VIOLENZA BASATA SUL GENERE Prevalenza, conseguenze sulla salute e interventi Heidi Stöckl, PhD Gender Violence & Health Centre Social & Mathematical Epidemiology Group London School of Hygiene and Tropical Medicine Tavistock Place, London WC1H 9SH,

Prevalenza: nel mondo 1 donna su 3 subisce violenze fisiche o sessuali da un partner o violenze sessuali da un altro uomo (non partner)

Misurare la violenza del partner IPV Intimate Partner Violence Violenza fisica – Schiaffeggiare la donna o gettare oggetti su di lei – Darle spintoni – Prenderla a pugni o colpirla con qualcosa – Prenderla a calci, picchiarla – Soffocarla o bruciarla deliberatamente – Minacciarla con pistola, coltello o altre armi o colpirla con un’arma Violenza sessuale – Forzarla ad avere un rapporto sessuale che non desidera – Forzarla a fare qualcosa che trova umiliante o degradante – La donna accetta un rapporto sessuale perché ha paura di quel che l’uomo potrebbe fare

L’autore più probabile di violenza sulle donne è il partner Source: WHO Multi-Country Study on Domestic Violence and Women’s Health 2005

In molti contesti, la violenza fisica del partner è più frequente della violenza sessuale Source: WHO Multi-Country Study on Domestic Violence and Women’s Health 2005

Violenza fisica e sessuale dal partner in Europa Source: Fundamental Rights Agency (FRA) 2013

Violenza psicologica dal partner in Europa Source: Fundamental Rights Agency 2013

Stalking in Europa Source: Fundamental Rights Agency 2013

La prevalenza della violenza fisica in gravidanza Nel mondo: 1-28% (WHO-Multicountry Study, DHS, IVAWS) – >90% degli aggressori è rappresentato dal padre del bambino – ¼-1/2 delle donne dicono di essere state picchiate o presi a calci nell‘addome – Associata con gravi violenze dal partner durante la vita

Violenza in gravidanza in Europa – un‘istantanea Belgio, reparto maternità (n=200): 11,0 %; 6% IPV fisica o sessuale (Jeanjot 2008) Belgio, 5 ospedali (n=537): 2,4% IPV fisica o sessuale (Roelens 2008) Danimarca, reparto maternità (n= 2652), 2.5% violenza fisica o psicologica(Finnbogadóttir 2011) Germany, reparto maternità (n=401), 2%; 1% violenza fisica and 1% sessuale (Stöckl et al 2010) Italia, reparto maternità (n=438): 2,5 violenza psicologica; 0,9, violenza fisica (Romito et al 2009) Portogallo, reparto maternità (2660): 9,7% violenza fisica(Rodrigues 2008) Turchia, Centro di salute (n=580 urban, n=244 rural) : 31.7 %; 8.1% violenza fisica, 9.7% sessuale and 26.7% psicologica(Karaoglu et al 2005) Turchia, ospedale (n=214): 4,7%; 3.4% violenza sessuale; 3.8% hanno paura del partner (Ergönen 2009)

Prevalenza della violenza dal partner (IPV) durante la gravidanza in Gran Bretagna Circa il 3% delle donne subisce violenza dal partner durante la gravidanza in corso (Bacchus et al 2003; Johnson 2003) La prevalenza della violenza dal partner in gravidanza aumenta se la domanda viene fatta ripetutamente : 1.8% alla prima visita, 5.8% a 34 settimane di gravidanza e 5.0% 10 giorni dopo il parto (Bacchus et al 2004) Le proporzioni di IPV sono addirittura più elevate nel periodo dopo il parto : - 18 settimane di gravidanza: 1% violenza fisica, 4.8% violenza psicologica - 33 mesi dopo il parto: 2.9% fisica, 10.8% psicologica

Nel mondo, almeno il 38% degli omicidi di donne, il 5% degli omicidi di uomini, e il 14% di tutti gli omicidi, sono compiuti da un partner Source: Stöckl et al, The Lancet 2013

Trends dell’insieme degli omicidi, e di quelli da partner, negli Stati Uniti – l’insieme degli omicidi è dominato dagli omicidi compiuti da uomini…

Negli anni, sono fortemente diminuite le vittime maschili. Molto meno le vittime femminili

In Gran Bretagna, si può osservare una tendenza simile

Conseguenze sulla salute della violenza da partner (IPV)

