SEXUAL AND GENDER BASED VIOLENCE IN AFRICA

ACKNOWLEDGEMENTS
We would like to thank Ms Victoria Rumbold, a consultant to the Population Council, for researching and preparing this review. Several members of the Council’s Sexual and Gender Based Violence partnership made valuable contributions of advice and information. We gratefully acknowledge the Swedish Norwegian (S-N) Regional HIV & AIDS team in Africa for providing funding for the literature review.

Acronyms
AIDS Acquired Immuno-deficiency Syndrome ART Anti-retroviral Therapy ARV Anti-Retrovirals BCC Behaviour Change Communication CBD Community-Based Distributor DHS Demographic and Health Survey DTC Diagnostic Testing & Counselling EC Emergency Contraception ECP Emergency Contraceptive Pill ECSA Eastern, Central and Southern Africa FGM/C Female Genital Mutilation/Cutting FPC First Point of Contact GAA Global AIDS Alliance GVRC Gender Violence Recovery Centre HIV Human Immuno-deficiency Virus HRW Human Rights Watch IASC Inter Agency Steering Committee IFPP International Family Planning Perspectives IGWG Interagency Gender Working Group IPV Intimate Partner Violence IPPF International Planned Parenthood Federation LVCT Liverpool Voluntary Counselling and Testing MAP Men as Partners MSM Men who have Sex with Men NASCOP National Aids & STDs Control Programme NGO Non Governmental Organisation PEP Post Exposure Prophylaxis PRC Post Rape Care RADAR Rural AIDS and Development Action Research Programme RHRCC Reproductive Health Response in Conflict Consortium
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SGBV Sexual and Gender-Based Violence STI Sexually Transmitted Infection TVEP Thohoyandou Victim Empowerment Trust UNFPA United Nations Fund for Population Activities UNGA United Nations General Assembly UNHCR United Nations High Commission for Refugees VCT Voluntary Counselling and Testing VEP Victim Empowerment Programme WHR Western Hemisphere Region
WHO World Health Organization
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Introduction
Sexual and Gender Based Violence (SGBV), in its various forms, is endemic in communities around the world, cutting across class, race, age, religion and national boundaries. Exposure to gender-based violence and sexual coercion significantly increases girls’ and women’s chances of early sexual debut, experiencing forced sex, engaging in transactional sex, and non-use of condoms. The impact of sexual and gender-based violence resonates in all areas of health and social programming: survivors of sexual violence experience increased rates of morbidity and mortality, and violence has been shown to exacerbate HIV transmission, among other health conditions (IGWG of USAID, 2006). While girls are the most visible survivors of sexual violence, they are far from being the only ones who suffer from the consequences: children of both sexes constitute the majority of abuse survivors, and adult men and the handicapped are minority groups who are often neglected in research and interventions. There is growing awareness of the links between sexual and gender-based violence, health, human rights and national development in East, Central and Southern Africa (ECSA). However, there are few programmes that simultaneously address the determinants and consequences of SGBV in an integrated and comprehensive manner, with responses being implemented separately by the NGO and public sectors, and by separate line ministries within national governments. In addition to this, few guidelines or frameworks exist to guide policymakers and programme managers in developing and implementing the comprehensive response necessary to address the health and criminal justice consequences of violence, and to reduce the determinants of violent behaviour within communities. Moreover, in most situations, organizations and ministries are undertaking activities without reference to or liaison with other key actors and networks within their country or more widely in the region. Objectives of the review This literature review is intended to inform partners in the Population Council-coordinated regional network that aims to develop a multi-sectoral and comprehensive response to SGBV in Eastern, Central and Southern Africa. The review is structured around seven components collectively designed to meet the medical, psychological and justice needs of survivors of sexual violence. The components consist of a comprehensive review of region-specific policies, programmatic experiences and best practices relating to the appropriate medical management of sexual violence, enabling effective criminal justice responses to all SGBV cases, and the reduction of levels of violence at the community level. Scope and limitations The review aims to synthesise published and unpublished literature on the relevant aspects of SGBV. There are certain limitations:
 Firstly, this review aspires to contextualise the specific components of the SGBV partnership programme. Lateral aspects of SGBV, such as violence in conflict settings and female genital mutilation/cutting (FGM/C), are deliberately not explored.
