SEXUAL VIOLENCE

INTRODUCTION
Sexual violence occurs throughout the world.
Although in most countries there has been little
research conducted on the problem, available data
suggest that in some countries nearly one in four
women may experience sexual violence by an
intimate partner (1–3), and up to one-third of
adolescent girls report their first sexual experience
as being forced (4–6).
 Def
Sexual violence is defined as: any sexual act,
attempt to obtain a sexual act, unwanted sexual
comments or advances, or acts to traffic, or
otherwise directed, against a person’s sexuality
using coercion, by any person regardless of their
relationship to the victim, in any setting, including
but not limited to home and work.
 Def
•Coercion can cover a whole spectrum of degrees of
force.
Apart from physical force, it may involve
psychological intimidation, blackmail or other
threats – for instance, the threat of physical harm, of
being dismissed from a job or of not obtaining a job
that is sought. It may also occur when the person
aggressed is unable to give consent – for instance,
while drunk, drugged, asleep or mentally incapable
of understanding the situation
 Sexual violence

Sexual violence includes rape, defined as

physically forced or otherwise coerced penetration
– even if slight – of the vulva or anus, using a penis,
other body parts or an object.

The attempt to do so is known as attempted rape.

Rape of a person by two or more perpetrators is

known as gang rape.

Sexual violence can include other forms of assault
involving a sexual organ, including coerced contact
 Forms and contexts of sexual violence
•A wide range of sexually violent acts can take place in
different circumstances and settings. These include, for
example:
—Rape within marriage or dating relationships;
—Rape by strangers;
—Systematic rape during armed conflict;
—Unwanted sexual advances or sexual harass- ment,
including demanding sex in return for favours;
—of people for the purpose of sexual exploitation.
Forms and contexts of sexual violence
—Sexual abuse of mentally or physically disabled people;
—Sexual abuse of children;
—Forced marriage or cohabitation, including the marriage
of children;
—Denial of the right to use contraception or to adopt other
measures to protect against sexually transmitted diseases;
—Forced abortion;
—violent acts against the sexual integrity of women,
including female genital mutilation and obligatory
inspections for virginity;
—
 trafficking for sexual
• There is no universally accepted definition of exploitation. The term

encompasses the organized movement of people, usually women, between

countries and within countries for sex work.

• Such trafficking also includes coercing a migrant into a sexual act as a

condition of allowing or arranging the migration.

• Sexual trafficking uses physical coercion, deception and bondage incurred

through forced debt.

•Trafficked women and children, for instance, are often promised work in the

domestic or service industry, but instead are usually taken to brothels where

their passports and other identification papers are confiscated. They may be

beaten or locked up and promised their freedom only after earning – through
Magnitude of the problem of sexual violence
 Sexual violence against men and boys
•Sexual violence against men and boys is a significant
problem. With the exception of childhood sexual abuse,
though, it is one that has largely been neglected in
research. Rape and other forms of sexual coercion
directed against men and boys take place in a variety of
settings, including in the home, the workplace, schools,
on the streets, in the military and during war, as well as
in prisons and police custody.
 Sexual violence against men and boys
•In prisons, forced sex can occur among inmates
to establish hierarchies of respect and discipline.
Sexual violence by prison officials, police and
soldiers is also widely reported in many countries.
Such violence may take the form of prisoners
being forced to have sex with others as a form of
‘‘entertainment’’, or to provide sex for the officers
or officials in command.
Consequences of sexual violence
• These include guilt, anger, anxiety, depression,
post-traumatic stress disorder, sexual
dysfunction, somatic complaints, sleep
disturbances, withdrawal from relation- ships
and attempted suicide. In addition to these
reactions, studies of adolescent males have also
found an association between suffering rape and
substance abuse, violent behaviour, stealing and
 Prevention and policy responses

In many countries the phenomenon is not adequately addressed in

legislation. In addition, male rape is frequently not treated as an equal

offence with rape of women.

• Many of the considerations relating to support for women who have been

raped including an understanding of the healing process, the most urgent

needs following an assault and the effectiveness of support services are also

relevant for men. Some countries have progressed in their response to male

sexual assault, providing special telephone hotlines, counselling,

support groups and other services for male victims. In many places,

though, such services are either not available or else are very limited ---

for instance, focusing primarily on women, with few, if any, counsellors on

 Prevention and policy responses
• In most countries, there is much to be done

before the issue of sexual violence against men

and boys can be properly acknowledged and

discussed, free of denial or shame. Such a

necessary development, though, will enable

more comprehensive prevention measures

and better support for the victims to be

 Sexual violence against sex workers

Whether trafficked or not, sex workers are at high

risk for both physical and sexual violence, particu-
larly where sex work is illegal. A survey of female sex
workers in Leeds, England, and Glasgow and
Edinburgh, Scotland, revealed that 30% had been
slapped, punched or kicked by a client while working,
13% had been beaten, 11% had been raped and 22%
had experienced an attempted rape
 Sexual violence in schools, health care set- tings, armed conflicts and refugee settings
Schools

•For many young women, the most common place where sexual
coercion and harassment are experienced is in school. In an
extreme case of violence in 1991, 71 teenage girls were raped
by their classmates and 19 others were killed at a boarding
school in Meru, Keny.
•Harassment of girls by boys is in all likelihood a global problem.
A report by Africa Rights found cases of school- teachers
attempting to gain sex, in return for good grades or for not
failing pupils.
 Health care settings

Sexual violence against patients in health

facilities has been reported in many places .
•sexual violence against female patients include

a)the involvement of medical staff in the

practice of clitoridectomy,
b)tforced gynecological examinations and
c)he threat of forced abortions, and
inspections of virginity .
Armed conflicts and refugee settings

