Co-creating a global shared research agenda on violence against women in low- and middle-income countries.

BACKGROUND: Despite a large growth in evidence on violence against women (VAW) over the last 25 years, VAW persists, as do gaps in the field's knowledge of how to prevent and respond to it. To ensure that research on VAW in low- and middle-income countries (LIMCs) is addressing the most significant gaps in knowledge, and to prioritise evidence needs to reduce VAW and better support victims/survivors, the Sexual Violence Research Initiative (SVRI) and Equality Institute (EQI) led a process of developing a global shared research agenda (GSRA) on VAW in LMICs. METHODS: The GSRA was developed through a six-stage adaptation of the Child Health and Nutrition Research Initiative (CHNRI) method, which draws on the principle of the 'wisdom of the crowd'. These steps included: a review of the literature on VAW in LMICs and development of domains; the generation of research questions within four domains by an Advisory Group; the consolidation of research questions; scoring of research questions by a Global Expert Group and the Advisory Group according to three criteria (applicability, effectiveness and equity); consultation and validation of the findings with the Advisory Group; and wide dissemination of the findings. RESULTS: The highest ranked research questions in the GSRA pertain to the domain of Intervention research, with some highly ranked questions also pertaining to the domain of Understanding VAW in its multiple forms. Questions under the other two domains, Improving existing interventions, and Methodological and measurement gaps, were not prioritised as highly by experts. There was strong consistency in top ranked research questions according to experts' characteristics, albeit with some important differences according to experts' gender, occupation and geographical location. CONCLUSIONS: The GSRA findings suggest that currently the VAW field is shifting towards intervention research after several decades of building evidence on understanding VAW, including prevalence, drivers and impacts of violence. The findings also suggest a strong emphasis on under-served populations, and under-researched forms of VAW. Future priority setting exercises in LMICs that seek to decolonise knowledge should ensure that methodologies, and modalities of engagement, put diverse voices at the centre of engagement. Trial registration Not applicable.

Enhancing a survivor-centred approach to healthcare provision in Afghanistan: Understanding and addressing the barriers faced by male victims/survivors of sexual violence.

BACKGROUND: Men and boys may experience sexual violence, particularly in conflict settings. However, in Afghanistan little is known about the barriers they face accessing healthcare services. OBJECTIVE: The objectives are to identify barriers to healthcare provision for male victims/survivors of sexual violence in Afghanistan and identify ways to enhance survivor-centred healthcare. PARTICIPANTS AND SETTING: Data were collected in three provinces with adult male victims/survivors of sexual violence (n = 27), healthcare providers (n = 44), and community health workers (n = 26). Boys were not interviewed due to ethical reasons; however, we include retrospective analysis where possible. METHODS: The methods include semi-structured, qualitative interviews with participants. Data were analyzed thematically according to a social ecological model of public health. The study was ethically approved by the Afghan Ministry of Public Health. RESULTS: Male victims/survivors of sexual violence in Afghanistan face multiple and cumulative barriers to accessing healthcare services. Stigmatization and fears of being sexually abused by healthcare providers are particularly accentuated for those victims/survivors with diverse sexual orientation, gender identity, gender expression, and sex characteristics (SOGIESC). Boy victims/survivors also face particular barriers, including healthcare providers' lack of knowledge of the evolving capacities of the child. CONCLUSIONS: Survivor-centred healthcare response to male victims/survivors of sexual violence should address barriers at multiple levels of the social ecological model, and respond to the needs of male victims/survivors from different vulnerable groups, including boys and those with diverse SOGIESC.

Peer victimization and experiences of violence at school and at home among school age children with disabilities in Pakistan and Afghanistan.

Background: Children with disabilities are more likely to experience violence or injury at school and at home, but there is little evidence from Central Asia. Objective: To describe the prevalence of disability and associations with peer violence perpetration and victimization, depression, corporal punishment, school performance and school attendance, among middle school children in Pakistan and Afghanistan. Method: This is a secondary analysis of data gathered in the course of evaluations of interventions to prevent peer violence conducted in Pakistan and Afghanistan as part of the 'What Works to Prevent Violence against Women and Girls Global Programme'. In Pakistan, the research was conducted in 40 schools, and disability was assessed at midline in 1516 interviews with Grade 7s. In Afghanistan, the data were from the baseline study conducted in 11 schools with 770 children. Generalized Linear Mixed Modeling was used to assess associations with disability. Results: In Afghanistan, the prevalence of disability was much higher for girls (22.1%) than boys (12.9%), while in Pakistan 6.0% of boys and girls reported a disability. Peer violence victimization was strongly associated with disability in Afghanistan and marginally associated in Pakistan. In Pakistan, perpetration of peer violence was associated with disability. In both countries, disability was significantly associated with higher depression scores. Food insecurity was strongly associated with disability in Afghanistan. Conclusion: Disability is highly prevalent in Afghanistan and Pakistan schools and this is associated with a greater risk of experiencing and perpetrating peer violence. It is important to ensure that all children can benefit from school-based prevention interventions.

