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RHO archives : Topics : Gender and Sexual Health

Annotated Bibliography

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Gender and women's health

Arnold, F. Gender Preferences for Children. DHS Comparative Studies No. 23. Calverton, Maryland: Macro International Inc. (1997).
This comparative study of 57 Demographic and Health Surveys (DHS) in 44 countries examines women's gender preference attitudes and their impact on demographic behavior and the treatment of daughters. Son preference is greatest in a band of countries stretching from North Africa, through the Near East, to South Asia. In some countries, son preference is associated with reduced contraceptive use, increased fertility, and skewed sex distributions of children. Girls are less likely than boys to attend school in nearly all countries studied. Discrimination against girls in immunization and health care leads to differential child mortality in countries with strong son preference. No differences were found in feeding practices and nutritional status.

Ashford, L.S. New population policies: advancing womens health and rights. Population Bulletin 56(1):1-44 (March 2001). Available at: www.prb.org/Content/NavigationMenu/PRB/AboutPRB/Population_Bulletin2/ New_Population_Policies__ Advancing_Womens_Health_and_Rights.htm.
This paper reviews the evolution of national population policies, particularly following the historic 1994 Cairo conference. The author describes the new focus on improving reproductive health and women's rights, examines how governments have tried to incorporate this new approach in their policies and programs, and looks at possible new directions for population policies.

Avotri, J.Y. and Walters, V. "You just look at our work and see if you have any freedom on earth": Ghanaian women's accounts of their work and their health. Social Science & Medicine 48:1123-1133 (1999).
In interviews about their health problems, 75 Ghanaian women did not emphasize reproductive health issues. Instead, they complained about psychosocial problems, such as thinking and worrying too much, and about bodily aches and pains. The women attribute their mental distress, which leads to fatigue, inability to sleep, weight loss, and headaches, to worry over providing for their families in increasingly difficult circumstances: women in Ghana are financially responsible for their children, and many respondents received little or no economic help from their male partners. The women attribute their physical aches and pains to their physically demanding and unending workload. The women describe a challenging series of responsibilities, including farming, money-earning jobs, child care, fetching water, food preparation, cleaning, and laundry, that leaves them with no time to rest or socialize with friends. The authors conclude that financial insecurity, gendered roles, and heavy workloads contribute to the health problems women experience in less developed countries. They argue that the emphasis on reproductive health has mistakenly defined women primarily as childbearers rather than workers.

Barnett, B. Gender norms affect adolescents. Network 17(3):10-13 (1997). Available at: www.fhi.org/en/fp/fppubs/network/v17-3/nt1733.html.
This article discusses the impact of gender on boys and girls. Topics include nutritional differences; pregnant girls dropping out of school; coerced or survival sex; female genital mutilation; and double standards for sexual behavior. Educational health programs have begun asking adolescents to rethink gender roles and stereotypes, while some reproductive health programs are trying to involve men.

Beegle, K. et al. Bargaining power within couples and use of prenatal and delivery care in Indonesia. Studies in Family Planning 32(2):130-146 (2001).
This article analyzes the economic and social power of Indonesian women relative to their husbands. Results show that, after controlling for household resources and background, the distribution of power between husband and wife has an independent influence on decision-making. When women own some of the households assets, when they are better educated or from a higher social status than their husbands, and when their father is better educated than their father-in-law, they have more influence over reproductive health decisions.

Currie DH, Wiesenberg SE. Promoting women’s health-seeking behavior: research and the empowerment of women. Health Care for Women International. 2003;24:880-899.
Providing health services for women does not guarantee that women will use them. To examine why, this article analyzes women’s health-seeking behavior as an individual decision-making process and presents a tool to identify barriers and facilitators to women's health seeking. The tool focuses on the sociocultural context, considering the woman’s threshold for illness, authority in the household, financial resources, the social value of women’s lost time, mobility, and attitudes toward the female body. The authors take an explicitly feminist approach and conclude that providing health services is not enough: it is also crucial to change the system of gender relations and create social and economic conditions that will lead women to utilize health services as an exercise of their rights.

Defo, B. Effects of socioeconomic disadvantage and women's status on women's health in Cameroon. Social Science and Medicine 44(7):1023-1042 (1997).
This 2-year longitudinal study of 10,000 women in Yaounde tested hypotheses about the impact of poverty and women's status on women's health. Data was gathered on demographic, medical, pregnancy-related, behavioral, and household risk factors as well as on episodes of illness experienced during the 2-year period following the birth of a child. Women's status was measured by education, work, marital status, and ethnic affiliation. Statistical modeling found that the burden of illness rested disproportionately on economically disadvantaged women and on women with low social status.

Dey, D.K. Factors influencing maternal mortality in Bangladesh from a gender perspective. Umea, Sweden: Umea University (1998). Available at: www.qweb.kvinnoforum.se/papers/bangladesh.html.
Data from Bangladesh suggest that maternal mortality can be viewed as a chronic disease, rooted in gender inequities, that develops over the entire course of a womans life, beginning with inadequate nutrition and health care in childhood. The paper relates various gender factors to each phase in the "Three Delays" model of safe motherhood.

Doyal L. Gender and the 10/90 gap in health research. Bulletin of the World Health Organization. 2004;82(3):162. Available at: www.who.int/bulletin/volumes/82/3/en/162.pdf.
This editorial argues that gender must be central to efforts to close the 10/90 gap in health research, that is, the fact the less than 10 percent of global research funding is spent on diseases that afflict more than 90 percent of the population. Failing to recognize the critical importance of sex and gender issues to all areas of health research will lead to bad science and avoidable mortality, morbidity, and disability. The author recommends that we build capacity for sex- and gender-sensitive research and that women play a more active role in health research.

Doyal, L. Gender equity in health: debates and dilemmas. Social Science & Medicine 51(6):931-939 (2000).
This article analyzes differences in the health risks faced by men and women, the health care open to them, and the biological and social bases for these differences. Men and women are not homogeneous groups, however, and socioeconomic, cultural, and age differences among men and women complicate the relationship between gender and health. After analyzing the policy implications of this analysis, the author recommends three policies to achieve gender equity in health: ensuring universal access to reproductive health care, eliminating gender inequalities in access to resources, and loosening the constraints imposed by rigidly defined gender roles.

du Guerny, J. et al. Inter-relationship between gender relations and the HIV/AIDS epidemic: some possible considerations for policies and programmes. AIDS 7:1027-1034 (1993).
This article describes how women's low status and traditional gender roles accelerate the spread of AIDS by making it impossible for women to demand safer sex. It also discusses the danger that relying on community care for AIDS victims will reinforce women's traditional care-taking roles and block efforts to raise their status. The authors argue that HIV/AIDS prevention programs should redefine their agendas based on a gender analysis of the socioeconomic and cultural causes and effects of the AIDS epidemic. Short-term goals should be to raise the status of women and re-distribute the caring role; long-term goals should include changing attitudes toward traditional gender roles and reducing women's economic dependence as well as developing new contraceptive and barrier methods.

Fikree FF, Pasha O. Role of gender in health disparity: the South Asian context. British Medical Journal. 2004;328:823-826. Available at: http://bmj.bmjjournals.com/cgi/reprint/328/7443/823.
This review examines the life cycle of gender discrimination in the countries of South Asia from sex selection before birth to women’s poor quality of life in old age. The authors argue that the perceived lack of economic utility of women underlies gender disparities and gender-based health differences in the region. They call for health and human rights practitioners in South Asia to respond to the violations of fundamental human rights of women and the detrimental health effects of gender.

Finkler, K. A theory of lifes lesions: a contribution to solving the mystery of why women get sick more than men. Health Care for Women International 21:433-455 (2000).
To explain higher rates of morbidity among women than men, this article proposes that sickness is rooted, in part, in the stress and anger resulting from adverse social relations, moral dilemmas, and unresolved contradictions in a persons life, which the author terms "lifes lesions." While gender inequalities at the household level shield men from the unresolvable contradictions they face in the outside world, domestic and marital relations add to lifes lesions for women. A case study of a Mexican woman is used to illustrate this theory.

Go, V.F. et al. Gender gaps, gender traps: sexual identity and vulnerability to sexually transmitted diseases among women in Vietnam. Social Science & Medicine 55:467-481 (2002).
A series of in-depth interviews and focus group discussions investigated gender roles, attitudes toward sexually transmitted diseases (STIs) and reproductive tract infections (RTIs), and their impact on womens health-seeking strategies in Vietnam. For Vietnamese women, RTIs are associated with poor hygiene and cleanliness, while STIs are associated with promiscuity. Both men and women agree that husbands would beat or divorce a wife who had an STI, while wives are expected to forgive a husband with an STI. Because of the stigma, women are reluctant to seek care at an STI clinic and may do so only after they experience severe symptoms, discover their husbands have an STI, and/or unsuccessfully try other treatments. The authors conclude that health programs aiming to prevent STIs and RTIs must disassociate their symptoms from traditional norms in order for women to acknowledge symptoms and seek care.

Gruskin, S., ed. Special Focus: Reproductive and Sexual Rights. Health and Human Rights 4(2):1-237 (2000).
This special issue of Health and Human Rights explores the current status of reproductive and sexual rights around the world based on the framework developed at the International Conference on Population and Development in Cairo and the Fourth World Conference on Women in Beijing. In a series of commentaries and articles, various authors discuss the scope and content of these rights, analyze the obstacles that have prevented their full implementation, and propose ways to further their progress. The articles address conditions in every region of the world, including both developing and developed countries.

Institute of Medicine. Exploring the biological contributions to human health: does sex matter? Journal of Womens Health & Gender-based Medicine 10(5):433-439 (2001).
This article reproduces the executive summary of a larger report from the Institute of Medicines Committee on Understanding the Biology of Sex and Gender Differences. The committees three overarching conclusions are (1) sex matters, (2) the study of sex differences is evolving into a mature science that should move from the descriptive to the experimental, and (3) barriers to the advancement of knowledge about sex differences in health and illness exist and must be eliminated. Research recommendations include promoting research on sex at the cellular level, studying sex differences from womb to tomb, mining cross-species information, investigating natural variations, expanding research on sex differences in brain organization and function, and monitoring sex differences and similarities for all human diseases that affect both sexes. Recommendations that address barriers to progress include clarifying use of the terms sex and gender, supporting and conducting additional research on sex differences, making sex-specific data more readily available, determining and disclosing the sex of origin of biological research materials, constructing longitudinal studies that can be analyzed by sex, identifying the endocrine status of research subjects, encouraging interdisciplinary research on sex differences, and reducing the potential for discrimination based on identified sex differences.

Kabira, W. et al. The effect of women's role on health: the paradox. International Journal of Gynecology & Obstetrics 58:23-34 (1997).
Because women are traditionally responsible for health in African countries and their status in society is low, the health sector has received relatively less attention and investment from African governments. Poverty, poor education, and poor nutrition adversely affect women's health. Equally detrimental to women's health is a patriarchal ideology that promotes violence against women, female genital mutilation, early marriage, polygamy and widow inheritance, and shifts the burdens of HIV/AIDS to women. To improve the health of women, the authors recommend encouraging women's participation at every level of the health care sector, including management, leadership, and policy-making roles; promoting gender awareness in education; and fostering women's economic independence.

Kapur, P. Girl child abuse: violation of her human rights. Social Change 25(2&3):3-18 (1995).
This commentary describes how various kinds of abuse and exploitation of girls in India violate their human rights. Abuse begins at or even before birth with female infanticide and female feticide. It continues with reduced access to education, overwork in the household, early marriage, and discrimination in nutrition and health care. Sexual abuse of various kinds is common, including child molestation, incest, rape, and pushing girls into prostitution. The following series of interrelated factors contributes to the abuse of girls: entrenched patriarchal value systems; traditions and customs that consider girls less desirable than boys; negative social attitudes that view girls as liabilities and commodities; illiteracy, ignorance, and poverty; low status of women; declining human and spiritual values; and the rise of consumerism and corruption. Combating this gender-based inequality calls for comprehensive strategies to promote human and spiritual values, to improve human character through effective education and mass media, and to strengthen and enrich family structures.

Khanna, R. et al. Community based retrospective study of sex in infant mortality in India. British Journal of Medicine 327:126-129 (2003). Available at: www.bmj.com/cgi/reprint/327/7407/126.pdf.
This study used verbal autopsy reports collected by a community health project in urban India to analyze infant mortality over a five-year period. The sex ratio at birth was 869 females per 1,000 males, but average mortality was 1.3 times higher in female infants than males (72 versus 55 per 1,000). Girls were twice as likely as boys to die from diarrhea (which accounted for 22 percent of deaths overall), which is an easily treated condition. In addition, three out of every four unexplained deaths (no preceding illness and no satisfactory cause found) were in girls. The authors speculate that these deaths are an extension of female feticide, since they generally occur soon after birth and in families with higher incomes. The authors conclude that excess infant mortality in girls may be due to gender discrimination.

Klasen S, Wink C. A turning point in gender bias in mortality? An update on the number of missing women. Population and Development Review. 2002;28:285-312.
This analysis updates previous calculations of the number of “missing women,” that is, the number of females of any age who have presumably died as a result of discriminatory treatment. The estimated number of women missing worldwide has risen from 87 million in the 1980s (or 7.7 percent of women alive at that time) to 94 million in the 1990s (or 6.9 percent of the larger number of women alive then). Regional data show considerable improvements in West Asia, North Africa, and parts of South Asia; small improvement in India; and deterioration in China. Further analysis of these trends suggests that improved female education and employment opportunities and rising incomes are acting to reduce gender bias in mortality, while the rising incidence of sex-selective abortions is having the opposite effect.

Krieger N. Genders, sexes, and health: what are the connections—and why does it matter? International Journal of Epidemiology. 2003;32:652-657.
Gender, which is a social construct, and sex, which is a biological construct, are distinct terms. However, they are often confused and used interchangeably in contemporary scientific literature. Depending on the health problem under study, either, neither, or both gender and sex may affect the risk of being exposed to an unhealthy situation and subsequently developing a health problem. To clarify differences between gender and sex and illustrate their importance for health, a series of diagrams illustrate how gender relations and sex-linked biology influence twelve health outcomes, ranging from chromosomal disorders to infectious and non-infectious diseases, trauma, pregnancy, and menopause.

