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
% had experienced physical or sexual intimate partner violence (IPV)
% 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
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

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

11. 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’

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
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)

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 site funded by the MacArthur Foundation, Ford Foundation, an anonymous donor, and the Norwegian Ministry of Foreign Affairs