Sexual and Gender-Based Violence

 

Welcome to the programmatic area on sexual and gender-based violence (SGBV) within MEASURE Evaluation’s Family Planning and Reproductive Health Indicators Database. This is one of the subareas found in the sexual and reproductive health (RH) section of the database. All indicators for this area include a definition, data requirements, data source(s), purpose, issues and—if relevant—gender implications. International studies and survey data confirm that SGBV is a widespread problem with serious repercussions in terms of personal suffering, health complications, disability, and death for women, children and men, in addition to having significant costs for healthcare systems and society at large (United States Agency for International Development [USAID], 2006; United Nations Population Fund [UNFPA]/AIDOS, 2003). Gender-based violence has been defined as involving men and women in which the female is usually the victim and which is derived from unequal power relations between men and women (USAID, 2010a). Lawry (2011) has broadened the definition to include any harm, including sexual violence to an individual, that is perpetrated against their will and is a result of power imbalances. Programs designed to prevent SGBV and provide treatment for victims can help promote gender equality, reduce child mortality, improve maternal health, and combat HIV and AIDS.  The core indicators selected for this database cover a range of SGBV topics from policy to access, quality and utilization of services, beliefs about SGBV, to prevalence of SGBV among men and women. Key indicators to monitor and evaluate SGBV can be found in the links at left.   Full Text International studies and survey data confirm that sexual and gender-based violence (SGBV) is a widespread problem with serious repercussions in terms of personal suffering, health complications, disability, and death for women, children and men, in addition to having significant costs for healthcare systems and society at large (USAID, 2006, UNFPA/AIDOS, 2003). Gender-based violence has been defined as involving men and women in which the female is usually the victim and which is derived from unequal power relations between men and women (USAID, 2010a). Based on documentation of occurrences of conflict zone violence perpetrated by women on men and other women (Johnson et al., 2010) and recorded cases of male victimization, Lawry (2011) has broadened the definition to include any harm including sexual violence to an individual that is perpetrated against their will and is a result of power imbalances. Programs designed to prevent SGBV and provide treatment for victims can help achieve Millennium Development Goals #3. promote gender equality and empower women; #4. reduce child mortality; #5 improve maternal health; and #6. combat HIV/AIDS.  Multiple global partners, such as WHO, USAID, UNFPA, RHRC, UNHCR, IPAS, IPPF, and Promundo have been developing programs targeting SGBV. The Global Health Initiative’s (GHI) first principle to ‘Implement a woman- and girl-centered approach’ by supporting long-term systemic changes to remove barriers and increase access to quality health services for women and girls is consistent with interventions to reduce SGBV. GHI strategies to engage men in RH, gender equity programs, training health providers on gender issues, and engaging civil society in partner countries to address gender equity in health care can help reduce SGBV against females and against males (GHI, 2010). SGBV can include physical, sexual, and psychological/emotional violence, rape and sexual abuse, child sexual abuse, child marriage, female genital cutting, marital rape, dowry-related violence, female infanticide, femicide, sexual harassment, forced prostitution, sex trafficking, and sexual violence used during war or conflicts as forms of intimidation and torture (USAID, 2006; Bloom, 2008; Lawry, 2011).  The prevalence of SGBV is high across many regions and countries, including many developing countries.  Based on DHS survey data from nine countries, Kishor and Johnson (2004) found the reported prevalence of any type of violence against women ages 15 to 49 ranged from 21 to 59 percent. Intimate partner violence is the most common type of SBGV and Kishor and Johnson (2004) reported that overall one in six women had been physically assaulted or raped by husbands or intimate partners. Women, children, and men in conflict zones and those displaced in emergency or refugee settings are at increased risk, as well as members of the lesbian, gay, bisexual, and transgender (LGBT) population (Ard and Makadon, 2011). Reporting on SGBV in conflict zones, Lawry (2010) found staggering rates as high as 39 percent of females and 23 percent of males had suffered SGBV in Ituri and South and North Kivu in the Democratic Republic of the Congo, between one-fourth to one-half million females in Rwanda were raped during the 1994 genocide, 76 percent of male political prisoners in El Salvador have suffered SGBV, and 80 percent of male camp detainees in Sarajevo reported sexual violence while in camp.  SGBV has effects on women’s reproductive health through a number of pathways including early and/or unintended pregnancy, general and psychological health issues and reduced productivity, as well as increased risk for sexually transmitted diseases (STIs) and HIV. Violence during pregnancy poses an immediate risks to the pregnant women and can lead to adverse pregnancy outcomes (Pool, et. al., 2014). Risks for male victims can include STIs and HIV, general and psychological health concerns, substance abuse, reduced productivity, and reassertion of their masculinity by repeating their own victimization but in the role of perpetrator. Policies and programs to prevent and respond to SGBV have been initiated worldwide and involve a range of sectors in order to address underlying factors including cultural norms perpetuating gender inequality and the more immediate determinants, such as behavior change (Bloom, 2008). In terms of improving health services for victims of SGBV, USAID (2010b) recommends a ‘systems approach’ that promotes broad reforms throughout the health organization. When monitoring and evaluating (ME) SGBV interventions, Watts (2008) recommends the importance of a mixed-methods approach that uses quantitative and complementary qualitative methods with a clear conceptual framework to guide evaluation, multiple forms of evidence, and costing data to determine and support feasibility of scale-up.   Indicator Selection     The ten core indicators selected for this database cover a range of SGBV topics from policy and legislation to access, quality and utilization of services, beliefs about SGBV and gender norms, to prevalence of SGBV among men and women.  Indicators have been drawn from several sources including DHS, the guide from  WHO/UNFPA (2008) on monitoring universal access to reproductive health and from the compendium of indicators on ‘Violence Against Girls and Women,’ (Bloom, 2008).  The compendium of indicators was designed for quantitative assessment of program performance at community, regional and national levels. Because some areas of SGBV can be captured better through qualitative methods, see Ellsberg and Heise (2005) for a discussion on when and how to conduct qualitative research. There are a number of challenges in ME, such as potential reporting bias related to gender and cultural norms. In general, SBGV tends to be underreported by both females and males, with male victims even less likely to report violence than females. Following interventions, women may feel more comfortable in reporting violence making it appear that the intervention is associated with an increase in violence, while men may be less likely to admit to perpetrating violence (Watts (2008). Watts also notes that reliable evidence on impact of interventions is difficult to collect and the use of control groups or communities can be complicated.            ____________  References: Ard K and Makadon HJ. Addressing Intimate Partner Violence in Lesbian, Gay, Bisexual, and Transgender Patients. Journal of General Internal Medicine. 2011, August: 26(8): 930-933. Bloom S, 2008, Violence against Women and Girls: A Compendium of Monitoring and Evaluation Indicators, Chapel Hill, NC: MEASURE Evaluation. Ellsberg MC and Heise L, 2005, Researching Violence against Women: A Practical Guide for Researchers and Activists, Washington, DC: WHO, PATH. http://www.path.org/files/GBV_rvaw_complete.pdf Kishor S and Johnson K, 2004, Profiling Domestic Violence- A multi-country study, Calverton, MD: ORC Macro.  Pool MS, Otupiri E, Owusu-Dabo E, de Jonge A, and Agyemang C. Physical violence during pregnancy and pregnancy outcomes in Ghana.  BMC Pregnancy and Childbirth. 2014, February 14(71).

