Welcome to our first session. Today we're going to be covering gender based violence an overview. An introduction to the epidemiology of leading forms of gender based violence. A brief discussion of the health impacts as well as frameworks for understanding risk factors and prevention strategies. So today we're going to be covering the prevalence of leading forms of gender based violence. You'll be able to explain some of the health consequences of gender-based violence, and apply a socio-ecological model to this issue. So, before we jump in, let's take a minute to think about our role in public health and the health sector when we're thinking about gender-based violence. So first and foremost, our goal is simply often to document gender based violence. This is a topic that's often swept under the rug, shielded from the light of day through the media, disbelief of victims and survivors of gender based violence. So often our role is really simply one of documentation, and that can make a big difference in the lives of survivors. Secondly, we're looking to apply the most rigorous methods that we can to understand the prevalence, the risk factors and the health impact of violence. We obviously want to be appropriately integrating in translating this knowledge into public health research, programming, policy, practice and certainly the clinical sector as well. We really have a big role to play as practitioners and policy makers, prevention researchers, in breaking the myths surrounding gender based violence and the culture of victim blaming. The culture that holds victims or survivors accountable for their actions, instead of looking at the behavior of perpetrators, those that are truly responsible for violence. Finally, I want to note that survivor invisibility and silence is something that really enables violence and other kinds of human rights violations. Again, victims are often pressured into silence through their family and friends. Through the myths that exist around violence so one of our roles is to start to shape that, really shift that culture of silence and victim blaming around the issue of gender based violence. So I'd like to start with this slide when we give an overview of GBV. And the slide is what's in a name? So we go to the literature, you go to the media, you go to clinical best practices, international recommendations, you'll see a lot of different terms out there. You'll domestic violence, referring to violence in the home, whether it's between partners or with children. You'll see gender-based violence. The title of our course, a very inclusive sort of terminology. Earlier on we saw a lot of use of the term violence against women. We certainly see intimate partner violence, and that would be abuse between partners so wives and husbands, could be dating partners, boyfriends or girlfriends. Talk about how that factors in. We hear the term rape oftentimes, and it's certainly in the media. Oftentimes, in some other criminal justice pieces. We know that's not a term that survivors are always comfortable with using. They rarely identify experiences of sexual violence as rape. So we have to be mindful and intentional about how we use some of these terms. I also offer you teen dating violence, a phenomenon and terminology that has come about more recently to really recognize a that violence can happen outside of a marital context, but indeed in a dating context. And as well the risk of violence to adolescents and young adults. That's often when we're seeing Issues of certainly dating, but also violence start to emerge. You want to be really attentive to that adolescent population. You'll see, and we'll interchange the terminology between victim and survivor in this course. Often you see the victim terminology in, certainly in the media, and in other places as well. And those of us that are working to really support victims and help them really transition into survivors will often use that survivor language to recognize and to help support greater empowerment for those that are indeed affected by gender-based violence. So to give you a context of that. I want to also give you some key milestones in this work, right? So you can see here in the 1990s is when we really started to see a global recognition of gender based violence as a public policy issue and a human rights issue. We saw the Declaration of the Elimination of Violence Against Women. In the United States we saw the VOWA, The Violence Against Women Act. And in 1995 we celebrated the Beijing Declaration and the platform for action. And this really calls on governments for the first time to prevent and respond to violence against women. We'll talk a little bit about how some of that terminology has shifted again over time more recently, moving forward I should say into 2005, this is when we saw our first multi-country study on domestic violence led by our colleagues at World Health Organization, who will be coming in later in the third week of our course. This was one of our first chances to really understand the prevalence of violence across different cultural contexts. Across different national settings, and as well, urban and rural settings. Some of our very first internationally comparable data, so very exciting. And of course, more recently, just a couple of years ago, in 2013, we saw coming out again from World Health Organization and colleagues, again, these global and regional estimates of violence against women. Pprevalence, health effects, health consequences, access to justice. So you can really see how the policy has shifted on this topic and as well how we have started to really gain a lot in terms of our knowledge about the prevalence