HEALTH RESPONSE TO SURVIVORS of GBV/SV
Federal Democratic Republic of ETHIOPIA
MINISTRY of HEALTH
2016
PA R TI CI PA NT MA NUA L | MO DULE O NE
INTRODUCTION to
GENDER and
GENDER-
GENDER - BASED VIOLENCE
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ACKNOWLEDGMENTS
This training manual is an outcome of a consultation process and document review. The FMOH
appreciates and acknowledges the contribution of WHO-Ethiopia for the technical and editorial work of
this modular training manual including the print out through DRT-F. The ministry also pays special
tributes to ICAP-Ethiopia for their technical and financial support for series of consultative meetings
while developing the package.
A particular note of appreciation goes to the following individuals engaged at different levels to
complete this manual.
Yamerot Andualem FMOH, director of WYA directorate
Fikir Melesse (Dr.) WHO-Ethiopia
Senait Beyene (Dr.) ICAP-Ethiopia
Contributors:
Leuleselassie Liben Federal First instance court, Ministry of Justice
Teodros Tamerat FMOH/Pathfinder
Heran Abebe Pathfinder IFHP
Negash Tulu (Dr.) ICAP-Ethiopia
Mekonnen Belete FSCE-Adama Area Program Office
Fikirte Sida CDC-Ethiopia
Catherine Kayser International UN Youth Volunteer at WHO-Ethiopia
Cover designed by Mr. Henok Ejigu, WHO-Ethiopia
The valuable contribution of health workers involved during the pre-testing was highly appreciated for
the completion of this training package.
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FOREWORD
Achieving gender equality is high up on the National Growth and Transformation Plan II (GTP II) that is
well aligned with the Global Agenda of the Sustainable Development Goals and deserves special
attention. A key challenge in achieving this goal is combatting gender-based violence/sexual violence
(GBV/SV), especially against women and girls.
The Federal Ministry of Health (FMOH) of Ethiopia has long acknowledged the important interlinkage
between gender and health and has accordingly taken significant steps in achieving gender equality in
the health sector. The progressive Health Sector Development Program IV (HSDP IV) and various
strategies and guidelines are just examples of how the FMOH is enhancing the health sector response in
relation to gender equality and gender equity.
The FMOH, through the Directorate of Women and Youth Affairs, has also made significant strides in
promoting and strengthening the health sector in its response to GBV/SV against women and girls in
particular.
An important and ongoing effort has been the improvement of primary health care services, with special
focuses on women, girls and boys to access the health services. The promotion of gender equality in
accessing health services is indeed one of the explicit objectives of the Health Extension Program (HEP).
With the aim of strengthening the understanding of gender and the overall health response to GBV/SV,
the development of a national standardized competency based Training Package is an important
measure to foster the Ministry’s determination to reduce gender inequalities.
We believe that by providing all health cadres in the primary health care units and tertiary level, with
appropriate training a more effective and comprehensive health response to GBV/SV can be achieved.
Gender-based violence is not just “women’s business” but also affects men and boys. Therefore, apart
from an effective clinical response along with psychological care and psychosocial support to help
survivors to recover from the incident and to re-integrate into society, it is crucial to educate and raise
awareness on the subject, improve strategies to prevent GBV/SV, and develop and maintain progressive
behavioral changes.
Prevention of GBV/SV in the community through health extension workers is thus one of the critical
interventions that the Ministry is devoted to. Indeed, improving health care workers’ comprehension
and knowledge on the concept of gender and gender equality and strengthening their practical skills in
assessing and handling cases involving GBV/SV plays a very significant preventive role. The Training
Package consequently not only seeks to enhance the purely medical aspects of clinical management of
these cases; it also stresses the importance of understanding the underlying causes and consequences
of GBV/SV in order to ensure effective prevention strategies and successful rehabilitation of survivors. In
line with these objectives, another significant purpose of this package is to promote and reinforce the
multi-sectoral approach as well as the referral system for the response and prevention of GBV/SV in
Ethiopia.
We are indeed grateful to the developing partners for their assistance in the development of this
Training Package. Also, special thanks to the World Health Organization, Country Office for their support
in the development, editorial, designing and printing of this Training Package.
Dr. Kebede Worku
State Minister of FMOH
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APPROVAL STATEMENT OF THE MINISTRY
The Federal Ministry of health of Ethiopia has been working towards standardization and
institutionalization of In-Service Trainings (IST) at national level. As part of this initiative the
ministry developed a national in-service training directive and implementation guide for the
health sector. The directive requires all in-service training materials fulfill the standards set in the
implementation Guide to ensure the quality of in-service training materials. Accordingly, the
ministry reviews and approves existing training materials based on the IST standardization
checklist annexed on the IST implementation guide.
As part of the national IST quality control process, this Health Response to Survivors of
GBV/SV IST package has been reviewed based on the standardization checklist and approved by
the ministry in November, 2016.
Dr Getachew Tollera
Human Resources Development & Administration
Directorate Director
Federal Ministry of Health, Ethiopia
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INTRODUCTION TO THE TRAINING MANUAL
BACKGROUND
Ethiopia’s Constitution, national laws and policies are consistent with international legal instruments on
gender equality, including the Convention on the Elimination of All Forms of Discrimination against
Women (CEDAW), the Beijing Platform for Action, the African Charter on Human and People’s Rights,
and the Convention on the Rights of the Child (CRC). Equality between men and women, and boys and
girls, is one of the central pillars of the Growth and Transformation Plan: A revised Federal Family Code,
based on the principle of gender equality, came into effect in July 2000. The new Ethiopian penal code
of 2005 criminalizes domestic violence and harmful traditional practices including early marriage,
abduction and female genital mutilation/cutting (FGM/FGC).
