|
Mapping
a Global Pandemic:
Review
of Current Literature on Rape, Sexual Assault and Sexual Harassment of
Women Consultation on Sexual Violence Against Women
Global Forum for Health Research
Introduction
Violence against women (VAW),
alternatively referred to as gender-based violence (GBV), has been
acknowledged as a global health problem in part because of its impact on
reproductive health, and hence on fetal outcome and child health as well
as women's health. Over the past 25 years, however, there has also been
growing recognition of its under-reporting and high prevalence, and
increased acknowledgement that it can affect women at any stage of their
lives and can occur in various forms that may involve physical,
psychological, sexual and/or economic abuse. This broader understanding
recognizes the systemic nature of VAW, its pervasiveness and the fact
that it is both caused by and perpetuates gender inequity. Violence
against women is a crucial violation of the human right to liberty and
freedom from fear, and is now recognized as a priority public health and
human rights issue (WHO, 1997).
Gender-based violence has an enormous
impact on women's lives. It causes physical and psychological harm
(including homicide and suicide) and on-going health problems; it
reduces women's autonomy and destroys their quality of life; it affects
their ability to care for themselves and their families; and it
diminishes their productivity in wider society and in the processes of
development (Garcia-Moreno, 1999: 4). VAW has enormous direct and
indirect costs in terms of government and community resources and
services, including health services, law enforcement and legal services
that respond to its occurrence, consequences, and prevention.
In 1993, participants at an
International Seminar on Sexual Coercion and Reproductive Health drew
attention to the imperative of encouraging research on sexual coercion
and reproductive health, and identified six primary research domains:
the socio-cultural contexts of violence; the epidemiology of sexual
coercion; interpretations and meanings of sexual coercion; the
consequences of coercion for reproductive health; processes that
maintain violence; and intervention strategies (Heise et al., 1995).
This was an important step in developing a practical agenda for research
into SVAW. It was also a radical move because it recognized sexual
violence in interpersonal relationships and in intimate settings. This
represented an important shift in emphasis from prior understandings of
VAW that associated sexual coercion with anonymity and societal
disruption, for example, rape by an unknown assailant, as an expression
of class or ethnic hostility (as in war), and in culturally-specific
contexts (e.g. female genital mutilation, suttee), or in association
with sex work.
Sexual violence against women lies at
the heart of inequality between men and women, within which issues of
violence and homelessness are interwoven. This shift recognises that
sexual violence against women is commonplace in environments in which
women might expect safety, that is, in their own homes and in other
familiar settings. If the idea of having a home encompasses the right to
physical and psychological safety and security, then a child or a woman
experiencing violence in the family home is, in a sense, homeless. Such
a woman (or child) may have shelter, but she does not have a place where
she has personal freedom or security (Burke, 1998). Further, while
sexual violence by a stranger tends to be a single event, violence in
the home, including sexual violence, tends to be repetitive and to
escalate over time (AMA, 1992; Duvvury, 2000).
Definition of the problem
The United Nations Declaration on the
Elimination of Violence Against Women (Article 1) defines violence
against women to include:
Any act of gender-based violence that results
in, or is likely to result in, physical, sexual or psychological harm
or suffering to women, including threats of such acts, coercion or
arbitrary deprivations of liberty, whether occurring in public or
private life.
Article 2 of the United Nations
Declaration further specifies that violence against women should
include, but not be limited to:
Acts of physical, sexual and psychological
violence whether they be in the family or the community. The acts of
violence specified in this article include: spousal battering, sexual
abuse of female children, dowry-related violence, rape including
marital rape, traditional practices harmful to women such as female
genital mutilation, non-spousal violence, sexual harassment and
intimidation, trafficking in women, forced prostitution, and violence
perpetrated or condoned by the state such as rape in war.
VAW occurs in numerous forms that are
pervasive and interconnected. This review, however, confines its focus
to forms of sexual violence most commonly experienced by women. These
include sexual harassment, sexual assault, and rape, perpetrated by
unknown assailants and by known assailants including spouses. The
concentration on these forms of violence reflects the focus of the
Consultation on Sexual Violence Against Women (1),
and the difficulty of addressing all significant forms of sexual
violence against women in a single review.
Sexual violence and forced sex are, as
we have noted, mundane: that is, it is most prevalent in everyday
contexts and environments and among individuals known to each other.
Although data sources are poor, there is compelling evidence that forced
sex and rape is less frequent between strangers, and most common among
family members, courtship partners, acquaintances and spouses (Berger,
1996; Eskow 1996; Garcia-Moreno, 1999; Heise et al., 1995; Jasinski
& Williams, 1998). While some forms of violence are perpetrated by
women themselves - between mothers-in-law/daughters-in-law,
mothers/daughters, and same-sex partners - the perpetrators of VAW and
particularly SVAW are overwhelmingly men (Connell, 1995; French, 1992).
In addition, rape, sexual assault and sexual harassment are the most
common forms of violence against women, although sexual violence rarely
occurs in isolation from other forms of violence. This is most evident
where sexual violence occurs in spousal relationships.
A characteristic shared by all forms of
SVAW is lack of consent, including where women are unable to resist or
verbalize their resistance due both to fear of the physical consequences
of sexual violence and fear of the secondary consequences of resisting
such violence (Heise et al. 1999). Sexual violence is often
conceptualized as a continuum, with rape (forced sex without consent)
and physically brutal forms of sexual violence at the extreme end of the
continuum, sexual assault, including a broader range of unwanted and
forced sexual contact, in the middle of the continuum, and sexual
harassment at the opposing end of the continuum. Sexual harassment -
including non-physical forms of abuse such as threats and intimidation,
verbal slander, unwanted sexual advances and attention, stalking, and
sexual humiliation - is represented as a lesser form of violence. While
it has been conventional to conceptualise sexual violence on a
continuum, this approach privileges specific acts and makes assumptions
about the nature of violence, specifically assuming that penile
penetration is a greater harm than, for example, manual penetration or
various acts of humiliation, abuse or threat. This categorical approach
does not take account of the impact on an individual of any form of
violence, and underestimates the effects on the woman of the terror
tactics that make harassment so effective as a means of control. The
degree of physical harm is neither predictive of its short nor
longer-term impact. Non-physical violence, threats of physical violence,
and sexual abuse, harassment and unwanted attention are all serious
crimes that may have highly negative consequences for women who
experience them. Every form of sexual violence perpetrated against women
is a violation of our fundamental human rights and can restrain women's
autonomy, whether it be our mobility, social, sexual or financial
autonomy, or our sense of personal safety.
Methodology of the Literature Review
This review is based on an extensive
survey of recently published literature on sexual violence against
women, located primarily with electronic databases. As a result, the
review concentrates on the published literature, although we have cited
some other public documents and "grey literature" (2).
The review is limited to English-language material, primarily to works
published since 1995. Even with these limitations, however, the result
was to create a database on sexual violence against women of over 1000
references (3).
The review provides a clear picture of
who is engaged in research on SVAW, and their fields of inquiry.
Contemporary research on SVAW is taking place in a variety of
disciplinary fields including social work and welfare, medical and
health research including epidemiology, psychology, reproductive health
and nursing; women's studies and feminist research; the fields of
interpersonal and/or family violence; sexuality and/or sexual abuse; and
law. Research on SVAW is also being conducted within sociology,
particularly criminology, and anthropology (4).
Research conducted in the United States
is most frequently represented in the literature reviewed, and here,
studies of sexual violence in college and educational settings are
especially prolific and repetitive. There are also substantial numbers
of papers reporting studies of sexual violence among ethnic minorities
in the USA. The predominance of US literature reflects the resources
available for this kind of research, the relatively greater potential
for publishing such research in English, and the critical mass of
researchers in this country. However, we wished to produce a review with
an international focus. This resulted in the identification of relevant
literature from 84 countries (5). Among
poorer countries with less developed economies, research into VAW and
SVAW was extensive for African countries and the Indian sub-continent.
This indicates the research interest and potential in these regions,
where there is local institutional capacity and interest to support and
expand the current scope of issues.
