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Global = Perspectives on=20 Sexual Violence

In 2002, the = World Health=20 Organization (WHO) released the World Report on Violence and = Health.=20 This report, the first of its kind, uses a public health approach to = examine=20 global youth violence, child abuse and neglect, violence by intimate = partners,=20 abuse of the elderly, sexual violence, self-directed violence, and = collective=20 violence. It draws from the information, findings, and insight of over = 160=20 experts from approximately 70 countries and from published literature on = violence. The Report views violence through an ecological lens and = discusses=20 biological, social, cultural, economic, and political factors that = influence its=20 occurrence and prevalence.

Developed from = the=20 World Report on Violence and Health, this booklet offers a = synopsis of=20 the Report=92s findings related to global sexual violence. The intent of = this=20 booklet is to promote a better understanding of global sexual violence, = spark=20 new research, and encourage collaborative efforts to prevent sexual=20 violence.

=93[World Report on Violence and Health] makes a = major=20 contribution to our understanding of violence and its impact on = societies. It=20 illuminates the different faces of violence, from the =91invisible=92 = suffering of=20 society=92s most vulnerable individuals to the all-too visible tragedy = of=20 societies in conflict=85And in doing so, it reminds us that safety and = security=20 don=92t just happen: they are the result of collective consensus and = public=20 investment.=94

Nelson Mandela
(Krug, et al., 2002) =

A Closer Look =

Working = Towards Sexual=20 Violence Prevention

Sexual violence = affects=20 millions of people worldwide and represents a serious global public = health=20 problem. Risk factors, rooted in social injustices and inequities = transcend=20 geographical boundaries and individual differences. The costs of sexual = violence=20 are devastating and jeopardize the health of individuals and entire = societies.=20

The National = Sexual=20 Violence Resource Center (NSVRC) recognizes that despite its prevalence = and=20 costs, sexual violence is not inevitable. A major goal of this booklet = is to=20 underscore the opportunity for those working to end sexual violence from = around=20 the world to partner and work together to identify and address its root = causes.=20 Today, a global perspective grows increasingly relevant for advocates = and policy=20 makers the world-over. War adds to the urgency. It not only ravages our = world,=20 people, and economies; war increases the risk of sexual violence. The = needs and=20 experiences of refugees and those that are trafficked illustrate the = importance=20 of building relationships and resources within a global community = context.=20

Advocacy = efforts have grown=20 out of a fundamental understanding of sexual violence as a human rights, = crime=20 victims=92 rights, and social justice issue. Anti-sexual violence = advocates have=20 historically worked to change the social conditions that perpetuate = violence.=20 Building networks has been a crucial part of that work. We have much to = give and=20 gain by examining international public health efforts that aim to end = sexual=20 violence through social change

Definition of = Sexual=20 Violence

Definitions of = sexual=20 violence may be influenced by cultural values, social norms, human = rights,=20 gender roles, legal initiatives and crime and may evolve over time. = While=20 defining sexual violence advances our global efforts to identify and = eliminate=20 sexual violence, it must be recognized that all definitions are arrived = at=20 through cultural, socio-political, and geographic lenses. The Report = attempts to=20 build connections between communities and propel our solutions forward = by=20 offering the following definition of sexual violence:

any sexual act, attempt to obtain a sexual act, unwanted = sexual=20 comments or advances, or acts to traffic, or otherwise directed, against = a=20 person=92s sexuality using coercion, by any person regardless of their=20 relationship to the victim, in any setting, including but not limited to = home=20 and work
(Jewkes, Sen, and = Garcia-Moreno, p. 149, 2002).

Additionally, = WHO=20 emphasizes that a person who commits sexual violence uses coercion, = which can=20 include =93physical force=85psychological intimidation, blackmail or = other=20 threats=96for instance, the threat of physical harm, of being dismissed = from a job=20 or of not obtaining a job that is sought. It may also occur when the = person=20 aggressed is unable to give consent=96for instance, while drunk, = drugged, asleep=20 or mentally incapable of understanding the situation=94 (Jewkes, = Sen, and=20 Garcia-Moreno, p. 149, 2002).