Existence of a policy on SGBV

Definition:

The existence of formal governmental declarations, laws, and statutes affecting sexual and gender-based violence (SGBV). Policy also can refer to operational regulations, guidelines, norms, and standards (Cross, Jewell, and Hardee, 2001).

Data Requirements:

Documentation outlining the policy. Evaluators may want to disaggregate by sex.

Data Sources:

Legislative records, administrative records, and other government documents (national, regional, and local); also, internal policy documents of an organization

Purpose:

The purpose of this indicator is to track changes in the policy environment that potentially affect the delivery of SGBV services and the well-being of victims of SGBV. Such changes can occur in the political arena (via for­mal governmental declarations and changes in legisla­ture, which some refer to as Policy with a capital "P" or at the organizational level (in terms of the policies and procedures used within reproductive health services and by institutions that refer women to these services, such as the police, judiciary, and social services (policy with a small "p"). This indicator is a specific case of the indi­cator on Existence of official national/subnational or organizational policies or strategic plans that promote equitable and affordable access to high-quality reproductive health ser­vices and information presented in this database under the cross-cutting area Policy.

Experts in this field maintain that any organization deal­ing with SGBV should articulate a policy (small "p") on its approach to SGBV. The organization may also take an advocacy stance and try to influence governmental policy and legislation (capital "P"), depend­ing on its mission.

In analyzing policy-related documents on SGBV, one should further consider how the document frames the issue:

Issue(s):

Whereas the existence of a policy on SGBV signals po­litical concern over the topic, it may be relatively mean­ingless if not translated into concrete actions. Any as­sessment of SGBV  policy should examine the actual struc­tures in place to respond to the needs of victims of SGBV, as well as the record of implementing the policy initia­tives to prevent violence in the future. Thus, a related indicator involves the existence of structures to (1) pro­vide services to those who experience SGBV  and (2) undertake initiatives aimed at reducing or eliminating SGBV  in the future.

Law prohibits marital rape

Definition:

National law makes it illegal for someone to use violence, the threat of violence, or coercion to force their wife or husband to have sex.  According to the definition provided by the Inter-agency Working Group on Reproductive Health in Crises, this can include the invasion of any part of the body with a sexual organ and/or the invasion of the genital or anal opening with any object or body part. Efforts to rape someone that do not result in penetration are considered attempted rape (2010).

In Bangladesh, for example, the law prohibits rape and physical spousal abuse, but it makes no specific provision for spousal rape as a crime.  This distinction must be clearly stated in the legal statutes in order to be counted for this indicator.

Data Requirements:

Verification of national law stating that it is an offence for anyone to coerce another into a sexual act by using force or threat of harm, even if they are legally married to that person.


Evaluators may want to disaggregate by sex.

Data Sources:

Penal codes; special statutes; court decisions

Purpose:

Those who have been raped by their spouse experience pain, humiliation and distress.  Marital rape prevents individuals from being able to take control of their own sexual and reproductive health.  In addition to the emotional and psychological effects, it causes public health problems including poor maternal and child health, repeat-infections with sexually-transmitted infections, and long-term exposure to the risk of HIV infection.

The right to be free from coercion and violence in relation to sex is a human right that is defined in several regional and international laws (i.e. the United Nations Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) and the Protocol on the Rights of Women in Africa).  However, when a national law fails to recognize this right within the context of marriage, those who suffer this form of violence have nowhere to go.

This indicator is used to gauge the political attitude toward discriminatory legislation, such as extending legal impunity for marital rape.  A law specifically prohibiting marital rape provides an initial indication of a country’s policy environment around sexual and gender-based violence.

Issue(s):

Marital rape laws can be highly misleading with regard to what authorities actually tolerate. Enforcement of laws varies by country and is often weak and inconsistent, especially in rural areas.  In cases that are filed, governments may infrequently prosecute.  Although a law may have been revised to acknowledge marital rape and make it a punishable crime, there may still be additional barriers for spousal rape victims such as different reporting requirements, different standards for burden of proof, and different definitions for spousal rape.

