Women's low status leaves them vulnerable to violence. A majority of women in some communities endure abuse from their intimate partners, risking their health and lives.
"He told me we were going to make love, and I did not want to," says Maria, a 32-year-old Bolivian woman who has endured years of violence from her husband. "He said, 'Why is it that you never want to?'" and began hitting her. Maria eventually fainted from the pain of his attack.
An FHI study in Bolivia, which included Maria and 131 other women and men, found that more than 50 percent of women had been physically assaulted by their partners, and a third had been forced to have sex against their will.1 "Some men said, 'Of course we beat our wives,'" says Donna McCarraher, an FHI researcher studying partner violence in Bolivia. "And women endured being beaten."
Both men and women accept and condone domestic violence in many parts of the world. Some blame beatings on a wife's failure to bear children or to carry out her domestic duties. Others simply accept violence as a fact of married life. In population-based surveys, between 20 percent and 50 percent of ever-married women in areas as diverse as Egypt, the United States and parts of Nicaragua and Zimbabwe, reported being beaten or otherwise physically abused by their partners. Many also reported sexual or psychological abuse.2
For these women, and for countless others, such violence is part of daily life and can lead to severe injuries and other health problems. These women have desperate needs for safety, and for medical, psychological and reproductive health care.
"The threat or fear of violent behavior prevents women from protecting themselves adequately from pregnancy, abortion and sexually transmitted diseases (STDs)," says Naana Otoo-Oyortey, a gender consultant with the International Planned Parenthood Federation (IPPF) in London. "It leads women to defer to male decision-making on what form of contraception they are allowed to use, which may not be what is effective or right for them."
Family planning and other health-care providers are in an excellent position to intervene because they represent one of the few institutions to come in contact with most women during their reproductive lives -- the time of highest risk for domestic violence. In order to improve the quality of care for abused women, some providers have instituted violence awareness programs, screening and referral techniques.
Domestic violence and sexual coercion are just a part of gender-based violence that includes female genital mutilation, forced sterilization, dowry murders and female infanticide. These abuses result from power imbalances between men and women, experts say. Although it is rare, men are sometimes the recipients of domestic violence. FHI's study in El Alto, Bolivia, found that some women report physically abusing their male partners, often in self defense.
Family planning providers must become aware of power imbalances and the resulting health effects. "They cannot do their jobs well without being concerned about how the issue of power affects women's reproductive health," says Lori Heise, co-director of the Washington-based Center for Health and Gender Equity. "If you do not know that a woman cannot control when she has sex, you are not going to counsel her appropriately. You need to know a woman's social realities."
For years, women's advocacy groups have encouraged the international community to recognize and prevent gender-based violence. As a result, the 1995 Fourth World Conference on Women, held in Beijing, emphasized violence as a critical area of concern. Some countries have recently enacted laws to allow women to divorce or prosecute abusive partners, an important step in making violence less socially acceptable.
The World Health Organization is beginning a collaborative study to examine partner violence and reproductive health in at least five countries, Heise says. Researchers hope to begin interviewing 3,000 women in each country in 1999. One of the strengths of the study is that it addresses methodological issues that plagued earlier research on domestic violence. For example, the reported prevalence of abuse depends heavily on how abuse is defined, which survey questions are used, how and when they are asked, the skill and training of interviewers, the degree of privacy insured, and who is included in the study.
No negotiation
Violent men typically seek control over their partner's behavior and sexuality. "Often, batterers are invested in a definition of manhood they have, including fertility," says Dr. Jacquelyn Campbell, a Johns Hopkins University researcher who studies domestic violence and women's health. Abused women are often unable to negotiate the timing of pregnancy, STD protection, or even health care, because bringing up such issues threatens their partner's sense of control or masculinity.
In a U.S. focus group study, Dr. Campbell found that violent men often dictated contraceptive choice. Some abused women got pregnant to please their partners, while others were forced into abortions against their will.3 In countries where abortion is illegal and unsafe, the procedure puts the woman's life at risk from infection and hemorrhage.