Engaging with faith groups to prevent VAWG in conflict-affected communities: results from two community surveys in the DRC.

BACKGROUND: An evaluation was conducted of a three-year intervention focused on violence against women and girls (VAWG) and implemented in the conflict-affected north-east of the Democratic Republic of Congo (DRC), a country with high rates of VAWG. The intervention addressed VAWG, and especially sexual violence, by specifically engaging with communities of faith and their leaders. METHODS: Two community surveys were conducted, one before and one after the intervention, in three health areas in Ituri Province in the DRC. At both baseline and endline, data was collected from male and female members of randomly selected households in 15 villages (five per health area) in which the intervention was being implemented. At baseline the sample comprised 751 respondents (387 women, 364 men) and at endline 1198 respondents (601 women, 597 men). Questionnaires were interviewer-administered, with sensitive questions related to experience or perpetration of violence self-completed by participants. RESULTS: The study showed significantly more equitable gender attitudes and less tolerance for IPV at endline. Positive attitude change was not limited to those actively engaged within faith communities, with a positive shift across the entire community in terms of gender attitudes, rape myths and rape stigma scores, regardless of level of faith engagement. There was a significant decline in all aspects of IPV in the communities who experienced the intervention. While the experience and perpetration of IPV reported at endline did not track with exposure to the intervention, it is plausible that in a context where social norm change was sought, the impact of the intervention on those exposed could have had an impact on the behaviour of the unexposed. CONCLUSION: This intervention was premised on the assumption that faith leaders and faith communities are a key entry point into an entire community, able to influence an entire community. Research has affirmed this assumption and engaging with faith leaders and faith communities can thus be a strategic intervention strategy. While we are confident of the link between the social norms change and faith engagement and project exposure, the link between IPV reduction and faith engagement and project exposure needs more research.

The impacts of combined social and economic empowerment training on intimate partner violence, depression, gender norms and livelihoods among women: an individually randomised controlled trial and qualitative study in Afghanistan.

Introduction: We assessed whether the Women for Women International (WfWI) economic and social empowerment programme could reduce women's experiences of intimate partner violence (IPV) and depression in Afghanistan. Methods: We conducted a two-arm individually randomised controlled trial in six urban and peri-urban communities. Communities were selected by WfWI for being conflict affected and showing signs of economic vulnerability (eg, little or no education, living in extreme poverty). Individual eligibility were female, aged 18-49, able to consent to participate and one woman per household. At 22 months, three primary outcomes were assessed: past year physical IPV experience; past year severe IPV experience; depressive symptoms. There was no blinding to arms. We conducted an intention-to-treat analysis, controlling for age. We also conducted qualitative interviews at endline, analysed using thematic analysis. Results: 1461 women (n=933 married) were recruited and randomised. Retention at endline was n=1210 (82%). Primary outcomes were in the hypothesised direction, but showed no significant impacts: physical IPV (adjusted OR (aOR) 0.88 (0.62 to 1.23)), severe IPV (aOR 0.75 (0.50 to 1.11)) and depressive symptoms (ß -0.35 (-1.19 to 0.48)). Women reported reduced food insecurity (ß -0.48 (-0.85 to -0.12)), higher earnings (ß 3.79 (0.96 to 6.61)) and savings (ß 11.79 (9.95 to 13.64)). Women reported less gender-inequitable attitudes (ß -0.89 (-1.15 to -0.62)), more household decision-making (ß 0.35 (-0.04 to 0.74)) and increased mobility (aOR 1.78 (1.27 to 2.50)). Twenty-eight in-depth interviews were conducted. Conclusion: The intervention did not impact IPV or depression. The intervention did improve livelihoods, create more gender-equitable relationships and increase women's mobility. Translating these gains into IPV and depression reduction is critical. Trial registration number: NCT03236948, registered 2 August 2017.

Bacha posh in Afghanistan: factors associated with raising a girl as a boy.

