"Hay que tener suerte": Gender-based Violence Service Provision in Quito, Ecuador.

This study utilized the United Nations' Essential Services Package for Women and Girls Subject to Violence, a technical guidebook on quality services in line with human rights declarations, to examine the characteristics of availability, accessibility, adaptability, and appropriateness from the viewpoint of 21 victim service users in Quito, Ecuador. Availability was evidenced by warm service providers willing to aid victims but was hindered by a failure to make available all desired services (such as those related to economic empowerment). Accessibility was aided by service locations that were easily accessible and by referrals, but a lack of information and conflicting schedules thwarted users' help-seeking efforts. Participants shared experiences of services adapted to their specific needs and experiences of violence, but additional services were needed to fully attend to their particular circumstances. Participants shared how service providers empowered them by listening to their experiences and helping them move forward in their lives. Nonetheless, participants shared experiences of victim-blaming and other harmful attitudes from providers. Overall, there was a great amount of variability in participants' service experiences. Areas for consideration include economic empowerment, expansion of services to men and children, increased access to information, and trauma-informed training of staff in order to better respond to gender-based violence.

Introduction

The Universal Declaration of Human Rights of 1948 states both that “no one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment” and that “everyone has the right to a standard of living adequate for the health and well-being of [themselves] and of [their] family.” Nonetheless, the bridging of the two human rights—protection from violence, specifically violence against women, and the right to health—remained elusive until the mid-1990s. Framing violence against women as a human rights violation is an important step in formally labeling this type of violence as unjust and socially wrong, with attached duties and responsibilities for accountability at the individual and state levels. It was not until the Declaration on the Elimination of Violence against Women and the Convention of Belém do Pará that violence against women was defined as a violation of human rights at the international level and freedoms and duties of states were delineated. These documents specified the desired outcome for services but did not indicate what specific services were needed nor how these services should be delivered. Our study uses recent multiagency guidance from the United Nations Joint Global Programme on Essential Services for Women and Girls Subject to Violence to examine gender-based violence services in the Ecuadorian capital of Quito.

The Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) was a significant advancement that recognized the confluence of violence, health, and human rights in the lives of women. In 1992, the CEDAW Committee—which monitors states’ compliance with the convention—issued General Recommendation No. 19 on violence against women, stating that “gender-based violence is a form of discrimination that seriously inhibits women’s ability to enjoy rights and freedoms on a basis of equality with men” and “states parties should establish or support services for victims of family violence, rape, sex assault and other forms of gender-based violence.” In 1993, the Declaration on the Elimination of Violence against Women, issued by the United Nations General Assembly, explicitly focused on physical, sexual, and psychological family violence; community violence; and state violence. The following year, the Convention of Belém do Pará affirmed that “violence against women constitutes a violation of their human rights and fundamental freedoms, and impairs or nullifies the observance, enjoyment and exercise of such rights and freedoms” and called on states to condemn all forms of violence against women and respond appropriately through legislation, specialized services, and assessment of efforts.

Women’s movements across Latin America have fought for the end of gender-based violence since the beginning of the 1970s and sought more recognition of gender-based violence as well as legal and service advancements. Ecuador ratified CEDAW in 1981, and, in 1995, shortly after the signing of the Convention of Belém do Pará, passed a law on violence against women and families that seeks to prevent violence and offer protection for victims (Law 103). Article 66 of Ecuador’s Constitution also acknowledges the right to live free from public and private violence and declares that “the state shall adopt the measures needed to prevent, eliminate, and punish all forms of violence, especially violence against women, children and adolescents,” further providing the vision for a human rights-based approach to violence prevention. Services are delineated in articles 35 and 78, which refer to specialized services, restitution, compensation, rehabilitation, and victim assistance. In addition, the main legal framework in Ecuador, the Organic Integral Penal Code, penalizes gender-based violence in a series of misdemeanors and crimes. This is further buttressed by a national plan to end gender-based violence, which acknowledges the individual, social, and economic costs of gender-based violence and sets out an intersectional model to, among other goals, create specialized services, avoid revictimization, train professionals, and facilitate collaboration among service providers.

