metadata: authors: 0: author: Machado,Ana Luiza
1: author: Muller,Miriam
2: author: Van Wie,Sara Hause
count: Brazil
docna: 0: docna: Fear is What Weighs Most : Experiences of
            Women in Situations of Violence in Accessing Support
            Services in Brazil
docty: Policy Research Working Paper
subtopic: Social Conflict and Violence,Health Care Services Industry,Social Cohesion,Gender and Development,Judicial System Reform
teratopic: Social Development,Law and Development,Industry,Gender
abstracts: cdata!: This paper seeks to fill a knowledge gap
            relative to the low uptake of services for women living in
            situations of violence. The phenomenon is observed in many
            countries, including in Brazil, despite its robust legal
            framework to prevent and protect women from domestic
            violence. Through qualitative research, this paper explores
            the experience of women survivors of violence against women
            (VAW) in seeking help to exit abusive relationships, with
            the aim of identifying avenues to strengthen service
            delivery and violence prevention policies. The experiences
            of research participants demonstrate that a complex set of
            issues related to social norms, individual agency and
            institutional weaknesses serve as strong barriers for
            service uptake. These include women's personal
            preparedness to seek support; the catalyzing or constraining
            function that families, friends, peers and people in
            authority can play; external barriers to accessing services;
            and the availability and quality of services in different
            settings. Data from this research also highlight the
            importance of psycho-social support services that help
            survivors make informed decisions about how to exit abusive
            relationships, to rebuild their emotional stability and
            self-esteem, establish economic autonomy, pursue justice,
            and ultimately reconstruct their lives.
geo_reg_key: 119228,517191
repnme: repnme: Fear is What Weighs Most : Experiences of
            Women in Situations of Violence in Accessing Support
            Services in Brazil
display_title: Fear is What Weighs Most :
            Experiences of Women in Situations of Violence in Accessing
            Support Services in Brazil
listing_relative_url: /research/2020/03/31870538/fear-weighs-most-experiences-women-situations-violence-accessing-support-services-brazil
topicv3: Domestic Violence m1326034 2441,Justice m1326106 840,Gender m1327621 615,Gender Based Violence m1504507 2901,Health m1504661 3480
publishtoextweb_dt: 2020-03-16T00:00:00Z
historic_topic: Social Development,Law and Development,Industry,Gender
origu: EFI-LCR-POV-Poverty and Equity (ELCPV)
no_of_pages: 37
author_keys: 0: author_key: 1221012
1: author_key: 1145168
2: author_key: 1217441
model_extractions: Policy Research Working Paper 9186 “Fear Is What Weighs Most...” Experiences of Women in Situations of Violence in Accessing Support Services in Brazil _Ana Luiza Machado Miriam Muller Sara Van Wie_ Poverty and Equity Global Practice March 2020
Policy Research Working Paper 9186

# **Abstract**

This paper seeks to fill a knowledge gap relative to the low uptake of services for women living in situations of violence. The phenomenon is observed in many countries, including Brazil, despite its robust legal framework to prevent and protect women from domestic violence. Through qualitative research, the paper explores the experience of women survivors of violence against women in seeking help to exit abusive relationships, with the aim of identifying avenues to strengthen service delivery and violence prevention policies. The experiences of research participants demonstrate that a complex set of issues related to social norms, individual agency, and institutional weaknesses serve as strong barriers for service uptake. These include women’s personal preparedness to seek support; the catalyzing or constraining function that families, friends, peers, and people in authority can play; external barriers to accessing services; and the availability and quality of services in different settings. Data from this research also highlight the importance of psycho-social support services that help survivors make informed decisions about how to exit abusive relationships, to rebuild their emotional stability and self-esteem, establish economic autonomy, pursue justice, and ultimately reconstruct their lives.

This paper is a product of the Poverty and Equity Global Practice. It is part of a larger effort by the World Bank to provide open access to its research and make a contribution to development policy discussions around the world. Policy Research Working Papers are also posted on the Web at http://www.worldbank.org/prwp. The authors may be contacted at mmuller1@worldbank.org.

_The Policy Research Working Paper Series disseminates the findings of work in progress to encourage the exchange of ideas about development issues. An objective of the series is to get the findings out quickly, even if the presentations are less than fully polished. The papers carry the names of the authors and should be cited accordingly. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors. They do not necessarily represent the views of the International Bank for Reconstruction and Development/World Bank and its affiliated organizations, or those of the Executive Directors of the World Bank or the governments they represent._ Produced by the Research Support Team
# **“Fear Is What Weighs Most...” Experiences of Women in Situations of Violence in Accessing Support Services in Brazil**

Ana Luiza Machado, Miriam Muller, Sara Van Wie J12: Marriage • Marital Dissolution • Family Structure • Domestic Abuse Key Words: Violence against women • Brazil • Maria da Penha Law • Abuse • Access to Services Acknowledgments: This paper was prepared by a World Bank team composed by Ana Luiza Machado (Consultant), Miriam Muller (Social Scientist and task team leader) and Sara Van Wie (Consultant). The team benefitted greatly from the valuable support from Rio de Janeiro’s local violence against women (VAW) network officers and staff from _Subsecretaria de Políticas para as Mulheres do Rio de Janeiro_ and Integrated Centres for Special Attention to Women: CIAM Baixada; CEAM Queimados, CIAM Marcia Lyra e da Casa da Mulher de Manguinhos. We thank the team of consultants who supported data collection and processing: Christiane Severo (Consultant), Naila Takahashi (Consultant) and Carolina Mazzi (Consultant). We are particularly grateful for the very valuable inputs received from Juliana Braga (Communications Associate), Bianca Bianchi Alves (Senior Urban Transport Specialist), Daniel Pulido (Senior Infrastructure Specialist), Flavia Carbonari (Senior Social Development Consultant), Paula Tavares (Senior Private Sector Specialist) and Liliana Sousa (Senior Economist) as well as for the guidance received from Oscar Calvo-Gonzalez (Director), Ximena del Carpio (Manager) and Pablo Ariel Acosta (Program Leader). Desiree Gonzalez (Program Assistant) and Karem Edwards Izquierdo (Program Assistant) provided support throughout the implementation of the study. The team would like to gratefully acknowledge the Umbrella Facility for Gender Equality (UFGE), which provided funds for data collection and analysis. The data collected for this study also informed a report implemented in the context of the Enhancing Public management for Service Delivery in Rio de Janeiro DPL.

Our deepest gratitude to the key informants and to the women who shared their personal stories with us. The opinions, interpretations, and conclusions expressed herein do not necessarily reflect the views of the World Bank, its Board of Executive Directors, or the Governments they represent.
# **1. INTRODUCTION**

Violence against women (VAW)<sup>1</sup> is a worldwide problem. According to WHO estimates, 1 out of 3 women globally have experienced violence by an intimate partner. Recognition of this endemic problem has increased – as has research to better understand the prevalence of VAW in different settings and identify the underlying causes and risk-factors associated with both victimization and perpetration of violence (Heise 2011). Women living in situations of violence (physical, sexual, emotional and economic) experience short- and long-term physical, mental and sexual reproductive health problems.<sup>2</sup> Violence also can affect their children, and lead to high social and economic costs for women, their families and communities (WHO 2017, PAHO 2012) and societies more broadly.<sup>3</sup> Experiencing violence by an intimate partner denies women their rights, their agency and their well-being (Perova et al. 2013, World Bank 2012).

A growing body of research has sought to understand the effectiveness of interventions that address VAW, but most rigorous evidence emerges from high-income settings with a focus on response, not prevention (Ellsberg et al. 2015). Within high-income countries, evidence shows greater success in physical and mental health outcomes and increased use of services for survivors, especially among women-centered, advocacy and home-visitation interventions (Ellsberg et al. 2015, see also Tiwari et al. 2005, Kiely et al. 2010, Sullivan and Bybee 1999, Taft et al. 2011, Bell and Goodman 2001). Even within the high-income country context, evidence to reduce revictimization is weak, and little evidence exists on the effectiveness of perpetrator-focused interventions (Ellsberg et al. 2015).

While evidence on effective response and prevention to VAW within low- and middle-income countries remains scarce, a small body of evidence reveals that interventions can achieve large effects in violence prevention, even within programmatic timeframes (Ellsberg et al. 2015). Interventions with the greatest recorded effects on VAW are multisectoral, support socioemotional skill development, and seek to transform entrenched gender norms relative to the acceptability of violence, gender roles and dynamics, and women’s economic dependence on men (Ellsberg et al. 2015, see also Bandiera et al. 2012, Sarnquist et al. 2014, Abramsky et al. 2014, Diop et al. 2004, Wagman et al. 2015, Hidorobo et al. 2013, Kim et al. 2007).

