Keys to preventing nonconsensual sex: promising interventions include multifaceted approaches, specific targets.

KEY POINTS

* More interventions to prevent nonconsensual sex in the developing world need to be well documented and evaluated.

* A multifaceted approach to prevention is recommended.

* Interventions should have specific targets and address particular risk factors.

Strong support of health and medicolegal services for victims of sexual violence is imperative, but it is wise to also think about financial support of prevention initiatives and their rigorous evaluation.

Some prevention efforts have already been implemented, mostly in the United States and other industrialized countries. "It would seem that there are also many programs aimed at the prevention of nonconsensual sex in developing countries, but most of these programs are not documented, making it difficult to describe the current range of interventions they deliver and the risk factors and target groups they aim to influence," says Dr. Alexander Butchart, coordinator of violence prevention at the World Health Organization (WHO). "Since so few of these programs have been evaluated, saying how successful they are is also difficult."

Nevertheless, based on reviews of programs evaluated worldwide and on discussions among prevention experts, some general characteristics that seem to help prevention efforts succeed have been identified.

Many contributing factors, strategies

At an individual level, a young man's abuse of alcohol or drugs may make him more likely to force a woman to have sex.

Or a woman may not recognize that nonconsensual sex is inappropriate. She may feel that it is normal or even that she deserves it. But nonconsensual sex is by no means simply an individual problem. Evidence suggests that relationship, community, and societal factors also contribute. (1) And most underlying causes of forced sex, which seem related to women's low status and to gender inequities, (2) are deeply rooted.

Due to these multiple contributing factors, prevention efforts need to be implemented at many levels. Consequently, a range of general approaches and specific prevention interventions have been documented (see chart below).

Within a specific prevention effort, either a single approach or several of these approaches can be employed. The possible benefits of implementing--but also the possible difficulties in evaluating--a multifaceted approach have been demonstrated by a study to prevent violence, including nonconsensual sex, among young female hawkers in Nigeria. (3)

Hawking, which is common in West Africa among women of all ages, is an informal way to make money by trading food, clothing, and other household goods. The study was conducted between April 2000 and August 2001 in six of the largest motor parks where hawking occurs in southwest Nigeria. The research, funded by the United Nations Development Fund for Women (UNIFEM), included 345 semistructured interviews with hawkers at baseline, a five-month intervention, and an interview-based evaluation among 374 hawkers one year later.

The five-month intervention involved distribution of more than 1,000 copies of educational materials about various forms of violence against women. Six three-day workshops for nearly 600 hawkers (and a one-day workshop for community members who were interested in preventing violence in the motor parks) included training on the definition and consequences of violence, the development of assertiveness skills, and care and support for victims. Finally, selected hawkers received loans of U.S. $20 for personal or educational purposes, intended to promote sound investments and accountability.

The reported rate of forced sexual intercourse decreased from 11.3 percent at baseline to 1.9 percent after the intervention, and the reported rate of rape decreased from 5.5 percent to nearly 0 percent. Rates of sexual harassment and attempted rape also declined significantly.

The study team from University College Hospital in Ibadan, Nigeria, and FHI acknowledge, however, certain limitations of the study. The reduction in rape should be interpreted with caution, they say, since underreporting of rape is common in the motor parks and because of the short interval between the intervention and the evaluation. Also, the populations interviewed at baseline and at the one-year evaluation were not identical. This is because not all hawkers necessarily participated in the interviews and because some hawkers may have moved into the area, while others may have stopped hawking or moved away, after the intervention.

"Hawkers are a very mobile group, but we hope that the knowledge and skills they acquired during the intervention will remain with them when they move and will influence their decisions in the future," says the study's principal investigator, Dr. Olufunmilayo Fawole of University College Hospital. An intended reevaluation of the intervention has not taken place because of lack of funding, but Dr. Fawole and colleagues recently implemented a similar project among vulnerable apprentices in the hairdressing, sewing, and medicine-selling sector in southwest Nigeria. Results are expected in 2005.

Appropriate targets

Multifaceted prevention strategies such as this one should have very specific targets, experts tend to agree. In a recent international review of interpersonal violence, WHO strongly encourages prevention efforts in low-resource settings to target subpopulations at highest risk. (4)

Many high-risk populations exist because nonconsensual sex is perpetrated in so many settings and under various circumstances. In many countries, one highrisk population is married women. Nonconsensual sex within marriage often occurs because of an underlying assumption, reinforced by social norms, laws, and policies, that a man does not need consent to have sex with his wife. CHANGE, a London-based international nongovernmental organization, is working to change this assumption through activities to promote women's sexual and human rights in marriage and to help men recognize and respect them. (5)

In the prevention effort conducted in Nigeria, hawkers were chosen as targets since "they are vulnerable because of their age, low socioeconomic status, and, ultimately, poverty," Dr. Fawole said. Thus, the intervention included efforts to decrease women's risks of nonconsensual sex by offering them educational and economic opportunities.

