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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions
"autonomy" can have little positive meaning for women (or men) who feel forced to sell sexual services. Even if selling sexual services is not invariably defined as the result of coercion, women and men who do so are at high risk of sexual violence (discussed in the next section), as well as high risk of sexually transmitted diseases (see Chapter 3).
Sexual violence, both within and outside a formal relationship, occurs in many women's lives (Heise, Pitanguy, and Germain, 1994; Heise, 1994). Data on it are limited, in part because violence has only recently been recognized as a public health issue and an important topic of research and in part because of methodological problems, such as unwillingness to discuss or report the problem and differences among existing studies in definitions, samples, and research methods. Enough is known, however, to justify inclusion of violence against women as a serious reproductive health problem. In population-based surveys in developing countries (using various reference periods), 30 percent of women report being beaten by spouses in two Caribbean islands; between 56 and 67 percent in stratified samples in Papua New Guinea; 20 percent in Colombia; and 60 percent in Santiago, Chile (summarized in Heise, Pitanguy, and Germain, 1994:Table 1). In a recent survey in Uttar Pradesh state, India, more than one-third of men reported that they beat their wives (Martin et al., 1997).
Violence against women resulting in death is seen across a range of economic and cultural conditions.4 The scope of the problem cannot be deduced from figures for homicide alone. Suicide, whether real or apparent, is often the outcome of predeath violence. The classic example is provided by the phenomenon of "dowry deaths" in parts of northern India, where young married women are often found to have died in accidents or committed suicide and where there is a very fuzzy dividing line between suicide or accidental injury and homicide. A cross-cultural survey drawn from research in Africa, Peru, Papua New Guinea, and other Melanesian islands found that marital violence was a defining feature in female suicide (Counts, 1987).5
Several anthropological and ethnographic reviews have documented the existence of societies and cultures in which male violence against women is not endemic, showing that current high levels in other societies are hardly inevitable (see, e.g., Gilmore, 1990; Levinson, 1989; Sanday, 1981; Counts, Brown, and Campbell, 1992).
Men are more likely to die from intentional injuries (homicide and suicide combined) than are women. Murray, Yang, and Qiao (1992) show death rates for males ranging from 2.5 to 10 times those for females in populations at different levels of adult mortality. Our focus here is on violence against women, though, because violence and the threat of violence against women are more directly connected to sexual coercion and other reproductive health problems than is the case for men.