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Inter-American Commission of Women
Inter-American Commission of Women (CIM)
Organization of American States
Ethical considerations for an integral response
to human rights, HIV and violence against women
in Central America
The Organization of American States (OAS) brings together the nations of the Western hemisphere
to promote democracy, strengthen human rights, foster peace, security and cooperation and advance
common interests. The origins of the Organization date back to 1890 when nations of the region formed the Pan American Union to forge closer hemispheric relations. This union later evolved into the OAS and in 1948, 21 nations signed its governing charter. Since then, the OAS has expanded to include the nations of the English-speaking Caribbean and Canada, and today all of the independent nations of North, Central and South America and the Caribbean make up its 35 member states.
The Inter-American Commission of Women (CIM) is the main hemispheric policy forum for the promotion of women’s rights and gender equality. Created in 1928 - in recognition of the importance of women’s social inclusion to democratic strengthening and human development in the Americas – CIM was the first inter-governmental organization established to promote women’s human rights and gender equality.
Ethical considerations for an integral response to human rights, HIV and violence against women in Central America Authors: MariJo Vázquez and Fiona Hale, Salamander Trust Associates (www.salamandertrust.net) Project Coordinator: Dinys Luciano Ferdinand, Development Connections Copyright ©2011 All rights reserved Inter-American Commission of Women.
Ethical considerations for an integral response to human rights, HIV and violence against women in Central America / Inter-American Commission of Women.
p. ; cm. (OAS Official Records Series ; OAS/Ser.L) ISBN 978-0-8270-5709-8
1. Women--Crimes against--Central America. 2. Women--Violence against--Central America. 3.
Women’s rights--Central America. 4. AIDS (Disease) in women--Central America. 5. HIV-positive women--Central America. I. Title. II. Vázquez, MariJo. III. Hale, Fiona. IV. Series. OAS Official Records Series ; OAS/Ser.L.
OAS/Ser.L/II.6.7 Comisión Interamericana de Mujeres (CIM) 1889 F Street NW, Washington, DC, 20006, United States Tel: 1-202-458-6084, Fax: 1-202-458-6094 Email: firstname.lastname@example.org Web: http://www.oas.org/cim Cover photo: María Celina Conte, CIM/OAS Design and layout: Sughey Abreu • Graphic Design / Illustration The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the CIM or the OAS concerning the legal status of any country, territory, city or area, or of its authorities, or concerning the delimitation of its frontiers or boundaries.
The opinions expressed are those of the authors and do not necessarily reflect the opinion of the OAS or the CIM.
2. Importance of taking ethical considerations into account 13 Current situation and sectoral challenges in relation to the integration of HIV and VAW in policies and programmes 21
How can programmes and policies respond ethically to the priorities of women and girls who are living with HIV and/or experiencing gender-based violence in Central America? What are the key ethical considerations to be taken into account in designing and implementing programmes and policies across the range of sectors which protect women and girls against violence and the negative impacts of HIV, by addressing gender inequalities and upholding human rights?
These are some of the key questions which are explored in the project “Human rights, HIV and violence against women in Central America:
Integrated Responses”, which takes place in four countries in Central America, and which is led by the Inter-American Commission of Women of the Organization of American States (CIM/OAS). The goal of the project is to contribute to national and regional efforts to reduce the prevalence of HIV and violence against women (VAW) through the development of a model of integrated policies and programmes addressing both epidemics.
This technical document presents ethical considerations for an integrated approach to policies and programmes on HIV and VAW from the perspective
of human rights in Central America, incorporating the following aspects:
a. Current situation and sectoral challenges (work, health, justice, education, women’s affairs mechanisms, bodies responsible for
b. The importance of ethical approaches to ensure that programmes and policies are ethically acceptable, fair and of benefit to women – in all their multiple identities – within sectoral systems, communities and families.
c. Ethical considerations by sector (work, health, justice, education, women’s affairs mechanisms, bodies responsible for the integrated risk management of disasters/emergencies, and others of relevance to Central America) in key areas for the promotion of
10 Ethical considerations forwomen in Central America an integral response to human rights, HIV and violence against The document does not claim to be the result of extensive academic research, nor does it provide a complete ethical framework. It draws on the many ethical guidelines which already exist concerning HIV and VAW respectively. It attempts to suggest ethical considerations for sectors beyond health, which traditionally have had less focus on HIV and/or violence against women, but where efforts to integrate violence against women and HIV may be particularly relevant.
Detailed discussion of each sector is beyond the scope of this document.
However, the authors draw on their experiences across sectors to explore some ethical considerations and principles which illuminate these. They bring the knowledge they have gained through their engagement with women, HIV and violence, in work with communities, and their gender perspective.
The intention is that by providing a guide to ethical thinking, multi-sectoral partnerships will be able to find common ground for ethical decisionmaking built on the meaningful involvement of those at the intersections of violence against women and HIV – particularly women living with HIV and women with experience of violence.
1 In other papers (such as Hale and Vázquez, 2011) the authors caution against the indiscriminate use of acronyms such as PLHIV, WLHIV, IDU, and argue that using acronyms to refer to people could constitute a specific form of cultural violence. The acronym VAW describes a phenomenon rather than a person, and therefore is perhaps less problematic. For this reason, and for ease of reading, ‘VAW’ will be used in this document.
