Gender Based Violence: Concepts, Responses, and Measurement

1. Gender Based Violence: Concepts, Responses, and Measurement Julie Pulerwitz, ScD Director, Social and Operational Research, HIV/AIDS Scientific Development Workshop Operations Research on GBV/HIV AIDS2014, Melbourne, July 22, 2014

2. United Nation’s Definition of 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 for women, including threats of such acts, coercion, or arbitrary deprivations of liberty, whether occurring in public or private life.”

3. Types of Gender-based Violence • Intimate Partner Violence (IPV), including physical, sexual, and psychological/emotional • Childhood sexual abuse • Rape (by non-partners) • Exacerbated in conflict situations • Trafficking • Also, considered by many: • Female genital mutilation/cutting (FGM/FGC) • Child marriage • Economic control/withholding

4. Why ‘Gender-based’ Violence (GBV)? • Gender norms can condone and perpetuate violence against both women and men (e.g., MSM) • Violence against women is used to support unequal gender roles • Gender influences patterns of violence among men vs. women (e.g., homicide)

5. Why Address GBV? • A violation of human rights • Has significant public health consequences • Rates of HIV and other STIs • Reproductive health: unwanted fertility, contraceptive use • Physical injury • Mental health: depression, suicide • Access to/use of services • Substance use and riskier behaviors • Has significant economic costs including loss of labor hours and increased health-care costs

6. Substantial Proportions of Women Ever Experience IPV Source: DHS data in Boorwankar et al. 2008

7. Most Common/’gold standard’ Measures of IPV (WHO)

8. Ecological Model: Useful to See HIV and GBV Intersections • UNAIDS 8 • July 21, 2014

9. Current Health Sector Responses • Increased attention to GBV in relation to HIV • Particular need to strengthen sexual assault services • Most health professionals have poor knowledge of GBV management • Management of child survivors is especially lacking

10. Which Services Should be included in a Comprehensive Response to Sexual Violence? Medical • Management of sexual violence at 1st point of contact with survivor. • Sensitive approaches to managing child survivors, and encouraging and enabling presentation by male survivors. • Screening for signs and symptoms of violence during routine health consultations. Community Justice System • Psychological counseling. • New or strengthened community-based prevention strategies. • Physical, psychological, and emotional violence between intimate partners addressed through behavior change messages. • Collection of forensic evidence and creation of a chain of evidence that can be used during prosecution. • Strong links between medical and police facilities to enable incidents to be referred in either direction.

11. Many Issues to Study… • What Types of Interventions are Most Effective for Different Groups? • Majority of survivors reporting sexual assault are children or adolescents...yet services are commonly designed for adults • Mostly girls, but can vary―how to reach both girls and boys? • Children more likely than adults to report knowing perpetrator; small proportion report being related

12. Many Issues to Study… 2. While the need for a multi-sectoral response is clear, how best to organize cooperation and collaboration between sectors, for policy and for service delivery, is not • Within health sector: RH-HIV-pharmacy... • Police links with judiciary • Role of Ministry/Dept of Gender? Social Services? • Links with GBV prevention activities • NGOs, CBOs, etc.

13. Many Issues to Study… 3. How best to screen for violence, and refer for and/or offer services? Many experiencing IPV/GBV will not seek help…. • Routine questioning of women about experience? For all, some? And without further victimizing survivors… • Feasibility/capacity of providing or referring for emotional support and medical services for those identified

14. Some Challenges for OR around GBV/HIV Programs • Hard to separate contribution of multiple strategies • Lack of investment in rigorous evaluation • Inconsistent use of GBV definitions and indicators • Sensitive nature of the information – both methodological and ethical issues • E.g., Changing violence levels hard to measure and interpret • E.g., How to collect data safely

15. Concluding Messages • Increased realization of prevalence and health consequences of GBV, and relationship with HIV • Minimal and often disjointed services available through health sector • Quality and effectiveness of existing and desired health sector responses poorly understood • Research, documentation and sharing of experiences critical for strengthening responses • Various methodological and ethical challenges to conducting good HIV and GBV research • Body of work growing that tackles these issues—examples to come….

17. Exercise for study design • A PMTCT program is being implemented in urban, low income areas in India. Programmers find high loss to follow up rates across the PMTCT cascade (e.g., HCT; infant testing; ART adherence). Anecdotal reports suggest one major reason for LTFU is due to fear of IPV after disclosure. • Design a study to 1. confirm role of IPV, and recommendations to improve current PMTCT program, and 2. test effects of improved program on GBV & PMTCT outcomes. • What are the main research questions? • What are the study design(s)? • What are the key outcomes/measures? • What are the main intervention components (e.g., counseling; community BCC campaign)? • What ethical issues should be taken into account?