The two most popular locations for
conducting research on SVAW and for the recruitment of study
participants in the USA and other industrialized countries were medical
settings, and college and other tertiary settings. Medical settings have
been used to recruit study participants to establish prevalence and
impact; these settings included primary health clinics, general
practices/family physician centers, reproductive, family planning and
sexual health clinics, psychiatric practices, and various hospital
departments including emergency, obstetrics and gynaecology and mental
health. A number of studies were also conducted in training institutions
for nurses and other medical personnel, again primarily to establish
questions of prevalence and impact. The research subjects in these
settings were overwhelmingly women who had experienced some form of
sexual violence and were subsequently seeking treatment. The majority of
these studies were concerned with identifying characteristic features of
those who had been subject to violence (demographic, social, economic
and psychological); they asked Who is subject to sexual violence? and
secondly, What effects has this had on them?.
One consequence of the high
concentration on women who have experienced violence and attended health
services for treatment is selection bias: the research studies do not
include women who have experienced violence but who do not seek
treatment. This distorts measures of prevalence and provides a biased
profile of the kinds of women subject to violence, in turn resulting in
the failure to capture the perspectives of women who do not seek
treatment and their reasons for not doing so. Minority women, for
example, are less likely than other women to report violence because of
their discomfort with the relations of power which they would have to
negotiate were they to report (Hammill, 2000). However, there is
reliable published data for many countries on the prevalence of VAW
collected from random national samples primarily through census and
public health surveys. A great deal of this prevalence data is
summarized in the World Health Organization Violence Against Women
Database (2000), which includes measures of the prevalence of violence
against women by an intimate male partner, the prevalence of physical
violence against women and the prevalence of sexual violence against
women. (6).
Research conducted in educational
settings focuses on college and university students; it tends to collect
quantitative data to determine the prevalence of experiences of violence
and to document student attitudes toward violence. These studies are
reminiscent of other sexual studies - studies of family planning, sexual
activity, and HIV/AIDS, for example (Manderson et al. 1997), that is,
they are mostly conducted among small non-representative populations and
rely on reports for behavioral data. A significant number of studies
conducted and published in the US also concentrate on minority ethnic
groups (Bourgois, 1996; Cunradi & Caetano et al., 1999; Hall &
Windover et al., 1998), focusing therefore on "at risk" groups
(if only by popular stereotype rather than by evidence), while holding
constant the opportunistic access to study populations through
recruitment in educational institutions. The validity of such samples is
questionable: it is not possible to generalize findings from educational
settings to the wider community, nor to infer trends and patterns on the
basis of this select population.
A significant amount of the research
describing interventions has also been conducted in educational settings
although there seems little rationale for this other than opportunity,
that is, the researchers were based again in a university and had access
to specific populations, ie. students. There is little evidence that
students per se experience or perpetrate violence against women
disproportionately, although campuses provide concentrations of young
adults that may well result in a higher incidence of stranger rape and
date rape (see Koss, 1994). However, ease of reporting may well have
resulted in the apparent over-representation of college students as
experiencing rape, and these results cannot be extrapolated to other
countries or cultural settings.
The final group of people who feature
dominantly in research into SVAW are male perpetrators of violence who
have either been reprimanded or convicted for crimes involving SVAW.
Such studies tend to focus on identifying the common characteristics of
male sex offenders, their attitudes towards women, and the acceptability
of violence towards women (Monson and Langhinrichsen-Rohling, 1998).
Some in-depth studies attempt to understand men's strategies of coercion
and how they are able to maintain violent relationships with the women
they abuse (Tyler and Hoyt et al., 1998, 2000). Other studies focus on
measuring the correlation between sexual arousal and aggression in male
sex offenders (Bernat & Calhoun, 1999; Ouimette & Riggs, 1998;
Scully, 1990). For this review, we limited the scope of research on male
perpetrators to research focused on interventions among men and to
studies theorizing the etiology of sexual violence.
Sexual harassment
The published research dealing
specifically with sexual harassment is sparse in comparison with rape
and sexual assault, and tends to focus almost exclusively on sexual
harassment in workplaces and in educational settings, suggesting the
opportunistic recruitment of study participants rather than any other
theoretical or methodological reason. Research into the effectiveness of
prevention strategies is important, but there are few published
evaluations of programs implemented to reduce harassment. It is often
limited to commentary on a particular instance of sexual harassment, or
to small-scale surveys of employees' definitions of and attitudes
towards harassment in their workplace. For instance, studies by Rosen
(1996a, 1996b), Schneider and Swan (1997), Sherer (1995), Shestowsky
(1999), Shim (1998), So-Kum Tang (1996) and Welsh and Nierobisz (1997)
have been conducted in both small and large organizations and
educational institutions, which reflect a commitment in a number of
countries to workplace policies that are free of sexual harassment.
Definitions of sexual harassment remain
highly contested, even among feminists, academics and activists seeking
to redress the problem. Sev'er (1999) provides a succinct overview of
the debates on the definition of sexual harassment and the legal
clarification of its impact in the Canadian context, as an introduction
to a special issue on sexual harassment of the Canadian Review of
Sociology and Anthropology on Sex. Authors of a number of studies
conclude that definitions of sexual harassment vary according to gender,
and they construct a theoretical explanation for sexual harassment based
on the notion of miscommunication (Webster & Smith et al, 1999;
Wiener & Hurt et al, 1997). These uncritical and weakly formulated
theoretical contributions do little to raise awareness that sexual
harassment is a crime in most countries and causes serious harm to those
to whom it is directed.
Sexual harassment in public spaces and
in the domestic sphere is understudied. Lenton and Smith (1999) provide
a model of the kind of research that is needed, in their study of
Canadian women's experiences of sexual harassment in public places, and
how women's fear of harassment shapes their use of such spaces, i.e. how
harassment contributes to the social control of women (see also Madge,
1997 and Pain, 1997 on the "geography of fear"). The general
oversight or lack of interest in sexual harassment reflects varying
social constructions of (public) spaces and gendered behaviour within
those spaces, and the difficulties of monitoring and/or preventing
harassment in settings other than those governed by institutional rules
such as workplaces and educational settings. Lack of attention to
harassment also reflects attitudes that privilege physical violence and
penetrative sex over other forms of abuse, and it overlooks the
consequences for women of psychological abuse. Large scale and
comparative studies on sexual harassment are still needed to provide
basic information on the prevalence of the problem, women's experiences
of it, and its impact on them subsequently.
The literature on sexual harassment is
conspicuously absent in the medical/health fields, in sharp contrast to
the strong focus on sexual assault and rape within medicine, psychology
and public health. This absence may reflect the lack of recognition or
acceptance that sexual harassment is a form of sexual violence against
women, a failure to acknowledge the negative health consequences of
sexual harassment, and/or an inability to appreciate the links between
sexual harassment and other forms of violence against women. Quick
(1998) defines sexual harassment as a "continuing chronic
occupational health psychology problem," thereby recognizing its
endemicity and pervasiveness. Increasingly, there is evidence that
sexual harassment of various forms influences self-esteem and women's
sense of well-being, safety and security (Kopels & Dupper 1999).
There is little discussion of
institutional policies and responses to sexual harassment in the
literature. This suggests a lack of clarity in legal and policy terms in
defining sexual harassment, preventing the successful prosecution of
perpetrators of harassment (Reed, 1996). In addition, at least some
writers minimize sexual harassment, seeing it as an over-reaction of
humorless women rather than a means by which women are intimidated and
undermined (Gardner, 1997 is a case in point) (Rosman & McDonald
1999). Research is needed to examine the inadequacy of legal and
institutional responses to sexual harassment and how these can be
corrected, and to identify and describe interventions that have provided
women with legal and/or personal redress. In particular, as Asquith
(2000) argued during the Consultation on Violence against Women
(Melbourne, May 2000), there is a need to explore how laws specific to
sexual harassment interact with other areas of civil law, such as
freedom of speech, and what problems this represents in terms of
preventing and redressing the crime of sexual harassment (Asquith,
1999).
