide for programming with women and girls, but with eliminating violence against women as a main principle of the UNAIDS Agenda, implementation of all the principles and actions contained in it through the Global Health Initiative will make important strides toward achieving gender equality and healthy and prosperous women and communities.

Melanne Verveer

Gender-based violence is a global epidemic. It is not unique to one country or continent. Rich and poor nations, urban and rural populations—all are afflicted, with devastating impacts on the lives of survivors and disastrous effects on the health and hopes of societies. The Obama Administration recognizes we must tackle this epidemic head on in order to advance our broader health and development goals. In fact, the Administration’s Global Health Initiative makes clear addressing gender-based violence (GBV) is a central to achieving gender equity.

There are many concrete examples of ways the Administration is prioritizing gender-based violence within the context of the Global Health Initiative. One example is an innovative partnership called “Together for Girls” and I am proud that the State Department’s Office of Global Women’s Issues is involved in this partnership. It brings the US Government together with private sector organizations including the Nduna Foundation, BD (Becton, Dickinson and Company), the CDC Foundation and Grupo ABC, and four United Nations agencies, led by UNICEF. The partnership is conducting national surveys to document the magnitude of sexual violence against girls, supporting coordinated action at the country-level, and bringing new resource, technical and communications partners to country efforts.

Together for Girls is just one tangible example of the administration’s resolve to address gender-based violence with the force of development, diplomacy and partnership.

Week 2

Question: What is the link between gender based violence and HIV?

Katherine Bliss

In Latin America and the Caribbean, HIV infection rates among women are rising, leading to what experts consider the feminization of the epidemic in the region. In some Caribbean and Central American countries, women make up nearly 50% of all infections; in North and South America the percentage of HIV infected people who are women, which tends to be closer to 25% or 30%, is rising in some communities, as well. There are several ways in which ideas about gender and power interact to increase women’s vulnerability to HIV/AIDS, but the low status of women in societies across the region is a significant factor. The fact that women tend to have less education, combined with expectations on the part of husbands or in-laws in some communities that female family members should confine their activities to the home, means that some women cannot access information about HIV/AIDS and how to protect themselves from infection.

As I discussed last week, up to 30% of women in Latin America and the Caribbean report having experienced some form of physical, psychological or sexual abuse from spouses or intimate partners over the course of their lifetimes. Women who face physical, psychological and sexual abuse within the home are at a disadvantage when it comes to negotiating the use of condoms or other safer sex practices, and studies in multiple countries have demonstrated that women in abusive or violent relationships face greater risks of HIV infection than other women. Rape exposes women and girls to situations in which they cannot protect themselves, and one UNFPA study estimated that 18% of girls in the Caribbean had been sexually abused before the age of 16. The region is also seeing increasing rates of human trafficking, including sex trafficking, with would-be migrants particularly vulnerable. Women who are made to engage in sexual activity by criminal organizations may face violence at the hands of procurers or clients and an inability to protect themselves against infection with HIV...

Click here to read the rest of Katherine's blog.

Janet Fleischman

Gender-based violence is both a cause and consequence of HIV/AIDS. Sexual violence increases women’s and girl’s risk of HIV transmission, and the threat of violence often prevents women and girls from negotiating safer sex and from accessing HIV information and services. The critical linkage between HIV/AIDS and GBV is increasingly recognized as a necessary part of a comprehensive response to HIV/AIDS, but greater human and financial resources are required to scale up effective programs.

In conflict and post-conflict situations, including Rwanda, Darfur, and Eastern DRC, sexual violence and rape have been both a weapon of war and a consequence of the breakdown of societal structures and the rule of law. In some cases, women and girls are raped by soldiers or combatants who may be at high risk of HIV, or they may be compelled to engage in transactional sex as a survival strategy. During the 1994 Rwandan genocide, an estimated 250,000 women were subjected to sexual violence as a tool of genocide, and many of these women became infected with HIV.

The multiple links between HIV/AIDS and GBV demand a multisectoral response, involving health providers and health systems, social services for women and children, legal assistance and legal reform, education, and economic empowerment. Ultimately, success in combating the dual epidemics of HIV/AIDS and of GBV will require integrated and comprehensive strategies, in the health sector and beyond.

Jennifer Redner

Sexual violence is one of the many ways in which violence is inflicted upon women and young people – and it has a particular set of implications for individuals and communities. For example, for girls, early or forced marriage – which is a violation of human rights on its own – often results in early and forced sex with men who are much older and have had several partners. This increases girls’ vulnerability to HIV and other sexually transmitted infections, isolation, and often results in further violence.

Gender inequality and violence against women are associated with a substantial number of new HIV infections among women globally. Young women and girls, moreover, are particularly vulnerable to sexual abuse and violence in their homes, neighborhoods, schools, and communities. In Swaziland, which has one of the highest prevalence rates of HIV globally, one-third of girls have been subjected to sexual violence, with nearly half experiencing violence prior to the age of 18. Females are less likely to use condoms or ask their partners to use them for fear of violence and are therefore more exposed to sexually transmitted infections, including HIV and unintended pregnancies.

