Fact Sheet on Youth Reproductive Health Policy
“Gender-based violence (GBV) is violence involving men and women, in which the female is usually the victim; and which is derived from unequal power relationships between men and women. Violence is directed specifically against a woman because she is a woman, or affects women disproportionately. It includes, but is not limited to, physical, sexual, and psychological harm. It includes that violence which is perpetuated or condoned by the state” (UNFPA, 1998).
GBV encompasses a range of physical, sexual, and psychological violence that disproportionately affects women and girls (IGWG/USAID, 2008). Violence against women is a major problem that negatively affects the reproductive health of women and girls. “Each year as many as 40 million children under 15 years old experience some form of violence. Many of them are girls, and many live in Africa” (African Child Policy Forum, 2006).
|Various forms of GBV include battering, intimate partner violence (including marital rape, sexual violence, and dowry-related violence), female infanticide, femicide, sexual abuse of female children in the household, honor crimes, early marriage, forced marriage, female genital cutting and other traditional practices harmful to women, sexual harassment in the workplace and educational institutions, commercial sexual exploitation, trafficking of girls and women, and violence perpetrated against domestic workers (USAID, 2009).
Although the global community has focused greater attention on GBV in recent years, levels of violence against women remain unchanged (UN General Assembly, 2006a). Eliminating GBV is a “profoundly political challenge, because it necessitates challenging the unequal social, political, and economic power of men and women and the ways in which this inequality is perpetuated through institutions at all levels of society” (Ward, 2005, p. 6).
The Importance of GBV as a Youth Reproductive Health Issue
- Youth at risk. Rates of physical violence by male intimate partners against young women are also high. A 2008 analytical study conducted by the Demographic Health Survey (DHS) pertaining to intimate partner violence among couples in 10 DHS countries found that women from nine of the 10 countries reported having forced sexual experiences. The data also show that a major factor related to experiences of sexual violence is age at first marriage. In countries such as Bangladesh, Bolivia, Dominican Republic, Kenya, Rwanda, and Zimbabwe, women who were younger than 20 years old when they first married or started living with their current husband or partner were more likely to report physical or sexual violence than those who reported being 20 years or older when they first married (Hindin et al., 2008). According to a World Health Organization study (WHO, 2005), 20-36 percent of women ages 15–19 years old in 10 of 15 study sites reported being subject to at least one act of physical violence in the previous year. Moreover, rates of current physical violence are higher in the 15–19 year age group, compared with older women ages 20-49 years old.
- Common forms of GBV particular to youth. The nature and extent of specific types of GBV can vary across cultures, countries, and regions. Some of the more common forms that involve young people include sexual exploitation, forced sex with children, early marriage, female genital mutilation/cutting, human trafficking, cross-generational sex, and GBV in schools (Betron and Doggett, 2006). Documentation and data on the following three forms of GBV show clear links with reproductive health outcomes for youth:
- Female genital cutting/mutilation. “An estimated 100 million to 140 million girls and women worldwide have undergone female genital mutilation/cutting (FGM/C)” (WHO, 2008a, p. 1). Another estimate states that more than 3 million girls are at risk for genital cutting each year on the African continent alone” (Yoder and Khan, 2007). “Female Genital Cutting (FGC) is the name given to traditional practices that involve the partial or total cutting away of the female external genitalia and/or other injury to the female genitals, whether for cultural or non-therapeutic reasons” (Feldman-Jacobs and Clifton, 2008; USAID, 2004). FGC is customarily practiced on girls between the ages of 4 and 12 years old, albeit in some cultures, it can be performed as early as a few days after birth or as late as just prior to marriage, during pregnancy, or after the first birth (PRB, 2005). Immediate health consequences of FGC at any age can include severe pain, shock, hemorrhage, tetanus or sepsis, urine retention, open sores in the genital region, and injury to nearby genital tissue. A 2006 WHO study found an association with FGC and increased complications in childbirth and even maternal deaths. Specific side effects of childbirth include severe pain, hemorrhage, tetanus, infection, infertility, cysts and abscesses, urinary incontinence, and psychological and sexual problems (WHO, 2008a).
