MAKALAH

PELAYANAN KEBIDANAN DALAM SISTEM PELAYANAN KESEHATAN

“Skrining dan Suport Kekerasan Ibu dan Anak”

Dosen Pengampu : Ernawati S.ST.,M.Kes.,M.Keb

Nama Kelompok :
1. Afwa Nur Azizah R (SB19001)
2. Alya Olifa Z (SB19002)
3. Amanda Amalia (SB19003)
4. Angela Clara (SB19004)
5. Aqaz Rohqiati (SB19005)
6. Aulia Rahmawati (SB19006)
7. Bella Putri Lathifah (SB19007)
8. Bencelina Parety (SB19008)
9. Chiendy Revina K P (SB19009)
10. Chusnul Karlina Lulu D (SB19010)
11. Ciendi Septiana (SB19011)
12. Chindy Maylani (SB19012)
13. Desya Fitria Dewimury (SB19013)

PROGRAM STUDI KEBIDANAN PROGRAM SARJANA DAN PROGRAM STUDI

PENDIDIKAN PROFESI BIDAN PROGRAM PROFESI
FAKULTAS ILMU KESEHATAN
UNIVERSITAS KUSUMA HUSADA SURAKARTA
2021/2022
 BAB I
PENDAHULUAN

A. Latar Belakang

Setiap manusia mendambakan rasa aman dan terlindungi dari rasa

takut terhadap segala bentuk kekerasan. Namun tak dapat dipungkiri bahwa dalam
kehidupan sehari-hari setiap orang tanpa memandang jenis kelamin dan status
dapat saja mendapatkan perlakuan kekerasan baik dari orang-orang terdekat
maupun orang yang tidak dikenal. Negara dalam hal ini memiliki kewajiban untuk
menjamin keamanan bagi warga negaranya termasuk negara Indonesia sebagai
negara hukum. Walaupun sudah ada beberapa peraturan yang dibuat untuk
melindungi warga negara terutama perempuan dan anak, namun perempuan dan
anak adalah individu yang lebih rentan dan mudah untuk menjadi korban, namun
angka kekerasan yang terjadi diberbagai wilayah di Indonesia termasuk masih
sangat tinggi dan cenderung bertambah setiap tahunnya.
Berdasarkan Survei Pengalaman Hidup Perempuan Nasional (SPHPN)
tahun 2016, 1 dari 3 perempuan usia 15-64 tahun mengalami kekerasan fisik
dan/atau seksual oleh pasangan dan selain pasangan selama hidupnya. Pada
SNPHAR tahun 2018, ditemukan bahwa 2 dari 3 anak laki-laki dan perempuan
berusia 13-17 tahun pernah mengalami salah satu kekerasan dalam hidupnya, baik
itu kekerasan fisik, seksual, maupun emosional

Dalam Catatan Tahunan Kekerasan terhadap Perempuan (Catahu)

tahun 2020, sepanjang tahun tersebut ditemukan 299.911 kasus kekerasan
terhadap perempuan. Data tersebut dihimpun dari pengadilan negeri dan agama,
lembaga layanan mitra Komnas Perempuan sejumlah, dan Unit Pelayanan dan
Rujukan (UPR). Jenis kekerasannya pun beragam dan yang paling menonjol
kekerasan di ranah pribadi atau privat, yaitu KDRT dan relasi personal. Di
antaranya terdapat kekerasan terhadap istri (KTI) menempati peringkat pertama
3.221 kasus (49 persen), disusul kekerasan dalam pacaran 1.309 kasus (20
persen), kekerasan terhadap anak perempuan sebanyak 954 kasus (14 persen),
sisanya kekerasan oleh mantan suami, mantan pacar, serta kekerasan terhadap
pekerja rumah tangga. Selanjutnya, kekerasan di ranah komunitas atau publik
tercatat kasus paling menonjol adalah kekerasan seksual sebesar 962 kasus (55
persen) yang terdiri dari dari pencabulan (166 kasus), perkosaan (229 kasus),
pelecehan seksual (181 kasus), persetubuhan sebanyak 5 kasus, dan sisanya
percobaan perkosaan dan kekerasan seksual lain. Di ranah dengan pelaku negara,
Catahu 2021 mencatat ada kasus-kasus yang dilaporkan. Setidaknya sepanjang
tahun 2020 ada 23 kasus (0,1 persen). Kekerasan di ranah negara antara lain kasus
perempuan berhadapan dengan hukum (6 kasus), kasus kekerasan terkait
penggusuran (2 kasus), kasus kebijakan diskriminatif (2 kasus). Kemudian, kasus
dalam konteks tahanan dan serupa tahanan (10 kasus) serta kasus dengan pelaku
pejabat publik (1 kasus). Pada tahun 2020, angka kekerasan terhadap perempuan
mengalami penurunan sekitar 31,5 persen dari tahun sebelumnya. Namun, yang
penting menjadi catatan adalah, penurunan jumlah kasus pada tahun 2020,
tidak berarti jumlah kasusnya menurun.

Data Catahu 2021 juga ditemukan lonjakan tajam pengaduan yang

terpengaruh oleh situasi pandemi, yaitu kekerasan berbasis gender siber (KBGS)
naik sebesar 348 persen, yaitu 409 kasus pada tahun 2019 menjadi 1.425 kasus
pada tahun 2020. Ancaman dan atau tindakan penyebaran materi bermuatan
seksual milik korban dan pengiriman materi seksual untuk melecehkan atau
menyakiti korban adalah dua jenis KBGS yang paling banyak terjadi. Pelakunya
adalah mantan pacar ataupun akun anonim. Peningkatan data pelaporan ini
dikarenakan intensitas penggunaan internet di masa pandemi, tersosialisasinya
pemahaman KBGS di kalangan publik, serta penguatan kecerdasan digital di
kalangan perempuan muda.

Kekerasan terhadap perempuan dan anak merupakan persoalan yang

perlu diselesaikan. Kerap kali, korban kekerasan tidak menyuarakan apa yang
mereka alami, baik itu kekerasan secara fisik, mental, maupun seksual. Banyak di
antara korban yang kesulitan melapor atau tak berani untuk melaporkan kekerasan
yang mereka alami. Maka dari uraian diatas bagaimana tenaga kesehatan
melakukan pelayanan untuk scrining dan support terhadap kekerasan pada
perempuan ( IBU dan ANAK).
B. Rumusan Masalah
1. Apa yang dimaksud kekerasan terhadap perempuan dan anak?
2. Bagaimana tenaga kesehatan berperan dalam melakukan scrining identifikasi
dan support dalam kekerasan yang dialami perempuan ibu dan anak?

C. Tujuan
1. Untuk mengetahui apa yang dimaksud kekerasan terhadap perempuan dan
anak
2. Untuk mengetahui peran tenaga kesehatan dalam skrining identifikasi dan
support terhadap kekerasan perempuan.
 BAB II
PEMBAHASAN

A. Kekerasan tehadap Perempuan

Kekerasan sangat sering terjadi di kehidupan sehari-hari baik di
lingkungan keluarga, masyarakat maupun teman sebaya. Kekerasan umumnya
sering menimpa orang-orang yang tidak berdaya. Maraknya isu kekerasan yang
terjadi terhadap perempuan menjadi suatu momok yang menakutkan bagi seluruh
perempuan khususnya perempuan yang memiliki kesibukan diluar mengurus
pekerjaan rumah meskipun demikian tidak menutup kemungkinan perempuan
yang mengurus pekerjaan rumah juga mengalami hal yang sama.
Definisi kekerasan terhadap perempuan menurut WHO mencakup
semua bentuk perlakuan yang salah baik secara fisik dan/atau emosional, seksual,
penelantaran, dan eksploitasi yang berdampak atau berpotensi membahayakan
kesehatan anak dan perempuan, perkembangan anak dan perempuan, atau harga
diri anak dan perempuan dalam konteks hubungan tanggung jawab. Berdasarkan
definisi tersebut, kekerasan anak dan perempuan dapat berupa kekerasan fisik,
kekerasan seksual dan kekerasan emosional atau psikis.
Dalam “Deklarasi tentang Penghapusan Kekerasan Terhadap
Perempuan (1993)”, kekerasan terhadap perempuan didefinisikan sebagai “suatu
tindakan kekerasan berbasis gender yang mengakibatkan, atau bisa
mengakibatkan, bahaya atau penderitaan fisik, seksual atau mental perempuan,
termasuk ancaman tindakan sejenis, pemaksaan atau perampasan kebebasan
secara sewenang-wenang, baik terjadi di ranah publik maupun kehidupan
pribadi.” Pemerintah Indonesia menandatangani Deklarasi tersebut pada tahun
2004 bersama dengan negara-negara ASEAN lainnya dan telah mempersiapkan
perangkat undang-undang dan kebijakannya. Tetapi, pelaksanaannya yang lambat
dan tidak memadai menjadikan perempuan di seluruh Indonesia tetap rentan
terhadap kekerasaan. Upaya yang dibutuhkan sekarang adalah memperkuat
penegakan hukum, mendidik penyedia pelayanan dan masyarakat luas tentang
kekerasan terhadap perempuan dan memperluas layanan untuk korban kekerasan
dan pelaku di perkotaan dan pedesaan. (Kemenpppa, 2011)
 Kekerasan terhadap anak adalah tindak kekerasan secara fisik, seksual,
penganiyaan emosional, atau pengabaian terhadap anak. Di Amerika Serikat,
Pusat Pengendalian dan Pencegahan Penyakit (CDC) mendefinisikan
penganiayaan anak sebagai setiap tindakan atau serangkaian tindakan wali atau
kelalaian oleh orang tua atau pengasuh lainnya yang dihasilkan dapat
membahayakan, atau berpotensi bahaya, atau memberikan ancaman yang
berbahaya kepada anak (Leeb, R.T, 2008). Sedangkan Menurut Journal of Child
Abuse and Neglect, penganiayaan terhadap anak adalah “setiap tindakan terbaru
atau kegagalan untuk bertindak pada bagian dari orang tua atau pengasuh yang
menyebabkan kematian, kerusakan fisik serius atau emosional yang
membahayakan, pelecehan seksual atau eksploitasi, tindakan atau kegagalan
tindakan yang menyajikan risiko besar akan bahaya yang serius (Herrenkohl, R.C,
2005)
Dari artikel penelitian (Anwar, 2020) menyatakan bahwa sebuah survei
menyatakan 60 % wanita (ibu ) lebih sering melakukan kekerasan dari pada laki
laki (ayah). begitu pula dengan tindak kekerasan terhadap perempuan,yang
dimana kebanyakan yang menjadi pelaku adalah orang orang yang berada paling
dekat dengan mereka, seperti ayah dan juga suami. Terdapat beberapa hal yang
melatar belakangi mengapa kekerasan terhadap anak lebih banyak dilakukan oleh
seorang ibu, diantaranya adalah stress dan juga kenangan masa lalu yang suram.
Kekerasan terhadap anak dan perempuan itu dapat menyebabkan berbagai macam
dampak negatif, diantaranya ialah fisik maupun psikis. Bahkan kekerasan
terhadap anak dan perempuan itu memiliki dampak yang sangat berbahaya, yaitu
dapat menyebabkan kematian terhadap korban. Dampak lainnya yang juga
berbahaya ialah trauma yang berkepanjangan, dikhawatirkan hal tersebut akan
memicu adanya pengulangan tindakan kekerasan yang pernah dialaminya, yang
menjadi korban adalah anak anak mereka dimasa depan. Pelaku tindakan
kekerasan ditindak tegas dalam peraturan perundangundangan. peraturan tidak
memandang bulu, walaupun pelaku adalah orang tuaq sendir tetap di tindak
dengan tegas guna meminimalisir dan juga menghentikan tindakan kekerasan
yang kerap terjadi.
Berdasarkan pengumpulan data milik KemenPPPA, kekerasan pada
anak di 2019 terjadi sebanyak 11.057 kasus, 11.279 kasus pada 2020, dan 12.566
kasus hingga data November 2021. Pada anak-anak, kasus yang paling banyak
 dialami adalah kekerasan seksual sebesar 45 persen, kekerasan psikis 19 persen,
dan kekerasan fisik sekitar 18 persen. Sementara pada kasus kekerasan yang
dialami perempuan, KemenPPPA mencatat juga turut mengalami kenaikan.
Dalam tiga tahun terakhir ada 26.200 kasus kekerasan pada perempuan. Pada
2019 tercatat sekitar 8.800 kasus kekerasan pada perempuan, kemudian 2020
sempat turun di angka 8.600 kasus, dan kembali mengalami kenaikan berdasarkan
data hingga November 2021 di angka 8.800 kasus.

B. Peran Tenaga kesehatan dalam Scrining dan Suport terhadap Kekerasan

Perempuan

Studi ini mengeksplorasi pandangan dan sikap penyedia layanan

kesehatan di Malaysia terhadap kekerasan pasangan intim (IPV) dan perempuan
yang dilecehkan dan mempertimbangkan apakah dan bagaimana pandangan
mereka mempengaruhi penyediaan atau kualitas layanan. Dampak dari sikap
pemberi layanan terhadap penyediaan layanan bagi perempuan yang mengalami
kekerasan sangat penting untuk dipahami karena ada kebutuhan untuk
memastikan bahwa perempuan-perempuan ini tidak menjadi korban kembali oleh
sektor kesehatan, tetapi diperlakukan secara sensitif.
Meskipun banyak penyedia tidak setuju dengan kekerasan sebagai
sarana untuk menyelesaikan konflik perkawinan dan melabelinya tidak adil,
menjadi bagian dari budaya yang mengabaikan kekerasan terhadap perempuan
tampaknya mempengaruhi pandangan beberapa profesional perawatan kesehatan.
Menyadari dampak pandangan dan sikap penyedia terhadap IPV dan peran
profesional mereka terhadap kualitas layanan IPV tidak hanya membantu kita
memahami mengapa mereka beroperasi dengan cara tertentu, tetapi juga membuat
kita menyadari kendala yang ada dalam mempromosikan penyediaan perawatan
kesehatan yang empatik dan mana yang perlu ditangani .Lebih banyak pelatihan
kesadaran dan kepekaan dapat membantu mereka merasa kurang memadai,
terutama jika kursus berfokus pada kebutuhan dan kekuatan perempuan,
bagaimana penyedia layanan kesehatan dapat memvalidasi ini dan berkontribusi
pada proses perubahan jangka panjang bagi para penyintas kekerasan. Lingkungan
yang mendukung dan memiliki sumber daya yang baik dalam hal layanan
dukungan hukum, konseling, dan polisi tidak diragukan lagi memengaruhi
persepsi kemampuan petugas kesehatan untuk merespons kekerasan. Panduan
yang jelas tentang cara mencatat riwayat pelecehan, mengajukan pertanyaan
secara sensitif dan memvalidasi pengalaman juga penting bersama dengan
pelatihan keterampilan komunikasi yang baik seperti mendengarkan dan
berempati.

Penelitian yang melibatkan 10 negara menunjukkan bahwa sektor kesehatan

memegang peranan penting dalam:

a. Mencegah kekerasan pada perempuan

b. Membantu identifikasi adanya kekerasan sedini mungkin
c. Menyediakan layanan kesehatan bagi korban
 d. Merujuk ke tempat layanan sesuai kebutuhan

Tempat layanan kesehatan Nyaman dan aman bagi korban memperhatikan

kebutuhan & kondisi psikologis Respek terhadap korban, empatik Tidak ada
stigma Dukungan yang berkualitas dengan informasi yang jelas. Pendekatan
melalui Sektor Kesehatan Masyarakat merupakan alternatif yang terbaik dan
memiliki potensi yang unik dalam penanganan kekerasan pada perempuan dan
anak, terutama melalui layanan kespro cakupan tinggi. Hambatan yang ditemukan
Stigma dan ketakutan yang membuat korban menutup diri serta Kesadaran nakes
dan pelatihan nakes mengindentifikasi korban kekerasan sebagai penyebab
masalah kesehatan yang membuat korban datang ke faskes, terutama di faskes
yang tidak menyediakan layanan tindak lanjut dan proteksi terhadap korban.

Peran Fasilitas Kesehatan

1. Perencanaan
• Mengumpulkan data dan informasi
• Melakukan analisa dan pemetaan sesuai hasil pengumpulan data
dan informasi
• Menyusun rencana kerja
• Melaksanakan sosialisasi
• Menyiapkan Tenaga Pelaksana
• Menyiapkan petugas konseling dan wawancara Menyiapkan
Prasarana dan Sarana
2. Pelaksanaan
• Pemeriksaan Kesehatan
• Tindakan Medis
• Wawancara dan konseling
• Penyuluhan
• Kunjungan Rumah
• Pencatatan
3. Pengawasan dan Pengendalian
• Monitoring dan Evaluasi
• Pertanggungjawaban
Standard Ketenagaan

1. Jenis tenaga
1) Dokter umum/spesialis
2) Dokter gigi
3) Perawat
4) Bidan
5) Ahli gizi
6) Analis Laboratorium
7) Petugas Promkes
8) Petugas administrasi (pencatatan & pelaporan)
2. Kompetensi yang harus dimiliki oleh tenaga kesehatan
1) Mampu tatalaksana kasus KtP/A
2) Mampu melakukan komunikasi interpersonal, teknik wawancara dan
konseling.

Identifikasi Korban

a. Tampak rendah diri

b. Menunjukkan sikap yang sangat mengagungkan kehidupan tradisionalisme,
kekuatan keutuhan keluarga dan memposisikan inferior dalam keluarga
c. Dapat menerima adanya kekerasan
d. Merasa bersalah, tetapi menyangkal adanya ancaman atau timbulnya rasa
marah
e. Menunjukkan muka yang pasif tetapi mampu memanipulasi lingkungan
seakan-akan aman untuk dirinya
f. Reaksi terhadap stress keluhan fisik atau psikis
g. Menggunakan hub-seks untuk menunjukkan keintiman dengan pasangannya
h. Merasa wajar mendapatkan hukuman
i. Merasa mampu menolong dirinya sendiri untuk keluar dari permasalahannya,
namun sering kali tidak mampu dan tidak dapat menyelesaikan
permasalahannya
j. enderung berusaha untuk melupakan kejadian, trauma dan rasa takut yang ada.

Kebutuhan Korban
a. Pelayanan medis
b. Keamanan
c. Kerahasiaan
d. Pelayanan yang sensitif terhadap trauma dan penderitaannya
e. Dokumentasi rekam medik yang komprehensif
Layanan komprehensif dan empatik menghilangkan keengganan korban untuk
mencari pertolongan
f. Dukungan atau Suport berlanjut
1. Setelah masalah terbuka, lakukan pelayanan medis
2. Tawarkan dukungan emosional/psikologis
3. Keamanan atau privasi aman
4. Dokumentasi Kekerasan
5. Sediakan informasi Community resource (Layanan shelter, aspek
hukum, social, dll)
 BAB III
PENUTUP

A. Kesimpulan
Kekerasan seksual yang dialami oleh perempuan sering dianggap hanya
berkaitan dengan faktor pribadi saja, tidak ada hubungannya dengan fenomena social
dan budaya, namun kenyataannya kekerasan seksual pada perempuan berkaitan
dengan banyak hal yang dapat memberikan dampak buruk bagi korban itu sendiri,
keluarga, masyarakat dan negara. Dapat dikatakan bahwa kondisi kaum perempuan
masih sangat rentan menjadi korban berbagai jenis tindak kekerasan. Terlebih lagi,
pada zaman modern tingkat kekerasan justru semakin tinggi dan banyak orang yang
menganggap bahwa kasus tersebut merupakan hal yang biasa. Perempuan sebagai
makhluk yang seharusnya dihargai dan dilindungi, justru menjadi objek dari tindak
kekerasan yang dilakukan oleh orang terdekatnya.
 DAFTAR PUSTAKA

Badan Pusat Statistik Indonesia. 2017. Prevalensi Kekerasan Terhadap

Perempuan di Indonesia, Hasil SPHPN 2016. Jakarta: Badan Pusat Statistik.
Colombini et al.: “I feel it is not enough...” Health providers’
perspectives on services for victims of intimate partner violence in Malaysia. BMC
Health Services Research 2013 13:65.
Herrenkohl, R.C. (2005). "The definition of child maltreatment: from
case study to construct". Child Abuse and Neglect. 29 (5): 413–24.
doi:10.1016/j.chiabu.2005.04.002. PMID 15970317.
Hidayat, Anwar (2020). "Kekerasan terhadap Perempuan dan Anak",
Indonesian journal of school Counseling Volume 5 no 22 DOI:
https://doi.org/10.23916/08702011
Kementerian Pemberdayaan Perempuan Dan Perlindungan Anak
Republik Indonesia. Prosedur Standar Operasional Penanganan Pengaduan
Perempuan Dan Anak Korban Kekerasan. Jakarta: KEMENPPPA; 2011.
Komnas Perempuan. (2020). CATAHU 2020: Kekerasan terhadap
Perempuan Meningkat: Kebijakan Penghapusan Kekerasan Seksual Menciptakan
Ruang Aman Bagi perempuan dan anak perempuan, Catatan Kekerasan Terhadap
Perempuan Tahun 2019.
Komnas Perempuan. (2021). CATAHU 2020 Komnas Perempuan:
Lembar Fakta dan Poin Kunci (6 Maret 2022).
Leeb, R.T. (1 January 2008). "Child Maltreatment Surveillance: Uniform
Definitions for Public Health and Recommended Data Elements". Centers for Disease
Control and Prevention. Diakses tanggal 6 Maret 2022
WHO (2005). Multi-country study on women's health and domestic
violence ( http://www.who.int/gender/violence/who_multicountry_study/en/ )
See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/237389201

WHO Multi Country Study on Women's Health and Domestic Violence Against
Women

Article · January 2005

CITATIONS READS

1,219 2,852

5 authors, including:

Mary Ellsberg Lori Heise

George Washington University Johns Hopkins Bloomberg School of Public Health
77 PUBLICATIONS   13,810 CITATIONS    216 PUBLICATIONS   19,676 CITATIONS   

SEE PROFILE SEE PROFILE

Charlotte Watts
London School of Hygiene and Tropical Medicine
303 PUBLICATIONS   26,886 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Good School Study View project

LINEA (Learning Iniative on Norms and Sexual Exploitation and Abuse of Children and Adolescents) View project

All content following this page was uploaded by Mary Ellsberg on 19 May 2014.

The user has requested enhancement of the downloaded file.

WHO฀Multi-country
Study฀on฀Women’s฀Health฀
and฀Domestic฀Violence฀
against฀Women฀

Initial฀results฀on
prevalence,฀health฀outcomes
and฀women’s฀responses

Claudia฀García-Moreno
Henrica฀A.F.M.฀Jansen
Mary฀Ellsberg
Lori฀Heise
Charlotte฀Watts
 Contents

WHO฀Library฀Cataloguing-in-Publication฀Data Preface฀ ฀ vi
WHO฀multi-country฀study฀on฀women’s฀health฀and฀domestic฀violence฀ Foreword฀ ฀ vii
against฀women฀:฀initial฀results฀on฀prevalence,฀health฀outcomes฀฀
and฀women’s฀responses฀/฀authors:฀Claudia฀García-Moreno฀...฀[et฀al.] Ac�nowledgements฀ ix
1.฀Domestic฀violence฀฀2.฀Sex฀offenses฀฀3.฀Women’s฀health฀฀
Executive฀summary฀ xii
4.฀Cross-cultural฀comparison฀฀5.฀Multicenter฀studies฀฀
6.฀Epidemiologic฀studies฀฀I.฀García-Moreno,฀ �ntroduction

1
�ntroduction฀ 3

CHAPTER
ISBN฀92฀4฀159358฀X฀ (NLM฀classification:฀WA฀309)
Background฀to฀the฀Study฀ 3
International฀research฀on฀prevalence฀of฀violence฀against฀women฀ 4
Study฀objectives฀ 6
Organization฀of฀the฀Study฀ 7
Participating฀countries฀ 7
References฀ ฀ 9
©฀World฀Health฀Organization฀2005
Methods
All฀rights฀reserved.฀Publications฀of฀the฀World฀Health฀Organization฀

2
can฀be฀obtained฀from฀WHO฀Press,฀World฀Health฀Organization,฀ Definitions฀and฀questionnaire฀development฀ 13

CHAPTER
20฀Avenue฀Appia,฀1211฀Geneva฀27,฀Switzerland฀(tel:฀+41฀22฀791฀
Definitions฀ ฀ 13
2476;฀fax:฀+41฀22฀791฀4857;฀email:฀bookorders@who.int).฀Requests฀
for฀permission฀to฀reproduce฀or฀translate฀WHO฀publications฀
Formative฀research฀ 16
–฀whether฀for฀sale฀or฀for฀noncommercial฀distribution฀–฀should฀be฀ Development฀of฀the฀questionnaire฀ 17
addressed฀to฀WHO฀Press,฀at฀the฀above฀address฀(fax:฀+41฀22฀791฀ Questionnaire฀structure฀ 17
4806;฀email:฀permissions@who.int).฀ Maximizing฀disclosure฀ 17
Country฀adaptation฀and฀translation฀of฀the฀questionnaire฀ 18
The฀designations฀employed฀and฀the฀presentation฀of฀the฀material฀
References฀ ฀ ฀18
in฀this฀publication฀do฀not฀imply฀the฀expression฀of฀any฀opinion฀ ฀

3
whatsoever฀on฀the฀part฀of฀the฀World฀Health฀Organization฀
Sample฀design�฀ethical฀and฀safety฀considerations�฀and฀response฀rates฀ 19

CHAPTER
concerning฀the฀legal฀status฀of฀any฀country,฀territory,฀city฀or฀area฀or฀
Sample฀design฀ 19
of฀its฀authorities,฀or฀concerning฀the฀delimitation฀of฀its฀frontiers฀or฀
boundaries.฀Dotted฀lines฀on฀maps฀represent฀approximate฀border฀ Ethical฀and฀safety฀considerations฀ 21
lines฀for฀which฀there฀may฀not฀yet฀be฀full฀agreement. Response฀rates฀ 22
฀ References฀ ฀ 24
The฀mention฀of฀specific฀companies฀or฀of฀certain฀manufacturers’฀
products฀does฀not฀imply฀that฀they฀are฀endorsed฀or฀recommended฀by฀ Results

4
the฀World฀Health฀Organization฀in฀preference฀to฀others฀of฀a฀similar฀
nature฀that฀are฀not฀mentioned.฀Errors฀and฀omissions฀excepted,฀the฀ Prevalence฀of฀violence฀by฀intimate฀partners฀ 27

CHAPTER
names฀of฀proprietary฀products฀are฀distinguished฀by฀initial฀capital฀letters. Physical฀and฀sexual฀violence฀ 28
Acts฀of฀physical฀violence฀ 30
All฀reasonable฀precautions฀have฀been฀taken฀by฀the฀World฀Health฀
Acts฀of฀sexual฀violence฀ 31
Organization฀to฀verify฀the฀information฀contained฀in฀this฀publication.฀
However,฀the฀published฀material฀is฀being฀distributed฀without฀ Overlap฀between฀physical฀and฀sexual฀violence฀ 32
warranty฀of฀any฀kind,฀either฀express฀or฀implied.฀฀The฀responsibility฀ Demographic฀factors฀associated฀with฀violence฀ 32
for฀the฀interpretation฀and฀use฀of฀the฀material฀lies฀with฀the฀reader.฀฀ Acts฀of฀emotional฀abuse฀ 35
In฀no฀event฀shall฀the฀World฀Health฀Organization฀be฀liable฀for฀ Controlling฀behaviour฀ 36
damages฀arising฀from฀its฀use.฀฀
Women’s฀violence฀against฀men฀ 36
Designed฀by:฀Grundy฀&฀Northedge฀Designers
Women’s฀attitudes฀towards฀violence฀ 39
Discussion฀ ฀ 41
Printed฀in฀Switzerland References฀ ฀ 42
 Contents฀฀(continued)

5
Prevalence฀of฀violence฀by฀perpetrators฀other฀than฀intimate฀partners฀since฀฀ ฀ Conclusions฀and฀recommendations฀
CHAPTER

10
the฀age฀of฀15฀years฀ 43
Summary฀of฀findings�฀conclusions�฀and฀areas฀for฀further฀research฀ 83

CHAPTER
Physical฀violence฀by฀non-partners฀since฀the฀age฀of฀15฀years฀ 43
Prevalence฀and฀patterns฀of฀violence฀ 83
Sexual฀violence฀by฀non-partners฀since฀the฀age฀of฀15฀years฀ 45
Association฀of฀violence฀with฀specific฀health฀outcomes฀ 85
Overall฀prevalence฀of฀non-partner฀violence฀since฀the฀age฀of฀15฀years฀ 45
Women’s฀responses฀and฀use฀of฀services฀ 86
Non-partner฀violence฀compared฀with฀partner฀violence฀ 46
Strengths฀and฀limitations฀of฀the฀Study฀ 87
Discussion฀ ฀ 46
Areas฀for฀further฀analysis฀ 88
References฀ ฀ 48
A฀basis฀for฀action฀ 89

6
Prevalence฀of฀sexual฀abuse฀in฀childhood฀and฀forced฀first฀sexual฀experience฀ 49 References฀ ฀ 89
CHAPTER

11
Sexual฀abuse฀before฀15฀years฀ 49
Recommendations฀ 90

CHAPTER
Forced฀first฀sex฀ 51
Strengthening฀national฀commitment฀and฀action฀ 90
Discussion฀ ฀ 52
Promoting฀primary฀prevention฀ 92
References฀ ฀ 54
Involving฀the฀education฀sector฀ 94

7
Association฀between฀violence฀by฀intimate฀partners฀and฀women’s฀physical฀ Strengthening฀the฀health฀sector฀response฀ 95
CHAPTER

and฀mental฀health฀ 55 Supporting฀women฀living฀with฀violence฀ 96
Women’s฀self-reported฀health฀and฀physical฀symptoms฀ 55 Sensitizing฀criminal฀justice฀systems฀ 96
Injuries฀caused฀by฀physical฀violence฀by฀an฀intimate฀partner฀ 57 Supporting฀research฀and฀collaboration฀ 97
Mental฀health฀ 59 References฀ ฀ 98
Discussion฀ ฀ 61
References฀ ฀ 62 Annex฀1฀ Methodology฀ 101

8
Annex฀2฀ Core฀Research฀Team฀and฀Steering฀Committee฀Members฀ 118
Associations฀between฀violence฀by฀intimate฀partners฀and฀women’s฀sexual฀and฀
CHAPTER

Annex฀3฀฀ Country฀research฀team฀members฀ 119

reproductive฀health฀ 63
Annex฀4฀฀ Questionnaire฀ 127
Induced฀abortion฀and฀miscarriage฀ 63
Use฀of฀antenatal฀and฀postnatal฀health฀services฀ 64
Statistical฀appendix฀ 166
Violence฀during฀pregnancy฀ 65
Parity฀ ฀ 66 �ndex฀ ฀ 198
Risk฀of฀sexually฀transmitted฀infections,฀including฀HIV฀ 66
Discussion฀ ฀ 69
References฀ ฀ 71