The Report = presents the=20 following forms of sexual violence (Jewkes, Sen, and Garcia-Moreno, = p. 149,=20 2002):

It asserts that = sexual=20 violence is used as a tool to punish and subjugate individuals for = perceived=20 transgressions of social or moral codes, noting its =93underlying = purpose is=20 frequently the expression of power and dominance over the person = assaulted=94=20 (Jewkes, Sen, and Garcia-Moreno, p. 149, 2002).

Prevalence of = Sexual=20 Violence

According to = the World=20 Health Organization =93the true extent of sexual violence is unknown=94 = (Jewkes,=20 Sen, and Garcia-Moreno, 2002). In part, this is due to the = significant=20 variations in research definitions and methods. There are also = significant gaps=20 in research that keep sexual violence invisible and off of = policymakers=92 agendas=20 (Krug, p. 172, 2002).

Regardless of = these=20 inconsistencies, the Report confirms what many advocates have known: = sexual=20 violence terrorizes women, men, girls, and boys across the globe. The = following=20 examples help illustrate the global prevalence of sexual violence: =

Sexual = Violence Risk=20 Factors

Sexual violence = does not=20 occur in isolation. Risk factors, deeply rooted in social injustices and = inequities, connect sexual violence to other forms of violence across = the globe.=20 Risk factors transcend boundaries and occur in individual, social, = cultural, and=20 economic contexts.

When viewing = sexual=20 violence through a public health lens, both reducing risk factors and = increasing=20 protective factors become paramount. Some of the individual risk factors = found=20 to increase men=92s risk of committing rape include using alcohol and = drugs,=20 lacking inhibitions to suppress associations between sex and aggression, = holding=20 attitudes and beliefs that are supportive of sexual violence and hostile = towards=20 women, associating with sexually aggressive peers, and having = experienced sexual=20 abuse as a child.

Societal risk = factors that=20 contribute to the occurrence of sexual violence and place certain groups = at=20 greater risk include gender-based inequality, magnification of male = honor and=20 entitlement, war, and absent or weak sanctions and human services. =

Gender-based=20 Inequality
Sexual violence is more likely to occur in = societies=20 with rigid and traditional gender roles: =93in societies where the = ideology of=20 male superiority is strong=97 emphasizing dominance, physical strength = and male=20 honor=97rape is more common=94 (Jewkes, Sen, and Garcia-Moreno, p. = 162,=20 2002). In some countries, the concept of gender equality disrupts a = deep-seated system of inequality, creating social unrest in the = short-term but=20 empowerment and greater equality for women in the long-term.

Male = Entitlement=20
Men are more likely to commit sexual violence in = communities where=20 concepts of male honor and entitlement are culturally accepted and where = sexual=20 violence goes unpunished. In many countries, the integrity of male honor = hinges=20 on female sexual purity. The rape of a woman taints the honor of her = husband=20 and/or family and she will likely face punishment as a way to restore = the=20 family=92s honor. Punishment may include her marriage to the rapist, = banishment=20 and/or varying degrees of violence against her, including her murder, or = =93honor=20 killing.=94 Social ideology entrenched in male entitlement may deny = women a=20 fundamental right to refuse sex and fail to recognize marital rape as a = problem.=20

Absent = or Weak=20 Sanctions and Services
Community tolerance of sexual = violence is=20 evidenced by the unresponsiveness of systems and services. Sexual = violence that=20 occurs in certain settings or forms is not recognized as =93sexual = violence=94 by=20 law in many countries. Evidence provided by victims is often not = considered to=20 be sufficient for a conviction. Victims do not come forward in many = places out=20 of fear of being punished by the criminal justice system. =93In some = places, rape=20 can even occur in public, with passers-by refusing to intervene=94 = (Jewkes,=20 Sen, and Garcia-Moreno,

p. 161, = 2002).=20 Weak or absent social sanctions and services contribute to and = exacerbate sexual=20 violence. Unresponsive systems fail to hold perpetrators accountable and = fall=20 short of victims=92 needs.