Research from different contexts has found lower rates of violence against women in societies that routinely hold perpetrators of violence against women accountable (PAHO 2012). Accountability in these cases may be enforced through legal sanctions or through informal family and community responses on behalf of women and girls who experience abuse. Social support networks can also

> 1 The United Nations defines violence against women as "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” (UN 1993).

> 2 VAW can result in: fatal outcomes, internal and external injuries, unintended pregnancy, increased likelihood of stillbirth, miscarriage and low-birthweight of children, sexually transmitted diseases, depression, post-traumatic stress disorder, suicide, anxiety disorders, sleep abnormalities, addictive behaviors, et. al.  Women may suffer isolation, inability to work or participate in regular activities, limited ability to care for themselves and their children.

> 3 Hoefler and Fearon (2014) estimate the direct and indirect costs of domestic violence to equal 5.23% of global GDP (5.18% from intimate partner violence and 0.05% resulting from female homicides by intimate partners). They also estimate costs by World Bank region, and state that these forms of violence produce losses of 9.0% of GDP in Latin America and the Caribbean (8.01% from intimate partner violence, and 0.9% from female homicides of intimate partners).

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be a protective factor against violence (Levinson 1989, Counts et al. 1999, Counts et al. 1992, Perova et al. 2013). However, a dearth of rigorous evidence exists on the effectiveness of legislative and justice sector responses (including specialized police stations for women) and onestop centers – comprehensive care centers for survivors of VAW – to reduce VAW or mitigate negative consequences for survivors (Ellsberg et al. 2015).

The focus of this study is on the help-seeking behavior of women experiencing VAW in Rio de Janeiro, Brazil. The severe difficulties facing women living in situations of violence in seeking support have been illustrated in the multi-country study on violence against women conducted by WHO (2005). The data collected showed that across countries, over half of physically abused women (between 55 percent and 95 percent) reported that they had never sought help from formal services (health, justice or shelter) or from people in positions of authority (police, NGOs, local leaders, and religious leaders). The study shows further that even in those countries where services are available to survivors of violence, barriers such as fear, stigma and the threat of losing their children impeded women from seeking help. On the other hand, the top facilitators for supportseeking were the severity of the violence, the expected impact on children, and support to reach out to services from friends and family. Those often serve as the first contact for women in violent relationships – something that had also been shown in previous research for the United States (Rose et al 2000, Counts et al. 1999) – though, as will be seen in this paper, such contact can bear both impeding or facilitating functions.

Brazil has increased efforts to address violence against women since the early 2000s. Since the creation of the Federal Secretariat for Women’s Policies in 2003, anti-VAW policies and legislation have been strengthened. Efforts include the enactment of the Maria da Penha Law (MdP) in 2006, which has been internationally lauded as one of the most innovative and comprehensive legal instruments in the world to addresses the issue of domestic violence (UNIFEM 2008).<sup>4</sup> The Maria da Penha Law establishes special courts and stricter sentences for offenders and mandates other instruments for prevention, including specialized police stations and shelters for women. The law also seeks to build civil society capacity to monitor and evaluate policies designed to combat VAW in Brazil.<sup>5</sup> However, despite a robust legal framework to prevent and protect women from domestic violence, several barriers challenge the effective implementation of laws and policies. Some critics defend that, although the established policy and legal frameworks are progressive in many aspects, they also embed regressive components such as the prioritization of punitive measures to the detriment of protective and preventive efforts (Machado et al. 2017).

Although there is a lack of official and systematic data that adequately measure the extent of VAW in Brazil in its physical and non-physical forms,<sup>6</sup> existing data reveal the pervasiveness of the issue. A specialized World Health Organization survey from 2000 showed that approximately 41

> 4 Law cited alongside Spanish Laws (2004) and the Mongolian Law on violence against women. Progress of the World’s Women 2008/2009, UNIFEM 2008, p. 76.

> 5 An overview of related laws, degrees as well as amendments to MdP can be found under:

> <u>http://www.compromissoeatitude.org.br/legislacao-sobre-violencia-contra-as-mulheres-no-brasil/</u>

> 6 There are two main sources of VAW data: data from specialized surveys and administrative data. The highest prevalence rates are obtained by specialized surveys that follow WHO ethical and safety standards. However, this type of data is expensive and not available in a continuous basis in Brazil. On the other hand, administrative data from security and health services are more accessible. However, they do not capture well non-physical forms of violence and tend to underestimate the problem due to underreporting and lack of technical capacity of service operators.

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percent of Brazilian women had suffered from sexual or physical violence at some moment in their lives. Among those who had ever had a partner, 27.2 percent said they had suffered physical violence committed by a partner at least once (Garcia-Moreno et al. 2005).<sup>7</sup> More recent research completed by the Foundation Perseu Abramo (2010) finds similar rates of violence against women: two out of five (40 percent) women suffered some type of domestic violence at least once in their lifetime; 24 percent reported experiencing control or restrictive behaviors; 23 percent psychological or verbal violence; and 24 percent physical threat or violence.<sup>8</sup> Data from DataSenado’s 2017 survey on domestic violence found an 11 percentage-point increase in women reporting they suffered some type of domestic violence between 2005 and 2017 – from 18 percent to 29 percent, respectively – and an increase in the percentage of women who knew a woman who had suffered domestic violence (56 percent in 2015 to 71 percent in 2017).

Since the enactment of the MdP law, services for support of VAW survivors have expanded, and measures to strengthen their quality have been established. These services encompass several areas - social assistance, justice, public safety and health – and include specialized and non-specialized services. Non-specialized services units include those that serve the population in general, including regular family courts; shelters; and health providers,<sup>9</sup> which can be trained to properly attend to cases of domestic violence. The main specialized services are: Specialized Police Stations for Women (DEAM – _Delegacia Especializada de Atendimento à Mulher_ ); Specialized Courts for dealing with domestic violence cases; and Integrated Centers for Special Attention to Women ( _Centro Integrado de Atendimento a Mulher -_ CIAM/CEAM/CRAM).<sup>10</sup> CIAMs, the service from which research participants for this study were recruited, provide various services including psychological support, legal assistance and referral to other services. While the responsibility for the instrumentation and implementation of MdP is decentralized to States and Municipalities, there are no built-in federal enforcement mechanisms or conditionality.

As stated above, critics of the MdP law defend that its implementation has led to a greater emphasis on punitive mechanisms and institutions (DEAMS, courts) to the detriment of protective and preventive ones (e.g. CIAMs) (Avila 2017; Machado et al. 2017). Some argue that the strong punitive emphasis of the law can alienate survivors, and point to the fact that, after cases are reported, the aggressor can be punished with or without a survivor’s consent (Machado et al. 2014).

In Brazil as in other countries, the issue of low uptake of services for women in situations of violence is often connected to the availability and quality of services, women’s awareness of their rights and knowledge of where they can go for help, and social norms, attitudes and support among family and friends (PAHO 2012, WHO 2019). Better understanding where, how, and from whom

> 7 The population-based research with a representative sample was conducted in Brazil in 2000-2001, as part of the WHO Multicountry Study on Women’s Health and Domestic Violence Against Women. The Brazilian part of the study interviewed 2,645 women of reproductive age in the city of São Paulo and the Forest Zone of the State of Pernambuco. Much of this information was reiterated in research conducted by the Perseu Abramo Foundation (2010), relating to women in public and private spheres, even though the questions for measuring physical or sexual violence were slightly different for the acts investigated. Husbands, exhusbands, boyfriends and sons were the main aggressors.

> 8 The survey “Brazilian women and gender research in public and private spaces,” carried out by the Perseu Abramo Foundation in August 2010 heard the views of 2,365 women and 1,181 men over 15 years of age, in 25 states.

> 9 Concerning health services, it is important to highlight that the National Disease Notification System (SINAN) requires mandatory notification for cases of domestic or sexual violence.

> 10Different denominations have been used to designate these specialized centers: _Centro Especializado de Atendimento à Mulher (CEAM), Centros de Referencia de Atendimento a Mulher (CRAM), Centros Integrados de Atendimento a Mulher (CIAM)._ In Rio de Janeiro, the most commonly adopted denomination is “CIAM,” which will also be used throughout the text.

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women seek help for violence is essential to bridge legislation and service delivery at the local, community, and national levels.

This paper seeks to fill knowledge gaps relative to the low uptake of services for women living in situations of violence and to identify avenues to strengthen service delivery and violence prevention policies. The qualitative methods employed through this research enable a greater understanding of what hinders women from seeking help and, ultimately, escaping situations of violence. Identification of barriers to the successful implementation of anti-VAW policy from survivors’ perspectives enables this research to explore opportunities for improvements to service provision and protection.

