Gender-based violence: a barrier to sexual and reproductive health and rights

The extent of violence against women and girls across the world is alarming and is increasingly recognised not only as a grave human rights violation, but also as a public health problem that affects the lives and physical and mental health of millions of women and girls globally. Rooted in gender inequality, violence against women and girls constitutes a major barrier to their sexual and reproductive health and rights.

The Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) adopted in 1979 has so far been ratified by 187^† countries.¹ The importance of bringing an end to all forms of violence against women and girls has further been reiterated in the Sustainable Development Goals (SDGs), which for the first time recognise this as central to the achievement of SDG 5 on gender equality and women’s empowerment, as well as several other SDG targets, including those related to health (SDG 3).² Despite these commitments, violence against women remains pervasive, and according to global estimates 35% of women and girls are subject to physical and/or sexual violence by an intimate partner or sexual violence by a non-partner during their lifetime.³

Reproductive Health Matters has dedicated the 47th issue of its journal to violence, aiming to deepen our knowledge about the different dimensions of gender-based violence, and expand our insights into effective responses. The journal issue sheds light on some of the many circumstances and forms of gender-based violence that impact negatively on people’s sexual and reproductive health and their rights, with papers highlighting how the risk of such violence is heightened in conflict and during migration.

Violence in conflict and crisis

Currently, more than 65 million people are forcibly displaced, more than half women and children.⁴ In armed conflicts and warfare, sexual violence against women, as well as men, is used as a tactic of war, with grave consequences on the physical, mental, and sexual and reproductive health of survivors of violence. Although sexual violence in conflict settings has received high-level policy level attention – exemplified by initiatives such as the Preventing Sexual Violence Initiative (PSVI) – there are many gaps in our understanding of such violence and the magnitude of the problem. Effective interventions to address sexual violence in humanitarian contexts are also very limited, underlining the need for improved data collection in these settings.^5,6

An article in this issue bring further attention to sexual violence against men in conflict settings, highlighting the need for a policy response that is inclusive of male survivors (Touquet and Gorris). Stigma and silence characterise sexual violence, and for men the stigma and silence is further aggravated by the culturally accepted views of masculinity and the perception of sexual violence as feminising.

Women and girls, however, are at greater risk of sexual violence, including forced transactional sex, rape and sexual abuse, not only in conflict settings, but also during migration and upon arrival in destination countries. Several papers in this journal issue focus on the current refugee crisis emerging from the conflict in Syria. One of the papers (Alsaba and Kapilashrami) takes a critical look at “the changing nature of violence and associated risks and lived experiences of women across a continuum of violence faced within the country and across national borders”, through the lens of political economy. Another paper (Freedman) highlights the multiple forms of violence that refugees, including Syrian women, are subject to throughout the different stages of their journey and in destination countries in Europe. As many European countries are focusing on tightening border control and enforcing restrictions, the paper emphasises how these efforts further exacerbate vulnerability to sexual violence by smugglers, and also by police and security forces at borders and in destination countries.

While sexual violence in conflict and post-conflict settings is receiving increasing attention, other types of violence faced by women, such as intimate partner violence, remain prevalent among the displaced population, as shown in several studies, and must not be overlooked.^7,8 The new circumstances created by migration, for instance, influence internal gender dynamics and power relations within families, with some indications of an increase in the incidence of domestic violence. In these situations, women face language barriers and stigma, while fear of officials and deportation increases their reluctance to report these abuses and hinders them from accessing medical, legal and psychological services. (Freedman) Another paper highlights the increased prevalence of violence, including early marriage and transactional sex, for women and girls among the refugee population in Lebanon. (Yasmine and Moughalian) The paper uncovers the systemic obstacles that affect refugee women’s access to sexual and reproductive health services, such as family planning, emergency obstetric care and safe abortion, as well as their decision making power. It further highlights widespread mistreatment and abuse of refugee women in health care settings, including refusal of admission while in labour and forced cesarean section.

Violence and mistreatment in healthcare settings

Abusive, disrespectful and neglectful treatment of women in childbirth in healthcare systems does not just occur among refugee women, but more generally, and is another emerging concern that is covered by some of the papers in this journal issue. (Sadler et al, Vacaflor, and Diaz-Tello) This problem is increasingly framed as a form of violence and named “obstetric violence” in some Latin American countries, where it is also included in legislation. The challenge here is having a definition that clearly identifies which acts constitute abuse and disrespect and which are problems related to poor quality of care within weak health systems. As argued in some of the papers, addressing this form of mistreatment and abuse from a human rights perspective, and within a violence against women framework, aims to highlight the structural dimension of this violence, increase its visibility and generate actions from health systems to ensure that all sexual and reproductive health services are provided in a manner that fully respects women’s choice, autonomy and rights. The same principle should apply to all individuals, including those whose sexual orientation or gender identity fall outside heteronormativity. One of the papers specifically addresses the medicalisation of intersex bodies, arguing how unnecessary medical intervention on healthy intersex bodies violates the rights to bodily autonomy and self-determination. (Carpenter)