9
Women’s฀coping฀strategies฀and฀responses฀to฀physical฀violence฀by฀
CHAPTER

intimate฀partners฀ 73
Who฀women฀tell฀about฀violence฀and฀who฀helps฀ 73
Agencies฀or฀authorities฀to฀which฀women฀turn฀ 74
Fighting฀back฀ 76
Women฀who฀leave฀ 77
Discussion฀ ฀ 79
References฀ ฀ 80
 vi
vi
WHO฀Multi-country฀Study฀on฀Women’s฀Health฀and฀Domestic฀Violence
฀฀฀฀
Preface
Violence฀against฀women฀by฀an฀intimate฀partner฀is฀a฀major฀contributor฀to฀the฀ill-health฀of฀
women.฀This฀study฀analyses฀data฀from฀10฀countries฀and฀sheds฀new฀light฀on฀the฀prevalence฀of฀
violence฀against฀women฀in฀countries฀where฀few฀data฀were฀previously฀available.฀It฀also฀uncovers฀
the฀forms฀and฀patterns฀of฀this฀violence฀across฀different฀countries฀and฀cultures,฀documenting฀the฀
consequences฀of฀violence฀for฀women’s฀health.฀This฀information฀has฀important฀implications฀for฀
prevention,฀care฀and฀mitigation.
The฀health฀sector฀can฀play฀a฀vital฀role฀in฀preventing฀violence฀against฀women,฀helping฀to฀
identify฀abuse฀early,฀providing฀victims฀with฀the฀necessary฀treatment,฀and฀referring฀women฀to฀
appropriate฀and฀informed฀care.฀Health฀services฀must฀be฀places฀where฀women฀feel฀safe,฀are฀
treated฀with฀respect,฀are฀not฀stigmatized,฀and฀where฀they฀can฀receive฀quality,฀informed฀support.฀
A฀comprehensive฀health฀sector฀response฀to฀the฀problem฀is฀needed,฀in฀particular฀addressing฀the฀
reluctance฀of฀abused฀women฀to฀seek฀help.฀
The฀high฀rates฀documented฀by฀the฀Study฀of฀sexual฀abuse฀experienced฀by฀girls฀and฀women฀
are฀of฀great฀concern,฀especially฀in฀light฀of฀the฀HIV฀epidemic.฀Greater฀public฀awareness฀of฀
this฀problem฀is฀needed฀and฀a฀strong฀public฀health฀response฀that฀focuses฀on฀preventing฀such฀
violence฀from฀occurring฀in฀the฀first฀place.฀
The฀research฀specialists฀and฀the฀representatives฀of฀women’s฀organizations฀who฀carried฀
out฀the฀interviews฀and฀dealt฀so฀sensitively฀with฀the฀respondents฀deserve฀our฀warmest฀thanks.฀
Most฀of฀all,฀I฀thank฀the฀24฀000฀women฀who฀shared฀this฀important฀information฀about฀their฀lives,฀
despite฀the฀many฀difficulties฀involved฀in฀talking฀about฀it.฀The฀fact฀that฀so฀many฀of฀them฀spoke฀
about฀their฀own฀experience฀of฀violence฀for฀the฀first฀time฀during฀this฀study฀is฀both฀an฀indictment฀
of฀the฀state฀of฀gender฀relations฀in฀our฀societies,฀and฀a฀spur฀for฀action.฀They,฀and฀the฀countries฀
that฀carried฀out฀this฀groundbreaking฀research฀have฀made฀a฀vital฀contribution.฀
This฀study฀will฀help฀national฀authorities฀to฀design฀policies฀and฀programmes฀that฀begin฀to฀
deal฀with฀the฀problem.฀It฀will฀contribute฀to฀our฀understanding฀of฀violence฀against฀women฀and฀
the฀need฀to฀prevent฀it.฀Challenging฀the฀social฀norms฀that฀condone฀and฀therefore฀perpetuate฀
violence฀against฀women฀is฀a฀responsibility฀for฀us฀all.฀Supported฀by฀WHO,฀the฀health฀sector฀
must฀now฀take฀a฀proactive฀role฀in฀responding฀to฀the฀needs฀of฀the฀many฀women฀living฀in฀violent฀
relationships.฀Much฀greater฀investment฀is฀urgently฀needed฀in฀programmes฀to฀reduce฀violence฀
against฀women฀and฀to฀support฀action฀on฀the฀study’s฀findings฀and฀recommendations.
We฀must฀bring฀the฀issue฀of฀domestic฀violence฀out฀into฀the฀open,฀examine฀it฀as฀we฀would฀
the฀causes฀of฀any฀other฀preventable฀health฀problem,฀and฀apply฀the฀best฀remedies฀available.
LEE฀Jong-Woo�
Director-General,฀World฀Health฀Organization
vii
Executive฀Summary
Foreword
Foreword
Violence฀against฀women฀is฀a฀universal฀phenomenon฀that฀persists฀in฀all฀countries฀of฀
the฀world,฀and฀the฀perpetrators฀of฀that฀violence฀are฀often฀well฀known฀to฀their฀victims.฀฀
Domestic฀violence,฀in฀particular,฀continues฀to฀be฀frighteningly฀common฀and฀to฀be฀accepted฀
as฀“normal”฀within฀too฀many฀societies.฀Since฀the฀World฀Conference฀on฀Human฀Rights,฀held฀
in฀Vienna฀in฀1993,฀and฀the฀Declaration฀on฀the฀Elimination฀of฀Violence฀against฀Women฀in฀the฀
same฀year,฀civil฀society฀and฀governments฀have฀acknowledged฀that฀violence฀against฀women฀
is฀a฀public฀policy฀and฀human฀rights฀concern.฀While฀work฀in฀this฀area฀has฀resulted฀in฀the฀
establishment฀of฀international฀standards,฀the฀task฀of฀documenting฀the฀magnitude฀of฀violence฀
against฀women฀and฀producing฀reliable,฀comparative฀data฀to฀guide฀policy฀and฀monitor฀
implementation฀has฀been฀exceedingly฀difficult.฀The฀WHO฀Multi-country฀Study฀on฀Women’s฀
Health฀and฀Domestic฀Violence฀against฀Women฀is฀a฀response฀to฀this฀difficulty.
The฀Study฀challenges฀the฀perception฀that฀home฀is฀a฀safe฀haven฀for฀women฀by฀showing฀
that฀women฀are฀more฀at฀risk฀of฀experiencing฀violence฀in฀intimate฀relationships฀than฀
anywhere฀else.฀According฀to฀the฀Study,฀it฀is฀particularly฀difficult฀to฀respond฀effectively฀to฀this฀
violence฀because฀many฀women฀accept฀such฀violence฀as฀“normal”.฀Nonetheless,฀international฀
human฀rights฀law฀is฀clear:฀states฀have฀a฀duty฀to฀exercise฀due฀diligence฀to฀prevent,฀prosecute฀
and฀punish฀violence฀against฀women.฀฀฀
Looking฀at฀violence฀against฀women฀from฀a฀public฀health฀perspective฀offers฀a฀way฀of฀
capturing฀the฀many฀dimensions฀of฀the฀phenomenon฀in฀order฀to฀develop฀multisectoral฀
responses.฀Often฀the฀health฀system฀is฀the฀first฀point฀of฀contact฀with฀women฀who฀are฀victims฀
of฀violence.฀Data฀provided฀by฀this฀Study฀will฀contribute฀to฀raising฀awareness฀among฀health฀
policy-makers฀and฀care฀providers฀of฀the฀seriousness฀of฀the฀problem฀and฀how฀it฀affects฀the฀
health฀of฀women.฀Ideally,฀the฀findings฀will฀inform฀a฀more฀effective฀response฀from฀government,฀
including฀the฀health,฀justice฀and฀social฀service฀sectors,฀as฀a฀step฀towards฀fulfilling฀the฀state’s฀
obligation฀to฀eliminate฀violence฀against฀women฀under฀international฀human฀rights฀laws.
Violence฀against฀women฀has฀a฀far฀deeper฀impact฀than฀the฀immediate฀harm฀caused.฀It฀has฀
devastating฀consequences฀for฀the฀women฀who฀experience฀it,฀and฀a฀traumatic฀effect฀on฀those฀
who฀witness฀it,฀particularly฀children.฀It฀shames฀states฀that฀fail฀to฀prevent฀it฀and฀societies฀that฀
tolerate฀it.฀Violence฀against฀women฀is฀a฀violation฀of฀basic฀human฀rights฀that฀must฀be฀eliminated฀
through฀political฀will,฀and฀by฀legal฀and฀civil฀action฀in฀all฀sectors฀of฀society.
This฀report฀of฀the฀WHO฀Multi-country฀Study฀on฀Women’s฀Health฀and฀Domestic฀Violence฀
against฀Women,฀along฀with฀the฀recommendations฀it฀contains,฀is฀an฀invaluable฀contribution฀to฀
the฀struggle฀to฀eliminate฀violence฀against฀women.฀฀
฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀฀฀฀฀฀฀฀
฀฀฀฀฀฀฀฀
Ya�ın฀Ertür�
Special฀Rapporteur฀on฀violence฀against฀women,฀its฀causes฀and฀consequences
viii
WHO฀Multi-country฀Study฀on฀Women’s฀Health฀and฀Domestic฀Violence
Executive฀Summary ix

Acknowledgements
฀฀฀฀

Foreword Acknowledgements

Each฀culture฀has฀its฀sayings฀and฀songs฀about฀the฀importance฀of฀home,฀and฀the฀comfort฀and฀ The฀Study,฀and฀this฀comparative฀report฀summarizing฀the฀major฀findings฀of฀surveys฀
security฀to฀be฀found฀there.฀Yet฀for฀many฀women,฀home฀is฀a฀place฀of฀pain฀and฀humiliation. conducted฀in฀10฀countries,฀was฀only฀possible฀because฀of฀the฀dedication,฀commitment฀and฀
As฀this฀report฀clearly฀shows,฀violence฀against฀women฀by฀their฀male฀partners฀is฀common,฀฀ hard฀work฀of฀all฀of฀those฀involved,฀both฀internationally฀and฀in฀the฀countries฀concerned.฀
wide-spread฀and฀far-reaching฀in฀its฀impact.฀For฀too฀long฀hidden฀behind฀closed฀doors฀and฀avoided฀in฀ In฀addition,฀the฀implementation฀of฀the฀Study฀was฀supported฀by฀many฀people฀in฀all฀of฀the฀
public฀discourse,฀such฀violence฀can฀no฀longer฀be฀denied฀as฀part฀of฀everyday฀life฀for฀millions฀of฀women.฀ participating฀institutions.฀The฀World฀Health฀Organization฀and฀the฀authors฀would฀like฀to฀
The฀research฀findings฀presented฀in฀this฀report฀reinforce฀the฀key฀messages฀of฀WHO’s฀World฀ thank฀all฀of฀those฀who฀contributed฀in฀different฀ways฀to฀making฀this฀Study฀happen,฀and฀
Report฀on฀Violence฀and฀Health฀in฀2002,฀challenging฀notions฀that฀acts฀of฀violence฀are฀simply฀ apologize฀to฀anyone฀who฀may฀inadvertently฀remain฀unnamed.฀
matters฀of฀family฀privacy,฀individual฀choice,฀or฀inevitable฀facts฀of฀life.฀The฀data฀collected฀by฀WHO฀ The฀recommendation฀for฀undertaking฀this฀research฀emerged฀from฀the฀WHO฀
and฀researchers฀in฀10฀countries฀confirm฀our฀understanding฀that฀violence฀against฀women฀฀is฀an฀ Consultation฀on฀Violence฀against฀Women,฀held฀in฀1996.฀The฀participants฀of฀that฀meeting,฀
important฀social฀problem.฀Violence฀against฀women฀is฀also฀an฀important฀risk฀factor฀for฀women’s฀ in฀particular฀the฀late฀Raquel฀Tiglao,฀an฀advocate฀for฀women’s฀health฀and฀for฀services฀
ill-health,฀and฀should฀receive฀greater฀attention. for฀abused฀women฀from฀the฀Philippines,฀Mmatshilo฀Motsei,฀and฀Jacquelyn฀Campbell,฀all฀
฀Experience,฀primarily฀in฀industrialized฀countries,฀has฀shown฀that฀public฀health฀approaches฀to฀ pioneers฀in฀this฀work,฀inspired฀us฀to฀action.
violence฀can฀make฀a฀difference.฀The฀health฀sector฀has฀unique฀potential฀to฀deal฀with฀violence฀against฀ ฀The฀Study฀was฀undertaken฀as฀a฀key฀activity฀of฀the฀Department฀of฀Gender,฀Women฀
women,฀particularly฀through฀reproductive฀health฀services,฀which฀most฀women฀will฀access฀at฀some฀ and฀Health฀(GWH)฀of฀the฀World฀Health฀Organization,฀and฀developed฀and฀supported฀by฀
point฀in฀their฀lives.฀The฀Study฀indicates,฀however,฀that฀this฀potential฀is฀far฀from฀being฀realized.฀This฀ the฀Core฀Research฀Team฀which฀is฀made฀up฀of:฀Charlotte฀Watts฀from฀the฀London฀School฀
is฀partly฀because฀stigma฀and฀fear฀make฀many฀women฀reluctant฀to฀disclose฀their฀suffering.฀But฀it฀is฀ of฀Hygiene฀and฀Tropical฀Medicine,฀Mary฀Ellsberg฀and฀Lori฀Heise฀of฀the฀Program฀for฀
also฀because฀few฀doctors,฀nurses฀or฀other฀health฀personnel฀have฀the฀awareness฀and฀the฀training฀ Appropriate฀Technology฀in฀Health฀(PATH)฀in฀Washington,฀DC,฀and฀Henrica฀AFM฀Jansen฀
to฀identify฀violence฀as฀the฀underlying฀cause฀of฀women’s฀health฀problems,฀or฀can฀provide฀help,฀ and฀Claudia฀García-Moreno฀(Study฀Coordinator)฀from฀WHO.฀
particularly฀in฀settings฀where฀other฀services฀for฀follow-up฀care฀or฀protection฀are฀not฀available.฀The฀
health฀sector฀can฀certainly฀not฀do฀this฀alone,฀but฀it฀should฀increasingly฀fulfil฀its฀potential฀to฀take฀a฀
First฀and฀foremost,฀we฀would฀like฀to฀ in฀Brazil�฀Lilia฀Blima฀Schraiber,฀Ana฀Flavia฀Lucas฀
proactive฀role฀in฀violence฀prevention.
acknowledge฀and฀thank฀the฀more฀than฀฀ D’Oliveira฀and฀Ivan฀França-Junior฀(University฀
Violence฀against฀women฀is฀both฀a฀consequence฀and฀a฀cause฀of฀gender฀inequality.฀Primary฀ 24฀000฀women฀who฀participated฀in฀the฀฀ of฀São฀Paulo,฀São฀Paulo),฀Carmen฀Simone฀
prevention฀programmes฀that฀address฀gender฀inequality฀and฀tackle฀the฀many฀root฀causes฀of฀ Study,฀and฀who฀gave฀their฀time฀to฀answer฀฀ Grilo฀Diniz฀(Feminist฀Collective฀for฀Health฀
violence,฀changes฀in฀legislation,฀and฀the฀provision฀of฀services฀for฀women฀living฀with฀violence฀are฀ our฀questions฀and฀share฀their฀life฀฀ and฀Sexuality,฀São฀Paulo),฀Ana฀Paula฀Portella฀
experiences฀with฀us. (SOS฀Corpo฀Genero฀e฀Cidadania,฀Recife),฀
all฀essential.฀The฀Millennium฀Development฀Goal฀regarding฀girls’฀education,฀gender฀equality฀and฀
We฀gratefully฀acknowledge฀the฀investigators฀ Ana฀Bernarda฀Ludermir฀(Federal฀University฀of฀
the฀empowerment฀of฀women฀reflects฀the฀international฀community’s฀recognition฀that฀health,฀ and฀collaborating฀institutions฀in฀the฀countries,฀฀ Pernambuco,฀Recife);฀
development,฀and฀gender฀equality฀issues฀are฀closely฀interconnected.฀ and฀the฀interviewers฀and฀other฀office฀and฀฀
WHO฀regards฀the฀prevention฀of฀violence฀in฀general฀–฀and฀violence฀against฀women฀in฀particular฀ field฀staff฀in฀the฀countries,฀who฀all฀worked฀฀ in฀Ethiopia�฀Yemane฀Berhane,฀Negussie฀
with฀immense฀dedication฀and฀commitment฀ Deyessa,฀Yegomawork฀Goyasse,฀Atalay฀Alem,฀
–฀a฀high฀priority.฀It฀offers฀technical฀expertise฀to฀countries฀wishing฀to฀work฀against฀violence,฀and฀urges฀
to฀ensure฀the฀successful฀implementation฀of฀ Derege฀Kebede฀and฀Alemayehu฀Negash฀(Addis฀
international฀donors฀to฀support฀such฀work.฀It฀continues฀to฀emphasize฀the฀importance฀of฀฀ ฀ the฀Study.฀Particular฀mention฀is฀made฀of฀฀ Ababa฀University,฀Addis฀Ababa),฀Ulf฀Hogberg,฀
action-oriented,฀ethically฀based฀research,฀such฀as฀this฀Study,฀to฀increase฀our฀understanding฀of฀the฀ the฀investigators:฀ Gunnar฀Kullgren฀and฀Maria฀Emmelin฀(Umeå฀
problem฀and฀what฀to฀do฀about฀it.฀It฀also฀strongly฀urges฀the฀health฀sector฀to฀take฀a฀more฀proactive฀ University,฀Sweden),฀Mary฀Ellsberg฀(PATH,฀
role฀in฀responding฀to฀the฀needs฀of฀the฀many฀women฀living฀in฀violent฀relationships. in฀Bangladesh�฀Ruchira฀Tabassum฀Naved฀and฀ Washington,฀DC,USA);
Abbas฀Bhuiya฀(ICDDR,B:฀Centre฀for฀Health฀
and฀Population฀Research,฀Dhaka),฀Safia฀Azim฀ in฀Japan�฀Mieko฀Yoshihama฀(University฀of฀
Joy฀Phumaphi (Naripokkho,฀Dhaka)฀and฀Lars฀Ake฀Persson฀ Michigan,฀Ann฀Arbor,฀USA),฀Saori฀Kamano฀
Assistant฀Director-General,฀Family฀and฀Community฀Health,฀WHO (Uppsala฀University,฀Sweden); (National฀Institute฀of฀Population฀and฀Social฀
 x xi
WHO฀Multi-country฀Study฀on฀Women’s฀Health฀and฀Domestic฀Violence
฀฀฀฀
Security฀Research,฀Tokyo),฀Hiroko฀Akiyama฀
(University฀of฀Tokyo,฀Tokyo),฀Fumi฀Hayashi฀(Toya฀
Eiwa฀University,฀Tokyo),฀Tamie฀Kaino฀(Ochanomizu฀
University,฀Tokyo),฀Tomoko฀Yunomae฀(Japan฀
Accountability฀Caucus,฀Beijing,฀Tokyo);฀
in฀Namibia�฀Eveline฀January,฀Hetty฀Rose-Junius฀
and฀Johan฀Van฀Wyk฀(Ministry฀of฀Health฀and฀
Social฀Services,฀Windhoek),฀Alvis฀Weerasinghe฀
(National฀Planning฀Commission,฀Windhoek);฀
in฀Peru�฀Ana฀Güezmes฀García฀(Centro฀de฀
la฀Mujer฀Flora฀Tristan,฀Lima),฀Nancy฀Palomino฀
Ramirez฀and฀Miguel฀Ramos฀Padilla฀(Universidad฀
Peruana฀Cayetano฀Heredia,฀Lima);
in฀Samoa�฀Tina฀Tauasosi-Posiulai,฀Tima฀Levai-
Peteru,฀Dorothy฀Counts฀and฀Chris฀McMurray฀
(Secretariat฀of฀the฀Pacific฀Community);฀
in฀Serbia฀and฀Montenegro�฀Stanislava฀
Otaševi�฀and฀Silvia฀Koso฀(Autonomous฀Women’s฀
Center฀Against฀Sexual฀Violence,฀Belgrade),฀
Viktorija฀Cucic฀(University฀of฀Belgrade,฀Belgrade);฀
in฀Thailand�฀Churnrurtai฀Kanchanachitra,฀
Kritaya฀Archavanitkul฀and฀Wassana฀Im-em฀
(Mahidol฀University,฀Bangkok),฀Usa฀Lerdsrisanthat฀
(Foundation฀for฀Women,฀Bangkok);฀
in฀the฀United฀Republic฀of฀Tanzania�฀
Jessie฀Mbwambo฀and฀Gideon฀Kwesigabo฀
(Muhimbili฀College฀of฀Medical฀Sciences),฀Joe฀
Lugalla฀(University฀of฀New฀Hampshire,฀Durham,฀
USA),฀Sherbanu฀Kassim฀(Women’s฀Research฀and฀
Documentation฀Project,฀Dar฀es฀Salaam).฀
WHO฀would฀also฀like฀to฀thank฀the฀members฀of฀
the฀Steering฀Committee฀of฀the฀Study:฀Jacquelyn฀
Campbell,฀Co-Chair฀(USA),฀Lucienne฀Gillioz฀
(Switzerland),฀Rachel฀Jewkes฀(South฀Africa),฀Ivy฀
Josiah฀(Malaysia),฀Olav฀Meirik,฀Co-Chair฀(Chile/
Norway),฀Laura฀Rodrigues฀(United฀Kingdom/
Brazil),฀Irma฀Saucedo฀(Mexico),฀Berit฀Schei฀
(Norway)฀and฀Stig฀Wall฀(Sweden).฀In฀addition฀
to฀their฀continued฀support฀to฀the฀Study,฀they฀
reviewed฀and฀gave฀valuable฀input฀to฀several฀drafts฀
of฀the฀report.
The฀Study฀would฀not฀have฀been฀possible฀
without฀the฀support฀of฀numerous฀individuals฀
within฀WHO:฀Tomris฀Türmen,฀David฀Evans,฀
Nafsiah฀Mboi,฀Daniel฀Makuto,฀Eva฀Wallstam฀
and฀Joy฀Phumaphi฀who,฀over฀the฀period฀of฀the฀
Study,฀have฀overseen฀WHO’s฀work฀on฀gender฀
and฀women’s฀health,฀under฀which฀this฀Study฀
was฀developed฀and฀implemented.฀Particular฀
thanks฀are฀due฀to฀colleagues฀in฀the฀Department฀
of฀Reproductive฀Health฀and฀Research,฀in฀
particular฀Paul฀Van฀Look,฀Timothy฀Farley฀and฀
Jane฀Cottingham,฀for฀their฀continuous฀support฀
since฀the฀Study’s฀early฀days.฀Linda฀Morison฀of฀the฀
London฀School฀of฀Hygiene฀and฀Tropical฀Medicine,฀
Timothy฀Farley฀of฀WHO฀and฀Stig฀Wall฀of฀Umeå฀
University฀provided฀advice฀on฀sampling฀and฀other฀
statistical฀matters฀during฀the฀planning฀stages.฀
Chandrika฀John,฀Eva฀Lustigova,฀Jenny฀Perrin,฀Lesley฀
Robinson,฀Lindsay฀Simmons,฀Margaret฀Squadrani฀
and฀Ludy฀Suryantoro฀provided฀administrative฀
support฀to฀the฀Study.฀
This฀report฀also฀benefited฀from฀the฀
contributions฀of฀a฀number฀of฀other฀people.฀In฀
particular,฀Alexander฀Butchart,฀Etienne฀Krug฀and฀
Alison฀Phinney,฀in฀the฀Department฀of฀Injuries฀and฀
Violence฀Prevention,฀provided฀valuable฀comments฀
on฀an฀earlier฀version฀of฀this฀report.฀Jose฀
Bertolote฀in฀the฀Department฀of฀Mental฀Health,฀
Jack฀Jones฀in฀School฀Health฀and฀Youth฀Health฀
Promotion,฀and฀Paul฀Van฀Look฀also฀reviewed฀
specific฀sections฀and฀provided฀useful฀comments.฀
WHO฀acknowledges฀the฀following฀contributions฀
to฀the฀production฀of฀the฀report:฀Andrew฀Wilson,฀
for฀preparing฀the฀summary฀of฀the฀report;฀Angela฀
Haden฀and฀Pat฀Butler,฀for฀editing฀the฀manuscript;฀
Susan฀Kaplan฀and฀Ann฀Morgan,฀for฀proofreading;฀
Barbara฀Campanini,฀for฀editing฀the฀references;฀Liza฀
Furnival,฀for฀preparing฀the฀index;฀Tilly฀Northedge,฀
for฀the฀layout฀and฀cover฀design;฀and฀Andrew฀
Dicker,฀for฀formatting฀the฀report.
Finally,฀the฀Study฀would฀not฀have฀been฀
possible฀without฀the฀generous฀financial฀support฀
given฀to฀WHO฀by฀the฀Governments฀of฀the฀
Netherlands,฀Norway,฀Sweden,฀Switzerland฀and฀
the฀United฀Kingdom.฀The฀Rockefeller฀Foundation฀
supported฀the฀implementation฀of฀the฀Study฀in฀
Namibia฀and฀the฀United฀Republic฀of฀Tanzania,฀and฀
provided฀the฀use฀of฀its฀meeting฀place฀in฀Bellagio฀
in฀May฀2004,฀where฀the฀initial฀preparations฀for฀
this฀report฀with฀representatives฀of฀all฀the฀country฀
research฀teams฀took฀place.฀This฀funding฀enabled฀
WHO฀to฀develop฀the฀Study฀methods฀and฀
materials,฀establish฀and฀work฀with฀the฀country฀
research฀teams฀to฀implement฀the฀Study.฀WHO฀
provided฀the฀funding฀for฀the฀implementation฀
of฀the฀Study฀in฀6฀of฀the฀8฀initial฀countries:฀
Brazil,฀Japan,฀Namibia,฀Peru,฀Thailand฀and฀the฀
United฀Republic฀of฀Tanzania,฀with฀some฀of฀these฀
countries฀receiving฀additional฀funds฀as฀detailed฀
in฀Annex฀3.฀In฀Bangladesh,฀the฀Study฀was฀funded฀
by฀the฀Urban฀Primary฀Health฀Care฀project฀of฀
the฀Government฀of฀Bangladesh;฀in฀Ethiopia฀by฀
the฀Swedish฀Agency฀for฀Research฀Cooperation฀
with฀Developing฀Countries฀(SAREC/Sida);฀
in฀Samoa,฀by฀the฀United฀Nations฀Fund฀for฀
Population฀Activities฀(UNFPA);฀and฀in฀Serbia฀and฀
Montenegro,฀by฀Trocaire.฀We฀also฀acknowledge฀
the฀contribution฀from฀the฀Global฀Coalition฀on฀
Women฀and฀AIDS.
About฀the฀authors
The฀authors฀make฀up฀the฀WHO฀Core฀Research฀
Team฀for฀the฀Study,฀involved฀in฀the฀development฀
of฀the฀study฀methodology,฀questionnaire฀and฀
manuals,฀proving฀technical฀and฀scientific฀support฀
to฀the฀countries฀in฀the฀study฀and฀responsible฀for฀
cross-country฀analysis฀and฀reports฀on฀the฀results฀
of฀the฀study.฀
Claudia฀García-Moreno฀is฀Coordinator฀in฀
the฀WHO฀Department฀of฀Gender,฀Women฀and฀
Health฀and฀is฀the฀Study฀Coordinator.฀She฀joined฀
Statistical฀appendix
Acknowledgements
WHO฀in฀1994฀and฀initiated฀and฀developed฀
its฀work฀on฀violence฀against฀women.฀She฀was฀
responsible฀for฀overseeing฀the฀implementation฀of฀
the฀Study,฀and,฀with฀Lori฀Heise,฀for฀developing฀the฀
initial฀proposal฀for฀it.
Henrica฀AFM฀(Henriette)฀Jansen฀is฀
Epidemiologist฀to฀the฀WHO฀Multi-country฀Study฀
on฀Women’s฀Health฀and฀Domestic฀Violence฀
against฀Women฀in฀the฀WHO฀Department฀of฀
Gender,฀Women฀and฀Health.฀She฀was฀the฀lead฀
person฀for฀the฀final฀versions฀of฀the฀questionnaire฀
and฀data฀entry฀and฀processing฀programs,฀and฀
managed฀data฀collection฀and฀analysis.
Charlotte฀Watts฀is฀a฀Senior฀Lecturer฀in฀
Epidemiology฀and฀Health฀Policy฀in฀the฀Health฀
Policy฀Unit,฀Department฀of฀Public฀Health฀and฀
Policy,฀London฀School฀of฀Hygiene฀and฀Tropical฀
Medicine฀and฀a฀Technical฀Adviser฀to฀the฀WHO฀
Multi-country฀Study฀on฀Women’s฀Health฀
and฀Domestic฀Violence฀against฀Women.฀She฀
developed฀the฀initial฀protocol฀and฀questionnaire฀
for฀the฀Study.
Mary฀Carroll฀Ellsberg฀is฀Senior฀Adviser฀for฀
Gender,฀Violence฀and฀Human฀Rights฀at฀PATH฀in฀
Washington,฀DC,฀USA.฀She฀is฀an฀epidemiologist฀
and฀has฀also฀participated฀in฀research฀on฀violence฀
against฀women฀in฀Nicaragua,฀Indonesia฀and฀
Ethiopia.฀She฀is฀the฀lead฀author฀of฀“Researching฀
violence฀against฀women:฀a฀practical฀guide฀for฀
researchers฀and฀activists”,฀which฀synthesizes฀the฀
experience฀from฀the฀WHO฀Study฀and฀other฀
research฀on฀violence฀against฀women.
Lori฀Heise฀is฀Director฀of฀the฀Global฀Campaign฀
for฀Microbicides฀at฀PATH฀and฀a฀research฀fellow฀
in฀health฀policy฀at฀the฀London฀School฀of฀Hygiene฀
and฀Tropical฀Medicine.฀She฀has฀worked฀for฀over฀
two฀decades฀on฀intersecting฀issues฀of฀gender,฀
power,฀sexuality฀and฀violence.฀She฀is฀a฀co-author฀
of฀“Researching฀violence฀against฀women:฀a฀practical฀
guide฀for฀researchers฀and฀activists”.
xii xiii

Executive฀summary
Statistical฀appendix
WHO฀Multi-country฀Study฀on฀Women’s฀Health฀and฀Domestic฀Violence

฀฀฀฀

Executive฀summary

This฀report฀of฀the฀WHO฀Multi-country฀Study฀on฀Women’s฀Health฀and฀Domestic฀Violence฀ choked,฀burnt฀on฀purpose,฀threatened฀with฀ Emotionally฀abusive฀acts฀and฀controlling฀

