VIOLENCE AND HEALTH VIOLENCE n The intentional use

VIOLENCE AND HEALTH

VIOLENCE n The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation” (World Health Organisation, 2002) n Gender-based violence, that is, violence that is directed against a woman because she is a woman or that affects women disproportionately. It includes acts that inflict physical, mental or sexual harm or suffering, threats of such acts, coercion and other deprivations of liberty. (Convention against all forms of discrimination against women-CEDAW)

Gender-based violence, which impairs or nullifies the enjoyment by women of human rights and fundamental freedoms under general international law or under human rights conventions. These rights and freedoms include: (a) The right to life; (b) The right not to be subject to torture or to cruel, inhuman or degrading treatment or punishment; (c) The right to equal protection according to humanitarian norms in time of international or internal armed conflict; (d) The right to liberty and security of person; (e) The right to equal protection under the law; (f) The right to equality in the family; (g) The right to the highest standard attainable of physical and mental health; (h) The right to just and favourable conditions of work.

n Domestic Violence is a pattern of assaultive and coercive behaviours, including physical, sexual and psychological attacks as well as economic coercion. , that adults or adolescents use against their family members, usually girls and women. Physical Violence: Beating, Slapping, Hitting, Biting, Kicking, Punching, Shoving Sexual Violence: Forced sexual intercourse; any unwelcome conduct of sexual nature; Economic Violence: Not providing you money for maintaining you or your children, Stopping you from working , Taking away your income from your salary, wages etc. or Not allowing you to use your salary, wages etc. , Forcing you out of the house you live in, Verbal and Emotional Violence: Insults; Name-calling; Accusations on your character/conduct etc. ; Insults for not having a male child; Insults for not bringing dowry etc. ; Restricting mobility, Forcing you to get married or preventing you from marrying a person of your own choice; n

n Sexual Violence is “any sexual act, attempt to obtain a sexual act, unwanted sexual comments/advances and acts to traffic, or otherwise directed against a person’s sexuality, using coercion, threats of harm, or physical force, by any person regardless of relationship to the victim in any setting, including but not limited to home and work. ”

Criminal Law Amendment Act, 2013: Section 375: Rape is: Penetration of penis/object/body part into any orifice (anus/vagina/mouth) Even the penetration of labia majora constitutes rape. It further states that a woman who does not physically resist to the act of penetration shall not by the reason only of that fact, be regarded as consenting to the sexual activity.

n Sexual harassment: “any unwelcome sexual advance, requests for sexual favours or other verbal or physical conduct of a sexual nature, when it interferes with work, is made a condition of employment, or creates an intimidating, hostile, or offensive work environment. ” q Unwelcome physical conduct of a sexual nature q Unwelcome verbal conduct of a sexual nature q Other unwelcome conduct of a sexual nature

CHILD SEXUAL ABUSE n Any injury to private parts of girls or boys constitute abuse within the meaning of criminal statute prescribing abuse of the girl or boy under 12 years with intent to have carnal knowledge of them; mere hurting private parts of boys or girls even though they are not bruised, cut, lacerated or torn is sufficient. (Juvenile Justice Act 1986) n Protection of Children from sexual offences Act 2012 (POCSO) – penentrative, non penetrative assault, sexual harassment (showing photographs, etc )

COMMON PERCEPTIONS o o o : The man is sad or mad than bad He is emotionally disturbed It was all booze She deserves it/she provokes it She has learnt to live with it: its their culture It can not be that bad, or she would have left the man

- Recognized as a public health issue only in 1992 PAHO Conference. - Recognition to the issue has come because of grassroots activism despite indifference of world leader. - WHO recognized it as a Public Health issue in 1993 only after women's health advocates rallied strongly.

