Caribbean Exploratory [NIMHD] Research Center of Excellence University of the Virgin Islands School of Nursing Grant Support: National Institute on Minority Health and Health Disparities, NIH (# P20MD002286). The Caribbean Exploratory [NIMHD] Research Center of Excellence and Global Health Research Collaboration: Protecting Haitian Women and Children Earthquake Survivors from Violence and Abuse

PRESENTERS Doris Campbell, PhD, ARNP, FAAN CERC, University of the Virgin Islands Phyllis Sharps, PhD, RN, FAAN Jacquelyn Campbell, PhD, RN, FAAN Nancy Glass, PhD, RN, FAAN School of Nursing, Johns Hopkins University Global Gender Based Violence among Women and Adolescent Girls Displaced by War, and Natural Disaster

Objectives At the conclusion of this presentation participants will be able to: I. Describe the magnitude of gender based violence against women displaced as a result of human and natural disasters. 2. Describe global research on gender based violence (GBV) against women (physical, sexual and psychological intimate partner violence, abuse during pregnancy rape, and forced sexual initiation) and health outcomes with an emphasis on GBV among displaced women. 3. Describe implications for practice and future research.

Overview I Gender Based Violence A. Definitions B. Types (physical, sexual and psychological intimate partner violence, abuse during pregnancy rape, and forced sexual initiation) C. Prevalence of GBV globally D. Prevalence of GBV in refugee settings II Overview of Research on GBV and Health Outcomes Globally A. WHO Multicountry Study B.DHS including GBV C. Abuse during pregnancy and maternal mortality D. GBV & HIV interface III. Future Directions A. Research needed 1.Improvements in methods 2.Safety Precautions for Research on GBV B. Practice Implications

Defining Gender Based Violence WHAT IS GENDER? Gender is a socially constructed derivative of sex and encompasses the different roles, rights, expectations, and obligations that culture and society attach to men and women. These different roles and rights translate into women's unequal access and control over knowledge and resources (USAID, Demographic and Health Surveys, DHS) In the wake of war or disaster, educational and health systems collapse, gender-based violence increases, HIV and other sexually transmitted infections spread, and infant and maternal mortality rates often skyrocket. (UNFPA, 2005)

What is “gender-based” violence? Gender-based violence 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.

What is “gender-based” violence? Includes, but is not limited to, physical, sexual, and psychological harm It includes that violence which is perpetuated or condoned by the state. (United National Population Fund UNFPA, Gender Theme Group); IGWG of USAID. 2006). WHO Intimate Partner Violence: Any behavior within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship, includes: physical aggression, psychological abuse, forced intercourse & other forms of sexual coercion, various controlling behaviors. (Krug, et. al. ’02)

Gender Based Violence Gender inequality and gender-based violence are violations of the human rights of women and have significant public health consequences, including effects on: –Maternal health –Unwanted fertility and contraceptive use –The spread of HIV and other STIs –Infant, child, and maternal mortality, and –Children’s access to immunization and other health care. Disempowerment of women and gender-based violence have significant economic costs, including low educational attainment, loss of women's labor hours, and increased health-care costs, among others. DHS, 2006

Forms of GBV Physical, sexual, and psychological/emotional violence within the family; Child sexual abuse; dowry-related violence; Rape and sexual abuse; marital rape; Sexual harassment in the workplace and educational institutions; Forced prostitution; trafficking of girls and women; and Female genital cutting.

Prevalence of Gender Based Violence How common is it? P revalence data difficult to collect on gender based violence Estimates vary depending on how researchers define violence, questions asked, timeframes explored and sample characteristics (Bott et al.,2005). Most surveys believed to underestimate prevalence, as survivors may not report violence because of fear, shame, and lack of adequate services—among other reasons. Multicountry study on the prevalence of gender-based violence conducted by the World Health Organization (WHO) using common definition, culturally validated instrument & population based sampling across countries & rural & urban populations confirms its widespread nature.

Prevalence of GBV Prevalence of Different Forms of Gender-Based Violence Physical intimate partner violence: 10 percent to over 69 percent of women around the world report being hit or physically harmed by an intimate partner at some point in their lives (WHO, 2002). –Most usual range in industrialized countries – % –Less industrialized – 25-40% –A few countries with extreme patriarchal norms or post conflict nations more than 50% - (majority) – e.g. Ethiopia, Peru (rural)

Prevalence of GBV Prevalence of Different Forms of Gender-Based Violence Sexual violence: –Nearly one in four women report sexual violence by an intimate partner in their lifetime (Ellsberg et al., 2000; Mooney, 1993; Hakimi et al., 2001). Forced sexual initiation: –Rates of ‘forced’ sexual debut range from 7 percent in New Zealand to – 46 percent in the Caribbean (Heise and Garcia Moreno, 2002).

