Strengthening Health System Responses to Gender-based Violence in Eastern Europe and Central Asia

A resource package

Defining Gender-Based Violence

Gender-based violence (GBV) or violence against women (VAW)?

The programmatic package available on this website uses the term gender-based violence (GBV).

“Gender-based violence (GBV) is the general term used to capture violence that occurs as a result of the normative role expectations associated with each gender, along with the unequal power relationships between the two genders, within the context of a specific society.” (Bloom 2008, p14).

While women, girls, men and boys can be victims of GBV, the main focus of this resource package is on violence against women and girls.

This is not to say that gender-based violence against men does not exist. For instance, men can become targets of physical or verbal attacks for transgressing predominant concepts of masculinity, for example because they have sex with men. Men can also become victims of violence in the family – by partners or children. (Bloom 2008, p14)

However, it has been widely acknowledged that the majority of persons affected by gender-based violence are women and girls, as a result of unequal distribution of power in society between women and men. Further, women and girls victims of violence suffer specific consequences as a result of gender discrimination. As summed up by UNFPA:

The primary targets of GBV are women and adolescent girls, but not only are they at high risk of GBV, they also suffer exacerbated consequences as compared with what men endure. As a result of gender discrimination and their lower socio-economic status, women have fewer options and less resources at their disposal to avoid or escape abusive situations and to seek justice. They also suffer (…) consequences [on their sexual and reproductive health], including forced and unwanted pregnancies, unsafe abortions and resulting deaths, traumatic fistula, and higher risks of sexually transmitted infections (STIs) and HIV.” (UNFPA Strategy and Framework for Action to Addressing GBV, 2008-2011, p. 7)


Definitions of GBV/VAW under international human rights law

For a long time, international human rights law has been silent on the issue of GBV/VAW. This is because until the late 1980s/early 1980s, VAW, in particular domestic violence, was not considered a matter to be dealt with by human rights law. For instance, the UN Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) adopted in 1979 – the major UN women’s rights treaty – does not contain a provision on violence against women. This gap was closed in 1992, when the CEDAW Committee, the body responsible for monitoring the implementation of CEDAW, adoptied General Recommendation No. 19 on VAW (GR 19). In this document the Committee clarifies that GBV against women is a form of discrimination and therefore covered by the scope of CEDAW. GBV is defined as “violence that is directed against a woman because she is a woman or that affects women disproportionately”, thereby underlining that violence against women is not something occurring to women randomly, but rather an issue affecting them because of their gender. Further, GBV is defined as including “acts that inflict physical, mental or sexual harm or suffering, threats of such acts, coercion and other deprivations of liberty.” GR 19 also specifies that GBV may constitute a violation or women’s human rights, such as the right to life, the right to equal protection under the law; the right to equality in the family; or the right to the highest standard attainable of physical and mental health. (Source: CEDAW General Recommendation No. 19 on VAW). For more information on CEDAW, please refer to the handout atthe bottom of the page.

The UN Declaration on the Elimination of Violence against Women (DEVAW) adoptedby the UN General Assembly in 1993 has been influenced by CEDAW General Recommendation No. 19. It defines VAW as: “Any act of gender-based violence that results in, or is likley to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivations of liberty, whether occurring in public or in private life.” (Article 1) The declaration encompasses all forms of gender-based violence against women (physical, sexual and psychological), no matter in which context or setting they occur:

  • in the family (such as  battery, marital rape; sexual abuse of female children; dowry-related violence; ; female genital mutilation/cutting and other traditional practices harmful to women);
  • in the general community (such as rape, sexual harassment and intimidation at work, in school and elsewhere; trafficking in women; and forced prostitution), and
  • violence perpetrated or condoned by the state, wherever it occurs (Article 2). 

Further, DEVAW specifies that violence against women is a manifestation of unequal power relationships between men and women and a violation of women’s human rights (preamble). Article 3 lists examples of these rights, such as the right to life, the right to equality, the right to the highest standard attainable of physical and mental health, or the right not to be subjected to torture, or other inhuman or degrading treatment or punishment. (Source: 1993 UN Declaration on the Elimination of Violence Against Women).

