Democracy, Human Rights, and Labor: FY 14: Gender-based violence among stateless and national populations in the Dominican Republic

November 2017

Report by Johns Hopkins University and Centro para la Observación Migratoria y Desarrollo Social en el Caribe (OBMICA)

Global estimates suggest that approximately 10 million people worldwide are living without any legal citizenship. Stateless persons face overwhelming obstacles that limit their access to basic entitlements and protections, leaving them vulnerable to discrimination and abuse. Research on health and access to care is generally limited among stateless persons and, currently, there is a dearth of information on statelessness and its relationship to gender based violence (GBV). In the Dominican Republic, Dominicans of Haitian ancestry have faced significant challenges to obtain legal citizenship and nationality. On 23 September 2013, the Constitutional Tribunal issued a judgment providing a new interpretation of the criteria for acquisition of Dominican nationality with regards to the Dominican-born children of migrant workers who were not residing legally in the country at the time of their children's birth. This ruling created a mass, arbitrary deprivation of nationality resulting in tens of thousands of persons becoming stateless, according to UNHCR. Because of the lack of national recognition, in a situation where Law 169-14 has been poorly implemented, stateless persons of Haitian ancestry are not protected adequately by national law and are therefore subject to abuse and discrimination from citizens, employers, state agencies, and health care providers. Stateless individuals are often unable to access even the most basic national health services, including health care, formal employment and education for their children, due to lack of documentation and/or restrictions on movement. The study presented here aimed to understand the demographics, experiences, and vulnerabilities to GBV and general health status among stateless populations in the Dominican Republic. This was part of a larger project to understand the role of statelessness in gender-based violence and health, which includes research in both the Dominican Republic and Cote d’Ivoire.

A mixed methodology approach was used to achieve the study aims. Qualitative research was conducted in February 2015 to obtain contextual descriptions of experiences related to documentation, GBV and GBV-related health issues, and access to health care. Twenty-five in-depth interviews were conducted with male and female participants who were of the affected population. Three focus groups of approximately eight participants per group were convened with service providers or community leaders. Two individual interviews were also convened with service providers. An epidemiologic survey, informed by the qualitative findings, was developed to collect data on demographics, GBV experiences and GBV-related health indicators. The survey was conducted in 77 communities (urban/peri-urban and rural settings) where stateless persons are known to reside and where local community leaders and their community were willing to participate in the survey. The proportions of key indicators relating to demographics, GBV, GBV-related health impacts and health care access among the stateless population were compared to the populations with legal citizenship. Unmeasured confounders related to socio-economic status and geographic distance to health facilities were controlled between stateless (Group B, persons who lacked any kind of identity document) and legal citizens by sampling the population with legal citizenship who live in closest proximity to the surveyed stateless participants. A total of 826 women, of which 423 were nationals and 403 were stateless, and 470 men participated, of which 260 were nationals and 210 were stateless. All data collection was anonymous and several methods were incorporated to further protect participant privacy and confidentiality. Ethical review and approval of the study aims and methodology was provided by the Johns Hopkins Institutional Review Board and an ad hoc advisory board comprised of experts in statelessness issues in the Dominican Republic.

Results from the quantitative survey highlight key demographic disparities between the stateless and national populations. The findings demonstrate the limited access to basic rights and services among stateless populations when compared to legal citizens. Significant findings include the following for stateless compared to national citizens: stateless females are 10 times (47% stateless vs. 4% national) and males 8 times (39% stateless vs. 5% national) more likely to encounter difficulties with getting married when compared to nationals; stateless persons are more than 60 times less likely to have health insurance (stateless females 1% vs. 68% nationals females and stateless males 3% vs. 65% nationals). Stateless persons and their partners are generally less likely be permitted to advance past secondary school; to have worked in the past month or have year-long employment; able to earn enough income to meet their monthly basic needs; and less likely to be legally able to open a bank account. Several stateless persons described situations in which they were robbed or exploited of their savings by trusted individuals who knew that the participant was unable to open a bank account. Children of stateless persons are similarly affected: less likely to be registered legally; less able to have health insurance; and less able to continue with their education.

Lack of citizenship and legal status is observed to increase vulnerabilities to violence and exploitation. Overall, stateless persons report greater experiences of lifetime violence victimization relative to national populations (stateless to national females, 52% vs 39%; stateless to national males 37% to 31%, respectively). Stateless women are found to have a statistically greater proportion of having experienced any lifetime violence victimization when compared to females with legal documentation, 52% vs 39% respectively. Specifically, stateless women were 50% more likely than national women to have experienced physical child abuse (22% vs 13%), any child physical or sexual abuse (28% vs 19%), and intimate partner violence (IPV) during pregnancy (15% vs. 10%). Stateless women were also more likely to have witnessed family violence as a child (89% vs. 77%), a known risk factor for violence victimization later in life and a correlate of lifetime violence victimization in this study. Qualitative participants provided contextual descriptions of experiences of violence and the role of statelessness in both increasing vulnerabilities to GBV and creating barriers to care following violence. One qualitative participant recounted prolonged sexually exploitation as a child by a neighbor and caretaker who promised to assist in obtaining documentation.

Fewer differences in violence victimization existed among men who are stateless compared to national participants, with the exception that stateless men were more likely to report experiences of physical violence victimization. Lifetime perpetration of violence against intimate partners and non-partners was lower among stateless men, but was not statistically different.

NOTE: IPV: intimate partner violence; NP: non-partner violence; * marginally or statistically significant difference

While there was no statistical difference in the self-assessment of one’s general health among stateless and national respondents, notable determinants were identified that could contribute to poorer health outcomes for stateless persons. Stateless women were more likely to report symptoms of depression (25% vs. 20%), difficulty in affording costs for medical advice or treatment (68% vs. 60%), and concerns about deportation when accessing healthcare (69% vs. 5%) relative to national women. Stateless men were less likely to have consulted a medical professional than national men (17% vs. 26%), were more likely to report symptoms of depression (31% vs. 19%), and were also more likely to report concerns about deportation when accessing healthcare (67% vs. 2%).

The research and analysis presented here describe the relationships between lack of national documentation, livelihoods, violence, and health outcomes. Being undocumented, or stateless, directly and indirectly affects multiple dimensions of people’s lives, increasing vulnerability to GBV victimization and perpetration, though not necessarily experiencing GBV, and at risk of facing challenges in accessing healthcare or legal reporting following cases of GBV. Statelessness promotes power imbalances within broader populations as well within relationships, providing opportunities for violence, limiting recourse to remedies for violence, increasing stress on relationships, and impeding access to or perceptions of access to health services.

TABLE OF CONTENTS

EXECUTIVE SUMMARY.................................................................................................................... 2

INTRODUCTION AND BACKGROUND............................................................................................. 6

METHODS........................................................................................................................................ 8

Overview....................................................................................................................................... 8

RESULTS........................................................................................................................................... 9

Demographic characteristics.......................................................................................................... 9

Reproductive health and children.................................................................................................. 12

Lifetime experiences of childhood, intimate partner, and non-partner violence among women...... 12

Lifetime experiences of childhood, intimate partner, and non-partner violence among men........... 14

Perpetration of intimate and non-partner violence among national and stateless men.................. 16

Correlates of violence victimization among stateless women and men........................................... 16

General Health............................................................................................................................. 20

Conclusions and recommendations:.............................................................................................. 25

JHU AND OBMICA STUDY TEAMS................................................................................................ 27

ACKNOWLEDGMENTS................................................................................................................... 27

APPENDIX...................................................................................................................................... 28

REFERENCES.................................................................................................................................. 51

Emerging research has been conducted to analyze the legal status, legal rights, and livelihoods of stateless persons, yet there is a dearth of evidence as to how statelessness impacts risks and experiences of gender-based violence (GBV), related health outcomes, and access to care for GBV. Global estimates suggest that approximately 10 million people worldwide are living without any legal citizenship.[1] The human rights of stateless persons are protected under international human rights law, though state recognition and respect for these rights is mixed.[2] Some states manipulate nationality and citizenship requirements in an effort to oppress and ostracize minority religious, ethnic and racial groups. As a result, stateless persons often face overwhelming obstacles that limit their access to basic entitlements and protections, leaving them vulnerable to discrimination and abuse.

Authorities in the Dominican Republic routinely deny citizenship and nationality to Dominicans of Haitian descent, persons born in the Dominican Republic, by claiming that they are part of a population ‘in transit’ and most recently have stripped people of Haitian descent of their citizenship, rendering them stateless, a decision that disproportionally affects generations of Dominicans of Haitian descent born on that territory.[3] Because of their lack of recognition, stateless persons are not protected by national law and are therefore subject to abuse and discrimination from citizens, employers, state agencies, and health care providers.[3] The absence of legal status leaves little recourse for redressing abuses, limits employment opportunities, and restricts or denies access to basic government services, including health care.[4] Stateless individuals are often unable to access even the most basic national health services due to lack of documentation and/or restrictions on movement.[5] Understanding how citizenship status affects social factors, such as GBV, and related health and mental health outcomes is the first step toward delivering stateless populations the health care and protections afforded to them by international law.

Prior to 2013, authorities in the Dominican Republic limited the right to nationality to Dominicans of Haitian descent through the arbitrary denial of birth registration to some children of irregular Haitian migrant workers. Administrative measures were also in place to cancel, or suspend indefinitely, the civil documents individuals had obtained in the past, leaving them without legal proof of Dominican nationality.[6] The official birth certificate is required for registering for schools, obtaining health insurance and for accessing other public services, as well as to obtain a passport up to the age of 18 years. At the age of 18 it becomes necessary for individuals to obtain an adult cédula de identidad. The cédula is a vital document for adults in both public and private spheres, including for enrolment in university and obtaining formal employment, for eligibility for health insurance and social security, and for the right to vote. It is also necessary for purchasing property, getting married and for registering and baptizing children. The cédula is currently valid for six years, after which it must be renewed.[7]

On 23 September 2013, the Constitutional Tribunal issued a judgment providing a new interpretation of the criteria for acquisition of Dominican nationality with regards to the Dominican-born children of migrant workers. This ruling was applied retroactively to 1929 and, as a result, concluded that several generations of Dominicans of Haitian descent, including those who were officially registered as Dominican citizens at birth, no longer meet the criteria for Dominican nationality. UNHCR estimates 133,770 nationality-stripped persons as a consequence of Sentence 168, but only includes the first generation born in country of Haitian ancestry, since there are no hard figures for subsequent generations. UNHCR further stated that this latest figure would be revised as and when official figures became available on the number of persons effectively restored their Dominican nationality with the implementation of Law 169-14, intended to mitigate the impact of the controversial judgment.[8]

The Constitutional Tribunal ordered three massive tasks to be carried out within a year’s time by three other sectors of government: the Ministry of the Interior and National Police with its Migration authorities, the JCE and the Dominican Congress. The court ordered the Police and Migration authorities to compile a list of everyone living in the country who does not have a legal residency permit. Second, it tasked the JCE to gather a list of “foreigners” (meaning the Dominican-born children of non-legally-resident foreign nationals) whose birth certificates have been “irregularly” inscribed in the nation’s Civil Registry since 1929. The Sentence ordered that all these people be stripped of Dominican citizenship if their birth may be traced to immigrant(s) without a legal permanent residence. Third and lastly, the Congress was asked by the high court to devise a National Plan of Regularization of Unauthorized Resident Foreigners (PNRE), as already called for in the General Migration Law of 2004. That plan would aim at providing a path to legal residency for both out-of-status immigrants and all those Dominican-born people who were to be stripped of their Dominican citizenship following forensic analysis of their birth certificates by the JCE.

However, the Dominican Congress with its Law 169-14, of May 2014, established a special protocol to affirm the Dominican citizenship of all those who have been granted official identity documents prior to 2007 on the basis of the registration of their birth on Dominican soil.[9] For those Dominican-born people of foreign ancestry whose names do not appear in the Civil Registry, the law also provides a path to legal residency and then citizenship, two years later.

Law 169-14, does not conceptualize persons born in the country to foreign parents with irregular status before 2007 as Dominicans. The first group affected (so-called Group A) who, according to the preamble of the law, “were led to believe” they were nationals because they received official documents, would obtain nationality because the State recognized its own administrative mistake, not because they were born on Dominican soil. The second group (so-called Group B) who lacked any kind of identity document, was directly classified as foreigners in their own country of birth and obligated to follow a naturalization process.

National statistics from the Dominican Republic highlight the prevalence of GBV in the country. From January through November 2013, more than 60,000 gender-based violence complaints were reported to authorities nationwide and approximately 1,117 women were killed between the years of 2008 – 2013, as a result of GBV. While the law criminalizes violence against women, reporting is low and violence statistics have changed little over the last few years. No information has been found with respect to the proportion of Dominicans of Haitian descent affected by the 2013 ruling of the Constitutional Court that may be affected by GBV.[6] However, the 2013 OBMICA study, Gender and the Risk of Statelessness for the Population of Haitian Descent in the Bateys of the Dominican Republic, found a connection between statelessness, unemployment, and economic dependency of women on men, which deepens unequal power relations and increases the risk of GBV.[10] The study also uncovered a potential link between young stateless women and internal sex trafficking to tourist areas of the Dominican Republic, which warrants further research. While there are important differences between Haitian migrants and Dominicans of Haitian descent, a recent qualitative research conducted by OBMICA among Haitian migrant women living at the Haitian-Dominican border helps to contextualize the problem. Reports of psychological, physical, and sexual violence, as well as human trafficking and sexual exploitation were common, often opportunistic in nature, and reportedly perpetrated by intimate partners and family members, host families or employer households, and other authority figures.[11] Lack of citizenship and legal status creates opportunities for “macuteo”, or “shake downs” by officials, which increases vulnerability to violence and exploitation of Haitian migrant women. Meanwhile, lack of access to health services and legal protection, language barriers, fear of deportation, family and social pressure or stigma, fear of retribution from the perpetrator, and lack of confidence in institutional capacity often form significant barriers to reporting and service seeking by these women.[11] In these border areas, female survivors do have access to government facilities and referral systems, including police, hospital, public prosecutors, and women’s affairs, as well as non-governmental services, though with some limited availability and reports of discrimination.[11] From this research, we may hypothesize that many of the risk factors that affect migrant women – lack of legal identity, which impacts access to protection, health services, and financial stability – also place stateless populations at risk for GBV and subsequent health outcomes but with minimal access to services.