Another risk factor for the hawkers was the environment in which they worked. Motor parks are frequented by drivers, bus conductors, auto mechanics, and other predominantly male workers who are often accused of social and moral misconduct, including sexual exploitation of young female hawkers. (6)

In general, men are an especially important group to involve in prevention efforts since they are "the main perpetrators of most types of violence," Dr. Butchart says. Men themselves can act as advocates for policies or laws that discourage or penalize nonconsensual sex. They can also participate in programs and organizations to raise awareness of or change (at the individual, family, or societal level) gender norms, perceptions, and beliefs that condone forced sex. (7) One such organization is the White Ribbon Campaign, the largest global effort of men working to end violence against women. Members work to increase awareness of the problem, support local women's groups, and raise money for international educational efforts. Established more than a decade ago in Canada, the campaign now has a presence in more than 30 countries, including Brazil, Cambodia, China, and the Philippines. (8)

Some secondary prevention programs have also targeted men by establishing treatment programs for those who commit violence (see articles, pages 24 and 25). But to be effective, says Dr. Butchart, primary prevention should address the underlying risk factors for both male and female behavior, such as early developmental experiences, poor parenting practices and family dysfunction, poverty and social isolation, and social and cultural norms that maintain or increase economic and social inequalities.

Working with youth

Youth are another general but important target, as research consistently shows that youth are at heightened risk of sexual victimization. (9) Working with youth also provides an opportunity to reverse gender norms that fuel sexual violence by teaching more egalitarian ways for young men and women to interact and by introducing concepts of equity, respect, and social justice.

A recent review of the prevalence, risk factors, and consequences of sexual assault among youth highlights the need for interventions to begin educating children, even before puberty, on issues related to nonconsensual sex. (10) "Early intervention can help shape the attitudes, knowledge, and behavior of children when they are more open to positive influences, and can affect their behavior over their lifetimes," Dr. Butchart says.

Most interventions, however, have been conducted among older youth. Many have taken place in educational settings, perhaps because conducting research there is convenient. (11) Nevertheless, schools are an ideal setting for prevention efforts since many young women experience nonconsensual sex there. (12) Schools are also "places where students learn values, as well as the information and skills they need to pass exams," says Judith Mirsky, codirector of the Panos Institute's Reproductive Health and Gender Programme, in a recent report on addressing sexual violence in the educational sector. (13) "As such, they [schools] can help break the cycle of violence. They need to address it vigorously where it happens, and ensure that curricular and extracurricular opportunities equip young people to navigate their sexual lives without violence," she says.

In 1996, the Tanzania-based HIV/AIDS project TANESA implemented a program to protect students in 185 primary schools from sexual exploitation, and a program evaluation that year demonstrated early success. (14)

For each school, one female teacher whom students could consult about sexual violence, sexual harassment, and other reproductive and sexual health issues was selected and trained as a "guardian." Structured interviews among female students, guardians, and other teachers from 40 schools with a guardian and 22 schools without one showed that having a guardian significantly increased the likelihood of school girls seeking help from guardians or other female teachers for sexual violence, sexual harassment, and other issues.

Guardians informed the school boards, courts, or district authorities about cases of rape, most of which were perpetrated by teachers and men from the community. Although punishment was often minor and alleged perpetrators were not always caught, educational authorities did prevent at least two teachers from continuing to teach at their current schools after they were accused of raping students. One of the most important initial effects of the program, it appeared, was that "sexual abuse of school girls by teachers has become less hidden and may have become more difficult than in the past, and that the negative publicity surrounding such events has probably had a preventive effect," reported the study team.

For cases of sexual harassment, most of which were perpetrated by school boys, the guardians held private talks with those involved, and boys were often punished with cane beatings or threatened with suspension from school. Research from Nigeria suggests that rape tends not to be an isolated incident; rather, it is often preceded by sexual harassment and increasingly violent behavior. (15) Thus, the guardian program may have thwarted rapes by increasing the school's awareness of sexual harassment and punishing perpetrators before their actions could escalate.

Evaluations

At the University of North Carolina at Chapel Hill, USA, Dr. Vangie Foshee and colleagues have conducted the first randomized controlled trial to determine the long-term effects of a school-based intervention that is one component of a program, called Safe Dates, to prevent nonconsensual sex and other forms of dating violence. (16)

The school-based component includes a theatrical production, classes, and a poster contest to change norms about dating abuse and to teach conflict-management skills to prevent violence. All participants are also encouraged to seek help if they become victims. The Safe Dates program also has a community-based component that enhances services to prevent dating violence, such as a crisis hot line and support groups. The community-based component also features training of local providers to more effectively help teen perpetrators and victims of dating abuse.

