Sexual violence legislation in sub-Saharan Africa: the need for strengthened medico-legal linkages

A Systematic Review of Criminal Justice Initiatives to Strengthen the Criminal Investigation and Prosecution of Sexual Violence in East Africa

Sexual violence (SV) is a widespread public health and human rights problem, with countries in East Africa having higher rates than the global average. Prosecutions of SV in East Africa are rare, and survivors face many challenges accessing medico-legal justice and services. Developing initiatives that support survivors in navigating the criminal justice system is vital, yet there is limited research on efforts to improve the criminal justice system's management and treatment of survivors. We conducted a scoping review of research on initiatives to strengthen responses toward investigating and prosecuting cases. We identified 25 academic articles and reports through a search of electronic databases and gray literature that address these initiatives in East Africa. The results reveal that seven types of initiatives have been studied: one-stop centers (OSCs), multisectoral referral networks, gender desks, community interventions, mobile applications, and specialized police and prosecution units. Upon review, we found that barriers to success include a lack of resources and facilities, a lack of trained health care, police, and judicial personnel to perform services, weak medico-legal partnerships, and stigma and impunity restricting the uptake and fair distribution of services. Overall, limited systematic evidence on the effectiveness and adaptability of initiatives exists, showing that SV interventions in East Africa remain an under-researched and under-resourced area, and need greater scientific rigor to inform practice and coordinated advocacy. This review is a call to action for policy makers and service providers working in East Africa-and for international bodies working toward achieving Sustainable Development Goals 5-to improve criminal justice initiatives.

Does healthcare decision-making capacity affect women's justification of sexual violence? The situation of sub-Saharan Africa

Sexual violence against women is commonly justified in sub-Saharan Africa (SSA) despite international commitments to halt it. This study investigated the association between healthcare decision-making capacity and the justification of sexual violence among women in SSA. We used current datasets of 30 sub-Saharan African countries published between January 2010 and December 2018. The sample included 259,885 women who were in sexual unions. We extracted and analysed the data with Stata version 14. Chi-square test and multilevel logistic regression models were used to analyse the data. Results for the regression analysis were presented as adjusted odds ratios (AOR) with their corresponding 95% confidence intervals (CIs). The results showed that women who decided on their healthcare alone had lower odds [AOR=0.93; CI=0.91-0.96] of justifying sexual violence compared to those who were not deciding alone. We also found that women aged 45-49 [AOR=0.85; CI=0.82-0.89], those with higher education [AOR=0.26; CI=0.24-0.29], cohabiting women (AOR=0.82, CI=0.80-0.85], richest women [AOR= 0.58; CI=0.56-0.60], women living in urban areas [AOR=0.74; CI=0.73-0.76], and Christians [AOR=0.52; CI=0.51-0.54] had lower odds of justifying wife beating if a woman refuses to have sex with her partner. On the contrary, women who engaged in agriculture had higher odds of justifying sexual violence than those who were not working [AOR=1.07; CI=1.04-1.09]. Groups that should be prioritised with anti-sexual violence initiatives are the poor, rural residents, and young women. It is also vital to institute policies and interventions focused on educating men about women's right to make decisions, and why partner violence is unjust and intolerable.

Intimate partner sexual violence during pregnancy and its associated factors in Northwest Ethiopian women

Background

Violence against women is a global problem. In pregnant women, it is a particular concern as a virtue of the additional risks to the unborn child. Of different acts of violence, sexual violence shares the major contribution that results in short and long-term physical, sexual, reproductive, and mental health problems of pregnant women. Little is known about sexual violence during pregnancy in Ethiopia.

Objective

this study aimed to assess the proportion and factors associated with intimate partners' sexual violence against pregnant women in Northwest Ethiopia.

Methods

A cross-sectional study was conducted among 409 pregnant women in Debre Markos town from March to April 2018. The study participants were selected using a systematic random sampling technique. A pre-tested and validated questionnaire was used. Binary logistic regression analyses were done to identify associated factors and the adjusted odds ratio (AOR) with its 95 % confidence interval (CI) at a p-value of <0.05 was used to declare a significant association.