Rape has been used as a strategy in many

conflicts. consequence of armed conflicts is
the ensuing economic and social
disruption which can force large numbers
of people into prostitution, an observation
that applies equally to the situation of
refugees, whether they are fleeing armed
conflicts or natural disasters such as
floods, earthquakes or powerful storms.
 ‘‘Customary’’ forms of sexual violence Child
marriage

•Marriage is often used to legitimize a

range of forms of sexual violence
against women. The custom of
marrying off young children,
particularly girls, is found in many
parts of the world.
Other customs leading to violence
Child marriage that result in sexual violence towards
women.
In the custom whereby a girl can be given to a family
as compensation for a death of a man caused by a
member of the girl’s family. On reaching puberty the
girl is expected to have sexual intercourse with the
brother or father of the deceased person, so as to
produce a son to replace the one who died.
•Another custom of wife inheritance – according to
which, when a married woman dies, her sister is
What are the risk factors for sexual violence?
There are factors increasing
the risk of someone being
coerced into sex, factors
increasing the risk of an
individual man forcing sex
on another person, and
factors within the social
environment include
 Factors increasing women’s vulnerability
Married or cohabiting with a partner.
1. Being young;
2. Consuming alcohol or drugs;
3. Having previously been raped or sexually abused;
4. Having many sexual partners;
5. Involvement in sex work;
6. Becoming more educated and economically
empowered, at least where sexual violence
perpetrated by an intimate partner is con-
cerned;
7. Poverty.
 Age

Young women are usually found

to be more at risk of rape than
older women
All victims of sexual assault are
aged 15 years or less
Certain forms of sexual violence,
for instance, are very closely
associated with a young age, in
particular violence taking place in
 Alcohol and drug consumption

Increased vulnerability to sexual

violence also stems from the use
of alcohol and other drugs.
Consuming alcohol or drugs
makes it more difficult for women
to protect themselves by
interpreting and effectively acting
on warning signs. Drinking alcohol
may also place women in settings
 Having previously been raped or sexually abused

There is some evidence linking experiences of

sexual abuse in childhood or adolescence with
patterns of victimization during adulthood. The
effects of early sexual abuse may also extend to
other forms of victimization and problems in
adulthood. Those who had experienced abuse
involving intercourse had more negative
outcomes than those suffering other types of
 Having many sexual partners

•Young women who have many sexual

partners are at increased risk of sexual
violence. It is not clear, though, if having
more sexual partners is a cause or
consequence of abuse, including childhood
sexual abuse.
 Educational level

Women are at increased risk of sexual

violence, as they are of physical violence by
an intimate partner, when they become
more educated and thus more empowered.
Women with no education are found to be
much less likely to experience sexual
violence than those with higher levels of
 Poverty

Poor women and girls may be more at risk of rape in the

course of their daily tasks than those who are better off,
for example when they walk home on their own from
work late at night, or work in the fields or collect
firewood alone. Children of poor women may have less
parental supervision when not in school, since their
mothers may be at work and unable to afford child care.
The children themselves may, in fact, be working and
thus vulnerable to sexual exploitation.
 Conti…Poverty

Poverty forces many women and girls into occupations

that carry a relatively high risk of sexual violence,
particularly sex work. It also creates enormous
pressures for them to find or maintain jobs, to pursue
trading activities and, if studying, to obtain good grades
– all of which render them vulnerable to sexual coercion
from those who can promise these things. Poorer
women are also more at risk of intimate partner
violence, of which sexual violence is often a
 Factors increasing men’s risk of committing rape

Among the factors increasing the risk of a

man committing rape are those related to
attitudes and beliefs, as well as behaviour
arising from situations and social conditions
that provide opportunities and support for
abuse.
 Alcohol and drug consumption

Alcohol has been shown to play a disinhibiting role in

certain types of sexual assault, as have some drugs,
notably cocaine. Alcohol has a psychopharmacological
effect of reducing inhibitions, clouding judgements and
impairing the ability to interpret cues . Thus men are
more likely to act violently when drunk because they do
not consider that they will be held accountable for their
behaviour.
 Psychological factors
There has been considerable research in
recent times on the role of cognitive
variables among the set of factors that
can lead to rape. Sexually violent men
have been shown to be more likely to
consider victims responsible for the rape
and are less knowledgeable about the
impact of rape on victims. Such men may
 Psychological factors
They have coercive sexual fantasies, generally
encouraged by access to pornography, and overall are
more hostile towards women than men who are not
sexually violent.
Sexual violence is also associated with a preference
for impersonal sexual relationships as opposed to
emotional bonding, with having many sexual partners
and with the inclination to assert personal interests at
the expense of others.
 Peer and family factors Gang rape

Some forms of sexual violence, such as gang

rape, are predominantly committed by young
men. Sexual aggression is often a defining
characteristic of manhood in the group and is
significantly related to the wish to be held in high
esteem. Sexually aggressive behaviour among
young men has been linked with gang
membership and having delinquent peers.
 Peer and family factors Gang rape

Gang rape is often viewed by the men involved,

and sometimes by others too, as legitimate, in
that it is seen to discourage or punish perceived
‘‘immoral’’ behaviour among woman – such as
wearing short skirts or frequenting bars
 Early childhood environments
There is evidence to suggest that sexual violence is also a learnt behaviour in
some men, particularly as regards child sexual abuse. Studies on sexually
abused boys have shown that around one in five continue in later life to
molest children themselves. Such experiences may lead to a pattern of
behaviour where the man regularly justifies being violent, denies doing
wrong, and has false and unhealthy notions about sexuality.

