Originally published in ARROW for Change (AFC) Vol. 11 Bumper Issue 2005

By Sivananthi Thanenthiran, ARROW

In 2009, the women’s movement will mark the 20th anniversary of the adoption of the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) and the 15th anniversary of the International Conference on Population and Development (ICPD); yet, in all these years, the multifarious forms of gender-based violence across the globe have not diminished.

Despite the substantial body of evidence that testifies to the fact that gender-based violence—physical, sexual and psychological—is a significant cause of ill-health and death among women, gender-based violence has not yet been adequately addressed as a public health issue at the national level. On the one hand, gender- based violence is recognised as a social phenomena; on the other, it is often sidelined into the private realm and treated as such. In fact, sexual and reproductive health is intimately intertwined with gender-based violence. This is the sequential outcome when women’s bodies continue to be the site wherein patriarchal powers stake their claim. This power struggle is enacted throughout the life cycle of women and results in a life cycle of gender-based violence.

Women’s rights to decide when to have children and the number of children to have; when to have sex, with whom, in what ways and how often (not to mention to give pleasure and be pleasured); and when and how to protect themselves from sexually-transmitted infections (STIs) have been consistently violated within the four walls of the home as well as in the world at large. And yet, many governments perceive these rights violations as primarily as a legal issue.

The importance of regarding gender-based violence as women’s rights and sexual rights issue cannot be underscored enough. In addition, however, framing gender-based violence as a public health issue and a reproductive health issue may help to expand not only the reporting mechanisms, but also the intervention mechanisms, and thus enable an intertwining and strengthening of perspectives and frameworks by the different sectors working on the issue.

One opportunity to frame gender-based violence as a public health issue would be to examine the close linkages between violence and maternal death. Different studies, from different parts of the world and in different times, have already done this. As early as 1995, the Women’s Aid Organisation (WAO) of Malaysia noted this in their National Survey on Battered Women. In 2000, it was acknowledged that “[t]he contribution of battering during pregnancy to maternal mortality tends to be neglected, along with that from other forms of domestic violence.”¹

A recent study by Espinoza and Camacho² suggests that the maternal mortality ratio itself needs to be gender- sensitised as it currently does not take into account deaths of pregnant women due to gender-based violence. Yet, the maternal mortality ratio could be modified to consider those deaths. The 2006 WHO Multi-Country Study on Women’s Health and Domestic Violence Against Women³ also extensively documents the impact of gender-based violence on women’s reproductive health. It reports, “Among ever- pregnant women, the prevalence of physical violence by an intimate partner during pregnancy ranged from 1% to 28%, with practically all the violence being perpetrated by the partner.

Between 23% and 49% of those abused reported being punched or kicked in the abdomen, with potentially serious consequences for the health of both the woman” and the foetus. The gender-based violence perspective would provide a gendered dimension to the Millennium Development Goals of maternal mortality.

Framing gender-based violence as a public health issue would also open up more opportunities to specifically and sensitively detect incidence as well as to intervene at the early stages. A paper by Dr. Diana Galimberti, titled “The impact of VAW on the reproductive health of women,”⁴ illustrates how women who suffer from gender-based violence may present a broad range of symptoms when seeking treatment from health facilities.

General injuries, disability, serious obesity, chronic pain syndrome, gastrointestinal disorders, fibromyalgia, post- traumatic stress, depression, anxiety, phobias/panic disorders, appetite disorders, sexual dysfunction, low self-esteem, drug abuse, unintended pregnancy, sexually transmitted infections (STI), HIV, gynaecological disorders, pelvic inflammatory disease, risky abortion and spontaneous abortion are amongst the many indirect symptoms. Health service providers, rather than merely treat each particular symptom, should also explore the possibility that the woman has experienced gender-based violence in such cases.

On the other hand, the most common direct symptoms of violence on the health of women and the foetus are the ‘battered foetus’ syndrome, abruption of the placenta, premature rupture of membranes, genital infection, premature birth, intrauterine growth retardation and low birth weight. Detection of possible violence survivors through the health services would enable them to be absorbed into a cycle of care and counselling early. Detection through the health services may also provide a realistic gauge of the actual incidence of violence.

Framing gender-based violence as a public health concern would also increase advocacy space for the issue. This is crucial as ARROW’s ICPD+10 Monitoring Report⁵ finds that seven of the eight countries studied have passed laws on gender-based violence but “governments have been slow to implement the new laws, showing no real awareness of urgency.” With laws in place in many countries, now is the time to mainstream a gender-sensitive response into other sectors, with the health sector being a key one. Framing gender-based violence as a public health concern at the country level may provide the much-needed push for implementing laws, mainstreaming gender-sensitive responses and initiating policy and programme change.

Healthcare providers should be empowered to make gender-sensitive interventions. ARROW’s definition of a gender-sensitive approach⁶ is one which addresses:

• women’s rights to be acknowledged and respected as an equal partner in initiating and declining sexual relations, safe sex practices and sexual pleasure;
• women’s right to be free from all forms of violence perpetuated by men;
• women’s right to decide if they want to be supported by their partner in the resolution of their health needs and problems; and
• the reproductive rights of women to decide whether and when to have children.

Once gender-sensitised, doctors, nurses, midwives and other healthcare providers will then become women’s health and rights advocates. This would enable an effective intervention implemented by different segments of society. Women themselves would be standing up to gender-based violence and asserting their sexual and reproductive rights, supported by health providers, protected by the law and assisted by feminist counselling and refuges. Change, then, would be inevitable.

Endnotes

1 Hayward, Ruth Finney. 2000. Breaking the Earthenware Jar: Lessons from South Asia to End Violence Against Women. Kathmandu, Nepal: UNICEF. 426p.

2 Espinoza, H.; Camacho, A.V. 2005. “Maternal death due to domestic violence: An unrecognized critical component of maternal mortality.” Pan American Journal of Health. Vol.17, No.2, pp. 123-129.

3 Moreno, C. G. [et al.] 2005. WHO Multi-Country Study on Women’s Health and Domestic Violence Against Women. Geneva, Switzerland: World Health Organization (WHO). 98p.

4 Galimberti, Diana M. “Impact of VAW on the reproductive health of women.” In Proceedings of the ARROW-FIGO Parallel Forums at the 18th Congress of the International Federation of Obstetricians and Gynaecologists, 6-9 November 2006. Kuala Lumpur, Malaysia: ARROW.

5 ARROW. 2006. Monitoring Ten Years of ICPD Implementation: The Way Forward to 2015 – Asian Country Reports. Kuala Lumpur, Malaysia: ARROW. 384p.

6 ARROW. 2003. Access to Quality Gender-Sensitive Health Services: Women-Centred Action Research. Kuala Lumpur, Malaysia: ARROW. 147p.