Gender-Based Violence – Magnitude and Types in Northwest Ethiopia

Introduction

Gender-Based Violence (GBV) refers to a broad category of unconsented actions (physical, sexual, or mental injury, threats, coercion, and abuse) motivated by distinctions between genders as male and female.¹ Most communities accept violent acts and perpetrators did not feel accountable for their crimes and kept violating other women. These practices also prevent women to use available services that she needs.²

The lifetime prevalence of GBV varies, from 11% to 47% in high-income countries and 16–47% in Africa. More than one-third (37%) of Ethiopian women experience the problem.³ Other studies also estimated that nearly 1 in 3 women experience physical/sexual intimate violence or non-partner sexual assault in their lifetime.⁴ Violence against Women (VAW) becomes a serious public health issue⁵ as it seriously affects survivors in the short- and long-term periods.⁶ WHO multi-country study found that VAW is more common in low- and middle-income countries (LMIC)⁷ and they face difficulties to provide the necessary care for survivors.⁸

GBV has psychological (post-traumatic stress, anxiety, and suicide);⁹ reproductive health-related (sexually transmitted infections, unplanned pregnancies, poor maternal health outcomes); and physical consequences.¹⁰ Women who experience violence have the possibility of experiencing it again and Intimate Partner Violence (IPV) survivors were more vulnerable. Individuals, families, communities, and the bigger socioeconomic and political circumstances contribute to VAW.¹¹ Risky sexual behaviors, homelessness, and having an orphaned teenager were characteristics associated with an individual or family.¹² Housemaids encounter various neglected health ailments from their employers other than the common forms of violence.¹³ Survivors had mental health problems like depression (44.9%) and anxiety (41.9%)¹⁴ as a result of sexual and physical abuse.¹⁴ Disruption of family relationships,¹⁵ peer pressure,¹⁶ family history of violence, and limited access to basic needs exacerbate GBV. In many societies, domestic violence has been accepted. Women were compelled to marry their abusers; forced to leave their home country, and endure other physical and sexual abuses along the way.¹⁷ VAW could also result from conflict and have an impact on the survivors’ overall health.¹⁸

GBV is now a common occurrence in Ethiopia, where the Amhara Region is home to many survivors and internally dsplaced populatons due to humanitarian crises. Women are exposed to violence and life-threatening situations daily due to human-made (political instability and ethnic- and religion-based conflict and war) and natural disasters, such as drought and flooding. The war impacted more than 10.6 million people and women children and the elderly were vulnerable health both directly (sexual violence massacre of civilians and displacement) and indirectly (lack of legal protection interruption of access to health care mental and psychological problems) are among the few. Unpublished regional reports showed that thirteen of the twenty-one zones were affected. Health facilities (50 hospitals 453 health centers and 150 health posts) were extensively damaged More than 720224 internally displaced persons are living in the region. Despite these circumstances, the burden, types, and effects of GBV are not well understood in the area. Our study sought to fill this knowledge vacuum and suggest strategies for the local GBV response and prevention actors and ensure the provision of quality survivors-centered care.

Methodology

Study Design and Setting,

Gondar Zone is bordered by neighboring countries and there is conflict due to ethnic, religious, land dominance, and border issues. The University of Gondar Comprehensive Specialized Hospital is located 735 km from the Northwest of the capital city, Addis Ababa. The hospital was established in 1954 to address locally available communicable diseases during the time. It serves for more than 13 million people and provides specialized and referral health services in all health disciplines including reproductive health, such as Gender-Based Violence in the catchment area. Currently, there are more than 960 beds and 30 wards/service delivery areas. In the hospital GBV services provided at Michu Clinic (Sexual and Reproductive Health service unit established in January 2017) under midwifery coordination offices. The service is provided by trained gynecologists and midwives. An institution-based retrospective study was conducted among women who visited the Hospital for GBV services.

Study Population and Sampling

All women who received GBV services during the study period were included, whereas those who had incomplete registration and lost medical records were excluded from our study.

