Elsevier

The Lancet

Volume 373, Issue 9679, 6–12 June 2009, Pages 1966-1972
The Lancet

Articles
Sexual violence and its health consequences for female children in Swaziland: a cluster survey study

https://doi.org/10.1016/S0140-6736(09)60247-6Get rights and content

Summary

Background

Despite concern, few studies have been done about sexual violence against girls younger than 18 years of age in sub-Saharan Africa. We report the prevalence and circumstances of sexual violence in girls in Swaziland, and assess the negative health consequences.

Methods

We obtained data from a nationally representative sample of girls and women aged 13–24 years from selected households in Swaziland between May 15, 2007, and June 16, 2007, with a two-stage cluster design. The questionnaire examined demographics, type of sexual violence that took place before the respondent was 18 years of age, circumstances of the incident, and health-related conditions. Information was gathered from 1244 women and girls (response rate 96·3%), of whom 1242 provided retrospective responses to questions about sexual violence. We used regression models adjusted for relevant demographics to estimate the odds ratios for the associations between sexual violence and health-related conditions.

Findings

33·2% (95% CI 29·9–36·7) of respondents reported an incident of sexual violence before they reached 18 years of age. The most common perpetrators of the first incident were men or boys from the respondent's neighbourhood (32·3% [28·8–36·1]) and boyfriends or husbands (26·2% [22·2–30·7]). The first incident most often took place in the respondent's own home (26·1% [21·6–31·2]). Sexual violence was associated with reported lifetime experience of sexually transmitted diseases (adjusted OR 3·69 [95% CI 1·78–7·66]), pregnancy complications or miscarriages (3·54 [1·47–8·55]), unwanted pregnancy (2·92 [1·87–4·55]), and self-report of feeling depressed (2·30 [1·70–3·11]).

Interpretation

Knowledge of the high prevalence of sexual violence against girls in Swaziland and its associated serious health-related conditions and behaviours should be used to develop effective prevention strategies.

Funding

UNICEF.

Introduction

Sexual violence against girls—defined as female children younger than 18 years of age—is a substantial global health and human-rights problem, and a growing concern in sub-Saharan Africa. According to WHO, about 150 million girls had experience of sexual violence with physical contact in 2002.1 In parts of South Africa and Tanzania, up to a third of adolescent girls reported that their first sexual experience was forced.2, 3, 4 A nationally representative study5 done in 1998 showed that 1·6% of South African girls and women aged 15–49 years reported that they had been raped before 15 years of age. Understanding the prevalence and nature of sexual violence is important because it has devastating short-term and long-term mental, reproductive, and physical health consequences. Some common consequences are pregnancy and gynaecological complications, infection with HIV and other sexually transmitted diseases, mental health problems (such as depression and post-traumatic stress disorder), and social ostracisation.6 Sub-Saharan Africa is the region most heavily affected by HIV worldwide—accounting for 67% of people living with HIV in 2007—and sexual violence might be an important route of HIV transmission.7 In particular, Swaziland is disproportionately affected; the country has the highest prevalence of HIV in girls and women aged 15–24 years of 22·6%.7

Previous studies of sexual violence against children in Swaziland have been limited to the school setting. For example, the global school-based student health survey8 showed that 9·8% of girls aged 13–15 years and 21·1% of girls aged 16 years and older reported having been physically forced into sexual intercourse. In select primary and secondary school students who had been abused, physical abuse (49·5%) and sexual abuse (19·2%) were most common, with those aged 10–15 years most vulnerable.9 Additionally, in a study of patterns of sexual behaviour,10 13% of secondary school students described their first sexual experience as involuntary. However, these school-based studies are not nationally representative because not all Swazi children attend school. About 9·4% of children of primary school age do not attend school.11 Moreover, children who are exposed to sexual violence at school might be more likely to drop out.12

To assess the prevalence, epidemiological patterns, and potential risk factors associated with sexual violence against children, the Swaziland office of UNICEF and the US Centers for Disease Control and Prevention administered a national survey to assist programme and policy development. We report the results of this survey.

Section snippets

Participants

National prevalence of sexual violence in girls younger than age 18 years was calculated from a household survey of Swazi girls and women aged 13–24 years between May 15, 2007, and June 16, 2007. We used a two-stage cluster survey design. The sampling frame was compiled by the Central Statistics Office of Swaziland for the national population census in 1997, which was the most reliable and recent source of population estimates available for the country. Women aged 18–24 years were included to

Results

Almost half the girls and women studied were aged 13–17 years and the proportion who were living in rural communities was almost six-fold higher than those in urban areas (table 1). More than a third were orphans (table 1) and only 9·7% were married.

A third of participants aged 13–24 years reported that they had had experience of some form of sexual violence before 18 years of age (table 2); the prevalence was 37·8% (95% CI 33·1–42·6) for those aged 18–24 years. The most common incidents were

Discussion

This study documents that sexual violence against girls younger than 18 years of age affected one in three women aged 13–24 years in Swaziland and has serious health consequences. About 5% of girls had forced intercourse and 9% had coerced intercourse before 18 years of age. About three-quarters of the perpetrators of sexual violence against girls were men or boys from the respondent's neighbourhood, boyfriends or husbands, or male relatives.

Thus, perpetrators of sexual violence are either

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