Concretely, this paper explores the experience of 16 women survivors of VAW in seeking help to exit abusive relationships in Rio de Janeiro, Brazil. Data were collected through (i) in-depth interviews with women who were receiving services at Integrated Centers for Special Attention to Women ( _Centros Integrados de Atendimento a Mulher_ – CIAMs) in four different locations of Rio de Janeiro state, and (ii) key informant interviews with coordinators of protective service units. Although the study was conducted with CIAM users, interviews also explored participants’ experience in seeking help from family and friends and through other services.

The findings demonstrate that a complex set of self-reinforcing issues related to social norms, individual agency and institutional failures serve as strong barriers for service uptake. These include women’s internal motivation and willingness to seek support and from whom; the catalyzing or constraining function that families, friends, peers and people in authority can play; external barriers to accessing services and the availability and quality of services in different settings. Data from this research highlight important psycho-social measures that support survivors’ rebuilding of their self-esteem, establishing economic autonomy, and reconstructing their lives and relationships.

“Fear is what weighs most...” was said by one research participant, a woman survivor of intimate partner violence, when asked which factors most influenced her decision to not seek help. The citation speaks to several key findings of this study. Women survivors of violence may not take action to change their situation, to pursue justice, or to rebuild their lives because of fear. The fear described by this woman is common among those facing VAW: fear signals a lack of selfconfidence and trust in one’s own capacity to endure difficult situations and can create a powerful personal barrier to seeking help or leaving abusive relationships. Secondly, women living in situations of violence often fear the reaction of family and friends, those from whom survivors first seek help, due to the fact that acceptance and normalization of violence against women is widespread in Brazil (as in many other countries) and can result in their closest relations discouraging them or blaming them for the violence they suffer. Finally, and importantly, women survivors may fear that formal services and institutions may not be sufficient to protect them from potential retaliation from their abusers. All of those ‘fears’ have been identified in this research and will be further elaborated in respective sections.

These findings suggest that, despite the progress in legal and policy frameworks to punish VAW, additional strategies and mechanisms may be needed to ensure women living in situations of violence have access to services that support their well-being and recovery. These could include the expansion or strengthening of psycho-social support services and legal counseling, the _5_
dissemination of information about their existence and benefits, and campaigns that challenge restrictive social norms and sensitize bystanders.

The paper is composed of this introduction and three additional sections. The first section presents the objective and methodology of the study, along with key research questions that guided the data collection. The second section presents key results relative to barriers and facilitators for women as they seek support and VAW services. The third section concludes with a summary of findings and recommendations in light of the findings of this research.

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# **2. METHODOLOGY**

This research explores barriers and facilitators for women in situations of violence to access VAWrelated services. The study looks at women’s decision-making process, attitudes of partners and their support network, as well as perceptions about law enforcement and service provision. By exploring the perspective of users, the goal is to better understand the issue of low uptake of protective services and identify opportunities to improve women’s access to such services.

The broad research questions that guided data analysis were<sup>11</sup> :

- a) Which factors weigh into VAW survivors’ decision to seek support?

- b) Which challenges – both formal and informal – do survivors in such situations face in seeking support?

- c) What are survivors’ perceptions about the existing network of services available to them and how do those perceptions shape decisions and preferences on who to reach out to?

- d) What can be done in order to improve women’s access and uptake of VAW-related services?

This research is characterized by an inductive method of data collection that explores the experiences and individual perceptions of respondents. The advantage of this approach is that it allows an in-depth investigation of sensitive and subjective themes based on a reduced sample. Tools utilized through this research enabled participants to express their thoughts and reactions in their own words, rather than choosing between pre-defined alternatives; and enabled interviewers to gather data on drivers of personal decisions and behaviors.

Data collection started off with a pilot, after which the research instrument was adjusted. Sixteen in-depth interviews were conducted in 2015 with women survivors of VAW, who were at this time receiving services at the Integrated Centers for Special Attention to Women (Centros Integrados de Atendimento a Mulher – CIAMs, see Box 1) in different locations of Rio de Janeiro state.

> 11 Data collection was initially conducted as part of a qualitative study whose objective was to propose strategies to facilitate women’s access to information on VAW, women’s rights and the service network for survivors of VAW in Rio de Janeiro through a World Bank-supported transport project. Nonetheless, the wealth of data collected from in-depth interviews called for a deeper analysis of the data.

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# Box 1. Integrated Centers for Special Attention to Women

According to Brazil’s National Secretariat of Women’s Policies, these centers –known as CRAMs or CIAMs--should provide the necessary care and attention to help women overcome their situation, contribute to the empowerment of women and to restoring their sense of citizenship (National Policy to Combat Violence Against Women 2011). The activities performed by the centers (according to the Technical Guidelines) should include: 1) Counseling in times of crisis, 2) Psychosocial support, 3) Legal counseling and advice, 4) Preventive actions, 5) Professional Qualification, 6) Articulation of local public and private services integrating the GBV network, and 7) Survey of local data on women in situations of violence. The CIAMs receive victims either by spontaneous demand or referrals. Most cases get forwarded by Women's Police Stations, although some women come on their own by word of mouth, either through friends, neighbors or other public services.

Data were collected from four different service units in Rio de Janeiro state, selected for practical reasons, as those were the ones maintained by the state government, which facilitated the team’s engagement. In addition, five key informants were also interviewed (one government representative, responsible for anti-VAW policies in the state and 4 CIAM service coordinators). Potential interviewees were identified by the staff of the CIAMs, and first approached by them to evaluate their interest to participate in this research. Interviews lasted about 90 minutes and were conducted by a researcher trained on VAW research. The research instruments were developed by the research team and with inputs of the Subsecretariat for Women Policies in Rio de Janeiro, under the State Secretariat for Social Assistance and Human Development (Subsecretaria de Políticas para as Mulheres do Rio de Janeiro sob a Secretaria Estadual de Assistência Social e Desenvolvimento Humano, SEASDH-RJ). All data collection followed the recommendations on the ethical conduct of research on domestic violence issued by the World Health Organization (2001). Although the profile of the interviewees was heterogeneous, most of the women were white, with low levels of education and aged between 40-59 years. Most were not working at the time of their interview. Partners and ex-partners were the most common perpetrators of violence, but some women also reported violence at the hand of siblings, children and grandchildren, overwhelmingly male. Almost all cases contained elements of psychological violence, such as controlling behavior, insults and threats and most cases involved physical and sexual violence. Most women interviewed had suffered at the hands of more than one aggressor over the course of their lives (see Table 1). Table 2 summarizes the themes explored during interviews.

**<u>Table 1: Sample characteristics</u>**

|Under 40|4|31%|
|---|---|---|
|40-59|6|38%|
|**Age**<br>Over 60|5|31%|
|Missing data|1|6%|
|**Total**|**16**|**100%**|
|**Number of**<br>One perpetrator|6|38%|
|**perpetrators over the**<br>**course of lifetime**<br>More than one<br>perpetrator|10|63%|

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||**Total**|**16**|**100%**|
|---|---|---|---|
|**Rlihi ih**|Partners|13|81%|
|**eatonsp wt**<br>**rtrtr()***|Other family members|8|50%|
|**pepeaos**|Other|3|19%|
|**Gender of the**|Male|16|100%|
|**perpetrator(s)***|Female|4|25%|
||Psychological/Emotional|15|94%|
|**T f il***|Sexual|1|6%|
|**ype o voence**|Physical|9|56%|
||Financial|7|44%|

*Each woman can be counted more than once in these categories

**-** **<u>Table 2: Themes explored during in depth interviews</u>**

|**Dimensions**|Themes explored|
|---|---|
|**Participants’ profile**|• Age, educational attainment, professional and income profile|
|**Relationships and**<br>**support systems**|• Family background, friendships and relationships<br>• Support system – persons and institutions she feels she can count on<br>for help when needed<br>• Living arrangements and household dynamics|
|**Context of violence**|• Relationship with perpetrator and dynamics of violence – when, types<br>of violence, duration, frequency, associated feelings<br>• Perceived consequences of violence suffered|
|**Decision process,**<br>**barriers and facilitators**<br>**for the use of VAW-**<br>**related services**|• Critical moments and factors in deciding to reach out for help<br>• Attitudes of partners, family, friends and bystanders in general<br>• Feelings before, during and after reaching out for help<br>• Knowledge and perceptions about existing laws and services before<br>accessing them and means for obtaining this information<br>• Experience of searching for and reaching out to support services -<br>what helped and what made it more difficult?<br>• Reasons for preferring among different services – police, social<br>assistance, CIAMs|
|**Perceptions about the**<br>**VAW-related service**<br>**network and policy**|• Perceptions about the different services used - availability, quality,<br>satisfaction<br>• Perceptions about the Maria da Penha Law and its applicability<br>• Recommendations for improving anti-VAW policy and institutions|

Research on VAW raises important ethical and methodological challenges. The nature of the subject means that issues of security, confidentiality and interviewer training are even more critical than for other areas of research. Interviewers must ensure privacy, earn women’s trust, and be prepared to provide emotional support and referrals when asking women about experiences of violence. The World Health Organization has developed recommendations on the ethical conduct of research on domestic violence (WHO 2001). For this study, measures taken to safeguard participants’ well-being included: _9_
- **Participant recruitment:** Aiming to minimize potential distress that could arise from discussing traumatizing experiences during interviews, CIAM coordinators identified research participants through the following procedure: 1) the research and its objectives were presented to women during a regular session of their ‘reflection group’; 2) an individual conversation to further clarify the research was conducted with women who expressed interest in participation; 3) CIAM social workers conducted a psychological evaluation to further safeguard each participant’s well-being.