Childhood environments that are physically violent, emotionally

unsupportive and characterized by competition for scarce resources have
been associated with sexual violence. Sexually aggressive behaviour in
young men, for instance, has been linked to witnessing family violence, and
having emotionally distant and uncaring fathers. Men raised in families with
strongly patriarchal structures are also more likely to become violent, to rape
and use sexual coercion against women, as well as to abuse their intimate
 Family honour and sexual purity
•Another factor involving social relationships is a family response to sexual
violence that blames women without punishing men, concentrating instead
on restoring ‘‘lost’’ family honour. Such a response creates an environment in
which rape can occur with impunity.
•While families will often try to protect their women from rape and may
also put their daughters on contraception to prevent visible signs should it
occur (136), there is rarely much social pressure to control young men or
persuade them that coercing sex is wrong. Instead, in some countries, there
is frequently support for family members to do whatever is necessary –
including murder – to alleviate the ‘‘shame’’ associated with a rape or other
sexual transgression. In a review of all crimes of honour occurring in Jordan
in 1995 (137), researchers found that in over 60% of the cases, the victim
died from multiple gunshot wounds – mostly at the hands of a brother. In
cases where the victim was a single pregnant female, the offender was
•Community factors
•Poverty
•Poverty is linked to both the perpetration of sexual violence and the risk of
being a victim of it. Several authors have argued that the relationship
between poverty and perpetration of sexual violence is mediated through
forms of crisis of masculine identity (95, 112, 138–140). Bourgois, writing
about life in East Harlem, New York, United States (138), described how young
men felt pressured by models of ‘‘successful’’ masculinity and family structure
passed down from their parents’ and grandparents’ generations, together with
modern- day ideals of manhood that also place an emphasis on material
consumption. Trapped in their slums, with little or no available employment,
they are unlikely to attain either of these models or expectations of
masculine ‘‘success’’. In these circumstances, ideals of masculinity are reshaped
to emphasize misogyny, substance abuse and participation in crime (138) –
and often also xenophobia and racism. Gang rape and sexual conquest are
normalized, as men turn their aggression against women they can no longer
control patriarchally or support economically.
•Physical and social environment
•While fear of rape is typically associated with being outside the
home (141, 142), the great majority of sexual violence actually
occurs in the home of the victim or the abuser. Nonetheless,
abduction by a stranger is quite often the prelude to a rape and the
opportunities for such an abduction are influenced by the physical
environment.
•The social environment within a community is, however, usually
more important than the physical surrounding. How deeply
entrenched in a com- munity beliefs in male superiority and male
entitlement to sex are will greatly affect the likelihood of sexual
violence taking place, as will the general tolerance in the community
of sexual assault and the strength of sanctions, if any, against
perpetrators (116, 143). For instance, in some places, rape can even
occur in public, with passers- by refusing to intervene (133).
Complaints of rape may also be treated leniently by the police,
particularly if the assault is committed during a date or by the
•Societal factors
•Factors operating at a societal level that
influence sexual violence include laws and
national policies relating to gender equality
in general and to sexual violence more
specifically, as well as norms relating to the
use of violence. While the various factors
operate largely at local level, within families,
schools, workplaces and communities, there
are also influences from the laws and norms
working at national and even international
 Laws and policies
There are considerable variations between coun- tries in their approach to
sexual violence. Some countries have far-reaching legislation and legal
procedures, with a broad definition of rape that includes marital rape, and
with heavy penalties for those convicted and a strong response in support-
ing victims. Commitment to preventing or con- trolling sexual violence is
also reflected in an emphasis on police training and an appropriate
allocation of police resources to the problem, in the priority given to
investigating cases of sexual assault, and in the resources made available to
support victims and provide medico-legal services. At the other end of the
scale, there are countries with much weaker approaches to the issue –
where conviction of an alleged perpetrator on the evidence of the women
alone is not allowed, where certain forms or settings of sexual violence are
specifically excluded from the legal definition, and where rape victims are
strongly deterred from bringing the matter to court through the fear of
being punished for filing an ‘‘unproven’’ rape suit.
•Social norms
•Sexual violence committed by men is to a large extent rooted in ideologies of male sexual entitlement. These belief
systems grant women extremely few legitimate options to refuse sexual advances (139, 144, 145). Many men thus simply
exclude the possibility that their sexual advances towards a woman might be rejected or that a woman has the right to
make an autonomous decision about participating in sex. In many cultures women, as well as men, regard marriage as
entailing the obligation on women to be sexually available virtually without limit (34, 146), though sex may be culturally
proscribed at certain times, such as after childbirth or during menstruation (147).
•Societal norms around the use of violence as a means to achieve objectives have been strongly associated with the
prevalence of rape. In societies where the ideology of male superiority is strong – emphasizing dominance, physical
strength and male honour – rape is more common (148). Countries with a culture of violence, or where violent conflict is
taking place, experience an increase in almost all forms of violence, including sexual violence (148–151).
•Global trends and economic factors
•Many of the factors operating at a national level have an international dimension. Global trends, for instance towards free
trade, have been accompanied by an increase in the movement around the world of women and girls for labour, including
for sex work (152). Economic structural adjustment programmes, drawn up by international agencies, have accentuated
poverty and unemployment in a number of coun- tries, thereby increasing the likelihood of sexual trafficking and sexual
violence (153) – something particularly noted in Central America, the Caribbean
•(114) and parts of Africa (113).
The consequences of sexual violence

•Physical force is not necessarily used

in rape, and physical injuries are not
always a consequence. Deaths
associated with rape are known to
occur, though the prevalence of
fatalities varies consider-ably across
the world. Among the more common
consequences of sexual violence are
those related to reproductive, mental
Pregnancy and gynaecological complications

Pregnancy may result from rape, though the rate varies between
settings and depends particularly on the extent to which non-barrier
contraceptives are being used.
•In many countries, women who have been raped are forced to bear
the child or else put their lives at risk with back-street abortions.
•Experience of coerced sex at an early age reduces a woman’s ability
to see her sexuality as something over which she has control. As a
result, it is less likely that an adolescent girl who has been forced into
sex will use condoms or other forms of contraception, increasing the
likelihood of her becoming pregnant A study of factors associated
with teenage pregnancy in Cape Town, South Africa, found that
forced sexual initiation was the third most strongly related factor,

after frequency of intercourse and use of modern contraceptives (4).