Li S, et al. Gender difference in child survival in contemporary rural China: a country study. Journal of Biosocial Science. 2004;36:83-109.
This paper uses data from a survey of deaths of children less than 5 years old in Shaanxi Province, China, to examine gender differences in child survival. Infant mortality was about 32 per thousand for males and 46 per thousand for females. A multivariate analysis of the circumstances of each death found that girls who died were 73 percent as likely as boys to receive medical treatment before death and were 76 percent more likely to die at home, suggesting discrimination against girls in curative health care. In contrast, there no obvious differences in food or immunization status between male and female child deaths. Logistic models link excess female mortality with a traditional preference for sons and the government’s family planning policy: girls were more likely to die if they only had a sister or if they were higher order births.

McDonough, P. and Walters, V. Gender and health: reassessing patterns and explanations. Social Science & Medicine 52: 547-559 (2001).
This article challenges the notion that women experience more ill-health than men as a result of stressful, gendered life experiences. Data are drawn from a representative household sample of 13,896 Canadians, aged 20 or older. Women had 23 percent higher distress scores than men and were 30 percent more likely to report chronic diseases, but men were five times as likely to report heavy drinking. There was little or no difference in self-rated health or activity restrictions between the sexes. Differential exposure to chronic stress and life events accounted for some of the gender differences in distress, but not in chronic conditions or drinking. Differential vulnerability to stressors did not explain health differences.

Moss, N.E. Gender equity and socioeconomic inequality: a framework for the patterning of womens health. Social Science & Medicine 54:649-661 (2002).
A comprehensive framework of factors influencing womens health is presented that brings together gender equity and socioeconomic inequality. Factors influencing womens health include the geopolitical environment (including economic, political, social, and legal policies and structures), culture (including discrimination based on socio-demographic characteristics), and womens roles in the household and workplace. For individual women and households, the impact of these factors on health is mediated through social support networks (friends and families), psychosocial factors (stress, mood, coping, and spirituality), access to health services, violence, and health behaviors (including sex, diet, contraception, and drinking).

Murphy, E. and Ringheim, K. (eds). Reproductive Health, Gender, and Human Rights: A Dialogue. Washington, DC : PATH (2001). Available at: www.path.org/files/RH-GHR-Dialogue.pdf.
This collection of articles by public health and human rights experts was presented at a December 1999 conference. The articles examine the common interests and significant differences that the two perspectives bring to reproductive health issues. A wide range of topics is covered, including sexuality, maternal mortality, family planning, abortion, HIV/AIDS, and violence against women.

Pandey, A. et al. Gender difference in healthcare-seeking during common illnesses in a rural community of West Bengal, India. Journal of Health, Population, and Nutrition 20(4):306-311 (2002).
Over a 12-month period, weekly surveillance detected 790 episodes of diarrhea, acute respiratory infections, and fever among 530 children (263 boys and 267 girls) aged less than five years in a rural community of West Bengal, India. Boys received better care than girls by every measure: Parents were more likely to give boys home fluids and oral rehydration solutions for diarrhea. They consulted qualified health professionals more often and sooner for boys and traveled longer distances to do so. They spent more money per episode on treatments for boys. The authors conclude that a behavioral change campaign is urgently needed to combat persistent gender discrimination.

PATH. Gender inequities and women's health. Outlook 16(4):1-6 (1999). Available at: www.path.org/files/eol16_4.pdf.
This article reviews the impact of gender-based social and economic inequities on women's health. Women's inability to control their own sexuality, both inside and outside of marriage, makes them vulnerable to unwanted pregnancy and sexually transmitted diseases. Gender roles also contribute to high levels of violence against women, including wife beating and rape as an act of war, and their health. Economic and social barriers make it more difficult for women to get appropriate, good-quality health care for their health problems. Health care programs can improve services for women by understanding how gender issues affect health, training their providers accordingly, and broadening their services to help the victims of violence and sexual exploitation and to address mental health needs.

Riley, N.E. Gender, power, and population change.Population Bulletin 52(1) (May 1997). Available at: www.prb.org/Content/NavigationMenu/PRB/AboutPRB/Population_Bulletin2/ Gender,_Power,_and_Population_Change.htm.
This report explores the connections between gender and current levels and trends in fertility and mortality in less industrialized countries. After defining gender as a social construct and power differential, the author reviews differences between men and women in education, work, family roles, and political representation. A further analysis describes the many ways in which female education and work can affect fertility rates. The final section addresses policy issues, including whether family planning programs should adapt to existing gender norms or whether they should challenge gender inequities in order to improve women's lives.

Santow, G. Social roles and physical health: the case of female disadvantage in poor countries. Social Science and Medicine 40(2):147-161 (1995).
his article examines how women's inferior status adversely affects their health and the health of their children. It discusses the health impacts of female infanticide, the differential allocation of food, social pressures to reproduce, women's inability to refuse sex, double standards of sexual behavior, and female genital mutilation. The article also describes how health care is allocated along lines of sex, age, and familial role, so that outside treatment is delayed for women and children. After reviewing largely unsuccessful efforts to change traditional modes of behavior, the author recommends focusing program efforts on men, since they possess the power in the marital relationship.

Shen, C. and Williamson, J.B. Maternal mortality, women's status, and economic dependency in less developed countries: a cross national analysis. Social Science & Medicine 49:197-214 (1999).
This study analyzes data on 79 less developed countries to test theories on the impact of modernization, economic dependency, and gender stratification on maternal morality. Women's status (as measured by education, age at first marriage, and reproductive autonomy) is a strong predictor of maternal mortality, even after controlling for a country's gross national product and economic growth rate. A nation's dependence on foreign investment has negative effects on maternal mortality because it tends to slow economic growth, reduce the status of women, and discourage contraceptive use. The authors conclude that action must be taken to change the social and economic status of women and their access to health services in order to reduce maternal mortality rates.

Tinker, A. et al. Improving Women's Health: Issues & Interventions. Washington, DC : World Bank (2000). Available at: www.worldbank.org/gender/beijing5/womenhealth.pdf.
This report was prepared for the Beijing+5 conference to update delegates about women's health issues. After reviewing the complex interaction of biological socioeconomic determinants of women's health, the authors focus on the five most pressing health concerns for women in the developing world: safe motherhood, sexually transmitted infections, malnutrition, violence against women, and female genital mutilation. Programs funded by the World Bank are used as examples in the discussion of needed policy reforms, and cost-effective interventions. The authors conclude that countries should (1) increase the accessibility, affordability, and quality of health services; (2) use legislation, legal enforcement, and communication to curb harmful practices such as gender discrimination and domestic violence; and (3) orient activities to men as well as women.

UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP). Women, reproductive health and international human rights. Progress in Human Reproduction Research 50(1) (1999). Available at: www.who.int/reproductive-health/hrp/progress/50/news50_1.en.html.
This article applies a broad human rights perspective to the analysis of health and gender. Based on the language of modern human rights conventions, health disadvantages suffered by women may be classified as social injustices and violations of human rights law. For example, high rates of maternal mortality may reflect violations of women's rights to readily available health care services, to education, and to the equitable distribution of national wealth to meet a population's basic needs. The article calls for states to meet their legal obligations and respect women's rights by taking action to overcome women's health disadvantages.

United Nations Population Fund (UNFPA). The State of World Population 2000. New York: UNFPA (2000). Available at: www.unfpa.org/swp/2000/english/index.html.
This year's report focuses on gender inequality, human rights, and development priorities. More equal power relations between men and women, combined with increased access to good reproductive health care, would save lives, avoid unwanted pregnancies and abortions, and reduce the number of STI infections worldwide. The report examines the relationship between gender and reproductive health, urges that violence against women become a human rights and health priority, considers how gender issues affect men as well as women, and quantifies the economic, social, and psychological costs of gender inequities. UNFPA calls on governments and donor countries to help end gender inequality by making legal changes, revising public policy, and contributing to international initiatives. Also available in French and Spanish.

Whelan D. Gender and HIV/AIDS: Taking Stock of Research and Programmes. Geneva: UNAIDS; 1999. UNAIDS Best Practice Collection. Available at: http://www.unaids.org/en/resources/publications.asp.
This publication examines research on how gender norms and societal pressures increase womens and, to a lesser extent, mens vulnerability to HIV/AIDS. It also reviews programmatic responses to reduce individual and societal risks by addressing gender issues. Programs have sought to reduce disease transmission by improving womens access to information, education, skills, services, and technologies that can help prevent HIV/AIDS, by reducing the vulnerability of female sex workers, improving womens social and economic status, and encouraging womens participation in decision making at every level. The author calls for increased research into how gender influences mens knowledge, attitudes, and sexual behavior; advocacy and resources for gender-sensitive care and support; and the development of indicators to measure reduction in gender inequalities relating to vulnerability to HIV/AIDS.

Williamson, J. et al. Female life expectancy, gender stratification, health status, and level of economic development: a cross-national study of less developed countries. Social Science and Medicine 45(2):305-317 (1997).
The authors use gender stratification theory to help explain differentials in female life expectancy in developing countries. Multiple regression models reveal a positive relationship between the status of women and female life expectancy at birth. Significant variables included the ratio of female to male years of schooling, women's relative activity in the industrial sector, and the use of contraception. The relationship between life expectancy and women's economic activity was complex: life expectancy was higher when women worked in more highly paid sectors.

Wong, G. et al. Seeking women's voices: setting the context for women's health interventions in two rural counties in Yunnan, China. Social Science and Medicine 41(8):1147-1157 (1995).
This article reports on 28 focus group discussions on health with village women in China. Women feel their biggest burden is sheer hard work: they are responsible for housework and child rearing in addition to agricultural labor. This means they have no leisure time - just one of many disparities they noted between men's and women's lives. Heavy labor, little rest, and a subsistence diet exhaust women and lead to health complaints such as muscle pain, headaches, and rheumatism. Cost, distance, and lack of transportation limit women's access to health care, and they complain that local providers lack remedies for their most frequent health problems. While women seek out prenatal care, they rely on an informal network of neighbors, relatives, and midwives for home deliveries. The authors recommend that health planners pay more attention to women's perspectives when designing health care systems.

World Health Organization (WHO). Gender and Health: A Technical Paper. WHO/FRH/WHD/98.16 (1998).
Available at: www.who.int/reproductive-health/publications/WHD_98_16_gender_and_health_technical_paper/ WHD_98_16_abstract.en.html.
The Gender Working Group of WHO's Women's Health and Development Programme produced this comprehensive review of the links between sex, gender roles, health status, and health care. A series of case studies illustrate how sex and gender affect the risk of developing a health problem and its course; tropical infectious diseases, HIV/AIDS and other STIs, and violence and injuries are covered. The paper also reviews evidence for the impact of gender roles on women's daily lives, including their nutritional status, exposure to environmental hazards, and workload. A substantial section examines gender inequality in health care, including medical research, access to care, and the quality of care. The paper ends with a series of policy and program recommendations. It also includes a glossary, an extensive bibliography, and a list of relevant WHO literature.

Zaidi, S. Gender perspectives and quality of care in underdeveloped countries: disease, gender and contextuality. Social Science and Medicine 43(5):721-730 (1996).
The author argues that gender inequalities in health in developing countries are due to economic and social structures. Access to health care for men, as for women, depends upon their location in the socio-economic hierarchy. Rich women in poor countries have good health care, as do both sexes in rich countries. Political ideology is also considered, by comparing the impact of socialist and capitalist systems on health standards and the status of women. The author argues that legal reforms cannot improve women's status because that depends on social, economic, property, and political rights.

Zurayk, H. et al. Women's health problems in the Arab world: a holistic policy perspective. International Journal of Gynecology & Obstetrics, 58:13-21 (1997).
This holistic review of women's reproductive health in the Arab world looks at the social and economic context of women's lives as well as their medical problems. It describes the limitations on women's education and work, women's inferior status within the family, and the high value placed on marriage and motherhood. It also reviews contraceptive use, maternal mortality, pregnancy and childbirth, gynecological morbidity, the widespread practice of female circumcision, and menopause. The authors identify three research priorities: organization of reproductive health services at the primary care level, physicians' perceptions of women's health, and women's perceptions of health and illness management.

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Violence against women

A guide for screening and counseling women who are abused. In: Zeidenstein, S. and Moore, K., eds. Learning About Sexuality: A Practical Beginning. New York: The Population Council (1996).
These practical guidelines can help health care providers screen and counsel women who are victims of domestic violence. The guide describes patient characteristics that might indicate a history of abuse, explains how to conduct the interview, lists critical questions to ask, and discusses which kinds of care and referrals are appropriate for battered women.

Ahmed MK, et al. Violent deaths among women of reproductive age in rural Bangladesh. Social Science & Medicine. 2004;59:311-319.
This case-control study draws on data from a longitudinal population-based demographic surveillance system to identify factors associated with death due to violence in rural Bangladesh. Women had a higher suicide rate than men (1.3 versus 0.8 per 10,000 person years) which is unusual compared with more developed countries. The homicide rate was lower for women than men (0.2 versus 0.5 per 10,000 person years). Death rates from violence (suicides plus homicides) remained stable during the study period (1982-1998), while death rates from other causes declined. Suicide and homicide were more common among unmarried women (often due to rejection by the marriage partner or out-of-wedlock pregnancy) and among married women without children (often due to marital strife related to childlessness). Death registration forms described beatings, torture, or other physical and mental abuse by husbands and relatives in 56 percent of violent deaths. Economic stress, childlessness, and forced marriages were factors in about 20 percent of cases. The authors conclude that gender inequality is an underlying social cause of the violence observed.

