Women and Gender Studies - Analyze the racial, gender, and sexual politics of 1 or 2 episodes of Orange is the New Black (except ep 1)

International Journal of Gynecology and Obstetrics 78 Suppl. 1(2002) S5–S14

0020-7292/02/$ - see front matter� 2002 International Federation of Gynecology and Obstetrics. Published by Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 0 2 0 - 7 2 9 2Ž0 2.0 0 0 3 8 - 3

A global overview of gender-based violence

L. Heise*, M. Ellsberg, M. Gottmoeller

Program for Appropriate Technology in Health (PATH), Washington, DC, USA

Abstract

This paper provides an overview of the extent and nature of gender-based violence and its health consequences, particularly on sexual and reproductive health. � 2002 International Federation of Gynecology and Obstetrics. Published by Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Violence; Women; Gender; Health

Violence against women is the most pervasive yet least recognized human rights violation in the world. It also is a profound health problem, sap- ping women’s energy, compromising their physical health, and eroding their self-esteem. In addition to causing injury, violence increases women’s long-term risk of a number of other health prob- lems, including chronic pain, physical disability, drug and alcohol abuse and depression. Women with a history of physical or sexual abuse are also at increased risk for unintended pregnancy, sexu- ally transmitted infections(STIs), and adverse pregnancy outcomes.

Despite its high costs, almost every society in the world has social institutions that legitimize,

*Corresponding author. Tel.:q1-202-822-0033; fax:q1- 202-457-1466.

E-mail address: [email protected](L. Heise), [email protected](M. Ellsberg).

obscure and deny abuse. The same acts that would be punished if directed at an employer, a neighbor, or an acquaintance often go unchallenged when men direct them at women, especially within the family.

For over two decades women’s advocacy groups around the world have been working to draw more attention to the physical, psychological, and sexual abuse of women and to stress the need for action. They have provided abused women with shelter, lobbied for legal reforms, and challenged the widespread attitudes and beliefs that support vio- lent behavior against womenw1x.

Increasingly, these efforts are having results. Today, international institutions are speaking out against gender-based violence. Surveys and studies are collecting more information about the preva- lence and nature of abuse. More organizations, service providers, and policy-makers are recogniz- ing that violence against women has serious

S6 L. Heise et al. / International Journal of Gynecology and Obstetrics 78 Suppl. 1 (2002) S5–S14

adverse consequences for women’s health and for society. 1. Extent and nature of the problem

Gender-based violence includes a host of harm- ful behaviors that are directed at women and girls because of their sex, including wife abuse, sexual assault, dowry-related murder, marital rape, selec- tive malnourishment of female children, forced prostitution, female genital mutilation, and sexual abuse of female children. Specifically, violence against women includes any act of verbal or physical force, coercion or life-threatening depri- vation, directed at an individual woman or girl that causes physical or psychological harm, humil- iation or arbitrary deprivation of liberty and that perpetuates female subordination(2).

2. Intimate partner violence

The most pervasive form of gender violence is abuse of women by intimate male partners. A recent review of 50 population-based studies car- ried out in 36 countries indicates that between 10 and 60% of women who have ever been married or partnered have experienced at least one incident of physical violence from a current or former intimate partnerw2x. Although women can also be violent and abuse exists in some same-sex rela- tionships, the vast majority of partner abuse is perpetrated by men against their female partners.

Representative sample surveys indicate that physical violence in intimate relationships is almost always accompanied by psychological abuse and, in one-third to over one-half of cases, by sexual abusew3–5x. Most women who suffer any physical aggression generally experience mul- tiple acts over time. However, measuring ‘acts’ of violence does not describe the atmosphere of terror that often permeates abusive relationships. For example, in Canada’s 1993 national violence sur- vey one-third of women who were abused physi- cally in a relationship said they had feared for their lives at some timew6x. Women often say that the psychological abuse and degradation are even more difficult to endure than the physical abuse itself.

3. Sexual coercion and abuse

Sexual coercion and abuse also emerge as defin- ing features of the female experience for many women and girls. Forced sexual contact can take place at any time in a woman’s life and includes a range of behaviors, from forcible rape to non- physical forms of pressure that compel girls and women to engage in sex against their will. The touchstone of coercion is that a woman lacks choice and faces severe physical or social conse- quences if she resists sexual advances.

Studies indicate that the majority of nonconsen- sual sex takes place among individuals known to each other—spouses, family members, courtship partners, or acquaintancesw7,8x. Ironically, much nonconsensual sex takes place within consensual unions. For example, in a 15-country qualitative study of women’s HIV risk, women related pro- foundly troubling experiences of forced sex within marriage. Respondents frequently mentioned being physically forced to have sex andyor to engage in types of sexual activity that they found degrading and humiliatingw9x.

Regrettably, much sexual coercion takes place against children or adolescents in both industrial and developing countries. Between one-third and two-thirds of known sexual assault victims are age 15 or younger, according to information from justice systems statistics and rape crisis centers in Chile, Peru, Malaysia, Mexico, Panama, Papua New Guinea and the United Statesw10x.

