Violence against Women
Claudia Garcia-Moreno, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
Heidi Stöckl, Department of Global Health & Development, London School of Hygiene and Tropical Medicine, London, UK
Ó 2017 Elsevier Inc. All rights reserved.
World Health Organization retains copyright in the manuscript and provides Elsevier the permission to publish the manuscript as a chapter in this book.
Introduction
Violence against women is a major public health problem with
serious consequences for women’s health. It is also a grave
violence of women’s human rights. It is pervasive worldwide,
although its prevalence varies between sites, as do the patterns
and forms it takes. Violence against women is an important
risk factor for women’s ill-health, resulting in a wide range
of negative outcomes for women’s health and well-being,
including their sexual and reproductive and their mental
health (García-Moreno and Stöckl, 2009).
Violence against women can take many forms, including
physical, sexual, and emotional abuse by an intimate partner;
rape and sexual assault whether by a partner, acquaintance, or
stranger, or in the context of armed conflict; sexual abuse during
childhood; trafficking for purposes of sex or forced labor; forced
prostitution; female genital mutilation, child marriage, and
other harmful traditional practices; and murders in the name
of honor or related to dowry. Violence against women is also
referred to as gender-based violence (GBV) because it is closely
associated with gender inequality and the social norms that
perpetuate women’s and girls’ subordinate status in society.
This article focuses on intimate partner violence (also
referred to as ‘domestic violence’), and sexual violence,
including during conflict and displacement, because they
are common forms of violence experienced by girls and
women globally and because of their particular impact on
sexual and reproductive health. It also touches on child
sexual abuse, trafficking of women and female genital muti-
lation, both while recognizing that the health consequences
of violence are far-ranging and include, importantly, mental
health problems, injuries, and other physical health prob-
lems, this article focuses on the sexual and reproductive
health aspects.
How Widespread Is Violence against Women?
A growing number of studies worldwide are documenting how
common violence against women is. Over the past decade, the
number of population based studies examining the prevalence
of physical and sexual (fewer studies also include emotional
abuse) intimate partner violence against women has grown
rapidly (Devries et al., 2013). Fewer studies so far have focused
on non-partner sexual violence and other forms of sexual abuse
(Abrahams et al., 2014). Trafficking of women, violence during
conflict and war, and other forms of violence against women
remain understudied and not so well documented (Oram
et al., 2012).
Intimate Partner Violence
In 2013, the World Health Organization, with the London
School of Hygiene and Tropical Medicine and the South
International Encyclopedia of Public Health, 2nd edition, Volume 7
African Medical Research Council published the first global
systematic review and synthesis of existing scientific data on
the prevalence and health effects of intimate partner violence
and non-partner sexual violence (World Health Organization,
2013a). It shows aggregated global and regional prevalence
estimates using population data from all over the world that
have been compiled in a systematic way. Worldwide, almost
one third (30%) of all women who have been in a relationship
have experienced physical and/or sexual violence by their inti-
mate partner (Devries et al., 2013; World Health Organization,
2013a). This study found considerable regional variation in
the prevalence of physical and/or sexual partner violence,
with up to 37% of women reporting violence by an intimate
partner in some regions (Devries et al., 2013; World Health
Organization, 2013a). Details are displayed in Figure 1. In
addition, globally, as many as 38% of all murders of women
are committed by intimate partners (Stöckl et al., 2013; World
Health Organization, 2013a).