Gender-based violence victimization and perpetration are globally prevalent and are both public health and human rights issues. Approximately 35% of women are estimated to experience lifetime physical or sexual violence that is perpetrated by a partner or non-partner.[12] Limited regional studies suggest that 25% to as high as 80% of men perpetrate intimate-partner violence within their lifetimes.[13] Consequences of violence victimization include poor health and mental health outcomes, infants born with low birth-weight, lower quality of life, premature death, intergenerational cycles of violence, and loss of productivity.[12, 14] There are wider economic costs to GBV, as well, including costs to the health system associated with treatment and care following victimization and costs borne by the criminal justice system related to apprehending and prosecuting offenders.

GBV is an umbrella term that refers to any physical, sexual, or other emotional violence that is perpetrated on the basis of socially ascribed gender differences and is inclusive of intimate partner violence (IPV) and violence that is perpetrated by non-partners as well.[15] The term has been recently extended to inclusive of male victimization, though few studies have investigated the prevalence of male violence victimization and female violence perpetration. Inherently, within this definition of GBV, there is a reflection on differential power dynamics within and across family, social, and structural relationships which promote vulnerability and risk for violence victimization and perpetration.[16] Stresses to livelihoods, family and societal roles, and access to protection, rights and justice exacerbate vulnerability to violence by changing power dynamics. These stresses are particularly common among populations with imperiled citizenship and documentation statuses, such as refugees, internally displaced persons, and migrant populations, among whom GBV that has been perpetrated by a range of individuals has been well-documented.[17-21] Stateless persons also share similar life stressors, as well as gender-discrimination in nationality laws, though no research has investigated the prevalence or vulnerabilities to GBV, health outcomes, and access to care.[2, 10] The study described here is part of a multi-country effort to understand the consequences of statelessness, relationship to GBV, and health outcomes among affected populations.

The aims of the project were to understand the demographics, experiences, and vulnerabilities of GBV and general health status among stateless populations. This study focused on stateless populations, which is defined as populations who have been born in Dominican Republic but who are not citizens of the Dominican Republic nor of another country and are recognized by UNHCR as stateless populations. This does not include migrants. Definitions and measures were guided by the 2011 UNHCR guidance document on measuring stateless populations.[22] The definition of gender-based violence followed the definition provided by the UN agencies, as “an umbrella term for any harmful act that is perpetrated against a person’s will, and that is based on socially ascribed (gender) differences between males and females. The nature and extent of specific types of GBV vary across cultures, countries, and regions.”[23]

To achieve study aims we utilized a mixed methodology approach, conducted in two phases. The first phase included qualitative research with stateless persons and key informants who serve these populations. Qualitative research enabled us to obtain contextual descriptions of experiences related to documentation, GBV and GBV-related health issues, and access to health care. The second phase included an epidemiologic survey conducted among stateless and national populations, which was informed by qualitative findings. The epidemiologic survey was developed to collect data on a wide array of GBV experiences and GBV-related health indicators as well as to assess availability and access to related GBV services. These two methods were complementary in nature, providing both numeric estimates and contextual support of the topics of interest. This study was conducted as a collaborative partnership between Johns Hopkins University and the Centro para la Observación Migratoria y Desarrollo Social en el Caribe (OBMICA).

Appendix 1 provides the detailed methodology of the qualitative and quantitative phases. The following description provides the results from the in-depth qualitative and quantitative analysis.

A total of 826 women participated, of whom 423 were nationals and 403 were stateless. Ninety-one percent of sampled sites included both stateless and national female participants. National women in the sample were on average older, with the median age at 33 years old (IQR: 24-43) compared to stateless women at 25 years (IQR: 20-32). Compared to national female participants, stateless females were less likely to have ever attended school (85.4% vs. 93.2%, respectively), less likely to have attended secondary school or college (among those who attended school), more likely to have ever been detained or deported (6.2% vs. 0.7%), and less likely to have grown up in a dual parent household (55.4% vs. 62.9%). Figure 1 describes demographic characteristics of male and female stateless and national participants.

Figure 1: Demographic differences among surveyed women

In addition, stateless female participants were less likely to be married (2.5% vs. 5.6%), more likely to have faced challenges with legally marrying someone due to their lack of birth registration (46.8% vs. 4.0%) and more likely to have experienced forced marriage (39.6% vs. 28.1%). Stateless female participants were also less likely to have worked in the past month (26.7% vs. 34.7%), more likely to have had seasonal work (among those who worked; 51.7% vs. 33.5%), less likely to be able to legally open a bank account (1.3% vs. 97.8%), and less likely to have health insurance (1.3% vs. 67.7%). In terms of partner characteristics, stateless women’s partners were less likely to be able to open a bank account (42.1% vs. 77.5%) and less likely to have health insurance (28.9% vs. 47.9%) relative to the partners of national women.

A total of 470 men participated, of whom 260 were nationals and 210 were stateless. Seventy-eight percent of sampled sites included both stateless and national male participants. National men were older on average, with the median age at 39 years (IQR: 27-50) compared to stateless men at 25 years (IQR: 20-30.5). Similar to stateless female participants, stateless males were less likely to have ever attended school (85.0% vs. 91.4%), less likely to have attended secondary school or college (among those who attended school), more likely to have ever been detained or deported (15.3% vs. 2.0%), less likely to have grown up in a dual parent household (53.4% vs. 70.2%), less likely to be married (1.0% vs. 8.4%), and more likely to have ever faced challenges with legally marrying someone (38.5% vs. 4.8%) when compared to their national counterparts. Stateless male participants were more likely to have worked in the past month (81.5% vs. 73.1%) but also more likely have had seasonal employment (among those who worked; 54.8% vs. 37.9%). In addition, stateless men were more likely to never have enough to meet basic needs each month (53.6% vs. 33.1%), less likely to be legally able to open a bank account (1.0% 98.8%), and less likely to have health insurance (2.9% vs. 65.1%). Stateless men’s partners were less likely than national men’s partners to be able to open a bank account (41.4% vs. 70.5%) and less likely to have health insurance (25.7% vs. 53.7%). Appendix Table 2 describes demographic characteristics of male and female stateless and national participants.

Figure 2: Demographic differences among surveyed men

Qualitative interviews provide insights into livelihood challenges related to lack of documentation. Specifically, these included barriers to employment, bank accounts, and health insurance. Without worker’s compensation, employers were reluctant to hire stateless persons. Stateless persons described challenges in finding formal, stable employment, leaving them to work in informal employment in agriculture, construction, or domestic work (remunerated or not) as a result.

“It has to do with worker’s comp. So if something happens to me during work, they will be fully responsible for everything that happens to me by law so they don’t want that. They want people to have their documents so that they can have insurance so if something happens to them, the bosses aren’t responsible for you.” ID 32, Male, 22yo

“I’m 28 years old. I have 2 children, one is 10 and the other one is 12. I’m a single mother. I have no job because of my lack of documentation and because of this lack of documentation I cannot even find a part-time job.” ID 28, Female, 28yo

Establishing a bank account also requires national documentation. Several participants described being robbed of their savings by others who knew of their inability to open a bank account.

“I started working in a household, taking care of the house. They were paying me 3000 pesos a month, which is the equivalent of $80 – $75 a month. So I was working and because I didn’t have any documents, a neighbor offered to keep the money for me, to save the money for me. And so I worked and worked for a long time and at that point I was pregnant with my first boy who is now eight years old. When I left the job I asked for my money back and she wouldn’t give it to me…. The limitations are very clear to people and they’re very clear to me. If I had documents I would have opened a bank account, either with my birth certificate or with my ID, I would have opened a bank account and I would have put my money directly there. I wouldn’t have to trust anybody, but this happens because you don’t have documents.” ID 26, Female 32yo

Stateless female participants were more likely to be currently using any kind of contraceptive method compared to national women (62.6% vs. 52.3%). Among those who were currently not using a method, however, stateless women were less likely to know where to obtain contraception (84.6% vs. 100.0%). Among those with children, stateless women were less likely to have registered all or at least some of their children as Dominican. Children of stateless women were also less likely to have access to health insurance (3.1% vs. 42.7%) and less likely to continue past secondary school. Appendix Table 3 provides descriptive characteristics of reproductive health among male and female stateless and national populations in the Dominican Republic.

Partners of stateless male participants were less likely to have ever been pregnant (59.9% vs. 79.9%). Among those with children, stateless men were less likely to have registered all of their children (51.3% vs. 79.7%), less likely to have children with access to health insurance (16.3% vs. 53.9%), and less likely to have children unable to continue past secondary school.

Qualitative study participants described the relationship between lack of documentation, health care, and their own educational advancement as well as that of their children.

“So it affects me, for example, in the fact that my children are not registered so I have them in this school and they know I don’t have documents so I know there will be a moment in which they will not accept them anymore.” - ID31, Female, 23yo

“I could go to 8th Grade and I couldn’t move any further because I didn’t have documents.” – ID 30, Female, 20yo.

“Well, she [participant’s daughter] can get a surgery but I haven’t had the opportunity to do it because I don’t have the resources to do that, she needs analysis, she needs some studies for the surgery and that costs a lot and I don’t have the money for that. So it has been really difficult and I don’t have a job, so things have become worse, due to my health situation, and the girl is growing up with that problem and she can be affected by that in the future. So it has been very difficult for me, and all is a consequence of the lack of documents. If I had my documents, I could include her in my health insurance. But I can’t because I haven’t had the opportunity to register my daughter because I don’t have my documents either. That has caused me a lot of problems.” ID 8, Male, 43 yo.

Thirty-nine percent (39%) of national female participants reported any lifetime physical or sexual violence victimization. Thirteen percent (13%) reported physical abuse during childhood (aged 15 years), 9% reported childhood sexual abuse, and 19% reported any childhood physical or sexual abuse. Ten percent reported lifetime physical IPV in adulthood, 6% lifetime sexual IPV, and 10% lifetime physical or sexual IPV. Lifetime IPV did not differ from IPV in the past year. Ten percent (10%) of national female participants also reported IPV during at least one pregnancy, among whom 65% reported ever being punched or kicked in the abdomen while pregnant. Twenty percent of the national women had ever reported IPV victimization to an authority. Seven percent of national women reported physical violence during adulthood by a non-partner, 5% sexual violence, and 11% any physical or sexual violence. Among those who reported sexual violence, 20% reported ever having been gang raped.

In terms of stateless female participants, 52% reported any lifetime violence victimization. Twenty-two percent (22%) reported physical abuse during childhood, 12% childhood sexual abuse, and 28% any childhood physical or sexual abuse. As adults, 10% of stateless women reported lifetime physical IPV, 7% sexual IPV, and 12% lifetime physical or sexual IPV. A similar proportion (11%) reported experiencing physical or sexual IPV in the past year. Fifteen percent (15%) of stateless female participants reported IPV during at least one pregnancy, among which 65% reported ever being punched or kicked in the abdomen while pregnant. Thirty-two percent (32%) reported violence victimization to an authority. Nine percent (9%) of stateless female participants reported physical violence during adulthood by a non-partner, 7% sexual violence, and 14% any physical or sexual violence. Appendix Table 4 provides results of lifetime experiences of violence among national and stateless women in the Dominican Republic.

National and stateless had similar experiences of IPV and non-partner violence. However, stateless women were more likely than national women to have experienced physical child abuse (22% vs 13%), any child physical or sexual abuse (28% vs 19%), IPV during pregnancy (15% vs. 10%), and any lifetime violence victimization (52% vs 39%). Stateless women were also more likely to have witnessed family violence as a child (89% vs. 77%). Specific forms of intimate partner violence, as reported by women and men, are included in Appendix Table 5. Female attitudes related to IPV among national and stateless participants were similar and generally low (less than 10%) in terms of justification for IPV. These data can be found in Appendix Table 6.

Figure 3. Violence victimization among surveyed women

Female qualitative study participants described a range of experiences of violence across the lifespan. For many, violence began in childhood, often reportedly perpetrated by family members.

“Because he used to hit me and abuse me and he used to hit my children as well. When he was drinking he would just be aggressive and he used to hit them a lot. When he was sober, he wasn’t like that.” ID 30, Female, 20yo.

One participant described being given to a neighbor at the age of 8 years old when her mother could not afford to raise her. That neighbor forced her into commercial sexual exploitation and continued to control the participant with promises of helping her to obtain documents.

“But my life has been a constant struggle, throughout my entire life. Very stormy. For instance I was born – my mom was taking care of me, but we were really, really poor and so there was a moment in which a neighbor started telling my mom that she had better resources, she didn’t have any kids, if she wanted to have me move in her house. And she took me and when I was about 13 [the neighbor] started using me so that other men would have sex with me and she didn’t give me any money and she just used me for that reason for a long time. Whenever I felt very uncomfortable she would beat me up and make me realize that I had to continue doing it. When I finally got the strength to report all of this the authorities didn’t pay any attention to me because I didn’t have any documents…. I only stayed for so many years because she was promising to give me papers.” – ID 26, Female 32yo

This example clearly illustrates the relationship between vulnerabilities brought on by statelessness and poverty and the inability to leave a violent situation.