Result

Of 409 pregnant women, 19.8% have experienced sexual violence by their intimate partner during their current pregnancy. Accordingly, the major intimate partner sexual violence during pregnancy was having unwanted sexual intercourse due to fear from the partner (13.4%), being forced to do something sexual that is degrading or humiliating (13.0%), and being physically forced to have sexual intercourse (9.8%). Living with her partner/husband (AOR: 3.73, 95% CI: 1.30, 10.69), uneducated educational status of partner (AOR: 2.43, 95% CI: 1.06, 5.56), and frequency of alcohol consumption (AOR: 3.20, 95% CI: 1.24, 8.26) were factors associated with increased occurrence of intimate partner sexual violence during pregnancy.

Conclusion

The proportion of sexual violence against pregnant women by their intimate partner(s) was found to be common in our study. Socio-demographic and behavioral-related factors were risk factors for sexual violence. As a result, preventive strategies and interventions centering on the empowerment of those facing the greatest barriers to reproductive freedom require a shift from traditional ways of thinking.

Intra-Urban Variation of Intimate Partner Violence Against Women and Men in Kenya: Evidence from the 2014 Kenya Demographic and Health Survey

Although urban areas are diverse and urban inequities are well documented, surveys commonly differentiate intimate partner violence (IPV) rates only by urban versus rural residence. This study compared rates of current IPV victimization among women and men by urban residence (informal and formal settlements). Data from the 2014 Kenya Demographic and Health Survey, consisting of an ever-married sample of 1,613 women (age 15-49 years) and 1,321 men (age 15-54 years), were analyzed. Multilevel logistic regression was applied to female and male data separately to quantify the associations between residence and any current IPV while controlling for regional variation and other factors. Results show gendered patterns of intra-urban variation in IPV occurrence, with the greatest burden of IPV identified among women in informal settlements (across all types of violence). Unadjusted analyses suggest residing in informal settlements is associated with any current IPV against women, but not men, compared with their counterparts in formal urban settlements. This correlation is not statistically significant when adjusting for women's education level in multivariate analysis. In addition, reporting father beat mother, use of current physical violence against partner, partner's alcohol use, and marital status are associated with any current IPV against women and men. IPV gets marginal attention in urban violence and urban health research, and our results highlight the importance of spatially disaggregate IPV data-beyond the rural-urban divide-to inform policy and programming. Future research may utilize intersectional and syndemic approaches to investigate the complexity of IPV and clustering with other forms of violence and other health issues in different urban settings, especially among marginalized residents in informal urban settings.

Sexual violence among young women in Nigeria: a cross-sectional study of prevalence, reporting and care-seeking behaviours

BACKGROUND

Only a few studies, mostly hospital-based, have examined sexual violence among young people women in Nigeria. We examined the prevalence, correlates, perpetrators, reporting of and health-seeking behaviour for sexual violence using data of 395 young women (aged 17-24) obtained from a Nigerian university.

METHODS

We selected participants using stratified sampling and defined sexual violence as sexual acts or attempts to obtain sexual acts by violence or coercion by any person irrespective of their relationship to the victim. Descriptive and inferential statistics were used to summarise the data obtained.

RESULTS

Our analysis shows that 39.5% of the respondents had experienced some form of sexual violence. Adequate family financial support was protective against sexual violence after adjusting for all background characteristics (AOR: 0.60 95% CI: 0.39-0.93). However, young women who use alcohol had higher odds of reporting sexual violence experience than those who never used alcohol. In most cases (78.5%), perpetrators were well known to the victims. Only 3.3% of sexual violence cases were reported to law enforcement agencies and just 13.1% of victims sought care from health providers.

CONCLUSION

Sexual violence occurs at a tragically high frequency, and victims rarely report incidents to law enforcement agencies or access the much-needed care. The findings suggest a need for interventions that address why victims of sexual violence rarely report to law enforcement or seek care.