Poverty =
Violence impacts certain groups disproportionately. Poverty = increases people=92s vulnerabilities to sexual exploitation in the = workplace,=20 schools, and in prostitution, sex trafficking, and the drug trade. = People with=20 the lowest socioeconomic status are at greater risk for violence. = Individuals=20 who lack sufficient economic resources to meet their basic needs, = specifically=20 women, may have to resort to bartering for essential goods with = sex.

War=20
The rape and torture of men, women, and children as = military=20 tactics have been widely documented. Rape has been used as a weapon of = war and=20 conflict. =93Rape is often used to terrorize and undermine communities, = to force=20 people to flee, and to break up community structures. Physical and = psychological=20 effects on victims are far-reaching=94 (Zwi, Garfield, and Loretti, = p. 218,=20 2002). Refugees who flee conflict and persecution are at extreme = risk for=20 sexual violence in their new settings, including refugee camps. War = often=20 depletes economic and social resources and pushes many people into = prostitution.=20

Promising = Approaches=20

A public health = approach to=20 ending sexual violence requires a collaborative, multi-disciplinary,=20 multi-level, and holistic strategy. The Report discusses many promising=20 approaches to ending sexual violence, including but not limited to the = efforts=20 described below.

The = Philippines=20 Task Force
Comprised of doctors, nurses, social scientists, = and=20 supported by the Department of Health, the Task Force on Social Science = and=20 Reproductive Health in the Philippines has developed training on gender = violence=20 for nursing and medical students (Jewkes, Sen, and Garcia-Moreno, p. = 167,=20 2002). This training has become a standard component of nursing and = medical=20 school curricula. Training modules are designed to increase students=92=20 understanding of the root causes of violence in cultural and gendered = contexts,=20 help them identify patients and families at risk for violence and to = prepare=20 them to provide primary and secondary interventions in collaboration = with other=20 professionals.

Sexual = Assault=20 Nurse Examiners (SANE)
Located in hospitals or police = stations,=20 SANE programs provide victims of sexual violence with a wide range of = services=20 through a collaborative approach that includes rape crisis centers, law=20 enforcement, district attorneys, and medical professionals (Jewkes, = Sen, and=20 Garcia-Moreno, p. 167, 2002). Sexual Assault Nurse Examiners (SANE) = provide=20 specialized and comprehensive health care services to victims of sexual=20 violence. SANE programs operate in a number of countries, including = Canada, the=20 United States, and Malaysia.

Stepping Stones=20
Originally developed in Africa and now used by many parts = of the=20 developing world, Stepping Stones links HIV/AIDS prevention with sexual = violence=20 prevention (Jewkes, Sen, and Garcia-Moreno, p. 165, 2002). This = program=20 is designed for female and male peer groups. A review of Stepping Stones = in=20 Africa and Asia showed the program=92s success in helping men take = responsibility=20 for their actions, communicate more effectively, and develop greater = respect for=20 women. Reductions in rates of violence against women have been reported = in=20 Cambodia, the Gambia, South Africa, Uganda and the United Republic of = Tanzania=20 as a result of this program.

Institute for=20 Health and Human Development
South Africa=92s Institute for = Health=20 and Human Development (IHDC) uses the mass media to promote health and = prevent=20 violence (Jewkes, Sen, and Garcia- Moreno, p. 168, 2002). = Prime-time=20 television and radio dramas discuss social and health issues including=20 interpersonal violence, bullying, gang violence, domestic violence, = rape, and=20 sexual harassment in ways that engage viewers of all ages on emotional = levels.=20 Of note is a popular children=92s program, Soul Buddyz, that reaches two = thirds of=20 South African children. In addition to TV and radio, IHDC produces and=20 disseminates booklets that provide more extensive information on various = topics.=20 IHDC also administers a hotline, through which crisis counseling and = referral=20 services are provided.