Sexual assault and rape
The amount of literature on sexual
assault was three times greater than that which dealt with sexual
harassment. While this partly reflects the lack of attention given to
sexual harassment, it also reflects the ambiguity of the term sexual
assault. Sexual assault is an inclusive term, which encompasses a range
of sexual crimes including penile or manual penetration, oral or anal
sex, the insertion of any object into a woman's vagina, the insertion of
a penis into a woman's mouth, and other acts that expose a woman's
and/or a man's genitals. Conventionally, the term implies physical
contact of some kind. While it lacks specificity in some situations, it
is useful in other contexts precisely because it allows research to
proceed without limiting the scope of sexual violence. It also allows
research on sexual violence to proceed in contexts where rape and sexual
harassment are yet to be fully recognized as forms of sexual violence
(for example, marital or acquaintance rape).
Rape is most commonly discussed in the
SVAW literature, with twice as many articles dealing with rape as with
other aspects of sexual assault and six times the number of articles
dealing with sexual harassment. The existing literature clearly
distinguishes rape in terms of the relationship between women and
perpetrators. Studies of rape have been explored in more cultural
contexts, including in poorer as well as wealthy and highly
industrialized countries, than any other form of sexual violence; this
includes studies of sexual coercion by spouses (Ellsberg & Pena et
al., 1999; Coker & Richter,1998; Nair, 1997; Diah, 1996)
In cultures where rape within marriage
is not yet recognized legally, researchers and activists are finding
paths to document and address this as domestic violence. Weisman has
discussed this strategy in Israel (1993) and Bradley for Papua New
Guinea (1998). Recent studies, both qualitative and quantitative, in
Bangladesh (Khan, 2000), India (Duvvury, 2000) and Indonesia (Idrus,
1999a,b) have provided data on the prevalence of domestic violence and
sexual violence against women in the marital home. These studies have
provided insight into causal and protective factors of sexual violence,
and popular cultural understandings of SVAW. In her ethnographic
research on marital rape in Indonesia Idrus (1999a,b) explores women's
experiences and understandings of sexual violence within marriage. Her
work provides a complex analysis of the enabling influences of popular
Indonesian interpretations of women's roles and duties within Islam,
cultural notions of honor (siri) among the Bugis of Sulewesi, and how
these ideologies underlie the acceptance of marital rape in Indonesia.
A multi-site study in rural Bangladesh
found that the most common, and frequently repeated, forms of violence
against women in marital relationships were verbal abuse (reported by
40% of women), slapping (44 %), severe beating (19 %) and forced sex (15
%) (Khan, 2000). The results of this study indicated that multiple
factors were significant in triggering husband's violence: a woman's
failure to satisfy her husband's expectations in household management,
men's perception of women's deviation from gender-based roles and
responsibilities, men's dissatisfaction with their sexual relationship,
dowry demands, poverty and the economic dependency of women on men.
Increased economic independence for women, in the form of a personal
bank account, was found to be a protective factor against spousal
violence.
In India, the result of a parallel
household survey on marital violence (Duvvury, 2000) mirrors the
alarming prevalence of violence reported in the Bangladesh study. This
study confirmed that spousal violence against women was pervasive across
regions and socio-economic groups, with consistently high prevalence of
forced sex and violence during pregnancy. Most women interviewed had
experienced multiple forms of violence; 70% of women had experienced two
or more forms of physical abuse and 50% had experienced all forms of
abuse identified in the survey. Violence in the marital home frequently
operated as a means of gender subordination and there was a high level
of acceptability of violence against wives within families and
communities. Moreover, the severity of violence experienced by women did
not appear to diminish over time.
At an international level, the
assumption of women's sexual consent within marriage is being actively
challenged by the CHANGE Programme on Non-Consensual Sex in Marriage.
This programme involves a current world-wide study on non-consensual sex
in marriage that aims to compile data in various contexts on women's
experiences of violence, legal and policy contexts of SV and strategies
for preventing and resisting such violence (Sen, 2000). The formulation
of a working definition of non-consensual sex in marriage, which can be
operationalized in cross-cultural research, is a significant
contribution of this research: "A woman is subjected to
Non-Consensual Sex in Marriage by her husband if she is involved in
sexual activity either without her consent or where her consent is
obtained under coercive conditions" (CHANGE 1999). This definition
recognizes women's right to bodily integrity in contexts where rape in
marriage is not criminalized, and is inclusive of multiple forms of
non-consensual sex in marriage such as anal intercourse, oral sex,
penetration with other objects and forced masturbation (7).
In western nations, the study of date
and acquaintance rape is well-established (Foshee & Linder et al.,
1996; Lenihan & Rawlins, 1994; Ryan, 1998), although again, research
is heavily focused in educational settings. Important studies have also
been conducted on the difference in women's experiences of stranger and
acquaintance rape, and the implications of this for recovery (Koss &
Deniro et al., 1988). Women are more likely to be raped by known rather
than unknown assailants. This has strong implications for the design of
interventions for SVAW.
Popular perception is the converse
however: that is, that rape is primarily by unknown assailants. Research
on rape myths and attitudes towards rape and sexual violence in general
has also been conducted in western settings, and findings suggest that
community attitudes and behaviour have changed little even when there
have been public health campaigns and growing awareness of violence and
sexism. For example, the most recent study in Australia, conducted for
the National Crime Prevention Authority and released early May 2000,
drew attention to young men's belief in their right to sex and to the
very high prevalence of forced sex among young women. The pervasiveness
of these enabling attitudes towards male sexual entitlement has been
documented in numerous cross-cultural contexts. In the Pacific, Ali
(2000) observes that many men still believe that they have the right to
unlimited sexual access to their partners and/or any woman. Similarly,
Jewkes (2000) has identified that sexual violence in South Africa is
commonly used by men as part of strategies to control women,
particularly to control women's sexuality, and is intimately bound up
with notions of masculinity and male sexual entitlement (ibid.:10).
There is some variation across cultures
of rates of sexual violence against women (Heise et al., 1994; Sanday,
1996; WHO, 1997; 2000b). Everywhere, however, women face a
disproportionately high risk of sexual violence compared with men.
Lifetime prevalence rates of rape for women in one large study conducted
were 9.2% and rates for molestation were 12.3% (Kessler et al., 1995).
The corresponding rates for men were 0.7% and 2.8% respectively (ibid.).
Other statistically sound studies have reported that between 20% and 30%
of adult women have experienced sexual abuse and assault during their
lifetimes. In a recent study of adolescents in Cape Town, South Africa,
11% of interviewees said they had been raped and a further 72% reported
being subject to forced sex. In other areas of South Africa, surveys
have confirmed alarmingly high incidences, between 28% and 30%, of
forced sexual initiation among young women (Jewkes, 2000). As noted
above, women are most at risk of assault from those known to them such
as partners or ex-partners (American College of Obstetrics and
Gynecology, 1989; Koss & Heslet, 1992; Koss, 1994).
The increased risk of violence from an
intimate has been documented for children as well as adults. Studies on
childhood sexual abuse have consistently found children are most at risk
of abuse from family members and others known to them, who often occupy
a care-taking role (Russell, 1983, 1986; Margolin, 1992; Yama, Tovey
& Fogas, 1993). Child abuse by a relative is more likely to occur
repeatedly and over a longer period of time, than if the abuser is
someone outside the family (Russell, 1986; Brown & Anderson, 1991;
Beitchman et al., 1992; Anderson et al., 1993; Fleming, 1997).
Methodologically strong research, based on random representative
community samples, suggests that around one woman in three has had
unwanted sexual experiences before the age of 16 years (Beitchman et
al., 1992; Anderson et al., 1993; Handwerker, 1993).
Research on rape across cultures and
communities remains uneven, but the findings worldwide on the impact of
rape on women's health and well being are consistent (see following
section). They provide a valid evidence base to inform interventions
aimed at the treatment and recovery of women who experience rape and
other forms of sexual violence.