Survivors of sexual violence must be provided with post-exposure prophylaxis and emergency contraception to reduce their susceptibility to HIV infection and unintended pregnancy. In addition to these and other medical interventions, social, economic, and legal support must be provided in safe spaces so that women and girls receive the care and services needed to ensure they have the opportunity to live just and healthy lives.

Kiersten Stewart

As others have already pointed out, violence both contributes to HIV and can be the consequence of it. Women who are victims of violence have much higher rates of HIV and often experience violence or abuse because of being HIV+. Women who are abused may also be more hesitant to get tested and those who test positive may forgo treatment or not share their status out of fear of violence.

It’s also important to highlight that the majority of violence experienced by women comes at the hands of husbands and partners, not strangers. While most see intuitively the way rape contributes to HIV infection, it is far more often the sexual and reproductive coercion and violence perpetrated by husbands and intimate partners that increases women’s risks for HIV. If we are to address women’s risk for HIV, we must address domestic violence specifically. Men’s use of coercion, threats, or violence to force wives and girlfriends to have sex or prevent them from using condoms must be addressed directly as should abusive men’s increased risk of contracting HIV themselves. Finally, it is essential that prevention programs for gender-based violence – and specifically sexual coercion perpetrated by intimate partners --- be understood as a central HIV prevention strategy and funded and supported accordingly. The evidence is now too great and the consequences too dire to not move the prevention of gender-based violence into the forefront of an aggressive and well-funded HIV prevention strategy.

Week 1

Question: What is the relationship between gender based violence and global health?

Katherine Bliss

Rates of gender based violence in Latin America are among the highest in the world, with serious health consequences for the region’s women, who are the most frequent victims. Violence directed by men towards women, because they are women, leads to injuries, the development of chronic conditions, psychological distress, and, in some cases, death. In Latin America, as in other parts of the world, gender-based violence regularly takes the form of domestic violence. Women who are pregnant are especially vulnerable; beyond physical injuries, pregnant victims of gender-based violence are more likely to give birth to underweight children. High rates of human trafficking in Latin America are also indicative of gender-based violence, reflecting efforts on the part of criminal organizations to coerce vulnerable women into forced labor arrangements, including sex work.

The Inter-American Development Bank estimates that between 30% and 50% of the region’s women involved in intimate partnerships have suffered psychological abuse, such as insults or threats, in the context of their relationships, and that 10 to 30% have suffered physical violence by male family members. In Bolivia, a 2003 study revealed that 53% of women had experienced physical violence by a spouse or partner, and 15% of women reported experiencing sexual abuse in the family context. A 2004-2005 study in Peru demonstrated that that 41% had experienced physical abuse, and 10% had experienced sexual violence, at the hands of male partners. More than 50% of women in Nicaragua reported being victims of intimate partner violence over their lifetimes, according to a 1999 study.

Click here to read the rest of Katherine's blog.

Janet Fleischman

Gender-based violence (GBV) is a global epidemic, although it has only recently been recognized as a major global health issue, with significant costs to individuals, health systems, and societies. GBV includes physical violence and sexual violence, and the accompanying emotional abuse. Evidence from around the world indicates that a substantial proportion of girls and women are subjected to domestic violence, sexual abuse, or forced or coerced sex. The global figures are chilling – one out of every three women experiences some form of abuse during her lifetime.

The health consequences of gender-based violence can be extreme, from death due to homicide, suicide, or AIDS-related causes, to traumatic injuries such as gynecological fistula, to chronic pain, to exposure to sexually transmitted infections, and often have severe consequences for maternal health. Globally, GBV is a major cause of disability and death among women. For all these reasons, a focus on the causes, consequences, and programmatic responses to GBV should be a cornerstone of global health policy.

Jennifer Redner

Globally, at least one in three women experiences violence in her lifetime – this is a daily atrocity. Beyond being a gross violation of human rights, violence has demonstrable impacts on a woman’s health and her ability to meaningfully participate in her community and the economy.

Violence undermines a person’s autonomy and personal agency – which has a ripple effect on her ability to, for example, pay for necessary health services or even be able to physically access services. Additionally, when not enough health workers are aware of the signs of violence in a patient, a further barrier is created.

Kiersten Stewart

Gender-based violence is at the heart of almost everything we do and care about when it comes to global health. HIV/AIDS is the most obvious – girls and women are raped by men who are HIV positive and, more commonly, are simply unable to negotiate abstinence, fidelity or condom use with partners and husbands because of violence or the threat of violence that enforces gender inequality and denies them any power over sexual decision-making. Violence also directly impacts maternal and child survival. Girls and women who are abused are more likely to be forced into pregnancy at much younger ages, have more and more complex complications from childbirth, and be less able to care for themselves or their children. Less well understood at this point though potentially as devastating are the consequences of chronic pain, chronic fear and the depression and substance abuse that often accompany abuse. Only now are we beginning to fully understand the chemical response to pain, fear, violence and trauma and the resulting health consequences. Importantly, there are solutions and programs that work. We just now need to put the same energy and resources into preventing GBV as we put into treating the devastating health consequences of abuse. Indeed it may be the single most effective use of funds because of its direct and indirect effect on all of our largest public health challenges.

Please let us know what you think.  If you have a question you would like our writers to answer next week, write it below.

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