Anderson A et al. Beyond Victims and Villains: The Culture of Sexual Violence in South Johannesburg. Johannesburg: CIETafrica and Johannesburg Southern Metropolitan Local Council (SMLC); 2000. Available at: www.ciet.org/www/image/country/safrica_victims.html.
Over a three-year period, the Preventing Sexual Violence project conducted extensive research into gender-based violence in South Africa, including two household surveys of 7,812 women, a survey of 2,060 men in the streets, three school surveys of 27,364 students, and interviews with 197 police, magistrates, prosecutors, health care providers, and other service workers. Results document a culture of violence, with an estimated 16 percent of women raped each year, high rates of sexual abuse among boys as well as girls, and widespread beliefs (shared by men and women of all ages) that women cause sexual violence and "ask" for rape. Violent men were more likely to have been exposed to domestic violence during childhood and to have sexually violent friends; employment and education did not play a role. The study also found weaknesses in the way police handle cases of sexual violence, with only a tiny minority of the incidents reported ever recorded as cases. The SMLC is networking with community groups to bring attention to the problem of sexual violence, improve services, and develop preventive strategies.

Asher, J. et al. Detection and treatment of domestic violence. Contemporary Ob/Gyn 9:62-72 (2001). Available at: www.contemporaryobgyn.net/be_core/g/index.jsp.
Domestic violence is the leading cause of injury to women in the United States, but obstetrician/gynecologists are missing opportunities to detect and assist victims. This article offers practical advice to physicians on how to recognize the signs and symptoms of domestic abuse, how to screen women during initial and repeat visits, and how to respond when abuse is detected.

Asling-Monemi, K. et al. Violence against women increases the risk of infant and child mortality: a case-referent study in Nicaragua. Bulletin of the World Health Organization 81(1):10-18 (2003). Available at: www.scielosp.org/scielo.php?script=sci_arttext&pid=S0042-96862003000100004&lng=en&nrm=iso.
This study compared 110 children who died before age 5 with 220 surviving children matched for sex and age; all were drawn from a demographic database covering a random sample of urban and rural households in Nicaragua. Mothers of children who died were significantly more likely than other mothers to have experienced physical or sexual violence during their lifetimes (61% versus 37%). Three other maternal characteristics were associated with higher child mortality: no formal education, older age, and higher parity. The authors argue that the type and severity of violence is probably more relevant than its timing, and they suggest that violence may impact child health through maternal stress or caregiving behaviors rather than through direct trauma.

Blaney, C. Abused women have special needs. Network 18(4):15-18 (1998). Available at: www.fhi.org/en/fp/fppubs/network/v18-4/nt1844.html.
Available in English, French, and Spanish, this article reviews evidence on the prevalence of domestic violence against women and how it affects their reproductive health. It also reports results from a study in Bolivia conducted as part of the FHI Women's Study Project. The author concludes that abused women have special contraceptive needs and require reproductive health care tailored to their circumstances, including access to emergency contraception and contraceptives that can be used secretly, STI/HIV testing, documenting evidence of violence and special counseling, and referrals to community resources such as legal services and shelters. The article also reviews the efforts of IPPF affiliates to address the problem of domestic violence.

Campbell, J. Health consequences of intimate partner violence. Lancet 359(9314):1331-36 (April 13, 2002). Available at: http://pdf.thelancet.com/pdfdownload?uid=llan.359.9314 .editorial_and_review.20723.1&x=x.pdf.
Research on abused women in various settings has documented a host of health consequences of domestic abuse. Abused women may present with obvious trauma at emergency rooms, but battering also leads to chronic central nervous system and gastrointestinal symptoms. Gynecological problems associated with forced sex are among the most consistent and longest lasting health consequences of violence against women. Abuse during pregnancy can lead to health consequences for the fetus as well as the mother. Common mental health effects include depression and post-traumatic stress disorder. As a result of all these health problems, abused women consume more medical care than others.

Castro R et al. Violence against women in Mexico: a study of abuse before and during pregnancy. American Journal of Public Health. 2003;93(7):1110-1116.
This study recruited 914 women in the third trimester of pregnancy who were undergoing routine prenatal exams at 27 clinics in Morelos, Mexico. Interviewers asked about violence during and prior to pregnancy, violence during childhood and against their own children, and socioeconomic indicators. The same proportion of women, 24 percent, experienced violence before and during pregnancy. However, the severity of emotional violence increased during pregnancy, while the severity of physical and sexual violence decreased. The strongest predictors of abuse were violence prior to pregnancy, low socioeconomic status, and parental violence during the childhoods of the women and their partners. The authors conclude that, while violence is common among pregnant women, pregnancy itself is not an initiating factor.

Chang JC. What happens when health care providers ask about intimate partner violence? A description of consequences from the perspective of female survivors. Journal of the American Medical Women’s Association. 2003;58:76-81.
A series of focus group discussions on the consequences of screening for domestic violence were conducted with 41 women attending support groups or living in shelters. The women identified three positive effects of screening on their attitudes, thoughts, and feelings: recognizing that the violence was a problem, decreased isolation, and feeling that the provider cared. They identified four negative consequences: feeling judged by the provider, anxiety about the unknown consequences of disclosing violence, feeling the intervention protocol involved too many steps and too many people, and disappointment in the provider’s response. Results indicate that screening may be harmful unless providers respond appropriately and convey compassion. The authors also suggest that screening may be more than a diagnostic tool: it may be a therapeutic opportunity for providers to give information, validation, and support.

Coker, A.L. et al. Physical and mental health effects of intimate partner violence for men and women. American Journal of Preventive Medicine 23(4):260-268 (2002).
This study analyzed data from a U.S. population-based study of 6,790 women and 7,122 men. About 29 percent of women and 23 percent of men had ever experienced physical, sexual, or psychological intimate partner violence. Women were more likely to report physical violence, sexual violence, and abuse of power and control. Men were more likely to report verbal abuse alone. For both men and women, intimate partner violence was associated with poor health, depression, substance abuse, chronic illness, chronic mental illness, and injury. When both physical and psychological abuse are considered together, levels of psychological abuse are more strongly associated with most health outcomes than levels of physical abuse.

Coker, AL et al. Assessment of clinical partner violence screening tools. Journal of the American Medical Women's Association 56:19-23 (2001).
This U.S. cross-sectional survey compared the results of two partner violence screening tools when applied to a group of 1,152 women attending family practice clinics. Because the Index of Spouse Abuse-Physical Scale (ISA-P) focuses narrowly on physical violence and injury, it missed almost half of the women suffering from intimate partner violence. The Womens Experience with Battering Scale (WEB) not only identified more victims of violence (17 percent of the sample, versus 10 percent for the ISA-P), it was also more strongly associated with self-perceived mental health, anxiety, depression, drug abuse, and low social support. These findings suggest the importance of using screening tools that consider the chronic experience of battering and the associated psychological terror.

Coker, A.L. et al. Intimate partner violence and cervical neoplasia. Journal of Womens Health & Gender-based Medicine 9(9):1015-1023 (2000).
This cross-sectional survey screened 1,152 women ages 18 to 65 recruited from family practice clinics in the U.S. Women who had ever experienced intimate partner violence had elevated risks of developing invasive cervical cancer (RR = 4.28) and preinvasive cervical neoplasia (RR = 1.47). The association was dose-dependent for women experiencing physical or sexual violence, but not for psychological violence. The authors speculate that intimate partner violence might increase the risk of cervical neoplasia either through chronic psychosocial stress or through the transmission of human papillomavirus during sexual assaults.

Coker, A.L. et al. Physical health consequences of physical and psychological intimate partner violence. Archives of Family Medicine 9:451-457 (2000).
This study screened 1,152 women seeking medical care from family practice clinics in the United States for physical, sexual, and psychological intimate partner violence. Of these women, 40 percent had experience physical and/or sexual violence while 13.6 percent had experienced psychological violence without physical violence. Women experiencing psychological violence had significantly increased risks for a variety of physical health problems, including arthritis (1.67), chronic pain (1.91), migraine (1.54), sexually transmitted infections (1.82), chronic pelvic pain (1.62), stomach ulcers (1.72), and spastic colon (3.62). The authors conclude that clinicians should screen for psychological as well as physical and sexual forms of intimate partner violence.

Coker, A. et al. Violence against women in Sierra Leone: frequency and correlates of intimate partner violence and forced sexual intercourse. African Journal of Reproductive Health 2(1):61-72 (1998).
Findings from an HIV/AIDS questionnaire confirm the high levels of violence against women in Sierra Leone. Of the 144 women surveyed, 67 percent reported being beaten by a boyfriend or husband and 74 percent reported being beaten by another family member. Some 51 percent of the women reported that they had been forced to have sexual intercourse against their will, almost always by a boyfriend or husband; for about two-thirds of these women, their first sexual intercourse was forced. Women reporting intimate partner violence and forced sex were more likely to be unemployed (OR = 2.2), under age 29 (OR = 2.3), Muslim (OR = 4.4), or circumcised (OR = 8.0); they also were more likely to believe that their risk of AIDS was high (OR = 2.4) and to hold traditional attitudes about sex. The authors discuss the health consequences of these patterns and explore the possible social links between various forms of violence against women, female circumcision, and traditional attitudes about sex.

Davidson, L.L. et al. Training programs for healthcare professional in domestic violence. Journal of Womens Health & Gender-Based Medicine 10(10):953-969 (2001).
Dozens of educational programs to improve the ability of health care providers to identify and treat abused women have been tested. A review of the published literature shows that most of these programs have consisted of a single brief session, with little effort to reinforce, follow up, or evaluate that session. Studies also suggest that while implementation of screening protocols may be successful in the short term, maintaining them is difficult. Methodological shortcomings prevent a clear conclusion about the effect of training in domestic violence on provider performance and the care of abused women. It is clear, however, that interventions must actively engage the staff if they are to be effective and that ongoing training and reinforcement must be institutionalized.

DAvolio, D. et al. Screening for abuse: barriers and opportunities. Health Care for Women International 22:349-362 (2001).
This article reviews the literature on screening for domestic violence and presents the authors own experiences in setting up screening systems at prenatal care sites as part of a larger research project. Health care providers everywhere are inconsistent in screening female patients for domestic violence, in part because of lack of knowledge, lack of written protocols for screening, and time constraints. Even with special training, however, providers do not screen consistently. Their personal attitudes toward the problem of domestic violence account for much of the difference. Some keys to implementing a screening program are integrating it into the routine of care, assigning a single nurse to do all of the intake screening, using a consistent screening tool, ensuring the commitment of key people, and convincing clinicians that help is available and that they will be able to respond appropriately when a woman reveals abuse.

Dunkle KL, et al. Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. Lancet. 2004;363:1415-1421. Available at: http://pdf.thelancet.com/pdfdownload?uid=llan.363.9419.original_research.29458.1&x=x.pdf.
This cross-sectional study interviewed 1,366 women who sought antenatal care at four health centers in South Africa and accepted routine antenatal HIV testing. After adjusting for age, current relationship, and women's risk behaviors, results show that women with violent or controlling male partners were one and a half times more likely to be infected with HIV than other women. Child sexual assault, forced first intercourse, and adult sexual assault by non-partners were not associated with HIV status. The authors conclude that gender-based violence is an important determinant of women’s HIV risk, and they postulate that abusive men are more likely to have HIV and to impose risky sexual practices on partners.

Ellsberg, M. and Heise, L. Bearing witness: ethics in domestic violence research. Lancet 359(9317):1599-1604 (May 4, 2002). Available at: http://pdf.thelancet.com/pdfdownload?uid=llan.359.9317 .editorial_and_review.20964.1&x=x.pdf.
Poorly designed research on domestic violence can put women in violent relationships at risk and cause mental distress. Ensuring womens safety and protecting their privacy and confidentiality should be top priorities of any research program. In addition, researchers are ethically obligated to provide women with information on relevant services and immediate referrals. To assure reliable results, it is essential to design questions and train interviewers to enhance disclosure rates of violence while making the interview itself a positive intervention. Both informed consent and mandatory reporting laws raise challenges for researchers.

Ellsberg, M. et al. Researching domestic violence against women: methodological and ethical considerations. Studies in Family Planning 32(1):1-16 (March 2001).
This article compares three population-based studies on violence against women in Nicaragua. A Demographic and Health Survey (DHS) of a nationally representative sample of women found a significantly lower lifetime prevalence of physical violence by a partner than either of two regional studies that focused specifically on violence (28% versus 52% and 69%, respectively). Further analysis of the data, along with focus-group discussions with field workers and staff from the three studies, indicate that underreporting in the DHS accounts for this discrepancy. Unlike the other studies, the DHS did not give interviewers the training and support needed to assure womens safety and enhance disclosure.

Ellsberg, M.C. et al. Womens strategic responses to violence in Nicaragua. Journal of Epidemiology and Community Health 55:547-555 (August 2001).
This cross-sectional population-based survey of León, Nicaragua, focuses on how 188 women aged 15 to 49 responded to physical partner abuse. Two-thirds of the women effectively defended themselves, either verbally or physically, from abuse; 41 percent left home temporarily; 20 percent sought help outside the home; and 70 percent eventually left abusive relationships. Lack of family and social support led many women to enduring abuse rather than end it. Strengthening community support networks and improving the response of health and legal institutions are critical to encourage women to reach out for help.

Ellsberg, M. et al. Candies in hell: womens experiences of violence in Nicaragua. Social Science & Medicine 51:1595-1610 (2000).
A population-based survey of 488 women aged 15 to 49 in León, Nicaragua, found that 52 percent of ever-married women had experienced physical partner abuse, for a median of 5 years. Many had also experienced sexual and emotional violence. Thirty-one percent of abused women suffered physical violence during pregnancy. Abusive relationships were marked by extreme jealousy and control. Womens feelings of shame and isolation, together with a lack of family and community support, contributed to their difficulty in leaving violent relationships.

Epstein, H. The intimate enemy: gender violence and reproductive health. PANOS Briefing No. 27. London: Panos Institute (March 1998). Available at: www.panos.org.uk/resources/reportdownload.asp?type=report&id=1028.
This extensive article was written to brief the media on the link between gender violence and reproductive health and to stimulate debate. It catalogs, in detail and with many personal examples, the types of violence that women experience throughout the life cycle and the health impacts. It also reviews efforts around the world to limit violence and address its health consequences through international declarations on human rights, the expansion of health care services, community prevention efforts, and advocacy. Community initiatives in Uganda, Nicaragua, Peru, and Chile are featured as examples of what can be done, and the briefing includes a list of key contacts at organizations around the world.