Research on the personal, societal
and family impact of SVAW
Medical and health-related research has
focused on the costs of SVAW, including the multiple short and long-term
negative physical and psychological effects. While a variety of
co-occurring adverse outcomes have been documented, the next stage in
research will require conceptually more sophisticated approaches to
decipher the precise causative and mediating factors in this complex web
of inter-relatedness to identify differences in specific negative
outcomes (Resnick, Acierno & Kilpatrick, 1997).
Multiple somatic complaints, physical
and psychological disorders and altered health behaviours have all been
documented as consequences of violence (Brown & Anderson, 1991;
Pribor & Dinwiddie, 1992; Walker & et al., 1997; Resnick,
Acierno & Kilpatrick, 1997; Roberts et al., 1999). These include:
chronic pelvic and other pain syndromes, negative pregnancy outcomes,
gastrointestinal problems such as irritable bowel syndrome and
inflammatory bowel disease, headaches, chronic fatigue and sleep pattern
disturbances, eating disorders, substance use disorders, post traumatic
and traumatic stress disorder, certain personality disorders, stress
related illnesses, suicidality and self harm, lowered self esteem,
depression, anxiety and other forms of psychological distress,
difficulties in sexual and interpersonal relationships, unsafe sex
behaviours and both delayed seeking of preventive and prenatal health
care and increased rates of emergency and primary health care
utilization and more days off work (Dietz et al., 1997; Irwin, Edlin
& Wong, 1995; Koss 1994; Koss & Heslet, 1992; Resnick, Acierno,
& Kilpatrick, 1997; Schei & Bakketeig, 1989; Walker et al.,
1995).
As noted above, the interconnections of
these multiple negative health outcomes have not been well investigated,
although violence can be seen to initiate a cascade of poor health. For
example, sexual violence impacts on women's reproductive health in
multiple ways. Unwanted and unplanned pregnancies are increased among
women living in violent situations. The coercive control exercized by a
violent partner often extends to preventing a woman from exercizing her
reproductive right to use birth control methods: women in violent
relationships experience constrained choice over family planning,
contraception and condom use (Heise et al.,1996; Kalichman &
Williams et al., 1998; Schei & Bakketeig, 1989; Wingwood &
Ralph, 1997). The experience of sexual violence has been found to
correlate with chronic pelvic pain, irregular bleeding, abnormal vaginal
discharge, painful menstruation, increased pre-menstrual distress,
pelvic inflammatory disease, and also increases the likelihood of sexual
dysfunction among women, including lack of desire, loss of pleasure,
fear of physical intimacy, and difficulty in relation to orgasm (Heise
et. al., 1995, 1999: Thelen & Sherman et al., 1998). While there is
some indication that violence against women increases with pregnancy,
high rates of violence have also been documented amongst women seeking
terminations of their pregnancies (Evins & Chescheir, 1996; Glander
et al., 1998). Women experiencing violence during pregnancy are more
likely to have poor maternal weight gain, anaemia and infections, to
give birth to a low birthweight baby and to smoke, drink alcohol and use
other drugs (with implications for their own health, that of their
unborn child, and the longer term health outcome of the child) (Parker
et al., 1994).
Mental health effects have also been
studied (Astbury, 2000), with particular attention to the incidence of
depression and suicide among women who have experienced sexual violence.
There is growing evidence that the relationship between violence and
depression is causal. This is suggested by several findings. First,
there are marked reductions in the level of depression and anxiety once
women stop experiencing violence (Campbell et al., 1998a) compared to
increases in depression and anxiety when violence is ongoing
(Sutherland, Bybee & Sullivan, 1998). Second, the severity of
violence appears to predict the severity of the psychological outcomes.
This ordinal relationship has been found in studies on the mental health
impact of family violence (Resnick et al., 1997) and of child sexual
abuse (Furgesson & Mullen, 1999). Third, case control studies have
found significantly different rates of depression and anxiety between
cases who have experienced violence, and controls who have not (Mullen
et al., 1988; Saunders & Hamberger, 1993).
Rates of traumatic and post-traumatic
stress disorder and depression are greatly increased amongst women who
have experienced violence as children, especially sexual abuse, and
among women who have experienced violence including sexual violence in
adult life (Mullen et al., 1988; Finkelhor et al., 1983; Bifulco, Brown
& Adler, 1991; American Medical Association on Scientific Affairs,
1992; Saunders & Hamberger, 1993). The relationship between women's
experiences of sexual violence and post-traumatic stress disorder
provides compelling evidence of the prevalence of this negative health
outcome among women who have experienced violence. There is need to
extend such research and widen its scope across different countries and
populations, including with respect to the psychological and
psychosocial impact as well as physical effects. The issue of
co-morbidity or co-occurring negative health outcomes for women
survivors is a relatively new area of study that will yield crucial
information on the long term consequences of SVAW and their associated
health costs.
In summary, the cumulative mental
health burden imposed by violence appears to be a function of complex
reciprocal relationships and research must be capable of elucidating
these. Kilpatrick et al's work (1997), for example, reveals not one but
several relationships between violence and substance use.
Violence interacts with the structural
determinants of women's social position. A number of earlier studies
showed that the risk of partner violence was increased when the partner
was unemployed and family income was at or below the poverty line (Hotaling
& Sugarman, 1986; Straus & Gelles, 1986; Gelles & Cornell,
1990; Reiss & Roth, 1993). O'Campo et al. (1995) demonstrated that
neighbourhood level variables related to the risk of partner-perpetrated
violence and modified individual level variables concerning the risk of
violence. Thus women living in poverty and minority women are at
heightened risk of victimization and experience higher rates of
frequent, uncontrollable and threatening life events, including
homelessness, than the general population (Belle, 1990; Browne, 1993).
Further, women who are homeless or in temporary inexpensive housing were
often subject to violence before their flight (Manderson et al., 1998);
homelessness is for many people an act of survival (Brough, 1996). In
other situations, women's decision to work and improve their financial
status and independence, is used as a justification by men for
perpetrating sexual violence against them. This is most apparent in
contexts where men perceive their interests are best served by
maintaining economic dominance over women, or the economic dependency of
their partners. In India, this dynamic was identified when rates of
reported violence were higher among employed women than those not
working for pay (Duvvury, 2000; Duvvury & Varia, 2000).
There is also increasing awareness of
the wider social impact of SVAW, with research interests expanding to
include a greater focus on the impact of SV on women's families and
communities as a whole. Women's resistance to and recovery from sexual
violence has received less attention. In researching recovery, it will
also be important to include community involvement in recovery processes
(Astbury, 2000). Recent research evidence suggests that violence can
impact negatively on women's capacity to participate fully in the paid
workforce. Women who have experienced violence have been found to take
increased time off work (WHO, 1997) Another large, prospective
longitudinal study found that women experience an increased risk for
victimization when their own income is below the poverty level and when
they are newly divorced. Violent victimization increases women's risk
for unemployment, reduced income and divorce (Byrne et al., 1999). In
other words, violence can further weaken women's social and material
position while increasing their psychological vulnerability to
depression and other disorders.
Links between sexual violence,
HIV/AIDS and reproductive health
Numerous studies have revealed how
women's sexual and reproductive autonomy may be compromized by their
fear or experiences of sexual violence (Heise et al.,1999; Khan,1998;
Petchesky & Judd, 1998). Multiple studies have determined that women
who have experienced sexual violence are at higher risk of teenage
pregnancy, unwanted pregnancy, high risk pregnancy, adverse pregnancy
outcomes and of contracting sexually transmissible diseases including
HIV/AIDS (Martin & Kilgallen et al., 1999). Much of the research
over the past decade ostensibly has been concerned with sexuality but
has focused on HIV/AIDS. Studies on sexual violence have tended to take
a broader perspective of reproductive and sexual health (Heise, 1995;
Zierler & Witbeck, 1996). This provides a useful corrective, but it
is also an interesting reflection of the way in which gender interests
have influenced the kinds of research questions examined in different
areas.
