Gender, GBV and Health

1. Gender, GBV and Health Dr. Sam Thenya, Group CEO-The Nairobi Women’s Hospital 5th GTZ Health Sector Network Meeting Mombasa 25th Feb 2010

2. Definitions. • Gender based violence is an umbrella term for any harmful act that is perpetuated against a person’s will and that is based on socially ascribed (gender) differences between male and female. • GBV results in physical, sexual or psychological harm. It includes threats to carry out such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life.

3. Cont… • All over the world GBV has a greater impact on women and girls than men and boys. The term GBV is used interchangeably with the term Violence Against Women (VAW). GBV highlights the relationship of female subordinate status in society and their increased vulnerability to violence.

4. CONCEPTS OF GENDER • Gender • Human Rights • Power • Violence • Informed Consent

5. GENDER • Social differences between males and females that are learned • …though deeply rooted in every culture, are changeable over time • …have wide variations both within and between cultures • Determines the roles, responsibilities, opportunities, privileges, expectations, and limitations for males and for females in any culture.

6. Human rights issue • Acts of GBV violate a number of women’s human rights principles enshrined in international human rights instruments. These include, amongst others the: -the right to life, liberty and security of the person; -the right to the highest standard of physical and mental health; -the right to freedom from torture or cruel, inhuman, or degrading treatment or punishment; -the right to freedom of opinion and expression, to education, to social security and to personal development

7. Power Power is the ability to influence or control. It includes access to decision- making processes. In most communities, cultures and societies, the gender roles assigned to women have less visibility and thus less power attributed to them. This lack of power and status make women vulnerable to acts of violence.

8. Violence Violence encompasses, but is not limited to, the following: • physical, • sexual, • socio-economic and • psychological violence occurring within the general community

9. Informed consent • Consent = agreement • Informed consent means making an informed choice (ie. an individual is aware of all his/her options and is able to make a decision without coercion) freely and voluntarily by people in an equal power relationship. i.e. Reproductive health rights and the number and spacing of children. • Children (people under 18) and individuals who are mentally challenged, are deemed unable to give informed consent for acts such as FGM, marriage, sexual relationships etc..

10. Concepts cont… • GENDER MAINSTREAMING This is a process that involves ensuring gender perspectives and attention to the goal of gender equality are central to all activities such as policy development, research, advocacy/ dialogue, legislation, resource allocation, planning , implementation and monitoring of programs or projects. This is a globally accepted strategy for promoting gender equality which is not an end in itself but means to achieving gender equality. • Provisions Refers to policy pronouncements on action to be taken.

11. Concepts cont… • Affirmative Action A policy or Programme of taking steps to increase the representation of certain designed groups seeking to redress discrimination or bias through active measures in education and employment. It is usually achieved through discrimination against other groups. • Empowerment A process through which men, women, boys and girls acquire knowledge, skills and attitudes to critically analyze their situation and take appropriate action to change the status quo of the underprivileged and other marginalized groups in society.

12. Cont… • Engender The process of ensuring that planning and programming is appropriate for and takes into account the female and male differences and concerns. • Gender analysis This identifies, analyzes and informs action. It addresses inequalities that arise from the different roles of men and women; the unequal power relations between them; and other contextual factors like: ethnicity, sexual orientation, employment, citizenship, etc.

13. Concepts cont… • Gender awareness Is the understanding that there are socially determined differences between men and women based on learned behavior, which affect ability to access and control resources Gender blindness • This is failure to recognize that gender is an essential determinant of social outcomes. It therefore impacts on project planning and implementation.

14. Concepts cont…. • Gender Discrimination Refers to unequal or preferential treatment of individuals or groups on the basis of their gender that results in reduced access to/ or control of resources and opportunities . • Gender Equality Refers to the equal treatment of women and men, girls and boys so that they can enjoy the benefits of development including equal access to and control of opportunities and resources.

15. Cont… • Gender Equity Refers to the practice of fairness and justice in the distribution of benefits, access to and control of resources, responsibilities, power, opportunities and services. • Gender needs Arise from the four components cited above. Since men and women have different gender roles, do different types of work, have different degrees of access to services and resources, and experience unequal

16. Cont… • Power relations Refers to capacity of individual or group to initiate action and determine outcomes which change existing social, political and economic systems and norms, to equalize gender relations. • Patriarchy It means ‘Rule of father’ and refers to the current male dominated social relations, ownership and control of power at many levels in society. It is thought to be the root cause of the existing system of gender discrimination.