- Early marriage. “Early marriageis the marriage of a person at an age at which she/he is not fully able to consent to the marriage and/or marriage at an age which results in vulnerability to reproductive health problems, psychosocial damage, or denial of education.” (Betron and Doggett, 2006, p. 10).” Societal norms, social status, isolation, and gender dynamics related to early marriage inhibit women and girls from having control over their own bodies and sexual and reproductive decisions. This can result in severe reproductive health problems, such as sexually transmitted infections; HIV; early childbearing (when the mother’s age is below the age of 18), leading to increased risk of maternal and infant mortality; unintended pregnancies; obstetric fistula; and other physical, psychological, and emotional damage associated with early childbearing (McIntyre, 2006; WHO and UNAIDS, 2008).
- Cross-generational sex. Cross-generational sex is often known as the “sugar daddy syndrome,” in which a young woman age 15-19 years old has a sexual relationship with a partner 5-10 years older in exchange for money or goods (Feldman-Jacobs and Worley, 2008). A 2008 DHS analytical study (Khan and Mishra, 2008) found that 12-29 percent of adolescent girls between the ages of 15-19 years old from Chad, Nigeria, and Senegal reported having high-risk sex in the past 12 months with a man 10 years or more older. In Uganda, the risk of HIV infection doubles for girls ages 15–19 years old who engage in sexual relations with male partners 10 or more years older (IWHC, 2008). Consequences of an unequal balance in age, gender, economic status, self-esteem, and power are believed to hinder adolescent girls’ ability to negotiate safe sexual practices. Cross-generational sex is not limited to sub-Saharan Africa, but most research on the practice has been conducted in that region. Studies from several countries in sub-Saharan Africa found that girls’ motivations for engaging in sexual relationships with older partners range from the need to find love, a spouse, and/or economic security; pay for school fees and supplies; and/or elevate their status among peers through material goods. Moreover, these girls may not realize the risks and severe health consequences (e.g., HIV, sexually transmitted infections, violence, unintended pregnancy, and other dangers) associated with these relationships (Hope, 2007).
GBV-related Health Consequences for Youth
GBV results in reproductive health problems—often with lasting physical, social, emotional, psychological, and economic consequences (IGWG/USAID, 2008; Patel et al., 2007; UN General Assembly, 2006b; WHO, 2005). Research has uncovered numerous links between exposure to GBV and subsequent health outcomes among youth:
- AIDS-related mortality
- Maternal mortality
||Sexual and Reproductive
||Psychological and Behavioral
- Chronic pain syndromes
- Permanent disability
- Gastro-intestinal disorders
- Sexually transmitted infections, including HIV
- Unintended pregnancy
- Pregnancy complications
- Traumatic gynecologic fistula
- Abortion complications
- Depression and anxiety
- Eating and sleep disorders
- Drug and alcohol abuse
- Poor self-esteem
- Post-traumatic stress disorder
Note: Adapted from Heise et al., 1999.
Key Areas for Policy Action
Effective action involves addressing both the complex root causes of GBV, as well as its immediate and long-term effects on victims. Reducing GBV requires countries to enact multisectoral policies, using myriad legal and policy instruments. Aside from the health sector, the education sector can play an important role in preventing and addressing GBV, particularly through health programs and policies in schools (Bott et al., 2005; Mirsky, 2005). In addition, the judicial sector and police can also play important roles by enforcing laws and policies aimed at GBV prevention and treatment. A comprehensive approach to addressing GBV as a youth reproductive health issue should include the following integrated and multisectoral policy actions:
- Enact policies to empower women and girls. To reduce gender imbalances at the root of GBV, key legal and policy actions should advocate for delayed marriage (IIPS and Population Council, 2008), promote equitable divorce and property laws that allow women the chance to leave abusive relationships (Global AIDS Alliance, 2007), and establish constitutional frameworks guaranteeing substantive equality for women (UN General Assembly, 2006a).