HIV/AIDS is critical to women's
experiences of sexual violence, because the risk of transmission adds an
additional layer of fear and anxiety. The risk of HIV transmission is
increased in the context of coercive sex, relative to that of consensual
sex, as physical trauma such as abrasions and cuts are more likely when
sex is forced and when the vagina is dry. Condom use is also highly
unlikely when sex is forced (Garcia-Moreno & Watts, 2000).
Garcia-Moreno and Watts (2000) have explored the links between HIV/AIDS
and VAW for a range of women. They comment on the particular
vulnerability of young women to both coerced sex and HIV infection,
noting that over half of new HIV infections world-wide are occurring
among young people between the ages of 15 to 24. In countries such as
South Africa, where forced sexual initiation is experienced by as many
as two thirds of young women, and 10% of the population has HIV, the
significance of forced sex in terms of HIV transmission cannot be over
emphasized (Jewkes, 2000). Understanding the cumulative risks of sexual
violence and HIV/AIDS for young people also requires an analysis of the
relationships between childhood sexual abuse and high risk sexual and
drug using behaviour of adult survivors. Thus, the risks of STD
transmission posed by sexual violence needed to be understood as both
long term and immediate.
Women's lack of power in negotiating
sex, whether real or perceived, underpins the risk of STD transmission
for many of the world's women in regular or spousal relationships.
Women's vulnerability to infection from partners is increased in
situations where they are unable to insist on condom use or monogamy,
and have no access to alternative protection such as the female condom.
The presumption of sex within spousal relationships, discussed above,
also reduces women's ability to negotiate safe sex in regular
relationships. For women engaged in forced prostitution, and who have
little control over their clients' behaviour, the risks of unprotected,
forced sex are also paramount. Women sex workers have also been found to
be particularly vulnerable to rape and sexual abuse in their work,
including rape by police (Jenkins, 1998).
As noted by Garcia-Moreno and Watts
(2000), sexual violence is not merely a cause of HIV/AIDS, but can also
be result of HIV infection. Women diagnosed as HIV positive are often at
risk of violence from their partners, family or community. Violence
perpetrated against women as a result, of disclosure of their HIV status
has been reported in the USA and in several African nations, including
South Africa, Kenya, Rwanda and Zambia (ibid.: 14). The risk of violence
against HIV positive women has serious implications for women's
disclosure of their status and for practices of partner notification and
needs to be further researched. The use and effectiveness of
post-exposure prophylaxis for women who have experienced forced sex is
another aspect of the links between SV and HIV/AIDS that demands further
inquiry. The recent review by Maman and Campbell et al. (2000) provides
a succinct summary of current research and literature on the
intersection of HIV/AIDS and violence against women. In particular, this
review examines how forced sex affects women's risk of HIV transmission,
how violence impacts on women's ability to negotiate condom use and
seeks to explore how the risk of violence may be grater for women who
are HIV positive - relative to women who are not. This review is based
on data gathered from 29 studies in Africa and the US, and provides
useful and plausible suggestions for the direction of future research
and interventions addressing SVAW and HIV/AIDS.
Interventions and evaluation of
interventions for SVAW
The existing literature on
interventions for SVAW focuses on those that are directed both at the
treatment and recovery of women, and those concerned with the treatment
of men who have perpetrated SVAW. From this overview of the research
literature, it is clear that the adverse health consequences of family
violence have been well described, including with respect to children
who are subject to or witnesses of violence (Fontes, 1998, Feerick &
Haugard 1999). By contrast, very little research has been undertaken on
the essential elements in recovery from family violence and optimal ways
of strengthening resilience.
Some research has been carried out on
the factors that positively mediate the relationship between childhood
sexual abuse and healthy psychological functioning in adult life (Roman
et al., 1995). There is also some work on therapeutic counseling to
reduce the traumatic stress associated with sexual violence (Resick
& Schnicke, 1992). However many of the counseling interventions,
currently used by service providers to assist women and children, have
not been rigorously evaluated. Informal sources of emotional support and
validation of the woman's experience have been shown to be significant
predictors of later health status (Ullman & Siegel, 1995). The
importance of such support underlines the critical role potentially
played by broader social attitudes in mediating outcome. Currently,
there are no standard, accepted definitions of 'recovery' from violence.
There are fewer publications on
preventative strategies, reflecting the fact that most interventions
deal with the problem of SVAW after the fact (i.e. rape crisis centers,
women's refuges) and that preventive strategies based on mass media
campaigns are difficult to evaluate. Documented interventions include
educational-based prevention programs delivered in secondary schools and
universities (Foshee, 1994; Ginorio,1998; Lloyd et al, 1994; Schmidt
& Peter, 1996), and interventions in medical settings which focus on
staff training and the capacity of clinicians (such as family
physicians) to deal with SVAW (Aylott, 1999; Burgess, 1996; Conti, 1998;
Cornell, 1998; Grandados, 1997; Harrison & Murphy, 1999; Hotch et
al.,1996). Some community interventions are described in the published
literature, including accounts produced by a staff member (Abar, 1996;
Fawcett et al.,1999; Ferris, 1994) and assessments from peer
organizations and independent researchers (Campbell, Baker et al, 1998c,
Ellis & Wight, 1997; Ellsberg, 1997b).
Less research appears to be conducted
on interventions for other aspects of SVAW, reflecting the different
roles of researchers and activists. In many instances, the people who
are best positioned to conduct or are most interested in research on
interventions are engaged in implementing them and lack the resources
and time to do research. In particular, research on small-scale
community-based interventions such as rape crisis centers, women's
shelters and community recovery groups is scarce. It has the potential,
however, to produce data to assess and design interventions and to
understand the problem of SVAW in its social context. People working in
such community-based interventions often have long-term experience and
represent considerable untapped expertise, as reflected in the Campbell,
Baker et al (1998c) study on rape crisis centers and Coulter and Kuehnle
et al. (1999) on domestic violence shelters. In their review of
community services for rape survivors, Campbell and Ahrens et al.
(1998b) also provide important insights into the successes and
limitations of community responses to SVAW.
The links between research,
interventions, and the monitoring and evaluation of interventions can be
appropriately strengthened by developing an agenda for action research
on SVAW. The benefits of integrating evaluation and monitoring
procedures within interventions targeted at SVAW is demonstrated by the
current IPPF intervention directed at addressing gender based violence
through the services of family planning associations. This initiative of
the IPPF Western Hemisphere Regional Office is being implemented in
family planning services in the Dominican Republic, Peru and Venezuela.
Monitoring and evaluation are a vital component of this intervention,
enabling the development of common screening tools, protocols and
guidelines, the comparison of experience between the participating
family planning associations. On-going evaluation has confirmed the
success of the intervention tolls by identifying an increase of 44% in
the number of clients reporting one or more forms of gender violence to
family planning providers in Venezuela (Otoo-Oyortey, 2000).
Law and policy addressing SVAW
There is a substantial literature on
legal aspects of SVAW and the sociology of law. Much of this literature
is written technically for legal experts, and is engaged in documenting
current developments in legal progress and in maintaining constant
criticism of the adequacy of legislation and legal institutions to deal
with SVAW. Another focus of legal studies is on educating people in the
legal profession about how to relate to and work with women who have
experienced sexual violence (Konrandi, 1996; Sandrick, 1996). Women's
experiences of secondary victimization in the legal system are also
documented (Bryne and Kilpatrick et al., 1999; Chesney-Lind, 1999; Eskow,
1996; Hudson, 1998). The continuing problem of defining sexual violence
is constantly debated, and the progress in prosecuting crimes using
different definitions is documented (Weiner & Hurt et al., 1997).
Again, this literature is heavily concentrated in western settings,
although major legal battles over SVAW and legislative gains are
commonly published in popular journals in most countries. The
involvement of the legal professions in researching both the legality of
sexual crimes against women, and women's experiences of legal systems,
needs to continue to be encouraged and funded. In particular, more
research needs to be conducted on the impediments women face in giving
evidence in court, the lack of law enforcement against perpetrators, the
inadequate penalties for SVAW, and the usefulness of protection orders.
