Sexual Abuse & Young Adult Reproductive Health

Shanler, Heise, Stewart, Weiss, 1998

Most young adult reproductive health programs generally operate on the premise that young people are engaging in consensual sex. Yet sexual abuse is unfortunately common among youth, though data on its prevalence is limited. Program managers and service providers should be aware that young people who have been sexually abused have different reproductive and sexual health needs those who are not victims, and develop their educational programs and services accordingly.

What is Sexual Abuse?

Sexual abuse is a violation perpetrated by a person who holds, or is perceived to hold, power over someone who is vulnerable. The abuse may have physical, verbal and emotional components. It includes such sexual violations as rape, sexual assault, sexual harassment, incest, and sexual molestation. The victim experiences sexual activity that is neither wanted nor agreed to. Some non-governmental organizations (NGOs) also consider very early age at marriage to be a form of sexual abuse.

Sexual abuse crosses cultural and socio-economic lines. It occurs in homes, schools, the workplace and other public places. The perpetrators are usually — but not always — male. They can be family members, neighbors, teachers, supervisors, schoolmates and, on occasion, strangers.

How Prevalent Is Sexual Abuse among Young Adults?

Because it is an exploitation of power, young people are more vulnerable to sexual abuse than are adults. Emerging data indicate sexual abuse is a major problem worldwide:

• In Uganda, half of sexually-active primary school girls reported being forced to have sexual intercourse.
• In a survey of 134 men and 202 women between 25-44 years of age in Nicaragua, 27% of women and 19% of men reported sexual abuse in childhood or adolescence.
• One-third of all reported rape victims in India are under the age of 16, and incidences increased 26% among 10-16 year olds between 1991-1998.
• In Sri Lanka, 7.4% of 314 young men surveyed reported having sexual intimacy with an older male at age 13 or younger under coercion.
• In Zimbabwe, 30% of 549 secondary school students reported they had been sexually abused; half were boys being abused by female perpetrators.
• All of the 143 Guatemalan street youth in a 1991 study reported being sexually abused, some by more than one perpetrator—53% by family members (often stepparents), 6% by friends, 3% by neighbors, and 46% by strangers.

How Does Sexual Abuse Affect Young Adult Reproductive Health?

The acute consequences of sexual abuse for both male and female victims include physical injury, sexually transmitted infections (STIs), and psychological trauma. For female victims, there is the added danger of unwanted pregnancy, injury, and the chronic complications of STI-related vaginal discharge, dysmenorrhea and pelvic pain.

As data emerge, it is clear that sexual abuse has long-term effects on the sexual and reproductive health of young adults. There is some evidence that adolescents who were sexually-abused as children are more likely than non-abused children to engage in high-risk sexual activity. They are more likely to engage in consensual sex earlier as well as to have unprotected sex and sex with multiple partners. ^{10,, ,} Victims of sexual abuse are often incapable of undertaking self-protective behavior, because the personal skills needed to prevent STIs and unintended pregnancy are exactly those life skills stunted by sexual abuse.^11,13 They may be unable or unwilling to make and follow through on decisions that will reduce abuse or remove them from harmful situations.^10,11 Sexual abuse can also result in low self-esteem, causing victims to seek acceptance through sex.

Adolescent girls who have been abused often have difficulty differentiating between sexual and affectionate behaviors, and have a higher incidence of teenage pregnancy and STI/HIV infection than in their non-abused peers.

• A study conducted in Barbados among 407 men and women found that sexual abuse was the most important determinant of high-risk behavior during adolescence and for men it correlated strongly with non-use of condoms in adulthood.¹²

• Victims of sexual abuse in one U.S. study began sexual intercourse a year earlier and were less likely to practice birth control than non-victims.¹⁴

How Can the Needs of Victims of Sexual Abuse Be Met?

Sexual abuse is being addressed in varying degrees across cultures and within communities. Program strategies range from raising awareness of the issue to implementing training workshops and developing counseling and referral networks. The impact of sexual abuse programs on young adult reproductive health is not fully understood, because most programs operate on a small scale and have little or no evaluation data.

There is, however, broad consensus that education and services are important tools for addressing sexual abuse among youth. The following recommendations are based on existing efforts, which demonstrate their programmatic feasibility in diverse settings.