- Pass laws to make sexual coercion and domestic violence illegal. It is just as important to have support for a legal and justice system that enforces these laws effectively (UN General Assembly, 2006a).
- Demonstrate clear political commitment to ending GBV. High-level government officials should consistently and publicly denounce GBV and support necessary changes in community norms that influence GBV-related behaviors of boys and young men (UN General Assembly, 2006b).
- Establish operational policies and guidelines to support program efforts. Public and private health facilities should institute policies and procedures to help providers recognize the signs of GBV and respond appropriately to meet the needs of GBV victims (IGWG/USAID, 2008).
- Ensure that national reproductive health, HIV, adolescent health, and maternal health policies and legislation specifically address the negative reproductive health consequences of GBV. Such policies should give clear guidance to health workers on their obligations in reporting and treating GBV (IGWG/USAID, 2008).Policies should also address the provision of emergency contraception and post-exposure antiretroviral prophylaxis to rape victims to protect against pregnancy and HIV infection.
- Ensure that school policies and guidelines directly address GBV. Schools may be a particularly unsafe place for young women (see box). Policies should strengthen the ability of teachers and administrators to address GBV (Mirsky, 2005) and also require them to report sexual violence against students (IGWG/USAID, 2008; USAID, 2007).
The USAID-funded Safe Schools Programstrives to reduce GBV (which includes sexual, physical, and psychological violence or abuse experienced by girls and boys) that occurs in and around school. The program works in 40 communities each in Ghana and Malawi, targeting male and female students ages 10–14 years old in upper primary and lower secondary school. The program works with a broad range of stakeholders, including teachers, parents, students, community members, and local NGOs, as well as government officials in education, health, and social welfare. Six key school-related GBV intervention strategies were designed to respond to school-related GBV: (1) a student life skills violence prevention program, (2) the teacher professional development program, (3) revision of the teachers’ code of conduct, (4) a community counselor program, (5) community mobilization campaigns, and (6) national advocacy efforts (USAID, 2007).
Outcomes of the Safe Schools Program in Malawi:
After implementing Safe Schools activities in schools in 30 communities:
- Community members conducted activities to prevent school-related gender-based violence: strengthening Parent-Teacher Associations, endorsing regulations that prohibit teachers from demanding children to engage in any form of labor during school hours.
- The Ministry of Education, Science, and Technology and the Teachers’ Union have agreed to use the revised school-related GBV Teacher’s Code of Conduct (Global AIDS Alliance, 2007).
Outcomes of the Safe Schools Program in Ghana:
After implementing Safe Schools activities in schools in 30 communities:
- The percentage of schoolchildren who believe they have the right to say “no” to unwanted touching increased from 66 percent to 72 percent.
- Communities implemented activities to prevent school-related gender-based violence, such as strengthening Parent-Teacher Associations and instituting a safe-school escort program for younger students (Global AIDS Alliance, 2007).
The State of Policymaking
Although many governments have adopted policies related to GBV, few of them specifically relate to young people. Furthermore, most supportive laws and policies are not enforced (Bott et al., 2005; Harvard SPH, 2006).
Examples of national policies that refer to GBV and youth include Kenya’s 2003 Adolescent Health and Development Policy, which addresses the reporting of adolescent rape and punishment of offenders. The 2003 National AIDS Policy in Malawi deals with sexual abuse of girls and women. Panama’s 1998 Framework for Formulation of Youth Policy and Action Plans has a section on sexual abuse of youth and intra-family physical violence against adolescents.
Education policies. South Africa is one of the few countries with a concerted policy effort to address GBV in schools (Bott et al., 2005). Its 1999 education sector policy on HIV/AIDS promotes education to help students “protect themselves against rape, violence, inappropriate sexual behavior, and contracting HIV” (South Africa, 1999: p. 4) and mandates that the HIV/AIDS curriculum emphasize “the role of drugs, sexual abuse and violence, and sexually transmitted diseases in the transmission of HIV, and empowering learners to deal with these situations” (South Africa, 1999: 6–14). South Africa’s 2007 National Policy for the Prevention and Management of Learner Pregnancy acknowledges the role and importance of teachers in educating students about sexual abuse, rape, and GBV and also directs school administrators to report cases of rape to the police.