and the health impact of violence. So I'll call your attention to some of the terminology in the UN Declaration on the Elimination of Violence against Women. And this was again in 1993. And this sets forth a nice definition that we can work from. It says violence against women means any act of gender-based violence that results in or is likely to result in, okay, physical, sexual, or psychological harm or suffering to women. And this includes the threat of these acts, coercion, arbitrary deprivation of liberty, so a very inclusion definition. Not just physical violence, right? And it also specifies that this could be occurring in public or private life. Why is this so groundbreaking? Why is this so important? Because in the past, historically, policy makers and health practitioners, they have said domestic violence happens in the home, it's not for the public view and therefore it's not something that we need to intervene on. So this terminology and this language specifying that things that happen in public or private life are the concern of governments, are the concern of the health sector, is really setting that forth as something we need to take a look at. Now I will say as well, now that we've evolved, here we are in 2015, the terminology around violence against women feels a little dated to many of us in the field in that we see violence against men and boys. We see violence directed against people that have various sexual identities or orientations and so this terminology that's very specific to women doesn't feel as inclusive as it needs to be. But I want to show you really where this came from, give you that historical context. [COUGH] So what are we looking at, in terms of the global prevalence? These are the data from our most recent World Health Organization estimates from 2013. And this is showing us that about one in three women throughout the world will experience physical or sexual violence by a partner or non partner across her lifetime. Okay and you can see that this varies around the world, but in general these are upwards of 20%, reaching even 37% in some settings. And you've got your reference to this in your readings list as well so you can investigate a little bit more deeply. What I want to really call your attention to and clarify for you is that partners, boyfriends, husbands, ex-partners, are the primary perpetrators of physical and sexual abuse globally. So here we see, again from that World Health Organization report. Then, among ever-partnered women, almost one-third, 30% experienced physical or sexual violence by their partner. By contrast, sexual violence by non-partners covers around 7% globally. It varies from setting to setting, certainly in conflict-affected settings. We see higher levels of sexual violence by non-partners. But the main message to you is that globally, dominantly, partners are the primary perpetrators of gender based violence against women. And as a result, you'll see a lot of discussion that's specific to intimate partner violence, of IPV. We'll rely heavily on that for our course, and I'll give you an overview of some of the prevalence of some of the other forms of violence as well. But just to really emphasize that it is partners that are the dominant perpetrators of violence globally. So defining the problem, this definition draws on an earlier report from World Health Organization and I think is a nice reference for you in terms of thinking about the broader scope of IPV, Intimate Partner Violence. And this is any behavior within an intimate relationship that causes physical, psychological or sexual harm. Certainly, physical aggression, but also psychological abuse, sexual coercion, controlling behaviors, isolating, monitoring, restricting and we, and battering. So that's when abuse would occur repeatedly in the same relationship. This is just an overview, sort of a Venn diagram to illustrate that physical abuse is often accompanied by psychological abuse as well as sexual abuse. So there's a lot of overlap in these forms of violence that we see for survivors worldwide. Sometimes they can occur in isolation, but often time we're seeing a synergy or an accumulation of different forms of abuse over time. This is an example of the Power & Control Wheel. This is often attributed to the Domestic Violence Intervention Project in Duluth, Minnesota in the United States. You can see various iterations that are very specific to women or men, girls, adolescent women, different types of violence. This is really illustrating some of the domains of abuse and some of the examples that we see different forms of intimate partner violence. So for example using threats or coercion, economic abuse. We often see perpetrators really minimizing, denying that abuse. Denying their own behavior, their culpability, as well as even blaming those victims for triggering that violence. We're really going to be calling your attention throughout the course to ways in which violence is perpetrated and also perpetuated. This context of blaming the victim is very often perpetrated or instigated by those perpetrators who are blaming those victims and trying to make them responsible. So this is an example drawing on our World Health Organization Multi-Country Student from 2005. I give this example to you as a way to illustrate to you really the variance in prevalence of physical violence as well as sexual violence in a whole variety of settings. You can see, generally from this slide, that it's more prevalent, or more commonly, reported experiences of physical abuse relative to those of sexual violence. In some studies sexual violence is more common, but generally when we do this work we tend to