•Pregnancy and gynaecological complications
•Gynaecological complications have been
con- sistently found to be related to forced
sex. These include vaginal bleeding or
infection, fibroids, decreased sexual desire,
genital irritation, pain during intercourse,
chronic pelvic pain and urinary tract
infections. Women who experience both
physical and sexual abuse from intimate
partners are at higher risk of health
problems generally than those
experiencing physical violence alone.
•Sexually transmitted diseases
•HIV infection and other sexually transmitted diseases
are recognized consequences of rape. Research on
women in shelters has shown that women who
experience both sexual and physical abuse from intimate
partners are signifi- cantly more likely to have had
sexually transmitted diseases. For women who have
been trafficked into sex work, the risks of HIV and other
sexually transmitted diseases are likely to be particularly
high. The links between HIV and sexual violence, and the
relevant prevention strategies
Mental health
Sexual violence has been associated with a number of mental health and behavioural
problems in adolescence and adulthood. In one population-based study, the
prevalence of symptoms or signs suggestive of a psychiatric disorder was 33% in
women with a history of sexual abuse as adults, 15% in women with a history of
physical violence by an intimate partner and 6% in non-abused women. Sexual
violence by an intimate partner aggravates the effects of physical violence on mental
health.
Abused women reporting experiences of forced sex are at significantly greater risk of
depression and post-traumatic stress disorder than non-abused women. Post-
traumatic stress disorder after rape is more likely if there is injury during the rape, or
a history of depression or alcohol abuse. A study of adolescents in France also found a
relationship between having been raped and current sleep difficulties, depres- sive
symptoms, somatic complaints, tobacco con- sumption and behavioural problems
(such as aggressive behaviour, theft and truancy) . In the absence of trauma
counselling, negative psychological effects have been known to persist for at least a
year following a rape, while physical health problems and symptoms tend to decrease
over such a period. Even with counselling, up to 50% of women retain symptoms of
•Suicidal behaviour
•Women who experience sexual assault in childhood or adulthood are more likely to attempt or commit suicide than other
women (21, 168–173). The association remains, even after controlling for sex, age, education, symptoms of post-traumatic
stress disorder and the presence of psychiatric disorders (168, 174). The experience of being raped or sexually assaulted
can lead to suicidal behaviour as early as adolescence. In Ethiopia, 6% of raped schoolgirls reported having attempted
suicide (154). A study of adolescents in Brazil found prior sexual abuse to be a leading factor predicting several health risk
behaviours, including suicidal thoughts and attempts (161).
•Experiences of severe sexual harassment can also result in emotional disturbances and suicidal beha- viour. A study of
female adolescents in Canada found that 15% of those experiencing frequent, unwanted sexual contact had exhibited
suicidal behaviour in the previous 6 months, compared with 2% of those who had not had such harassment (72).
•Social ostracization
•In many cultural settings it is held that men are unable to control their sexual urges and that women are responsible for
provoking sexual desire in men (144). How families and communities react to acts of rape in such settings is governed by
prevailing ideas about sexuality and the status of women.
•In some societies, the cultural ‘solution’ to rape is that the woman should marry the rapist, thereby preserving the integrity
of the woman and her family by legitimizing the union (175). Such a ‘solution’ is reflected in the laws of some countries,
which allow a man who commits rape to be excused his crime if he marries the victim (100). Apart from marriage,
families may put pressure on the woman not to report or pursue a case or else to concentrate on
•Sexual violence and HIV/AIDS
•Violent or forced sex can increase the risk of transmitting HIV. In forced vaginal penetration, abrasions and cuts commonly occur, thus facilitating the entry of the
virus --- when it is present --- through the vaginal mucosa. Adolescent girls are particularly susceptible to HIV infection through forced sex, and even through unforced
sex, because their vaginal mucous membrane has not yet acquired the cellular density providing an effective barrier that develops in the later teenage years. Those
who suffer anal rape --- boys and men, as well as girls and women --- are also considerably more susceptible to HIV than would be the case if the sex were not forced,
since anal tissues can be easily damaged, again allowing the virus an easier entry into the body.
•Being a victim of sexual violence and being susceptible to HIV share a number of risk behaviours. Forced sex in childhood or adolescence, for instance, increases
the likelihood of engaging in unprotected sex, having multiple partners, participating in sex work, and substance abuse. People who experience forced sex in
intimate relationships often find it difficult to negotiate condom use
•--- either because using a condom could be interpreted as mistrust of their partner or as an admission of promiscuity, or else because they fear experiencing violence
from their partner. Sexual coercion among adolescents and adults is also associated with low self-esteem and depression --- factors that are associated with many of
the risk behaviours for HIV infection.
• Being infected with HIV or having an HIV-positive family member can also increase the risk of
•suffering sexual violence, particularly for women. Because of the stigma attached to HIV and AIDS in many countries, an infected woman may be evicted from her home.
In addition, an AIDS-related illness or death in a poor household may make the economic situation desperate. Women may be forced into sex work and consequently be
at increased risk for both HIV/AIDS and sexual violence. Children orphaned by AIDS, impoverished and withno one to care forthem, may be forced to live on the streets,
at considerable risk of sexual abuse.
•Among the various ways of reducing the incidence of both sexual violence and HIV infection, education is perhaps the foremost. For young people, above all,
there must be comprehensive interventions in schools and other educational institutes, youth groups and workplaces. School curricula should cover relevant aspects
of sexual and reproductive health, relationships and violence. They should also teach life skills, including how to avoid risky or threatening situations --- related to
such things as violence, sex or drugs --- and how to negotiate safe sexual behaviour.
•For the adult population in general there should be full and accessible information on sexual health and the consequences of specific sexual practices, as well as
interventions to change harmful patterns of behaviour and social norms that hinder communication on sexual matters.
•It is important that health care workers and other service providers receive integrated training on gender and reproductive health, including gender-based
violence and sexually transmitted diseases such as HIV infection.
•For rape victims, there should be screening and referral for HIV infection. Also, the use of postexposure prophylaxis for HIV --- given soon after the assault,
together with counselling --- may be considered. Similarly, women with HIV should be screened for a possible history of sexual violence. Voluntary counselling
programmes for HIV should consider incorporating violence prevention strategies.
 What can be done to prevent sexual violence?