Nevertheless, violence against women remains high and access to quality services remains difficult. In Ecuador, a recent national survey of 18,880 women over the age of 15 revealed that about 49% had experienced partner violence in their lifetime. The forms of violence experienced include psychological (43.4%), physical (35.0%), sexual (14.5%), and patrimonial violence (10.7%). The health impact of violence against women is undeniable. Violence against women damages women’s physical, mental, sexual, and reproductive health while also increasing morbidity and mortality.

The Essential Services Package for Women and Girls Subject to Violence, written by the United Nations Joint Global Programme on Essential Services for Women and Girls Subject to Violence, identifies the essential services that the health care, social service, police, and justice sectors should provide for women and girls who suffer violence. The framework outlined by the Essential Services Package is in line with human rights declarations and includes key principles (for example, a rights-based approach and perpetrator accountability), common characteristics (for example, appropriateness, informed consent, and confidentiality), essential services and actions, guidelines for national-local coordination (for example, in the areas of law and policymaking), and foundational elements (for example, training and workforce development). The need for the Essential Services Package arises from the enduring effects of violence and the demand for a coordinated set of quality services equipped to respond to various forms of violence. While all of these elements are necessary for an effective response to violence against women, we chose four common characteristics on which to focus our study: availability, accessibility, adaptability, and appropriateness. These elements should be readily observable by service users and build on a long line of work related to health care access. However, the recent application of these characteristics to gender-based violence services in low- and middle-income countries, as done in the Essential Services Package, allows for a more tailored and context-sensitive application of these characteristics. Given the coverage and specificity of this model, we believe it provides a hitherto unexplored way of studying these issues.

The essential package underscores the need for services to be readily available to all in sufficient quality and quantity. Services should be available to all populations and sectors, without geographic or social discrimination. With regard to quantity, it is clear that most governmental and nongovernmental services in Quito are concentrated in the center and center-north areas of the city, while they are in very short supply in other areas. Governmental services, although more evenly distributed (with at least one specialized court per administrative zone), are very scarce in some areas, which underlines the need for the participation and aid from local nongovernmental organizations (NGOs) to broaden service coverage for women, especially marginalized women. However, even with NGOs’ help, a large part of the population still has low access to services. In Quito, there exists only one medical unit specialized in intimate partner violence and sexual violence and only one battered women’s shelter, which has a 10-women capacity. Services are often in high demand, revealing the need for more personnel. Thus, looking at the basic requirement that services be available, there appears to be a lack of availability in Quito.

A call for higher-quality services has been present in publications as early as 1999. In Ecuador, the “Critical Path” study funded by the World Health Organization identified sociocultural perceptions of violence as the main limitation to quality services. The majority of service providers in that study were found to favor the family unit over the integrity of the victim. Moreover, they found that justice and policing services were practiced unevenly, were heavily bureaucratized, and favored individual connections over institutional connections. This results in an irregular quality of services due to a lack of sensitive and qualified personnel, which in turn leads to an underestimation of the issue, long and inefficient processes, and victim-blaming.

Accessibility centers on the idea that services should be geographically, economically, and linguistically accessible to all women. The most common identified barriers for accessibility are economic barriers and the lack of knowledge about the procedures. Though services are stipulated as free in Ecuador, in most cases there are hidden costs such as transportation, legal fees, and document photocopies for legal services. A study that focused on five Ecuadorian NGOs found that there is general ignorance about the functioning of the legal system, its jurisdiction, the rights of victims, and legal responsibility and obligations of the service institutions by service providers. Additionally, most services are not adapted for disabilities, and not all disabilities are contemplated.

Adaptability calls attention to the fact that violence does not affect all women in the same way, and different needs require different service approaches. Thus, essential services should adapt to users’ demands and must be equipped to understand the different situations of violence women might find themselves in. The “Critical Path” study found that service providers generalized across victims, thus precluding a response adapted to each victim’s particular circumstances. This lack of understanding is also exacerbated by ignorance of the particularities of different ethnic groups. But, by far, the most complex and prevalent problem is the lack of adaptability in the speed of procedures and the hidden economic barriers, which are not subsidized for women with a lower economic status.

