POLICY FORUM
Ethiopia, Japan, Peru, Namibia, Samoa,
Serbia and Montenegro, Thailand, and the
United Republic of Tanzania (19). In 13 of
the 15 sites studied, between one-third and
three-quarters (35 to 76%) of women had
Claudia Garcia-Moreno,1* Lori Heise,2 Henrica A. F. M. Jansen,1
been physically or sexually assaulted by
someone since the age of 15. In all the setMary Ellsberg,2 Charlotte Watts3
tings but one, the majority of this violence
he Millennium Development Goals change norms that condone violence was perpetrated by a current or previous
commit the 191 member states of the against women; equipping young people partner, rather than by other persons.
Overall, 15 to 71% of women who ever
United Nations to sustainable, human with skills for healthy relationships;
development and recognize that equal expanding women’s access to economic and had a partner had been physically or sexurights and opportunities for women and social resources and to support services; ally assaulted by an intimate partner (see
men are critical for social and economic providing training for health services to bet- figure, this page). In most settings, about a
progress (1). This must include addressing ter identify and support women experienc- half of these respondents reported that the
violence against women—a concrete mani- ing violence and to integrate violence pre- violence (20) was cur rently ongoing
festation of inequality between the sexes. vention into existing programs, including (occurred in the past 12 months preceding
Policies to prevent this violence should be for HIV prevention; and promotion of ado- the interview). In the majority of settings,
too, a greater proportion of
implemented as part of the agendas for
Ever
women had experienced “severe”
equality, development, public health, and
Brazil city
Current (past
physical violence than those sufhuman rights (2). Although statements and
12 months)
fering “moderate” physical viointernational declarations have called for
Brazil province
lence (21). Much of the violence
the eradication of violence against women
Ethiopia province
reported was hidden: More than
(3, 4), many agencies, governments, and
one-fifth (21 to 66%) of women
policy-makers view it as a relatively minor
reporting physical violence in the
Japan city
social problem.
study had never told anyone of
There is a growing body of evidence from
Namibia city
their partner’s violence before the
research that suggests that violence against
study interview.
women is highly prevalent, with an estimated
Peru city
The study findings confirm that
one in three women globally experiencing
women around the world are at
some form of victimization in childhood,
Peru province
significant risk of physical and
adolescence, or adulthood (5–10). This viosexual violence from their partner,
lence has a direct economic impact along
Samoa
but also highlight that there is subwith the human and emotional costs. A study
stantial variation both within and
in the USA estimated the costs of intimate
Serbia and
Montenegro city
between countries. In the WHO
partner rape, physical assault and stalking as
study, the lowest prevalence of
exceeding $5.8 billion each year, nearly $4.1
Thailand city
lifetime and current partner viobillion of which is for direct medical and
lence was found in urban Japan
mental health care services (11).
Thailand province
and Serbia and Montenegro,
Violence against women also has a subwhich suggests that rates of abuse
stantial impact on health (12–15). In the United Republic of
may reflect, in part, different levAustralian state of Victoria, violence by
Tanzania city
els of economic development.
intimate partners is calculated to result in United Republic of
Tanzania province
However, a study in two sites in
more ill health and premature death among
0 10 20 30 40 50 60 70 80 90 100 New Zealand that replicated the
women of reproductive age than any other
Percentage
WHO methodology found liferisk factor, including high blood pressure,
Note: Bangladesh data not included.
time prevalence of partner vioobesity, and smoking (16). Intimate partner
violence is also an important cause of Percentage of ever-partnered women reporting physical or lence as high as that found in
many WHO developing country
death, accounting for 40 to 60% of female sexual violence, or both, by an intimate partner, by site.
sites (22). The rates of current viohomicides in many countries, and an important portion of maternal mortality in India, lescent health. States must take responsibil- lence were much lower (less than 6% in
Bangladesh, and the United States (17).
ity for the safety and well-being of their citi- both sites), which suggests that women in
The evidence suggests that violence can zens and must tackle the problem with the industrialized nations may find it easier to
leave abusive relationships.
be prevented. Policies to prevent violence urgency it requires.