17. Gender and Health Care • Gender refers to the social – cultural attributes associated with being man or woman, boy or girl. Societies have different roles, responsibilities and expectations for men and women. • These gender roles exert various degrees of constraints, the more rigid the gender role in a society, the sharper the gender division of labour and the lower the status accorded to women. • Health care on the other hand connotes the attention given to the well being of person weather physically, socially, mentally and emotionally. • Different valuation for different roles means that women and men everywhere do not have equal access to the material and emotional resources needed to sustain health. Underlying causes of women health problems such as domestic violence or examining their living and working conditions have been ignored. • There is considerable evidence of gender differences in access to health care, affetced by medical knowledge and Literacy levels . Processes of pregnancy and childbearing for instance have been turned into medical events with control taken away from women themselves.

18. Effects of Gender Roles in Health Sector • Women remain economically dependent on men and/or men have control over family resources making it difficult for women to pay for health care or transportation costs to health care facilities. • Social- cultural believes/ norms deny women the right to travel alone or be in the company of men outside their immediate family or making the decision to access health facilities. FGM viewed as an essential for marriage. • Domestic/household chores which lead to opportunity costs of medical treatment to be greater example during harvesting attending to health care concerns would be unacceptable burden on the household considering that women provide the highest number of farm labourers. • Discriminatory legislations examples policies restricting reproductive rights, maternity leave and/or sick leaves.

19. Gender Based Violence (GBV) in relation to Health Care • Gender based violence is an umbrella term for any harmful act that is perpetuated against a person’s will and that is based on socially ascribed (gender) differences between male and female. The term GBV is used interchangeably with the term Violence Agaisnt Women (VAW). • Gender violence is a human rights violation that has serious health implications example effects of domestic violence. Sadly it’s used as a weapon of war or dispute resolution. • Gender roles render women vulnerable to Gender based violence a profound human rights and public health problem. It is a leading cause of injury and death of women in Kenya and is also a major cause of HIV/AIDS; fear of violence prevents women from insisting on safe sex.

20. Dimensions of Gender Based violence • Domestic • Sexual • Physical • Cultural • Religious • Socio – economic • Patriarchy The factors that promote GBV form the basis of the form they take. They are promulgated by the agents of the society who include custodian of culture, media, religious leaders, discriminatory legislations, economic dependency, myths among others.

21. Brief Statistics • The Demographic and Health Survey, 2003 reports that that half (53%) of all women in their 30’s and 49.4% in their 40’s have experienced violence since age 15. • 15% of married women in Kenya report having experienced marital rape. • One out of every four girls and young women report loosing their virginity through forces. • Police statistics for 2006 show a 35% increase in child rape cases since 2005. • Women comprise 52% of Kenya’s population. Approximately half of the poor in Kenay are women in rural areas. Women also make 67% of the unemployed. • Women and girls education levels are low hence denying them better economic opportunities and empowerment. Generally, the statistics of sexual violence more or less represent the rate of spread of HIV/AIDS. GBV is no longer just a human rights issue but a national health issue which threatens to set back the multibillion gains which Kenya has made in fighting HIV/AIDS.

22. Case Study: Gender Based Violence Interventions Nairobi Women’s Hospital/ Gender Violence Recovery Centre Experience) • The Nairobi Women’s hospital was set up in March 2001 with the aim of providing holistic care to the women and children though men also benefit from the health services. The hospital specializes in Obstetrics and Gynecology, but is also competent to handle all other general medical conditions • As a way of giving back to the society NWH established GVRC as a non- profit and non partisan charitable trust of the hospital who main mandate is to provide free specialized medical treatment and psychosocial support to the survivors of GBV; the only such facility in East and Central Africa and a one stop medical centre for women and children. • The hospital provides gynecology services in the out patient department as a primary health care service, breast clinic managed by a consultant surgeon and is a leading example in provision of emergency health care to sexually violated persons within the recommended first 72 hours.

23. Gender Based Violence Expereince Since inception the hospital has received over 14,000 GBV Survivors; • 90% of the cases are of Sexual violence (Rape, Defilement & Sexual assault) • 9% are Domestic violence cases • 1% Physical violence • 49% were children • 45% were women • 6% were men • The youngest GBV survivor was 1 ½ months old baby, the oldest 106 yrs, both complained of sexual violation. • NWH/GVRC figures intensified during the post election violence. For the period 27th December 2007 to 26th March 2008, 612 GBV survivors were treated at the hospital, 229 children and 383 adults. 502 were complaints of sexual violence and 110 Domestic and Physical violence. Most of the sexual violence was perpetrated by gangs of young men ranging from 2 to 11 men per act. Over 2,500 people were treated through medical camps held in different crisis centre countrywide and over 150,000 people received psychosocial support.

