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Excerpt from ‘The World Report on Violence and Health’, WHO Publications, Geneva, 2002; (Edited by Etienne G. Krug, Linda L. Dahlberg, James A. Mercy, Anthony B. Zwi, and Rafael Lozano. Used by permission. Full text available at the WHO website. From the chapter, ‘Sexual Violence’.

Background: Sexual violence occurs throughout the world. Although in most countries there has been little research conducted on the problem, available data suggest that in some countries nearly one in four women may experience sexual violence by an intimate partner (1–3), and up to one-third of adolescent girls report their first sexual experience as being forced (4–6). Sexual violence has a profound impact on physical and mental health. As well as causing physical injury, it is associated with an increased risk of a range of sexual and reproductive health problems, with both immediate and long-term consequences (4, 7–16). Its impact on mental health can be as serious as its physical impact, and may be equally long lasting (17–24). Deaths following sexual violence may be as a result of suicide, HIV infection (25) or murder – the latter occurring either during a sexual assault or subsequently, as a murder of ‘‘honour’’ (26). Sexual violence can also profoundly affect the social wellbeing of victims; individuals may be stigmatized and ostracized by their families and others as a consequence (27, 28). Coerced sex may result in sexual gratification on the part of the perpetrator, though its underlying purpose is frequently the expression of power and dominance over the person assaulted. Often, men who coerce a spouse into a sexual act believe their actions are legitimate because they are married to the woman. Rape of women and of men is often used as a weapon of war, as a form of attack on the enemy, typifying the conquest and degradation of its women or captured male fighters (29). It may also be used to punish women for transgressing social or moral codes, for instance, those prohibiting adultery or drunkenness in public. Women and men may also be raped when in police custody or in prison. While sexual violence can be directed against both men and women, the main focus of this chapter will be on the various forms of sexual violence against women, as well as those directed against young girls by people other than caregivers.

How is sexual violence defined? Sexual violence is defined as: any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work. Coercion can cover a whole spectrum of degrees of force. Apart from physical force, it may involve psychological intimidation, blackmail or other threats – for instance, the threat of physical harm, of being dismissed from a job or of not obtaining a job that is sought. It may also occur when the person aggressed is unable to give consent – for instance, while drunk, drugged, asleep or mentally incapable of understanding the situation. Sexual violence includes rape, defined as physically forced or otherwise coerced penetration – even if slight – of the vulva or anus, using a penis, other body parts or an object. The attempt to do so is known as attempted rape. Rape of a person by two or more perpetrators is known as gang rape. Sexual violence can include other forms of assault involving a sexual organ, including coerced contact between the mouth and penis, vulva or anus.

Forms and contexts of sexual violence: A wide range of sexually violent acts can take place in different circumstances and settings. These include, for example: — rape within marriage or dating relationships; — rape by strangers; — systematic rape during armed conflict; — unwanted sexual advances or sexual harassment, including demanding sex in return for favours; — sexual abuse of mentally or physically disabled people; — sexual abuse of children; — forced marriage or cohabitation, including the marriage of children; — denial of the right to use contraception or to adopt other measures to protect against sexually transmitted diseases; — forced abortion; — violent acts against the sexual integrity of women, including female genital mutilation and obligatory inspections for virginity; — forced prostitution and trafficking of people for the purpose of sexual exploitation.

There is no universally accepted definition of trafficking for sexual exploitation. The term encompasses the organized movement of people, usually women, between countries and within countries for sex work. Such trafficking also includes coercing a migrant into a sexual act as a condition of allowing or arranging the migration. Sexual trafficking uses physical coercion, deception and bondage incurred through forced debt. Trafficked women and children, for instance, are often promised work in the domestic or service industry, but instead are usually taken to brothels where their passports and other identification papers are confiscated. They may be beaten or locked up and promised their freedom only after earning – through prostitution – their purchase price, as well as their travel and visa costs (30–33).

The extent of the problem: Data on sexual violence typically come from police, clinical settings, nongovernmental organizations and survey research. The relationship between these sources and the global magnitude of the problem of sexual violence may be viewed as corresponding to an iceberg floating in water (34) (see Figure 6.1). The small visible tip represents cases reported to police. A larger section may be elucidated through survey research and the work of nongovernmental organizations. But beneath the surface remains a substantial although unquantified component of the problem. In general, sexual violence has been a neglected area of research. The available data are scanty and fragmented. Police data, for instance, are often incomplete and limited. Many women do not report sexual violence to police because they are ashamed, or fear being blamed, not believed or otherwise mistreated. Data from medico-legal clinics, on the other hand, may be biased towards the more violent incidents of sexual abuse. The proportion of women who seek medical services for immediate problems related to sexual violence is also relatively small. Although there have been considerable advances over the past decade in measuring the phenomenon through survey research, the definitions used have varied considerably across studies. There are also significant differences across cultures in the willingness to disclose sexual violence to researchers. Caution is therefore needed when making global comparisons of the prevalence of sexual violence.

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