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Title: Gender%20and%20Health%20Unit%20Pan-American%20Health%20Organization

Gender and Health UnitPan-American Health
Violence against Women The Health Sector Responds
  • Regional Office of the World Health Organization

Violence against Women The Health Sector Responds
  • Published May 2003
  • Result of 10 years of work
  • Collaborative effort between PAHO, PATH, CDC and
  • Funding from SIDA and NORAD

GBV is one of the most widespread human rights
abuses and public health problems in the world
GBV is devastating, affecting women and girls
long-term physical and mental well-being
The ripple effects of GBV compromise the
well-being of families, communities and societies
A strategy to address the problem is needed - for
health workers, decision-makers and communities
The Health Sector Responds to GBV
  • Over the last decade, GBV has been widely
    recognized as a public health and human rights
  • Several conventions and declarations (CEDAW,
    DEVAW, Belem do Para) have established
    international/governmental commitment to
    addressing and eliminating GBV
  • GHU has played a pivotal role in these
    developments within the Americas
  • Our primary emphasis has been on the involvement,
    not only of the health sector, but of women
    themselves, their families and communities

The Health Sector Responds to GBV
Chapter I - Gender-Based Violence A Public
Health and Human Rights Problem.
  • VAW is any act of gender based violence that
    results in, or is likely to result in, physical,
    sexual or psychological harm or suffering to

- Being male - Witnessing marital violence as a
child - Absent or rejecting father - Being
abused as a child - Alcohol use
- Marital conflict - Male control of wealth and
decision-making in the family
- Poverty, low socioeconomic status,
unemployment - Associating with delinquent
peers - Isolation of women and family
- Norms granting men control over female
behaviour - Acceptance of violence as a way to
resolve conflict - Notion of masculinity linked
to dominance, honour or aggression - Rigid
gender roles
The Health Sector Responds to GBV
Chapter I - Gender-Based Violence A Public
Health and Human Rights Problem.
Nature and Extent
  • 10-50 of women have been victims of
    intimate-partner violence
  • Women are at greatest risk of violence from men
    they already know
  • Violence is a complex problem - cannot be
    attributed to one cause

  • Increased risk of physical/reproductive and
    mental health problems
  • Increased exposure to STIs and HIV
  • Increase in negative health behaviours
    (drug-use/sexual risk-taking)
  • Homicide, suicide, maternal mortality,

The Health Sector Responds to GBV
Chapter II - The Critical Path From Research
to Action.
  • In response to this reality, PAHOs Gender and
    Health Unit...
  • Developed and implemented the Critical Path that
    Women Follow when Affected by Family Violence in
    16 communities of 10 countries

RESPONSE FACTORS - Availability/Quality of
services - Social representations of service
providers - Obtained results
MOTIVATING FACTORS - Information/Knowledge -
Perceptions/Attitudes - Previous experiences -
Support from close people
The Health Sector Responds to VAW
Chapter II - The Critical Path From Research
to Action.
  • The study found that...
  • All women interviewed were victims of physical
    and/or psychological, sexual and economic
  • Women were generally unaware of their rights
  • Even when they took steps to resolving their
    situation, the women met with frustrating results
  • For the majority of women, violence started
    following co-habitation or marriage, and was
    exacerbated by pregnancy
  • Women tolerated abuse out of fear, social
    pressure or lack of financial resources
  • Women identified the negative attitudes of
    service providers as primary obstacles

The Health Sector Responds to VAW
Chapter III - Joining Forces to Address GBV.
  • Out of the Critical Path study grew the
    Integrated Model for Addressing GBV...