Research into policy on SVAW tends to
be conducted by government agencies. As a result, much information about
policy at local and national levels is not widely distributed or
published for public access; that is, government documents often remain
confidential. Further research into thE comprehensiveness of the policy
environment influencing sexual violence, and the need for and benefits
of multi-sectoral approaches to SVAW is warranted. Such research would
ideally involve sectors such Health and Welfare, Education, Legal,
Police/Law enforcement, Prisons, Immigration, Employment,
Defense/Military, Housing, Foreign Affairs/Trade, Finance, Rural
Development and Industry. The effectiveness of national policies that
respond to the problem of SVAW will clearly be greater when they are
underpinned by research, formulation and evaluation or the roles of
multiple sectors.
Policy developed at the international
level tends to be more readily available, particularly via the internet,
and so is better distributed. In order to promote policy reform and the
successful implementation of policy to prevent SVAW, there needs to be
wider involvement in formulating such policy, greater accountability and
wider access to policy documents. At local and national levels,
comprehensive research into policy environments will ensure that policy
addressing SVAW takes into account the social and cultural context of
communities, so that it is in effect "home grown".
Theoretical frameworks and the
etiology of SVAW
Quantitative research on sexual
violence is particularly weak in theoretical development. This may
reflect its concentration on measuring sexual violence; however the
hypotheses underlying this research and the theoretical assumptions
which inform survey questions need to be made more explicit and further
developed. It is also important for researchers to remain mindful of the
fact that cross-sectional studies do indicate causality, and to avoid
extracting theories of causation from such studies without real basis or
without the triangulation of complementary data obtained via other
methods.
While there is greater attention to
theoretical questions in qualitative research, reflecting the explicitly
interpretative nature of the research, a large number of studies were
descriptive rather than analytic and failed to fully theorize their
findings. While rigorous and useful theoretical work on SVAW does exist
(Bograd, 1990; Herman, 1992; Hammill, 2000; Schwartz, 1997), theoretical
approaches to understanding SVAW and its etiology need greater
attention. Many of the popular theoretical frameworks simplify and/or
universalize the etiology of sexual violence. While these models are
useful as polemic and raise awareness among readers, they should not be
accepted without criticism. There have been a number of recent
developments in the definition of different forms of sexual violence,
including the inclusive definition of non-consensual sex in marriage,
discussed above. Jewkes (2000) has also developed a sophisticated model
of different forms of SVAW in order to understand the epidemiology of SV
in South Africa, which takes into account both the visibility and nature
of various forms of violence, and the type of coercion employed in
different acts. This model, referred to as the Iceberg of Sexual
Coercion, includes: fatal sexual assault; rape reported to police; rape
reported in surveys; rape not reported due to shame or fear of blame;
forced sex in marriage and dating relationships; unwanted sex agreed to
as a result of pleading, blackmail, threats or trickery; and the sexual
exploitation of minors. At the tip of this iceberg are the forms of
violence which become visible and most readily quantifiable, such as
fatal sexual assault and rapes reported to the police. However, these
visible crimes are considered to be a small proportion of all sexual
violence perpetrated against women, and the most common forms of
violence that occur within marriages, dating relationships and families
are the least visible. These invisible crimes, and the silenced women
who survive them, represent the vast majority of sexual crimes committed
against women and occupy the lower levels of the iceberg which are never
reported in surveys or to the police.
There is an absence of theory focusing
on the social construction of gender and sexuality in research on SVAW,
and little attention to the links between SV and sexuality (e.g., see
Manderson et al. 1999). Women's studies literature and research into
masculinity are the exceptions to this (Connell, 1995; Gilmore, l990).
Researchers and activists have asserted the need for positive
conceptualizations of sexual rights, in the context of research into
sexual violence, that not only recognize women's right to freedom from
violence and coercion, but also their right to pleasure, sexual
expression and love (GFHR, 2000). The position of women as sites of
expert knowledge on SV needs to be considered routinely in theorizing
SVAW. Theorizing women's experiences and resistance of SV requires us to
affirm commonalities between women, and to value and celebrate
difference. The diversity we need to consider in our conceptualizations
of SVAW including differences in women's life cycle, age, sexual
preference, race and ethnicity, socioeconomic class, religion, ability
and/or disability, and whether women live in urban, rural or remote
areas.
Links between sexual violence and other
forms of VAW are widely accepted, but remain under theorized and deserve
continued attention. The lack of cross-disciplinary research has
arguably constrained theoretical developments. Cross-disciplinary
dialogue, in which a range of vocabularies, concepts and frameworks are
exchanged, has the potential to generate more theoretically oriented
enquiry into SVAW. Feminist activists and researchers in particular have
been engaged in critiquing the vocabularies used in fields such as
public health and epidemiology, that are pervaded by medicalized
terminology. They suggest alternative terms that are sociocultural and
not primarily medical in derivation, such as engagement rather than
intervention, and healing, survival or empowerment rather than recovery
(GFHR, 2000). The explicit recognition of human rights, and
incorporation of a human rights vocabulary, in the design and
implementation of research has also been strongly advocated by many
women active in the fields of researching SVAW and human rights (GFHR,
2000).
Methods and ethical issues in
research on sexual violence against women
Quantitative (survey) methods dominate
this field, although the instrumentation of the research usually is not
published. The research tools that were described often summarized
women's responses in technical language and variables. Quantitative
tools need to be informed by qualitative research into the ways in which
women define and experience sexual violence. Researchers such as
Campbell and Rose et al. (1998a) have demonstrated the benefits of
careful study design in their contextual and longitudinal study of
women's responses to violence. In her national study of US college
students, Mary Koss (1989) emphasized the importance of gathering
scientifically defensible estimates of violence against women through
the careful design of research questions and tools that take into
account the full range of experiences and behaviours of the respondents.
Researchers such as Koss (International Seminar on Sexual Coercion and
Reproductive Health 1993 cited in Heise et al. 1995) and Smith (1994)
have demonstrated that by asking multiple, behaviour-specific questions
when probing for incidences of sexual violence, respondents' recall and
responses are much higher than when simple yes/no questions are asked,
or when general questions such as, "have you ever been raped or
sexually abused?" are asked.
Information on the epidemiology of
sexual violence against women needs consolidation. Large-scale
prevalence surveys are important tools for mapping the magnitude of the
problem and identifying which women are most at risk of sexual violence
in different cultures and communities. Accurate estimates of the extent
of SVAW are critical to break the silence and myths that surround sexual
violence against women, and to gain political support for action at
local, national and international levels. Data derived from this kind of
research is useful in planning and lobbying for resources for the
prevention and treatment of SVAW.
The balance of qualitative and
quantitative research into SVAW must also be addressed. Ethnographic and
narrative methodologies appear under-utilized (Sleutel, 1998), arguably,
as a result of the dominance of psychology as the primary social science
discipline of enquiry and also because of the difficulties in conducting
and presenting ethnographic data (Hammill, 2000). Ethnographic studies
such as the George et al (1995) study of sexuality among poor women in
Bombay, Mary Ellsberg's study (1997a) of domestic violence against women
in Nicaragua, and Anne-Marie Hilsdon's study (1992) of gender violence
in the Philippines, provide rich detail of the social context of SVAW
and the ways that women resist, suffer and recover from such violence.
Qualitative research produces in-depth data about how women experience
and define sexual violence, how they resist and recover from such
violence, and how their perspectives and experiences vary across
different communities and cultures (Kelly, 1990).
