Gender and Health
(Violence against women:
Cost of violence)
Objectives to learns
Basic concepts:
• Sex, Gender, Gender equality, Gender Equity, Gender discrimination
How does gender influence health of women & men?
What is violence? What is Gender Based Violence (GBV) and Violence Against Women (VAW);
Health impacts of violence;
Global feature on violence against women;
Cost violence and its type
Definition
• Gender: A social term that refers to different roles, responsibilities, perspective, behaviors and status of women and men that are determined by the society and culture. This role may vary from country to country or within countries, can also change over time
• Example:
• Sex: Biological differences between women and men which are unchangeable (without considerable surgery)
Example:
Definition
• Gender equality means that women & men and girls & boys
enjoy the same rights, resources, opportunities and protections.
(Education, employment, health, political participation, safety and justice). Its also fundamental human rights
• Example:
Definition
• Gender Equity is the process of allocating resources, programs and decision making fairly to both males and females without any discrimination on the basis of sex. It also addressing any imbalances in the benefits available to men and women.
• To address the equality often requires women-specific needs projects and programs to end existing inequities
• Example:
Gender equality
• Gender discrimination refers to any distinction, exclusion or restriction made on the basis of socially constructed roles and norms which prevents a person from enjoying full human rights.
• Give some example in health arena
What are the challenges
• The goal of achieving equality between women and men is based
on principles of human rights and social justice. Empowerment of women is more over a prerequisite for achieving people centered development…..The abolition of poverty can not be achieved until men and women have equal access to the resources and services necessary to achieve their individual potential and fulfil their obligations to household, community and, more broadly society.’’(UK White Paper on International Development, 1997)
How does gender influence
health of women & men?
Global magnitude
• 70% of the world’s (1.3 bln) people living in poverty are women
• Women represent two thirds (960 mil) non-literate people
• Boys enrolment in school exceeds that of girls (In developing countries)
• Approximately two thirds of the 130 mil children of school age who do not or can not go to school are girls
• Globally, violence against women causes more deaths and
disability among women aged 15 to 44 than do cancer, malaria, traffic accidents or war
• 2 million girls are at risk each year of female genital mutilation
Sex and health
• Biological differences between men and women that lead to differential health outcomes
• Disparity in perinatal mortality –female infants have a lower mortality rate than male infants
• The effect of sex differences is fairly stable across societies
• Our focus is on how risks/ protective factors are different for men & women because of how society is organized
• Women reproductive health
Women’s and men’s health
• Women live longer than men but they tend to be “sicker” than men (Apfel, 1982; Waldron, 1994)
• Longer life expectancy holds across ethnic groups and nations, but the gap is decreasing (Verbrugge, 1985; Walsh, et al., 1995)
• While social discrimination increase, women’s life expectancy decreases (Waldron, 1983)
Compared to women:
• Men have higher rates of fatal illnesses
• Men have more toxic occupational exposure
• Men have higher rates of injuries (Verbrugge, 85; Walsh, et al., 1995
How does gender influence health of women & men
• Affects exposure to health risks and vulnerability
• Influences access to resources (income, power and time) for promoting health
• Influences perception of symptoms and health seeking behaviour
• Impacts on access to care and quality of care received
• Double burden
• Lack of access to education, knowledge and power/status in relationships at household
Gender roles: Related to health?
