Strengthening Health System Responses to Gender-based Violence in Eastern Europe and Central Asia

A resource package


Bride kidnapping
The act of taking a woman or girl against her will through deception or force and using physical or psychological coercion to force her to marry one of her abductors (HRW 2006).

Cognitive behavioural therapy
Cognitive behavioural therapy (CBT) is based on the concept that thoughts, rather than external factors such as people or events, are what dictate one’s feelings and behaviour. People may have unrealistic or distorted thoughts, which if left unchecked, could lead to unhelpful behaviour. CBT typically has a cognitive component (helping the person develop the ability to identify and challenge unrealistic negative thoughts), as well as a behavioural component. CBT varies, depending on the specific mental health problems (WHO 2013).

Every human being below the age of eighteen years unless under the law applicable to the child, majority is attained earlier (CRC 1989).

Child marriage (or early marriage)
The union of two persons at least one of whom is under 18 years of age (CoE PA 2005).

Clinical enquiry (or case-finding)
In the context of intimate partner violence, this refers to the identification of women experiencing violence who present to health-care settings, through use of questions based on the presenting conditions, the history and, where appropriate, examination of the patient. These terms are used as distinct from “screening” or “routine enquiry” (WHO 2013).

Domestic violence
“All acts of physical, sexual, psychological or economic violence within the family or domestic unit or between former or current spouses or partners, whether or not the perpetrator shares or has shared the same residence with the victim” Article 3 Istanbul Convention). The two main forms of domestic violence are intimate partner violence between current or former spouses or partners and inter-generational violence which typically occurs between parents and children (Istanbul Convention Explanatory Report).

Early marriage (see child marriage)

Economic violence
Economic violence is used to deny and control a woman’s access to resources, including time, money, transportation, shelter, insurance, food or clothing. Acts of economic violence include: prohibiting a woman from working; excluding her from financial decision making in the family; withholding money or financial information; refusing to pay bills or maintenance for her or the children; and destroying jointly owned assets (adapted from Warshaw/Ganley 1996).

Eye movement desensitization reprocessing
This therapy entails standardized procedures that include focusing simultaneously on (a) spontaneous associations of traumatic images, thoughts, emotions and bodily sensations, and (b) bilateral stimulation, most commonly in the form of repetitive eye movements. Unlike CBT with a trauma focus, eye movement desensitization reprocessing therapy involves treatment that is conducted without detailed descriptions of the event, without direct challenging of beliefs, and without extended exposure (WHO 2013).

The process of helping women to feel more in control of their lives and able to take decisions about their future, as articulated in Dutton’s empowerment theory. Dutton notes that battered women are not “sick”, rather they are in a “sick situation” and responses need to demonstrate an understanding, and take into account, their differing needs for support, advocacy and healing. Empowerment is a key feature of advocacy interventions and of some psychological (brief counseling) interventions (Dutton 1992, cited in WHO 2013).

The systematic collection and analysis of data in order to assess the relevance, effectiveness and impact of activities in light of project objectives. It involves assessing the strengths and weaknesses of projects, programs, strategies and/or policies to improve their effectiveness. It involves giving feedback about the progress to donors, implementers and beneficiaries of the project. Evaluations are generally done either during the span of a program (mid-term evaluation) to measure and allow for mid-stream program adjustments or upon completion of programs (ex-post evaluation) (ICMPD 2010).

Forced marriage
The union of two persons at least one of whom has not given their full and free consent to the marriage (CoE PA 2005).

The socially constructed roles, behaviours, activities and attributes that a given society considers appropriate for men and women. While sex and its associated biological functions are programmed genetically, gender roles and the power relations they reflect are a social construct – they vary across cultures and through time, and thus are amenable to change. Gender roles and characteristics do not exist in isolation, but are defined in relation to one another and through the relationship between women and men, girls and boys (adapted from MWIA 2002, WHO undated).