Experiences and Perpetration of Recent Intimate Partner Violence Among Women and Men Living in an Informal Settlement in Nairobi, Kenya: A Secondary Data Analysis

Evidence suggests an overlap between intimate partner violence (IPV) experience and perpetration. However, few studies in sub-Saharan Africa have investigated experience and perpetration of IPV among women and men within the same community. This study reports prevalence of past-year IPV experience and perpetration among women and men living in an informal settlement in Nairobi, Kenya, and factors associated with IPV. Data analyzed for this study involved a geographically distributed random sample of 273 women and 429 men who participated in a community survey. We approximated prevalence of IPV experience and perpetration and used logistic regression for estimating associations between individual-level factors and IPV. Women and men experienced similar levels of IPV, but a significantly higher proportion of men reported physical and sexual IPV perpetration. Witnessing violence between parents in childhood was associated with women's physical and sexual, and men's sexual IPV experience; and with women perpetrating emotional, and men perpetrating sexual IPV. Less equitable gender attitudes were associated with men's perpetration of physical IPV. More equitable gender knowledge was associated with women's experience of sexual IPV, and with men perpetrating IPV. Perceived skills to challenge gender inequitable practices were negatively associated with men perpetrating sexual IPV. In conclusion, we found IPV experience and perpetration were highly correlated, and that, contrary to commonly reported gender gaps, men and women experienced similar rates of IPV. We make suggestions for future research, including on IPV prevention interventions in areas with such IPV prevalence that would be beneficial for women and men and future generations.

Effect of sexual violence on planned, mistimed and unwanted pregnancies among women of reproductive age in sub-Saharan Africa: A multi-country analysis of Demographic and Health Surveys

Introduction

Sexual violence plays a key role in women's pregnancy intention. We investigated the influence of sexual violence on planned, mistimed, and unwanted pregnancies in sub-Saharan Africa (SSA).

Materials and methods

Data from the Demographic and Health Survey (DHS) of 22 countries in SSA were used in this study. Both descriptive and inferential analyses were conducted. We carried out a multinomial logistic regression analysis to examine the effect of sexual violence on planned, mistimed, and unwanted pregnancies. STATA version 14.2 was used to carry out all analyses. Statistical significance was declared at p<0.05.

Results

At the descriptive level, we found that 74.1% of women of reproductive age in SSA had planned pregnancies, with the remaining 25.9% having either mistimed (20.4%) or unwanted (5.5%) pregnancies. Women in Nigeria had the lowest proportion of mistimed pregnancies (7.5%) whereas those in Burundi had the greatest percentage of unwanted pregnancies (12.4%). Women who had history of sexual violence had increased risk of mistimed [ARRR = 1.5, CI = 1.3–1.7] and unwanted pregnancies [ARRR = 1.6, CI = 1.3–2.0], compared to those with no history of sexual violence. Women aged 40–44 [ARRR = 3.3, CI = 1.4–7.6] and 45–49 [ARRR = 4.4, CI = 1.7–11.2] had higher risk of unwanted pregnancies, compared to women aged 15–19. Women who were cohabiting had higher risk of mistimed [ARRR = 1.3, CI = 1.1–1.4] and unwanted pregnancies [ARRR = 1.6, CI = 1.3–2.1], compared to married women.

Conclusion

Sexual violence plays a key role in mistimed and unwanted pregnancies. It is, therefore, prudent to develop various assessment techniques to detect sexual violence in unions and refer victims to appropriate services to diminish the risk of mistimed and unwanted pregnancies. Our findings provide a basis for developing and implementing policies and interventions aimed at reducing mistimed and unwanted pregnancies.

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Sexual violence is a global concern.

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Sexual violence plays a key role in women's pregnancy intentions.

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74% of pregnancies in SSA are planned.

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25.9% are either mistimed (20.4%) or unwanted (5.6%).

