Primary Health Care Gender-Based Violence Training

Module 1: Introduction to Gender-Based Violence

In this module, you’ll learn about gender-based violence (GBV): how common it is globally and in South Africa, its causes and risk factors, and common myths about it. The module will also cover the consequences of GBV for individuals and communities.

Learning Objectives

By the end of this module, you will be able to:

Define “gender-based violence” (GBV), “sexual gender-based violence” and “intimate partner violence”.
Describe the rates of GBV globally and in South African communities.
Identify the causes and risk factors of GBV.
List the common myths around GBV and effects on survivors.
Describe consequences and outcomes of GBV.
Describe the rates and effects of child abuse in South Africa.
Explain the importance of the public health sector in addressing GBV.

Learning Activities

Reading: Lindiwe (5 min)

You are the staff nurse at Thaba Thusang PHC. One Friday morning, a woman, about 40 years of age, enters with a friend. She appears exhausted, distressed, and in shock. Her friend also appears upset. The patient, Lindiwe, has bruises on the side of her face and her hair is a mess. Her clothes, while clean, appear put on haphazardly.

You watch as she registers with the reception. A short while later, you receive Lindiwe in the exam room. As she sits down, her friend blurts out, “You must help my friend—she was attacked by a stranger last night!”

Take a moment to reflect. What would you do next to help Lindiwe? What exams, services, and referrals would you offer to her? What kind of questions will you ask and how will you ask them?

This training will give you the knowledge and skills you need to be able to provide respectful, effective, quality care for Lindiwe and survivors of gender-based violence.
Reading: What Is Gender-Based Violence? (10 min)
Gender-Based Violence

Gender-based violence is an umbrella term for any harm that is done against a person’s will, or without consent, as a result of unequal power based on gender roles.¹ A person has not consented if they have been intimidated, forced or threatened in any way, compelled by someone who abuses their power or authority, or is asleep, unconscious, under the influence of drugs or alcohol, under the age of 12, or has a mental disability.^2,3

Most gender-based violence is committed by men against women, but it is important to recognize that men and boys can also be survivors of gender-based violence. Gender-based violence can be physical, sexual, psychological, economic, or socio-cultural. Those who commit gender-based violence can be family members, community members, religious leaders, people working in the health or education systems, and people working in government institutions. Anyone can be a survivor of gender-based violence, and anyone can be a perpetrator of gender-based violence.

In this training, we’ll focus on care and services for survivors of IPV and sexual gender-based violence.

Sub-categories/important concepts for gender-based violence:

Click or tap on each term to read its definition.
Intimate Partner Violence

Rape & Sexual Assault

Emotional/ Psychological Abuse

Child Abuse & Child Sexual Abuse
Intimate Partner Violence

Intimate partner violence (IPV) is actual or threatened physical or sexual violence or psychological and emotional abuse directed toward a spouse, ex-spouse, current or former boyfriend or girlfriend, or current or former dating partner. Intimate partners can be of the same or opposite sex.⁴

Rape & Sexual Assault

South African law defines sexual assault as the sexual violation of another person without their consent. This includes genital contact without penetration, sexual contact with the mouth, and making someone believe that they will be sexually violated.⁵ A more general definition of sexual assault also includes forcing a woman to have sex without protection from pregnancy or sexually transmitted infection, including HIV.

In South Africa, rape is defined as the penetration of a person’s genitals, anus, or mouth, without their consent. Included in this definition is penetration by a person’s genitals, by any part of an animal, or by an object. Rape can occur between a husband and wife; this is called marital rape and it is illegal in South Africa.⁶

Emotional/Psychological Abuse

Emotional or psychological abuse is when someone subjects or exposes another person to behaviour that may result in psychological trauma, including anxiety, chronic depression, or post-traumatic stress disorder. These behaviours include ongoing criticism, threatening to hurt a survivor or their family members, threatening to destroy things they cares about, humiliating them in public or in front of family and friends, calling them names, telling them they are ugly or stupid, isolating them from friends and family, and exhibiting controlling behaviors (insisting on knowing where they are at all time, often being suspicious, leaving them without money for basic expenses, etc.). Emotional and psychological abuse can be committed by a spouse, partner, friend, co-worker, parent or other family member, or acquaintance.