- **Consent:** Prior to all interviews, participants were given consent forms stating: broad objective of the research and its confidential nature; potential sensitive questions that would be covered during interviews; their right to withdraw their participation at any point before, during or after the research; and their right to choose not to answer any questions.

- **Privacy:** All interviews were conducted in private rooms in CIAMs to ensure participants’ right to privacy.

- **Confidentiality:** All interviews were audio-recorded and transcribed. Transcripts were stored in a protected database managed by the research coordinator, along with observation sheets, audio files and consent forms. Consent forms with participants’ names had no direct link to the data, which was anonymized and stored under unique identifiers. No names were written on instruments or observation notes.

- **Providing support:** CIAM counselors were on-duty at the time any interviews were being conducted to attend to participants if necessary.

- **Team training:** Interviewers received specialized training prior to fieldwork, including: basic introduction to concepts and issues related to gender and VAW; principles of conducting human subjects research; how to respond to disclosures of sensitive information in a way that avoids revictimization of participants; interview questions that are appropriate or inappropriate to ask survivors;  how to stop or change the topic to protect participants from distress; and procedures to forward participants to CIAM counsellors.

Qualitative interviews were coded using the following strategy: 1) identification of themes that emerged inductively from the data; 2) categorization of data segments of each transcript according to those themes; 3) identification of patterns and similarities within each category of data.

The methodology employed in this paper has limitations inherent in all qualitative research since it is not based on representative samples. In addition, specific limitations resulting from the research process are noted. First, interviews were conducted during business hours, potentially preventing the participation of younger working women. Second, the racial diversity of the sample was limited due to the fact that many of the participants were recruited from a center in which a greater percentage of users self-identify as white. The smaller share of black women is a clear limitation of this research, since violence rates are higher for this population in Rio de Janeiro and have been increasing in recent years (Waiselfisz 2015). Third, the research sample included women who had sought protective services at CIAMs _and_ who had already participated in group reflection exercises. These women may have different experiences, opinions and recommendations than those who instead prefer to only seek punitive action or those who do not seek assistance of any form after experiencing domestic violence. The research team recognizes that women who _10_
have access to some form of service may provide rich information on this particular group, but do not uncover coping strategies used more generally by women living in situations of violence.

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# **3. FACILITATORS AND BARRIERS WOMEN EXPERIENCE IN ACCESSING FORMAL VAW SERVICES**

In this section, data from in-depth interviews with users from the four selected centers providing psychosocial services are analyzed. The purpose of these interviews was to understand the experiences of women living in situations of violence and factors that influence their decisions to reach out to formal support services. By identifying the barriers and facilitators of women’s help-seeking, women’s experiences can inform policies that improve the accessibility and effectiveness of services and, ultimately, provide better and more comprehensive protection and support to survivors.

## 3.1 **Profiles and context of interviewees**

Although the profile of the interviewees was heterogeneous, most of the women were white, with low levels of education and aged between 40-59 years. Most were not working at the time of their interview.<sup>12</sup> Almost all cases contained elements of psychological violence, such as controlling behavior, insults and threats. Most cases involved physical and sexual violence. Most women interviewed had suffered at the hands of more than one aggressor over the course of their lives. Interviewees notably described violent family contexts with more than one case of domestic violence in their households or in their original families, some of which involved other survivors such as small children or older family members.

Many women described how their arrival at the support center (CIAM) was triggered by a recent episode of violence and how, after a series of sessions with the social worker or psychologist, they recognized the extent of the abuse they were experiencing or that they had suffered several other episodes of abuse throughout their lives. This process of “discovery” shows the workings of ingrained naturalization of domestic violence, which must not be understood as a particular experience (Campbell et al. 1998, Campbell et al. 1999, Kirkwood 1992, Moss et al. 1997). As shown in other research, this is partly due to the fact that physical abuse is often so intertwined with psychological and sexual degradation that it becomes virtually indistinguishable to the women themselves (Ellsberg et al. 2001). Women pass through various stages of recognition of violence before they are able to take action to overcome it (Landenburger 1989). Research shows that it is only after guided reflection and time that many women are able to reframe their experiences and see them through a de-naturalized lens (Brown 1997, Landenburger 1989, WHO 2019).

Partners and ex-partners were the most common perpetrators of violence, but some women also reported violence at the hand of siblings, children and grandchildren, overwhelmingly male. The descriptions of the relationships between women and their abusers were complex, embedded in close family ties and often in relationships of financial and emotional dependence. One woman (63-years old) in Nova Iguaçú described her experience in this way: “In my house, I was the one taking care of the kids, but I didn’t have the right to buy my own underwear. He even provided for my underwear, because I had no access to money. I didn’t work, because he took me out of my job when we got married, he told me I had to leave

> 12 As noted in the section delineating this research, interviews were conducted during business hours, possibly precluding younger working women from participating.  Income quintile is not strictly correlated with exposure to VAW. In most surveys in Latin America reviewed in PAHO 2012, women in the highest wealth quintile reported the lowest rates of physical or sexual intimate partner violence. At the same time, the prevalence of intimate partner violence did not decline steadily as wealth increased in most countries. Instead, most countries showed the highest prevalence rates among women in the third- or fourth-income quintiles (Bolivia 2003, El Salvador 2008, Guatemala 2008/9, Haiti 2005/6, Nicaragua 2006/7, and Peru 2007/8).

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that job.” As a result of dependence on abusers, women described confusion over how to feel about the perpetrator or how to deal with the situation. There were many cases of women who were or had been in abusive relationships with their partners for several years.

Those women who suffered violence from an (ex)-partner, increasingly experienced controlling behaviors that culminated in their loss of autonomy. Their stories often noted increased demonstrations of jealously followed by the gradual intensification of their partner’s controlling behaviors. These behaviors included appeals for the woman not to work or study; control of her leaving the home; and restricted communication with friends and family. For example, a woman (31-years) in Queimados described controlling behaviors of her partner: “I couldn’t go out a lot. I worked and went straight home...he created this bubble; it was so effective that I actually believed that he was protecting me, but he wasn’t, you see? He wasn’t. I couldn’t go out to have a conversation with anybody. When I went to my sister’s house, he called me every five minutes, ‘where are you?’ ‘are you coming?’” As women conformed to demands – often to please the partner or protect the relationship – the controlling behaviors slowly led to their isolation from the workplace, from family and friends. These patterns are consistent with cross-cultural comparisons of data on domestic violence that argue that social isolation of women is both a cause and a consequence of wife abuse (Heise 1998); and studies have found that women living in situations of violence have fewer interactions with friends, neighbors and relatives (Neilsen, Russell and Ellington 1992, Cazenave and Straus 1979).

Events like changing neighborhoods or cities and pregnancy contributed to deepened social isolation. By staying at home to take care of the house and children, women lost contact with the outside world and with their social support systems. In these cases, restrictive social norms that naturalize the role of women as primary caregivers within the home and reinforce the stereotype of the “good wife” as the submissive, passive and accepting “homemaker” further remove women from protective social networks and access to information (see also Ellsberg et al. 2000). Social isolation became a conducive context for the escalation of the violence towards more physical forms, as the survivor lost financial and emotional autonomy. Many women cited the intensification of violence as a motivation to consider seeking help to put an end to the situation - either with family members or friends. Notably, it is also when they reported facing the first challenges to exit the abusive relationship in the attempt to break out of social isolation.

