In 2002, the World Health Organization (WHO) released the World Report on Violence and Health. This report, the first of its kind, uses a public health approach to examine global youth violence, child abuse and neglect, violence by intimate partners, abuse of the elderly, sexual violence, self-directed violence, and collective violence. It draws from the information, findings, and insight of over 160 experts from approximately 70 countries and from published literature on violence. The Report views violence through an ecological lens and discusses biological, social, cultural, economic, and political factors that influence its occurrence and prevalence.
Developed from the World Report on Violence and Health, this booklet offers a synopsis of the Report’s findings related to global sexual violence. The intent of this booklet is to promote a better understanding of global sexual violence, spark new research, and encourage collaborative efforts to prevent sexual violence.
“[World Report on Violence and Health] makes a major contribution to our understanding of violence and its impact on societies. It illuminates the different faces of violence, from the ‘invisible’ suffering of society’s most vulnerable individuals to the all-too visible tragedy of societies in conflict…And in doing so, it reminds us that safety and security don’t just happen: they are the result of collective consensus and public investment.”
Nelson Mandela
(Krug, et al., 2002)
Sexual violence affects millions of people worldwide and represents a serious global public health problem. Risk factors, rooted in social injustices and inequities transcend geographical boundaries and individual differences. The costs of sexual violence are devastating and jeopardize the health of individuals and entire societies.
The National Sexual Violence Resource Center (NSVRC) recognizes that despite its prevalence and costs, sexual violence is not inevitable. A major goal of this booklet is to underscore the opportunity for those working to end sexual violence from around the world to partner and work together to identify and address its root causes. Today, a global perspective grows increasingly relevant for advocates and policy makers the world-over. War adds to the urgency. It not only ravages our world, people, and economies; war increases the risk of sexual violence. The needs and experiences of refugees and those that are trafficked illustrate the importance of building relationships and resources within a global community context.
Advocacy efforts have grown out of a fundamental understanding of sexual violence as a human rights, crime victims’ rights, and social justice issue. Anti-sexual violence advocates have historically worked to change the social conditions that perpetuate violence. Building networks has been a crucial part of that work. We have much to give and gain by examining international public health efforts that aim to end sexual violence through social change
Definitions of sexual violence may be influenced by cultural values, social norms, human rights, gender roles, legal initiatives and crime and may evolve over time. While defining sexual violence advances our global efforts to identify and eliminate sexual violence, it must be recognized that all definitions are arrived at through cultural, socio-political, and geographic lenses. The Report attempts to build connections between communities and propel our solutions forward by offering the following definition of sexual violence:
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
(Jewkes, Sen, and Garcia-Moreno, p. 149, 2002).
Additionally, WHO emphasizes that a person who commits sexual violence uses coercion, which can include “physical force…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” (Jewkes, Sen, and Garcia-Moreno, p. 149, 2002).
The Report presents the following forms of sexual violence (Jewkes, Sen, and Garcia-Moreno, p. 149, 2002):
It asserts that sexual violence is used as a tool to punish and subjugate individuals for perceived transgressions of social or moral codes, noting its “underlying purpose is frequently the expression of power and dominance over the person assaulted” (Jewkes, Sen, and Garcia-Moreno, p. 149, 2002).
According to the World Health Organization “the true extent of sexual violence is unknown” (Jewkes, Sen, and Garcia-Moreno, 2002). In part, this is due to the significant variations in research definitions and methods. There are also significant gaps in research that keep sexual violence invisible and off of policymakers’ agendas (Krug, p. 172, 2002).
Regardless of these inconsistencies, the Report confirms what many advocates have known: sexual violence terrorizes women, men, girls, and boys across the globe. The following examples help illustrate the global prevalence of sexual violence:
Sexual violence does not occur in isolation. Risk factors, deeply rooted in social injustices and inequities, connect sexual violence to other forms of violence across the globe. Risk factors transcend boundaries and occur in individual, social, cultural, and economic contexts.
When viewing sexual violence through a public health lens, both reducing risk factors and increasing protective factors become paramount. Some of the individual risk factors found to increase men’s risk of committing rape include using alcohol and drugs, lacking inhibitions to suppress associations between sex and aggression, holding attitudes and beliefs that are supportive of sexual violence and hostile towards women, associating with sexually aggressive peers, and having experienced sexual abuse as a child.