Many women face violence in their relationships from a very early age. In South Africa, "there is a great deal of forced first sex" for adolescent girls, says Katharine Wood of the London School of Hygiene and Tropical Medicine, who has studied this behavior with colleague Dr. Rachel Jewkes.4
"Men use coercion or violence to prevent girls from using family planning," she says. Some men oppose contraceptive use, complaining that they believe contraception would make them infertile or would reduce sexual pleasure. Teenage pregnancy commonly results from the combination of sex, violence and refusal to allow use of contraception. Young, single women also face other problems. "Teenagers report being verbally harassed by [family planning] nurses, and they are afraid to go to clinics," Wood says.
For many women, pregnancy does not halt the beatings. Up to 20 percent of pregnant women in the United States and other developed countries report having been abused by their partners, with most studies indicating a range of about 4 to 8 percent. Pregnant adolescents may face an even higher rate of abuse.5
Some women are first abused during pregnancy, while for others, the violence is part of an ongoing pattern. Unintended pregnancy may result from violence. An unintended pregnancy may also contribute to violence.6 Women who are beaten during pregnancy are more likely to miscarry or have low-birth-weight babies, and they are more likely to postpone prenatal care. Physical abuse may contribute substantially to maternal mortality in some countries.7
Fear of violence also leaves many women open to disability or death from STDs. But trying to convince a violent man to use a condom may endanger a woman in a more immediate way. In many cultures, condom use is linked with infidelity, the suspicion of which often triggers domestic violence.
Sexual and physical violence also can lead to pelvic inflammatory disease, chronic pelvic pain, and vaginal bleeding or discharge, which may have no obvious physical cause. Violence also increases the risk of depression, substance abuse, other mental health problems, suicide and murder.8
If a woman is beaten, it affects not only her health and well-being, but that of her children. An abused woman is more likely to beat her children, as is her abusive partner, says Dr. Penn Handwerker, director of the medical anthropology program at the University of Connecticut. The effects on children extend to adulthood. In Barbados, children in households marred by violence were more likely to act out high-risk sexual behavior that can lead to STDs, such as becoming sexually active earlier and having multiple partners during adolescence, according to one study.9
"If you experience violence as a child, it sets you on a different path" from children who are not abused, says Dr. Handwerker, the study's author. "An experience of childhood violence is the single best predictor of whether a girl gets pregnant and bears children during adolescence."
Special contraceptive needs
Abused women clearly have special needs, including medical, psychological and legal support, and safe housing for themselves and their children, according to Kathryn Tolbert of the Population Council in Mexico. "To be effective, solutions must acknowledge the whole problem," she says.
These women also need reproductive health care tailored to their circumstances. "Women need access to emergency contraception and testing for STDs and HIV/AIDS," Tolbert says. "This is true for all women, but especially for those in violent relationships.
"The most important contraceptive service for women in violent relationships is counseling," she says. "Such counseling must include a recognition of the woman's difficulties with her partner and help for her to choose the method that will not make those difficulties worse. Ideally, it will include referral or in-house professional counseling regarding violence issues and the resources available in her community."
Battered women who cannot protect themselves from STDs through condom use may need repeat screening and treatment for STDs. Developing an effective microbicide that could be controlled by women without a partner's knowledge is crucial for their health and safety.
Emergency contraception also is a pressing need for many battered women. To address this need, a Population Council project in Ho Chi Minh City, Vietnam, is surveying calls from abused women to a crisis hotline to find out what reproductive health problems they report. Based on the survey, a curriculum will be developed for hotline workers, which will probably include information on emergency contraception, says Dr. Lynellyn Long, a Population Council country representative in Vietnam.