Sexual exploitation of children is widespread in virtually all societies. Child sexual abuse refers to any sexual act that occurs between an adult or immediate family member and a child, and any nonconsensual sexual contact between a child and a peer. Laws generally consider the issue of con- sent to be irrelevant in cases of sexual contact by an adult with a child, defined variously as someone under 13, 14, 15, or 16 years of age.

Because of the taboo nature of the topic, it is difficult to collect reliable figures on the preva- lence of sexual abuse in childhood. Nonetheless, the few representative sample surveys provide cause for concern. A recent review of 17 studies worldwide indicate that anywhere from 11 to 32% of women report behavior constituting sexual

S7L. Heise et al. / International Journal of Gynecology and Obstetrics 78 Suppl. 1 (2002) S5–S14

abuse in childhood. Although both girls and boys can be victims of sexual abuse, most studies report that the prevalence of abuse among girls is at least 1.5 to 3 times that among boysw11x. Abuse among boys may be underreported compared with abuse among girls, however.

Studies consistently show that, regardless of the sex of the victim, the vast majority of perpetrators are male and are known to the victimw12–14x. Many perpetrators were themselves sexually abused in childhood, although most boys who are sexually abused do not grow up to abuse others w15x.

Although for some children the effects of sexual abuse are severe and long-term, not all will expe- rience consequences that persist into later life w16,17x. Sexual abuse is most likely to cause long- term harm when it extends over a long period, is by a father or father figure, involves penetration, or uses force or violencew16,18,19x.

4. Explaining gender-based violence

While violence against women is widespread, it is not universal. Anthropologists have documented small-scale societies—such as the Wape of Papua

New Guinea—where domestic violence is virtually absentw20,21x. This reality stands as testament to the fact that social relations can be organized in such a way to minimize abuse.

Why is violence more widespread in some places than in others? Increasingly, researchers are using an ‘ecological framework’ to understand the interplay of personal, situational, and sociocultural factors that combine to cause abusew22x. In this model, violence against women results from the interaction of factors at different levels of the social environment.

The model can best be visualized as four con- centric circles. The innermost circle represents the biological and personal history that each individual brings to his or her behavior in relationships. The second circle represents the immediate context in which abuse takes place: frequently the family or other intimate or acquaintance relationship. The third circle represents the institutions and social structures, both formal and informal, in which relationships are embedded in neighborhoods, the workplace, social networks, and peer groups. The fourth, outermost circle is the economic and social environment, including cultural norms.

S8 L. Heise et al. / International Journal of Gynecology and Obstetrics 78 Suppl. 1 (2002) S5–S14

A wide range of studies agree on several factors at each of these levels that increase the likelihood that a man will abuse his partner: (1) At the individual level these include being

abused as a child or witnessing marital violence in the homew23x, having an absent or rejecting father w24x, and frequent use of alcoholw25x. (2) At the level of the family and relationship,

cross-cultural studies have cited male control of wealth and decision-making within the familyw21x and marital conflict as strong predictors of abuse w23x. (3) At the community level women’s isolation

and lack of social support, together with male peer groups that condone and legitimize men’s violence, predict higher rates of violencew26,27x. (4) At the societal level studies around the

world have found that violence against women is most common where gender roles are rigidly defined and enforced and where the concept of masculinity is linked to toughness, male honor, or dominancew22x. Other cultural norms associated with abuse include tolerance of physical punish- ment of women and children, acceptance of vio- lence as a means to settle interpersonal disputes, and the perception that men have ‘ownership’ of womenw21,22x.

By combining individual-level risk factors with findings of cross-cultural studies, the ecological model contributes to understanding why some societies and some individuals are more violent than others and why women, especially wives, are so consistently the victims of abuse.

Other factors combine to protect some women. For example, when women have authority and power outside the family, rates of abuse in intimate partnerships are lowerw21x. Likewise, prompt intervention by family members and friends appears to reduce the likelihood of domestic vio- lence. By contrast, where the family is considered ‘private’ and outside public scrutiny, rates of wife abuse are higherw21x.

Justifications for violence frequently evolve from gender norms—that is, social norms about the proper roles and responsibilities of men and women. Many cultures hold that men have the right to control their wives’ behavior and that

women who challenge that right—even by asking for household money or by expressing the needs of the children—may be punished. In countries as different as Bangladesh, Cambodia, India, Mexico, Nigeria, Pakistan, Papua New Guinea, Nicaragua, Tanzania, and Zimbabwe, studies find that violence is frequently viewed as physical chastisement— the husband’s right to ‘correct’ an erring wifew2x. As one husband said in a focus-group discussion in Tamil Nadu, India, ‘If it is a great mistake, then the husband is justified in beating his wife. Why not? A cow will not be obedient without beatings’ w28x.

Worldwide, studies identify a consistent list of events that are said to ‘trigger’ violence. These include: not obeying her husband, talking back, not having food ready on time, failing to care adequately for the children or home, questioning him about money or girlfriends, going somewhere without his permission, refusing him sex, or expressing suspicions of infidelity. All of these represent transgression of dominant gender norms.

