A woman visits a clinic, but she is reluctant to remove her clothes for a physical exam. Another woman attends a counseling session with her husband, but is afraid to speak openly about her wishes regarding contraception. Such cases sometimes hide an ugly truth: the worldwide plague of domestic violence.

The phenomenon is widespread, irrespective of race, class, or education. A 1994 World Bank report from 35 countries revealed that between 25% and 50% of women had been physically abused by a current or former partner. Studies of women in Bolivia found that 37% had suffered either physical or verbal abuse; 42% of those women said violence occurred often.

More than half of all rural and urban women in Papua New Guinea report physical abuse. In the United States, more than 50% of female murder victims are killed by a spouse or former spouse.

Timothy Phiri (above) leads local teens in an attitude-assessment activity at a PPASA training in Johannesburg.

South Africa

Recent work in South Africa illustrates that violence against women is an important issue in reproductive health. Since 1997, AVSC has been assisting the Planned Parenthood Association of South Africa (PPASA) to develop a men's reproductive health program.

The effort began with a study to assess the knowledge, attitudes, and practices of men. Almost half of the men surveyed said that women were raped because they dressed provocatively; 58% said rape could not occur within marriage.

Misconceptions like these, in addition to other findings, prompted PPASA and AVSC to make the issue of violence against women a priority in the program. Otherwise, it would be futile to talk to men about their role as constructive partners in reproductive health.

The two agencies are working together to train community health workers in how to educate men about violence prevention. PPASA staff are now educating men in seven provinces in South Africa.

But the South Africa program and others like it face a number of challenges.

Support for Change

One of the chief obstacles is the lack of social and legal support for change. Without sanctions against offenders, abusers have little incentive to end violent behavior. Perpetrators must be confronted by someone who commands their respect.

Many men have grown up in an environment where abusing women is the norm. Men need to have role models and community programs to help them learn new patterns of behavior.

Pressure should come from as many sectors as possible. Judges, police officers, and community leaders can have as much of an impact as legislation.

Currently, CORIAC, a reproductive health organization in Latin America, is organizing an international campaign for men to speak out against gender-based violence. Other organizations around the world are conducting similar efforts.

The Difficulty of Intervening

A U.S. study found that many women were protective of their partners when police arrived. Further questioning revealed that women feared further abuse if they aided in their partner's apprehension.

A provider or educator who becomes aware of an abusive situation may be forced to decide which course of action is least damaging to the client.

If such offenses are not legally punishable and if the society resists changing the status quo, the health care worker's job is even more difficult.

Working Toward Gender Equity

Power is one of the predominant themes when dealing with violence in the home. In many cultures, a man's power is defined by the subordinate roles of his wife and children.

Imagine the predicament of a woman who wishes to discuss joint responsibility for reproductive health with her partner, but he is abusive and wants complete control in the relationship. To combat this barrier, educators, counselors, and clinicians must work with men to introduce the concept of equal power in relationships, households, and communities.

Resources

Because many women are both financially and emotionally dependent on men, leaving is often difficult, particularly if there are children to consider. Intervention efforts are virtually impossible without special services for victims of abuse, such as housing, financial support, and counseling. Yet few countries have adequate services.

How Providers Can Help

Health care providers can play a critical role in helping survivors of domestic violence. They can learn to ask questions about domestic violence in a sensitive, nonjudgmental manner. They can help clients develop awareness by providing general information about abuse and its signs.

Providers can document signs of abuse in the client's medical record. Having medical records that reflect the injuries a survivor sustained can be essential in the legal process.

Finally, providers can refer clients to local resources or help establish such resources, if they do not exist.

Domestic violence is an entrenched and complex problem. Efforts to end it must occur on several fronts. Reproductive health care staff have a role to play. AVSC is eager to learn more about how our work can help address this global problem.

Andrew Levack is a program associate and Naadu Blankson-Seck is an editor/writer for AVSC.