A good example for a survey from which the Global Burden
of Disease Study drew its estimates is the World Health Organi-
zation’s (WHO’s) Multi-country Study on women’s health and
domestic violence, which was designed to document the magni-
tude and nature of violence that women experienced, with
a focus on intimate partner violence, with comparable methods
across countries. Over 24 000 women were interviewed in
15 sites in 10 countries: Bangladesh, Brazil, Ethiopia, Japan,
Namibia, Peru, Samoa, Serbia, Thailand, and the United
Republic of Tanzania (comparable data are now also available
from Equatorial Guinea, the Maldives, and New Zealand). The
study found that the lifetime prevalence of physical intimate
partner violence was between 13% and 61%, with most sites
reporting between 23% and 49%. The lifetime prevalence of inti-
mate partner sexual violence was between 6% and 59%. Overall,
between 15% and 71% of women reported physical or sexual
violence, or both, in their lifetime (García-Moreno et al.,
2005). Emotional abuse was also measured, asking about the
presence and frequency of acts such as being insulted or made
to feel bad, belittled, or humiliated in front of others, or threats
to hurt someone you loved. Controlling behaviors were also
measured and included: keeping a woman from seeing her
friends, restricting contact with her family, insisting on knowing
where she is at all times, expected to ask permission to seek
health care, etc. Although there is less agreement about what
constitutes emotional abuse globally, making it hard to deter-
mine its prevalence in a comparable way, women often report
this as a most disempowering and devastating aspect of abuse
by an intimate partner. Controlling behaviors by an intimate
partner in the WHO study were found to be associated with
perpetration of physical and sexual abuse. The study confirmed
that there is wide variation in prevalence both between and
within countries. The difference is particularly striking when
looking at violence in the past year, with women in developing
countries generally having a much higher prevalence.
http://dx.doi.org/10.1016/B978-0-12-803678-5.00483-5 337
338 Violence against Women
Figure 1 Lifetime prevalence of physical and/or sexual intimate partner violence among ever-partnered women by WHO region in 2013.
Intimate Partner Violence during Pregnancy
Partner violence often persists during pregnancy, with negative
consequences for both maternal and infant health. A secondary
analysis of data from the Demographic and Health Surveys (20
surveys from 15 countries) and the International Violence
Against Women Surveys (4 surveys from 4 countries) carried
out between 1998 and 2007 found a prevalence of intimate
partner violence during pregnancy between approximately
2.0% in Australia, Cambodia, Denmark and the Philippines
to 13.5% in Uganda among ever-pregnant, ever-partnered
women. The majority of surveys estimated the prevalence to
be between 3.9% and 8.7% (Devries et al., 2010). In the
WHO Multi-country Study, the prevalence of physical abuse
during pregnancy, among ever pregnant women, ranged from
4% to 12% in most sites (García-Moreno et al., 2005). Abuse
during pregnancy often involves blows to the abdomen, which
may have serious consequences for both the mother and the
infant. Overall, it would appear that this violence is a continu-
ation of ongoing violence, with a small but varying percentage
of women, depending on the site, reporting that this abuse
started during the pregnancy. The evidence suggests that in
some settings, pregnancy may offer protection, with violence
decreasing during this time, while in others violence
may increase (or start) as a result of pregnancy (Stöckl and
Gardner, 2013).
Sexual Violence, Including during Conflict and
Displacement
Sexual violence is a global problem that until recently has
remained hidden. It happens predominantly to women and
girls, but boys and men are also sexually assaulted. The above
mentioned WHO report found that globally, 7% of women
have been sexually assaulted by someone other than a partner
(Abrahams et al., 2014; World Health Organization, 2013a).
Sexual violence includes a range of behaviors, including rape
and attempted rape but also other unwanted sexual behaviors.
Rape is usually defined as the nonconsensual penetration of the
vagina, mouth, or anus by a penis, although legal definitions
may vary. When an object other than the penis is used, the
term assault is usually employed.
There is increasing concern about the violence that women
and children, primarily girls, experience during conflict and
displacement. The nature and size of sexual violence in conflict
remains unknown, as the evidence is still limited. Studies have
been conducted in conflict settings in Africa, Asia, eastern
Europe, and Latin America; however, the estimates of preva-
lence vary widely, ranging from 4–3% in Kosovo to 39–7%
in eastern Democratic Republic of Congo (DRC) (Johnson
et al., 2010; Stark and Ager, 2011). Vu et al. (2014) estimated
the prevalence of sexual violence among female refugees in
complex emergencies as 21% following a systematic review
and meta-analysis. Due to the different definitions and meth-
odologies these studies used, they are not comparable. While
sexual violence during conflict is an important problem, it is
important to understand that women also continue to experi-
ence sexual violence by other perpetrators, including intimate
partners, during conflict. For example, a study in 12 rural
districts of Côte d’Ivoire showed that 33% of women surveyed
reported an experience of sexual violence since the age of
15 years (Hossain et al., 2014). Out of those, 29% reported
their husband or intimate partner, 10% reported someone
other than an intimate partner, and only 0.3% reported an
armed combatant as the perpetrator. A population-based study
from the DRC found similar results, with 35% of women
reporting sexual violence from their intimate partner
and 16% reporting non-partner sexual violence (Peterman
et al., 2011).