There are various forms of gender-based violence (GBV) including physical violence, sexual violence (SV)
and emotional violence. However, available data suggests that the majority of victims of sexual violence
are women and girls. Studies indicate that in every society regardless of culture, class and economic
status, the majority of the perpetrators are intimate partners.
Sexual violence is socially condoned and seriously affects the wellbeing of the victims and the society at
large. It negatively affects women’s and men’s physical, sexual and reproductive, mental and behavioral
health. The health risks and consequences could range from subtle behavioral problems and no physical
findings to chronic health outcomes and even death.
History tells us that the health sector had initiated a systematic approach to GBV in some hospitals in
Ethiopia. St. Paul hospital in Addis Ababa was a pioneer in dealing with sexual violence. Yekatit 12
hospital had a project Child Abuse and Neglect Unit (CANU) that started in 2001 with a multi-disciplinary
team including clinical psychologists and police for child abuse investigations. Moreover, Gandhi
Memorial hospital established a one stop center with a special unit for female victims of GBV/SV in
2004. The multi-sectoral approach was initiated with support of partners and convened by the Ministry
of Justice in 2007.
The Health Sector Development Plan IV (HSDP IV) has given much emphasis to gender issues; it has put
significant efforts into the strengthening and scaling up of these initiations to a level that ensures
comprehensive and multi-disciplinary response to gender-based violence and sexual violence against
women and children.
The primary purpose of this training manual is to improve the knowledge and skills of health care
workers in providing adequate health care for survivors of GBV, especially sexual violence, including
collecting forensic evidence. Due to the fact that health care workers are not able to handle the entire
multi-faceted spectrum of services of GBV alone, dealing effectively with GBV and sexual violence
requires a multi-sectoral, well-orchestrated approach. Training health managers, health care workers
and the community will thus help to standardize the health services across all health facilities and
improve community health care for survivors of GBV/SV.
The training manual is organized into five modules that will facilitate health workers to easily look up
relevant information and thereby reinforce their knowledge, capacities and skills. Moreover, these
different training modules are designed on competency based principles to improve skill and cognition
of participants.
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RATIONALE FOR A MODULAR TRAINING PACKAGE
Each of the five modules of the Participant Manual emphasizes skills and knowledge required in
different health cadres and thus allows filling capacity gaps depending on the area of capacity deficit.
For instance, clinicians can use Module II to reinforce their skills of clinical service they provide to
survivors of GBV/SV whereas Module III can be used by clinical psychologists to enhance their
knowledge and skills regarding psychological and psychosocial support of GBV/SV survivors.
Furthermore, Module IV can be used as a tool by health extension workers (HEWs) to promote healthy
attitudes towards GBV/SV and to develop and improve GBV/SV prevention strategies.
Consequently, if capacity and knowledge gaps are observed during quality service monitoring, then the
different modules can be used to re-train the staff to reach excellence in the provision of their services.
CORE COMPETENCIES
The Training Manual is designed to provide participants with the following core competencies:
MODULE I: Knowledge on the definition and types of GBV. Cognitive skill to change behavior and attitude.
MODULE II:
Cognitive:
Section 2.1 Knowledge on use of the principles of GBV approach; Explain state to survivors and families; Understand
common terminologies.
Section 2.2 Knowledge on initial management; Interpretation of physical assessment and laboratory results.
Section 2.3 Describe the purpose, schedule and activities of follow-up care.
Skill:
Section 2.1 Use of job aids; Proper counseling and ethical soundness in handling victims; Screening for HIV; STIs;
Hepatitis B and counseling; Collection of forensic data.
Section 2.2 Use of job aids; Prescription of treatment; Proper counseling on treatment; Proper documentation.
Section 2.3 Demonstrate ability to provide comprehensive care at each follow-up visit; Prescribe referral and produce
medico-legal certificate.
MODULE III
Cognitive: Explain the major psychological consequences of GBV/SV; Able to provide service for range and
levels of psychological and social interventions.
Skill: Provide counseling to survivors of GBV/SV.
MODULE IV
Cognitive: Describe key principles of GBV/SV prevention; Describe roles of health care providers in the
prevention of GBV/SV.
Skill: Actively identify survivors of GBV/SV; Lead health education sessions at health facilities; Being able to
support health extension workers to lead community mobilization and community dialogue.
MODULE V
Cognitive: Describe the purpose and value of M&E in post-sexual violence care.
Skill: Producing reports using the indicators; Use and complete of register for post-sexual violence care.
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COURSE SYLLABUS
Course Description
This five-day training course is intended to update the knowledge and skills of health care providers
including health extension workers, who work in the area of prevention of GBV/SV.
Course Goal
The goal of the course is to provide the participants with updated knowledge and skills necessary to
deliver comprehensive health services to survivors of GBV/SV.
Participant Learning Objectives
Participants will acquire knowledge and skills in the following areas to enable them to deliver GBV/SV
services to survivors:
Introduction
Module I: Introduction to the Basics of Gender
Module II: Clinical Response and Management to GBV/SV
Module III: Psychological Support
Module IV: Prevention of GBV/SV
Module V: Monitoring and Evaluation
Training/Learning Methods
• Illustrated lectures and group discussions
• Individual and group exercises
• Role plays and case studies
• Guided practice in form of a clinical practicum in a simulated classroom setting, with
feedback from trainers.
Learning Materials
This course is designed to be used with the following materials:
• National Comprehensive GBV/SV Training Package:
o Participant Manual: Training Modules I-V
o Facilitator Guide
o PowerPoint (PP) slides
• National Policy and Guidelines on HCT, Hepatitis, Management of STIs, FP, SOP for Response and
Prevention of Sexual Violence in Ethiopia
Participant Selection Criteria
The participants of this course should be facility-level service providers who are proficient in providing
Emergency Care service, out-patient service including Reproductive, Maternal, Newborn and Child
Health (RMNCH) or are responsible for the management of GBV/SV services including health extension
workers and clinical psychologists.