Prevent Sexual Abuse: Include training skills for refusing sex, improving communication, and resolving conflict in all young adult reproductive health education efforts, as well as in other appropriate forums.

• In Honduras, the NGO Casa de la Mujer uses a gender approach to work with young women who have been abused to help them develop assertive behavior, including the capacity to set limits, defend their rights and strengthen self-esteem.

• Maiti Nepal, an NGO, has a prevention program in rural districts of Nepal with high rates of sex trafficking. The program raises awareness among girls and their parents about the dangers of prostitution and how girls are kidnapped or lured into the sex industry. Girls are also given non-formal and vocational training to enable them to earn a livelihood and improve their self-esteem.

• In the Alexandria section of Johannesburg, South Africa, a former advisor to Nelson Mandela heads a group working to decrease the incidence of rape by teaching adolescents appropriate ways to relate to one another. The project is funded by UNIFEM’s Trust Fund for Actions to Eliminate Violence Against Women.²¹

Raise Awareness and Advocate for Legal Sanctions: Create societal awareness by bringing the issue of sexual abuse into the public domain. Target policymakers, parents, teachers, community leaders, police and the media with educational campaigns.²¹ Create systems for data collection to monitor the incidences and prevalence of abuse and publicize the results.²⁴ Advocate for the review, revision and enforcement of laws to protect victims and punish abusers.

• A Nepalese non-profit organization, Media Alert, is creating a full-length film to expose the realities of girls’ lives who are trafficked to brothels in India. The film will be shown in mobile video vans to educate high-risk villagers living in remote areas. It will be released with Hindi and English subtitles to raise awareness among the male clients of young girls who have been trafficked.²²

• A Peruvian organization of professionals working with youth, Redess Jovenes, sponsored a widely- publicized workshop on violence and sexual abuse in young people. As a result, a municipal agency conducted a media education campaign that resulted in a 140% increase in requests for help for sexual abuse. Fifty-eight percent of the victims were under the age of 12, and 42% were young adults age 12-18.²¹

• In Pakistan, the NGO Sahil analyzed child sexual abuse laws and is advocating for the total legal protection of children. They are, for example, working to repeal an ordinance which makes it possible for victims—rather than the perpetrators—of sexual abuse to be penalized.

Screen for Sexual Abuse: Train health providers, teachers and peer educators to identify individuals who have been victims of sexual abuse by including questions about abuse in health assessments. Health care providers, in particular, need to be aware that not all clients are having consensual sex, pregnancy may result from incest or rape, and introducing condom use may put young women at risk of reprisal. ^11,13

• In Turkey, the NGO Human Resource Development Foundation is implementing a curriculum to train future teachers in sexual health issues, including sexual abuse. The project is developing a sexual health training program to enable teachers to function as sexual health counselors by identifying victims of sexual abuse and making appropriate referrals for counseling and legal services.

• A leading family planning organization in Colombia, Profamilia, has a screening program that identifies sexually-abused individuals during clinic visits and offers information, counseling and legal assistance. It assists clients in recovering self-esteem and improving their body image and relationships with the opposite sex.²¹

Respond with Services: Create a protocol for responding to clients who have been sexually abused and, when necessary, develop a referral system to health, legal and other services. ¹²

• In Soweto, South Africa, the Zamokuhle Child Abuse Center has a medical/legal clinic which sees 150-200 child sex abuse cases a month. The clinic uses a multi-disciplinary approach to integrate medical and psychological services with legal management. It holds workshops for young people on life skills and personality development issues.²³

• INPPARES, in Peru, has integrated sexual abuse into its educational activities. Peer counselors helped to produce a video on sexual abuse that is used in schools, public meetings, workshops, and presentations to policymakers. Its service centers provide counseling to abused young adults and their family members or partners when appropriate. It also refers clients to outside services for assistance in legal processes.

The Brazilian Family Planning Association, BEMFAM, demonstrates how all four recommendations can be incorporated within the work of a single organization. It trains staff to identify victims of sexual abuse and has developed health care and counseling guidelines for young women who report violence. It distributes materials promoting the availability of clinic staff to work with victims of violence, and works with schools to raise awareness about sexual abuse and help teachers respond to young people facing abuse. It also has established a referral system to special courts that handle youth issues and agencies that provide therapy for victims of violence.²⁶

The In FOCUS series summarizes for professionals working in developing countries some of the program experience and limited research available on young adult reproductive health concerns. This issue was prepared by Stephanie Shanler based on presentations prepared by Lori Heise, Lindsay Stewart and Ellen Weiss, and reviewed by outside experts and the staff of the FOCUS program.