Gender Implications:

Prevailing gender stereotypes makes it difficult to afford marital rape the same legitimacy or validity as other forms of sexual violence.  The belief that a husband has a right to sex, and has a right to use his wife’s body for this purpose, along with the idea that women aren’t supposed to enjoy sex, but just put up with it, prevents successful prosecutions of marital rape where the question of consent is clouded by societal beliefs about marriage.  Beliefs rooted in traditional religious teachings (e.g. Judaism, Christianity, Islam, etc.) have also served to perpetuate the problem of marital rape by putting extreme emphasis on a wife's responsibility to please and to be subordinate to her husband, and by urging her to stay with him no matter what (Kiffe, 2010).  Cultural attitudes are slow to change and in societies with rigid gender roles, the recognition and persecution of all forms of rape will take time.

References:

Inter-agency Working Group on Reproductive Health in Crises. 2010. Inter-agency Field Manual on Reproductive Health in Humanitarian Settings: 2010 Revision for Field Review.

Bangladesh Woman, January 30, 2010.  http://bangladeshwoman.blogspot.com/2010/01/law-prohibits-rape-and-physical-spousal.html 

African Population and Health Research Center (APHRC), Policy Brief No. 13, 2010, Marital rape and its impacts: A policy briefing for Kenyan members of parliament.

Kiffe B.  Marital Rape.  Dakota County Sexual Assault Services, 2010.  

Availability of social services within an acceptable distance

Definition:

The number and type of organizations in a community that provide social services pertaining to the prevention and response to sexual and gender-based violence (SGBV), at one point in time. Social services include but are not limited to:

Accessibility needs to be locally defined, depending on the geographic area and the modes of transportation and communication that are readily available to most of the population.

Data Requirements:

Count of the number of organizations that provide any social-welfare services directed at the prevention of and response to SGBV in a specified geographic area (community, province, region).  Data should be disaggregated by type of service provided, per the checklist above.

Evaluators may want to disaggregate by sex.

Data Sources:

In places where agencies providing services might use websites or telephone directories (e.g., in urban centers of South-east Asia), a list should be compiled from these information sources. A list should also be generated by checking governmental offices, such as women’s ministries or departments of social welfare, as well as non-governmental organizations in the geographic area of interest. In many places, consulting informally with key informants in the community, or running a mapping exercise such as the second step of the MEASURE Evaluation PLACE protocol will be needed to generate a list. The list of service organizations should be verified by either calling or visiting the agencies to ascertain what types of, if any, services are provided to SGBV survivors.

Count the resources listed and disaggregate by type of social welfare-based services provided. If one or more organizations provides comprehensive services (and thus multiple types), the organization would be classified under a category called “integrated services”, noting which actual services are provided.

Purpose:

Those who experience violence in the home or elsewhere need help in a number of areas not specifically addressed by health, educational, or legal programs. This output indicator measures whether there are social services and what type of social-welfare services, directed towards the prevention of and response to SGBV, are available in a community. The disaggregated indicator can be used to identify gaps and, with measurements at multiple time points, trends in availability of specific types of services.    

Issue(s):

Generating a comprehensive list of organizations may be difficult, and some organizations may be missed, depending on the methods used. Unless organizations are listed accurately, double-counting could occur. If organizations are missed at one count, and included in the next count, the increase in the number of organizations will not reflect growing service availability in social welfare. A true increase in organizations over time may reflect a number of things, including more need (a growing population of affected individuals), increased funding and focus on the problem, or increased attention and awareness within communities.

References:

Bloom S.  “Violence Against Women and Girls: A Compendium of Monitoring and Evaluation Indicators.”  USAID, IGWG, and MEASURE Evaluation, 2008.

MEASURE Evaluation Project.  2005.  PLACE: Priorities for local AIDS control efforts, a manual for implementing the PLACE method.  USAID & MEASURE Evaluation, MS-05-13.

Number of individuals using SGBV social services

Definition:

The number of men, women, and children who used sexual and gender-based violence (SGBV) services during a specified time period (e.g., during the past 12 months). Social services include but are not limited to:

Data Requirements:

Count of the number of individuals who used SGBV services during a specified time period. Data should be disaggregated by organization and by type of service provided, per the checklist above.

Reviewing the records and compiling the count at individual organizations will yield a figure disaggregated by organization. The counts can then be added together to get a total figure representing utilization within the given geographic area. The disaggregated count by type is calculated by grouping together organizations by the type of services they provide, and then tallying those totals together per type.

In this instance, case management services should note the specific type of services listed in that category. If one or more organizations provides comprehensive services (and thus multiple types), the organization would be classified under a category called “integrated services,” noting which actual services are provided.

Evaluators may want to disaggregate by sex.  Depending on the program or project collecting this data, data collection may also want to specify if the individual was lesbian, gay, bisexual, or transgeneder as members of this population are at increased risk for sexual violence.

Data Sources:

Records from all organizations providing social services in a given area. This indicator should be measured in conjunction with the indicator, “Availability of social services within an accessible distance” since the organizations identified in that count would constitute those whose records would be reviewed.

Purpose:

This output indicator provides a crude utilization measure of SGBV social services.

Issue(s):

Measurement of this indicator relies on records maintained at organizations that provide services for SGBV survivors. The data collected will only be as good as the original records. If identifiers are not used in the records, double counting of individuals can occur when one person is using more than one service organization. A true increase in the number of individuals using these organizations over time may reflect a number of things, including more need (a growing population of affected individuals), increased funding and focus on the problem, or increased attention and awareness within communities.

Gender Implications:

With the focus on women and girls being the victims of SGBV, males may be reluctant to seek out social services because of cultural beliefs that boys and men can’t be victims.  Additionally, social services may be ill-equipped to address male survivors of SGBV.  Although none or a small number of males may report using SGBV social services, one must be cautious to extrapolate the data to estimate the scale of the problem in the larger population since only a small fraction of male survivors of sexual assault actually report the crime and/or seek out supportive services.