Women also described experiences of physical and sexual violence perpetrated by intimate partners as well as, to a lesser degree, strangers.

“He used to use anything within his reach to hit me with. So sometimes it would be his fist, sometimes it would be a piece of wood, sometimes it would be a rock. This big mark I have on my arm is because of a machete that he used, that he had bought new.” ID 25, Female, 34 yo

“This happened when I was 18. I was living far from home. I was living where I was working. Some man entered the house where I was living. He kicked in – he kicked the door. He put a gun to my head and raped me… Yes, I recognized him. In fact, after I could – the court. I went to the court and opened up a file. He looked for me and told me that he would kill me. So that’s why I had to leave that place and come back here where my family is. [Interviewer: Did the court offer any protection at that time?] No, they didn’t give me any protection. Their only advice was you have to leave this place and go back to where you came from in order for you to protect your life.” ID 28, Female, 28 yo.

Service providers who participated in focus group discussions described the existing burden of violence against women in the Dominican Republic (among all populations) and challenges in the reporting system, predominantly related to institutional barriers.

“And I want to say that gender violence is an epidemic here in the DR. Last year alone we had 172 deaths as a result of gender violence. In terms of medical numbers, it kills more than dengue, but dengue becomes this social thing and it's all over the news. Whereas gender violence deaths are hardly expressed at all in the news.” FGD1, Health provider

“So out of the many cases we reported in the past to the Ministry of women , there was no real response and in particular cases, for instance, we had this woman in the hospital for 15 days, she was really badly injured. We contacted the Ministry many times, we wanted to follow up on this particular case, as in many in the past, and the Minister did not give us any information beyond the first call that we always attempted. We found through the news that the person who beat her up was in jail, he was in prison, but we didn't find out from the Minister. So now we understand that as a waste of time when we contact the Ministry and try to get help.” FGD1, Health provider

“If there's not involvement, then the situation will continue as such. I want to tell you that what we need is an interdisciplinary action. It's a matter for all of us who have access to these cases to articulate a response together. But it cannot be the work of one person, it has to be an inter-institutional effort.” - FGD1, Ministry of Women

Thirty-one percent (31%) of national male participants reported any lifetime violence victimization. As a child, 19% reported experiencing physical abuse, 4% childhood sexual abuse, and 21% any childhood physical or sexual abuse. Seven percent (7%) reported physical violence during adulthood, 4% sexual violence, and 15% any physical or sexual violence by a partner or non-partner. One national male participant reported ever having been gang raped.

In terms of stateless male participants, 37% reported any lifetime violence victimization. Some 22% reported experiencing physical abuse as a child, 4% childhood sexual abuse, and 24% any childhood physical or sexual abuse. Thirteen percent (13%) reported physical violence during adulthood, 3% sexual violence, and 22% any physical or sexual violence by a partner or non-partner.

National and stateless men differed in a few of the violence indicators. Compared to national men, stateless men were more likely to have witnessed their mother hit their father (18% vs. 11%), more likely to report an experience of physical violence during adulthood (12% vs. 7%), and more likely to report any physical or sexual violence during adulthood (37% vs. 31%). Appendix Table 7 provides results of lifetime experiences of violence among national and stateless men in the Dominican Republic.

Male attitudes related to IPV among national and stateless participants were similar and generally low (less than 10%) in terms of justification for IPV. These data can be found in Appendix Table 6.

Figure 4. Violence victimization and perpetration among surveyed men

Male qualitative participants generally described violence often as situations of disagreements within the community or among neighbors. However, some participants also described violence perpetrated by their female partners as well as family or friends of their female partners.

One female participant described violence that she perpetrated toward her husband, as well as another community member.

“In December I was fighting with a woman that was pregnant with my husband’s child. So I was fighting with her, fighting with her, she became very violent. I had been drinking so I was very violent as well… My husband intervened and so I stabbed him instead. He had to go to the hospital. There was a big hole in his belly, but it was only three stitches. We thought it was nothing. He wouldn’t open up a case against me because we have two children together and at that point I was pregnant. –ID31, Female, 23yo

One male participant, who both perpetrated violence and was victimized by his wife, described his experiences witnessing parental violence and the role this played in his experiences as an adult.

“My mother had problems with my father, she was very aggressive and she had a lot of problems because of her temper, she had problems with my stepfather, he wasn’t my father and I saw him with cuts and wounds, my mother was very aggressive. [Interviewer: And do you think that affected you?] Of course, when you are raised in a violent environment, when your parents are aggressive because children behave according to their parents’ behavior, so if you live with an aggressive person, then you are going to learn that behavior. And I learned to change that but I was aggressive because my mother used to be like that.” –ID 8, Male, 43 yo.

Eight percent (8%) of national male participants reported lifetime physical IPV perpetration, 10% physical IPV perpetration during a partner’s pregnancy, 4% sexual IPV perpetration, and 10% physical or sexual IPV perpetration. In terms of non-partner violence, 9% of national male participants reported lifetime physical violence perpetration, 1% sexual violence perpetration, and 26% physical or sexual violence perpetration. Most common reasons for sexual violence perpetration against a non-partner were sexual attraction, desire for sex, and feeling it was one’s right.

Among those with any intimate partner in their lifetime, three percent (3%) of stateless male participants reported lifetime physical IPV perpetration, 2% physical IPV perpetration during partner’s pregnancy, no sexual IPV perpetration, and 3% lifetime physical or sexual IPV perpetration. In addition, 9% of stateless men reported lifetime physical violence against a non-partner, 4% sexual violence, and 24% any physical or sexual violence. Most common reasons for sexual violence perpetration against a non-partner were desire to have sex, sexual attraction, and desire to show that they could do it.

In contrast, fewer stateless male participants endorsed violence perpetration. When comparing national versus stateless male participants, stateless men were less likely to report lifetime physical IPV perpetration (3% vs. 8%), lifetime sexual IPV perpetration (0 vs. 4%), and lifetime physical or sexual IPV perpetration (3 vs. 10%). Stateless male participants, however, were more likely to have reported sexual violence perpetration against a non-partner (4% vs 1%) and report that a victim was injured due to violence/abuse (12% vs. 3%). Appendix Table 8 provide results of perpetration of intimate and non-partner violence among stateless and national men in the Dominican Republic. Physical and sexual IPV tactics among male perpetrators of IPV can be found in the Appendix Table 5.

One participant described situations in which he tended to be violent toward one of his partners, which he attributed to his current state of financial instability.

“Well, I have had financial problems at home, sometimes your wife makes some demands, she demands more than you can give to her. And when you are aware you have to earn money, and you only have 50 pesos to provide and she is just demanding more and more money then you get angry. You go out to the street to earn money for food and you only get half of the money you need and your wife is telling you things about money and she says that money is not enough, and she is not going to cook anything and drops the money, of course, you’re going to get mad, and that’s when you have problems at home.” –ID 8, Male, 43 yo

Table 6 summarizes the relationship between demographic factors, partner characteristics, and lifetime violence victimization among stateless women. Stateless women who reported any lifetime experience of violence were more likely to be younger ages (18-20 years old or 31-40 years old) and ever witnessed violence in their families, relative to those without lifetime experiences of violence. With respect to partners, women who reported violence also described earning less income than their partner, having a partner who entered/completed secondary school but not college, and having a partner who consumed alcohol more frequently.

Table 6. Correlates of lifetime violence victimization among stateless women
	Lifetime experience of violence victimization
	No (N=151)	Yes (N=165)	Total (N=316)
	n (%)	n (%)	n (%)	p-value
Age (years) (n=316)
18-20	27 (17.9)	42 (25.5)	69 (21.8)	0.027**
21-30	69 (45.7)	73 (44.2)	142 (44.9)
31-40	23 (15.2)	33 (20.0)	56 (17.7)
>41	32 (21.2)	17 (10.3)	49 (15.5)
Highest level of school attended (n=257)
Primary	102 (82.3)	96 (72.2)	198 (77.0)	0.055*
Secondary	22 (17.7)	37 (27.8)	59 (23.0)
Worked in the past month (n=313)	38 (25.5)	46 (28.0)	84 (26.8)	0.612
Among those worked, employment was seasonal (n=137)	33 (51.6)	35 (47.9)	68 (49.6)	0.673
Legally able to open a bank account (n=313)	2 (1.3)	2 (1.2)	4 (1.3)
Each month participant has enough to… (n=298)				0.923
Meet basic needs of the family	8 (5.6)	14 (9.0)	22 (7.4)	0.133
Meet basic needs for most but not all of the month	13 (9.2)	10 (6.4)	23 (7.7)
Meet basic needs for about half of the month	19 (13.4)	17 (10.9)	36 (12.1)
Meet basic needs for less than half of the month	18 (12.7)	35 (22.4)	53 (17.8)
Never have enough to meet basic needs	84 (59.2)	80 (51.3)	164 (55.0)
House ownership (n=316)
Alone	54 (35.8)	45 (27.3)	99 (31.3)	0.021**
Jointly	13 (8.6)	31 (18.8)	44 (13.9)
Does not own	84 (55.6)	89 (53.9)	173 (54.7)
Ever been detained/ deported (n=307)	9 (6.3)	14 (8.6)	23 (7.5)	0.437
Ever saw or heard family violence (n=55)	13 (72.2)	36 (97.3)	49 (89.1)	0.005**
Participant under 18 at first marriage (n=101)	28 (68.3)	40 (66.7)	68 (67.3)	0.864
Forced marriage (n=99)	19 (46.3)	22 (37.9)	41 (41.4)	0.403
Partner school level (n=81)
Primary	18 (62.1)	33 (63.5)	51 (63.0)	0.018**
Secondary	7 (24.1)	19 (36.5)	26 (32.1)
College	4 (13.8)	0 (0)	4 (4.9)
Partner employment status (n=91)
Works occasionally	26 (78.8)	49 (84.5)	75 (82.4)	0.283
Looking for work/ unemployed	4 (12.1)	8 (13.8)	12 (13.2)
Retired	2 (6.1)	0 (0)	2 (2.2)
Studying	1 (3.0)	1 (1.7)	2 (2.2)
Partner alcohol use (n=112)
Never	18 (41.9)	34 (49.3)	52 (46.4)	0.086*
	16 (37.2)	13 (18.8)	29 (25.9)
Few times per week/ daily	9 (20.9)	22 (31.9)	31 (27.7)
Money that participant earns is more than partner (n=27)	6 (60.0)	4 (23.5)	10 (37.0)	0.058*
*Marginally significant **Significant

Several women who described having experienced violence, particularly IPV, as an adult also reported being witness to or experiencing violence between or perpetrated by parents or care givers. One woman who was a survivor of IPV described her experience with her step-father’s violence when she was a young child.

“We grew up with a different guy than my father. I never got to meet my dad. So when this other guy would hit my mom, I would cry as a normal kid. I was three, four years old and he would come and hit me as well.” ID 25, Female, 34 yo

Quantitative findings highlighted the association between financial disparities between husband and wife with lifetime experiences of violence among women. Similarly, one male participant who reported perpetrating violence against his wife described similar challenges related to these disparities and the relationship with aggression.

“Yes, it’s going to affect, if the woman is working and I’m not, then she is supporting me; she earns 100 pesos, and I just earned 50 and she solves financial problems in the house, so in that situation she thinks she is better than her husband because she is working and providing for all our needs, so that is something bad for the couple. It is not the same if both of them are working because it is easier for women to get a job, and that is not good for the couple. That’s one of the situation causing a lot of violence. [Interviewer: Who against whom?] She’s working, and sometimes she wants to drink beer, use some jeans and yell and offend her husband, so when the husband feels humiliated then he is going to hit her. So that’s one of the reasons for violence, and that affects a lot in a family. I have seen that myself.” ID 8, Male, 43 yo.

Table 7 summarizes the demographic and partner correlates of lifetime violence victimization among stateless men. Stateless men who report lifetime violence victimization tended to report never having enough to meet basic needs each month, owned a house jointly rather than alone, made healthcare decisions jointly with their partner, and had a partner who was legally able to open a bank account. In addition, stateless men who reported victimization were more likely to report depression symptomatology.