Child Abuse & Child Sexual Abuse

Child maltreatment, sometimes referred to as child abuse and neglect, includes all forms of physical and emotional ill-treatment, sexual abuse, neglect, and exploitation that results in actual or potential harm to the child’s health, development or dignity. Within this broad definition, five subtypes can be distinguished – physical abuse; sexual abuse; neglect and negligent treatment; emotional abuse; and exploitation (WHO, 2013).
More terms and definitions are in the glossary in the resources section.
Quiz: Knowledge Check (5 min)

Match the following terms to their definitions.
Gender-based violence by, for example, a boyfriend or girlfriend Penetration of a person’s genitals, anus, or mouth without the spouse’s consent Harm that is done against a person’s will as a result of unequal power based on gender roles/behaviours expected of men and women according to their sex The sexual violation of another person without their consent Someone subjects another person to behaviour that may result in psychological trauma Penetration of a person’s genitals, anus, or mouth, without their consent. Penetration can be with a penis, but also includes fingers or other objects.
Reading: Local and National Context (5 min)
GBV World-Wide

GBV is a problem all over the world.
Take your best guess: What percentage of women worldwide report experiencing physical or sexual violence by an intimate partner in their life time?
1. 10%
2. 30%
3. 50%
4. 70%
B is correct. A study by the World Health Organization (WHO) found that worldwide 30% of all woman who have been in a relationship reported physical and/or sexual violence by an intimate partner in their lifetime.
Sexual gender-based violence is usually committed by men against women. However, men can also be survivors of sexual violence.

GBV in South Africa
An estimated 1 in 4 women in South Africa will experience sexual assault or rape during their lifetime.
1. True
2. False
The correct answer is true.
Research from the University of Pretoria has shown that in South Africa:
- More women are killed by their current or former intimate male partner than in any other country in the world.
- IPV is the most common form of violence experienced by women.
- IPV is the leading cause of death among women.
- A woman dies every eight hours on average, at the hands of an intimate partner.
Click or tap on each example of cultural practices that worsen gender-based violence in South Africa:
Ukuthwala

A form of abduction that involves kidnapping a girl or a young woman by a man and his friends or peers with the intention of forcing the girl or young woman’s family to agree into marriage.

Lobola

A practice associated with gift giving, usually in the form of money or livestock, to the parents of a bride to be. The groom’s family is in charge of providing these gifts after negotiation between the two families. Some men may justify abuse by assesrting that "I paid lobola" for you.

Virginity testing

This entails testing whether or not young girls are virgins. This practice invades the privacy of young women.
Activity: Myth or Fact? (10 min)
Myth or Fact: For each statement, select whether it is a myth or a fact about GBV. Sources from this activity can be found in the reference list at the end of this module, (references 7 - 10).
1GBV only includes physical abuse (hitting, punching, and pushing).
1. Myth
2. Fact
This is a myth. Physical abuse is just one form of violence. Other types of violence include:
- Emotional
- Verbal
- Psychological
- Economic (such as preventing someone from being allowed to work to earn money or limiting the resources available to him/her)
Examples of these kinds of violence include:
- Degrading or humiliating conduct towards another
- Repeated insults, ridicule or name-calling
- Repeated threats to cause emotional pain
- Being obsessively possessive or jealous to such an extent as to cause a serious invasion of privacy, integrity, or security.
2A person doesn’t have to be physically hurt to have been raped.
1. Myth
2. Fact
This is a fact.
3A woman can’t be raped by her husband.
1. Myth
2. Fact
This is a myth. According to South African law, forcing someone to have sex, even if that person is your husband or wife, is rape and it is illegal.
4A woman can prevent rape if she tries hard enough.
1. Myth
2. Fact
This is a myth. Each person reacts to harm differently. Some women may be too scared to fight or prevent an attack. Many men have the strength to physically overpower a woman. Men can also use threats or weapons to make a woman comply.
5Women allow themselves to be abused. They could leave their partners if they really wanted to.
1. Myth
2. Fact
This is a myth. Abusive partners often use tactics that make it very difficult for women to escape the violence. Women who try to leave an abusive relationship often face an increased risk of ongoing and even escalating violence.
6Rape is the most underreported crime.
1. Myth
2. Fact
This is a fact. Out of shame, fear, and stigma, survivors of sexual assault choose not to report rape. Some survivors do not report it because they were unaware that it was rape, or because they were unconscious or too far under the influence of alcohol when the assault occurred.