Gender-based violence
Violence “that is directed against a woman because she is a woman or that affects women disproportionately” (CEDAW GR 19, Article 3 Istanbul Convention). This manual uses the terms “gender-based violence” and “violence against women” interchangeably.

Gender-biased sex selection
Gender-biased sex-selection in favour of boys may take place before a pregnancy is established, during pregnancy through prenatal sex detection and selective abortion, or following birth through infanticide or child neglect (OHCHR/UNFPA/UNICEF/UN Women/WHO 2011). Pre-natal sex selection refers to the practice of using medical techniques to choose the sex of offspring. This term “sex selection” encompasses a number of practices including selecting embryos for transfer and implantation following in vitro fertilization, separating sperm, and selectively terminating a pregnancy (WHO Genomic resource centre).

Health-care provider
An individual or an organization that provides health-care services in a systematic way. An individual health-care provider may be a health-care professional, a community health worker, or any other person who is trained and knowledgeable in health. This can include lay health-care workers who have received some training to deliver care in their community. Organizations include hospitals, clinics, primary care centres and other services delivery points. In these guidelines, the term “health-care provider” usually refers to the primary care provider (nurse, midwife, doctor or other) (WHO 2013).

Health system
A health system is the sum total of all the organizations, institutions and resources whose primary purpose is to improve health. A health system needs staff, funds, information, supplies, transport, communications and overall guidance and direction to provide services that are responsive and financially fair, while treating people decently
A good health system delivers quality services to all people, when and where they need them. The exact configuration of services varies from country to country, but in all cases requires a robust financing mechanism; a well-trained and adequately paid workforce; reliable information on which to base decisions and policies; well maintained facilities and logistics to deliver quality medicines and technologies.
Who identified the following building blocks for health system strengthening: service delivery; health workforce; information; medical products, vaccines and technologies financing and leadership and governance (stewardship)( WHO 2005b; WHO health topics)


Harmful practices
All practices done deliberately by men on the body or the psyche of other human beings for no therapeutic purpose, but rather for cultural or socio-conventional motives and which have harmful consequences on the health and the rights of the victims. Examples of harmful practices include early/forced marriages, female genital mutilation/cutting, gender-biased sex-selection and widowhood rites (adapted from UN Women Virtual Knowledge Centre).

“Honour” killings
A practice in which women and girls suspected of defiling their family's honour by their misconduct can be killed by their brother, father, uncle or another relative who thus restores the said honour. Honour killings are executed for instances of rape, infidelity, flirting or any other instance perceived as disgracing the family's honour, and the woman is then killed by a male relative to restore the family's name in the community. The allegation of misconduct alone is considered enough to defile a man's or family's honour, and is therefore enough to justify the killing of the woman. The men who commit the murder typically go unpunished or receive reduced sentences (UN Women Virtual Knowledge Centre).

Any action undertaken with the aim to eliminate GBV. Interventions can be preventive or reactive and can have different formats, such as laws, policies, large-scale programmes, or single projects. In the context of health system responses to GBV, interventions are understood as any actions set by health care professionals vis-à-vis a survivor of GBV, aimed at identifying GBV, providing first-line support and other medical care as well as referring the survivor to other services.

Intimate partner violence
Behaviour by an intimate partner that causes physical, sexual or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviours. It covers violence by both current and former spouses and other intimate partners (WHO 2013).

Mandatory reporting
Refers to legislation passed by some countries or states that requires individuals or designated individuals such as health-care providers to report (usually to the police or legal system) any incident of actual or suspected domestic violence or intimate partner violence. In many countries, mandatory reporting applies primarily to child abuse and maltreatment of minors, but in others it has been extended to the reporting of intimate partner violence (WHO 2013).

Means of verification
Sources of qualitative or quantitative information, which can measure whether the indicators and results have been achieved (ICMPD 2010).