# 3.2 **The decision to reach out for some form of support**

The experiences shared by the women who were interviewed demonstrate that women tended to reach out first to family and friends. Interactions with formal services generally occurred after interacting with informal support networks. This finding is in line with population-based surveys (RHS/DHS data available for Latin America) that show that, while help-seeking behaviors by women who experience violence vary widely by country, women in the region tend to seek help from informal institutions (social networks, family and friends) at much higher rates than formal institutions (PAHO 2012).<sup>13</sup> It is commonly the immediate social network rather than formal services that serve as a first point of contact for women in

> 13 Among those women who experienced violence from a partner within the past 12 months, one-third (29.3 percent) in Honduras 2005/6 to almost two-thirds (65.5 percent) in El Salvador 2008 sought the help of family or friends. In all countries, the share of those who sought help from any institution was below that, ranging from 8.2 percent in Ecuador 2004 to 36.0 percent in El Salvador 2008. The share of women who reported physical or sexual violence by a partner in the past 12 months and sought any institutional (police, health center, women’s organization, church or religious institution) help varied between countries, ranging from 8.2 percent in Ecuador (2004) to 36 percent in El Salvador (2008). Police was consistently the most common sought-after institution among all the countries in the study.

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violent relationships (Garcia-Moreno et al. 2005, Rose et al. 2000, Counts et al. 1999). Research conducted by Foundation Perseu Abramo in 2010 confirms these findings within the Brazilian context, where helpseeking reaches one-half to two-thirds of domestic violence cases following threats or physical violence, with the majority of women reporting to mothers, sisters and other relatives.

The decision to speak out was usually associated with a “critical moment” marked by escalated violence. This is consistent with findings from the 2005 WHO multi-country study: In all sites, women who had experienced severe physical violence were more likely to report that they had told someone than women who had experienced moderate violence (Garcia- Moreno et al. 2005). More frequent or severe physical or verbal forms of aggression or violence in front of or against children or other family members were some of the key triggers mentioned by participants in this study. A 26-year old woman in Nova Iguaçú reported that escalating and increased frequency of violence informed her decision to reach out for help: “The last three weeks were the most painful ones for me, the ones I was most beaten, the ones I cried the most, and the ones that I really opened my mind to make the decision that I had had it... because it was happening frequently, every day it was happening... We exchanged two words and there was fighting... He simply started to attack me, even in front of my father.” Approximately half of the women interviewed looked for police stations as the first formal support. However, help-seeking from police was not associated with a stated preference for this specific service, but due largely to the fact that most women needed protection in an emergency situation and lacked information on the existence of alternative services. Women generally arrived at regular police stations after police responded to calls from the women themselves or by third parties in emergency situations. Women who had planned ahead to report generally sought out specialized police stations through the indication of family or friends, through her own research or through referrals from the health system in cases where, due to the severity of the aggression suffered, women had to receive medical attention.

Approximately half of the women interviewed sought CIAMs’ services as the first formal support. However, the stories of their arrivals demonstrate the extent of the lack of knowledge on the existence of these services. Many women reported having arrived there because they thought it was a police station, a place where they could walk in and make a formal legal complaint. According to a CIAM coordinator, it is common that the women will come to CIAM "in the heat of the moment" with the desire to take revenge on the perpetrator, but without understanding the consequences of following through with the complaint - both for the offender and for themselves. In this sense, the legal and psychological counseling provided by CIAMs has the important role of providing information and supporting the individual’s decision to report or not report.

# 3.3 **Barriers in the search for support**

Besides external constraints - such as difficulties in accessing service units or the lack of their existence in certain locations - other barriers may prevent women from accessing services as this study will explore. This research considers two main types of support available to women seeking to exit violent situations: informal and formal. The informal support systems consist of family, friends, churches or other personal support systems. Formal support includes regular police stations or specialized ones (DEAMs), CIAMs, Public Defender's Office, the Special Courts of the Public Ministry (MP), among others. Based on this research, barriers to accessing support systems (formal and informal) can be grouped into three types: personal barriers, attitudes of bystanders, and institutional weaknesses. Annex 2 summarizes the specific manifestations among each of these three barriers. Additionally, it attempts to explain the sources of these specific barriers based on the data reviewed as well as literature on the subject matter.

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# 3.3.1 Personal barriers

The following section presents a set of barriers identified in the qualitative data that constitute _personal_ barriers or factors related to women’s motivation to reach out for support and take action when experiencing domestic violence. It is important to note that, while these factors are framed as ‘personal,’ many relate to norms or projections society, communities, families and peers make, and women internalize (Pasinato 2014). The social context in which the interviewees live impacts on how they view themselves and what they understand to be acceptable, desirable and possible behavior. In that sense, the structural context frames the agency these women can exert. Regional studies have found widespread agreement in the Latin America region with norms that reinforce gender inequality, discourage women from seeking help, or downplay the duty of bystanders to intervene in situations of abuse, with wide variations both among and within individual countries (PAHO 2012).<sup>14</sup> This research finds that shame and guilt are the main personal barriers women had to overcome in their search for help. Because they felt shame for what others think of them, of their marriages and of their children, survivors often hid their suffering of violence from friends and family. It was common for survivors to express feelings of guilt for the offender's behavior and for wanting to leave the relationship, in addition to feelings of failure for being unable to change their partner’s behavior. Feelings of shame and self-blame are noted in other studies as barriers to seeking help (Landenburger 1989, Pasinato 2014, Garcia-Moreno et al. 2005, Kishor 1996), particularly because domestic violence strikes at the core of a woman’s social identity as a wife and mother (Ellsberg et al. 2000).

Interviewees who were mothers cited the fear of losing the relationship with their children as a significant barrier to seeking help. Women not only feared being distanced from their children but also, they feared being held responsible for ‘destroying the family’ if they were to separate and/or to take action to protect themselves. Additionally, some noted that their family of origin did not support a potential separation from the abuser. In these cases, losing the connection and bonds to their families created additional disincentives for seeking help (see also Section 3.3.2).

Interviewees described how emotional violence produced and reinforced low self-esteem and feelings of hopelessness and negatively affected their ability to seek help or exit a relationship. Threats of aggressors and verbal attacks -- "you are nothing" or "no one else will want you" – paralyzed survivors. Women feared reporting their experiences or telling others would lead to an escalation of violence or retaliation.

Women exposed to emotional violence reported not believing in themselves, in their capabilities and their ability to take action to change their lives by themselves. Narratives presented by interviewees are consistent with dynamics described by international research, which links physical abuse with the abuse of power and control over a woman’s daily life, including her social contacts and financial autonomy. This body of research acknowledges that domestic violence creates feelings of shame, fear, isolation,

> 14 For example, the share of women who agreed that a wife should obey her husband even if she disagreed with him ranged from just over one-fourth of women in urban Paraguay 2008 to nearly three-fourths of women in rural Guatemala 2008/9. Findings from a 2005 WHO study demonstrate the remarkable degree to which women in some settings have internalized social norms that justify abuse.  Similar to the surveys analyzed for PAHO 2012, the share of women who agreed with statements justifying wife-beating was higher among women who had experienced abuse than among those who had not, and may indicate either that women experiencing violence learn to “accept” or rationalize this abuse, or that women are at greater risk of violence in communities where a substantial proportion of individuals accept and tolerate abuse (Garcia-Moreno et al. 2005).

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entrapment, lowered self-esteem, loss of autonomy and diminished functional capacity (Smith et al. 1995, Counts et al. 1992, Landenburger 1989, Kirkwood 1992, Walker 1994, Ellsberg et al. 2000).

Dependence on abusers created powerful disincentives for women to act or reach out to any form of support. This dependence was often both economic and emotional, and reinforced by the fact that abusers had cut women off from their networks and support, isolating them from options external to the relationship – way before the escalation of violence. This behavior is in line with the findings of GarciaMoreno et al. (2005) that show that violent partners often keep women isolated from potential sources of help. Many women had never had financial autonomy and had difficulty envisioning their ability to provide for themselves and children. In these cases, women chose to remain in violent relationships for lack of choice.

Women’s hope that the violent partner would change also created personal barriers to help-seeking. Women described cyclical patterns of abuse – violence followed with contrition – making it difficult for them to leave relationships of emotional dependence.<sup>15</sup> In Manguinhos, one woman, age 38, described this cycle: “I was without him for a period, right? But then he asked me back, he said he wouldn’t do anything bad to me, he came here, cried, and I believed it. In the first week, it was great, then he started to get worse and worse.” Risks associated with the exit of a relationship led women to “try again” with the hope that the partner’s violent behavior will cease.

