Adopted by the 61st WMA General Assembly, Vancouver, Canada, October 2010
Violence is a worldwide, institutionalised phenomenon, and a complex issue, which includes many manifestations. The nature of the violence experienced by victims is at least partly dependent upon the social, cultural, political and economic contexts within which the victims and their abusers live. Some violence is deliberate, systematic and widespread while others will experience it in covert circumstances; this is especially true of domestic violence in settings where women enjoy legislated equal and protected rights to those of men but culturally still have an increased likelihood of experiencing life-threatening domestic violence.
There is clear evidence in most countries that men can be and are often the victims of violence, including intimate partner violence. They are also statistically far more likely to be the victims of random violence on the streets. Research shows that while men frequently experience such events, they are not associated with systemic abuse in terms of denial of rights, which makes the experience of women so much worse in many cultures. Nothing in this paper suggests that violence against men including boys should be condoned. Actions to protect women and girls are likely to reduce everyone’s experience of violence.
Definitions of violence vary (see footnote), but it is essential that the various forms violence may take are recognised by policy makers. Violence against women and girls includes violence within the family, within the community and violence perpetrated by (or condoned by) the state. Many excuses are given for violence generally and specifically; in cultural and societal terms these include tradition, beliefs, customs, values and religion. Although rarely cited the traditional power differential between men and women is also a major cause.
Within the family and domestic settings violence includes the denial of rights and freedoms enjoyed by boys and men. This includes female feticide and infanticide, systematic and deliberate neglect of girls, including poor nutrition and denial of educational opportunities1 as well as direct physical, psychological and sexual violence. Specific cultural practices that harm women, including female genital mutilation, forced marriages, dowry attacks and so-called “honour” killings are all practices that may occur within the family setting.
Within society, attitudes towards rape, sexual abuse and harassment, intimidation at work or in education, modern slavery, trafficking and forced prostitution, are all forms of violence condoned by some societies. One extreme form of such violence is sexual violence used as a weapon of war. In several recent conflicts (e.g. the Balkans, Rwanda) rape was both associated with ethnic cleansing and specifically, in some cases, used to introduce widespread AIDS into a community. The ICRC has examined this issue, and recognises that sexual violence of this sort may be commonly perpetrated against women and girls.2
Sexual violence or the threat of it can also be used against men, but culturally, women are more vulnerable and more likely to be targeted. Current conflicts are not based upon battles fought in far away places, but are increasingly concentrated around dense centres of population increasing the exposure of women to soldiers and armed groups. In war and in immediate post-conflict situations, societal fabric can collapse, making women increasingly vulnerable to group attacks.
Lack of economic independence, and of basic education, also mean that women who survive abuse are more likely to be or to become more dependent upon the state or society and less able to support themselves and contribute to that society. Biologically and behaviourally, women are likely to outlive men; denial of the opportunity to be economically independent leaves society with a cohort of older, economically dependent women.
All these forms of violence may be condoned by the state, or it may remain silent on them, refusing to condemn or act against them. In some cases the state may legislate to allow violent practices (for example rape within marriage) and itself become a perpetrator.
All human beings enjoy certain fundamental human rights; the examples listed above of violence against women and girls involve denial of many of those rights, and each abuse can be examined against the UN convention on human rights (and for children the Convention on the Rights of the Child).3
In health terms, the denial of rights and the violence itself have health consequences to the girls and women and to the society of which they are a part. In addition to the specific and direct physical and health consequences, the general way in which girls and women are treated can lead to an excess of mental health problems; suicide is the second leading cause of premature death in women.
CONSEQUENCES OF VIOLENCE
The direct health consequence of the violence depends upon the nature of the act. Female genital mutilation for example may kill the woman at the time of infliction, may lead to difficulty in voiding the body of waste products including those of menses, and will give rise to difficulties in childbearing. It also reinforces the ideological concept of women as the possessions of men (on its own, a form of abuse) who control their sexuality. Gang rape or other forms of sexual violence may result in long-term gynaecological, urological and intestinal difficulties including the development of fistulae and incontinence, which further diminishes societal support for the abused female.
The short and long term mental health consequences of violence may severely influence later wellbeing, enjoyment of life, function in society and the ability to provide appropriate care for dependants.
Gathering evidence is an important role for doctors. Currently many countries do not have mandatory registration of all births, making evidence about infanticide or the effects of neglect difficult to document. Equally, some countries allow marriage at any age, exposing girls to the high risks associated with childbearing before their own bodies are fully mature, let alone the mental health risks involved. The health consequences of such policies and their relationship to other health costs must be better documented.
Denial of good nutritional opportunities leads to generations of women with poorer health, poorer growth and development leading to women who are less fit to survive pregnancy and childbirth or to rear their families. Denial of educational opportunities leads to poorer health for all the family members; good education is a major factor in the mother providing optimal care for all her family. In addition to being wrong in and of itself, violence against women is also socially and economically damaging to the family and to society. There are direct and indirect economic consequences to violence against women that are far greater than the direct health sector costs.
The costs and consequences of violence, including neglect, against women have been reported in many fora including by WHO4 . The health consequences to the women, their children and thus to society are clear and need to be made explicit to policy makers.
WHAT CAN THE WMA DO?