against฀Women฀analyses฀data฀collected฀from฀over฀24฀000฀women฀in฀10฀countries฀ a฀weapon,฀or฀having฀a฀weapon฀used฀against฀ behaviours
her)฀ranged฀from฀4%฀in฀Japan฀city฀to฀49%฀in฀ Emotionally฀abusive฀acts฀by฀a฀partner฀included:฀
representing฀diverse฀cultural,฀geographical฀and฀urban/rural฀settings:฀Bangladesh,฀Brazil,฀
Peru฀province.฀The฀vast฀majority฀of฀women฀ being฀insulted฀or฀made฀to฀feel฀bad฀about฀
Ethiopia,฀Japan,฀Peru,฀Namibia,฀Samoa,฀Serbia฀and฀Montenegro,฀Thailand,฀and฀the฀United฀ physically฀abused฀by฀partners฀experienced฀acts฀ oneself;฀being฀humiliated฀in฀front฀of฀others;฀
Republic฀of฀Tanzania.฀The฀Study฀was฀designed฀to:฀ of฀violence฀more฀than฀once. being฀intimidated฀or฀scared฀on฀purpose;฀or฀
being฀threatened฀directly,฀or฀through฀a฀threat฀
1 estimate฀the฀prevalence฀of฀physical,฀sexual฀and฀emotional฀violence฀against฀women,฀with฀ Sexual฀violence฀by฀intimate฀partners to฀someone฀the฀respondent฀cares฀about.฀
particular฀emphasis฀on฀violence฀by฀intimate฀partners; The฀range฀of฀lifetime฀prevalence฀of฀sexual฀ Across฀all฀countries,฀between฀20%฀and฀75%฀฀
2 assess฀the฀association฀of฀partner฀violence฀with฀a฀range฀of฀health฀outcomes;฀ violence฀by฀an฀intimate฀partner฀was฀between฀6%฀ of฀women฀had฀experienced฀one฀or฀more฀of฀
(Japan฀city฀and฀Serbia฀and฀Montenegro฀city)฀and฀ these฀acts,฀most฀within฀the฀past฀12฀months.฀
3 identify฀factors฀that฀may฀either฀protect฀or฀put฀women฀at฀risk฀of฀partner฀violence;
59%฀(Ethiopia฀province),฀with฀most฀sites฀falling฀ Data฀were฀also฀collected฀about฀partners’฀
4 document฀the฀strategies฀and฀services฀that฀women฀use฀to฀cope฀with฀violence฀by฀an฀ between฀10%฀and฀50%.฀While฀in฀most฀settings฀ controlling฀behaviours,฀such฀as:฀routinely฀
intimate฀partner.฀ sexual฀violence฀was฀considerably฀less฀frequent฀ attempting฀to฀restrict฀a฀woman’s฀contact฀with฀
than฀physical฀violence,฀sexual฀violence฀was฀ her฀family฀or฀friends,฀insisting฀on฀knowing฀
This฀report฀presents฀findings฀on฀objectives฀1,฀2,฀and฀4.฀The฀third,฀analysis฀of฀risk฀and฀ more฀frequent฀in฀Bangladesh฀province,฀Ethiopia,฀ where฀she฀is฀at฀all฀times,฀and฀controlling฀her฀
protective฀factors,฀will฀be฀addressed฀in฀a฀future฀report.฀ province฀and฀Thailand฀city.฀ access฀to฀health฀care.฀Significantly,฀the฀number฀
of฀controlling฀behaviours฀by฀the฀partner฀was฀
Physical฀and฀sexual฀violence฀by฀intimate฀ associated฀with฀the฀risk฀of฀physical฀or฀sexual฀
Organization฀of฀the฀Study used฀female฀interviewers฀and฀supervisors฀trained฀ partners violence,฀or฀both.
using฀a฀standardized฀3-week฀curriculum.฀Strict฀ For฀ever-partnered฀women,฀the฀range฀of฀
The฀Study฀consisted฀of฀standardized฀฀ ethical฀and฀safety฀guidelines฀were฀adhered฀to฀in฀ lifetime฀prevalence฀of฀physical฀or฀sexual฀
population-based฀household฀surveys.฀In฀five฀ each฀country. violence,฀or฀both,฀฀by฀an฀intimate฀partner฀ Women’s฀attitudes฀towards฀violence
countries฀(Bangladesh,฀Brazil,฀Peru,฀Thailand,฀and฀ was฀15%฀to฀71%,฀with฀estimates฀in฀most฀sites฀
the฀United฀Republic฀of฀Tanzania),฀surveys฀were฀ ranging฀from฀30%฀to฀60%.฀Women฀in฀Japan฀city฀ In฀addition฀to฀women’s฀experience,฀the฀Study฀
conducted฀in฀(a)฀the฀capital฀or฀a฀large฀city฀and฀ Violence฀against฀women฀by฀฀ were฀the฀least฀likely฀to฀have฀ever฀experienced฀ investigated฀women’s฀attitudes฀to฀partner฀
(b)฀one฀province฀or฀region,฀usually฀with฀urban฀ intimate฀partners physical฀or฀sexual฀violence,฀or฀both,฀by฀an฀ violence฀including:฀(a)฀the฀circumstances฀in฀
and฀rural฀populations.฀One฀rural฀setting฀was฀used฀ intimate฀partner,฀while฀the฀greatest฀amount฀ which฀they฀believed฀it฀was฀acceptable฀for฀a฀
in฀Ethiopia,฀and฀a฀single฀large฀city฀was฀used฀in฀ The฀results฀indicate฀that฀violence฀by฀a฀male฀ of฀violence฀was฀reported฀by฀women฀living฀in฀ man฀to฀hit฀or฀physically฀mistreat฀his฀wife,฀and฀
Japan,฀Namibia,฀and฀Serbia฀and฀Montenegro.฀In฀ intimate฀partner฀(also฀called฀“domestic฀violence”)฀ provincial฀(for฀the฀most฀part฀rural)฀settings฀ (b)฀their฀beliefs฀about฀whether฀and฀when฀
Samoa,฀the฀whole฀country฀was฀sampled.฀In฀this฀ is฀widespread฀in฀all฀of฀the฀countries฀included฀ in฀Bangladesh,฀Ethiopia,฀Peru,฀and฀the฀United฀ a฀woman฀may฀refuse฀to฀have฀sex฀with฀her฀
report,฀sites฀are฀referred฀to฀by฀country฀name฀ in฀the฀Study.฀However,฀there฀was฀a฀great฀deal฀ Republic฀of฀Tanzania.฀Likewise,฀regarding฀฀ husband.฀There฀was฀wide฀variation฀in฀women’s฀
followed฀by฀either฀“city”฀or฀“province”;฀where฀ of฀variation฀from฀country฀to฀country,฀and฀from฀ current฀violence฀–฀as฀defined฀by฀one฀or฀฀ acceptance฀of฀different฀reasons,฀and฀indeed฀of฀
only฀the฀country฀name฀is฀used,฀it฀should฀be฀taken฀ setting฀to฀setting.฀This฀indicates฀that฀this฀violence฀ more฀acts฀of฀physical฀or฀sexual฀violence฀฀ the฀idea฀that฀violence฀was฀ever฀justified.฀While฀
to฀refer฀to฀both฀sites. is฀not฀inevitable. in฀the฀year฀prior฀to฀being฀interviewed฀–฀the฀฀ over฀three฀quarters฀of฀women฀in฀the฀city฀
Work฀was฀coordinated฀by฀WHO฀with฀a฀ range฀was฀between฀3%฀(Serbia฀and฀ sites฀of฀Brazil,฀Japan,฀Namibia,฀and฀Serbia฀and฀
core฀research฀team฀of฀experts฀from฀the฀London฀ Physical฀violence฀by฀intimate฀partners Montenegro฀city)฀and฀54%฀(Ethiopia฀province),฀ Montenegro฀said฀no฀reason฀justified฀violence,฀
School฀of฀Hygiene฀and฀Tropical฀Medicine฀ The฀proportion฀of฀ever-partnered฀women฀฀ with฀most฀sites฀falling฀between฀20%฀and฀33%.฀ less฀than฀one฀quarter฀thought฀so฀in฀the฀
(LSHTM),฀the฀Program฀for฀Appropriate฀ who฀had฀ever฀suffered฀physical฀violence฀by฀a฀ These฀findings฀illustrate฀the฀extent฀to฀which฀ provincial฀settings฀of฀Bangladesh,฀Ethiopia,฀and฀
Technology฀in฀Health฀(PATH),฀and฀WHO฀ male฀intimate฀partner฀ranged฀from฀13%฀in฀฀ violence฀is฀a฀reality฀in฀partnered฀women’s฀ Peru.฀Acceptance฀of฀wife-beating฀was฀higher฀
itself.฀A฀research฀team฀was฀established฀in฀each฀ Japan฀city฀to฀61%฀in฀Peru฀province,฀with฀฀ lives,฀with฀a฀large฀proportion฀of฀women฀ among฀women฀who฀had฀experienced฀abuse฀
country,฀including฀representatives฀from฀research฀ most฀sites฀falling฀between฀23%฀and฀49%.฀฀ having฀some฀experience฀of฀violence฀during฀ than฀among฀those฀who฀had฀not.
organizations฀and฀women’s฀organizations฀ The฀prevalence฀of฀severe฀physical฀violence฀฀ their฀partnership,฀and฀many฀having฀recent฀ Respondents฀were฀also฀asked฀whether฀they฀
providing฀services฀to฀abused฀women.฀The฀survey฀ (a฀woman฀being฀hit฀with฀a฀fist,฀kicked,฀dragged,฀ experiences฀of฀abuse. believed฀a฀woman฀has฀a฀right฀to฀refuse฀to฀have฀
xiv
WHO฀Multi-country฀Study฀on฀Women’s฀Health฀and฀Domestic฀Violence
฀฀฀฀
sex฀with฀her฀partner฀in฀a฀number฀of฀situations,฀
including:฀if฀she฀is฀sick,฀if฀she฀does฀not฀want฀to฀
have฀sex,฀if฀he฀is฀drunk,฀or฀if฀he฀mistreats฀her.฀
In฀the฀provinces฀of฀Bangladesh,฀Ethiopia,฀Peru,฀
and฀the฀United฀Republic฀of฀Tanzania,฀and฀in฀
Samoa,฀between฀10%฀and฀20%฀of฀women฀felt฀
that฀women฀did฀not฀have฀the฀right฀to฀refuse฀sex฀
under฀any฀of฀these฀circumstances.
Non-partner฀physical฀and฀sexual฀violence
In฀addition฀to฀partner฀violence,฀the฀WHO฀Study฀
also฀collected฀data฀on฀physical฀and฀sexual฀abuse฀
by฀perpetrators฀–฀male฀and฀female฀–฀other฀than฀
a฀current฀or฀former฀male฀partner.฀
Non-partner฀physical฀violence฀since฀฀
age฀15฀years
Women’s฀reports฀of฀experience฀of฀physical฀
violence฀by฀a฀non-partner฀since฀the฀age฀of฀
15฀varied฀widely.฀By฀far฀the฀highest฀level฀of฀
non-partner฀physical฀violence฀was฀reported฀
in฀Samoa฀(62%),฀whereas฀less฀than฀10%฀of฀
women฀in฀Ethiopia฀province,฀Japan฀city,฀Serbia฀
and฀Montenegro฀city,฀and฀Thailand฀reported฀
non-partner฀physical฀violence.฀Commonly฀
mentioned฀perpetrators฀included฀fathers฀and฀
other฀male฀or฀female฀family฀members.฀In฀some฀
settings฀(Bangladesh,฀Namibia,฀Samoa,฀and฀the฀
United฀Republic฀of฀Tanzania),฀teachers฀were฀also฀
frequently฀mentioned.฀
Non-partner฀sexual฀violence฀since฀฀
age฀15฀years
The฀highest฀levels฀of฀sexual฀violence฀by฀฀
non-partners฀since฀age฀15฀years฀–฀between฀10%฀
and฀12%฀–฀were฀reported฀in฀Peru,฀Samoa,฀and฀
the฀United฀Republic฀of฀Tanzania฀city,฀while฀levels฀
below฀1%฀were฀reported฀in฀Bangladesh฀province฀
and฀Ethiopia฀province.฀The฀perpetrators฀included฀
strangers,฀boyfriends฀and,฀to฀a฀lesser฀extent,฀male฀
family฀members฀(excluding฀fathers)฀or฀male฀
friends฀of฀the฀family.฀฀
Comparing฀partner฀and฀non-partner฀violence฀
since฀age฀15฀years
A฀common฀perception฀is฀that฀women฀are฀more฀
at฀risk฀of฀violence฀from฀strangers฀than฀from฀
partners฀or฀other฀men฀they฀know.฀The฀data฀show฀
that฀this฀is฀far฀from฀the฀case.฀In฀the฀majority฀
of฀settings,฀over฀75%฀of฀women฀physically฀or฀
sexually฀abused฀by฀any฀perpetrator฀since฀the฀age฀
of฀15฀years฀reported฀abuse฀by฀a฀partner.฀In฀only฀
two฀settings,฀Brazil฀city฀and฀Samoa,฀were฀at฀least฀
40%฀of฀women฀abused฀only฀by฀someone฀other฀
than฀a฀partner.฀
Sexual฀abuse฀before฀age฀15฀years
Early฀sexual฀abuse฀is฀a฀highly฀sensitive฀issue฀
that฀is฀difficult฀to฀explore฀in฀a฀survey.฀The฀
Study฀therefore฀used฀a฀two-stage฀process฀
allowing฀women฀to฀report฀both฀directly฀and฀
anonymously฀(without฀having฀to฀reveal฀their฀
response฀to฀the฀interviewer)฀whether฀anyone฀
had฀ever฀touched฀them฀sexually,฀or฀made฀
them฀do฀something฀sexual฀that฀they฀did฀not฀
want฀to฀before฀the฀age฀of฀15฀years.฀In฀all฀but฀
one฀setting,฀anonymous฀reporting฀resulted฀in฀
substantially฀more฀reports฀of฀sexual฀abuse,฀and฀
large฀differences฀were฀recorded฀in฀Ethiopia฀
province฀(0.2%฀using฀direct฀reporting฀versus฀
7%฀anonymously),฀Japan฀city฀(10%฀versus฀14%),฀
Namibia฀city฀(5%฀versus฀21%),฀and฀the฀United฀
Republic฀of฀Tanzania฀city฀(4%฀versus฀11%).฀“Best฀
estimates”฀based฀on฀the฀method฀that฀yielded฀the฀
higher฀rate,฀indicate฀that฀prevalence฀of฀sexual฀
abuse฀before฀15฀years฀of฀age฀varied฀from฀1%฀
(Bangladesh฀province)฀to฀21%฀(Namibia฀city).฀
The฀most฀frequently฀mentioned฀perpetrators฀
were฀male฀family฀members฀other฀than฀a฀father฀
or฀stepfather.฀
Forced฀first฀sex
In฀10฀of฀the฀15฀settings,฀over฀5%฀of฀women฀
reported฀their฀first฀sexual฀experience฀as฀forced,฀
with฀more฀than฀14%฀reporting฀forced฀first฀sex฀
in฀Bangladesh,฀Ethiopia฀province,฀Peru฀province,฀
and฀the฀United฀Republic฀of฀Tanzania.฀In฀all฀sites฀
xv
Statistical฀appendix
Executive฀summary
except฀Ethiopia฀province,฀the฀younger฀a฀woman฀ more฀likely฀to฀have฀had฀problems฀walking฀and฀
at฀first฀experience฀of฀sex,฀the฀greater฀the฀ carrying฀out฀daily฀activities,฀pain,฀memory฀loss,฀
likelihood฀that฀this฀was฀forced.฀In฀more฀than฀half฀ dizziness,฀and฀vaginal฀discharge฀in฀the฀4฀weeks฀
the฀settings,฀over฀30%฀of฀women฀who฀reported฀ prior฀to฀the฀interview.฀An฀association฀between฀
first฀sex฀before฀the฀age฀of฀15฀years฀described฀ recent฀ill-health฀and฀lifetime฀experience฀of฀violence฀
that฀sexual฀experience฀as฀forced.฀In฀some฀ suggests฀that฀the฀physical฀effects฀of฀violence฀
countries฀(notably฀Bangladesh฀and฀Ethiopia฀ may฀last฀a฀long฀time฀after฀the฀actual฀violence฀has฀
province),฀high฀levels฀of฀forced฀first฀sex฀are฀likely฀ ended,฀or฀that฀violence฀over฀time฀may฀have฀a฀
to฀be฀related฀to฀early฀sexual฀initiation฀in฀the฀ cumulative฀effect.
context฀of฀early฀marriage,฀rather฀than฀being฀by฀
perpetrators฀other฀than฀partners. Mental฀health฀and฀suicide
In฀all฀settings,฀women฀who฀had฀ever฀experienced฀
physical฀or฀sexual฀violence,฀or฀both,฀by฀an฀
Violence฀by฀intimate฀partners฀and฀ intimate฀partner฀reported฀significantly฀higher฀
women’s฀health levels฀of฀emotional฀distress฀and฀were฀more฀
likely฀to฀have฀thought฀of฀suicide,฀and฀to฀have฀
Although฀a฀cross-sectional฀survey฀cannot฀ attempted฀suicide,฀than฀women฀who฀had฀never฀
establish฀whether฀violence฀causes฀particular฀ experienced฀partner฀violence.฀
health฀problems฀(with฀the฀obvious฀exception฀
of฀injuries),฀the฀Study฀results฀strongly฀support฀ Reproductive฀health฀and฀violence฀during฀
other฀research฀which฀has฀found฀clear฀associations฀ pregnancy
between฀partner฀violence฀and฀symptoms฀of฀ In฀the฀majority฀of฀settings,฀ever-pregnant฀
physical฀and฀mental฀ill-health. women฀who฀had฀experienced฀partner฀physical฀
or฀sexual฀violence,฀or฀both฀were฀significantly฀
Injury฀resulting฀from฀physical฀violence more฀likely฀to฀report฀having฀had฀at฀least฀one฀
The฀prevalence฀of฀injury฀among฀women฀who฀ induced฀abortion฀than฀women฀who฀had฀never฀
had฀ever฀been฀physically฀abused฀by฀their฀partner฀ experienced฀partner฀violence.฀Similar฀patterns฀
ranged฀from฀19%฀in฀Ethiopia฀province฀to฀55%฀ were฀found฀for฀miscarriage,฀but฀the฀strength฀of฀
in฀Peru฀province฀and฀was฀associated฀with฀the฀ the฀association฀was฀less.฀
severity฀of฀the฀violence.฀In฀Brazil,฀Peru฀province,฀ The฀proportion฀of฀ever-pregnant฀women฀
Samoa,฀Serbia฀and฀Montenegro฀city,฀and฀Thailand,฀ physically฀abused฀during฀at฀least฀one฀pregnancy฀
over฀20%฀of฀ever-injured฀women฀reported฀ exceeded฀5%฀in฀11฀of฀the฀15฀settings.฀Between฀
that฀they฀had฀been฀injured฀many฀times.฀At฀least฀ one฀quarter฀and฀one฀half฀of฀women฀physically฀
20%฀of฀ever-injured฀women฀in฀Namibia,฀Peru฀ abused฀in฀pregnancy฀were฀kicked฀or฀punched฀in฀
province,฀Samoa,฀Thailand฀city,฀and฀the฀United฀ the฀abdomen.฀In฀all฀sites,฀over฀90%฀were฀abused฀
Republic฀of฀Tanzania฀reported฀injuries฀to฀the฀ by฀the฀biological฀father฀of฀the฀child฀the฀woman฀
eyes฀and฀ears. was฀carrying.฀The฀majority฀of฀those฀beaten฀
during฀pregnancy฀had฀experienced฀physical฀
Physical฀health violence฀before,฀with฀between฀8%฀and฀34%฀
In฀the฀majority฀of฀settings,฀women฀who฀had฀ever฀ reporting฀that฀the฀violence฀got฀worse฀during฀
experienced฀partner฀violence฀were฀significantly฀ the฀pregnancy.฀However,฀from฀13%฀(Ethiopia฀
more฀likely฀to฀report฀poor฀or฀very฀poor฀health฀ province)฀to฀about฀50%฀(Brazil฀city฀and฀Serbia฀
than฀women฀who฀had฀never฀experienced฀ and฀Montenegro฀city)฀were฀beaten฀for฀the฀first฀
partner฀violence.฀Ever-abused฀women฀were฀also฀ time฀during฀pregnancy.
xvi
WHO฀Multi-country฀Study฀on฀Women’s฀Health฀and฀Domestic฀Violence
฀฀฀฀
Ris�฀of฀H�V฀and฀other฀sexually฀
transmitted฀infections
The฀WHO฀Study฀explored฀the฀extent฀to฀which฀
women฀knew฀whether฀or฀not฀their฀partner฀
had฀had฀other฀sexual฀partners฀during฀their฀
relationship.฀Across฀all฀sites฀except฀Ethiopia,฀a฀
woman฀who฀reported฀that฀her฀intimate฀partner฀
had฀been฀physically฀or฀sexually฀violent฀towards฀
her฀was฀significantly฀more฀likely฀to฀report฀that฀
she฀knew฀that฀her฀partner฀was฀or฀had฀been฀
sexually฀involved฀with฀other฀women฀while฀฀
being฀with฀her.฀
Women฀were฀also฀asked฀whether฀they฀
had฀ever฀used฀a฀condom฀with฀their฀partner,฀
whether฀they฀had฀requested฀use฀of฀condom,฀
and฀whether฀the฀request฀had฀been฀refused.฀฀
The฀proportion฀of฀women฀who฀had฀ever฀
used฀a฀condom฀with฀a฀current฀or฀most฀
recent฀partner฀varied฀greatly฀across฀sites.฀฀
No฀significant฀difference฀was฀found฀in฀use฀of฀
condoms฀between฀abused฀and฀non-abused฀
women,฀with฀the฀exception฀of฀Thailand฀฀
and฀the฀United฀Republic฀of฀Tanzania,฀where฀
women฀in฀a฀violent฀relationship฀were฀more฀
likely฀to฀have฀used฀condoms.฀However,฀in฀a฀
number฀of฀sites฀(cities฀in฀Peru,฀Namibia,฀and฀
the฀United฀Republic฀of฀Tanzania)฀women฀in฀
violent฀partnerships฀were฀more฀likely฀than฀
non-abused฀women฀to฀have฀asked฀their฀
partner฀to฀use฀condoms.฀Women฀in฀violent฀
partnerships฀in฀these฀sites,฀as฀well฀as฀in฀Brazil฀
city,฀Peru฀province,฀and฀Serbia฀and฀Montenegro,฀
were฀significantly฀more฀likely฀than฀non-abused฀
women฀to฀report฀that฀their฀partner฀had฀
refused฀to฀use฀a฀condom.฀These฀findings,฀as฀well฀
as฀the฀high฀levels฀of฀child฀sexual฀abuse,฀are฀of฀
concern฀in฀the฀transmission฀of฀HIV฀and฀other฀
STIs,฀and฀underline฀the฀urgent฀need฀to฀address฀
this฀hidden฀but฀widespread฀abuse฀against฀
women.฀
Women’s฀responses฀to฀physical฀violence฀
by฀an฀intimate฀partner
Who฀women฀talk฀to
In฀all฀countries,฀the฀interviewer฀was฀the฀first฀
person฀to฀whom฀many฀abused฀women฀had฀ever฀
talked฀about฀their฀partner’s฀physical฀violence.฀
Two฀thirds฀of฀women฀who฀had฀been฀physically฀
abused฀by฀their฀partner฀in฀Bangladesh,฀and฀about฀
one฀half฀in฀Samoa฀and฀Thailand฀province,฀said฀
they฀had฀not฀told฀anybody฀about฀the฀violence฀
prior฀to฀the฀interview.฀In฀contrast,฀about฀80%฀of฀
physically฀abused฀women฀in฀Brazil฀and฀Namibia฀
city฀had฀told฀someone,฀usually฀family฀or฀friends.฀
But฀this฀means฀that฀even฀in฀these฀settings,฀two฀
out฀of฀ten฀women฀had฀kept฀silent.฀Relatively฀few฀
women฀in฀any฀setting฀had฀told฀staff฀of฀formal฀
services฀or฀individuals฀in฀a฀position฀of฀authority฀
about฀the฀violence.฀
Which฀agencies฀or฀authorities฀women฀turn฀to
Over฀half฀of฀physically฀abused฀women฀
(between฀55%฀and฀95%)฀reported฀that฀they฀
had฀never฀sought฀help฀from฀formal฀services฀
(health฀services,฀legal฀advice,฀shelter)฀or฀
from฀people฀in฀positions฀of฀authority฀(police,฀
women’s฀nongovernmental฀organizations฀
(NGOs),฀local฀leaders,฀and฀religious฀leaders).฀
Only฀in฀Namibia฀city฀and฀Peru฀had฀more฀than฀
20%฀of฀women฀contacted฀the฀police,฀and฀only฀
in฀Namibia฀city฀and฀the฀United฀Republic฀of฀
Tanzania฀city฀had฀more฀than฀20%฀sought฀help฀
from฀health฀care฀services.
Low฀use฀of฀formal฀services฀reflects฀in฀฀
part฀their฀limited฀availability.฀However,฀even฀฀
in฀countries฀relatively฀well฀supplied฀with฀
resources฀for฀abused฀women,฀barriers฀such฀
as฀fear,฀stigma฀and฀the฀threat฀of฀losing฀their฀
children฀stopped฀many฀women฀from฀seeking฀
help.฀In฀all฀settings,฀the฀most฀frequently฀given฀
reasons฀for฀seeking฀help฀were฀related฀to฀the฀
severity฀of฀the฀violence,฀its฀impact฀on฀the฀
children,฀or฀encouragement฀from฀friends฀฀
and฀family฀to฀seek฀help.
Leaving฀or฀staying฀with฀a฀violent฀partner
Between฀19%฀and฀51%฀of฀women฀who฀had฀
been฀physically฀abused฀by฀their฀partner฀had฀ever฀
left฀home฀for฀at฀least฀one฀night.฀Between฀8%฀
and฀21%฀reported฀leaving฀2–5฀times.฀In฀most฀
settings,฀women฀mainly฀reported฀going฀to฀their฀
relatives,฀and฀to฀a฀lesser฀extent฀to฀friends฀or฀
neighbours.฀Shelters฀were฀mentioned฀only฀in฀
Brazil฀city฀and฀Namibia฀city฀(by฀less฀than฀1%฀of฀
women฀who฀left).฀Again,฀these฀patterns฀are฀likely฀
to฀reflect฀both฀the฀availability฀of฀places฀of฀safety฀
for฀women฀and฀their฀children,฀as฀well฀as฀culturally฀
specific฀factors฀relating฀to฀the฀acceptability฀of฀
women฀leaving฀or฀staying฀somewhere฀without฀
their฀partner.฀
Areas฀for฀further฀analysis
This฀first฀report฀provides฀descriptive฀
information฀on฀some฀of฀the฀main฀elements฀
addressed฀by฀the฀WHO฀Study.฀However,฀it฀
represents฀only฀the฀first฀stage฀of฀analysis฀of฀
an฀extensive฀database฀which฀has฀the฀potential฀
to฀address฀a฀range฀of฀important฀questions฀
regarding฀violence฀against฀women.฀Questions฀
that฀will฀be฀explored฀during฀the฀next฀stage฀
of฀analysis฀include฀risk฀profiles฀for฀violence฀
in฀terms฀of฀the฀timing฀and฀duration฀of฀the฀
relationship฀with฀the฀violent฀partner;฀risk฀and฀
protective฀factors฀for฀partner฀violence฀and฀
whether฀they฀are฀context-specific฀or฀spanning฀
all฀or฀most฀contexts;฀issues฀around฀definitions฀
and฀prevalence฀of฀emotional฀abuse;฀฀more฀
in-depth฀analysis฀of฀the฀relationship฀between฀
violence฀and฀health฀and฀of฀patterns฀of฀women’s฀
responses฀to฀violence;฀and฀the฀impact฀of฀
violence฀on฀other฀aspects฀of฀women’s฀lives,฀
including฀the฀effect฀on฀their฀children.฀These฀
questions฀are฀of฀great฀relevance฀to฀public฀
health,฀and฀exploring฀them฀will฀substantially฀
improve฀our฀understanding฀of฀the฀nature,฀
causes฀and฀consequences฀of฀violence,฀and฀the฀
best฀ways฀to฀intervene฀against฀it.฀
xvii
Statistical฀appendix
Executive฀summary
Recommendations
In฀keeping฀with฀their฀responsibility฀for฀the฀
well-being฀and฀safety฀of฀their฀citizens,฀national฀
governments,฀in฀collaboration฀with฀NGOs,฀donors฀
and฀international฀organizations,฀need฀to฀implement฀
the฀following฀recommendations.฀These฀are฀based฀
on฀the฀Study฀findings,฀and฀are฀grouped฀by฀theme.
Strengthening฀national฀commitment฀and฀action฀
1.฀ Promote฀gender฀equality฀and฀women’s฀
human฀rights,฀in฀line฀with฀relevant฀
international฀treaties฀and฀human฀rights฀
mechanisms,฀including฀addressing฀women’s฀
access฀to฀property฀and฀assets,฀and฀
expanding฀educational฀opportunities฀for฀฀
girls฀and฀young฀women.
2.฀ Establish,฀implement฀and฀monitor฀action฀
plans฀to฀address฀violence฀against฀women,฀
including฀violence฀by฀intimate฀partners.
3.฀ Enlist฀social,฀political,฀religious,฀and฀other฀
leaders฀in฀speaking฀out฀against฀violence฀
against฀women.
4.฀ Enhance฀capacity฀and฀establish฀systems฀for฀
data฀collection฀to฀monitor฀violence฀against฀
women,฀and฀the฀attitudes฀and฀beliefs฀that฀
perpetuate฀the฀practice.
Promoting฀primary฀prevention฀
5.฀ Develop,฀implement฀and฀monitor฀
programmes฀aimed฀at฀primary฀prevention฀
of฀intimate฀partner฀violence฀and฀sexual฀
violence฀against฀women.฀These฀should฀
include฀sustained฀public฀awareness฀activities฀
aimed฀at฀changing฀the฀attitudes,฀beliefs฀and฀
values฀that฀condone฀partner฀violence฀as฀
normal฀and฀prevent฀it฀being฀challenged฀or฀
talked฀about.฀
6.฀ Give฀higher฀priority฀to฀combating฀sexual฀
abuse฀of฀girls฀(and฀boys)฀in฀public฀health฀
programmes,฀as฀well฀as฀in฀responses฀by฀other฀
sectors฀such฀as฀the฀judiciary,฀education,฀and฀
social฀services.
xviii
WHO฀Multi-country฀Study฀on฀Women’s฀Health฀and฀Domestic฀Violence
฀฀฀฀
7.฀ Integrate฀responses฀to฀violence฀against฀women฀
into฀existing฀programmes฀for฀the฀prevention฀
of฀HIV฀and฀AIDS,฀and฀for฀the฀promotion฀
of฀adolescent฀health,฀including฀to฀promote฀
the฀prevention฀of฀sexual฀violence฀as฀well฀as฀
intimate-partner฀violence฀against฀women฀as฀
an฀integral฀part฀of฀these฀programmes.
8.฀ Make฀physical฀environments฀safer฀for฀฀
women,฀through฀measures฀such฀as฀identifying฀
places฀where฀violence฀often฀occurs,฀
improving฀lighting,฀and฀increasing฀police฀and฀
other฀vigilance.
Involving฀the฀education฀sector
9.฀ Make฀schools฀safe฀for฀girls,฀by฀involving฀
education฀systems฀in฀anti-violence฀efforts,฀
including฀eradicating฀teacher฀violence,฀as฀well฀
as฀engaging฀in฀broader฀anti-violence฀efforts.
Strengthening฀the฀health฀sector฀response
10.฀ Develop฀a฀comprehensive฀health฀sector฀
response฀to฀the฀various฀impacts฀of฀violence฀
against฀women,฀and฀in฀particular฀address฀
the฀barriers฀and฀stigma฀that฀prevent฀abused฀
women฀from฀seeking฀help.฀This฀includes฀
supporting฀mental฀health฀services฀to฀฀ Introduction
address฀violence฀against฀women฀as฀an฀
important฀underlying฀factor฀in฀women’s฀
mental฀health฀problems.
11.฀ Use฀reproductive฀health฀services฀as฀entry฀
points฀for฀identifying฀and฀supporting฀women฀
in฀abusive฀relationships,฀and฀for฀delivering฀
referral฀or฀support฀services.
Supporting฀women฀living฀with฀violence
12.฀ Strengthen฀formal฀and฀informal฀support฀
systems฀for฀women฀living฀with฀violence.฀
Sensitizing฀criminal฀justice฀systems
13.฀ Sensitize฀legal฀and฀justice฀systems฀to฀฀
the฀particular฀needs฀of฀women฀victims฀฀
of฀violence.
Supporting฀further฀research฀and฀collaboration฀
and฀increasing฀donor฀support
14.฀ Promote฀and฀support฀further฀research฀on฀the฀
causes฀and฀consequences฀of฀violence฀against฀
women฀and฀on฀effective฀prevention฀measures.
15.฀ Increase฀support฀to฀programmes฀to฀reduce฀
and฀respond฀to฀violence฀against฀women.฀
฀
 1
CHAPTER
This survey should have been conducted
10 years ago. Now I have two daughters. I hope they
will benefit from it.
Woman interviewed in Bangladesh
Thank you so much, I needed to talk to
someone. I have never told anyone what I told you,
but I would like that it happens more often that
someone comes to talk. There should be more
people who come to talk.
Woman interviewed in Peru
Introduction
Bac�ground฀to฀the฀Study
Until฀recently,฀most฀governments฀and฀฀
policy-makers฀viewed฀violence฀against฀women฀
as฀a฀relatively฀minor฀social฀problem฀affecting฀a฀
limited฀number฀of฀women.฀The฀general฀view฀was฀
that฀cases฀of฀violence฀could฀be฀appropriately฀
addressed฀through฀the฀social฀welfare฀and฀justice฀
systems.฀During฀the฀past฀decade,฀however,฀the฀
combined฀efforts฀of฀grass-roots฀and฀international฀
women’s฀organizations,฀international฀experts,฀
and฀committed฀governments฀have฀resulted฀in฀
a฀profound฀transformation฀in฀public฀awareness฀
regarding฀this฀issue฀(1).฀Violence฀against฀women,฀
also฀known฀as฀gender-based฀violence,฀is฀now฀
widely฀recognized฀as฀a฀serious฀human฀rights฀
abuse,฀and฀increasingly฀also฀as฀an฀important฀
public฀health฀problem฀that฀concerns฀all฀sectors฀฀
of฀society฀(2,฀3).฀
Recognition฀of฀violence฀as฀a฀health฀and฀
rights฀issue฀was฀underscored฀and฀strengthened฀
by฀agreements฀and฀declarations฀at฀key฀
international฀conferences฀during฀the฀1990s,฀
including฀the฀World฀Conference฀on฀Human฀
Rights฀(Vienna,฀1993)฀(4),฀the฀International฀
Conference฀on฀Population฀and฀Development฀
(Cairo,฀1994)฀(5)฀and฀the฀Fourth฀World฀
Conference฀on฀Women฀(Beijing,฀1995)฀(6).฀
Through฀these฀international฀agreements,฀
governments฀have฀increasingly฀recognized฀
the฀need฀to฀develop฀broad฀multisectoral฀
approaches฀for฀the฀prevention฀of฀and฀
response฀to฀violence฀against฀women,฀and฀have฀
committed฀themselves฀to฀implement฀฀
the฀institutional฀and฀legislative฀reforms฀
necessary฀to฀achieve฀this฀goal.฀Despite฀this฀
progress,฀many฀governments฀still฀do฀not฀
acknowledge฀the฀problem฀of฀violence฀฀
against฀women฀or฀take฀measures฀to฀prevent฀
and฀address฀it.฀While฀the฀many฀health฀
consequences฀of฀violence฀are฀also฀increasingly฀
recognized,฀the฀involvement฀of฀the฀health฀
sector฀in฀responding฀to฀the฀problem฀is฀still฀
inadequate฀in฀many฀countries.
Why฀did฀WHO฀embark฀on฀a฀study฀of฀violence฀
against฀women?
In฀1995,฀the฀Beijing฀Platform฀for฀Action฀฀
identified฀the฀lack฀of฀adequate฀information฀฀
on฀the฀prevalence,฀nature,฀causes,฀and฀
consequences฀of฀violence฀globally฀as฀a฀serious฀
obstacle฀to฀the฀development฀of฀effective฀
strategies฀to฀address฀violence.฀Governments฀
were฀urged฀to฀invest฀in฀research฀to฀improve฀
the฀relevant฀knowledge฀base฀on฀the฀prevalence,฀
causes,฀nature,฀and฀consequences฀of฀violence฀
against฀women฀(6,฀p.129a).
฀WHO’s฀work฀on฀gender-based฀violence฀
began฀in฀1996฀with฀the฀convening฀of฀an฀expert฀
consultation฀on฀violence฀against฀women.฀The฀
consultation฀brought฀together฀researchers,฀health฀
care฀providers฀and฀women’s฀health฀advocates฀
from฀several฀countries฀(7).฀The฀participants฀
agreed฀that฀there฀was฀a฀dearth฀of฀comparable฀
data,฀particularly฀from฀developing฀countries,฀that฀
many฀governments฀were฀reluctant฀to฀recognize฀
violence฀against฀women฀as฀a฀problem,฀and฀
that฀health฀was฀an฀important฀perspective฀from฀
which฀to฀address฀this฀issue.฀The฀consultation฀
recommended฀that฀WHO฀promote฀and฀support฀
international฀research฀to฀explore฀the฀dimensions,฀
health฀consequences฀and฀risk฀factors฀of฀violence฀
against฀women.฀In฀the฀same฀year,฀the฀World฀
Health฀Assembly฀declared฀the฀prevention฀of฀
violence,฀including฀violence฀against฀women฀and฀
children,฀to฀be฀a฀public฀health฀priority฀needing฀
urgent฀action.฀In฀response,฀in฀1997,฀WHO฀
initiated฀the฀development฀of฀the฀Multi-country฀
Study฀on฀Women’s฀Health฀and฀Domestic฀
Violence฀against฀Women฀(hereafter฀referred฀to฀
as฀the฀WHO฀Study฀or฀the฀Study)฀(8).
More฀recently,฀WHO฀published฀the฀World฀
report฀on฀violence฀and฀health฀(9),฀which฀included฀
a฀global฀overview฀of฀available฀information฀−฀
including฀prevalence฀data฀−฀on฀intimate฀partner฀
and฀sexual฀violence฀and฀their฀impact฀on฀the฀
health฀and฀well-being฀of฀women฀(Chapters฀
4฀and฀6).฀That฀report฀recognized฀the฀need฀
for฀sound฀and฀reliable฀information฀on฀the฀
 4 5
WHO฀Multi-country฀Study฀on฀Women’s฀Health฀and฀Domestic฀Violence
magnitude,฀the฀nature฀and฀the฀consequences฀
of฀violence,฀as฀an฀essential฀foundation฀for฀the฀
public฀health฀approach฀to฀violence,฀including฀
violence฀against฀women.฀This฀Study฀both฀
informed฀the฀WHO฀report฀and฀is฀an฀important฀
contribution฀to฀meeting฀the฀need฀for฀information฀
on฀violence,฀both฀nationally฀(in฀the฀countries฀
that฀participated)฀and฀globally.฀The฀results฀of฀
the฀Study฀will฀also฀feed฀into฀and฀inform฀WHO’s฀
Global฀Campaign฀on฀Violence฀Prevention,฀which฀
was฀launched฀in฀2002฀(for฀more฀information,฀see฀
http://www.who.int/violence_injury_prevention/
violence/global_campaign/en/).฀
฀ the฀forms฀of฀violence฀considered,฀the฀range฀of฀
�nternational฀research฀on฀prevalence฀of฀
violence฀against฀women
The฀Declaration฀on฀the฀Elimination฀of฀Violence฀
against฀Women฀adopted฀by฀the฀United฀Nations฀
General฀Assembly฀in฀1993฀defined฀violence฀
against฀women฀as฀“any฀act฀of฀gender-based฀
violence฀that฀results฀in,฀or฀is฀likely฀to฀result฀in,฀
physical,฀sexual฀or฀psychological฀harm฀or฀suffering฀
to฀women,฀including฀threats฀of฀such฀acts,฀coercion฀
or฀arbitrary฀deprivation฀of฀liberty,฀whether฀
occurring฀in฀public฀or฀in฀private฀life”฀(10).฀It฀goes฀
on฀to฀define฀the฀various฀forms฀that฀this฀violence฀
can฀take.฀Although฀intimate-partner฀violence฀
