LbP as CWb Pe . 2-- 55 U 121 World Bank Discussion Papers -Violence Against W;Vonmen The Hidden Health Burden Lori L. Heise XXT;t ofl lllif Pit-ancrivu *andJ Ad n'en e rm ai n J and Adrienne Germain Recent World Bank Discussion Papers No. 1'9' l9 rrtnor Chnrership a/ofAdjitenit Pl'rrants andtthe fl'hnnal El2onoy *iRer.;m Joiui -I Jo hnson ard Subliman S. Wasw No. 2(3 S,ocial lyniatnecture Consrnacrion in the .Sahel: Optionsf ir Improvuik Current Practices. Beniard Abcil; and Jean-Marie Lanrtrn No. 2111 1 Trbariizatin.. Agricuwlsral Drivedlopment. and Land.-llioation. I)ip;ias Blhadra arid Antznuio Salazar PR Br2ndlo No. 2(12 Alakzng AlodnOd &rfr Anic Tinkcr and Marjone A. Koblinskv No. 2(13 Poerrry Reduction in East .4sia: Tlhe Silent Revolution. FndaJohanscn No. 2134 MUana.gin thke C-itil Sevtcen: 77li Les,in. ol-Re/orn in Indiustrial Couuitnes. Iarbara Nuiberg No. 2115 1ksitniug a Systen of labor Market Statistics and lnjormnation. Robhrt S. Goldfiarb and Arvil V. Adamis No. 21(6 Informiaion echinology ira Wl-orld Batik lxudirn : Increasing the Developmental Impact. Nalg Hanna and Sandor boySon No. 2117 Pr-oceedings o.fa Confrrence on C:urency Substiiurion and Currency Boardj. Edited by Nissan Liviatan No. 2(08 Developinge EI&ertive Em:rplolyment Serv'ices. i)avid Fretwell and Susan Goldberg No. 2119 l:r'obviri Legal Iramenorksfi.r Private Sector Derelopnrrenr in Central and Easternl Europe. Cheryl W- Gray and AssociatEs No. 21(1 .M1arne Biotecihtnolqgy and 1X veeIspir, countries. Raymond A. Zilinskas and Carl Gustaf Lundin No. 211 Reriealizint. AqtricrltUral Researchl in dhe Salel: A. Prtposed Framewvorkifir Action. Jan Wcijenberg. Josut~ Dionie. Michacl Fuchs-Carsch. Adolphe Kn. and Jacques Lerort No. 212 Institutrional Options rr tie Prevision oj !fh srnctrure. Christine Kcssides No. 213 nTe (Contributions ofinfiustrutaure to EFconoic Dleelopmnent: A Reieu- of Experience and Political Implicarions. Christine Kcssidcs No. 214 Fromn .-lacroeconomic Correction to Public Sector Reform: The Critical Role of Evaltiation. Eduardo Wiesncr D. No. 215 Ch'ina: Reforn ard Devfelopmeit in 1992-93. Pctcr Harrold and lkajiv LII No. 216 The Refornm ofPublic Erpperditiuresfor Agricdtkure. Bonni van Blarcomn. Odin Knudscn. andJohn Nash No. 217 .M1anaging Fishery Resoulrres: Proceedings of a Symposiium Co-Sponsored by tile Wtorld Bank and Prruvian M1inistry of Fisleries held in lima, Peru.June 1992. Eduardo A. Loayza No. 218 Cooperatites and the Breakup of Lar.e Merchanized Farms: Thcoretical Perspectives and Empirical Evidence. Klaus W. I)einingcr No. 219 De'elop-menr .f Rural Financial M arkets in aSub-Saharan .Afiica Sabapathy Thillairajah No. 22(1 7he M1aritime Transport Crisis. HansJ. Peters No. 221 Policy-Based Finanice: the E.xperience ofPostuwarjapar. ThcJapanese Devclopment Bank and The Japan Economic Research Institutc No. 222 Mllacrocconomic Management in China: Proccedinges of a Conference in DalianrJune 1993. Edited by Pctcr Harrold. E. C. Hva. and Lou jiwci No. 223 fire Development ofrkic Private Sector in a Small LEconiomy in Transition: nhe Case of Monqolia. Hongijoo Hahm No. 224 Toward an Environmental Strategyfor Asia. Carter Brandon and Rarmesh Ramankuty No. 225 "rFortress Euzrope and Other XMyths about 7Trade: Potliies toward 'Merdctandise lrnports in tlle EC and Other Mlfajor Industrral Economnies (and Whlat They Mteanfor Developing Countries). Jean Bancth No. 226 Mlfongolia: Finanrcirn? Education durin. E conomic Transition. Kin Bing Wu No. 227 Cities wititout Land Mklarkets: Lessons oft/re railed Socialist Experiment. Alain Bertaud and Bcrtnnd Rcnaud (Continued on the inside back cover.) 2 55 1231 World Bank Discussion Papers V iolence Against Wvomen The Hidden Health Burden Lori L. Heise with Jacqueline Pitanguy and Adrienne Germain The World Bank Washington, D.C. Copyright C 1994 The International Bank for Reconstruction and Development/THE WORLD BANK 1818 H Street, N.W. Washington, D.C. 20433, U.S.A. All rights reserved Manufactured in the United States of America First printingjuly 1994 Discussion Papers present rcsults of country analysis or research that are circulated to cncourage discussion and commnent within the development community. To prescnt these results witl the least possible delay, the typescript of this paper has not been prepared in accordance with the procedures appropriate to fornal printed texts, and the World Bank accepts no responsibility for errors. Some sources cited in this paper may be informal documents that are not readily available. 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ISSN: 0259-210X Lori L. Heise is director of dte Violence, Health and Development Project, Pacific Institute for Womreis Health, Washington, D.C. jacqueline Pitanguy is president and founder of CEPIA (Ctizenship, Studies, Infonnation and Action), Rio dejareiro, Brazil. Adrienne Germain is vice president of the International Women's Health Coalition, New York. At the time of writing, al were consultants to the World Bank's Population, Health and Nutrition Department Library of Congress Cataloging-in-Publication Data Heisi, Lori. Violence against women: the hidden health burden / Lori L. Heise withjacqueline Pitanguy and Adrienne Germain. p. cnL - (World Bank discussion papers ; 255) Includes bibliogrphical references (p. ). ISBN 0-8213-2980-4 1. Wife abuse-Health aspects. 2. Wouien-Crimes against-Health aspects. 3- Sex crimes-Health aspects. I. Pitanguy, Jacqueline. [I. Germain, Adrienne. III. International Bank for Reconstruction and Dcvclopment [V. Tide. V. Serics. HV6626.H38 1994 362.1'968582200973-dc2O 9427745 CIP "Wife beating is an accepted custom ...we are wasting our time debating the issue." Comment made by parliamentarian during floor debates on wife battering in Papua New Guinea ("Wife Beating," 1987). 