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Health outcomes of partner and non-partner sexual violence in the Democratic Republic of the Congo, SVRI 2011
- 1. Health Outcomes of Intimate Partner and Non-Partner Violence against Women in the Democratic Republic of the Congo: PRIORITIZING RESOURCES INTHEWAKEOFCONFLICT Katie Robinette, MPH Association of Schools of Public Health (ASPH) Center for Disease Control and Prevention (CDC) Allan Rosenfield Global Health Fellow Sexual Violence Research Initiative Forum October 10-13, 2011 ∙ Cape Town, South Africa This research was supported under a cooperative agreement from the CDC through ASPH. The contents of this article are solely the responsibility of the author and do not necessarily represent the official views of CDC or ASPH.
- 2. KEY MESSAGE
- 3. WOMEN’S HEALTH IS POSITIVELY CORRELATEDTO DEVELOPMENT. Individual health Women’s HEALTH Children’s health Community health DEVELOPMENT Economic prosperity and stability Impacts achievement on all MDGs
- 4. Sexual & physical VIOLENCE IS INVERSELY CORRELATEDTO WOMEN’S HEALTH. Physical injury VIOLENCE Mental health STIs and HIV Women’s Birth outcomes ADVERSE HEALTH OUTCOMES Access to health care Death
- 5. therefore… ↓VIOLENCE = ↑ WOMEN’S HEALTH = ↑ DEVELOPMENT “Investing in women’s health has a direct impact on decreasing poverty and achieving wider social and economic goals” -Elizabeth Lule, World Bank Population & Reproductive Heath Advisor
- 6. There are many types of VIOLENCE that can affect women’s health. SEXUAL & PHYSICAL INTIMATE PARTNER & NON-PARTNER CONFLICT-RELATED & “EVERYDAY”
- 7. In the DRC, previous research has focused mainly on conflict-related sexual violence and is often limited to the eastern provinces.
- 8. 42% 59% 41% 64% Intimate partner 34% 56% violence in DRC is among the highest 28% 50% in the world, 36% 38% yet there is little 40% research or programmatic attention on it.
- 9. ResearchQuestion How do health effects of intimate partner violence compare to health effects of non-partner violence for women in the DRC?
- 10. Population & Data Nationally representative 2007 DHS 2,859 Women Ever married or lived with a man as if married
- 11. Independent variable: VIOLENCE % Married Women Reporting Violence Emotional Intimate Partner Violence Moderate Physical Severe Physical Any Physical Sexual IPV Physical and/or sexual Any IPV… Physical, Non-Partner Intimate partner Sexual, Ever violence is widespread Other Sexual, last 12 months and affects an alarmingly high First sex forced number of women.
- 12. Dependent variable: HEALTH Outcomes Infertility Sexually Transmitted Poor birth outcomes INFECTIONS HIV risk During the last 12 months, • have you had a disease which you got through sexual contact? • have you had a bad smelling abnormal genital discharge? • have you had a genital sore or ulcer?
- 13. Women who experienced violence of any kind had higher rates of STIs .
- 14. % women reporting STI in past 12 months, by type of sexual violence 2 sexual No Reported Violence violence Reported Violence Variables: 13.9% 13.0% Intimate Partner 6.9% Sexual Violence 5.1% Ever Sexual Violence Sexual IPV Sexual, Ever Intimate Partner Other Violence Violence
- 15. “Ever sexual violence” ≠ non-partner violence (necessarily) } Has anyone ever forced you to have sexual intercourse (Who?) against your will?
- 16. “Sexual IPV” = intimate partner sexual violence Has your husband/partner ever: } • physically forced you to have sexual This can intercourse with him even when you clarify partner did not want to? vs. non- partner • forced you to perform any sexual acts violence that you did not want to do?