•The number of initiatives addressing sexual

violence is limited and few have been
evaluated. Most interventions have been
developed and implemented in
industrialized countries. How relevant they
may be in other settings is not well known.
The interventions that have been developed
can be categorized as follows.
•Individual approaches
•Psychological care and support
•Counselling, therapy and support group initiatives have been found
to be helpful following sexual assaults, especially where there may
be complicat- ing factors related to the violence itself or the process
of recovery. There is some evidence that a brief cognitive-
behavioural programme adminis- tered shortly after assault can
hasten the rate of improvement of psychological damage arising
from trauma (177, 178). As already mentioned, victims of sexual
violence sometimes blame themselves for the incident, and
addressing this in psychological therapy has also been shown to be
important for recovery (179). Short-term counsel- ling and
treatment programmes after acts of sexual violence, though, require
considerable further evaluation.
•Formal psychological support for those experi- encing sexual
violence has been provided largely by the nongovernmental sector,
particularly rape crisis centres and various women’s organizations.
In- evitably, the number of victims of sexual violence with access to
these services is small. One solution to extend access is through
establishing telephone helplines, ideally ones that are free of
•Programmes for perpetrators
•The few programmes targeting perpetrators of sexual
violence have generally been aimed at men convicted of
assault. They are found mainly in industrialized countries
and have only recently begun to be evaluated (see
Chapter 4 for a discussion of such programmes). A
common response of men who commit sexual violence is
to deny both that they are responsible and that what
they are doing is violent (146, 181). To be effective,
programmes working with perpetrators need to make
them admit responsibility and to be publicly seen as
responsible for their actions (182). One way of achieving
this is for pro- grammes that target male perpetrators of
sexual violence to collaborate with support services for
victims as well as with campaigns against sexual
violence.
•Life-skills and other educational programmes
•In recent years, several programmes for sexual and reproductive health
promotion, particularly those promoting HIV prevention, have begun to
intro- duce gender issues and to address the problem of sexual and physical
violence against women. Two notable examples – developed for Africa but
used in many parts of the developing world – are ‘‘Stepping Stones’’ and ‘‘Men
As Partners’’ (183, 184). These programmes have been designed for use in
peer groups of men and women and are delivered over several workshop
sessions using participatory learning approaches. Their comprehensive ap-
proach helps men, who might otherwise be reluctant to attend programmes
solely concerned with violence against women, participate and discuss a
range of issues concerning violence. Furthermore, even if the men are
perpetrators of sexual violence, the programmes are careful to avoid
labelling them as such.
•A review of the effect of the Stepping Stones programme in Africa and Asia
found that the workshops helped the men participating take greater
responsibility for their actions, relate better to others, have greater respect
for women and communicate more effectively. As a result of the
programme, reductions in violence against women have been reported in
communities in Cambodia, the Gambia, South Africa, Uganda and the United
Republic of Tanzania. The evaluations to date, though, have generally used
qualitative methods and further research is needed to adequately test the
effectiveness of this programme (185).
•Developmental approaches
•Research has stressed the importance of encoura- ging nurturing,
with better and more gender- balanced parenting, to prevent sexual
violence (124, 125). At the same time, Schwartz (186) has
developed a prevention model that adopts a developmental
approach, with interventions before birth, during childhood and in
adolescence and young adulthood. In this model, the prenatal
element would include discussions of parenting skills, the
stereotyping of gender roles, stress, conflict and violence. In the
early years of child- hood, health providers would pursue these
issues and introduce child sexual abuse and exposure to violence in
the media to the list of discussion topics, as well as promoting the
use of non-sexist educational materials. In later childhood, health
promotion would include modelling behaviours and attitudes that
avoid stereotyping, encouraging children to distinguish between
‘‘good’’ and ‘‘bad’’ touching, and enhancing their ability and con- fidence
to take control over their own bodies. This intervention would allow
room for talking about sexual aggression. During adolescence and
young adulthood, discussions would cover myths about rape, how
to set boundaries for sexual activity, and breaking the links between
•Health care responses
•Medico-legal services
•In many countries, where sexual violence is reported the health sector has the duty to collect
medical and legal evidence to corroborate the accounts of the victims or to help in identifying
the perpetrator. Research in Canada suggests that medico-legal documentation can increase the
chance of a perpetrator being arrested, charged or convicted (187, 188). For instance, one study
found that documented physical injury, particularly of the moderate to severe type, was
associated withcharges being filed – irrespective of the patient’s income level or whether the
patient knew the assailant, either as an acquaintance or an intimate partner (188). However, a
study of women attending a hospital in Nairobi, Kenya, following a rape, has highlighted the fact
that in many countries rape victims are not examined by a gynaecologist or an experienced
police examiner and that no standard protocols or guidelines exist on this matter (189).
•The use of standard protocols and guidelines can significantly improve the quality of treatment
and psychological support of victims, as well as the evidence that is collected (190).
Comprehensive protocols and guidelines for female victims of assault should include:
—recording a full description of the incident, listing all the assembled evidence;
—listing the gynaecological and contraceptive history of the victim;
—documenting in a standard way the results of a full physical examination;
—assessment of the risk of pregnancy;
—testing for and treating sexually transmitted diseases, including, where appropriate, test- ing
for HIV;
—providing emergency contraception and, where legal, counselling on abortion;
—providing psychological support and referral.
•In some countries, the protocol forms part of the procedure of a ‘‘sexual assault evidence kit’’ that
includes instructions and containers for collecting evidence, appropriate legal forms and
documents for recording histories (191). Examinations of rape victims are by their nature
extremely stressful. The use of a video to explain the procedure before an examination has been
shown significantly to reduce the stress involved (192).
•Training for health care professionals
•Issues concerning sexual violence need to be addressed in the training of all health
service staff, including psychiatrists and counsellors, in basic training as well as in
specialized postgraduate courses. Such training should, in the first place, give health
care workers greater knowledge and aware- ness of sexual violence and make them
more able to detect and handle cases of abuse in a sensitive but effective way. It
should also help reduce instances of sexual abuse within the health sector, something
that can be a significant, though generally unac- knowledged, problem.
•In the Philippines, the Task Force on Social Science and Reproductive Health, a body
that includes doctors, nurses and social scientists and is supported by the
Department of Health, has produced training modules for nursing and medical
students on gender-based violence. The aims of this programme are (193):
. To understand the roots of violence in the context of culture, gender and other
social aspects.
. To identify situations, within families or homes that are at a high risk for violence,