'A wife married is like a pony bought; rIll ride her and whip her as I like." Chinese proverb (Croll 1980). "Women should wear purdah [head-to-toe coverini to ensure that innocent men do not get uecessarily excited by women's bodies and are not unconsciously forced into becoming rapists. If women do not want to fall prey to such men, they should tske the necessary precautions instead of forever blaming the men." Comment made by a parliamentarian of the ruing Banrsan National Party during floor debates on reform of rape laws in Malaysia (Heise 1991). 'The boys never meant any harm to the girls. They just wanted to rape." Statement by the deputy principal of St. Kizito's boarding school in Kenya after 71 girls were raped and 19 others died in an attack by boys in the school ascribed to the girls' refusal to join them in a strike against the schol's headnaster (P'rlez 1991). Breast bruised, brains battered, Skin scarred, soul shattered, Can't scream-neighbors stare, Cry for help-no one's there. Stanza from a poem by Nenna Nehru, a battered Indian woman (APDC 1989). "The child was sexually aggressive." Justification given by a judge in British Colwnbia, Canada, for suspending the sentence of a 33-year-old man who had sexually assaulted a three-year-old girl (Canada, House of Commons 1991). "Are you a virgin? If you are not a virgin, why do you complain? This is normal." Response by the assistant to the public prosecutor in Peru when nursing student Betty Fernande reported being sexually molested by police officers while in custody (Kirk 1993). u.l Contents Foreword vii Acknowledgments viii Abstract ix 1. Introduction 1 2. The scope and evolution of the problem 3 Definition of violence against women 3 Dimensions of the problem 4 3. A primer on violence against women 14 4. Health consequences of gender-based violence 17 Health effect of abuse by intimate partners 18 Health effects of rape and sexual assault 19 Health effects of child and adolescent sexual abuse 20 Health effects of genital mutilation 21 Effects of violence against women on the health care system 22 S. Implications of gender violence for health and development 24 Effect on socioeconomic development 24 Effect on maternal health 25 Effect on family planning 26 Effect on STD and AIDS prevention 27 Effect on children 28 6. Steps toward eliminating violence against women 29 Justice system reform 30 Health care system reform 33 Prevention programs 36 Programs to assist victims 38 Treatment progmms for perpetrators 39 7. Research needs 41 8. Conclusions 43 ontft, Appendixes A. Recommendations for government action to combat violence aguinst women 44 B. Definition of violence agauinst women 46 C. Methodology for estimating the bealthy yeas of life lost due to domestic violence and rpe 48 D. Sample danger assessment 50 E. Treatment protocols for battered women 51 Notes 58 Biblioraphy 61 Tables 1. Prealence of wife abuse, selected countries 6 2. Prevalence of rape among college-age women, selected countries 10 3. Statistics on sexual crmes, selected countries 11 4. Women age 20 to 24 today who were married before age 15, selected countries 13 5. Estimated global health burden of selected conditions for women age 15 to 44 17 Boxes 1. Evidence of women's interest in gender-based violence 4 2. Gender violence thrusgbout the life cycle 5 3. Health consequences of gender-based violence 18 4. Correlates of gender violence in cross-cultual stuies 29 5. Government initiatives agnst gender-based violence 31 6. Inovative justice system reform projects 33 7. Abuse assessment screen 34 8. Initiatives to prevent gender-based violence 37 9. Priority research needs on gender-based violence and health 41 Si VIOUINCa AMNr IMN: TM DDWN EALTH DWRD8N Foreword Violence agastwomenhas recendybeenacknowledged extnt and consequences of violece agpinst women. It as a human rights concemwith a profound impact on the also exa the iato of genderviolece f*rhealth physical and mental well-being of tose affcted by it, and develpment and uggess practical steps that can be but itlas receved lite attention as a public bealth issue. tkn owad elinntigviolewe against women Aldugl The WorkdBank recoges that much more needs to be this paper is directed toward the healt sector, sategs knowwn bout the health consequences of genderviolence, that can be taken i other sectors are also discssed. lie as wel as teir broader socieonomic effects on prmary audie e of the paper i d e staff of the Warld development This paperpulls togethrall the infiomation Bank, but we hope the paper wil also benefit the desip available on the score of the problem and the leson to and p mnaiolofhealthprmgnsofodhri_ 1 be larned friom developing countries regurding how agnciesdgovernment4azadu vernmnta violence can be addressed trouugh progmmatic Thispaper8 is o ina seres of papers relaed to the brade inte!entons. issues affiectig women's health. Tlis parAr was prepaed to raise awarenes of the Janet de Merode Director Populaion, Heah and Nutrition Department Human Resources Development and Openrtions Poliov Forew Acknowledgments The authors would like to thank the following people for their help in preparing and reviewing this document: Jacquelyn Campbell, Elizabeth Shrader Cox, Lea Guicio, Simone Grilo Dinez, Kirrin Gill, Rita Raj Hashim, Emmanuel Jimenez, Mary Koss, JoAnne Leslie, Lisa Morris, Helen Saxenien, and Anne Tinker. wai ViouLNce AOAnr xmN: THE T DDeN HEALT WRDN Abstract Gender-basd violen-icludeig rae, domesic violnce, forWomen (UNIFEM) recenly observed, wWomen cat mutilation, murder, and sexual abuse-is a profound lendtheirlabor or creative ideas fully if tey are