References:

Bloom S.  “Violence Against Women and Girls: A Compendium of Monitoring and Evaluation Indicators.”  USAID, IGWG, and MEASURE Evaluation, 2008.

Number of cases of SGBV reported to health services

Definition:

"Service visits” are counted as the number of occasions on which a woman, man, or child seeks sexual and gender-based violence (SGBV) assistance from a given center.  The total number of visits may include repeat visits and thus may be larger than the total number of individuals using the center or program in a given year.

Note: An individual may receive more than one service on a given visit (counseling plus referral for other health problems). Program managers and evaluators may find it useful to track the different types of services (e.g., counseling, screening, referrals, treatment for injuries from violence) to better understand the needs of the clientele. For example, this tracking would yield data on the number of referrals made from SGBV centers to related services in the course of a reference period (e.g., one year).

Data Requirements:

Number of visits per center, aggregated across multiple centers (if such exist)

Data Sources:

Service statistics from the center or program

Purpose:

This indicator measures the volume of services the pro­gram provides to its clientele. During the early years of the program, evaluators should monitor details regard­ing the visits to better understand the problems and po­tential needs of the clientele (e.g., reason for the visit, type[s] of services provided).

Several related indicators (for reproductive health (RH) facilities) include the following:

Clients coming to the facility for other services are more likely to divulge an episode of violence if they sense providers will be sensitive to their problem.

Issue(s):

Evaluators should recognize that the number of SGBV incidents reported to health facilities represents just a fraction what the actual SGBV problem is in a community.  For many valid reasons, survivors of SGBV are very reluctant to report their experiences.  This is especially so with men and child victims of SGBV.

The interpre­tation of this indicator is somewhat ambiguous. The number of visits could increase over time, not because sexual violence is mounting, but rather because more people are more willing to come forward and disclose this problem, especially if the word-of-mouth informa­tion about the center is favorable. In fact, an increase in service delivery should reflect favorably upon the pro­gram.

This information is useful to demonstrate to donor agen­cies that the organization is providing a service within the community.  But the indicator gives little sense of whether the individuals who receive the service perceive it to be helpful, although an increase in numbers may re­flect favorable word-of-mouth publicity.  Also, the num­ber should rise as a result of mass media publicity or other behavior change communication interventions on SGBV. Ideally, the statistics on number of visits will also rise, especially during the early years of the program, as more people in need learn that services are available and helpful to those who experience violence.

Although the program may not be able to demonstrate effects at the population level, data on service utilization will help justify the continued existence of the services to donors interested in assisting women, men, and children with the prob­lem of SGBV.

Percent of target audience who say that wife beating is an acceptable way for husbands to discipline their wives

Definition:

Proportion of people who consider wife beating an acceptable way for a husband to discipline his wife for any reason, at a specified period in time.  The “target population” describes a group intended to benefit from domestic violence messaging.

Based on WHO’s checklist found in the Study on Women’s Health and Domestic Violence Against Women evaluators may ask: Sometimes a husband is annoyed or angered by things that his wife does. In your opinion, is a husband justified in hitting or beating his wife:

This indicator is calculated as:

(Number of respondents who respond “yes” to any of the questions related to what justifies wife beating by husbands, as listed above/Total number of people surveyed) x 100

Data Requirements:

Responses to a set of questions such as those listed above under the definition, which can be included in a population-based survey questionnaire.  Disaggregating this by the number of reasons given by people will give more information about respondents’ beliefs. For example, it will be useful to programs to know if most of the people included in the numerator only cite one reason versus most people citing four or five. People living in areas where only one or two reasons were answered affirmatively may have less general acceptance for intimate partner violence than in areas where most people respond affirmatively to most or all reasons asked.  Where data is available, this indicator can be disaggregated by sex of the respondent, age group, marital status, and other relevant factors such as education, income, and urban/rural residence.

Data Sources:

Population-based survey.

Purpose:

This outcome indicator measures the level of acceptability of wife-beating in an area (region, country, community) for any reason, at the point in time that it is measured. A high proportion would indicate that most people in the targeted population feel that wife beating is acceptable under certain conditions.

Focus group discussions with residents of communities, key informant interviews with community leaders and women’s group leaders may assess the level of tolerance for wife-beating (or more broadly, violence against women and girls) in communities. While most cases of wife beating take place in the home, most of the interventions are implemented at the community level in the form of awareness-raising activities and human rights education.

Thus, tracking the measurement of this indicator over time is of value for program managers and planners. While a direct causal relationship cannot be established, a decrease in the proportion of people who tolerate wife beating in a community may indicate that community-based awareness-raising activities and human rights education interventions are having a positive effect on norms and attitudes at the community level.

Issue(s):

The responses to the questions listed under the definition above are prone to social desirability bias. Respondents may be inclined to provide responses that they perceive to be more socially acceptable or appropriate rather than what they actually feel.

Although this indicator is one measurement of attitudes toward interpersonal violence, it only addresses attitudes toward violence against women.  Even though this is more common, men also suffer from sexual abuse and bear the brunt of the adverse physical, emotional, and mental consequences.  According to UNHCR's report on Working with Men and Boy Survivors of Sexual and Gender-Based Violence in Forced Displacement (2012), "where social and cultural norms reinforce gender inequality by casting men as inherently strong and expected to protect women and children, sexualised attacks against men serve not only to diminish their masculinity in their own eyes and the eyes of perpetrators, but can be interpreted by the survivor, perpetrators, and the wider community to be an expression of his sexual orientation or gender identity."  Program evaluators should consider including questions that also measure the acceptability and level of tolerance of violence against boys and men.

References:

Bloom S.  “Violence Against Women and Girls: A Compendium of Monitoring and Evaluation Indicators.”  USAID, IGWG, and MEASURE Evaluation, 2008.