This paper examines the factors associated with the cultural phenomenon of bacha posh in Afghanistan (in which girls are dressed and raised as boys), which occurs against a background of rigid gender norms and the male-centric nature of Afghan families. Survey data were collected from 1463 women in two provinces of Afghanistan, Kabul and Nangarhar. The primary outcome is a nominal variable, derived from the question, 'Do you have any girl in your family who has been raised for any time as a boy?' Independent variables comprise women's socio-demographic characteristics, family composition, economic characteristics, patriarchal gender attitudes and perceptions of community patriarchal attitudes. Factors associated with bacha posh include women having fewer sons and more daughters, working in the past three months and having less patriarchal gender attitudes. That bacha posh is often driven by a large number of daughters in the family with a corresponding low number of sons suggests that bacha posh is a response to very contextual features of Afghan life, including the preference for sons. Bacha posh in the family is linked to less patriarchal gender norms and can be a way for girls and women to acquire education, mobility and engagement in income-generating activities.

Factors associated with 'honour killing' in Afghanistan and the occupied Palestinian Territories: Two cross-sectional studies.

'Honour killing', the murder of women to preserve family reputation, is well recognised but infrequently systematically researched. This paper has three hypotheses. First, in families where women report an 'honour killing' there is more violence against women and girls, second these women are more likely to report more patriarchal gender attitudes than others, and third these families are exposed to higher levels of poverty. We asked (n = 1461) women enrolled in a trial in Afghanistan, and (n = 535) in a population-based sample in the occupied Palestinian Territories (oPT) if there had ever been an 'honour killing' in their family. In Afghanistan, 2.3% (n = 33), and the oPT 7.7% (n = 41), reported this. We built separate multivariable logistic regression models for each country, and for married and unmarried women in each country. Among Afghan married women, 'honour killing' was associated with borrowing because of hunger (adjusted odds ratio [aOR]8.71, 95%CI 2.27-33.40), easier access to money in emergency (aOR11.39, 95%CI 3.05-42.50), and violence within the family; intimate partner violence (IPV) (aOR3.73, 95%CI 1.12-12.36), and IPV and mother-in-law violence (aOR10.52, 2.60-42.56). For unmarried women in Afghanistan, 'honour killing' was associated with easier access money in an emergency (aOR4.06, 95%CI 0.85-19.37), household violence (hit by parent or sibling, or parent and sibling [aOR5.47, 95%CI 0.82-36.70; aOR7.37, 95%CI 1.24-43.86, respectively]); more childhood traumas (aOR1.24, 1.11-1.38), and more patriarchal personal gender attitudes (aOR1.24, 1.00-1.54). In the oPT experiencing IPV (aOR3.07, 1.02-9.23) and borrowing and experiencing IPV (aOR5.89, 1.84-18.79) were risks for married women. For unmarried women borrowing because of hunger was associated with higher risk (aOR2.33, 95%CI 1.18-4.85). Despite limitations-specifically the potential women were reporting the same 'honour killing'-our analysis suggests 'honour killings' are associated with violence, patriarchy, and poverty. Research is needed for the prevention of 'honour killing', which must address the root causes. Trial Registration: ClinicalTrials.gov NCT03236948.

What works to prevent violence against children in Afghanistan? Findings of an interrupted time series evaluation of a school-based peace education and community social norms change intervention in Afghanistan.

BACKGROUND: Against a backdrop of more than four decades of war, conflict and insecurity, Afghanistan is recognised as suffering from endemic violence and children are exposed to multiple forms of violence, including at the family and school levels. This paper presents the results of an evaluation of school-based peace education and a community-based intervention to change harmful social norms and practices related to gender and the use of violence in conflict resolution, implemented in Afghanistan with the aim of reducing violence against and between children. METHODS: The evaluation consisted of a cross-sectional, interrupted time series design with three data collection points over 12 months. Data was collected from students in 11 secondary schools (seven girls' and four boys' schools) in Jawzjan province of Afghanistan, with a total of 361 boys and 373 girls sampled at endline. All children were interviewed with a questionnaire developed for the study. Key outcomes included children's experience of peer violence (both perpetration and victimization) at school, corporal punishment both at home and at school, and observation of family violence. Other outcomes included children's gender equitable attitudes, attitudes towards child punishment, depression and school performance. RESULTS: Between baseline and endline evaluation points, there were significant reductions in various forms of violence at the school level, including both boys' and girls' past month experience of peer violence victimization, peer violence perpetration, and corporal punishment by teachers. There were also significant reductions in boys' and girls' experience of corporal punishment at home and observation of family violence, with a particularly strong effect observed among girls. Both boys and girls had significantly more equitable gender attitudes and significantly less violence-supportive attitudes in relation to children's punishment, and significantly fewer symptoms of depression. Girls' school attendance was also significantly higher at endline. DISCUSSION: To our knowledge this is the first time that a peace education program has been evaluated in Afghanistan, with or without a community intervention to change harmful social norms and practices related to gender and the use of violence for conflict resolution. The evaluation suggests that the intervention may have led to a reduction in various forms of violence, including children's peer violence, corporal punishment of children both at school and at home, and in children's reports of domestic violence against women at the household level.