Assault by a partner was a direct cause
include promoting social awareness to
The results from the WHO Study on
Women’s Health and Domestic Violence of injuries, with between one in five and
1Department of Gender, Women and Health, World
against Women released this week (18) one-half of women reporting that they had
Health Organization, Geneva, Switzerland. 2PATH,
greatly extend the geographic range and been injured as a result of physical vioWashington, DC; 3 London School of Hygiene and
scope of available data. The results in this lence, often more than once. In addition,
Tropical Medicine, London, UK. The authors write on
report are based on over 24,000 interviews women who experienced violence by a
behalf of the WHO Multi-Country Study on Women’s
with 15- to 49-year-old women from 15 partner were more likely to report poor
Health and Domestic Violence against Women. *Author
for correspondence. E-mail: garciamorenoc @who.int
sites in 10 countries: Bangladesh, Brazil, general health and greater problems with
P U B L I C H E A LT H
Violence Against Women
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walking and carrying out daily activities,
pain, memory loss, dizziness, and vaginal
discharge in the 4 weeks before the interview. The study also found that abused
women were more likely to experience
emotional distress and to have considered
or attempted suicide. An association
between recent ill health and lifetime
experience of violence suggests that physical and mental effects may last long after
the violence has ended.
Although pregnancy is often considered
a time when women are more likely to be
protected from harm, 1 to 28% of women
who had ever been pregnant reported being
beaten during pregnancy. More than 90% of
these women were abused by the father of
the unborn child, and between a quarter and
half of them had been kicked or punched in
the abdomen. In most cases, the abuse during pregnancy was a continuation of previous violence. However, for some women,
the abuse started during pregnancy.
Intimate partner violence was also associated with an increased number of induced
abortions and, in some settings, with miscarriage. In all sites except urban Thailand
and Japan, women who experienced violence were significantly more likely to have
more children than other women.
Despite these health associations, over
half of physically abused women (55 to
95%) reported that they had never sought
help from formal services or from people in
positions of authority. Only in Namibia and
in both sites in Peru had more than 20% of
women contacted the police, and only in
Namibia and in urban Tanzania had about
20% sought help from health-care services.
Family, friends, and neighbors, rather than
more formal services, most often provide
the first point of contact for women in violent relationships.
The study also demonstrates the
remarkable degree to which women in
some settings have internalized social
norms that justify abuse. In about half of
the sites, 50 to >90% of women agreed that
it is acceptable for a man to beat his wife
under one or more of the following circumstances: if she disobeys her husband,
refuses him sex, does not complete the
housework on time, asks about other
women, is unfaithful, or is suspected of
infidelity. This was higher among women
who had experienced abuse than among
those who had not, and may indicate either
that women experiencing violence learn to
“accept” or rationalize this abuse, or that
women are at greater risk of violence in
communities where a substantial proportion of individuals condone abuse.
The association between the prevalence
of partner violence and women’s belief
that such violence is normal or justified
constitutes one of the most salient findings
of the WHO study. The data also highlight
the degree to which women in some settings feel that it is unacceptable for women
to refuse sex with her husband, even in circumstances where it could put them at risk.
In three of the rural provincial sites, as
many as 44 to 51% of women believe that a
woman is not justified in refusing her husband sex if he mistreats her. The fact that
the association is particularly marked in
rural and more traditional societies reinforces the hypothesis that traditional gender norms are a key factor in the prevalence of abuse and that transforming gender relations should be an important focus
of prevention efforts.
Violence against women is a complex
social problem, and our knowledge on how
to address it is evolving. Tackling the problem requires coordinated action that
engages communities and many different
sectors—including health, education, and
justice—to challenge the inequities and
social norms that give rise to violence and
to provide emotional and physical support
for victims. Early intervention, particularly
targeting children who witness violence or
are abused, is a promising yet underdeveloped area for action. Developing curricula
for children and young people to learn emotional and social skills, including nonviolent methods of conflict resolution, could
be an important contribution to violence
prevention. Support services for abused
women and programs to sensitize legal systems are also needed.
Health providers need to be trained to
identify women experiencing violence and
to respond appropriately to those who disclose abuse. Health services that women are
most likely to use, such as those for family
planning, prenatal care, or post-abortion
care, offer potential entry points for providing care, support, and referral to other services. Existing programs, particularly those
involved in prevention of HIV, promotion of
adolescent health, and reduction of teenage
pregnancy, need to address women’s and
girl’s vulnerability to abuse.