Societal risk factors that contribute to the occurrence of sexual violence and place certain groups at greater risk include gender-based inequality, magnification of male honor and entitlement, war, and absent or weak sanctions and human services.
Gender-based Inequality
Sexual violence is more likely to occur in societies
with rigid and traditional gender roles: “in societies
where the ideology of male superiority is strong—
emphasizing dominance, physical strength and male
honor—rape is more common” (Jewkes, Sen, and
Garcia-Moreno, p. 162, 2002). In some countries, the
concept of gender equality disrupts a deep-seated
system of inequality, creating social unrest in the
short-term but empowerment and greater equality for
women in the long-term.
Male Entitlement
Men are more likely to commit sexual violence in
communities where concepts of male honor and
entitlement are culturally accepted and where sexual
violence goes unpunished. In many countries, the
integrity of male honor hinges on female sexual
purity. The rape of a woman taints the honor of her
husband and/or family and she will likely face punishment
as a way to restore the family’s honor.
Punishment may include her marriage to the rapist,
banishment and/or varying degrees of violence
against her, including her murder, or “honor killing.”
Social ideology entrenched in male entitlement may
deny women a fundamental right to refuse sex and
fail to recognize marital rape as a problem.
Absent or Weak Sanctions and Services
Community tolerance of sexual violence is evidenced
by the unresponsiveness of systems and services.
Sexual violence that occurs in certain settings or forms
is not recognized as “sexual violence” by law in many
countries. Evidence provided by victims is often not
considered to be sufficient for a conviction. Victims do
not come forward in many places out of fear of being
punished by the criminal justice system. “In some
places, rape can even occur in public, with passers-by
refusing to intervene” (Jewkes, Sen, and Garcia-Moreno,
p. 161, 2002). Weak or absent social sanctions and services contribute to and exacerbate sexual violence. Unresponsive systems fail to hold perpetrators accountable and fall short of victims’ needs.
Poverty
Violence impacts certain groups disproportionately.
Poverty increases people’s vulnerabilities to sexual
exploitation in the workplace, schools, and in
prostitution, sex trafficking, and the drug trade.
People with the lowest socioeconomic status are at
greater risk for violence. Individuals who lack
sufficient economic resources to meet their basic
needs, specifically women, may have to resort to
bartering for essential goods with sex.
War
The rape and torture of men, women, and
children as military tactics have been widely
documented. Rape has been used as a weapon of war
and conflict. “Rape is often used to terrorize and
undermine communities, to force people to flee, and
to break up community structures. Physical and
psychological effects on victims are far-reaching” (Zwi, Garfield,
and Loretti, p. 218, 2002). Refugees who flee conflict and persecution are at extreme risk
for
sexual violence in their new settings, including
refugee camps. War often depletes economic and
social resources and pushes many people into
prostitution.
A public health approach to ending sexual violence requires a collaborative, multi-disciplinary, multi-level, and holistic strategy. The Report discusses many promising approaches to ending sexual violence, including but not limited to the efforts described below.
The Philippines Task Force
Comprised of doctors, nurses, social scientists, and
supported by the Department of Health, the Task
Force on Social Science and Reproductive Health in
the Philippines has developed training on gender
violence for nursing and medical students (Jewkes,
Sen, and Garcia-Moreno, p. 167, 2002). This training has
become a standard component of nursing and medical
school curricula. Training modules are designed to
increase students’ understanding of the root causes of
violence in cultural and gendered contexts, help them
identify patients and families at risk for violence and
to prepare them to provide primary and secondary
interventions in collaboration with other professionals.
Sexual Assault Nurse Examiners (SANE)
Located in hospitals or police stations, SANE
programs provide victims of sexual violence with a
wide range of services through a collaborative
approach that includes rape crisis centers, law
enforcement, district attorneys, and medical
professionals (Jewkes, Sen, and Garcia-Moreno, p. 167,
2002). Sexual Assault Nurse Examiners (SANE)
provide specialized and comprehensive health care
services to victims of sexual violence. SANE programs
operate in a number of countries, including Canada,
the United States, and Malaysia.