see a higher prevalence of physical violence rather than sexual violence. But they're both very high and you can see that across the board here. Okay, and this is unpacking, this slide is also from that study. And it's also unpacking the percentage of ever partnered women that have experienced different forms of sexual violence. We generally tend to see high levels of fear of having sex because you might be afraid of what a partner might do as well as physically forced to have sexual intercourse. Many people are reluctant to define their experiences as physically forced. So for example, those of us that have worked in rape crisis through hot lines or clinical service, we know that many survivors present and they say I wasn't forced, but. And they'll go on to explain a situation that was highly coercive. They felt highly pressured, they felt threatened, etc. So we want to be aware of that as providers and as policy makers to recognize, it's rare for people to really come out and say I was forced. But we want to be very inclusive, recognizing the potential for coercive forms of sexual violence, pressure, threats, etc. This slide is giving you an overview of who women share abuse with. Again, from our World Health Organization multi-country study. And this is really illustrating to you that, worldwide, many women don't share experiences of abuse with anybody. And we worry about the harm that may come from that. And inability to get support, validation, and certainly healthcare as well as safety kinds of planning for women that don't disclose their experiences. By and large, we see that women are more comfortable sharing experiences with friends or neighbors, or even family members. And then that last column, that gray bar shows us that seeking services, health services, crisis services and discussing this with authorities, police Is generally very rare, okay? So, a couple things to note from this. We know that very few people go on to report those experiences to police, right? So our police records then, on gender-based violence, become really very biased, and also just not representative of the true scope, the true prevalence of abuse that may be happening in a community. The other reason that I call this to your attention is that we know that survivors don't always come forward for that care. So, we have a big role to play in screening and supporting, getting the messages out to people. We know that they won't necessarily come forward. It's our role to make sure that people know how to access safe police reporting. How to access emergency department support services, if that's available. How to access crisis services. It's on us to help people access the services and raise their awareness about what is available. We know they wont always do that on their own. Here are a few examples of why don't survivors share experiences of abuse. You can see here fear of retribution, fear that the partner is going to find out and somehow blame or harm her. This is a very legitimate fear. Shame, disbelief, many women don't identify their own experiences as abusive until for some time. Some of them may feel that they themselves are some how to blame. Fear of bringing shame to the family. Fear certainly for children, and that others may become endangered. And finally the belief, and this breaks our hearts as service providers, as advocates, as practitioners, and policy makers. It breaks our heart to know that survivors may believe or actually experience that will not be believed if they share these experiences of violence. So, these are some of the things that we need to really be mindful of as we shape an evidence-based response to this issue. I offer to you some of the other experiences or the other factors that may be going on for survivors in not disclosing these experiences of abuse. Many of you that are working in the field will be able to come up with a long list of other reasons that they don't share those experiences and I encourage you to do that, perhaps, on our discussion board. This slide gives you really a very nice overview of some of the health outcomes or health consequences of violence. And this is inclusive of partner abuse, sexual assault and childhood sexual abuse. Non fatal outcomes, certainly spanning physical health, injury, chronic conditions, mental health. We're going to go specifically into sexual and reproductive health and HIV later in this week's sessions. Certainly, negative health behaviors as well. Smoking, alcohol, physical inactivity, overeating. I think this is a really nice framework for looking at all of the possible outcomes around this. And I also call your attention to those fatal outcomes as well. Homicide, suicide, maternal mortality. Okay. These are other things that we need to be really mindful of. I'll share some of the homicide review results with you as well. But just to note that, we're obviously not picking up homicides in our ongoing surveillance, right? Individuals that have experienced that level of severe abuse to the point of homicide. We're not able to count them as easily. We don't know the prevalence that they have not being able to participate in some of our survey research. And we want to be really mindful of this as well when we're thinking about a policy response in engaging the criminal justice sector. So, let's take a look at some of the data on health outcomes. I've given you some broader references and review articles on this topic, but I'll highlight here a couple of the health outcomes and some of the data that came out of the multi-country study as well. And this really spans problems with walking. You can see an increased risk for that based on partner violence