World Health Organization. WHO Multi-country Study on Women’s Health and Domestic Violence Against Women: Summary Report of Initial Results on Prevalence, Health Outcomes and Women’s Responses. Geneva, Switzerland: World Health Organization; 2005 & Macro International, DHS Module A.

UNHCR. Working with Men and Boy Survivors of Sexual and Gender-Based Violence in Forced Displacement, Geneva, Switzerland, 2012.

Number of service providers trained to identify, refer, and care for SGBV survivors

Definition:

The number of health service providers trained in a sexual and gender-based violence (SGBV) training program during a specific time (e.g. the past year).

Data Requirements:

Type of provider trained; sex; community, region, or province; area in which they work (urban or rural)

If targeting and/or linking to inequity, classify trainees by areas served (poor/not poor) and disaggregate by area served.

Evaluators may want to disaggregate by sex of provider trained.  Because few SGBV trainings include male survivors of SGBV, evaluators may want to disaggregate by type of training received (i.e. female victims of SGBV, male victims, or both).  See the Purpose section below for more details.

Data Sources:

Records of the training program that reflect training program participants among current staff. The record should reflect, at minimum, what type of provider the participant was and where they practice.

Purpose:

Health service delivery programs are key in the prevention and response to SGBV. Every clinic visit made by a SGBV survivor presents an opportunity to address and ameliorate the effects of violence as well as help prevent future incidents. In order to take advantage of these opportunities, providers need to be prepared to deliver appropriate services, including identification of survivors, necessary health services, counseling, and referrals to community-based resources such as legal aid, safe shelter and social services. This indicator is an output measure for a program designed to provide training to health service providers in SGBV service provision. This will provide a measure of coverage of trained personnel per geographic area of interest, and will help monitor whether or not a program is attaining its target number of providers trained.

To be comprehensive, this indicator should capture number of providers trained in SGBV against females and males. According to UNHCR's report on Working with Men and Boy Survivors of Sexual and Gender-Based Violence in Forced Displacement (2012), "Entrenched gender norms combined with cultural and religious taboos, and scarce services, make it very difficult for males to disclose that they are survivors of sexual violence, while service providers may not recognize the male experience of SGBV."  Because healthcare providers are rarely trained to identify, treat and care for male SGBV survivors, without specifying that they have been trained to address male SGBV survivors, it will not be possible to adequately monitor programmatic changes for men.

Issue(s):

This indicator will provide a count of providers trained, but not how well they integrate the information disseminated or how well they use it later in their own practice. Presumably, if they are allowed to participate in the training program, there is a level of support in the health unit in which they practice for service provision to SGBV survivors. This is one among several factors that may influence overall care provided in any place by any one provider.

Only a follow-up indicator, such as number/percent of service providers providing SGBV services, will assess if the providers are actually practicing what they were trained on.  Even then, it is important to observe if all presenting clients of SGBV abuse are receiving the necessary care since prevailing attitudes toward certain groups, such as male survivors of sexual violence, grossly undermine the necessary care and services they receive.

Gender Implications:

People’s reactions to SGBV can be greatly influenced by personal and societal gender stereotypes.  These may include the belief that a woman who dresses provocatively is to blame for being sexually assaulted; it’s not rape if the couple is dating or is married; women cannot be perpetrators of SGBV; and men cannot be victims of SGBV.  Training providers specifically in SGBV is essential for ensuring that clients’ needs are handled with sensitivity, compassion, and impartiality.

References:

Bloom S.  “Violence Against Women and Girls: A Compendium of Monitoring and Evaluation Indicators.”  USAID, IGWG, and MEASURE Evaluation, 2008.

UNHCR. Working with Men and Boy Survivors of Sexual and Gender-Based Violence in Forced Displacement, Geneva, Switzerland, 2012.

Percent of health units with at least one service provider trained to care for and refer SGBV survivors

Definition:

The percent of health facilities in the geographic region of study (e.g., country, region, community) with at least one provider who has been trained within the past three years in the identification, care and support of sexual and gender-based violence (SGBV) survivors.

This indicator is calculated as:

(Number of health facilities reporting that they have both documented  and adopted a protocol for the clinical management of SGBV survivors/Total number of health facilities surveyed) x 100

Data Requirements:

Verification by a health facility manager of staff who have participated in a training on the service provision for SGBV survivors within the past three years. Facilities with at least one staff member who has undergone such training are counted in the numerator.

Evaluators may want to disaggregate by sex.

Data Sources:

A survey of health units, with a query about staff participation in training on the provision of SGBV services.  The survey would ideally be part of a specific study on SGBV service delivery, such as the IPPF assessment. The survey could also be part of a more general study of health units and service provision. Either way, a probability sample of health units should be selected in order to assess the situation in the geographic area of interest.

Purpose:

This is an indicator of readiness for health units to provide SGBV services. Health professionals need institutional support, supervision, incentives, and training to address SGBV adequately. If staff have undergone no specific training, the provision of such services could be done in an inappropriate or detrimental manner. For various reasons, however, training providers has posed particular challenges. For example, many health professionals have not been trained to recognize violence against women as a public health issue, and they often share prejudices and misconceptions about SGBV common in the wider society (USAID, 2006).  Nonetheless, to increase support and care for SGBV survivors, training staff is an important step in improving access to and quality of services.

Issue(s):

It may be difficult to get accurate information on the participation of staff in training programs without interviewing each one. Even if the staff replies affirmatively, without knowing anything about the curriculum of the program, how intensive or long it was, this indicator may not tell us very much. It might be better to query staff about their own readiness to deliver services based on their training experience, which could be done using the module for the provider interview included in the IPPF Knowledge, Attitude and Practices Survey. In addition, the number of total providers in a facility should be considered, when interpreting this indicator. For example, one provider trained in a small facility with only five total providers would be a good ratio. If the facility was large and had only one provider trained out of 20, this would be only slightly better than no providers trained since a woman would have little chance of being seen by that provider. In addition, there would be no way to know if affected individuals were actually referred to that provider.

