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Mapping a Global Pandemic: Sexual Violence Against Women

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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




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.


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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.

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