Fikree, F.F and Bhatti, L.I. Domestic violence and health of Pakistani women. International Journal of Gynecology and Obstetrics 65:195-201 (1999).
Of 150 currently married women in Karachi, 34 percent reported experiencing physical abuse, 15 percent while pregnant. Nearly three-quarters of physically abused women were anxious or depressed. Physical abuse was the single strongest predictor for anxiety and depression even after controlling for other key factors, such as income and education. The authors conclude that the physical and mental health consequences of domestic violence pose a serious reproductive health concern in Pakistan.

Fischbach, R. et al. Domestic violence and mental health: correlates and conundrums within and across cultures. Social Science and Medicine 45(8):1161-1176 (1997).
Three patterns of domestic violence - marital rape, dowry-related deaths, and exposure to HIV/AIDS - are used to illustrate the way cultural norms justify and perpetuate the threat to women around the world. The article details the mental health consequences of domestic violence, which extend far beyond the physical harm inflicted. These include depression, alcohol and substance abuse and dependence, anxiety, post-traumatic stress disorder, and suicide. The authors conclude that a significant proportion of the mental disorders observed in women are directly related to their experiences as victims of domestic violence. Research priorities are suggested, as are changes in the social, legal, and medical responses to domestic violence.

Garcia-Moreno, C. Dilemmas and opportunities for an appropriate health-service response to violence against women. Lancet 359(9316):1509-1514 (April 27, 2002). Available at: http://pdf.thelancet.com/pdfdownload?uid=llan.359.9316 .editorial_and_review.20874.1&x=x.pdf.
Randomized, controlled trials are needed to determine which health care interventions are most effective against domestic violence. Evidence from developed countries suggests that introducing protocols or screening tools for domestic violence into health services can increase the identification of victims in the short term, but that it is difficult to sustain the gains. Often, appropriate interventions are not successfully implemented because training is inadequate. Effective training programs address providers own values, attitudes, prejudices, and personal experiences of violence as well as technical issues. While primary health care and reproductive health services in developing countries have the potential to identify abused women, these often are too overstretched and undertrained to take on an additional task. Also, any health care response must be accompanied by legal, law enforcement, and social changes.

Gerbert, B. et al. How health care providers help battered women: the survivors' perspective. Women & Health 29(3):115-135 (1999).
This qualitative analysis of interviews with 25 battered women in the United States explores how health care providers can help abused women. Disclosure and identification was a complicated process because the women sometimes revealed only part of their situation, dropped hints, minimized the violence, or lied. There was no one ideal response by providers: direct questions, probing around the issue, and indirect communication all were effective on some occasions. The greatest help providers offered was validation, that is, labeling the batterer's behavior as wrong and telling the woman that she deserved better treatment. Validation provided an immediate sense of relief and set off a long-term process in which women recognized the seriousness of their situation and the need to change it. The authors recommend that providers express tacit validation even when they are not sure if abuse is taking place, by showing concern, documenting physical complaints, and confirming that no one deserves to be abused for any reason.

Go VF, et al. Crossing the threshold: engendered definitions of socially acceptable domestic violence in Chennai, India. Culture, Health, & Sexuality. 2003;5(5):393-408.
As part of a multi-site HIV intervention trial, researchers conducted 48 in-depth interviews and 14 focus groups with men and women in two low-income communities in Chennai, India. Respondents reported that husbands regularly beat wives in most marriages, and they perceived violence to be a necessary tool to discipline wives and enforce gender norms. Factors outside the marriage, such as poverty and unemployment, intensified the marital conflicts that triggered episodes of violence, while rigid gender roles facilitated violence. Both men and women accepted some level of violence, but women set the threshold for socially objectionable violence (defined in terms of its intensity, frequency, and justification) lower than men. The authors recommend interventions that change the accepted threshold for violence.

Gordon, P. and Crehan K. Dying of Sadness: Gender, Sexual Violence and the HIV Epidemic. SEPED Conference Paper Series #1. UNDP (2000). Available at: www.undp.org/seped/publications/dyingofsadness.pdf.
This literature review examines the relationship between the HIV epidemic and sexual violence, including violence in conflict situations and violence against sex workers. The authors conclude that sexual violence is a complex phenomenon with multiple causes, consequences, and manifestations. Effective responses to the problem must operate simultaneously at the local, national, and international levels. Short-term strategies must be sensitive to the local context and provide support services for individual victims as well as punishment for perpetrators. Long-term strategies must consider the gendered and sexualized nature of the violence and address it at the level of community and culture, rather than the individual.

Guedes, A. et al. Integrating systematic screening for gender-based violence into sexual and reproductive health services: results of a baseline study by the International Planned Parenthood Federation, Western Hemisphere Region. International Journal of Gynecology and Obstetrics 78 (Suppl. 1):S57-S63 (2002).
IPPF affiliates in the Dominican Republic, Peru, and Venezuela have launched a coordinated effort to integrate screening, referral, and services for gender-based violence into their reproductive health services. Three standardized instruments (a survey of providers knowledge, attitudes, and practices; a clinic interview and observation guide, and an institutional assessment questionnaire) were used to gather baseline data and help develop an action plan. Providers showed a high degree of support for screening about violence, but many blamed female victims for violence and had limited knowledge of the topic. Most clinics lacked some of the resources needed to address the issue, including directories of community services. A field test in Venezuela of a four-question screening tool for domestic violence was highly successful: the percentage of new reproductive health clients identified as survivors of gender-based violence rose from 7 to over 30 percent after the tool was introduced.

Guo SF et al. Physical and sexual abuse of women before, during, and after pregnancy. International Journal of Gynecology and Obstetrics. 2004;84(3):281-286.
This community-based survey interviewed 12,044 Chinese women with children aged 6 to 18 months. The prevalence of physical and sexual abuse before pregnancy was 8.5 percent, compared with 3.6 percent during pregnancy, and 7.4 percent during an average postpartum period of 11 months. Most abuse was recurrent and not severe. Abuse before pregnancy was a strong indicator of abuse during and after pregnancy, and past abuse was a strong indicator of subsequent abuse. The authors recommend routine screening for abuse as part of maternal care.

Heise, L. et al. Ending violence against women. Population Reports, Series L, No. 11. Baltimore, Maryland: Johns Hopkins University School of Public Health, Population Information Program (1999). Available in English, French, and Spanish at: www.infoforhealth.com/pr/online.shtml#j.
This comprehensive literature review focuses on the two dominant forms of violence against women: the abuse of women within marriage and coerced sex. It documents the magnitude of the problem around the world, describes typical behavior patterns of abusers and their victims, and describes the psychological and social factors that contribute to violence against women. A detailed analysis of the impact of violence on women's health covers unwanted pregnancies, risky sexual behavior, STIs and HIV/AIDS, high-risk pregnancies, gynecological problems, physical injuries and illnesses, and mental health disorders. The report, together with an accompanying pull-out guide for service providers, offers practical recommendations to health care workers about identifying and supporting women who have been abused. The report also reviews broader efforts to deter violence through health, social, and law enforcement initiatives.

Heise, L. Health workers: potential allies in the battle against women abuse in developing countries. Journal of the American Medical Women's Association 51(3):120-122 (1996).
The health care system has a special role to play in combating violence against women because it is one of the few institutions in developing countries that has ongoing contact with women. Abused women who are unable or unwilling to seek help from the police or government authorities often admit abuse in private consultations with supportive health workers. In addition, the legal system in many countries requires a doctor's report before women can file a complaint for rape or domestic violence. The author recommends training health workers to detect abuse, react in a supportive manner, and make appropriate referrals. The article describes pilot projects in Latin American that are developing systems to identify and respond to victims of domestic violence in health care facilities.

Heise, L. et al. Violence against women: a neglected public health issue in less developed countries. Social Science and Medicine 39(9):1165-1179 (1994).
This article reviews key studies on the prevalence of domestic and sexual violence in less developed countries and its sequelae, including physical injuries, unwanted pregnancy, STIs, psychological trauma, suicide, and homicide. It concludes that gender-based violence is a significant burden on health care systems. Cultural, economic, legal, and political factors all help to perpetuate violence against women. While grassroots women's organizations around the world have put violence on the political agenda and successfully lobbied for legal and police reforms, the authors argue that it is time for researchers and health workers to get involved - by acknowledging the problem, identifying and referring victims, and promoting policy reform.

Hesperian Foundation. Special issue on violence. Women's Health Exchange: A Resource for Education and Training Number 2 (1998).
Women's Health Exchange provides practical tools and information for health workers in economically poor communities throughout the world. This issue, which is available in English and Spanish, reviews the facts about domestic violence and abuse, why women stay in situations of violence, and how health programs can address the issue of domestic violence. It includes a useful training guide for health workers on leading community discussions about domestic violence, with role plays and other learning activities.

Hindin, M. Understanding women’s attitudes towards wife beating in Zimbabwe. Bulletin of the World Health Organization 81(7):501-508 (2003). Available at: www.who.int/bulletin/volumes/81/7/en/Hindin0703.pdf.
A nationally representative survey of 5,907 women of reproductive age in Zimbabwe asked respondents about their attitudes toward wife beating in five situations: if a wife goes out without telling her husband, neglects the children, argues with him, refuses to have sex with him, and burns the food. More than half (53%) believed wife beating was justified in at least one of these five situations. Women were more likely to believe wife beating was justified if they were younger, lived in rural areas, came from poorer households, had less education, and had lower occupational status. They were less likely to believe wife beating was justified if they made household decisions jointly with their partners. Given the gender norms and expectations of younger women in Zimbabwe, the author concludes that a variety of interventions will be needed to reduce domestic violence.

Hindin, M.J. and Adair, L.S. Whos at risk? Factors associated with intimate partner violence in the Philippines. Social Science & Medicine 55:1385-1399 (2002).
This article analyzes data on 2,050 currently married women who participated in the 1994 Cebu Longitudinal Health and Nutrition Survey in the Philippines, as well as in-depth interviews with a randomly selected subset of 56 women. Thirteen percent of women had experienced physical violence from their husbands. According to a multivariate analysis, the strongest predictors of intimate partner violence were patterns of household decision-making and urban residence. When couples made household decisions jointly, women were four times less likely to experience violence. Household wealth, husbands church attendance, and use of modern family planning also were associated with intimate partner violence. Contrary to other studies, alcohol use was only modestly linked with violence.

Hyman, A. Domestic violence: legal issues for health care practitioners and institutions. Journal of the American Medical Women's Association 51(3):101-105 (1996).
As the first and sometimes only outside contact for battered women, health care providers have a responsibility to advise these women about their safety and their legal options. Although this article uses the U.S. legal system as an example, it discusses issues that are relevant to countries around the world. The first step is for providers to become familiar with local laws and the criminal justice system so that they can explain what will happen if women call the police, help them navigate the criminal justice system, and minimize the risk of retaliation by the partner. Health care organizations should maintain an up-to-date referral list of community organizations that offer low-cost legal services to battered women. Health providers also must understand how they can contribute to the legal outcome of a case by documenting abuse. The author recommends that health care programs tap the expertise of domestic violence programs in the community.

Interagency Gender Working Group (IGWG). Gender-Based Violence and Reproductive Health & HIV/AIDS: Summary of a Technical Update. Washington, DC: Population Reference Bureau (October 2002). Available at: www.prb.org/pdf/Genderbasedviolence.pdf.
This paper summarizes the presentations and discussion that took place at one-day technical update on gender-based violence, reproductive health, and HIV/AIDS that brought together more than 130 program managers, policy makers, service providers, and trainers. Representatives from various organizations spoke about their programs to address gender-based violence in developing countries. Participants expressed concern about three problems: reaching people who do not come to health centers, overburdening providers, and challenging social norms. They also recognized the difficulty of measuring gender-based violence and hence program impact. Participants were convinced that gender-based violence was integrally linked to womens health and needed to be addressed to achieve reproductive health goals.

IPPF International Medical Advisory Panel. IMAP statement on gender-based violence. IPPF Medical Bulletin 34(2):1-2 (April 2000). Available at: www.ippf.org/medical/bulletin/pdf/e0004.pdf.
Women often are willing to discuss sensitive, personal problems, such as gender-based violence, with reproductive health care providers if they are given the opportunity and encouragement. Posters, pamphlets, and other materials on gender-based violence should be readily available in the waiting rooms of family planning clinics. Staff must be trained to understand and be sensitive to the problem of violence, to ask questions in a non-judgmental and empathetic manner, and to continue their inquiries over several visits, if necessary, when abuse is suspected. Once victims are identified, clinic staff must be prepared to document their history, offer health services and counseling, make referrals to specialized services, run support groups, and develop strategies to change the violent behavior of male perpetrators. Family planning clinics also can help prevent violence by integrating messages about gender-based violence into existing community education activities, by addressing men, and by advocating for action from governments and any other groups in a position to make a difference.

Jacobs, T. and Jewkes, R. Vezimfilho: a model for health sector response to gender violence in South Africa. International Journal of Gynecology and Obstetrics 78 (Suppl. 1):S51-S56 (2002).
The Vezimfilho initiative in South Africa focuses on training primary health care workers to identify, manage, and refer survivors of gender violence. Broad consultation during the development of the project ensured the participation and support of stakeholders across several sectors and at provincial, regional and district levels. Their involvement was essential to create a supportive environment that permitted health workers to implement the training. Evaluation of the initial wave of training in two districts found that it was informative and empowering and broke down barriers to the identification of abuse. However, participants were concerned about their ability to apply new skills on the job, given resource constraints and broader social attitudes. The authors conclude that training health workers is essential to a health sector response to gender violence but that broader systems changes also are needed.

