It is an outcome of state of art systematic review of literature. It provides insights about the cause, consequences and future concerns of violence against women in India

1. A MONOGRAPH
ON
GENDER-BASED VIOLENCE [GBV] & HEALTH CARE IN INDIA
Date of Approval February 2013
Date for completion June 2015
Principal Investigator
Dr. Meerambika Mahaptaro
Associate Professor, Dept. of Social Sciences

2. Need for a Monograph
1. Data and survey indicate rise in magnitude and nature of the problem
in India.
2. Limited analysis of empirical evidence of determinants, outcome and
their relationship.
3. Lack of systematic review on Gender Based Violence and Health Care
in India
4. Thus , it was important to draw a perspective based on published
literature to capture women’s experiences of different forms of
violence, and its impact on health.

3. General Objective
 To develop a monograph on gender-based violence and health care.
Specific Objectives
1. To critically review a range of books reports, scientific articles and other published
and unpublished materials that focus upon gender –based violence and health.
2. To provide a wider perspective of the relation between gender-based violence and
health consequences (especially maternal & child health, nutrition, accessibility and
utilization of health care, and contraceptive issues etc.)
3. To highlight potential role of doctors and health professionals
4. To draw policy imperatives and strategic options regarding help seeking, coping and
prevention of gender-based violence.
The Project

4. Methodology
 Systematic review on gender-based violence, compiling evidence from both peer-reviewed
literature and grey literature.
 Biomedical databases (British Medical Journal, British Nursing Index, Cumulative Index, Nursing &
Allied Health Literature Cochrane Library, Medline, PubMed, Science Direct, Wiley-Interscience),
social sciences databases (International Bibliography of Social Sciences, PsychINFO, Web of
Science, JSTOR, Global Health, Index Medicus for the WHO Global Health, Index Medicus for the
WHO Eastern Mediterranean Region, Medicus) & report of international agencies like UNFPA,
WHO, ICRW & population council. Citations were also followed up for international surveys on
violence against women. Specific data sets included NFHS-2 and NFHS-3, crime record buaere
2012 & additional analysis of five major study reports carried out in India such as the WHO multi-
country study on women’s health and domestic violence against women (2013), INDIA SAFE study
report (Inclean, 2000), ICMR report(2009) were referred.
 Data on lifetime & current (past year) exposure to partner & non-partner violence were
considered. Any author definitions of intimate partner violence & gender violence were included.
 More than 1000 abstracts were reviewed but relevant studies were included. Review of 213
important studies carried since 1990 till April 2015 (few studies included of 70s and 80s).
 Thematic categorization of literature was done and placed in five different chapters

5. Page No.
Executive Summary i – v
Chapter-1 Introduction 1- 19
Chapter-2 Methodology 20-21
Chapter-3 Relationship between gender based
violence and health
22-33
Chapter-4 An assessment of existing health
care provision
and role of health care providers
34-43
Chapter-5 Policy and Legal System 44-51
Chapter-6 Conclusion and Recommendation 52-56
Annexure Bibliography 57-73
The Monograph

6.  Gender-based violence is a significant public health problem, and a
fundamental violation of women’s human rights.
 It ‘s a global problem affecting millions of women and girls irrespective of
culture, religion, socio-economic strata, educational level and other diversity.
 It limits women’s participation in society and lack in decision making for
utilization of the services & opportunities , damaging their health and well-
being.
 It manifests in physical, psychological, sexual, social and cultural forms and
affects approximately one third of women globally.
 CEDAW, ICPD, and Beijing agreements
 Millennium Development Goals (MDG 3 – Eliminate gender disparities) – to
be achieved by 2015 from 1990 levels (now in SDG)
Introduction
Chapter One