Health service policies. Some organizations have adopted specific operational policies and procedures to address GBV among youth in clinical settings. Health nongovernmental organizations in the Dominican Republic, Peru, and Venezuela trained staff and instituted new clinical history forms, policies and procedures, and in-house services and referrals (Goldberg, 2006). The very first national policy for youth and sexual reproductive health was developed by Nicaragua. Developed by the government in 1996, The National Integrated Child and Adolescent Policy integrates reproductive health into a broader framework of citizenship, peer education, and political participation. Following a nationwide consultation with adolescents, the government integrated adolescent reproductive health needs into its poverty reduction strategy. In 2002, Nicaragua also developed a National Policy against the Sexual Exploitation of Children and Adolescents.
Search for more GBV-related policies in the Youth-Policy Database.
Research Findings to Support Policy Development
Guidelines for Integrating Sexual and Reproductive Health into the HIV/AIDS Component of Country-Coordinated Proposals to Be Submitted to the Global Fund to Fight AIDS, Tuberculosis, and Malaria, Round 7 and Beyond (Doupe, 2007). Prepared by the Global AIDS Alliance and partners.
Intimate Partner Violence among Couples in 10 DHS Countries: Predictors and Health Outcomes (Hindin et al., 2008). This report analyzes DHS data from 10 countries: Bangladesh, (2004), Bolivia (2003-2004), Dominican Republic (2002), Haiti (2005), Kenya (2003), Malawi (2004), Moldova (2005), Rwanda (2005), Zambia (2001-2002), and Zimbabwe (2005-2006). The report focuses mainly on health outcomes in relation to intimate partner violence in married and cohabiting relationships.
Journal of Adolescent Health, special issue focusing on sexual violence, various authors (JAH 2005), subscription only. This edition has several articles that highlight factors associated with rape and coercive sex, including sexually transmitted infections, other forms of violence, early menarche, and psychosocial problems.
Multi-Country Study on Women’s Health and Domestic Violence against Women (WHO, 2005). This study included interviews with 24,000 women in 15 sites in 11 countries (Bangladesh, Brazil, Ethiopia, Japan, Montenegro, Namibia, Peru, Samoa, Serbia, Tanzania, and Thailand). Report findings document the prevalence of intimate partner violence and its association with women’s physical and mental health. The data cover nonpartner violence, sexual abuse during childhood, forced first sexual experience, women’s responses to violence, and incidence of violence by age group.
MEASURE DHS Youth Corner. This website contains DHS reports that focus on data on various health factors related to youth sexual and reproductive health in 38 countries. The reports include information on issues that pertain to GBV (i.e., information on the proportion of girls and young women who experience physical violence, intimate partner violence, and nonconsensual sex).
National Cross-Sectional Study of Views on Sexual Violence and Risk of HIV Infection and AIDS among South African School Pupils (Andersson et al., 2004). This survey of more than 200,000 South African students aged 10–19 years old found that both males and females accepted the reality of sexual coercion and had adopted attitudes to survive in a violent society.
Profiling Domestic Violence: A Multi-Country Study (Kishor and Johnson, 2004). This report synthesizes DHS data from nine countries: Cambodia, Colombia, Dominican Republic, Egypt, Haiti, India, Nicaragua, Peru, and Zambia.
Female Genital Cutting in the Demographic and Health Surveys: A Critical and Comparative Analysis, DHS Comparative Reports (Yoder et al., 2004). This comparative report summarizes DHS country data on FGC that were collected between 1989 and 2002. It gives the reader access to basic information on the distribution and practice of FGC.