Jacobs, T. and Suleman, F. Breaking the Silence: A Profile of Domestic Violence in Women Attending a Community Health Centre. Durban, South Africa: Health Systems Trust (November 1999). Available at: www.hst.org.za/publications/27.
As part of a study of domestic violence in Cape Town, South Africa, researchers interviewed 412 women who attended a community health center over a four-month period. Almost half (48.5%) reported past or current abuse, although most cases were not documented in the center's medical records. The overwhelming majority of the women, regardless of whether or not they had been abused, supported screening for abuse by health care providers. Over three-quarters of abused women had sought help at some time from family, friends, doctors, in-laws, the police, or religious leaders, but they frequently did not receive the help they needed. The women offered many suggestions for improved services for abused women. The authors recommend making gender violence a health priority; developing health protocols to identify, manage, and refer survivors of violence; training health care workers in gender sensitivity and management skills; providing comprehensive services for abused women, including health and legal services; coordinating services between the NGO and government sectors; strengthening provincial and regional networks addressing gender violence; and raising public awareness.

Jejeebhoy, S. Associations between wife-beating and fetal and infant death: impressions from a survey in rural India. Studies in Family Planning 29(3):300-308 (1998).
This article analyzes data from a 1993-94 community-based survey in Uttar Pradesh and Tamil Nadu which included a few questions on domestic violence. Of 894 women who were married for ten years or less and had experienced at least one pregnancy, 38 percent said their husband had beaten them, although underreporting is likely. Most of the women believed that beating is justified when a wife is disobedient. Less than 10 percent believed that a woman is justified in leaving her husband if he beats her regularly. Women who had been beaten were significantly more likely to have experienced fetal wastage or infant death, even after controlling for the effect of education, age, parity, work status, religion, economic status, region, and women's autonomy. The author speculates that the direct causal link between violence during pregnancy and miscarriage is less important than an indirect link between domestic violence and women's powerlessness, inability to seek health care, and poor nutrition.

Jewkes, R. Intimate partner violence: causes and prevention. Lancet 359(9315):1423-1429 (April 20, 2002). Available at: http://pdf.thelancet.com/pdfdownload?uid=llan.359.9315 .editorial_and_review.20787.1&x=x.pdf.
Two ideologies underlie intimate partner violence: male superiority and a culture of violence. Together they legitimize the use of force by men to discipline women, often for transgressions of female gender roles. Low female educational levels, limited public roles for women, lack of family and social and legal support for women, lack of economic power for women, lack of economic opportunities for men and inequality with women, heavy alcohol consumption, witnessing abuse of ones mother, and experiencing childhood beatings also contribute to the likelihood of intimate partner violence. Prevention strategies include: empowering women and improving their social status, reducing norms of violence, and reducing poverty and alcohol consumption.

Jewkes, R. et al. Risk factors for domestic violence: findings from a South African cross-sectional study. Social Science &Medicine 55:1603-1617 (2002).
A 1998 survey of a representative sample of 1,306 women in three provinces of South Africa found that 24.6 percent of women had ever experienced physical violence from a current or ex-husband or boyfriend; 9.5 percent reported such violence in the past year. Multivariate analysis of risk factors for domestic violence found that it was significantly associated with the following womens characteristics: childhood violence, limited education, liberal ideas on womens roles, alcohol consumption, having more than one partner, and having a confidant(e). It was also associated with the male partners preference for a boy child, conflict over his drinking, and frequent conflict generally. Financial support from a third party and living in the Northern Province were protective factors. Based on this study and other research, the authors propose a model of causation of intimate partner violence at the heart of which lies ideas about masculinity, the position of women in society, and ideas about the use of violence.

Jutla RK, Heimbach D. Love burns: an essay about bride burning in India. Journal of Burn Care and Rehabilitation. 2004;25(2):165-170.
This article reviews the incidence and etiology of burn cases in India that involve young, newly married women whose dowries are considered inadequate by their husbands and in-laws. In most cases, the women are deliberately doused with kerosene and set on fire. After considering medical and legislative efforts to curtail dowry-related deaths in India, the authors recommend training for doctors, police, and the judiciary to ensure that they fully investigate and collect essential evidence in burn cases.

Kim JC et al. Rape and post-exposure prophylaxis: addressing the dual epidemics in South Africa. Reproductive Health Matters. 2003;11(22):101-112.
This paper examines the rationale for and implementation of HIV post-exposure prophylaxis (PEP) following rape in South Africa. It draws on in-depth interviews with 18 key informants in South Africa and the experience of two initiatives to integrate PEP into standard clinical and forensic treatment for post-rape care in South Africa. The public health and social justice rationales for implementing PEP in South Africa are strong, given the scale of the HIV epidemic and high rates of sexual violence. Efforts to implement PEP face two major obstacles, however: delays in accessing PEP caused by the public justice system and lack of training for service providers. The authors conclude that services for post-rape care in South Africa need reform, with more attention paid to the link between sexual violence and HIV/AIDS prevention.

Kim, J. and Motsei, M. "Women enjoy punishment": attitudes and experiences of gender-based violence among PHC nurses in rural South Africa. Social Science & Medicine 54:1243-1254 (2002).
Research was conducted on a class of 38 nurses enrolled in a 12-month residential training program on primary health care in rural South Africa. Focus-group discussions explored their attitudes toward and experiences of gender-based violence, after which nurses had one week of intensive training on gender violence. The research found that the nurses had internalized dominant cultural beliefs that physical abuse is a form of discipline or an expression of love, that women are responsible for provoking assaults, and that problems of abuse should be kept within the family unless injuries are severe. In addition, 69 percent of the female nurses said that they had experienced abuse by an intimate partner, while 75 percent of male nurses admitted being guilty of abuse themselves. The training intervention first had to address these beliefs and experiences before addressing nurses professional roles.

Kimberg, L. Addressing intimate partner violence in primary care practice. Medscape Womens Health 6(1) (2001). Available at: www.medscape.com/viewarticle/408937. Medscape requires free online registration.
Primary care providers should routinely screen patients for intimate partner violence because of its high prevalence (as much as 23 percent in primary care settings) and serious impacts on health. Detailed practical advice is offered on how to ask about and intervene in cases of intimate partner violence. Also discussed is how to overcome the personal and institutional barriers that limit clinical responses to intimate partner violence.

Kishor S, Johnson K. Profiling Domestic Violence: a Multi-Country Study. Calverton, Maryland: ORC Macro; 2004. Available at: www.measuredhs.com/pubs/pdf/OD31/DV.pdf.
This study uses household and individual-level data from Demographic and Health Surveys (DHS) in nine countries (Cambodia, Colombia, Dominican Republic, Egypt, Haiti, India, Nicaragua, Peru, and Zambia) to examine the prevalence, correlates, and health consequences of domestic violence. The proportion of ever-married women reporting intimate partner violence ranged from 18 percent in Cambodia to 48 percent in Zambia. Most women (ranging from 41% in Nicaragua to 78% in Cambodia) did not seek help for the violence. Women report higher rates of violence when they are divorced, separated, or married more than once; married at a young age; have multiple children; or are older than their husbands. Other strong risk factors are husbands frequently returning home drunk and a family history of domestic violence. Data on women’s participation in household decisions, attitudes toward wife-beating and the right to refuse sex, and controlling behaviors by husbands suggest that gender relations and roles may affect the prevalence of domestic violence. The surveys also document a range of negative health outcomes of domestic violence for women and their children, including unwanted births, STIs, child mortality, and lower vaccination coverage.

Klevens, J. Violencia física contra la mujer en Santa Fe de Bogota: prevalencia y factores asociades. Revista Panamericana de Salud Publica 9(2):78-83 (2001).
Interviews were conducted with 3,157 women who had a child less than 6 months old, were currently in an intimate relationship, and used public health services for childbirth or pediatric care in Bogata, Colombia. Results show that 26.5 percent of the women had been slapped or pushed by their current partners, 13.3 percent had been hit, kicked, beaten or threatened with a gun or knife; and 26.2 percent had had some prohibition put on their social activities or work. Early detection and intervention programs should be established at public health services to identify and serve victims of domestic violence.

Koenig MA et al. Coercive sex in rural Uganda: prevalence and associated risk factors. Social Science & Medicine. 2004;58:787-798.
In a community-based survey of 4,279 reproductive-aged women in Uganda, one in four reported coercive sex with their current male partner. A regression analysis found that the risk of coercive sex was related to behavioral risk factors rather than socio-demographic characteristics, most notably younger age of women at first intercourse and alcohol consumption before sex by the male partner. Perceived, but not actual, HIV status is also a risk factor: women who think it more likely that their partner has been exposed to HIV are significantly more likely to report coercive sex, perhaps because women are more reluctant to have sex when they are suspect their partner has HIV

Koenig, M.A. et al. Domestic violence in rural Uganda: evidence from a community-based study. Bulletin of the World Health Organization 81(1):53-60 (2003). Available at: www.who.int/bulletin/pdf/2003/bul-1-E-2003/81(1)53-60.pdf.
This community-based survey of 5,109 women aged 15-49 and 3,881 men aged 15-59 living in Uganda found that 40 percent of women had experienced verbal abuse and 30 percent physical threats or violence from their current partner. Womens risk of domestic violence was 4.6 times greater when their partner frequently drank alcohol prior to sex, 3.7 time greater when the women believed their male partner was very likely to be infected with HIV, and 1.9 times greater when the woman was under age 15 at first intercourse. Having more than six living children, more than eight years of education, and more than ten years in the current relationship reduced womens risks of violence. About 70 percent of men and 90 percent of women viewed beating a wife or female partner as justifiable in at least some circumstances, and attitudes condoning domestic violence were more common among younger men and women.

Krug, E.G. et al., eds. World Report on Violence and Health. Geneva: World Health Organization (2002). Available at: www.who.int/violence_injury_prevention/violence/world_report/wrvhl1/en.
Violence is a leading cause of death worldwide among 15-44 year olds and also causes substantial morbidity. The health sector is uniquely placed to understand violence and its consequences and has a special social responsibility to combat it. The interdisciplinary, science-based, collective approach of public health also has great potential to prevent violence. Individual chapters review prevalence rates, risk factors, consequences, and prevention approaches for intimate partner violence, sexual violence, youth violence, child abuse and neglect, abuse of the elderly, self-directed violence, and collective violence.

Kulwicki, A.D. The practice of honor crimes: a glimpse of domestic violence in the Arab world. Issue in Mental Health Nursing 23:77-87 (2002).
This study reviewed the court files of 38 homicides involving female victims in Jordan in 1995. Of these, 61 percent were reported as honor crimes, and a male relative of the victim (most often a brother) committed the murder. Cultural norms and legal practices distinguish between honor crimes and other forms of crime and support the practice of killing women for sexual misconduct. Perpetrators receive relatively light punishment.

Maman, S. et al. The intersections of HIV and violence: directions for future research and interventions. Social Science & Medicine 50:459-478 (2000).
This article reviews 28 studies from United States and sub-Saharan Africa on the links between HIV and gender-based violence. These include thirteen studies on whether forced or coercive sexual intercourse is a risk factor for HIV, four studies on whether violence limits women's ability to negotiate condoms use, eight studies on whether childhood sexual abuse leads to a pattern of HIV risk taking behaviors in adulthood, and six studies on whether women living with HIV infections are at increased risk for violence. The authors conclude that further research is needed to overcome the methodological limitations of existing studies and decide these questions. They call for prospective studies, standardized definitions and measurement tools, the inclusion of men's perspectives, qualitative research, and cross-cultural studies. However, the authors conclude that health services should take advantage of the overlap between HIV and violence, for example, by having HIV counseling and testing programs also identify and assist women at risk for violence or by having violence prevention programs also offer counseling for STIs and HIV.

Martin, S.L. et al. Domestic violence across generations: findings from northern India. International Journal of Epidemiology 31:560-572 (2002).
This study examines whether men raised in violent homes as children are more likely to abuse their wives. One-third of the 6,902 married men surveyed had witnessed violence between their parents. Compared to others, these men were significantly more likely to believe that husbands had a right to control their wives and to engage in physical or sexual abuse of their wives. Further analysis concluded that 35 percent of wife abuse could have been prevented if these men had grown up in non-violent homes. The authors conclude that in addition to cultural and social norms, individual factors also play an important role in the etiology of domestic violence.

Martin, S.L. et al. Sexual behaviors and reproductive health outcomes: associations with wife abuse in India. Journal of the American Medical Association 282(20):1967-1972 (1999).
In structured face-to-face interviews, 46 percent of 6,632 married men in Uttar Pradesh reported physically and/or sexually abusing their wives. After controlling for sociodemographic factors, a multivariate analysis found a strong association between wife abuse and extramarital sex, current or past STI symptoms, and unwanted pregnancy. In each instance, the association was strongest for men who physically forced their wives to have sex, intermediate for men who coerced sex without physical force, and weakest for men who physically abused their wives but did not engage in sexual coercion. The authors hypothesize that men who engage in wife abuse, which is not culturally sanctioned, also are more likely to violate social norms against extramarital sex; this, in turn, increases the risk of STI infections. Women married to abusive men are at risk both of unplanned pregnancies and STI infections.

McCaw, B. et al. Beyond screening for domestic violence: a systems model approach in a managed care setting. American Journal of Preventive Medicine 21(3):170-176 (2001).
This article describes a multifaceted intervention that more than doubled the number of clinician referrals and patient self-referrals for domestic violence in a California health facility. The first component of the intervention created a supportive environment in the clinic: various print materials informed health plan members about the importance of domestic violence and encouraged discussions with practitioners. The second component used staff training, environmental prompts, feedback on referrals, and job aids to encourage clinicians to screen and refer patients. The third component established a full range of onsite domestic violence services by a specially trained psychiatric social worker. The fourth component established links with community agencies so that victims would have access to emergency housing, legal assistance, and other support services.