For essential services to be appropriate, they must respect the victim’s dignity, avoid any secondary victimization, and respect her decisions regarding the services she wishes to use, as well as provide options to empower her and address her needs, preserve confidentiality, and promote autonomy. According to the Ecuadorian Constitution (art. 76), victims have rights to due process; and according to the Integral Organic Penal Code (art. 1), essential services must respect dignity, allow autonomy, and abstain from any practice that might cause secondary victimization. Nevertheless, reality is another matter: essential services personnel do not necessarily know or apply the law. A lack of training and adequate funding leads to legal, medical, and psychological services without scientific rigor and service providers that harbor sexist perceptions and beliefs prioritizing familial stability over women’s safety. Some studies have reported just plain rude and unqualified service operators who revictimize and do not empower victims. Thus, from the available research, it seems that while these qualities are advanced in the letter of policies, practice has not followed suit.

Overall, most research on the provision of quality services is not recent or generally informed by service providers. During Ecuador’s latest political period, many aid agencies and NGOs left or closed, leaving mostly state-funded research and programs. Thus, there is a clear need to examine these qualities from the perspective of service users. Our study assumes this task via a series of focus groups with women who have accessed victim services in Quito.

Method

Procedure

In order to understand the availability, accessibility, adaptability, and appropriateness of services from the perspective of victims, we conducted three semi-structured focus groups with users of victim services in May 2016. After we built relationships with victim service organizations, three of them consented to allow us to hold focus groups with their users. Only users that have been engaged with services and were not in crisis were recruited. Each organization handled its own recruitment efforts as best suited to its style. Generally, staff personally invited users to participate. Each focus group took place at the site of the organization at a time deemed suitable by the participants. The three organizations were (1) a nonprofit domestic violence service provider (n = 12), (2) a city organization that provides counseling and legal assistance (n = 3), and (3) a city-supported organization that provides counseling and legal assistance (n = 6). All organizations were in Quito, Ecuador. Focus groups were conducted, transcribed, and analyzed in Spanish by the primary author and collaborators. Quotations for this manuscript were translated by two bilingual researchers. All focus group participants were informed about the study and the nature of the questions before beginning the focus groups. Each woman provided her verbal informed consent to participate. Focus groups lasted between one and a half and two hours each. Women were compensated either with US$5 or a lunch equivalent to US$5. Three institutional review boards approved this work—one in the United States and two in Ecuador.

Participants

Demographic information is available in Table 1. The sample was racially/ethnically homogenous, with 100% of those responding indicating they identified as mestiza (which translates to mixed race, especially referring to European and indigenous). The average age of the sample was 38 years old. The majority of the sample was employed (63.2%), and more than half had a high school education (secondary school) or above (52.6%). Aggressors were primarily husbands (42.1%), and abusive relationships tended to last 10 years or more (55.6%). About a third of the women were still in a relationship with the aggressor (35.3%), and 68.4% had experienced self-defined violence within the last year. On average, the sample was engaged with services for 5.82 months, although this ranged from zero months (new client) to two years of services. One of the focus groups consisted primarily of refugees from Colombia.

Measures

Focus group protocol. The focus groups began by asking participants to describe their decision to seek services, then centered on participants’ perceptions of the four main characteristics (availability, accessibility, adaptability, and appropriateness) of services, and closed by asking about participants’ satisfaction with services and recommendations for improvement. The semi-structured format probed the Essential Services Package characteristics (availability, accessibility, adaptability, and appropriateness) by explaining each attribute and asking participants about their experiences with each. Questions and probes were altered and added as needed to understand experiences with and impressions of victim services. All of the groups also explored participants’ prior experiences with victim services, particularly criminal justice services.

Questionnaire. At the end of each session, we asked participants to complete a demographic questionnaire. Questions asked about ethnic/racial identification, work status, educational attainment, relationship with abuser, last violent episode, and when services were sought. Responses relied on participants’ own interpretations of violence and their own recollection of events.

Data analysis

Transcripts were reviewed by three research team members, and segments reflecting the categories (availability, accessibility, adaptability, and appropriateness) were coded as such. Each theme was further subdivided into positive and negative examples. Accounts of previous services were also coded but kept separate from experiences with the focal service providers. Thus, an a priori (deductive) coding method was used based on the Essential Services Package. Codes were applied by two research team members, reviewed by the primary author, and then discussed and recoded to ensure conceptual and definitional consistency by two research team members. At the end of the process, there was 100% agreement on the codes applied to the data. Codes were then entered into NVivo.

