Scandinavian Journal of Public Health, 2006; 34: 1–4
EDITORIAL
Violence against women: A global public health crisis
MARY C. ELLSBERG
PATH, Washington, DC, USA
Violence against women and girls, once seen as a
relatively rare occurrence, has now gained interna-
tional recognition, not only as serious violation of
human rights, but as a significant public health
concern, as well as a barrier to social and economic
development. Globally, at least one woman in every
three is beaten, raped or otherwise abused during
her lifetime [1]. Most often the violence is com-
mitted by someone close to her, usually an intimate
partner, although violence for the purpose of
commercial exploitation or as a weapon of war has
increased at an alarming rate over the last decade.
Although the specific forms of violence against
women vary among countries, they share common
roots in unequal power relations between men and
women. Therefore, efforts to reduce violence must
be framed in the context of promoting gender equity
and women’s empowerment.
The scope of violence against women
The UN Declaration on the Elimination of All forms
of Violence against Women (1993) identified three
main types of violence against women, also called
gender-based violence, namely: violence in the
family, the general community, and perpetrated or
condoned by states, clarifying that such violence can
take physical, sexual, and psychological forms [2].
This broad definition encompasses such diverse
forms of violence as intimate partner violence, sexual
assault, child sexual abuse, neglect of girl children,
female genital mutilation, trafficking of women and
girls, femicide, and sexual violence in armed conflict
situations. The following is a brief overview of
available data on different forms of GBV.
Correspondence: Mary Carroll Ellsberg, PhD, Senior Advisor, Gender, Violence and Human Rights, PATH, 1800 K St. NW Suite 800, Washington, DC
20006, USA. E-mail: mellsberg@path-dc.org
ISSN 1403-4948 print/ISSN 1651-1905 online/06/010001-4 # 2006 Taylor & Francis
DOI: 10.1080/14034940500494941
Intimate partner violence
This is the most common form of violence against
women, encompassing physical, sexual, psychologi-
cal, or economic violence by a current or former
intimate partner. A review of 70 population-based
studies found a lifetime prevalence of physical
partner violence between 10 and 60 percent [1].
Results from recent studies in Scandinavia fall
somewhere in the middle of this range, with a
reported lifetime prevalence of 18% in Sweden,
27% in Norway and 30% in Finland [3–5]. A
much greater difference can be seen between
industrialized and developing countries with
regard to current (last 12 months) abuse, estimated
at 4% in Sweden, and 6% in Norway, whereas in
many developing countries as many as half of ever-
abused women experienced violence within the
last 12 months prior to the interview. This
probably reflects the greater access that women in
industrialized countries have to support services and,
hence, more opportunities to escape from violent
relationships.
Sexual assault and child sexual abuse
Obtaining accurate figures on the prevalence of
sexual assault by non-partners and child sexual
abuse is particularly difficult because of the stigma
attached to it. A review of 25 studies world-
wide indicates that between 2% and 32% of
women report that they experienced sexual abuse
in childhood [6]. Although both girls and boys can
be victims of sexual abuse, most studies report that
the prevalence of abuse among girls is at least 1.5 to
3 times that among boys [7].
2 M. C. Ellsberg
Female genital mutilation
In more than 30 countries throughout Africa and
the Middle East, over 100 million women and
girls have undergone female genital mutilation
(FGM), a painful and dangerous practice involving
the partial or total removal of the external genitalia
[8]. FGM carries lifelong consequences for women’s
sexual and reproductive health, and can lead to
death from hemorrhaging and complications in
childbirth.
Trafficking of women and girls
Trafficking in women and girls for forced labor and
sexual exploitation is another type of gender-based
violence that has grown rapidly during the past
decade, largely as a result of war, displacement, and
economic and social inequities between and within
countries. Although reliable statistics on the number
of women and children who are trafficked are
lacking, rough estimates suggest that from 700,000
to 2 million women and girls are trafficked across
international borders every year. These women face
many risks, including physical violence and rape,
both in their work and when trying to negotiate
safer-sex practices [8].
Sexual violence in armed conflict situations
Another aspect of gender-based violence that has
been largely overlooked until recently is violence
against women in situations of armed conflict.
Recent reports have documented systematic rape
in many conflicts, including the former Yugoslavia,
Rwanda, Liberia, Sierra Leone, and Uganda [9,10].
These reports have highlighted the extent to which
rape has been used as a deliberate strategy to
‘‘destabilize populations, advance ethnic cleansing,
express hatred for the enemy or supply combatants
with sexual services’’ [11]. In 2002, the Interna-
tional Criminal Tribunal in The Hague recog-
nized the seriousness of sexual offences in war
as a crime against humanity. International relief
agencies are also calling attention to the precarious
situation of women in refugee settings where
rape and child sexual abuse, intimate partner
violence, and other forms of sexual exploitation are
widespread.
Femicide
It is estimated that between 40% and 60% of
murders of women around the world are committed
by intimate partners [12]. In South Africa, a recent
study estimated that a woman is killed by a partner
every six hours [13]. Although intimate partners
are the most common perpetrators of femicide,
in some regions women are murdered by family
members and in-laws in the name of ‘‘honour’’ or
to settle dowry disputes. Studies in Nicaragua
and Bangladesh suggest that a significant proportion
of maternal mortality due to indirect obstetric
causes may be due to domestic violence [14,15].