- 17. Partner vs. non-partner SEXUAL VIOLENCE Partner and non-partner violence (maybe) Partner Non-partner No sexual violence violence violence n=228 only only n=1,443 n=620 n=133
- 18. Partner = STIs Partner VIOLENCE (regardless of “ever sexual violence”) Anyone ever forced respondent to perform sexual acts No Yes Total * 5.1% 6.8% * No 5.3% Ever experienced (n=74/1443) (n=9/133) sexual intimate partner violence 10.8% 18.3% Yes 12.9% (n=67/620) (n=42/228) Total 6.8% 14.1% *p<0.001 *p=0.002 P value calculated with Chi-Squared test
- 19. Non-partner = Partner VIOLENCE STIs (but only for women who also report partner violence) Anyone ever forced respondent to perform sexual acts No Yes Total No 5.1% 6.8% 5.3% Ever experienced (n=74/1443) (n=9/133) sexual intimate * partner violence 10.8% 18.3% Yes 12.9% (n=67/620) (n=42/228) Total 6.8% 14.1% *p=0.004 P value calculated with Chi-Squared test
- 20. STI rate and ever experienced sexual violence, by partner sexual violence 18.3% * For women who have not *p=0.004 experienced sexual partner violence, STI in past 12 months rate of STI is 10.8% * Partner violence? No 6.8% Yes 5.1% whether they report “ever sexual violence” No Yes or not. Ever sexual violence?
- 21. Is “ever sexual violence” actually measuring partner violence? It is still significantly correlated with STIs even when controlling for No. partner violence with LOGISTIC REGRESSION Association between intimate partner sexual violence, ever sexual violence and STIs Sexual IPV only model Ever SV only model IPV plus Ever SV Odds Ratio Odds Ratio Odds Ratio (95% CI) p (95% CI) p (95% CI) p Intimate partner 3.08 (2.26-4.21) <0.001* .. .. 2.65 (1.90-3.69) <0.001* sexual violence Ever been forced .. .. 2.20 (1.52-3.18) <0.001* 1.75 (1.19-2.56) 0.004* to have sex *statistically significant All logistic regression models are adjusted for respondent’s age, highest level of education, geographic province, urban/rural, household wealth quintile, total number of children and marital status.
- 22. No partner violence Experienced partner violence n=1576 n=848 Odds Ratio (95% CI) p Odds Ratio (95% CI) p Ever been forced to 1.16 (0.53-2.50) 0.706 2.23 (1.36-3.64) 0.001* have sex *statistically significant All logistic regression models are adjusted for respondent’s age, highest level of education, geographic province, urban/rural, household wealth quintile, total number of children and marital status.
- 23. If we had an intervention that could eliminate all non-partner violence in all of DRC…
- 24. If we had an intervention that could eliminate all non-partner violence in all of DRC…
- 25. If we had an intervention that could eliminate all partner violence in all of DRC…
- 26. If we had an intervention that could eliminate all partner violence in all of DRC…
- 27. In fact, sexual intimate partner violence explains a lot (but not all) of the STI risk associated with other types of violence
- 28. Intimate Partner Sexual Violence is more strongly correlated with Sexually Transmitted INFECTIONS than any other type of violence, partner or non-partner.