Results

Availability relates to services being available in sufficient quantity and quality without any form of discrimination. Positive aspects of service quality that participants identified include being organized, being professional, offering appointments quickly, valuing users, and being warm to users. Participants also reported being pleased with workshops and particular staff members:

You notice she [the staff member] has more charisma just by seeing her, without taking into account her professional degree. … The other one didn’t even offer a breathing exercise, not even a glass of water. At least the one from here she impressed me, I swear she impressed me, she got up and brought me a cup of tea.

In terms of services that were not available, women indicated that they would like to see services for youth in schools, support for couples, services for children (including day care), prevention and awareness, microenterprise support, and services for men. Participants’ support for services for men was based on two arguments: (1) men also suffer from violence and (2) helping abusive men heal their wounds would in turn help women. One participant said, “Then it would be good if at some time they do workshops with them, not always, but it would be good if every so often they did it. That would also help them realize how much the partner of that person affects the woman.” Many women mentioned microenterprise and economic empowerment as a way to escape violence. Participants advocated for workshops, skills training, and other types of support to start small businesses, such as crafts and baking:

Although perhaps I think that the change would be from us, like the girl over there says. It would be to prepare us to be able to go out and support ourselves between all women, have perhaps a connection to someone who can teach us about entrepreneurship. For example, we could make a plan and help each other out and make an idea, a microenterprise, no? Then we would not suffer economically, we would stop trying to see if we sell or not, we would have some income, but all united as women, well that’s my suggestion.

Accessibility centers on the ability to access services without barriers, including physical, economic, and linguistic ones. Women’s access to services was fostered by locations that were close to their homes, transportation routes, or jobs; referrals from other service providers and friends and relatives; an ample and flexible schedule for attending to users; and websites describing services. Barriers that limited their access to services included those identified in the Essential Services Package, such as economic accessibility (for example, the inability to pay a psychologist or purchase medication). Some participants also mentioned how work and child care obligations limited their ability to access services. The difficulty in this situation of finding available appointment times reflects some of the administrative barriers to services. However, the most common barrier identified by focus group participants was a lack of information. This included not knowing that the services existed or how to access them, not knowing what other services were available, and not understanding how appointments were made:

I think that there should be more publicity, because there are so many of us who need this process to help ourselves. There are some people who don’t receive this process because they don’t [file a police] report, it’s because of that that you are sent here, that’s why you know about it. Many people don’t know about this place.

Adaptability includes recognition of the differentiated impacts of violence according to each individual’s particular circumstances. In other words, it allows for different options within services to best meet users’ unique needs. Focus group participants talked about service providers listening to them and helping them clarify their situations, which was a form of individualized attention. Specific circumstances to which service providers were responsive include recognizing a woman’s co-dependent relationship with her son; addressing aggressive behavior on the part of a woman; helping women improve their economic stability through skills training; incorporating spiritual aspects into psychological treatment; treating children; offering psychiatric services; teaching life skills such as cooking; and supporting well-being through yoga classes. Service providers also tailored services by assisting with cases of physical abuse, sexual abuse, psychological abuse, and/or child maltreatment. Further, some participants spoke about their children and their partners also receiving services, which allowed them to feel hopeful about ending violence in their families:

So, then I searched for help. I know that they will help us here, with individual therapy, group therapy. It has already cleared my mind and has helped me a lot. In couples therapy, we’ve said everything, like he said his things and I said my things. I said everything that I felt because of all he has done to me. We said everything. I don’t know, it was like a relief, and I feel very good.

Negative adaptability generally centered on services that participants needed but that were not available at a particular service site, such as child psychologists, services for men, medical services, and legal aid. Participants commonly mentioned their desire to start a small business or learn skills in order to increase their economic productivity. “Of course it would be good, here we are women who are fighters who want to establish our own businesses.”

Services that are appropriate are delivered in ways that maintain users’ dignity and confidentiality, while minimizing secondary victimization. Service users should feel that services are agreeable to them and empower them. Participants talked freely about what they gained from services—a sense of self, confidence, support, and encouragement, all in line with appropriateness:

I learned to hug, I learned about everything, everything changed for me, even people who knew me told me that now that I am 42 years old, they see me looking better than when I was 20. Yes, and that encourages me. It’s difficult, but yes I learned a lot. I mean, I learned in one year what I didn’t learn in 40 years—to love myself, to accept myself as a woman.