# 3.3.2 Barriers created by bystanders

People to whom women have a close relation play a critical role in facilitating or discouraging access to formal support services. Data from Brazil shows that women who seek help are much more likely to do so from family and friends than from formal institutions. Research from Foundation Perseu Abramo (2010) shows that help-seeking reaches one-half to two-thirds of domestic violence cases following threats or physical violence, with the majority of women reporting to mothers, sisters and other relatives. Of the 20 dimensions of violence investigated, mothers are the primary source of help-seeking in all but 4 dimensions.<sup>16</sup> Social norms suggesting toleration of abusive relationships and, more generally, relegating the phenomenon of domestic violence and its response to the private sphere are still quite prevalent in Brazil as in several other contexts. These norms play a significant role in constraining survivors in their search for support and in their effective access to services (Perova et al. 2013). Research by IPEA (2014) investigating perceptions related to VAW in Brazil finds that 42.7 percent of respondents agreed completely with the phrase “A woman that is battered by her partner continues in the relationships because she likes to be beaten,” and 22.4 percent of respondents partially agreed with the phrase. Furthermore, a common saying in Brazil - _“Em briga de marido e mulher – ninguém mete a colher”_<sup>17</sup> – reflects attitudes and behaviors defined by social norms that may influence family and peers within a survivor’s informal support network: namely, that conflict between men and women, especially between spouses, is private, and outsiders should not interfere. These findings are also consistent with population-based survey data from other Latin American countries, which find that substantial proportions of women did not agree that

> 15 Landenburger (1989) argues that women who have become entrapped in abusive relationships go through a four-stage recovery process, which includes periods of denial, self-blame, and endurance before they are able to recognize the abuse and identify with women in similar situations.

> 16 The research examines 20 dimensions of violence within the following categories: controlling behaviors, physical violence and threats, psychological and verbal abuse, sexual violence and harassment.

> 17 Literal translation: “In a husband and woman fight, no one sticks in a spoon.”

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outsiders should intervene to help a woman who was being abused by her husband or that family problems should be discussed with those outside the family.<sup>18</sup> In the context of this research, many women described how family and friends hindered their intention to seek help and tried to convince women to endure the abusive relationship. Women were encouraged to accept abusive behavior from their partners through a variety of arguments. One group of women stated that family members encouraged them to be more ‘understanding’ and suggested the behavior of the abuser was related to a health condition. "You're exaggerating," "It is not that bad, leave it there," were other commonly quoted family reactions. In Queimados, a 26-year old woman reported: “His family, his sister, they’ve always said, ‘Oh, he doesn’t beat you, like, leaving bruises, so you will see, this will pass.’ When I went crying to her, she discouraged me [from seeking help].” Other women experienced blame from family members: "You knew he was like that" or "You must have done something for him to have acted that way". Many women reported that blaming often came from their mothers and children. In Nova Iguaçú, a woman reported: “[The kids said] ’Mom, no wonder [this is happening], you don’t give attention to my dad’... I mean, a woman is attacked, humiliated, and still has to be available for the man.” Interviewees also lamented the fact that their decision to leave the relationship or to seek help would result in the loss of family support. A woman in Manguinhos (age 38) reported that her mother, also a victim of domestic violence, told her: “Bad with your father, worse without your father.” Some feared their family would reject them completely, leaving them lonely and isolated. Several women referred to potential alienation from their children in this context: even though the children had witnessed their father’s aggression, some still opposed the mother’s desire to separate from her husband or reach out for help. This resistance stemmed from the children’s wish for a “complete” family and created pressure for the women to remain in a situation of violence. These pressures from children intensified feelings of survivors’ guilt for attempting exit of the relationship and placed additional responsibility on the survivor to endure violence for the sake of the family.

In addition to family and friends, members of religious communities can be central players in women’s informal support networks and influence their decision to seek help. Religious beliefs can create powerful and complex systems of meanings, symbols and behaviors in communities (Stump 2008), especially with regard to gender roles (King 1995). Several participants in this study reported barriers to help-seeking that emerged either from direct interactions with religious leaders or from their personal interpretation of religious teachings. In one case, a woman in Nova Iguaçú sought counsel from a priest about verbal abuse from her husband. The woman was discouraged from leaving the relationship because it was her “duty” before God to fulfill a marriage vow that included “good times and bad.” Two other women reported remaining in violent relationships because they believed they were paying penance or "something done in other lives." Not all interactions with clergy cited in interviews were discouraging of help-seeking. However, one woman found encouragement and support in her (female) pastor to leave the abuser and start a new life free from violence (See Section 4.4.1).

> 18 The share of women who agreed with norms about family privacy and the duty of outsiders to not intervene if a man abuses his wife ranged from 64.1 percent (Jamaica 2008/09) to 91.2 percent in El Salvador (2008) (PAHO, 2012).  It is important to note that these restrictive social norms contribute to the acceptance of abusive behavior and the naturalization of violence suffered.

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# 3.3.3 Institutional barriers

This section explores the barriers that women faced as they considered or pursued help from formal institutions. Several types of barriers were described by research participants, which include: fear of retaliation from abusers, distrust in the effectiveness of the justice and police systems, negative experiences in reporting domestic violence to protective services, lack of information about services available, inefficient transition between services for survivors, and cost/distance of travel. Institutional failures (both real and perceived) compounded other risks and costs associated with a survivor’s search for help and created additional barriers for the women interviewed.

# _Fear of Retaliation_

The most common factor preventing women from reaching out to formal services or support was fear of retaliation by the abuser. This reflects at the same time the lack of trust women survivors may have in the system’s ability to effectively guarantee their confidentiality, protection and safety. As described earlier, women in situations of domestic violence are usually closely supervised by the attackers. Thus, seeking help from formal institutions involves a risk of being seen, having their activity revealed to the aggressor and suffering retaliation.<sup>19</sup> A 38-year-old woman from Manguinhos recalls how seeking help for the first time made her suffer more at the hands of her aggressor: “When he knew that I had come the first time, he went on to lock me up (in the house) ... I did not return again for a long time.” Findings from this research also show that when a survivor lives in a community context with low levels of anonymity or with service centers that are very exposed in the community, the risk of retaliation increases. In areas dominated by drug trafficking, women also reported fear of reprisals from traffickers, due to the fact that reporting domestic violence or accessing services could attract police activity into their communities.

# _Distrust of Judiciary and Police_

Another significant barrier to help-seeking was lack of trust in the judiciary and police. Participants in this research described the process of reporting and adjudicating crimes as costly and risky – physically, emotionally and financially. In both cases, survivors lack the necessary trust in the justice and the police system to act quickly and effectively enough to guarantee their safety and adequately protect them. Women communicated doubt that the justice system would actually punish perpetrators; and many perceived that the judicial process would be too lengthy. Women expressed serious concerns for safety, especially to the period between filing a complaint and conviction of a crime. One woman described her concerns this way: “Will my words before the judge be stronger than his words? A man talking to another man? And then, I’ll have to go back to that house and keep living with this man from that time on? The game would turn, but it would not turn in my favor, it would turn against me.” Another asserted, “women would die [waiting for the investigation after reporting] and only after that the man will be arrested.” Without a guarantee of safety, women who reported abusers acknowledged high emotional costs,

> 19 In DataSenado’s 2017 survey, an overwhelming 71 percent of respondents cite “fear of the aggressor” as the primary reason women do not report domestic violence. Fear of aggressor was by far the most important reason for not reporting domestic violence, according to survey participants. Other reasons included: concerns for raising children (32 percent), financial dependence on aggressor (29 percent), lack of punishment (25 percent), and shame (20 percent). Avon (2011) finds “fear of being killed” as the third most important reason why women continue in abusive relationships (after financial dependence and concerns for welfare of children). According to research by Patricia Galvao Institute, 85 percent of people feel that women who report their partners or ex-partners when beaten are at greater risk of being killed (2013); and 92 percent believe that when assaults occur frequently, the risk of death from domestic violence may be imminent (2016).

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including living in a constant state of alert due to fear of retribution and further physical and emotional harm.

Women interviewed also expressed serious concern that police and/or the judiciary would not believe their reports. These perceptions appear to be rooted in low self-esteem, perpetrators’ expectation of impunity, and discouraging attitudes of informal networks, but also in women’s own negative experiences in reporting violence. Together, perceptions of inadequate response from law enforcement and justice services contribute to women’s considerations that their actions to report violence will be in vain. Abusers also reinforce these fears: “He used to say, ‘there is no point in going anywhere for help because the judicial system doesn’t lead anywhere. You have to do what I want and that is it . . . the Maria da Penha Law is there, but there is no point. When we want to do something, we will do it and that is it. We may get arrested, but soon we come out.’ And it’s true.” While many women had contemplated denouncing their abusers, and some had already registered complaints, only a few proceeded with legal processes because of their negative perceptions, experiences and the risks associated with punitive action.

Several women described experiences in police stations that reinforced feelings of humiliation, guilt and shame. Many commented that, as they arrived to file a complaint, they were received by male police officers who did not treat them respectfully and minimized the seriousness of their cases. In one case, a male police officer discouraged the woman from reporting the crimes of her abuser, stating that she "should not leave her husband because he was sick." A woman in Nova Iguaçú reported, “They say I'm crazy and that I am old. They said I threw myself on the floor on purpose.” Rude, demeaning treatment and long service times left women feeling humiliated and frustrated.