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 Secondly, this review has a specific purpose: to inform the SGBV partnership. There are a number of existing literature reviews on post rape care (PRC) and interventions for survivors of sexual violence, which have collectively proved a valuable resource for this review. While this review may indicate gaps in research or programming, it is not the primary objective.
 Thirdly, the review focuses on evidence from Eastern, Central and Southern Africa, with material from outside the region used only where deemed relevant in the African context.
 Finally, the review aims to synthesise the findings from evidence-based interventions. However, there is little published evidence on many aspects of the framework, especially those outside medical management. The relative absence of well-designed and monitored research interventions conducted in resource-poor settings indicates a critical need for monitoring and documentation of SGBV programmes in the ECSA region.
Structure of the review The review is envisaged as an information resource to enable the development of a comprehensive model of care, support and prevention that partner countries can adapt, as a whole or as particular components. The seven components are presented in Box 1:
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The review is divided into four thematic sections, into which the seven programmatic components are classified:
1. Characteristics of sexual and gender-based violence and of survivors of sexual violence
2. Medical and psychosocial management
3. Forensic and judicial aspects of sexual violence
4. Developing institutional and community linkages
The first section defines the terminology used throughout the review, and discusses the prevalence and consequences of SGBV. It considers the implications of the disproportionate programmatic focus on adult women survivors, and explores approaches to managing child and male survivors of sexual violence. The second section presents regional policies and programming relating to the medical and psychosocial management of survivors. The third section discusses the forensic, referral and judicial requirements of successful prosecutions. It examines the necessary constituents of a “chain of evidence”, and the prevalence and characteristics of referral linkages between institutions. The fourth section considers the role that community and institutional linkages play in the prevention of SGBV, and examines the extent to which violence is addressed through messages communicated during prevention strategies, and through routine screening.
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1. Characteristics of Sexual Violence and Survivors of Sexual Violence
1.1 WHAT IS SEXUAL AND GENDER BASED VIOLENCE?
There is no single or universal definition of gender-based or sexual violence. Understandings differ according to country, community and legal context. For instance, prevalent definitions of sexual violence exclude children. The lack of a clear and commonly accepted language inhibits the development of an effective reporting system and/or databases, and thus restrains prevention, monitoring and advocacy efforts1 (Baker, 2007). The term sexual and gender based violence, in its widest sense, refers to the physical, emotional or sexual abuse of a survivor. This review focuses exclusively on the sexual elements of abuse, and discusses the management of physical and emotional abuse only where it relates to accompanying sexual abuse. The classification of violence and abuse is explored in more detail in Annex 1. This document adopts the inclusive terminology employed by the World Health Organization, which defines sexual violence as “any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic women’s sexuality, using coercion, threats of harm or physical force, by any person regardless of relationship to the survivor, in any setting, including but not limited to home and work”. The scope of the definition is here expanded to include the forced sex, sexual coercion and rape of adult and adolescent men and women, and child sexual abuse. The definition also includes:
 The use of physical violence or psychological pressure to compel a person to participate in a sexual act against their will, whether or not the sexual act is consummated.
 A sexual act (whether attempted or consummated) involving a person who is incapable of understanding the nature or significance of the act, or of refusing, or of indicating his or her refusal to participate in the act, e.g. because of disability, or because of the effect of alcohol or other substances, or because of intimidation or pressure.
 Abusive sexual contact (WHO, 2003b; Saltzman et. al., 1999).
The term sexual violence is used to represent much behaviour that may otherwise fall under the rubrics of sexual abuse, sexual assault, and any other sexual violations, such as sexual harassment and voyeurism. The term gender-based violence is widely used as a synonym for violence against women, in order to highlight the gender inequality in which much violence is rooted (IGWG of USAID, 2006). However, while this review acknowledges that the overwhelming recipients of violence are female, the term gender-based violence is here used to encompass all women, men, girls and boys who have experienced sexual violence.
1An evaluation conducted by UNHCR on its GBV programmes in Tanzania found that each implementing body counted and classified SGBV incidents differently, resulting in significant variations in monthly incident reports (UNHCR, 2000).
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Although many who work in the field of sexual violence use the word "victim" to describe the person on whom the sexual violence is inflicted, the word "survivor" is used in this review in an effort to reflect the positivity encouraged in psychosocial care.