Women who choose to use family planning methods may face violence, although contraceptive use may be just one of many triggers in a pattern of abusive behavior, rather than the main cause. A recent study in Bolivia through FHI's Women's Studies Project (WSP) found that of 300 women interviewed, 5 percent were physically abused and 15 percent verbally abused by their partners because of their contraceptive use. While women who discontinued oral contraceptive use were no more likely to be beaten than women currently using the pill, there was more partner violence among women who discontinued pill use and did not adopt a new method.10
A WSP-funded study by the Research Institute for Mindanao Culture in the Philippines found that women who had ever used contraception were more likely to be abused, with more violence linked to longer use.11 And other studies from Mexico, Peru and Kenya report that women are even afraid to bring up the subject of contraception because of possible retribution from their partners.12
Because of this fear, a woman may adopt a family planning method in secrecy. "I never told my husband anything" before having an IUD inserted, says Justina, a 32-year-old Bolivian woman with four children. "If he knew, he would beat me worse."
Abused women in Zimbabwe reported hiding their oral contraceptives in bags of maize in the kitchen or burying them in the garden because they were afraid of a partner's violent or otherwise negative reaction.13 Other women -- including many adolescents in South Africa -- opt for injectables, which can easily be used without a partner's knowledge. Requiring a partner's consent before providing contraception may doom victims of violence to further abuse or repeated unwanted pregnancies.
Natural family planning is a poor contraceptive option for women in violent relationships because they cannot rely on their partners to respect the safe period (abstinence during a woman's fertile time). Condoms, because of their requirement for partner cooperation, are not the ideal choice either.
Quality care
Screening for violence, developing referral networks of legal and other resources, offering treatment tailored to victims' needs, and involving men in family planning programs where it does not compromise women's safety all help provide high-quality care to abused women. In addition, providers may consider documenting evidence of violence in case a woman decides to take legal action.
Despite these deep needs, many providers already are overwhelmed by their other duties, and may be unable or unwilling to intervene. "For many people who provide family planning services, the system is taxed and resources are short," says McCarraher of FHI. "It is also difficult to talk to women about [violence]. They are afraid to tell, and providers are afraid to ask because of fear of reprisal from husbands."
Still, not addressing violence can lead to ineffective care or put the woman in danger, experts say. And many abused women are willing to discuss their situation, if asked in an attentive, appropriate way.
One of the most important steps providers can take for these women requires simply a shift in attitude -- providing a nonjudgmental atmosphere. "If they can do nothing else except ask questions and say, 'This is not your fault,' it can help eliminate self-blame," says Heise of the Center for Health and Gender Equity.
In order to do this, providers need training and education about the problem of domestic violence and possible solutions. Training should be integrated into existing quality of care and family life education programs, not handled as a separate issue, Heise says.
New approaches
In Caracas, Venezuela, IPPF is launching a pilot project to train providers in recognizing, treating and referring victims of sexual and physical violence. The three-day intensive training at the Asociación Civil de Planificación Familiar (PLAFAM) will educate physicians, nurses and social workers about the psychological and physical effects of gender-based violence on women's lives.
"A big part of training is making providers comfortable with the topic," says Lynne Stevens, an IPPF consultant directing the effort. "Some have fears about learning about this part of life. For others, it brings up their own family history. And many have been trained to think they have to 'fix' people, but you can not 'fix' survivors of gender-based violence solely with medical interventions," she says.
During the training, staff will learn how to identify victims of violence by asking questions, listening effectively, and observing physical and behavioral symptoms. Researchers have found that a partner's violent behavior often can be detected with a few interview questions, such as: Within the last year, have you been hit, slapped, kicked or otherwise physically hurt by someone? Within the last year, has anyone forced you to have sexual activities? Are you afraid of your partner (or anyone else you mentioned in previous answers)?14 With such information, a provider can offer more appropriate counseling on STDs, contraception and pregnancy care, experts say.
The IPPF project will help staff adapt record-keeping to track abused women and offer them special care, including safety assessment and violence education. Stevens is collecting posters, videos and books, so clients can learn about violence themselves while in the clinic waiting room. And staff members are developing a referral network of local agencies.