burdened healdth problem for women across the globe. Although with de physical and psychological scars of abuse (CariLo genderviolence is a significant cause of feadle morbidity 1992, p.11). and mortality, it is almost never seen as a public health This pper dws gereg data on the dimensio_s issue. Recent World Bank estimates of the global burden of violence agai womenwoddwide and reviews availble of disease indicate that in established market economies literatue on the health consequences of abuse. It also gender-based victimimtionis responsible for one out of elesteaionsbipbetweeaviolenceaxldotberu every five healthy days of life lost to women of repro- issues, such as matern mortality, health careutilization, ductive age. On a per capita basis, the health burden child survival, AlDS prevention, and socioeconomic imposed by rape and domestic violence in the indusil development. and developig woddis roughly equvalent, but because To asss policymnaers in addresig this issue, the the total disease burden is so much greater in the pae exploesi inrvenio in pmimny pevenion, justice developing world, the percentage attributable to gender- system refoxm, health care response, progmms to assist based victimiation is smaller. Nonetheless, on a global victims, and treatment and reeducation programs for basis, the health burden from npr-based victimization pprt argues atbatysrategytoombatviolence i comparble to that from other conditions already high must atack the root causes of the problem in addition to on the world agenda. treating its symptoms. This means chalengig the social Female-focused violence also represents a hidden ob- attitudes and beliefs that undergr men's violence and stacle to economic and social development. By sappig eg the meaning of gender and sexulity and women'senergy, undeTmining theirconfidence, andcom- thebalnc of powerbetweenwomen andmenatalllevels promising their health, gender violence deprives society of society. ofwomen'sfilparticipation.AstheUnitedNationsFund Ab ma 1. Introduction For decades women's orgaizations around the world have Moties teach their daughters to accept the roles that society worked against gender-based violence through advocacy, assigns tdem, and they punish "deviant" behavior to ensue victim services, and consciousness-raising. Iargely be- their seual and social acceptane. causeoftheirefforts,violenceagainstwomenhasrecently But violence is not inevitable. Cross-ctunl research been recognized as a legitimate human rights issue by the shows that, although violence againstwomen is an integral United Nations and by some governments. Yet almost no part of virually all cultures, there are societies in which policy attention has been given to addressing violence genderbased abuse does not exist (Sanday 1981; Levinon against women as a public health issue, and even less to 1989). Such societies stand as proof that social relations tackling its underlying causes. Efforts to gain recognition can be organized in a way that minimizes or eliminates of violence as an issue warranting international concern violence against women. Even where violence remains have been hampered by lack of population-based data on endemic, skategic iterven by the state, the communiy, abuse and its health consequences. But the data that exist and women's organizations can save lives, reduce injury, are nonetheless sufficient to justify increased atention to and lessen the long-tm effects of victimization on women this neglected-yet important-women's health issue. and their children. Existing iwnteions need to be refined As difficult and intactable as other health issues are, and systematicaly evalated, and new approaches to violence against women may be even more so. Deeply prevention explared, but itis wrong to conclude tat nohinig embedded attitudes about male-female reltions, social can be done to combat violence against women. taboos against discussing private matters" in public, and Womens organizations and, more recendy, some the lack of a "technological fix" all work against a governments have done much to assist victims and to solution. Althougb violence against women is almost document and publicize violence against women. Virtualy universal, its patterns and their causes can be fully everywheremth efforhtsave encountred sh g reistonce understood and remedied only in specific social and from organized religion, health professionals, thejudicial cultural contexts. Each society has mechanisms that system, and the police, aU of whom see the home as legitimize, obscure, deny-and therefore perpetuate- sacrosanct and thereby tolerate-indeed condone-most violence. Even where a particular act of violence might of the violence against women and girls. Police in many be deplored, powerfil social institutions-the state, countries wil not iotervene in "domestic quarrels and families, normative systems that regulate genderrelations do not consider wife beating a crime. In some courts men -colludeinmaintainingthe statusquo. Thusvictimsoften who confess to murdering their wives are acquitted in the have a difficult time escaping violent relationships. name of "legitimate defense of honor." And women are A variety of mechanisms, from oral traditions to for- frequently raped by the very men charged with their mal educational and legal systems, define standards of protection-the police, military officers, and other agents acceptablebehaviorformenandwomen. These standards of the state. are learned from an early age in the family and reinforced Cbaly, efforts to protect women must be stength- by peer pressure, community institutions, and the mass ened and expanded at the local and national levels. But media. In many societies children learn that males