Furthermore, this indicator reflects training, but not the quality of the training, or how well the staff member integrated what they learned into practice.  It also does not indicate if it was a one-off training (which is generally insufficient for changing providers’ attitudes or practices) or if the training was ongoing.

Gender Implications:

People’s reactions to SGBV can be greatly influenced by personal and societal gender stereotypes.  These may include the belief that a woman who dresses provocatively is to blame for being sexually assaulted; it’s not rape if the couple is dating or is married; and women cannot be perpetrators of SGBV.  Training providers specifically in SGBV is essential for ensuring that clients’ needs are handled with sensitivity, compassion, and impartiality.

References:

Bloom S.  “Violence Against Women and Girls: A Compendium of Monitoring and Evaluation Indicators.”  USAID, IGWG, and MEASURE Evaluation, 2008.

International Planned Parenthood Federation. 2004. Improving the health sector response to gender-based violence: A resource manual for health care professionals in developing countries. IPPF/WHR Tools/02/September 2004. http://www.endvawnow.org/uploads/browser/files/Improving%20Health%20Sector%20Response%20to%20GBV:%20Resource%20Manual%20Dev%20Countries_English.pdf

IGWG, “Addressing Gender-based Violence Through USAID’s Health Programs: A Guide for Health Sector Program Officers”, Washington DC, July 2006.

Percent of health units that have documented and adopted protocol for the clinical management of SGBV services

Definition:

The percent of health facilities in the geographic region of study (e.g., country, region, community) that have a protocol in place for the clinical management of sexual and gender-based violence (SGBV) survivors that has been both documented and adopted. “Documented” means that staff should be able to show the protocol during an assessment. “Adopted” means that the health unit reports that they use it to guide practice.  Adopted protocols should include the care for male survivors in addition to the usual protocols.

This indicator is calculated as:

(Number of health facilities reporting that they have both documented and adopted a protocol for the clinical management of SGBV survivors/ Total number of health facilities surveyed) x 100

Data Requirements:

Health units (at any level: primary, referral or tertiary care) must be able to show a documented protocol outlining the procedures to be used for identifying, providing care for and referring SGBV survivors who present to the unit.  They should also be able to produce the protocols for care of male SGBV survivors, particularly if their current protocols exclude this.  Health unit staff should be able to state where they can access the protocol when they need to refer to it (e.g., it is posted somewhere, or kept in a place readily accessible to staff).  Units would be asked about the specific elements of clinical management, such as identification of affected women and girls, services to be provided, etc, as outlined in standard assessments such as IPPF, UNFPA, and SVRI. All health units that can answer the question affirmatively about policies and procedures and show a corresponding document are entered into the numerator.

If targeting and/or linking to inequity, classify outlets by location (poor/not poor).

Data Sources:

A survey of health units. The survey would ideally be part of a specific study on readiness of health units, using a tool such as the IPPF assessment.  The survey could be part of a more general study of health units and service provision. Either way, a probability sample of health units should be selected in order to assess the situation in the geographic area of interest.

Purpose:

Health service delivery programs are key in the prevention and response to SGBV. Every clinic visit made by a SGBV survivor presents an opportunity to address and ameliorate the effects of violence as well as help prevent future incidents. In order to take advantage of these opportunities, health facilities and providers need to be prepared to deliver appropriate services, including identification of survivors, necessary health services, counseling, and referrals to community-based resources such as legal aid, safe shelter and social services. This indicator measures whether or not a health unit has a standard protocol to guide the identification, service provision and referral mechanism for SGBV survivors. The protocol should describe the elements of care that should be provided, and the way in which it should take place. The protocol should be displayed or be otherwise accessible to health facility staff.

Issue(s):

Ideally we would want to measure how the protocol is implemented, but this would involve a complex assessment.  The IPPF, UNFPA and SVRI documents include examples of such an assessment of health unit readiness to deliver services to SGBV survivors, which includes questions pertaining to a protocol. This indicator should be considered as a single part of other indicators assessing how prepared health units are to deliver services.

Gender Implications:

Male survivors of SGBV are typically excluded from the discussion - and subsequently standards of practice - on SGBV.  It is important for evaluators to verify that health units have adopted protocols that include the care of this population as a step toward ensuring their needs are met.

References:

Bloom S.  “Violence Against Women and Girls: A Compendium of Monitoring and Evaluation Indicators.”  USAID, IGWG, and MEASURE Evaluation, 2008.

International Planned Parenthood Federation. 2004. Improving the health sector response to gender-based violence: A resource manual for health care professionals in developing countries. IPPF/WHR Tools/02/September 2004. http://www.endvawnow.org/uploads/browser/files/Improving%20Health%20Sector%20Response%20to%20GBV:%20Resource%20Manual%20Dev%20Countries_English.pdf

Stevens, L. 2002. ‘A practical approach to gender-based violence: A programme guide for health care providers and managers’ developed by the UN Population Fund. Int. J of Gyn & Obstet. 78 (Suppl. 1): S111-S117.

Sexual Violence Research Initiative. 2008. Assessment Instruments Used to Study Healthcare-Based Interventions for Women Who Have Experienced Sexual Violence. Available at: http://www.svri.org/sites/default/files/attachments/2016-04-13/Assessment%20Instruments%20Used%20to%20Study%20Healthcare.pdf 

Attitudes of health care providers towards SGBV survivors or services

Definition:

The attitudes of service providers towards women and men‘s socially prescribed sex-roles, the issue of sexual and gender-based violence (SGBV), the SGBV service they provide, and those who receive the services

Attitude is defined as a person‘s favorable or unfavor­able assessment of a behavior or situation.