 Violence against Women 339

Abductions, sexual servitude, and violent rape by armed
actors have also been reported. In situations of conflict and
displacement, women may be exposed to rape and sexual
abuse during the flight, on arrival, and in camps, and after
the conflict due to increased societal disruption and presence
of weapons. Services are difficult to find in these situations,
making things even more difficult, and women may be forced
to trade sex for food, money, or safety.
Child Sexual Abuse and Forced First Sex
Women and girls are most at risk of sexual violence from
people they know, whether partners or other family members,
boyfriends, neighbors, acquaintances, and less frequently
strangers. Precise estimates are difficult to give since sexual
violence, particularly during childhood, remains a highly stig-
matized and taboo subject in most societies. However, studies
from around the world show that approximately 20% of
women and 5–10% of men report having been sexually abused
as children (World Health Organization and International
Society for Prevention of Child Abuse Neglect (ISPCAN),
2006). In the WHO Multi-country Study the most commonly
reported perpetrators of this were family members, particularly
male family members other than fathers and stepfathers,
although strangers were also an important category (García-
Moreno et al., 2005). Abuse during childhood has been found
to be associated with abuse in later life (Coid et al., 2001;
Fergusson et al., 1997). It is also associated with many
unhealthy outcomes, particularly behavioral and psychological
problems, low self-esteem and depression, and with high,
sexual risk-taking behaviors, such as increased number of
partners and increased use of alcohol and other substances
(Paolucci et al., 2001).
Forced sexual initiation is also a common occurrence. The
WHO Multi-country Study confirmed that a substantial
proportion of young women reported their first experience
of sexual intercourse as coerced or forced, which is consistent
with studies from other countries, such as Uganda (Koenig
et al., 2004) and Ghana (Glover et al., 2003). This was more
likely to be the case the younger the reported age of the first
sexual encounter (Figure 2). Coerced sex has been linked
with lower use of modern contraception and of condom at
last intercourse, more unwanted pregnancies, and more
genital tract symptoms among young girls in Uganda (Koenig
et al., 2004).
Trafficking of Women
This form of violence is hard to document, particularly as it is
an illegal practice, often carried out by bands of organized
crime. Several organizations collect data on human trafficking,
and while there is no agreement on what is the best estimate,
there is agreement that it affects hundreds of thousands of
people, particularly women and children, who are trafficked
across borders in many parts of the world. Initially, trafficking
of women and girls for forced sex work and, to a lesser extent,
domestic servitude, were the sole focus of advocacy and assis-
tance. Today, there is recognition that women, children and

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Figure 2 Percentage of women reporting forced first sexual intercourse by site and by age at the time of first sexual experience. Reproduced from
Garcia-Moreno, C., et al., 2005. WHO Multi-country Study on Women’s Health and Domestic Violence. Initial Results on Prevalence, Health Outcomes
and Women’s Responses. World Health Organization, Geneva.
340 Violence against Women

men are trafficked into many different forms of labor, and for
sexual exploitation. Evidence on health and human trafficking
also remains extremely limited. A systematic review published
in 2012 only identified 16 studies, suggesting a high prevalence
of violence and of mental distress among women and girls traf-
ficked for sexual exploitation (Oram et al., 2012). One of these
studies, for example, a 2006 quantitative study of approxi-
mately 200 trafficked women in Europe found that the
majority of trafficked women reported high levels of physical
or sexual abuse before (59%) and during (95%) their exploita-
tion, and multiple concurrent physical and mental health prob-
lems immediately after their trafficking experience (Hossain
et al., 2010).
Female Genital Mutilation
Other forms of violence against women include harmful prac-
tices such as female genital mutilation (FGM). FGM is a global
concern (WHO, 2008). The WHO estimates that about 100–
140 million women have been subjected to FGM in 28 coun-
tries in Africa as well as among immigrants in Australia, New
Zealand, Canada, Europe, and the United States. It appears
that FGM is also practiced in some countries of Asia especially
among certain populations in India, Indonesia, and Malaysia.