The continuous, regular, systematic and purposeful observation, gathering of information, and recording of activities, projects, programs, strategies and/or policies. To monitor is to check on how planned activities are progressing, to identify operational difficulties and to recommend actions. Monitoring is aimed at improving the efficiency and effectiveness of an initiative and at ensuring that activities are transformed into results/outputs. It involves giving feedback about the progress to donors, implementers and beneficiaries of the project. Monitoring is always undertaken during the implementation of activities, projects, programs, strategies and/or policies (ICMPD 2010).

The intended physical, financial, institutional, social, environmental, or other results to which an intervention is expected to contribute (OECD-DAC 2009).

The likely or achieved short-term and medium-term effects of an intervention’s outputs (OECD-DAC 2009).

The products, capital goods and services which result from an intervention; may also include changes resulting from the intervention which are relevant to the achievement of outcomes (OECD-DAC 2009).

A person, group, or institution that directly inflicts, supports and/or condones violence against a person or a group of persons.

Physical violence
The use of physical force that results in bodily injury, pain, or impairment. The severity of injury ranges from minimal tissue damage, broken bones to permanent injury and death. Acts of physical violence include: slapping, shoving, pushing, punching, beating, scratching, choking, biting, grabbing, shaking, spitting, burning, twisting of a body part, forcing the ingestion of an unwanted substance; restraining a woman to prevent her from seeking medical treatment or other help; and using household objects to hit or stab a woman, using weapons like knives or guns (adapted from Warshaw/Ganley 1996).

Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) may develop after a person is exposed to one or more traumatic events, such as sexual assault, serious injury, or the threat of death. The diagnosis may be given when a group of symptoms, such as disturbing recurring flashbacks, avoidance or numbing of memories of the event, and hyper arousal continue for more than a month after the traumatic event (APA 2013).

Psychological violence
An action or set of actions that directly impair the woman’s psychological integrity. Acts of psychological violence include: threats of violence and harm against the woman or somebody close to her, through words or actions (e.g. through stalking or displaying weapons); harassment and mobbing at the work place; humiliating and insulting comments; isolation and restrictions on communication (e.g. through locking her up in the house, forcing her to quit her job or prohibiting her from seeing a doctor); and use of children by a violent intimate partner to control or hurt the woman (e.g. through attacking a child, forcing children to watch attacks against their mother, threatening to take children away, or kidnapping the child). These acts constitute both, violence against children as well as violence against women (adapted from Warshaw/Ganley 1996).

The number of persons having a specific characteristic or problem, divided by the number of persons in the study population who are considered to be at risk of having the problem, usually expressed as a percentage (WHO/PATH 2005).

Prevalence study
In the context of GBV, prevalence studies seek to measure the scope of GBV. Usually, prevalence research is undertaken through population-based surveys. These surveys use randomly selected samples; therefore, their results are representative of the larger population (UN Secretary-General 2006).

The physically forced or otherwise coerced penetration of the vulva or anus with a penis, other body part, or object, although the legal definition of rape may vary and, in some cases, may also include oral penetration (WHO 2002, cited in WHO 2013).

The process of how a woman gets in touch with an individual professional or institution about her case and how professionals and institutions communicate and work together to provide her with comprehensive support. Partners in a referral network usually include different government departments, women’s organizations, community organizations, medical institutions and others (UNFPA 2010).

Referral system
A comprehensive institutional framework that connects various entities with well-defined and delineated (albeit in some cases overlapping) mandates, responsibilities and powers into a network of cooperation, with the overall aim of ensuring the protection and assistance of survivors, to aid in their full recovery and empowerment, the prevention of GBV and the prosecution of perpetrators (the so-called 3 p’s). Referral mechanisms work on the basis of efficient lines of communication and establish clearly outlined referral pathways and procedures, with clear and simple sequential steps (UNFPA 2010).

Umbrella term for the output, outcome (medium-term change), or impact (long-term change) -intended or unintended, positive and/or negative - of an intervention.

Results-based Management
A management strategy focusing on performance (inputs, activities) and achievement of outputs, outcomes, and impacts. Results-based management identifies strategic elements, such as results, outcomes, impact and outputs and their causal relationship, following a number of assumptions and risks identified. It involves the formulation of relevant indicators to measure success and performance (OECD-DAC 2009).