But when you feel the need to pull out what you have inside and tell it to people, like the psychologist, like in my case they have listened to me. And to me, that’s very important—to be heard and not necessarily be given something. I know that you need stuff, but I believe that in one of these houses it’s important that they listen to you, that you can release the pain you have inside, and you can start to love yourself and respect yourself more, and to me that’s the most important thing.

One participant spoke about feeling trapped in the shelter with little attention to her particular needs and desires. For example, serving meat, but no eggs, to a vegetarian and shutting off the hot water early in the morning. Another stated that her wounds are so deep that no amount of psychological treatment would be able to heal them. Other issues that affected the appropriateness of services include staff turnover and feeling cut off from family members.

During the course of the focus groups, participants also shared their experiences with other service providers, which ranged from helpful to endangering. Positive experiences with other service providers mirrored some of the positive experiences with current services; however, women were generally more restrained in their praises. A few participants indicated that other service providers had been helpful and had taken them seriously. With regard to the criminal justice system in particular, one participant commented that her case did not take a long time (three to four months), and another felt understood by the judge and was pleased that instead of arresting her partner, the court ordered him to undergo counseling.

On the whole, however, women’s experiences with other services were negative. For example, some women felt that these other providers had not been helpful: “We, like I told you, had received psychological help as a couple and individually over here in the district attorney’s office, but by the looks of it, it didn’t help us. Well, I did learn a lot, but it didn’t help him absolutely at all.” Others felt that the services had not been organized, safe, or confidential. Serious complaints were also made of victim-blaming, not believing victims, and not taking violence seriously unless very severe, especially psychological abuse or physical abuse without injury. Service providers were portrayed as insensitive, untrained, indifferent, and unknowledgeable:

Of course, and more than anything in all of the state offices, you see some pretty ignorant people, forgive my language. People think like Maria said, that they’re doing us a favor and knowing that a person goes to them and on top of that they tell them, “Why did you let yourself get hit?” There are a lot of people who don’t even have a little bit of training on how to treat people, how to treat people who are suffering violence. There’s quite a bit of that in Quito.

I’ve been in this for 12 years, but I come because I have a need. So then at first they humiliate you to be able to give you anything. First they humiliate you, then they throw it in your face, they don’t give it to you, if they give it to you first they humiliate you, if they give it to you, if they help you with something, but first they humiliate you psychologically and then later they give you something.

Participants also expressed frustration with services that forced them to retell their stories over and over again or that offered fragmented services such that the women needed to go to several different offices, with none actually helping:

First you arrive at the psychologist of whichever place, “Well, what’s your name?” they say. Click, click, click. “You know that you are going to get care, and this and that.” “Ok, tell me what’s going on.” Click, click, click. And you feel that the regret comes back and you give another go of things that you don’t want to talk about anymore, you don’t even want to remember it anymore, you want to put it in a book and burn it, make the ashes disappear and even the dust because all of it is traumatic for you. So then at the third appointment they tell you, “Ok, girl, you need to make decisions, you alone need to heal yourself.” Please … we don’t live off slaps to the face, we didn’t come here so that someone could hit us.

They also noticed the irony in mental health professionals ushering them to change their lives in a short period of time or treating the victim with medication and not doing anything about the abusive behavior itself. One participant even reported being sexually harassed by a psychologist at a previous service location. Others shared stories of how their abusive partners used the criminal justice system to further abuse and control them:

He filed two complaints against me. He accused me of psychological violence, when he was the one who attacked me, he hit me, I endured it and I never said anything, trying to preserve my marriage and everything else. He yelled at me, he kicked me, he hit me, sometimes he hit me in the face, horrors, and I said nothing. Later, what happens, he gets a restraining order, and they lock me up for a whole day, without notifying me before. They had to notify me.

One woman summed it up by saying, “Hay que tener suerte [you need to have luck] so that the person says, ‘Yes, we are going to support you.’”

Discussion

The way in which victim services are delivered is an important human rights issue that has a substantial bearing on women’s ability to live violence-free and healthy lives. Quality victim services enhance the well-being of survivors, while a failure to respond adequately poses yet another violation to victims’ human rights. Available, accessible, adaptable, and appropriate services are needed across the domains of health, criminal justice, and social services in order to advance human rights. From this sample of users of particular social and legal services, there appears to be wide variability across experiences. While participants tended to report more positive experiences with their current service providers, their difficulties in accessing services (accessibility) and receiving all of the support they needed (availability and adaptability) showed that these services still need to be improved to meet international standards. Further, women’s recollections of previous service experiences, especially concerning the criminal justice system, were negative overall.