and฀sexual฀coercion฀are฀the฀most฀common฀and฀
“universal”฀types฀of฀violence฀affecting฀women฀and฀
girls,฀in฀many฀parts฀of฀the฀world฀violence฀takes฀
on฀special฀characteristics฀according฀to฀cultural฀
and฀historical฀conditions,฀and฀includes฀murders฀
in฀the฀name฀of฀honour฀(so-called฀“honour฀
killings”),฀trafficking฀of฀women฀and฀girls,฀female฀
genital฀mutilation,฀and฀violence฀against฀women฀in฀
situations฀of฀armed฀conflict.
International฀research฀conducted฀over฀the฀
past฀decade฀has฀provided฀increasing฀evidence฀
of฀the฀extent฀of฀violence฀against฀women,฀
particularly฀that฀perpetrated฀by฀intimate฀male฀
partners.฀The฀findings฀show฀that฀violence฀against฀
women฀is฀a฀much฀more฀serious฀and฀common฀
problem฀than฀previously฀suspected.฀A฀review฀
of฀over฀50฀population-based฀studies฀performed฀
in฀35฀countries฀prior฀to฀1999฀indicated฀that฀
between฀10%฀and฀52%฀of฀women฀around฀the฀
world฀report฀that฀they฀have฀been฀physically฀
abused฀by฀an฀intimate฀partner฀at฀some฀point฀in฀
their฀lives,฀and฀between฀10%฀and฀30%฀that฀they฀
have฀experienced฀sexual฀violence฀by฀an฀intimate฀
partner.฀Between฀10%฀and฀27%฀of฀women฀and฀
girls฀reported฀having฀been฀sexually฀abused,฀either฀
as฀children฀or฀as฀adults฀(9,฀11).
While฀these฀studies฀helped฀focus฀attention฀
on฀the฀issue,฀they฀also฀raised฀many฀questions฀
regarding฀the฀methods฀used฀to฀obtain฀estimates฀
of฀violence฀in฀different฀countries.฀There฀were฀
many฀differences฀in฀the฀way฀violence฀was฀defined,฀
measured฀and฀presented.฀For฀example,฀some฀
studies฀of฀partner฀violence฀include฀only฀physical฀
violence,฀while฀others฀may฀also฀include฀sexual฀or฀
emotional฀violence.฀Some฀studies฀measure฀lifetime฀
experiences฀of฀violence,฀whereas฀others฀include฀
only฀experiences฀in฀the฀current฀relationship,฀or฀
in฀a฀defined฀period.฀Studies฀also฀differ฀in฀other฀
important฀respects,฀such฀as฀the฀definition฀of฀the฀
study฀population฀(for฀example,฀฀in฀terms฀of฀the฀
age฀range฀and฀partnership฀status฀of฀the฀women),฀
questions฀asked,฀and฀whether฀measures฀were฀
taken฀to฀ensure฀privacy฀and฀confidentiality฀of฀
interviews.฀Such฀factors฀have฀since฀been฀shown฀to฀
greatly฀affect฀prevalence฀estimates฀by฀influencing฀
a฀woman’s฀willingness฀to฀disclose฀abuse฀(12,฀13).฀
These฀methodological฀differences฀between฀
studies฀have฀made฀it฀difficult฀to฀draw฀meaningful฀
comparisons฀or฀to฀understand฀the฀similarities฀and฀
differences฀in฀the฀extent,฀patterns,฀and฀factors฀
associated฀with฀violence฀in฀different฀settings฀(4).฀
In฀response฀to฀the฀methodological฀and฀
ethical฀challenges฀associated฀with฀research฀on฀
prevalence฀of฀gender-based฀violence฀in฀developing฀
countries,฀a฀group฀of฀researchers฀and฀advocates฀
from฀around฀the฀world฀came฀together฀in฀the฀
early฀1990s฀to฀form฀the฀International฀Research฀
Network฀on฀Violence฀against฀Women฀(IRNVAW).฀฀
The฀purpose฀of฀the฀network฀was฀to฀create฀a฀
forum฀for฀sharing฀insights฀and฀for฀addressing฀key฀
challenges฀faced฀by฀investigators฀interested฀in฀
gender-based฀violence,฀such฀as:฀how฀to฀ensure฀the฀
safety฀of฀respondents฀and฀researchers฀throughout฀
the฀research฀process,฀and฀how฀to฀define฀and฀
measure฀violence฀in฀a฀way฀that฀allowed฀results฀to฀
be฀compared฀across฀diverse฀cultural฀settings฀(14).฀
The฀design฀and฀implementation฀of฀the฀WHO฀
Study฀incorporated฀the฀recommendations฀of฀
IRNVAW.฀It฀also฀built฀on฀methodological฀work฀
and฀research฀on฀violence฀by฀partners,฀carried฀out฀
primarily฀in฀the฀United฀States฀using฀the฀Conflict฀
Tactics฀Scale฀(15,฀16),฀as฀well฀as฀critiques฀of฀this฀
methodology฀by฀other฀researchers฀(17).฀Since฀
the฀initiation฀of฀the฀WHO฀Study,฀a฀number฀of฀
other฀international฀research฀initiatives฀have฀also฀
used฀population-based฀surveys฀to฀estimate฀the฀
prevalence฀of฀different฀forms฀of฀violence฀against฀
women฀across฀countries฀and฀cultures.฀These฀
include:฀the฀World฀Surveys฀of฀Abuse฀in฀Family฀
Environments฀(WorldSafe)฀supported฀by฀the฀
International฀Clinical฀Epidemiology฀Network฀
(INCLEN)฀(18),฀and฀the฀International฀Violence฀
Against฀Women฀Survey฀(IVAWS)฀conducted฀
by฀the฀European฀Institute฀for฀Crime฀Prevention฀
and฀Control,฀affiliated฀with฀the฀United฀Nations฀
(HEUNI),฀the฀United฀Nations฀Interregional฀
Crime฀and฀Justice฀Research฀Institute฀(UNICRI)฀
and฀Statistics฀Canada.฀These฀studies฀provide฀
useful฀comparisons฀with฀aspects฀of฀the฀WHO฀
Study฀and,฀taken฀together,฀are฀beginning฀to฀give฀a฀
more฀comprehensive฀picture฀of฀violence฀against฀
women฀around฀the฀world.
In฀addition,฀the฀Demographic฀and฀Health฀
Surveys฀(DHS),฀supported฀by฀MACRO฀
International฀and฀the฀United฀States฀Agency฀
for฀International฀Development฀(USAID),฀and฀
the฀International฀Reproductive฀Health฀Surveys฀
(IRHS),฀supported฀by฀the฀United฀States฀Centers฀
for฀Disease฀Control฀and฀Prevention฀(CDC),฀
now฀contain฀a฀number฀of฀questions฀or฀a฀module฀
on฀violence฀against฀women฀as฀part฀of฀broader฀
household฀surveys฀on฀a฀range฀of฀health฀issues฀
(19).฀These฀surveys฀offer฀the฀advantages฀of฀
large฀sample฀size,฀efficiency฀of฀data฀collection,฀
standardization฀of฀measurement฀instruments฀
and฀the฀possibility฀of฀being฀generalized฀to฀the฀
national฀population.฀It฀has฀been฀shown,฀however,฀
that฀focused฀studies฀on฀violence฀against฀women฀
tend฀to฀give฀higher฀prevalence฀estimates฀than฀
larger฀health฀or฀other฀surveys฀which฀include฀
only฀one฀or฀a฀small฀number฀of฀questions฀on฀
violence฀(13).฀As฀a฀result,฀the฀DHS฀have฀moved฀
away฀from฀single฀or฀limited฀questions฀to฀use฀of฀
a฀full฀violence฀module฀in฀countries฀that฀wish฀to฀
explore฀this฀issue.฀The฀module฀was฀developed฀
on฀the฀basis฀of฀an฀early฀draft฀of฀the฀WHO฀
Study฀protocol฀and฀so฀provides฀opportunities฀
for฀expanding฀the฀database฀of฀comparable฀data.฀
Furthermore,฀DHS฀now฀recommend฀the฀use฀
of฀the฀WHO฀ethical฀and฀safety฀guidelines฀when฀
applying฀the฀violence฀module.฀This฀is฀important,฀
as฀the฀safety฀of฀respondents฀and฀interviewers฀
is฀an฀important฀concern฀when฀questions฀about฀
violence฀are฀included฀in฀the฀context฀of฀larger฀
surveys฀on฀other฀issues.
The฀1990s฀also฀saw฀rapid฀growth฀in฀the฀
number฀of฀studies฀exploring฀the฀potential฀
health฀consequences฀of฀violence,฀particularly฀
in฀the฀United฀States฀and฀other฀industrialized฀
countries.฀For฀years,฀clinicians฀and฀policy-makers฀
had฀focused฀on฀injury฀as฀the฀primary฀health฀
outcome฀of฀violence฀–฀if฀they฀considered฀health฀
outcomes฀at฀all.฀Then,฀research฀began฀to฀draw฀
attention฀to฀a฀range฀of฀other฀health-related฀
conditions฀associated฀with฀intimate-partner฀
violence฀and฀sexual฀abuse฀of฀women,฀such฀
as฀chronic฀pain฀syndromes,฀drug฀and฀alcohol฀
abuse,฀complications฀of฀pregnancy,฀increased฀
risk฀of฀unwanted฀pregnancy฀and฀sexually฀
transmitted฀infections,฀mental฀health฀problems,฀
gynaecological฀problems,฀and฀decreased฀
Chapter฀1฀฀Introduction
physical฀functioning฀(20–23).These฀studies฀
suggested฀that,฀in฀addition฀to฀causing฀injury฀and฀
other฀immediate฀sequelae,฀violence฀increased฀
women’s฀risk฀of฀future฀ill-health.฀Awareness฀of฀
this฀is฀causing฀a฀significant฀shift฀in฀the฀way฀health฀
professionals฀conceptualize฀violence.฀Rather฀
than฀being฀seen฀as฀just฀a฀health฀problem฀in฀and฀
of฀itself,฀violence฀can฀also฀be฀understood฀as฀a฀
risk฀factor฀that฀–฀like฀smoking฀or฀unsafe฀sex฀–฀฀
increases฀women’s฀risk฀of฀a฀variety฀of฀diseases฀
and฀conditions฀(24,฀25).
During฀the฀1990s,฀researchers฀and฀
practitioners฀also฀began฀exploring฀patterns฀of฀
violence฀in฀different฀settings.฀Data฀increasingly฀
suggested฀that฀the฀level฀of฀partner฀violence฀
against฀women฀varied฀substantially,฀both฀between฀
and฀within฀countries฀(26).฀This฀raised฀the฀
question฀of฀what฀combination฀of฀factors฀could฀
best฀explain฀the฀variation.฀What฀insights฀could฀
be฀gained฀from฀this฀analysis฀that฀would฀advance฀
violence฀theory฀and฀intervention?฀฀
Increasingly,฀researchers฀and฀practitioners฀
–฀as฀well฀as฀WHO฀–฀are฀using฀an฀“ecological฀
framework”฀to฀understand฀the฀interplay฀of฀
personal,฀situational,฀and฀sociocultural฀factors฀
that฀combine฀to฀cause฀interpersonal฀violence฀
(9,฀27).฀Introduced฀in฀the฀late฀1970s,฀the฀
ecological฀model฀was฀first฀applied฀to฀child฀abuse฀
(28,฀29),฀and฀subsequently฀to฀youth฀violence฀
(30,฀31).฀More฀recently,฀it฀has฀been฀used฀to฀
understand฀intimate฀partner฀violence฀(32)฀and฀
abuse฀of฀the฀elderly฀(33,฀34).฀In฀the฀ecological฀
model,฀interpersonal฀violence฀results฀from฀the฀
interaction฀of฀factors฀at฀different฀levels฀of฀the฀
social฀environment.฀
The฀model฀can฀best฀be฀conceptualized฀as฀
four฀nested฀circles฀(Figure฀1.1).฀The฀innermost฀
circle฀represents฀the฀biological฀and฀personal฀
history฀that฀each฀individual฀brings฀to฀his฀or฀her฀
behaviour฀in฀relationships.฀The฀second฀circle฀
represents฀the฀immediate฀context฀in฀which฀
violence฀takes฀place฀–฀frequently฀the฀family฀or฀
other฀intimate฀or฀acquaintance฀relationship.฀The฀
third฀circle฀represents฀the฀institutions฀and฀social฀
structures,฀both฀formal฀and฀informal,฀in฀which฀
relationships฀are฀embedded฀–฀neighbourhood,฀
workplace,฀social฀networks,฀and฀peer฀groups.฀The฀
fourth,฀outermost฀circle฀is฀the฀economic฀and฀
social฀environment,฀including฀cultural฀norms.
The฀WHO฀Study฀incorporates฀an฀ecological฀
model฀for฀understanding฀partner฀violence฀by฀
including,฀at฀each฀level฀of฀the฀social฀ecology,฀
variables฀hypothesized฀to฀increase฀or฀decrease฀a฀
woman’s฀risk฀of฀partner฀violence.
Analyses฀at฀national฀and฀international฀
level฀comparing฀settings฀with฀high฀and฀low฀
prevalence฀of฀partner฀violence฀provide฀an฀
 6
WHO฀Multi-country฀Study฀on฀Women’s฀Health฀and฀Domestic฀Violence฀฀
Figure฀1.1 Ecological฀model฀for฀understanding฀violence
Society Community
Source:฀฀Reproduced฀from฀reference฀9.
opportunity฀to฀identify฀potential฀individual,฀
community฀and฀societal฀factors฀associated฀with฀
its฀occurrence.฀Comparative฀analysis฀could฀
be฀used฀to฀test฀whether฀there฀are฀identifiable฀
risk฀factors฀within฀the฀immediate฀and฀larger฀
community฀that฀could฀possibly฀be฀reduced฀
through฀community฀activities.
To฀date,฀the฀lack฀of฀comparability฀among฀
studies฀has฀made฀this฀type฀of฀analysis฀difficult,฀
if฀not฀impossible.฀To฀explore฀potential฀risk฀and฀
protective฀factors฀with฀any฀rigour฀requires฀
a฀study฀that฀minimizes฀all฀methodologically฀
induced฀variation฀among฀sites.฀Although฀there฀
will฀always฀be฀sources฀of฀variation฀that฀cannot฀
be฀fully฀controlled฀(such฀as฀cultural฀variation฀in฀
women’s฀willingness฀to฀disclose฀violence),฀the฀
WHO฀Study฀included฀a฀variety฀of฀measures฀
designed฀to฀maximize฀the฀comparability฀of฀data฀
across฀sites฀(see฀Annex฀1).
In฀future฀analyses,฀the฀data฀from฀this฀study฀
will฀be฀used฀to฀explore฀individual,฀household,฀
and฀community฀risk฀and฀protective฀factors฀
in฀greater฀depth.฀Greater฀insights฀into฀the฀
situations฀and฀contexts฀in฀which฀violence฀฀
does฀and฀does฀not฀occur฀will฀be฀sought฀฀
through฀multivariate฀and฀multilevel฀analysis฀
of฀possible฀combinations฀of฀factors฀acting฀at฀
different฀levels฀(35,฀36).
Clearly,฀if฀the฀potentially฀modifiable฀risk฀
factors฀–฀and฀potentially฀protective฀factors฀
–฀could฀be฀identified,฀this฀would฀have฀important฀
implications฀for฀the฀development฀of฀preventive฀
interventions฀both฀locally฀and฀internationally.
Study฀objectives฀
The฀WHO฀Multi-country฀Study฀on฀Women’s฀
Health฀and฀Domestic฀Violence฀against฀Women฀
was฀designed฀to฀address฀some฀of฀the฀major฀
Relationship �ndividual
gaps฀in฀the฀international฀literature฀on฀violence฀
against฀women,฀especially฀related฀to฀intimate-
partner฀violence฀in฀developing฀country฀settings฀
and฀its฀impact฀on฀women’s฀health.฀It฀attempted฀
to฀overcome฀the฀obstacles฀to฀comparability฀
encountered฀in฀previous฀studies฀by฀carrying฀out฀
population-based฀surveys฀using฀a฀standardized฀
questionnaire,฀with฀standardized฀training฀and฀
procedures฀across฀sites.
฀ The฀WHO฀Study’s฀objectives฀were฀as฀follows:
•฀ to฀obtain฀valid฀estimates฀of฀the฀prevalence฀
and฀frequency฀of฀different฀forms฀of฀physical,฀
sexual฀and฀emotional฀violence฀against฀
women,฀with฀particular฀emphasis฀on฀violence฀
perpetrated฀by฀intimate฀male฀partners;
•฀ to฀assess฀the฀extent฀to฀which฀violence฀by฀
intimate฀partners฀is฀associated฀with฀a฀range฀
of฀health฀outcomes;
•฀ to฀identify฀factors฀that฀may฀protect฀or฀put฀
women฀at฀risk฀for฀intimate-partner฀violence;฀
•฀ to฀document฀and฀compare฀the฀strategies฀and฀
services฀that฀women฀use฀to฀deal฀with฀the฀
violence฀they฀experience.
The฀study฀aimed฀to฀provide฀a฀strong฀฀
evidence฀base฀for฀informing฀policy฀and฀
action฀at฀the฀national฀and฀international฀level.฀
Additional฀goals฀included:฀developing฀and฀
testing฀new฀instruments฀for฀measuring฀violence฀
cross-culturally;฀increasing฀national฀capacity฀
and฀collaboration฀among฀researchers฀and฀
women’s฀organizations฀working฀on฀violence;฀
and฀increasing฀sensitivity฀to฀violence฀among฀
researchers,฀policy-makers฀and฀health฀care฀
providers.฀To฀achieve฀these฀goals,฀WHO฀adopted฀
an฀action-oriented฀model฀of฀research฀that฀
encouraged฀the฀active฀engagement฀of฀women’s฀
organizations฀with฀expertise฀on฀violence฀against฀
women.฀The฀model฀also฀gave฀priority฀to฀ensuring฀
women’s฀safety฀and฀well-being.฀
This฀first฀report฀describes฀the฀findings฀฀
related฀to฀three฀of฀the฀four฀study฀objectives:฀to฀
assess฀prevalence,฀determine฀health฀outcomes,฀
and฀document฀women’s฀coping฀strategies.฀
Analysis฀of฀risk฀and฀protective฀factors฀for฀
violence฀will฀be฀addressed฀in฀a฀future฀report.฀
More฀in-depth฀multivariate฀and฀multilevel฀analysis฀
of฀study฀outcomes฀will฀be฀explored฀in฀individual฀
papers฀to฀be฀submitted฀for฀publication฀in฀the฀
peer-reviewed฀scientific฀literature.
The฀original฀plan฀for฀the฀WHO฀Study฀
included฀a฀survey฀of฀men.฀However฀this฀was฀not฀
implemented฀(see฀Box฀1.1).
Box฀1.1 Studying฀men
The฀original฀plan฀for฀the฀WHO฀Study฀included฀
interviews฀with฀a฀subpopulation฀of฀men฀about฀
their฀experiences฀and฀perpetration฀of฀violence,฀
including฀partner฀violence.฀This฀would฀have฀
allowed฀researchers฀to฀compare฀men’s฀and฀
women’s฀accounts฀of฀violence฀in฀intimate฀
relationships฀and฀would฀have฀yielded฀data฀
to฀investigate฀the฀extent฀to฀which฀men฀are฀
physically฀or฀sexually฀abused฀by฀their฀female฀
partners.฀On฀the฀advice฀of฀the฀Study฀Steering฀
Committee,฀it฀was฀decided฀to฀include฀men฀only฀
in฀the฀qualitative,฀formative฀component฀of฀the฀
study฀and฀not฀in฀the฀quantitative฀survey.฀
฀ This฀decision฀was฀taken฀for฀two฀reasons.฀
First,฀it฀was฀considered฀unsafe฀to฀interview฀men฀
and฀women฀in฀the฀same฀household,฀because฀
this฀could฀have฀potentially฀put฀a฀woman฀at฀risk฀
of฀future฀violence฀by฀alerting฀her฀partner฀to฀the฀
nature฀of฀the฀questions.฀Second,฀to฀carry฀out฀
an฀equivalent฀number฀of฀interviews฀in฀separate฀
households฀was฀deemed฀too฀expensive.฀
฀ Nevertheless,฀it฀is฀recognized฀that฀men’s฀
experiences฀of฀partner฀violence,฀as฀well฀as฀
the฀reasons฀why฀men฀perpetrate฀violence฀
against฀women,฀need฀to฀be฀explored฀in฀future฀
research.฀Extreme฀caution฀should฀be฀used฀
in฀any฀study฀of฀partner฀violence฀that฀seeks฀
to฀compile฀prevalence฀data฀on฀men฀as฀well฀
as฀women฀at฀the฀same฀time฀because฀of฀the฀
potential฀safety฀implications.
Organization฀of฀the฀Study
The฀study฀was฀implemented฀by฀WHO฀
through฀a฀core฀research฀team฀made฀up฀of฀
international฀experts฀from฀WHO฀(including฀
the฀study฀coordinator),฀the฀London฀School฀
of฀Hygiene฀and฀Tropical฀Medicine,฀and฀the฀
Program฀for฀Appropriate฀Technology฀in฀Health฀
in฀Washington,฀DC฀(see฀Annex฀2฀for฀a฀list฀of฀
participants฀in฀the฀core฀research฀team).฀This฀
core฀research฀team฀had฀overall฀responsibility฀
7
Chapter฀1฀฀Introduction
for฀designing฀the฀study,฀and฀supporting฀its฀
implementation฀and฀analysis.฀WHO฀also฀
established฀an฀expert฀steering฀committee฀that฀
included฀internationally฀known฀epidemiologists,฀
advocates฀and฀researchers฀on฀violence฀against฀
women,฀from฀different฀regions฀of฀the฀world.฀
This฀steering฀committee฀provided฀technical฀
and฀scientific฀oversight฀to฀the฀study,฀and฀met฀
periodically฀to฀review฀the฀progress฀and฀outputs฀
of฀the฀study฀(see฀Annex฀2฀for฀a฀list฀of฀members฀
of฀the฀steering฀committee).
Within฀each฀participating฀country,฀a฀
collaborative฀research฀team฀was฀established฀to฀
implement฀the฀study.฀This฀generally฀consisted฀
of฀representatives฀of฀research฀organizations฀
experienced฀in฀conducting฀survey฀research,฀
a฀women’s฀organization฀with฀experience฀of฀
providing฀services฀to฀women฀experiencing฀
violence฀and,฀in฀some฀places,฀government฀and฀
national฀statistics฀offices฀(see฀Annex฀3฀for฀a฀list฀of฀
country฀participants).
Each฀country฀research฀team฀also฀
established฀an฀advisory฀group฀to฀support฀the฀
implementation฀of฀the฀study฀and฀ensure฀the฀
dissemination฀of฀the฀results.฀The฀membership฀
of฀the฀groups฀differed฀between฀countries,฀
but฀generally฀included฀key฀decision-makers,฀
representatives฀of฀women’s฀organizations฀and฀
researchers.฀The฀study฀also฀aimed฀to฀ensure฀that฀
representatives฀from฀relevant฀divisions฀within฀the฀
ministry฀of฀health฀and฀other฀concerned฀ministries฀
or฀bodies฀were฀included.฀Where฀possible,฀
existing฀multisectoral฀committees฀on฀violence฀
against฀women฀formed฀the฀core฀membership฀
of฀the฀advisory฀group.฀Members฀of฀the฀country฀
research฀teams฀met฀regularly฀with฀the฀advisory฀
group฀to฀review฀progress฀and฀to฀discuss฀
emerging฀issues.฀
Participating฀countries
Participating฀countries฀were฀identified,฀following฀
discussions฀with฀the฀WHO฀regional฀offices,฀on฀
the฀basis฀of฀the฀following฀criteria:
• ฀ presence฀of฀local฀women’s฀groups฀working฀
on฀violence฀against฀women฀that฀could฀฀
use฀the฀data฀generated฀for฀advocacy฀and฀
policy฀reform;
• ฀ absence฀of฀existing฀population-based฀data฀on฀
violence฀against฀women;
• ฀ presence฀of฀strong฀potential฀partner฀
organizations฀known฀to฀WHO;฀
• ฀ a฀political฀environment฀receptive฀to฀taking฀up฀
the฀issue;
• ฀ absence฀of฀recent฀war-related฀conflict;
• ฀ representation฀of฀the฀different฀WHO฀regions.
 8
WHO฀Multi-country฀Study฀on฀Women’s฀Health฀and฀Domestic฀Violence฀฀
1฀The฀data฀set฀from฀New฀
Zealand฀was฀not฀available฀when฀
this฀report฀was฀being฀prepared.฀
However,฀the฀first฀results฀from฀
New฀Zealand฀have฀recently฀
been฀published฀(37).
The฀first฀countries฀selected฀were:฀
Bangladesh,฀Brazil,฀Japan,฀Namibia,฀Peru,฀Samoa,฀
Thailand,฀and฀the฀United฀Republic฀of฀Tanzania.฀A฀
second฀group฀of฀countries฀later฀replicated฀the฀
study:฀Ethiopia,฀New฀Zealand,฀and฀Serbia฀and฀
Montenegro.฀Other฀countries,฀including฀Chile,฀
China,฀Indonesia,฀and฀Viet฀Nam,฀have฀adapted฀or฀
used฀parts฀of฀the฀study฀questionnaire.
This฀first฀report฀presents฀the฀findings฀from฀
the฀countries฀that฀participated฀in฀the฀first฀round฀
Box฀1.2 Preliminary฀impact฀of฀the฀WHO฀Multi-country฀Study฀on฀Women’s฀Health฀and฀
Domestic฀Violence฀against฀Women
Even฀before฀the฀data฀were฀available,฀the฀WHO฀
Study฀brought฀about฀several฀positive฀changes฀at฀
different฀levels.฀
• ฀The฀WHO฀Study฀contributed฀to฀increased฀
awareness฀among฀researchers,฀interviewers฀and฀
others฀involved฀in฀doing฀the฀research,฀as฀well฀as฀
among฀the฀women฀interviewed.฀Most฀importantly,฀a฀
pool฀of฀over฀500฀trained฀interviewers,฀researchers฀
and฀other฀staff฀have฀been฀sensitized฀to฀the฀problem฀
of฀violence฀against฀women฀and฀have฀acquired฀
understanding฀and฀skills฀to฀investigate฀it.฀A฀large฀
number฀of฀the฀female฀staff฀have฀reported฀making฀
major฀changes฀in฀their฀personal฀or฀professional฀lives฀
as฀a฀result฀of฀their฀involvement฀in฀the฀Study.฀Many฀of฀
those฀involved฀in฀the฀Study,฀both฀men฀and฀women,฀
continue฀to฀be฀actively฀engaged฀in฀working฀to฀
address฀violence฀against฀women฀in฀their฀countries.
• ฀The฀WHO฀Study฀contributed฀to฀the฀inclusion฀
of฀violence฀by฀intimate฀partners฀in฀several฀
policies฀and฀educational฀programmes฀of฀the฀
partner฀universities฀and฀ministries฀of฀health.฀In฀
Peru,฀for฀example,฀violence฀against฀women฀has฀
Figure฀1.2 Countries฀participating฀in฀the฀WHO฀Multi-country฀Study฀on฀Women’s฀Health฀
and฀Domestic฀Violence฀against฀Women
Countries฀in฀first฀round
Countries฀in฀second฀round
Brazil
Samoa Peru
Namibia
of฀the฀study,฀conducted฀between฀2000฀and฀
2003฀–฀Bangladesh,฀Brazil,฀Japan,฀Namibia,฀Peru,฀
Samoa,฀Thailand,฀and฀the฀United฀Republic฀of฀
Tanzania฀–฀as฀well฀as฀from฀two฀countries฀that฀
participated฀in฀the฀second฀round฀–฀Ethiopia฀
and฀Serbia฀and฀Montenegro.1฀In฀combination,฀
the฀results฀provide฀evidence฀of฀the฀extent฀of฀
physical฀and฀sexual฀violence฀from฀15฀sites฀in฀
10฀geographically,฀culturally฀and฀economically฀
diverse฀countries฀(Figure฀1.2).฀
been฀incorporated฀into฀the฀Masters฀course฀
on฀reproductive฀health฀and฀sexuality฀in฀the฀
Faculty฀of฀Public฀Health฀of฀the฀Cayetano฀
Heredia฀University฀and฀has฀been฀discussed฀with฀
local฀community฀leaders฀in฀the฀provincial฀site.฀
In฀Brazil,฀medical฀and฀social฀science฀students฀
were฀involved฀in฀the฀study,฀and฀violence฀against฀
women฀has฀been฀included฀in฀postgraduate฀
training฀at฀the฀University฀of฀São฀Paulo.฀
• ฀The฀WHO฀Study฀prompted฀further฀research.฀
For฀example:฀one฀of฀the฀researchers฀in฀Peru฀is฀
now฀doing฀a฀study฀on฀men฀and฀violence฀against฀
women;฀researchers฀in฀Brazil฀have฀done฀a฀study฀
on฀women฀attending฀health฀centres฀in฀São฀Paulo,฀
using฀the฀same฀instrument฀as฀in฀the฀WHO฀Study;฀
researchers฀in฀Thailand฀and฀the฀United฀Republic฀
of฀Tanzania฀report฀using฀the฀ethical฀and฀safety฀
guidelines฀for฀research฀on฀other฀issues.฀
• ฀At฀the฀grass-roots฀level,฀networks฀of฀service฀
providers฀have฀been฀established฀or฀identified,฀
and฀information฀on฀local฀organizations฀has฀been฀
compiled฀and฀distributed฀widely.
Serbia฀and฀Montenegro
Japan
Thailand
Ethiopia
Bangladesh
United฀Republic
of฀Tanzania
New฀Zealand
In฀each฀country,฀the฀findings฀from฀the฀national฀
analysis฀have฀already฀been฀written฀up฀as฀a฀country฀
report,฀and฀disseminated฀at฀the฀local฀and฀national฀
level฀in฀a฀variety฀of฀ways.฀The฀dissemination฀
activities฀were฀coordinated฀by฀the฀country฀
research฀teams,฀and฀drew฀on฀the฀experience฀
and฀resources฀made฀available฀by฀each฀country’s฀
advisory฀group฀and฀WHO.฀Where฀possible,฀
the฀findings฀are฀being฀fed฀into฀advocacy฀and฀
intervention฀activities฀concerned฀with฀violence฀
against฀women฀–฀such฀as฀the฀16฀days฀of฀action฀
against฀violence฀against฀women฀in฀Namibia,฀the฀
development฀of฀the฀national฀plan฀of฀action฀for฀
the฀elimination฀of฀violence฀against฀women฀and฀
children฀in฀Thailand,฀and฀the฀development฀of฀the฀
national฀policy฀and฀plan฀of฀action฀for฀violence฀
prevention฀in฀Brazil.฀In฀addition,฀the฀study฀has฀
already฀resulted฀in฀various฀important฀changes฀
(Box฀1.2).฀WHO฀country฀offices฀and฀relevant฀
ministries,฀together฀with฀the฀researchers,฀are฀
helping฀to฀disseminate฀the฀findings฀to฀different฀
sectors,฀and฀to฀the฀donor฀community.
References
1.฀ Heise฀L.฀Violence฀against฀women:฀global฀organizing฀
for฀change.฀In:฀Edleson฀JL,฀Eisikovits฀ZC,฀eds.฀Future฀
interventions฀with฀battered฀women฀and฀their฀families.฀
Thousand฀Oaks,฀CA,฀Sage฀Publications,฀1996:7–33.
2.฀ Joachim฀J.฀Shaping฀the฀human฀rights฀agenda:฀the฀case฀
of฀violence฀against฀women.฀In:฀Meyer฀MK,฀Prugl฀E,฀eds.฀
Gender฀politics฀in฀global฀governance.฀Lanham,฀MD,฀
Rowman฀and฀Littlefield฀Publishers฀Inc.,฀2000:142–160.
3.฀ Mayhew฀S,฀฀Watts฀C.฀Global฀rhetoric฀and฀individual฀
realities:฀linking฀violence฀against฀women฀and฀
reproductive฀health.฀In:฀Lee฀K,฀Buse฀K,฀Fustukian฀S,฀
eds.฀Health฀policy฀in฀a฀globalising฀world.฀Cambridge,฀
Cambridge฀University฀Press,฀2002:159–180.
4.฀ Vienna฀Declaration฀and฀Programme฀of฀Action.฀
Adopted฀by฀the฀World฀Conference฀on฀Human฀Rights,฀
Vienna,฀14–25฀June฀1993.฀New฀York,฀NY,฀United฀
Nations,฀1993฀(document฀A/CONF.157/23).
5.฀ International฀Conference฀on฀Population฀and฀
Development฀(ICPD),฀Cairo,฀Egypt,฀5–13฀September฀
1994.฀New฀York,฀NY,฀United฀Nations,฀1994฀
(document฀A/CONF.171/13).
6.฀ The฀Fourth฀World฀Conference฀on฀Women,฀Beijing,฀
China,฀4–15฀September฀1995.฀New฀York,฀NY,฀United฀
Nations,฀1995฀(document฀A/CONF.177/20).
7.฀ Violence฀against฀women:฀WHO฀Consultation,฀
Geneva,฀5–7฀February฀1996.฀Geneva,฀World฀Health฀
Organization,฀1996฀(document฀FRH/WHD/96.27,฀
available฀at:฀http://whqlibdoc.who.int/hq/1996/FRH_
WHD_96.27.pdf,฀accessed฀18฀March฀2005).฀
8.฀ WHO฀Multi-country฀Study฀on฀Women’s฀Health฀and฀
Domestic฀Violence฀against฀Women:฀study฀protocol.฀
9
Chapter฀1฀฀Introduction
Geneva,฀World฀Health฀Organization,฀2004.฀
9.฀ Krug฀EG฀et฀al.฀eds.฀World฀report฀on฀violence฀and฀
health.฀Geneva,฀World฀Health฀Organization,฀2002.฀
10.฀ Declaration฀on฀the฀elimination฀of฀violence฀against฀
women.฀New฀York,฀NY,฀United฀Nations,฀1993฀(United฀
Nations฀General฀Assembly฀resolution,฀document฀
A/RES/48/104).
11.฀ Heise฀L,฀Ellsberg฀M,฀Gottemoeller฀M.฀Ending฀
violence฀against฀women.฀Baltimore,฀MD,฀Johns฀
Hopkins฀University฀Press,฀1999.
12.฀ Koss฀MP.฀Detecting฀the฀scope฀of฀rape:฀a฀review฀of฀
prevalence฀research฀methods.฀Journal฀of฀Interpersonal฀
Violence,฀1993,฀8:198–222.
13.฀ Ellsberg฀M฀et฀al.฀Researching฀domestic฀violence฀against฀
women:฀methodological฀and฀ethical฀considerations.฀
Studies฀in฀Family฀Planning,฀2001,฀32:1–16.
14.฀ Measuring฀violence฀against฀women฀cross-culturally:฀
notes฀from฀a฀meeting.฀Takoma฀Park,฀MD,฀Health฀and฀
Development฀Policy฀Project,฀1995.
15.฀ Straus฀MA.฀Measuring฀intrafamily฀conflict฀and฀
violence:฀the฀Conflict฀Tactics฀Scale฀(CTS).฀Journal฀of฀
Marriage฀and฀the฀Family,฀1979,฀41:75–88.฀
16.฀ Straus฀MA฀et฀al.฀The฀revised฀Conflict฀Tactics฀Scale฀
(CTS2).฀Journal฀of฀Family฀Issues,฀1996,฀17:283–316.฀
17.฀ Dobash฀RE,฀Dobash฀RD.฀The฀myth฀of฀sexual฀
symmetry฀in฀marital฀violence.฀Social฀Problems,฀1992,฀
39:71–91.
18.฀ Hassan฀F฀et฀al.฀Physical฀intimate฀partner฀violence฀in฀
Chile,฀Egypt,฀India฀and฀the฀Philippines.฀Injury฀Control฀
and฀Safety฀Promotion,฀2004,฀11:111–116.
19.฀ Kishor฀S,฀Johnson฀K.฀Domestic฀violence฀in฀nine฀
developing฀countries:฀a฀comparative฀study.฀Calverton,฀
MD,฀MACRO฀International,฀2004.
20.฀ Campbell฀J฀et฀al.฀Intimate฀partner฀violence฀and฀
physical฀health฀consequences.฀Archives฀of฀Internal฀
Medicine,฀2002,฀162:1157–1163.
21.฀ Gazmararian฀JA฀et฀al.฀The฀relationship฀between฀
pregnancy฀intendedness฀and฀physical฀violence฀in฀
mothers฀of฀newborns.฀The฀PRAMS฀Working฀Group.฀
Obstetrics฀and฀Gynecology,฀1995,฀85:1031–1038.
22.฀ Golding฀J.฀Sexual฀assault฀history฀and฀women’s฀
reproductive฀and฀sexual฀health.฀Psychology฀of฀Women฀
Quarterly,฀1996,฀20:101–121.
23.฀ Murphy฀CC฀et฀al.฀Abuse:฀a฀risk฀factor฀for฀low฀birth฀
weight?฀A฀systematic฀review฀and฀meta-analysis.฀Canadian฀
Medical฀Association฀Journal,฀2001,฀164:1567–1572.
24.฀ Campbell฀JC.฀Health฀consequences฀of฀intimate฀
partner฀violence.฀Lancet,฀2002,฀359:1331–1336.
25.฀ Counts฀D,฀Brown฀JK,฀Campbell฀JC,฀eds.฀To฀have฀
and฀to฀hit,฀2nd฀ed.฀Chicago,฀IL,฀University฀of฀Chicago฀
Press,฀1999.
26.฀ Levinson฀D.฀Violence฀in฀cross฀cultural฀perspective.฀
Newbury฀Park,฀CA,฀Sage฀Publications,฀1989.
27.฀ Bronfenbrenner฀V.฀฀The฀ecology฀of฀human฀
development:฀experiments฀by฀nature฀and฀design.฀
Cambridge,฀MA,฀Harvard฀University฀Press,฀1979.
28.฀ Garbarino฀J,฀Crouter฀A.฀Defining฀the฀community฀
10
WHO฀Multi-country฀Study฀on฀Women’s฀Health฀and฀Domestic฀Violence
context฀for฀parent–child฀relations:฀the฀correlates฀of฀child฀
maltreatment.฀Child฀Development,฀1978,฀49:604–616.
29.฀ Belsky฀J.฀Child฀maltreatment:฀an฀ecological฀
integration.฀American฀Psychologist฀1980;35:320–335.
30.฀ Tolan฀PH,฀Guerra฀NG.฀What฀works฀in฀reducing฀
adolescent฀violence:฀an฀empirical฀review฀of฀the฀field.฀
Boulder,฀CO,฀University฀of฀Colorado,฀Center฀for฀the฀
Study฀and฀Prevention฀of฀Violence,฀1994.
31.฀ Chaulk฀R,฀King฀PA.฀Violence฀in฀families:฀assessing฀
prevention฀and฀treatment฀programs.฀Washington,฀DC,฀
National฀Academy฀Press,฀1998.
32.฀ Heise฀L.฀Violence฀against฀women:฀an฀integrated,฀
ecological฀framework.฀Violence฀Against฀Women,฀1998,฀
4:262–290.
33.฀ Schiamberg฀LB,฀Gans฀D.฀An฀ecological฀framework฀for฀
contextual฀risk฀factors฀in฀elder฀abuse฀by฀adult฀children.฀
Journal฀of฀Elder฀Abuse฀and฀Neglect,฀1999,฀11:79–103.
34.฀ Carp฀RM.฀Elder฀abuse฀in฀the฀family:฀an฀interdisciplinary฀
model฀for฀research.฀New฀York,฀NY,฀Springer,฀2000.
This฀is฀an฀“A”฀heading฀here
35.฀ O’Campo฀P฀et฀al.฀฀Violence฀by฀male฀partners฀against฀
women฀during฀the฀childbearing฀year:฀a฀contextual฀
analysis.฀American฀Journal฀of฀Public฀Health,฀1995,฀
85:1092–1097.
36.฀ Koenig฀MA฀et฀al.฀฀Women’s฀status฀and฀domestic฀
violence฀in฀rural฀Bangladesh:฀individual-฀and฀
community-level฀effects.฀Demography,฀2003,฀40:269–
288.
37.฀ Fanslow฀J,฀Robinson฀E.฀฀Violence฀against฀women฀in฀
New฀Zealand:฀prevalence฀and฀health฀consequences.฀ Methods
New฀Zealand฀Medical฀Journal,฀2004,฀117:1173–1184.
 2