Between October 1994 and March 1999, the randomized controlled trial was conducted among nearly 2,000 eighth- and ninth-grade students (approximately ages 13 and 14) from 14 public schools in rural North Carolina. Students from seven randomly allocated schools were exposed to both school- and community-based activities, while students from the other seven schools were exposed only to community-based activities and served as controls. The project was then evaluated several times over four years for outcomes that included rates of forced sexual intercourse.

Analyses found that adolescents who were exposed to school-based as well as community-based Safe Dates activities reported less sexual dating violence perpetration at one, two, three, and four years after the program, than adolescents in the control group. However, potential limitations of the study were high attrition of student participants and reliance on self-reports of dating violence. This illustrates the considerable difficulty of rigorously evaluating such interventions.

"Whatever the approach, whatever the intervention, and whatever the sector involved in implementation, every prevention program needs to provide data-driven answers to three key questions," Dr. Butchart says. "These are 'What is the problem? What are the causes? And what works to prevent violence?' Programs answer the third question by indicating how interventions are designed, tested, and evaluated for efficacy. In this way, assessments of effectiveness are based on solid empirical evidence."

References

(1) Butchart A, Phinney A, Check P, et al. Preventing Violence. A Guide to Implementing the Recommendations of the World Report on Violence and Health. Geneva, Switzerland: World Health Organization, 2004.

(2) Jewkes R, Abrahams N. The epidemiology of rape and sexual coercion in South Africa: an overview. Soc Sci Med 2002;55(7):1231-44.

(3) Fawole OI, Ajuwon AJ, Osungbade KO, et al. Interventions for violence prevention among young female hawkers in motor parks in south-western Nigeria: a review of effectiveness. Afr J Reprod Health 2003;7(1):71-82.

(4) Krug EG, Dahlberg LL, Mercy JA, et al., eds. World Report on Violence and Health. Geneva, Switzerland: World Health Organization, 2002.

(5) CHANGE. Non-consensual Sex in Marriage: A Worldwide Programme. Information sheet. London, UK: CHANGE, 1998.

(6) Fawole.

(7) Lang JL. Working with men to end gender-based violence: lessons for the South Asian context. In Elimination of Violence against Women in Partnership with Men. Gender and Development Discussion Paper Series No. 15. Bangkok, Thailand: United Nations Economic and Social Commission for Asia and the Pacific, 2003.

(8) Kaufman M. Speech to White Ribbon Campaign Public Meeting in Beijing. Toronto, Ontario: The White Ribbon Campaign, 2002.

(9) Danielson CK, Holmes MM. Adolescent sexual assault: an update of the literature. Curr Opin Obstet Gynecol 2004;16(5):383-88.

(10) Danielson.

(11) Bennett LR, Manderson L, Astbury J. Mapping a Global Pandemic: Review of Current Literature on Rape, Sexual Assault and Sexual Harassment of Women Consultation on Sexual Violence against Women. Geneva, Switzerland: Global Forum for Health Research, 2000.

(12) Krug.

(13) Mirsky J. Beyond Victims and Villains: Addressing Sexual Violence in the Education Sector. London, UK: The Panos Institute, 2003.

(14) Mgalla Z, Schapink D, Boerma JT. Protecting school girls against sexual exploitation: a guardian programme in Mwanza, Tanzania. Reprod Health Matters 1998;6(12):19-30.

(15) Ajuwon AJ, Olley BO, Akin-Jimoh I, et al. Experience of sexual coercion among adolescents in Ibadan, Nigeria. Afr J Reprod Health 2001;5(3):120-31.

(16) Foshee VA, Bauman KE, Ennett ST, et al. Assessing the effects of the dating violence prevention program "Safe Dates" using random coefficient regression modeling. Unpublished paper. University of North Carolina at Chapel Hill, 2004; Foshee VA, Bauman KE, Ennett ST, et al. Assessing the long-term effects of the Safe Dates program and a booster in preventing and reducing adolescent dating violence victimization and perpetration. Am J Public Health 2004;94(4):619-24.

Approaches to Preventing Sexual Violence

Approach           Interventions

Individual         Life skills and other educational programs, programs
                   for perpetrators, psychological care and support
                   for victims

Developmental      Targeting individuals at multiple life stages such
                   as childhood, adolescence, and young adulthood

Health care        Medicolegal responses, training for health care
                   professionals, comprehensive care for victims

Community-based    Media and other prevention campaigns, community
                   activism by men, school-based programs

Legal and policy   Reporting and handling cases of perpetration, legal
                   reform, international treaties that set standards
                   of unacceptable behavior

Source: Krug EG, Dahlberg LL, Mercy JA, et al., eds. World
Report on Violence and Health. Geneva,
Switzerland: World Health Organization, 2002.