Evaluators may want to disaggregate by sex.

Data Requirements:

Responses to surveys; transcripts from focus groups

Data Sources:

Interviews of service providers; and focus groups

Purpose:

The indicator identifies providers who hold victim-blam­ing, fatalistic, passive or other attitudes inconsistent with gender-sensitive quality of care. Illustrative examples of attitudes to measure are presented below. These individual-level provider attitudes are important to track because they constitute barriers to (1) reporting and seeking SGBV services and (2) the deliv­ery of sensitive and appropriate services.

This information demonstrates to donor agencies that the organization is providing the service compassionately and sensitively within the community.  In addition, the indicator reflects the quality of training that the organization provides to its health care providers.

Illustrative Attitudes to be Assessed among Health Care Workers for SGBV

  • Sex-stereotyping:

A woman must be a virgin when she marries;

A wife should never contradict her husband;

It is acceptable for women to have a career, but marriage and family should come first;

There is something wrong with a woman who does not want to marry and raise children;

Men always want and benefit from sex with women;

Men and boys are invulnerable to sexual exploitation; and

Sexual activity between a woman and a boy is always wanted by the boy.

  • Acceptance of interpersonal violence:

Being roughed-up is sexually stimulating and/ or a sign of a man‘s love for a woman;

Women will pretend that they do not want to have intercourse because they do not want to seem loose, but they are really hoping the man will force them;

A wife should move out of the house if her husband hits her;

A man is sometimes justified in hitting his wife;

Women are incapable of abuse;

Female perpetrators of abuse can never be as violent as men;

If a male is sexually abused by another male, he must be gay;

If a gay male or female is sexually abused by another of the same sex as themselves, they enjoy it.

Sources: Burt (1980) and Munro (2000).

  • Acceptance of homosexuality

Homosexuality is immoral;

Homosexual men molest children;

Somebody who is lesbian, gay, bisexual, or transgender (LGBT) is confused and doesn't know what they want;

To be bisexual implies that a person has multiple partners;

Homosexuals are promiscuous and do not develop long-term relationships;

People have a choice whether or not to be gay;

Mothers of gay individuals must have done something wrong in their parenting;

LGBTs can not be good parents;

Rape doesn't occur within the LGBT community.

 

Issue(s):

Attitudes can be revealed in one's tone, body language, speech, and actions.  Thus, it is highly subjective.  Evaluators should be cognizent of this when conducting interviews and focus groups - both in their own verbal and body language when they pose the questions and conduct the interviews as well as in how the responses are interpreted.

Traditionally, assessments of attitudes toward male or LGBT survivors of SGBV have been absent.  It is not enough to assume if there are or are not issues with providing services to these groups.  Asking health care providers specific questions about their attitudes toward these groups is an important component of this indicator.

Gender Implications:

People’s reactions to SGBV can be greatly influenced by personal and societal gender stereotypes.  These may include the belief that a woman who dresses provocatively is to blame for being sexually assaulted; it’s not rape if the couple is dating or is married; and women cannot be perpetrators of SGBV.  Training providers specifically in SGBV is essential for confronting and dealing with harmful attitudes toward SGBV survivors and ensuring that clients’ needs are handled with sensitivity, compassion, and impartiality.

References:

The Treatment Needs of Sexually Abused Men.  Kali Munro, 2000.  Available at: http://www.kalimunro.com/article_malesurclinical.html

Prevalence of SGBV among men and women

Definition:

Proportion of the population surveyed who have experienced sexual and gender-based violence (SGBV).  Depending on the study, this can be “ever experienced”, including when they were a child, or in a specific time period (i.e. past year).  Sexual violence is any violence, physical or psychological, carried out through sexual means or by targeting sexuality and includes:

Gender-based violence is a term describing any harm perpetrated against a person that results from unequal power relationships determined by social roles ascribed to males and females (Women’s Wellness Center, 2006). This encompasses a broad range of abuses, from physical and sexual assault to emotional and institutional abuse or the threat of such abuse.  For example:

This indicator is calculated as:

(Number of people who have experienced SGBV (in a specific time period)/ Total number of people surveyed ) x 100

Data Requirements:

“Yes” response to having experienced any of the forms of SGBV listed by the interviewer.  Data should be disaggregated by sex and can be disaggregated by type of SGBV experienced, relationship with perpetrator, current age of respondent, age when respondent first experienced SGBV, region, ethnicity, or other appropriate group (only if the sample size can support sub-group analysis). If the data is measured in a survey using a probability sample, this estimate can be generalized back to the target population (e.g. people living in a particular region).

Data Sources:

Special surveys.  In some instances this information can be gathered from clinic data if client SGBV history is gathered from both men and women. 

Note: Clinical data only reflects those who come to care, which is not representative of the actual problem.  It is well acknowledged that women who experience GBV often do not readily admit to having been abused when directly screened, and estimates of the rate of under-reporting range as high as 70% (Kothari C and Rhodes K, 2006) and may be higher in disaster settings.

Purpose:

This indicator measures the extent to which a given population has experienced SGBV by anyone – stranger, intimate partner, relative, etc.  When gathered, SGBV data is often collected from women and girls only. The inequality of power that is the foundation of SGBV, coupled with women’s inferior status in virtually all societies, makes women and girls the primary targets of SGBV around the globe.  However, SGBV is unfortunately not uncommon among boys and men as well, particularly among gay, bisexual, and transgender males, in conflict situations, and in communities where homosexuality is considered an aberration from the expectations of how men should behave.  In a South African study on sexual violence against men, about 1 in 10 men reported having experienced sexual violence by another man and about half of the male sexual violence survivors said they had raped a women.  The findings revealed that men's violence towards other men overlaps significantly with physical abuse of female partners (IRIN, 2011). Unless information is collected from both men and women and the full scope of SGBV is assessed, it will be difficult to structure programs to prevent and respond to the problem. 