CHAPTER
Definitions฀and฀questionnaire฀development

฀
The฀questions฀�฀challenge฀women’s฀ 1฀
The฀term฀“intimate-partner฀ Definitions฀

experience�฀attitudes�฀opinions�฀and฀statements.฀
By฀telling�฀at฀the฀end�฀�฀felt฀liberated.
Woman฀interviewed฀in฀Serbia฀and฀Montenegro
�฀�฀feel฀very฀good฀because฀�฀believe฀it฀will฀help฀
many฀women฀�nowing฀about฀these฀things�฀and฀even฀
if฀this฀help฀will฀not฀reach฀me�฀�฀�now฀it฀will฀reach฀
many฀women.฀
Woman฀interviewed฀in฀Peru
violence”฀is฀now฀used฀in฀
•฀ self-directed฀violence,
•฀
preference฀to฀the฀term฀
“domestic฀violence”,฀which฀
One฀of฀the฀main฀challenges฀facing฀international฀ interpersonal฀violence,
is฀not฀specific฀and฀could฀
include฀child฀abuse,฀intimate฀
researchers฀on฀violence฀against฀women฀is฀to฀ •฀ collective฀violence.
develop฀clear฀operational฀definitions฀of฀different฀
partner฀violence฀and฀abuse฀of฀
types฀of฀violence฀and฀tools฀for฀measuring฀ These฀categories฀are฀each฀divided฀further฀to฀
the฀elderly.฀This฀report฀uses฀
intimate-partner฀or฀partner฀ violence฀that฀permit฀meaningful฀comparisons฀ reflect฀specific฀types฀of฀violence฀(Figure฀2.1).
violence,฀except฀in฀the฀name฀ among฀diverse฀settings.฀
of฀the฀Study,฀which฀was฀
Researchers฀have฀used฀many฀criteria฀to฀
agreed฀before฀the฀appearance฀
of฀the฀World฀report฀on฀violence฀ define฀violence.฀A฀common฀method฀is฀to฀ Measuring฀violence
classify฀violence฀according฀to฀the฀type฀of฀act:฀ The฀WHO฀Study฀focused฀primarily฀on฀“domestic฀
and฀health฀(1).฀
for฀example,฀physical฀violence฀(e.g.฀slapping,฀ violence”,1฀or฀violence฀by฀an฀intimate฀partner,฀
2
฀The฀Study฀focused฀on฀
violence฀by฀male฀partners฀ hitting,฀kicking,฀and฀beating),฀sexual฀violence฀(e.g.฀ experienced฀by฀women.฀Included฀in฀this฀were฀acts฀of฀
only,฀mainly฀because฀most฀ forced฀intercourse฀and฀other฀forms฀of฀coerced฀ physical,฀sexual฀and฀emotional฀abuse฀by฀a฀current฀or฀
intimate฀partners฀of฀women฀ sex),฀and฀emotional฀or฀psychological฀violence฀ former฀intimate฀male฀partner,฀whether฀cohabiting฀or฀
throughout฀the฀world฀
are฀male.฀Indeed,฀in฀some฀
(e.g.฀intimidation฀and฀humiliation).฀Violence฀can฀ not.2฀In฀addition,฀it฀looked฀at฀controlling฀behaviours,฀
countries฀it฀would฀not฀be฀ also฀be฀defined฀by฀the฀relationship฀between฀the฀ including฀acts฀to฀constrain฀a฀woman’s฀mobility฀or฀฀
culturally฀acceptable฀to฀ victim฀and฀perpetrator;฀for฀example,฀intimate฀ her฀access฀to฀friends฀and฀relatives,฀extreme฀jealousy,฀
ask฀about฀female–female฀
partner฀violence,฀incest,฀sexual฀assault฀by฀a฀ etc.฀The฀Study฀also฀included฀physical฀and฀sexual฀฀
relationships.฀In฀addition,฀
the฀Study฀was฀intended฀ stranger,฀date฀rape฀or฀acquaintance฀rape.฀ violence฀against฀women,฀before฀and฀after฀฀
as฀a฀contribution฀to฀the฀ In฀the฀World฀report฀on฀violence฀and฀health฀ 15฀years฀of฀age,฀by฀perpetrators฀other฀than฀intimate฀
understanding฀of฀gender-based฀
(1),฀WHO฀adopted฀a฀typology฀that฀categorizes฀ partners.฀Definitions฀of฀each฀of฀these฀aspects฀of฀
violence฀as฀an฀expression฀of฀
gender฀inequality฀in฀relations฀ violence฀in฀three฀broad฀categories,฀according฀to฀ violence฀were฀operationalized฀in฀the฀study฀using฀
between฀women฀and฀men. those฀committing฀the฀violent฀act: a฀range฀of฀behaviour-specific฀questions฀related฀

Figure฀2.1 A฀typology฀of฀violence

Violence

Self-directed �nterpersonal Collective

Suicidal Self-abuse Family/ Community Social Political Economic

behaviour partner

Child Partner Elder Acquaintance Stranger

Nature฀of
violence
Physical

Sexual

Psychological

Deprivation
or฀neglect

Source:฀Reproduced฀from฀reference฀1.
14
WHO฀Multi-country฀Study฀on฀Women’s฀Health฀and฀Domestic฀Violence
to฀each฀type฀of฀violence฀(Annex฀4).฀The฀study฀did฀
not฀attempt฀to฀document฀an฀exhaustive฀list฀of฀acts฀
of฀violence,฀but฀instead฀asked฀a฀limited฀number฀
of฀questions฀about฀specific฀acts฀that฀commonly฀
occur฀in฀violent฀partnerships.฀This฀approach฀has฀
been฀used฀widely฀in฀studies฀of฀partner฀violence฀
in฀the฀United฀States฀and฀elsewhere,฀and฀has฀been฀
shown฀to฀encourage฀greater฀disclosure฀of฀violence฀
than฀approaches฀that฀require฀respondents฀to฀
identify฀themselves฀as฀abused฀or฀battered฀(2,฀3).฀
Given฀that฀the฀conceptualization฀of฀violence฀differs฀
between฀individuals฀and฀communities,฀a฀fairly฀
conservative฀definition฀of฀violence฀was฀used.฀Thus฀
the฀prevalence฀estimated฀in฀this฀manner฀is฀more฀
likely฀to฀underestimate฀rather฀than฀overestimate฀
the฀true฀prevalence฀of฀violence.฀The฀acts฀used฀
to฀define฀each฀type฀of฀violence฀measured฀in฀the฀
Study฀are฀summarized฀in฀Box฀2.1.
Violence฀by฀intimate฀partners
While฀there฀is฀widespread฀agreement,฀and฀
some฀standardization,฀regarding฀what฀acts฀are฀
included฀as฀physical฀violence,฀this฀is฀less฀true฀for฀
sexual฀violence.฀There฀is฀even฀less฀agreement฀
on฀how฀to฀define฀and฀measure฀psychological฀or฀
emotional฀abuse,฀especially฀in฀a฀cross-cultural฀
Box฀2.1 Operational฀definitions฀of฀violence฀used฀in฀the฀WHO฀Multi-country฀Study฀on฀
Women’s฀Health฀and฀Domestic฀Violence฀against฀Women
Physical฀violence฀by฀an฀intimate฀partner
• ฀Was฀slapped฀or฀had฀something฀thrown฀at฀her฀฀
฀ that฀could฀hurt฀her
• ฀Was฀pushed฀or฀shoved฀
• ฀Was฀hit฀with฀fist฀or฀something฀else฀that฀could฀hurt
• ฀Was฀kicked,฀dragged฀or฀beaten฀up
• ฀Was฀choked฀or฀burnt฀on฀purpose
• ฀Perpetrator฀threatened฀to฀use฀or฀actually฀used฀a฀฀
฀ gun,฀knife฀or฀other฀weapon฀against฀her
Sexual฀violence฀by฀an฀intimate฀partner
• ฀Was฀physically฀forced฀to฀have฀sexual฀intercourse฀฀
฀ when฀she฀did฀not฀want฀to
• ฀Had฀sexual฀intercourse฀when฀she฀did฀not฀฀
฀ want฀to฀because฀she฀was฀afraid฀of฀what฀partner฀฀
฀ might฀do
• ฀Was฀forced฀to฀do฀something฀sexual฀that฀she฀฀
฀ found฀degrading฀or฀humiliating
Emotional฀abuse฀by฀an฀intimate฀partner฀
• ฀Was฀insulted฀or฀made฀to฀feel฀bad฀about฀herself
• ฀Was฀belittled฀or฀humiliated฀in฀front฀of฀฀
฀ other฀people
• ฀Perpetrator฀had฀done฀things฀to฀scare฀or฀฀
฀ intimidate฀her฀on฀purpose,฀e.g.฀by฀the฀way฀he฀฀
฀ looked฀at฀her,฀by฀yelling฀or฀smashing฀things
• ฀Perpetrator฀had฀threatened฀to฀hurt฀someone฀฀
฀ she฀cared฀about
perspective,฀because฀the฀acts฀that฀are฀perceived฀
as฀abusive฀are฀likely฀to฀vary฀between฀countries฀
and฀between฀socioeconomic฀and฀ethnic฀groups,฀
and฀according฀to฀the฀overall฀level฀of฀violence฀
in฀the฀group.฀Because฀of฀the฀complexity฀of฀
defining฀and฀measuring฀emotional฀abuse฀in฀a฀way฀
that฀is฀relevant฀and฀meaningful฀across฀cultures,฀
the฀questions฀regarding฀emotional฀violence฀
and฀controlling฀behaviour฀in฀the฀WHO฀Study฀
questionnaire฀should฀be฀considered฀as฀a฀฀
starting-point,฀rather฀than฀a฀comprehensive฀
measure฀of฀all฀forms฀of฀emotional฀abuse.฀
The฀questions฀on฀physical฀partner฀violence฀
were฀divided฀into฀those฀related฀to฀“moderate”฀
violence,฀and฀those฀considered฀“severe”฀violence฀
(Box฀2.2).฀The฀distinction฀between฀moderate฀
and฀severe฀violence฀is฀based฀on฀the฀likelihood฀of฀
physical฀injury.฀For฀each฀act฀of฀physical,฀sexual,฀or฀
emotional฀abuse฀that฀the฀respondent฀reported฀
as฀having฀happened฀to฀her,฀she฀was฀asked฀
whether฀it฀had฀happened฀ever฀or฀in฀the฀past฀฀
12฀months,฀and฀with฀what฀frequency฀(once฀or฀
twice,฀a฀few฀times,฀or฀many฀times)฀(Questions฀
704,฀705,฀706).฀The฀answers฀to฀these฀questions฀
made฀it฀possible฀to฀assess฀the฀level฀of฀sexual฀or฀
physical฀violence฀by฀current฀or฀former฀partners.
Controlling฀behaviours฀by฀an฀intimate฀
partner
• ฀He฀tried฀to฀keep฀her฀from฀seeing฀friends
• ฀He฀tried฀to฀restrict฀contact฀with฀her฀family฀of฀birth
• ฀He฀insisted฀on฀knowing฀where฀she฀was฀at฀all฀times
• ฀He฀ignored฀her฀and฀treated฀her฀indifferently
• ฀He฀got฀angry฀if฀she฀spoke฀with฀another฀man
• ฀He฀was฀often฀suspicious฀that฀she฀was฀unfaithful
• ฀He฀expected฀her฀to฀ask฀permission฀before฀฀
฀ seeking฀health฀care฀for฀herself
Physical฀violence฀in฀pregnancy
• ฀Was฀slapped,฀hit฀or฀beaten฀while฀pregnant
• ฀Was฀punched฀or฀kicked฀in฀the฀abdomen฀฀
฀ while฀pregnant
Physical฀violence฀since฀age฀15฀years฀by฀
others฀(non-partners)
• ฀Since฀age฀15฀years฀someone฀other฀than฀partner฀฀
฀ beat฀or฀physically฀mistreated฀her
Sexual฀violence฀since฀age฀15฀years฀by฀
others฀(non-partners)
• ฀Since฀age฀15฀years฀someone฀other฀than฀partner฀฀
฀ forced฀her฀to฀have฀sex฀or฀to฀perform฀a฀sexual฀act฀฀
฀ when฀she฀did฀not฀want฀to
Childhood฀sexual฀abuse฀(before฀age฀15฀years)
• ฀Before฀age฀15฀years฀someone฀had฀touched฀her฀฀
฀ sexually฀or฀made฀her฀do฀something฀sexual฀that฀฀
฀ she฀did฀not฀want฀to
Box฀2.2 Severity฀scale฀used฀for฀level฀of฀
violence฀(see฀Question฀705฀of฀
the฀WHO฀Study฀questionnaire)฀
“Moderate”฀violence:฀respondent฀
answers฀“yes”฀to฀one฀or฀more฀of฀the฀
following฀questions฀regarding฀her฀
intimate฀partner฀(and฀does฀not฀answer฀
“yes”฀to฀questions฀c–f฀below):฀
(a)฀[Has฀he]฀slapped฀you฀or฀thrown฀something฀฀
฀ at฀you฀that฀could฀hurt฀you?
(b)฀[Has฀he]฀pushed฀you฀or฀shoved฀you?
“Severe”฀violence:฀respondent฀answers฀
“yes”฀to฀one฀or฀more฀of฀the฀following฀
questions฀regarding฀her฀intimate฀partner:฀฀
(c)฀[Has฀he]฀hit฀you฀with฀his฀fist฀or฀with฀฀
฀ something฀else฀that฀could฀hurt฀you?
(d)฀[Has฀he]฀kicked฀you,฀dragged฀you฀or฀beaten฀฀
฀ you฀up?
(e)฀[Has฀he]฀choked฀or฀burnt฀you฀on฀purpose?฀
(f)฀฀[Has฀he]฀threatened฀to฀use฀or฀actually฀used฀฀
฀ a฀gun,฀knife฀or฀other฀weapon฀against฀you?
Psychometric฀analysis฀was฀performed฀on฀the฀
violence฀questions฀used฀in฀the฀Study฀to฀ascertain฀
the฀appropriateness฀of฀the฀behavioural฀items฀
included฀in฀the฀different฀measures฀of฀physical,฀
emotional฀and฀sexual฀violence.฀In฀general,฀there฀
was฀good฀internal฀consistency฀among฀the฀items฀
for฀each฀measure,฀indicating฀that฀the฀instrument฀
provided฀a฀reliable฀and฀valid฀measure฀for฀each฀of฀
the฀types฀of฀violence.
An฀exposure฀chart฀(Question฀716)฀was฀used฀
to฀collect฀information฀about฀the฀timing฀of฀the฀
onset฀of฀physical฀or฀sexual฀violence฀by฀an฀intimate฀
partner฀and฀when฀such฀violence฀last฀occurred.฀This฀
was฀an฀important฀aspect฀of฀the฀data฀collection,฀
which฀partly฀addressed฀the฀inherent฀limitations฀
of฀the฀cross-sectional฀study฀design,฀as฀information฀
about฀the฀timing฀of฀different฀forms฀of฀violence฀can฀
be฀compared฀with฀details฀about฀the฀timing฀of฀the฀
start฀and฀end฀of฀the฀relationship฀or฀marriage.฀This฀
information฀allows฀for฀analysis฀of฀the฀extent฀to฀
which฀different฀forms฀of฀violence฀occur฀prior฀to฀or฀
during฀marriage฀or฀cohabitation,฀or฀after฀separation.฀
The฀data฀can฀also฀be฀used฀to฀understand฀how฀
women’s฀risk฀of฀intimate-partner฀violence฀changes฀
over฀the฀duration฀of฀the฀relationship.
Ever-partnered฀women
The฀definition฀of฀฀“ever-partnered฀women”฀
is฀central฀to฀the฀study,฀because฀it฀defines฀the฀
population฀that฀could฀potentially฀be฀at฀risk฀
of฀partner฀violence฀(and฀hence฀becomes฀the฀
denominator฀for฀prevalence฀figures).฀Although฀the฀
study฀tried฀to฀maintain฀the฀highest฀possible฀level฀
of฀standardization฀across฀countries,฀it฀was฀agreed฀
that฀the฀same฀definition฀could฀not฀be฀used฀in฀all฀
15
Chapter฀2฀฀Definitions฀and฀questionnaire฀development
the฀countries,฀because฀the฀concept฀of฀฀“partner”฀
is฀culturally฀or฀legally฀defined.฀In฀developing฀the฀
country-specific฀definitions฀of฀฀“ever-partnered฀
women”,฀the฀study฀researchers฀were฀aware฀of฀
the฀need฀to฀use฀a฀broad฀definition฀of฀partnership,฀
since฀any฀woman฀who฀had฀been฀in฀a฀relationship฀
with฀an฀intimate฀partner,฀whether฀or฀not฀they฀had฀
been฀married,฀could฀have฀been฀exposed฀to฀the฀
risk฀of฀violence.฀It฀was฀also฀recognized฀that฀the฀
definition฀of฀ever-partnered฀women฀would฀need฀
to฀be฀narrower฀in฀some฀contexts฀than฀others.฀
For฀example,฀in฀Bangladesh฀it฀was฀considered฀
inappropriate฀to฀ask฀unmarried฀women฀about฀฀
non-marital฀partners;฀in฀any฀case,฀an฀unmarried฀
woman฀in฀Bangladesh฀cohabiting฀with฀a฀partner฀
would฀most฀likely฀have฀identified฀herself฀as฀being฀
married฀and฀so฀be฀included฀in฀the฀study฀population.฀
In฀general,฀the฀definition฀of฀฀“ever-partnered฀
women”฀included฀women฀who฀were฀or฀had฀ever฀
been฀married฀or฀in฀a฀common-law฀relationship.฀In฀
countries฀where฀premarital฀sexual฀relationships฀
are฀common,฀the฀definition฀covered฀dating฀
relationships฀–฀defined฀as฀regular฀sexual฀partners,฀
not฀living฀together.฀Former฀dating฀partners฀were฀
not฀included,฀except฀in฀Japan,฀Namibia฀and฀Peru,฀
where฀many฀women฀never฀live฀with฀regular฀sexual฀
partners,฀even฀if฀they฀have฀children฀by฀them.฀฀
Box฀2.3฀gives฀the฀definitions฀of฀฀“ever฀partnered”฀
used฀in฀the฀countries฀taking฀part฀in฀the฀WHO฀Study.฀
Violence฀by฀non-partners฀
The฀survey฀also฀explored฀the฀extent฀to฀which฀
women฀report฀experiencing฀violence฀by฀
perpetrators฀other฀than฀a฀current฀or฀former฀
male฀partner.฀It฀included฀questions฀on฀physically฀
abusive฀behaviour฀by฀such฀perpetrators฀since฀
the฀age฀of฀15฀years,฀in฀different฀contexts฀(at฀
school฀or฀work,฀by฀a฀friend฀or฀neighbour฀or฀
anyone฀else).฀Follow-up฀questions฀explored฀the฀
frequency฀of฀violence฀for฀each฀perpetrator.
Box฀2.3 Country-specific฀definitions฀
of฀“ever-partnered฀women”
Bangladesh Ever฀married
Brazil,฀Ethiopia,฀ Ever฀married,฀ever฀
Serbia฀and฀Montenegro,฀ lived฀with฀a฀man,฀
Thailand,฀United฀
Republic฀of฀Tanzania
currently฀with฀a฀
regular฀sexual฀partner
Japan,฀Namibia,฀Peru Ever฀married,฀ever฀
lived฀with฀a฀man,฀ever฀
with฀a฀regular฀sexual฀
partner
Samoa Ever฀married,฀ever฀
lived฀with฀a฀man
16
WHO฀Multi-country฀Study฀on฀Women’s฀Health฀and฀Domestic฀Violence
Likewise,฀the฀survey฀explored฀the฀extent฀
to฀which฀the฀women฀had฀been฀sexually฀abused฀
by฀others,฀including฀before฀age฀15฀years฀(child฀
sexual฀abuse).฀As฀this฀is฀a฀highly฀sensitive฀issue,฀
four฀methods฀were฀used฀to฀enhance฀disclosure฀
of฀different฀forms฀of฀abuse.฀Respondents฀were฀
asked฀whether,฀since฀the฀age฀of฀15฀years,฀any฀
person฀other฀than฀their฀partner฀or฀husband฀had฀
forced฀them฀to฀have฀sex฀or฀to฀perform฀a฀sexual฀
act฀when฀they฀did฀not฀want฀to฀(Question฀1002).฀
Again,฀probing฀questions฀were฀used฀to฀explore฀
the฀different฀contexts฀in฀which฀this฀might฀have฀
occurred.฀For฀respondents฀who฀reported฀having฀
experienced฀this฀type฀of฀abuse,฀information฀was฀
collected฀about฀the฀perpetrator฀and฀the฀frequency.฀
Second,฀respondents฀were฀asked฀whether,฀before฀
the฀age฀of฀15฀years,฀anyone฀had฀ever฀touched฀
them฀sexually฀or฀made฀them฀do฀something฀sexual฀
that฀they฀did฀not฀want฀to฀do฀(Question฀1003).฀
Follow-on฀questions฀asked฀about฀the฀perpetrator,฀
the฀ages฀of฀the฀respondent฀and฀the฀perpetrator฀
at฀the฀time,฀and฀the฀frequency.฀Third,฀respondents฀
were฀asked฀how฀old฀they฀were฀at฀their฀first฀sexual฀
experience฀(Question฀1004),฀and฀whether฀it฀had฀
been฀something฀they฀had฀wanted฀to฀happen,฀
something฀they฀had฀not฀wanted฀but฀that฀had฀
happened฀anyway,฀or฀something฀that฀they฀had฀
been฀forced฀into฀(Question฀1005).฀Finally,฀at฀the฀
end฀of฀each฀interview฀the฀respondent฀was฀offered฀
an฀opportunity฀to฀indicate฀in฀a฀hidden฀manner฀
whether฀anyone฀had฀ever฀touched฀her฀sexually฀
or฀made฀her฀do฀something฀sexual฀against฀her฀will฀
before฀the฀age฀of฀15฀years,฀without฀having฀฀
to฀disclose฀her฀reply฀to฀the฀interviewer฀฀
(Question฀1201).฀For฀this฀question,฀respondents฀
were฀handed฀a฀card฀that฀had฀a฀pictorial฀
representation฀for฀yes฀and฀no฀and฀asked฀to฀record฀
their฀response฀in฀private฀(Figure฀2.2).฀In฀most฀sites,฀
the฀respondent฀then฀folded฀the฀card฀and฀placed฀
it฀in฀an฀envelope฀or฀a฀bag฀containing฀other฀cards฀
before฀handing฀it฀back฀to฀the฀interviewer,฀thus฀
Figure฀2.2 Sample฀response฀card
Pictorial฀representation฀of฀response฀to฀Question฀1201฀
concerning฀sexual฀abuse฀before฀15฀years฀of฀age:฀
tearful฀face฀indicates฀“yes”;฀smiling฀face฀indicates฀“no”
keeping฀her฀answer฀secret฀from฀the฀interviewer.฀In฀
Serbia฀and฀Montenegro฀and฀the฀United฀Republic฀
of฀Tanzania,฀the฀sealed฀envelope฀with฀the฀card฀
was฀attached฀to฀the฀questionnaire฀to฀allow฀the฀
information฀to฀be฀linked฀to฀the฀individual฀woman฀
at฀the฀time฀of฀data฀entry.฀The฀use฀of฀a฀card฀was฀
intended฀to฀increase฀the฀likelihood฀of฀obtaining฀a฀
more฀complete฀estimate฀of฀the฀prevalence฀of฀฀
childhood฀sexual฀abuse.
Formative฀research
The฀WHO฀Study฀incorporated฀formative฀research,฀
including฀research฀on฀definitional฀issues,฀in฀each฀
of฀the฀country฀sites.฀The฀aim฀of฀this฀work฀was฀to฀
gain฀insights฀that฀could฀be฀used฀in฀designing฀and฀
translating฀the฀questionnaire,฀and฀in฀interpreting฀the฀
survey฀findings.฀The฀research฀included:฀interviews฀
with฀key฀informants;฀in-depth฀interviews฀with฀
survivors฀of฀violence;฀and฀focus฀group฀discussions฀
with฀women฀and฀men฀of฀different฀age฀groups.
Key฀informants
Informants฀included฀representatives฀from฀
nongovernmental฀organizations฀focusing฀on฀฀
areas฀such฀as฀violence฀against฀women,฀฀
HIV/AIDS,฀women’s฀health,฀women’s฀rights฀and฀
their฀awareness฀of฀those฀rights,฀or฀women’s฀
education฀and฀development.฀
In-depth฀interviews฀with฀survivors
In฀each฀country,฀in-depth฀semi-structured฀
interviews฀were฀held฀with฀at฀least฀five฀women฀
who฀were฀known฀to฀have฀been฀abused฀by฀their฀
partners฀or฀former฀partners.฀Participants฀were฀
recruited฀through฀different฀support฀services,฀by฀
means฀of฀“snowball”฀techniques.฀These฀interviews฀
were฀used฀to฀gain฀a฀better฀understanding฀of฀how฀
women฀describe฀their฀experiences฀of฀domestic฀
violence,฀the฀ways฀in฀which฀they฀have฀responded,฀
and฀how฀such฀violence฀has฀influenced฀their฀lives.฀
The฀structure฀of฀the฀interviews฀reflected฀the฀
forms฀of฀information฀to฀be฀collected฀during฀
the฀survey.฀The฀women’s฀narratives฀helped฀
inform฀the฀development฀and฀translation฀of฀the฀
relevant฀modules฀within฀the฀core฀and฀country฀
questionnaires.฀The฀information฀is฀also฀being฀
used฀to฀help฀in฀interpreting฀the฀quantitative฀
research฀findings,฀and฀to฀supplement฀the฀
quantitative฀data฀obtained.
During฀the฀interviews,฀careful฀attention฀was฀
given฀to฀the฀ethical฀and฀safety฀issues฀associated฀
with฀the฀study฀(see฀Chapter฀3).฀This฀included฀
recognizing฀that฀the฀interviews฀might฀be฀
distressing,฀and฀ensuring฀that฀adequate฀follow-up฀
support฀was฀provided.฀Care฀was฀also฀taken฀to฀
ensure฀that฀strict฀confidentiality฀was฀maintained,฀
and฀that฀the฀respondent฀could฀not฀be฀identified฀in฀
follow-up฀dissemination฀activities.฀Each฀interview฀
aimed฀to฀end฀on฀a฀positive฀note,฀identifying฀the฀
respondent’s฀strengths฀and฀abilities.฀All฀tapes฀were฀
erased฀once฀transcripts฀had฀been฀made.
Focus฀group฀discussions
Focus฀group฀discussions฀were฀held฀with฀women฀
and฀men,฀young฀and฀old,฀in฀both฀urban฀and฀rural฀
settings.฀The฀aim฀was฀again฀to฀explore฀local฀
views฀and฀language฀about฀violence฀and฀obtain฀
descriptions฀of฀different฀forms฀of฀violence.฀Focus฀
group฀discussions฀were฀conducted฀using฀a฀script฀
and฀short฀scenarios;฀participants฀were฀left฀to฀
complete฀the฀story-line.
Box฀2.4 Translation฀of฀the฀
questionnaire
The฀working฀language฀for฀the฀development฀฀
of฀the฀questionnaire฀was฀English.฀Before฀฀
pre-testing฀in฀each฀country,฀the฀questionnaire฀
was฀professionally฀translated฀into฀the฀relevant฀
local฀languages.฀The฀formative฀research฀was฀used฀
to฀guide฀the฀forms฀of฀language฀and฀expressions฀
used,฀with฀the฀focus฀being฀on฀using฀words฀and฀
expressions฀that฀were฀widely฀understood฀in฀
the฀study฀sites.฀In฀settings฀where฀a฀number฀of฀
languages฀were฀in฀use,฀questionnaires฀were฀
developed฀in฀each฀language.฀
฀ Previous฀research฀experience฀in฀South฀Africa฀
and฀Zimbabwe฀found฀that฀professional฀฀
back-translations฀were฀not฀a฀reliable฀way฀to฀
check฀the฀accuracy฀of฀questions฀on฀violence฀and฀
its฀consequences.฀For฀this฀reason,฀the฀translated฀
questionnaire฀was฀first฀checked฀by฀local฀
researchers฀involved฀in฀the฀study฀who฀compared฀
the฀English฀and฀translated฀versions.฀Lengthy฀
oral฀back-translation฀sessions฀with฀step-by-step฀
discussion฀of฀each฀question฀were฀conducted฀
with฀people฀not฀familiar฀with฀the฀questionnaire฀
but฀fluent฀in฀the฀language฀and฀with฀people฀who฀
understood฀the฀questionnaire฀and฀violence฀issues.฀
The฀main฀purpose฀of฀this฀exercise฀was฀to฀identify฀
differences฀in฀translations฀that฀could฀alter฀the฀
meaning฀of฀questions฀and฀to฀establish฀cognitive฀
understanding฀of฀the฀items฀in฀the฀questionnaire.฀
Adjustments฀were฀made฀where฀needed.฀Once฀
the฀translation฀had฀been฀finalized,฀the฀questions฀
were฀again฀discussed฀during฀interviewer-training฀
sessions฀on฀the฀basis฀of฀a฀question-by-question฀
description฀of฀the฀questionnaire.฀Having฀
interviewers฀from฀various฀cultural฀backgrounds฀
aided฀in฀ascertaining฀whether฀wording฀used฀was฀
culturally฀acceptable.฀During฀the฀training฀itself,฀
further฀revisions฀to฀the฀translated฀questionnaires฀
were฀made.฀Final฀minor฀modifications฀to฀fine-tune฀
the฀translated฀questionnaire฀were฀usually฀made฀
during฀the฀pilot฀survey฀in฀the฀field,฀in฀the฀third฀
week฀of฀interviewer฀training.฀
17
Chapter฀2฀฀Definitions฀and฀questionnaire฀development
Development฀of฀the฀questionnaire
The฀study฀questionnaire฀was฀the฀outcome฀of฀a฀long฀
process฀of฀discussion฀and฀consultation.฀Following฀
an฀extensive฀review฀of฀a฀range฀of฀pre-existing฀
study฀instruments,฀and฀consultation฀with฀technical฀
experts฀in฀specific฀areas฀(including฀violence฀against฀
women,฀reproductive฀health,฀mental฀health,฀and฀
tobacco฀and฀alcohol฀use),฀the฀core฀research฀team฀
developed฀a฀first฀draft฀of฀the฀questionnaire.฀This฀was฀
then฀reviewed฀by฀the฀expert฀steering฀committee฀
and฀experts฀in฀relevant฀fields,฀and฀suggestions฀
for฀revision฀were฀incorporated.฀The฀revised฀
questionnaire฀was฀then฀reviewed฀by฀the฀country฀
teams฀during฀an฀international฀meeting.฀Discussion฀
focused฀on฀incorporating฀country฀priorities,฀
and฀achieving฀a฀balance฀between฀exhaustively฀
exploring฀specific฀issues฀and฀compiling฀less฀detailed฀
information฀on฀a฀range฀of฀issues.฀
The฀questionnaire฀was฀then฀translated฀฀
(see฀Box฀2.4)฀and฀pretested฀in฀six฀countries฀
(Bangladesh,฀Brazil,฀Namibia,฀Samoa,฀Thailand,฀and฀
the฀United฀Republic฀of฀Tanzania).฀The฀experiences฀
from฀these฀pretests฀were฀reviewed฀at฀the฀third฀
meeting฀of฀the฀research฀teams,฀and฀used฀to฀make฀
further฀revisions฀to฀the฀questionnaire.฀
Following฀a฀final฀pretest,฀the฀questionnaire฀
for฀the฀Study฀was฀completed฀as฀version฀9.9฀
(Annex฀4),฀and฀was฀used฀in฀Bangladesh,฀Brazil,฀
Ethiopia,฀Japan,฀Namibia,฀Peru,฀Samoa,฀Thailand,฀
and฀the฀United฀Republic฀of฀Tanzania.฀An฀updated฀
version฀of฀the฀questionnaire฀(version฀10),฀which฀
incorporates฀the฀experience฀in฀the฀first฀eight฀
countries,฀was฀used฀in฀Serbia฀and฀Montenegro.
Questionnaire฀structure
The฀questionnaire฀consisted฀of฀an฀administration฀
form,฀a฀household฀selection฀form฀a฀household฀
questionnaire,฀a฀women’s฀questionnaire,฀and฀
a฀reference฀sheet.฀The฀women’s฀questionnaire฀
included฀an฀individual฀consent฀form฀and฀฀
12฀sections฀designed฀to฀obtain฀details฀about฀the฀
respondent฀and฀her฀community,฀her฀general฀and฀
reproductive฀health,฀her฀financial฀autonomy,฀her฀
children,฀her฀partner,฀her฀experiences฀of฀partner฀
and฀non-partner฀violence,฀and฀the฀impact฀of฀
violence฀on฀her฀life฀(see฀Box฀2.5฀for฀an฀outline฀of฀
the฀questionnaire).
Maximizing฀disclosure
From฀the฀outset฀of฀the฀study฀it฀was฀recognized฀
that฀violence฀is฀a฀highly฀sensitive฀issue,฀and฀that฀
there฀was฀a฀danger฀that฀women฀would฀not฀
18
WHO฀Multi-country฀Study฀on฀Women’s฀Health฀and฀Domestic฀Violence
Box฀2.5 WHO฀Multi-country฀Study฀
on฀Women’s฀Health฀and฀
Domestic฀Violence฀against฀
Women:฀topics฀covered฀by฀the฀
women’s฀questionnaire
Section฀1:฀฀฀ Characteristics฀of฀the฀respondent฀฀
฀ and฀her฀community
Section฀2:฀฀฀ General฀health
Section฀3:฀฀฀ Reproductive฀health฀
Section฀4:฀฀฀ Information฀regarding฀children
Section฀5:฀฀฀ Characteristics฀of฀current฀or฀most฀฀
฀ recent฀partner
Section฀6:฀฀฀ Attitudes฀towards฀gender฀roles
Section฀7:฀฀฀ Experiences฀of฀partner฀violence฀
Section฀8:฀฀฀ Injuries฀resulting฀from฀partner฀฀
฀ violence
Section฀9:฀฀฀ Impact฀of฀partner฀violence฀and฀฀
฀ coping฀mechanisms฀used฀by฀women฀฀
฀ who฀experience฀partner฀violence
Section฀10:฀฀ Non-partner฀violence฀
Section฀11:฀฀ Financial฀autonomy
Section฀12:฀฀ Anonymous฀reporting฀of฀childhood฀฀
฀ sexual฀abuse;฀respondent฀feedback
disclose฀their฀experiences฀of฀violence.฀For฀this฀
reason,฀in฀designing฀the฀questionnaire,฀an฀attempt฀
was฀made฀to฀ensure฀that฀women฀would฀feel฀
able฀to฀disclose฀any฀experiences฀of฀violence.฀
The฀questionnaire฀was฀structured฀so฀that฀early฀
sections฀collected฀information฀on฀less฀sensitive฀
issues,฀and฀that฀more฀sensitive฀issues,฀including฀
the฀nature฀and฀extent฀of฀partner฀and฀non-
partner฀violence,฀were฀explored฀later,฀once฀
a฀rapport฀had฀been฀established฀between฀the฀
interviewer฀and฀the฀respondent.฀
Partner฀violence฀often฀carries฀a฀stigma,฀and฀
women฀may฀be฀blamed,฀or฀blame฀themselves,฀
for฀the฀violence฀they฀experience.฀For฀this฀
reason,฀all฀questions฀about฀violence฀and฀its฀
consequences฀were฀phrased฀in฀a฀supportive฀
and฀non-judgemental฀manner.฀The฀word฀
“violence”฀itself฀was฀avoided฀throughout฀the฀
questionnaire.฀In฀addition,฀careful฀attention฀was฀
paid฀to฀the฀wording฀used฀to฀introduce฀the฀
different฀questions฀on฀violence.฀These฀sections฀
forewarned฀the฀respondent฀about฀the฀sensitivity฀
of฀the฀forthcoming฀questions,฀assured฀her฀that฀
the฀questions฀referred฀to฀events฀that฀many฀
women฀experience,฀highlighted฀the฀confidentiality฀
of฀her฀responses,฀and฀reminded฀her฀that฀she฀
View publication stats
3
CHAPTER
could฀choose฀not฀to฀answer฀any฀question฀or฀to฀
stop฀the฀interview฀at฀any฀point.฀For฀example,฀
the฀wording฀used฀to฀introduce฀the฀section฀on฀
intimate-partner฀violence฀was:฀
“When฀two฀people฀marry฀or฀live฀
together,฀they฀usually฀share฀both฀good฀and฀
bad฀moments.฀I฀would฀now฀like฀to฀ask฀you฀
some฀questions฀about฀your฀current฀and฀past฀
relationships฀and฀how฀your฀husband/partner฀
treats฀(treated)฀you.฀If฀anyone฀interrupts฀us฀I฀
will฀change฀the฀topic฀of฀conversation.฀I฀would฀
again฀like฀to฀assure฀you฀that฀your฀answers฀will฀
be฀kept฀secret,฀and฀that฀you฀do฀not฀have฀to฀
answer฀any฀questions฀that฀you฀do฀not฀want฀to.฀
May฀I฀continue?”฀฀
This฀form฀of฀introduction฀also฀ensured฀that฀
women฀were฀given฀a฀second฀opportunity฀(in฀
addition฀to฀the฀informed฀consent)฀to฀decline฀to฀
answer฀questions฀about฀violence.
Country฀adaptation฀and฀translation฀of฀
the฀questionnaire
Once฀the฀questionnaire฀had฀been฀finalized,฀
country฀teams฀were฀able฀to฀make฀minor฀
adaptations.฀Country฀modifications฀generally฀
involved฀either฀adding฀a฀limited฀number฀of฀
questions฀to฀explore฀country-specific฀issues฀
or฀modifying฀the฀response฀categories฀used฀to฀
make฀them฀appropriate฀to฀the฀particular฀setting.฀
To฀ensure฀that฀cross-country฀comparability฀
was฀not฀jeopardized,฀all฀proposed฀changes฀
were฀reviewed฀by฀the฀core฀research฀team.฀
Relatively฀significant฀changes฀were฀made฀to฀the฀
questionnaire฀only฀in฀Ethiopia,฀Japan,฀and฀Serbia฀
and฀Montenegro฀(see฀Annex฀1).
References
1.฀ Krug฀EG฀et฀al.฀World฀report฀on฀violence฀and฀health.฀
Geneva,฀World฀Health฀Organization,฀2002.
2.฀ Straus฀MA,฀Gelles฀RJ.฀Societal฀change฀and฀change฀
in฀family฀violence฀from฀1975฀to฀1985฀as฀revealed฀
by฀two฀national฀surveys.฀Journal฀of฀Marriage฀and฀
the฀Family,฀1986,฀48:465–480.
3.฀ Straus฀MA฀et฀al.฀The฀revised฀Conflict฀Tactics฀Scales฀
(CTS2).฀Journal฀of฀Family฀Issues,฀1996,฀17:283–316.
Sample฀design,฀ethical฀and฀safety฀
considerations,฀and฀response฀rates฀
This฀chapter฀contains฀basic฀information฀
on฀sample฀design,฀the฀ethical฀and฀safety฀
considerations฀in฀the฀study฀methodology,฀฀
and฀the฀response฀rates฀in฀the฀study฀sites.฀฀
Details฀on฀the฀following฀subjects฀are฀given฀in฀
Annex฀1฀Methodology:฀
1.฀฀ Ensuring฀comparability฀across฀sites฀and฀฀
sampling฀strategies
2.฀฀ Enhancing฀data฀quality฀
3.฀฀ Interviewer฀selection฀and฀training฀
4.฀฀ Respondents’฀satisfaction฀with฀the฀interview฀
5.฀฀ Data฀processing฀and฀analysis
6.฀฀ Characteristics฀of฀respondents฀
7.฀฀ Representativeness฀of฀the฀sample.
Sample฀design฀
In฀each฀country,฀the฀quantitative฀component฀
of฀the฀study฀consisted฀of฀a฀cross-sectional฀
population-based฀household฀survey฀conducted฀in฀ each฀site฀would฀give฀sufficient฀power฀to฀meet฀
one฀or฀two฀sites฀(Box฀3.1).฀
In฀Bangladesh,฀Brazil,฀Peru,฀Thailand,฀and฀
the฀United฀Republic฀of฀Tanzania,฀surveys฀were฀
conducted฀in฀two฀sites:฀one฀in฀the฀capital฀or฀
a฀large฀city;฀and฀one฀in฀a฀province฀or฀region,฀
usually฀with฀urban฀and฀rural฀populations.฀One฀
rural฀setting฀was฀used฀in฀Ethiopia,฀and฀a฀single฀
large฀city฀in฀Japan,฀Namibia,฀and฀Serbia฀and฀
Montenegro.฀In฀Samoa฀the฀whole฀country฀was฀
sampled.฀In฀this฀report,฀sites฀are฀referred฀to฀
by฀country฀name฀followed฀by฀either฀“city”฀or฀
“province”;฀where฀only฀the฀country฀name฀is฀used,฀ very฀large,฀a฀multistage฀procedure฀was฀used฀
it฀should฀be฀taken฀to฀refer฀to฀both฀sites.
The฀following฀criteria฀were฀used฀to฀help฀
select฀an฀appropriate฀province:
• ฀ availability฀of,฀or฀the฀possibility฀of฀establishing,฀ Either฀explicit฀or฀implicit฀stratification฀by฀an฀
support฀services฀for฀women฀who,฀through฀
the฀course฀of฀the฀survey,฀were฀identified฀as฀
having฀experienced฀some฀form฀of฀violence฀
and฀needing฀support;
• ฀ location฀broadly฀representative฀of฀the฀
country฀as฀a฀whole,฀in฀terms฀of฀the฀range฀of฀ in฀the฀study.฀
communities,฀ethnic฀groups฀and฀religions;
•฀ population฀not฀marginalized,฀and฀not฀
perceived฀as฀being฀likely฀to฀have฀higher฀
฀ levels฀of฀partner฀violence฀than฀in฀the฀rest฀of฀
the฀country.
In฀general,฀a฀woman฀was฀considered฀eligible฀
for฀the฀study฀if฀she฀was฀aged฀between฀15฀and฀
49฀years,฀and฀if฀she฀fulfilled฀one฀of฀the฀following฀
three฀conditions:
• ฀ she฀normally฀lived฀in฀the฀household;฀
• ฀ she฀was฀a฀domestic฀servant฀who฀slept฀for฀
five฀nights฀a฀week฀or฀more฀in฀the฀household;฀
• ฀ she฀was฀a฀visitor฀who฀had฀slept฀in฀the฀
household฀for฀at฀least฀the฀past฀4฀weeks.฀
In฀Japan,฀where฀for฀legal฀reasons฀it฀was฀not฀
feasible฀to฀interview฀women฀under฀18฀years฀of฀
age,฀women฀aged฀18–49฀years฀were฀sampled.฀
The฀initial฀sample฀size฀calculations฀suggested฀
that฀an฀obtained฀sample฀size฀of฀1500฀women฀in฀
the฀study฀objectives฀(see฀Chapter฀1).฀In฀order฀to฀
make฀up฀for฀losses฀to฀the฀sample฀as฀a฀result฀of฀
households฀without฀eligible฀women,฀refusals฀to฀
participate,฀or฀incomplete฀interviews,฀the฀initial฀
number฀of฀households฀to฀be฀visited฀was฀set฀
approximately฀20–30%฀higher฀than฀the฀target฀
sample฀size฀in฀most฀sites.฀Appendix฀Table฀1฀shows฀
details฀of฀the฀sample฀sizes฀obtained.฀
For฀most฀sites,฀a฀two-stage฀cluster฀sampling฀
scheme฀was฀used฀to฀select฀households.฀In฀
settings฀where฀the฀site฀(city฀or฀province)฀was฀
in฀which฀districts฀(or฀analogous฀administrative฀
units)฀were฀first฀selected,฀and฀then฀clusters฀
were฀selected฀from฀within฀the฀chosen฀districts.฀
appropriate฀socioeconomic฀indicator฀was฀used฀
to฀ensure฀that฀the฀sample฀was฀representative฀
of฀all฀socioeconomic฀groups.฀Depending฀on฀the฀
sampling฀frame,฀between฀22฀and฀200฀clusters฀
were฀selected฀from฀each฀of฀the฀sites฀participating฀
 SCHOULID: Indonesian Journal of School Counseling (2020), 5(2), 57-66
ISSN (Print): 2548-3234| ISSN (Electronic): 2548-3226
Open Access Journal: https://jurnal.iicet.org/index.php/schoulid
DOI: https://doi.org/10.23916/08702011