• Most of the world, women are less involved in salaried job than men and so they earn less money than men
• In Bangladesh, men smoke many times higher than women. So men are at higher risk of lung cancer than women
• Women travel and drive less than men especially in Muslim countries, so change of traffic accident is chance higher to men
• Men are more exposure to risk factors activities
• Women are often the health care gatekeeper for the family
• Access to and control over resources
•
Gender issues in health
• Access to healthcare facilities
• Cultural norms and practices (Lower status/social value in the hh)
• Son preference
• Violence and abuse
• Poverty
• Female Genital Mutilation (FMG)
• Lower education and awareness or access to information
• Discrimination in the health facilities
• Public health issues like violence, alcoholism, smoking
Gender and tuberculosis
• Globally, 8.4 million people are estimated to develop TB each year, nearly 2 million deaths and 90% of them in developing countries
• Poorest people from poorest countries most affected by TB
• TB incidence and prevalence is higher in adult men than women
• Women of reproductive age are more susceptible to fall sick than men of the same age
• TB in pregnancy enhances the risk of a poor pregnancy outcome
• Genital tuberculosis frequently leads to infertility in women
• Social and economic consequences of TB varies by gender
• Women have a longer period of delay before diagnosis
• Men are more likely not to complete treatment
WHO: Gender and Rights in Reproductive Health
Article
• Addressing access barriers to health services: an analytical
framework for selecting appropriate interventions in low-income Asian countries
Authors: Bart Jacobs,1* Por Ir,2,3 Maryam Bigdeli,4 Peter Leslie Annear5 and Wim Van Damme3
Book: How can gender equity be addressed through health systems?
Authors: Sarah Payne
Violence against women: Cost of
violence
What is violence
• Violence is the use of physical force to injure people or property.
Violence may cause physical pain to those who experience it directly, as well as emotional distress to those who either experience or witness it. Individuals, families, schools, workplaces, communities, society, and environment all are harmed by violence
• Violence is defined by the World Health Organization as "the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, which either results in or has a high likelihood of resulting in injury, death, psychological harm, mal-development, or deprivation", but acknowledges that the inclusion of "the use of power" in its
definition expands on the conventional meaning of the word
Gender-based violence (GBV)
• Gender-based violence (GBV) is violence that is directed against a person on the basis of gender. It constitutes a breach of the fundamental right to life, liberty, security, dignity, equality between women and men, non-discrimination, physical and mental integrity
• Gender-based violence reflects and reinforces inequalities between men and women
• Gender-based violence and violence against women are often used interchangeably as most gender-based violence is inflicted by men on women and girls. It is estimated that 20 to 25% of women in Europe have suffered physical violence. The no of women who suffered from other forms of gender-based violence is much higher
What is violence against women?
• Any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion, or arbitrary deprivations of liberty, whether occurring in public or private life
(Article 1, United Nations Declaration for the Elimination of Violence against Women)
• Violence against women (VAW) is, collectively, violent acts that are primarily or exclusively committed against women.
Sometimes considered a hate crime, this type of violence targets a specific group with the victim's gender as a primary motive.
(Wikipedia)
WHO statement
Common types of violence against women
• Physical Violence: Physical violence occurs when someone uses a part of their body or an object to control a person’s actions
• Sexual Violence: Sexual violence occurs when a person is forced to unwillingly take part in sexual activity
• Emotional Violence: Emotional violence occurs when someone says or does something to make a person feel stupid or worthless
• Psychological Violence: Psychological violence occurs when
someone uses threats & causes fear in an individual to gain control
• Economical violence: Deprive from economic needs
• Spiritual violence: Spiritual (or religious) violence occurs when someone uses an individual’s spiritual beliefs to manipulate, dominate or control that person
Spousal violence
• Physical and sexual violence
• Push, shake, or throw something
• Slap or twist arm
• Punch with fist or with something that could hurt
• Kick or drag
• Try to strangle or burn?
• Threaten with a knife, gun, or other type of weapon
• Attack with a knife, gun, or other type of weapon
• Physically force to have sexual intercourse
• Force to perform other sexual acts
Sexual violence
•Sexual violence occurs when a person is forced to unwillingly take part in sexual activity. This includes,
–Touching in a sexual manner without consent (i.e., kissing, grabbing, fondling);
–Forced sexual intercourse;
–Forcing a person to perform sexual acts that may be degrading or painful;
–Beating sexual parts of the body;
–Forcing to view pornographic material; forcing participation in pornographic filming;
–Using a weapon to force compliance;
–Exhibitionism;
–Making unwelcome sexual comments or jokes; leering behaviour;
–Withholding sexual affection;
–Denial of a person’s sexuality or privacy (watching);
–Denial of sexual information and education;
–Humiliating, criticizing or trying to control a person’s sexuality;
–Forced prostitution;
–Purposefully exposing the person to HIV-AIDS or sexually transmitted infections
Impact of violence
• Physical impact:
– Please give some example
• Mental or psychological Impact :
– Please give some example
• Social Impact:
– Please give some example
Health impacts of violence:
• Death and injury- 38% of all women who were murdered were murdered by their intimate
partners, and 42% of women who experienced physical or sexual violence at the hands of a partner had experienced injuries as a result.