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1.2 PREVALENCE, CONSEQUENCES AND RISK FACTORS ASSOCIATED WITH SEXUAL VIOLENCE
Overview Social, economic, and gender issues are increasingly recognized as significant factors in countries of east and southern Africa that underlie the HIV epidemic, keep maternal mortality and fertility rates high, and increase the likelihood that sex will not be safe, voluntary, or pleasurable. Violence against women and children, of both sexes, has gained international recognition as a serious social and human rights concern affecting all societies. Epidemiological evidence shows that violence is a major cause of ill health among women and girls, as seen through death and disabilities due to injuries, and through increased vulnerability to a range of physical and mental health problems (Krug et al., 2002; Mugawe & Powell, 2006). Female survivors of sexual violence not only sustain physical injuries, but are more likely than other women to have unintended pregnancies, report symptoms of reproductive tract infections, have multiple partners, and less likely to use condoms and other contraceptives (IFPP, 2004; Campbell & Self, 2004). Violence, and the fear of violence, severely limits women’s contribution to social and economic development, thereby hindering achievement of the Millennium Development Goals and other national and international development goals. Rape and domestic violence account for 5-10% of healthy years lost by women (WHO, 2001). As described by the World Bank’s Gender and Development Group, such violence can include, but is not limited to:
 Physical violence (slapping, kicking, hitting, or use of weapons)
 Emotional violence (systematic humiliation, controlling behaviour, degrading treatment, threats)
 Sexual violence (coerced sex, forced into sexual activities considered degrading or humiliating)
 Economic violence (restricting access to financial or other resources with the purpose of controlling a person).
Violence may be experienced at separate and multiple stages of the life cycle: Table 1: Types of Violence commonly experienced at various phases of the life cycle Phase Type of Violence Prenatal Prenatal sex selection, battering during pregnancy, coerced pregnancy (rape during war) Infancy Female infanticide, emotional and physical abuse, differential access to food and medical care Childhood Genital cutting; incest and sexual abuse; differential access to food, medical care, and education; child prostitution Adolescence Dating and courtship violence, economically coerced sex, sexual abuse in the workplace, rape, sexual harassment, forced prostitution Reproductive Abuse of women by intimate partners, marital rape, dowry abuse and murders, partner homicide, psychological abuse, sexual abuse in the workplace, sexual harassment, rape, abuse of women with disabilities Old Age Abuse of widows, elder abuse (which affects mostly women)
Source: Heise, L. 1994. Violence Against Women: The Hidden Health Burden. World Bank Discussion Paper. Washington. D.C. The World Bank
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Both men and women can be survivors or perpetrators of violence. It is important to recognise, however, that although male against female violence is more common, a not insignificant proportion of males, and especially boys, suffer all four types of violence outlined above. Prevalence Gender-based violence and forced sex are highly prevalent in the region:
 In Zambia, DHS data indicate that 27 percent of ever-married women reported being beaten by their spouse/partner in the past year; this rate reaches 33 percent of 15-19 year-olds and 35 percent of 20-24 year-olds. 59 percent of Zambian women have ever experienced any violence by anyone since the age of 15 years (Kishor & Johnson, 2004).
 In South Africa, 7 percent of 15-19 year-olds had been assaulted in the past 12 months by a current or ex-partner; and 10 percent of 15-19 year-olds were forced or persuaded to have sex against their will (South Africa DHS, 1998).
 In Kenya, 43% of 15-49 year old women reported having experienced some form of gender-based violence in their lifetime, with 29% reporting an experience in the previous year; 16% of women reported having ever been sexually abused, and for 13%, this had happened in the last year (Kenya DHS, 2003).
 In rural Ethiopia, 49% of ever-partnered women have ever experienced physical violence by an intimate partner, rising to 59% ever experiencing sexual violence (WHO, 2005).
 In rural Tanzania, 47% of ever-partnered women have ever experienced physical violence by an intimate partner, while 31% have ever experienced sexual violence (WHO, 2005).