In addition, they should currently be working in a facility or supervising a facility where these services
are provided or planned to be introduced.
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Trainer Selection Criteria
The trainers of this course should be Master Trainers or trainers who have received Training of Trainers
(ToT) and who have clinical experience in addressing the sensitive issues of GBV.
Methods of Evaluation
Participant:
• Pre- and post-training knowledge assessment
• Performance on group activities, case studies, role plays, and clinical station practicum
Course:
• Workshop evaluation (to be completed by each participant)
Course duration: Four days – approximately 21 hours in classroom activities with stations for clinical
practicum.
Course Venue: Trainings will be conducted in the national IST centers.
Suggested Course Composition: Up to 30 participants and 3-4 nationally certified GBV/SV trainers.
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Module I: Background and Introduction to the Basics of Gender
TABLE OF CONTENTS
Acronyms ........................................................................................................................................ 10
Introduction .................................................................................................................................... 11
Section 1: Gender Concept and Terminologies .................................................................................. 11
1.1 Learning Objectives ........................................................................................................................... 11
1.2 Concept of Gender ............................................................................................................................ 11
1.3 Definitions of Common Terminologies ............................................................................................. 12
Section 2: GBV and Types of Violence ............................................................................................... 14
2.1 Learning Objectives ........................................................................................................................... 14
2.2 Gender-based Violence ..................................................................................................................... 14
2.3 Types of Gender-based Violence ...................................................................................................... 15
Section 3: Magnitude and Consequences of Gender-based Violence ................................................. 19
3.1 Learning Objectives ........................................................................................................................... 19
3.2 Magnitude of GBV ............................................................................................................................. 19
3.3 Consequences of GBV ....................................................................................................................... 19
Section 4: Multi-sectoral Response/Approach to Gender-based Violence .......................................... 21
4.1 Learning Objectives ........................................................................................................................... 21
4.2 Multi-sectoral Response ................................................................................................................... 21
Section 5: Legal Context and Professional Ethics in Response to GBV ................................................. 24
5.1 Learning Objective ............................................................................................................................ 24
5.2 The Legal Context in Response to GBV ............................................................................................. 24
5.3 Professional Ethics in Response to GBV/SV ...................................................................................... 26
Summary of Module I....................................................................................................................... 27
Participant Self-Evaluation ............................................................................................................... 27
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Acronyms
CEDAW Convention on the Elimination of All Forms of Discrimination Against Women
CRC Convention on the Rights of the Child
FDRE Federal Democratic Republic of Ethiopia
GA General Assembly
GBV Gender-based Violence
HIV Human Immuno-deficiency Virus
IPV Intimate Partner Violence
SOP Standard Operating Procedure
STI Sexually Transmitted Infection
SV Sexual Violence
TB Tuberculosis
UN United Nations
UAMs Unaccompanied Minors
WHO World Health Organization
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Introduction
This module consists of five sections that will establish a common understanding of the concept of
gender, thereby providing the basis for the subsequent training modules. The first section will give
insight into gender concepts and will provide definitions of common terminologies. Section two will
explain the basics of GBV/SV and the different types that exist. Section three will discuss the magnitude
and consequences of gender-based violence and the fourth section covers the importance of the multi-
sectoral approach to GBV. Lastly, the fifth section will outline the legal context of GBV/SV with regard to
health, giving an overview of the relevant national laws and policies, as well as the international legal
instruments which Ethiopia has ratified.
Section 1: Gender Concept and Terminologies
1.1 Learning Objectives
Core Competencies
At the end of this section, participants will be able to: - Knowledge on the basic concept
of gender
o Explain the basic concept of gender and relate it to health
- Ability to describe gender
o Describe common terminologies in relation to gender - Use common terminologies
appropriately
1.2 Concept of Gender
Gender is a social construct that defines the norms, roles and relations for males and females in the
process of socialization. It defines how men and women, girls and boys behave and act in a given
society.
Sex is the biologic difference between men and women. On the other hand, sex is also a biological and
physiological constitution that determines the characteristics of either male or female. This difference is
influenced by societal norms, and guides the different opportunities and engagements of male and
female in their development at large.
The concept of health covers a complex human condition in which biological characteristics interact with
gender (social determinants), which in turn affects disease pattern, risks, treatment, and outcomes.
Exercise 1.1
Read the following statements and answer whether it is “gender” or “sex” in the spaces provided.
You have 3 minutes to complete the exercise. Your facilitator will then take you through the answers.
1. Women give birth to babies; men do not. ____________
2. The majority of surgeons in Ethiopia are men. ____________
3. Cardiac infarction is less common in females than men. ____________
4. Women are more affected by oesophageal cancer than males. ____________
5. In SNNP men are engaged in weaving jobs in their house. ____________
6. Women are at increased risk of acquiring HIV than men. ____________
7. Many sexually abused women do not seek medical care. ____________
8. High cure rate of TB is marked among males and high incidence among women. ____________
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1.3 Definitions of Common Terminologies
It is important to know and have a common understanding on some frequently used terminologies
when referring to gender. Understanding gender terms and their impact on gender-based sexuality can
help to create a society free from sexual violence.
Below are some common terms and their definitions:
o Gender norms: refer to a set of societal “rules” or “regulations” (a form of socio-cultural
regulations) that encourage socially desirable behavior in the way women and men “should” look,
behave or act.