7. Defining Gender-Based Violence (GBV)
 GBV is any act that result in, or are likely to result in, physical, sexual, psychological or economic harm or
suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether
occurring in public or in private life - Council of Europe, 2011.
 GBV is violence that is directed against a person on the basis of gender. It constitutes a breach of the
fundamental right to life, liberty, security, dignity, equality between women and men, non-discrimination
and physical and mental integrity - UN Declaration on the Elimination of Violence 1993.
 GBV reflects and reinforces inequalities between men and women. GBV is considered to be any harmful
act directed against individuals or groups of individuals on the basis of their gender (Standing Committee,
2005; EDAW, 1992).
 The Working Group on Women’s Agency and Empowerment, 12th Plan , “Violence against a woman (VAW)
affects her sense of self-esteem, demolishes her self-confidence and is often used as a potent tool of
subjugation and disempowerment”.
Domestic Violence Act of 2005 -“any act, omission or commission or conduct of the respondent shall
constitute domestic violence in case it:
harms or injures or endangers the health, safety, life, limb or well-being, whether mental or physical,
of the aggrieved person or tends to do so and includes causing physical abuse, sexual abuse, verbal and
emotional abuse and economic abuse; or
•harasses, harms, injures or endangers the aggrieved person with a view to coerce her or any other
person related to her to meet any unlawful demand for any dowry or other property or valuable
security; or
•has the effect of threatening the aggrieved person or any person related to her by any conduct
mentioned in clause (a) or clause (b); or
•otherwise injures or causes harm, whether physical or mental, to the aggrieved person.”

8. Gender-Based Violence
Broadly Classified as:
1. Domestic violence, sexual harassment, rape, sexual violence
during conflict and harmful customary or traditional practices
such as female genital mutilation, forced marriages and
honour crimes;
2. Trafficking in women, forced prostitution and violations of
human rights in armed conflict (in particular murder,
systematic rape, sexual slavery and forced pregnancy);
3. Forced sterilisation, forced abortion, coercive use of
contraceptives, female infanticide and prenatal sex selection.

9. Forms of Gender-Based Violence
Domestic Violence
1. Physical Violence: Physical violence is manifested as physical assault Physical violence
refers to any act of physical aggression
2. Psychological Violence: The behavioral aspects that can be placed under psychological
violence
3. Sexual violence: The attributes to sexual violence are coerced sex, denial of sexual rights,
abusive conjugal relationship and sexual hurt/ injury, female infanticide and prenatal sex
selection. Forced sterilisation, forced abortion, coercive use of contraceptives,
Other forms of Violence
1. Economic Violence
2. Socio-cultural Violence
3. Physical Violence in the Public Sphere
4. Psychological Violence in the Public Sphere
5. Rape, Sexual Harassment and Sexual Exploitation
6. Trafficking of Women and Girls

10. GBV throughout the Life Cycle
Phase Type of Violence
Prenatal Sex-selective abortion (China, India, Republic of Korea), battering during pregnancy (emotional
and physical effects on the women: effects on birth outcome); coerced pregnancy (for example,
mass rape in war)
Infancy Female infanticide; emotional and physical abuse; differential access to food and medical care
for girl infants
Childhood Child marriage; genital mutilation; sexual abuse by family members and strangers; differential
access to food and medical care; child prostitution
Adolescence Dating and courtship violence (acid-throwing in Bangladesh; date rape in the United States);
economically-coerced sex (African schoolgirls having to take up with "sugar daddies" to afford
school fees); sexual abuse in the workplace; rape; sexual harassment; forced prostitution;
trafficking in women eve teasing
Reproductive
Age
Abuse of women by intimate male partners; marital rape; dowry abuse and murders; partner
homicide; psychological abuse; sexual abuse in the workplace; sexual harassment; rape; abuse
of women with disabilities
Old Age Abuse of widows; elder abuse (in the United States, the only country where this data are now
available, elder abuse mostly affects women).
Source: Heise, Lori; Pitanguy, Jaqueline; Germain, Adrienne, Violence against Women. The Hidden Health Burden, Washington, DC: The Work Bank, 1994

11. Factors that Perpetuate Violence
1. Socio-cultural factors: Socio-cultural factors like unequal power relations, low
status of women in society
2. Legal factors: inadequate legal provisions, inaccessibility of legal services, and
ignorance of rights and responsibilities.
3. Policies and practices: There are factors like negative policy environment, gender
insensitive policies .
4. Economic factors: Economic factors include economic dependence, poverty,
limited opportunities and income sources, lack of control of own resources .
5. Education: Illiteracy and limited educational opportunity
6. Institutional factors: lack of or inadequate victim support services and distances
from courts, health facilities, police services, etc. which does not provide enabling
atmosphere.