5. The impact of violence on women’s repro- ductive health

A growing number of studies document the ways in which coercion and violence undermine women’s sexual and reproductive autonomy and jeopardize their physical and mental health(see Table 1). Although violence can have direct health consequences, it also increases women’s risk of future ill health. Physical violence and sexual abuse can put women at risk of infection and unwanted pregnanciesdirectly, if women are forced to have sex, for example, or fear using contraception or condoms because of their part- ners’ potentially violent reaction. A history of sexual abuse in childhood also can lead to unwant- ed pregnancies and STDsindirectly by increasing sexual risk-taking in adolescence and adulthood. Therefore, like tobacco or alcohol use, victimiza- tion can best be conceptualized as a risk factor for a variety of diseases and conditionsw2x.

5.1. Reduced sexual autonomy leads to unwanted pregnancies and STIsyHIV

In many parts of the world marriage is inter- preted as granting men the right to unconditional

S9L. Heise et al. / International Journal of Gynecology and Obstetrics 78 Suppl. 1 (2002) S5–S14

Table 1 Health outcome of violence against women

Partner abuse, sexual assault, child sexual abuse

Fatal outcomes Homicide Suicide Maternal mortality AIDS-related

Nonfatal outcomes Physical health

Injury Functional impairment Physical symptoms Poor subjective health Permanent disability Severe obesity

Chronic conditions Chronic pain syndromes Irritable bowel syndrome Gastrointestinal disorders Somatic complaints Fibromyalgia

Mental health Post-traumatic stress Depression Anxiety Phobiasypanic disorder Eating disorders Sexual dysfunction Low self-esteem Substance abuse

Negative health behaviors Smoking Alcohol and drug abuse Sexual risk-taking Physical inactivity Overeating

Reproductive health Unwanted pregnancy STIsyHIV Gynecological disorders Unsafe abortion Pregnancy complications Miscarriageylow birth weight Pelvic inflammatory disease

sexual access to their wives and the power to enforce this access through force if necessary. Women who lack sexual autonomy often are pow- erless to refuse unwanted sex or to use contracep- tion and thus are at risk of unwanted pregnancies.

As a 40-year-old woman in Uttar Pradesh said, ‘What can I do to protect myself from these

unwanted pregnancies unless he agrees to do something? Once when I gathered the courage and told him I wanted to avoid sex with him, he said what else have I married you for? He beats me for the smallest reasons and has sex whenever he wants’ w29x.

Many women are afraid to raise the issue of contraception for fear that their partners might respond violentlyw30–36x. In some cultures hus- bands may react negatively because they think that protection against pregnancy would encourage their wives to be unfaithful. Where having many children is a sign of male virility, a wife’s desire to use family planning may be interpreted as an affront to her husband’s masculinityw30x.

For women living with men who are violent, the fear of a negative reaction is often enough to cut off discussion of contraception. As one woman said of her husband, ‘Whenever he hears people discussing family planning over the radio, he fumes and shouts« If he can threaten a wireless, what would he do to me if I open the topic?’w33x.

Violence influences the risk of HIV and other STIs directly when it interferes with women’s ability to negotiate condom use. For many women, asking for condoms can be even more difficult than discussing other contraceptives because con- doms are often associated with promiscuity, infi- delity, and prostitution.

Raising the issue of condom use within marriage or other primary partnerships is especially difficult w37x. As a 46-year respondent in Brazil said, ‘‘If I ask my husband to use a condom now, he is going to ask ‘why?’ He is going to think I am fooling around or that I am accusing him of fooling around, two things that shouldn’t be happening’’ w38x.

Sexual victimization in childhood appears to place young women at increased risk of pregnancy during their teenage years. In the early 1990s studies began to find a consistent association between sexual abuse in childhood and adolescent pregnancyw39–41x. The studies also found a clear and consistent link between early sexual victimi- zation and a variety of risk-taking behaviors, including early sexual debut, drug and alcohol use, more sexual partners, and less contraceptive use.

S10 L. Heise et al. / International Journal of Gynecology and Obstetrics 78 Suppl. 1 (2002) S5–S14

Childhood abuse has also been linked to unin- tended pregnancies among adult women. A study of 1200 women in the US found that women who reported being psychologically, sexually andyor physically abused, or whose mother was beaten by a partner, had higher rates of unintended first pregnancies than women who did not experience abuse. The likelihood of an unintended first preg- nancy increased with both the number of different types of abuse women experienced, and its fre- quencyw42x.

In a 1999 speech, Peter Piot, the Executive Director of UNAIDS, noted that violence against women has many links to HIVyAIDS. ‘Violence against women is not just a cause of the AIDS epidemic,’ he noted, ‘it can also be a consequence of it.’ Sexual abuse in childhood appears to increase the incidence of STIs among adults, large- ly through its effect on high-risk sexual behavior (w43–50x). Several studies have linked a history of sexual abuse to higher risk of selling sex for money or drugsw39,50–53x. Abuse in childhood also increases the risk of HIVyAIDS through its effect on drug use. Sexually abused or assaulted women often turn to drugs as a coping mechanism, in addition to such unhealthy behavior as having unprotected sex and trading sex for money or drugsw54–61x.