where it would be appropriate to undertake:

—primary interventions, in particular in collaboration with other professionals;
—secondary interventions, including identi- fying victims of violence,
understanding basic legal procedures and how to present evidence, referring
and following up patients, and helping victims reintegrate into society.
•These training modules are built into the curricula for both nursing and medical
students. For the nursing curriculum, the eleven modules are spread over the 4 years
of formal instruction, and for medical students over their final 3 years of practical
training.
•Prophylaxis for HIV infection
•The possibility of transmission of HIV during rape is a major cause for concern, especially in countries with a high
prevalence of HIV infection (194). The use of antiretroviral drugs following exposure to HIV is known in certain contexts to
be reasonably effective. For instance, the administration of the antiretroviral drug zidovudine (AZT) to health workers
following an occupational needle-stick exposure (puncturing the skin with a contaminated needle) has been shown to
reduce the subsequent risk of developing HIV infection by 81% (195).
•The average risk of HIV infection from a single act of unprotected vaginal sex with an infected partner is relatively low
(approximately 1–2 per 1000, from male to female, and around 0.5–1 per 1000 from female to male). This risk, in fact, is of
a similar order to that from a needle-stick injury (around 3 per 1000), for which postexposure prophylaxis is now routine
treatment (196). The average risk of HIV infection from unprotected anal sex is considerably higher, though, at around 5–30
per 1000. However, during rape, because of the force used, it is very much more likely that there will be macroscopic or
microscopic tears to the vaginal mucosa, something that will greatly increase the probability of HIV transmission (194).
•There is no information about the feasibility or cost-effectiveness in resource-poor settings of routinely offering rape
victims prophylaxis for HIV. Testing for HIV infection after rape is difficult in any case. In the immediate aftermath of an
incident, many women are not in a position fully to comprehend complicated information about HIV testing and risks.
Ensuring proper follow-up is also difficult as many victims will not attend further scheduled visits for reasons that probably
relate to their psychological coping following the assault. The side-effects of antiretroviral treatment may also be
significant, causing people to drop out from a course (195, 197), though those who perceive themselves as being at high
risk are much more likely to be compliant (197).
•Despite the lack of knowledge about the effec- tiveness of HIV prophylaxis following rape, many organizations have
recommended its use. For instance, medical aid schemes in high-income countries are increasingly including it in their
care packages. Research is urgently needed in middle- income and low-income countries on the effective- ness of
antiretroviral treatment after rape and how it could be included in patient care.
•Centres providing comprehensive care to victims of sexual assault
•Because of the shortage of doctors in many countries, specially trained nurses have been used in some places to assist
victims of sexual assault (187). In Canada, nurses, known as ‘‘sexual assault nurse examiners’’, are trained to provide
comprehensive care to victims of sexual violence. These nurses refer clients to a physician when medical intervention is
needed. In the province of Ontario, Canada, the first sexual assault care centre opened in 1984 and since then 26 others
have been established. These centres provide or coordinate a wide range of services, including emergency medical care
and medical follow-up, counselling, collecting forensic evidence of assault, legal sup- port, and community consultation
and education (198). Centres that provide a range of services for victims of sexual assault, often located in places such as a
hospital or police station, are being developed in many countries (see Box 6.3). Specialized centres such as these have
the advantage of providing appropriately trained and experienced staff. In some places, on the other hand, integrated
centres exist providing services for victims of different forms of violence.
•Community-based efforts
•Prevention campaigns
•Attempts to change public attitudes towards sexual violence using the media have included advertising on hoardings
(‘‘billboards’’) and in public trans- port, and on radio and television. Television has been used effectively in South Africa and
Zimbabwe. The South African prime-time television series Soul City is described in Box 9.1 of Chapter 9. In Zimbabwe, the
nongovernmental organization Musasa has produced awareness-raising initiatives using theatre, public meetings and
debates, as well as a television series where survivors of violence described their experiences (199).
•Other initiatives, besides media campaigns, have been used in many countries. The Sisterhood Is
•Global Institute in Montreal, Canada, for instance, has developed a manual suitable for Muslim
•communities aimed at raising awareness and stimulating debate on issues related to gender equality and violence
against women and girls (200). The manual has been pilot-tested in Egypt, Jordan and Lebanon and – in an adaptation for
non- Muslim settings – used in Zimbabwe.
•A United Nations interagency initiative to combat gender-based violence is being conducted in 16 countries of Latin
America and the Caribbean (201). The campaign is designed:
— to raise awareness about the human, social and economic costs of violence against women and girls;
— to build capacity at the governmental level to develop and implement legislation against gender violence;
— to strengthen networks of public and private organizations and carry out programmes to prevent violence against
women and girls.
•Community activism by men
•An important element in preventing sexual and physical violence against women is a collective initiative by men. Men’s
groups against domestic violence and rape can be found in Australia, Africa, Latin America and the Caribbean and Asia, and
in many parts of North America and Europe. The underlying starting point for this type of initiative is that men as
individuals should take measures to reduce their use of violence (202). Typical activities include group discussions,
education campaigns and rallies, work with violent men, and workshops in schools, prisons and workplaces. Actions are
frequently conducted in collaboration with wom- en’s organizations that are involved in preventing violence and providing
services to abused women.
•In the United States alone, there are over 100 such men’s groups, many of which focus specifi- cally on sexual violence.
The ‘Men Can Stop Rape’ group in Washington, DC, for instance, seeks to promote alternative forms of masculinity that foster
non-violence and gender equality. Its recent activities have included conducting presentations in secondary schools,
designing posters, producing a handbook for teachers and publishing a youth magazine (202).
•School-based programmes
•Action in schools is vital for reducing sexual and other forms of violence. In many countries a sexual relation between a
teacher and a pupil is not a serious disciplinary offence and policies on sexual harass- ment in schools either do not exist or