This is a “pattern” of what individuals, as members of a group, or representing a particular social
position, should do and what is required of them under given circumstances. For the norm to
fulfill this purpose, it needs to represent a certain social control mechanism, characterized by
generality (it can be applied in different contexts – it is not a set of specific partial “instructions”
but rather “principles”) and consciousness (individuals are aware of the general rules which
control the activity of individuals – for the norm to fulfill the regulatory role, it must be “known”)
and if the norm is perceived as a regulation, sanctions are always associated with it.
o Gender roles: is a social role. It is “a set of expectations associated with the perception of
masculinity and femininity”.
Social roles are always closely related to the value system of the society which forms them. The
respective role is thus a sort of “prescribed” behavior and action. Therefore, “actual performance
of roles by individuals may be different due to the ideal role: required behavior (holder of the role
behaves as she/he must) desirable behavior (holder of the role behaves as she/he should),
acceptable behavior (holder of the role behaves as she/he can) and unacceptable behavior (holder
of the role behaves as she/he may not). The performance of social roles is therefore flexible, but is
subject to social control and sometimes social sanctions”.
o Gender relations: refer to social relations between and among women and men that are based on
gender norms and roles.
o Gender stereotypes: a gender stereotype is a very stable element in consciousness, i.e.
psychological and social mechanisms regulating perception and evaluating certain phenomena,
subsequently influencing opinions, judgment, attitudes and behavior. With regards to a
stereotype, an undifferentiated overall attribution of certain characteristics to all members of the
group is typical. A stereotype is characterized by emotionality and irrationality, as well as
simplistic interpretations of events and is therefore often abused in propaganda.
Masculinity and femininity are not perceived equally in society. The disparagement/degrading of
one sex (more often women) or the rejection of any other than stereotypical perceptions of
masculinity and femininity is called sexism. Comparably to racism, sexism is the manifestation of
intolerance. However, while racism means the disparaging of people because of their race or
ethnicity, sexism means the disparaging of people because of their sex.
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o Gender equity: the process of e.g. allocating resources, programs, and the power of decision-
making fairly to both males and females without any discrimination on the basis of sex, while at
the same time addressing any imbalances regarding the benefits available to males and females in
accordance to their needs. Gender equity thus also includes recognizing that women and men
have different needs.
o Gender equality: refers to the equal rights, responsibilities and opportunities of women and men
and girls and boys. Gender equality implies that the interests, needs and priorities of both women
and men are taken into consideration, recognizing the diversity of both groups. Gender equality is
achieved when women and men enjoy the same rights and opportunities across all sectors of
society, including economic participation and decision-making, and when the different behaviors,
aspirations and needs of women and men are equally valued and favored.
o Gender empowerment: empowerment is a multidimensional social process that enables people
to gain power and control over their lives. It involves awareness-raising, building self-confidence,
expansion of choices, increased access to and control over resources, and actions to transform the
structures and institutions which reinforce and perpetuate gender discrimination and inequality.
This implies that to be empowered is not only to have equal capabilities (such as education and
health) and equal access to resources and opportunities (such as land and employment), but the
individual must also have the means to use these rights, capabilities, resources and opportunities
to make strategic choices and decisions (such as are provided through leadership opportunities
and participation in political institutions).
o Gender mainstreaming: the process of assessing the implications for women and men for any
planned action, including legislation, policies or programmes, in any area and at all levels. It is a
strategy for making women’s and men’s concerns and experiences an integral dimension in the
design, implementation, monitoring and evaluation of policies and programmes in all political,
economic and societal spheres so that women and men benefit equally, and inequality is not
perpetuated. The ultimate goal is to achieve gender equality.
Exercise 1.2 Card sorting
Your facilitator will arrange pre-prepared statements on the flip chart and mount the paper to a wall.
You will be asked to pick a random card from the pile of cards labelled with the different terms related
to gender and to match your card with the corresponding statement on the flip chart.
This activity will take approximately 10 minutes to complete. Your active participation is very important.
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Section 2: GBV and Types of Violence
2.1 Learning Objectives
At the end of this section, participants will be able to: Core Competencies:
o Define GBV - Knowledge on the definition and
o Describe common types of gender-based violence types of GBV
2.2 Gender-based Violence
There are various but similar definitions for gender-based violence.
Gender-based violence includes all forms of violence involving women and men in which the female is
usually the victim. The term ‘gender-based’ is used to highlight the need to understand violence within
the context of women’s and girl’s subordinate status in society. Such violence cannot be understood,
therefore, in isolation from the norms, social structure, and gender roles within the community, which
greatly influence women’s vulnerability to violence.
Domestic violence is a term used with many meanings. The most common usage is with reference to
violence by the spouse or intimate partner. However, the term is also used sometimes to describe
violence within the family, where the perpetrators are usually male members, as for example violence
by the father against the daughter, son against mother and so on.
Violence against women and girls is a term often used synonymously with gender-based violence.
However, the term does not make it clear whether or not the violence is derived from unequal power
relationships between women and men in society.
According to the United Nations, violence against women is “any act of gender-based violence that
results in or is likely to result in physical, sexual, or psychological harm or suffering to women, including
threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or private
life.” (United Nations General Assembly, Declaration on the Elimination of Violence Against Women,
1993).
Gender-based violence occurs due to a power imbalance in relationships, i.e. physical
(muscularity/strength, size, use of weapons, controlling access or security); age (often, the young and
elderly are vulnerable); economic (control of money or access to goods/services/favors); social (peer
pressure, bullying, leader, teacher, parents); political (elected leaders, authorities, discriminatory laws).
Perpetrators (often men) can have “real” or “perceived” power in one or more of the power relations
mentioned above. Power is directly related to choice. The more power one has, the more choices are
available and vice versa. Underpowered people have fewer choices and are therefore more vulnerable
to abuse. Gender-based violence thus involves the abuse of power.