- 29. Limitations & Considerations Data “Has anyone besides your husband/partner…” Sexual Non-partner Violence Limited interpretation: could be anyone Not conflict vs. non-conflict violence comparison
- 30. KEY MESSAGE
- 31. “Where gender inequality persists, efforts to reduce poverty are undermined… Promoting equality between women and men helps economies grow faster, accelerates poverty reduction, and enhances the dignity & well-being of men, women, and children.” -James Wolfensohn, World Bank Group
Hinweis der Redaktion
- For gender-based violence resources to have the greatest impact on development and stability in DRC, they must be allocated to include intimate partner violence on a national level, in addition to addressing other types of violence that women facevs. the current situation, where almost all GBV resources are limited to addressing only conflict-related sexual violence only in a few particular regionsIn this presentation, I am going to discuss the research that I conducted and how it ties in with the key message here. But first, this key point relies on 2 well-proven concepts…
- First: Previous literature has shown many times over that women’s health is positively related to development and stability. When women’s health increases, development follows.Increase in women’s health and equality leads to…Individual health and well-being: Increase life expectancy of both women and menChildren’s Health and Well Being: decrease in maternal mortality, child mortality and nutrition, better birth spacing, better access to health care during and after pregnancy, higher prioritization of health and education investments for their own childrenEconomic Prosperity and stability: Increase in GDP per capita, increase women’s participation in labor force, increase productivity, decrease in children’s participation in labor forceAgriculture and food security: Women get title to land, increasedagricultural activity, adoption of new technologies, increase of agro-biodiversity, slowing of environmental degradation . Increase access to safe water and sanitationGender equality has an impact on achievement of all of the Millennium Development GoalsReferences: UNIFEM. Gender Equality Now: Accelerating the Achievement of the Millennium Development Goals. World Bank. Focus on Women and Development: Improving women’s health and girls’ education are key to reducing poverty. 2004. http://www.sidsnet.org/archives/other-newswire/2004/msg00157.html
- Second: Sexual and physical violence are inversely related to women’s health. When violence goes up, women’s health goes down.Violence had been shown to be related to…Physical injury and chronic painMental health and social functioning(emotional distress, sexual dysfunction, depression, stress/anxiety disorders, PTSD, drug and alcohol abuse)Birth outcomes(miscarriage, abortion, unwanted or unintended pregnancy, pre-term labor, fetal distress, low birth weight)STIs and HIVHealth Care(Decreased access to pre-natal care, PMTCT, HIV counseling and testing, modern contraceptives)Death(femicide, suicide, maternal mortality)References:WHO Multi-Country Study on Women’s Health and Domestic ViolenceUN 61st session of the General Assembly, Advancement of Women. In-Depth study on all forms of violence against women. Report of the Secretary-General.
- Taking these two concepts into consideration, we can see that when violence against women decreases, we see an improvement in women’s health and development follows in the form of individual, family and community health, well-being, prosperity, and stability.So, we’ll keep this idea in the background as I talk continue…
- I think this audience is familiar with the accepted definition of gender based violence, so I won’t go over that.Of course, there plenty of other types of violence that women undergo and can affect health that are not listed here, but these are some types of violence that are particularly relevant to Congo that I’ll focus on here.By “everyday” violence, (for lack of a better term) I’m referring to domestic violence, or community violence… violence that happens outside of extraordinary events like war or emergencies
- Almost all academic research on gender-based violence in DRC so far has focused only on conflict-related sexual violence, and almost all of it is limited to a few select regions in the East of the country where the conflict is most severe, namely around the cities of Bukavu and Goma, in the North and South Kivu provinces, and in the Ituri region of Orientale province.This is the case for most programmatic efforts as well: a focus on conflict-related sexual violence in certain areas in the east of the country.As a side note, you can see how big DRC is on the map of Africa. Now that Sudan has split into two countries, DRC is the 2nd largest country in Africa after Algeria.Earlier this year, there was one journal article by Peterman, Palermo and Bredenkamp on estimates and determinants of sexual violence. This was the first study I had seen to mention “everyday” violence along with conflict-related, and to analyze violence at a national level.
- These figures are for the % of women reporting sexual and/or physical intimate partner violence within their lifetime. This comes from a document compiled by UN Women as of March 2011 of violence against women statistics from around the world, using mainly DHS, WHO, International Violence Against Women Survey, and other national surveys. Of the countries for which data is available, DRC has the 3rd highest prevalence of intimate partner violence in the world, following only Ethiopia (at 71%) and Kiribati, an island in the South Pacific (at 68%).The data here compares DRC with neighboring African countries where data is available.
