State of the Art: sexual and intimate partner violence Prof Rachel Jewkes Director, Gender & Health Research Unit, Medical Research Council, South Africa, and Secretary, Sexual Violence Research Initiative

Introduction Sexual violence and intimate partner violence are fundamental violations of victim human rights – the rights to dignity, bodily integrity, life and health Their health impact is magnified by their role as risk factors for other major diseases, notably HIV in women Our goal is prevention of sexual and intimate partner violence

What does sexual and IPV encompass? Rape/ sexual violence against adults

Primary prevention Strategies must be tailored around evidence of who perpetrates and what is driving SV/IPV perpetration Based on interventions with a sound theoretical basis from which one can realistically anticipate impact on behaviour change Targeting perpetration, tackling underlying causes First step: research to understand the problem: Research on victimisation and on perpetration

Prevalence of victimisation: Has been the predominant focus of research globally on GBV, notably the WHO multi-country study found: 1 - 21% had experienced sexual abuse < age 15 years 15 - 71% had experienced physical or sexual intimate partner violence (IPV) 0.3 - 11.5% had experienced sexual violence by a non-partner when > 15 years

Risk factors for sexual violence victimisation: Young age Poverty Physical disability Dysfunctional homes Mental vulnerability: learning difficulties, depression, PTSD etc Prior victimisation Substance abuse These are ALL vulnerability factors – they do not CAUSE sexual violence

Prevalence of rape perpetration Gang rape: 20% of men had been involved in a gang rape; 9% had actually had sex in a gang rape; 4% had had sex in more than one gang rape

Prevalence of physical & sexual intimate partner violence in ever partnered South African & Indian men (and all Croatians)

Distribution of victim numbers among men who have raped

SV/IPV are important adolescent health problems Men who will perpetrate normally do so for the first time during adolescence: In South Africa, 73% of adult men who have raped have done so for the first time by the age of 20 years In the US, most college (adult) rape perpetrators are first sexually aggressive when at school (White & Hall Smith 2004, Abbey & McAuslan 2004) Victims normally first experience violence as adolescents: WHO found 3-24% force first sex IPV is common in dating relationships

Angry and violent motivations: Anger, Punishment (her), Punishment (another) Rape as fun or a game: Wanted to have fun, it was a joke or game , Friends forced or pressurised me Sexual entitlement or experimentation: Sexually desired her, Wanted sex, Wanted to prove I could do it, Experimenting with sex Circumstances of gang rape: 61% had been drinking (+/- with the victim); 51% woman agreed to sex with one man; 29% boyfriend organised the rape; 44% it was a ‘game’

Childhood environment & trauma

Multivariable model of factors associated with raping (age adjusted)

What are the key areas for intervention to prevent sexual violence? Structural factors: poverty, education, Gender inequality: Essential differential valuation of men & women (esp. seen in sanctions/impunity) Generates expectations of gendered powerfulness, permits exploration of power Legitimisation of male control of women and the use of violence against women Childhood: exposure to adversity, trauma

What about intimate partner violence perpetration? Many of the risk factors are the same Notable differences: Women are placed at risk by their own acquiescence to patriarchy (need to promote empowered femininities) Women’s material/political empowerment generally and specifically is protective Relationship discord & poor conflict skills are risk factors

Translating this into an intervention agenda: Need intervention at all levels – societal, community, family and individual Need to combine actions: those aimed at reducing perpetration those protecting victims responses for victims those aimed at removing impunity Need a long term view of change

Need evidence of effectiveness What works in sexual and IPV prevention? (WHO review 2010) High income countries: The only interventions that have been evaluated in RCTs and shown effective are school-based programmes aimed at reducing perpetration – examples Safe Dates and Fourth R (USA & Canada) Middle and low income countries: Stepping Stones – reduced perpetration of IPV IMAGES – microfinance, community action, reduced women’s victimisation Neither study has yet been replicated

Evidence (not yet from RCTs) to support: Interventions with abuse-exposed children to prevent IPV School programmes to raise awareness of CSA risk Alcohol use reduction interventions to prevent IPV Gender norms interventions with men and boys we have also learnt some interventions do NOT work (see WHO, 2010)

Secondary prevention Responses to assist victim/ survivors of rape/sexual violence and IPV

Responses to rape in the health sector The tools are available for the health sector: Model policies Management guidelines e.g. FIGO’s Training curriculum e.g. South African National Department of Health’s Comprehensive package of post-rape care is needed Tailoring of care depending on whether the care is started soon after the (last) event or whether there has been a delay (months or years) Tailored for both adults and children

State of the Art post-rape care: Comprehensive Survivor centred Provided by trained health care providers with clear protocols/guidelines Integrates adult and child care (except in high resource settings) Integrates psychological support/ mental health care for survivors Tailored to maximise medication course completion – especially PEP – e.g. using tenofovir/FTC regimen; progestogen-only emergency contraception Abortion

Health sector responses to IPV Evidence that asking women about IPV / SV experience is critical and offering simple messages and practical assistance is valuable; documentation may be valuable Challenge – is implementation This must include introducing gender-based violence into undergraduate / basic training for nurses and doctors In-service training may be best but its is a greater challenge to resource and implement and so there are challenges for coverage

Secondary prevention responses must be multi-sectoral: Include: Health sector Social workers/ designated child protection agencies Police Prosecution service / courts

Good post-rape care has to be provided within a human-rights framework Survivor-centred comprehensive post-rape care requires changing the ethos, policies and practices of social work, police and criminal justice system Confronting gender inequitable value systems upon which their policies and operations are based is essential Analysing the nature of the challenge and developing strategies for change which appropriately balance deployment of evidence and engagement with underlying politics and values is critical One of the greatest challenges in providing post-rape care is trying to keep victim needs central when engaging with political and CJ systems here is a belief that what is needed for the ‘best’ policy is scientific evidence, but a lot of what occurs in responses to rape is not about science, its about politics, morality and social systems What are the challenges? e.g we need to be realistic about the challenges presented by the system – such as the perceived need for ‘forensic’ evidence in order to get a conviction – it can be changed e.g. in SA by changing the belief placed on the word of women victims – removing the ‘cautionary rule’ – which is often applied overtly or covertly and states that women’s assertions need to be treated with ‘caution’ (viewed as inherently untrustworthy)

Conclusions Essential that we keep our eyes on the prize: prevention sexual violence and IPV We need: national strategies that are tailored around a local understanding of the problem to implement what works and theoretically-informed best practice to escalate the intervention research to develop services for victims in tandem with rolling out prevention interventions High level political support globally, nationally and within communities is essential

Authors from the South African Study & IMAGES South African study team: Rachel Jewkes, Yandisa Sikweyiya, Robert Morrell, Kristin Dunkle Funded by: the UK Department For International Development (DFID), and grant was managed by their local partner Human Life Sciences Partnership (HLSP) IMAGES Principal Investigators : Gary Barker, Meg Greene, ICRW, Washington Croatia data: Natasa Bijelic, C E S I - Centar za edukaciju, savjetovanje i istrazivanje, Zagreb, Croatia India data: Ravi Verma, Ajay Singh, Gary Barker, ICRW, Delhi IMAGES Study: the project overall and India site funded by the MacArthur Foundation, Ford Foundation, an anonymous donor, and the Norwegian Ministry of Foreign Affairs