Moore, M. Reproductive health and intimate partner violence. Family Planning Perspectives 31(6):302-306 (1999).
This article reports on a 1999 conference on reproductive health and partner violence sponsored by the U.S. Centers for Disease Control and Prevention (CDC). Violence contributes to infection with HIV and other STIs, poor birth outcomes, and unintended pregnancies. Providers of reproductive health care are in a unique position to screen for intimate partner violence, but there is disagreement over whether providers should inquire about abuse during every visit. Because violence is relatively common during pregnancy, obstetricians should consistently screen pregnant women for the problem. Providers must be aware that adolescents have different needs from adults and also may be the subject of special legal requirements. Possible approaches to preventing violence include improved surveillance during pregnancy, universal screening at family planning and prenatal clinics, improved physician training, anti-violence education targeted to men, and evaluations of the effectiveness of particular interventions.

Narayan D et al. Gender relations in troubled transition. In: Voices of the Poor: Crying Out for Change. New York: Oxford University Press; 2000. Available at: www-wds.worldbank.org.
This is the second of a three-volume series reporting on participatory poverty assessments in 50 countries and a 23-country comparative study conducted by the World Bank. The chapter places domestic violence and abuse within a broader context, showing how male unemployment and economic stress have contributed to changes in women’s and men’s roles, alcohol and drug abuse by men, and domestic conflict. In some communities these changes have led to increasing levels of domestic physical violence, due to men’s anger and humiliation over failing to maintain their role as breadwinner. In other communities, women’s heightened economic role, together with outside support from NGOs, churches, and the media, has led to decreased levels of domestic physical violence.

Nasir, K. and Hyder, A.A. Violence against pregnant women in developing countries. European Journal of Public Health 13:105-107 (2003).
This literature review examines six studies on the domestic violence in pregnancy from less-developed countries in Asia and Africa. Prevalence ranged from 4 percent to 29 percent. The main risk factors for abuse during pregnancy were: low income, low education in both partners, and unplanned pregnancy.

Olavarrieta, C. et al. Domestic violence in Mexico. Journal of the American Medical Association 275(4):1937-1941 (1996).
This article documents widespread domestic violence in rural Mexico and discusses its cultural roots, including the tradition of violence against vulnerable people in rural Mexico, stereotypes of machismo, and attitudes toward marriage. Also described are judicial obstacles to battered women filing complaints. There are growing efforts in Mexico to reform the law and offer social services to the victims of domestic violence, in which the authors suggest physicians should play a leading role.

Omorodion, F.I., et al. The social context of reported rape in Benin City, Nigeria. African Journal of Reproductive Health 2(2):37-43 (1998).
This article examines 396 confirmed cases of rape retrieved from the files of the Police Doctor's Clinic in Benin City, Nigeria. Most victims (83%) were aged 13-19, and 57 percent had never been married; this may reflect older women's greater reluctance to report incidents of rape rather than differences in the actual prevalence of rape. Gang rape accounted for 46 percent of the cases; rape by an ex-boyfriend or acquaintance, 32 percent; and rape by a stranger, 18 percent. The case files document substantial psychological trauma among the victims, both due to the rape itself and to the total lack of social and legal support for victims of rape.

Pan American Health Organization (PAHO). Health workers: are we part of the problem? Fact Sheet No. 7, Program on Women, Health and Development (February 1999).
This two-page graphic powerfully summarizes how health workers may contribute to the problem of gender-based violence by normalizing victimization, violating confidentiality, trivializing and minimizing abuse, blaming the victim, not respecting her autonomy, and ignoring her need for safety. In contrast, health workers can advocate for and empower the victims of violence by respecting confidentiality, believing and validating her experiences, acknowledging the injustice, respecting her autonomy, helping her plan for future safety, and promoting access to community services.

PATH. Violence against women: effects on reproductive health. Outlook 20(1): 1-8 (2002). Available at: www.path.org/files/EOL20_1.pdf.
Violence against girls and women occurs throughout the lifetime and is common worldwide. It has a profound effect on womens mental and physical health, including their reproductive and sexual health. Reproductive health programs have the opportunity and obligation to identify and help women who are victims of abuse. Identifying women who have experienced abuse requires: training practitioners to ask women about abuse; overcoming barriers to screening at the provider and health care system levels; sensitizing providers to their own beliefs and training them in essential skills; and adopting tools and techniques to facilitate screening. Screening is only useful, however, if providers are able to offer appropriate services to women who have experienced abuse. Key to this is empowering both providers and clients to act, coordinating with other organizations to provide the full range of services needed, and reaching out to the community for its support in changing attitudes, behaviors, and policies.

Peedicayil A et al. Spousal physical violence against women during pregnancy. BJOG: an International Journal of Obstetrics and Gynaecology. 2004;111:682-687.
This population-based household survey in India interviewed 9,938 women aged 15 to 49 years who were living with a child under age 18. It covered rural, urban slum, and urban non-slum areas. Sixteen percent of women reported being slapped during pregnancy, 10 percent hit, 10 percent beaten, 9 percent kicked, 5 percent attacked with a weapon, and 6 percent harmed in some other way. Logistic regression found the main risk factors for moderate to severe violence during pregnancy were suspicion of infidelity, dowry harassment, husband having an affair, husband being regularly drunk, and low education of husband.

Peltzer, K. et al. Attitudes and practices of doctors toward domestic violence victims in South Africa. Health Care for Women International 24:149-157 (2003).
A mail survey of 402 randomly selected doctors in South Africa found that each doctor treated an average of 11.4 patients for domestic violence per month. Doctors reported suspecting domestic violence largely because of physical injuries, evasive answers to questions about those injuries, or repeated injuries to the same part of the body; they also suspected battering in cases of emotional problems. More than one-third of doctors said the appropriate response was a referral, whereas almost as many others would somehow investigate or confront the problem themselves. The vast majority of doctors felt that wife battering should be treated as a medical syndrome and that doctors had an important role to play. They were generally sympathetic and supportive toward victims. Less than 10 percent, however, had any training on domestic violence.

Ramsay, J. et al. Should health professionals screen women for domestic violence? Systematic review. British Medical Journal 325(7359):314-327 (2002). Available at: http://bmj.com/cgi/content/full/325/7359/314.
This article reviews 20 published quantitative studies on screening women for domestic violence in healthcare settings. Surveys found that from 43 to 85 percent of women found such screening acceptable, but that two-thirds of physicians and almost half of emergency department nurses did not favor screening. While research suggests that screening does identify a greater proportion of abused women and increases referral rates, there is insufficient evidence that the intervention reduces violence, improves womens quality of life, and does not subject them to potential harm. The authors conclude that it is premature to introduce screening programs for domestic violence in health care settings, and they call for more research on its benefits and risks.

Sahin HA, Sahin, HG. An unaddressed issue: domestic violence and unplanned pregnancies among pregnant women in Turkey. European Journal of Contraception & Reproductive Health Care. 2003;8(2):93-98.
Individual interviews with a representative sample of 475 pregnant women in eastern Turkey gathered data on their experience of domestic violence before and during the current pregnancy and on a range of sociodemographic characteristics. One-third of the women reported physical or psychological abuse since becoming pregnant. While the husband was the abuser in most cases, the husband’s relatives were also involved in one-third of cases. Compared with pregnant women who were not abused, abused women were less educated, had lower incomes, had more children, had been married longer, behaved violently towards their children, were not contributing to family decisions, were less satisfied with their sexual life, and were more likely to have unplanned pregnancies. The authors recommend modifying antenatal care protocols in Turkey to address domestic violence and the factors that contribute to it.

Schuler, S. et al. Credit programs, patriarchy and men's violence against women in rural Bangladesh. Social Science and Medicine 43 (12):1729-1742 (1996).
Findings from ethnographic research and a random sample survey in six Bangladeshi villages illustrate the links between domestic violence, women's roles and status, and women's economic independence. Wife beating is common, socially accepted, and supported by the police and the courts. It helps maintain patriarchal norms and keeps women socially isolated and dependent on their husbands. The survey found that women were less likely to be beaten if they were older, had sons, or participated in a village credit program. The impact of the credit program was twofold: it funneled a valuable resource - loan money - through women, and it gave women regular public exposure at weekly meetings. However, women who developed a regular income of their own had to endure a period of increased domestic violence, as their husbands beat them in an effort to get control of the money and punish them for breaking out of a woman's traditional role.

Shrader, E. and Sagot, M. Domestic Violence: Women's Way Out. Washington, DC : Pan American Health Organization (2000). Available in PDF format at www.paho.org/english/DBI/OP111.htm.
After outlining a conceptual framework for approaching domestic violence as a health and development problem in Latin America, this book presents a research protocol to investigate the paths women follow as they search for care and try to solve their domestic violence problems. Information is gathered from field interviews with women, service providers, and community members. The authors hope that this type of research will contribute to the development of a model for the prevention of domestic violence and the care of its victims. The protocol has been tested in 10 countries in Latin America. Also available in Spanish.

South African AIDS Training (SAT) Programme. Counselling Guidelines on Domestic Violence. Harare, Zimbabwe: SAT and Canadian International Development Agency (CIDA); 2001. HIV Counselling Series No. 4. Available at: www.satregional.org/attachments/Publications/Skills%20Training%20E/Domestic%20Violence.pdf. These counseling guidelines provide background information on the cycle of domestic violence, its consequences, and its link with HIV. After dispelling common myths and misconceptions, the guidelines offer counselors practical advice on how to recognize the signs and symptoms of domestic violence, how to empower the survivor of domestic violence, and how to help women explore and weigh their options.

Spindel, C. et al. With an End in Sight: Strategies from the UNIFEM Trust Fund to Eliminate Violence Against Women. New York: United Nations Development Fund for Women (2000). Available at: www.unifem.org/index.php?f_page_pid=71.
This book reports on innovative efforts to end violence against women that have been funded by the UNIFEM Trust Fund since 1996. The goal of these small grants is to test strategies and identify successful approaches that can be replicated on a large scale in many countries. Grantees have explored a wide variety of activities, such as documenting the extent of violence; providing services to women survivors and male perpetrators of violence; creating a sense of community responsibility; reviewing legislation; training police, judges, health professionals and other public employees; using the media to increase public understanding; and advocating for institutional and public support. The seven case studies presented in the book demonstrate how women's organizations can work together with judicial and law enforcement systems, community and youth groups, policy makers and international organizations to end gender-based violence.

Stewart, S. "Changing Attitudes Toward Violence Against Women." In: Zeidenstein, S. and Moore, K., eds. Learning About Sexuality: A Practical Beginning. New York: The Population Council (1996).
The Musasa Project began tackling the problems of rape and domestic violence in Zimbabwe in 1988. The first step was to understand the culture of rape that nurtures or supports violent behavior toward women. The project team found that Zimbabweans shared two universal beliefs: that the female victim is to blame and that the male perpetrator is driven by uncontrollable sexual needs. This article describes how the Musasa project has improved police handling of rape cases and, through the police, begun exerting pressure on the court system. More recently, the project has broadened its efforts to address the issues of gender and status that underlie violence against women.

Taket A et al. Routinely asking women about domestic violence in health settings. British Medical Journal. 2003;327:673-676. Available at: http://bmj.bmjjournals.com/cgi/content/full/327/7416/673.
This article recommends routine inquiry rather than screening to identify women experiencing partner abuse. Routine inquiry is more flexible than screening because it does not standardize procedures. Questions are asked routinely but only in certain settings or if indicators of abuse arise. Routine inquiry is acceptable to and has substantial health benefits for women. Like screening, routine inquiry must be accompanied by information on support services and safety planning. Health professionals need training and protocols to undertake routine inquiry safely.

United Nations Population Fund (UNFPA). A Practical Approach to Gender-Based Violence: A Programme Guide for Health Care Providers and Managers. New York: UNFPA (2001). Available in English, French, and Spanish at: www.unfpa.org/publications/index.cfm?ID=69.
This publication offers step-by-step guidance on how reproductive health facilities can design and implement their own gender-based violence projects. Facilities can choose between three project options based on their resources and capabilities. The simplest option is to display materials about gender-based violence, including information about where to get help, in public and private areas of the facility. Facilities with greater resources can have providers ask all clients if they have experienced gender-based violence and refer survivors to outside groups for treatment. The most comprehensive option offers onsite treatment for survivors.

UNICEF. Domestic violence against women and girls. Innocenti Digest No. 6. Florence, Italy: Innocenti Research Centre (June 2000). Available as a PDF file at: www.unicef-icdc.org/publications/pdf/digest6e.pdf.
This review article examines the extent of physical, sexual, and psychological violence against women and traditional practices that affect women's health and lives. It discusses the cultural, economic, legal, and political factors that perpetuate domestic violence; the consequences of violence for fundamental human rights, human development goals, and health; and the socio-economic costs of violence. The authors recommend an integrated approach that addresses structural causes of violence against women while providing immediate services to victims. They recommend establishing partnerships with the widest possible array of stakeholders and simultaneously working with families, local communities, civil society, states, and international organizations.

Valladares E. et al. Physical partner abuse during pregnancy: a risk factor for low birth weigh in Nicaragua. Obstetrics and Gynecology. 2002;100:700-705.
This hospital-based case-control study in Nicaragua matched each of 101 newborns with low birth weight (under 2500 grams) with two controls (birth weight over 2500 grams) born the same day. Three-quarters of the low birth weight infants were small for gestational age, and 40 percent were preterm. Among cases, 22 percent of mothers were physically abused during pregnancy, compared with 5 percent of mothers in the control group. Multiple regression analysis found that low birth weight was associated with physical partner abuse even after adjusting for age, parity, smoking, and socioeconomic status (OR 3.9).

Velzboer M et al. Violence Against Women: The Health Sector Responds. Washington, DC: Pan American Health Organization (PAHO); 2003. Occasional Publication No. 12. Overview and first chapter available online in English at www.paho.org/English/DPM/GPP/GH/VAWhealthsector.htm and in Spanish at www.paho.org/Spanish/DPM/GPP/GH/VAWhealthsector.htm.
This book describes a strategy for addressing violence against women and supplies concrete approaches for how policy makers and health care providers can carry it out. The Pan American Health Organization (PAHO) produced the first three chapters, which review why gender-based violence is a public health problem, present results from qualitative research on the “critical path” women follow to solve domestic violence problems, and discuss PAHO’s integrated strategy for addressing gender-based violence. The Program for Appropriate Technology in Health (PATH) produced the next four chapters, which describe how the seven countries of Central America applied the integrated strategy and discuss lessons learned at the political, health sector, clinic, and community levels. The World Health Organization (WHO) contributed the final chapter which offers a global perspective on how to apply the lessons learned and the integrated strategy to communities around the world.