The WMA has a number of policies on violence including the WMA Statement on Violence and Health and the WMA Statement on Family Violence. This current (Statement/resolution/ declaration) brings some of these policies together with a coordinated set of action points for the WMA, NMAs and individual physicians.
As most human beings look first for the advantages to themselves, their families and their societies in enabling change, making the benefits of change obvious from the beginning creates a “win:win” solution. Concentrating first on the health aspects, for women, their children, and the broad family is therefore a useful way to enter the debate.
Doctors have a unique insight into the combined effects upon wellbeing of social, cultural, economic and political environments. If all persons are to achieve health and wellbeing, all these factors need to operate positively. The holistic view from doctors can be used to influence society and politicians. Gaining societal support for improving the rights, freedom and status of women is essential.
- Asserts that violence is not only about physical, psychological and sexual violence but includes abuses such as harmful cultural and traditional practices, and actions such as complicity in trafficking of women, and is a major public health crisis.
- Recognizes the linkage between better education and other rights for women with family and societal health and wellbeing and emphasizes that equality in civil liberties and human rights is a health issue.
- Will prepare briefing and advocacy materials for NMAs to use with national governments and intergovernmental groups addressing the health and wellbeing implications of discrimination against women and girls, including adolescents. This material will include relevant references about the impact of violence on family wellbeing and on societal financial sustainability
- Will work with others to prepare and distribute to physicians and other health workers briefing and advocacy materials dealing with harmful traditional and cultural practices, including female genital mutilation, dowry, and honour killings, and emphasizing the health impact as well as the violations of human rights.
- Prepare practical examples of the impact of violence and strategies for reducing it, such as consensus guidelines that are based upon the best available evidence.
- Will advocate at WHO, other UN agencies and elsewhere for ending discrimination and violence against women.
- Will work with others to prepare templates of educational materials for use by individual practitioners for documenting and reporting individual cases of abuse.
- Encourages others to develop free educational materials online to provide guidance to front line health care workers on abuse and its effects, and on prevention strategies.
- Encourage legislation that classifies gang rape used as a weapon of war as a crime against humanity that is eligible for litigation through the jurisdiction of the International Criminal Court system.
- Use and promote the available materials on preventing and treating the consequences of violence against women and girls and act as advocates within their own country.
- Seek to ensure that those devising and delivering education to doctors and other health care workers are aware of the likelihood of exposure to violence, its consequences, and the evidence on preventative strategies that work, and place appropriate emphasis on this in undergraduate, graduate and continuing education of health care workers.
- Recognise the importance of more complete reporting of the sequelae of violence and encourage the development of training that emphasises violence awareness and prevention, in addition to using better reporting and research into incidence, prevalence and health impact of all forms of violence.
- Encourage medical journals to publish more of the research on the complex interactions in this area, thus keeping it in the professions’ awareness and contributing to the development of a solid research base and ongoing documentation of types and incidence of violence.
- Encourage medical journals to consider publishing theme issues on violence including neglect of women and girls.
- Advocate for universal registration of births, and a higher age limit for marriage.
- Advocate for effective implementation of universal human rights.
- Advocate for parental education and support on the care, nurturing, development, education and protection of children, especially girls.
- Advocate for the monitoring of statistics on children, including both positive and negative indicators of health and well-being, and social determinants of health.
- Advocate for legislation against specific harmful practices including female feticide, female genital mutilation, forced marriage, and corporal punishment.
- Advocate for the criminalisation of rape in all circumstances including within marriage.
- Condemn the use of gang rape as a weapon of war and work with others to document and report it.
- Advocate for the development of research data on the impact of violence and neglect upon primary and secondary victims and upon society, and for increased funding for such research.
- Advocate for the protection of those who speak out against abuse, including physicians and other health workers.
- Use the material developed for their education to better inform themselves about the effects of abuse and the successful strategies for prevention.
- Provide health care and protection to children, (especially in times of crisis) and document and report all cases of violence against children, taking care to safeguard the patient’s privacy as much as possible.
- Treat and reverse, where possible, the complications and adverse effects of female genital mutilation and refer the patient for social support services.
- Oppose the publication or broadcast of victims’ names, addresses or likenesses without the explicit permission of the victim.
- Assess for risk of family violence in the context of taking a routine social history.
- Be alert to the association between current alcohol or drug dependence among women and a history of abuse.
- Support colleagues who become personally involved in work to end abuse.
- Work to establish the necessary relationship of trust with abused women and children including respect for confidentiality.
- Support global and local action to better understand the health consequences both of abuse and of the denial of rights, and advocate for increased services for victims.
1 At first glance neglect does not seem to equate with violence. But the acceptance of neglect and the lesser rights given to women and girls are major factors in reinforcing an acceptance of causal and systematic violence. In that it denies basic rights, many would classify neglect as a form of violence in and of itself.
2 Rape is considered to be a method of warfare when armed forces or groups use it to torture, injure, extract information, degrade, displace, intimidate, punish or simply to destroy the fabric of the community, The mere threat of sexual violence can cause entire communities to flee their homes. from Women and War, ICRC 2008
3 Women’s Health and Human Rights: the Promotion and Protection of Women’s Health through International Human Rights Law. Rebecca Cook. Presented at the 1999 Adapting to Change Core Course
4 Women and Health: Today’s Evidence, Tomorrow’s Agenda. WHO November 2009. ISBN 978 92 4 156385 7