Violence is the use of force/power. “Force” might be physical, emotional, social or economic in nature. It
may also involve coercion or pressure. Force also includes intimidation, threats, persecution, or other
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forms of psychological or social pressure. The target of such violence is compelled to behave as
expected or to do what is being requested, for fear of real and harmful consequences or promissory
gains. Using violence (violation of rights) involves forcing someone to do something against her/his will
also know as “consent”.
“Consent” means agreeing to or approving something; making decisions on informed “choices”, freely
and voluntarily, by persons in an equal power relationship. Acts of violence override the right of an
individual to her/his decision-making power or coerce the victim to comply with the order under duress.
In addition, children (under the age of 18) are legally prohibited to provide any consent without the
knowledge of their parent or guardian.
Exercise 1.3 True or False
Write true or false for the following statements in the space provided.
You have 4 minutes to complete the exercise individually. Your facilitator will take you through the
correct answers.
1. _______ GBV is one of the components of sexual violence.
2. _______ Domestic violence is GBV that occurs in a family.
3. _______ Gender-based violence can occur in women and girls and men and boys.
4. _______ In adults, if consented to the sexual action, but excessive force is used during the act it
may not be regarded as GBV upon complaint.
5. _______ GBV on children is an unlawful act only if it results in physical, sexual, or psychological
harm or suffering.
6. _______ GBV occurs due to power imbalances that usually favor men.
7. _______ Violence is the use of force that is based on unequal power distribution and includes
actions that influence the free and voluntary decision-making of an individual.
2.3 Types of Gender-based Violence
GBV occurs in different forms and can range from subtle to blatant actions, which can even result in
death of the victim. Before going through the various types of gender-based violence, it is important to
understand some related terms to standardize the perception.
Survivors/Victims:
“Survivor” and “victim” are terms that can be used interchangeably. Both refer to the subject or target
of the incident. “Victim” is used both for those who survived or died due to the exposed incident.
However, when speaking in terms of health, it is better to use the word “survivor” as it deals with the
living. Moreover, the word “victim” conjures an image of someone who is weak, sick, small, hunched
over, crying, clothed in rags and unable to function in the world. It is a sad, disempowering word. The
word “survivor” on the other hand conjures an image of someone who stands straight and tall, uses eye
contact, walks with confidence, lives life to the fullest. It is a powerful, empowering word.
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Survivors/victims can include:
• Children, especially Unaccompanied Minors (UAMs), fostered children
• Women because they are usually considered second class and inferior
• Unaccompanied females, without male protection
• Single women, female headed households
• Mentally and/or physically disabled females and males
• Economically disempowered people
• Junior staff males and females, students, less privileged community members
• Minority groups: e.g., ethnic, religious
• Asylum seekers, refugees, displaced persons
Perpetrators:
A perpetrator is the doer or committer of the action(s). The perpetrator could be a person, group, or
institution that inflicts, supports, or condones violence or other forms of abuse against a person or
group of persons.
The characteristics of perpetrators include:
• Persons with real or perceived power
• Persons in decision making positions
• Persons in authority
The list of categories of people who are potential perpetrators is long but most common are:
• Intimate partners (husbands, boyfriends)
• Influential community members (teachers, leaders, politicians)
• Security forces, soldiers, peacekeepers
• Humanitarian aid workers (international, national, refugee staff)
• Strangers
• Members of the community
• Relatives (brothers, uncles, parents, aunts, sisters, etc.)
• Anyone who is in a position of power
For any incident of GBV/SV, there is a survivor and a perpetrator. Therefore, all our actions in prevention
and response need to address both the survivor and the perpetrator.
Human Rights:
Human rights are universal, inalienable, indivisible, interconnected and interdependent.
• Everyone is entitled to all the rights and freedoms, without distinction of any kind, such as race,
color, sex, language, religion, political or other opinion, national or social origin, property, birth
or other status.
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• Prevention of and response to gender-based violence is directly linked to the protection of
human rights.
• Acts of gender-based violence violate a number of human rights principles enshrined in
international human rights instruments. These principles include, amongst others:
- The right to life, liberty and security of person
- The right to the highest attainable standard of physical and mental health
- The right to freedom from torture or cruel, inhuman, or degrading treatment or punishment
- The right to freedom of opinion and expression, to education, to social security and to
personal development
Types of Gender-based Violence
1. Physical violence is defined as the intentional use of physical force with the potential to cause
death, disability, injury, or harm.
Physical violence includes, but is not limited to: scratching, pushing, shoving, throwing, grabbing, biting,
choking, shaking, poking, hair pulling, slapping, punching, hitting, burning, use of a weapon (gun, knife
or other object), and use of restraints or one’s body, size, or strength against another person. Physical
violence also includes coercing other people to commit any of the above-mentioned acts. It also
includes, often in children, the acts or omissions of deprivation/neglect.
2. Sexual violence/abuse is the act of sexual activity without consent and/or any sexual act on a
person who could not give consent, such as children and persons with disabilities.
This act includes:
(1) The use of physical force to compel a person to engage in a sexual act against his or her will,
whether or not the act is completed. Harassment, rape, marital rape, abuse/exploitation, sexual
child abuse/incest, sexual abuse (non-penetrating), forced prostitution (“willing” but
involuntary), child prostitution, sexual trafficking and forced abortion, etc.
(2) An attempted or completed sex act involving a person who is unable to understand the nature
or condition of the act, to decline participation, or to communicate unwillingness to engage in
the sexual act (e.g. because of illness, disability, or the influence of alcohol or other drugs, or
due to intimidation or pressure).
(3) The act of an adult or someone older than a child involving the child in any form of sexual
activity, ranging from fondling the child’s sexual parts to actual or attempted sexual acts.