Both, CEDAW GR 19 and DEVAW explicitly encompass violence perpetrated by either, state officials or private persons such as family members, acquaintance or employers. In doing so, they close an important gap under international human rights law which originally excluded from the human rights agenda the so-called private sphere in which many women’s rights violations occur. The Beijing Platform for Action adopted in 1995furtherexpanded on the definition of DEVAW to include: violations of the rights of women in situations of armed conflict, including systematic rape, sexual slavery and forced pregnancy; forced sterilization, forced abortion, coerced or forced use of contraceptives; prenatal sex selection; and, female infanticide. It further recognized the particular vulnerabilities of women belonging to minorities; the elderly and the displaced; indigenous, refugee and migrant communities; women living in impoverished rural or remote areas, or in detention. 1995 Beijing Platform for Action

Exercise: Behavioral aspect of violence against women(15 Minutes)
For the trainer: Ask participants to use the definitions and then to list out 2-3 examples of physical gender-based violence that they have heard about or seen in their practice as health care professionals.
Keep the emphasis on physical abuse at this point. This exercise about physical abuse gives participants a place to begin to ground the concepts they heard in the discussion of definitions.

Depending on the amount of time available for this exercise, trainers may want to either facilitate a discussion in the bigger group or split up participants in small groups and ask them to then report back to the bigger group.


Forms of GBV

Following the discussion on the definitions of gender-based violence, it is important also to discuss both, physical and non-physical forms of violence. Following is a list of examples, what categories of  violence occur and what forms they might take. The trainer might show the powerpoint slides showing the main categories and ask the participants to come up with examples for each category. At this stage it is important for the participants to understand the complexity of the situation of survivors when different forms of violence are used against them. There is also a handout available at the bottom of this page; this can be handed out after the collective brainstorming.

Forms of violence against women

Domestic violence

Domestic violence is not an isolated, individual event, but rather a pattern of perpetrator behaviors used against a survivor. The pattern consists of a variety of abusive acts, occurring in multiple episodes over the course of the relationship. Some episodes consist of a sustained attack with one tactic repeated many times (e.g., punching), combined with a variety of other tactics (such as name calling, threats, or attacks against property). Other episodes consist of a single act (e.g., a slap, a “certain look”). One tactic (e.g., physical assault) may be used infrequently, while other types of abuse (such as name calling or intimidating gestures) may be used daily. Some parts of the pattern are crimes in most countries (e.g., physical assault, sexual assault, menacing, arson, kidnapping, harassment) while other battering acts are not illegal (e.g., name calling, interrogating children, denying the survivor access to the family automobile). All parts of the pattern interact with each other and can have profound physical and emotional effects on survivors. Survivors respond to the entire pattern of perpetrators’ abuse rather than simply to one episode or one tactic.

Physical violence

Physical abuse may include spitting, scratching, biting, grabbing, shaking, shoving, pushing, restraining, throwing, twisting, slapping (with open or closed hand), punching, choking, burning, and/or use of weapons (e.g., household objects, knives, guns) against the survivor. The physical assaults may or may not cause injuries.

Sexual violence

Sexual violence can take many forms and take place under very different circumstances. A person can be sexually violated by one individual or several people (e.g. gang-rapes); the incident may be planned or a surprise attack. Although sexual violence occurs most commonly in the survivor's home (or in the perpetrator’s home), it also takes place in many other settings, such as the workplace, at school, in prisons, cars, the streets or open spaces (e.g. parks, farmland). The perpetrator of a sexual assault may be a date, an acquaintance, a friend, a family member, an intimate partner or former intimate partner, or a complete stranger, but more often than not, is someone known to the survivor. There is no stereotypical perpetrator; sexually violent men come from all backgrounds, rich and poor, academic and uneducated, religious and non-religious. Perpetrators may be persons in positions of authority who are respected and trusted (e.g. a doctor, teacher, tourist guide, priest, police officer) and thus less likely to be suspected of sexual violence. Sexual violence is common in situations of war and armed conflict. Specifically, rape and sexual torture are frequently used as weapons to demoralize the enemy; women are sometimes forced into “temporary marriages” with enemy soldiers. Women who are incarcerated may be subjected to sexual violence by prison guards and police officers. Other forms of sexual violence include, but are not limited to:

  • sexual slavery
  • sexual harassment (including demands for sex in exchange for job promotion or advancement or higher school marks or grades)
  • trafficking for the purpose of sexual exploitation
  • forced exposure to pornography
  • forced pregnancy
  • forced sterilization
  • forced abortion
  • forced marriage
  • female genital mutilation
  • virginity tests
  • incest

(WHO Guidelines for Medico-legal care of victims of Sexual Violence)

Psychological violence

There are different types of psychological assaults.