• Depression - Partner violence is a major contributor to women’s mental health problems, with women who have experienced partner violence being almost twice as likely to experience depression compared to women who have not experienced any violence.
• Alcohol use problems – Women experiencing intimate partner violence are almost twice as likely as other women to have alcohol-use problems.
• Sexually transmitted infections – Women who experience physical and/or sexual partner violence are 1.5 times more likely to acquire syphilis infection, chlamydia, or gonorrhoea. In some regions (including sub-Saharan Africa), they are 1.5 times more likely to acquire HIV.
• Unwanted pregnancy and abortion – Both partner violence and non-partner sexual violence are associated with unwanted pregnancy; the report found that women experiencing physical and/or sexual partner violence are twice as likely to have an abortion than women who do not experience this violence.
• Low birth-weight babies – Women who experience partner violence have a 16% greater chance of having a low birth-weight baby.
Health impacts of violence:
• Intimate partner violence and sexual violence can lead to unintended pregnancies, induced abortions, gynaecological problems, and sexually transmitted infections, including HIV.
• The 2013 analysis that women who physically or sexually abused were 1.5 times more likely to have a sexually transmitted infection and, in some regions, HIV, compared to women who had not experienced partner violence
• They are also twice as likely to have an abortion.
• Intimate partner violence in pregnancy also increases the likelihood of miscarriage, stillbirth, pre-term delivery and low birth weight babies
• These forms of violence can lead to depression, post-traumatic stress disorder, sleep difficulties, eating disorders, emotional distress and suicide attempts.
• Health effects can also include headaches, back pain, abdominal pain, fibromyalgia, gastrointestinal disorders, limited mobility, poor overall health
• Sexual violence, particularly during childhood, can lead to increased smoking, drug and alcohol misuse, emotional disturbances, and risky sexual behaviours in later life
• Intimate partner violence has also been associated with higher rates of infant and child mortality and morbidity (e.g. diarrhoeal disease, malnutrition).
• Sexual violence are enormous & have ripple effects throughout society. Women may suffer isolation, inability to work, loss of wages, lack of participation in regular activities and limited ability to care for themselves and their children that lead to ill health and sickness.
Health impacts of violence:
Health and Social Consequences of VAW
Fatal outcomes Non-fatal Outcomes
Physical Sexual Reproductive Psychological & Behavioral
- Femicide - Suicide
- AIDS-related mortality
- Maternal mortality
- Fractures
- Chronic pain syndromes - Fibromyalgia
- Permanent disability - Gastro-intestinal disorders - Obesity (children)
- Sexually-transmitted infections including HIV - Unwanted pregnancy - Pregnancy complications - Traumatic gynecologic fistula
- Unsafe abortion
- Depression and anxiety - Eating and sleep disorders - Drug and alcohol abuse - Poor self-esteem
- Post-traumatic stress disorder - Self harm
- Increased sexual risk taking - Smoking
- Perpetrating or being victims of violence later (child & adolescent)
Source WHO, 2008)
Impact of violence against women
Effects on children of women who
experience abuse/violence Effects on families Socio-economic effects
-Higher rates of infant mortality -Behaviour problems
-Anxiety, depression, attempted suicide -Poor school performance
-Experiencing or perpetrating violence as adults
-Physical injury or health complaints - Lost productivity in adulthood
-Inability to work
-Lost wages and productivity - Housing instability
-Costs of services incurred by victims and families (health, Social, justice)
-Lost workplace productivity and costs to employers
- Perpetuation of violence
Source WHO, 2008)
Female genital mutilation (FMG) and VAW
• Health Consequences of FGM: FGM is generally performed by an individual who has no medical training and does not use anaesthetics or antiseptics. Several girls may be cut using the same instrument. This may result in physical and mental health issues, such as haemorrhage, infection, transmission of HIV and other viruses, decrease of sexual sensation, difficulties in childbirth, incontinence, scarring, reproductive health issues, psychological trauma and death. Ill health of women in turn has negative social consequences – women and girls with poor health cannot as easily contribute to the broader community, seek employment, or access education.