12. Magnitude of Violence
 The crime against women during the year 2012 has increased by 6.1% over
the year 2011 (NCRB, 2012)
 In India 35% of women reported physical violence (IIPS, NFHS-3, 2007), 78%
Psychological violence and 14% sexual violence respectively (ICMR, 2009)
with wider state variations.
 Global prevalence of the % of DV for India (40%) is higher; next to
Bangladesh (47%) for various types of crimes
 Experts believe that the problem is more serious than what is being
reported.
 There is a myth that violence is part of our culture. The fact is that violence
is a crime that is culturally condoned but is punishable by law.

13. Crime against women (2008 – 12) & % variation
Sl.
No.
Crime head Year %
variation
2012 over
2011
2008 2009 2010 2011 2012
1 Rape (Sec. 376 IPC) 21,467 21,397 22,172 24,206 24,923 3.0
2 Kidnapping & abduction (Sec.
363 to 373 IPC)
22,939 25,741 29,795 35,565 38,262 7.6
3 Dowry death (Sec. 302 / 304 IPC) 8,172 8383 8391 8618 8233 -4.5
4 Cruelty by husband and relatives
(Sec. 498-A IPC)
81,344 89,546 94,041 99,135 106,527 7.5
5 Assault on women with intent to
outrage her modesty (Sec. 354
IPC)
40,413 38,711 40,613 42,968 45,351 5.5
6 Insult to the modesty of women
(Sec. 509 IPC)
12,214 11,009 9,961 8,570 9,173 7.0
7 Importation of girl from foreign
country
(Sec. 366-B IPC)
67 48 36 80 59 -26.3
Total IPC crime against Women 186,616 194,835 205,009 219,142 232,528 6.1
Source: National Crime Records Bureau (2012)

14. %ofSpousalViolence
State Percentage who have experienced
Emotional Violence Physical Violence Sexual Violence
India 15.8 35.1 10.0
Delhi 4.9 16.1 2.1
Haryana 8.7 25.5 7.1
Himachal Pradesh 3.8 5.9 1.8
Jammu & Kashmir 8.9 11.5 3.9
Punjab 10.7 24.4 7.2
Rajasthan 22.9 40.3 20.2
Uttaranchal 8.9 27.3 6.1
Chhattisgarh 12.7 29.2 6.9
Madhya Pradesh 22.5 44.0 11.0
Uttar Pradesh 16.1 41.2 9.4
Bihar 19.7 55.6 19.1
Jharkhand 18.0 34.7 12.5
Orissa 19.8 33.5 14.7
West Bengal 12.3 32.7 21.5
Arunachal Pradesh 16.6 37.5 9.5
Assam 15.6 36.7 14.8
Manipur 13.9 40.7 14.0
Meghalaya 7.1 12.6 1.6
Mizoram 11.0 22.0 2.0
Nagaland 12.6 14.0 3.0
Sikkim 10.2 14.8 4.8
Tripura 22.8 40.9 19.0
Goa 12.0 16.5 2.8
Gujarat 18.5 25.7 7.5
Maharashtra 17.5 30.6 2.0
Andhra Pradesh 13.3 35.0 4.1
Karnataka 8.1 19.5 4.0
Kerala 10.1 15.3 4.8
Tamil Nadu 16.8 41.9 3.2Source: NFHS-3

15. Problems in Measuring Prevalence
 Domestic Violence is often described as a 'hidden crime' takes place silently and less
likely to come to the notice of the police or criminal justice system
 Considered only when women report the crime before the court / police or availability
of tangible evidence.
 In India, culture allows the women to rationalize and justify domestic violence.
 Problem of under-reporting is because
 Women report only severe physical violence and lack evidence on psychological /sexual
violence.
 Doesn't know whom to approach and how to approach.
 Do not know about the source of help, advice and a safe place available.
 Do not report correctly due to stigma and embarrassment.
 Emotional relationship with the perpetrator, sense of breakdown of family
 Financial dependence, Family Pressure, effect on children.
 Low self confidence to report and take a decision.