In Guatemala and Mexico, femicide related to
organized crime and gang-related violence has
reached epidemic proportions. The death toll in
Guatemala has exceeded 1,600 women since 2001.
The great majority of these deaths have gone
unpunished [16].
Health consequences of violence
Gender-based violence is associated with serious
health problems affecting both women and children,
including injuries, gynecological disorders, mental
health disorders, including depression and post-
traumatic stress disorder, adverse pregnancy out-
comes, and sexually transmitted diseases, including
HIV and AIDS [17,18]. Women who have been
abused also tend to experience poorer physical
functioning, more physical symptoms, and more
days in bed than do women who have not been
abused [19]. Violence can have direct consequences
for women’s health, and it can increase women’s
risk of future ill health. Therefore, victimization,
like tobacco or alcohol use, is best viewed as a risk
factor for a variety of diseases and conditions,
rather than primarily as a health problem in and of
itself.
Gaps in existing knowledge
Although great strides have been made to draw
attention to this issue internationally, the lack of data
on the prevalence, characteristics, and epidemiology
of the various types of violence against women is
regularly highlighted as a major barrier to effective
policy-making. Moreover, many of the existing data
are difficult to compare, because of inconsistencies
in the way that violence is measured. Studies vary in
the definition of study populations (all women, ever-
partnered, etc.), types of violence (physical, sexual,
or psychological), timeframes (lifetime, last 12
months) and the wording of questions [20]. Some
studies are specifically dedicated to the study of
violence, whereas in others questions on violence are
embedded in larger surveys intended primarily for
other purposes, such as the Demographic Health

Surveys [21]. Another promising approach has been
to embed questions on violence in epidemiological
studies on different health issues. For example,
researchers from the University of León, Nicaragua
and Umeå University included questions on violence
in several case-referent studies nested in a demo-
graphic surveillance system in Leon, Nicaragua.
These studies demonstrated significant associations
between experiences of physical and sexual violence
and such diverse health problems as infant and child
mortality [22], low birth weight [23], emotional
distress among women [24], adolescent pregnancy
[25], and high-risk sexual behavior [26]. This type of
nested research is particularly useful as it permits
estimations of population attributable risk and
contributes to revealing the hidden health burden
due to violence.
Putting women’s safety first
Another key challenge faced by researchers is to
conduct surveys that do not put women at risk of
harm [27]. The WHO has developed recommenda-
tions to address this concern, which are increasingly
accepted as a standard for the ethical conduct of
research on violence against women. The guidelines
include such measures as ensuring complete privacy
during interviews, using carefully chosen and trained
interviewers, interviewing only one woman per
household, and offering emotional support for both
respondents and field staff who become distressed as
a result of participating in the research [28].
The WHO Multi-country Study on Women’s
Health and Domestic Violence
In an effort to develop a standard methodology for
researching violence, the World Health Organization
has carried out a Multi-country Study on Women’s
Health and Domestic Violence against Women [29].
This ambitious study involved over 24,000 women
from 10 countries and 15 sites, and constitutes the
most comprehensive effort to obtain comparable
data on different forms of violence against women in
different cultural and economic contexts. The study
focused primarily on physical and sexual violence
against women by current and former intimate
partners, although it also collected information on
child sexual abuse and sexual assault by non-
partners.
The findings of the WHO Study, released in
November 2005, demonstrate that intimate partner
violence is common throughout all the sites studied,
although considerable variation was found within
Violence against women 3
and between countries. Overall, between 15% and
71% of ever-partnered women had been physically
or sexually assaulted by an intimate partner. In most
settings about half of these respondents reported
that the violence was currently ongoing. Between 1%
and 28% of ever-pregnant women reported being
abused during one or more pregnancies, with the
majority of sites falling between 4% and 12%. Much
of the violence reported was hidden: between 20%
and 66% of women reporting violence in the study
had never told anyone of their partner’s violence
prior to the study interview.
Women who had experienced sexual or physical
violence were consistently more likely to report a
series of physical and mental health symptoms,
including pain, difficulties with daily activities,
emotional distress, suicidal thoughts, and suicidal
attempts. One of the most striking findings of the
study was the degree to which violence against
women is considered acceptable in many parts of the
world. In about half of the sties, 50–90% of women
agreed that it is acceptable for a man to beat his wife
under certain circumstances, including if she does
not complete housework, refuses sex, is unfaithful,
or disobeys him.
Putting research into action
The WHO report provides 15 recommendations for
strengthening national commitments and action on
violence against women, including promoting vio-
lence prevention through educational systems,
strengthened responses from the healthcare sector,
support for women living with violence, and
sensitized criminal justice systems. Health providers
can play an important role in this effort, by
identifying and providing appropriate support to
victims of violence, as well as raising public aware-
ness around the issue [30]. Although few interven-
tions have been rigorously evaluated, recent
international reviews have found a number of
programmes within sexual and reproductive health
services that successfully address violence-related
problems. Interventions to prevent violence by
challenging cultural norms around gender and
violence have also shown promising results in
Brazil, South Africa, and Nicaragua [31]. Several
of these programmes have specifically targeted men
and youth as key partners in violence prevention.
Public health researchers are already playing an
important role in uncovering the true extent and
consequences of violence against women. The next
challenge is to improve the quality of monitoring and
evaluation research, in order to ensure the best use
of scarce resources and efforts to reduce violence.
4 M. C. Ellsberg
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