Violence against Afghan women by husbands, mothers-in-law and siblings-in-law/siblings: Risk markers and health consequences in an analysis of the baseline of a randomised controlled trial.

BACKGROUND: Violence by mothers-in-law, as well as husbands, is a recognised problem in many countries. It has been given little attention in research on violence and its importance as a health problem, and aggravator of husband violence, has not been well established. Our aim was to describe patterns and the frequency of mother-in-law and sibling-in-law/sibling physical violence in relation to physical violence from husbands, and to describe risk characteristics and associated health behaviours of women with different abuse exposures. METHODS: 1,463 women aged 18-48 were recruited into a randomised controlled trial (RCT) to evaluate a women empowerment intervention in 6 villages of Kabul and Nangarhar provinces. The women were interviewed at baseline. The analysis uses bi-variable and multivariable logistic regression. RESULTS: 932 of the women were currently married. Of these, 14% of women experienced mother-in-law physical violence and 23.2% of women experienced physical spousal violence in the previous 12 months. For 7.0% of women, these exposures were combined. Physical violence was associated with food insecurity and having to borrow for food, being in a polygamous marriage, living with their mother-in-law, as well as province of residence (higher in Nangarhar). Women who had earnings were relatively protected. Whilst most mothers-in-law were described in positive terms, those who used physical violence were much less likely to be described so and a quarter were described as very strict and controlling and 16.8% as cruel. Overall slightly more women described their husband in positive terms than their mother-in-law, but there was a very strong correlation between the way in which husbands were perceived and the violence of their mothers. Women's mental health (depression, suicidal thoughts and PTSD symptoms score), self-rated general health, disability and beating of their children were all strongly associated with intimate partner violence (IPV) exposure. The strength of the association was much greater for all of these problems if the IPV was combined with physical violence from a mother-in-law or sibling-in-law/sibling. Experienced alone, violence from the mother-in-law or a sibling-in-law/sibling was associated with an elevated risk of all of these problems except depression. INTERPRETATION: Mother-in-law and sibling-in-law/sibling physical violence is an appreciable problem among the women studied in Afghanistan, linked to poverty. It has a major impact on women's health, componding the heath impact of IPV. In this setting conceptualising women's risk and exposure to violence at home as only in terms of IPV is inadequate and the framing of domestic violence much more appropriately captures women's risks and exposures. We suggest that it may be fruitful for many women to target violence prevention at the domestic unit rather than just at women and their husbands.

Trauma exposure and IPV experienced by Afghan women: Analysis of the baseline of a randomised controlled trial.

BACKGROUND: Four decades of conflict has indelibly impacted the lives of Afghans, exposing many to different forms of trauma. The aim of this paper investigate a hypothesis that (mostly war related) trauma is a key driver of partner violence in Afghanistan. METHODS: 1,463 women aged 18-48 were recruited into a randomised controlled trial (RCT) to evaluate a women empowerment intervention in 8 villages of Kabul and Nangarhar provinces. The women were interviewed at baseline. The analysis uses multivariable logistic regression and structural equation modelling (SEM) to describe relationships between measures. RESULTS: 57.4% of women reported exposure to one of four types of trauma: 23.3% an armed attack, 39.4% had felt close to death, 10.6% witnessed a friend or family member being killed and 21.4% witnessed the death of a stranger or someone unknown. Trauma exposure was associated with being older, Pashtan, madrassa educated, and food insecure. Women who were trauma exposed were more likely to have ever experienced IPV, have hit their children in the last 4 weeks, and be hit by a sibling or relative of their husband or their mother-in-law in the last year. They held less patriarchal personal gender attitudes and perceived the community to be more patriarchal. The SEM showed that all pathways between trauma exposure and IPV were ultimately mediated by either (mostly mental) ill-health or quarrelling, but not both of these. There were multiple paths through which trauma exposure impacted women's past year experience of physical IPV. One was mediated by childhood trauma exposure and a latent variable for ill health. Other paths were mediated by women's education and personal gender attitudes and ill-health, or else by quarrelling. Trauma exposure was related to lower educational levels. Another path was mediated by less patriarchal personal gender attitudes and ill health. Community gender attitudes was a mediating variable on a path which was also mediated by ill health and another mediated by quarrelling. It was also a mediator on a path which included personal gender attitudes and ill-health. Food insecurity mediated another path with ill health. It was also connected to childhood trauma, community gender attitudes and educational level. CONCLUSION: Trauma exposure due to conflict will persist until the conflict ends but the impact on women can be ameliorated. This analysis suggests interventions to reduce women's exposure to IPV should focus on reducing poverty, changing social norms on gender, providing relationship skills to help reduce quarrelling and supporting women's mental health.