Table 7. Correlates of lifetime violence victimization among stateless men
	Lifetime experience of violence victimization
	No (N=127)	Yes (N=74)	Total (N=201)
	n (%)	n (%)	n (%)		p-value
Age (years) (n=201)
18-20	35 (27.6)	18 (24.3)	53 (26.4)		0.942
21-30	61 (48.0)	38 (51.4)	99 (49.3)
31-40	22 (17.3)	12 (16.2)	34 (16.9)
>41	9 (7.1)	6 (8.1)	15 (7.5)
Highest level of school attended (n=170)
Primary	78 (73.6)	50 (78.1)	128 (75.3)		0.629
Secondary	27 (25.5)	14 (21.9)	41 (24.1)
College	1 (0.9)	0 (0)	1 (0.6)
Worked in the past month (n=201)	105 (82.7)	58 (78.4)	163 (81.1)		0.453
Among those worked, employment was seasonal (n=193)	68 (55.3)	38 (54.3)	106 (54.9)		0.893
Legally able to open a bank account (n=201)	1 (0.8)	1 (1.4)	2 (1.0)		0.698
Each month participant has enough to… (n=193)
Meet basic needs of the family	2 (1.7)	11 (15.3)	13 (6.7)		0.002**
Meet basic needs for most but not all of the month	8 (6.6)	10 (13.9)	18 (9.3)
Meet basic needs for about half of the month	15 (24.1)	7 (9.7)	22 (11.4)
Meet basic needs for less than half of the month	26 (21.5)	11 (15.3)	37 (19.2)
Never have enough to meet basic needs	70 (57.9)	33 (45.8)	103 (53.4)
House ownership (n=201)
Alone	28 (22.0)	11 (14.9)	39 (19.4)		0.082*
Jointly	9 (7.1)	12 (16.2)	21 (10.4)
Does not own	90 (70.9)	51 (68.9)	141 (70.1)
Ever been detained/ deported (n=197)	18 (14.5)	12 (16.4)	30 (15.2)		0.717
Ever saw or heard family violence (n=21)	4 (80.0)	14 (87.5)	18 (85.7)		0.676
Partner school level (n=25)
Primary	8 (72.7)	8 (57.1)	16 (64.0)		0.561
Secondary	3 (27.3)	5 (35.7)	8 (32.0)
College	0 (0)	1 (7.1)	1 (4.0)
Partner employment status (n=23)
Works occasionally	5 (45.5)	7 (58.3)	12 (52.5)		0.684
Looking for work/ unemployed	3 (27.3)	1 (8.3)	4 (17.4)
Retired	1 (9.1)	1 (8.3)	4 (17.4)
Studying	2 (18.2)	3 (25.0)	5 (21.7)
Partner legally able to open a bank account (n=21)	5 (41.7)	7 (77.8)	12 (57.1)		0.098*
Partner alcohol use (n=21)
Never	16 (76.2)	8 (57.1)	24 (68.6)		0.285
	4 (19.0)	3 (21.4)	7 (20.0)
Few times per week/ daily	1 (4.8)	3 (21.4)	4 (11.4)
Money that participant earns is more than partner (n=14)	9 (81.8)	3 (100.0)	12 (85.7)		0.425
Person who makes decisions about healthcare for participant (n=30)
Participant	14 (82.4)	8 (61.5)	22 (73.3)		0.088*
Participant and partner jointly	1 (5.9)	2 (15.4)	3 (10.0)
Other family member	0 (0)	3 (23.1)	3 (10.0)
Other	2 (11.8)	0 (0)	2 (6.7)
*Marginally significant **Significant

Quantitative study findings highlight power dynamics in relationships that promote intimate partner violence victimization, which were echoed by qualitative participants. In some cases, these were exacerbated in partnerships in which one participant was stateless and the other national. One male qualitative participant described violence perpetrated by his wife who was a national. Their problems began when they could not register their children under his name due to his status; as their relationship worsened, she physically abused him, set his house on fire, stole his money that he saved in his house when he could not open a bank account, and encouraged male family members to threaten him.

“She was Dominican from Dominican parents and so her family are usually with Haitians and so they were always abusing Haitians in those bateys, so they were always… they always had the upper hand…. And she was accustomed to seeing this. So when we got together, I had a good standing… economic standing and education and everything… but now that I have lost my documentation and lost means to get… to earn a good living… she has seen it, and she has become the aggressor to take everything away and make me suffer.” --ID 22, male, 41yo

Few female participants self-rated their health as poor or very poor (national: 9% vs. stateless: 9%). Among those who consulted a medical professional, the majority of female participants most often consulted a doctor, with national women more likely to report having consulted a doctor when compared to stateless women (97% vs. 91%). Stateless women were more likely to report symptoms of depression (25% vs. 20%), difficulty getting money for medical advice or treatment (68% vs. 60%), and concerns about deportation when accessing healthcare (69% vs. 5%) relative to national women. Stateless women were more likely to report never drinking alcohol (67% vs. 60%).

Similarly, few male participants self-rated their health as poor or very poor (national: 8% vs. stateless: 6%). Stateless men were less likely to have consulted a medical professional than national men (17% vs. 26%); among those who did consult, the majority of both stateless and national participants most often consulted a doctor. Stateless men were more likely to report symptoms of depression (31% vs. 19%) and were also more likely to report concerns about deportation when accessing healthcare (67% vs. 2%). Appendix Table 9 provides findings of the general health among male and female stateless and national populations in the Dominican Republic.

Qualitative participants similarly described challenges accessing healthcare without documentation. Stateless persons can access basic healthcare free of charge, even without health insurance. However, more extensive tests and prescriptions are often not covered. For stateless persons without health insurance, who often have unstable income, these costs are often prohibitive.

“So in my case – I haven’t counted them, but it’s a lot of time because I have problems with one of my breasts. I have problems with chronic gastritis and problems with my kidneys. So for example, the pills that I have to get for my breasts are almost 3000 pesos, which is the equivalent of $75. So it’s really tough for me to come up with that money. Now another pill that I should get very often is for my stomach is 28 pesos each pill. So it adds up and I don’t have the money for this.” ID 25, Female, 34 yo

One qualitative participant who reported being engaged in sex work in order to support three children and after failing to find alternative employment. Following an experience of physical violence during pregnancy, which was perpetrated by a client, she was able to access health services. Service seeking, however, was delayed to prevent raising awareness in the community of her work. At that visit, she learned that she acquired Hepatitis C virus but was ultimately unable to afford appropriate tests and treatment.

“Without documentation you cannot have access to medicines. You have to pay for them. But even for some analysis, in my case, for example, I have Hepatitis and the problem right now is that I have to get this test which is 5000 pesos and I don’t have them right now so I cannot get access to this test or the medicines that go along with the treatment.” ID 29, Female, 24 yo

Limited educational and employment opportunities create further challenges to obtaining needed health services that are not covered.

“So people say that it’s easy to live without documents, but it is absolutely not. Without them you don’t have access to health. You can graduate from high school, but you cannot access – without documents, you cannot access university. If you don’t access college, you don’t earn a good living. If you don’t earn a good living, you end up not being able to pay for your medicine.” ID 21, male, 31yo

“A person that works hard and works the entire day gets about 300 pesos which is the equivalent of $6, $7 a day and so 300 pesos per day that they would get from their work in the sugar fields. And everything would cost you 150, 200. I can explain to you this way. If you get 300 pesos a day, but the following day, you’re sick. You have money to pay up for that day’s medicine, but you didn’t go to work that day and so you would have enough money just to pay off for one more day knowing that they didn’t make money either.” ID 21, Male, 31 yo

DISCUSSION

There is currently a scarcity of literature on the situation of stateless populations, contexts of gender-based violence (GBV), and GBV-related health impacts among stateless populations. This study utilized mixed methods research to understand the demographic characteristics, experiences of GBV victimization and perpetration, and associated health and mental health among stateless populations of Haitian ancestry compared to the population with legal citizenship in the Dominican Republic.

Results from the quantitative survey highlight key demographic disparities between the stateless and national populations. Our findings demonstrate the limited access to basic rights and services among stateless populations when compared to legal citizens. Significant findings include the following for stateless compared to national citizens: stateless females are 10 times (47% stateless vs. 4% national) and males 8 times (39% stateless vs. 5% national) more likely to encounter difficulties with getting married when compared to nationals; stateless persons are more than 60 times less likely to have health insurance (stateless females 1% vs. 68% nationals females and stateless males 3% vs. 65% nationals). Stateless persons and their partners are generally less likely be permitted to advance past secondary school; to have worked in the past month or have year-long employment; able to earn enough income to meet their monthly basic needs; and less likely to be legally able to open a bank account. Several stateless persons described situations in which they were robbed or exploited of their savings by trusted individuals who knew that the participant was unable to open a bank account.

Children of stateless persons are similarly affected. They are less likely to be registered legally; less able to have health insurance; and less able to continue with their education into and past secondary school. Qualitative interviews supported these quantitative findings and provided insights into lack of documentation and related livelihood challenges including education, employment status, and health insurance. Stateless persons described challenges in finding formal, stable employment.

Lack of citizenship and legal status is associated with increased vulnerabilities to violence and exploitation. Stateless women are found to have a statistically significant greater proportion of having experienced any lifetime violence victimization when compared to females with legal documentation, 52% vs 39% respectively (Figure 5). Specifically, stateless women were 50% more likely than national women to have experienced physical child abuse (22% vs 13%), any child physical or sexual abuse (28% vs 19%), and IPV during pregnancy (15% vs. 10%). As in other research, lack of access to health services and legal protection, fear of deportation, family and social pressure or stigma, fear of retribution from the perpetrator, and lack of confidence in institutional capacity often form significant barriers to reporting and service seeking by these women.[11] Stateless women were also more likely to have witnessed family violence as a child (89% vs. 77%), which is a known risk factor for violence victimization later in life and was a correlate of lifetime victimization in this study.[24, 25]

Fewer differences in violence victimization existed among men who are stateless compared to national participants, with the exception that stateless men were more likely to report experiencing physical violence victimization (Figure 6). Comparing estimates of self-reported perpetration of violence, both stateless and national tended to be the same across various forms of perpetration. Stateless participants did report slightly higher levels of non-partner sexual violence perpetration (4% vs 1%) but reported lower levels of physical IPV perpetration (3% vs 8%) and sexual IPV perpetration (0% vs 4%), relative to national populations. These estimates are, however, too low for broader interpretation to the target populations. Overall, lifetime rates of any IPV or non-partner violence perpetration were marginally lower among stateless than national men (21% vs. 29%).

Analyses focused on correlates of lifetime victimization revealed that stateless women who reported any lifetime experience of violence were more likely to be younger ages (18-20 years old or 31-40 years old), relative to those without lifetime experiences of violence. Women who experienced violence also reported ever having witnessed violence in their families, a finding which was equally supported by qualitative research in which female survivors of IPV tended to report witnessing violence or being abused as children. With respect to partners, women who reported violence also described earning less income than their partner, having a partner who entered/completed secondary school but not college, and having a partner who consumed alcohol more frequently. Stateless men who report lifetime violence victimization tended to report never having enough to meet basic needs each month, owning a house jointly rather than alone, making healthcare decisions jointly with their partner, and having a partner who was legally able to open a bank account, relative to those who had not experienced violence. Stateless men who reported victimization were also more likely to demonstrate symptoms of depression, which is consistent with other research among male and female survivors of violence.[24] Male qualitative participants likewise described power imbalances, often related to family finances, which were related to being a victim and/or perpetrator of violence.

Globally, GBV and vulnerabilities to GBV are inherently the result of power imbalances. In this study, substantial power imbalance associated with statelessness was evident both across wider populations and within relationships. Statelessness directly limits education, employment, and economic empowerment and these limitations are mutually reinforcing and exacerbating. For example, where lack of educational advancement further limits employment and economic opportunities, and feed into wider issues such as depression and access to health care and treatment. Such situations create disadvantages for stateless persons and create opportunities for exploitation and abuse by employers, neighbors and partners who have Dominican nationality and who are aware of challenges faced by stateless persons. Despite claims by service providers and authorities that stateless persons can access justice for violence or exploitation, there is a common perception among stateless that reporting experiences of violence or exploitation will provide no benefit, risk exposing one’s stateless identity and lead to possible deportation. This ultimately results in low levels of reporting, lack of recourse for violence, and continued perpetration of abuse. Within partnerships and families, underlying propensity towards IPV and domestic violence appears to be exacerbated by stresses related to livelihood (particularly employment and financial status) and income disparity between partners. The results presented by this study confirms the correlation found in the literature about men’s frustration at being unable to perform their traditional gender role of economic provider and the susceptibility to perpetrate violence as a result.[10, 11] Associated with this, the lack of employment and economic dependency of female partners has been linked to greater likelihood of being unable to leave violent situations. These findings are supported by recent qualitative research conducted by OBMICA study, that describes the connection between statelessness, unemployment, and economic dependency of intimate partners, which deepens unequal power relations and increases the risk of experiencing GBV and barriers to ending the relationship.[10] Other research outside of the Dominican Republic of undocumented or contingently documented persons similarly describes vulnerabilities to GBV and barriers to accessing health services as they relate to documentation status and associated livelihood.[20, 21] This study also found that stateless women were more likely than national women to experience or witness violence as children and, consistent with theories of intergenerational transmission of violence, were more likely to experience violence as an adult. Taken together, the environments and contexts of statelessness, promote and perpetuate vulnerability to gender-based violence among stateless relative to national populations living in similar geographic regions and with similar socio-economic statuses.

The health and psychological effects of statelessness are poorly understood. Findings from this study show that while there is no statistical difference in the self-assessment of one’s general health among stateless and national respondents, notable determinants were identified that could contribute to poorer health outcomes for stateless persons. Stateless men and women were more likely to report symptoms of depression relative to national counterparts. Also, stateless men were less likely to have consulted a medical professional than national men (17% vs. 26%). Such reports of depression and disappointment associated with statelessness and lack of documentation in the Dominican Republic have been similarly described in recent qualitative research.[26] Outside of the Dominican Republic, other research documenting the impact of statelessness, The Cost of Stateless, documented lower health expectancy among stateless populations relative to citizen populations.[27] Stateless men and women also report greater barriers to health access related to financial cost medical advice or treatment (68% vs. 60%) and concerns about deportation when accessing healthcare (69% vs. 5%), consistent with global reports of inaccessibility to health care among stateless persons due to direct restrictions as well as barriers related to lack of access to health insurance and national health services, fear of discrimination and stigma, and concerns about potential expatriation.[5, 28]

The findings presented in this study show marked similarities and differences when compared to a recent and related survey of GBV among national and stateless populations in Cote d’Ivoire. Though the mechanisms of statelessness are different in these two countries, findings from both studies from Cote d’Ivoire and the Dominican Republic highlight significant disparities in basic rights, such as: access to education, register children as nationals, open a bank account, legally marry and divorce, purchase land and/or housing, and gain legal, formal employment. A stark contrast, however, was the difference in the relative prevalence of GBV; in the Dominican Republic, stateless women were more likely to experience gender-based violence as children or adults than national women, whereas in Cote d’Ivoire, such a difference did not exist. Both studies found that stateless women who experience GBV have low access to healthcare and protection services. Also noteworthy was the finding that stateless persons in both countries reported avoiding healthcare because of fear of deportation, despite the fact that stateless persons in Cote d’Ivoire are reportedly not at risk of deportation. Ultimately, GBV is high in both countries and access to appropriate services to address GBV among stateless persons is exceedingly limited.