are any stratgy to combat violence must attack the root dominant and that violence is an acceptable means of causes of the problem in addition to treating its symp- assertingpower and resolving conflict Women, as moth- toms. This means challenging the social atttdes and ers and mothers-i-law, unwittingly perpetuate violence beliefs that undergird male violece and renegotiating by socializing girls and boys to accept male dominance the meaning of gender and sexuality and the balance of and by acquiescing throughout life to male demands. power betwev . women and men at all levels of society. bnudon I Violonceo againat women hs evolved in part from a effort, this paper draws together existing date on violence sytm of gender rltion which posits that men are apinst women worldwide and reviews tho literatune on supnior to women. The idea of male dominance-even the health consequences of abuse. The paper descnrbes male ownerhip of women-is present in most societies the scope and evolutionofthe problem, reviews the health and reflected in thefr laws and customs. Thus violence conquene of gender-basd abuse, and prvidesa prmer xould not be consiered an abermtion, but an extension onviolence agpinst women. It then discss the implie' ioui of a continm of belief that grants men the right to of gender violence for health and development and control women's behavior. As }Fauveau and Blanchet recommends steps toward eliminating the violence. obsorved in their pathbreaking study of violent deaths Appendices recommend government actions to combat among women in Banglaesh: violenceagainstwomen, discussissuesrelatingtodefining such violence, and provide a methodology for estimatiz The underlying causes of violent deaths among the global health burden from the abuse and rape of women. women of reproductive age, i.e. complications of They also provide a sample 'danger assessment' for an induced ab_rtin, sicide and homicide, ane drly screening women at risk and discuss treatment protocols sociaL Many of them may be seen as a consequce for battered women. of the stric control enforced by males over dte sual Bring the cycle of abuse will require concered action life of women and reproduction. (1989, p. 1127) across several sectors, including education, mass media, the legislative system, the judiciary, and the health sector. Combating violence agunst women requires chal- Appendix A provides detailed suggestions for action in lengiyg the way that gender roles and power relations are each of these sectors. articulate in society. To marshal support for such an 2 VILc AON VIMw: TM HIDDEN sML1H 3umDW 2. The scope and evolution of the problem In the past decade violence against women has bcome Dernition of violence against women increasinglyrecognizedasdeserviginternationalconcern and action. Women's orgmaizations around the world em- In September 1992 the United Nations Commision on braced gender violence as a priority issue during the the Status of Women convened a special worlkig group United Nations Decade for Women (1975 to 1985). Te todraftadeclarationagainstvioleuewagainatwomen.This United Nations (UN) General Assembly passed its first declaration, adopted by the General Assembly in the fill resolution onviolence againstwomenin November 1985. of 1993, offers for the first time an official UN definition Since then, the UN has sponsored severl Expert Group of gender-based abuse. According to Article 1 of the Meetings on Violence against Women and pursued the declaration, violence against women includes: issue through its Commission on the Status of Women, the Economic and Social Council, the UN Statistical any act of gender-basd violence that results in, Office, and its Committee on Crime Prevention and or is likely to result in, pbysicd, sexul or Control. Recently two new intemrtional instrumentsbave psychogical harm ornwff&ring to women, includg been '-i forward that would recognize all gender-based threats of sds acts coerci or asiiay deivatim violencea sanabuseofhumanrights-theUNDeclaration of liberty, whether occurring in public or private on Violence agist Women and the firder-reachig Draft life. (cnomic and Social Council 1992) Inter-American Convention to Prevent, Punish, and Eadicate Violence agaist Women (negotiated trough Article2ofthe declrtionstatesttthe definition should te Orgpnization of American States). Also, the Pan- beuundersood to encompass, but notbe lmited to, physica American Health Organization has recopized gender- sexual,andpsychologicalviolenceoccurringinthefamily based violence as its priority theme for 1994 under its and in the community, including battering, sexual abuse Women, Health, and Development P?rogam, and the of female children, doway-rlated violence, marital ape, United Nations Fund for Women (UNIFM) recenty female genital mutilaon and other traditional practices published a major doment oudining the impact of gender harmful to women, nonspousal violeoce, violence relted violence on socioeconomic development (Carrillo 1992). to explibtio, semal harasment, andintmidatioat work, The growing international recognition of the impor- in educational institutions, and elsewher, trafficking in tance of genderbased abuse comes on the heels of almost women, forced prostitution, and violence perpeatd or two decades of organizing by women's groups to draw condoned by the state. attention to the issue. Women have been saying in a Significandy, this definition recognizes both physical nultiplicity of ways that violence is a major concern for and psychological harm and threats of such harm in both them (box 1). Recently more than 200 women's non- the public and te private spher. The definition also efrs governmental organizations (NGOs) combined