Consequences Such violations of bodily integrity and freedom from violence are of concern as adverse outcomes in and of themselves, and because they are correlated with poor reproductive health. Studies from diverse settings – e.g., China, Peru, the USA, and Uganda – have found that girls and/or young women who had previously experienced sexual coercion are significantly less likely to use condoms, and more likely to experience genital tract infection symptoms, unintended pregnancy and a higher incidence of unsafe abortion (Gazmararian et al., 1995; Campbell & McPhail, 2002). Lack of sexual autonomy and control stemming from actual or threatened violence, together with fear of repercussion from use of condoms or contraception, are direct pathways to unwanted pregnancy and increased risk of STIs (Kishor & Johnson, 204). Moreover, intimate partner violence has been found to be independently associated with HIV infection (Fonck et al., 2005; Auerbach et al., 2005). The following table outlines the potential physical, reproductive health, psychological and behavioural consequences of sexual and gender-based violence:
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Table 2: Fatal and non-fatal outcomes of SGBV Non-fatal outcomes Fatal outcomes Physical injuries and chronic conditions Sexual and reproductive sequelae Psychological and behavioural outcomes  Femicide  Suicide  AIDS-related mortality  Maternal mortality  Fractures  Abdominal/thoracic injuries  Chronic pain syndromes  Fibromyalgia  Permanent disability  Gastrointestinal disorders  Irritable bowel syndrome  Lacerations and abrasions  Ocular damage  Gynaecological disorders  Pelvic Inflammatory disease  Unsafe abortion  Unwanted pregnancy  Pregnancy complications  Sexual dysfunction  Miscarriage / low birth weight  Sexually-transmitted infections, including HIV  Depression and anxiety  Eating and sleep disorders  Drug and alcohol abuse  Phobias and panel disorder  Poor self-esteem  Post-traumatic stress disorder  Psychosomatic disorders  Self harm  Unsafe sexual behaviour:  high-risk views on sexual violence & HIV infection  less likely to use condoms & contraceptives
Sources: Adapted from Heise and Garcia Moreno, 2002; and Heise, Ellsberg and Gottemoeller, 1999. The impact of SGBV resonates further than the primary victim. Research indicates a link between maternal experience of violence and evidence of increased mortality and undernutrition among children of abused mothers (Jejeebhoy, 1998; Ganatra et al., 1998; Asling-Monemi et al., 2003, in Kishor & Johnson, 2004). DHS data from Zambia signifies a link between short birth intervals (less than two years) and the mother’s experience of violence. The association between short birth intervals and infant health and survival is well documented (Lawn & Kerber, 2006). This link additionally illustrates the disintegration of reproductive autonomy amongst those who experience violence.
Sexual and gender-based violence both contributes to, and is exacerbated by, the economic and socio-political discrimination experienced by women in many countries. Women’s lack of economic empowerment is reflected in lack of access to and control over economic resources in the form of land, personal property, wages and credit (UN-GA, 2006). Power,
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and the lack of power, is a recurring factor in all types of violence: the powerlessness of survivors, whether women, men or children, is also manifest in their relative lack of resources and access to support institutions. Causes and risk factors Certain community and societal-level risk factors are associated with higher or more severe rates of sexual and gender-based violence. The World Health Organization identifies the following evidence-supported factors (Krug et al., 2002):
 Traditional gender norms that support male superiority and entitlement
 Social norms that tolerate or justify violence against women
 Weak community sanctions against perpetrators
 Poverty
 High levels of crime and conflict in society more generally
Research on violence against women shows an increased risk of current physical or sexual violence among women of a younger age, especially those aged 15 to 19 (Krug et al., 2002; WHO, 2005a; Kishor & Johnson, 2004). Women who are separated or divorced (or, to a lesser degree, cohabiting) report a higher lifetime prevalence of all forms of violence (WHO, 2005a). Alcohol or drug consumption, and previous experience of sexual abuse, also correlate with sexual violence in adulthood (Krug et al., 2002). The literature holds differing opinions on the relationship of education to sexual violence. The World Report on Violence and Health (Krug et al., 2002) cites South African and Zimbabwean studies that show a correlation between higher levels of female education and increased vulnerability to sexual violence. The authors reason that female empowerment is accompanied by a resistance by women to patriarchal norms, which in turn provokes men to violence in an attempt to regain control (Jewkes et al., 2002). However, they suggest that female empowerment confers greater risk of physical violence only up to a certain level, after which it confers protection (Jewkes, 2002). This theory is supported by evidence from the WHO multi-country study, which found that the protective effect of education started only when women’s education progressed beyond secondary school (2005a). Factors increasing men‟s risk of committing rape Research into individual-level risk factors indicates violence is a learned behaviour: for instance, boys who witness or experience violence as children are more likely to use violence against women as adults, and a history of sexual abuse distorts perceptions about sexual violence and the risk of HIV infection (IGWG, 2006; Andersson et al., 2004).