are not implemented. In recent years, though, some coun- tries have introduced laws prohibiting sexual rela- tions
between teachers and pupils. Such measures are important in helping eradicate sexual harassment in schools. At the same
time, a wider range of actions is also needed, including changes to teacher training and recruitment and reforms of
curricula, so as to transform gender relations in schools.
•Legal and policy responses Reporting and handling cases of sexual violence Many countries have a system to encourage people to
report incidents of sexual violence to the police and to improve the speed and sensitivity of the processing of cases by the
courts. The specific
•mechanisms include dedicated domestic violence units, sexual crime units, gender training for the police and court
officials, women-only police stations and courts for rape offences. Some of these mechanisms are discussed in Chapter 4.
•Problems are sometimes created by the unwill- ingness of medical experts to attend court. The reason for this is
frequently that the court schedules are unpredictable, with cases often postponed at short notice and long waits for
witnesses who are to give short testimonies. In South Africa, to counter this, the Directorate of Public Prosecutions has
been training magistrates to interrupt proceedings in sexual violence cases when the medical expert arrives so that
testimonies can be taken and witnesses cross-examined without delay.
•Legal reform
•Legal interventions that have been adopted in many places have included:
— broadening the definition of rape;
— reforming the rules on sentencing and on admissibility of evidence;
— removing the requirements for victims’ accounts to be corroborated.
 •In 1983, the Canadian laws on rape were reformed, in particular removing the requirement that accounts of rape be
corroborated. Nonetheless, an evaluation has found that the prosecutors have tended to ignore this easing of the
requirement for corroboration and that few cases go to court without forensic evidence (203).
•Several countries in Asia, including the Philip- pines, have recently enacted legislation radically redefining rape and
mandating state assistance to victims. The result has been a substantial increase in the number of reported cases.
Campaigns to inform the general public of their legal rights must also take place if the reformed legislation is to be fully
effective.
•To ensure that irrelevant information was not admitted in court, the International Criminal Tribu- nal for the Former
Yugoslavia drew up certain rules, which could serve as a useful model for effective laws and procedures elsewhere. Rule 96 of
the Tribunal specifies that in cases of sexual assault there is no need for corroboration of the victim’s testimony and that the
earlier sexual history of the victim is not to be disclosed as evidence. The rule also deals with the possible claim by the
accused that there was consent to the act, stating that consent as a defence shall not be allowed if the victim has been
subjected to or threatened with physical or psychological violence, or detention, or has had reason to fear such violence or
detention. Furthermore, consent shall not be allowed under the rule if the victim had good reason to believe that if he or she
did not submit, another person might be so subjected, threatened or put in fear. Even where the claim of consent is allowed
to proceed, the accused has to satisfy the court that the evidence for such a claim is relevant and credible, before this
evidence can be presented.
•In many countries, judges hand out particularly short sentences for sexual violence (204, 205). One way of overcoming
this has been to introduce minimum sentencing for convictions for rape, unless there are extenuating circumstances.
•International treaties
•International treaties are important as they set standards for national legislation and provide a lever for local groups to
campaign for legal reforms.
•Among the relevant treaties that impinge on sexual violence and its prevention include:
— the Convention on the Elimination of All Forms of Discrimination Against Women (1979);
— the Convention on the Rights of the Child (1989) and its Optional Protocol on the Sale of Children, Child Prostitution
and Child Pornography (2000);
— the Convention Against Transnational Orga- nized Crime (2000) and its supplemental Protocol to Prevent, Suppress
and Punish Trafficking in Persons, Especially Women and Children (2000);
— the Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (1984).
•A number of other international agreements set norms and limits of behaviour, including behaviour in conflicts, that
necessitate provisions in national legislation. The Rome Statute of the International Criminal Court (1998), for instance,
covers a broad spectrum of gender-specific crimes, including rape, sexual slavery, enforced prostitution, forced preg-
nancy and forced sterilization. It also includes certain forms of sexual violence that constitute a breach or serious violation
of the 1949 Geneva Conventions, as well as other forms of sexual violence that are comparable in gravity to crimes
against humanity. The inclusion of gender crimes in the definitions of the statute is an important historical development
in international law (206).
•Actions to prevent other forms of sexual violence
•Sexual trafficking
•Initiatives to prevent the trafficking of people for sexual purposes have generally aimed to:
— create economic programmes in certain countries for women at risk of being trafficked;
— provide information and raise awareness so that women at potential risk are aware of the danger of trafficking.
•In addition, several government programmes and nongovernmental organizations are develop-
•ing services for the victims of trafficking (207). In Cyprus, the Aliens and Immigration Department approaches women
entering the country to work in the entertainment or domestic service sectors. The Department advises the women on
their rights and obligations and on available forms of protection against abuse, exploitation and procurement into
prostitution. In the European Union and the United States, victims of trafficking willing to cooperate with the judicial
system in prosecuting traffickers can receive temporary residence permits. In Belgium and Italy, shelters have been set
up for victims of trafficking. In Mumbai, India, an anti- trafficking centre has been set up to facilitate the arrest and
prosecution of offenders, and to provide assistance and information to trafficked women.
•Female genital mutilation
•Addressing cultural practices that are sexually violent requires an understanding of their social, cultural and economic
context. Khafagi has argued
•(208) that such practices – which include female
•genital mutilation – should be understood from the perspective of those who perform them and that
•such knowledge can be used to design culturally appropriate interventions to prevent the practices.
•In the Kapchorwa district of Uganda, the REACH programme has been successful in reducing rates of
•female genital mutilation. The programme, led by the Sabiny Elders’ Association, sought to enlist the
•support of elders in the community in detaching the practice of female genital mutilation from the cultural values it
purported to serve. In its place,
•alternative activities were substituted, that upheld the original cultural tradition (209). Box 6.4
•describes another programme, in Egypt, to prevent female genital mutilation.
 .

