State of the Art: sexual and intimate partner violence

1. 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

2. 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

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

4. 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

5. 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

6. 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

7. Prevalence of rape perpetration

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

9. Distribution of victim numbers among men who have raped

10. 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

12. Childhood environment & trauma

16. Multivariable model of factors associated with raping (age adjusted)

18. 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

19. 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

20. 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

21. 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

22. 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)

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

24. 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

25. 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

26. 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

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

28. 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

29. 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

30. 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 sitefunded by the MacArthur Foundation, Ford Foundation, an anonymous donor, and the Norwegian Ministry of Foreign Affairs