forces to specifically to the gender-based roots of such violence. protest violence against women during 'Sixteen Days of in this paper we use the United Nations definition, but Activism against Gender Violence" (November 25 to wealsoincludeadiscuuionofdefinitaonaliuuesinappendix December 10). During this anmul event groups sponsor B. The catalogue of abuses in the UN definition is not workshopA, conferences, and street theater and organize exhaustive, nor does it presume to be. For the sake of media coveage to raise public awareness of gender brevity, diepper will not address in depth certain fors violence and to demand a response from public officials. of vioence, incldig roed paodibion eual hareamnt The scope and evoution of the peblk 3 traffickinginwomen, orviolence perpetratedby the state. are harmful to women. Box 2 presents an overview of This omission in no way reflects the relative importance violence as it occurs through the life cycle. A life-cycle ofthes issues. In fact, all forms of gender-basedviolence approch to gender-based victimization provides important have common roots and can best be understood as points insights into the immediate as weD as the cumulative effects on a spectum. of violence on the lives of women and girls. Violence can occur during any phase of a woman's life; many women Dimensions of the problem experience multiple episodes ofviolence throughout their lives. A life-cycle perspective also reveals that violence Accuratelyestimatingthe global healthburdenofviolence experienced in one phase can have long-term effects that against women is hampered by lack of data on the predispose the victim to severe secondary health risks, incidence and the health impact of abuse. Crime statistics such as suicide, depression, and substance abuse. Evidence arevirtually uselessinestimatingthe incidence of gender- suggests that the earlier in a woman's life violence occurs- based abuse because of gross underreporting. According especially sexual violence-the deeperand more enduring to recent victimization surveys in the United States, only are its effects (Burnam and others 1988). 2 percent of intrafamilial child sexual abuse, 6 percent of extrafamilial sexal abuse, and 5 to 8 percent of adult Prevalence of abuse by intimate partners sexual assault cases are reported to the police. By comparison, 61.5 percent of robberies and 82.5 percent Themostendemicformofviolenceagainstwomeniswife of burglaries are reported (KOSs 1990). Nonetheless, abuse-or, more accurately, abuse of women by intimate significant progre has been made in recent years in male partners. The 35 studies from a wide variety of estimating the prevalence of wife abuse inboth industrial countries summazed in table 1 show that in many counties and developing cuies. Because of the stigma associated one-quarter to more than half of women report having with sexual violation, data on rape and sexual abuse are been physically abused by a preSEnt or former partner. less easily collected, although large-scale epidemiologic Anevenlargerpercentagehavebeensubjectedtoongoing surveys of sexlud assault are beginning to emerge in emotional and psychological abuse, a form of violence industrl countries. that many battered women consider worse than physical Tlhe foliowing section reviews the data available on abuse. Although some of these studies are based on the different types of violence covered in this report: conveniences,apls, mostarebasedonprobability samples abuse ofwomen, sexual assault, sexual abuse of children, with a large numiber of respondents (Colombia, Kenya, neglect of girl children, and culture-bound practices that Mexico, the United States). Box 1 Evidence of women's interest in gender-based violence When MATCH International, a Canadian funding were submitted on issues relating to violence dtan on organization, surveyedwomen's groups indeveloping any other single theme (Marcelo 1992). countries for suggestions on future funding priorities, The National Black Women's Health Project bas violence against women was the number one reply identified violence as the number one health issue for (Carrillo 1992). African American women in the United States (Avery At a recent 12-country workshop held in China on 1990). women'snonformaleducation,participantswereasked Women amud the woldd colected more than 400,000 to name the worst aspect of being female. The almost signatures (representing 124 counties) on a petition unanimous answerwas fearofnmen'sviolence (Bradley demanding that the United Nations Human Rights 1990). Conference held in June 1993 recognize violence against At a recent meeing on women's reproductive health women as an abuse of women's human rights (Center in Asia, sponsored by the Population Council and the for Women's Global Leadership 1993). Indonesian Epidemiology Network, violence was When the National Council for Women's Rights identfied as one of two priority areas (Population in Brazil sponsored a meeting in 1986 to develop a Council 1991). list of women's demands for the upcoming constitution- At the November 1991 biannual conference of the wviting process, women demanded a new constitutional Association of Women in Development, international clause rewcogizingviolence againstwomen (Pitanguy, participants identified violence agaist women as one personal communication, 1993). of their five priority health conces. More abstrats 4 VIxLECE AaINIr WOhE: TuB HDDB "mLTH DEmN Each of the studies is individually valid, but they are suggest that between one in five and one in seven U.S. not directly comparable because each uses a different set womenwill be de victim ofa completed npe inher lifeime of questions to probe for abuse. Most of the studies ask (Koss 1993; Kilpatrick, Edmunds, and Seymour 1992)? the respondents whether they have been "abused," The U.S. data are consistent with studies of rape in other 'beaten," or 'involved ina violent relationship. " A subset puls of the world Sudies of rspe among colege wx (the studies from Barbados, Chile, and the United States) in Canada, New Zealand, the United Kingdom, and the makes this determination using a list of "acts" that a UnitedStatesrevealremarkablysimilarratesofcompleted woman may or may not have been subjected to during rape acrosscountries(DeKeseredyandKelly 1993; Gavey herlifetime(beinghitwithanobjectorfist,beingbitten).' 