• FGM has been documented in 28 African countries, with prevalence varying greatly. High FGM prevalence rate countries include:
- Eritrea 89% - Ethiopia 80% - Mali 92%
- Sierra Leone 94% - Somalia 98% - Sudan 90%
- Middle east ( no data available)
Source WHO, 2008)
Violence Against
Women
a significant cost to the resources of the wider society a violation of women’s human rightsa cause and consequence of gender inequality
a major cause of women’s ill health
a detriment to their well-being
often a crime
Rape
Sexual Abuse
Sexual
Harrassment
Trafficking in Women
Forced
Prostitution
My husband slaps me, has sex with me
against my will and I have to conform. Before being interviewed I didn't really think about this. I thought this is only natural. This is the way a husband behaves.
Woman interviewed in Bangladesh during the WHO Multi-country Study on Women’s Health and Domestic Violence Against Women
“
”
Physical, sexual and
psychological violence
condoned by the state.
If I protest I’ll be marked in the society and then my daughter
wouldn’t be able to get married…
If I voice my protest the
community will blame me for not bearing it in silence. This
helplessness is a torture in itself.
Woman, 43 years old, interviewed in Bangladesh during the WHO Multi-country Study on Women’s Health and Domestic Violence Against Women.
“
”
Global feature on violence against women
• 35 per cent of women worldwide experienced either physical and/or sexual intimate partner violence or non-partner sexual violence.
• Some national violence studies show that up to 70 % of women experienced physical and/or sexual violence in their lifetime from an intimate partner
• It is estimated that of all women killed in 2012, almost half were killed by intimate partners or family members
• A study based on interviews with 42,000 women across the 28 European countries revealed that 14 % of women reported most serious incident of intimate partner
violence to police, 13 %reported most serious incident of non-partner violence to police
• Worldwide, more than 700 million women alive today were married as children (below 18 years of age). More than one in three—or some 250 million—were married before 15
Source: Global review of available data-2013)
• Child brides are often unable to effectively negotiate safer sex, leaving themselves vulnerable to STI infections, including HIV, along with early pregnancy.
• If girls are not physically mature enough to give birth, places both mothers and babies at risk. Poor girls are 2.5 times more likely to marry in childhood
• Among ever-married girls, current/ former intimate partners are the most commonly reported perpetrators of physical violence
• Around 120 million girls worldwide (slightly more than 1 in 10) have experienced forced intercourse or other forced sexual acts at some point in their lives
• More than 133 million girls and women have experienced some form of female genital mutilation (FGM) in the 29 countries in Africa and the Middle East
• Beyond extreme physical & psychological pain, girls who undergo FGM are at risk of prolonged bleeding, infections, infertility, complications at pregnancy and death
Source: Global review of available data-2013)
Global feature on violence against women
• Trafficking trap millions of women and girls in modern-day slavery. Women and girls represent 55% of the estimated 20.9 million victims of forced labour
worldwide, and 98% forced into sexual exploitation
• Between 40 and 50 %of women in European countries experience unwanted sexual advances, physical contact or other forms of sexual harassment at work
• In the United States, 83 per cent of girls in grades 8 through 11 (aged 12 to 16)have experienced some form of sexual harassment in public schools
• Women in urban areas are twice as likely as men to experience violence, particularly in developing countries
• In New Delhi, a 2010 study found that 66% of women reported experiencing sexual harassment between two and five times during the past year
Feature on violence against women
• Research conducted in different countries has documented associations
between HIV and physical and/or sexual violence, both as a risk factor for HIV infection and as a potential consequence of being identified as living with HIV
• A decade of cross-sectional research from African countries, Rwanda, Tanzania, South Africa and more recently, India, has consistently found women who have experienced partner violence to be more likely to be infected with HIV
• In the USA, 11.8 per cent of new HIV infections among women more than 20 years old during the previous year were attributed to intimate partner violence