(4) Rape/Attempted rape is an act of non-consensual sexual intercourse. 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. Rape and attempted rape involve the use of force, threat
of force, and/or coercion. Any penetration is considered rape. Efforts to rape someone which do
not result in penetration are considered attempted rape.
Rape of women and of men is often used as a weapon of war, as a form of attack on the enemy,
typifying the conquest and degradation of its women or captured male fighters. It may also be used to
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punish women for transgressing social or moral codes, as for instance those prohibiting adultery or
drunkenness in public. Women and men may also be raped when in police custody or in prison.
Rape or attempted rape may include:
• Rape of an adult female
• Rape of a minor (male or female), including incest
• Gang rape, if there is more than one assailant
• Marital rape, between husband and wife
• Male rape, sometimes known as sodomy
3. Psychological/emotional violence/abuse and neglect are acts of coercion or use of abusive
language (e.g. verbal assaults) and arbitrary deprivation of liberty, whether occurring in public or in
private life.
Psychological/emotional abuse can include but is not limited to: humiliating a person; controlling what
the person can and cannot do; withholding information from the person; getting annoyed if the person
disagrees; deliberately doing something to make the person feel diminished (e.g. less smart, less
attractive); deliberately doing something to make the person feel embarrassed; isolating the person
from friends and family; prohibiting access to transportation or telephone; denying access to money and
other resources; threatening loss of custody of children; smashing the person’s objects or destroying his
or her property.
Moreover, it includes threats of acts, coercive tactics when there has also been prior physical or sexual
violence, or prior threat of physical or sexual violence.
Exercise 1.4 Hide and Seek
Your facilitator will take you through this exercise. This debate exercise will enable you to create ideas
on hiding or concealing the situation of GBV and will also teach you how to define the type of occurring
GBV.
A different scenario will be given to each of you and it is up to the small groups to debate whether to
hide/conceal the situation or whether to try to resolve and unveil the situation and label the type of
GBV occurring.
This activity will take approximately 20 minutes to complete. Your active participation is important.
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Section 3: Magnitude and Consequences of Gender-based Violence
3.1 Learning Objectives
Core Competencies:
At the end of this section, participants will be able to: - Knowledge on the magnitude
o Explain the magnitude of GBV and consequences of gender-
o Describe economic, social and health consequences of based violence
GBV - Ability to apply knowledge to
interventions in cases of GBV
3.2 Magnitude of GBV
Among all human rights violations, GBV is the most common one. Worldwide, it is estimated that one in
three women will be physically or sexually abused in her lifetime; and one in five women have already
experienced rape (attempted or completed). Men also experience GBV but its magnitude and effects on
health are more severe for women.
Intimate partner violence (IPV) is among the common types of GBV. The lifetime prevalence of women
exposed to intimate partner violence ranges from 20 % in Japan and 70 % in Ethiopia (EDHS 2011). 4 to
32 % of women are also exposed to intimate partner violence during their pregnancy. IPV is more
prevalent in low income countries (14 to 32 %) compared to high income countries (4 to 11 %).
3.3 Consequences of GBV
Exercise 1.5 Brainstorming Consequences of GBV
You will be asked to brainstorm what are the consequences of GBV. Your facilitator will write down your
answers and align them in the following categories: (1) health, (2) economic, (3) social, and (4) others.
This exercise will take approximately 15 minutes to complete. Your participation and contribution are
important.
GBV has complex consequences for adult and child victims as well as for those children witnessing
violence. Victims/survivors of GBV often have the tendency to blame themselves (self-blame) and feel
guilt or shame. They are stigmatized and blamed by family, friends and the society. GBV also
undermines the right, autonomy, security of the victims and reinforces gender inequality in the society.
Furthermore, GBV has an economic impact for the society. It is estimated that domestic violence and
rape are risk factors for increased morbidity and mortality by contributing 5 to 16 % of healthy years of
life lost in 15 to 44 aged females.
GBV also has complicated health related consequences. It negatively affects physical, mental and
reproductive health. The physical health consequences range from bruises and laceration to the loss of
body parts subsequently leading to disabilities and disfigurement to death. The mental health
consequences include post-traumatic stress disorder, depression, anxiety, phobia, panic disorders, self-
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harm, suicide, intergenerational violence, sleeping disorders, low self-esteem, altered sexual orientation
and the like. The sexual and reproductive health problems that are caused by GBV include pelvic
inflammatory disease, sexually transmitted infections (STIs) including HIV/AIDS, cervical cancer, sexual
dysfunction, unwanted pregnancy, abortion, miscarriages, fetal injuries, oral lesions, and the like.
Health Consequences of GBV:
GBV is a very common and universal problem. There is however limited data regarding the extent of
GBV and post-GBV care in Ethiopia. Due to lack of appropriate training, lack of resources and inadequate
physical settings, GBV services are not always properly handled in the health facilities.
The health care sector is an essential actor in the fight to end GBV. It can contribute to minimizing the
prevalence and impact of GBV through community awareness and prevention programs; early
identification and treatment of GBV survivors; by providing long-term counseling and mental health
GBV can result in women’s and children’s deaths. Fatal outcomes may be the immediate result of a
victim being killed by the perpetrator, or in the long-term, the consequence of other adverse health
outcomes. For example, mental health problems resulting from trauma can lead to suicidality, or to
conditions such as alcohol abuse or cardiovascular diseases that can in turn result in death. Moreover, a
HIV infection as a consequence of sexual violence can cause AIDS and ultimately lead to death.