1991; Beattie 1992; Koss, Gidycz, and Wisniewkic 1987; Clinical and research experience suggests that question table 2). A study among adult women (many ofthem college formats that require a woman to self-identify as abused students) in Seoul, Korea, yielded a slightly lower rate generally underestimate the physical and psychological of completed rape, but an equally high rate of attempted violence in intimate relationshipsO In many cultures rape (Shim 1992). All of these studies used adaptations women are socialized to accept physical and emotional of the same survey instrument, based on the Sexual chastisement as a husband's marital prerogative, limiting Experiences Survey (SES) by Koss and Oros (1982). the range of behavior they consider abuse. Moreover, The estimates in table 2 are based on legal definitions women are sometimes reluctant to report abuse out of of rape in the United States, which recognize as rape the shame or out of fear of incriminating other family penetration of any orifice by physical force or threat of members. Both factors suggest that the prevalence rates force, or because a woman is incapacitaed due to drugs in table 1 likely underestimate the abuse of women. oralcohol. (For comparison, the U.K. data include forced anal and oral penetration, although the legal definition Prevaknce of rape and sexul assault of rape in the United Kingdom includes only vagina pentration by a penis.) Statistics fom around the world suggest that sexual Womenhave alsobeen subjected, throughouthistory, coercion is common in the lives of women and girls. Six to repeated and especially brutal rape as part of war. In well-designedstudies from theUnitedStates, forexample, recent years mass rape in war has been documented in Box 2 Gender violence throughout the life cycle Phase Type of violence present Prebirth Sex-selective abortion (China, India, Republic of Korea); battering during pregnancy (emotional and physical effects on the woman; effects on birth outcome); coerced pregnancy (for example, mass rape in wary. infancy Female infanticide; emotional and physical abuse; differential access to food and medical care for girl infants. Girlhood Child marriage; genital mutilation; sexul abuse by family members and strangers; differential access to food and medical care; child prostitution. Adolescence Datng and courtship violence (for example, acid thuowing in Bangladesh, date rape in the United States); economically coerced sex (African secondary school girls having to take up with 'sugar daddies" to afford school fees); sexual abuse in the workplace; rape; sexual harassment; forced prostitution; trafficking in women. Reproductive Abuse of women by intimate male partners; marital rape; dowry abuse and murders; age partner homicide; psychological abuse; semal abuse in the workplace; sexual harassment; rape; abuse of women with disabilities. Elderly Abuse of widows; elder abuse (in the United States, the only country where data are now available, elder abuse affects mostly of women). Ike fcor, cad evoldi of dwi probia 5 Table I Prevaence of wie abuse. selected countries Conmtry Sampoe Smple typ. Aindib Commt Antigua 97 women Random subset of 30 percent of women 50 percent of women (Handwerker 1993b) age 20 to 45 netiond probabilitv battered a adults and men report that sample their mothers were beaten Barbados 264 women and Islandwide national 30 percent of women 50 percent of women (Hand werker 19938) 243 men age 20 to probability sample battered as adults and men report that 45 their mothers were beaten Belgium 956 women be- Random sample from 3 percent had experi- Survey queried wor- (Bruynnooghe and tween the eges of 62 municipalities enced very serious en on 15 types of others 1989) 30 and 40 throughout the countrV violence, 13 percent physical violence moderatelV serious ranging from blows violence, end 25 per- with the hand to life- cent less serious vio- threatening forms lence such a strangulation and gun wounds Canda Face-to-face inter- Random sample of aD 27 percent report being 36 percent of women (Haskell and Randall views with 402 residential addresses ever physically reporting abuse 1993) women between the (ncluding apartments) assaulted by an intimate report fearing that ages of 18 and 64in in Toronto partner they would be killed Toronto bV the man who assaulted then Cnada 1,045 men and 454 face-to-face inter- 11.2 percent of respon- This is a one-year (Kennedy and Dutton women in province views with residents of dents report physical rate 1989) of Alberta households randomly abuse within past year s"ected from census enumerations; 244 telephone interviews with residents of Calgary and 347 with residents in rest of province, selected by random-digit dialing Canada 426 married or co- Random sample using 17.8 percent of women Ths is a one-year (Lupri 1989) habitating women face-to-face interviews report physical violence rate and mailed question- by a partner within the naires past year Canada 604 presently or Phone survey using 36A4 percent report 14A4 percent report (Smith 1987) formerly married or random-digit