Comment Research priorities to address violence against women and girls Men and Gender Equality) Study,8 but we need to better understand the drivers of violence perpet ration. Furthermore, we require a more comprehensive knowledge of resilience and why some children who are exposed to violence go on to perpetrate it whereas others do not. In relation to the health impacts, data exist on a range of health effects of partner violence, including physical injuries, mental health, and sexual and reproductive health.6 Much of the data, however, are based on cross-sectional studies that do not establish causal links between violence and these health outcomes. There is a need for more longitudinal studies and improved study designs to advance our understanding of the health effects of violence. Efforts to address violence against women and girls have largely emphasised legal, justice sector, and legislative responses, awareness raising, and, to a limited extent, health-sector response. More recently, prevention has become a higher priority. However, evidence on effective programmes to prevent violence against women from happening in the first place is incomplete; as Mary Ellsberg and colleagues1 point out in this Series, that evidence comes predominantly from high-income countries and is focused on response, with more research needed on primary prevention, including in low-income and middle-income countries. Moreover, most interventions have been tested in only one site and many studies have small sample sizes www.thelancet.com Published online November 21, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61840-7 Published Online November 21, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61840-7 See Online/Series http://dx.doi.org/10.1016/ S0140-6736(14)61703-7, http://dx.doi.org/10.1016/ S0140-6736(14)61837-7, http://dx.doi.org/10.1016/ S0140-6736(14)61683-4, http://dx.doi.org/10.1016/ S0140-6736(14)61797-9, and http://dx.doi.org/10.1016/ S0140-6736(14)61830-4 Paul Davey/Demotix/Corbis Violence against women and girls is increasingly visible on the global health and development agenda—both as a matter of social justice and equality for women and as a public health priority. After many years of dedicated efforts, more is known about the epidemiology of some forms of violence against women, and knowledge is increasing about what works to prevent and respond to such violence. However, as this Lancet Series on violence against women and girls1–5 highlights, in terms of research and evidence this is still an emerging field. The gaps in research and evidence include: lack of data on some forms of violence from certain regions; an incomplete understanding of the full scope of health and other consequences; a limited knowledge on what works to prevent and respond to violence against women and girls; and a general bias of published literature towards high-income countries. In 2013, WHO, the London School of Hygiene & Tropical Medicine, and the South African Medical Research Council produced the first global and regional estimates of the prevalence and health effects of two common forms of violence against women: partner violence and non-partner sexual violence.6 Population-based survey data on intimate partner violence is now available from 85 countries.6 However, data quality varies across the available surveys and many countries have no population-based data on partner violence or have surveys that date from more than 10 years ago. Gaps in availability of data on prevalence are most pronounced in some regions, in particular central sub-Saharan African, east Asian, Caribbean, and central Asian regions. Even fewer countries have data on sexual violence by non-partners,6 and knowledge is scarce about trafficking, honour killings, child marriage, violence in conflict, and other humanitarian settings. Little is also known about how violence affects particular groups that are not captured in population-based surveys, including women from indigenous communities, those who live in prisons, other institutions, and humanitarian settings, and women with disabilities. Some data are available for violence perpetration with the studies of men in Asia, the Pacific,7 and in other countries through the IMAGE (International 1 Comment and short follow-up periods. Overall, there is a need to expand the evidence base on what interventions are effective for primary and secondary prevention and to improve the health and wellbeing of women and girls already experiencing violence. More and better programme evaluation is needed to assess promising practices, and to identify and develop new approaches that can be tested through