- Non-partner violence, especially conflict-related sexual violence that has been documented and widespread within some regions in the DRC, can be incredibly brutal.On the other hand, sexual violence at the hands of an intimate partner may or may not be as brutal, but may be repeated over a much longer duration of time. It also affects significantly more women than non-partner violence in DRC, and it affects women throughout the entire country, not only in specific regions, as is the case for conflict-related violence.This study aims to understand the health effects of intimate partner and non-partner violence in DRC. I hypothesized that intimate partner violence is just as strongly associated with poor health outcomes for women in DRC as non-partner violence, if not more so.
- Nationally representative sample of women who participated in the 2007 Demographic and Health Survey and answered a subset of questions on history of violence. DHS is the only national survey that has looked at violence against women, and 2007 is the most recent data available. It’s not perfect (I’ll go in to that in a minute)… but we can work with it to try and answer this research question. Since the objective of this study is to compare partner violence and other violence, only women who answered questions about both partner violence and other violence were included in analysis. The way that the questionnaire was structured, only women who were currently/ ever married or currently/ever living with a man as though they were married were asked the intimate partner violence questions.Women who were never married or had never lived with a man as if they were married were classified as single and only asked if they had ‘ever been forced to have sex’, but were not asked a follow-up question about who was the perpetrator of this/these act(s)(n=577). Since there is no way to differentiate for single women whether the violence took place at the hands of a boyfriend or ex-boyfriend, or rather somebody else, these women were excluded from analysis, rather than assuming that all sexual violence reported by single women was committed by a non-partner.After excluding women who were not asked about domestic violence, the total included in the study was 2859(3436-577)
- The independent variable: Let’s look at a general overview of the different types of violence and the rates of that women reported in DRC.Emotional IPV= partner says something to humiliate you in front of others, threatens to hurt or harm you or someone close to youModerate physical violence=Slapped or twisted arm; Pushed, shaken, or thrown to the ground; Punched; Kicked or dragged on the ground Severe physical IPV=Strangled or burned; Threatened or attacked with a weapon Sexual IPV= Forced to have intercourse; Forced to perform other sexual acts Non-IPV physical violence = most commonly perpetrated by mother/mother-in-law and father/father-in-lawIntimate partner violence (IPV) is widespread throughout the entire country and affects a much larger number of women than does non-partner violence.Despite this, very few studies and programs have addressed domestic violence, focusing, rather, on conflict-related sexual violence in the east. Since domestic violence is so widespread, this study looks at violence on a national level, instead of focusing only on particular regions.For this presentation, I’ll focus on the results for sexual violence. We’ll look at the differentiations between partner and non-partner violence in a more detail in a moment…
- The dependent variable: Health outcomesThere possible health outcome variables from this data set- including antenatal care, unintended pregnancy, pregnancy termination, pregnancy outcome, contraceptive use and condom negotiation (Hindin,Kishor, Ansara. 2008)For this presentation, I’m going to focus on the results for sexually transmitted infections as the health variable of interest. STIs are related to significant morbidity and mortality that can affect both women’s health and their children’s health through poor birth outcomes. STIs are also related to HIV riskRespondents were counted as having had a sexually transmitted disease if they answered “yes” to any of these questions:
- Across the board, women who reported violence- any type of violence- had higher rates of STIs than women who didn’t report violence.
- Since this is the Sexual Violence Research Initiative, I am going to focus on the data analysis for sexual violence and the health outcome, STIs.This graph shows 2 variables that were measured and included in this data set: Sexual intimate partner violence and Ever sexual violence, both of which seem to be correlated with STIsLet’s take a closer look at these variables and how they were measured…
- I’m going to refer to this variable as “ever sexual violence”. Let’s take a look at how it was measured:These questions were not followed up with a question asking who forced the respondent.Nor were they phrased “Has anyone other than your husband/partner…” (as they should have been)Although these questions were probably meant to measure non-partner violence (and may be misinterpreted as such), the way these questions are worded, women reporting “ever sexual violence” are not necessarily reporting non-partner violence. With these questions alone, we can’t tell if respondents who answered yes are reporting partner violence or non-partner violence, or both… which is a problem because we’re trying to differentiate the 2 (remember I said that the DHS data wasn’t perfect…)
- However, respondents were also asked these questions with regarding to their current or last husband or partner. I’m going to refer to this variable as “Sexual IPV”With this information, we can start to clarify different effects on health outcomes for partner violence and non-partner violence.
