WUNRN
Also Via SVRI - Sexual Violence
Research Initiative
What
Evidence Exists for Initiatives to Reduce Risk and Incidence of Sexual Violence
in Armed Conflict and Other Humanitarian Crises? A Systematic Review
Jo Spangaro, Chinelo Adogu, Geetha Ranmuthugala, Gawaine Powell
Davies, Léa
Steinacker, Anthony Zwi
Abstract - See website link for full
Study Documentation:
Sexual violence is highly prevalent in armed conflict and other humanitarian crises and attracting increasing policy and practice attention. This systematic review aimed to canvas the extent and impact of initiatives to reduce incidence, risk and harm from sexual violence in conflict, post-conflict and other humanitarian crises, in low and middle income countries. Twenty three bibliographic databases and 26 websites were searched, covering publications from 1990 to September 2011 using database-specific keywords for sexual violence and conflict or humanitarian crisis. The 40 included studies reported on seven strategy types: i) survivor care; ii) livelihood initiatives; iii) community mobilisation; iv) personnel initiatives; v) systems and security responses; vi) legal interventions and vii) multiple component interventions. Conducted in 26 countries, the majority of interventions were offered in African countries. Despite the extensive literature on sexual violence by combatants, most interventions addressed opportunistic forms of sexual violence committed in post-conflict settings. Only one study specifically addressed the disaster setting. Actual implementation of initiatives appeared to be limited as was the quality of outcome studies. No studies prospectively measured incidence of sexual violence, although three studies provided some evidence of reductions in association with firewood distribution to reduce women's exposure, as did one program to prevent sexual exploitation and abuse by peacekeeping forces. Apparent increases to risk resulted from lack of protection, stigma and retaliation associated with interventions. Multiple-component interventions and sensitive community engagement appeared to contribute to positive outcomes. Significant obstacles prevent women seeking help following sexual violence, pointing to the need to protect anonymity and preventive strategies. This review contributes a conceptual framework for understanding the forms, settings, and interventions for conflict and crisis-related sexual violence. It points to the need for thorough implementation of initiatives that build on local capacity, while avoiding increased risk and re-traumatisation to survivors of sexual violence.
Citation: Spangaro J, Adogu C, Ranmuthugala G, Powell Davies G, Steinacker L, et al. (2013) What Evidence Exists for Initiatives to Reduce Risk and Incidence of Sexual Violence in Armed Conflict and Other Humanitarian Crises? A Systematic Review. PLoS ONE 8(5): e62600. doi:10.1371/journal.pone.0062600
Editor: Patricia Kissinger, Tulane University, United States of America
Received: December 22, 2012; Accepted: March 26, 2013; Published: May 15, 2013
Copyright: © 2013 Spangaro et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This project was funded by the the United Kingdom Department for International Development (DFID),the International Initiative for Impact Evaluation (3ie) and the Australian Agency for International Development (AusAID) as part of the 2011 round of the Australian Development Research Awards Scheme via a competitive grants application (SR3/1515) [http://www.ausaid.gov.au/Pages/home.aspx]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Introduction
Sexual violence in armed conflict,
despite being documented through history [1], gained attention in the 1990 s following
widespread assaults of women in Rwanda and the former Yugoslavia. These abuses
prompted United Nations (UN) interventions [2] and led to five resolutions by the UN
Security Council; these recognised sexual violence as a tactic of war, called
for accountability, and established monitoring mechanisms [3], [4], [5], [6], [7]. Current evidence suggests 4%–22% of
women experience sexual violence in conflict [8], although the data are considered
incomplete [2], [9], [10]. Reports consistently point to children
and women as the primary targets, but it is recognised that men are also, at
times, victims [11], [12], [13]. Globally, sexual violence has profound
impacts on physical and mental health, including injuries, HIV and other
infections, sexual and reproductive health problems, deaths as a result of
suicide, murder or ‘honour killings,’ maiming, stigmatization, and ostracism by
families and communities [14]. Additional recorded effects in times of
conflict include forced pregnancy, elevated rates of traumatic fistula [15], abandonment of children conceived
through rape, cultural destruction and exacerbated stigma when the assailant is
a hostile combatant [16].
Sexual violence is understood as a sexual
act committed against a person, or in which a person is caused to engage in
sexual acts by force, threat of force or coercion such as that caused by fear
of violence, duress, detention, psychological oppression or abuse of power, or
by taking advantage of a coercive environment or a person's incapacity to give
genuine consent [17]. Attention has also been drawn to sexual
violence in disaster and post-disaster settings, with a three-fold increase
reported in Sri Lanka after the Indian Ocean tsunami [18], and similar spikes following the 2010
Haiti earthquake [19]. Armed conflict, post-conflict settings
and disaster all share high rates of population displacement along with
breakdown of the social and legal systems that deter criminal behaviour [10]. All three settings pose risks for sexual
exploitation and abuse, the umbrella term for acts by peace keepers and
humanitarian workers who abuse positions of power and trust for sexual purposes
in emergencies [20]. Low and middle income countries (LMICs)
are disproportionately affected by both conflict and other humanitarian crises,
with fewer resources to respond, thereby warranting particular attention.
A proliferation of policy and other
initiatives aimed at addressing sexual violence in crisis followed the UN
Security Council resolutions [21], [22], [23], [24], [25], [26], [27]. A key development was the introduction
of the International Criminal Court (ICC) in 1998, based on the legal code
known as the Rome Statute, following judgements by the International Criminal
Tribunals for the former Yugoslavia and Rwanda. The effectiveness of the ICC in
prosecuting and deterring future crimes is uncertain [28]. Other legal measures to address
conflict-related sexual violence include sign off by selected countries on
aligning criminal codes with the Rome Statute and use of tribunals such as the
Gacaca community courts, in Rwanda [29].
It is timely to consider the impact of these initiatives. Studies on the scope and effectiveness of programs to prevent and respond to conflict-related sexual violence have been identified as research priorities [30]. Although one review of the prevalence of sexual violence in conflict has been published [8], the evidence for interventions to reduce or prevent sexual violence have not been systematically reviewed to date. The current review, commissioned by the Australian Agency for International Development (AusAID) of the evidence for reducing risk or incidence of conflict and crisis-related sexual violence begins to address this gap.
This review sought to answer the over-arching
question: What is the evidence of the impact of initiatives to reduce risk
and incidence of sexual violence in conflict and post-conflict states and
humanitarian crises in low and middle-income countries?
These questions recognize the low likelihood of identifying reduced incidence as a consequence of an intervention, due to both the difficulty in establishing causation in a complex area and recognition of the challenges of conducting research in crisis settings. Accordingly, the questions are deliberately broadly based and include as outcomes, evidence of implementation of interventions as well as for reduced risk of sexual violence.
Sexual violence in conflict and crisis is a
complex social and legal problem with multiple contributors for which a range
of interventions from diverse disciplines have been developed and deployed.
Through preliminary review of the literature we developed a conceptual
framework to guide the review in relation to the forms and settings in which
sexual violence in conflict, post-conflict and disaster occurs, as well as the
type of interventions. We identified four forms or contexts in which sexual
violence occurs. Militarized sexual violence is a deliberate and
systematic means of terrorising and humiliating communities [10] and may be instituted as a form of
“ethnic cleansing” [31]. It is not always possible to determine
whether this is the intent behind sexual violence by combatants and not all
sexual violence in conflict takes this form. Opportunistic sexual violence
involves a broader range of perpetrators who take advantage of opportunities
presented by individuals being unprotected by family or statutory agencies and
an environment of impunity to commit acts of sexual violence. Perpetrators
include armed militias, national or invading military forces, international
peace-keeping troops, security or border personnel, humanitarian workers or
bandits. Sexual abuse and exploitation (SEA) by peacekeepers or
humanitarian staff, may be considered a third form of sexual violence in these
settings: where personnel abuse their positions of power and trust for sexual
purposes, for example through exchanging emergency relief supplies for sexual
acts. Finally, in every community, sexual violence pre-dates emergencies but is
exacerbated by heightened gender inequalities [32], breakdown of regular norms, additional
stresses on relationships [24], and attempts by men to reassert control
[33].
Drawing on the ecological model for understanding contributors to intimate partner violence [34], a second dimension of our conceptual framework identifies nine strategy types which can be understood as operating at the individual, community or societal level, as described in Table 1. Individual level strategies are directed at individuals, community level strategies are operated by or engage whole communities, and societal level strategies in general work at a higher level, implemented by state bodies or international agencies.
Each of these strategies may be implemented separately or as part of
multiple component interventions. This review includes survivor care strategies
aimed at addressing effects of sexual violence on individuals. While not having
a direct preventive effect this type of intervention is often part of forensic
examination used for prosecution, which is itself a potentially important
strategy for deterrence [35]. Furthermore, provision of responses to
victims, may operate as secondary prevention, that is, reduced harm as
a result of the event.
Our conceptual framework also included measures for reduced risk, which entailed a set of indicators listed below which we identified as an analytical tool, prior to the searching.
These indicators reflect the type of
interventions being deployed in the field and built on recommendations for
monitoring and evaluating gender-based violence (GBV) initiatives [36].
In light of this being a relatively new field of practice, the need to understand the diversity of practice and the low likelihood of quality research being conducted in crisis settings, we adopted an inclusive approach to this review, incorporating empirical and grey literatures identified from scientific and academic databases, web sites and targeted searches.
Method
This project was informed by realist approaches to research and systematic reviews [37]; this aspect of the analysis will be covered in detail separately. The review was registered with EPPI-Centre, a British registration body for reviews of social and health interventions with a focus on interventions in low to middle income countries through which the review protocol is available [38]. We established and were advised by an international reference group to source insights from potential review users.
We examined peer-reviewed journal articles
and published and unpublished grey literature with a publication date between
January 1990 and August 2011. A comprehensive search strategy of 23
bibliographic databases was undertaken : Medline (PubMed on Ovid), CINAHL,
PsycInfo, PAIS, Global Health, ASSIA, Gender studies, Violence & Abuse
Abstracts, Wageneingen University Disaster Studies, Proquest Dissertations
& Abstracts, Lexis-Nexis, UNICEF Children in armed conflict, GDNet
Knowledge Base, African Journals Online, 3ie database of impact evaluations,
Bibliomap & TRoPHI (EPPI-Centre), World Health Organization Library
(WHOLIS), EBM Reviews, Cochrane Database of Systematic Reviews, Johanna Briggs
systematic review and Campbell Collaboration databases. Search terms for
bibliographic databases were “sexual violence” and “conflict” or
“post-conflict” or “humanitarian crisis” and their synonyms. As an example the
Medline search strategy was. “abused women[tw] OR “abused woman”[tw] OR
“forced sex”[tw] OR “enforced sex”[tw] OR gbv[tw] OR “gender based
violence”[tw] OR rape[tw] OR raped[tw] OR rapist[tw] OR raping[tw] OR “sexual
abuse”[tw] OR “sexual coercion”[tw] OR “sexual violence”[tw] OR “sexual assault
”[tw] OR “sexual exploitation”[tw] OR “sexual slavery”[tw] OR “violence against
women”[tw] OR “unwanted sex”[tw] OR “unlawful sex”[tw] OR “sexual exploitation
and abuse”[tw] “militarised sexual violence”[tw] OR “forced pregnancy”[tw] OR
“enforced pregnancy” [tw] AND “armed conflict”[tw] OR “armed incursion”[tw] OR
“post conflict”[tw] OR “human security”[tw] OR “war zone”[tw] OR coup[tw] OR
invasion[tw] OR insurrection[tw] OR “peace keeping”[tw] OR “peace building”[tw]
OR “child soldiers”[tw] OR “boy soldiers”[tw] OR “internally displaced
persons”[tw] OR “displaced populations”[tw] OR “displaced persons”[tw] OR
“refugee camps”[tw] OR “humanitarian response”[tw] OR “humanitarian
assistance”[tw] OR “humanitarian crisis”[tw] OR “humanitarian crises”[tw] OR
“post-crisis” [tw] OR “post-crises”[tw] OR war[mh] OR Refugees [mh] OR
Disasters [Mesh:noexp] OR Disaster Planning [mh] OR Mass Casualty Incidents[mh]
OR Relief Work[mh] OR Rescue Work[mh] OR Avalanches[mh] OR Earthquakes[mh] OR
Landslides[mh] OR Tidal Waves[mh] OR Tsunamis[mh] OR Volcanic Eruptions[mh] OR
Fires[mh] OR Cyclonic Storms[mh] OR Floods[mh].
Twenty three websites searched were: HRH
Global Resource Center http://www.hrhresourcecenter.org/, Sexual
Violence Research Initiative web site http://www.svri.org/, UNWomen http://www.unwomen.org/,
End violence against women http://www.endviolenceagainstwomen.org.uk/,
United Nations Population Fund) http://www.unfpa.org/public/, Gender and
Disaster Network http://www.gdnonline.org/, United
Nations High Commission on Refugees http://www.unhcr.org/cgi-bin/texis/vtx/home,
Stoperapenow http://www.stoprapenow.org/advocacy-resources/index/?t=10&p=1.
Women's Initiatives for Gender Justice http://www.iccwomen.org/,
GBV One response http://gbv.oneresponse.info, Gender-based
Violence Network: Essential Tools for GBV Prevention and Response in
Emergencies http://www.gbvnetwork.org/, Bridge (http://www.bridge.ids.ac.uk/),
JOLIS (World bank and IMF library catalogue) http://jolis.worldbankimflib.org/e-nljolis.htm,
USAID http://www.usaid.gov/,
Overseas Development Institute http://www.odi.org.uk/resources/,
ELDIS http://www.eldis.org/,
Governance and Social Development Resource Centre http://www.gsdrc.org/,
International Centre for Research on Women http://www.icrw.org/icrw-library,
International Development Research Centre http://publicwebsite.idrc.ca/EN/Pages/default/aspx,
Public Policy Pointers http://www.policypointers.org/, British
Library Development Studies catalogue http://blds.ids.ac.uk/search-the-collection,
Women's International League for Peace and Freedom International Rescue
http://womenpeacesecurity.org/members/wilpf/,
International Committee of the Red Cross http://www.icrc.org/eng/,
UN Disarmament, Demobilisation and Reintegration Resource Centre www.unddr.org/index.php,
Reproductive Health Response in Crisis (RHRC) Consortium's GBV in conflict
online bibliography http://www.rhrc.org/resources/gbv/bib/index.cfm?category=prev.
In addition three journals were hand searched: Violence Against Women; Medicine, Conflict and Survival and Disasters which were identified by team and Advisory Group members as likely sources of eligible studies. In addition we consulted key informants including the nine members of our Advisory Group in respect of journals, data bases and web sites to search. We also searched the reference lists of identified studies.
See website link for full Study Documentation: http://www.plosone.org/article/info:doi/10.1371/journal.pone.0062600