Many local and national organizations
exist to combat violence against women and
to promote gender equality, and these vital
efforts deserve increased support. At the
international level, the WHO Global
Campaign for the Prevention of Violence
aims to increase awareness about the impact
of violence on public health and the role of
public health in its prevention, and seeks to
support governments in their efforts to prevent violence and to develop policies and
programs for this (23).
There is nothing “natural” or inevitable
about men’s violence toward women.
Attitudes can and must change; the status of
www.sciencemag.org
SCIENCE
VOL 310
Published by AAAS
women can and must be improved; men and
women can and must be convinced that violence is not an acceptable part of human
relationships.
References and Notes
1. Resolution A/55/2, The United Nations Millennium
Declaration [United Nations (UN), New York, 8
September 2000]; (www.un.org/millennium/declaration/ares5552e.htm).
2. “Addressing violence against women and achieving
the Millennium Development Goals” [World Health
Organization (WHO), Geneva, 2005].
3. “Declaration on the elimination of violence against
women” (UN General Assembly resolution, document
A/RES/48/104, UN, New York, 1993).
4. The Fourth World Conference on Women, Beijing,
China, 4 to 15 September 1995 (document
A/CONF.177/20, UN, New York, 1995).
5. L. Heise, M. Ellsberg, M. Gottemoeller, Ending Violence
Against Women (Johns Hopkins Univ. Press, Baltimore,
MD, 1999).
6. L. Heise, C. Garcia-Moreno, in World Report on Violence
and Health, E. G. Krug et al., Eds. (WHO, Geneva, 2002).
7. H. Johnson, Dangerous Domains: Violence Against
Women in Canada (International Thomson, Ontario,
1996).
8. P. Tjaden, N. Thoennes, “Extent, nature and consequences of intimate partner violence: Findings from
the National Violence Against Women Survey”
(National Institute of Justice,Washington, DC; Centers
for Disease Control and Prevention,Atlanta, GA, 2000).
9. F. Hassan et al., Inj. Control Saf. Promot. 11, 111
(2004).
10. S. Kishor, K. Johnson, “Profiling domestic violence: A
multi-country study” (ORC MACRO, Calverton, MD,
2004).
11. National Center for Injury Prevention and Control
“Costs of intimate partner violence against women in
the United States” (Centers for Disease Control and
Prevention, Atlanta, GA, 2003).
12. J. C. Campbell, Lancet 359, 1331 (2002).
13. S. B. Plichta, M. Falik, Womens Health Issues 11, 244
(2001).
14. S. B. Plichta, C. Abraham, Am. J. Obstet. Gynecol. 174,
903 (1996).
15. H. S. Resnick, R. Acierno, D. G. Kilpatrick, Behav. Med.
23, 65 (1997).
16. “The health costs of violence: Measuring the burden of
disease caused by intimate partner violence:A summary
of findings” (VicHealth, Carlton South,Australia, 2004).
17. E. G. Krug et al., Eds., World Report on Violence and
Health (WHO, Geneva, 2002).
18. C. Garcia-Moreno, H. A. F. M. Jansen, M. Ellsberg, L.
Heise, C . Watts, “WHO multi-country study on
women’s health and domestic violence against
women: Initial results on prevalence, health outcomes,
and women’s responses” (WHO, Geneva, 2005).
19. In Bangladesh, Brazil, Peru, Thailand, and the United
Republic of Tanzania two sites were studied: the capital
and a province with a rural-urban mix. The remaining
countries had one study site only: in Ethiopia, a rural
province; in Japan and Serbia and Montenegro, an urban
site; and in Samoa, the whole country was included.
20. The term “violence” without further qualification
refers to physical (either moderate or severe) or sexual
violence, or both.
21. A woman was said to have experienced severe physical
violence if she reported that she had been kicked,
dragged or beaten up; hit with a fist or something else
that could hurt; choked or burned on purpose; or if her
partner had threatened to use or had actually used a
gun, knife, or other weapon against her. A woman is
considered to have experienced moderate violence if
she has only been slapped, pushed, shoved, or had
something thrown at her.
22. J.Fanslow,E.Robinson, J.N.Z.Med.Assoc. 117,341 (2004).
23. “Milestones for a global campaign for violence prevention” (WHO, Geneva, 2005).
Supporting Online Material
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