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Table 3: Factors influencing men’s risk of committing rape Individual factors Relationship factors Community factors Societal factors Alcohol and drug use Coercive sexual fantasies and other attitudes and beliefs supportive of sexual violence Impulsive and antisocial tendencies Preference for impersonal sex Hostility towards women History of sexual abuse as a child Witnessed family violence as a child Associate with sexually aggressive and delinquent peers Family environment characterized by physical violence and few resources Strongly patriarchal relationship or family environment Emotionally unsupportive family environment Family honour considered more important than the health and safety of the victim Poverty, mediated through forms of crisis of male identity Lack of employment opportunities Lack of institutional support from police and judicial system General tolerance of sexual assault within the community Weak community sanctions against perpetrators of sexual violence Societal norms supportive of sexual violence Societal norms supportive of male superiority and sexual entitlement Weak laws and policies related to sexual violence Weak laws and policies related to gender equality High levels of crime and other forms of violence
Source: Krug, Etienne, Linda Dalhberg, James Mercy, Anthony Zwi, and Rafael Lozano, Eds. 2002. World Report on Violence and Health. Geneva: WHO. Programmatic flaws Many sub-Saharan African counties lack systematic and reliable data on sexual and gender-based violence. There is need for systematic data collection on the prevalence and forms of SGBV in SSA, which would in turn inform the development of meaningful strategies. Programme design is hampered by the absence of evaluation of the impact of former preventative or responsive interventions. The UN Secretary-General’s report on violence against women includes valuable suggestions for the collection of data, and also highlights the programmatic areas that are currently under-researched (UN-GA, 2006). The overwhelming focus, in both research and programmatic interventions, is on researching and alleviating the impact of sexual violence on women. However, the majority – not the minority – of sexual abuse survivors presenting for services are children of both sexes, and not adult women, who are the default group for whom most services are designed (Askew & Ndhlovu, 2006; WHO, 2001). Programme managers and policy makers continue to see adult women as the norm and modal group. There are limited examples of programmes that have explicitly sought to address the needs of children, males or other minority groups (such as the physically or mentally handicapped), rather than trying to serve them as an additional or special category. The following sections examine approaches to enabling presentation and managing cases of child and male survivors.
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1.3 ETHICAL CONSIDERATIONS FOR RESEARCHING SGBV
The ethical principles of confidentiality and respect are especially relevant in the research field of SGBV, due to the traumatic and sensitive nature of the subject material. Ill-conceived or implemented research may have dangerous consequences for the respondents and/or interviewers. Research designs should consider issues of confidentiality, problems of disclosure, and the need to ensure adequate and informed consent (Ellsberg & Heise, 2005). The basic ethical principles of research involving human subjects include:
 Respect for persons (including respect for confidentiality, the need to protect vulnerable populations, and respect for autonomy);
 Nonmaleficence (minimizing harm);
 Beneficence (maximizing benefits); and
 Justice.
The key ethical principles of research are universally applicable, but the details may need to be adapted to local settings, in order to minimise misunderstandings or potential harm. Researchers are under obligation to consider how the information will be used and reported, and to whom, and who will benefit from it, and when. These considerations may be especially important in conflict environments (WHO, 2007). The principle of respect for persons incorporates two fundamental ethical principles: respect for autonomy and protection of vulnerable persons. These are commonly addressed by individual informed consent procedures that ensure that respondents understand the purpose of the research and that their participation is voluntary (see Annex IV for template of informed consent form) (Ellsberg & Heise, 2005). The following recommendations have proved effective guidelines for research on violence: BOX 2: ETHICAL AND SAFETY RECOMMENDATIONS FOR RESEARCHING SGBV  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 underreporting of abuse.  Protecting confidentiality is essential to ensure both participants’ safety and data quality.  All research team members should be carefully selected and receive specialized training and ongoing support.  The study design must include a number of actions aimed at reducing any possible distress caused to the participants by the research.  Fieldworkers should be trained to refer participants requesting assistance to available sources of support. Where few resources exist, it may be necessary for the study to create short-term support mechanisms.  Researchers and donors have an ethical obligation to help ensure that their findings are properly interpreted and used to advance policy and intervention development.  Violence questions should be incorporated into surveys designed for other purposes only when ethical and methodological requirements can be met.