Data Collection and Quality Control

A five-year of data (from January 2017 to January 2022- these periods were selected as the hospital started the services in an organized manner having separate dedicated rooms, register books and service providers) were collected from written GBV register logbooks and medical record books for some variables. The data was collected using a tool prepared by refereeing literature and adapting locally available resources and researchers’ experiences. A two-day training was given to two data collectors and one supervisor on the objective of the study, the confidentiality of participant records, and other issues. The collected data were assessed for accuracy and incomplete data were filled in by referring medical records of the participants. The tool was prepared in English and has socio-demographic variables, sexual characteristics, and questions on the type, consequences, and management of GBV services provided to the participants.

Data Management and Analysis

Data were entered into Epi-info 7 and exported to SPSS 23 for analysis. Descriptive statistics like frequencies, percentages, means and standard deviations are computed for all variables. The data was presented using tables and graphs.

Result

Socio-Economic and Obstetric Characteristics

In our study, out of 612 eligible women on the logbooks, 578 had complete and accurate data and the remaining were excluded due to incomplete data. More than two-fifths (43.8%) were between the ages 15–19 years, while sixty-one (10.6%) were below nine years old. About three-fifths (60.4%) were urban dwellers. Regarding their relationship, 529 (91.3%) were single, and nineteen (3.2%) were married. The majority of the survivors were students (89.8%), while fourteen (2.1%) were daily-laborer. Three hundred ninety-four (66.2%) had a regular menstrual pattern and were nulliparous (98.2%) (Table 1).

Table 1 Socio-Economic and Obstetric Characteristics of Study Participants in Northwest Ethiopia, 2022

Sexual Characteristics of the Respondents

About three-fifths (60.4%) were sexually active and forty-seven (8.1%) had experienced prior GBV. More than one-third (35.6%) of the incidents were performed in hotels/pensions and were performed by an intimate-partners (boyfriend/husband) (29.4%). More than one-third of the perpetrators (37.4%) were strangers and use (29.1%) alcohol, drugs, and knives at the time of the incident to threaten and/or weaken the survivors. Regarding sexual intercourse, almost all (98.8%) were through the vaginal route, and about three fourth (75.1%) of the survivors visited the health facility within threes day after the incident (Table 2).

Table 2 Sexual Characteristics Study Participants in Northwest Ethiopia, 2022

Magnitude of GBV

Nearly three-fourth (122) of the incidents occurred in the year 2020 (Figure 1). The lifetime proportion of sexual and physical violence was 81% and 5%, respectively, while 3% of women experienced both forms. The majority (86%) had extra-genital injuries and experienced painful examinations (68%). After genital examination, about one-fourth (25%) had fresh hymenal tears, and overall positive laboratory results (including HIV/AIDS, sperm analysis, and pregnancy tests) were found in 4% of the survivors (Table 3).

Table 3 Consequences of GBV on Survivors in Northwest Ethiopia, 2022

Figure 1 Number of GBV survivors disaggregated by year of Incident in Northwest Ethiopia 2023.

Management/Treatments Provided for GBV Survivors

GBV management includes interventions for immediate emergencies and wound care; provision of prophylaxis for prevention of pregnancy, sexually transmitted infections (STIs), and wound infections (if occurred); and vaccination for Hepatitis B and other locally available vaccines. In our study, 54 (9.3%) of the survivors received wound care and broad-spectrum antibiotics. More than half (52.8%) received contraceptives, majorly (62%) emergency pills, for the prevention of pregnancy.

Regarding Sexually Transmitted Infections, three hundred seventy (64%) received prophylaxis. Three hundred forty-seven (60%) were eligible for post-exposure prophylaxis for HIV/AIDS and provided with 1E Regimen- TDF-3TC-EFV, while eight (1.4%) received the Hepatitis B virus vaccine after checking their negative status.

All the survivors got psychological counseling from a clinical psychologist and about one-fourth (25.6%) were linked to legal and economic support (Table 4).

Table 4 Management and/or Treatments Provided for GBV Survivors in Northwest Ethiopia, 2022

Discussion

Nowadays GBV becomes common to everyone and everywhere irrespective of their differences in terms of multiple aspects. The magnitude of the problem is the a hidden iceberg and conducting studies assessing the magnitude of the different forms could have an input on all the efforts of prevention and responses. The Ethiopian government also prepared a Standard Operating Procedure for the response and prevention of sexual violence in Ethiopia and our study investigated the burden of the problem and comprehensive responses to the psychological, medical, social, and legal needs of GBV survivors after the launching of this guideline¹⁹ and purposed to deliver evidence for policy input.