randomised controlled trials or other rigorous approaches. As highlighted by Rachel Jewkes and colleagues,3 programmes need to be based on robust theories of change that act across multiple risk factors at many different levels. Research on what works to change social and cultural norms that sanction violence against women and girls, and men’s control over women, is needed, since these factors underlie many forms of violence against women.3,9 We need to build on successful examples of community-based approaches used to prevent female genital mutilation10 or intimate partner violence.11 More complex multidisciplinary research and evaluation of interventions is needed; this requires partnerships between programme planners, implementers, policy makers, politicians, and researchers, as noted by Claudia García-Moreno and colleagues5 in the Series call to action. Research on what works in humanitarian settings is also urgently needed.12 There is also a need to evaluate the cost-effectiveness of interventions. Implementation research, particularly within health systems, is necessary to investigate the introduction, adaptation, and scaling up of interventions that seem to be effective or promising. In 2013, WHO launched clinical and policy guidelines for responding to intimate partner violence and sexual violence against women,13 which highlighted the limitations of the evidence base on health-care interventions for survivors of violence and on developing effective service delivery models. A health-system research agenda for strengthening the response to violence against women and girls is urgently needed.13 This agenda is particularly important in light of the 2014 World Health Assembly Resolution that calls on countries to strengthen the role of health systems in addressing violence, particularly against women and girls.14 For this resolution to be implemented, countries will need to know what the most effective clinical care interventions are, and what works for strengthening capacity of health-care providers and to scale up services. 2 For this field to retain its momentum and progress, investment is necessary to allow measurement of the magnitude and nature of the problem within individual countries as well as across countries, together with assessment of the effectiveness of interventions for prevention and response and methods to scale up effective interventions. More research is needed on forms of violence about which we have insufficient knowledge. Capacity needs to be strengthened in middle-income and low-income countries to enable local researchers to undertake research. Funding for epidemiological, behavioural, operational, and implementation research is also important if we are to advance the field. Additionally, we need to develop a larger menu of well evaluated interventions that can be implemented and scaled up, which would stimulate innovation and engagement of all actors as we move forward. Initiatives to strengthen research and build evidence on different forms of violence are welcome. More such initiatives are urgently needed to accelerate evidence-based programming efforts to prevent and respond to violence against women and girls. Marleen Temmerman Department of Reproductive Health and Research, World Health Organization, CH-1211 Geneva 27, Switzerland [email protected] I am Director of WHO’s Department of Reproductive Health and Research (RHR) and have no competing interests. I thank Claudia García-Moreno, Avni Amin, and Christina Pallitto of RHR, WHO. © 2014. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved. 1 2 3 4 5 6 7 Ellsberg M, Arango DJ, Morton M, et al. Prevention of violence against women and girls: what does the evidence say? Lancet 2014; published online Nov 21. http://dx.doi.org/10.1016/S0140-6736(14)61703-7. García-Moreno C, Hegarty K, Lucas d’Oliveira AF, Koziol-Maclain J, Colombini M, Feder G. The health-systems response to violence against women. Lancet 2014; published online Nov 21. http://dx.doi.org/10.1016/ S0140-6736(14)61837-7. Jewkes R, Flood M, Lang J. From work with men and boys to changes of social norms and reduction of inequities in gender relations: a conceptual shift in prevention of violence against women and girls. Lancet 2014; published online Nov 21. http://dx.doi.org/10.1016/S01406736(14)61683-4. Michau L, Horn J, Bank A, Dutt M, Zimmerman C. Prevention of violence against women and girls: lessons from practice. Lancet 2014; published online Nov 21. http://dx.doi.org/10.1016/S0140-6736(14)61797-9. García-Moreno C, Zimmerman C, Morris-Gehring A, et al. Addressing violence against women: a call to action. Lancet 2014; published online Nov 21. http://dx.doi.org/10.1016/S0140-6736(14)61830-4. WHO, London School of Hygiene & Tropical Medicine, the South African Medical Research Council. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: World Health Organization, 2013. Jewkes R, Fulu E, Roselli T, García-Moreno C. Prevalence and risk factors for non-partner rape perpetration: findings from the UN Multi-country Cross-sectional Study on Men and Violence in Asia and the Pacific. Lancet Glob Health 2013; 1: e187–207. www.thelancet.com Published online November 21, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61840-7 Comment 8 Barker G, Contreras JM, Heilman B, Singh AK, Verma RK, Nascimento M. Evolving men: initial results from the International Men and Gender Equality Survey (IMAGES). Washington, DC: International Center for Research on Women, 2011. 9 Heise L, Kotsadam A. Exploring cross-national and multi-level correlates of partner violence: a test of the gender hypothesis Lancet Glob Health (in press). 10 Diop NJ, Faye MM, Moreau A, et al. The TOSTAN Program: evaluation of a community based education program in Senegal. New York: Population Council, 2004. 11 Abramsky T, Devries K, Kiss L, et al. Findings from the SASA! Study: a cluster randomized controlled trial to assess the impact of a community mobilization intervention to prevent violence against women and reduce HIV risk in Kampala, Uganda. BMC Med 2014; 12: 122. 12 Spangaro J, Adogu C, Ranmuthugala G, Davies GP, Steinacker L, Zwi A. What evidence exsists for initiatives to reduce risk and incidence of sexual violence in armed conflict and other humanitarian crises? A systematic review. PLoS One 2013; 8: e62600. 13 WHO. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: World Health Organization, 2013. 14 67th World Health Assembly. Strengthening the role of the health systems in addressing violence, in particular against women and girls and against children. World Health Assembly, 2014. Resolution 67.15. http://apps.who.int/ gb/ebwha/pdf_files/WHA67/A67_R15-en.pdf?ua=1 (accessed Oct 22, 2014). www.thelancet.com Published online November 21, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61840-7 3 Comment THELANCET-D-14-08273 S0140-6736(14)62217-0 Embargo: November 21, 2014—00:01 (BST) Patriarchy and violence against women and girls ongoing threat to public health and social progress. The international community is undertaking a review of commitments articulated in the Millennium Development Goals, notably MDG 3, so that a sustained process will enrol nations into the urgent task of reversing these patterns of behaviour. Our society has become increasingly desensitised to violence. The recent GamerGate controversy revealed the severe harassment of women who seek to expose and mitigate extreme violence depicted in popular video games.13 Media critic Anita Sarkeesian has highlighted how vicious treatment of women is used as decoration in these games, giving the impression that women have no reason to exist except to be brutalised.14 Sarkeesian faced death threats as a result of her work.13 A 2008 Pew survey found that where the internet is available 97% of youths aged 12–17 years play video games on a regular basis.15 It defies credulity that attitudes and tolerance for violence among our young men and women are not influenced by these engrossing experiences. Violence is accepted in these and many other spheres of life. As long as this is true, abuse of women and girls will continue. Efforts to promote non-violence within our families, culture, communities, and between nations must be increased. Our churches, mosques, and synagogues can be a source of peace, justice, and spiritual nourishment, but entrenched patriarchy often condones violation of women’s rights. www.thelancet.com Published online November 21, 2014 http://dx.doi.org/10.1016/S0140-6736(14)62217-0 Published Online November 21, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)62217-0 See Online/Series http://dx.doi.org/10.1016/ S0140-6736(14)61703-7, http://dx.doi.org/10.1016/ S0140-6736(14)61837-7, http://dx.doi.org/10.1016/ S0140-6736(14)61683-4, http://dx.doi.org/10.1016/ S0140-6736(14)61797-9, and http://dx.doi.org/10.1016/ S0140-6736(14)61830-4 Jenny Matthews/Panos In the nearly 20 years since the Beijing World Conference on Women,1 there have been both advances and setbacks for women and girls. Many of the 30 000 activists who gathered there have continued the struggle for equal human rights, making important progress. More women are rising up and making their voices heard in every sphere of life. Yet age-old patriarchal structures and attitudes make sustained progress difficult. Most societies were shaped by