The practice is being reported in the Middle East, particularly
in northern Saudi Arabia, southern Jordan, Iraq, and Yemen.
It has been estimated that approximately 3 million girls are
mutilated each year (Yoder et al., 2004). The prevalence of
FGM varies from country to country, and also varies between
different ethnic groups within each country. The practice is
almost universal in Somali, Guinea, Djibouti, and Egypt with
prevalence levels above 90%, while it affects only 1% of girls
and women in Cameroun and Uganda (UNICEF, 2013).
Most of the women and girls with FGM live in only four coun-
tries: Egypt, Ethiopia, Nigeria, and Sudan (UNICEF, 2013). The
most severe form of FGM, Type III, involves excision of the
labia minora and labia majora and suturing of the vaginal
opening (with only a small opening left for urinating). FGM
procedures are generally carried out under unhygienic condi-
tions, and they commonly result in short- and long-term
complications and sequelae, including during childbirth
(Adam et al., 2010).
The Health Consequences of Violence
Violence against women is associated with a wide range of
negative health outcomes (Campbell, 2002), including death,
injuries, a range of mental health and physical problems, and
adverse effects on sexual and reproductive health (see Figure 3).
The WHO Report on global and regional estimates on violence
against women found that women who have been physically or
sexually abused by their partners report higher rates of
a number of important health problems. For example, they
are 16% more likely to have a low-birth-weight baby. They
are more than twice as likely to have an abortion, almost twice
as likely to experience depression, and, in some regions, are 1.5
times more likely to acquire HIV, as compared to women who
have not experienced partner violence (World Health Organi-
zation, 2013a). The report also found that 42% of women
who have experienced intimate partner violence have suffered
injuries as a result (World Health Organization, 2013a).
The sexual and reproductive health consequences include:
unwanted pregnancies and STIs, including HIV/AIDS, gyneco-
logical problems, and abortion (Jewkes et al., 2006; Pallitto
et al., 2013; Sharps et al., 2007). Vesico-vaginal and rectal
fistulas can also result from violent rape, and this is particularly
common in some conflict settings. There are both direct and
indirect pathways leading to sexual and reproductive ill health.
Rape, including by partners, and sexual assault, for example,
can directly result in unwanted pregnancies, abortions, and
STIs, including HIV. In addition, violence and fear of violence
make it difficult to use contraception and to negotiate condom
use and safe sex, thereby also leading to unwanted pregnancy
and STIs. Sexual abuse during childhood has been associated

Partner abuse
Sexual assault
Child sexual abuse

Fatal outcomes Nonfatal outcomes

Homicide
Suicide
Maternal mortality
AIDS related

Negative health behaviors Reproductive health
Smoking Unwanted pregnancy
Alcohol and drug abuse STIs/HIV
Sexual risk-taking Gynecological disorders
Physical inactivity Unsafe abortion
Overeating Pregnancy complications
Miscarriage/low birth weight
Pelvic inflammatory disease
Physical health Chronic conditions Mental health
Injury Chronic pain syndromes Post traumatic stress
Functional impairment Irritable bowel sydrome Depression
Physical symptoms Gastrointestinal disorders Anxiety
Poor subjective health Somatic complaints Phobias/panic disorder
Permanent disability Fibromyalgia Eating disorders
Severe obesity Sexual dysfunction
Low self-esteem
Substance abuse

Figure 3 Health outcomes found to be associated with violence against women. Reproduced from Heise, L., et al., 1999. Ending violence against
women. In: Population Reports Series L, No 11. Johns Hopkins University, School of Public Health, Baltimore, MD.

with high-risk sexual behavior during adolescence and later in
life, including an increased number of partners and early and
unprotected sex, and use of alcohol and drugs – all factors
that are associated with a higher risk of HIV infection. Violence
against women is associated with HIV and AIDS in a variety of
ways. Violence by an intimate partner and fear of violence affect
the opportunities for women to protect themselves and to
request safer sex practices including condom use, and can
also act as a barrier to HIV testing. Rape by an infected person
can be responsible for HIV transmission or lead to other STIs
and tears and lacerations, which increase the likelihood of
HIV infection. Violence also interferes with women’s ability
to access care and treatment. Lastly, violence can be an outcome
of taking an HIV test and of disclosure of a positive serostatus
(Dunkle et al., 2004; Maman et al., 2000). Intimate partner
abuse often persists during pregnancy (although, as stated
previously, for some women this may be a protected time
during which the violence is reduced). Abuse during pregnancy
has been associated with premature delivery, second and third
trimester bleeding, risk behaviors such as smoking and
substance abuse during pregnancy, and late entry into prenatal
care. It is also associated with low birth weight and prematurity.