In other programs, referral has ranged from helping a woman find a safe haven from her partner to directing her to legal assistance, mental health care or abortion services, where possible. To protect privacy, a program in Nicaragua is developing cards with referral information that can be slipped into a woman's bra, Heise says.
In another effort, the United Nations Population Fund (UNFPA) has prepared a guidance note on its role in addressing gender-based violence and its effects on reproductive health. Topics included adding emergency contraception to the method mix, placing materials on violence in public information packages, and training providers on meeting the needs of abused women. UNFPA's Ecuador office is training public-sector health providers in Cuenca to recognize and refer victims of violence.
Educating men and boys, and involving them in reproductive health programs, is an important component of addressing partner violence, experts say. Such programs are rare, but they are beginning to appear. For example, an IPPF affiliate in Jamaica has begun training providers to run men's support groups that discuss gender-based violence. And the French IPPF affiliate is researching men's behavior in order to find ways to better address violence against women.
Some family planning programs have even begun offering on-site domestic violence services. For example, the Luxembourg IPPF affiliate offers group therapy and self-defense instruction for victims of violence, and it links women with legal services, says Otoo-Oyortey of IPPF. "Providers are the first point of contact," she says. "They are strategically placed to assist and protect women victims."
-- Carol Lynn Blaney
Note: Carol Lynn Blaney is a free-lance science writer based in San Jose, CA.
References
- Camacho A, Rueda J, Ordóñez E, et al. Impacto de la Regulación de la Fecundidad sobre la Estabilidad de la Pareja, la Sexualidad y la Calidad de Vida. La Paz, Bolivia: Proyecto Integral de Salud and Family Health International, 1997.
- Women's Health and Development Programme, World Health Organization. Fact sheet on violence against women in families. In: Violence Against Women Information Pack, WHO/FRH/WHD/97.8. Geneva: World Health Organization, 1997.
- Campbell JC, Pugh LC, Campbell D, et al. The influence of abuse on pregnancy intention. Women's Health Issues 1995;5(4):214-22.
- Wood K, Maforah F, Jewkes R. 'He forced me to love him': putting violence on adolescent sexual health agendas. Soc Sci Med 1998;47(2):233-42.
- Gazmararian JA, Lazorick S, Spitz AM, et al. Prevalence of violence against pregnant women. JAMA 1996;275(24):1915-20; Campbell JC. Addressing battering during pregnancy: reducing low birth weight and ongoing abuse. Semin Perinatol 1995;19(4):301-06.
- Gazmararian JA, Adams MM, Saltzman LE, et al. The relationship between pregnancy intendedness and physical violence in mothers of newborns. Obstet Gynecol 1995;85(6):1031-38; Campbell; Gazmararian, 1996.
- Heise LL, Pitanguy J, Germain A. Violence Against Women: The Hidden Health Burden. World Bank Discussion Papers 255. Washington: The World Bank, 1994.
- Heise; Eby KK, Campbell JC, Sullivan CM, et al. Health effects of experiences of sexual violence for women with abusive partners. Health Care Women Int 1995;16:563-76.
- Handwerker WP. Gender power differences between parents and high-risk sexual behavior by their children: AIDS/STD risk factors extend to a prior generation. J Women's Health 1993;2(3):301-16.
- Quiroga M, Brouset R, Jiménez V, et al. Oral Contraceptive Use among Family Planning Clients in Santa Cruz, El Alto and La Paz, Bolivia, FHI Final Report. Research Triangle Park, NC: Family Health International, 1997.
- Cabaraban MC, Morales BC. Social and Economic Consequences of Family Planning Use in the Case of Southern Philippines, Final Report Prepared for the Women's Studies Project. Research Triangle Park, NC: Research Institute for Mindanao Culture, Xavier University and Family Health International, 1998.
- Heise.
- Njovana E, Watts C. Gender violence in Zimbabwe: a need for collaborative action. Reprod Health Matters 1996;7:46-54.
- 14. Campbell.
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