Many survivors do not report it out of fear that they will not be believed or because they think that nothing will be done about it.
7Women who wear revealing clothing or stay out late at bars are inviting rape. Nice girls don’t get raped.
1. Myth
2. Fact
This is a myth. Sexual assault can happen to anyone. Clothing, appearance, and behavior are not invitations for unwanted sex. People are raped no matter what they wear or how they behave, including grandmothers, nuns in habits, babies in nappies, and churchgoers. Rape is never the fault of the survivor; it is the fault of the person who chooses to commit rape.
8A sex worker cannot be raped or assaulted.
1. Myth
2. Fact
This is a myth. Sexual assault is about a non-consenting person being forced to have unwanted sex, and is absolutely possible to be experienced by a sex worker.
9The vast majority of rape reports are found to be true.
1. Myth
2. Fact
This is a fact. The rate of false reporting for rape is relatively low, and is equal to the amount of false reports for other crimes; this means that most rape reports truthful. Given the difficulties associated with reporting rape—stigma, guilt, difficult legal procedures—it is not likely or logical for a survivor to be fabricating her report.
10People who drink alcohol or take drugs are inviting rape.
1. Myth
2. Fact
This is a myth. Although alcohol or drug use increase the risk of sexual and physical assault, this does not cause others to commit assault. Sex without your consent is not a choice; it is a crime.

Some people choose to take advantage of the situation and commit sexual assault on the person who is incapacitated.
11Most sexual offences occur at night in strange and unfamiliar places.
1. Myth
2. Fact
This is a myth. Most rapes take place in the home, at a party, or in a car. Most rapes are committed by people that are known to the survivor, including family members, teachers, and friends.
12Violence against women is a human rights violation, regardless of where it happens.
1. Myth
2. Fact
This is a fact.
13A survivor of rape may appear calm.
1. Myth
2. Fact
This is a fact. Each person will react to trauma in their own way. A survivor of rape may show outward signs of distress or they may appear calm.
14Gay men and lesbians deserve to be raped.
1. Myth
2. Fact
This is a myth. Some people do not approve of homosexuality and believe that rape will “cure” it. Rapists will rape in order to hurt and scare people who do not live according to their way of life. This is illegal under South African law.
15Men and women are equally violent to each other.
1. Myth
2. Fact
This is a myth. The majority of those affected by GBV, particularly IPV, are women and girls.
Reading: Causes and Risk Factors (5 min)
Causes of GBV

Gender-based violence, including sexual violence, arise from dynamics of power and control. Cultural and social attitudes and beliefs about the roles of men and women are important factors in gender-based violence. In addition, people learn from the actions and beliefs of those around them; if they see others treating women violently, or failing to condemn violence or demonstrating negative attitudes towards women, they may think it is acceptable to act or believe in similar ways, too.¹¹

Gay men, lesbians, bi-sexual, and transgender individuals are especially targeted for rape, physical assault, and murder. This can occur as an attempt to “cure” their homosexuality or non-conforming gender identity (that is, identifying or behaving in ways that do not follow masculine and feminine stereotypes). Physical assault and murder may occur out of sexual prejudice and stigma toward gay men, lesbians, bisexual individuals, and transgendered individuals. Homosexuality or non-conforming gender identity are not conditions that can be cured; furthermore, rape cannot be considered a cure or remedy for any condition or circumstance.¹²Violence can also occur within the context of same-sex relationships.