Factors associated with recent intimate partner violence experience amongst currently married women in Afghanistan and health impacts of IPV: a cross sectional study.

BACKGROUND: Intimate partner violence (IPV) is exceedingly common in conflict and post-conflict settings. We first seek to describe factors associated with past 12 month IPV amongst currently married women in Afghanistan, focused on the factors typically assumed to drive IPV. Second, to describe whether IPV is independently associated with a range of health outcomes. METHODS: Cross-sectional analysis of currently married Afghan women, comprising the baseline study of a trial to prevent IPV. We use multinomial regression, reporting adjusted relative-risk ratios to model factors associated with the different forms of IPV, comparing no IPV, emotional IPV only, and physical IPV and emotional IPV. Second we assessed whether experience of emotional IPV, and physical IPV, were independently associated with health outcomes, reporting adjusted ß coefficients and adjusted odds ratios as appropriate. RESULTS: Nine hundred thirty five currently married women were recruited, 11.8% experienced only emotional IPV and 23.1% experienced physical and emotional IPV. Emotional IPV only was associated with attending a women's group, greater food insecurity, her husband having more than one wife, experiencing other forms of family violence, and more inequitable community gender norms. Experiencing both physical IPV and emotional IPV was associated with attending a women's group, more childhood trauma, husband cruelty, her husband having more than one wife, experiencing other forms of family violence, more inequitable community gender norms, and greater reported disability. Emotional IPV and physical IPV were independently associated with worse health outcomes. CONCLUSION: IPV remains common in Afghanistan. Economic interventions for women alone are unlikely to prevent IPV and potentially may increase IPV. Economic interventions need to also work with husbands and families, and work to transform community level gender norms. TRIAL REGISTRATION: NCT03236948 . Registered 28 July 2017, retrospectively registered.

Children's peer violence perpetration and victimization: Prevalence and associated factors among school children in Afghanistan.

BACKGROUND: Child peer violence is a global problem and seriously impacts children's physical and psychological health, and their education outcomes. There are few research studies on children's peer violence available in South Asian countries, particularly in Afghanistan. This paper describes the prevalence of children's peer violence perpetration and victimization and associated factors among school children in Afghanistan. METHODS: A total of 770 children were recruited into a baseline study conducted as part of an intervention evaluation in 11 schools (seven girls' and four boys' schools). All children were interviewed with a questionnaire developed for the study. The main outcome is a three-level peer violence variable consisting of (a) no violence, (b) victimization only, or (c) perpetration (with or without victimization). Peer violence victimization was measured through the Multidimensional Peer-Victimization Scale, and peer violence perpetration was measured through an adjusted version of the same scale with wording changed to measure perpetration. RESULTS: 49.7% of boys and 43.3% of girls reported having experienced more than one instance of violence victimization in the past month, and 31.7% of boys and 17.6% of girls disclosed perpetration of more than one instance of violence in the past month, with considerable overlap found between experience of victimization and perpetration, particularly among boys. Multinomial models of factors associated with peer violence show that for boys, food insecurity was associated with perpetration of peer violence but not with victimization, and experiencing corporal punishment at school in the last month was significantly associated with both peer victimization and perpetration. For girls, food insecurity, more depressive symptoms and experiencing any beating at home were associated with both violence victimization and perpetration. Having a disability was associated with victimization only, and having witnessed their father fighting and experiencing any kind of corporal punishment were associated with peer violence perpetration only. DISCUSSION: Peer violence in Afghanistan is linked to food insecurity, exposure of children to witnessing family violence, and children's experience of physical violence at home and corporal punishment at school. School-based settings provide an important platform for interventions to reduce and prevent peer violence; however, such interventions may benefit from broader violence-prevention initiatives conducted at the community level.