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Section 4: Multi-sectoral Response/Approach to Gender-based Violence
4.1 Learning Objectives
At the end of this section, participants will be able to:
Core Competencies:
o Describe the rationale to work in collaboration with
relevant actors in the prevention of, and response to, - Knowledge on the value of a
GBV/SV (especially against women and girls) multi-sectoral response to
GBV/SV
o Explain the relevance of norms and standards of
- Understanding of and use of the
procedures relating to SV (against women and children) general concept of the SOP of the
o Describe the basics of the Standard Operating multi-sectoral approach to SV
Procedure (SOP) in response to sexual violence (against women and children)
centering the victim
4.2 Multi-sectoral Response
Acknowledging that gender-based violence as “violence involving men and women in which the female
is usually the victim” that often occur due to “power imbalance” and the different forms of violence,
physical, sexual and psychological/emotional violence and economic abuse and exploitation that are
interrelated and connected; affirming that there is no single agency that contains the resources and
expertise required to comprehensively respond to the needs of victims; and asserting that various stake
holders (health, justice and social welfare systems) play essential roles in enabling victims to have access
to immediate and comprehensive care and support services to reduce long term effects related to the
violation of their rights, the Ethiopian government with its commitment to end violence against women
as enshrined in the FDRE Constitution and other legislative frameworks established a national multi-
sectoral coordinating body to address the prevention and response to sexual violence.
The Standard Operating Procedure (SOP) for the Response and Prevention of Sexual Violence in Ethiopia
was developed by the national multi-sectoral coordinating body with an overall objective to standardize
national preventive, protective and service provision amenities for the prevention and elimination of all
forms of sexual violence and ensure multi-sectoral mechanisms to support women and children.
The SOP defines the roles and responsibilities of each of the relevant sectors and actors centering the
victim to better respond to the immediate needs and prevent the long term consequences as well as the
ways to respond to the services.
For example:
A successful multi-sectoral approach to survivors of GBV requires the presence of an operational link
between relevant sectors/actors with a flow of connection that adds value to the survivor. A survivor of
sexual violence or abuse may present herself or himself to police or hospital. If first presented to the
police, the latter will link the survivor to health care for a clinical check-up after having undertaken the
necessary procedures. On the other hand, if the initial presentation of the survivor is to the health care
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facility, after processing the necessary care and treatment, links can be made to the law enforcing
body/police.
If the case is domestic in nature, for reasons of protection of the victim from further violence, the
survivor should be linked to emergency protection or safe house (Social Affairs or Ministry of women and
children affairs); if the survivor requires legal support, a link to the legal system (law prosecution office)
must be established. In case of a child survivor who is underage and may not understand the
circumstances, the child must be linked to a medical social worker (social affairs) who will prepare
her/him for the court proceedings. The engagement of the community will add value in identifying
current and ongoing cases of abuse and will thus be involved in handling such cases. Consequently, a
multi-sectoral “wheel” (see Exercise 1.7) in an attempt to close the gaps of the different necessary
components when dealing with cases of GBV/SV will facilitate the smooth and effective handling of and
response to the needs of survivors.
Exercise 1.6 Short questions and answers
You have 15 minutes to complete the exercise individually. Your facilitator will then take you through the
correct answers.
1. What is the purpose of the multi-sectoral approach to survivors of GBV?
2. Why is it important to prepare the child survivor for trial hearing and who should be responsible
for this process?
3. Why do you think it is important to build the capacity of local government (community level) on
the protection of vulnerable groups?
4. Why is it important that the health sector be part of the multi-sectoral approach to GBV?
5. Why do we need a SOP for the prevention of and response to sexual violence?
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Exercise 1.7 Wheel of Intervention for Survivors of GBV
You will be asked to fill in the different components/areas of support in the “Wheel of Intervention for
Survivors of GBV” centering the survivor.
You have 5 minutes to complete the exercise individually before your facilitator will go through the
correct answers with you. Your participation is important.
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Section 5: Legal Context and Professional Ethics in Response to GBV
5.1 Learning Objectives
At the end of this section, participants will be able to:
o Describe the basic human rights specific to violence Core Competencies:
Cognitive
against women (VAW) and violence against children
- Knowledge on the basics of
o Describe the existing international conventions and the human rights and existing
national legal framework designed to protect the rights international conventions and
of women and children national legal framework
o Increase the potential of health workers to improve the specific to women and children
protection of the rights of survivors of sexual violence Skill
o Explain the professional ethical practice of health - Proficient in translating
professional ethics to practice
workers with regards to the care of survivors of GBV
5.2 The Legal Context in Response to GBV
International human rights and the national laws of countries across the world recognize a range of
substantive and procedural rights of women both in criminal and civil matters. However, the practical
realization of human rights requires that violations and non-fulfillment of rights be remedied or
addressed immediately in systemic manner.
Being able to seek remedies in order to recover from violations or non-fulfillment of rights of victims of
violence assumes the availability and accessibility of the health, justice and social system to all without
discrimination. Accordingly, the rights of access to justice, fair trial and equality before the law are
recognized as fundamental human rights of every person, including every woman and child.
Equality of rights for women is a basic principle of the United Nations (UN), and is highlighted in the
Charter of the United Nations (UN Charter). In accordance with the terms of the UN Charter, all member
states are legally bound to strive towards the full realization of human rights and fundamental
freedoms, including the equal rights of men and women. The International Bill of Rights and the
Universal Declaration of Human Rights both contain similar language.
The International Convention on the Elimination of All Forms of Discrimination against Women
(CEDAW) was adopted by the UN General Assembly in 1979 and entered into force on September 3,
1981. Ethiopia signed CEDAW on July 8, 1980 and ratified the convention on September 10, 1981.
CEDAW is often described as the international bill of rights for women. It is a treaty which affirms the
reproductive rights of women and targets culture and tradition as influential forces shaping gender roles
and family relations. States must take measures to seek to eliminate prejudices and customs based on
the idea of the inferiority or the superiority of one sex or on stereotyped roles for men and women.