In some places, fear of men’s reaction has also hindered efforts to encourage voluntary HIVy AIDS counseling and testing among womenw62x. This has implications both for controlling sexual transmission of the virus and for efforts to reduce mother to child transmission.

5.2. Violence increases risks for other gynecolog- ical problems

Sexual and physical violence appears to increase women’s risk for many common gynecological disorders, some of which can be debilitating. An example is chronic pelvic pain(CPP), which in many countries accounts for as many as 10% of all gynecological visits and one-quarter of all hysterectomiesw63–65x.

Although CPP is commonly caused by adhe- sions, endometriosis, or infections, about half the cases of CPP do not have any identifiable pathol-

ogy. A variety of studies have found that women suffering from CPP are consistently more likely to have a history of childhood sexual abusew64x, sexual assaultw63,66–69x, or physical and sexual abuse by their partnersw70,71x.

Past trauma may lead to CPP via unidentified injuries, by stress, or by somatization—the expres- sion of psychological distress through physical symptomsw63x. Also, sexual abuse in childhood has been linked to increased sexual risk-taking, and thus to STIs, which can lead to CPP, often due to pelvic inflammatory disease.

Other gynecological disorders associated with sexual violence include irregular vaginal bleeding w72x, vaginal discharge, painful menstruation w68,73x, pelvic inflammatory diseasew74x, and sexual dysfunction(difficulty in orgasms, lack of desire and conflicts over frequency of sex) w71,73,74x. Sexual assault also increases risk for premenstrual distress, a condition that affects 8 to 10% of menstruating women and causes physical, mood, and behavioral symptomsw75x. The number of gynecological symptoms appears to be related to the severity of abuse suffered, whether there was both physical and sexual assault, whether the victim knew the offender, and whether there were multiple offendersw76,77x.

5.3. Violence leads to adverse pregnancy outcomes

Around the world, as many as one woman in every four is physically or sexually abused during pregnancy, usually by her partnerw78–87x. Esti- mates vary widely, however. Within the US, for example, estimates of abuse during pregnancy range from 3 to 11% among adult women and up to 38% among teenage mothersw80x. Some of this variation is likely due to differences in how the questions were asked, how often, and by whom w81,88x.

Violence before and during pregnancy can have serious health consequences for women and their children. Pregnant women who have experienced violence are more likely to delay seeking prenatal care w80,89–94x and to gain insufficient weight w80,95x. They are also more likely to have a history of STIs w96x, unwanted or mistimed pregnancies w81,94,97x, vaginal and cervical infections

S11L. Heise et al. / International Journal of Gynecology and Obstetrics 78 Suppl. 1 (2002) S5–S14

w80,90,91x, kidney infectionsw97x, and bleeding in pregnancyw80,90x.

Violence may also have a serious impact on pregnancy outcomes. Violence has been linked with increased risk of miscarriages and abortions w83,98x, premature laborw97x, and fetal distress w97x. Several studies also have focused on the relationship between violence in pregnancy and low birth weight, a leading contributor to infant deaths in the developing worldw80,90,93,94,97– 103x. Although the findings are inconclusive, sev- eral studies suggest that violence during pregnancy contributes substantially to low birth weight, at least in some settings. In one study at the regional hospital in Leon, Nicaragua, for example, research- ers found that after controlling for other risk factors, violence against pregnant women was associated with a threefold increase in the inci- dence of low birth weightw94x.

How violence puts pregnancies at above-average risk is unclear, but several explanations have been suggestedw82,88x. Blunt abdominal trauma can lead to fetal death or low birth weight by provok- ing preterm delivery. Extreme stress and anxiety provoked by violence may also lead to preterm delivery or fetal growth retardation by increasing stress hormone levels or immunological changes. Finally, violence may affect pregnancy outcome indirectly by increasing women’s likelihood of engaging in such harmful health behaviors as smoking and alcohol and drug abuse, all of which have been linked to low birth weight.

6. The role of reproductive health professionals

Health professionals can do much to help their clients who are victims of gender-based violence. Yet providers often miss opportunities to help by being unaware, indifferent or judgmental. With training and support from health care systems, providers can do more to respond to the physical, emotional and security needs of abused women and girls. First, health care providers can learn how to ask women about violence in ways that their clients find helpful. They can give women empathy and support. They can provide medical treatment, offer counseling, document injuries and

refer their clients to legal assistance and support services.

Reproductive health professionals have a partic- ular responsibility to help because:

● Abuse has a major—although little recog- nized—impact on women’s reproductive health and sexual well-being;

● Providers cannot do their jobs well unless they understand how violence and powerlessness affect women’s reproductive health and deci- sion-making ability;

● Reproductive health care providers are strategi- cally placed to help identify victims of violence and connect them with other community support services.

