ArticlesSexual violence and its health consequences for female children in Swaziland: a cluster survey study
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.
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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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