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1.4 APPROACHES TO MANAGING CHILD SURVIVORS OF SEXUAL VIOLENCE
Children are especially vulnerable to sexual violence by nature of their relatively weak social position, economic dependence and lack of political protection. The World Health Organization estimated in 2001 that 40 million children are annually subjected to physical or sexual abuse: the number of abused children several years on will in all probability have risen (WHO, 2001). Myths that sex with young virgins can cleanse the perpetrator of the HIV virus have contributed to the rising phenomenon of child rape in Africa (Kim et al., 2003). There are increasing cases of forced sexual initiation, particularly among girls. Population-based surveys in South Africa recorded 28% of girls reporting forced sexual initiation (Matasha et al., 1998, in Krug et al., 2002). In provincial Tanzania and urban Namibia, 43% and 33% respectively of women reporting first sex before the age of 15 years described that experience as forced (WHO, 2005a). The consequences of sexual abuse during childhood are widely recognised. Child sexual abuse has far-reaching emotional and physical implications, and people who themselves experienced abuse during childhood are more likely to perpetrate abuse against others. A study among adolescents in South Africa found that 66% of males and 71% of females who admitted to forcing someone else to have sex had themselves been forced to have sex (Andersson et al., 2004). Moreover, a history of forced sex was a powerful determinant of high-risk views on sexual violence and risk of HIV infection (ibid.). The perpetrators of child sexual abuse across sub-Saharan Africa are frequently either known to the family, or a family member. Children are relatively more likely to present to police or health facilities than adults (Keesbury et al., 2006; RADAR, 2006; Kilonzo & Taegtmeyer, 2005), which may reflect the widespread perception that sexual abuse of children is a crime, as opposed to the more complex attitudes towards sexual abuse of adults. Although more children present, this trend is not necessarily representative of abuse in the general population. However, the disproportionate numbers of children seeking services, relative to adults, does suggest that the current focus on adult medical management should be balanced with protocols relating specifically to child survivors. The medical, psychological and legal needs of children are not adequately addressed and require revision. Management of child sexual abuse The dynamics of child sexual abuse differ from those of adult sexual abuse. Children tend to disclose as part of a process rather than a single event, over a longer period of time than adults (WHO, 2003), which can have negative implications for medical management and the collection of forensic evidence. The evaluation of children requires special skills and techniques in history taking, forensic interviewing and examination (ibid.). The health provider may need to reassure and counsel the carers or parents of the child, and address issues of consent and reporting of child abuse. Many countries have laws requiring mandatory reporting of cases of child abuse to the local authorities or police, and health care workers should be aware of the obligations in their own country.
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The medical and psychosocial management of child survivors is explored in more detail in section 2. Programmatic implications Two studies piloting PEP in Kenya and Malawi observed that the majority of child abuse survivors present in time for PEP with adherence and completion rates similar to those in adults, but children show lower rates of follow-up HIV testing at six weeks (Speight et al., 2005; Ellis et al., 2005). Ellis posits that reasons may be carer or child related, and may include lack of awareness of the purpose of follow-up or lack of access to child-care or traumatic associations among child survivors. Community-based follow up and awareness-raising may assist children and their carers to benefit from long-term support. Studies conducted in Kenya, Zambia and South Africa discovered that most child survivors report to the police, prior to referrals to health facilities. This pattern, as discussed above, reflects the widespread perception of child abuse as a criminal act, and also illustrates a pervasive lack of awareness about available health services. The involvement of the police at this early stage emphasises the need for police sensitisation and for the development and reinforcement of effective referral networks. Most children report within 72 hours, with positive implications for PEP, EC (when eligible) and the collection of forensic evidence (Keesbury et al., 2006; Speight et al., 2005). The policy environment across ECSA does not address the needs or characteristics of abused children. For instance, although the South African government has developed national guidelines for PEP treatment for individuals 14 years and older, there are no corresponding guidelines for children under 14. Many health care providers consequently lack basic information about how, and even in what circumstances, to provide PEP to children under fourteen (HRW, 2003). The abuse of children, and particularly adolescents, often occurs within the school environment, and is perpetrated either by teachers or school peers. Just as police and health personnel require sensitisation on child needs and rights, teachers and other education professionals also need training to recognize child abuse, as well as referral links to medical or social services. Preventive programmes and counselling would also serve to protect children from abuse (WHO, 2005).