Sexualised violence against children: a review of laws and policies in Kenya

Child sexual abuse (CSA) is a major global health challenge. Extant literature shows that CSA is prevalent in Kenya. As a signatory of the United Nations Convention on the Rights of the Child and the African Charter on the Rights and Welfare of the Child, the Kenyan government is mandated to ensure that children are protected from sexual abuse through sound laws and policies. This paper reviews existing laws and policies on CSA and highlights their strengths and weaknesses. Our findings indicate that laws on child protection exist and are protective to a large extent, as harsh penalties are outlined for sexual offences. Survivors of CSA are entitled to free legal and medical services. However, there are no reparations offered to survivors in criminal proceedings. Moreover, there is no legislation on age-appropriate comprehensive sexuality education which plays an important role in cultivating positive gender norms and describing what constitutes CSA and reporting procedures. The national standard operating procedures for the management of sexual violence against children lack CSA screening procedures. There is urgent need for review of these laws and policies and development of multisectoral protocols at the national and county level, that outline roles and responsibilities for various service providers, supervisory and accountability measures and referral networks.

The gender-based violence and recovery centre at Coast Provincial General Hospital, Mombasa, Kenya: An integrated care model for survivors of sexual violence

Marleen Temmerman and colleagues describe a model of care for people who have experienced sexual violence, set in Kenya.

The Health Care Sector Response to Intimate Partner Violence in Kenya: Exploring Health Care Providers' Perceptions of Care for Victims

Intimate partner violence (IPV) is prevalent in Kenya, yet few studies have examined the role of health care providers (HCPs) in addressing IPV. Interviews with 18 Kenyan HCPs explored how they recognize and support IPV victims, including barriers to care. HCPs most commonly see victims of physical abuse. Medical responses to victims included counseling, treatment, and referrals, although rural HCPs reported fewer available services than in urban settings. HCPs attributed the limited response to IPV victims to unclear laws and fragmented care, especially in a culture where IPV remains largely unspoken and underreported. These results underscore the need for increased training on IPV assessment and response for HCPs in Kenya, with emphasis on standardized care guidelines for victims.

Postrape care services to minors in Kenya: are the services healing or hurting survivors?

Child sexual abuse is a global problem and a growing concern in Sub-Saharan Africa. It constitutes a profound violation of human rights. To address this problem, Kenya has established the Sexual Offences Act. In addition, Kenya has developed national guidelines on the management of sexual violence to grant minors access to health care. However, little is known about the experiences of sexually abused minors when they interact with the health and legal system. Accordingly, this study uses a triangulation of methods in the follow-up of two adolescent girls. Health records were reviewed, interactions between the girls and service providers were observed, in-depth interviews were conducted with the girls, and informal discussions were held with guardians and service providers. Findings indicated that the minors’ rights to quality health care and protection were being violated. Protocols on postrape care delivery were unavailable. Furthermore, the health facility was ill equipped and poorly stocked. Health providers showed little regard for informed assent, confidentiality, and privacy while offering postrape care. Similarly, in the justice system, processing was met with delays and unresponsive law enforcement. Health providers and police officers are in grave need of training in sexual and gender-based violence, its consequences, comprehensive postrape care, and sexual and reproductive health rights to ensure the protection of minors’ rights. Health administrators should ensure that facilities are equipped with skilled health providers, medical supplies, and equipment. Additionally, policies on the protection and care of sexually abused minors in Kenya require amendment.

Risk of Sexual Violence: Perspectives and Experiences of Women in a Hospital in the Democratic Republic of Congo

Sexual violence in conflict situations is gaining worldwide recognition as a human rights issue. There is growing awareness and concern about the risks associated with sexual violence against women. This study was conducted in order to explore the perceptions and experiences of the risk of sexual violence in the Democratic Republic of Congo. The study draws on qualitative, in-depth interviews with women at a hospital in Bukavu. The findings show that women suffered humiliation, torture and beatings during their rape. Most women were raped by a number of men and others were forced to have sex with close family members. The rapist often used extreme brutality against the women which had major long-term consequences for women including unwanted pregnancies and/or HIV/AIDS. Many of the women experienced great uncertainty about their future and that of their children.