16. Risk Factor
• Higher among young, lower household income, partner who drinks heavily & partner who
was exposed to violence against his mother in his childhood (Mahapatro, 2012; Bunge &
Locke, 2000)
• Higher who lack of social networks, greater marital control by husband, distress of their
children, and history of marital violence in either the wife’s or husband’s family of origin
were all found to be important risk factors in the study by Ellsberg et al ,1999; Gage, 2005.
• Koenig, Stephenson, Ahmed, Jejeebhoy and Campbell (2006) used multilevel modeling
among a sample of 4520 married men to examine the individual-level and community-level
influences on domestic violence in Uttar Pradesh.
– Results indicated that physical and sexual domestic violence was associated with the
individual-level variables of childlessness, economic pressure, and intergenerational
transmission of violence.
– A community environment of violent crime was associated with elevated risks of both
physical and sexual violence. Community-level norms concerning wife beating were
significantly related only to physical violence. Higher socioeconomic status was found
to be protective against physical but not sexual violence.

17. Relationship between Gender-Based Violence and Health
General Health Consequences (injury,
disability, pain, organ damage, general
sickness, burn etc.
Physical Violence
Reproductive Health Consequences
Isex selective abortion, still birth, low
birth weight baby, RTI/STD, infertility,
etc
Gender Based
Violence
Psychological
Violence
Psychological Health Consequences
(Fear, depression, retaliation, anger,
suicidal ideas/attempts, self harm)
Sexual Violence
Social and Economic Consequences
(stigma, forced marriage to rapist or
abductor, imprisonment and loss of self
and social-esteem, loss of productivity
cost of health care and cost of legal and
judicial investigation and prosecution).
Chapter Three

18. General Health Consequences
 At global level, health burden from GBV is comparable to that posed in by HIV, TB, cancer
or cardiovascular diseases put together (World Bank, 1993).
 Health professionals reveals that most of the eye and orthopedic injuries are largely
because of violence, UNFPA, 2012
 Women often have less direct access to health services and resources, such as PHC/
hospitals (Agyepong, 1992b, Ettling et al 1989) & lack of purchasing power (Okonofua,
1992 in Tanner & Vlassoff, 1998).
 Low accessibility and utilization for general illness by the victims (Mahapatro, 2011)
 Studies reveal that role of socio-economic and cultural factors influencing women’s status
effecting health (Sen et al., Hartigan et al, Ostlin, 2002).
 Violence puts her in a position of low health status, which makes her susceptible to various
infections, poor nutritive condition, and a vulnerable state of mind further deteriorating
her health.
 This further compromises her fertility, increasing her dependence on her family and
creating a vicious circle of dependency, subordination, and exploitation

19. Reproductive Health Consequences
• Violence has an association with miscarriage, stillbirth, preterm labor, birth
fetal injury, and death as well as low-weight birth baby and increased the risk
of infant and under-5 mortality (Bacchus, Bewley, & Mczey, 2001; Gissler,
Kauppila, Merilainen, Toukomaa, & Hemminki, 1997; Kajsa et al., 2003;
McFarlane, Parker, & Soeken, 1996; Reardon et al., 2002).
• Women who suffered violence during pregnancy were two times more likely
than others to miscarry and four times more likely to give birth to low weight
baby - Stark et al, 1981, Bullocak & McFarlane, 1989
• Association between gender discrimination, general neglect, domestic
violence, sexual coercion, etc. and adverse reproductive health of women has
also been reported in various studies (Breen, Sen et al., 2002).
• Abused women are less likely to seek pre-natal care –(Mahapatro et al, 2011;
Heise et al, 1994) 19

20.  Physical violence against pregnant women increases the risk of
preterm labour -(Berenson et al 1994)
 Those who suffered physical or sexual abuse or were stalked by
an intimate partner were delivered premature baby (13.4%),
4.9% of the women had third trimester bleeding, and 10.9% had
preclampsia - Zaleznik, 2009
 Homicideis a leading cause of death among pregnant women.
(Gissler, Kauppila, Merilainen, Toukomaa, Hemminki. 1997;
Reardon, Ney, Scheuren, Cougle, Coleman, Strahan, 2002).
 Homicide is the leading cause of injury related deaths among
pregnant women - Krulewitch et al 2001, Horon & Cheng, 2001
 The majority (89%) of homicide deaths occurred in the late
postpartum period- Family Violence Prevention Fund, 2008
Abuse During Pregnancy

