1. INVISIBLE MAKING THE INVISIBLE VISIBLE: Measuring Domestic Violence and Its Consequences Sunita Kishor (Ph.D.) Senior Gender Advisor Demographic and Health Research Macro International, Inc. Maryland, USA

2. Overview Gender and gender-based violence (GBV) The role of the Demographic and Health Surveys in making the invisible VISIBLE The nitty-gritty of measurement: substantive and ethical challenges What we now know: prevalence, correlates, and consequences Continuing challenges

3. ...the different roles, rights, and obligations that culture and society attach to individuals according to whether they are born with male or female sex characteristics A digression: What is gender? What is gender? Not just different, but UNEQUAL… Not just UNEQUAL, but SUBORDINATE but SUBORDINATE GBV an inherent part, an expression, an outgrowth, of this gender inequality

4. 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. United Nations Population Fund (UNFPA) Gender Theme Group

5. Gender-Based Violence Over the Life Cycle (adapted from Watts and Zimmerman, 2002) Others Intimate partner Family members Prebirth/ Infancy Adolescence Reproductive Older ages Violence by states (e.g. rape in war) Trafficking Acid throwing Non-partner rape/harassment/violence Dowry deaths/honor killings Differential access to food/medical care Psychological abuse; Coerced sex/rape/harassment; Physical violence; Violence during pregnancy Female infanticide; FGC/M Sex-selective abortion Differential access to food/medical care Violence in pregnancy Physical and sexual violence Psychological abuse

6. Sources of Domestic Violence Data Institutional sources:Institutional sources: Police, hospital, court records; data from shelters Incomplete coverage; provide data on only very severe cases Qualitative, ethnographic studies:Qualitative, ethnographic studies: Cannot be generalized; good for in-depth study Survey sources:Survey sources: –Surveys on GBV: Rare and costly e.g., WHO Multi-Country Study of Domestic Violence –Surveys on other topics with questions on GBV e.g., Demographic and Health Surveys (DHS)

7. What is the DHS? A demographic, nutrition, and health survey program for the developing world since1984, primarily funded by USAID Nationally-representative household surveys with large samples (typically 6000 +; India-100,000+) Nationally-representative household surveys with large samples (typically 6000 +; India-100,000+) Usually repeated every 5-7 years Usually repeated every 5-7 years Provide indicators for monitoring at the national and sometimes, sub-national level Provide indicators for monitoring at the national and sometimes, sub-national level Comparable across countries and over time Comparable across countries and over time More recently include biomarkers, e.g., syphilis and HIV, and domestic violence More recently include biomarkers, e.g., syphilis and HIV, and domestic violence DHS surveys considered the gold standard by countries and development partners

9. DHS Countries with Domestic Violence Data Africa –Cameroon 2004 –DRC 2007 –Egypt 1995 & 2005 –Ghana 2008* –Kenya 2003 –Liberia 2006/07 –Malawi 2004 –Mali 2006 –Rwanda 2005 –South Africa 1998 –Uganda 2006, 2009* –Zambia 2001/02; 2007* –Zimbabwe 2005/06 Asia/South Asia –Bangladesh 2004, 2007* –Cambodia 2000 & 2005 –India 1998/99 & 2005/06 –Jordan 2007* Latin America/Caribbean –Bolivia 2003 –Colombia 1990, 1995, 2000, 2005 –Dominican Republic 2002 & 2007 –Haiti 2000 & 2005 –Honduras 2005 –Nicaragua1997/98 –Peru 2000 & 2004 Eurasia –Azerbaijan 2006 –Moldova 2005 –Turkmenistan 2001 –Ukraine 2007* * Data not yet available.

10. Defining what violence to measure Defining what violence to measure Ensuring validity of the measures: thehow Ensuring validity of the measures: thehow Ensuring safety and ethical standards Ensuring safety and ethical standards Determining what else to measure other than prevalence Determining what else to measure other than prevalence Measurement Challenges Measurement Challenges

11. Validity of Data No catch-all term to capture violence Recommendation: Ask about different types of violent acts separately, eg: have you been slapped NOT have you experienced any violence or have you been beaten? Risk of underreporting of violence Recommendations: Build rapport, ensure privacy, provide multiple opportunities to reveal abuse

12. Measures of Spousal Violence Physical violence Physical violence Any of the following acts perpetrated by her husband: Pushed her, shook her, or threw something at her Slapped her Twisted her arm or pulled her hair Punched her Kicked her, dragged her, or beat her up Tried to choke her or burn her on purpose Threatened her or attacked her with a weapon Sexual violence Sexual violence Any of the following any of the following acts: Forced her to have sexual intercourse when she did not want it Forced her to perform sexual acts she did not want to Emotional violence