dCialing ever being physically physical abuse within cohabitating women abused in a relationship; the past year gge 18 to 50 in 11.3 percent report netropolitan Toronto sever physical sbuse Canade Nationally represen- In-depth interview by 25 percent of women 65 percent of victirm (Statisics Canada taive sample of phone using random- (29 percent of ever- were saulted more 19933 12.300 women 18 digit dialing married women) report than once, 32 per- and older being physically assault- cent more than 11 ed by a current or for- times; 45 percent of mer male partner since wife assault incidents age 16 resulted in injury 6 VIOLNCE AONNr wom: Txu nDum NEALTH BURDEN Country Sapnw Scnpl type rnii7gs Cnbff t Chile 1,000 women in Stratified random sam- 60 percent have been 70 percent of those (Larrain 1993) Santiago age 22 to pie with a mmxiamum abused by a male inti abused are abused 55 involved in a sampling error of 3 mate; 26.2 percent mnore than once a relationship for 2 percent have been physically year years or more abused (severe violence -that is. more severe than pushes, slaps, or having object thrown at them) Colombia 3,272 urban National random 20 percent physically Part of Colombia's (PROFAMILIA 1990) women. 2,118 rural sarnple abused; 33 percent Demographic and women psychologically abused; Health Survey 10 percent raped by husband Costa Rica 1,388 women Convenience sarnple of 54 percent report being Sponsored by (Chacon and others women attending child physically abused UNICEF/PAHO 1990) welfare clrnic Ecuador 200 low-income Convenience sample of 60 percent had been 37 percent of those (CEPLAES 19921 women Quito barrio beaten by a partner beaten were assault- ed from once a rnonth to every day Guatemala 1.000 women Random sample of 49 percent abused. 74 Indudes physical, (1990 study by women in percent by an intimate emotional, and sexual Frodarico Coy, cited Sacatepequez male partner abuse in adulthood; in Castillo and others sponsored by 1992) UNICEF/PANO India 109 men and 109 50 percent sample of 75 percent of sched- 75 percent of (Mahajan 19901 women from village all scheduled-caste uled-caste men adnit to scheduled- (ower-) in Jullundur District, households and 50 beating their wives; 22 caste wives report Punjab percent of non- percent of higher-caste being beaten fre- scheduled-caste men admit to beatings quently households India 170 women of 100 percent sample of 22 percant of women Author notes that (Rao 1993) childbearing age in 3 potter comwnunity in report being physically informal interviews villages in rural each village based on assaulted bV their and ethnographic southarn Kamataka previous census husbands; 12 percent data suggest that report being beaten prevalence rates are within the past month, vastly under- on average 2BS5 times reported' Japan 796 women from all Convedience sample 58.7 percent report 44 percent of sample (Domestic Violence over Japan (17 based on survey physical abuse by a experienced all three Research Group percent retum on distnrbuted nationally partner; 65.7 percent types of abuse 1993) 4,675 question- through women's report emotional abuse; simultaneously. This naires) groups, adult education 59.4 percent report is not a repre- classes, media, etc. sexual abuse sentative sample Kenya 733 women from Districtwide cluster 42 percent beaten regu- Taken from contra- (Reikes 1990) Kissi District sanple lady ceptive prevalence survey Ske scope ard evohaio of the problm 7 County Smple Seanm type R fings Comment Korea, Rep. of 707 women and Three-stage, stratified 37.5 percent of wives 12.4 percent report (Kim and Cho 1992) 609 men who had random sample of report being battered bv serious physical lived with a partner entire country; face-to- their spouse in last year abuse within last Vwr for at least two face interviews vears Korea. Rep. of 708 women in Convenience sample; 42.2 percent have been 14 percent report (Shim 1988) Suwon and Seoul besed on distributed beaten bV husband after being beaten bV their questionnaires marrige husband within the last year Malavsia 713 women and National random sam- 39 percent of women 15 percent of adults (WAO 1992) 508 men over 15 ple of Peninsular Malay- were physically beaten (22 percent of Ma- sia by a partner in 1989 lays) consider wife beating acceptable Mexico 1,163 rural women Random household 56.7 percent of urban In more than 60 (Ramirez and and 427 urban survey of women on women and 44.2 percent of cases the Vazquez forthcom- wonen in the state DIF (social welfare) percent of rural women principal aggressor ing) of Jalisco register had experienced some was the husband form of interpersonal violence Mexico 342 women age 15 Random sample of 33 percent had lived in Of abused women, (Shrader Cox and or older, low- to households in Mexico a violent relationship; 6 66 percent had been Valdez Santiago middle-income City peri-urban percent had experienced physically abused. 76 1992) neighborhood marital rape percent psycho- logically aburnd, and 21 percent sexuaUy abused Netherlands 1,016 women age Face-to-face inter- 20.8 percent had Half of those (Romkens 1989) 20 to 60 views experienced physical reporting abuse (11 violence in a hetero- percent) had expe- sexual relationship rienced severe, repeated violence New Zealand 3,000 women in Random sample of 22A percent had been 20.7 percent of those (Anderson and others Otago sent ques- women selected from physically abused since physically abused by forthcomingl tionnaire; 497 electoral rolls; all age 16. 