References

1. Kidman, C. April/May 1993. Non-consensual sexual experience & HIV education: an educator’s view. SIECUS Report 21 (4).
2. Admassu, E. 1998. Pathfinder International, Ethiopia. Personal communication. August 10.
3. Atta, S. 1998. Sahil in Interior Sindh. Sahil 7.
4. Alan Guttmacher Institute. 1998. Into A New World: Young Women’s Sexual and Reproductive Lives. New York: Alan Guttmacher Institute.
5. Olsson, A. 1998. Umea University, Sweden. Personal communication. September 4.
6. Kabir, K. 1998. "Exploitation of and Violence Against Adolescents." (Theme paper for the UNFPA South Asia Conference on the Adolescent, July 21-23, New Delhi, India.)
7. Silva, T.K., S.L. Schensul, J. Schensul et. al. 1997. "Youth and Sexual Risk in Sri Lanka." Women and AIDS Program Research Report Series, Phase II, No 3. Washington DC: International Center for Research on Women.
8. Khan, N. 1998. Sexual and physical abuse: a threat to reproductive and sexual health. Sexual Health Exchange 1.
9. Casa Alianza. 1995. Street Children: An Overview. <http://www.casa-alianza.org/children/ child2.html> (online cited July 9, 1998)
10. Heise, L. 1998. "Violence, Sexuality & Women’s Lives." (Presentation before the SIECUS Board Meeting, New York, February 21.)
11. Heise, L., K. Moore and N. Taubia. 1995. Sexual Coercion and Reproductive Health. New York: The Population Council.
12. Handwerker, W.P. 1993. Gender power differences between parents and high-risk sexual behavior by their children: AIDS/STD risk factors extend to prior generation. Journal of Women’s Health 2 (3).
13. Stewart, L., A. Sebastiani, G. Delgado and G. Lopez. 1995. "Dealing with Sexual Abuse in Adolescents." Planned Parenthood Challenges 1. London: International Planned Parenthood Federation.
14. Boyer, D. and D. Fine. January/February 1992. Sexual abuse as a factor in adolescent pregnancy and child maltreatment. Family Planning Perspectives 24 (1).
15. Moore, K., C.W. Nord and J.L. Peterson. May/June 1989. Nonvoluntary sexual activity among adolescents. Family Planning Perspectives 21 (3).
16. Luster, T. and S. Small. Sept/Oct 1997. Sexual abuse and sexual risk-taking among sexually abused girls. Family Planning Perspectives 29(5).
17. Stock, J. et al. Sept/Oct 1997. Adolescent pregnancy and sexual risk-taking among sexually abused girls. Family Planning Perspectives 29 (5).
18. Heise, L. 1994. Gender-based violence and women’s reproductive health. International Journal of Obstetrics and Gynecology 46.
19. Butler, J.R., L.M. Burton. January 1990. Rethinking teenage childbearing: is sexual abuse a missing link. Family Relations 39.
20. Stewart, L. et. al. May 1996. Sex and pregnancy: two of the consequences of sexual abuse of adolescents. Reproductive Health Matters 7.
21. Stewart, L. 1997. "Dealing with the Sexual Abuse of Children and Adolescents." (Presentation to the Adolescent Interest Group, USAID, Washington DC, November 19, 1997.)
22. Friedman, M. 1998. USAID/Kathmandu. Personal e-mail communication. July 5.
23. Paone, D. and W. Chavkin. April/May 1993. From the private family domain to the public health forum: sexual abuse, women and risk for HIV infection. SIECUS Report 21 (4).
24. Sahil. 1998. Child Sexual Abuse and Exploitation in Pakistan: A Report by Sahil. Islamabad: Sahil. Email: <info@sahil.org>
25. Cokar, M. 1998. Human Resources Development Foundation. Personal e-mail communication. June 30 - July 2.
26. Cohen, S. 1998. IPPF/WHR. Personal e-mail communication. July 2, 1998.