Violence against women also impacts on women’s mental
health, in particular it has been associated with depression,
post-traumatic stress disorder and other anxiety disorders,
sleeping and eating disorders, alcohol use (García-Moreno
and Riecher-Rössler, 2013). Women who experience sexual
violence and intimate partner often carry a burden of shame
and guilt and may experience stigma and rejection from family,
or other community members.
FGM, particularly the more severe form, is associated with
recurrent urinary tract infections, dyspareunia (pain during
sexual intercourse), and genital ulcers. A recent study in six
African countries found that compared to women without
FGM, women who had Type III genital mutilation were signif-
icantly more likely to experience cesarean section, postpartum
hemorrhage, and prolonged hospitalization after delivery.
Babies of women with FGM were more likely to require resus-
citation and to be stillborn or suffer neonatal death (Banks
et al., 2006). A systematic review of psychological, social, and
sexual consequences of FGM found that data was of limited
quality, but there was a suggestion that women who had
suffered FGM were more likely to experience pain during inter-
course, reduced sexual satisfaction and reduced sexual desire
(Berg et al., 2010).
Responding to Violence against Women
Preventing violence from occurring in the first place (i.e.,
primary prevention) is a public health priority, and the health
sector can play an important role in gathering evidence and
advocating for this. However, early childhood interventions,
community-based and school-based, media, and other
approaches to challenge social norms and promote behavior
change among men may be better suited for this (Figure 3).
Health-care services, particularly for sexual and reproductive
health, have an important role to play in secondary and tertiary
prevention by identifying women who are suffering intimate
partner violence as early as possible and contributing to
Violence against Women 341
prevent its recurrence and mitigate its effects on women’s
health (and lives) and that of their children. Most women
come into contact with sexual and reproductive health services
at some point in their lives, either for family planning, child-
birth, post abortion care, antenatal care, or postpartum care,
and these contacts provide an opportunity for early identifica-
tion and referral.
These opportunities are, however, often lost because of
health providers’ lack of training, lack of time, and fear of
offending women, among other constraints. Wijma et al.
(2003), for example, documented that despite the high preva-
lence of physical, sexual, and emotional abuse among women
attending gynecological clinics in five Nordic countries, most
victims of abuse were not identified by their gynecologists.
This may mean that abused women do not get the care they
need. Since violence affects both women’s health and the rele-
vance and effectiveness of the care received, it is important that
health-care providers understand and identify the problem as
they may knowingly or unknowingly impair women’s ability
to deal with this violence, offer inappropriate care, or put
women at risk. The World Health Organization recently pub-
lished new guidelines on the health sector response to intimate
partner violence and sexual violence against women. The
guidelines stress that health care providers are in a unique posi-
tion to address the health and psychological needs of women
who have experienced violence, provided that certain require-
ments are met: the health care provider is trained, standard
operating procedures are in place, consultation takes place in
a private setting, confidentiality is guaranteed, a referral system
is in place to ensure that the woman has access to related
services, the healthcare setting is equipped to provide a compre-
hensive response, addressing both mental and physical conse-
quences and health care providers can gather forensic evidence
if needed (World Health Organization, 2013b).
More needs to be done to educate physicians, nurses,
midwives, and other primary health-care providers on gender
equality and equity issues and on violence, whether this is
a focus of their work or not. The most promising approaches
in this regard are those that use a systems approach that goes
beyond training individual providers. Profamilia, the family
planning association in the Dominican Republic, provides an
example of such an approach, in which attention to
gender-based violence was systematically integrated
throughout all of the organization’s services and at all levels
(Population Council, 2006).
Typically, these programs address all elements of care
including both clinical and psychosocial support and establish
partnerships with nongovernmental organizations or other
service providers to ensure referral to other support is possible.