Prevalence of GBV in Post Conflict/Post Disaster Settings Evidence of increased IPV post disaster (Hurricanes Andrew, Katrina) related to PTSD & stress (Harville et al 2010; Norris et al ‘99) Evidence of increased GBV post conflict – including in refugee camps (Burkle 2010) –Democratic Republic of the Congo (Glass et al., 2010; Mukwege & Nangini, 2009)

Community Factors Associated With High Levels of Violence against Women Traditional gender norms that support male superiority and entitlement Social norms that tolerate or even justify violence against women Weak community sanctions against perpetrators Poverty High levels of crime and conflict in society more generally (Brown, Counts & Campbell, 1999; Heise et al 2002; Ellsberg, Garcia- Moreno et al, 2010)

Women Waiting for Prenatal and Pediatric Clinic Services Port Au Prince,Haiti

Consequences of GBV on Reproductive Health Unintended Pregnancy (Pallito et al 2006) Maternal and child impacts- Abuse during & post pregnancy increases risk of preterm, low birth rate infants, increased maternal mortality (Campbell, Garcia- Moreno & Sharps, 2004) Abused women higher death rate of children under age of five years

Consequences of GBV on Reproductive Health Increased risks of chronic health problems- depression, substance abuse, bleeding, lack of access to prenatal care, and poor maternal weight gain. (WHO multi-country study) STIs/HIV. Forced and unprotected sex and related trauma increase the risk that women will be infected by STIs and HIV. (Campbell et al, 2008)

Abuse During Pregnancy –Industrialized Countries (Campbell, Garcia-Moreno & Sharps ’04) *2 studies; ** many

Abuse During Pregnancy – Developing Countries (Campbell, Garcia-Moreno & Sharps ’04) *1 st antenatal visit; 8% sexual+83.2% sexual ‘07

Abuse During Pregnancy WHO Multicountry Study

Specific Haiti Context of GBV Before earthquake GBV in Haiti relatively high –Incidence higher than most of North America, Caribbean (except Dominican Republic), Moldovia, lower than Bangladesh, Bolivia, comparable to countries in Africa (e.g. Kenya, Zimbabwe) IPV (DHS 2008 )

Specific Haiti Context of GBV During earthquake all 3 major Haitian leaders of GBV initiatives killed –New rape laws had just been passed –First DV shelter had recently been opened Post earthquake –Many reports of rape around refugee camps –Exact prevalence unknown Amnesty International, 2011

Factors contributing to GBV in Camps in Haiti Women interviewed by Amnesty International identified the following factors as those increasing the risks of gender based violence in the camps: the lack of security and policing inside the camps and the inadequate response by police officers to victims of rape; the lack of lighting at night; insecure and inadequate shelters – tents, tarps and sometimes just blankets and sheets –available to displaced people; Amnesty International, 2011

Factors contributing to GBV in Camps in Haiti Women interviewed by Amnesty International identified the following factors as those increasing the risks of gender- based violence in the camps: inadequate toilets/latrines and washing facilities in and around the camps; the breakdown of law and order, with armed gangs carrying out attacks in the camps with total impunity; overcrowding in the camps; the lack of access to any means of earning a living or generating income; the unequal distribution of humanitarian and emergency aid between and within camps; »Amnesty International 2011

Marie used to live with her extended family in Cité Plus, one of the most deprived areas of Port-au-Prince. Several of her relatives were killed in the earthquake, including her mother and her husband, and her home was destroyed. She and her eight-year-old daughter now live in a makeshift shelter Marie herself built in Place Pétion, in Champ-de-Mars. This camp, which houses an estimated 30,000 displaced people is just a few meters from the Presidential Palace and Port-au-Prince’s main police station. However, Marie said she has never seen the police patrolling Place Pétion. She described to Amnesty International how she was gang raped just metres from the police station: “On 10 June, at around 1am, some people forced their way into my shelter… They blindfolded us, me and my friend… MARIE © UNICEF/NYHQ /Noorani© UNICEF/NYHQ /Noorani