•Child marriage
•Child marriage has a cultural basis and is often legal, so the task of achieving change is considerable. Simply outlawing
early marriages will not, of itself, usually be sufficient to prevent the practice. In many countries the process of registering
births is so irregular that age at first marriage may not be known (100). Approaches that address poverty –an important
factor underlying many such mar- riages – and those that stress educational goals, the health consequences of early
childbirth and the rights of children are more likely to achieve results
•Rape during armed conflicts
•The issue of sexual violence in armed conflicts has recently again been brought to the fore by organizations such as the
Association of the Widows of the Genocide (AVEGA) and the Forum for African Women Educationalists. The former has
supported war widows and rape victims in Rwanda and the latter has provided medical care and counselling to victims in
Sierra Leone (210).
•In 1995, the Office of the United Nations High Commissioner for Refugees released guidelines on the prevention of and
response to sexual violence among refugee populations (211). These guide- lines include provisions for:
— the design and planning of camps, to reduce susceptibility to violence;
— documenting cases;
— educating and training staff to identify, respond to and prevent sexual violence;
— medical care and other support services, including procedures to avoid further trau- ma to victims.
•The guidelines also cover public awareness campaigns, educational activities and the setting up of women’s groups to
report and respond to violence. Based on work in Guinea (212) and the United
•Republic of Tanzania (96), the International Res- cue Committee has developed a programme to
•combat sexual violence in refugee communities. It includes the use of participatory methods to assess the prevalence of
sexual and gender-based violence
•in refugee populations, the training and deploy- ment of community workers to identify cases and
•set up appropriate prevention systems, and meas- ures for community leaders and other officials to
•prosecute perpetrators. The programme has been used in many places against sexual and gender-
•based violence, including Bosnia and Herzegovina, the Democratic Republic of the Congo, East Timor,
•Kenya, Sierra Leone and The former Yugoslav Republic of Macedonia.
•Putting an end t o female genital m u t i l a t i o n : t h e case o f Egypt
•Female genital mutilation is extremely common among married women in Egypt. The 1995 Demographic and Health Survey found that the age group in which the
practice was most frequently used was 9--13 years. Nearly half of those performing female circumcisions were doctors and 32% were midwives or nurses. Sociological
research has found that the main reasons given for practising female circumcision were to uphold tradition, to control the sexual desires of women, to make women
‘‘clean and pure’’ and, most importantly, to make them eligible for marriage.
•Largely stemming from the public awareness created by the International Conference on Population and Development held in Cairo in 1994, a movement against
female genital mutilation, spanning a broad range of sectors, was built up.
•In terms of the response from health officials and professionals, a joint statement in 1998 from the Egyptian Society of Gynaecology and Obstetrics and the
Egyptian Fertility Care Society declared that female genital mutilation was both useless and harmful, and constituted unethical practice for a doctor. The Egyptian
Minister of Health and Population also issued a decree banning anyone from performing female genital mutilation.
•Religious leaders in the Muslim world also voiced their opposition to the practice. The Grand Mufti put out a statement pointing out that there was no mention
of female circumcision in the Koran and that sayings (hadith) attributed to the Prophet Muhammad on the subject were not definitively confirmed by evidence.
Furthermore, in 1998, the Conference on Population and Reproductive Health in the Muslim World adopted a recommendation calling on Islamic countries to move
to end all forms of violence against women, with a reminder that under Islamic law (sharia) no obligation existed to circumcise girls.
•Egyptian nongovernmental organizations have mobilized on the issue, disseminating information on female genital mutilation and including it in community
development, health awareness and other programmes. A task force of some 60 nongovernmental organizations has been set up to combat the practice.
•Several nongovernmental organizations --- often working through male community leaders --- are now actively involving men, educating them about the dangers
of female genital mutilation. In this process, young men are being encouraged to declare that they will marry uncircumcised women.
•In Upper Egypt there is a programme aimed at various social groups --- including community leaders, religious leaders and professional people --- to train them as
campaigners against female genital mutilation. Counselling is also offered to families who are considering not circumcising their daughters and discussions are
conducted with health workers to dissuade them from performing the practice.
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