Inter-American=20 Coalition for the Prevention of Violence
The Inter-American = Development Bank, Organization of American States, Pan American Health=20 Organization, United National Educational, Scientific and Cultural = Organization,=20 United States Centers for Disease Control and Prevention, and the World = Bank=20 joined forces to form the Inter-American Coalition for the Prevention of = Violence to respond to the problem

of violence = (Krug, et=20 al., p. 252, 2002). The coalition supports the public awareness = efforts,=20 research, policy, training, media outreach, collaborative, and = preventive=20 efforts of organizations on a national scale by helping to mobilize = resources=20 and partners at local levels.

Developmental=20 Approaches
There are a number of developmental approaches = to health=20 promotion and violence prevention. One model that targets children at = every=20 stage of their development is the Schwartz model (Jewkes, Sen, and=20 Garcia-Moreno, p. 166, 2002). With this tool, health providers = explore=20 parenting, gender stereotypes, stress, conflict, and violence issues = with=20 expecting parents. Health providers explore the following issues along=20 children=92s developmental continuum: child sexual abuse, violence in = the media;=20 =93good and bad=94 touch, sexual aggression; rape myths and facts, = boundaries and=20 the link between sex, violence, and coercion.

Men as = Activists=20
Men=92s collective involvement in sexual violence = prevention is=20 growing, with over 100 groups in the United States alone (Jewkes, = Sen, and=20 Garcia-Moreno, p. 169, 2002). At the core of the male activist = movement is=20 the need for men to take responsibility for reducing violence. To that = end, such=20 groups often work with women=92s groups to raise public awareness about = violence,=20 promote violence alternatives, explore the meaning of masculinity, and = provide=20 educational programs in community settings.

Legal = and Policy=20 Responses
Legal and policy efforts have improved the health = and=20 quality of life of people throughout the world. In Asia, a broadening of = legal=20 definitions of rape coupled with mandated state assistance to victims = has=20 resulted in more victims reporting and coming forward (Jewkes,=20

Sen, and = Garcia-Moreno,=20 p. 170, 2002). Rule 96 of the International Criminal Tribunal for = the=20 former Yugoslavia lends itself as a model for reform elsewhere = (Jewkes, Sen,=20 and Garcia-Moreno, p. 170, 2002). Rule 96 removes the corroboration = requirement in victims' testimony and prohibits prior sexual history of = victims=20 from being admitted as evidence. Policy changes have made a difference = in=20 victims=92 lives and the systems they encounter.

International=20 Rescue Committee
The International Rescue Committee (IRC) = employs a=20 collaborative model to prevent and address sexualand gender-based = violence=20 against refugees (Jewkes, Sen, and Garcia-Moreno, p. 171, = 2002).=20 Community workers connect victims to services. Community attorneys = prosecute=20 perpetrators. IRC has helped refugee populations in Bosnia and = Herzegovina, the=20 Democratic Republic of the Congo, East Timor, Kenya, Sierra Leone and = the former=20 Yugoslav Republic of Macedonia.

Child = Abuse Public=20 Awareness Campaign in Kenya
Coalition members from = governmental,=20 nongovernmental, and community-based backgrounds came together in 1996 = to=20 respond to a study that showed a high prevalence of child abuse and = neglect in=20 Kenya (Runyan, et al., p. 77, 2002). The response was = three-tiered and=20 included training, advocacy, and child protection efforts. Through = drama, music,=20 and essay competitions, children shaped the coalition=92s efforts. = Success is=20 illustrated in a strengthened reporting and management of child abuse = cases,=20 creation of a legal network for abused children, organization and = provision of=20 national and regional conferences, and heightened public awareness about = child=20 abuse and neglect.

The Way = Forward=20

Much can and = has been done=20 to address sexual violence, but =93the world has not yet fully measured = the size=20 of the task and does not yet have all the tools to carry it out=94 = (Krug=20 et al., p. 254, 2002). While the report findings reveal gaps in = sexual=20 violence research, prevention, and intervention across the world, there = are=20 clear steps that advocates, researchers, and policy-makers can take to = help=20 light the way forward.