Global feature on violence against women
The cost of violence
• Annual costs of intimate partner violence have been calculated at USD 5.8 billion in the USA in 2003 and GBP 22.9 billion in England and Wales in 2004
• A 2009 study in Australia estimated the cost of violence against women and children at AUD 13.6 billion per year
• A recent estimation of the costs of domestic violence against women at the hh level to the economy in Viet Nam suggests that expenditures and lost earnings represent nearly 1.4 % of GDP
• An estimate of overall productivity loss however, comes to 1.8 per cent of GDP
• Asia did not have any such calculation
• Bangladesh ( no data) lots of cost direct indirect cost due to VAW
Cost of gender based violence
• Gender-based violence (GBV), and in particular violence against women, is one of the most expensive public health problems globally and has a fundamental impact on economic growth which can span several generations. (Dalal and Dawad, 2011)
• More than 30 studies, mostly from developed countries, have attempted to quantify the costs of various forms of violence against women. These studies focus largely on the costs of services, and the economic losses due to lost output, decreased productivity and lower earnings resulting from violence.
(Duvvury et al., 2012)
• Some of the most comprehensive studies, in both developed and developing countries, estimate the cost of violence to be between 1-2% of GDP, and these are widely accepted to be under-estimates, given the conservatism of the methodology and the gross underreporting of violence.
Why is GBV/VAW an issue?
• The global and local literature on the impact of GBV is significant. A brief overview of the problem of violence is provided below.
• It is a breach of human rights and quality of life. its also fundamental right to life, liberty, security, dignity, non-discrimination, physical and mental integrity
• Violence in women’s lives ranks higher than smoking, obesity or high blood pressure as a contributor to death, disability and illness
• There are significant links between GBV and a range of other reproductive and sexual health
problems, including sexually transmitted disease, unwanted pregnancy, contraception and abortion, maternal morbidity and mortality and adverse pregnancy outcomes
• There is a significant association between perceived or actual HIV-risk and higher levels of GBV
• Evidence from India has established a link between GBV and chronic malnutrition (Duvvury, Carney, Huu Minh, 2012)
• Children who witness or experience violence have lower educational attainment
• Female victims of violence exhibit risk taking behaviours like unhealthy feeding habits, substance abuse, alcoholism and even suicidal behaviours
• GBV perpetuates and reinforces gender inequality.
Types of costs
• Direct, or tangible, costs: Those representing actual paid expenses, or real money spent, on the provision of services, facilities, or expenses incurred by the victim or the household
– Health cost (public and private – includes treatment of victim and others)
• Prescription costs, Medical care, Travel to medical facility, GPs and hospitals
• Reproductive health costs e.g termination of pregnancy, treatment of STIs
• Psychological and/or psychiatric treatment (counseling or other therapy)
– Government costs (excluding health and justice)
• Children caught up in violence – foster care, shelter etc. while mother is unavailable
• Special education for children with behavioural problems and learning disabilities as a result of witnessing violence
• Police, Prosecution, Court costs, Prison, Travel costs
– Second generation
• Health care costs if children also victims of violence
• Psychological support where children are victims or witnesses of violence
• Childcare, Changing schools, Child protection services, Remedial/ducation.
Costs conti……
• Indirect, or intangible costs: Those which don’t have a monetary value, such as pain, fear and suffering or social and psychological costs of violence. These costs may be approximated by a quality or value of life measure or use of a reasonable proxy measure, such as those used credibly in the justice system for establishing compensation
• Pain and suffering
• Premature mortality (years of life lost)
• Disability or impaired functioning
• Loss of a loved one
• Reduced educational attainment in victims and witnesses of violence
• Missed work from injuries, legal proceedings, post-traumatic stress
• Reduced productivity and output, r profits, Reduced earning potential
• Permanent loss of labour capacity, Lost promotion opportunities
• Lost employment if unreliable, Job search if job is lost.