Limitations: Findings of this study should be reviewed with consideration to the study's limitations. First, we conducted household sampling in the context of multiple challenges. Ongoing political events and frequent observations of immigration officials involved in deportation round-ups in locations where people of Haitian descent lived made sampling difficult. Community members sometimes indicated concern that the study team might have been sent by immigration officials. We aimed to overcome this by ensuring all data that were collected were anonymous and working with local promoters and community members to explain the purpose of the study. Hiring of staff who were of Haitian descent themselves and understood the situations faced by the communities also helped to improve response rates. Second, we collected data during the daytime to ensure staff safety. This, however, reduced our response rates among men, who were often out of the house during the daytime for work or socializing. Conducting data collection during the weekends, however, facilitated recruitment of more men. Third, no sampling frame exists for stateless persons in the Dominican Republic that would allow for probability-based sampling, which would allow for better estimates of prevalence of indicators of interest that is representative of the target population. We overcame this challenge by collecting data among stateless and neighborhood-matched national persons who were residing in the same areas. This matched approach to sampling allowed us to control for unmeasured confounders related to socio-economic status and geographic distances of stateless and national participants. These national participants were predominantly of Haitian descent or of mixed descent themselves. Qualitative participants, however, often described discrimination and verbal abuse that appeared to be xenophobic in nature; thus, given our two comparison groups and lack of comparison to participants who are ethnically Dominican, we are unable to tease apart the extent to which general racism may play into experiences of inequity and violence.

Gender-based violence is prevalent among women in the Dominican Republic, with over 60,000 complaints of GBV and 1,100 murders of women reported between 2008-2013. No national statistics describe the experiences or prevalence of violence against men. Even less is known about experiences of GBV among stateless populations in the country. The research and analysis presented here describe the relationships between lack of national documentation, livelihoods, violence, and health outcomes. Being undocumented, or being stateless, directly and indirectly affects multiple dimensions of people’s lives, increasing vulnerability to GBV, though not necessarily experiencing GBV, and at risk of facing challenges in accessing healthcare or legal reporting following cases of GBV. Sentence 168-13 of the Constitutional Tribunal Court made a significant number of Dominicans of Haitian nationality stateless, thereby placing tens of thousands of affected persons and their family members in situations of vulnerability and increased risk of GBV.

The following recommendations are drawn from this study:

1. Process of documentation: Lack of citizenship and legal status is associated with increased vulnerabilities for the stateless population. Our findings demonstrate the limited access to basic rights and services among stateless populations when compared to legal citizens. The government of the Dominican Republic needs to address and reverse the Sentence 168-13 of the Constitutional Tribunal Court. In addition, the government should initiate measures to facilitate the documentation process to eventual legal status for persons who are currently stateless (both Group A and Group B). Such legal status and documentation would enable protection and access to basic rights and services that stateless persons are currently deprived of in the Dominican Republic
2. Access to education for children: Currently, stateless children are not allowed to advance to secondary schooling and beyond due to lack of legal documentation. The government should enact legislation to remove this restriction. Access to education will ensure children a path toward improving their future socio-economic status.
3. Access to health: Currently, all persons living in the Dominican Republic have access to basic medical care. However, this does not include preventive health services or specialty care for patients that have advanced diseases and who cannot afford medication and diagnostic tests requiring out of pocket payment. Governmental health services should be expanded to include affordable preventative care and specialty care to be available for persons, but particularly for survivors of GBV. The government should ensure that that GBV programs are scaled up and accessible regardless of nationality and without risk of deportation for those without documentation, which will allow stateless persons who experience GBV to access appropriate services.
4. Access to justice: Access to justice is limited by a poorly implemented national strategy for prevention and response to violence. Providers are often unaware of national reporting protocols for cases of violence and those who are aware describe situations in which they avoid reporting cases of violence to police out of concern that there is no benefit, only risk, to survivors in such report. In many locations, the capacity of local law enforcement is too low to offer protection for survivors who report, thus increasing the risk of retaliation by perpetrators. Strengthening access to justice for survivors of violence and removing deportation risk for those without documentation will aid in opening the pathway to reporting cases and ensuring protection against GBV for stateless populations who experience violence.

The study was designed, collected, analyzed, and interpreted by the following team members:

Johns Hopkins University	OBMICA
Dr. Andrea Wirtz	Bridget Wooding
Sahnah Lim	Allison Petrozziello
Emily Clouse	Ivrance Martine
Dr. Alexander Vu (Principal Investigator)

The achievement of this study is due to the support and involvement of many people and organizations. The United Nations High Commissioner for Refugees, particularly Radha Govil, Mark Manly, and Federico Martinez provided critical academic support and input to the overall study design, implementation, and interpretation. Data were collected by our tireless survey team: Marie Solange Damis, Antonia Guerrero, Ylemis Jean (Malena) Lamas, Ernest Rodolphe, Antonia Villinia Santana, Rubens Dely, Roudy Joseph, Nickenson LaForest, Jose P. Victor Ruiz, and Juan Telemin. We thank the Movimiento Sociocultural de Trabajadores Haitianos (MOSCTHA), Centro para el Desarrollo Sostenible (CEDESO), Centro de Formacion y Accion Social y Agraria (CEFASA), and the Asociación Scalabriniana al Servicio de la Movilidad Humana (ASCALA) for their support in connecting us with local communities and in some locations providing housing for our study team. OBMICA research associates Carlos Abaunza and Natalia Riveros provided interpretation and translation services during qualitative and quantitative data collection, respectively. We acknowledge and appreciate the input of Dr. Leslie Roberts and Dr. Nancy Perrin who provided consultation to sampling and statistical methodology. We are grateful for Dr. Nancy Glass for generous financial contributions to enable the extension of the data collection to meet the target sample size.

This project was funded as a gift of the U.S. Government (U.S. Department of State, Bureau of Population, Refugees, and Migration).

APPENDIX:

Appendix 1: Detailed Study Methodology

Qualitative research was conducted from February 14 to 20, 2015 in two sites of the Dominican Republic: Consuelo in San Pedro de Macorís province and Mata Mamón in Santo Domingo Norte. The areas around Consuelo are predominantly sugar plantations and offer access to people living in nearby bateys. Mata Mamón is located in the northern periphery of Santo Domingo and offers access to more rural towns where Haitian migrants or descendants of Haitian migrants live and work.

Participants: Inclusion criteria for in-depth interviews required participants to be ≥18 years, born in the DR, born to Haitian parents or from a single head of household that is a Haitian migrant, and currently without national identity documents. These criteria encompass those who have never been registered and are still without documentation (Group B). Service providers were required to have at least one year of experience serving the stateless population, providing service in some capacity to the target population. These participants included hospital physicians, health promoters, psychologists, administrators for the Ministry of Women, local Mayor, and other hospital staff.

Recruitment and consent: Recruitment was facilitated by local promoters who were familiar with the locations in which qualitative research took place. Promoters identified candidate participants, described the purpose of the study, and escorted interested candidate participants to the interview site. Prior to commencement of interviews, the interviewer read a consent script, which described the study purpose, procedures, and risks related to participation. The interviewer asked for the participant’s consent to participate and, separately, for consent to record the interview/discussion. All data collection was anonymous and audio recordings were saved on password protected computers at the end of each working day and erased from the audio recorder to protect participant information and confidentiality.

Data collection: Twenty-five in-depth interviews were conducted with participants who were of the affected population. Three focus groups of approximately eight participants per group were convened with service providers or community leaders. Two individual interviews were also convened with service providers (one curandero or medicine man in Mata Mamón and one Director of the local Ministry of Women office in San Pedro). In-depth interviews and focus group discussions followed semi-structured interview/discussion guides and were conducted directly in Spanish or in English with Spanish interpretation.

Data analysis: All audio recordings were transcribed and translated by certified transcription agencies and de-identified transcripts were entered into ATLAS.ti qualitative data analysis software. Transcripts underwent thematic analysis based on areas of interest that guided the development of the interview guide and themes that emerged from the data following grounded theory.[29, 30] Codes were refined and elaborated during the analysis through the constant comparison method. The finalized codebook was applied to all transcripts by the analytic team (AW, SL, EC) in order to minimize bias.

A quantitative cross sectional survey was conducted throughout the Dominican Republic from October 6-31, 2015 and November 10-15, 2015, in urban/peri-urban and rural settings (77 communities) where stateless populations are known to reside and where local community leaders and their community were willing to participate in the survey.

Table 1: Communities that participated in quantitative survey

Provinces	#	Village name	Provinces	#	Village name
Santo Domingo	1	Duquesa	Eastern region	41	Batey Cambalache
	2	Mata San Juan		42	Batey La Altagracia
	3	San Joaquin, La Victoria		43	Batey Laja
	4	Mata Mamon, La Victoria		44	Batey Las Pajas
	5	Juan Tomas, La Victoria		45	Batey Soco
	6	Batey Bienvenido		46	Batey La Esperanza
	7	Batey Yaco		47	Loma Larga
	8	Villa Linda		48	Guayabal
	9	Sector Punta, Villa Mella		49	Canotillo
	10	El 18 de Villa Mella		50	Villa Vilorio
	11	Palamara		51	Pringamosa
	12	Arroyo Indio		52	Batey Ulloa
	13	Cancino Adentro		53	Prudencio
	14	Manguito		54	Batey Siria
	15	Paraíso		55	Batey Cacata
	16	Marmora		56	Batey Los Tocones
	17	Villa Esperanza		57	Batey Nuevo
	18	Canaan III	Santiago	58	Los Pérez
	19	El Licey, Villa Mella		59	Calle Veinte
Bahoruco	20	Santa Maria		60	Calle Ocho
	21	Santana		61	Villa Verde
	22	Batey 5		62	Calle Siete
	23	Batey 9		63	Pontezuela
	24	Batey Cuchilla		64	Canca
Barahona	25	Batey 7		65	Tamboril
	26	Batey 4		66	Cuesta Abajo
	27	Batey 6	North of Santiago	67	Batey Baraguana
Santo Domingo Norte	28	Guanuma	Puerto Plata	68	Ingenio Amistad
	29	La Jagua	Northern region	69	Batey Saballo
Monte Plata	30	Luisa Prieta		70	Loma Blanca
	31	Bermejo		71	Mejía
	32	Guazumita		72	Batey libertad
San Cristobal	33	La Magdalena, Haina		73	La Altagracia
Santo Domingo Oeste	34	Caballona		74	Maizal
	35	Lechería		75	Guayacanes
	36	Palave	Villa Altagracia	76	Batey 43
San Pedro de Macorís	37	Batey Vasca		77	Batey Basima
	38	Haití Mejía
	39	Inocencia
	40	Monte Cristi

Map of provinces surveyed

Survey development: With input from OBMICA, portions of previously validated sets of surveys were adapted and included from: 1) WHO Multi-country Study on Women’s Health and Domestic Violence against Women[31] which includes collection of both intimate partner violence (IPV) and non-partner violence victimization; 2) UN research on perpetration of violence[13, 32, 33]; 3) the Hopkins Symptom Checklist- Depression subscale[34]; and items developed by our research team focusing on social norms about violence and others derived from qualitative findings. The adapted questionnaire was translated from English to Spanish and then back-translated by local translators; back-translations were then reviewed by the research team and the local OBMICA team. Additional edits were made through an iterative process to ensure that the translation captured the essence of each question. The surveys were then programmed in English and Spanish for tablet-based data collection, which was deemed a more secure method than paper-based data collection.

Sampling frame: To the best of our knowledge, a sampling frame of stateless persons living in the Dominican Republic is not available. In 2012, The first National Survey of Immigrants in the Dominican Republic (ENI-2012) was conducted to estimate the population size of all immigrants who live in the Dominican Republic as well as the first generation of descendants of immigrants born in country.[35] The report did not, however, provide a sampling frame focused on stateless persons. The research team undertook an exhaustive effort to establish a sampling frame through consultations with UNHCR, local organizations working with stateless persons, and local community leaders. Ultimately, we derived that such an accurate sampling frame was not possible due to multiple factors, including the limited information available, the geographic spread of the population, and the concern about possible expatriation on the part of stateless persons.

Sampling Plan: The aim of the study was to measure proportions of key indicators relating to demographics, GBV, GBV-related health impacts and health care access among the stateless population, compared to the populations with legal citizenship. We controlled for socio-economic status between stateless and legal citizens by sampling the population with legal citizenship who live in closest proximity to the surveyed stateless participants. Given the challenge of the sampling frame that could not be established, we adjusted our sampling methodology as follows:

1. Identification of all communities (bateys/urban neighborhoods) where stateless populations are known to reside;
2. Consult, inform and request for participation in the survey from local non-governmental organizations and stateless community leaders who work in the respective communities;
3. Raise awareness of the survey’s goals, objectives and expected date of survey with community leaders within communities that have agreed to participate in the survey;
4. Upon arrival to the prospective community being surveyed, local community promoters informed community members about the survey. Community leaders were consulted on the general map of the community being surveyed using satellite Google Earth images and estimates of the number of stateless persons living in the community.
5. The community was divided into subsections, from which a subsection was randomly selected using a random number table. If the subsection had more than approximately 30 households, it was further divided and the process of random selection was repeated until an area was chosen with approximately 30 households to facilitate the process of randomly selecting a household. A house was selected randomly to look for the first stateless person to interview using the inclusion criteria described below under participant recruitment. If the household did not have a stateless person, surveyors went to the next nearest household as measured from the front door of one dwelling to the front door of the next.
6. When a survey with a stateless person was completed, the surveyor then identified and interviewed the next nearest person of legal citizenship of the same gender using the same method above. If the person who has legal citizenship is not found based on the inclusion criteria, the surveyor will proceed to the next nearest house until the target respondent type is found. This process was repeated, alternating between a person who was stateless and one with legal citizenship, using the most recent house with a completed survey as the reference for the selection of the next nearest house to sample. If the interviewer could not find a person to sample, most often a person of legal citizenship in that same community, after one hour, then the surveyors continued sampling for only the stateless persons until they had surveyed eight respondents/interviews. The team would then proceed to the next nearest community to sample for the match of persons with citizenship and to match for the same gender.
7. Staff trained as survey supervisors oversaw the household selection process and reviewed completed surveys on the iPad to assure completeness.