Featured Research

Kekerasan Terhadap Anak dan Perempuan

Anwar Hidayat
Institut Agama Islam Negri (IAIN) purwokerto
*) Correspondence Author, e-mail: elanwar290701@gmail.com

Abstrak: Kekerasan yang terjadi terhadap anak dan perempuan tanpa kita sadari sering
dilakukan oleh orang orang dewasa. Padahal mereka adalah orang yang memiliki tugas
sebagai pelindung anak dan perempuan yang paling utama. Parahnya sebuah survei
menyatakan 60 % wanita (ibu ) lebih sering melakukan kekerasan dari pada laki laki
(ayah). begitu pula dengan tindak kekerasan terhadap perempuan,yang dimana
kebanyakan yang menjadi pelaku adalah orang orang yang berada paling dekat dengan
mereka, seperti ayah dan juga suami. Terdapat beberapa hal yang melatar belakangi
mengapa kekerasan terhadap anak lebih banyak dilakukan oleh seorang ibu,
diantaranya adalah stress dan juga kenangan masa lalu yang suram. Kekerasan terhadap
anak dan perempuan itu dapat menyebabkan berbagai macam dampak negatif,
diantaranya ialah fisik maupun psikis. Bahkan kekerasan terhadap anak dan
perempuan itu memiliki dampak yang sangat berbahaya, yaitu dapat menyebabkan
kematian terhadap korban. Dampak lainnya yang juga berbahaya ialah trauma yang
berkepanjangan, dikhawatirkan hal tersebut akan memicu adanya pengulangan tindakan
kekerasan yang pernah dialaminya, yang menjadi korban adalah anak anak mereka
dimasa depan. Pelaku tindakan kekerasan ditindak tegas dalam peraturan perundang-
undangan. peraturan tidak memandang bulu, walaupun pelaku adalah orang tuaq
sendir tetap di tindak dengan tegas guna meminimalisir dan juga menghentikan
tindakan kekerasan yang kerap terjadi.
Kata kunci: Kekerasan, anak, perempuan
Article History: Received on 02/03/2020; Revised on 08/06/2020; Accepted on 12/06/2020;
Published Online: 11/7/2020.
This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited. ©2020 by author.
PENDAHULUAN
Retirement Salah satu tindak kejahatan yang menjadi fenomena akhir-akhir ini
adalah kekerasan seksual terutama terjadi terhadap anak-anak. Anak adalah anugerah
yang tak ternilai yang dikaruniakan oleh Tuhan pada setiap pasangan manusia untuk
dipelihara, dilindungi, dan dididik dengan baik. Ia adalah manusia yang mempunyai
kemampuan fisik, mental, dan sosial yang masih terbatas untuk mengatasi berbagai
resiko dan bahaya yang dihadapinya dan juga secara otomatis masih bergantung pada
pihak-pihak lain terutama anggota keluarga yang berperan aktif untuk melindungi dan
menjaganya. Perlindungan terhadap hidup dan penghidupan anak masih menjadi
tanggungjawab kedua orangtua, keluarganya, masyarakat dan juga negara. Perlindungan
ini dapat berupa pemenuhan kebutuhan sandang, pangan, dan papan. Tidak hanya
itu, perlindungan yang diberikan terhadap seorang anak juga dapat berupa perlindungan

57
58 Kekerasan Terhadap Anak dan Perempuan

terhadap kondisi psikologis atau mental dari anak yaitu terutama perkembangan
kejiwaannya.
Dalam pandangan islam kekerasan itu dilarang, Indonesia sebagai negara dengan
penduduk muslim terbanyak memiliki kasus kekerasan yang tinggi. Deputi Bidang
Perlindungan Anak Kementerian Pemberdayaan Perempuan dan Perlindungan Anak
(Kemen PPPA), Nahar mengatakan, sejak Januari hingga 31Juli 2020 tercatat ada 4.116
kasus kekerasan pada anak di Indonesia.Menurut dia, dari angka tersebut yang paling
banyak dialami oleh anak adalah kekerasan seksual.Hal itu ia katakan berdasarkan data
Sistem Informasi Online Perlindungan Perempuan dan Anak (Simfoni PPA) sejak 1
Januari hingga 31 Juli 2020."Dari angka ini (4.116 kasus), angka yang paling tinggi itu
angka korban kekerasan seksual.
Kurangnya kesadaran dan rendahnya pendidikan berpotensi menimbulkan tindak
kekerasan seksual. Tanggung jawab orang tua terhadap anak sangat penting
dibandingkan dengan orang lain, namun harus ada dukungan masyarakat dalam
menjaga antar sesama dan peduli dengan masalah kekerasan ini agar dapat
mencegah kekerasan seksual terhadap anak. Maka dari itu harus ada upaya untuk
mangajak orang tua agar mengajarkan pendidikan seksual yang baik pada anak dan
meningkatkan kesadaran masyarakat tentang pentingnya menjaga anak dari kekerasan
seksual.
Kekerasan seksual pada anak dapat terjadi di waktu, tempat dan pelaku yang tak
terduga. Namun pelaku kekerasan seksual pada anak umumnya adalah orang yang
dikenal anak (66%) termasuk orang tuanya sendiri (7,2%) (Paramastri, 2010: h.2). Fakta
tersebut menunjukan bahwa pelaku kekerasan seksual pada anak kebanyakan bukan dari
orang lain yang belum pernah dikenal anak melainkan sebaliknya. Huraerah (2012)
menjelaskan bahwa kekerasan seksual sering terjadi di rumah (48%), tempat umum
(6,1%), sekolah (4,1%), tempat kerja (3,0%), lain- lain (0,4%). Hal ini menunjukan bahwa
rumah merupakan tempat yang pada umumnya sering dijadikan tempat kekerasan
tersebut.Jika masalah ini terus dibiarkan, maka jumlah kasus seksual pada anak
akan terus mengalami peningkatan dan akan berdampak buruk bagi anak. Dampak
dari kekerasan seksual secara fisik dapat berupa luka pada bagian intim anak, Dampak
psikologi meliputi trauma mental, ketakutan, malu, kecemasan bahkan keinginan atau
percobaan bunuh diri. Selain itu dampak sosial yang akan dialami anak adalah perlakuan
sinis dari masyarakat di sekelilingnya dan takut untuk berinteraksi. Kekerasan seksual
terhadap anak akan menjadi trauma yang berkepanjangan hingga dewasa, disamping
itu kekerasan seksual terhadap anak akan berdampak pada masalah kesehatan di
kemudian hari.
Berangkat dari latar belakang masalah tersebut maka penulis menawarkan
pendekatan keterkaitan kekerasan dengan hukum agama. Dalam khazanah Islam, tindak
kekerasan adalah tindakan penganiayaan atau perbuatan dzalim kepada orang lain
yang dilarang,penulis dengan ini mengharapkan kekerasan seksual dapat
diminimalisir bahkan bisa dicegah.

SCHOULID: Indonesian Journal of School Counseling

Open Access Journal: https://jurnal.iicet.org/index.php/schoulid
 Anwar Hidayat 59

PEMBAHASAN
Sejak kecil kita semua telah mengenal berbagai macam bentuk kekerasan, baik
kekerasan terhadap ana maupun kekerasan terhadap perempuan. Kekerasan
tersebut berupa kekerasan verbal, kekerasan fisik bahkan kekerasan seksual. Kekerasan
sudah sangat melekat dengan diri kita sejak kecil. Kekerasan bisa menimpa siapa saja,
kapan saja dan dimana saja.Tindakan kekerasan adalah tindakan fisik baik dengan
sengaja maupun dalam bentuk lainnya seperti ancaman ataupun perbuatan lainnya
terhadap orang yang dapat menyebabkan cidera, depresi, kerugian psikologi bahkan
kematian. Kekerasan terhadap anak ialah segala perbuatan yang dapat menimbulkan
suatu kesengsaraan dan penderitaan baik secar fisikfisik, mental, seksual, psikologis
termasuk perlakuan yang merendahkan martabat anak.
Definisi kekerasan terhadap anak menurut WHO mencakup semua bentuk
perlakuan yang salah baik secara fisik dan/atau emosional, seksual, penelantaran, dan
eksploitasi yang berdampak atau berpotensi membahayakan kesehatan anak,
perkembangan anak, atau harga diri anak dalam konteks hubungan tanggung
jawab. Berdasarkan definisi tersebut, kekerasan anak dapat berupa kekerasan fisik,
kekerasan seksual dan kekerasan emosional atau psikis. Kekerasan fisik terhadap anak
merupakan kekerasan yang kemungkinan besar terjadi. Termasuk dalam kekerasan fisik
adalah ketika seseorang menggunakan anggota tubuhnya atau obyek yang bisa
membahayakan seorang anak atau mengontrol kegiatan/tindakan anak. Kekerasan fisik
dapat berupa mendorong, menarik rambut, menedang, menggigit, menonjok,
membakar, melukai dengan benda, dan jenis kekerasan fisik lain termasuk
membunuh. Kekerasan terhadap anak juga dapat dipandang dari sisi perlindungan anak.
UNICEF mendefiniskan ‘perlindungan anak’ sebagai cara yang terukur untuk
mencegah dan memerangi kekerasan, eksploitasi, memperlakukan tidak semestinya
terhadap anak termasuk eksploitasi seksual untuk tujuan komersial, perdagangan anak,
pekerja anak dan tradisi yang membahayakan anak seperti sunat perempuan dan
perkawinan anak. Dalam kontek tersebut jelas bahwa kekerasan anak tercermin dalam
berbagai aspek terkait perlindungan anak sesuai dengan definisi dari UNICEF. Jenis
kekerasan terhadap anak berikutnya adalah kekerasan seksual dan psikis. Kekerasan
seksual terhadap anak mencakup beberapa hal seperti menyentuh anak yang
bermodus seksual, memaksa hubungan seksual, memaksa anak untuk melakukan
tindakan secara seksual, memperlihatkan bagian tubuh untuk dipertontonkan,
prostitusi dan eksploitasi seksual, dan lain-lain. Selanjutnya kekerasan psikis terjadi
ketika seseorang menggunakan ancaman dan menakut- nakuti seorang anak termasuk
mengisolasi dari keluarga dan teman. Kekerasan yang juga sangat dekat dengan
kekerasan psikis adalah kekerasan emosional melalui perkataan atau perbuatan yang
membuat anak merasa bodoh atau tak berharga. Kekerasan emosional mencakup antara
lain mengkritik terus menerus, menyalahkan semua masalah keluarga kepada anak,
memalukan anak di depan orang lain, intimidasi, dan lain-lain.
Kekerasan seksual pelakunya bisa guru/dosen, tenaga pendidik, tokoh agama
yang berperan sebagai pendidik, tokoh masyarakat, guru besar/professor, teman, pacar,
teman, pejabat stuktural sekolah/kampus, pihak luar sekolah/kampus yang berperan
membantu Terselenggaranya pendidikan. Fakta menemukan bahwa kebanyakan pelaku
kekerasan seksual adalah orang-orang yang dikenal oleh korban.
60 Kekerasan Terhadap Anak dan Perempuan

Kekerasan terhadap anak yang dilakukan oleh orang tua yang stress antara lain: (1)
Kekerasan fisik yaitu merupakan segala tindakan yang dapat mengakibatkan kerusakan
yang dapat dilihat seperti memukul, menendang, menusuk, menyayat, menampar dan
lain lain. Seringkali semua orang tua tidak mampu menahan emosi mereka ketika anak
tidak patuh dan sering membuat marah mereka, orang tua Sering sekali meresponnya
dengan tindakan fisik, seperti memukul, mencubit, menendang, menjewer dan lain
sebagainya. Mereka tidak sadar atas apa yang mereka lakukan terhadap anak anak
mereka. Seharusnya orang tua menanggapi perilaku anak mereka yang nakal dengan cara
kasih sayang, dengan cara seperti itu anak akan lebih mudah untuk menyadari
kesalahannya. (2) Kekerasan psikologis yang mengarah kepada tindakan yang dapat
mengintimidasi dan mengancam. tidak peduli, menghina, mengisolasi, penolakan dan
teror merupakan bagian dari klasifikasi kekerasan psikologis. Orang tua pada masa
sekarang ini banyak yang tidak peduli terhadap anaknya sendiri, diera globalisasi ini
teknologi semakin canggih. mereka lebih sibuk dan asik bermain gadget yang semakin
melupakan kewajiban orang tua terhadap anak. (3)Kekerasan seksual yang sering terjadi
pada anak anak, merek dipaksa dan diancam untuk melakukan tindak seksual yang tidak
mereka inginkan. Kekerasan seksual sering terjadi dilingkungan keluarga yang kurang
akan pendidikan, jika seorang anak mengenal seks tanpa disertai edukasi yang baik, otak
anak akan rusak karena mengalami kecanduan terhadap segala sesuatu yang berbau
seksual. Hal seperti ini dapat mengganggu atau bahkan menghancurkan masa depan
anak tersebut. (4)Kekerasan ekonomi adalah kekerasan yang berupa tindakan tindakan
penolakan kebutuhan dasar anak. Kebutuhan makanan dan gizi anak tidak
terpenuhi secara maksimal, hal tersebut dapat mengganggu pertumbuhan anak, sehingga
anak akan kesulitan dalam menggapai masa depannya
Faktor faktor penyebab kekerasan terhadap anak diantaranya ialah (1) Pernikahan
usia muda,hal ini menjadi salah satu penyebab terjadinya kekerasan, hal ini disebabkan
karena orang yang melakukan pernikahan usia muda belum siap menjadi pembimbing
bagi anak anak mereka. Orang tua yang menikah pada usia muda masih memiliki
keinginan untuk merasakan kebebasan, dan merek belum tau apa tanggung jawab
mereka terhadap Anak anak mereka. (2)Kurangnya ilmu, orang tua yang memiliki
kekurangan dalam ilmu tidak dapat menangani dan memahami fase pertumbuhan
dan kebutuhan anak. Mereka lebih sering melakukan tindakan yang berbau kekerasan
tanpa memikirkan dampak yang ditimbulkan terhadap psikologi anak. (3) Masalah
ekonomi,orang tua yang memiliki permasalahan dalam ekonomi kurang memperhatikan
kebutuhan anaknya. Bahkan ada orang tua yang mengeksploitasi anaknya demi
memenuhi kebutuhan ekonomi keluarga. (4) Konflik keluarga, konflik antara suami dan
istri sering terjadi dalam kehidupan sehari-hari. Hal tersebut berpengaruh terhadap
emosi orang tua yang sulit dikontrol, bahkan orang tua yang sedang mengalami konflik
bisa saja melampiaskan kemarahannya terhadap anak. (5) Perceraian, banyak terjadi
pada pasangan suami istri yang mengalami masalah, orang yang mengalami
perceraian akan memiliki tanggung jawab yang lebih besar. Hubungan dengan anak bisa
menjadi renggang dan anak akan menemukan jati diri mereka dengan cara pergaulan
yang salah. (6) Kegagalan dalam bersosialisasi dengan masyarakat, kegagalan orang tua
untuk bersosialisasi dengan masyarakat akan menyebabkan pengucilan terhadap
keluarga tersebut. Hal ini akan berdampak juga terhadap anak, anak akan dikucilkan oleh
teman temannya bahkan anak anak akan mendapatkan perlakuan kekerasan. (7) Luka

SCHOULID: Indonesian Journal of School Counseling

Open Access Journal: https://jurnal.iicet.org/index.php/schoulid
 Anwar Hidayat 61

batin, orang tua yang memiliki luka batin akan sulit membedakan mana tindakan yang
salah dan mana tindakan yang benar. Mereka akan cenderung lebih emosional dan hal
tersebut akan berdampak buruk bagi anak anaknya.

Kekerasan terhadap anak yang dilakukan orang tua dimasa pandemi covid 19
Kekerasan terhadap anak pada masa pandemi covid 19 dimulai pada saat
pemerintah menerapkan PSBB terhadap masyarakat. Pemerintah menganjurkan
masyarakat untuk tetap berada di rumah dan menggunakan protokol kesehatan dalam
rangka memutuskan mata rantai virus covid 19. Kekerasan terhadap anak terjadi
karena dua faktor, yang pertama ialah konflik yang terjadi anatar orang tua dengan
anaknya. Kedua ialah faktor ekonomi yang semakin menurun yang terjadi akibat covid
19.
Upaya yang dapat dilakukan guna meminimalisir kekerasan tersebut diantaranya:
1)Saling memberi pemahaman bahwasanya setiap anak berhak mendapatkan
perlindungan dari orang tua,2) Orang tua harus meningkatkan rasa kepedulian terhadap
anak mereka.3) Pemerintah harus lebih tegas dalam menegakkan hukum.
Teori tentang penyebab tindak kekerasan terhadap perempuan diambil dari
literatur tentang agresi dan kekerasan umum. Baik penelitian tentang kekerasan
umum maupun kekerasan terhadap perempuan menunjukkan bahwa kekerasan timbul
dari interaksi antara faktor sosial dan psikososial individu dan proses sosial (misalnya
Reiss dan Roth, 1993). Tetapi yang jelas bahwa faktor penyebab terjadinya kekerasan bisa
sangat kompleks. Hosking (2005) menyebutkan bahwa secara umum penyebab terjadinya
tindak kekerasan dapat dikelompokkan menjadi dua yaitu faktor individu dan faktor
sosial. Faktor individu berkaitan erat dengan kecendrungan individu untuk berbuat
kekerasan. Sementara itu, faktor sosial merupakan kondisi lingkungan yang mendorong
seseorang berbuat kekerasan.
Faktor individu
Dari sisi psikologis, motivasi utama untuk melakukan tindak kekerasan dapat
dipandang sebagai ketidakmampuan untuk menahan emosi, bahkan kekerasan
digunakan media mengeskpresikan perasaan seseorang seperti marah, frustasi atau sedih
(Jacobson 2011). Kesulitan mengontrol emosi sering menjadikan seseorang berbuat
kekerasan. Perilaku kekerasan terkadang juga disebabkan karena orang tumbuh di
lingkungan dimana kekerasan sering dipertontonkan, sehingga kekerasan dipahami
sebagai perilaku yang wajar. Terkadang kekerasan yang dilakukan individu digunakan
sebagai cara-cara memengaruhi orang lain untuk mengendalikan situasi.
Beberapa faktor yang melekat pada individu pelaku kekerasan juga dapat
dipengaruhi oleh berbagai hal seperti pengaruh teman sejawat, kurang perhatian, merasa
tidak berharga keberadaannya, pernah mengalami perlakuan buruk, dan menyaksikan
kekerasan di rumah atau di luar rumah.Menurut Hosking (2005), faktor utama akan
kecenderungan seseorang untuk berbuat kekerasan adalah kurangnya rasa empati.
Meskipun seorang bayi yang lahir dipenuhi kapasitas empati pada dirinya, akan tetapi
tumbuhnya rasa empati tersebut bergantung pada apa yang dia pelajarai dan lihat dari
reaksi orang dewasa terhadap penderitaan atau rasa sakit orang lain.
62 Kekerasan Terhadap Anak dan Perempuan

Faktor Sosial Budaya

Kondisi sosial yang dapat mendorong terjadinya kekerasan sering merefleksikan
adanya ketimpangan sosial atau ekonomi antar kelompok masyarakat. Terkait dengan
kekerasan terhadap perempuan Hosking (2005) menyatakan bahwa sejumlah penelitian
mengidentifikasi keterkaitan antara ketimpangan gender dengan tingkat kekerasan
terhadap perempuan. Jacobson (2011) mengidentifikasi beberapa faktor sosial yang
mungkin menciptakan kondisi yang mengantarkan pada terjadinya kekerasan antara
lain: a) Sikap permisif masyarakat akan kekerasan terhadap perempuan, b) Kontrol laki-
laki dalam pengambilan keputusan dan pembatasan terhadap kebebasan perempuan
c) Identitas dan peran laki-laki dan perempuan yang kaku di masyarakat d. Hubungan
antar sesama yang merendahkan perempuan e) lingkungan kumuh dan padat penduduk
f) Keterpaparan pada kekerasan.

Kekerasan terhadap perempuan

Kekerasan terhadap perempuan merupakan realita yang terjadi sepanjang
masa. Hal yang telah terjadi ini, juga menarik perhatian untuk dibicarakan. Banyak
media yang digunakan dari agama, budaya sampai persoalan sosial politik. Akibatnya,
sikap yang timbul menjadi lebih beragam antara satu dengan yang lain, pendekatan dan
teorinya juga berbeda beda keinginan untuk melindungi hak-hak perempuan
menyebabkan munculnya gerakan lembaga atau organisasi, Pelanggaran seperti
pelecehan seksual yang sering terjadi di masyarakat, telah diatur dalam undang-undang
hukum pidana. peran lembaga yang turut melindungi hak-hak kaum perempuan
dari tindak kerkerasan bisa kita lihat. Persoalanya, terkadang perlindungan hukum
terhadap kaum perempuan kurang menjangkau rumah tangga. Bahkan yang sering
melakukan tindak kekerasan tersebut merupakan suaminya sendiri. Dengan hal ini kita
bisa mengetahui bahwa adanya pemahaman yang kurang tentang hak dan kewajiban.
Kondisi pada masa lalu, tidak mutlak diterapkan pada masa sekarang. Kita boleh
mengaplikasikan konsep keagamaan dalam bingkai kekinian. Salah satu penyebabnya
tindak kekerasan terhadap perempuan, adalah dominannya penafsiran yang salah
yang sering dilakukan oleh kaum laki-laki. Sekalipun agama secara mutlak tidak
pernah membedakan kedudukan laki-laki dan perempuan, penafsiran terhadapnya
sangat rentan mengarah kepada kedudukan perempuan. Agama dengan begitu sering
dijadikan sebagai sebuah dalil kekerasan terhadap perempuan. Parahnya, saat
bertemunya agama dengan budaya, hal ini sudah menjadi barang baku yang tidak bisa
dipertentangkan.
Pada hakikatnya agama tidak mengajarkan kezaliman atau kekerasan.oleh karena
itu agama harus menjunjung keadilan, sekalipun budaya pada hakikatnya adalah produk
manusia dan karena itu pula budaya dapat dirubah. Dalam asumsi penulis, aplikasi
keagamaan perlu dilakukan dalam situasi kekinian. penafsiran konsep atau teks, perlu
disesuaikan dengan masa saat ini. Dalam situasi ini,para tokoh agama sangat berperan
penting dalam memberikan ajaran terhadap masyarakat. Selain itu para tokoh
agama juga harus mampu melakukan pendekatan budaya. peranan tokoh agama
bisa memuaskan segala pihak yang terlibat.