Risk factors for GBV

Knowing the risk factors for GBV can help you better identify survivors. Risk factors specifically associated with intimate partner violence include:
- History of violence
- Marital discord and dissatisfaction
- Difficulties in communicating between partners
- Lower levels of education (perpetration of sexual violence and experience of sexual violence)
- Exposure to child maltreatment (perpetration and experience)
- Witnessing family violence (perpetration and experience)
- Antisocial personality disorder (perpetration)
- Harmful use of alcohol (perpetration and experience)
- Having multiple partners or suspected by their partners of infidelity (perpetration)
- Attitudes that are accepting of violence and gender inequality (perpetration and experience)
- Living in communities that have high unemployment rates and a lack of legal framework to address violence
More information on GBV is available in the resources section.
Reading: Consequences and Outcomes of GBV (10 min)
Let’s look at the effects of gender-based violence on people’s health and the social and economic aspects of their lives. We’ll also discuss its impact on children, families, and the community.

Health Consequences

Intimate partner and sexual violence can cause serious short- and long-term physical, sexual, and reproductive health problems for survivors. Violence against women can have fatal outcomes like homicide or suicide. Click or tap on each topic to read more about the affect of violence.
Physical health

Physical health and well-being consequences and outcomes include:

Poor overall health

Injuries

Gynecological problems

Sexually transmitted infections, including HIV

Unintended pregnancies

Headaches

Back pain or abdominal pain

Fibromyalgia

Gastrointestinal disorders

Sexual dysfunction

Severe Injuries leading to death

Obesity

Women who have experienced intimate partner or sexual violence are more likely to have a sexually transmitted infection and are more likely to have an abortion compared to women who have not experienced violence.¹⁶ In South Africa, women presenting at antenatal clinics who had experienced physical or sexual violence were 53% more likely to test HIV-positive than women who had not experienced violence.¹⁷

WHO 2017

End VAW Now, UN Women. 2017
Mental health

Mental health and well-being consequences and outcomes include:

Depression

Post-traumatic stress and other anxiety disorders

Sleep difficulties

Eating disorders

Suicide attempts

Substance abuse, including increased smoking

Risky sexual behaviours (e.g., multiple sex partners, inconsistent use of protection against sexually transmitted infections)

Women who have experienced intimate partner or sexual violence are more likely experience depression or abuse alcohol; these rates are even higher for women who experienced non-partner sexual violence. ¹⁸

WHO 2017
During pregnancy

Intimate partner violence during pregnancy increases a woman’s chances of:

Miscarriage and stillbirth

Pre-term delivery

Low birth weight baby

Hypertension

Physical injuries

Stress and depression

Maternal death

Physical abuse targeting the woman’s abdomen not only risks the health of the woman, but also may jeopardize the pregnancy (WHO).

Review the Sexual GBV care pathway diagram.
Social & Economic Costs
List 2-3 social and economic consequences of GBV. Then click or tap the compare answer to see an expert's response.
Women who are unable to function normally due to physical, mental, or emotional consequences of interpersonal or sexual gender-based violence may be unable to:
- Work
- Care for themselves or their children
- Participate fully in their normal activities within the family and community
This results in:
- Lost wages
- Social isolation
- Broken relationships
Impact on Children

List 2-3 consequences GBV has on the lives of children. Then click or tap the compare answer button to see an expert's response.

Children who grow up in families where there is violence have a greater chance of having developmental, behavioural, and emotional challenges. They are also more likely to commit or experience violence when they are older.

List 2-3 consequences GBV has on communities. Then click or tap the compare answer button to see an expert's response.

When mothers and other caregivers are affected by violence to the point where they are less able to care for their children, the children may suffer from neglect. Intimate partner violence has also been associated with higher rates of infant and child mortality and illness (e.g., diarrhoeal disease, malnutrition).¹⁹

Rape Crisis Cape Town Trust

Impact on Families & Community

Survivors themselves are not the only ones to feel the effects of sexual violence and interpersonal violence. Family and friends may feel shock, anger, shame, sadness, and guilt. They might feel as if they don’t know the right thing to say or do for their loved one. “While not all survivors may wish to talk about their experience or feelings with those close to them, in some instances this may be an important source of support for survivors.”¹³ Family and friends can seek support, as well, to deal with their feelings and get advice about how to support their loved one. This can help avoid hurting the survivor further by responding in an insensitive way.