DETECTION First step towards breaking the cycle
of violence
Advocate for improved policies and legislation
ATTENTION AND CARE Imperative that providers have
the necessary policies, materials, protocols
and procedures
Build capacity, develop instruments and systems
PROMOTION AND PREVENTION Raising awareness about
GBV is key to preventing it
Form networks, organize campaigns and self-help
and support groups
The Health Sector Responds to VAW
Chapter III - Joining Forces to Address VAW.
What has the Integrated Model achieved?
  • At the regional level...
  • Symposium 2001 Gender-Based Violence, Health and
    Rights in the Americas
  • Technical exchanges between Central American and
    Caribbean countries
  • Political commitment to address GBV
  • At the national level...
  • Inter-sectoral coalitions formed in 10 countries
  • GBV legislation passed in 10 countries
  • Critical Path results published in 10 countries
  • GBV prevention campiagns in 10 countries
  • GBV detection, prevention and care incorporated
    in health-sector reform policies in 5 countries
  • At the sector level...
  • Instruments and systems developed and implemented
  • Norms and protocols in 10 countries
  • Surveillance systems in 5 countries
  • Training modules in 10 countries
  • At the community level...
  • Formation of more than 150 community networks
  • Support groups for men and women formed in 5
  • Self-help groups formed in 8 countries
  • Zero tolerance campaigns and other non-violence
    activities promoted in numerous communities

Lessons Learned from Central America
  • July/August 2001 - Participatory evaluation of
    the Integrated model project to determine...
  • Whether health providers changed the way they
    thought about and addressed violence
  • Whether womens Critical Path had become less
  • What lessons were learned through the
    implmentation of the project

  • A review of project and country documents
  • Interviews with informants (PAHO consultants, MOH
    staff, etc) carried out in each country
  • Focus group discussions with stakeholders

Lessons Learned from Central America
Chapter IV - Policy and Legal Reforms.
  • Increasing international and national
    recognition of GBV as a public health and human
    rights problem
  • Creation of National Plans on preventing violence
    against women in several countries (for e.g.
    PLANOVI in Costa Rica, Mesa Nacional in Peru)
  • Legislative reform throughout Central America -
    for example
  • Establishment of protective measures
  • Expanding the concept of injury
  • Establishing family ties as an aggravating
  • Changing the status of sex crimes/spousal
    violence to public offenses

Lessons Learned from Central America
Chapter IV - Policy and Legal Reforms.
Putting the laws into effect...
  • Interpretation of laws may be biased by culture
    or other factors
  • Little coordination between family and criminal
    justice courts
  • Contradictions between family law and domestic
    violence law
  • Allowing offenders curative treatment instead
    of prison time
  • Mediation is neither forgiveness nor
  • Mandatory reporting dicourages providers from
    asking questions
  • Legal proof may be required fron forensic
    physicians (very few)

Lessons Learned from Central America
Chapter V - Building an integrated approach.
  • Why is GBV invisible in the health sector?
  • Theres simply no time to talk or perform
    special exams for women reporting violence
  • I thought that there were just a few people
    living like this and that it was something

Statements from health workers
  • Women do not speak for fear that the husband
    will be put in jail and then no money will come
    into the household
  • People think that our indigenous costumes make
    us stupidIn the health centre we have to wait
  • When someone isnt sensitized he can get annoyed
    and thinkNow how am I going to get rid of her?
  • I wanted to get things off my chest but I felt
    rejected by the other health workers
  • Health workers - doctors, nurses, health
    inspectors - are men first before they are health

Lessons Learned from Central America
Chapter V - Building an integrated approach.
  • PAHOs Integrated Approach emphasizes.
  • Development of national policies recognizing
    violence as a public health problem
  • Drafting of norms and protocols that define the
    kind of care that should be offered to victims of
  • A training plan for health personnel on use of
    the norms
  • Creation of support groups for violence survivors
  • Promotion of male involvement in violence
  • Development of an information system to track
    reports of GBV through the health sector
  • Development of community-level public awareness
  • Establishment of community networks