Participants: The inclusion criteria for stateless persons (Group B) were: 1) aged 18 years or older; 2) both parents are migrants; 3) participant was born in the Dominican Republic; and 4) had never been legally registered in the Dominican Republic. The inclusion criteria for a person with legal citizenship were: 1) aged 18 years or older; 2) both parents are not migrants; 3) participant was born in the DR; and 4) legally registered in the Dominican Republic. To avoid potentially raising undue concern, we did not ask participants to provide documentation for verification of nationality.

Recruitment and consent: Recruitment was facilitated by local community leader who was familiar with the community to be sampled. Prior to commencement of interviews, the interviewer read a consent script, which described the study purpose, procedures, and risks related to participation. The interviewer asked for the participant’s consent to participate and, separately, for consent to record the interview/discussion. Verbal consent was obtained from all participants from a standardized consent script that was read to the participants by the surveyors. Verbal – in lieu of written consent – was used to ensure that all data collection was anonymous; a written consent would have otherwise been the only linking identifier of the data with the participant. A copy of the informed consent was made available for the participants if they preferred to retain a copy. All participants were provided with information essential for informed consent prior to participation in the discussion/interviews. All participants were informed about the potential risks in participating in the study and measures taken by the study team to protect participants. All participants were notified that they could withdraw from the study at any time without penalty. All data collection was anonymous and data was recorded on an iPad tablet. The data on the iPad table was then uploaded on an encrypted and password protected server at the end of each working day. The data on the iPad was erased from the tablet after uploading of data to protect participant information and confidentiality.

Data analysis: Quantitative data collected from household surveys were reviewed and cleaned by the JHU study team (AW). The final data set was restricted to consenting and eligible participants from the stateless and national populations and data were cleaned using systematic methods to check for and remove inconsistencies or errors. Analyses were descriptive in nature, comparing demographic, health, and GBV data between stateless and national populations and between men and women separately. Because participants were generally matched 1:1 across the stateless and national populations, we did not include additional adjustments for population size or clustering by site location. Variables of interest were tabulated and Pearson chi-squared statistics were calculated to assess for significant differences across stateless and national populations.

Ethics approval: Prior to initiation of all qualitative and quantitative data collection, ethical approval was obtained from the Johns Hopkins School of Medicine Institutional Review Board and the local Institutional Review Board composed of an ad-hoc expert review committee. In public health research, local approval is typically sought from a local research institution with topical expertise. In the Dominican Republic, however, there is virtually no academic research being carried out on statelessness, hence we created an ad hoc committee to serve as the local IRB. Additionally, because the subject is so sensitive in the local context, utmost discretion was required in ensuring that all the ethical concerns are taken into account in ways in which the guarantors of health rights for all residing on Dominican territory may be duly called to account. The ad-hoc expert review committee was comprised of four members who were lawyers, social workers, advocacy experts, and/or affected persons themselves with expertise in gender and development; issues of statelessness; public health and research programs associated with migrant health matters; and mental health among the affected population in the Dominican Republic.

A protocol was developed for data collection with participants to ensure confidentiality and safety, including no requirement to provide names in order to protect participant confidentiality and minimize sensitivity. Participants in focus group discussions were asked to respect the privacy of each participant by not talking about the content of the discussion with other individuals who did not attend the group. The research plan was developed with deliberate attention toward minimizing the risk of harm to participants. The research team members were trained to stop the discussion/interview if a participant appeared to be upset or distressed by participation. All research staff and participating partner organizational staff members were trained to read and review the consent prior to commencing the study and answer any questions from the participants. Steps to be taken to protect the safety and confidentiality of information about all participants included the use of study code numbers for identification, reporting aggregate data only, omitting identifiers on the tapes, transcripts and demographic survey. All study data were stored on a password-protected computer in locked files secured by the research team. No data was shared with individuals outside the research team. All study team members and data collectors were required to complete training and provide a certificate of training in human subjects research prior to data collection. All research team members were trained on the purpose of the study, qualitative or quantitative research methods, human subjects protections and consent, and were required to adhere to institutional codes of conduct and policies prohibiting sexual exploitation and abuse.

Appendix Table 2. Demographics among national and stateless adults
	Females								Males
	National (N = 423)	Stateless (N = 403)				Total			National (N = 260)	Stateless (N = 210)			Total
	n (%)	n (%)				n (%)		p-value	n (%)	n (%)			n (%)		p-value
Demographics
Median age (IQR)	33 (24-43)	25 (20-32)						N/A	39 (27-50)	25 (20-30.5)
Ever attended school (women, n=804; men, n=409)	385 (93.2)	334 (85.4)				718 (89.4)			233 (91.4)	176 (85.0)			409 (88.5)		0.033**
Highest level of school attended (women, n=720; men, n=408)
Primary	201 (52.2)	244 (72.8)				445 (61.8)			120 (51.7)	133 (75.6)			253 (62.0)
Secondary	151 (39.2)	91 (27.2)				242 (33.6)			97 (41.8)	42 (23.9)			139 (34.1)
College	33 (8.6)	0 (0)				33 (4.6)			15 (6.5)	1 (0.6)			16 (3.9)
Religion (women, n=764; men, n=443)
Catholicism	149 (38.1)	102 (27.3)				251 (32.9)			80 (32.8)	58 (29.1)			138 (31.2)
Evangelical	138 (35.3)	153 (41.0)				291 (38.1)			72 (29.5)	62 (31.2)			134 (30.2)
Other	103 (26.3)	116 (31.1)				219 (28.7)			92 (37.7)	78 (39.2)			170 (38.4)
Moved to current town (women, n=767; men, n=431)	160 (40.9)	148 (39.4)				308 (40.2)		0.660	88 (37.1)	63 (32.5)			151 (35.0)		0.313
Ever been detained/ deported (women, n=787; men, n=36)	3 (0.7)	24 (6.2)				27 (3.4)			5 (2.0)	31 (15.3)			36 (8.0)
Dual parent household during childhood (women, n =807); men, n=454)	258 (62.9)	220 (55.4)				478 (59.2)		0.030**	174 (70.2)	110 (53.4)			284 (62.6)
Marital status (women, n=807; men, n=455)
Divorced/separated	76 (18.4)	56 (14.2)				132 (16.4)		0.023**	42 (16.9)	25 (12.1)			67 (14.7)
Engaged	1 (0.2)	1 (0.3)				2 (0.2)			3 (1.2)	5 (2.4)			8 (1.8)
Living with someone, but not married	264 (64.1)	256 (64.8)				520 (64.4)			122 (49.0)	79 (38.3)			201 (44.2)
Married	23 (5.6)	10 (2.5)				33 (4.1)			21 (8.4)	2 (1.0)			23 (5.1)
Never married	38 (9.2)	60 (15.2)				98 (12.1)			53 (21.3)	95 (46.1)			148 (32.5)
Widowed	10 (2.4)	12 (3.0)				22 (2.7)			8 (3.2)	0 (0)			8 (1.8)
Ever faced challenges with legally marrying someone due to registration issues (women, n=235; men, n=122)	5 (4.0)	51 (46.8)				56 (23.8)			4 (4.8)	15 (38.5)			19 (15.6)
Median age of participant when first partnered (IQR)	17 (15-19)	16 (15-18)						N/A	22 (20-25)	20 (19-24)
Forced marriage (women, n=234; men, n=121)	36 (28.1)	42 (39.6)				78 (33.3)		0.063*	47 (56.6)	19 (50.0)			66 (54.5)		0.497
Worked in the past month (women, n=798; men, n=458)	142 (34.7)	104 (26.7)				246 (30.8)		0.015**	185 (73.1)	167 (81.5)			352 (76.9)		0.035**
Among those who worked, employment was seasonal (women, n=378; men, n=424)	69 (33.5)	89 (51.7)				158 (41.8)			86 (37.9)	108 (54.8)			194 (45.8)
Each month participant has enough to…(women, n=750; men, n=438)
Meet basic needs of the family	28 (7.3)	23 (6.3)				51 (6.8)		0.294	27 (11.2)	13 (6.6)			40 (9.1)
Meet basic needs for most but not all of the month	42 (10.9)	28 (7.7)				70 (9.3)			31 (12.8)	18 (9.2)			49 (11.2)
Meet basic needs for about half of the month	51 (13.1)	45 (12.3)				96 (12.8)			44 (18.2)	22 (11.2)			66 (15.1)
Meet basic needs for less than half of the month	74 (19.3)	63 (17.2)				137 (18.3)			60 (24.8)	38 (19.4)			98 (22.4)
Never have enough to meet basic needs	189 (49.2)	207 (56.6)				396 (52.8)			80 (33.1)	105 (53.6)			185 (42.2)
Legally able to open a bank account (women, n=793; men, n=453)	395 (97.8)	5 (1.3)				400 (50.4)			246 (98.8)	2 (1.0)			248 (54.7)
Health insurance (women, n=791; men, n=453)	273 (67.7)	5 (1.3)				278 (35.1)			162 (65.1)	6 (2.9)			168 (37.1)
House ownership (women, n=800; men, n=455)
Alone only	154 (37.7)	104 (26.5)				258 (32.2)			99 (39.4)	39 (19.1)			138 (30.3)
Does not own	178 (43.6)	236 (60.2)				414 (51.7)			32 (12.7)	21 (10.3)			53 (11.6)
Jointly only	76 (18.6)	52 (13.2)				128(16.0)			120 (47.8)	144 (70.6)			264 (58.0)
Partner demographics and behavior
Current/most recent partner ever attended school (women, n=285; men, n=126)	137 (89.0)	110 (84.0)				247 (86.7)		0.217	79 (89.8)	31 (81.6)			110 (87.3)		0.205
Current partner employment status (women, n=; men, n=81)
Works occasionally	94 (79.7)	81 (81.8)			175 (80.6)			0.766	25 (43.9)	12 (50.0)			37 (45.7)		0.584
Looking for work/unemployed	14 (11.9)	13 (13.1)				27 (12.4)			19 (33.3)	5 (20.8)			24 (29.6)
Retired	7 (5.9)	3 (3.0)				10 (4.6)			6 (10.5)	2 (8.3)			8 (9.9)
Studying	3 (2.5)	2 (2.0)				5 (2.3)			7 (12.3)	5 (20.8)			12 (14.8)
Legally able to open bank account (women, n=165; men, n=90)
No	12 (13.5)	30 (39.5)				42 (25.5)			4 (6.6)	9 (31.0)			13 (14.4)		0.004**
Yes	69 (77.5)	32 (42.1)				101 (61.2)			43 (70.5)	12 (41.4)			55 (61.1)
Maybe/ don't know	8 (9.0)	14 (18.4)				22 (13.3)			14 (23.0)	8 (27.6)			22 (24.4)
*Marginally significant **Significant

Appendix Table 3. Reproductive health and children among stateless and national participants
	Females					Males
	National (N = 423)		Stateless (N = 403)	Total		National (N = 260)	Stateless (N = 210 )	Total
	n (%)		n (%)	n (%)	p-value	n (%)	n (%)	n (%)	p-value
Ever used any contraceptive method (women, n=749; men, n=420)~	285 (74.0)		265 (72.8)	550 (73.4)	0.705	127 (54.5)	90 (48.1)	217 (51.7)	0.194
Currently using any contraceptive method (women, n=550; men, n=208) ~	149 (52.3)		166 (62.6)	315 (57.3)	0.014**	63 (51.2)	47 (55.3)	110 (52.9)	0.270
Current/most recent partner ever refused to use contraceptive method (women n=504; men n= 403)%		21 (8.6)	28 (10.8)	49 (9.7)	0.413	14 (6.3)	16 (8.9)	30 (7.4)	0.321
If currently not using a method, knows where to obtain contraception (women, n=42)	16 (100.0)		22 (84.6)	38 (90.5)	0.099*
Location where participants can obtain contraceptives (women, n=38)
Family planning clinic	2 (12.5)		2 (9.1)	4 (10.5)	0.204
Fieldworker	1 (6.2)		0 (0)	1 (2.6)
Pharmacy	4 (25.0)		1 (4.5)	5 (13.2)
Public Health Center	1 (6.2)		4 (18.2)	5 (13.2)
Public Hospital	8 (50.0)		15 (68.2)	23 (60.5)
Ever been pregnant (women, n=751; men, n=411)~	357 (92.2)		326 (89.6)	683 (90.9)	0.200	183 (79.9)	109 (59.9)	292 (71.0)
Number of children able to register as a Dominican national (women, n=672; men, n=275)
all	277 (78.7)		19 (5.9)	296 (44.0)		141 (79.7)	15 (15.3)	156 (56.7)
none	28 (8.0)		268 (83.8)	296 (44.0)		22 (12.4)	8 (8.2)	30 (10.9)
some, but not all	47 (13.4)		33 (10.3)	80 (11.9)		14 (7.9)	75 (76.5)	89 (32.4)
All children have access to health insurance (women, n=671; men, n=276)	150 (42.7)		10 (3.1)	160 (23.8)		96 (53.9)	16 (16.3)	112 (40.6)
Number of children not able to continue to with school (women, n=271; men, n=114)
none	29 (18.4)		33 (29.2)	62 (22.9)		72 (40.0)	18 (18.0)	90 (32.1)
all	14 (8.9)		20 (17.7)	34 (12.5)		4 (2.2)	9 (9.0)	13 (4.6)
some, but not all	115 (72.8)		60 (53.1)	175 (64.6)		7 (3.9)	4 (4.4)	11 (3.9)
~For males, questions refer to their female partner; %For males, question refers to participant's refusal of wife's contraceptive use
*Marginally significant **Significant