Women who sought help in women’s police stations (DEAMs) generally had more favorable experiences, except for one stand-out case. In most cases, women reported that police in the DEAMs attended them and listened calmly and explained the ways they could continue the process. Negative experiences of women seeking justice services serve as powerful reminders of the need for consistent and repetitive training of police personnel, even within specialized services. For example, one woman recounted an exchange with the officer in the DEAM in Nova Iguaçú: “He said he would kill me, and I went [to the DEAM]. When I arrived at the police station willing to report there was a policeman who said, ‘Does he drink?’ I said, ‘He does.’ ‘Does he have a firearm?’ ‘No.’ ‘Ma’am, can’t you see that this man needs help? This man needs to be forwarded to Alcoholics Anonymous, not that you file a report against him.’ This was in the women’s police station! I was already humiliated, I felt even more humiliated and left without reporting the case. I never returned but it is still something that stays with me because I think the women’s police station should only have women – it shouldn’t have men.” Data from Brazil show public perception of the effectiveness of Maria da Penha Act in protecting women against domestic and family violence: 26 percent believe the law protects women, 56 percent that the law protects only partially, and 20 percent thought that the law did not protect women (DataSenado 2017). Among women who said they had not suffered violence, only 17 percent said that MdP did not protect women; however, among those who reported having been survivors of some form of domestic or family violence, the percentage rose to 29 percent (DataSenado 2017).

# _Lack of Information_

Skepticism of the effectiveness of protective and justice services is compounded by the lack of understanding of the MdP law and other services available to women in situations of violence. Avon (2011) acknowledges information gaps relative to the outcomes of MdP when a victim takes action. In its _19_
survey, 60 percent of respondents believe that the offender, when denounced, will be arrested, but much smaller numbers cite other consequences, such as the opening of an investigation, trial, or special protection of women. The research also notes that other penalties imposed by the law are little known,<sup>20</sup> and the authors argue for wider dissemination of the various forms of enforcement of MdP.

The lack of information about psychological support services also emerged as a significant information gap for women survivors. Nearly all research participants noted that, prior to accessing any service related to VAW, they had no knowledge of psychological support for survivors provided by the CIAMs. A 26year old woman in Queimados said, “People know the Maria da Penha Law, but they don’t really know how it works. When you call the 180 hotline, they take information about your case, but they don’t give you broader information about psychological support services, only about regular and specialized police stations . . . sometimes the staff at police stations don’t even know that this place [CIAM] exists.” Another lamented, “Nobody knows about this, nobody... If I had known what it was, the CIAM, I would have come earlier. For me, this was a bad thing, like a mental institution, or they were going to arrest me, you know? I thought that.” Many women reported arriving at CIAMs by mistake, having confused it with justice services (DEAMs). Those women who did report knowledge of specialized services were not aware of the details, functioning or eligibility requirements to access these services. Interviews suggest that women with higher income and education seem to have greater access to information relative to domestic violence services through TV and the internet.

# _Insufficient Coordination between Services_

Another barrier to women’s access to services is the failure of institutions to refer women to complementary services. Theoretically, the service network is structured to enable women to access a comprehensive menu of services, but interview participants reported institutional failures in forwarding mechanisms did not function optimally. Although most interview participants had, at some point, visited police stations, only three were referred directly to CIAMs from other institutions (one from a police station, two from hospitals) in order to receive additional services. Women reported that service providers and police were not properly informed and, at times, gave conflicting recommendations. One woman described her experience like this: “From there [the DEAM Police Station]...I started looking for ways to put the protective order in place...the path at the moment is not clear... each person informs you something different. Because you call 180 [to report], they take all the information, record your case, but they don’t give you any further guidance.” Women reported having to "run after everything" to get information and "make the process advance,” and felt burdened by telling their stories to each service provider. These experiences add time, financial and emotional costs of accessing the service network. On the other hand, the successful referrals speak to the catalyzing importance of well-educated civil and health staff to facilitate access to a wide range of services (legal, protective, psychosocial, economic, etc.) available to women living in situations of violence.

# _Mobility_

Finally, women’s lack of mobility was noted as an important barrier to women’s access to services. Women in situations of violence may have their freedom curtailed by the aggressors and cannot leave the

> 20 Other penalties, including restraining orders, mandatory community service, reeducation, or fines, were infrequently cited as consequences for MdP violation.

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house. In other cases, women may not have the financial autonomy to afford the cost of travel or emotional autonomy to move alone. A 62-year old woman from Centro depended on her father to take her because she was not familiar with public transportation or with the city center.

# 3.4 **Facilitators in the search for formal support**

The following section presents a set of facilitators identified in the qualitative data that support women living in situations of violence to overcome personal and external barriers and seek help. It will explore how both informal institutions – family, friends and religious institutions – and formal institutions facilitate women’s help-seeking behaviors in Brazil within the context of this research.

3.4.1 Support from family, friends and community – Informal institutions Data from Brazil points to an increasing mobilization of society to support the victims of aggression. DataSenado’s 2017 national survey on domestic and family violence against women found that 90 percent of those interviewed would report a witnessed act of aggression against a woman. Recent research from Research Institute Avon (2016)<sup>21</sup> explores the role of men in the deconstructing of “ _machismo_ ,” finds that the majority of respondents recognize and reject inequality between men and women, 79 percent believe that machismo is something negative in Brazilian society, and 84 percent believe that all should fight for a world that is less “ _machista._ ” Importantly, the research also finds that 34 percent of men recently ceased to practice some sexist behavior.<sup>22</sup> While the study does not identify the drivers of attitude and behavioral change relative to VAW in Brazil, a growing body of global research has documented and analyzed the effectiveness of prevention programs targeting men, women and communities to reduce VAW in the midto long-term (see Alexander-Scott, Banjeree et al. 2017, Bell and Holden 2016, Cares et al. 2014, Ellsberg et al. 2015, Jewkes et al. 2015, Promundo 2012, UN Women 2015b, Verma et al. 2008).<sup>23</sup> International research finds that women who report that they have support from family and friends have been found to cope more successfully with violence and suffer less with regards to their mental health (Coker et al. 2002, Ellsberg et al. 2000). In the context of this research, women reported that family and friends helped them realize the seriousness of the situation and urged survivors to exit the violent relationship or seek institutional support. A 26-year old woman in Nova Iguaçú remembered encouragement she received from family: “My family always said, ‘Get out of his life because this man will kill you from the inside.” Another woman in the same center reported that the local school principal called her and informed her about the CIAM after her daughter told her classmates about a violent incident involving a knife. Yet another mentioned a local pastor who told her, “’This boy is pushing you away from your freedom . . . you are becoming blind – you like to dance, you like to be active, you like to talk to everybody. Now you are very quiet, you are very introspective...you are not coming around here that often anymore.’ Here is someone I regret not having listened to.” With the security that she will not be

> 21 After completing six in-depth interviews with experts from public agencies, the press and civil society organizations, the Institute held single-sex discussions with men and women aged 16 to 30 years in São Paulo.  These foundational conversations led to the national quantitative instrument, conducted face-to-face with 1,800 participants aged 16 and over in 70 municipalities across five regions of Brazil. Research was completed between September and November 2016.

> 22 These behaviors include: criticism of women who wear short or low-cut clothing, catcalling, saying a woman was promoted because of appearance or because of relations with superior, sharing nude photos of women without their consent, use of terms “slut” or “piranha” to describe women, use of violence (physical or verbal) to win argument with a woman, be aggressive with women to whom they are related, to try to take advantage of an intoxicated woman.

> 23 Approaches studied range from large-scale communications campaigns and “edutainment” series, to economic empowerment and asset ownership programs for women, to community mobilization or group education efforts to promote behavioral change specifically among men and boys and educate bystanders on response to VAW.

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alone and helpless emotionally and financially, women felt safer to leave the relationship and bear the risks and costs of the breakup.

# 3.4.2 Physical presence of formal institutions

**In addition to the encouragement and support of family and friends, the physical presence of formal institutions providing services for women in situations of violence is critically important to their access** .  Several women interviewed in this research accessed CIAMs after being exposed to them as a part of their daily lives.  Physical structures where survivors can receive services can serve as powerful and consistent reminders that help is available to them.  Many women reported passing service centers, during walks through their community, on visits to family, or during commutes to and from work. Knowing their existence and location enabled them, during a moment of crisis, to enter and inquire for help. A 54-year old woman in Queimados remembered passing the CIAM with her children: “I said any day I would enter here. I resisted two times . . . one time he said to me, ‘you are incompetent as a mother.’ This was the key word for me to look for the CIAM. It was the drop in the bucket.”