Threats of violence and harm

The perpetrator’s threats of violence or harm may be directed against the survivor or others important to the survivor or they may be suicide threats. Sometimes the threat includes killing the victim and others and then committing suicide. The threats may be made directly with words (e.g., “I’m going to kill you,” “No one is going to have you,” “Your mother is going to pay,” “I cannot live without you”) or with actions (e.g., stalking, displaying weapons, hostage taking, suicide attempts).

Emotional violence

Emotional abuse is a tactic of control that consists of a wide variety of verbal attacks and humiliations, including repeated verbal attacks against the survivor’s worth as an individual or role as a parent, family member, friend, co-worker, or community member. In domestic violence, verbal attacks and other tactics of control are intertwined with the threat of harm in order to maintain the perpetrator’s dominance through fear. While repeated verbal abuse is damaging to partners and relationships over time, it alone does not establish the same climate of fear as verbal abuse combined with the use or threat of physical harm. The presence of emotionally abusive acts may indicate undisclosed use of physical force or it may indicate possible future domestic violence.

Emotional abuse may also include humiliating the victim in front of family, friends or strangers. Perpetrators may repeatedly claim that survivors are crazy, incompetent, and unable “to do anything right.” Not all verbal insults between partners are acts of violence. In order for verbal abuse to be considered domestic violence, it must be part of a pattern of coercive behaviours in which the perpetrator uses or threatens to use physical force.


Perpetrators often try to control survivors’ time, activities and contact with others. They gain control over them through a combination of isolating and disinformation tactics. Isolating tactics may become more overtly abusive over time. Through incremental isolation, some perpetrators increase their psychological control to the point where they determine reality for the survivors. Perpetrators’ use of disinformation tactics such as distorting what is real through lying, providing contradictory information, or withholding information is compounded by the forced isolation of the survivors. For example, perpetrators may lie to survivors about their legal rights or the outcomes of medical interventions. While many survivors are able to maintain their independent thoughts and actions, others believe what the perpetrators say because the survivors are isolated from contrary information. Through his survivor’s isolation, the perpetrator prevents discovery of the abuse and avoids being held responsible for it.

Use of children

Some abusive acts are directed against or involve children in order to control or punish the adult victim (e.g., physical attacks against a child, sexual use of children, forcing children to watch the abuse of the survivor, engaging children in the abuse of the survivor). A perpetrator may use children to maintain control over his partner by not paying child support, requiring the children to spy, requiring that at least one child always be in the company of the survivor, threatening to take children away from her, involving her in long legal fights over custody, or kidnapping or taking the children hostage as a way to force the survivor’s compliance. Children are also drawn into the assaults and are sometimes injured simply because they are present (e.g., the victim is holding an infant when pushed against the wall) or because the child attempts to intervene in the fight.

Economic Violence

Perpetrators control survivors by controlling their access to all of the family resources: time, transportation, food, clothing, shelter, insurance, and money. It does not matter who the primary provider is or if both partners contribute. He may actively resist the survivor becoming financially self-sufficient as a way to maintain power and control. Conversely, he may refuse to work and insist that she support the family. He may expect her to be the family “bookkeeper,” requiring that she keep all records and write all checks, or he may keep financial information away from her. In all instances he alone makes the decisions. Survivors are put in the position of having to get “permission” to spend money on basic family needs. When the survivor leaves the battering relationship, the perpetrator may use economics as a way to maintain control or force her to return: refusing to pay bills, instituting legal procedures costly to the survivor, destroying assets in which she has a share, or refusing to work “on the books” where there would be legal access to his income. All of these tactics may be used regardless of the economic class of the family.

Source: Ganley, Anne L. (1998);  Improving the Health Care Response to Domestic Violence: A Resource Manual for Health Care Providers

Gender-based violence through the lifecycle

Violence against girls and women occurs at different points in their lifecycle. Many women experience multiple episodes of violence that may start in the prenatal period and continue through childhood to adulthood and old age. The table describes violence that may be experienced at different points in a girl's/woman's lifecycle. The lifecycle approach to gender-based violence helps one understand the cumulative impact of violence experienced by girls and women, especially in terms of its physical and mental health consequences.
Source: WHO 2005, Integrating Poverty and Gender into Health Programmes: A Sourcebook for Health Professionals, p. 5-6

Violence and the female lifecycle