Providers can reassure women that violence is unacceptable and that no woman deserves to be beaten, sexually abused, or made to suffer emo- tionally. As one client said, ‘Compassion is going to open up the door. And when we feel safe and are able to trust, that makes a lot of difference’ w104x.

References

w1x Heise L. Violence against women: global organizing for change. In: Edleson JL, Eisikovits ZC, editors. Future interventions with battered women and their families. Thousand Oaks, California: Sage Publications, 1996. p. 7 –33.

w2x Heise L, Ellsberg M, Gottemoeller M. Ending violence against women. Population Reports. Baltimore: Johns Hopkins University, 1999.

w3x Ellsberg M, Pena R, Herrera A, Liljestrand J, Winkvist˜ A. Candies in hell: women’s experiences of violence in Nicaragua. Soc. Sci. Med. 2000;51:1595 –1610.

w4x Koss MP, Goodman LA, Browne A, Fitzgerald LF, Keita GP, Russo NF. No safe haven: male violence against women at home, at work, and in the community. Washington DC: American Psychological Association, 1994.

w5x Yoshihama M, Sorenson SB. Physical, sexual, and emotional abuse by male intimates: experiences of women in Japan. Violence Victims 1994;9:63 –77.

w6x Rodgers K. Wife assault: the findings of a national survey. Juristat Serv. Bull. Can. Centre Justice Statistics 1994;14:1 –22.

w7x Heise L, Moore K, Toubia N. Sexual coercion and women’s reproductive health: a focus on research. New York: Population Council, 1995. p. 59

S12 L. Heise et al. / International Journal of Gynecology and Obstetrics 78 Suppl. 1 (2002) S5–S14

w8x World Health Organization. Violence against women: a priority health issue. WHO: Geneva 1997.

w9x Weiss E, Gupta GR. Bridging the gap: addressing gender and sexuality in HIV prevention. Washington DC: Inter- national Center for Research on Women, 1998. p. 31

w10x Heise L, Pitanguy J, Germain A. Violence against women: the hidden health burden. World Bank Discus- sion Paper�255: Washington DC 1994.

w11x Finkelhor D. The international epidemiology of child sexual abuse. Child Abuse Neglect 1994;18:409 –417.

w12x Sinal SH. Sexual abuse of children and adolescents. South. Med. J. 1994;87:1242 –1258.

w13x Sas LD, Cunningham AH. Tipping the balance to tell the secret: public discovery of child sexual abuse. Ontario, Canada: London Family Court Clinic, 1995.

w14x Olsson A, Ellsberg M, Berglund S, Herrera A, Zelaya E, Persson L-A. Sexual abuse during childhood and˚ adolescence among Nicaraguan men and women: a population-based anonymous survey, submitted for publication.

w15x Watkins B, Bentovim A. The sexual abuse of male children and adolescents: a review of current research. J. Child Psychol. Psychiat. 1992;33:197 –248.

w16x Kendall-Tackett KA, Williams LM, Finkelhor D. Impact of sexual abuse on children: a review and synthesis of recent empirical studies. Psychol. Bull. 1993;113:164 – 180.

w17x Mullen PE, Martin JL, Anderson JC, Romans SE, Herbison GP. The effect of child sexual abuse on social, interpersonal and sexual function in adult life. Brit. J. Psychiat. 1994;165:35 –47.

w18x Rind B, Tromovitch P. A meta-analytical review of findings from national samples on psychological corre- lates on child sexual abuse. J. Sex Res. 1997;34:237 – 255.

w19x Beitchman JH, Zucker KJ, Hood JE, daCosta GA, Akman D, Cassavia E. A review of the long-term effects of child sexual abuse. Child Abuse Neglect 1992;16:101 –118.

w20x Counts DA, Brown J, Campbell J. Sanctions and sanc- tuary: cultural perspectives on the beating of wives. Boulder, Colorado: Westview Press, 1992.

w21x Levinson D. Violence in cross cultural perspective. Newbury Park, California: Sage Publishers, 1989.

w22x Heise L. Violence against women: an integrated, eco- logical framework. Violence Against Women 1998;4:262 –290.

w23x Hotaling GT, Sugarman DB. An analysis of risk markers in husband to wife violence: the current state of knowl- edge. Violence Victims 1986;1:101 –124.

w24x Dutton DG. The domestic assault of women: psycholog- ical and criminal justice perspectives. Vancouver, British Colombia: University of British Colombia Press, 1995.

w25x Tjaden P, Thoennes N. Extent, nature and consequences of intimate partner violence: findings from the National Violence Against Women Survey. Washington, DC:

National Institute of Justice, Centers for Disease Control and Prevention, 2000. p. 72

w26x Fournier M, de los Rios R, Orpinas P, Piquet-Carneiro L. Multicenter Study on Cultural Attitudes and Norms towards Violence(ACTIVA project): methodology. Rev. Panam. Salud. Publica. 1999;5:222 –231.