Communities are also affected by GBV. The social and economic costs described earlier take their tolls on communities when they are multiplied by many instances of violence. In addition, community togetherness becomes threatened or broken by fear, mistrust, blame, and anger. “Instances of community violence and vigilante justice against those suspected of rape are well documented within the South African media”.¹⁴
Reading: Your Role as a PHC Nurse (5 min)
Given the rates of GBV in South Africa, you, as the primary health care provider, will encounter survivors. When survivors of GBV present at primary health care facilities, they need the following:
- Immediate attention to physical injuries and complications, including HIV and pregnancy prevention and STI treatment (sexual GBV)
- Immediate care for emotional responses to trauma
- Immediate information about legal options, including reporting to the police
- Immediate assistance with establishing safety
- Referral to ongoing physical, mental, and emotional care and support
This care should be given with respect for the survivor, their choices, and their rights. This training will cover the knowledge and skills you will need to provide this care with quality and excellence. While this training is giving you skills to decrease lost to follow up among GBV survivors, this may be the only time a survivor sees a health care providor about this issue. You can make a difference in someone's life.
Reading: Key Points (5 min)
Here are some key points from this module.
- Gender-based violence is harm that is done against a person’s will as a result of unequal power based on gender roles/behaviours expected of men and women according to their sex.
- GBV affects every region in the world, and has a high rate in South Africa.
- Women, girls, men, and boys can be survivors of GBV including sexual assault.
- Myths about GBV and about survivors can prevent them from getting the care and support they need.
- GBV has serious physical, mental, emotional, and social consequences for women, their families, and for communities.
References
- ¹United Nations Declaration on the Elimination of Violence Against Women, 1993.
- ²Dartnall, L, Rachel Jewkes, Jill Astbury & Carol Ajema. (2008). Medico-Legal Response: Research Priorities for Strengthening the Medico-Legal Response to Sexual Violence in Eastern, Central and Southern Africa.
- ³Saltzman LE, Fanslow JL, McMahon PM, Shelley GA. (1999). Intimate partner violence surveillance: Uniform definitions and recommended data elements. Version 1.0 Atlanta, GA: CDC, National Center for Injury Prevention and Control.
- ⁴National Centre for Injury Prevention and Control, 2002.
- ⁵Republic of South Africa Criminal Law (Sexual Offences Related Matters) Amendment Act, No 32, 2007.
- ⁶Republic of South Africa Criminal Law (Sexual Offences Related Matters) Amendment Act, No 32, 2007.
- ⁷Rape Crisis Cape Town Trust, 2018. Accessed November 14, 2017.
- ⁸The Idaho Coalition Against Sexual & Domestic Violence Advocacy Training, 2013. Accessed December 10, 2017.
- ⁹Gender, Health and Justice Research Unit Tools for Talking Taboos, University of Cape Town, 2014.
- ¹⁰Gender Health Justice & Research Unit; Chapter 10: Sexual Offences. Accessed November 14, 2017.
- ¹¹IRC/RHRC Communication Skills in Working with Survivors of GBV, 2014.
- ¹²Seedat, M. et al. (2009). Violence and injuries in South Africa: priotising an agenda for prevention. The Lancet, Version 374 No. 9694, pp 1011-1022.
- ¹³Rape Crisis Cape Town Trust, 2016.
- ¹⁴Rape Crisis Cape Town Trust, 2016.

Module 1: Introduction to Gender-Based Violence

Learning Objectives

Learning Activities

Intimate Partner Violence

Rape & Sexual Assault

Emotional/Psychological Abuse

Child Abuse & Child Sexual Abuse

GBV World-Wide

GBV in South Africa

Ukuthwala

Lobola

Virginity testing

Causes of GBV

Risk factors for GBV

Health Consequences

Physical health

Mental health

During pregnancy

Social & Economic Costs

Impact on Children

Impact on Families & Community