In addition, a number of publications
deal specifically with using multiple methods to research sexual
violence. These tend to be academic in their orientation, available only
in English, and not widely distributed (Schwartz, 1997). Published works
on sexuality, domestic violence and VAW in general also embody many
relevant insights for the study of SVAW. The demand for practical, easy
to use guides on methodology and ethics for researching SVAW is now
being widely expressed, particularly in resource-poor settings. Such
guides may well take the form of manuals that can be used for designing
and implementing projects, monitoring and evaluating research and
interventions, and to train researchers in this field. These manuals
need to address methodological and ethical issues particular to the
cultural, economic and historical context of communities in which
research is being conducted. This approach has been used with some
success to develop national HIV/AIDS programs (Manderson et al., 1997),
and has been advocated for family planning and reproductive health
purposes (Manderson, 1997). A draft manual, Researching Violence Against
Women: A Practical Guide for Researchers and Advocates, has been
developed by the Centre for Health and Gender Equity and WHO and is
currently under review (8). While this
manual focuses on VAW in its broader context, it has been developed by
researchers with many years of experience in dealing with both sexual
and other forms of violence perpetrated against women, and is highly
suited for research into SVAW. The manual provides a conceptual
framework for researching violence, and discusses the health,
development and ethical implications of doing so. The manual also gives
detailed consideration to the development of research strategies and the
logistics of conducting both qualitative and quantitative research. It
also includes practical information on training for researchers, various
instruments for measuring violence, informed consent, data analysis and
the relationship between research and action on VAW.
Ethical issues are complex. In part,
they relate to the importance of maintaining the privacy of women's
experiences of sexual violence and confidentiality of the information
collected. Failure to ensure privacy can not only cause women to suffer
further embarrassment and social stigma, but can put them in direct
danger of further abuse, experienced most dramatically in the case of
honor killings (Ben Baraka cited in Heise et al., 1995). Miller and
Miller et al. (1999) have problematized the conflict that arises between
reporting crimes and respecting women's privacy in the case of women who
have experienced statutory rape in the USA. Researcher's awareness of
the need for privacy is now beginning to be translated into the design
of research methodology. In a recent household survey on violence
against women in the marital home, conducted in seven Indian cities,
strict guidelines were followed to assure women of the privacy of
interviews. This involved ensuring that only one women per household was
interviewed, and that interviews were temporarily ceased in the case of
interruption. The successful application of these ethical guidelines was
confirmed by a follow-up survey, which confirmed less than 1% of women
reported an incidence of violence as result of the survey, and in all
cases where the survey appeared to have provoked violence, the women had
divulged the subject matter of the survey to their husbands (Duvvury,
2000).
Lack of privacy also compromises the
quality of data, as women are most likely to disclose details of
difficult and painful experiences when they have the full attention and
support of the researcher. In addition to the risks involved for
respondents if privacy is not maintained, researchers may also be in
threat of violence if they are too open about the research, particularly
if the perpetrators of violence fear exposure or reprimand. In some
contexts research on sexuality, or even research that challenges the
exclusivity of male power over women in marriage, can be viewed as
inherently threatening and shameful. Consequently, women who choose such
work can be labeled as immoral and considered valid targets for sexual
violence themselves. For instance, Jennifer Huff (1997) discusses the
status of female researchers, and common assumptions of our
"incompetence and powerlessness". She explores how the
identities of female researchers can leave us particularly vulnerable to
sexual harassment when researching sexual violence. Huff also explores
the complexities of maintaining rapport with informants whilst being
assertive and self-protective, and offers potential strategies for
limiting inappropriate behavior and sexual harassment in research
contexts.
The secondary victimization of women
who participate in research, or seek treatment or legal redress for
violence, also raises core ethical issues (Campbell & Raja, 1999).
The imperative of avoiding re-traumatization is an issue shared among
many who come into contact with women who experience sexual violence. We
need to address how ethics must operate in multiple contexts, not simply
in the interaction between researchers and women (Cain, 1992). The issue
of trauma is also pertinent for women researchers, who are considered to
be at high risk of vicarious trauma (Huff, 1997; Schauben & Frazier,
1995; Stanko, 1997). Stanko (1997) provides a nuanced discussion of the
emotionality of women's experiences of researching sexual violence. She
rejects the ideal of objectivity and argues that it is not possible to
detach ourselves from our research or its consequences. Stanko (1997)
acknowledges how the emotions of anger, grief, shock, trauma and fear
for our respondents and ourselves are common experiences for researchers
in this field. She argues that these emotional consequences can best be
managed when they are recognized and dealt with. Another issue is that
of the ethical considerations that arise when research occurs in
cross-cultural contexts, where the values and beliefs of researchers'
may diverge greatly from those of the women with whom they are working (Fontes,
1998). A question that straddles both ethical and methodological debates
is men's involvement in research on SVAW, and the importance of gender
in the researcher/informant relationship.
While individual researchers, and a
growing number collaborative projects, give ethical issues due
consideration, extensive ethical guidelines for SVAW research still need
to be ratified and adopted as standard practice. Researchers in the
fields of anthropology and women's studies have been particularly
engaged in reflexive activity and have published discussion of the
ethics of their own research. In terms of collective efforts to address
ethics issues, an important step was taken at the Seminar on Sexual
Coercion and Reproductive Health in 1993, where "10 Principles to
Guide Research on Sexual Coercion" were developed by this group (Heise
et al., 1995). These guidelines represented significant progress, but
they lack detail and were formulated specifically in relation to sexual
coercion within marriage. Further progress has been made by the
collaborative development of the WHO ethical and safety guidelines for
researching violence against women: Putting Women First: Ethical and
Safety Recommendations for Research on Domestic Violence Against Women.
These guidelines provide a detailed and practical tool for the design
and implementation of research that safeguards women participating in
research on violence, and researchers in this field.
Core assertions addressed in these
guidelines include: the safety of respondents and the research team is
paramount, and should infuse all project decisions; prevalence studies
need to be methodologically sound and to build upon current research
experience about how to minimize the under-reporting of abuse; and
protecting confidentiality is essential to ensure both women's safety
and data quality. The document also addresses key roles and
responsibilities of researchers, stating that research team members
should be carefully selected, receive specialized training and on-going
support. The study design should incorporate strategies aimed at
reducing any distress caused to women by the research. Moreover,
fieldworkers should be trained to refer women requesting assistance and
where few resources exist, the study should create short-term support
mechanisms. The guidelines further specify the ethical obligations of
researchers and donors to ensure that research findings are properly
interpreted and used to advance policy and intervention development.
Finally, the ethical and methodological requirements of incorporating
violence questions into surveys designed for other purposes, are
addressed. These guidelines were initially prepared in the context of
preparation of the World Health Organization Multi-Country Study on
Women's Health and Domestic Violence and are being tested through the
implementation of this study (Garcia-Moreno, 2000) (9).
While these guidelines have been prepared for research into domestic
violence, their comprehensiveness clearly encompasses the cores issues
faced when conducting research on SVAW, and their suitability for such
research were debated and agreed upon by participants at the recent
Consultation on Sexual Violence Against Women.
Conclusion: Gaps in existing research
and challenges in researching SVAW
The above account has mapped the fields
of current inquiry into sexual violence against women, and provided some
idea of the gaps that presently exist. As noted, the literature is
weighted towards the USA, towards opportunistic populations and
particularly youth enrolled in tertiary institutions, and towards rape.
Conversely, we know little of the pervasive, diffuse and corrosive forms
of sexual violence that occur on an everyday basis among those familiar
with each other and among strangers - explicit photographs, unwanted
touches, insinuations, jokes, allusions, and pressures to which women
everywhere are subjected epidemically and routinely. We know little of
class and regional differences, and little of how some communities may
be able to inhibit sexual harassment and assault without sequestering
women. And we know little - and understand little - about sexual
violence in most countries of the world, and hence of its impact on most
women subjected to it.
A first step is to promote a research
agenda that will address the geographical unevenness of research on SVAW,
and recognize and assist countries and communities which have very
limited resources available for research. Short-term training courses
have proved a valuable means to supplement local research capability,
but the ethical issues implicated in this research means that this
cannot be achieved simply. There is also a need to expand the
populations recruited to participate in research on SVAW, to stretch the
research agenda beyond its existing focus on women who seek treatment
for sexual violence, perpetrators and students. All women are at risk
and therefore are potential participants in research; and women who are
at treatment centers are only a subset of those who have been raped,
abused, threatened or embarrassed. The families of women who experience
sexual violence are an important group to be included in research,
although an exclusive focus on children who have been witness to their
mothers' abuse also distorts the sample and overlooks how violence, more
broadly, may inhibit interpersonal relations including ways of
mothering.