21. Family Planning
 Those women facing domestic violence are less likely to opt for
family planning measures compared to the women not facing
violence (Mahapatro et al, 2011)
 Violence may escalate if victims use or try to negotiate FP/BC
options
 51% of young mother on public assistance experienced birth
control sabotage - Centre for Impact Research, 2000
 39.5% women seeking abortion (Leung et al. 2002; Glander, 1998)
 Women who experienced physical & sexual abuse 3 times more
likely to have rapid repeat pregnancies within 12 months (Jacoby et
al, 1999)
 Many victims do not have control over their sexual decision making
 Sexual assault is rarely detected or disclosed without inquiry

22.  40% Women with history of abuse diagnosed to have one or more STIs,
Letourneaue, 1999
 Based on a study of 310 HIV positive women: 68% experienced physical
abuse, 32% experienced sexual abuse, and 45% experienced abuse after
being diagnosed with HIV, Gielen et. al., 2000
 The average number of diseases per women was 3.6 and reproductive tract
infections contributed half of this morbidity (Bang et al, 1989).
 Women with physical abuse were 3 time more likely to have STIs and
women with psychological abuse were 2 time more likely to have STIs,
Cooker, 2000
 A review of 13 studies supports a correlation between forced sex and HIV
risk; Maman et al, 2000
 Client may not be able negotiate safe sex with abusive partner, Mahapatro,
2012
STI/HIV

23.  Psychological abuse by an intimate partner is a stronger predictor than physical abuse
 Victims are 12 times more likely to attempt suicide.
 Psychosocial distress
 depression
 suicidal – gestures, thoughts, attempts
 anxiety
 sleep disorders
 Long term mental illnesses
 The consequences of psychological abuse are generally overlooked
 Victims of abuse use numerous methods to protect their children form the perpetrator
off violence and she curse herself for………….
 Abused women are at greater risk for substance abuse, Plecheta, 1992
 Spousal abuse scores the strongest predictor of alcoholism in women, Miller et al. 1989
 Increased risk for post partum depression
Mental /Psychological Health Issues

24. Parenting Skills
• Mothers who were victimized by a partner were more likely
to have maternal depressive symptoms and report harsher
parenting
• Mothers depression and harsh parenting were directly
associated with children’s behavioural problem (Dubowitz et
al., 2001)

25. An Assessment of Existing Health Care Provision and
Role of Health Care Providers
 In India, current health care response is inadequate
• Healthcare may be a survivor’s first or only point of contact with health
professionals
• 80% women in a violent relationship seek help from health services at least once and
make 7-8 visits to health professionals, either on their own or on someone else’s
behalf, before disclosure of abuse (Tiwari et al, 2010)..
 The detection occurs very late, spend 5 to 10 years on average until the woman
reported the incident. Or justify, 61% of cases women justify the husband’s act of
violence (IIPS, NFHS-2, 2000).
• Despite the relevance of the problem, the detection is very low and it is estimated that
only few complaint cases that occur.
Chapter Four

26.  In such situation, the low detection by health professionals is a cause for
concern .
 An integrated multiple risk factor intervention addressing psychosocial and behavioral
risks delivered mainly during pregnancy can have beneficial effects in risk reduction
postpartum (Ayman et al, 2008).
 Incorporation of an abuse assessment protocol into the routine procedures of
prenatal clinics increase the assessment from 0% to 88%, identification from 0.8% to
7% and documentation (Wiist and McFarlane, 1999).
 Study reveals that intervention women had significantly fewer preterm infants
(p=0.03) and an increased mean gestational age (p=0.016) (Kiely et al, 2010).
Contd………..