Understanding how Afghan women utilise a gender transformative and economic empowerment intervention: A qualitative study.

The processes through which women's economic empowerment interventions are envisaged to improve women's health are strongly embedded in notions of building women's agency and autonomy. Yet despite the ubiquity of such interventions, there remains incredibly little qualitative work exploring how women actually utilise interventions to reshape their lives and wellbeing. Drawing on 9 focus groups discussions among 52 women who participated in the Women for Women International intervention in Afghanistan, an economic strengthening and social empowerment intervention, we explore processes of change. Data showed women learnt new skills around numeracy and animal husbandry; they perceived themselves to have become more respected within the household setting; they invested cash they received for intervention attendance in businesses, primarily their husband's or family's, and saved cash. Women did not, however, report their relationships to have been radically restructured. Rather women described incremental changes in their relationships within their household and used what they gained from the intervention to secure and sustain this. This conceptualisation of agency and empowerment reflects approaches to understanding agency, which move away from 'action-oriented' understandings, to ones that recognise 'distributed agency' as pathways to change through interventions.

An individually randomized controlled trial to determine the effectiveness of the Women for Women International Programme in reducing intimate partner violence and strengthening livelihoods amongst women in Afghanistan: trial design, methods and baseline findings.

BACKGROUND: Intimate Partner Violence (IPV) is the most common form of violence in conflict and post-conflict settings, but there are few evaluations of interventions to prevent IPV in such settings. METHODS: The Women for Women International (WfWI) intervention is a year-long combined economic and social empowerment intervention for marginalized women survivors of conflict. Primarily, it seeks to support women to achieve four key outcomes: women earn and save money; women improve their health and well-being; women influence decisions in their homes and communities; women connect to networks for support. The organization recognizes Violence Against Women and Girls (VAWG) as a significant barrier to women's empowerment and expects to see reduction in VAWG, and specifically IPV, as part of building women's social and economic empowerment. This program is being quantitatively evaluated through an individually randomized control trial amongst women in Afghanistan, with a 24-month follow up. A comparison of baseline characteristics of participants is also included as well as a discussion of implementation of the baseline research. DISCUSSION: There is a high demand amongst Afghan women for such interventions, and this posed challenges in completing the randomization and baseline. In addition, the complex security situation in Afghanistan also posed challenges. However, despite these issues, recruitment was successfully achieved and the arms were balanced on socio-demographic measures. The evaluation will contribute to the limited evidence base on interventions to prevent IPV in conflict-affected settings. TRIAL REGISTRATION: NCT03236948 . Registered 28 July 2017, retrospectively registered.

Challenges of Bystander Intervention in Male-Dominated Professional Sport: Lessons From the Australian Football League.

Programs aimed at preventing violence against women have increasingly adopted bystander approaches, yet large gaps remain in our knowledge about what drives bystanders to act or not, particularly in settings where there is an increased risk of violence against women occurring. This article contributes to this gap by examining data from research with professional male athletes from the Australian Football League. Drawing from a mixed methods approach, including a survey and interviews with football players, we outline some of the challenges to bystander intervention faced by professional athletes and discuss some of the possible similarities and differences between these and other groups of men.

Falling through the cracks: the gap between evidence and policy in responding to depression in gay, lesbian and other homosexually active people in Australia.

OBJECTIVE: To examine the evidence for a national policy response to depression among gay, lesbian and other homosexually active people in Australia. METHODS: A literature review using database searches on depression among non-heterosexual people then a web-based search of national policy investigating how mental health needs in this population are addressed in Australia. RESULTS: The literature review found that non-heterosexual people experience depression at higher rates, but the literature on interventions was sparse. The policy analysis found no mention of depression or the broader mental health needs of non-heterosexual people in key national mental health policy documents. These documents outline a policy approach for population groups with a higher prevalence of mental health problems, and stigma and discrimination are relevant associated factors, but only the National Suicide Strategy considers non-heterosexual people an 'at-risk group'. CONCLUSIONS: The results suggest that the evidence on higher rates of depression in non-heterosexual people is strong, but that this is not recognised in current national policy. IMPLICATIONS: Defining non-heterosexual people as an 'at-risk' group is appropriate, as is prioritising access to mental health services that are socially and culturally appropriate. Addressing homophobia as an associated factor would require a strategic policy approach across a range of sectors.