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

A resource package

1.6. Gender-based violence and multiple discrimination

Forms and manifestations of violence against women are shaped by gender inequalities (see sections 1.1 and 1.3). At the same time, women are not a homogenous group. A number of additional factors influence what form of violence women experience, as well as their ability to seek help. This includes for instance, class, migrant or refugee status, age, sexual orientation, marital status, disability or HIV status (UN Secretary-General 2006, Department of Health 2004). Healthprofessionals should be aware of the interplay of these factors with gender and understand the specific risk and/or needs of women belonging to one or more marginalized groups. Further, specific strategies may be needed to improve outreach to and access of women belonging to these groups to health care.

This sub-chapter provides an overview of specific groups of women, who, due to their specific situation or status are at greater risk of violence and/or face specific obstacles in accessing medical help and others services. The section 1.6. 1 provides an overview of the situation of the women in conflict and post-conflict situations, the section 1.6.2 on the situation of women with disabilities, the 1.6.3 on the situation of migrant women, 1.6.4 on the situation of adolescent girls and the 1.6.5 on the situation of the older women. Finally the section 1.6.6 examines of the situation of rural women.

1.6.1 Women in conflict and post-conflict situations

While situations of conflict or post conflict affect civilians due to the overall lack of security and the proliferation of violence and arms, women and girls are at a particular risk of violence, especially sexual violence. This is because conflicts exacerbate existing gender inequalities in society (CEDAW GR 30). Perpetrators of violence against women and girls in conflict and post-conflict are diverse, such as military personnel, paramilitaries, border guards, resistance units, male refugees and others with whom women and girls come in contact with (CEDAW GR 30, UN Secretary-General 2006). Women and girls are exposed to various forms of violence, such as sexual violence, torture and mutilation, abduction, trafficking, forced marriage, forced prostitution, and forced sterilization. Sexual violence against women is also being used against women and girls as a weapon of war in order to destabilize and demoralize the enemy (Gender-based Violence Area of Responsibility Working Group 2010, CEDAW GR 30).Refugee and displaced women are at a particular risk of violence during all stages of displacement- during flight, in refugee camps and in countries where they seek asylum (CEDAW GR 30, UN Secretary-General 2006). For women and girls, violence does not stop with the official end of the conflict. During the post-conflict phase, women can experience even more violence due to the absence of rule of law, states’ failure to prevent, investigate and punish all forms of GBV, as well as ineffective disarmament and demobilization and reintegration processes. As a consequence, women and girls in conflict and post conflict areas are at greater risk of unwanted pregnancies, STIs, including HIV, and severe sexual and reproductive injuries.

Factors such as inadequate infrastructure, lack of professionals, lack of basic medicines and health care supplies, the destruction of health services, and restrictions on women’s mobility and freedom of movement, all impede women and girls’ access to appropriate services during conflict and post-conflict (CEDAW GR 30).  They are also less likely to report in these circumstances due to fear of reprisals, the high level of stigma associated especially with sexual violence and fear of exclusion from their communities (UN Secretary-General 2006, Gender-based Violence Area of Responsibility Working Group 2010).  

1.6.2 Women with disabilities

Women with disabilities experience discrimination and stereotypical attitudes because they are both women and persons with disabilities (UN Special Rapporteur VAW 2012). Some factors expose both men and women with disabilities to a greater risk of violence, compared to persons without disabilities, such as stereotypes regarding them as recipients of charity or objects of others’ decisions, rather than holders of rights; or isolation faced by individuals with intellectual and psychosocial disabilities, particularly those living in institutionalized settings (OHCHR 2012). In addition, women experience disability different than men and this difference is largely shaped and determined by gender (Habib 1995, cited in OHCHR 2012).

As a consequence, women with disabilities are more likely to experience violence and/or be less able to come for support and escape situations of violence, compared to both, men with disabilities and women without disabilities (OHCHR 2012). For example, stereotypes wrongly portraying women and girls with disabilities as non-sexual beings, being compliant and timid, contribute not only to sexual violence against them, but also to a lack of credibility when abuse is reported, resulting in impunity of the perpetrators. Further, women with disabilities experience other forms of violence, such as withholding of medication or communication aids; refusal of caregivers to assist with daily living such as bathing, dressing or eating; or controlling behaviours to restrict access to family, friends or phone calls (Habib 1995, cited in OHCHR 2012). Women with disabilities are often denied control of their sexual and reproductive choices, which may lead to forced sterilization or forced termination of wanted pregnancies, under the paternalistic guide that it is for “their own good” (UN Special Rapporteur VAW 2012).

1.6.3 Migrant women

Due to their double status as migrants and as women, migrant women are at a high risk of GBV (UN DESA 2004, cited in UN Secretary-General 2006). Limited options for women’s legal employment in countries of destination, as well as gendered notions of what constitutes appropriate work for women leads to an overrepresentation of women in the informal sector (e.g. domestic work, agricultural work, or sex work), which lacks legal protection and puts women at an increased risk of violence (UN Women Virtual Knowledge Centre, CEDAW GR 26). Access to justice and health care may be limited by factors such as language barriers, lack of information on rights and available options, or lack of coverage by national health insurance schemes (CEDAW GR 26).