Physical Health and Functional disorders Injury, Functional impairment, physical symptoms, poor subjective health, disability, chronic pain syndromes, Irritable bowel syndrome, gastrointestinal disorders, Somatic complaints, fibromyalgia Physical Health and Functional disorders Injury, Functional impairment, physical symptoms, poor subjective health, disability, chronic pain syndromes, Irritable bowel syndrome, gastrointestinal disorders, Somatic complaints, fibromyalgia Reproductive Health Unwanted pregnancy, STIs/HIV, gynaecological disorders, unsafe abortion, pregnancy complications, miscarriage/low birth weight, pelvic inflammatory disease Reproductive Health Unwanted pregnancy, STIs/HIV, gynaecological disorders, unsafe abortion, pregnancy complications, miscarriage/low birth weight, pelvic inflammatory disease Mental health and injurous health behaviours Post traumatic stress, depression, anxiety, phobias/panic disorders, eating disorders, sexual dysfunction, low self- esteem, mental distress, substance abuse disorders, smoking, alcohol and drug use, sexual risk-taking, physical inactivity Mental health and injurous health behaviours Post traumatic stress, depression, anxiety, phobias/panic disorders, eating disorders, sexual dysfunction, low self- esteem, mental distress, substance abuse disorders, smoking, alcohol and drug use, sexual risk-taking, physical inactivity Direct and indirect fatal outcomes Homicide, suicide, maternal mortality, AIDS-related Direct and indirect fatal outcomes Homicide, suicide, maternal mortality, AIDS-related Physical Health and Functional disorders Reproductive Health Mental health and injurous health behaviours Direct and indirect fatal outcomes

WHO Multi-Country Study-Studio multicentrico dell’OMS L’IPV aumenta il rischio di pensieri suicidi e di tentati suicidi Source: WHO Multi-Country Study on Domestic Violence and Women’s Health 2005 “Three suicidal outcomes were included in this analysis: suicidal thoughts in the past four weeks, ever thinking about suicide, and ever attempting suicide (asked of those who had ever thought about it). In Ethiopia, data on lifetime thoughts and attempts were not available for analysis.“

Devries et al 2013 Addiction Evidenze da studi longitudinali Violenza da partner (IPV) e consumo di alcool

Devries et al 2013 Addiction Evidenze da studi trasversali

Source: Buler et al 2013 Plos Medicine Effetti sulla salute e comporta- menti sessuali a rischio in “MSM” (uomini che hanno rapporti sessuali con uomini), vittime di violenza del partner

I costi della violenza sono enormi In Francia, la “violenza domestica” costa 2.5 bilioni di Euro / anno 1 donna uccisa ogni 3 giorni.  483 milioni di Euro per cure sanitarie  355 milioni di Euro per servizi sociali e giudiziari  1099 milioni di Euro per perdite produttive per causa di morte, detenzione in carcere, assenteismo  535 milioni di Euro per i costi umani dello stupro

Violenza del partner e maltrattamento sui bambini >70% of abused womenhave children Co-occur in time, space and family Similar risk factors Similar health outcomes Child abuse is a risk factor for intimate partner violence

Conseguenze sulla salute dell‘IPV in gravidanza Intimate partner violence Antenatal & Delivery Care Antenatal risk behaviour Direct trauma Infant & toddler care Physical and mental health Child outcomes (a selection) Low birth weight Fetal death Abortion and miscarraige Insufficient child nutrition Child abuse potential Higher levels of anxiety Lack of attachment Increased risk of emotional, physical and sexual abuse Bed wetting Lower levels of breastfeeding Asthma Obesity Underimmunization Conduct problems...and many more Child outcomes (a selection) Low birth weight Fetal death Abortion and miscarraige Insufficient child nutrition Child abuse potential Higher levels of anxiety Lack of attachment Increased risk of emotional, physical and sexual abuse Bed wetting Lower levels of breastfeeding Asthma Obesity Underimmunization Conduct problems...and many more Fetal growth and pregnancy complications

Fattori di rischio della violenza del partner Source: Heise 2013: What works

OGNI DONNA UOMO E BAMBINA/O, HA IL DIRITTO DI ESSERE LIBERA DA OGNI TIPO DI VIOLENZA GRAZIE!

Health care worker intervention

Promising interventions: ANC counselling 30 minutes counselling intervention by ANC provider Reduce s psychological abuse, minor physical abuse and depression Evaluations in progress also measure child outcomes (e.g. attachment, immunization) Intervention content: -Acknowledge abuse and state that it is wrong -Evaluating danger -Cyclical nature of intimate partner violence -Developing safety strategies -Discussing options -Available resources -Emphatic listening Inquiry for IPV during ANC Abused women receive intervention

Promising intervention: MOZAIC: Health sector approach Multi-agency intimate partner violence service at Guy‘s and St Thomas UK Women who report intimate partner violence : – have the abuse documented confidentially in their records – are referred to an advocacy service – receive information on resources Source: Bacchus et al Reproductive Health Matters

Programme for first time mothers of low socio-economic status Sucessfully reduces child maltreatment Does not work with women who experience intimate partner violence Intimate partner violence module has been developed Similar programmes exist in Europe that can be build on – midwives and nurse home visits Promising interventions: Nurse Family Partnership Source: Jack et al BMC Health Services Research

Source: Colombini M, Mayhew SH, Ali SH, Shuib R, Watts C. An integrated health sector response to violence against women in Malaysia: lessons for supporting scale up. BMC Public Health 2012; 12(1): 548. Knock-on effects of challenges across levels

Defining the health sector response to domestic violence Improving health worldwide Create a safe & confidential environment for… Medical management of violence at point of first contact Confidential documentation of violence in medical records Develop referral pathways to support services Identification

Calendar that gives questions health care providers can ask when women present with specific issues

One sided information for health care providers on how to conduct screening and refer patients- RADAR Intervention

Poster displayed at the toilet of an antenatal care clinic in London where urine samples are collected

Source: WHO