76 percent by a a partner were also women interviewed figures weighted back male intimnate (17 sexually abused in (half sexually abused from interview sample percent of total) the relationship and half control to main postal sample group) New Zealand 2,000 women sent Random sample 20.1 percent report (Mullen and others questionnaire; selected frorn electoral being hit and physically 1988) stratified random rolls of five contiguous abused by a male sample of 349 parliamentary partner; 58 percent of women selected for constituencies these women (>10 pe:- interview cent of sample) were battered more than 3 times 8 VIOLzCE AAINSr MEN: THE HIDDN HEALTH BIDN Country Sampl/ San4Ph type M;adMrg Coennt Norway 1S0 women age 20 Random sample 25 percent had been Definition includes (Schel and Bakketeag to 49 In Trondhelm selected from census physically or sexually only forms of vio- 1989) date abused by a male lence more severe pertner than pushing, slap- ping, or shoving Papua New Guinea Ruwal: 736 men, 715 Rural survey In 19 67 percent of rural Almost perfect agree- (Toft 1985) women villages in all regions women beaten ment between per- and provinces centage of women who claim to hae Urban: low-income, Urban survey with 56 percent of urban been beaten and 358 men. 298 oversample of elites low-income women percentage of men women; efltes, 178 beaten; 62 percent of who admit to abuse men, 99 women urban elite women beaten Sri Lanka 200 low-income Convenience sample 60 percent have been 51 percent said hum- (Sonali 1990) women from various from low-income beaten bands used weapons ethnic groups in neighborhood Colombo Tenzania 300 women from Convenience sample 60 percent had been (Sheikh-Heshim and Dar em Salaam from three districts physicafly abused by a Gebba 1990) -lial, Temeke. and partner rinondoni linterviews) Uganda 80 women (16 from House-to-house written 46 percent of 73 An additional 7 (Wakabi and each of Kampala's survey; 7 women women responding women reported Mwesigve 1991) five divisions) refused to answer reported being physi- beatings by family cally abused by a members and another partner S assaults or rapes by outsiders United States 6,000 women Statewide random 39 percent have been More than 12 percent (Grant. Preda, and statewide in Texas sample based on abused by male partner have been sexuaely Martin 1989) sent questionnaires; women holding valid since age 18; 31 abused by male 1,539 usable driver's licenses percent have been partner imce age 18 questionnaires physically abused returned United States 2.143 married or National probability 28 percent report at 11.3 percent report (Straus and Gelles cohabitating couples sample using random- least one episode of abuse within past 1386) digit dialing physical violence year United States 3,000 rural woren Random somple from 40.2 percent have been 22 percent abused (Teske and Parker in Texas sent communities of 50.000 abused since age 18: within the past 12 1983) questionnoires or less 31 percent have been months physically abused Zambia 171 women age 20 Convenience sample of 40 percent beaten by a 7 percent aid they 'Phiri 1992) to 40 women from shanty partner; another 40 thought that phsical compounds, medium- percent mentally abused or mental abuse was and high-density sub- a norma part of mar- urbs of Lusaka and riage Kafue Rural The scope and evoiwbn ofdie problem 9 Table 2 Prevalence of rape among colege-ege women, selected countrios Study Definition of Rate of Rate of cotarwed Country author Sample rape used' comweted rpe and atrtmpted rape Canada DaKeseredy National probability Anal, oral, or vaginal 8.1 parcent 23.3 percent and Kelly sample of 1,835 intercourse by force (by dating (rape or sexual 1993 women at 95 or threat of force partners mince assoult by anyone colleges and SES 9.10 high school) ever) universities New Gavey 1991 347 female Anal, oral, or vaginal 14.1 percent 25.3 Zealand pschology students intercourse by force percent (convenience sample) or threat, or because * man gave alcohol or drugs SES 8,9.10 United Beattie 1,476 women at 22 Anal, oral, or vaginal 11.7 19.4 Kingdom 1992 universities and intercourse by force percent percent polytechnics or because a man (convenience samp4le) gave alcohol or drugs SES 8,9,10 United Koss. Gidycz, Representative SES 8,9,10 15.4 27.5 States and sample of 3,187 percent percent Wisniewski women at 32 (since age 14) 1987 colleges and universities United Moore, Nord, Nationady Forced to have sex 12.7 percent of States and Peatrson representative against will, or raped whites: 8 percent 1989 sample of 18- to of blacks 22-year-olds (before age 21) Seoul, Shim 1992 2.270 adult woman SES 9,10 7.7 percent 21.8 percent Republic of (quota anplel Korea a. SES nmunbwr indicate which of the folowin quetions taken from the Sexual Experiences Suwey (KCo and Oros 1982) wer used in the study to estknate rates of rape nd attempted rape: 4. Has a man attempted exual intercourse (getdng on top of you, attempting to insert hs pweis) when you didn't want to by threatenin or using some degree of physica force (twisting your arm, holding you down, etc.), but intrcours did not occur? 8. Hae you had sxual intercoure when you didn't want to because a man gave you alcohol or drugs? 9. Have you had sexual intercoure when you didn't want to because a man threaened or used some dogree of physcal force (twistng your arm, holding you down, etc.) to make you? 10. Hae you engaged In sex acts (anal or oral itercourse or penetration by objec other than a pedal when you didn't want to becaue a man threatened or used some degree of physical force (twistng your mnm, holding you down, etc.) to make you? Bosnia, Cambodia, IJberia, Peru, Somalia, and Uganda its prevalence can be estimatedL Thc few sudits that do (Swiss and Giller 1993). A European Community fact- existandampleindirectevidencesuggestthatsexualabuse finding team estimates that more than 20,000 Muslim of children and . '