Global estimates: n n n 35% worldwide have experienced either physical and/or sexual violence 30% of women in intimate relationships have experinced phsyical and /or sexula violence 38% of all murders of women committed by intimate partners

Health consequences of VAW Domestic violence (Physical and/or sexual) n Women who have been abused report higher rates of number of health problems 16% more likely to have low birth babies (less than 2500 g) q More than twice as likely to have an abortion q Twice as likely to experience depression q 1. 5 times more likely to acquire HIV (in some regions) Sexual violence by non-partner -2. 6 times more likely to experience depression or anxiety q

Health consequences

n A number of studies have identified domestic violence as a leading cause of emergency room visits and injuries for female patients (Abbott et al, 1995; Goldberg et al, 1984, Mc. Leer et al, 1989; Stark et al, 1979). n Domestic violence is also associated with an increased risk of female suicide attempts (Coker et al, 2002; Golding et al, 1994; Stark & Flitcraft, 1995). n Domestic violence victims often do not have control over their sexuality and are at higher risk of experiencing forced sex, sexually transmitted infections, unplanned pregnancies, pelvic inflammatory disease and other health problems.

Data from India q q n n n NFHS: 39% women experiencing physical and/or sexual violence Community based studies (35% to 64%) Study conducted across 18 states found that 63% women faced psychological violence, 26% physical violence and 22% faced sexual violence during their last pregnancy (Mahapatro et. al. 2011). A study conducted among pregnant antenatal women admitted to a hospital in North India found that 28% of women had faced violence during pregnancy (Khosla 2005). Deaths due to domestic violence were the second-

HOSPITAL BASED STUDIES Study of the medico legal records of women at the emergency department of a public hospital for one year indicated that (Daga, 1996): n n 22. 6% women coming to the emergency department were definite cases of domestic violence 34 % women were possible cases of domestic violence (women tried to hide)

KEY RESEARCH FINDINGS OF STUDY CONDUCTED IN AN URBAN SLUM, (KHOT 2002) § 64% of women reported violence at some point in marital life and 17% reported violence during the last 12 months. § Psycho-social violence was most prevalent, followed by physical & economic violence § If it occurs, violence is most likely to occur in 1 st year of marriage § Women facing violence experience serious health problems (5% of sample had attempted suicide due to violence) § Most women seeking help utilized informal support systems in response to DV

Role of health systems and professionals

PRIMARY PREVENTION Prevention of injury & ill health-. SECONDARY PREVENTION Minimize harm already done and prevent further injury (screening, IEC ) TERTIARY PREVENTION Treatment and rehabilitation

Examples of clinical conditions associated with intimate partner violence (WHO, 2013) • Symptoms of depression, anxiety, PTSD , sleep disorders • Suicidality or self-harm • Alcohol and other substance use • Unexplained chronic gastrointestinal symptoms • Unexplained reproductive symptoms, including pelvic pain, sexual dysfunction • Adverse reproductive outcomes, including multiple unintended pregnancies and/or terminations, delayed pregnancy care, adverse birth outcomes • Unexplained genitourinary symptoms, including frequent bladder or kidney infections or other • Repeated vaginal bleeding and sexually transmitted infections

n n Chronic pain (unexplained) Traumatic injury, particularly if repeated and with vague or implausible explanations n Problems with the central nervous system – headaches, cognitive problems, hearing loss n Repeated health consultations with no clear diagnosis Intrusive partner or husband in consultations n

Women Centred Approach: Health-care providers should, as a minimum, offer first-line support when women disclose violence. First-line support includes: • being non-judgemental and supportive and validating what the woman is saying • providing practical care and support that responds to her concerns, but does not intrude • asking about her history of violence, listening carefully, but not pressuring her to talk (care should be taken when discussing sensitive topics when interpreters are involved) • helping her access information about resources, including legal and other services that she might think helpful • assisting her to increase safety for herself and her children, where needed • providing or mobilizing social support.

Providers should ensure: • that the consultation is conducted in private • confidentiality, while informing women of the limits of confidentiality (e. g. when there is mandatory reporting) If health-care providers are unable to provide first-line support, they should ensure that someone else (within their health-care setting or another that is easily accessible) is immediately available to do so.

Minimum requirements for asking about partner violence • A protocol/standard operating procedure • Training on how to ask, minimum response or beyond • Private setting • Confidentiality ensured • System for referral in place