experiences. Pain, problems with memory. This is really illustrating this range of outcomes and finally simply self-rated health status as poor or very poor at the very top there, gives you an idea of the range of health outcomes, again, that are associated with this experience. Another example again is looking at thoughts of suicidality based on experiencing abuse versus not having experienced abuse, and these to me are quite striking, especially in some locations. Urban centers in Peru, Thailand, and Brazil in particular, where we see really strong disparities in suicidal thoughts based on experiences of violence. And finally, I give you an example that's really from right here in my own backyard, in Maryland in the United States. Looking at the leading causes of pregnancy associated death, and this was a real surprise to a lot of people. And you can see here that homicide was actually the leading cause of pregnancy-associated death over this time period, over a ten-year plus time period. Cardiac disorders and accidents as the second and third leading causes of death. Intimate partners were responsible for about 54% of these homicides. And those were restricted actually to perpetrators that were married to, living with or estranged from a spouse or a current or former cohabitating partner. So, we're likely missing in this instances of homicide that could be perpetrated between individuals, especially adolescents, that may not be living together or may not have had a marital relationship. I'm going to point you as well to a more recent global homicide review that highlights some of the gender differences in violence-related homicide. So, this was a wonderful review of data from 66 countries. We've never been able truly to have this level of review before, so I think it's telling that we're able to conduct a review of this level. Overall, about 13% of homicides to men and women were committed by an intimate partner. And where you see the gender disparity is really in this intimate partner violence homicide where you see that female homicides, 38% were committed by a partner in comparison for male homicides, this was 6%. So, when we're looking at gender differences in violence victimization, homicide is a place where we really see a gender difference. Where those partner violence homicides much more likely to be women relative to men. I want to move on to a couple of the other forms of gender-based violence that are relevant around the world and particularly so in some settings. The first of which is female genital mutilation and these are procedures that intentionally alter or cause injury to female genital organs for non-medical purposes, okay? So, an estimated 90% of cases included types one or two in cases where genitals are nicked but no flesh is removed that would be type four. And about 10% are type three. We see that about 100 to a 140 million girls and women worldwide have been subjected to one of the first three types of female genital mutilation. And it's estimated that about three million girls in Africa are at risk of female genital mutilation annually. This is increasingly an issue with other settings with migration, right? People are coming out from settings where this is most common and most prevalent, into other places where providers, particularly medical providers in the health sector may not be familiar with, or may not have experience in, in treating or caring for woman that have had this type of procedure. Okay. And this gives you sort of a picture of really some of the high prevalence areas for female genital mutilation also called female circumcision among women ages 15 to 49. And as you can see, it really, really varies from setting to setting and there's a core area in Africa where we'll really see this is most prevalent. This gives us a picture of how these patterns are changing over time. We're really looking at women who have undergone this procedure and women who have a daughter that have undergone a procedure like this. And you can see that for women, You can see that across many of these countries, almost every setting we see that women themselves, the prevalence is much greater for women themselves as compared to their daughters, okay. So this is giving us a sense that this is starting to taper off. Things are starting to change over time. We obviously need to really have some sustained attention to this topic especially in very high prevalence settings, Egypt, Mali, Sudan, in particular. But it gives us a sense that we're seeing some changes over time. And finally I want to talk about so called honor killings, I put this in quotes because there's really no honor involved in this at all and this is homicide that's brought about, based on a belief that a victim has brought shame or dishonor upon a family or a community. Some examples are refusing an arranged marriage, having a relationship that's not approved of, sexual activity, and even rape victimization. And this really breaks our hearts as advocates and practitioners That somebody could experience gender based violence and then go on to be killed as a result. Okay? So I ask, why is this so called? I've already answered this question right? There's no honor involved in this. The media perpetuates this terminology. And for those of us that are working in the field on this topic, we know that this is really a misnomer in terms of terminology. The data on this are very scarce, it's hard to come by good homicide data to begin with and then getting at that intent is often very difficult. Scholars and practitioners that are trying to work in this area often really rely on media reports, case studies to sort of get at this. I don't offer you