My daughter started to cry and they kicked her. My nephew started to cry and they beat him as well. They wounded me with a knife. There were five men, three raped me… Some were carrying guns, others knives... When you call [for help], people hear but they don’t come out to help when there are people with guns around… I don’t have any money to go to the doctor… I would have loved to [go to the police] but... [the police] don’t listen, they don’t listen to what you are saying”. Marie is still in Place Pétion and lives in constant fear. Amnesty International, 2011 © UNICEF/NYHQ /Noorani© UNICEF/NYHQ /Noorani

Life in the Camps Insecure and inadequate shelters – tents, tarps and sometimes just blankets and sheets –available to displaced people; Inadequate toilets/latrines and washing facilities in and around the camps; The breakdown of law and order, with armed gangs carrying out attacks in the camps with total impunity; overcrowding in the camps; The lack of access to any means of earning a living or generating income; The unequal distribution of humanitarian and emergency aid between and within camps; The lack of protective measures for survivors of sexual violence, putting them at risk of revictimization; The lack of information about the concrete steps a survivor of sexual violence can take to get help Amnesty International, 2011

Life In The Camps

Recommendations to the Haitian Government and the International community Treat the issue of violence against women as a priority for the humanitarian and the reconstruction effort in Haiti. Develop and implement a comprehensive strategy to prevent and respond to gender-based violence in the camps. Ensure effective and broad consultation and participation of women and girls in the conception and implementation of the strategy aimed at preventing and responding to gender-based violence. Amnesty International, 2011

Research Needs Conduct a comprehensive situation analysis on the risks confronting women and girls in the camps to fill in the gaps in data needed to develop protection measures against sexual and gender-based violence; Establish a surveillance systems to systematically collect information related to the nature and extent of gender-based violence in and around the camps; Establish a uniform and nation-wide mechanism to record reported cases of sexual and gender-based violence, providing tracking support to health care providers, the Haitian National Police, judicial authorities, and women’s rights organizations;

Research Needs Explore links between gender-based violence and infectious diseases, apart from sexually transmitted infections such as HIV, for example tuberculosis Mapping out sexual and gender-based violence

Practice Implications Increase access to survivor centered services through capacity building Increase understanding and skills to meet standards of care (health care providers, social service workers, law enforcement, governmental agencies) Train health care providers to meet the unique needs of displaced children and adolescent survivors. Provide safe shelter for displaced women and girl survivors

_______________________________________________________________________________________ Gender based violence is a major public health problem for adult women and adolescent girls around the world. Globally between 15 – 59% of adult women report intimate partner violence (IPV) and among women and adolescent girls displaced (by war, natural disaster, famine) the prevalence of partner violence and sexual assault is even higher. This presentation will give an overview of research on gender based violence (IPV and sexual assault) and physical and mental health outcomes globally among women with an emphasis on those displaced by war and natural disaster. Types of violence covered will include physical, sexual and psychological intimate partner violence, abuse during pregnancy rape, and forced sexual initiation in refugee camps and other post war and disaster settings. Outcomes covered will include depression, PTSD, suicidality, HIV and STI’s, pregnancy related outcomes for mothers and infants including maternal mortality, injury, disability and poorer health status. The research available will be critiqued in terms of methods and samples. Implications for nursing practice and policy among these populations will be suggested as well as recommendations for future research including appropriate participant safety strategies. _______________________________________________________________________________________ Gender based violence is a major public health problem for adult women and adolescent girls around the world. Globally between 15 – 59% of adult women report intimate partner violence (IPV) and among women and adolescent girls displaced (by war, natural disaster, famine) the prevalence of partner violence and sexual assault is even higher. This presentation will give an overview of research on gender based violence (IPV and sexual assault) and physical and mental health outcomes globally among women with an emphasis on those displaced by war and natural disaster. Types of violence covered will include physical, sexual and psychological intimate partner violence, abuse during pregnancy rape, and forced sexual initiation in refugee camps and other post war and disaster settings. Outcomes covered will include depression, PTSD, suicidality, HIV and STI’s, pregnancy related outcomes for mothers and infants including maternal mortality, injury, disability and poorer health status. The research available will be critiqued in terms of methods and samples. Implications for nursing practice and policy among these populations will be suggested as well as recommendations for future research including appropriate participant safety strategies.

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