religious doctrine mandated by male authorities, so attitudes and systems that promote male dominance have become the norm. Such doctrine came from religious leaders who distorted religious scriptures by selecting texts that depict women as inherently inferior or subservient to men.2 Alongside such patriarchal systems, violence in society has also become normalised.2 My nation, the USA, and other countries accept violence as a way to solve problems—from the use of the death penalty and mass incarceration in addressing crime, to pre-emptive and unjust warfare abroad. Many societal structures are built around the expectation of violence, and this is illustrated by the existence of brutality in the family. Violence against women and girls happens far too often, from intimate partner violence to honour killings. The numbers are horrifying: globally, one in three women will be assaulted in her lifetime; homicide of a woman as a result of domestic abuse is six times more likely when a firearm is in the home, illustrating the deadly consequences of permissive gun laws; and one in five women in the USA is sexually assaulted during her time in higher education.3,4 Poverty is also a factor in these societal structures. Women employed full-time in the USA earn around 22% less than men on average, making it much harder for poor women to lift themselves out of poverty.5 Young girls also suffer under such societal structures. More than 1·5 million girls worldwide are married each year who are younger than 15 years.6 Unbelievably, about 160 million girls are missing around the world, as a result of selective abortion of female fetuses or female infanticide, because families believe a son will be a better provider than a girl in societies where girls are deprived of education and gainful employment.7 As the Lancet Series on violence against women and girls8–12 shows, the abuses I describe here pose an 1 Comment Patriarchy is not new. It is a system created and maintained by men of faith and politics who hold the levers of economic, cultural, and political power and who confuse strength and masculinity with domination and brutality. Patriarchy must be replaced by a system in which equal human rights and non-violence are promoted and accepted. This will happen if we embrace the kind of love and mutual respect exemplified and preached by the founders of the world’s great religions, and through the persistent efforts of those who speak out and work for a more equal and less violent world.2 Equal human dignity is a human right, as codified in many global treaties. It is my hope that political and religious leaders will step forward and use their influence to communicate clearly that violence against women and girls must stop, that we are failing our societies, and that the time for leadership is now. Jimmy Carter The Carter Center, Atlanta, GA 30307, USA [email protected] I was the 39th President of the USA and am the founder of The Carter Center and a member of The Elders. I declare no competing interests. 1 2 3 2 UN. United Nations Report on the Fourth World Conference on Women. Beijing, Sept 4–15, 1995. http://www.un.org/womenwatch/daw/beijing/ pdf/Beijing%20full%20report%20E.pdf (accessed Nov 13, 2014). Carter J. A call to action: religion, women, violence and power. New York: Simon and Schuster, 2014. Black MC, Basile KC, Breiding MJ, et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 summary report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2011. 4 5 6 7 8 9 10 11 12 13 14 15 Krebs CB, Lindquist CH, Warner TD, Fisher BS, Martin SL. The Campus Sexual Assault (CSA) study final report. Washington, DC: National Institute of Justice, 2007. Hegewisch A, Williams C, Hartmann H, Hudiburg SK. The gender wage gap 2013: differences by race and ethnicity, no growth in real wages for women. Washington, DC: Institute for Women’s Policy Research, 2014. Brown G. Out of wedlock, into school: combatting child marriage through education. The Office of the UN Special Envoy for Global Education. London: The Office of Gordon and Sarah Brown, 2013. Hvistendahl M. Unnatural selection: choosing boys over girls, and the consequences of a world full of men. New York: Public Affairs, 2012. Ellsberg M, Arango DJ, Morton M, et al. Prevention of violence against women and girls: what does the evidence say? Lancet 2014; published online Nov 21. http://dx.doi.org/10.1016/S0140-6736(14)61703-7. García-Moreno C, Hegarty K, Lucas d’Oliveira AF, Koziol-Maclain J, Colombini M, Feder G. The health-systems response to violence against women. Lancet 2014; published online Nov 21. http://dx.doi.org/10.1016/ S0140-6736(14)61837-7. Jewkes R, Flood