The Essential Services Package calls for social service organizations to provide specific forms of support, including crisis counseling, safe accommodations, woman-centered support, psychosocial counseling, services for children, community outreach, and assistance toward economic independence. These were all concerns of our focus group participants. Across the focus groups, participants expressed a desire for support for economic independence via skills training and sponsorship (availability) so that they could navigate their particular economic situation (adaptability). Other areas that appear to be limited in availability, as mentioned in the Essential Services Package, include community outreach (mentioned by one participant), help lines (dedicated help lines not mentioned by any participant), and prevention (mentioned as a suggestion). Accessibility was largely limited by a lack of information, including for the women who sought services. One aspect of limited availability that focus group participants mentioned was services for children and men in conjunction with services for women. The women in our sample did not focus on separation and independence as the only way to gain safety; in fact, one-third were currently in their abusive relationships. Rather, some appeared to want solutions that maintained the family structure. Lastly, the appropriateness of services, particularly previous services, was diminished by a lack of sensitivity among personnel.

As revealed by participants, the issue of accessibility extended beyond physical, economic, and linguistic barriers and included the juggling of multiple roles (for example, employee, mother) and a lack of information. Indeed, several participants commented on how their knowledge of services was limited—either they did not know about services or their network did not know about available services. This lack of information is a specific barrier that could be overcome with an organized effort. Effective strategies include the training of public employees such as those working in police departments, district attorney’s offices, public aid offices, and the like; the distribution of information via educational and community institutions; general public service announcements; and the distribution of directories. The Essential Services Package acknowledges the importance of making crisis information available and accessible in a variety of locations in different formats. It notes that community information, which should be available in culturally appropriate ways, includes information on the rights of women, where to seek help, available services and how to access them, and what to expect when seeking services. This appears to be an area in need of attention in Quito.

The issue of adaptability requires service providers to understand the particular circumstances of victims and to meet those needs. Participants noted that this was done in a variety of situations, but they yearned for more alternatives with regard to economic empowerment. Economic empowerment can be helpful in decreasing women’s dependence on potentially abusive partners and improving the economic well-being of the family unit; but it can also be linked to increased violence in abusive relationships if the abusive partner views economic empowerment as a threat or seeks to control economic productivity. Economic empowerment programs tend to focus on financial literacy, economic self-efficacy, and economic self-sufficiency. While participants focused on economic self-sufficiency (specifically microenterprises), other aspects of economic empowerment (such as obtaining and navigating loans and learning about business accounting) may also be helpful. Women’s insistence on the ability to make their own money via skills such as cooking echoes the fact that 95% of businesses in Ecuador are microenterprises. Yet, violence against women could thwart the success of such businesses (for example, lost days of work due to violence, destruction of property by abusive partner, and emotional distress). In fact, more than half of women entrepreneurs in Ecuador have suffered from partner violence. Thus, while economic empowerment is a vital and worthy goal, there are still complex safety issues that need to be addressed. Furthermore, a realistic understanding of these businesses is important: there is no fixed income, there are very few labor laws for protection, and there are no benefits such as health insurance and investments. Economic advancement initiatives need to account for the complexity of issues at play, as well as respond to the context of such endeavors.

Another aspect of adaptability that was stressed by focus group participants includes services for children and partners. The desire for services for children often stemmed from an acknowledgement of the difficulties that children in abusive families have lived through. Research shows that child witnesses to domestic violence suffer from psychological, social, and academic problems. Participants desired help so that their children could understand and negotiate relationships in a healthy way. Additionally, children have the right to such protections through international instruments such as the Convention of the Rights of the Child, which indicates that states must protect children from maltreatment and abuse. Similarly, participants desired services for men so that they could heal from the violence they too have endured. While family preservation was not an explicit goal of most participants, many did want more aid than just for themselves. There was a sense of unfairness and irony identified by participants: their partners are abusive, yet the women are the ones seeking psychological services. Thus, family preservation could be one of the driving goals, but this desire could also speak to a need for abusive men to be held accountable for their actions and could be seen as a way to rebuke victim-blaming attitudes.