In addition, fear of losing residency status may prevent migrant women who experience violence by an employer or an intimate partner from accessing justice and leaving an abusive work or intimate relationship, which perpetuates the violence. Undocumented migrant women are at a particular risk of exploitation and abuse. Their irregular residence status may prevent them from accessing support and protection services, which may be due to fear of deportation or restrictive policies of government donors in several countries limiting reimbursement of costs incurred by shelters to clients with regular resident status, thereby excluding  undocumented migrant women who experienced violence (PICUM 2012). A qualitative research study undertaken by the University Hospital Geneva, Switzerland, documents the intersection of undocumented status and women’s sexual and reproductive health- undocumented pregnant women were found more likely to have unintended pregnancy, to access prenatal care at a later stage and to experience violence during pregnancy, compared to legal residents (Wolff et al 2008, cited in PICUM 2012).

1.6.4 Adolescent girls

Adolescents are in a difficult transitional period between childhood and adulthood that puts them particularly at risk of several forms of violence, such as child marriage, incest, sexual violence, trafficking or intimate partner violence (UN Women Virtual Knowledge Centre). Adolescents in most cases know the perpetrators and may often depend on them (CAADA 2011). Adolescent survivors of GBV face additional barriers compared to adult survivors. Often, they are less aware of existing services, lack financial resources to access services and are hesitant to seek services due to lack of confidentiality. Adolescents are also less likely to report violence, because they might not recognize the behaviour of perpetrators as violence, or are afraid of not being believed or taken seriously (CAADA 2011, UN Women Virtual Knowledge Centre).

Due to their age and stage of development, adolescent girls face particular consequences of GBV, compared to adults. Adolescent pregnancy, which may result from sexual violence is associated with the risk of low birth-weight for new-borns, higher pre-natal, neonatal and infant mortality and morbidity (WHO undated, cited in UNFPA 2013). Furthermore, adolescent girls who become pregnant, due to lack of physical maturity, at a high risk of pregnancy-related complications, which is a leading cause of death among girls age 15-19 in developing countries (WHO 2011a, cited in UNFPA 2014). In some countries of EECA, nearly 30% of maternal deaths are caused by unsafe abortion (WHO undated,cited in UNFPA 2013). Adolescent girls in most countries of the EECA region are affected by early marriage, a practice with severe physical, intellectual, psychological and emotional impacts on women and girls. Child brides experience a total lack of control over their bodies, they are traumatised by adult sex and forced to bear children before their bodies are fully mature, in addition to reproductive health problems like fistula. They typically move in with the husband’s family, which implies taking on a large burden of unpaid domestic work and care responsibilities and exposure to domestic violence from husbands and in-laws. Child marriage also deprives girls from accessing educational opportunities, which leaves them without any qualifications or professional skills (adapted from UNFPA 2014).

1.6.5 Older women

Older women may suffer multiple forms of discriminations, on the basis of gender and age (CEDAW GR 27).  Age-specific factors such as their physical vulnerability, possible illness, isolation, dementia or dependence to the family or social care workers put older women at greater risk of violence compared with women of younger age. Older women who experience violence are more likely to have severe consequences such as fear, anger, depression, exacerbation of existing illness, confusion and distress and life-threatening injuries (WHO 2011a, Department of Health 2004). Further, they are especially vulnerable to economic abuse especially in case of deferment of their legal capacity to somebody else (CEDAW GR 27).

Older women are more likely to know their perpetrators and to depend on them, which limits their access to appropriate services.  Other barriers include lack of information about services, their age, lack of resources (CAADA 2011, WHO 2011a), as well as fear that they will not be believed and that their claims are dismissed as illness or amnesia. Older women can also be accustomed to the abuse with the time, or not recognize abusive behaviour like domestic violence (CAADA 2011).

1.6.6 Rural women

As a result of social isolation, a lower level of education and literacy and less access to services and resources, rural women are at higher risk of GBV. Another root cause is the traditional perceptions regarding the subordinate role of women, which persist in most rural regions. Consequentially, rural women have greater difficulties to access services, compared to women living in non-rural regions. First of all, services may not exist, be limited or inaccessible due to long distance or the lack of transportation (CAADA 2011, CEDAW 2011). Even when services exist, the lack of confidentiality in small villages, rural women may be deterred from accessing these services (CAADA 2011). Where women decide to leave the rural communities to find a job in a city, she may be at risk of violence and sexual exploitation. Due to poverty and the lack of opportunities in rural regions, women who stay in the village may also be at risk of GBV, including trafficking, sexual exploitation and forced labour (CEDAW 2011).