Areas for potential public health
intervention have for some decades drawn attention to the need to
involve, consult with, or establish the participation of communities, on
the grounds that their participation establishes an
"ownership" of the project which will ensure its
sustainability. While this is not necessarily true where a program
requires capital outlay as well as commitment, a move to eliminate SVAW
relies primarily on attitude and people's ability to change it.
Community involvement in operations research, in terms of prevention and
recovery from SVAW, is one way to draw attention to the prevalence and
social and personal costs of sexual violence, by which means it might be
expected that the community would take on the challenge of a local
response.
We have argued the value of research
manuals or a rapid assessments toolkit to identify the need for
interventions. Specific and comprehensive ethical guidelines for
research on SVAW, such as the WHO Ethical and Safety Guidelines, need to
be ratified and made widely available. Research needs to be informed by,
and engaged in, producing more sophisticated theories of the etiology of
sexual violence, women's experiences of sexual violence and
interventions for sexual violence. The balance of qualitative and
quantitative research needs addressing. While there are political
advantages in establishing prevalence, it seems important too for more
nuanced studies that examine the interpersonal dynamics of sexual
violence, and the various meanings that women, perpetrators and the
wider community attribute to such violence. Moreover, cross-sectional
studies that establish prevalence cannot provide the crucial insight
needed into the etiology of violence that is needed for interventions
aimed at prevention and elimination of SV in different social and
cultural milieus.
In addition to supporting more
qualitative research, we advocate greater use of research models that
utilize a mix of methods and triangulation of methods. Greater focus is
needed on co-morbidity, recovery and women's resistance to such
violence. Women's own perspectives on sexual violence need to be made
central to the design of research. In this context, new approaches being
taken by the social sciences in health research, for instance the notion
of sexual violence as an embodied experience may prove valuable,
improving our understanding of the ways in SV impacts upon women's
corporeality and identity. The social construction of sexuality and
gender need to be considered more widely and in more depth when
researching SV. Sexual violence is about sex and power, not just power,
but researchers have tended to avoid dealing with sex directly. This is
relevant not in terms of male motivation to rape, but it is relevant to
this agenda with respect to a woman's need to heal, and her ability to
weave around the episode of sexual violence that has left her feeling
humiliated, frightened, denigrated and maligned.
Comparative research would be valuable
in exploring the overlapping issues of etiology, intervention and
recovery. This could be conducted with multiple populations and/or
cross-culturally. All forms of sexual violence against women need to be
given consideration in research agenda's, not merely those forms that
are most visible, as all form of SV are criminal acts and involve the
violation of women's right to freedom from violence. In particular,
sexual harassment needs more attention in terms of research and needs to
be recognized as a serious form of sexual violence against women. The
links between different forms of VAW and SV, that are so often co-occuring
for women who experience abuse, also deserve on-going attention.
Research on interventions for SVAW, and the evaluation and monitoring of
those interventions, is key and needs to be promoted in research
agendas. This reflects the need to strengthen links between research and
interventions, so that research conducted on sexual violence directly
contributes to its reduction, to women's recovery, and to the long term
goal of eliminating sexual violence against women.
1.
The Consultation was held at The University of Melbourne,18-20 May 2000,
hosted by the Key Centre for Women's Health in Society, under the
auspices of the Global Forum for Health Research. This review is
informed by papers presented at the Consultation and by comments of
consultation participants.
2.
The scope of the review was set using the key terms SEXUAL VIOLENCE -
WOMEN. Using this search terminology, we focused our review more
specifically on the literature dealing with sexual harassment, sexual
assault, and rape by known/unknown assailants or spouses. Core sources
searched include six electronic data-bases: Proquest, Expanded Academic,
Medline, Web of Science, Current Contents and Voice of the Shuttle. Each
database was searched for entries from 1995 onwards, and Medline was by
far the most useful resource with the greatest number of relevant
entries. Two international bibliographies were also searched: the WHO
Bibliographic Database on Violence Against Women (WHO, 2000) on line (http://www.who.int/violence_injury_prevention/pages/)
and the WHO Annotated Bibliography on VAW: A Health and Human Rights
Concern (WHO, 1999). While the electronic searches were limited to a
five year time span, in this review we included relevant literature from
outside of this time frame where it focused on developing countries, or
was considered to be a key text in the field of SVAW. For example, key
texts included work by Brownmiller (1975), Dobash and Dobash (1979),
French (1992), Russell (1990) and Sanday (1981,1996).
3.
Bennett, L.R., Singer, M and J. Canon. 2000. Sexual Violence Against
Women: A Working Bibliography - Consultation on Sexual Violence Against
Women (CD-ROM). Geneva: Global Forum for Health Research.
4.
Frequently referenced journals include: Journal of Family Violence,
Journal of Interpersonal Violence, Psychology of Women Quarterly, Social
Science & Medicine, Violence and Victims, Violence Against Women,
Women Studies International Forum, Women's Studies Quarterly, Sexual
Abuse: A Journal of Research and Treatment, American Journal of
Community Psychology, American Journal of Emergency Medicine, American
Journal of Obstetrics and Gynaecology, Archives of Sexual Behaviour,
Archives of Psychiatric Nursing, Behavioural Medicine, International
Journal of Gynecology & Obstetrics, JAMA-Journal of the American
Medical Association, Journal of Anxiety Disorders, Journal of Consulting
and Clinical Psychology, Journal of Emergency Nursing, Journal of Sex
Research, Journal of Social Psychology, Journal of Women's Health,
Lancet (medical journal), Medicine & Law, Sex Roles: A Journal of
Research.
5.
A total of 84 countries are represented in the literature review for
this publication and are listed below by region.
AFRICA: Botswana,
Ethiopia, Central African Republic, Kenya, Namibia, Nigeria, Rwanda,
Senegal, Sierra Leone, South Africa, Sudan, Tanzania, Trinidad
&Tobago, Uganda, Yemen, Zambia and Zimbabwe.
ASIA: Bangladesh,
Cambodia, China, East Timor, Hong Kong, India, Indonesia, Kashmir,
Korea, Malaysia, Pakistan, Philippines, Singapore, Sri Lanka, Thailand
and Vietnam.
CENTRAL & SOUTH
AMERICA &THE CARIBBEANS: Argentina, Barbados, Bolivia, Brazil,
Chile, Columbia, Costa Rica, Dominican Republic, Ecuador, El Salvador,
Grenada, Guatemala, Haiti, Jamaica, Mexico, Nicaragua, Peru, Puerto
Rico and Venezuela.
EUROPE:
Countries with references in this region include: Bosnia, Croatia,
Denmark, England, Finland, Former Yugoslavia, France, Germany,
Hungary, Iceland, Ireland, Norway, Poland, Russia, Scotland, Serbia,
Sweden, and Switzerland.
MIDDLE EAST: Egypt,
Israel, Kuwait, Lebanon, Palestine, Saudi Arabia and Turkey.
NORTH AMERICA: Canada,
United States of America (including Hawaii).
PACIFIC: Australia,
Fiji, New Zealand, Papua New Guinea and Vanuatu.
6. To link to the WHO
Database on Violence Against Women go to: http://www.who.int/violence_injury_prevention/
7. Other key definitions
developed parallel to that of non-consensual sex in marriage include,
definitions of sexual activity, consent and rape in marriage. These
definitions are accessible via internet at: http://www.ncsm.net/ncsm-briefing/definitions.html
8. Ellsberg, M., L.
Heise, and E. Shrader. (n.d.). Researching Violence Against Women a
Practical Guide for Researchers and Advocates (Draft only), Geneva:
Center for Health and Gender Equity, WHO.
9. The WHO Ethical
and Safety Recommendations for Research on Domestic Violence Against
Women (WHO/EIP/GPE/99.2) are available from WHO. |