Appendix Table 4. Lifetime experiences of violence among national and stateless women in the Dominican Republic
	National (N = 423)	Stateless (N = 403)	Total (N=826)
	n (%)	n (%)	n (%)	p-value
Exposure to violence
Mother ever hit father (n=484)	44 (16.8)	47 (21.2)	91 (18.8)	0.219
Father ever hit mother (n=482)	40 (15.4)	53 (23.9)	93 (19.3)	0.019**
Ever saw or heard family violence (n=127)	44 (77.2)	62 (88.6)	106 (83.5)	0.086*
Divorced/separated due to violence (n=183)	36 (37.1)	34 (39.5)	70 (38.3)	0.737
Physical violence against participant due to partner's drinking (n=153)	13 (15.3)	2 (2.9)	15 (9.8)	0.011**
Childhood violence
Physical child abuse (n=758)	50 (13.1)	82 (21.9)	132 (17.4)	0.001**
Perpetrator of physical child abuse (n=132)
Mother	10 (20.0)	19 (23.2)	29 (22.0)	0.670
Father	11 (22.0)	14 (17.1)	25 (18.9)	0.483
Other female family member	6 (12.0)	15 (18.3)	21 (15.9)	0.338
Stranger	5 (10.0)	10 (12.2)	15 (11.4)	0.700
Other male family member	8 (16.0)	6 (7.3)	14 (10.6)	0.116
Stepfather	3 (6.0)	7 (8.5)	10 (7.6)	0.593
Someone from another community	3 (6.0)	6 (7.3)	9 (6.8)	0.771
Stepmother	2 (4.0)	6 (7.3)	8 (6.1)	0.438
Male friend of family	1 (2.0)	5 (6.1)	6 (4.5)	0.273
Someone at school	3 (6.0)	0 (0)	3 (2.3)	0.025**
Female friend of family	1 (2.0)	1 (1.2)	2 (1.5)	0.772
Other	2 (4.0)	13 (15.9)	15 (11.4)	0.037**
Sexual child abuse (n=752)	34 (9.0)	46 (12.3)	80 (10.6)	0.142
Perpetrator of sexual child abuse (n=80)
Stranger	13 (38.2)	23 (50.0)	36 (45.0)	0.296
Male friend of family	6 (17.6)	7 (15.2)	13 (16.2)	0.771
Boyfriend	4 (11.8)	6 (13.0)	10 (12.5)	0.864
Other male family member from participant's family	6 (17.6)	3 (6.5)	9 (11.2)	0.120
Father/stepfather	1 (2.9)	6 (13.0)	7 (8.8)	0.114
Other female family member from participant's family	1 (2.9)	2 (4.3)	3 (3.8)	0.743
Someone at school/work	0 (0)	1 (2.2)	1 (1.2)	0.387
Other male family member from husband's family	1 (2.9)	0 (0)	1 (1.2)	0.242
Other	7 (20.6)	4 (8.7)	11 (13.8)	0.127
Any child physical or sexual abuse (n=758)	72 (18.8)	104 (27.7)	176 (23.2)	0.004**
Ever been injured as result of child physical/sexual abuse (n=171)	23 (32.9)	39 (38.6)	62 (36.3)	0.441
Ever went to hospital (among those with injuries; n=61)	10 (43.5)	19 (50.0)	29 (47.5)	0.621
Ever received healthcare for injury (among those with injuries; n=60)	10 (45.5)	19 (50.0)	29 (48.3)	0.734
Intimate partner violence (IPV)
Lifetime physical IPV (n=735)	39 (10.1)	34 (9.7)	73 (9.9)	0.851
Physical IPV past year (n=735)	37 (9.6)	32 (9.1)	69 (9.4)	0.828
Lifetime sexual IPV (n=735)	22 (5.7)	24 (6.9)	46 (6.3)	0.523
Sexual IPV past year (n=735)	22 (5.7)	23 (6.6)	45 (6.1)	0.628
Lifetime physical or sexual IPV (n=735)	40 (10.4)	41 (11.7)	81 (11.0)	0.567
Physical or sexual IPV past year (n=735)	38 (9.9)	39 (11.1)	77 (10.5)	0.574
Ever beaten/physically assaulted by partner during pregnancy (n=674)	34 (9.7)	48 (14.9)	82 (12.2)	0.040**
Ever punched/kicked in abdomen while pregnant (n=82)	22 (64.7)	31 (64.6)	53 (64.6)	0.991
Ever reported violence victimization to an authority (n=74)	7 (19.4)	12 (31.6)	19 (25.7)	0.232
Among those who reported violence (n=19)
Fiscalia	6 (85.7)	7 (58.3)	13 (68.4)	0.216
Police	3 (42.9)	8 (66.7)	11 (57.9)	0.311
Women's bureau	1 (14.3)	0 (0)	1 (5.3)	0.179
Village leader	0 (0)	1 (8.3)	1 (5.3)	0.433
Non-partner violence (adult; ages 15 and older)
Physical violence (n=745)	26 (6.9)	34 (9.2)	60 (8.1)	0.240
Perpetrator of physical violence (n=60)
Boyfriend	10 (38.5)	9 (26.5)	19 (31.7)	0.322
Stranger	4 (15.4)	9 (26.5)	13 (21.7)	0.302
Other male family member	3 (11.5)	5 (14.7)	8 (13.3)	0.721
Female family member	2 (7.7)	3 (8.8)	5 (8.3)	0.875
Mother	0 (0)	3 (8.8)	3 (5.0)	0.120
Stepfather	1 (3.8)	2 (5.9)	3 (5.0)	0.720
Soldier/ militia	1 (3.8)	0 (0)	1 (1.7)	0.249
Female friend of family	0 (0)	1 (2.9)	1 (1.7)	0.378
Someone at school	1 (3.8)	0 (0)	1 (1.7)	0.249
Stepmother	1 (3.8)	0 (0)	1 (1.7)	0.249
Other	5 (19.2)	6 (17.6)	11 (18.3)	0.875
Sexual violence (n=746)	20 (5.3)	26 (7.0)	46 (6.2)	0.332
Perpetrator of sexual violence (n=46)
Stranger	9 (45.0)	15 (57.5)	24 (52.2)	0.393
Other male family member	2 (10)	4 (15.4)	6 (13.0)	0.591
Male friend of family	5 (25.0)	1 (3.8)	6 (13.0)	0.035**
Boyfriend	1 (5.0)	4 (15.4)	5 (10.9)	0.262
Someone at school	2 (10.0)	0 (0)	2 (4.3)	0.099*
Stepfather	0 (0)	1 (3.8)	1 (2.2)	0.375
Someone at work	0 (0)	1 (3.8)	1 (2.2)	0.375
Other	3 (15.0)	3 (11.5)	6 (13.0)	0.730
If forced sex, ever gang raped (n=46)	4 (20.0)	1 (3.8)	5 (10.9)	0.081*
Among those with sexual violence (n=43)
safe shelter	1 (5.6)	2 (8.0)	3 (7.0)	0.756
legal services	2 (11.1)	6 (24.0)	8 (18.6)	0.284
report to an authority figure	3 (16.7)	7 (28.0)	10 (23.3)	0.385
Any physical or sexual non-partner violence (n=726)	41 (11.1)	51 (14.2)	92 (12.7)	0.209
Ever been physically injured as a result of violence (n=41)	6 (31.6)	8 (36.4)	14 (34.1)	0.747
Ever hurt badly enough requiring healthcare	4 (66.7)	3 (37.5)	7 (50.0)	0.280
Ever received healthcare for injury	4 (66.7)	3 (37.5)	7 (50.0)	0.280
Ever exchanged sex (n=46)	8 (40.0)	14 (53.8)	22 (47.8)	0.351
Among those who exchanged sex (n=22)
someone benefited/made money/received goods	4 (50.0)	6 (42.9)	10 (45.5)	0.746
made to travel to another area	5 (62.5)	3 (21.4)	8 (36.4)	0.054*
Any lifetime violence victimization (n=652)	132 (39.3)	165 (52.2)	297 (45.6)	0.001**
*Marginally significant **Significant

Appendix Table 5. Self-reported IPV tactics among women and men in the Dominican Republic

	Females				Males
	National (N=)	Stateless (N=)	Total		National (N=206)	Stateless (N=122)	Total
	n (%)	n (%)	n (%)	p-value	n (%)	n (%)	n (%)	p-value
IPV Tactics (women, n=735ϕ; men, n=328)
Ever slapped them or thrown something	22 (5.7)	21 (6.0)	43 (5.9)	0.869	6 (2.9)	1 (0.8)	7 (2.1)	0.205
Ever pushed or shoved them	17 (4.4)	20 (5.7)	37 (5.0)	0.421	8 (3.9)	3 (2.5)	11 (3.4)	0.489
Ever hit them with fist or something else	13 (3.4)	16 (4.6)	29 (3.9)	0.406	2 (1.0)	0 (0)	2 (0.6)	0.275
Ever kicked , dragged, or beaten them up	5 (1.3)	5 (1.4)	10 (1.4)	0.879	2 (1.0)	0 (0)	2 (0.6)	0.275
Choked or burnt them on purpose	5 (1.3)	7 (2.0)	12 (1.6)	0.454
Threatened to/actually used a gun, knife or other weapon	8 (2.1)	9 (2.6)	17 (2.3)	0.657
Ever refused them contact with other people	9 (2.3)	5 (1.4)	14 (1.9)	0.368	3 (1.5)	1 (0.8)	4 (1.2)	0.612
Ever denied them food or water	9 (2.3)	2 (0.6)	11 (1.5)	0.049**	1 (0.5)	0 (0)	1 (0.3)	0.441
Ever forced them to do something sexual that they found degrading or humiliating	10 (2.6)	6 (1.7)	16 (2.2)	0.413	1 (0.5)	0 (0)	1 (0.3)	0.441
Ever coerced sexual intercourse because they were afraid of what I would do	18 (4.7)	18 (5.1)	36 (4.9)	0.769	4 (1.9)	0 (0)	4 (1.2)	0.121
Ever coerced sexual intercourse because it was my right	17 (4.4)	16 (4.6)	33 (4.5)	0.919	4 (1.9)	0 (0)	4 (1.2)	0.121

ϕWomen’s report of the intimate partners IPV tactics; Men’s report are self-reported perpetration tactics

Appendix Table 6. Attitudes related to intimate partner violence among female and male national and stateless participants
	Females				Males
	National (N = 423)	Stateless (N = 403)	Total		National (N =260 )	Stateless (N =210 )	Total
	n (%)	n (%)	n (%)	p-value	n (%)	n (%)	n (%)	p-value
GBV Attitudes
A husband is justified in hitting/beating his wife if…
she goes out without telling him (women, n=797; men, n=452)	16 (3.9)	22 (5.6)	38 (4.8)	0.264	6 (2.4)	11 (5.4)	17 (3.8)	0.094*
she neglects the children/household (women, n=794; men, n=454)	20 (4.9)	34 (8.7)	54 (6.8)	0.033**	8 (3.2)	15 (7.4)	23 (5.1)	0.042**
she wants to go to school (women, n=794, men, n=454)	0 (0)	1 (0.3)	1 (0.1)	0.308	0 (0)	0 (0)	0 (0)	0 (0)
she asks for money from partner (women, n=796; men, n=455)	1 (0.2)	2 (0.5)	3 (0.4)	0.542	0 (0)	3 (1.5)	3 (0.7)	0.054*
she disobeys orders (women, n=795; men, n=451)	16 (4.0)	29 (7.4)	45 (5.7)	0.034**	9 (3.6)	9 (4.5)	18 (4.0)	0.622
she earns money (women, n=793; men, n=454)	1 (0.2)	1 (0.3)	2 (0.3)	0.979	0 (0)	1 (0.5)	1 (0.2)	0.266
she argues with him (women, n=788; men, n=452)	19 (4.7)	32 (8.3)	51 (6.5)	0.042**	6 (2.4)	7 (3.4)	13 (2.9)	0.511
she refuses to have sex with him (women, n=789; men, n=454)	10 (2.5)	17 (4.4)	27 (3.4)	0.134	7 (2.8)	4 (2.0)	11 (2.4)	0.573
she burns the food (women, n=794; men, n=454)	11 (2.7)	14 (3.6)	25 (3.1)	0.468	7 (2.8)	4 (2.0)	11 (2.4)	0.563
she makes household decisions without him (women, n=792; men, n=454)	16 (4.0)	24 (6.2)	40 (5.1)	0.153	13 (5.2)	9 (4.4)	22 (4.8)	0.697
*Marginally significant **Significant

