Nonconsensual sex undermines sexual health: young and old, females and males are at risk.

KEY POINTS

* Forced sex is associated with serious reproductive health problems.

* Many victims are young and female, but older individuals and males are also at risk.

* Nonconsensual sex is a worldwide problem often rooted in long-standing societal norms.

Often and by a variety of means, children, adolescents, and adults--men and women alike--are pressured to have sexual relations that they do not want. Too commonly, the behavior of perpetrators, thoroughly interwoven into long-standing traditions and customs, is condoned. Meanwhile, the stigma that many victims face plunges them into a resigned silence that hinders them from getting help and masks the scope of the problem.

Thus, nonconsensual sex--accepted or merely overlooked--continues unabated. Meanwhile, its full magnitude, risk factors, and physical and mental health consequences remain poorly understood, particularly in the developing world (see article, page 4). Although strong associations between various forms of sexual coercion and adverse reproductive health consequences have been identified, the design of studies usually makes it impossible to determine a direct cause-effect relationship. In fact, the same factors that increase health risks may also increase risks for nonconsensual sex.

But experts warn that nonconsensual sex may underlie some of the most tenacious and often life-threatening reproductive health problems of the time: unintended pregnancy (and its complications) and the acquisition of not only HIV but also other sexually transmitted infections (STIs) that can cause cervical cancer and infertility. (1) The widespread existence of forced sex means that common STI/HIV prevention approaches emphasizing abstinence, faithfulness in relationships, and condom use cannot protect all people from these infections.

Definitions of nonconsensual sex vary, complicating attempts to measure its overall prevalence or to compare its prevalence among various settings. However, all definitions rest on a common foundation: a lack of full and free choice in decisions to engage in sexual relations. Physical force or the threat of it can rob victims of this choice. But intense psychological, emotional, and financial pressure or a fear of social consequences also can compel individuals to relinquish their right to resist unwanted sexual advances. While rape is one of the most extreme and immediately traumatic forms of coerced sex (see article, page 5), other forms may have a greater health impact.

Types and characteristics of nonconsensual sex reported from diverse settings throughout the world cover a broad spectrum. But the following trends are clear:

* Settings that would appear to provide the greatest protection against abuse, such as homes, schools, and even health care facilities, often present considerable risk.

* Most victims know their abusers.

* A substantial proportion of victims are young.

* Most victims are women or girls.

* Such forms of sexual coercion as child or marital sexual abuse are ongoing and may grow worse over time. (2)

Children and young adolescents

Sexual abuse of children and young adolescents is widespread in all societies. The World Health Organization (WHO) estimates that overall prevalence is 25 percent for girls and 8 percent for boys, (3) although these figures differ with the population studied and definitions used. A father or other male relative is the most common perpetrator, but abuse by peers, teachers, child caregivers, family friends, religious leaders, and neighbors also occurs. Boys and girls between ages seven and 13 years are at greatest risk. (4)

Associations between childhood sexual abuse and many short- and long-term adverse mental and physical health effects abound. For example, studies have found childhood sexual abuse to be associated not only with adolescent pregnancy (5) and HIV infection, (6) but also with a tendency for victims to later force someone else to have sex (7) and with an assortment of gynecological and reproductive health problems, including chronic pelvic pain, premenstrual distress, and inadequate or excessive prenatal weight gain. Other adverse mental and physical effects include such emotional problems as depression and anxiety, sexualized behavior, binge eating in women, and substance abuse. (8)

Whether childhood sexual abuse directly causes reproductive and other health problems remains unclear, since many of the factors that put a child at risk for sexual abuse also put a child at risk for adverse health outcomes later in life. These factors include family instability, parental psychopathology, childhood neglect and physical abuse, lower social class, unemployment, parental alcohol and drug abuse, and poverty. (9) As a result, the interrelatedness of childhood sexual abuse with multiple adverse childhood experiences should be considered in the design of studies, treatment, and programs to prevent childhood sexual abuse. (10)

Sexual abuse of young adolescents can directly and immediately result in unintended pregnancy or STI/HIV acquisition. Over the long term, childhood sexual abuse appears to be associated with these same adverse outcomes by means of two mechanisms. First, such abuse has been linked to sexual risktaking in adolescence. Second, it has been associated with later sexual victimization of women. (11)