M, Lang J. From work with men and boys to changes of social norms and reduction of inequities in gender relations: a conceptual shift in prevention of violence against women and girls. Lancet 2014; published online Nov 21. http://dx.doi.org/10.1016/S01406736(14)61683-4. Michau L, Horn J, Bank A, Dutt M, Zimmerman C. Prevention of violence against women and girls: lessons from practice. Lancet 2014; published online Nov 21. http://dx.doi.org/10.1016/S0140-6736(14)61797-9. García-Moreno C, Zimmerman C, Morris-Gehring A, et al. Addressing violence against women: a call to action. Lancet 2014; published online Nov 21. http://dx.doi.org/10.1016/S0140-6736(14)61830-4. Wingfield N. Feminist critics of video games facing threats in “GamerGate” campaign. The New York Times Oct 15, 2014. Sarkeesian A. Tropes vs women in video games. YouTube Feministfrequency March 7, 2013. https://www.youtube.com/playlist?list=PLn4ob_5_ttEaA_ vc8F3fjzE62esf9yP61 (accessed Nov 13, 2014). Lenhart A. Teens, video games and civics: what the research is telling us. Pew Research Internet Project, Pew Research Center. Nov 2, 2008. http:// www.pewinternet.org/2008/11/02/teens-video-games-and-civics-whatthe-research-is-telling-us/ (accessed Nov 13, 2014). www.thelancet.com Published online November 21, 2014 http://dx.doi.org/10.1016/S0140-6736(14)62217-0 Comment Prevention of violence against women and girls: a new chapter Series, and steered the expert teams of authors to cover crucial aspects of this issue. The five papers assess the evidence base for prevention interventions,5 discuss the vital role of the health sector in care and prevention,6 show the need for men and women to be involved in effective programmes,4 provide practical lessons from experience in countries,7 and present a call for action with five key recommendations and indicators to track progress during the next 5 years.8 What do the papers tell us? The most successful strategies are complex, using multiple approaches, across many different sectors, with an essential role for the health sector.5,6 Success requires the involvement of men and women, in single-sex and mixed group discussions, over a substantial period of time.4 Interventions that not only discuss the implications of violence, but also explicitly address the underlying issue of inequality and seek to transform gender norms by promoting more equitable relationships between men and women, are essential to achieve lasting change.4 Programming requires action at the individual, community, and societal levels and sufficient investment with specifically allocated budgets.7,8 The Series also highlights the substantial limitations in data quality and quantity in this field, and an accompanying Comment by Marleen Temmerman9 discusses these concerns. The gaps in knowledge should act as a rallying call for funders and researchers to strengthen the evidence base. Published Online November 21, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61775-X See Online/Comment http://dx.doi.org/10.1016/ S0140-6736(14)61840-7 See Online/Series http://dx.doi.org/10.1016/ S0140-6736(14)61703-7, http://dx.doi.org/10.1016/ S0140-6736(14)61837-7, http://dx.doi.org/10.1016/ S0140-6736(14)61683-4, http://dx.doi.org/10.1016/ S0140-6736(14)61797-9, and http://dx.doi.org/10.1016/ S0140-6736(14)61830-4 Heidi Brady/Raising Voices/Kivulini In Margaret Atwood’s novel, The Handmaid’s Tale, set in the near future, a totalitarian state has come to power in the USA having cracked down on women’s rights, forbidding them to own property or hold jobs.1 In this futuristic dystopia, women have strict roles in society. Those of healthy reproductive age, Handmaids, are enslaved to elite couples unable to conceive to bear them children. Although Atwood’s book is a fictional work, the underlying themes will be familiar to many women and girls around the world, and certainly to those working to eliminate violence against this population. Every day, millions of women and girls experience violence. This abuse takes many forms, including intimate physical and sexual partner violence, female genital mutilation, child and forced marriage, sex trafficking, and rape. The burden is substantial. One in three women will experience physical and/or sexual violence by a partner or sexual violence from someone other than a partner in their lifetime, constituting a “global public health problem of epidemic proportions”, according to WHO.2 Women’s health and wellbeing can be affected by this violence in many ways, including physical and mental trauma, increased vulnerability to HIV/AIDS, and sexual and reproductive health problems. Childhood experience of violence, directly