Issue(s):

While it is useful to measure the prevalence of any form of SGBV, there are several concerns to consider related to both the way this information is obtained as well as to how the results are interpreted. A woman who experiences intimate partner violence or other violence may be endangered by participating in a study if her partner or another perpetrator discovers that she disclosed this information. The interview also needs to be conducted in a sensitive manner in order to protect the respondent as much as possible from experiencing distress if s/he discloses their experiences.  All research in this area should adhere to ethical guidelines which were established as standards to maintain safety and confidentiality. (See the WHO documents, “Ethical and safety recommendations for researching, documenting, and monitoring sexual violence in emergencies” and “Putting Women First: Ethical and Safety Recommendations for Research on Domestic Violence Against Women”, for examples.) In addition, data based on self-reports can be biased by any number of factors. 

Even after adhering to the ethical guidelines and providing a good setting in which to conduct interviews, there will always be some who will not disclose this information. This means that estimates will likely be lower than the actual level of violence which has taken place in the surveyed population. Under reporting may occur for many reasons, including cultural contexts where some types of violence perpetrated by intimate partners is viewed as normal, when someone fears reprisal upon disclosure, or where the level of stigma around such violence in the given society is high. Therefore, estimated levels of SGBV and the patterns associated with factors such as education and socio-economic status should be interpreted with caution (Bloom, 2008).

Gender Implications:

Because of the high prevalence of violence against women and girls globally, it is easy to forget that men and boys are victimized too and the prevalence of SGBV among males may be higher than previously thought.  SGBV against men and boys conflicts with male stereotypes of machismo. There is also a myth that women do not have the capacity to commit sexual violence atrocities despite prosecutions for such crimes. Policymakers and donors need to adjust societal paradigms of sexual violence and direct attention to female perpetrators and male survivors in regard to rehabilitation and justice. Furthermore, collecting data on SGBV prevalence reinforces the need to include men in sexual violence definitions and policies and consider the protections of men and boys by the United Nations as it has with women and children (Johnson et al., 2010).

References:

Johnson K, Asher J, Rosborough S, Raja A, Panjabi R, Beadling C, and Lawry L. “Association of Combatant Status and Sexual Violence with Health and Mental Health Outcomes in Postconflict Liberia,” JAMA (300) 2008: 676-690.

Women’s Wellness Center and The Reproductive Health Response in Conflict Consortium. Prevalence of Gender-Based Violence: Preliminary Findings from a Field Assessment in Nine Villages in the Peja Region, Kosovo, 2006.

Bloom S.  “Violence Against Women and Girls: A Compendium of Monitoring and Evaluation Indicators.”  USAID, IGWG, and MEASURE Evaluation, 2008.

Watts, C et al. Putting Women First: Ethical and Safety Recommendations for Research on Domestic Violence Against Women. Document WHO/FCH/GWH/01.1.  Geneva, World Health Organization. Available at: http://www.who.int/gender/violence/womenfirtseng.pdf

Johnson K, Scott J, Rughita B, Kisielewski M, Asher J, Ong R, and Lawry L. “Association of Sexual Violence and Human Rights Violations with Physical and Mental Health in Territories of the Eastern Democratic Republic of the Congo,” JAMA (304) 2010: 553-562.

WHO’s Ethical and safety recommendations for researching, documenting and monitoring sexual violence in emergencies.  WHO, 2007.  Available at: http://www.who.int/gender/documents/OMS_Ethics&Safety10Aug07.pdf

Kothari C and Rhodes K. “Missed opportunities: emergency department visits by police-identified victims of intimate partner violence,” Annals of Emergency Medicine, 47(2) 2006: 190-199.

IRIN PlusNEws. "South Africa: Sexual violence against men neglected."  October 20, 2011. 

Number of programs implemented for men and boys that include examining gender and culture norms related to SGBV

Definition:

The number of programs implemented in a country, region or community for men and boys that include activities aimed at examining and challenging men’s and boys’ gender and cultural norms related to sexual and gender-based violence (SGBV), in a specified time period.

With reference to cultural context, the following issues should be addressed and integrated into program curricula and/or activities:

All three issues must be included in the program or curricula to be counted.

Data Requirements:

The number of programs aimed at men and boys that includes curricula and activities aimed at changing men’s and boys’ views on the cultural acceptability of SGBV.  Disaggregate by program coverage (how many people participate), age, region.

Data Sources:

A survey of organizations implementing programs aimed at men and boys.

Purpose:

Addressing gender norms with men and boys has been shown to improve reproductive health outcomes for both women and men including a reduced incidence of HIV. This indicator is a measure of programmatic effort at raising awareness about, changing attitudes towards and changing behavior related to SGBV, particularly violence against women and girls. Programmatic efforts aimed at getting men and boys to be more aware of their own health issues as well as those of their partners have broadened to include the social issues underpinning those health outcomes. A good example is the Men as Partners program. Educating and listening to men and boys about masculinity and intimate partner and sexual violence combined with their participation in activities geared towards enhancing their understanding of how detrimental these issues are in their community will ideally influence changes in beliefs and actions.

Issue(s):

Large programmatic efforts may be fairly easy to identify, but smaller programs could be missed if they are implemented by smaller organizations. Coverage of the program is important to assess, since a large program in a country could target people in different regions and cover a larger population than several smaller programs.

References:

Bloom S.  “Violence Against Women and Girls: A Compendium of Monitoring and Evaluation Indicators.”  USAID, IGWG, and MEASURE Evaluation, 2008.

EngenderHealth & Planned Parenthood Association of South Africa (PPASA). 2001. Men as Partners: a program for supplementing the training of life skills educators. A program developed by EngenderHealth and the PPASA. www.engenderhealth.org/files/pubs/gender/ppasamanual.pdf