In both cases, emotional harm caused by childhood sexual abuse appears to undermine normal, healthy psychological development that would enhance victims' ability to protect their sexual health. In numerous studies, victims have reported guilt, anxiety, and depression; feelings of worthlessness and powerlessness; inability to distinguish sexual from affectionate behavior; difficulty in maintaining appropriate personal boundaries; and inability to refuse unwanted sexual advances. (12)

Sexual risktaking associated with childhood sexual abuse manifests itself in several ways. Compared with nonvictims, victims are more likely to start voluntary sex earlier; have sex with multiple partners; abuse alcohol and use other drugs; trade sex for money or drugs; and not use contraception, including condoms. (13) All of these behaviors may increase risk of unintended pregnancy as well as STIs, including HIV. An association between childhood sexual abuse and a decreased likelihood of having a Pap smear (14) may indicate yet another form of risktaking, since the test helps ensure timely diagnosis and treatment of cervical cancer and its precursors. Cervical cancer is a major killer of women worldwide.

School settings

School, like home, should be a safe haven for young people. Yet, many girls and--to a lesser extent, boys--are sexually harassed and coerced there. (15) Teachers have been reported to offer good or passing grades to girls in exchange for sex. (16) Not uncommonly, peers and older students prey on girls as they walk to school or while they board in dormitories. And "sugar daddies" target girls in the vicinity of schools, luring them into sexual relations with gifts and money. Many girls feel that their survival depends on such arrangements. For example, a quarter of students interviewed in a study in Zimbabwe of school-based sexual abuse said they regularly went hungry. (17)

Research conducted in junior secondary schools in Zimbabwe, Malawi, and Ghana has found that sexual abuse of girls by teachers, older male pupils, and sugar daddies is largely accepted. Authorities may not act against it. Teachers are generally unwilling to report each other's sexual misconduct. And not all girls or their parents necessarily disapprove of sexual relations between teachers or older men and girls. (18) Similar patterns of sexual harassment and rape by teachers or peers have been reported in university settings in such diverse areas as China, Ethiopia, Malawi, South Africa, Sri Lanka, Tanzania, and Zimbabwe. (19)

Boys and young men

Although research about sexual abuse of boys is scarce and study sample sizes are small, 4 percent to 20 percent of adolescent males studied in developing countries report having been victims of sexual assault. In most cases, perpetrators are peers; occasionally they are older men. As with female victims of childhood sexual abuse, male victims are likely to suffer such psychological consequences as anxiety and depression. (20) Largely due to the stigmatization that knowledge of their victimization may cause, few male victims seek help and most tend to suffer in silence. In some cases, their distress may lead to more sexual risktaking (see article, page 11).

Sexual abuse of boys has been associated with their later impregnation of girls. Surveys of some 54,000 sexually experienced female and male high school students in Minnesota, USA, found that impregnation of girls and associated risk behaviors (little or no condom use; regular alcohol or other drug use before sex) were at least twice as common among abused males as among their nonabused peers. (21) A survey that included some 1,600 sexually experienced adolescents in Massachusetts, USA, found that both female and male adolescents with a history of sexual abuse reported greater sexual risktaking than did those without a history; however, the impact of sexual abuse on sexual risktaking appeared to be greater for boys. Notably, researchers pointed out that the boys reported even more dysfunctional family environments than did the girls and that lack of a supportive family in conjunction with the abuse itself could make boys more prone to risktaking behaviors. (22)

In studies conducted in settings as varied as Brazil, Colombia, India, Kenya, the Philippines, and Thailand, forced sex among young men--particularly those living on the street--has been associated with them forcing sex themselves or becoming involved in transactional sex exchanging sex for money, gifts, or favors) with older men and women. (23)

Older adolescents and men also may be at risk for nonconsensual sex at home, at school, at work, on the street, in the military, during war, in prisons, and in police custody. Usually, perpetrators are other men. But sometimes they are women. About a quarter of some 1,500 male college students or men of college age participating in U.S. and German studies have reported incidents of sexual coercion by women, including sexual intercourse. While women are reported to most commonly use psychological pressure or men's intoxication to engage in unwanted sex, they occasionally use force: hitting, sitting on, tying up, or locking up their victims. Women may succeed in having sexual intercourse with unwilling men because the anger, fear, and pain that such intimidation can evoke, although unwelcome, can cause sexual arousal or even orgasm. (24)