w27x Koenig M, Hossain MB, Ahmed S, Haaga J. Individual and community-level determinants of domestic violence in rural Bangladesh in Hopkins Population Center Paper on Population. Baltimore: Johns Hopkins School Public Health, Department of Population and Family Health Sciences, 1999.

w28x Jejeebhoy SJ. Wife-beating in rural India: a husband’s right? Econo. Political Weekly(India) 1998;23:588 – 862.

w29x Khan ME, Townsend JW, Sinha R, Lakhanpal S. Sexual violence within marriage. New Dehli, India: Population Council, 1996.

w30x Shedlin M, Hollerbach PE. Modern and traditional fertility regulation in a mexican community: the process of decision making. Studies Family Planning 1981;12:278 –296.

w31x Blanc AK, Wolff B, Gage AJ, Ezeh AC, Neema S, Ssekamatte-Ssebuliba J. Negotiating reproductive out- comes in Uganda.Institute of Statistics and Applied Economics and Macro International Inc, 1996. p. 215

w32x Ezeh AC. The influence of spouses over each other’s contraceptive attitudes in Ghana. Studies Family Plan- ning 1993;24:163 –174.

w33x Bawah AA, Akweongo P, Simmons R, Phillips JF. Women’s fears and men’s anxieties: the impact of family planning on gender relations in northern Ghana. Studies Family Planning 1999;30:54 –66.

w34x Folch-Lyon E, Macora L, Schearer SB. Focus group and survey research in family planning in Mexico. Studies Family Planning 1981;12:409 –432.

w35x Fort AL. Investigation of the social context of fertility and family planning: a qualitative study in Peru. Int. Family Planning Perspect. 1989;15:88 –94.

w36x Choque ME, Schuler SR, Rance S. Reasons for unwant- ed fertility and barriers to use of family planning services among urban Aymara in Bolivia. Arlington, Virginia: John Snow, Inc, 1994. p. 19

w37x Zoysa Id, Sweat MD, Denison JA. Faithful but fearful: reducing HIV transmission in stable relationships. AIDS 1996;10:S197 –S203.

w38x Goldstein D. The cultural, class, and gender politics of a modern disease: women and AIDS in Brazil. ABIA, ColectivoFeminista Sexualidade e Saude 1992;92.

w39x Boyer D, Fine D. Sexual abuse as a factor in adolescent pregnancy. Family Planning Perspect. 1992;24:4 –11.

w40x Butler JR, Burton LM. Rethinking teenage childbearing: is sexual abuse a missing link. Family Relations 1990;39:73 –80.

w41x Beitchman JH, Zucker KJ, Hood JE. A review of the short term effects of child sexual abuse. Child Abuse Neglect 1991;15:537 –556.

S13L. Heise et al. / International Journal of Gynecology and Obstetrics 78 Suppl. 1 (2002) S5–S14

w42x Dietz PM, Spitz AM, Anda RF, et al. Unintended pregnancy among adult women exposed to abuse or household dysfunction during their childhood. J. Am. Med. Assoc. 1999;282:1359 –1364.

w43x Fergusson DM, Horwood LJ, Lynskey MT. Childhood sexual abuse, adolescent sexual behaviors and sexual revictimization. Child Abuse Neglect 1997;21:789 –803.

w44x Zierler S, Femgold L, Lufer D. Adult survivors of childhood sexual abuse and subsequent risk of HIV infection. Am. J. Public Health 1991;81:572 –575.

w45x Handwerker W. Gender power differences between par- ents and high-risk sexual behavior by their children: AIDSySTD risk factors extend to a prior generation. J. Women’s Health 1993;2:301 –316.

w46x Cunningham RM, Stiffman AR, Dore P, Earls F. The association of physical and sexual abuse with HIV risk behaviors in adolescence and young adulthood: impli- cations for public health. Child Abuse Neglect 1994;18:233 –245.

w47x Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences(ACE) Study. Am. J. Prevent. Med. 1998;14:245 –258.

w48x Johnsen LW, Harlow LL. Childhood sexual abuse linked with adult substance use, victimization, and AIDS-risk. AIDS Educat. Prevent. 1996;8:44 –57.

w49x Roosa MW, Tein J-Y, Reinholtz C, Angelini PJ. The relationship of childhood sexual abuse to teenage preg- nancy. J. Marriage Family 1997;59:119 –130.

w50x Rotheram-Borus MJ, Mahler KA, Koopman C, Langa- beer K. Sexual abuse history and associated multiple risk behavior in adolescent runaways. Am. J. Orthop- sychiat. 1996;66:390 –400.

w51x James J, Meyerding J. Early sexual experiences and prostitution. Am. J. Psychiat. 1977;132:1381 –1385.

w52x Stevens-Simon C, Reichert S. Sexual abuse, adolescent pregnancy, and child abuse: a developmental approach to an intergenerational cycle. Arch. Pediatr. Adoles. Med. 1994;148:23 –27.