Waalens, J. et al. Screening for intimate partner violence by health care providers. American Journal of Preventive Medicine 19(4):230-237 (2000).
This article reviews 12 research studies that identify barriers to screening for intimate partner violence and 12 studies that evaluate the effectiveness of interventions to increase screening. From providers perspective, leading barriers to screening are lack of education, lack of time, lack of effective interventions when patients do disclose violence, fear of offending patients, and non-disclosure by patients. Provider education alone does not increase screening or identification rates. Effective interventions have combined provider education with the introduction of clinical guidelines or protocols, the assignment of victim advocates, and regular debriefing sessions.

Wathen, C.N. and MacMillan, H. L. Interventions for violence against women. Journal of the American Medical Association 289(5):589-600 (2003).
The authors located and reviewed the quality of 22 studies on interventions aimed at preventing abuse or reabuse of women. Although there is evidence that screening can identify abuse, there is no data on how screening affects outcomes for women. There is fair evidence that women who spend at least one night in a shelter and receive a program of advocacy and counseling services have a decreased rate of re-abuse and a better quality of life. There is a lack of well-designed research testing the outcomes of other intervention strategies. Another limitation is that studies do not assess the potential harm caused by interventions.

Watts, C. and C. Zimmerman. Violence against women: global scope and magnitude. Lancet 359(9313):1232-1237 (April 6, 2002). Available at: http://pdf.thelancet.com/pdfdownload?uid=llan.359.9313. editorial_and_review.20680.1&x=x.pdf.
This international review defines and examines the magnitude of the most serious forms of violence against women, including intimate partner violence, rape and sexual coercion, forced sexual initiation, sexual abuse of girls, trafficking, violence against sex workers, rape in war, and female infanticide.

Zachary, M.J. et al. Provider evaluation of a multifaceted system of care to improve recognition and management of pregnant women experiencing domestic violence. Womens Health Issues 12(1):5-15 (2002).
This article reports on a pilot intervention for domestic violence during the perinatal period that was mounted in a family medicine health center serving a low-income, urban area of the U.S. The intervention included domestic violence training for staff, a domestic violence protocol with chart prompts, informational print materials for patients posted throughout the health center, regular feedback to medical providers about individual patients, quarterly reports on domestic violence services to promote quality improvement, and an onsite domestic violence coordinator who provided crisis counseling and coordinated with local police, legal support, and shelter agencies. Providers were excited about the project and reported changes in their self-efficacy and behavior but showed little change in attitudes or knowledge. They stressed the importance of easy access to the domestic violence coordinator and ongoing reinforcement but said the protocol was not useful.

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Trafficking in humans for forced labor

Busza J, et al. Trafficking and health. British Medical Journal. 2004;328:1369-1371. Available at: http://bmj.bmjjournals.com/cgi/reprint/328/7452/1369.
Using research on child migrants from Mali to the Ivory Coast and on Vietnamese sex workers in Cambodia, the authors demonstrate how anti-trafficking groups and measures often misinterpret the cultural context of migration and fail to distinguish between forced and voluntary migrants. As a result, these efforts actually increase health risks and reduce access to services for migrants and victims of trafficking. The authors recommend that: (1) policy makers facilitate safe, assisted migration; (2) programs provide appropriate services at destination points rather than try to repatriate migrants; (3) programs do not assume that all intermediaries are traffickers seeking to exploit migrants; and (4) organizations document cases of abuse and advocate for improved labor conditions.

Costello Daly, C. et al. Prevention of Trafficking and the Care and Support of Trafficked Persons in the Context of an Emerging HIV/AIDS Epidemic in Nepal. Joint Report of Horizons and the Asia Foundation. New Delhi, India: Population Council (2001). Available at: www.popcouncil.org/pdfs/horizons/trafficking1.pdf.
This investigation of trafficking in Nepal examined national laws and anti-trafficking projects; interviewed key policy makers, program managers, and activists; surveyed nearly 1,300 adolescent girls; and held focus group discussions with community members. The authors conclude that current efforts to prevent trafficking violate human rights because they confuse trafficking with prostitution and seek to prevent all migration by women. The emphasis on rescue and rehabilitation of trafficked women—rather than on their support and protection—also reinforces the stigma that trafficked women are immoral and infected with HIV. The authors call for a rights-based response to trafficking that empowers women.

Gushulak, B.D. and MacPherson, D. Health issues associated with the smuggling and trafficking of migrants. Journal of Immigrant Health 2(2):67-78 (2000).
This review uses a three-stage framework to analyze the impact of human trafficking on health. Prior to the journey, conditions in the place of origin determine health risks for trafficked migrants, such as their nutritional status or whether they carry a communicable disease. During the migratory phase, unsafe modes of transportation expose trafficked migrants to death and injury. After arrival, unregulated and substandard work conditions place trafficked migrants at high risk for occupational disease or injury, including sexually transmitted infections if they work in the sex industry. Violence, substandard living conditions, and their irregular legal status also contribute to the health problems of trafficked migrants. Trafficking can increase the health burden of the recipient country’s population as well as the migrants themselves.

Huntington, D. Anti-Trafficking Programs in South Asia: Appropriate Activities, Indicators, and Evaluation Methodologies, Summary Report of a Technical Consultative Meeting. New Delhi: Population Council (March 2002). Available at: www.popcouncil.org/pdfs/rr/anti_trafficking_asia.pdf.
This publication summarizes presentations and discussion from a 2001 technical consultative meeting on trafficking in south Asia. Varying definitions of trafficking and uncertainties over the legal status of trafficked persons have hindered the development of a conceptual framework. The confusion between trafficking, sex work, HIV/AIDS, and voluntary migration for work also has led to unwanted consequences from interventions. Some anti-trafficking efforts in south Asia have restricted women’s rights, exacerbated the stigma associated with trafficking, and encouraged corruption. Various evaluation strategies and methodologies are proposed to help assess and improve interventions designed to prevent trafficking or aid its victims.

Hynes, H.P. and Raymond, J.G. Put in harm’s way: the neglected health consequences of sex trafficking in the United States. In: Policing the National Body: Sex, Race, and Criminalization, edited by J. Silliman and A. Bhattacharjee. Cambridge, Massachusetts: South End Press (2002). Available at: http://action.web.ca/home/catw/readingroom.shtml?sh_itm= 16ccc34b56c4fe955ac694bd32cbfeed&AA_EX_Session= bad49c813ec4b7264aac4c8b3468c44c.)
Trafficking in women for sexual entertainment is rooted both in longstanding gender inequality and contemporary arguments that redefine sexual exploitation as work. An economic and political analysis shows that trafficking and other forms of migration grow out of poverty and underemployment, economic development policies in sending countries that encourage the export of labor, postcolonial policies in receiving countries, and the globalization and opportunism of the sex industry. Three sources of information are used to describe the harm suffered by trafficked women: studies of the health effects of prostitution, studies of the health burden of violence against women, and interviews with Russian women trafficked to the United States. Although health practitioners have generally been interested in prostitutes only as vectors of communicable disease, sex workers (especially trafficked women) also face serious injuries due to violence and psychological trauma. The authors recommend that governments provide rights and protections for women in sex trafficking and prostitution; reject policies that legitimize, legalize, or regulate prostitution; decriminalize women in conditions of sex trafficking and prostitution while penalizing traffickers, pimps, procurers and customers; and prohibit sex tourism and the sale of mail-order brides.

International Human Rights Law Group (IHRLG). The Annotated Guide to the Complete UN Trafficking Protocol. Washington, DC: IHRLG; 2002. Available at: www.walnet.org/csis/papers/UN-TRAFFICK.PDF.
This guide can help advocates apply a human rights framework to national anti-trafficking laws and policies. It includes three key international documents on trafficking, including the entire Protocol to Prevent, Suppress and Punish Trafficking in Persons; portions of the Convention Against Transnational Organized Crime, especially Women and Children; and the Interpretative Notes to the Trafficking Protocol. Unofficial annotations help readers understand the technical language and broader context of these documents.

Orhant, M. Trafficking in persons. In: Reproductive Health and Rights: Reaching the Hardly Reached, edited by E. Murphy and A. Hendrix-Jenkins. Seattle, Washington: PATH (2002). Available at: www.path.org/files/RHR-Article-1.pdf.
Public health organizations have little awareness of and few are working with trafficked persons, despite their need for health services. Obstacles include the reluctance of trafficked persons to seek help, interference by organized crime syndicates that run trafficking operations, and the illegal immigration or occupational status of trafficked persons. Successful outreach efforts in countries of destination enlist a wide range of individuals, organizations, and agencies to identify victims of trafficking and refer them to health services. Health workers also can be trained to identify trafficked persons by asking about labor conditions, housing, and nutrition. Public health organizations also can play an important role in countries of origin by teaching potential migrants about safe sex practices and how to avoid being trafficked, and by treating the health problems of trafficked persons after they return home.

Orhant, M. Trafficking in persons: myths, methods, and human rights. Population Reference Bureau (2001). Available at: www.prb.org/Template.cfm?Section=PRB&template= /ContentManagement/ContentDisplay.cfm&ContentID=5261.
The majority of trafficked people are women and children from Asia. Trafficking is a big business, with subservience maintained through debt bondage, passport confiscation, physical and psychological abuse, rape, torture, threats of arrest and deportation, and threats to the trafficked person’s family. Trafficked people often suffer from a multitude of physical and psychological problems. Women are vulnerable to reproductive and other gender-specific health problems in trafficking situations because they have little access to reproductive health care. Poverty, unemployment and lack of education are root causes of trafficking. Governments and international organizations are beginning to address trafficking as a human rights issue rather than an immigration problem.

Phinney, A. Trafficking of Women and Children for Sexual Exploitation in the Americas. Washington, DC : Inter-American Commission of Women (Organization of American States) and the Women, Health, and Development Program (Pan American Health Organization) (2002). Available at: www.oas.org/cim/English/Proj.Traf.AlisonPaper.htm.
According to the conceptual framework described in this publication, sex trafficking flourishes because of three factors. First is men’s demand for women and children for exploitation. Second is the supply of women living in poverty who want a better life. Third is the inadequacy of laws and law enforcement that allow traffickers to work with impunity. Although less analyzed than other parts of the world, the Americas have a significant problem with trafficking women and children for prostitution and sex tourism. The trafficking process and subsequent sexual exploitation create potentially lifelong and life-threatening health consequences, including physical injuries, HIV and other STIs, unwanted pregnancy, mental health problems, and substance abuse. Organizations in the Americas are only just beginning to address the problem of trafficking.

Pisklakova, M. and A. Sinelnikov. What dreams may become: trafficked women and their resultant health issues. CommonHealth 10(1):64-68 (Summer 2002). Available at: http://wwwold.aiha.com/english/pubs/summer02/Pisklakova.pdf.
Limited employment opportunities in Russia make young women vulnerable to traffickers’ promises of good jobs overseas. Once in the country of destination, the traffickers control the women and force them into prostitution by confiscating their passports, placing them in debt bondage, threatening them with arrest, and physically and sexually assaulting them. The trauma of being trafficked, the high levels of violence they experience, and their sex work lead to a host of physical, reproductive, and mental health problems. Reproductive health effects include STIs, HIV, unsafe abortions, chronic pelvic pain, and other gynecological disorders. Most trafficked women lack the resources and mobility to seek professional health care. Health care providers can play an important role in combating trafficking by disseminating information about the threat of trafficking, identifying this kind of abuse among their female patients, and offering trafficked women the support they need.

Raymond, J.G. et al. A Comparative Study of Women Trafficked in the Migration Process. New York: Coalition Against Trafficking in Women (2002). Available at: http://action.web.ca/home/catw/readingroom.shtml?sh_itm= 45bf9bad199a86b329c4f979692b56a4.
Based on extensive structured interviews with 146 women who had been trafficked, this book describes the patterns, profiles, and health consequences of sexual exploitation in Indonesia, the Philippines, Thailand, Venezuela, and the United States. The study documents high rates of injury, infection, and psychological effects resulting from the arduous transportation process as well as participation in the sex industry. It also describes the women’s access to health services in each country.

United States. Department of State. Trafficking in Persons Report. Washington, DC : U.S. State Department (June 2003). Available at: www.state.gov/g/tip/rls/tiprpt/2003.
In the third annual report mandated by the Trafficking Victims Protection Act, the U.S. State Department reviews current data on the scope and consequences of trafficking in persons, describes international low-cost best practices to combat trafficking, and rates the efforts of 116 countries to prevent trafficking, prosecute traffickers, and protect victims.

Zimmerman C et al. The Health Risks and Consequences of Trafficking in Women and Adolescents. Findings from a European Study. London: London School of Hygiene & Tropical Medicine; 2003. Available at: www.lshtm.ac.uk/hpu/docs/trafficking.pdf.
This two-year multi-country study on women’s health and trafficking in the European Union collected information from interviews with women who had been trafficked, health care and other service providers, NGOs working against trafficking, law enforcement officials, and policy makers. The report details the health risks, consequences, and barriers to services for trafficked women throughout the trafficking process, beginning before they depart, while they travel, at their destination, during detention and deportation, and during their re-integration. Service providers commonly divide their work into three stages: (1) crisis intervention and meeting a woman’s practical needs, (2) meeting women’s medical needs and setting personal goals, and (3) recognizing longer term mental health issues and helping women look towards the future. The authors make a series of recommendations regarding health-related prevention and intervention strategies for trafficking.