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1.5 APPROACHES DEVELOPED FOR ENCOURAGING AND ENABLING PRESENTATION BY MALE SURVIVORS
Prevalence and experiences of male sexual abuse Sexual abuse of male adults and children is vastly under-reported and poorly understood. The limited research in this area suggests that sexual violence against boys and men is endemic in many areas of the world. Population-based studies conducted among adolescents in developing countries indicate that 3.4% of males in Namibia and 13.4% in Tanzania have experienced a sexual assault. 11% of male adolescents in South Africa and 29.9% in Cameroon reported forced sexual initiation (Krug 2002). Men who have sex with men (MSM) are frequently targets of homophobic violence, which may or may not be sexual. In Kenya, nearly 40 percent of men who had sex with men reported having been raped outside their home and 13 percent report having been assaulted by the police (Niang et al. 2002 in Barker and Ricardo, 2005). Men most commonly experience sexual violence in the form of receptive anal intercourse, forced masturbation of the perpetrator, receptive oral sex, or forced masturbation of the victim (WHO, 2003). Sexual abuse is not solely perpetrated by males. Women are also responsible for coercing males, particularly adolescents, into sexual acts (Ganju, 2004; Jejeebhoy & Bott, 2003). In Zimbabwe, 30% of secondary school boys reported sexual abuse; half of these cases involved abuse by women (FOCUS, 1998, in Barker & Ricardo, 2005). In the baseline study for Stepping Stones evaluation in the Eastern Cape of South Africa, almost 3 percent of men reported having been coerced into sex by a man and 12 percent reported being coerced by a woman (Sikweyiya et al., forthcoming, in Betron & Doggett, 2006). Yet, with the exception of research of male sexual abuse in specific contexts, such as on the street and in prison, there is a dearth of research on the nature and prevalence of sexual violence against men (Barker & Ricardo, 2005). The data that exists is likely an under-representation of male rape survivors, as males are even less likely than females to report their experience of sexual assault due to prejudices regarding male sexuality that compound guilt, fear, and shame (Krug et al., 2002; Jejeebhoy & Bott, 2003). Pervasive cultural attitudes and legal discrimination can also inhibit male survivors from seeking medical care, or legal or psychosocial support: for instance, men having sex with men is criminalised in certain countries across ECSA, and injuries or trauma resulting from homophobic rape may not be treated with due attention by police or health personnel. Medical management of adult male survivors of sexual violence
Male survivors of sexual violence require the same physical examination and medical interventions as women, although the genital examination requires a specific approach. Men require treatment for STIs, hepatitis B and tetanus, and need an HIV-test followed by HIV prophylaxis, if eligible. Male survivors tend to be reluctant to access counselling due to the perceived and actual stigma related to the abuse. However, men have the same psychological needs as women, and should be encouraged to receive trauma and follow-up
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counselling (WHO, 2003)2. Counsellors may need to reassure male survivors about perceived challenges to their sexuality or masculinity. Experiences in encouraging and enabling presentation by male survivors Programmatic interventions targeting male abuse survivors are extremely limited and there is little evidence of effective approaches towards preventing and managing male abuse. Researchers in Dakar, Senegal, found little support for a special facility due to the perception that this resource would risk reinforcing MSM ostracism (Niang et al., 2003). Concerns over stigma act as a barrier to seeking care for anal symptoms, although less for penile symptoms. This finding reinforces other sources that observe anxiety about interpretations of sexuality among male survivors of rape. The Gender Violence Recovery Centre in Nairobi Women’s Hospital treats sexual abuse survivors of all ages and genders. The presentation of male survivors (albeit 85% 15 and under) has increased steadily over the last four years, which is attributed to increased awareness among the population (personal communication, 2006 with GVRC counsellor). The hospital conducts awareness campaigns, during which they advertise the availability of services to male survivors. Services, both medical and psychological, are broadly the same as those offered to women, with the exception of pregnancy prevention. Men rarely seek legal redress, due to the stigma attached (Ganju et al., 2004). The consensus among the literature is that health providers, the police and judiciary require sensitization on the needs and concerns of male survivors of sexual violence. The existing research and programmatic focus on female survivors should be expanded to include men who experience sexual abuse. RADAR in South Africa has developed protocols for all elements of post-rape care that include a tailored approach to managing sexual violence experienced by males.