The Kenyan national response to internationally agreed sexual and reproductive health and rights goals: a case study of three policies

While priorities for, and decision-making processes on, sexual and reproductive health and rights have been determined and led mainly at the international level, conflicting power dynamics and responses at the national level in some countries have continued to pose challenges for operationalising international agreements. This paper demonstrates how these conflicts have played out in Kenya through an analysis of three policy-making processes, which led to the Adolescent Reproductive Health and Development Policy (2003), the Sexual Offences Act (2006), and the National Reproductive Health Policy (2007). The paper is based on data from a broader study on the drivers and inhibitors of sexual and reproductive health policy reform in Kenya, using a qualitative, case study design. Information was gathered through 54 semi-structured, in-depth interviews with governmental and civil society policy actors and an extensive review of policy documents and media reports. The paper shows that the transformative human rights framing of access to sexual and reproductive health, supported by both a strong global women's rights movement and progressive governmental and inter-governmental actors to defeat opposition to sexual and reproductive health and rights at the international level, has not been as influential or successful at the national level in Kenya, and has made comprehensive national reforms difficult to achieve.

Measuring improvements in sexual and reproductive health and rights in sub-Saharan Africa

Recent studies on development aid from European donors revealed that their funding of the health sector in sub-Saharan Africa rarely includes performance measures suitable for tracking operational progress in improving sexual and reproductive health and rights. Analysis of health sector agreements verifies this. Particularly lacking are metrics related to four critically important areas: (1) reducing mortality and morbidity from unsafe abortion, (2) preventing and treating gender-based violence, (3) reducing unwanted pregnancies among the poorest women, and (4) reducing unwanted pregnancies among adolescents. During 2011 and the first half of 2012, the authors interviewed 85 experts in health service delivery, ministries of health, human rights, development economics and social science from sub-Saharan Africa, Europe and the United States. We asked them to identify measures to assess progress in these areas, and built on their responses to propose up to four practical performance measures for each of the areas, for inclusion in health sector support agreements. These measures are meant to supplement, not replace, current population-based measures such as changes in maternal mortality ratios. The feasibility of using these performance measures requires political commitment from donors and governments, investment in baseline data, and expanding the role of sexual and reproductive health and rights civil society in determining priorities.

Estimates and determinants of sexual violence against women in the Democratic Republic of Congo

OBJECTIVES

We sought to provide data-based estimates of sexual violence in the Democratic Republic of Congo (DRC) and describe risk factors for such violence.

METHODS

We used nationally representative household survey data from 3436 women selected to answer the domestic violence module who took part in the 2007 DRC Demographic and Health Survey along with population estimates to estimate levels of sexual violence. We used multivariate logistic regression to analyze correlates of sexual violence.

RESULTS

Approximately 1.69 to 1.80 million women reported having been raped in their lifetime (with 407 397-433 785 women reporting having been raped in the preceding 12 months), and approximately 3.07 to 3.37 million women reported experiencing intimate partner sexual violence. Reports of sexual violence were largely independent of individual-level background factors. However, compared with women in Kinshasa, women in Nord-Kivu were significantly more likely to report all types of sexual violence.

CONCLUSIONS

Not only is sexual violence more generalized than previously thought, but our findings suggest that future policies and programs should focus on abuse within families and eliminate the acceptance of and impunity surrounding sexual violence nationwide while also maintaining and enhancing efforts to stop militias from perpetrating rape.

The African Women's Protocol: bringing attention to reproductive rights and the MDGs

Andrew Gibbs and colleagues discuss the African Women's Protocol, a framework for ensuring reproductive rights are supported throughout the continent and for supporting interventions to improve women's reproductive health, including the MDGs.