or witnessing violence in the home, is a risk factor for a range of high-risk health behaviours, such as smoking and unsafe sexual practices, and, for boys, for violence perpetration in adolescence and adulthood.3 Men are victims of unacceptable violence too. However, different strategies are likely to be needed to address this health problem, since the largest burden among men is likely to be from street or gang violence perpetrated by other men.4 Such violence is common in many inner-cities around the world, with a particularly high burden in regions such as Latin America.4 Violence against women and girls, meanwhile, is widespread but often hidden, and has a common root cause—gender inequality—perpetuated by entrenched social norms and structures that exist in every economic setting. Although a developing field, primary and secondary prevention is possible, and this is the central theme of the Lancet Series on violence against women and girls.4–8 We thank Charlotte Watts, Claudia García-Moreno, and Cathy Zimmerman, who conceived the idea for this Community members and leaders in Mwanza, Tanzania, talk about their role in preventing violence against women www.thelancet.com Published online November 21, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61775-X 1 Comment There is one sector that lags behind in its vital role in addressing violence against women and girls: the health sector. Health workers have a crucial part to play not only in treating the consequences of violence, but also helping women to disclose that they are victims of violence and to understand that what they are experiencing is abuse. This type of supportive—potentially life-saving—response requires non-judgmental, respectful, and compassionate care. As noted by García-Moreno and colleagues,6 systems-wide changes are needed to enable health workers to address violence against women and girls, such as regular training, protocols, and referral networks. Health professionals also have a role in championing primary prevention and being agents of change not only in clinical settings but also in the wider community, for example by promoting the health benefits of delayed marriage for girls. The women’s movement has been, and will continue to be, instrumental in advocacy and government action on violence against women and girls, but it is time for the campaign to be broadened. We hope this Series will initiate a new health and sustainable development movement for 2015 and beyond, one that involves women and girls, men and boys, health-care workers, 2 researchers, teachers, religious leaders, the judiciary, police, and politicians, and one that can eventually eliminate violence against women and girls. Udani Samarasekera, Richard Horton The Lancet, London NW1 7BY, UK We thank Alison Morris-Gehring for her help coordinating this Series. 1 2 3 4 5 6 7 8 9 Atwood, M. The handmaid’s tale. London: Jonathan Cape, 1985. WHO. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: World Health Organization, 2013. http://www. who.int/reproductivehealth/publications/violence/9789241564625/en/ (accessed Oct 28, 2014). Krug RG, Mercy JA, Dahlberg LL, Zwi AB. World report on violence and health. Lancet 2002; 360: 1083–88. Jewkes R, Flood M, Lang J. From work with men and boys to changes of social norms and reduction of inequities in gender relations: a conceptual shift in prevention of violence against women and girls. Lancet 2014; published online Nov 21. http://dx.doi.org/10.1016/S0140-6736(14)61683-4. Ellsberg M, Arango DJ, Morton M, et al. Prevention of violence against women and girls: what does the evidence say? Lancet 2014; published online Nov 21. http://dx.doi.org/10.1016/S0140-6736(14)61703-7. García-Moreno C, Hegarty K, Lucas d’Oliveira AF, Koziol-Maclain J, Colombini M, Feder G. The health-systems response to violence against women. Lancet 2014; published online Nov 21. http://dx.doi.org/10.1016/ S0140-6736(14)61837-7. Michau L, Horn J, Bank A, Dutt M, Zimmerman C. Prevention of violence against women and girls: lessons from practice. Lancet 2014; published online Nov 21. http://dx.doi.org/10.1016/S0140-6736(14)61797-9. García-Moreno C, Zimmerman C, Morris-Gehring A, et al. Addressing violence against women: a call to action. Lancet 2014; published online Nov 21. http://dx.doi.org/10.1016/S0140-6736(14)61830-4. Temmerman M. Research priorities to address violence against women and girls. Lancet 2014; published online Nov 21. http://dx.doi.org/10.1016/ S0140-6736(14)61840-7. www.thelancet.com Published online November 21, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61775-X
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