- So when we look at the responses to these 2 questions, we can start to tease out partner violence and the non-partner violence by categorizing into 4 groups based on these 2 sexual violence questions:1,443 reported no sexual violence, partner or otherwise.620 women reported sexual violence by their partner, but said no to “ever sexual violence”. For this study, I am assuming that these women interpreted that question as “anyone other than your partner”, and so we can say that these women have not experienced non-partner violence.133 women said yes to “ever sexual violence”, but did not report partner violence. We can say that these women only experienced non-partner violence.That’s pretty straightforward…However, for the 228 women who responded yes to both “ever sexual violence” and “sexual IPV”, we don’t know whether they have experienced partner and non-partner violence, or partner violence only (we don’t know who they were referring to their partner’s violence or non-partner violence when they answered “ever sexual violence”)So, we’ll have to use statistics to control for this…
- Using this same table to show responses for both of the violence questions, now we’ll look at the health outcome: STI in the past 12 months.First, let’s look at whether partner sexual violence has an effect on STIs, grouped by the respondent’s answer for “ever sexual violence”We see that sexual intimate partner violence is significantlyassociated with higher rates of STIs, regardless of whether the respondent reported “ever sexual violence” or not
- Now, let’s look at whether non-partner sexual violence has an effect on STIs, grouped by the respondent’s answer for “sexual IPV”We see that non-partner violence is significantlyassociated with higher rates of STIs, but only for the group of women that also report sexual violence by their partners as well. This association is not significant for women who do not report partner violence. In other words, for women whose partners don’t force them to have sex, their rate of STIs is statistically the same whether they report non-partner violence or not.
- This graph shows these same results. When we look at STIs for women who report partner violence (in orange), we can see that reporting “ever sexual violence” is significantly related to higher STIs (10.8% vs. 18.3%, p=0.004). This is the case for 35% of women in the survey. However, because of the vague wording of the question, we don’t know for sure using this statistical process that this increase is due to non-partner violence.However, when we look at STIs for women who report nopartner violence (in gray), the STI risk stays statistically the same regardless of what they report for “ever sexual violence”. In other words, for these women, non-partner violence has no significant affect on STIs. This is the case for 65% of women in the survey.This looks like partner violence is more strongly associated with this health outcome, STIs… but let’s do some more math to find out more
- Logistic regression was used to analyze associations between violence and sexually transmitted infections while controlling for demographic characteristics.Since the “ever sexual violence” question is so vague, is it actually measuring intimate partner sexual violence? (In which case, sexual IPV is causing the association with STIs instead of non-partner violence)No (or at least not completely). “Ever sexual violence” is still significant even when controlling for Sexual IPV with logistic regression, so we know that “ever sexual violence” does correlate with STIs even when we of control for any overlap with sexual intimate partner violence.
- However, when we run this regression model while stratifying for intimate partner sexual violence, this correlation between “ever sexual violence” and STIs is only significant for the 35% of women who also report sexual intimate partner violenceWhat does this mean??For the 65% of women who are not raped by their husbands, it doesn’t matter whether they report “ever sexual violence” or not, their rate of STI is statistically the same.For the 35% of women that report being raped by their partners, if they report “ever sexual violence”, they are at an increased risk of STIs.