Lessons Learned from Central America
Chapter V - Building an integrated approach.
  • Lessons learned from the Integrated Approach.
  • Establishment of a specific health sector policy
    outlining the role of health providers in
    addressing violence is a key step towards
    institutionalizing violence programs and raising
    awareness among personnel
  • The placement of program coordination for care
    for GBV or family violence in the areas of
    womens health and reproductive health services
    facilitates lateral integration into other
    programs and services
  • Inter-programmatic coordination is essential for
    enabling violence programs to become integrated
    laterally into key health programs and for
    ensuring the sustainability of the violence
  • Having oficially approved norms and protocols
    helps to ensure the quality of care and also
    facilitates the scaling up of pilot experiences
  • It is important to train all health personnel on
    the identification of and basic care for women
    suffering violence. This creates a favourable
    environment so that individuals may be identified
    and referred for care.
  • Surveillance systems for violence should consider
    collecting as a minimum, information identifying
    the type of violence (physical, sexual,
    psychological), the sex and age of the victim, as
    well as the age and relationship of the
    perpetrator to the victim.
  • Information systems are only valid if the data
    are used to improve services. Not only is it a
    waste of resources, but it is also unethical to
    collect information or carry out active screening
    for violence with the sole purpose of
    information-gathering, if no services are offered
    in return

Lessons Learned from Central America
Chapter VI - What Happens at the Clinic?
  • How can health workers support women living with

Assess for immediate danger
Provide appropriate care
Document the womans condition
Develop a safety plan
Inform the woman of her rights
Refer the woman to other community resources
Lessons Learned from Central America
Chapter VI - What Happens at the Clinic?
  • Lessons learned from the Integrated Approach.
  • It is not enough to simply wait for women to
    disclose violence on their own. Experience has
    shown that many women are willing to talk about
    violence, but it isw usually necessary for health
    personnel to take the initiative and open the
  • Encouraging health personnel to screen women for
    violence in their regular practice can be an
    excellent exercise for raising general awareness
    and helping personnel to become more confident in
    treating cases of violence. Ideally the
    screening tool should include questions on
    physical, emotional and sexual violence, as well
    as violence during pregnancy
  • It is not necessary to have specialized personnel
    in mental health to provide quality care for
    victims. What is essential is to motivate and
    train staff and to organize services so that
    women that need support receive treatment with a
    human quality and in a timely manner
  • Emotional support is essential for health
    providers who care for survivors of violence.
    Activities to ensure support for personnel should
    be included in norms and implemented at the local

Lessons Learned from Central America
Chapter VII - Beyond the Clinic.
  • Lessons learned from the Integrated Approach.
  • Community healh leaders have a crucial role to
    play in violence prevention, through the
    promotion of nonviolent relationships, and by
    informing the community about their legal and
    social rights - and providing information and
    appropriate referrals to abused women.
  • The establishmet of community networks can
    greatly help in coordinating services form
    victims of violence and in developing joint
    programs for violence prevention
  • Abusers treatment groups should not be confused
    with mens refelction groups. The purpose of the
    reflection groups is to encourage men to
    challenge prevailing cultural views on
    masculinity and to become more sensitive to
    gender-equitable norms. Mens groups can be an
    effective way to involve both adults and young
    men in violence prevention activities
  • Support groups can be a very effective technique
    for helping violence survivors. Nevertheless,
    health providers do need training and ongoing
    support to be effective facilitators

Lessons Learned from Central America
Chapter VIII - Global Implications of the
Integrated Approach.
  • Expanding the model beyond Central America.
  • The approach is flexible and non-prescriptive
  • The approach calls for action at several levels
  • A multi-sectoral approach achieves the best
  • Partnerships and networks provide the necessary
  • The health sector has a fundamental role to play
    in violence-prevention and caring for victims of
  • Training is critical to developing and sustaining
    the health sectors role in violence prevention
    and care
  • The health sector should be pro-active in raising
    community awareness about GBV

Lessons Learned from Central America
Chapter VIII - Global Implications of the
Integrated Approach.
  • The most important lesson we have learned is

Violence can be preventedIn our own countries
and around the world we have shining examples of
how violence has been countered. Governments,
communities and individuals can make a
difference Nelson Mandela