w53x Yates G, MacKenzie R, Pennbridge J, Cohen E. A risk profile comparison of homeless youth involved in pros- titution and homeless youth not involved. J. Adoles. Health 1991;12:545 –548.

w54x Fullilove MT, Lown EA, Fullilove RE. Crack’hos and skeezers: traumatic experiences of women crack users. J. Sex Res. 1992;29:275 –287.

w55x Paone D, Chavkin W, Wilets IPF, DesJarlais D. The impact of sexual abuse: implications for drug treatment. J. Women’s Health 1992;1:149 –153.

w56x Sherman SG, Steckler A. ‘‘What the ‘caine was tellin’ me to do.’’ Crack users’ risk of HIV: an exploratory study of female inmates. Womens Health 1998;4:117 – 134.

w57x Bartholow BN, Doll LS, Joy D, et al. Emotional, behavioral and HIV risks associated with sexual abuse

among adult homosexual and bisexual men. Child Abuse Neglect 1994;18:747 –761.

w58x Strathdee SA, Patrick DM, Archibald CP, et al. Social determinants predict needle-sharing behaviour among injection drug users in Vancouver, Canada. Addiction 1997;92:1339 –1347.

w59x Britton BM. Gender, power and HIV: the impact of partner violence in the context of poverty on women’s risk of infection in the USA(abstract� 23466) in 12th World Conference on HIVyAIDS, Geneva, Switzerland 1998.

w60x Richie BE, Johnsen C. Abuse histories among newly incarcerated women in a New York city jail. J. Am. Med. Womens Assoc. 1996;51(114):7.

w61x Klein H, Chao BS. Sexual abuse during childhood and adolescence as predictors of HIV-related sexual risk during adulthood among female sexual partners of injection drug users. Violence Against Women 1995;1:55 –76.

w62x Brown D. In Africa, fear makes HIV an inheritance in Washington Post 1998.

w63x Ehlert U, Heim C, Hellhammer DH. Chronic pelvic pain as a somatoform disorder. Psychother. Psychoso- mat. 1999;68:87 –94.

w64x Walker EA, Katon WJ, Hansom J, et al. Medical and psychiatric symptoms in women with childhood sexual abuse. Psychosomat. Med. 1992;54:658 –664.

w65x Lee NC, Dicker RC, Rubin GL, Ory HW. Confirmation of the preoperative diagnoses for hysterectomy. Am. J. Obstetr. Gynecol. 1984;150:283 –287.

w66x Chapman JD. A longitudinal study of sexuality and gynecologic health in abused women. J. Am. Osteopat. Assoc. 1989;89:619 –624.

w67x Collett BJ, Cordle CJ, Stewart CR, Jagger C. A com- parative study of women with chronic pelvic pain, chronic nonpelvic pain and those with no history of pain attending general practitioners. Brit. J. Obstetr. Gynaecol. 1998;105:87 –92.

w68x Jamieson DJ, Steege JF. The association of sexual abuse with pelvic pain complaints in a primary care popula- tion. Am. J. Obstetr. Gynecol. 1997;177:1408 –1412.

w69x Rapkin AJ, Kames LD, Darke LL, Stampler FM, Nali- boff BD. History of physical and sexual abuse in women with chronic pelvic pain. Obstetr. Gynecol. 1990;76:92 – 96.

w70x Schei B. Psycho-social factors in pelvic pain. A con- trolled study of women living in physically abusive relationships. Acta Obstetricia et Gynecologica Scandi- navica 1990;69:67 –71.

w71x Schei B, Bakketeig LS. Gynaecological impact of sexual and physical abuse by spouse: a study of a random sample of Norwegian women. Brit. J. Obstetr. Gynaecol. 1989;96:1379 –1383.

w72x Golding J. Sexual assault history and women’s repro- ductive and sexual health. Psychol. Women Quart. 1996;20:101 –121.

S14 L. Heise et al. / International Journal of Gynecology and Obstetrics 78 Suppl. 1 (2002) S5–S14

w73x Golding JM, Wilsnack SC, Learman LA. Prevalence of sexual assault history among women with common gynecologic symptoms. Am. J. Obstetr. Gynecol. 1998;179:1013 –1019.

w74x Schei B. Physically abusive spouse—a risk factor of pelvic inflammatory disease? Scand. J. Primary Health Care 1991;9:41 –45.

w75x Golding JM, Taylor DL. Sexual assault history and premenstrual distress in two general population samples. J. Women’s Health 1996;5:143 –152.

w76x Golding JM. Sexual assault history and limitations in physical functioning in two general population samples. Res. Nursing Health 1996;19:33 –44.

w77x Golding JM, Cooper ML, George LK. Sexual assault history and health perceptions: seven general population studies. Health Psychol. 1997;16:417 –425.

w78x Ballard TJ, Saltzman LE, Gazmararian JA, Spitz AM, Lazorick S, Marks JS. Violence during pregnancy: measurement issues. Am. J. Public Health 1998;88:274 – 276.

w79x Campbell JC. Addressing battering during pregnancy: reducing low birth weight and ongoing abuse. Semin. Perinatol. 1995;19:301 –306.