In September = 2004, WHO=20 released Preventing Violence: a Guide to Implementing the = Recommendations of=20 the World Report on Violence and Health to provide step-bystep = conceptual,=20 policy and practical suggestions on how to implement these = recommendations=20 (WHO, 2004). WHO offers a series of concrete recommendations = for=20 multi-level social change that include:

Summary =

Sexual violence = is a human=20 rights and public health concern that transcends boundaries and incurs a = devastating global human cost. Gender inequalities, male entitlement, = absent=20 and/or weak social sanctions and services, poverty, and war put certain=20 populations at greater risk for sexual violence. Sexual violence = terrorizes=20 individuals throughout the world and undermines communities and systems. = Change=20 is possible through a commitment to the protection of human rights and a = national sexual violence prevention strategy.

The WHO Report = shows that=20 sexual violence is preventable and social change is possible. However, = lasting=20 social change requires the commitment and collaboration of advocates,=20 policy-makers, researchers, medical personnel, educators, police = officers,=20 prosecutors, and other professionals across the globe. Sexual violence=20 prevention requires rigorous advances in research, including the = development and=20 implementation of consistent definitions and methods and the sharing of=20 analyses. Through the commitment of members of society at every level, = new=20 programs and policies can emerge to significantly eliminate sexual=20 violence.

Current = WHO=20 Initiatives
Following the Report=92s release, WHO launched = the Global=20 Campaign for Violence Prevention to raise awareness about the problem of = violence and the value of a public health approach and to encourage = global=20 action at every level of society. For more information on the campaign, = visit:=20 http://www.who.int/violence_injury_prevention/media/news/08_09_20= 04/en/.=20

For a detailed = description=20 of how to implement recommendations that were referenced on page 14, = visit: http://www.who.int/violence_injury_prevention/media/news/= 08_09_2004/en.=20

References

Krug, EG et = al., eds.=20 World Report on Violence and Health. Geneva, = World=20 Health Organization, 2002.

Krug, EG et = al.,=20 The Way Forward: Recommendations for Action. = In: Krug=20 E., Dahlberg, L., Mercy, J.A., Zwi, A.B., Lozano, R. World Report of = Violence=20 and Health. Geneva, Switzerland: The World Health Organization. 2002: = 241-254.=20 (Available on the Internet: http://www.who.int/violence_injury_%20prevention/violence= /global_campaign/en/chap9.pdf)=20

Jewkes, R., Sen = P.,=20 Garcia-Moreno, C. Sexual Violence. In: Krug = E.,=20 Dahlberg, L., Mercy, J.A., Zwi, A.B., Lozano, R. World Report of = Violence and=20 Health. Geneva, Switzerland: The World Health Organization. 2002: = 147-181.=20 (Available on the Internet: http://whqlibdoc.who.int/publications/2002/9241545615_cha= p6_eng.pdf)=20

Runyan, D. et = al.=20 Child Abuse and Neglect by Parents and Other=20 Caregivers. In: Krug E., Dahlberg, L., Mercy, J.A., Zwi, = A.B.,=20 Lozano, R. World Report of Violence and Health. Geneva, Switzerland: The = World=20 Health Organization. 2002: 147-181. (Available on the Internet: http://www.who.int/violence_%20injury_prevention/violence= /global_campaign/en/chap3.pdf)=20

Zwi, AB, = Garfield, R.=20 Loretti, A. Collective Violence. In: Krug E.,=20 Dahlberg, L., Mercy, J.A., Zwi, A.B., Lozano, R. World Report of = Violence and=20 Health. Geneva, Switzerland: The World Health Organization. 2002: = 213-239.=20 (Available on the Internet: http://whqlibdoc.who.int/publications/2002/9241545615_cha= p8_eng.pdf)=20

Buchart, A., = Phinney, A.,=20 Check P., Villaveces A. Preventing violence: a guide to = implementing=20 the recommendations of the world report on violence and = health.=20 Department of Injuries and Violence Prevention, world Health = Organization,=20 Geneva, 2004. (Available on the internet: http://whqlibdoc.who.int/publications/%202004/9241592079.= pdf)=20

The full World = Report on=20 Violence and Health is available at the World Health Organization=92s = web site: http://www.who.int/violence_injury_prevention/violence/wo= rld_report/en/.=20