24. Gender Based Violence Interventions Gender based violence interventions in healthcare are attempts or efforts to promote good health behaviour or to prevent bad health behaviour. These interventions reduce or end suffering. Types of interventions. • Comprehensive medical examination and treatment including; • Provision of post exposure prophylaxis (PEP) – Postinor, Euvax, ARVs etc • Laboratory tests (Pregnancy, HIV/AIDs, High Vaginal swab, Hepatitis, Urinalysis, Liver function, Pregnancy), • Continuous supply of variety of prescriptions & palliative care for terminal illness • Reproductive health care including family planning options • Psychosocial support • Professional counseling of survivors of GBV and their families (Individuals and support groups) • Distribution of aid materials such as clothes, food, sanitary towels etc

25. Cont… • Training and capacity building of health workers in other health facilities, police, prosecutors, magistrates, community based organizations among others on impact of GBV in the society and how to handle GBV survivors. (Medical and Psychosocial aspects). • Referrals for accommodation (Shelter homes) and legal aid services. This is done through partnerships/networks with other like minded organizations such as FIDA Kenya, WRAP, Goal Kenya, CLAN, The CRADLE and COVAW. • Increase GBV survivors’ access to justice by providing testimonies and/or evidence in court in favour of the survivors and enactment of favourable legislations example Sexual opffences Act, Children’s Act and upcoming Gender Bills(Domestic Violence (Family Protection) Bill, Marriage Bill, Matrimonial Property Bill and Equal Opportunities Bill), domestication of human rights instruments. • Community awareness programmes (Community trainings and media coverage) to enhance awareness of the nature, manifestation, dynamics and impact of GBV & HIV/AIDS with the aim of influencing public opinion and perceptions on GBV and enroll public to fight GBV and HIV/AIDS (reduce levels of GBV). Includes Legal awareness.

26. Lessons learnt • There is need to expand medical services to reach the people at the grassroots level. Includes expansion of personnel and infrustracture. • Need to enhance community awareness on nature, manifestation, dynamics and impact of GBV & HIV/AIDs with the aim of influencing public opinion and perceptions on GBV and HIV/AIDS. • Need for counseling to also target possible perpetrators to stop the inhuman acts and also benefit service providers who are vulnerable to burn out. • Need to enhance networks to reach out for emergency response example contacts for emergency evacuations to reach survivors of humanitarian crisis, media alerts etc. (hotline responses) • Need for adequate supply of prescriptions of certain medical conditions example diabetes, cancer, high blood pressure, physically challenged among others. • Political will is inadequate in Kenya.

27. Outcomes in relation to Health and Human rights Gender Based Interventions bring out collective results including; • Improvement of the physical and psychological health. • Increased appreciation of self-worth (Self esteem) achieved through counseling.- (Human rights component). • Legislation reforms which include enactment of; • The children’s act No. 8 of 2001 • The Sexual Offences Act, 2006 and the establishment of a task force to ensure implementation of the Act, • National Action Plan for the eradication of Female Genital Mutilation. • HIV/AIDS Prevention and Control Act 2006 whose objective is to provide measures for the prevention, management and control of HIV and AIDS. • National Policy on Gender Equality and Development, 2000 and Sessional Paper No. 2 of 2006 on Gender equality and Development. • Adolescent and Reproductive Health and Development Policy, 2003 • Gender Bills • National framework on GBV (Multisectoral intervention to prevent and respond to GBV). • Millennium Development Goals achievements.

28. Recommendations • It is very important that all people working in humanitarian organizations, public service, health sectors, religious organizations among others to have a comprehensive understanding of gender, health and human rights, the three must not be addressed separately. GBV is part and parcel of health care services and should be in all training institutions and where possible all service providers be subjected to regular refresher courses on Gender and health. • It is also important to have a fair grasp of relevant legislations including, Human rights instruments, the Children’s Act No. 2 of 2001, the Sexual Offences Act, 2006 and HIV/AIDS Act, 2006. • Basic counseling and psychological support skills are crucial for any health care giver or service provider including those working in humanitarian organizations. Listening is a therapeutic. All health systems must listen to the woman. • There is also need to lobby development partners to highlight gender concerns as one of the conditions of funding in any projects. This will enable gender to be visible in development plans, policies and legislations • Lobby for state obligation over human rights.

30. Supporting survivors and families to heal.