• 2nd Generation:
• Missed school days if school fees
• Missed school days, poor marks
• Increased future use of government services
• Increased juvenile and adult crime
• Lost school fees if changing schools.
Cost
• Opportunity costs: Sometimes also regarded as indirect costs, are the costs foregone when a victim’s options are limited by the circumstances of violence, such as being in or leaving a violent relationship. They represent the loss of potential which have a monetary value that can be estimated.
Global cost of violence
Country Year of study Cost of Violence
(USD) GDP (%) Types of
Violence
CHILE 1999 1.6 bn 2.08 IPV
BANGLADESH 2010 1.8 bn 2.05 DV
VIETNAM 2010 1.3 bn 1.41 VAW, DV
AUSTRALIA 2009 14.7 bn 1.1 VAW, DV
BRAZIL 2007 13.9 bn 1.02 IPV
UK 2008 22.8 bn 0.85 DV, IPV
NICARAGUA 1999 30 m 0.61 IPV
CANADA 2011 6.9 bn 0.39 IPV
EUROPEAN UNION 2006 21.1 bn 0.14 IPV
FINLAND 2002 98 m 0.07 VAW, IPV
USA 2003 5.8bn 0.05 IPV, VAW
FRANCE 2009 3.6 bn 0.14 IPV
SWEDEN 2004 453 m 0.13 IPV
SWITZERLAND 1999 263 m 0.09 DV, IPV
WHO/Duvvury, Carney, Huu Minh, 2012
Cost categories
• Health
• Justice
• Government and civil societies
• Consumptions
• Loss earnings
• Pain and suffering
Figure 6.4
Discussion topics
• We will discuss two articles on VAW for this class
• Article 1: Community Economic Status and Intimate Partner Violence Against Women in Bangladesh: Compositional or Contextual Effects? (Kristin E.
VanderEnde1, Lynn M. Sibley1, Yuk Fai Cheong1, Ruchira Tabassum Naved2,and Kathryn M.
Yount1. journal:-Violence Against Women 2015, Vol. 21(6) 679–699)
• Article 2:Indonesian Men’s Perceptions of Violence Against Women (Pam Nilan1, Argyo Demartoto2,Alex Broom3, and John Germov1: journal:-Violence Against Women 2014, Vol. 20(7) 869– 888)
Community economic Status & Intimate Partner VAW in Bangladesh: Compositional or Contextual Effects?
• Abstract: In this research, we used a multi-level contextual-effects analysis to disentangle the household- and community-level associations between income and intimate partner violence (IPV) against women in Bangladesh. Our analyses of data from 2,668 women interviewed as part of the World Health Organization (WHO) multi-country study on women’s health and domestic violence against women showed that household income was negatively associated with women’s risk of experiencing IPV.
Controlling for residence in a low-income household, living in a low-income community was not associated with women’s risk of experiencing IPV. These results support a household level, not community-level, relationship between income and IPV in Bangladesh.
Indonesian Men’s Perceptions of Violence Against Women
• Abstract: This article explores male perceptions and attitudes toward violence against women in Indonesia. It analyzes interview data from Indonesian men collected as part of a large multimethod Australian government–funded project on masculinities and violence in two Asian countries. Reluctance to talk about violence against women was evident, and the accounts of those men who did respond referred to three justificatory discourses: denial, blaming the victim, and exonerating the male perpetrator. The findings support continuation of government and nongovernmental organization (NGO) projects aimed at both empowering women and reeducating men.
Discussion
• A surveillance data showed that under 5 boys hospitalization
rate due Rota virus diarrhea is almost double than the girls. But while compared the data among the hospitalization under five children, it was revealed that both group equally affected by the Rota virus. Explain the causes why under five girls hospitalization rate is half compare to under five boy.
Assignment
• Question: Women live longer than men in most countries of the world (WHY?) But women in many communities also tend to report more sickness and distress than men do (WHY?)