Another important issue identified by participants is the lack of understanding and empathy among some service providers. Protocols in Ecuador explicitly identify the need for specialized and trained professionals to provide ample information to victims so they can make decisions without being revictimized. This is also specified in the Convention of Belém do Pará. However, few women in the focus groups experienced such understanding and empathy. More generally, they reported insensitive, untrained personnel who did not aid in their treatment. Efforts to counteract these trends could include thorough trauma-informed training from a rights-based perspective for all personnel and could extend to seeking cultural shifts in the understanding of violence against women, as specified in the convention. Unfortunately, victim-blaming attitudes, based in gender inequality, continue to prevail in many countries, including Ecuador.

Conclusion

The findings here show mixed support with respect to the standards set out in the Convention of Belém do Pará, including the rights to dignity, to equal protection before the law, and to be free of stereotyped patterns of behavior based on gender inequality. While services and legal remedies were offered, they were offered unevenly. Further, the convention indicates that the state should train staff delivering these services, “provide readjustment and training programs to enable [victims] to fully participate in public, private and social life,” raise the awareness of the public, and provide “counseling services for all family members where appropriate.” Efforts such as violence prevention, public awareness raising, economic empowerment, trauma-informed services, and services for children are in line with fulfilling these mandates and the desires of victims. A very important contribution of these women is how they connect the violence they have experienced to their well-being in various aspects of their lives. This underscores other dimensions of human rights: interdependence and interrelatedness. Human rights are interdependent—all rights are connected and needed to achieve well-being. Economic rights are linked to the right to live free from violence. Thus, other state obligations, such as those outlined in the International Covenant on Economic, Social and Cultural Rights (which, among other things, underscores the need for gender equality in work and pay), can work to foster nonviolence.

Some of the limitations of this study include a racially and linguistically homogenous sample, which restricted our ability to understand accessibility for diverse groups. Further, the goal of the focus groups was not to obtain a detailed account of each service rendered but rather to discuss participants’ current service experiences. Our recruitment of focus group participants was facilitated by the service providers, meaning that dissatisfied or hard-to-reach users could have been excluded. A comprehensive evaluation of services would include various other dimensions, such as objective outcome measures, inclusion of those who discontinue services, and observation of service provision. Nonetheless, the sample of 21 service users provides meaningful insights into gender-based violence service provision in Quito, Ecuador, from users’ own perspectives.

The Essential Services Package provides a roadmap for increasing access to services for women who are victims of gender-based violence in low-income countries. Using this framework, which is guided by a rights-based approach to health, has proven effective for discovering some of the strengths and weaknesses of the victim service delivery model in Quito. Overall, there are a limited amount of services available, but the experiences shared by participants underscore the vital and life-saving role of victim services. Continued efforts—including more funding, staff, programs, and training—are needed to meet the varied and complex needs of victims and to realize all women’s right to health in situations of gender-based violence.

Acknowledgments

We appreciate the contributions of Melissa Romero von Buchwald and Nancy Contreras, who aided with the focus groups and coding of the data.

Table 1.

Participants’ demographic information

Attribute	Number (N=19)	%
Race/ethnicity
Mestiza	17*	100
Employment
Worked last week	11	57.9
Didn’t work last week but had job	1	5.3
Looking for work for the first time	2	10.5
Looking for work and worked before	2	10.5
Student	1	5.3
Housewife	2	10.5
Education
None	1	5.3
Did not finish primary school	3	15.8
Finished primary school	1	5.3
Did not finish secondary school	4	21.1
Finished secondary school	5	26.3
Did not finish college	3	15.8
Finished college	2	10.5
Relationship to aggressor
Married	8	42.1
Separated	2	10.5
Civil union	3	15.8
Family member	3	15.8
Unrelated/armed conflict	3	15.8
In current relationship with aggressor?
Yes	6	35.3
No	11	64.7
Length of relationship with aggressor
6–11 months	1	5.6
3 years	1	5.6
5 years	1	5.6
6 years	1	5.6
8 years	1	5.6
9 years	1	5.6
10 years	2	11.1
More than 10 years	10	55.6
Length of time since violence occurred
There is currently violence	3	15.8
2–3 weeks	1	5.3
2–3 months	3	15.8
4–5 months	2	10.5
6–7 months	3	15.8
8–9 months	1	5.3
One year	2	10.5
More than one year	4	21.1
	Mean	Standard deviation
Age in years	38.00	9.71
Length of service engagement in months	5.82	6.84