SCHOULID: Indonesian Journal of School Counseling

Open Access Journal: https://jurnal.iicet.org/index.php/schoulid
 Anwar Hidayat 63

Tindak kekerasan terhadap perempuan sering dilihat dari satu sisi agama,
kekerasan dalam rumah tangga yang dialasi dengan agama sangat merugikan
perempuan. Dalam hal inilah, konsep pluralisme beragama menemukan
bentuknya dengan konsep hukum positif bangsa Indonesia. Pemilihan gender sebagai
salah satu permasalahan yang mewarnai wacana pemikiran Islam, menuju asumsi bahwa
persoalan ini memang sangatlah menarik untuk dikaji. Bukan hanya karena
permasalahan gender adalah suatu elemen yang penting dalam struktur
masyarakat,akan tetapi karena di dalamnya terdapat elemen-elemen lain yang cukup
bersangkut paut dengan agama, politik dan budaya. Permasalahan gender dalam
pemikiran Islam muncul karena adanya kesadaran dalam memahami sebuah wawasan
Islam tentang perempuan.
Mengomentari hal di atas, Nurcholis Madjid mengatakan bahwa permunculan
masalah perempuan adalah absah, otentik dan sejati. Ia juga mengatakan bahwa Islam
pemuncul masalah ini, juga terasa bersifat emosional, apologi, ideologis dan tidak jarang
subjektif, sekalipun menurut Cak Nur memancarkan perenungan dan pemikir kreatif
orisinal. Seperti diketahui, dalam pandangan sosiologis, agama tidak hanya dilihat secara
ideologis sebagai kepercayaan terhadap Tuhan, akan tetapi juga dilihat secara praktis
sebagai sebuah peribadatan. Agama adalah salah satu struktur institusional penting
yang melengkapi keseluruhan sistem sosial. Atau dengan kata lain, fungsi sosial agama
merupakan faktor yang sangat menentukan berlangsungnya sistem sosial. Signifikansi
tersebut dapat dilihat dari adanya tujuan keberagamaan yang dilakukan manusia;
misalnya untuk mendapatkan kebahagiaan, ketenangan dan keteraturan. Oleh karena itu,
dalam pandangan sosiologis, masyarakat dianggap sebagai suatu "lembaga" sosial yang
berada dalam keseimbangan yang merupakan kegiatan manusia berdasarkan
normanorma yang dianut bersama serta dianggap sah dan mengikat peran serta manusia
itu sendiri. muncul karena adanya sebuah penafsiran terhadap Kitab Suci yang berbicara
tentang kedudukan laki-laki dan perempuan. Dalam al-Quran, misalnya, Tuhan
mengatakan bahwa "laki-laki adalah pemimpin bagi perempuan". Dalam beberapa kasus,
kedudukan perempuan dianggap berada di bawah laki-laki,hal ini sering dijadikan
sebuah alasan menganggap bahwa seorang laki-laki lebih tinggi dibandingkan
perempuan. Pendapat ini berdasarkan pemahaman bahwa agama telah memberikan
keistimewaan terhadap laki-laki yang berbeda dengan apa yang dimiliki oleh perempuan.
Secara sosiologis, pemberian tersebut telah memunculkan sikap dan pemahaman
terhadap budaya patriarki. Islam merupakan agama yang diturunkan di tanah Arab,
Sebagai agama yang menjunjung prinsip kesetaraan, Islam menegaskan bahwa manusia
yang paling mulia adalah mereka yang paling bertakwa kepada allah SWT. Menurut
penulis, penafsiran terhadap teks-teks Kitab Suci seperti disebutkan dalam kasus ini,
sering dijadikan justifikasi terhadap suatu realitas. Dalam keadaan seperti ini, kita
menemukan sebuah pertentangan terhadap penafsiran yang dianggap berat sebelah.
Fatimah Mernissi, Nawal Sa'adawi dan Aminah Wadud Muhsin, serta beberapa nama
yang bersifat lokal di Indonesia seperti Wardah Hafidz, Lies Marcoes Natsir dan Siti
Ruhaini, berusaha membongkar berbagai macam pengetahuan yang normative.
Pandangan klasik Islam yang membuat subordinasi terhadap perempuan dalam
berbagai sektor, tidak diterima secara tegas oleh kaum feminis. Penolakan yang didasari
karena pertimbangan ideologis tersebut dilakukan untuk menghilangkan kecenderungan
64 Kekerasan Terhadap Anak dan Perempuan

penerapan sifat-sifat keperempuan (female medest) seperti emosional, penurut dan milik
laki-laki. Penerapan ini juga yang kemudian menimbulkan implikasi sosiologis dan
membawa kaum perempuan kepada posisi ditindas, dianiaya dan dizalimi. Terdapat
banyak kasus dari kecenderungan subordinasi ini membuat perempuan diperlakukan
secara tidak adil oleh laki-laki yang mengatasnamakan agama. penganiayaan terhadap
istri bisa dianggap sebagai suatu tindak kekerasan terhadap perempuan.
Bentuk bentuk kekerasan seksual
Bentuk kekerasan seksual antara lain 1) Pemerkosaan yang merupakan tindakan
pemaksaan seksual yang menggunakan alat kelamin laki-laki ke alat kelamin perempuan.
Perkosaan adalah konspirasi politik patriarkis. Sistem patriarki menempatkan
perempuan sebagai makhluk kelas dua. Posisi perempuan sebagai subordinat bermula
dari konsep dikotomik atau oposisi biner. 2) Intimidasi seksual yaitu Tindakan intimidasi
seksual akan berpengaruh terhadap psikis korban. 3) Pelecehan seksual yaitu tindakan
fisik dengan sasaran bagian seksual korban. 4) Prostitusi, merupakan tindakan dimana
perempuan dipaksa sebagai pekerja seksual. 5) Pemaksaan aborsi yaitu tindakan yang
memaksa untuk menggugurkan kandungan.
Komitmen pemerintah dalam melindungi perempuan dan anak ditunjang oleh
peraturan perundang-undangan. Sejumlah undang-undang yang mendukung program
mengakhiri kekerasan terhadap perempuan dan anak antara lain Undang-Undang
Dasar 1945, Undang-Undang Nomor 4 Tahun 1979 tentang Kesejahteraan Anak,
Undang-Undang Nomor 29 Tahun 1999 tentang Ratifikasi Penghapusan Diskriminasi
Rasial,Undang-Undang Nomor 39 Tahun 1999 tentang Hak Azasi Manusia, Undang-
Undang Nomor 1 Tahun 2000 tentang Pengesahan Konvensi ILO Nomor 182, Undang-
Undang Nomor 23 Tahun 2002 tentang Perlindungan Anak, Undang-Undang Nomor 13
Tahun 2003 tentang Ketenagakerjaan, Undang-Undang Nomor 20 Tahun 2003
tentang Sistem Pendidikan Nasional, dan Undang-Undang Nomor 23 Tahun 2004
tentang Penghapusan Kekerasan Dalam Rumah Tangga. Kemudian untuk Undang-
Undang Nomor 23 Tahun 2002 tentang Perlindungan Anak diperbaharui dan dirubah
dengan Undang-Undang Nomor 35 Tahun 2014.
Perlindungan yang dilakukan oleh pemerintah terhadap anak dan juga perempuan
dilakukan oleh Kementerian Pemberdayaan Perempuan dan Perlindungan Anak serta
kementerian dan lembaga terkait. Agar kekerasan terhadap anak dan perempuan dapat
berakhir, pemerintah perlu mengambil tindakan tindakan yang dapat menghentikan
kekerasan yang terjadi. Diantaranya ialah : 1) Menjamin informasi hak aperempuan dan
anak yang menjangkau seluruh masyarakat Indonesia. 2) Memastikan berfungsinya
kelembagaan di tingkat desa untuk menjamin pemenuhan hak perempuan dan anak. 3)
Memastikan berfungsinya Satgas Perlindungan Perempuan dan Anak di daerah. 4)
Menggalang dukungan yang masif dari pemangku kepentingan.
Perlindungan terhadap wanita adalah suatu upaya dalam melindungi hak hak
seorang wanita, terutama untuk memberikan sebuah rasa aman dalam pemenuhan hak-
haknya dengan memberikan perhatian yang konsisten dan sistematik yang pada
hakekatnya ditujukan untuk mewujudkan keadilan dan kesetaraan gender.
Dalam Undang-undang Nomor 23 tahun 2004, pemerintah berupaya menghapus
kekerasan khususnya kekerasan terhadap perempuan yang terjadi dalam rumah tangga.

SCHOULID: Indonesian Journal of School Counseling

Open Access Journal: https://jurnal.iicet.org/index.php/schoulid
 Anwar Hidayat 65

Kekerasan terhadap perempuan dalam Undang-undang tersebut didefinisikan sebagai

setiap perbuatan terhadap seseorang terutama perempuan, yang berakibat timbulnya
kesengsaraan atau penderitaan secara fisik, seksual, psikologis, dan/atau
penelantaran rumah tangga termasuk ancaman untuk melakukan perbuatan,
pemaksaan, atau perampasan kemerdekaan secara melawan hukum dalam lingkup
rumah tangga. Dalam undang-undang tersebut, penghapusan kekerasan dalam
rumah tangga bertujuan untuk mencegah segala bentuk kekerasan dalam rumah tangga,
melindungi korban kekerasan dalam rumah tangga, menindak pelaku kekerasan dalam
rumah tangga, dan memelihara keutuhan rumah tangga yang harmonis dan sejahtera.
Berikut ini adalah kekerasan yang dilakukan oleh pasangan dan anggota keluarga :
1) Kekerasan ekonomi termasuk tindakan menolak memberikan uang belanja, menolak
memberikan makan dan kebutuhan dasar, dan mengendalikan akses terhadap pekerjaan.
2)Kekerasan seksual seperti pemaksaan hubungan seksual melalui ancaman, intimidasi
atau kekuatan fisik, memaksakan hubungan seksual yang tidak diinginkan atau memaksa
hubungan seksual dengan orang lain. 3) Kekerasan fisik seperti menampar, memukul,
memutar lengan, menikam, mencekik, membakar, menendang, ancaman dengan benda
atau senjata, dan pembunuhan. Ini juga termasuk praktek berbahaya bagi perempuan
seperti mutilasi alat kelamin perempuan 4) Kekerasan psikologis yang meliputi perilaku
yang dimaksudkan untuk mengintimidasi dan menganiaya, dan bentuk ancaman berupa
ditinggalkan atau disiksa, dikurung di rumah, ancaman untuk mengambil hak asuh anak-
anak, penghancuran benda-benda, isolasi, agresi verbal dan penghinaan terus
menerus.
Sumber yang paling utama dalam islam adalah al Quran, al Quran merupakan
sebuah kitab yang didalamnya berisi sebuah petunjuk. Al Quran sendiri bukanlah
sebuah Kitab sains dimana akan berbahaya apabila menyandingkannya dengan sains.
Epistemologi keilmuan Islam akan menjawab pertanyaan pertanyaan ilmiah yang ada
didalam al Quran. Kajian kajian perilaku keagamaan umat muslim yang
dilakukan oleh Frederick M denny, pendekatan sosiologis yang terlalu sosiologis kurang
memiliki kedalaman pemaknaan ajaran dan ekspresi keagamaan yang lahir dalam ajaran
ajaran tersebut.
Islam secara tegas dan jelas melarang kekerasan terhadap anak. Tetapi ada salah
satu hadist mengatakan ‚Perintahkanlah anak-anakmu untuk solat ketika mereka
berumur tujuh tahun. Pukulah mereka jika sampai berusia sepuluh tahun mereka tetap
enggan untuk melaksanakan solat‛ (Abu Daud:495 dan Ahmad:6650, dishahihkan oleh
Al-Albany dalam Irwa’u Ghalil, no. 247). Hadist tersebut tentunya bertentangan dengan
konsep bahwa anak tidak boleh mendapatkan kekerasan. Namun, adanya hadist ini
bukanlah semata-mata tanpa adanya alasan yang jelas. Hukuman fisik diberikan bukan
hukuman yang dapat menimbulkan efek trauma dan cidera pada anak. Kekerasan anak
dalam islam diperbolehkan jika tidak melebihi batas dan digunakan sebagai langkah
akhir yang ditempuh. Kekerasan ini akan dilakukan jika dirasa tidak ada lagi hukuman
yang dapat membuat anak jera. Hal ini juga hanya digunakan sebagai upaya yang
mendidik bukan dengan tujuan untuk menghukum tanpa alasan. Karena jika anak
dibiarkan bebas tanpa aturan, maka akan berdampak buruk bagi anak. Anak bisa
menyimpang dari aturan agama, bertindak semaunya, dan perilaku negatiflainnya.
Jadi kesimpulannya, kekerasan anak dalam Islam tidak diperbolehkan kecuali dalam
66 Kekerasan Terhadap Anak dan Perempuan

kondisi yang darurat dan tidak ada cara lain lagi. Namun itupun harus dilakukan dengan
syarat hukuman tersebut bersifat ringan dan tidak menganiaya. Islam lebih
menganjurkan untuk memperlakukan anak-anak dengan kasih sayang dan pemahaman
nilai agama semenjak dini. Dengan begitu anak pun tumbuh menjadi pribadi yang
berakhlaqul karimah.

KESIMPULAN
Berdasarkan pembahasan yang telah dipaparkan, maka dapat disimpulkan
bahwa pada hakikatnya agama tidak mengajarkan kezaliman atau kekerasan.oleh karena
itu agama harus menjunjung keadilan, sekalipun budaya pada hakikatnya adalah produk
manusia dan karena itu pula budaya dapat dirubah. Dalam asumsi penulis, aplikasi
keagamaan perlu dilakukan dalam situasi kekinian. penafsiran konsep atau teks, perlu
disesuaikan dengan masa saat ini. Dalam situasi ini,para tokoh agama sangat berperan
penting dalam memberikan ajaran terhadap masyarakat. Selain itu para tokoh agama juga
harus mampu melakukan pendekatan budaya. peranan tokoh agama bisa memuaskan
segala pihak yang terlibat.

REFERENSI
Kementrian pemberdayaan perempuan dan perlindungan anak. (2017). Mengenal
Kekerasan terhadap perempuan dan anak. Jakarta : Kementerian Pemberdayaan
Perempuan dan Perlindungan Anak.
Ahsinin, adzkar. diyah stiawati. Fr. Yohana Tantria Wardhani. Prof. Dr. Sulistiyowati
Irianto. MAVeronica,SH.,MA.Mencegah dan Menangani Kekerasan Seksual terhdap
Perempuan dan Anak di Lingkungan Pendidikan.
Maknun,lulu'il.(2016). Kekerasan terhadap anak oleh orang tua yang stres. Jakarta:UIN Syarif
Hidayatullah.
kandedes, lin. (2020). Kekerasan terhadap anak dimasa pandemi covid19 .Jakarta : UIN Syarif
Hidayatullah.
Hasbi, Muhammad. (2017). kekerasan terhadap perempuan menurut tinjauan agama dan
sosiologi . Watampone : STAIN watampone.
Hana, lidwina.( 2016).'Kasus Pemerkosaan dan Pembunuhan Yuyun dalam Kacamata
Kultur Patriarki". Jurnal studi kultural volume 1 ( hal 126) Komnas perempuan. 15
bentuk kekerasan seksual.
Kementerian Pemberdayaan Perempuan dan Perlindungan Anak. Mengakhiri kekerasan
terhadap perempuan dan anak di Indonesia.
Hidayat, fahri.(2015). "Pengembangan Paradigma Integrasi Ilmu: Harmonisasi Islam dan
Sains dalam Pendidikan", Jurnal pendidikan Islam Volume 4 ( Hal. 317).
Hidayat, fahri. (2019). "Perspektif Peneliti Outsider Terhadap Perilaku Keagamaan Masyarakat
Muslim (Kajian pada Pemikiran Frederick M. Denny)". Jurnal studi islam volume 14 ( Hal
111).

SCHOULID: Indonesian Journal of School Counseling

Open Access Journal: https://jurnal.iicet.org/index.php/schoulid
Colombini et al. BMC Health Services Research 2013, 13:65
http://www.biomedcentral.com/1472-6963/13/65

RESEARCH ARTICLE Open Access

“I feel it is not enough. . .” Health providers’

perspectives on services for victims of intimate
partner violence in Malaysia
Manuela Colombini1*, Susannah Mayhew1, Siti Hawa Ali2, Rashidah Shuib3 and Charlotte Watts1

Abstract
Background: This study explores the views and attitudes of health providers in Malaysia towards intimate partner
violence (IPV) and abused women and considers whether and how their views affect the provision or quality of
services. The impact of provider attitudes on the provision of services for women experiencing violence is
particularly important to understand since there is a need to ensure that these women are not re-victimised by the
health sector, but are treated sensitively.
Methods: In-depth interviews were conducted with 54 health care providers responsible for providing services to
survivors of IPV and working in health care facilities in two Northern States in Malaysia. A thematic framework
analysis method was employed to analyse the emerging themes. Interviews were coded and managed by using
NVIVO (N7), a qualitative software package.
Results: We found that when providers follow the traditional role of treating and solving IPV as “medical problem”,
they tend to focus on the physical aspect of the injury, minimise the underlying cause of the problem and ignore
emotional care for patients. Providers frequently felt under-trained and poorly supported in their role to help
women beyond merely treating their physical injuries. What emerged from the findings is that time shortages may
well impact on the ability of medical officers to identify cases of abuse, with some saying that time limitations
made it more difficult to detect the real problem behind the injury. However, data from the interviews seem to
suggest that time constraints may or may not end up resulting in limited care, depending on the individual interest
of medical professionals on violence issues.
Conclusions: Promoting empathetic health care provision is challenging. More awareness training and sensitisation
could help, especially if courses focus on women’s needs and strengths and how health providers can validate
these and contribute to a longer term process of change for victims of violence. Clear guidance on how to record
history of abuse, ask questions sensitively and validate experiences is also important together with training on good
communication skills such as listening and being empathetic.
Keywords: Health providers, Intimate partner violence, Malaysia, Views and Attitudes

* Correspondence: manuela.colombini@lshtm.ac.uk
1
Department of Global Health and Development, London School of Hygiene
and Tropical Medicine, London, UK
Full list of author information is available at the end of the article