Others have attempted to provide all types of service in one
location, usually in a hospital setting, as is the case with the
One Stop Centers in Malaysia now spreading to many other
countries (Colombini et al., 2011).
Programs need to be adapted to the specific context and
the realities of health systems in different parts of the world.
Everywhere, sexual and reproductive health-care providers
must rise to the challenge of responding to women’s needs.
Recognizing how common violence against women is and
its impact on women’s health and lives is an important
first step.
342 Violence against Women
Conclusion
Violence against women is an important determinant of
women’s sexual and reproductive health and a public health
concern in all parts of the world. Health providers, particularly
those who care for women, need to understand the nature of
the problem, its dynamics and how it impact on women’s health
and that of their families. They also need to have the knowledge
and skills to respond appropriately so that they can and provide
the care and support that women need, as well as mitigate the
consequences and prevent recurrence of such violence.
See also: Burns and Scalds; Child Abuse/Treatment; Child
Witness to Violence; Disasters and Emergency Planning;
Drowning; Elder Abuse; Falls; Forced Migration and Health;
Gender Aspects of Sexual and Reproductive Health;
Humanitarian Response to Complex Emergencies and Natural
Disasters; Injury Epidemiology; Occupational Injuries and Work
Place Violence; Reproductive Rights; Road Traffic Injuries;
Serial and Mass Murderers; Sexual Violence; Sports Injuries;
Suicide and Self-directed Violence; Terrorism; Violence/
Intentional Injuries – Epidemiology and Overview; Violence/
Intentional Injuries – Prevention and Control; Weapons of Mass
Destruction; Young People and Violence.
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World Health Organization, 2013a. Global and Regional Estimates of Violence against
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Further Reading
Ellsberg, M., 2005. Violence against women and the Millennium Development Goals:
facilitating women’s access to support. Int. J. Gynecol. Obstet. 94, 325–332.
Ellsberg, M., Heise, L., 2005. Researching Violence against Women: A Practical Guide
for Researchers and Activists. PATH/WHO, Washington, DC.
Garcia-Moreno, C., Jansen, H.A.F.M., Ellsberg, M., Heise, L., Watts, C., 2005. Health
Outcomes and Women’s Responses. World Health Organization, Geneva,
Switzerland.
Guedes, A., 2004. Addressing Gender-Based Violence from the Reproductive Health/
HIV Sector. A Literature Review and Analysis. The Population Technical Assistance
Project (POPTECH Publication Number 04–164–020), Washington, DC. http://
www.igwg.org (accessed January 2008).
Ramsay, J., Rivas, C., Feder, G., 2005. Interventions to Reduce Violence and Promote
the Physical and Psychosocial Well-Being of Women Who Experience Partner
Violence: A Systematic Review of Controlled Evaluations. Final Report. Barts and
the London Queen Mary’s School of Dentistry, London.
Violence against Women 343
Spitz, A.M., Goodwin, M.M., Koenig, L., et al., 2000. Special issue: violence and
reproductive health. Matern. Child Health J. 4 (2), 77–154.
United Nations, 2006. Ending Violence against Women. From Words to Action. Study
of the Secretary-General. United Nations, New York.
United Nations, 2006. World Report on Violence and Children. Secretary-General’s
Report. United Nations, New York.
World Health Organization, 2005. Addressing Violence against Women and Achieving
the Millennium Development Goals. WHO, Geneva, Switzerland.
Relevant Websites
http://www.ippfwhr.org/programs/program_gbv_e.asp – International Planned
Parenthood Federation, Western Hemisphere region (IPPF/WHR).
http://www.kunnskapssenteret.no/publikasjoner/_attachment/9602?
_ts¼129270c7367&download¼false – Kunnskapssenteret, n. d.
http://www.rhrc.org – Reproductive Health Response in Conflict Consortium.
http://www.stoprapenow.org – Stop Rape Now, UN Action on Sexual Violence in
Conflict.
http://www.un.org/womenwatch/daw/vaw/SGstudyvaw – UN Division for the
Advancement of Women, Violence against Women.
http://www.who.int/gender – WHO Department of Gender, Women and Health (GWH).
http://www.who.int/violence_injury_prevention – WHO Department of Violence and
Injury Prevention and Disability (VIP).