- To demonstrate this, let’s take a hypothetical situation where we have a program that eliminated all non-partner violence in the whole country…
- … we could hope to see a change like this:STI rates should drop, but only for women who also experience sexual intimate partner violence.We wouldn’t expect to see the gray columns change (women who haven’t experienced sexual IPV), because they are statistically the same to begin with
- Now, let’s take a hypothetical situation where we have a program that eliminated all sexual intimate partner violence in the whole country…
- … we could hope to see a change like this:STI rates would drop to the point where they would be statistically the same as the rates for women who have never experienced sexual violence, regardless non-partner sexual violence.
- This indicates that Sexual IPV can explain much of the STI risk that is associated with other violence. For “Any physical violence”, the effect on STI is no longer significant when controlling for SIPV, indicating that the effect is predicted mainly by SIPV. Though this is not entirely the case for “Severe physical violence”. For emotional violence, SexualIPV explains some of the effect on STI, but certainly not all. This is consistent with Dunkle, Jewkes, et al (2004) (“GBV, relationship power and risk of HIV infection in women attending ANC in South Africa”), that there is something else within relationship power imbalances (besides physical violence) that puts women at risk for HIV/poor health outcomes.Non-partner violence stays about the same whether controlling for SIPV or not, which is what we’d expect (non-partner violence would not logically be related to SIPV).All of the “Other” types of sexual violence, however, are explained to some extent by intimate partner violence. This could be because the questions themselves may be measuring Sexual IPV for some of the respondents.Sexual intimate partner violence stays significant at p<0.001 for all of the regression models above.
- Among different types of intimate partner violence, sexual violence is the strongest predictor of STI, though emotional and severe physical violence increase risk of STIs, even when controlling for sexual IPV.For “Ever sexual violence”, although it is significantly correlatedwith higher STI rates for women in DRC, sexual intimatepartner violence actually explains some, but not all, of this correlated.
- Data quality: This would have been a lot easier if women were just asked right from the start “Has anyone besides your husband/partner…” Hopefully in the next DHS in 2012, the GBV questions will be more specificAlso, the “non-partner violence” in this data set is quite limited in interpretation. Care must be taken not to interpret this as conflict-related violence because this is not necessarily the case. Besides military or police, perpetrators could range from family members, friends, teachers, employers, and even (with the way that the questionnaire was worded) former partners or boyfriends that the respondent is not living with. So, these results can NOT be interpreted as a comparison of conflict vs. non-conflict violence.
- For gender-based violence resources to have the greatest impact on development and stability in DRC, they must be allocated to include intimate partner violence on a national level, in addition to addressing other types of violence that women face……vs. the current situation, where almost all GBV resources are limited to addressing only conflict-related sexual violence only in a few particular regionsThis is not to say that we should stop addressing conflict violence.On the contrary, conflict-related sexual violence in the east is ongoing and (as we’ve seen) is a gross violation of human rights and can have devastating and severe effects on physical and mental health. But treating victims of conflict-related violence is not going to stop the conflict, and it’s not going to stop the violence.Considering at the country as a whole, intimate partner violence puts many more women at risk of, and is more strongly correlated to, poor health outcomes for women… which, as we talked about earlier, is linked with development . So when we’re talking about development, about stability, about economic prosperity- the types of things that can help stop the conflict in the east- addressing intimate partner violence is essential in DRC. Many of DRC’s neighboring countries have programs addressing violence against women that include intimate partner violence, some of which are very strong models of DV programs (Liverpool VCT in Kenya, Raising Voices in Uganda, etc…)For a country as huge as DRC, with an IPV prevalence as high as DRC’s…… it is unwise to allocate almost all resources toward conflict related sexual violence in a relatively small section of the country, while ignoring widespread intimate partner violence that affects the rest of the women in DRCIt is time to expand our thinking, our research and our resources to reach all Congolese women that are affected by violence
- Reference for quote: Improving Women’s Lives: World Bank Actions Since Beijing. The World Bank Gender and Development Group, 2005. http://siteresources.worldbank.org/INTGENDER/Resources/Beijing10Report.pdf