The percentage of sexual violence and physical violence was 81% and 5%, respectively. Our finding was higher than other studies conducted in different areas of Ethiopia²⁰ and other countries.²¹ This implies how prevalent the problem is and still women are at risk of sexual and physical assault, as well as having limited political and social sway. Additionally, in the region most of the community accepts male dominance over females as a cultural norm/practice, creating an unfavorable environment and devaluing women’s preferences, and exposed to different reproductive health problems.²² Furthermore, early marriage, the low educational status of women and men, and a lack of community awareness regarding earlier prevention of violence might contribute to the observed findings in our study area.²³ In this study, the majority (86%) of survivors of violence reported extra genital injuries, and 68% of survivors had painful examinations. After genital inspection, one-fourth (25%) of the survivors had recent/fresh hymenal tears. The occurrence of such additional injuries may have further effects, and an individual’s sense of self and self-esteem can be seriously damaged, which may have a further psychological impact. According to reports, young people who experience psychological abuse “feel worthless, broken, rejected, undesired, or in danger”.^24,25 Conflict, post-conflict, and displacement scenarios now in Ethiopia could increase current violence and introduce new types of VAW.

WHO recommends the provision of care and support as early as possible, including prophylaxis within 72 hours for prevention of pregnancy and HIV/AIDS and the provision of locally available vaccines for Hepatitis B Virus and Tetanus Toxoid.²⁶ In our study, about one-fourth (24.9%) of the survivors were not able to visit the health facility within threes day after the incident and miss the aforementioned prophylaxis. This will have an impact on the women’s reproductive health life’s and necessitate to have a strong referral and linkage between the different healthcare levels and community networks. Moreover, only eight (1.4%) received vaccines for Tetanus Toxoid and Hepatitis B Virus. This indicates the existence of disorganized and disintegrated service delivery and a gap in vaccination coverage for GBV survivors and has to be accessible and affordable to break the afterward sequel and violates the guiding principles.¹⁹

More than one-third (35.6%) of the incidents were performed in hotels/pensions by an intimate-partners (boyfriend/husband) (29.4%). This indicates the need to identify stakeholders for GBV response and prevent locally available means of committing violence against women, which include police, social welfare, women and children affairs, justice, community representatives, professional associations, and GBV actors. These stakes need to intervene on supportive laws and regulations, places, times/seasons, and other circumstances, which have contributed factors to the occurrence of violence.

In this study, the majority (62%) of the survivors received emergency medications, and prophylaxis to prevent pregnancy (52.8%). Clinical psychologists provided psychological therapy and support to all survivors, and about one-fourth (25.6%) were connected with other psychosocial supports like legal and financial aid. However, a lack of resources frequently led to people being placed on lengthy waiting times, making prompt early intervention particularly challenging. As a result, women received care when they were in immediate danger and life-threatening conditions. The short-term nature of funding was also detrimental to establishing and preserving relationships with survivors and hindered organizations’ ability to expand and continue to create successful programs. This was evident in that vaccination coverage for Hepatitis B Virus and Tetanus Toxoid was very low (1.4%) due to frequent interruptions of supplies.

Conclusion and Recommendations

GBV is prevalent in North West Ethiopia, and it is a public health and human rights problem. We suggest that research may be most fruitful where it involves sensitive methods and grounded approaches that listen to survivors’ accounts of their experiences and views on local gender cultures and other relevant contextual factors. In addition, effective community networks served as both enablers and barriers to support survivors, demonstrating the importance of strong linkages between health facilities and communities. Establishing fully equipped and supplemented One-Stop-Centers (OSC) for GBV survivors in the hospital could help to provide survivor-centered care and solve unnecessary delays in receiving timely care - to meet the recommended standards - and facilitate the legal process as they are integrated and provided under one roof. Regional Health Bureaus also better to work with the community and other stakeholders working in the area to tackle GBV facilitators in the society at regional level.

Strengths and Limitations of the Study

The study shares the limitations of cross-sectional study design and secondary data collection and under-reporting of data might exist. The study also did not explore survivors’ experiences in the facility. Manual register logbooks also lack data on other forms of GBV. The unavailability of an Electronic version of data registration was a challenge during the data collection process and the reasons were not assessed by the authors. The study also did not assess the legal aspects of the services.