From Rhetoric to Reality: Policy Implementation Tips
At the national level, many governments fail to formulate and implement effectively policies that express their commitment in addressing GBV (Bott et al., 2005). The Africa’s Health in 2010 project conducted a desk review about domestic violence based on DHS data in seven sub-Saharan African countries. The review sought to answer the following questions: “1. Is GBV addressed in the national planning documents (e.g., National Plans of Action [NPAs] and first and second generation Poverty Reduction Strategy Papers [PRSPs]? 2. In what sections is GBV addressed in the national planning documents, and is it included in the list of priorities? 3. Have DHS findings on domestic violence informed policies and programs in the national planning documents?”(Borwankar et al., 2008, p. 8).
The results of the review found the following:
- Five of the six country PRSPs reviewed mentioned GBV, but only two countries addressed GBV in a detailed manner. Of the four NPAs reviewed, Uganda and Zambia’s have a more complete approach to GBV compared with the PRSPs.
- GBV is not considered a priority in national planning documents and is usually mentioned in the narrative or under the cross-cutting gender and security law enforcement sections. Furthermore, “little emphasis is placed on addressing GBV as a public health issue (including to the linkages with HIV/AIDS, reproductive health) and to school-related GBV” (Borwankar et al., 2008, p. 11). Some countries cite DHS data and other health indicators.
- However, the data from the DHS domestic violence module were not cited in any of the national planning documents.
The review concluded that, despite the evidence cited on GBV prevalence in these countries, it is still not seen as an issue that merits national-level priority. The review stressed that it is imperative for governments and national stakeholders to recognize the importance of GBV as a health-related concern and allocate resources to a national GBV response that is multisectoral (sectors should include HIV/AIDS, reproductive health, mental health, education, law, criminal justice, human rights, social welfare, and gender) at the policy and program levels.
Watch Out For …
Well-intentioned GBV-related policies that could negatively affect provision of reproductive health services. Laws requiring health workers to report GBV cases can run counter to principles of confidentiality. Without clear guidelines and careful training of health workers, such policies may inadvertently diminish the willingness of both victims and health workers to discuss violence (Bott et al., 2005). Health workers must be trained to recognize the symptoms of GBV and assist victims of GBV in a knowledgeable manner. Victims should feel secure that health workers will not blame them or divulge confidential information to relatives, thus putting the victims at additional risk of violence. Furthermore, HIV prevention services, sexual and reproductive health services, antenatal care, maternal and child health services, and voluntary counseling and testing services need to address GBV in an integrated manner (Doupe, 2007).
Q. Can boys and men also be the victims of gender-based violence?
Yes. Traditional gender norms also fuel much violence that is experienced by men. This type of violence should also be recognized as a form of gender-based violence. According to WHO, “Rape and other forms of sexual coercion directed against men and boys take place in a variety of settings, including in the home, the workplace, schools, on the streets, in the military and during war, as well as in prisons and police custody” (Betron et al., 2006, p. 23). GBV against men tends particularly to occur in situations where men do not live up to “masculine” standards. For example, men who have sex with men who are outwardly open about their homosexuality have suffered violence and social ostracism. In Kenya, nearly 40 percent of men who have sex with men reported having been raped outside their home and 13 percent report having been assaulted by the police (Barker and Ricardo, 2005).
Q. Which international legal instruments address gender-based violence?
Several international agreements and policies address GBV and can be useful for formulating national laws and policies and conducting advocacy:
Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) (1979)
Convention on the Rights of the Child (1990)
The World Conference on Human Rights Vienna Declaration and Programme of Action (1993)
The UN Declaration on the Elimination of Violence against Women (1993)
International Conference on Population and Development Programme of Action (1994)
Inter-American Convention on the Prevention, Punishment, and Eradication of Violence against Women (1994)
UN Fourth World Conference on Women Beijing Declaration and Platform for Action (1995)
Organization of African Unity Protocol to the African Charter on Human and People’s Rights on the Rights of Women in Africa (1995)
For more on international policies, see Guedes, 2004; Bott et al., 2005; Prevent GBV Africa website; and UN Division for the Advancement of Women website.
Addressing Gender-Based Violence from the Reproductive Health/HIV Sector: A Literature Review and Analysis (Guedes, 2004). This USAID-commissioned literature review analyzes programs in developing countries and includes chapters on policy and on youth-focused programming.