Appendix Table 7. Lifetime experiences of violence among national and stateless men in the Dominican Republic
		National (N = 260)		Stateless (N =210 )		Total
		n (%)		n (%)		n (%)		p-value
Exposure to violence
Mother ever hit father (n=286)		19 (10.9)		20 (18.0)		39 (13.6)		0.085*
Father ever hit mother (n=283)		29 (16.8)		17 (15.5)		46 (16.3)		0.771
Ever saw or heard violence (n=54)		26 (81.2)		18 (81.8)		44 (81.5)		0.958
Divorced/separated due to violence (n=95)		11 (18.3)		5 (14.3)		16 (16.8)		0.611
Childhood violence
Physical child abuse (n=455)		48 (19.1)		44 (21.6)		92 (20.2)		0.518
Perpetrator of physical child abuse (n=92)
Father		23 (47.9)		14 (31.8)		37 (40.2)		0.116
Other male family member		5 (10.4)		8 (18.2)		13 (14.1)		0.285
Someone from the community		5 (10.4)		7 (15.9)		12 (13.0)		0.435
Other female family member		4 (8.3)		7 (15.9)		11 (12.0)		0.263
Stranger		6 (12.5)		3 (6.8)		9 (9.8)		0.359
Stepfather		4 (8.3)		5 (11.4)		9 (9.8)		0.625
Someone from another community		3 (6.2)		3 (6.8)		6 (6.5)		0.912
Male friend of family		1 (2.1)		1 (2.3)		2 (2.2)		0.950
Street gang		1 (2.1)		1 (2.3)		2 (2.2)		0.950
Teacher		1 (2.1)		1 (2.3)		2 (2.2)		0.950
Someone at school		1 (2.1)		0 (0)		1 (1.1)		0.336
Police		1 (2.1)		0 (0)		1 (1.2)		0.336
Foreign soldier		1 (2.1)		0 (0)		1 (1.1)		0.336
Community leader		0 (0)		1 (2.3)		1 (1.1)		0.294
Other		3 (6.2)		3 (6.8)		6 (6.5)		0.912
Sexual child abuse (n=455)		9 (3.6)		9 (4.4)		18 (4.0)		0.653
Perpetrator of sexual child abuse (n=18)
Someone from another clan		6 (66.7)		2 (22.2)		8 (44.4)		0.058*
Stranger		3 (33.3)		3 (33.3)		6 (33.3)		1.000
Female friend of family		0 (0)		1 (11.1)		1 (5.6)		0.303
Any child physical or sexual abuse (n=455)		52 (20.7)		49 (24.0)		101 (22.2)		0.399
Ever been injured as result of child physical/sexual abuse (n=99)		15 (30.0)		14 (28.6)		29 (29.3)		0.876
Ever went to hospital (among those with injuries; n=29)		3 (20.0)		6 (42.9)		9 (31.0)		0.184
Ever received healthcare for injury (among those with injuries; n=27)		3 (21.4)		6 (46.2)		9 (33.3)		0.173
Violence victimization in adulthood (ages 15 and older)
Physical violence (n=449)		18 (7.3)		26 (12.9)		44 (9.8)		0.048**
Perpetrator of physical violence (n=44)
Someone from another family		4 (22.2)		6 (23.1)		10 (22.7)		0.947
Stranger		5 (27.8)		5 (19.2)		10 (22.7)		0.506
Wife/Partner		1 (5.6)		5 (19.2)		6 (13.6)		0.194
Father		2 (11.1)		2 (7.7)		4 (9.1)		0.698
Other		1 (5.6)		3 (11.5)		4 (9.1)		0.497
Someone at work		2 (11.1)		2 (7.7)		4 (9.1)		0.698
Other male family member		3 (16.7)		0 (0)		3 (6.8)		0.031**
Police		1 (5.6)		2 (7.7)		3 (6.8)		0.782
Female family member		0 (0)		2 (7.7)		2 (4.5)		0.228
Soldier/ Militia		1 (5.6)		1 (3.8)		2 (4.5)		0.789
Female friend of the family		0 (0)		1 (3.8)		1 (2.3)		0.400
Street gang		0 (0)		1 (3.8)		1 (2.3)		0.400
Foreign Soldier		0 (0)		1 (3.8)		1 (2.3)		0.400
Someone at school		1 (5.6)		0 (0)		1 (2.3)		0.224
Sexual violence (n=445)		9 (3.7)		5 (2.5)		14 (3.1)		0.470
Perpetrator of sexual violence (n=14)
Someone from another family		3 (33.3)		3 (60.0)		6 (42.9)		0.334
Female friend of the family		3 (33.3)		0 (0)		3 (21.4)
Wife/Partner		2 (22.2)		0 (0)		2 (14.3)		0.255
Stranger		1 (11.1)		0 (0)		1 (7.1)		0.439
Male friend of family		0 (0)		1 (20.0)		1 (7.1)		0.164
Religious Leader		1 (11.1)		0 (0)		1 (7.1)		0.439
Someone at school		0 (0)		1 (20.0)		1 (7.1)		0.164
Street gang		0 (0)		1 (20.0)		1 (7.1)		0.164
If forced sex, ever gang raped (n=14)		1 (11.1)		0 (0)		1 (7.1)		0.439
Any physical or sexual violence (n=442)		37 (15.3)		44 (22.0)		81 (18.3)		0.070*
Ever received healthcare for injury (n=18)		7 (70.0)		6 (75.0)		13 (72.2)		0.814
Ever reported violence to an authority figure (n=81)		0 (0)		1 (2.3)		1 (1.2)		0.356
Ever sex exchange (n=440)		19 (7.9)		20 (10.1)		39 (8.9)		0.426
Among those who exchanged sex (n=40)
someone benefited/made money/received goods		5 (26.3)		6 (28.6)		11 (27.5)		0.873
made to travel to another area		1 (20.0)		0 (0)		1 (11.1)		0.343
Any lifetime violence victimization (n=444)		75 (30.86)		74 (36.82)		149 (33.56)			0.186
*Marginally significant **Significant

Appendix Table 8. Perpetration of intimate and non-partner violence among stateless and national men in the Dominican Republic
	National (N = 260 )	Stateless (N = 210 )	Total
	n (%)	n (%)	n (%)	p-value
Intimate Partner Violence
Lifetime physical IPV perpetration (n=328)	16 (7.8)	3 (2.5)	19 (5.8)	0.047**
Physical IPV perpetration past year (n=328)	13 (6.3)	2 (1.6)	15 (4.6)	0.050**
Partner pregnant at time when participant physically hurt her (n=14)	1 (9.1)	0 (0)	1 (7.1)	0.588
Lifetime sexual IPV perpetration (n=328)	9 (4.4)	0 (0)	9 (2.7)	0.019**
Sexual IPV perpetration (n=328)	10 (4.9)	0 (0)	10 (3.0)	0.013**
Reason for forced sex (n=8)
I was sexually attracted to her	8 (100.0)	N/A	8 (100.0)
I wanted to have sex	6 (85.7)	N/A	6 (85.7)
It was my right	5 (62.5)	N/A	5 (62.5)
I was bored	4 (50.0)	N/A	4 (50.0)
I wanted to have fun	3 (37.5)	N/A	3 (37.5)
I was angry with her	2 (25.0)	N/A	2 (25.0)
I wanted to punish her	2 (25.0)	N/A	2 (25.0)
I had been drinking	2 (25.0)	N/A	2 (25.0)
Lifetime physical or sexual IPV perpetration (n=328)	20 (9.7)	3 (2.5)	23 (7.0)	0.013**
Partner ever been injured as a result of violence (n=25)	1 (4.8)	1 (25.0)	2 (8.0)	0.171
Partner ever received healthcare for injury (n=2)	1 (100.0)	1 (100.0)	2 (100.0)
Partner ever spend any nights in hospital due to injury (n=2)	1 (100.0)	0 (0)	1 (50.0)	0.157
Partner ever reported victimization to authority (n=23)	1 (5.0)	0 (0)	1 (4.3)	0.692
Ever threatened partner to prevent reporting (n=22)	2 (10.5)	0 (0)	2 (9.1)	0.556
Non-Partner Violence
Ever physically hurt a woman (n=439)	21 (8.6)	18 (9.3)	39 (8.9)	0.796
Physically hurt a woman past year (n=38)	4 (20.0)	4 (22.2)	8 (21.1)	0.867
Ever forced sex with another woman (n=414)	3 (1.3)	8 (4.4)	11 (2.7)	0.049**
Forced sex with another woman past year (n=11)	3 (100.0)	8 (100.0)	11 (100.0)	0.621
Reason for forced sex (n=11)
I was sexually attracted to her	3 (100.0)	7 (87.5)	10 (90.9)	0.521
I wanted to have sex	3 (100.0)	8 (100.0)	11 (100.0)
I wanted to have fun	3 (100.0)	3 (37.5)	6 (54.5)	0.064*
Wanted to show that I could do it	2 (66.7)	4 (50.0)	6 (54.5)	0.621
It is my right	2 (66.7)	3 (37.5)	5 (45.5)	0.387
I was angry with her	1 (33.3)	1 (12.5)	2 (18.2)	0.425
I wanted to punish her	1 (33.3)	2 (25.0)	3 (27.3)	0.782
I was bored	1 (33.3)	0 (0)	1 (9.1)	0.087*
I had been drinking alcohol	3 (100.0)	2 (25.0)	5 (45.5)	0.026**
Ever forced/pressured a woman into sex exchange (n=437)
no	198 (81.5)	164 (84.5)	362 (82.8)	0.447
yes, to have sex with me	44 (18.1)	28 (14.4)	72 (16.5)
yes, to have sex with someone else	1 (0.4)	2 (1.0)	3 (0.7)
If forced sex exchanged…
benefited financially (n=74)	19 (42.2)	10 (34.5)	29 (39.2)	0.506
made her travel to another area (n=75)	14 (31.1)	5 (16.7)	19 (25.3)	0.159
Lifetime non-partner violence perpetration (n=411)	60 (26.0)	43 (23.9)	103 (25.1)	0.628
Victim ever injured due to violence/abuse (n=100)	2 (3.4)	5 (12.2)	7 (7.0)	0.090*
Victim ever went to safe shelter (n=96)	12 (21.1)	9 (23.1)	21 (21.9)	0.814
Victim reported violence/abuse to someone (n=96)	1 (1.8)	4 (10.3)	5 (5.2)	0.066*
Ever threatened victim to prevent reporting (n=94)	1 (1.8)	2 (5.3)	3 (3.2)	0.347
*Marginally significant **Significant

Appendix Table 9. General health among male and female stateless and national populations in the Dominican Republic
	Females				Males
	National (N = 423)	Stateless (N = 403)	Total		National (N = )	Stateless (N = )	Total
	n (%)	n (%)	n (%)	p-value	n (%)	n (%)	n (%)	p-value
General Health Rating (women, n=782; men, n=450)
Excellent/good	197 (49.7)	207 (53.6)	404 (51.7)	0.492	145 (58.5)	135 (66.8)	280 (62.2)	0.185
Fair	164 (41.4)	144 (37.3)	308 (39.4)		83 (33.5)	55 (27.2)	138 (30.7)
Poor/very poor	35 (8.8)	35 (9.1)	70 (9.0)		20 (8.1)	12 (5.9)	32 (7.1)
Health problems during the past month (women, n=769; men, n=440)~	94 (24.0)	86 (22.8)	180 (23.4)	0.673	51 (20.9)	45 (23.0)	96 (21.8)	0.603
Consulted a doctor, other profession or traditional health worker (women, n=783; men, n=448)	149 (37.6)	161 (41.6)	310 (39.6)	0.255	63 (25.6)	35 (17.3)	98 (21.9)	0.035**
Doctor (women, n=310; men, n=98)	144 (96.6)	146 (90.7)	290 (93.5)	0.033**	58 (92.1)	33 (94.3)	91 (92.9)	0.682
Nurse (women, n=310; men, n=98)	7 (4.7)	15 (9.3)	22 (7.1)	0.114	3 (4.8)	0 (0)	3 (3.1)	0.190
Counselor (women, n=310; men, n=98)	1 (0.7)	4 (2.5)	5 (1.6)	0.205	1 (1.6)	0 (0)	1 (1.0)	0.454
Pharmacist (women, n=310; men, n=98)	7 (4.7)	9 (5.6)	16 (5.2)	0.723	4 (6.3)	3 (8.6)	7 (7.1)	0.682
Traditional Healer (women, n310; men, n=98)	1 (0.7)	1 (0.6)	2 (0.6)	0.956	2 (3.2)	0 (0)	2 (2.0)	0.287
Depression (women, n=706; men, n=413)~	72 (19.7)	86 (25.2)	158 (22.5)	0.080*	42 (18.5)	58 (31.2)	100 (24.2)	0.003**
Greatest challenges in accessing healthcare:
Problems getting money needed for advice/treatment (women, n=779; men, n=449)	235 (59.5)	261 (68.0)	496 (63.7)	0.014**	141 (56.9)	120 (59.7)	261 (58.1)	0.543
Problems with distance to health facility (women, n=779; men, n=448)	207 (52.4)	190 (49.5)	397 (51.0)	0.414	102 (41.3)	81 (40.3)	183 (40.8)	0.831
Problems not wanting to go alone (women, n=779; men, n=449)	105 (26.6)	121 (31.5)	226 (29.0)	0.130	74 (29.8)	61 (30.3)	135 (30.1)	0.907
Concern about deportation (women, n=779; men, n=448)	18 (4.6)	264 (68.8)	282 (36.2)		6 (2.4)	134 (66.7)	140 (31.2)
Frequency of alcohol consumption (women, n=588; men, n=352)
Never	178 (59.3)	193 (67.0)	371 (63.1)	0.051*	95 (47.3)	79 (52.3)	174 (49.4)	0.643
	69 (23.0)	44 (15.3)	113 (19.2)		57 (28.4)	39 (25.8)	96 (27.3)
Few times per week/daily	53 (17.7)	51 (17.7)	104 (17.7)		49 (24.4)	33 (21.9)	82 (23.3)
Frequency of partner's alcohol consumption (women, n=258; men, n=119)
Never	51 (37.5)	54 (44.3)	105 (40.7)	0.265	52 (62.7)	25 (69.4)	77 (64.7)	0.769
	52 (38.2)	35 (28.7)	87 33.7)		19 (22.9)	7 (19.4)	26 (21.8)
Few times per week/daily	33 (24.3)	33 (27.0)	66 (25.6)		12 (14.5)	4 (11.1)	16 (13.4)
~cutoff based on 75th percentile; *Marginally significant **Significant

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