Results chain
The causal sequence for a development intervention that stipulates the necessary sequence to achieve desired objectives beginning with inputs, moving through activities and outputs, and culminating in outcomes, impacts, and feedback (OECD-DAC 2009).

Routine enquiry (or universal screening)
Sometimes used to refer to investigating intimate partner violence without resorting to the public health criteria of a complete screening programme; it can also be used to denote a low threshold for women being routinely asked about abuse in a health-care setting, but not necessarily all women (WHO 1968, Taket et al 2003, all cited in WHO 2013).

Sexual assault
A subcategory of sexual violence, sexual assault usually includes the use of physical or other force to obtain or attempt sexual penetration. It includes rape, defined as the physically forced or otherwise coerced penetration of the vulva or anus with a penis, other body part, or object, although the legal definition of rape may vary and, in some cases, may also include oral penetration (WHO 2002, cited in WHO 2013).

Sexual harassment
“Any form of unwanted verbal, non-verbal or physical conduct of a sexual nature, with the purpose or effect of violating the dignity of a person, in particular when creating an intimidating, hostile, degrading, humiliating or offensive environment” (Article 2 Directive 2006/54/EC). At the work place, sexual harassment often takes two forms: when the harasser makes a job benefit - such as a pay rise, a promotion, or even continued employment - conditional on the person acceding to demands to engage in some form of sexual behaviour; or when the harasser’s conduct creates a hostile and intimidating working environment for the person concerned (adapted from ILO undated).

Sexual violence
Any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed against a person’s sexuality, using coercion, by any person, regardless of their relationship to the victim, in any setting, including, but not limited to, home and work (WHO 2002, cited in WHO 2013).

Suicides following experiences of domestic violence
Suicides committed by women to escape violence and oppression, sometimes prompted by pressure from family members for in adherence to “proper” or “honourable” conduct. In some cases, recorded suicide cases may also be disguised murders (UN Special Rapporteur VAW 2007).

Refers to a woman or girl who has experienced any form of GBV. International law defines “victim” as “any natural person who is subject to [violence against women or domestic violence]” (Article 1 Istanbul Convention). Both terms are often used synonymously. In order to underline that women and girls who experienced violence are not “passive” victims but are actively trying to stop violence and seeking protection and support (WAVE 2008), the present publication uses the term “survivor”, with the exception of references to terminology used in international human rights standards or context-specific terminology (for instance when referring to homicide).

Trafficking in women (Тhe UN publication uses the term "trafficking in person" but due to the specificity of our publication the term "trafifcking in women is used")
The recruitment, transportation, transfer, harbouring or receipt of a woman, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over a woman, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude or the removal of organs. The recruitment, transportation, transfer, harbouring or receipt of a child for the purpose of exploitation shall be considered “trafficking in persons” even if this does not involve any of the coercive means listed above (adapted from UN 2000).

The use of three or more theories, sources or types of information, or types of analysis to verify and substantiate an assessment. By combining multiple data sources, methods, analyses or theories, evaluators seek to overcome the bias that comes from single informants, single methods, single observer or single theory studies (OECD-DAC 2009).

Universal screening (see routine enquiry)

Violence against women
“Any act of gender-based violence that results in, or is likely to result in, physical, sexual or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life (Article 1 DEVAW). Violence against women encompasses, among others: “(a) Physical, sexual and psychological violence occurring in the family; including battering, sexual abuse of female children in the household, dowry-related violence, marital rape, female genital mutilation and other traditional practices harmful to women, non-spousal violence and violence related to exploitation; (b) Physical, sexual and psychological violence occurring within the general community; including rape, sexual abuse, sexual harassment and intimidation at work, in educational institutions and elsewhere, trafficking in women and forced prostitution; (c) Physical, sexual and psychological violence perpetrated or condoned by the State, wherever it occurs” (Article 2 DEVAW). This manual uses the terms “gender-based violence” and “violence against women” interchangeably.