Context Violence against women is a worldwide problem of significant scale (WHO, 2005). For many women around the world, partner violence is a feature of daily life, although it is rarely discussed, even with friends and family (Garcia Moreno, 2006). Violence is associated with immediate and long term health outcomes including injuries, physical and mental health problems, substance abuse, and death (WHO, 2011). Violence against women is intimately linked with HIV. Women who have experienced violence are more likely to acquire HIV, and women living with HIV are highly likely to experience violence (Dunkle et al, 2004; Human Rights Watch, 2007; Maman et al, 2002; Murray et al, 2006; Picasso, 2008ª and b; Watts, 2009; World Health Organisation and London School of Hygiene and Tropical Medicine, 2010). Gender inequalities and other social markers, such as ethnicity, class, age, disability, and HIV status, intersect with structural processes to place women in positions of vulnerability to violence in many different settings: in the home, within the larger family setting, in the community, the workplace, in health, education and other service settings (Luciano, 2009; Sandelowski et al, 2009). Women also experience structural and cultural violence (Farmer et al, 2006) in the form of laws, policies, practices, and aspects of culture which undermine their rights and expose them to repression, marginalisation, exploitation and further violence.
As awareness of violence against women has increased, a number of different, but overlapping, approaches have been developed to understand, describe and systematise knowledge related to violence
against women. These approaches include:
A decade ago, international organisations working on HIV and women’s human rights identified links between the two epidemics. A number of international agreements – including the Declaration of Commitment on HIV/ AIDS (UN, 2001) and the San Salvador Declaration on Gender, HIV and Violence against Women (CIM/OAS, 2007) – acknowledged that eliminating violence against women contributes to reducing the spread of HIV.
However, translating this commitment into practice raises practical dilemmas such as scarcity of resources or the lack of specific training among those working on the ground. It also raises ethical dilemmas in relation to concepts such as justice, respect for autonomy and beneficence. These impact directly on the distribution of existing resources, on the extent to which training is valued and carried out, and so on. The integration of HIV and VAW is firmly based on ethical 14 Ethical considerations forwomen in Central America an integral response to human rights, HIV and violence against considerations founded on equity and social justice, utility, efficacy and efficiency (Luciano, 2007). It is important not because someone has taken an arbitrary decision that integration is good, or because of the demands of women or professionals working in the sector, but because not to do so would undermine personal and professional ethics and would lead to practices which ultimately are damaging to those affected and, consequently, to society itself.
This section will address the current situation and sectoral challenges (work, health, justice, education, women’s affairs mechanisms, bodies responsible for the integrated risk management of disasters/emergencies, and others relevant to Central America) for the integration of programmes and policies on HIV and VAW, from the perspectives of justice, equality, gender equity and human rights.
Both VAW and HIV have a huge impact on women’s access to work, health, justice, education and services generally. In any sector, those policies and programmes which do not take into account the needs of women may exacerbate the effects of violence and HIV (Hale y Vázquez, 2011). Even when they are well-intentioned, they inevitably expose women to greater levels of violence, or pose problems for HIV prevention, care, treatment and support for women.
With the global rise in HIV prevalence among women, and growing awareness of the worldwide problem of violence against women, there is increasing support for the idea that the development of ethical policies and programmes on HIV on the one hand, and on violence against women on the other, must find ethical approaches to crucial issues such as women’s empowerment and rights, equality, and gender equity, as well as the role of power dynamics in any initiative to address the structural factors common to both violence against women and HIV. It is equally necessary to increase the understanding of professionals that violence against women is something which intersects with HIV throughout the life cycle (Picasso, 2008a y 2008b), and that responses to violence must include and be adapted to the different life cycles of men and women.
‘I am 17. I have a 3 month old baby. I acquired HIV/AIDS from my mother. She had the virus because she was raped by her step-father. He raped her, my aunts, and he had sexual relations with my grandmother, his wife. They all got HIV. My mum could leave, so she did. She left home and got together with my dad when she was 13 or 14. She passed the virus on to my dad without knowing it… My little sister is 14 and luckily her health is good, like mine is, but her situation is different to mine – she does not have the virus... My mum died when she was 19 and I was 3, and my dad died at 33 when I was 12… When my mum and dad had both died, I went to live with my grandmother. At first she treated us well, but as my body started to develop when I was 10, my step-grandfather raped me and my sister. We told my grandmother, but she didn’t want to listen. I did not really have a childhood or adolescence.’ Morena, 19, Panamá (ICW Latina, 2007, pp. 69-70) In Central America there is a good basis for integration. In all four participating countries and across all sectors, there is enthusiasm for the project of integration of HIV and VAW (CIM, 2010ª-h). Furthermore, the project countries have taken some initial steps; El Salvador and Honduras (along with Nicaragua) were the only three countries in a ninecountry study to have developed HIV prevention programmes focused on the links between gender violence and HIV (Kendall et al, 2011).
A global problem is the fact that research into the links between violence and HIV has been fragmented. In Central America, there is also a lack of systematic data collection, although there have been some descriptive studies which document some of the ways in which HIV and VAW are linked (PAHO, 2006, cited in CIM, 2010c, p. 44; PAHO, 2008, cited in CIM, 2010ª, p. 53). However, there is a high degree of acknowledgement of the links between the two in the region, which is clearly expressed in documents as significant as the Convention of Belem do Pará (OAS,
1994) and the Declaration of San Salvador (CIM, 2007).
However, despite these declarations of understanding and intent with regard to integration of HIV and VAW, situation analyses and mappings 16 Ethical considerations forwomen in Central America an integral response to human rights, HIV and violence against of social actors conducted in El Salvador, Guatemala, Honduras and Panama under the CIM project detail a number of sectoral challenges.
We will not reproduce these here, but will briefly summarise some of the