Health system response

While abuse and mistreatment in health care settings are to be confronted, sexual and reproductive health services offer a unique entry point to begin to address violence against women. WHO’s Global Plan of Action on Strengthening the Role of the Health System in Addressing Violence, in particular against women and girls, was recently approved by the World Health Assembly and is an important document that highlights how well-trained health providers that know how to identify and provide a supportive response can make an enormous difference to the lives of women and reduce the impact and, at times, the recurrence of violence.^9,10 Most women will attend sexual and reproductive health services, be it for family planning, antenatal care, delivery, a sexually transmitted infection, an abortion, or for their children’s health, at some point in their lives, and this is a window of opportunity for the prevention of violence and provision of adequate care and support. However, evidence is required to guide the optimal integration models. A paper in this issue presenting women’s and providers’ view on integrating services addressing intimate partner violence into abortion care in the UK, concludes that integration of two stigmatised services was not ideal in this setting. This study stresses the need for relevant and context-specific data that also takes into account the acceptability and feasibility of new care models. (Penn Kekana et al)

Domestic violence

The role of the health system in identifying victims of domestic violence is further highlighted by a paper from India, which reveals how the gendered nature of burn injuries in India is going unnoticed by health care providers. (Bhate-Deosthali and Lingam) An estimated 91,000 women die annually in India from burns-related injuries, according to the Indian national burns programme.¹¹ These deaths are entirely preventable. While many, if not most, are the result of domestic violence, these cases are often categorised as accident, suicide and sometimes homicide, without being linked this violence. This emphasises the need for more data, and also awareness among health care providers about the underlying gendered pattern of burn injuries and introduction of interventions to identify and support burn survivors earlier and before they result in deaths.

While burn injuries as a form of violence go unremarked in the media, much of the public discourse and policy attention in India has been on sexual violence, particularly on “stranger rape”, despite the high burden of domestic violence. In contrast, narratives of middle-class men and women from Delhi speak to the pervasiveness of sexual and other forms of abuse within intimate relationships and at home, as highlighted by another paper from India. (Edmunds and Gupta) In the domestic sphere, the understandings of consent, safety and sexual pleasure are not only more negotiated, but also ambiguous, not least because marital rape is not recognised as a crime in Indian law.

While most studies show how men are frequently perpetrators of violence, men may also experience different forms of violence. Men may also play a critical role in ending violence against women and elimination of harmful practices. In this issue, Brown discusses how young men in Kenya consider themselves as allies towards elimination of FGM, highlighting the need for interventions that meaningfully engage men alongside women to drive change in cultural and social norms that reinforce FGM and normalise violence. This is relevant for all forms of violence against women, particularly sexual violence, intimate partner violence and dating violence.

Progress requires evidence

The issue includes other important contributions, and while these studies and perspectives from different parts of the world help to enhance our knowledge, they also raise additional research questions and highlight the need for further investments in research on gender-based violence to expand our understanding, both in terms of types of violence as well as in terms of sub-populations that are at higher risk.

As we move forward with evidence building, it will be helpful to enhance the precision of our language and how we refer to different forms of violence. The term gender-based violence was coined initially to highlight gender inequality (i.e., unequal power dynamics between women and men and unequal access to resources for women) that put women and girls at higher risk of certain forms of violence. It is, however, increasingly being used also to refer to violence on the basis of a person’s sex, sexual orientation or gender identity. Notions of masculinity and femininity underpin both violence against women, and against groups with diverse sexualities and gender identities, nonetheless, the gender dynamics and the underlying drivers for each form of violence are not necessarily the same. Violence on the basis of sexual orientation or gender identity needs to be studied and understood in its own right. Documenting the magnitude and nature of violence faced by individuals on the basis of their sexual orientation and gender identity will help develop more targeted approaches to addressing such violence and address the many barriers, including stigma and discrimination, which limit their access to services.

We need more evidence on other forms of violence that women and adolescent girls are exposed to, such as trafficking; child, early and forced marriage; and on violence as an issue of intersectionality targeting specific groups of women, such as those with disabilities and indigenous women, who we know are affected by high rates of violence. Additional data are required to provide further insights into root causes of violence, structural determinants and what constitutes an effective response

Violence against women is prevalent; one in three women experience physical and/or sexual violence by an intimate partner or sexual violence by a non-partner during their lifetime.³ If this were a disease, the world’s researchers would have been mobilised and resources would have been invested in research to find a way to prevent the spread of the disease and discover a cure and treatment. With increasing recognition of the extent of the problem, and growing political momentum to eliminate gender-based violence, more research and better data collection are not only important, but urgent if we are to tackle the issue at many different levels and achieve the ambitions of the SDGs. Realisation of lofty SDGs requires a comprehensive research agenda that goes hand in hand with firm commitments to increase investment in research, including policy analysis, implementation research and programme evaluation that can generate relevant, context-specific evidence as to what actually works, where and for whom.

Acknowledgements

The authors would like to thank Avni Amin for valuable input to the editorial, and Pathika Martin for careful review and editing. The editors would like to particularly acknowledge the support and contribution of the editorial committee for this issue, namely Avni Amin, Tine Gammeltoft, Ana-Cristina Gonzalez, Barbara Klugman and Heidi Stöckl.

Notes

† The United States, Iran, Sudan, South Sudan, Somalia, and two small Pacific Island nations (Palau and Tonga) have not ratified CEDAW.