13. Selected Domestic Violence Indicators in the DHS Prevalence of spousal violence: ever and 12 months Timing of initiation of spousal violence Injuries related to spousal violence Wives initiating spousal violence Violence by others (ex-spouse, boyfriend, family, others) Forced first sexual intercourse* Violence during pregnancy * Lifetime prevalence of sexual violence by anyone Help seeking by abused women

14. Safety and Ethical Concerns Confidentiality and informed consentConfidentiality and informed consent –Only one woman per household receives the DV questions –Men not asked DV questions in the same household –Informed consent obtained –Translators not used for this section –Interview discontinued if privacy not assured Respondent and interviewer safetyRespondent and interviewer safety –DHS guidelines are modeled on WHOsGuidelines for the Ethical Conduct of Domestic Violence research (WHO, 2002) DHS has sought to strike the right balance between ethical concerns and information needs DHS has sought to strike the right balance between ethical concerns and information needs

15. Prevalence of Spousal Physical or Sexual Violence: Selected Countries Percent of ever-married women age 15-49 Only 1-7% of married women have ever initiated violence have ever initiated violence against their husbands.

16. Correlates of Spousal Violence India 2005-06 Percent of ever-married women age 15-49

17. Correlates: Husbands Drinking of Alcohol Correlates: Husbands Drinking of Alcohol Adjusted odds of experiencing violence among ever-married women age 15-49 (ns) Odds of experiencing violence = 1 if husband does not drink; then odds of experiencing violence if husband: are: Kishor and Johnson, 2004

18. Intergenerational Aspects of Violence Intergenerational Aspects of Violence Adjusted odds of women (ever-married, 15-49) reporting violence ever Odds of experiencing violence if father did not beat mother =1; Adjusted odds of experiencing violence if father beat mother = Kishor and Johnson, 2004

19. Immediate Health Consequences Immediate Health Consequences Among women who have ever experienced spousal violence Percent who have had:

20. Selected Adverse Health Outcomes Had an STI Discontinued modern contraceptive Base line risk: 1.0 Never experienced spousal violence, odds = 1; If experienced violence, adjusted odds =

21. MORE Adverse Health Outcomes Never experienced spousal violence, odds = 1; If experienced violence adjusted odds = Pregnancy termination Unwanted birth Base line risk: 1.0 Kishor and Johnson, 2006

22. What we do know… Spousal violence varies from about 14% in Cambodia to 59% in Uganda Typically, half or more of the women who have ever experienced spousal violence have experienced it in the past 12 months Spousal sexual violence is reported by 5-20 percent of women Physical violence is the most common type of violence Violence begins early in the marriage Violence results in injuries Women rarely seek help Further analysis shows that there are strong links to health outcomes for mothers and their children

23. What Perpetuates GBV? Gender norms that Rigidly define gender roles and what a good woman is Tolerate and accept male aggression and risky sexual behavior as part of being a man Give men the right to discipline and control wives Cultural norms that treat domestic violence as a private matter Womens lower status in society that results in: Limited access to and control over resources Less education and skill development Dependency on men, on sons

24. Is a husband justified in hitting or beating his wife if she… Neglects the children Answers back/argues with him Goes out without telling him Refuses sex with him Burns the food DHS Question on Norm Socialization

25. Evidence of Norm Socialization One of the most common reasons: Neglects the children Country Percentage who agree with any reason for wife beating WomenMen Moldova2122 Malawi2816 Zimbabwe4837 India5451 Kenya6863 Uganda7060 Zambia8569

26. Solution: Multifaceted Interventions A Health-Sector Example Womens RH Womens experience of GBV Effectiveness of health provision HEALTH SERVICE DELIVERY PROGRAMS Community mobilization programs Communication for social & behavior change programs Norms Laws Institutions Funding Policy discourse Correct diagnosis Appropriate care No harm to patient Care attuned to physical +psychological needs Health policy programs

27. Measurement of mens experience of violence from women other types of intimate partner violence Doing more to minimize under-reporting Recognize the limitations of large scale surveys Doing more in-depth and longitudinal studies to fill in gaps Going beyond the measurement of prevalence Analysis, dissemination, action Gaps and Continuing Challenges

28. www. measuredhs.com

29. sunita.kishor@macrointernational.com Photo credits: Photos courtesy of M/MC Photoshare at jhuccp.org/mmc References Kishor S. and K. Johnson. 2006. Reproductive Health and Domestic Violence: Are the Poorest Women Uniquely Disadvantaged? Demography Vol. 43(2 ): 293-307 --. 2004. Profiling domestic violence: A multi-country study. ORC Macro, Calverton, Maryland Watts. C. and C. Zimmerman. 2002. Violence against women: global scope and magnitude Lancet Vol. 359( 9313):1232 – 1237 World Health Organization. 2001. Putting women first: Ethical and safety recommendations for research on domestic violence against women. Department of Gender and Women's Health, Geneva, Switzerland For Specific Questions: