Introduction

Sexual violence, in addition to violating a woman’s rights, can result in immediate and long-term health consequences for women. These are briefly described in this chapter. Sexual violence includes a range of acts, from rape and genital mutilation to forced marriages, and can occur in contexts such as armed conflicts or emergency situations. Although the health consequences and health needs resulting from all forms of sexual violence follow a similar pattern, there are some distinguishing features with certain acts of sexual violence that will be elaborated on further in this chapter.

Sexual violence often occurs with other forms of abuse: physical, emotional and financial. In cases of intimate partner violence, few women suffer from sexual abuse alone. In South Africa, two separate studies found that only 2% of women experience sexual intimate partner violence exclusively, whereas, in the USA, 40–50% of women who are physically assaulted by intimate partners have been reported to have also been sexually abused. These forms of abuse interact in a complex web of gender-based violence. Although the focus is solely on the health consequences of sexual violence in this chapter, one should remember that women may be facing, or may have faced, multiple forms of abuse in their lifetime.

The focus of many investigators working in this field has been on wider forms of abuse of intimate partner violence and gender-based violence, and a dearth of information is available on the consequences of sexual violence per se . Women who have experienced physical and sexual intimate partner violence are at a higher risk of experiencing health problems, especially mental, than those facing physical violence alone. Women may have also experienced childhood sexual abuse, which has been shown to have longstanding health consequences as well as increasing the risk of intimate partner violence and sexual violence by a non-partner in later life.

Overview of health consequences

Health consequences can be broadly grouped into more immediate effects directly stemming from the incident of sexual violence, whereas medium- to long-term consequences occur in the period after the sexual violation. Indirect health consequences, such as engaging in risky sexual behavior, may occur long after the violent incident. Furthermore, outcomes of sexual violence against women can be fatal or non-fatal, depending on the extent of injuries and health problems. Studies conducted in the USA have shown an increased risk of femicide with sexual violence, with significantly more risk factors reported by sexually assaulted women compared with women who were only physically assaulted. A broad overview of the potential health consequences a woman could face from sexual violence is presented in Fig. 1 .

Health consequences of sexual violence. AIDS, autoimmune deficiency syndrome; HIV, Human immunodeficiency virus.

Overview of health consequences

Health consequences can be broadly grouped into more immediate effects directly stemming from the incident of sexual violence, whereas medium- to long-term consequences occur in the period after the sexual violation. Indirect health consequences, such as engaging in risky sexual behavior, may occur long after the violent incident. Furthermore, outcomes of sexual violence against women can be fatal or non-fatal, depending on the extent of injuries and health problems. Studies conducted in the USA have shown an increased risk of femicide with sexual violence, with significantly more risk factors reported by sexually assaulted women compared with women who were only physically assaulted. A broad overview of the potential health consequences a woman could face from sexual violence is presented in Fig. 1 .

Health consequences of sexual violence. AIDS, autoimmune deficiency syndrome; HIV, Human immunodeficiency virus.

Immediate health concerns of the sexual violence survivor

The immediate health concerns of a sexual violence survivor include the management of acute injuries. This may require the survivor to be stabilized, and pain and symptom relief may be necessary with anti-tetanus toxoid for contaminated wounds. If the survivor accesses health services within 3–5 days after the assault, she can be offered care to prevent an unwanted pregnancy, and to prevent sexually transmitted infections, including hepatitis B and human immunodeficiency virus (HIV). The mental health sequelae of sexual violence may begin from the point of the assault to months and years later. It may be necessary to identify these and provide appropriate care over a longer period. The provision of information to survivors, verbally and in print material, can be valuable, as they may experience symptoms later and be uncertain about how to approach these. At this point, medico-legal requirements, such as the collection of evidence for DNA analysis, are also important.

Medium- to long-term physical health consequences

A review conducted by the World Health Organization and the Sexual Violence Research Initiative provides an overview of physical and mental health sequelae after sexual violence. Gastrointestinal symptoms are found to be common with female survivors of sexual violence. In a random survey of women in Los Angeles, sexually assaulted women had twice the risk of reporting symptoms such as nausea, vomiting, abdominal pain, diarrhoea, and bloatedness (41%) compared with non-assaulted women (26%). Furthermore, a study conducted with women who were sexually violated found that they were significantly more likely to think that they were fat, had sudden weight changes including substantial weight loss, and symptoms of anorexia compared with non-violated women.

Chronic conditions are increased in female survivors with much health impairment; they have a poor perception of health and seek medical care more frequently. They are, therefore, either unable to work or have a high use of sick leave. It has been reported, however, that female survivors have lower rates of mental health service and preventive health care use. In addition, survivors are found to have a high reported number of cardiopulmonary and neurologic-type symptoms, including shortness of breath, palpitations, cardiac arrhythmias, chest pain, asthma, hyperventilation, choking sensation, numbness, weakness or faintness, insomnia and fatigue. In addition, chronic pain with back and facial pain, and fibromyalgia, have been reported. Migraines and other frequent headaches have also been reported.

Medium- to long-term reproductive health consequences

Women who are sexually violated may suffer from genital injuries that result in long-term complications. Other gynaecological complaints include vaginal bleeding or infection, genital irritation, fibroids, chronic pelvic pain, pre-menstrual syndrome and urinary tract infections. In a random survey of 3419 women in two communities in the USA, sexually assaulted women had over twice the risk of reporting painful menstruation (21% v 14%), painful intercourse (6% v 3%), and lack of sexual pleasure (15% v 4%) compared with women without a history of assault.

Forced sex can also result in an unplanned or unwanted pregnancies, and a large longitudinal study with 4008 women in the USA found that, over a 3-year period, the national rape-related pregnancy rate was 5.0% per rape among victims aged 12–45 years, producing over 32,101 pregnancies nationally among women from rape each year. In this study, 50% of the women underwent an elective abortion, whereas 12% had a spontaneous miscarriage. In Ethiopia, 17% of adolescents in a school-based study reported falling pregnant after a rape, whereas two separate studies in crises centres in Mexico reported figures of 15% and 18% for their patients. In India, unplanned pregnancies were significantly more common among wives of sexually abusive men (OR, 2.62; 95% CI, 1.91 to 3.60). In some areas, women face undergoing backstreet abortions or may be forced to keep the child. Sexual assault can also place the women under an increased risk of suffering from sexually transmitted infections.

Psychological health consequences

Sexual assault can have immediate and long-term psychological consequences. Immediate reactions include feelings of shock, denial, fear, confusion, anxiety, panic, phobias, withdrawal, guilt or nervousness. Sleep and eating disorders also occur. Some women may repress their feelings and appear calm and subdued. Symptoms are found to peak at 3 weeks after the sexual violence, remain high for 1 or 2 months, and begin to decline from 2 months onwards. More long-term consequences include anxiety, phobias, panic disorders, depression and suicide. Post-traumatic stress disorder (PTSD) symptoms can occur immediately, and have been reported up to 1 year after the assault, especially if not treated. Women who experience sexual violence as part of intimate partner violence are also reported to be at greater risk of developing PTSD or depression.

Sexually violated women are more at risk of attempting or committing suicide. In a study conducted with women suffering from intimate partner violence, it was found that women reporting sexual violence were 5.3 (95% CI 1.3 to 21.5) times more likely to report threatening or attempt suicide within 3 months compared with women who were only physically abused. Similarly, in a national study conducted in the USA with 627 women aged between 15 and 54 years, age of first sexual assault was compared with age of first suicide attempt, and it was found that both suicidal ideation and suicide attempts were three times more likely to follow a sexual assault as to occur before or within the same year of sexual assault.

Health behaviours

Sexual violence has been linked to high-risk sexual behaviours, such as having unprotected sex, having multiple sexual partners, participating in sex work or transactional sex, having sex while under the influence of alcohol or drugs, and having high-risk sexual partners. Eating disorders and unhealthy eating habits associated with sexual violence include fasting, vomiting, abusing diet pills and overeating. Other unhealthy behaviors found to be associated with sexual violence include the use of cigarettes, heavy alcohol and illicit drug use, and a reliance on prescription medication. Many of these habits, such as the use of alcohol or high-risk sexual behaviour and substance abuse, can place the survivor at high risk of revictimisation. This has especially been reported in women with a history of child sexual abuse.

Genital mutilation

The cultural practices of partially or totally removing the external female genitalia for non-medical reasons are referred to as female genital mutilation (FGM). It is carried out on infants, girls and women of all ages, and is often linked to cultural practices mainly in Africa, Asia and the Middle East. Immigrants from these areas living elsewhere may also continue these practices in their adopted countries.

An extensive systematic review conducted by the World Health Organization in 2000, and a more recent review conducted in 2008, showed that FGM has significant health consequences for a woman’s physical, mental, gynecological and reproductive health. The gravity of the health consequence depends on the type of FGM experienced by the woman. The more severe forms of FGM contribute to serious health consequences, especially if not managed appropriately, such as complications during child birth leading to infant and maternal mortality.

Short-term health problems include severe pain, bleeding from physical trauma to the genital area, acute urinary retention, infection such as tetanus and urinary infections, trauma to adjacent structures, such as the urethra and bladder, and the psychological trauma of having one’s genitals cut. Long-term health consequences include scarring, painful sexual intercourse, strain during urination, recto–vaginal fistulas, anal incontinence, hypersensitivity of the genital area, cysts, painful menstruation, retention of menstrual blood, recurrent infections, pain and difficulty during gynecological examinations, increased risk of sexually transmitted infections and HIV, and even infertility.

Female genital mutilation also doubles the risk of maternal deaths during child birth owing to difficulty during labour. There is more reliance on caesarian sections, and an increased risk of neonatal deaths, stillbirths, and children born with cerebral palsy. Women with FGM may later need surgeries to widen vaginal openings for sexual intercourse and childbirth.

On the contrary, some researchers have reported mixed results on the health consequences of FGM. Obermeyer found some associations between circumcision and infections, but no statistically significant associations with other health conditions, such as urinary problems and maternal and infant mortality. Another systematic review reported that women with FGM were more likely to experience painful sexual intercourse and reduced sexual desire, but that the evidence on psychological and social consequences was inconclusive.

Forced marriages

Forced marriages are often seen in children and women in whom their parents, relatives, or both, force or coerce them into marriages or alliances for monetary, traditional and cultural purposes. This is again common in Africa, the Middle East and Asia. When a relationship is forced on the girl child or woman, the ensuing sexual relationship may be physically and mentally traumatic to the female partner. If their husbands or partners are significantly older than them, which is often the case, the risk of sexually transmitted infections and HIV is high. Biological factors, such as hormonal fluctuations, immature genital tracts and permeability of vaginal tissue in young girls, also contribute to increased risk of HIV. A recent review, however, reported mixed findings towards HIV transmission risk, calling for more research on the pathways that result in poorer health outcomes.

Many young girls in these marriages have unintended pregnancies or miscarriages. Furthermore, the pelvis of a young girl is not yet fully developed and, if pregnant, can lead to complications during pregnancy and child birth. Prolonged and obstructed labour can further lead to haemorrhage, severe infection and maternal death. Young mothers are prone to deliver low-birth-weight babies with neonatal complications.

The age difference between partners may also cause a power differential in the marriage. A girl child or woman, for example, may be subjected to domestic abuse and intimate partner violence in the relationship. The other consequences to health and well-being include having no or poor access to education, which affects the ability of the girl-child to take care of her family.

A systematic review of 10 studies conducted by Acharya et al. looked at factors associated with teenage pregnancy in South Asia. The reviewers found that, owing to poor understanding, poor use of health services, and a lack of empowerment, many girls were falling pregnant at a young age. The review also determined that anaemia, pre-term delivery, neonatal complications, low-birth-weight babies, pregnancy-induced hypertension and spontaneous miscarriages were common.

Sexual violence in complex settings

Complex settings in this context mainly include disasters, armed conflict and migration. Migration or forced displacement can result from disasters or armed conflict, and again women are vulnerable and often victims of sexual violence in such situations. During periods of armed conflict, rape, sexual exploitation and gender-based violence against women are quite common. The sexual violence is often more aggressive and perverted (e.g. boys being forced to rape their mothers or relatives). Gang rapes are also more common. It is thus possible that genital trauma is more severe in such scenarios. High rates of psychosocial and mental-health needs have been reported in victims of sexual violence in areas of armed conflict. These include anxiety disorders, substance abuse and PTSD. Furthermore, situations in camps can put both the women and their children at risk. Women may be restricted to conduct activities, such as collecting firewood and water out of fear of being raped or assaulted.

More attention it seems has been given to sexual violence during armed conflict and less to sexual violence during natural disasters such as earthquakes, floods, landslides and the like. Carballo et al. studied the effect of the 2004 Tsunami on the reproductive health of women in affected areas. During disaster situations, women, children, sick and elderly people, are often the most at risk. Sexual violence is a real threat for women in such situations. It was shown that the number of reported cases of rape increased significantly in both Sri Lanka and Indonesia after the Tsunami in 2004.

The lack of or disruption of normal health services in such situations further compounds the problems faced by affected women. Access to condoms and family planning, and even usual health care, may be completely disrupted during periods of armed conflict or disasters. High rates of unplanned and unwanted pregnancies, miscarriages and unsafe abortions may also result.