Furthermore, the Convention on the Right of the Child (CRC) was adopted by the UN General Assembly
in 1989 and was acceded by Ethiopia in 1991.
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The international instruments which Ethiopia ratifies are transposed into the Ethiopian legal framework,
thus making them part of the national laws of the country. Indeed, Article 9(4) of the Constitution of the
Federal Democratic Republic of Ethiopia (FDRE Constitution) provides that “all international agreements
ratified by Ethiopia are an integral part of the law of the land.”
Accordingly and with regard to the international conventions discussed above, the FDRE Constitution
guarantees equality between women and men in all spheres of political, social and economic efforts and
benefits. Article 13(2) further states that the interpretation of the fundamental rights and freedoms
recognized under Chapter 3 of the Constitution (entitled “Fundamental Rights and Freedoms”) shall be
consistent with the Universal Declaration of Human Rights and all other international human rights
covenants and conventions ratified by Ethiopia.
In addition, access to justice is recognized as a right in the FDRE Constitution: Article 37(1) of the
Constitution states that “Everyone has the right to bring a justiciable matter to, and to obtain a decision
or judgment by, a court of law or any other competent body with judicial power.”
The Constitution further recognizes equality before the law (Article 25): “All persons are equal before
the law and are entitled without any discrimination to the equal protection of the law. […].” Moreover,
in its Article 35, the Constitution specifically addresses the equal rights of women by articulating that,
“Women have the right to equality with men in the enjoyment and protection of rights provided for by
this Constitution.” This article further guarantees that women’s right are to be protected by the state
from harmful customs and that “laws, customs and practices that oppress women or cause bodily or
mental harm to them are prohibited.”
One of the key aspects of a person having a right is that there is a corresponding responsibility on
someone else to ensure that the right is fulfilled or respected. Victims, survivors and witnesses of sexual
offences and domestic violence have in the recent past enjoyed much publicity. This has been
occasioned by both a rising awareness about the impact of victimization on them, their families and the
communities they live in as well as the rising numbers of reported offences.
Recently, there have been several initiatives in Ethiopia aimed at placing sexual violence victims on the
national agenda. These initiatives are reflected in the constitutional protection introduced in the FDRE
Constitution for vulnerable groups like children and women, a growing awareness of victims’ needs as
well as the recent reforms introduced in the criminal justice policy, the creation of an interdepartmental
management team at federal level and the practical changes taking place in line with international
standards in the police force, prosecution and the court system which will help to avoid secondary
victimization.
In order to avoid accusations that the rights of offenders may be unfairly jeopardized by focusing on the
victims of crime, the key is to focus on victims from a human rights perspective as the latter is based on
an uncompromising commitment to build respect for human rights for both victims and offenders. The
balance can be best achieved by investing considerable energy in the development of a victim-centered
crime prevention program. This program must be rooted in the effective delivery of victim support and
empowerment, which demonstrates that the human rights of victims are treated as a priority – without
compromising the rights of any alleged perpetrator or accused person.
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5.3 Professional Ethics in Response to GBV/SV
There is a basic interrelation between laws and ethics. Law is the rule of conduct or action prescribed
and formally recognized or enforced by the controlling authority whereas ethics refers to a standard
behavior that is expected from a professional. In other words, ethics is the concept of doing right and
wrong beyond that of legal consideration in a given situation. The moral value is overemphasized to
serve as a basis for ethical conduct and is therefore influenced by family, culture and society.
Ethics serves as a fundamental source of law in any legal system. Its application in health could be
explored with regards to the communication and actions during the patient and client interphase:
• Consent and providing technical information: giving attention, active listening, clarifying and
ensuring understanding, and seeking for consent (informed or written as appropriate) are the
prime constituents for practical ethics.
• Patient-physician confidentiality: ensuring confidentiality of the patient’s case is important as
individual health information is obtained.
• Respect and trust: treating clients with respect and dignity and demonstrating compassionate
and caring attitudes are part of professional ethics as defying the trust and being disrespectful
may result in less compliance to treatment and medical advices with negative consequences.
Exercise 1.8 Case scenario
Case 1: An elderly 63 year old female visits a clinic and complains about consistent severe headaches
and discharge from her private part. A physician on-duty took a very brief history of the primary
complaints, checked her blood pressure (result was normal for age) and prescribed treatment for STI
syndromic management. The patient politely asked for her diagnosis and in response, the physician said
“Emama, though I didn’t expect this at your age, you have STI, for which I gave you the treatment.”
You have 5 minutes to answers the questions individually. Your facilitator will then take you through the
answers.
1. Identify the areas of ethical misconduct. Underline the unethical behaviors in the scenario.
2. What is or are the behavioral component/s missing or that should have been corrected?
3. What would have been your approach if you had been the treating physician?
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Summary of Module I
This module provided a comprehensive overview of the concept of gender and gender-
based violence. The different types of GBV were identified and explained and the
magnitude of GBV and the serious consequences of such violence for the survivors/victims
were emphasized. Moreover, the importance of adapting a multi-sectoral approach when
dealing with GBV/SV was elaborated on and the different sectors were defined.
Furthermore, the concept of human rights and the link to women’s health rights;
particularly relevant concepts for fully understanding women’s human rights in health
were explained and important consideration was be given to gender-based violence (GBV)
and sexual violence against women (SV) as violations of women’s human rights. The
module showed how women’s human rights are enshrined in the Convention on the
Elimination of All Forms of Discrimination against Women (CEDAW) and the Convention
on the Rights of the Child (CRC) and how these provisions were transposed into the legal
context of Ethiopia. The role of the Government of Ethiopia in implementing and
protecting those rights was also emphasized.
Participant Self-Evaluation
What did you learn?
What knowledge and skills were you able to improve?
What knowledge and skills still need improvement?
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