w80x Curry MA, Perrin N, Wall E. Effects of abuse on maternal complications and birth weight in adult and adolescent women. Obstetr. Gynecol. 1998;92:530 –534.

w81x Gazmararian JA, Lazorick S, Spitz AM, Ballard TJ, Saltzman LE, Marks JS. Prevalence of violence against pregnant women. J. Am. Med. Assoc. 1996;275:1915 – 1920.

w82x Newberger EH, Barkan SE, Lieberman ES, et al. Abuse of pregnant women and adverse birth outcome. Current knowledge and implications for practice. J. Am. Med. Assoc. 1992;267:2370 –2372.

w83x Rosales J, Loaiza E, Primante D, Barberena A, Blandon Sequeira L, Ellsberg M. Encuesta Nicaraguense de demografia y salud 1998. Managua, Nicaragua: Instituto Nacional de Estadisticas y Censos, INEC, 1999

w84x El-Zanaty F, Hussein EM, Shawky GA, Way AA, Kishor S. Egypt demographic and health survey 1995. Calver- ton, Maryland: Macro International, 1996.

w85x Larrain SH. Violencia puertas adentro: la mujer golpea- da. Santiago, Chile: Editorial Universitaria, 1994.

w86x Johnson H. Dangerous domains: violence against wom- en in Canada. In: Nelson, editor. Crime in Canada, Ontario, Canada: International Thomson Publishing.

w87x Nelson E, Zimmerman C. Household survey on domes- tic violence in Cambodia. Phnom Penh, Cambodia: Ministry of Women’s Affairs (MoWA) and Project Against Domestic Violence(PADV), 1996. p. 82

w88x Petersen R, Gazmararian JA, Spitz AM, et al. Violence and adverse pregnancy outcomes: a review of the

literature and directions for future research. Am. J. Prevent. Med. 1997;13:366 –373.

w89x Dietz PM, Gazmararian JA, Goodwin MM, Bruce FC, Johnson CH, Rochat RW. Delayed entry into prenatal care: effect of physical violence. Obstet. Gynecol. 1997;90:221 –224.

w90x Parker B, McFarlane J, Soeken K. Abuse during preg- nancy: effects on maternal complications and birth weight in adult and teenage women. Obstetr. Gynecol. 1994;84:323 –328.

w91x McFarlane J, Parker B, Soeken K. Abuse during preg- nancy: associations with maternal health and infant birth weight. Nurs. Res. 1996;45:37 –42.

w92x Taggart L, Mattson S. Delay in prenatal care as a result of battering in pregnancy: cross-cultural implications. Health Care Women Int. 1996;17:25 –34.

w93x Valdez-Santiago R, Sanin-Aguirre LH. Domestic vio- lence during pregnancy and its relationship with birth weight. Salud Publica Mexicana 1996;38:352 –362.

w94x Valladares E, Ellsberg M, Pena R, Hogberg U, Persson˜ ¨ LA. Physical abuse during pregnancy: a risk factor for˚ low birth weight, submitted for publication.

w95x Berenson AB, Wiemann CM, Rowe TF, Rickert VI. Inadequate weight gain among pregnant adolescents: risk factors and relationship to infant birth weight. Am. J. Obstetr. Gynecol. 1997;176:1220 –1224.

w96x Martin SL, Matza LS, Kupper LL, Thomas JC, Daly M, Cloutier S. Domestic violence and sexually trans- mitted diseases: the experience of prenatal care patients. Public Health Rep. 1999;114:262 –268.

w97x Cokkinides VE, Coker AL, Sanderson M, Addy C, Bethea L. Physical violence during pregnancy: maternal complications and birth outcomes. Obstetr. Gynecol. 1999;93:661 –666.

w98x Amaro H, Fried LE, Cabral H, Zuckerman B. Violence during pregnancy and substance use. Am. J. Public Health 1990;80:575 –579.

w99x Berenson AB, Wiemann CM, Wilkinson GS, Jones WA, Anderson GD. Perinatal morbidity associated with vio- lence experienced by pregnant women. Am. J. Obstetr. Gynecol. 1994;170:1760 –1769.

w100x Bullock LF, McFarlane J. The birth-weightybattering connection. Am. J. Nurs. 1989;89:1153 –1155.

w101x Dye TD, Tollivert NJ, Lee RV, Kenney CJ. Violence, pregnancy and birth outcome in Appalachia. Paediatr. Perinatal Epidemiol. 1995;9:35 –47.

w102x Grimstad H, Schei B, Backe B, Jacobsen G. Physical abuse and low birthweight: a case-control study. Brit. J. Obstetr. Gynaecol. 1997;104:1281 –1287.

w103x Schei B, et al. Does spousal physical abuse affect the outcome of pregnancy? Scand. J. Soc. Med. 1991;19:26 –31.

w104x Rodriguez MA, Quiroga SS, Bauer HM. Breaking the silence: battered women’s perspectives on medical care. Arch. Family Med. 1996;5:153 –158.