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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.
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?
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…
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
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
Notes de l'éditeur
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