Stepping Stones
Originally developed in Africa and now used by
many parts of the developing world, Stepping Stones
links HIV/AIDS prevention with sexual violence
prevention (Jewkes, Sen, and Garcia-Moreno, p. 165,
2002). This program is designed for female and male
peer groups. A review of Stepping Stones in Africa
and Asia showed the program’s success in helping
men take responsibility for their actions, communicate
more effectively, and develop greater respect for
women. Reductions in rates of violence against
women have been reported in Cambodia, the Gambia,
South Africa, Uganda and the United Republic of
Tanzania as a result of this program.
Institute for Health and Human Development
South Africa’s Institute for Health and Human
Development (IHDC) uses the mass media to promote
health and prevent violence (Jewkes, Sen, and Garcia-
Moreno, p. 168, 2002). Prime-time television and radio
dramas discuss social and health issues including
interpersonal violence, bullying, gang violence,
domestic violence, rape, and sexual harassment in
ways that engage viewers of all ages on emotional
levels. Of note is a popular children’s program, Soul
Buddyz, that reaches two thirds of South African
children. In addition to TV and radio, IHDC produces
and disseminates booklets that provide more
extensive information on various topics. IHDC also
administers a hotline, through which crisis counseling
and referral services are provided.
Inter-American Coalition for the
Prevention of Violence
The Inter-American Development Bank, Organization
of American States, Pan American Health
Organization, United National Educational, Scientific
and Cultural Organization, United States Centers for
Disease Control and Prevention, and the World Bank
joined forces to form the Inter-American Coalition for
the Prevention of Violence to respond to the problem
of violence (Krug, et al., p. 252, 2002). The coalition supports the public awareness efforts, research, policy, training, media outreach, collaborative, and preventive efforts of organizations on a national scale by helping to mobilize resources and partners at local levels.
Developmental Approaches
There are a number of developmental approaches
to health promotion and violence prevention. One
model that targets children at every stage of their
development is the Schwartz model (Jewkes, Sen, and
Garcia-Moreno, p. 166, 2002). With this tool, health
providers explore parenting, gender stereotypes,
stress, conflict, and violence issues with expecting
parents. Health providers explore the following issues
along children’s developmental continuum: child sexual
abuse, violence in the media; “good and bad”
touch, sexual aggression; rape myths and facts,
boundaries and the link between sex, violence, and
coercion.
Men as Activists
Men’s collective involvement in sexual violence
prevention is growing, with over 100 groups in the
United States alone (Jewkes, Sen, and Garcia-Moreno, p.
169, 2002). At the core of the male activist movement
is the need for men to take responsibility for reducing
violence. To that end, such groups often work with
women’s groups to raise public awareness about
violence, promote violence alternatives, explore
the meaning of masculinity, and provide educational
programs in community settings.
Legal and Policy Responses
Legal and policy efforts have improved the health and
quality of life of people throughout the world. In Asia,
a broadening of legal definitions of rape coupled with
mandated state assistance to victims has resulted in
more victims reporting and coming forward (Jewkes,
Sen, and Garcia-Moreno, p. 170, 2002). Rule 96 of the International Criminal Tribunal for the former Yugoslavia lends itself as a model for reform elsewhere (Jewkes, Sen, and Garcia-Moreno, p. 170, 2002). Rule 96 removes the corroboration requirement in victims' testimony and prohibits prior sexual history of victims from being admitted as evidence. Policy changes have made a difference in victims’ lives and the systems they encounter.
International Rescue Committee
The International Rescue Committee (IRC) employs a
collaborative model to prevent and address sexualand
gender-based violence against refugees (Jewkes,
Sen, and Garcia-Moreno, p. 171, 2002). Community
workers connect victims to services. Community
attorneys prosecute perpetrators. IRC has helped
refugee populations in Bosnia and Herzegovina, the
Democratic Republic of the Congo, East Timor, Kenya,
Sierra Leone and the former Yugoslav Republic of
Macedonia.
Child Abuse Public Awareness Campaign
in Kenya
Coalition members from governmental, nongovernmental,
and community-based backgrounds came
together in 1996 to respond to a study that showed
a high prevalence of child abuse and neglect in Kenya
(Runyan, et al., p. 77, 2002). The response was
three-tiered and included training, advocacy, and
child protection efforts. Through drama, music, and
essay competitions, children shaped the coalition’s
efforts. Success is illustrated in a strengthened
reporting and management of child abuse cases,
creation of a legal network for abused children,
organization and provision of national and regional
conferences, and heightened public awareness about
child abuse and neglect.
Much can and has been done to address sexual violence, but “the world has not yet fully measured the size of the task and does not yet have all the tools to carry it out” (Krug et al., p. 254, 2002). While the report findings reveal gaps in sexual violence research, prevention, and intervention across the world, there are clear steps that advocates, researchers, and policy-makers can take to help light the way forward.
In September 2004, WHO released Preventing Violence: a Guide to Implementing the Recommendations of the World Report on Violence and Health to provide step-bystep conceptual, policy and practical suggestions on how to implement these recommendations (WHO, 2004). WHO offers a series of concrete recommendations for multi-level social change that include:
Sexual violence is a human rights and public health concern that transcends boundaries and incurs a devastating global human cost. Gender inequalities, male entitlement, absent and/or weak social sanctions and services, poverty, and war put certain populations at greater risk for sexual violence. Sexual violence terrorizes individuals throughout the world and undermines communities and systems. Change is possible through a commitment to the protection of human rights and a national sexual violence prevention strategy.
The WHO Report shows that sexual violence is preventable and social change is possible. However, lasting social change requires the commitment and collaboration of advocates, policy-makers, researchers, medical personnel, educators, police officers, prosecutors, and other professionals across the globe. Sexual violence prevention requires rigorous advances in research, including the development and implementation of consistent definitions and methods and the sharing of analyses. Through the commitment of members of society at every level, new programs and policies can emerge to significantly eliminate sexual violence.
Current WHO Initiatives
Following the Report’s release,
WHO launched the Global Campaign for Violence Prevention to raise
awareness about the problem of violence and the
value of a public health approach and to encourage
global action at every level of society. For more
information on the campaign, visit: http://www.
who.int/violence_injury_prevention/violence/
global_campaign/campaign/en/.
For a detailed description of how to implement recommendations that were referenced on page 14, visit: http://www.who.int/violence_injury_prevention/media/news/08_09_2004/en.
Krug, EG et al., eds. World Report on Violence and Health. Geneva, World Health Organization, 2002.
Krug, EG et al., The Way Forward: Recommendations for Action. In: Krug E., Dahlberg, L., Mercy, J.A., Zwi, A.B., Lozano, R. World Report of Violence and Health. Geneva, Switzerland: The World Health Organization. 2002: 241-254. (Available on the Internet: http://www.who.int/violence_injury_ prevention/violence/global_campaign/en/chap9.pdf)
Jewkes, R., Sen P., Garcia-Moreno, C. Sexual Violence. In: Krug E., Dahlberg, L., Mercy, J.A., Zwi, A.B., Lozano, R. World Report of Violence and Health. Geneva, Switzerland: The World Health Organization. 2002: 147-181. (Available on the Internet: http://www.who.int/violence_injury_prevention/ violence/global_campaign/en/chap6.pdf)
Runyan, D. et al. Child Abuse and Neglect by Parents and Other Caregivers. In: Krug E., Dahlberg, L., Mercy, J.A., Zwi, A.B., Lozano, R. World Report of Violence and Health. Geneva, Switzerland: The World Health Organization. 2002: 147-181. (Available on the Internet: http://www.who.int/violence_ injury_prevention/violence/global_campaign/en/chap3.pdf)
Zwi, AB, Garfield, R. Loretti, A. Collective Violence. In: Krug E., Dahlberg, L., Mercy, J.A., Zwi, A.B., Lozano, R. World Report of Violence and Health. Geneva, Switzerland: The World Health Organization. 2002: 213-239. (Available on the Internet: http://www.who.int/violence_injury_prevention/ violence/global_campaign/en/chap8.pdf)
Buchart, A., Phinney, A., Check P., Villaveces A. Preventing violence: a guide to implementing the recommendations of the world report on violence and health. Department of Injuries and Violence Prevention, world Health Organization, Geneva, 2004. (Available on the internet: http://whqlibdoc.who.int/publications/ 2004/9241592079.pdf)
The full World Report on Violence and Health is available at the World Health Organization’s web site: http://who.int/ violence_ injury_ prevention/violence/world_report.