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Child sexual abuse

Argent, A.C. et al. Child abuse services at a childrens hospital in Cape Town, South Africa. Child Abuse & Neglect 19(11):1313-1321 (1995).
This article assesses child abuse patients seen at a comprehensive childrens hospital in South Africa and the demands they place on the staff. Rising numbers of abused children are coming to the hospital. Over a one-year period from 1989 to 1990, 503 children were seen. Their median age was less than seven, and 70 percent were female. Sexual abuse was proven or suspected (60%) more often than physical abuse (40%). Half of the children were seen outside of normal working hours, and most (79%) were treated by non-specialist medical staff in the trauma unit who have little pediatric experience. Social workers, who have more relevant training, play a pivotal role in counseling and managing cases of child abuse at the hospital. The authors conclude that child abuse patients do not need to be seen by specialists but that they should be seen by medical staff with the most expertise, in this case, staff from the pediatric service rather than the trauma unit. All staff need basic training on abuse, however.

Boyer, D. and Fine, D. Sexual abuse as a factor in adolescent pregnancy and maltreatment. Family Planning Perspectives 24(1):4-11, 19 (1992).
Of 535 young women in the United States who became pregnant as adolescents, two-thirds had been sexually abused. Compared with adolescents who became pregnant but were not abused, victims of sexual abuse began intercourse a year earlier, were more likely to have used drugs and alcohol, and were less likely to practice contraception. They also were more likely to have been hit, slapped, or beaten by a partner; to have exchanged sex for money, drugs, or a place to stay; and to report that their own children had been abused or been taken from them by Child Protective Services.

Cheasty, M. et al. Relation between sexual abuse in childhood and adult depression: case-control study. British Medical Journal 316:198-201 (1998). Available at: http://bmj.bmjjournals.com/cgi/content/full/316/7126/198.
This study screened 1,189 women over age 18 attending general practice surgeries in Ireland for depression. Follow-up interviews were conducted with those who were depressed as well as a systematic sample of those who were not depressed. Depressed women were significantly more likely to report childhood sexual abuse than non-depressed women (37% versus 23%). Further analysis showed that this association was due entirely to more severe forms of abuse, that is, when there was attempted or actual intercourse. Women who had experienced severe sexual abuse also were significantly more likely to be separated or divorced (26% versus 7.5%). Women who had experienced any type of childhood sexual abuse were significantly more likely to report housing difficulties (25% versus 9%), problems with children at school (21% versus 3%), and sexual problems (43% versus 18%); these associations remained significant even when depression was controlled for as a confounding variable.

De Villiers, F.P.R., and Prentice, M.A. Accumulating experience in a child abuse clinic. South African Medical Journal 86:147-150 (1996).
A record review of all cases at the Child Abuse and Neglect Clinic of the Transvaal Memorial Institute during its first year of operation found that most were female (80%), most presented with sexual abuse (90%), and most were young (7% under age 3 and 55% under age 10). Where the certainty of sexual abuse was high, 60 percent of the girls and 45 percent of the boys had suffered penetrative abuse. Most perpetrators were family members (66%), and few were strangers (7%). Nearly three-quarters of the children experienced behavior problems (73%), including school problems, masturbation, clingy behavior, and withdrawal and depression. The authors recommend specifying how certain the diagnosis is and differentiating between types of abuse, for example, penetrative versus non-penetrative. The next step is to train primary health care providers how to manage child abuse, so that more children can receive appropriate care.

Fergusson, D.M. et al. Childhood sexual abuse, adolescent sexual behaviors and sexual revictimization. Child Abuse & Neglect 21(8):789-803 (1997).
This study followed a cohort of 520 New Zealand women from birth to age 18, when retrospective reports of child sexual abuse were gathered. Women who experienced child sexual abuse, especially sexual abuse involving intercourse, were significantly more likely than others to engage in a variety of risky sexual activities, including consensual sex at an early age, multiple sexual partners, and unprotected intercourse. As a result, they were more likely to experience teenage pregnancy and sexually transmitted diseases. They were also more likely to experience sexual assault after age 16. Analysis suggests that (1) the childhood and family factors related to child sexual abuse also are associated with increased sexual risks during adolescence and (2) exposure to child sexual abuse encourages the early onset of sexual activity which increases sexual risks during adolescence.

Finkelhor, D. The international epidemiology of child sexual abuse. Child Abuse and Neglect 18(5):409-417 (1994).
This article compares surveys of child sexual abuse in large, nonclinical, adult populations from 19 different countries. Differences in the definition of child sexual abuse and in methods of data collection and analysis complicate comparisons. However, overall prevalence rates around the world are comparable with those in North America. The prevalence of child sexual abuse in these studies ranged from 7 to 36 percent for women and from 3 to 28 percent for men. In most studies, women were 1.5 to 3 times more likely to be abused than men. The author concludes that child sexual abuse poses a problem worldwide.

Handwerker WP. Gender power difference between parents and high-risk sexual behavior by their children: AIDS/STD risk factors extend to a prior generation. Journal of Women’s Health. 1993;2(3):301-316.
This study uses data from a national survey of Barbados and from participant-observation to assess links between gender power differences, family violence, sexuality, and high-risk sexual behavior. Two distinct patterns of family interaction were found. In situations of gender inequality—where women did not own a home and lacked a good job, education, family, and friends—domestic violence and child abuse were common. Children raised in these violent homes started sexual activity early and had more sexual partners. In contrast, powerful women elicited affection from their husbands towards their children as well as themselves, and the children were less likely to engage in high-risk sexual behaviors.

Human Rights Watch. Suffering in silence: the links between human rights abuses and HIV transmission to girls in Zambia. New York: Human Rights Watch (November 2002). Available at: www.hrw.org/reports/2003/zambia/zambia1202.pdf.
Sexual abuse and sexual violence contribute to the much higher prevalence of HIV among girls than boys under age 18. This report documents three categories of abuse: sexual assault by family members and teachers, abuse of girls who are heads of household and trade sex for their own and their siblings survival, and abuse of girls who live on the street. The AIDS epidemic is fueling the problem of sexual abuse by creating orphans who are particularly vulnerable to abuse and by encouraging men to target young girls for sex since they are assumed to be HIV-negative. The criminal justice system has failed to deal adequately with complaints of sexual abuse, while family members also remain silent about the problem. The report concludes that progress in reducing HIV prevalence in Zambia is threatened by abuses that put girls at risk of infection.

Jewkes, R. et al. The rape of girls in South Africa. Lancet 359:319-320 (2002). Available at: http://pdf.thelancet.com/pdfdownload?uid=llan.359.9303.original_research. 19268.1&x=x.pdf. This analysis of the 1998 South Africa Demographic and Health Survey, which included a nationally representative sample of 11,735 women, found that 1.6 percent of women reported being raped (defined here as forcible or unwanted sex) before the age of 15. Most of these incidents (85%) took place between the ages of 10-14, while 15 percent took place between the ages of 5-9. School teachers were responsible for 33 percent of the rapes, followed by relatives (21%), strangers or recent acquaintances (21%), and boyfriends (10%). Ethnic origin, province, and age cohort were associated with child rape. Younger women were significantly more likely to report child rape than older women, suggesting that it is becoming more common. Over 3 percent of women aged 15-19 reported rape before age 15. Child rape fuels the HIV epidemic by increasing the likelihood that these girls will engage in unsafe sexual practices later in life and by providing foci of infection within each emerging age group. Rape, especially by teachers, also forces girls out of school and places them and their children at greater economic and health risks in future.

Kendall-Tackett, K.A. et al. Impact of sexual abuse on children: a review and synthesis of recent empirical studies. Psychological Bulletin 113(1):164-180 (1993). Available at: www.unh.edu/ccrc/pdf/VS69.pdf.
This review of 45 studies found that child sexual abuse does not cause any specific syndrome, but is associated with a variety of symptoms, including fears, post-traumatic stress disorder, behavior problems, sexualized behaviors, and poor self-esteem. Approximately one-third of victims have no symptoms, and some symptoms are specific to certain ages. Symptoms are more severe when the abuse includes penetration, occurs frequently or over a long period, involves force, or is carried out by a close relative such as the father. Maternal support mitigates symptoms. About two-thirds of abused children show recovery during the first 12-18 months.

Larsen, J.V. et al. Child sexual abuse in KwaZulu-Natal, South Africa. Transactions of the Royal Society of Tropical Medicine and Hygiene 92:262-264 (1998).
A hospital serving a largely rural population in South Africa treated 99 sexually abused children over a period of 9 years and 2 months, most of whom were girls. The incidence of abuse peaked between 4 and 9 years of age. Two-thirds had at least one sexually transmitted infection. The abuser, when identified, was more commonly an acquaintance or stranger than a family member. Because of limited resources in developing countries, medical personnel must take the lead in identifying and managing children with sexual abuse, yet their case loads may preclude them from doing an adequate job.

Leach F et al. An Investigative Study of the Abuse of Girls in African Schools. Sevenoaks, UK: Department for International Development (DFID); 2003. DFID Educational Paper No. 54. Summary available at: www.id21.org/Education/e2fl1g2.html.
Researchers gathered existing information on the abuse of girls, conducted school-based studies of the abuse of girls in Ghana, Malawi, and Zimbabwe, and piloted small-scale strategic interventions to counter the types of abuse uncovered by the research. In all three countries, peer pressure, poverty, and physical assault coerce girls into sexual relationships with male pupils, sugar daddies, and teachers, while authorities condone the situation. The abuse of girls is part of a wider problem of school-based violence, including corporal punishment and bullying, which in turn reflects broader patterns of violence in society. Fighting abuse and gender violence in the schools requires a holistic approach, involving school administrators, teachers, parents, pupils, and government officials at all levels.

Meursing, K. et al. Child sexual abuse in Matabeleland, Zimbabwe. Social Science & Medicine 41(12):1693-1704 (1995).
This exploratory study draws on data from a review of police, hospital, court, and newspaper records; interviews with social service workers, victims of sexual abuse and their parents, and juvenile offenders; and focus group discussions with traditional healers and midwives, teachers, young people, adults, and community health workers. Child sexual abuse makes up 35 to 40 percent of rape cases reported to the police in Bulawayo, while many more cases go unreported. Possible contributing factors are the recommendations of traditional healers for men with STIs to cleanse themselves by having sex with a virgin, mens belief that a girls physical maturity indicates her readiness to have sex, cultural limits on how women can communicate about sex with older men, and erosion of traditional family structure and sex education. The majority of rapists are men over age 25, and they are known to their victims. In half of cases, men use threats to get girls cooperation and silence; in one-quarter they offer money or other rewards. Half of abused children are detected through an STI, pregnancy, or physical injuries; they do not report the abuse for fear of the rapist or punishment by their parents. Common consequences include STIs, HIV, pregnancy, physical injuries, psychological trauma, and stigmatization by the community. There are numerous problems with legal treatment of these cases.

Mullen, P.E. et al. The effect of child sexual abuse on social, interpersonal and sexual function in adult life. British Journal of Psychiatry 165:35-47 (1994).
In-depth interviews were conducted with 248 women reporting a history of child sexual abuse along with an equal number of controls. Results show that women reporting child sexual abuse are more likely, as adults, to suffer social, interpersonal, and sexual difficulties, including declines in socioeconomic status, sexual problems, and disruptions in intimate relationships. Part, but not all, of these negative outcomes was explained by the link between child sexual abuse, disturbed and disrupted families, and physical and emotional abuse.

Paolucci, E.O. et al. A meta-analysis of the published research on the effects of child sexual abuse. Journal of Psychology 135(1):17-36 (2001).
This meta-analysis includes 37 studies involving 25,367 people, mostly in the United States. Results show that child sexual abuse is related to all six outcomes examined: posttraumatic stress disorder (PTSD), depression, suicide, sexual promiscuity, victim-perpetrator cycle, and poor academic performance. Potential mediating variables, including gender, socioeconomic status, type of abuse, age when abused, relationship to perpetrator, and number of abuse incidents, had no significant impact on effect sizes. The authors conclude that child sexual abuse has negative short- and long-term effects on development but that there is no specific sexual abuse syndrome.

Rind, B. and Tromovitch, P. A meta-analytic review of findings from national samples on psychological correlates of child sexual abuse. Journal of Sex Research 34(3):237-255 (1997).
In an effort to overcome the sampling biases of most studies of child sexual abuse, this meta-analysis is restricted to seven studies that used national probability samples (from Canada, Great Britain, Spain, and the United States) rather than clinical or legal samples. Results show that females and males respond differently to child sexual abuse, with females more likely than males to perceive negative effects (68 versus 42%). The gender difference may reflect the fact that women tend to be younger than men when abused, to be coerced, and to experience incest. The authors conclude that results from clinical samples overstate the psychological or sexual adjustment problems resulting from child sexual abuse and that only a small proportion of people abused as children are permanently and intensely harmed. A combination of individual disposition and situational factors (e.g., the use of force or incest) may determine the degree of harm.

Shanler et al. Sexual abuse and young adult reproductive health. In FOCUS (September 1998). Available at: www.pathfind.org/pf/pubs/focus/IN%20FOCUS/sexabuseinfocus.html.
This brief is one of a series published by FOCUS on Young Adults. This review examines data on the prevalence of sexual abuse among young people in developing countries and its impact on their health. It also describes dozens of programs around the world that are addressing this problem by trying to prevent sexual abuse, screening for sexual abuse, or providing services to the victims of sexual abuse.

Tang, C.S. Childhood experience of sexual abuse among Hong Kong Chinese college students. Child Abuse & Neglect 26:23-37 (2002).
An analysis of 2,147 questionnaires completed by college students in Hong Kong found an overall prevalence of noncontact and contact sexual abuse of 7.4 percent among women and 4.3 percent among men, but only a small fraction of these cases involved sexual intercourse. The mean age at the time of sexual abuse was 11 for both girls and boys. Most abusers were male (88%); more than two-thirds were known to the victim; and they included friends (22%), family members (20%), relatives (14%), and teachers (7%). Abuse happened more than once for over half the victims. Most victims (62%) remained silent about their experience of abuse, and the remainder mostly told friends or family members. The author concludes that rates of more severe forms of sexual abuse are lower than in western studies, and Chinese victims more reluctant to disclose abuse.

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