27. Role of Health Care Provider
 Healthcare professionals are inadequately trained to care for abused women (Davidson et
al. (2004).
 Expertise in system approach and case management
 Direct treatment of health condition
 Physical injury
 Mental complications
 Expertise in addressing at risk behavior have unique opportunity to
 Screen
 Diagnose
 Treat
 Refer
 Prevent abuse or neglect
 Provide sample drugs, display hotline in office & encourage for routinely inquire essential
for effective diagnosis and care ; Give her info/discuss with her info on available resources

28. Guidelines for Health Care Providers
1. Identify Abuse
– Look for signs and symptoms of abuse
– Inquire with sensitivity
– Assure the client of confidentiality and make her safety a priority
2. Medical Support
– Assess for current and past incidence of violence
– Attend to all injuries
– Offer specialized services for victims of sexual violence
3. Emotional Support
– Listen carefully
– Believe in the client
– Convey that violence is not the client’s fault
– Assure the client that she is not alone
4. Documentation
– Register a medico-legal case
– Make a domestic incident report
5. Information and Referral
– Inform the client of her rights
– Convey the importance of filing a police complaint
– Ask about the client’s safety
– Refer the client to legal and social agencies for further help

29. A Systems Approach
1. An integrating attention to gender-based violence within health
services rather than setting up parallel services
2. An Incorporating routine screening for violence in health services
provided that women’s confidentiality and safety can be ensured;
3. An improving health workers’ and doctors/ managers’
understanding of local and national laws and policies related to
violence
4. A supporting long-term efforts to sensitize and train health
professionals at all levels about gender-based violence, and
5. Ensuring adequate monitoring and evaluation of services to
survivors of violence.

30. Policy and Legal System
 The are various Acts and policy are at place.
 Broadly there are following areas where the legal provision has been formed to
protect women. These are
 Dowry deaths,
 Dowry harassment,
 Molestation,
 Eve teasing and
 Rape.
 The civil wrong of domestic violence
 There are various Act like dowry prohibition Act 1961, Criminal law Act 1983, Sati
prevention Act 1987, and The Indian evidence Act 1872 and Criminal Law Amendment
Act, 2013
 Sexual Harassment of women at Workplace (Prevention, Prohibition and Redressal)
Act, 2013.The Protection of Women from Domestic Violence Act 2005.
 The act does not extend to Jammu and Kashmir, which has its own laws, and which
enacted in 2010 the Jammu and Kashmir Protection of Women from Domestic
Violence Act, 2010.
Chapter Five

31.  Kerala Model : under NRHM in 14 districts of Kerala domestic violence cell for
counseling and treatment is operationalized.
 BMC, Mumbai using the guildline for routine screening
 One-Stop Crisis Centres (OSCC) that does handholding of women affected by
violence provide medical, legal and psychological support services under one roof
to women survivors is an enabling women-friendly environment.
 One Stop Centres will be set up at three hospitals, namely Deen Dayal Upadhyay
Hospital, Sanjay Gandhi Memorial Hospital and Guru Tegh Bahadur Hospital.
 One Stop Centers, to be known as Nirbhaya Centres, will be setup in all the
districts across the country (640 districts and additional 20 locations in 6 metros)
 Apart from MoHFW, nodal departments/organizations are the Department of
Women and Child Development, Government of India, The National Commission
for Women (NCW), The National Human Rights Commission (NHRC), UNIFEM,
ICRW, and Canadian International Development Agency (CIDA).
Integration of GBV and Health Care

32. Conclusion & Recommendation
 Gender-based violence is a significant public health problem, as well as a fundamental violation
of women’s human rights.
 There is strong association between GBV and health
 Current health care response is inadequate in routine screening and treatment of violence-
related injuries and trauma.
 The cumulative evidences suggest an urgent need for integration of women safety, health, laws
and policies.
1. Effective strategies for dealing with gender-based violence as life cycle approach can only be
developed when the concepts, forms, consequences, factors and the impact of violence are
understood and integrated across the concerned public departments.
2. There should be clinical and policy guidelines for better health-sector response and to integrate
issues related to violence into clinical training to understand the relationship between exposure
to violence and women’s ill health, and are able to respond appropriately.
3. Comprehensive post violence care services need to be made available and accessible at a much
larger scale than is currently provided.
Chapter Six