Gender-based violence: more research (funding) please
Authors: Zoë Mullan
Journal: The Lancet Global Health (2014)

Around this time 2 years ago, a 23-year-old medical student was raped and beaten by six men on a bus. She later died of her injuries. Earlier this year, two teenage girls were gang-raped and hanged while walking to use a nearby field in lieu of a toilet. Both crimes took place in India, provoking worldwide condemnation of the country's “rape problem”, yet gender-based violence is a pervasive global issue and takes many forms—some insidious; all devastating. A study published in The Lancet earlier this year found that an estimated 7% of women globally have been sexually assaulted by a person who was not their partner. Data from the Asia Pacific region published in this journal show that, in some communities, the figure may reach an astonishing 27%. Most violence against women is perpetrated by partners, however, and estimates indicate that a further 30% of women globally have experienced physical or sexual violence from a partner. Additionally, around 125 million girls and women alive today have been subjected to female genital mutilation, including more than 90% of those living in Egypt, Djibouti, Guinea, and Somalia. Sexual violence also continues to be used as a weapon of war in ongoing conflicts. November 25, International Day to End Violence Against Women, marked the beginning of 16 days of activism against gender-based violence. Activism, such as that induced by the shocking cases above, is essential to changing entrenched notions of women's status and men's entitlements. However, evidence for what interventions actually work at the community or relationship level is still thin on the ground. A paper published last week as part of The Lancet's Series on violence against women summarised existing evidence and concluded that more than 80% of high-quality research had been done in high-income settings, and two-thirds addressed intimate partner violence only. Most studies, particularly those in high-income countries, focused on response rather than prevention, and most only involved women themselves. Such relatively scarce data are partly a reflection of the limited research funding afforded to violence against women. In his message to mark the International Day last year, UN Director-General Ban Ki-Moon lamented that donor commitments to the UN Trust Fund to End Violence against Women had decreased by 60% in recent years, “while the demand for its grants has more than doubled”. Research does continue, however, and two papers published in The Lancet Global Health this month contribute to what is known about the link between HIV and intimate partner violence. Mechanisms are thought to be directly causal in both directions (in that forced sex may increase the risk of HIV transmission through mucosal damage, and that a disclosure of HIV positivity by a woman may induce partner violence) and involve shared risk factors (such as social norms that give men power over women, having concurrent sex partners, alcohol and substance misuse, and low or inconsistent condom use). In their study, Dick Durevall and Annika Lindskog used Demographic and Health Survey data to drill down further into these associations, finding that the determinants of a statistically significant association were the presence of controlling behaviour in men (defined as not allowing their partners to see female friends or family) and a local HIV prevalence of more than 5%. Such details are extremely useful for targeting scarce resources towards interventions with the highest likelihood of success. Jennifer Wagman and colleagues' study in Rakai, Uganda, is one example of such success. The researchers used community activities to address attitudes about the acceptability of violence against women and encourage non-violent methods of conflict resolution, together with activities to encourage better disclosure of HIV results, reduce the number of non-marital sexual partners, reduce alcohol use with sex, and increase consistent use of condoms. The intervention reduced physical and sexual partner violence by about 20% and HIV incidence by about 30%. Although the study was not truly randomised (again, owing to funding limitations), the findings are encouraging. Aside from being a human rights abuse, violence against women is undeniably a health issue: it is associated with HIV and other sexually transmitted infections; it causes disability and mental health disorders; and it can result in unintended pregnancy, with all its consequences. The issue is enormously complex, but only with rigorous research into those complexities and what works to counter them will progress be made. Activism should prompt action: and not least by donors and funding bodies.