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3.4.3 Comprehensive support services – Initial steps to the empowerment of women living in situations of violence Findings from this research show the immense benefits of comprehensive psycho-social and other support services provided by the CIAMs to women living in situations of violence. Not only are those shown to beneficial for survivors’ well-being, but they seem to be an essential first step towards women’s escaping situations of violence. CIAMs provide several of the common elements identified by the WHO’s RESPECT framework as critical to prevent violence against women, including: 1) addressing unequal gender power relations; 2) using participatory approaches to enable women to critically reflect on power and to strengthen their agency; and 3) and facilitation of women’s access to a variety of services across organizations and sectors (WHO 2019).

In general, women reported very positive effects of their attendance at CIAMs. Women considered the services they received in these facilities – psychological support, legal support, academic and job training, and participation in reflection groups – as key to their empowerment and their effectively breaking cycles of violence in their lives.

Notably, of the services provided by CIAMs, women emphasized the role of reflection groups as the most important and impactful service in which they participated. They noted that access to women’s groups not only increased awareness of their rights but provided relationships and encouragement from other women facing similar life situations. Together, women were able to challenge social norms governing their lives and actions, rebuilt social networks, and increased their self-esteem.

These findings echo qualitative work carried out by Perova et al. (2013) in Brazil, which has shown that interactions with others (particularly women who had experienced similar situations) was instrumental for women in deciding to break the cycle of violence and to take practical steps to achieve this goal. Likewise, Landenburger (1989) frames recovery from abusive relationships as a four-stage process that includes periods of denial, self-blame, and endurance before women are able to recognize abuse and identify with others who have suffered similarly. It is only at this point, he argues, that women begin the process of disengagement and recovery from the abusive relationship.

The qualitative data from this research show that exposure to the psycho-social support received plays a critical role for women in the “detangling” of shame, fear and isolation that have been a result of physical, psychological and sexual abuse they have suffered. Women participating in this research considered CIAMs fundamental to their perceptions of the violence they have suffered. Many remarked how they came to the CIAM because of one particular kind of violence, but through the course of their time receiving services and participating in groups, they began to understand the various forms of violence they had experienced throughout their lives. As in Landenburger’s theory (1989), they were able to begin to recognize abuse as abuse, build relationships with other women in similar situations, and begin moving forward with their lives. A woman interviewed in the CIAM Centro described the catalyst effect reflection groups had for her: “Where you most talk, where people most share, where you cry and actually let things go, where you discover things, is in the [reflective] group.” In addition to providing space for women to begin a process of recovery, CIAMS also provided them with practical help to enable them to become financially independent. Some women attended academic courses _23_
and others sought job placement services. With each step, women cited increased self-esteem and pride in their autonomy over their own lives and within their families.

It is important to note, however, that increased self-esteem and autonomy that came through their involvement in the CIAMs did not necessarily result in the women in this study filing formal legal complaints against their abusers. Nearly all women interviewed had not reported (and did not during the course of the study) the case of violence against them. Women interviewed as a part of this study noted that their motives for accessing judicial staff and police was to get advice with respect to their rights and about bureaucratic procedures involved in filing a case under MdP, information they lacked in order to make an informed decision. Women also reported reaching out to police because they needed counsel and emotional support, not necessarily because they wanted to file a complaint. The CIAMs fill a critical gap for women living in situations of violence as they process the violence they are experiencing, learn about their rights and options, and make informed decisions about their next steps. A 63-year-old woman from Nova Iguaçu pondered about the empowering effect of knowing her rights and options: “What has changed with the CIAM? Today, I am a very different person...I have more tranquility to view the situation that I’ve experienced... Before I thought I had no way out, I had to put up with this because I had no choice... Today, I know I have a choice. I have not acted upon it yet, but I know I can take a stand, that I have the law on my side." Survivors perceive CIAMs’ services as foundational for allowing them to use other services available to their best interests. The exposure to CIAMs provides them with the strength and emotional stability needed to pursue justice and possibly exit abusive relationships and so responding directly to what was referred to earlier as ‘personal barriers.’ The support provided by other women in similar situations and the personal contact with social workers or counselors who listen to their stories without judgment can also function as a replacement of other ‘bystanders’ in survivors’ lives who may not have been supportive. Moreover, CIAMs also offer the potential to counter some of the institutional weaknesses identified in this research, such as a more effective referral system to other branches of the specialized support system to survivors and the provision of information about rights and services available under the MdP Law.

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# **4. Discussion and conclusion**

This paper fills knowledge gaps relative to the low uptake of services for women living in situations of violence despite comprehensive legal frameworks, exploring more in-depth a case study in Brazil, through the analysis of personal experiences of women survivors of VAW in the State of Rio de Janeiro and the identification of barriers and facilitators towards effective support.

Across all dimensions studied through this research, many findings echo those of international research on VAW. First, reinforcing and overlapping forms of violence – psychological, physical, economic and sexual – result in significant personal barriers for women to seek help, including shame, low self-esteem, loss of autonomy and fear. Survivors pass through various stages before they are ready and able to take action to overcome it, and this process often happens while a woman is still living with or continues in a relationship with her abuser. Second, women’s personal constraints – compounded by social norms that are acceptive of violence, promote female submissiveness, and exalt the preservation of “family” – can be further reinforced by negative responses from family and friends, whom they often turn to first before seeking help from formal institutions. On the contrary, bystanders can also be powerful catalysts by helping women acknowledge the effect of violence on their lives or providing them information about specialized services. Finally, institutional weaknesses (both real and perceived) create barriers to women seeking help outside their immediate social networks. Distrust in police and judicial response to VAW, grounded in fear of inadequate protection in the case of reporting violence and fear of reprisals from abusers, discourage women from pursuing help. Nevertheless, the physical presence of institutions providing VAW services within communities serves as a powerful and consistent reminder to women that help is available to them.

Several findings specific to the Brazilian urban context also emerge in this research. Notably, the dearth of information about the variety of VAW services available in Brazil affects women’s ability to make informed decisions about when, where and how they will seek help. Women still lack basic information about how the MdP law functions in practice, and are largely unaware of non-punitive network services, such as CIAMs, which support their psychological and physical health and economic empowerment needs. Next, women living in neighborhoods controlled by gangs or drug traffickers face additional constraints to accessing services – namely, the fear of violent reprisal for attracting police activity into their communities. Next, mobility constraints limit survivors’ ability to access services due to the control of abusers over their daily activities and lack of economic autonomy. Finally, women may prioritize support services that enable them to rebuild their lives, and measures that contribute to their self-esteem, emotional and financial autonomy are considered transformative for female survivors. The women interviewed consider CIAMs an integral part of this process and that play a critical role in ensuring survivors’ wellbeing and supporting them in understanding the process and consequences of reporting so that they can make informed decisions to safely exit abusive relationships and re-establish their lives.

One important measure for policy consideration (see Annex 2 for a summary of findings and recommendations) emerging from this research relates to ensuring that women (and those in relationship to them) understand the entire range of services – from justice to health to psychosocial and economic empowerment – so that women can be empowered to access services according to their own priorities and needs. This could entail the promotion and publicizing of _25_
CIAMs, and the psychosocial and economic empowerment activities they provide (including linking women to vocational courses and job search support), which remain largely unknown to women prior to entering CIAMs. Having more survivors access and benefit from CIAM services could help them reduce those challenges identified earlier as personal barriers – shame and fear, among others – that women experience in deciding whether or not to report the violence they suffer and regain their agency, considered a precondition to help seeking.

Another measure towards more effective protection of survivors relates to the quality of services provided at several entry-points into the specialized and non-specialized service network. Adequate training and resources of specialized (and non-specialized) staff are important to avoid negative experiences of women who seek help from public institutions. Furthermore, the improved integration of services through more efficient forwarding mechanisms and consistent information sharing is another step towards more effective protection and support. No matter which public institution they decide to access first – police, judiciary, hospitals or health centers, etc. – survivors of domestic violence should receive consistent information about specialized social and justice services available to them.

A final consideration to strengthen the VAW framework and policies relates to the role of citizens as bystanders as catalysts for action on behalf of female survivors **.** By framing VAW as a societal problem, in which friends and family are key players to a woman’s successful recovery from domestic violence, social communications can incentivize bystanders to de-naturalize violence, support survivors and ensure they have information about services available to them. Additional research to explore perpetrators’ perceptions and attitudes regarding VAW and impact studies on male-only interventions aimed to raise men’s awareness on VAW and change behavior would fill vital knowledge gaps, specifically in the Brazilian context. In addition, multi-sectoral engagement around the de-naturalization of violence against women would also be needed to reduce violence acceptance and tolerance among the general population. Communication strategies that deconstruct social norms that favor VAW and build new norms promoting more equal gender relations can achieve more lasting and structural results, especially when coordinated with other multi-sectoral strategies.

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