Men do not always report these forced acts to be unpleasant, but researchers estimate that at least one of five men has a strong negative reaction. (25) Most studies of forced sex by women have been conducted among university students in developed countries, but instances of women raping men at gunpoint to deliberately infect those men with HIV have been reported in South Africa. (26)

Older unmarried adolescents and women

Like young adolescents in school settings, older female adolescents may enter sexual relationships with substantially older men in exchange for gifts or money. (27) Similarly, male adolescents have reported being pressured by older women to engage in such transactional sex. (28) Some may freely choose this course. But transactional sex is often motivated by pressing economic need, (29) and thus is essentially nonconsensual.

Regardless of age, women engaging in transactional sex may be at increased risk for HIV infection. In a study conducted in Soweto, South Africa, among nearly 4,000 pregnant women ages 15 to 44 years, transactional sex was associated with HIV seropositivity. Women in transactional sexual relationships may be at increased risk for HIV, the researchers suggested, because they are less likely to use condoms and their male partners are more likely than other men to be HIV-infected, perhaps because they often have multiple sexual partners. (30)

Husbands or steady partners

Women often fear rape by a stranger. But many are more likely to be sexually coerced by the men they know best: their husbands and long-term boyfriends. Sexual assault by husbands is reported two to eight times more often than is assault by strangers. (31) In various studies throughout the world, up to a quarter of women have reported being forced by a current or former husband or cohabiting partner. (32) In some settings, rates may be far higher (see article, page 12).

Not all countries recognize marital rape as a crime or penalize it. Instead, gender norms in many settings result in marriage often being seen as giving men unconditional sexual access to their wives. Furthermore, while rape by a stranger tends to be a one-time event, marital rape may occur repeatedly and thus pose a continuing threat to a woman's reproductive health.

A study conducted in Uttar Pradesh, India, found that unplanned pregnancies were 2.6 times more common among wives of abusive men, especially sexually abusive men who used force, than among wives of nonabusive men. (33) In a study in rural Tamil Nadu, India, among 66 women and 44 of their husbands, nonconsensual sex was the single most important indicator distinguishing women who had terminated their pregnancies from those who had not. (34)

In a study of forced sex among some 750 women accessing services at a women's health clinic in an impoverished area of rural Haiti, women whose current pregnancy was unplanned were 1.7 times more likely to have experienced forced sex than were other women in the study. Of note, forced sex (reported by more than half of the women) was more common in relationships of more than four years. Researchers suggested that the economic dependence of some women in longer-term relationships may increase their risk of forced sex. (35)

"Most of the women in this area of rural Haiti live in harsh poverty, earning U.S. $10 to U.S. $30 monthly, and 80 percent report spending half of their earnings on food," says Dr. Joia Mukherjee, medical director of the U.S.-based Partners in Health, who presented results of the study at the XV International AIDS Conference in Bangkok. "Without poverty alleviation, stressing prevention of unintended pregnancy and STIs/HIV by means of abstinence, faithfulness to partners, or condom use will have very limited utility since many of these women do not have the power to protect themselves. Many are faithful but, because of their economic dependence, they have no power over when and under what circumstances they have sex."

Male extramarital sex, combined with forced marital sex, not only puts wives at risk of STIs/HIV but also can endanger an unborn child. If an HIV-infected man forces sex upon his pregnant wife and she becomes infected, the virus may be transmitted to her fetus. Thus, newborns become the last link in the long chain of victims of nonconsensual sex.

References

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Nonconsensual Sex within Marriage

Percentages of ever-married women ages 15 to 49 years ever reporting
physically forced sexual intercourse by husband

Cambodia   Colombia   Dominican Republic   Haiti   Nicaragua   Zambia *

   3.4      11.0             6.0           16.7       8.7        5.1

* In Zambia, women were asked whether they had ever been
forced to have sex by anyone, including their husbands.

Source: Kishor S, Johnson K. Profiling Domestic Violence--A
Multi-Country Study. Calverton, MD: ORC Macro, 2004. (Data
are derived from Demographic and Health Surveys.)