© 2013 Colombini et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
Colombini et al. BMC Health Services Research 2013, 13:65
http://www.biomedcentral.com/1472-6963/13/65
Background
Intimate partner violence (IPV) against women is a
human rights violation and a global public health con-
cern, as demonstrated by research over the past decade
[1-3]. Globally, the WHO multi-country study on
women’s health and domestic violence found that the
lifetime prevalence of physical or sexual partner vio-
lence, or both, varied between 15% and 71% in 10 coun-
tries [4].
A major concern often argued in the provision of
services for violence against women is to ensure that
women are not re-victimised by the health sector, but
are treated sensitively [5]. Many studies have discussed
health providers’ views and beliefs on IPV and their im-
pact on the quality of services [6-13]. Others have shown
that their judgmental and directive attitudes and their
lack of knowledge represent a major obstacle for abused
women, often resulting in low disclosure [14-18].
Misconceptions and stereotypes around IPV are present
among many clinicians, who may feel that violence is
normal, who may hold negative views about providing
services for IPV, or think that women are to blame for
their husband’s aggression, [2,19-25], or who seem to be
more focused on physical illness [7,26]. Health care
providers’ clinical responses are shaped by own personal
experiences and socio-cultural beliefs [27]. Providers
often share the same cultural norms and practices of
their patients, and similar gender values on IPV of the
community – often experiencing violence themselves, as
demonstrated by research from South Africa and the UK
[7,22].
Moreover, the lack of training and knowledge about
IPV combined with new tasks associated with IPV
services have resulted in some health providers feeling
overwhelmed and poorly equipped to intervene with
abused women, and uncomfortable approaching IPV
issues [9,23], especially when time is limited to deal with
its social aspects [6,28-30].
Responses to IPV in Malaysia
Health provider responses to IPV and their effect on ser-
vice provision are context and situation specific. This
article focuses on a Malaysian model of health response
to violence against women called One-Stop Crisis Centre
(OSCC).
The OSCC model has been implemented in emer-
gency departments of regional, specialized and district
public hospitals (with various degrees of differences) by
the Ministry of Health to offer medical and health
services to domestic and sexual violence. At the OSCCs,
women who experienced domestic violence receive on-
site medical, psychological, and social support [31]. The
first OSCC was established in 1994 at the General Hos-
pital, Kuala Lumpur, in collaboration with women's non-
Page 2 of 11
governmental organizations (NGOs), and was located
within the Accident and Emergency (A&E) Department.
Soon after, the Malaysian OSCC became a unique
integrated model of care to women experiencing abuse,
being implemented nationally through public hospitals
across the entire country [32]. Subsequently, other coun-
tries in the South East Asian region also replicated this
model [33,34].
Only a few studies have been published in Malaysia
about providers’ views and attitudes towards violence
against women in general, mostly at primary health care
levels [35-38]. For instance, a study to assess the know-
ledge, attitudes and practices of primary health care
providers regarding the identification and management
of domestic violence in a hospital setting in Malaysia
found that 28% of the clinicians and 51.1% of the nurs-
ing staff had inappropriate personal values regarding do-
mestic violence and blamed the women for having done
something to trigger their partner’s reaction [37]. More-
over, the same study shows an underlying belief that do-
mestic abuse is a rare and 'private matter'. More than
half of the clinicians and a third of the nursing staff
reported a fear of offending patients in asking about
abuse. Over sixty percent of health care providers
believed that the prevalence of domestic violence among
their patients to be low [37].
However, these studies do not fully reflect the range of
attitudinal and systems challenges health workers are fa-
cing when trying to integrate a new package of services
for women experiencing abuse. This article aims to fill
this gap by exploring the views and attitudes of health
providers towards IPV and abused women, and to inves-
tigate their impact on the provision and the quality of
OSCC integrated services in Malaysia.
Methods
We employed a case study approach in this qualitative
descriptive study allowing in-depth analysis of seven
hospitals in 2 states in Malaysia. The aim was to analyse
barriers and opportunities to implement and integrate
effective health service responses to IPV at different
levels of the health system in two Northern States in
Malaysia. In particular, the overall study sought to: 1) ex-
plore and understand providers’ attitudes towards vio-
lence, 2) assess the training and organisational support
they might receive to implement the policy around IPV,
and 3) the challenges they faced when offering IPV
services. The findings on policy developments and
health systems issues have been published elsewhere
[39,40]; this article presents the results from the health
staff interviews on their views and opinions towards
abuse and abused women (definition, acceptability, and
their role as service providers) and how these can affect
service provision.
Colombini et al. BMC Health Services Research 2013, 13:65
http://www.biomedcentral.com/1472-6963/13/65
In-depth interviews were selected as they can provide
reliable and comparable data [41], and allow for control
over the questions and the topics to be covered in the
discussion while leaving the interviewee the opportunity
to tell his/her own account of issues related to the
selected topics [3]. Between January to April 2007, a
total of 54 in-depth interviews were conducted with
selected health providers (including nurses, medical
officers, gynaecologists, medical social workers and hos-
pital managers) who were responsible for providing
services to abused women at different levels of hospital
care: tertiary specialised facilities (Regional specialised
hospitals), secondary ones (semi-specialised hospitals)
and basic district settings (basic facilities with no
specialists on site). Table 1 provides a summary of the
type of providers interviewed.
Staff were interviewed at a total of seven hospitals
selected in two Northern States. In each State, a tertiary
specialised hospital was selected, together with a second-
ary and a district setting (to get a sample of different
levels of service with an OSCC). Snowball sampling was
used to identify health providers, with the assistance of
the local partners from the Universiti Sains Malaysia and
the Head of A&E Departments. Respondents were
selected according to their profession and their experi-
ence with violence issues and their connection with
OSCCs.
Semi-structured interview guides were developed –
and subsequently field- tested - to offer core questions
around providers’ views about violence and their
challenges when providing services to abused women.
Key topics contained in the interview guides were:
– Perceptions and views around domestic violence,
abused women and their role as providers of IPV
care: to understand whether providers’ attitudes
impact on the services provided.
– Clinical management: to help map the process of
OSCC care and the daily practices around clinical
management of abuse cases.
Table 1 Numbers of interviews per type of providers
Respondents Penang Kelantan
Counsellors 1 1
Medical assistants 0 2
Medical officers 14 8 22
Medical Social Workers 3 2
Obstetrics and Gynaecologists (OBGYN) 3 2
Psychiatrists 2 2
Staff Nurse/Nurse 8 6
Total 31 23
Page 3 of 11
– Guidelines and protocols: to get a sense of providers’
awareness and knowledge of hospital’s protocols and
procedures around violence.
– Training: to get a sense of knowledge of IPV that
providers may have.
– Collaboration with other agencies: to understand
whether processes of collaboration among various
sectors exist and how it works, and also providers
views about it.
– Perceptions of challenges faced when providing IPV
services: to understand personal opinion about
perceived barriers/challenges when dealing with
abused women.
Written informed consent was obtained from each re-
spondent. The majority of interviews were conducted in
English by the principal investigator. Twelve interviews
(primarily with nurses) were conducted in Bahasa Malaysia
by two local research assistants, who had been previously
trained on conducting qualitative interviews and on the
content of the interviews-topic guides. The average length
of each interview was around 45 minutes.
Digitally recorded interviews were saved onto a com-
puter and subsequently transcribed. The twelve Malay
interviews were subsequently translated verbatim into
English. A local person and the field supervisor in
Kelantan checked their fidelity towards the Malay ver-
sion. A framework analysis method was then employed
to analyse the emerging themes [3,42]. It consists of a
content analysis method allowing for a systematic classi-
fication and organisation of data by major themes, cat-
egories and concepts within a thematic framework [3].
This approach encourages the preservation and integrity
of the voices and accounts of the interviewees, keeping
the researcher grounded in the data, as the information
is summarised and classified within a thematic matrix all
along the analysis [3].
The transcripts of in-depth interviews were read re-
peatedly to become familiar with the text, to have a full
picture of the data collected, and to begin to identify
some main themes throughout such initial reading.
Once the cross-cutting thematic code framework was
finalised, interviews were coded and managed by using
Total NVIVO (N7), a qualitative software package.
2
Throughout the analysis, the code framework was fur-
ther revised where new sub-codes and themes were
2
identified and as linked themes were grouped together,
reducing the number of broad overarching issues.
5 Ethical approval was granted by the Ethics Committees
5 of the LSHTM and the World Health Organisation. Eth-
4 ical permission for the study was also granted by the
Economic Planning Unit of the Prime Minister’s Office
14
and the Ministry of Health national ethical review com-
54
mittee in Malaysia.
Colombini et al. BMC Health Services Research 2013, 13:65
http://www.biomedcentral.com/1472-6963/13/65
Results
Fifty-four in-depth interviews were conducted with
health providers (nurses and medical officers) from
seven public hospitals (regional and district settings) in
two Northern States in Malaysia (see Table 1). We
explored how IPV and abused women were perceived by
health care providers and the main effects of this on the
perceptions of their role as providers. We then looked at
the challenges faced by service providers when offering
care to abused women.
Health providers views and perceptions concerning IPV
Over half of the respondents defined IPV as both phys-
ical and emotional harm caused to the woman, and
included acts such as scolding, hitting, beating, threats,
emotional stress and deprivation.
“It doesn’t have to be physical, it could be emotionally
and not just physically, just. . .some people would just
abuse whoever women in their life, either physically
hurt them but could be emotionally as well. That is
considered abuse for me. . .like if you feel threatened by
somebody or if you feel uncomfortable by somebody I
think this is considered violence. . .I mean if you are
violated in some ways.” (Pen/45, OBGYN, female)
Very few providers perceived IPV as hitting and phys-
ical abuse only.
“Mainly I think now, it is more on physical rather
than those things [emotional deprivations]. . .” (Pen/3,
medical officer, female)
When talking about physical abuse, one medical
officer said that many health professionals still refer to it
as “just” a social problem, and not as a criminal offence,
unlike child or sexual abuse. Moreover, he added that
some male medical professionals seem to judge it more
as a “social problem” if abused women presented with
minor injuries, which may reflect the A&E goal of
responding to emergency situations. Therefore, urgency
among some medical personnel seems to be related
more to the severity of the physical injury.
Only a quarter of the providers in Penang mentioned
sexual abuse among the types of acts that may char-
acterise domestic violence. One medical respondent
clearly stated that rape was not a form of family
violence.
“I: Would it also be sexual? Would also be considered?
R: Sexual abuse, rape, I don’t think, sexual abuse no.”
(Kel/11, medical officer, female).
Page 4 of 11
This may reflect the legal dimension of domestic vio-
lence in Malaysia, which (at the time) did not include
marital rape in its definition.
Some minor discrepancies in the overall definition of
domestic violence existed between providers’ views in
the two States, but there did not appear to be marked
differences based on the sex of the health professionals.
In Penang, most people referred to IPV as causing both
physical and psychological harm, unlike in Kelantan,
where respondents referred primarily to hitting and
beating and any physical injury. These differences may
be caused by the more limited referral resources in
Kelantan State or by the religious context.
Attitudes towards acceptability of IPV
Over three quarters of the providers interviewed thought
IPV was something that should not be tolerated. The
majority of all the health care respondents said that
no form of violence by the husband or partner was ac-
ceptable or used as a tool to solve arguments among
couples.
“I think it is unfair, unfair. It is unfair, it is illegal, I
mean things can be done because we are both humans
and uh, being a family means a family shares
everything. Not, nobody is higher or lower than the
other one.”(Kel/10, medical officer, female)
One staff nurse even said that offending husbands
should be punished.
“If a husband beats his wife,. I think he should be put
behind bars. . .I guess police have to take action
against her husband for treating his wife like that, take
a legal action.”(Pen/13, staff nurse, female)
Despite generally intolerant views towards IPV, there
were still a small minority of medical officers and staff
nurses at district and more specialised hospitals who
accepted it or minimised it, referring to physical abuse
(such as a slap) as a “small thing”. However, even among
the very few providers who reported they would con-
done minor occasional physical abuse, one medical
officer stated that if the violence was severe and fre-
quent, he thought it should be tackled.
“If it happens only once, we may be able to
compromise. If it has happened many times and has
left behind a deep effect (on the victim), such as
excessive injury marks on the victim’s body, I would
suggest that the wife be divorced from her husband, for
her safety and peace of mind. We can forgive the
husband if the abuse is the first time. When the abuse
happens for the second time, we can still forgive the
Colombini et al. BMC Health Services Research 2013, 13:65
http://www.biomedcentral.com/1472-6963/13/65
husband. The abuse could be unintentional or the
husband is under a certain pressure. But if the abuse
happens frequently, I think it is no more a peaceful
home but a hell for the victim.” (Kel/16, medical social
worker, male)
Among a minority of providers who accepted violence
as a normal part of married life, a nurse offered a differ-
ent kind of advice to women. She would tell them to be
patient and stay with the husband - because of the chil-
dren - or advise them not to divorce.
“I: so what do you tell them to calm them?
R: (laughs) what did I tell? I advise them to be patient,
that’s all. [..]..I mean, you be patient, you have to think
about your children [..] So we just say sabar (patience).
What to do, isn’t it? Just sabar (patience). Be calm.”
(Pen/19, staff nurse, female)
Over half of the medical doctors and staff nurses
viewed women as passive and powerless actors accepting
or tolerating abuse for many years. According to nearly
half of all the providers, women hid the abuse and were
often not telling the truth, did not want to disclose or
report violence because of fear of repercussions, because
they wanted to save their marriage, or due to cultural
reasons. This image may be a function of the perception
of the community about violence as culturally tolerated
within a family – but publicly unaccepted – and to be
kept hidden.
The majority reported that most of the time women
tolerated the abuse and continued to bear it for many
years because they were not aware that marital violence
was wrong.
“Because it’s probably awareness. They do not know
probably even know that it’s wrong to do violence
against them. Awareness I think. They do not know it
is wrong. To not know it’s wrong, you do not complain,
they just accept it.” (Pen/45, OBGYN, female)
This could be due to the widespread silence and denial
surrounding IPV among the community.
“[..] They do not even know that it’s wrong to do
violence against them. [..] They do not know it is
wrong. To not know it’s wrong, you do not complain,
they just accept it.” (Pen/45, OBGYN, female)
Four doctors reported that women who were in abu-
sive relationships saw no other way out than staying.
Page 5 of 11
“I think the majority, they are stuck in an abusive
relationship. Especially the women can’t see a way out
I think, just carry on with the abusive relationship.”
(Pen/4, medical officer, male)
Others stated that some women would blame them-
selves for the abuse, thinking “that they deserve to be
treated that way.” (Pen/27, counselor, female)
Perceptions of services: expectations and roles
Providers’ views on women’s expectations from the OSCC
services
To explore their perceptions of women’s needs and
whether these may impact on the services provided,
practitioners were asked about their views on women’s
expectations from OSCC services. When asked what
women expected from them, a range of different
perspectives were given. Nearly half of the providers
reported that women just wanted medicine and to get
medical treatment and a diagnosis of whether their in-
jury was serious, and did not want any counselling or
referral.
“They just want to make sure that they’re alright. . ...
very few of them would want to be counselled.” (Pen/
20, medical officer, female)
On the other hand, several respondents (both clinical
and non clinical staff ) also felt that some women went
to OSCC to receive counselling and advice from the
health staff to help them solve their problem, and that
they did not solely come because of the injury.
“To help them, what they expect actually is to help
them. [. . .]. . . they don’t come because of their pain,
err. . . they come because of their problems.. like
domestic violence,.. probably they want us to help. . .”
(Pen/42, medical officer, female)
Few clinicians admitted that women used hospitals as
their first entry point for a “help call”, even when they
present with minor injuries.
“..sometimes they do not know where to go, so that’s
why they come to see doctor, the injury is not that
severe but they don’t know where to go. . .” (Pen/42,
medical officer, female)
More than ten providers stated that some women
came to the services because they wanted to obtain a
medical report to get a proof of the abuse and their
suffering in order to make a police report for a divorce
or take other legal action against their husband.
Colombini et al. BMC Health Services Research 2013, 13:65
http://www.biomedcentral.com/1472-6963/13/65
Providers’ perception of their role as “health care workers”
Providers were asked about the perception of their role
as “health care workers” in order to explore whether
their view would affect the provision of OSCC services.
What emerged was that health professionals viewed their
role as varying between a purely medical one – focusing
primarily on offering treatment and diagnosis – to a
broader role as “advisers” guiding abused women and
channelling them to proper services to tackle the under-
lying causes.
Some differences in response existed across levels of
hospital care. At the tertiary level, several providers
reported they had a duty to reassure women and offered
them “options” about available services.
“[..] It is the duty of the medical officer to inform them
of these options because they will not go directly to the
women crisis centre, unless they are very educated.
The non-educated patients will not know that this
crisis centre exists.[..] But they know that there are
doctors in the hospital that they can seek treatment
from. [..] I think that is the role of the medical officers.”
(Pen/3, medical officer, female)
Helping women solve their problem was a common
explanation of their professional role among various
health providers at higher level of care. Help could be
offered in the form of advice on support services, re-
assurance and by referring women. The majority of
providers at the tertiary level stated they would provide
further support to women by assisting them beyond
treatment by referring them to other departments,
though noting that hospitals could only focus primarily
on physical and counselling aspects.
“. . .as a medical officer, this is the way I can help
them. . . try to calm them, try to see that it is not the
end of life yet and we have the way to solve their
problem, and try to refer them to the respective
persons who are able to solve their problem. . .
Hospital mainly they can concentrate on physical and
counselling aspect only. ”(Kel/6, medical officer, male)
Many also reported that they would ensure women felt
comfortable, and reassured them that there was some-
one to help them. However, one doctor mentioned that
their role was limited because they could only make
suggestions about where to seek help because they were
too busy.
“So we will try to offer whatever we have. . . we are
giving them some suggestions where they can find
solutions. That’s the only thing we can do, more than
Page 6 of 11
that I don’t. . . because we [A&E] are a busy setting. . .”
(Pen/2, medical officer, female)
Many clinicians seemed to show empathy towards
women, especially at tertiary level. For instance, thirteen
reported they would go slowly with them, lower their
voice, close the curtains or clear the examination area to
make women more comfortable. They would talk slowly,
minimise the examination discomfort and listen sympa-
thetically. On the other hand, at district hospitals, the
main focus of health personnel seemed to be more on
physical examination treatment.
“[..] Actually, for us it is physical treatment only, [for]
the social problem, social welfare is supposed to take
over. . .” (Pen/12, medical officer, male)
Some of those who stated that their role was focussed
on the medical aspect of IPV also reported that the so-
cial part was done by the police.
“. . .we let the police take over the case. Why it
happened, what causes, we don’t bother about that. [..]
No further history about the event, the causes. There
we need to let the police take over about that. . .we
really concentrated at the physical examination and
do diagnosis. . . we are not interested [in the causes]
because we are also not counsellors.” (Kel/12, medical
officer, male)
Challenges of service provision
Frustrations reported by providers
Nearly half of the health professionals at all levels
expressed at least some frustrations because of their feeling
of inadequacy, as they could not assist women properly. In
particular, at district hospitals, some confessed their frus-
tration for their inability to help women solve their
problems beyond medical treatment.
“. . ..what I am doing now, I feel it is not enough
because I’m just doing the basic counselling, identify
their problem and referring them to the other units,
you see. [. . .] most of them won’t come back but I feel
very depressed because I can’t do much.” (Pen/7, staff
nurse, female)
Some doctors at tertiary level also reported feelings
of inadequacy, as if IPV was beyond their reach and
should be dealt with by psychologists or social
workers. The problem was raised particularly when
there was a need for long-term care to women such
as solving marriage and family problems, which they
stated were not included in their traditional medical
role. Some said they could only offer short-term help
Colombini et al. BMC Health Services Research 2013, 13:65
http://www.biomedcentral.com/1472-6963/13/65
for physical and emotional abuse, but they could not
impact on any longer-term problems.
At least a quarter of the providers suggested that
health personnel’s anxiety was the result of the lack of
any training or awareness on how to manage cases prop-
erly and the lack of basic counselling skills (e.g. how to
offer advice to women or ask questions sensitively). This
was particularly evident at district level, where no
specialists are available and where several providers
reported they felt women with minor injuries were more
in need of counselling and someone to talk to than of
medical help.
At district level particularly, it seemed that providers’
perceptions of their role was influenced by the level of
resources available in their settings. For instance, some
reported that they felt their role was limited to treat-
ment, medication and referral to further specialised sup-
port, as there was very little they could do at district
level apart from listening and offering their advice to
women. In this case, their role seemed limited not by
their unwillingness to help or by their view of their role
as purely medical, but more by the availability of
resources.
“There’s very little we can do. That we can only
reassure them that there’s nothing wrong, medication,
tell them we’re around here if they need anything.”
(Pen/18, medical officer, female)
Despite being committed and empathetic, nearly half
of all providers - when talking about their professional
role - reported some frustrations whilst dealing with
abused women. Some workers reported feeling helpless
because they could not force women to receive assist-
ance. If women were not willing to be assisted or
advised, providers felt they could not do much. For in-
stance, some reported they got frustrated because
women did not want to report to the police or be re-
ferred to specialists. Some of the reasons stated were
related to women wanting to save the marriage (because
they love their husband), to protect the children or be-
cause they do not have any other income besides the
husband.
Frustration also seemed to be common among all
providers when women did not disclose and were
hiding the truth, making it more difficult for health
care workers to identify and address the problem.
The low disclosure was attributed to various causes.
Some health care workers at tertiary and secondary
level hospitals attributed the unwillingness to dis-
close among abused women to the local culture,
reflecting the general view about IPV as a family pri-
vate issue.
Page 7 of 11
At least ten providers reported frustration with
repeated cases, when women kept coming back to hos-
pital with the “same” problems.
“Once they come, after treatment, they go back to their
old instincts, and then relax and they come back
again. Similarly. . ..when the patient came in, we gave
treatment and back and they come again for the same
mistakes. It happens again and again and the similar
problems will be coming in A&E. That’s what we
feel.. . .” (Kel/13, medical assistant, male)
Several providers also stated they felt frustrated with
feeding information to women and not knowing whether
women may accept their advice on referrals or not.
Others also reported they could not understand women’s
decisions to remain in abusive relationships, despite the
abuse, and felt frustrated because they could not influ-
ence their decisions.
“Sometimes they [providers] feel very frustrated
because we try to help them [women] from being
abused, then they go back to the same person and get
abused again. It’s very frustrating. . .” (Kel/7, OBGYN,
female)
Only two respondents seemed to recognise the cour-
age that it takes for a woman to disclose the abuse and
seek help.
Time pressure
Over thirty providers cited time pressure as an import-
ant constraint to providing quality OSCC care. Doctors
mentioned that time pressures were a constraint, as they
examined women, and short examination time was a
particularly common issue at lower levels of care, where
some doctors said they were busy with other patients.
These pressures were not reported by nurses although
time constraints were said to be an embedded problem
of the frenetic environment of A&E as other emergency
cases kept coming in all the time.
[. . .] here most of the time is very busy (laughing) we
cannot really concentrate on them [abuse cases]
actually, we just treat them as usual patient, just take
history, examine and then go back just like that la. . .
(Pen/44, medical officer, female)
What emerged from the findings is that time shortages
may well impact on the ability of medical officers to
identify cases of abuse, with some saying that time
limitations made it more difficult to detect the real prob-
lem behind the injury - especially when women did not
disclose. It was also cited as a barrier to asking the
Colombini et al. BMC Health Services Research 2013, 13:65
http://www.biomedcentral.com/1472-6963/13/65
proper questions to assess women’s emotional needs for
further referral.
“. . .we don’t have enough time, because a lot of
cases. . . the outpatient cases after office hours also
come here, so we don’t have enough time to go in the
separate room, to take a long history, so what usually
happens, we are not going to ask the reasons why she
was battered and go in deep depth on that. We just
ask about what time, place, what weapon or thing
that was used to hit the woman, do the physical
examination then ask whether they are willing [to
have] some counselling or refer. . .” (Pen/6, medical
officer, male)
Nevertheless, data from the interviews seem also to
suggest that the individual interest of medical
professionals on violence issues may influence whether
or not time constraints result in limited care. For in-
stance, some doctors stated that if the physical injury
was minor, and if they saw IPV as just a physical prob-
lem, they might spend very little time with such cases.
“[. . .] sometimes they [doctors] have cases, we have the
room available, but they prefer to see the case here.
They want to see it very fast, for them is to see the
injury. . .” (Pen/7, medical officer, female)
At a secondary care level, it was also a matter of some
providers being committed to “go the extra mile” and be
interested in the woman’s story. A gynaecologist
reported that most of the time, doctors would just ask
very few questions and then go over to the next patient.
“Most of the time we don’t give that much time. We
just go to these patients, ok, ask them a few
questions. . . and not willing to talk anymore, but you
don’t go the extra miles. I mean, if you put them in a
room somewhere and ask them more questions they
probably want to tell you more. But sometimes it’s just
‘ok, next patient. . . next patient’.” (Pen/45, OBGYN,
female)
At other times, clinicians reported that they might not
feel “comfortable” to spend a long time with women, es-
pecially when they would not disclose and would remain
silent.
“We don’t give the [women] that much time. We just
ask “ok, what happened? Ah ah”. Because there will be
some women and there will just be silent and do not
know what to say to you. . . sometimes we don’t give
them that time. . . ok, silence now, [we] are not
comfortable now, better ask another question, time’s
Page 8 of 11
out now. . . we jump to another question, so that
would be the problem sometimes.” (Pen/45, OBGYN,
female)
The discomfort expressed by some providers in asking
women about more “personal” questions may prevent
them from identifying the real problem behind the
abuse. Some providers felt ill equipped to talk to women,
to ask them the proper questions about the abuse, and
thus they may use shortage of time as an excuse to have
a quick consultation and move on to the next patient.
Some also saw the process as merely a clinical task,
therefore they may be unable to focus on more personal
questions during the “examination process”.
Discussion
Most health care providers interviewed defined IPV as
physical and emotional abuse only, and included acts
such as scolding, hitting, beating, threats, emotional
stress and deprivation. Only a few providers mentioned
sexual abuse among the types of acts that may character-
ise IPV. There seemed to be some hesitation in defining
IPV, as if the providers never thought of it before. This
could reflect the lack of any reflective training when the
OSCC services were integrated.
Our study also shows that there is a predominant per-
ception of IPV as a family or marital issue, and therefore
IPV is not seen as a public health matter, despite the fact
that some acknowledged the physical and emotional
consequences resulting from it. In general, IPV is not
perceived as a priority health issue, probably, as some
doctors said, because it is not “life threatening”. Al-
though many disagree with violence as a means to solve
marital conflict and label it unfair, being part of a culture
that closes its eyes to violence against women seems to
impact on the views of some health care professionals,
and therefore may fall down the list of priorities in a
busy A&E context, where most of the abuse cases may
be found.
The findings presented in this article support the view
that providers’ attitudes to IPV and their perception of
their role could affect the quality of the services they
offer. Our interviews showed that there seemed to be a
link between providers’ view of IPV and of their
perceived role and how they therefore responded to
survivors of IPV. Providers who demonstrated less
understanding of the socio-cultural determinants of
abuse were also the ones who were more likely to focus
on the injuries. For those who were more focused on the
physical consequences of IPV, the emotional part of the
care was frequently disregarded or not seen as part of
their role. Thus if providers thought that their role was
just within the medical domain, they might fail to rec-
ognise the complex interaction between medical and
Colombini et al. BMC Health Services Research 2013, 13:65
http://www.biomedcentral.com/1472-6963/13/65
psycho-social aspects of IPV care, and were less likely to
refer women for any additional services they may need.
This reflects the findings of another study which shows
that the psycho-social aspects of medical care are often
undervalued, where the emotional aspect of IPV care
goes often ignored and its ‘social emergency’ is unrecog-
nised [43]. This lack of awareness of the psycho-social
dimensions of IPV risks perpetuating the view that IPV
is purely about a couple quarrelling which in turn can
lead to inappropriate responses that could jeopardise
women’s safety and impact on women’s views of the
services as they can lose trust in the provider.
The study findings show that many providers could not
empathise with women’s decisions of going back to their
husbands, and women’s evasiveness and underreporting
were often causes of frustration for them. Their sense of
medical responsibility towards abused women and the
perception of their role as “solver of patients’ problems”
might have limited their empathy towards women – espe-
cially the ones who chose to remain in abusive
relationships and do not accept their advice. In fact, des-
pite their willingness to help, some still lacked respect for
women’s choices. This may arise more from lack of
understanding about how difficult it is for women to dis-
close or to leave an abusive relationship, especially with-
out specialist support (emotional, practical, legal etc.), and
also derives from low understanding about IPV being
characterised by power and control issues. For exam-
ple the existing literature [9,23] found that health pro-
fessionals often do not comprehend that some women do
not really have any alternatives, and often feel incapable
of trying to influence patients to report, seek additional
care and in referring them appropriately.
Our data show that some doctors see women as an
obstacle in their perceived self-efficacy in the manage-
ment of IPV, and do not understand the barriers women
may face such as their financial and legal dependency
on their husband, or the blame of the community, and
the shame of a divorce. Not all respondents really
recognised the courage required from women when
seeking help. Such an attitude could be linked to the
way some providers tend to focus on “fixing” the med-
ical aspect of abuse and would tell a woman to leave the
husband, rather than thinking about what the woman
may really want. This may reflect the medical culture,
which is primarily curative and thus sees the provider as
the main decision-maker [44]. This behaviour may also
be related to a social class divide between doctors, who
often belong to a higher socio-economic class than
women who experienced abused. Moreover, this feeling
of frustration, especially with “uncooperative women”,
could be linked to the fact that providers think that it is
difficult to offer an effective solution to women, espe-
cially when “successful” means convincing them to leave
Page 9 of 11
their husband. This issue is also raised in other settings
[7]. Providers may lack understanding of women’s dis-
empowerment – and the social context of abuse and the
gender inequalities leading to IPV - due to their social
distance from the community, and thus their lack of
understanding of the problem. Moreover, there was no
understanding that their role may be feeding in a longer
term process of change among abused women. Even if a
woman does not feel able to leave a violent relationship,
she would like recognition and support from her health
provider, without being pressured to any action. This
issue has been explored in other industrialised countries
[16]. Some women may not be ready to leave their hus-
band and if health providers do not understand it, they
may place women at more risk. More patient-centred
and “stage-matched” interventions could be elaborated
according to the various stages of change with regard to
abuse [17]. Health professionals should at least support
women’s decisions, and, in the long run, contribute to
the women’s ability in making a change to their situation
[45]. Referral to community support groups or NGOs,
where they exist, can also be done and has been quite
successful for example in Uganda (Michau and Nakar
2003).
There is the ongoing question about health care
workers’ roles and in what ways they should be expected
to help women. The contentious issue is whether their
role should be purely medical or go beyond treatment
[27,46]. The holistic management of IPV is not univer-
sally accepted as part of health personnel’s medical rou-
tine [7,47]. Our study shows that when providers follow
the traditional role of treating and solving IPV as a
“medical problem”, they tend to focus on the physical
aspect of the injury and minimise the underlying cause
of the problem. This does ensure that they at least treat
the physical injuries of the patients, but it risks
detaching providers from women’s personal experiences
of IPV. Many practitioners seemed to feel helpless or in-
adequate when offering care to abused women. This was
particularly true among staff at lower levels of hospital
care, particularly where they had scarce resources, lack
of local support services and limited access to training
on IPV. Studies from other fields of health care also
reported how some providers find offering emotional
care to patients more difficult than any other aspects of
clinical care [26,48]. The medicalised approach focuses
mainly on the physical aspects of abuse and cannot help
resolve women’s problem in the long term.
The feelings of inability or lack of self efficacy form an
important part of the whole debate about what are real-
istic expectations for medical staff in terms of what they
can do when addressing violence issues. In our study,
providers’ sense of lack of self-efficacy is strongly bound
up in the expectations of their professional role and
Colombini et al. BMC Health Services Research 2013, 13:65
http://www.biomedcentral.com/1472-6963/13/65
what the meaning of successful patients’ outcome is. It
seems that for many health providers the inability to re-
solve an abuse case – with a woman either reporting or
leaving the husband – led to a feeling of inadequacy in
their job.
On the other hand, our findings show that some
doctors and nurses who would go beyond the limited
medical role and argue they could provide more com-
prehensive care to women, taking a more proactive “ad-
vocate” role, offering advice and options of referrals and
help channel women to additional care. This is an image
that seems to be perceived primarily at tertiary care
level, where they feel their role is to help women solve
their problem not only by reassuring and calming them,
but also by offering advice on support services. At dis-
trict level, providers seemed to see their role as primarily
being medical. Sometimes, this was due to unavailability
of services on-site and locally, rather than unwillingness
to help women. In general though, there seems to be a
widespread uncertainty among providers about what
their role should include. More sensitisation can help
health care workers feel less inadequate.
The systematic and documented data collection and
analysis employed in the study helped ensure that the
process is auditable and replicable. Respondent valid-
ation was also used, which involved feeding back the re-
search evidence to the research participants to confirm
the findings. However, the study has several limitations.
Firstly, it is based on a relatively small sample of
practitioners and like all qualitative work is context-
specific. However, it still sheds light on the dilemmas
and frustrations that many health providers may face
when responding to IPV, which could be addressed in
training programmes and medical curricula to improve
health responses to IPV. Secondly, it does not bring the
perspective of the female clients directly, as they could
not be interviewed because of ethical issues. However,
the extensive literature research done to conceptualise
this study does focus on women’s issues in order to voice
their needs when implementing an integrated response.
Conclusion
Although many providers disagree with violence as a
means to solve marital conflict and label it unfair, being
part of a culture that ignores violence against women
seems to affect the views of some health care pro-
fessionals, and therefore it falls down the list of priorities
in a busy A&E context.
Recognizing the impacts that providers views and
attitudes on IPV and on their professional role can have
on the quality of IPV services not only helps us compre-
hend why they operate in certain ways, but also make us
realize the constraints that exist in promoting empathetic
health care provision and which need to be addressed.
Page 10 of 11
More awareness training and sensitisation can help them
feel less inadequate, especially if courses focus on
women’s needs and strengths, how health providers can
validate these and contribute to a longer term process of
change for survivors of violence. A supportive, well
resourced environment in terms of legal, counselling and
police support services undoubtedly influences a health
worker’s perceived ability to respond to violence. Clear
guidance on how to record history of abuse, ask questions
sensitively and validate experiences is also important to-
gether with training on good communication skills such
as listening and being empathetic.
Competing interests
The authors declared that they have no competing interests.
Authors’ contributions
MC conceived the project, coordinated and conducted the study, analysed
the data, and drafted the manuscript. SM helped in the conception of the
study, contributed to data analysis and drafting of the manuscript. SHA
participated in data analysis and help draft the manuscript. RS helped in the
supervision of data collection, and contributed to data analysis. CW helped
in the conceptualized the idea for the manuscript and the draft of the
manuscript. All authors read and approved the final manuscript.
Acknowledgements
We thank the many individuals who made this study possible. We would
especially like to thank the healthcare providers who took the time to
participate in the study. Development of this paper was primarily supported
by a grant by the World Health Organization, which included preliminary
field visits, travel support to collect data and dissemination of findings. Other
funding was obtained by DFID and Sigrid Rausing Trust.
Author details
1
Department of Global Health and Development, London School of Hygiene
and Tropical Medicine, London, UK. 2School of Health Sciences, Universiti
Sains, Penang, Malaysia. 3Women's Development Research Centre (KANITA),
Universiti Sains, Penang, Malaysia.
Received: 30 August 2012 Accepted: 14 February 2013
Published: 18 February 2013
References
1. Campbell JC: Health consequences of intimate partner violence. Lancet
2002, 359(9314):1331–1336.
2. Heise L, Ellsberg M, Gottemoeller M: Ending Violence Against Women.
Baltimore: Johns Hopkins University School of Public Health, Population
Information Program; 1999:1–44. Population Reports, Series L, No. 11.
3. Dutton MA, et al: Intimate partner violence, PTSD, and adverse health
outcomes. J Interpers Violence 2006, 21(7):955–968.
4. Garcia-Moreno C, et al: WHO multi-country study on women’s health and
domestic violence against women: initial results on prevalence, health
outcomes and women’s responses. Geneva: World Health Organization;
2005:1–207.
5. Rastam A (Ed): The rape report, an overview of rape in Malaysia.: AWAM/SIRD
(All Women’s Action Society/Strategic Info Research Development);
2002:210.
6. Roelens K, et al: A knowledge, attitudes, and practice survey among
obstetrician-gynaecologists on intimate partner violence in Flanders,
Belgium. BMC Public Health 2006, 6(1):238.
7. Mezey G, et al: Midwives' perceptions and experiences of routine enquiry
for domestic violence. British J Obtetrics Gynaecol 2003, 110(8):744–752.
8. Francois I, et al: Domestic violence: what are the difficulties for
practitioners? Analysis of interviews among 19 practitioners within a
town-hospital care network aimed at a global approach of patients.
Presse Medical 2004, 33(22):1561–1565.
9. Sugg NK, et al: Domestic violence and primary care. Attitudes, practices,
and beliefs. Arch Fam Med 1999, 8(4):301–306.
Colombini et al. BMC Health Services Research 2013, 13:65
http://www.biomedcentral.com/1472-6963/13/65
10. Bott S, Guedes A, Guezmes A: The health service response to sexual
violence: lessons from IPPF/WHR member associations in Latin America.
In Non-consensual sex and young people: perspectives from the developing
world. Edited by Jejeebhoy S, Shah I, Thapa S. New York: Zed Books;
2005:251–268.
11. Gerbert B, et al: Domestic violence compared to other health risks: a
survey of physicians' beliefs and behaviors. Am J Prev Med 2002, 23(2):
82–90.
12. Rodriguez-Bolanos Rde L, Marquez-Serrano M, Kageyama-Escobar Mde L:
Gender based violence: knowledge and attitudes of health care providers in
Nicaragua. Salud Publica Mex 2005, 47(2):134–144.
13. Minsky-Kelly D, et al: We've had training, now what? Qualitative analysis
of barriers to domestic violence screening and referral in a health care
setting. J Interpers Violence 2005, 20(10):1288–1309.
14. Burge SK, et al: Patients' advice to physicians about intervening in family
conflict. Ann Fam Med 2005, 3(3):248–254.
15. Chang JC, et al: Health care interventions for intimate partner violence:
what women want. Womens Health Issues 2005, 15(1):21–30.
16. Feder GS, et al: Women exposed to intimate partner violence:
expectations and experiences when they encounter health care
professionals: a meta-analysis of qualitative studies. Arch Intern Med 2006,
166(1):22–37.
17. Zink T, et al: Medical management of intimate partner violence
considering the stages of change: precontemplation and contemplation.
Ann Fam Med 2004, 2(3):231–239.
18. Robinson L, Spilsbury K: Systematic review of the perceptions and
experiences of accessing health services by adult victims of domestic
violence. Health Soc Care Community 2008, 16(1):16–30.
19. Pan American Health Organization: Violence against Women: the Health
Sector Responds.: Pan American Health Organization; 2003:114.
20. Lavis V, et al: Domestic violence and health care: opening Pandora's box.
Challenges and dilemmas. Feminism & Psychol 2005, 15(4):441–460.
21. Battaglia TA, Finley E, Liebschutz JM: Survivors of Intimate Partner
Violence speak out. J Gen Intern Med 2003, 18(8):617–623.
22. Kim J, Motsei M: "Women enjoy punishment": attitudes and experiences
of gender-based violence among PHC nurses in rural South Africa. Soc
Sci Med 2002, 54(8):1243–1254.
23. Garimella R, et al: Physician beliefs about victims of spouse abuse and
about the physician role. J Womens Health Gend Based Med 2000, 9(4):
405–411.
24. Guedes A, Bott S, Cuca Y: 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. Int J Gynaecol Obstet 2002, 78(Suppl. 1):
S57–S63.
25. D'Oliveira AF, Schraiber LB: Violence against women: overview, gaps and
challenges. In Violence against women: a statistical overview, challenges and
gaps in data collection and methodologies and approaches for overcoming
them. Geneva, Switzerland: Expert Group Meeting; 2005.
26. Herrera C, et al: Entre la negacion y la impotencia: prestadores de
servicios de salud ante la violencia contra las mujeres en Mexico. Salud
Publica Mex 2006, 48(Suppl 2):S259–S267.
27. Warshaw C: Domestic violence: changing theory, changing practice. J Am
Med Womens Assoc 1996, 51(3):87–91. 100.
28. Guezmes A, Vargas L: Proyecto para combatir la violencia basada en
genero en America Latina. Informe final de la comparacion entre Linea
Basal y Linea de Salida en INPPARES. PLAFAM y PROFAMILIA 2003,
IPPF/WHR.
29. Ramsay J, et al: Should health professionals screen women for domestic
violence? Systematic review. Br Med J 2002, 325(7359):314.
30. Waalen J, et al: Screening for intimate partner violence by health care
providers: barriers and interventions. Am J Prev Med 2000, 19(4):230–237.
31. Yut-Lin W, Othman S: Early detection and prevention of domestic
violence using the Women Abuse Screening Tool (WAST) in primary
health care clinics in Malaysia. Asia Pac J Public Health 2008, 20(2):102–116.
32. Hawa Ali S: The Women's Centre for Change, Penang: empowering the
women of Malaysia. In Improving people’s lives: lessons in empowerment
from Asia. Edited by Sharma M. New Delhi: Sage; 2003:56–100.
33. Ministry of Women and Children Affairs: Multi-sectoral Programme on
Violence Against Women. Dhaka, Bangladesh.
Page 11 of 11
34. Grisurapong S: Establishing a one-stop crisis center for women suffering
violence in Khonkaen hospital, Thailand. Int J Gynaecol Obstet 2002, 78
(Suppl 1):S27–38.
35. Hawa Ali S: Review of health service model for the provision of care to persons
who experience sexual violence: the Malaysian Model: 2002.
36. Rastam A: The rape report. An overview of rape in Malaysia. AWAM/SIRD
2002, 208.
37. Othman S, Mat NA: Adenan, Domestic violence management in Malaysia:
A survey on the primary health care providers. Asia Pacific. Fam Med 2008,
7(1):2.
38. Sivagnanam G, Bairy KL, D'Souza U: Attitude towards rape: a comparative
study among prospective physicians of Malaysia. Med J Malaysia 2005,
60(3):286–293.
39. Colombini M, et al: One Stop Crisis Centres: A Policy Analysis of the
Malaysian Response to intimate partner violence. Health Res Policy Syst
2011, 9:25.
40. Colombini M, et al: An integrated health sector response to violence
against women in Malaysia: lessons for supporting scale up. BMC Public
Health 2012, 12(1):548.
41. Bernard HR: Research methods in anthropology. Qualitative and quantitative
approaches. Walnut Creek: AltaMira press; 2002:754. 754.
42. Ritchie J, Spencer L: Qualitative Data Analysis for applied policy research.
In Analysing Qualitative Data. Edited by Bryman A, Burgess RG. Routledge,
London; 1994:173–194.
43. Roberts GL, et al: Impact of an education program about domestic
violence on nurses and doctors in an Australian emergency department.
J Emerg Nurs 1997, 2(3):220–227.
44. Shelton JD: The provider perspective: human after all. Int Fam Plan
Perspect 2001, 27(3):151–153.
45. Hegarty K, Taft A, Feder G: Violence between intimate partners: working
with the whole family. BMJ 2008, 337(a839):346–351.
46. Tower M: Intimate partner violence and the health care response: a
postmodern critique. Health Care Women Int 2007, 28(5):438–452.
47. Aksan HA, Aksu F: The training needs of Turkish emergency department
personnel regarding intimate partner violence. BMC Public Health 2007,
7(1):350.
48. Stein J, Lewin S, Fairall L: Hope is the pillar of the universe: health-care
providers' experiences of delivering anti-retroviral therapy in primary
health-care clinics in the Free State province of South Africa. Soc Sci Med
2007, 64(4):954–964.
doi:10.1186/1472-6963-13-65
Cite this article as: Colombini et al.: “I feel it is not enough. . .” Health
providers’ perspectives on services for victims of intimate partner
violence in Malaysia. BMC Health Services Research 2013 13:65.
Submit your next manuscript to BioMed Central
and take full advantage of:
• Convenient online submission
• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at
www.biomedcentral.com/submit
Kekerasan pada
perempuan
Nama Anggota
1. Afwa Nur Azizah R (SB19001)
2. Alya Olifa Z (SB19002)
3. Amanda Amalia (SB19003)
4. Angela Clara (SB19004)
5. Aqaz Rohqiati (SB19005)
6. Bella Putri Lathifah (SB19007)
7. Bencelina Parety (SB19008)
8. Chiendy Revina K P (SB19009)
9. Chusnul Karlina Lulu D (SB19010)
10. Ciendi Septiana (SB19011)
11. Chindy Maylani (SB19012)
12. Desya Fitria Dewimury (SB19013)
13. Dhini Susan Marina (SB19014)
 PEMBAHASAN
1. Apa yang dimaksud kekerasan terhadap perempuan dan anak?
2. Bagaimana tenaga kesehatan berperan dalam melakukan scrining
identifikasi dan support dalam kekerasan yang dialami perempuan
ibu dan anak?
 BUKTI 2020

K. LAINYA
Dalam Catatan Tahunan Kekerasan terhadap Perempuan
17 % (Catahu) tahun 2020, sepanjang tahun tersebut ditemukan
299.911 kasus kekerasan terhadap perempuan. Data tersebut
dihimpun dari pengadilan negeri dan agama, lembaga layanan
mitra Komnas Perempuan sejumlah, dan Unit Pelayanan dan
Rujukan (UPR). Jenis kekerasannya pun beragam dan yang
K. ANAK PEREMPUAN KTI
14 % paling menonjol kekerasan di ranah pribadi atau privat, yaitu
49%
KDRT dan relasi personal. Di antaranya terdapat kekerasan
terhadap istri (KTI) menempati peringkat pertama 3.221 kasus
(49 persen), disusul kekerasan dalam pacaran 1.309 kasus (20
persen), kekerasan terhadap anak perempuan sebanyak 954
K.PACAR kasus (14 persen), sisanya kekerasan oleh mantan suami,
20 % mantan pacar, serta kekerasan terhadap pekerja rumah tangga
 BUKTI 2019-2021
2019 2020 2021
15,000

Berdasarkan pengumpulan data milik KemenPPPA, kekerasan

pada anak di 2019 terjadi sebanyak 11.057 kasus, 11.279 kasus
pada 2020, dan 12.566 kasus hingga data November 2021.
10,000
Pada anak-anak, kasus yang paling banyak dialami adalah
kekerasan seksual sebesar 45 persen, kekerasan psikis 19
persen, dan kekerasan fisik sekitar 18 persen.

KemenPPPA mencatat juga turut mengalami kenaikan. Dalam

5,000 tiga tahun terakhir ada 26.200 kasus kekerasan pada
perempuan. Pada 2019 tercatat sekitar 8.800 kasus kekerasan
pada perempuan, kemudian 2020 sempat turun di angka 8.600
kasus, dan kembali mengalami kenaikan berdasarkan data
hingga November 2021 di angka 8.800 kasus.

0
Series 1
 KEKERASAN PEREMPUAN DAN ANAK
Definisi kekerasan terhadap perempuan menurut WHO mencakup semua bentuk perlakuan yang salah baik
secara fisik dan/atau emosional, seksual, penelantaran, dan eksploitasi yang berdampak atau berpotensi
membahayakan kesehatan anak dan perempuan, perkembangan anak dan perempuan, atau harga diri anak
dan perempuan dalam konteks hubungan tanggung jawab. Berdasarkan definisi tersebut, kekerasan anak dan
perempuan dapat berupa kekerasan fisik, kekerasan seksual dan kekerasan emosional atau psikis.

Dalam “Deklarasi tentang Penghapusan Kekerasan Terhadap Perempuan (1993)”, kekerasan terhadap perempuan didefinisikan
sebagai “suatu tindakan kekerasan berbasis gender yang mengakibatkan, atau bisa mengakibatkan, bahaya atau penderitaan
fisik, seksual atau mental perempuan, termasuk ancaman tindakan sejenis, pemaksaan atau perampasan kebebasan secara
sewenang-wenang, baik terjadi di ranah publik maupun kehidupan pribadi.” Pemerintah Indonesia menandatangani Deklarasi
tersebut pada tahun 2004 bersama dengan negara-negara ASEAN lainnya dan telah mempersiapkan perangkat undang-undang
dan kebijakannya. Tetapi, pelaksanaannya yang lambat dan tidak memadai menjadikan perempuan di seluruh Indonesia tetap
rentan terhadap kekerasaan. Upaya yang dibutuhkan sekarang adalah memperkuat penegakan hukum, mendidik penyedia
pelayanan dan masyarakat luas tentang kekerasan terhadap perempuan dan memperluas layanan untuk korban kekerasan dan
pelaku di perkotaan dan pedesaan. (Kemenpppa, 2011)
Peran Tenaga kesehatan dalam Scrining dan Suport terhadap Kekerasan Perempuan
Studi ini mengeksplorasi pandangan dan sikap penyedia layanan kesehatan
di Malaysia terhadap kekerasan pasangan intim (IPV) dan perempuan yang
dilecehkan dan mempertimbangkan apakah dan bagaimana pandangan
mereka mempengaruhi penyediaan atau kualitas layanan. Dampak dari
sikap pemberi layanan terhadap penyediaan layanan bagi perempuan yang
mengalami kekerasan sangat penting untuk dipahami karena ada
kebutuhan untuk memastikan bahwa perempuan-perempuan ini tidak
menjadi korban kembali oleh sektor kesehatan, tetapi diperlakukan secara
sensitif.

Meskipun banyak penyedia tidak setuju dengan kekerasan sebagai sarana

untuk menyelesaikan konflik perkawinan dan melabelinya tidak adil, namun
sudah menjadi bagian dari budaya yang mengabaikan kekerasan terhadap
perempuan tampaknya mempengaruhi pandangan beberapa profesional
perawatan kesehatan.
Peran Tenaga kesehatan dalam Scrining dan Suport terhadap Kekerasan Perempuan
Penelitian yang melibatkan 10 negara menunjukkan bahwa
sektor kesehatan memegang peranan penting dalam:
– Mencegah kekerasan pada perempuan
– Membantu identifikasi adanya kekerasan
sedini mungkin
– Menyediakan layanan kesehatan bagi korban
– Merujuk ke tempat layanan sesuai kebutuhan

Tempat layanan kesehatan

Nyaman dan aman bagi korban
memperhatikan kebutuhan & kondisi psikologis
Respek terhadap korban, empatik
Tidak ada stigma
Dukungan yang berkualitas dengan informasi yang jelas
Peran Tenaga kesehatan dalam Scrining dan Suport terhadap Kekerasan Perempuan
Pendekatan melalui Sektor Kesehatan Masyarakat
– merupakan alternatif yang terbaik.
– memiliki potensi yang unik dalam penanganan kekerasan
pada perempuan dan anak, terutama melalui layanan kespro =
cakupan tinggi.

Hambatan
Stigma dan ketakutan yang membuat korban menutup diri
Kesadaran nakes dan pelatihan nakes↓
– mengindentifikasi korban kekerasan sebagai
penyebab masalah kesehatan yang membuat
korban datang ke faskes
– terutama di faskes yang tidak menyediakan
layanan tindak lanjut dan proteksi terhadap korban
Peran Fasilitas
Kesehatan
Mengumpulkan data dan informasi
Melakukan analisa dan pemetaan
sesuai hasil pengumpulan data dan
informasi
Perencanaan Menyusun rencana kerja
Melaksanakan sosialisasi
Menyiapkan Tenaga Pelaksana
Menyiapkan petugas konseling dan
wawancara
Menyiapkan Prasarana dan Sarana
Peran Fasilitas
Kesehatan

Pemeriksaan Kesehatan

Pelaksanaan Tindakan Medis

Wawancara dan konseling
Penyuluhan
Kunjungan Rumah
Pencatatan
Peran Fasilitas
Kesehatan

Pengawasan dan Pengendalian

Monitoring dan Evaluasi

Pertanggung jawaban
Peran Fasilitas
Kesehatan

Pemeriksaan Kesehatan

Pelaksanaan Tindakan Medis

Wawancara dan konseling
Penyuluhan
Kunjungan Rumah
Pencatatan
Standart Ketenagaan
Jenis Tenaga Kompetensi
Dokter umum/spesialis Mampu tatalaksana kasus KtP/A
Dokter gigi Mampu melakukan komunikasi
Perawat interpersonal, teknik wawancara dan
Bidan konseling.
Ahli gizi
Analis Laboratorium
Petugas Promkes
Petugas administrasi (pencatatan & pelaporan)
Identifikasi Korban
a. Tampak rendah diri
b. Menunjukkan sikap yang sangat mengagungkan kehidupan tradisionalisme,
kekuatan keutuhan keluarga dan memposisikan inferior dalam keluarga
c. Dapat menerima adanya kekerasan
d. Merasa bersalah, tetapi menyangkal adanya ancaman atau timbulnya rasa
marah
e. Menunjukkan muka yang pasif tetapi mampu memanipulasi lingkungan
seakan-akan aman untuk dirinya
f. Reaksi terhadap stress keluhan fisik atau psikis
g. Menggunakan hub-seks untuk menunjukkan keintiman dengan pasangannya
h. Merasa wajar mendapatkan hukuman
i. Merasa mampu menolong dirinya sendiri untuk keluar dari permasalahannya,
namun sering kali tidak mampu dan tidak dapat menyelesaikan
permasalahannya
j. cenderung berusaha untuk melupakan kejadian, trauma dan rasa takut yang ada.
Kebutuhan Korban
a. Pelayanan medis
b. Keamanan
c. Kerahasiaan
d. Pelayanan yang sensitif terhadap trauma dan penderitaannya
e. Dokumentasi rekam medik yang komprehensif
Layanan komprehensif dan empatik menghilangkan keengganan korban untuk
mencari pertolongan
f. Dukungan atau Suport berlanjut
1. Setelah masalah terbuka, lakukan pelayanan medis
2. Tawarkan dukungan emosional/psikologis
3. Keamanan atau privasi aman
4. Dokumentasi Kekerasan
5. Sediakan informasi Community resource (Layanan shelter, aspek
hukum, social, dll)
kesimpulan
Kekerasan seksual yang dialami oleh perempuan sering dianggap hanya berkaitan dengan faktor
pribadi saja, tidak ada hubungannya dengan fenomena social dan budaya, namun kenyataannya
kekerasan seksual pada perempuan berkaitan dengan banyak hal yang dapat memberikan dampak
buruk bagi korban itu sendiri, keluarga, masyarakat dan negara. Dapat dikatakan bahwa kondisi
kaum perempuan masih sangat rentan menjadi korban berbagai jenis tindak kekerasan. Terlebih
lagi, pada zaman modern tingkat kekerasan justru semakin tinggi dan banyak orang yang
menganggap bahwa kasus tersebut merupakan hal yang biasa. Perempuan sebagai makhluk yang
seharusnya dihargai dan dilindungi, justru menjadi objek dari tindak kekerasan yang dilakukan oleh
orang terdekatnya. Maka dari itu membutuhkan Peran Tenaga kesehatan dalam memberikan
suport dan Pendidikan terkait kekerasan pada perempuan ini.
 Daftar
Pustaka
Thank you for
participating!