a prevalence cause I don't think we have a good estimate of it but I do want to bring this to your attention and they will talk a little bit about sex trafficking. We're going to come back to this for those that are interested in one of our sort of special sessions at the end of our course. But I'll highlight this now for you and that is, the forced or coerced migration within or across national borders, and this is for the purpose of sexual exploitation. This is recognized as a human rights violation. The definitions really vary from place to place. They vary in law and they vary in practice. We'll come back to that when we talk about policy, but generally, some of the common elements of this are entry to sex work through force, fraud or coercion, pressure, deception or under the age of 18 as a quote unquote minor. [COUGH] I'm going to show you a little about some of the ways that scholars and policy makers, practitioners have tried to organize some of the risk factors for gender based violence. Really with an eye towards how can we guide prevention efforts. And this draws on the often known as the framework. It's a socio-economic framework for violence. And here we see features of the macro system, tolerance of abuse, policy pieces at this level that are community level norms that are really supporting or enabling abuse. Or on the flip side supporting survivors or challenging victim blaming myths right? Exosystem, this would be our social support and our networks. Factors that the micro system for example marital conflict marital communication issues and certainly personal history. These are going to be individual sort of level risk factors. Age is a big one, right? Rural or urban setting, other factors such as experiences of childhood sexual abuse can prompt risk for subsequent experiences of abuse. This is a way to organize our thoughts, and a way to think about what are the most promising levels to intervene on. I give this to you, not so much that we're going to review every known risk factor for violence, but actually to help you organize your thoughts, and organize the data or your knowledge in your specific settings around what is enabling abuse, what's enabling access to health systems or justice for abuse victims. A way for you to organize your thinking around, how can we intervene? What are the promising areas for intervention? How might we think about systems change versus targeting individuals that are at risk for violence, or at risk for not getting the support that they may need? Couple of contextual factors that I want to really flag for you. Certainly the policy context. Criminalization of gender-based violence. We've seen sweeping changes over the past two decades in laws that criminalize gender-based violence, marital violence, rape. So having the laws on the books is one aspect of the policy context, it's very important. Another piece is practice, right. Practices that enable access to justice or undermine access to justice. Barriers to police reporting. We're going to come back to that one when we talk about policy but I wanted to flag those two policy pieces for you. As well as the underlying context of gender inequality or gender equity. We have some really nice indicators globally around Gender inequality. We have a gender development index. I give you the index from UNDP here. There are other measures, and for those of you working in various settings, you can often, at least at the national level, get a sense of where things are both in terms of policy around gender-based violence as well as an overall climate of gender equality or inequality that may factor into GVV. Couple of data sources for you, you're going to be part of this overview is to help you understand the global prevalence. But also give you some tools to start to pinpoint what's happening in your communities. That may be at the national level. It may be at the city level or a state level. All kinds of different levels. Want to help you get some tools to think about how you could approach the prevalent and some of the dominant issues in your areas. So data sources. Medical records. This is compelling for us as providers often, but we know that violence isn't always documented in our medical records much as we may wish it to be, so that's a red flag there. We've talked a little bit about police records, very valuable source of data in terms of who's reporting what's the nature of the reports we also know that few victims or survivors actually make those police reports. So, that's always taken with a grain of salt, as we would say. We also have from the World Health Organization the Global Health Observatory Data Repository. Great source of data on all kinds of health topics including gender-based violence. And then I guide you as well to our Demographic and Health Surveys Program. This is the DHS for those of you that are familiar is conducted every couple of years, sometimes every two or five years, in many developing nations around the world. A great source of data on maternal health, child health, and now gender based violence as well. So you can download country reports. You can look at our stat compiler there. Searchable on domestic violence and I give you the reference there so you can start to take a look at that if you haven't already. And that brings us to the end of our session for today. Hopefully, this has given you an idea of prevalence of major forms of gender based violence as well as some tools to start thinking about the profiles in your specific setting or your community and some ideas about how you can learn more about the epidemic that's in your setting, to really start to pinpoint an evidence based response.