UNFPAState of World Population 2002
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CHAPTER 3:
Sexual and Reproductive
Self-determination


Photo:Mark Edwards/Still Pictures

 

"Human sexuality and gender relations are closely interrelated and together affect the ability of men and women to achieve and maintain sexual health and manage their reproductive lives. Equal relationships between men and women in matters of sexual relations and reproduction, including full respect for the physical integrity of the human body, require mutual respect and willingness to accept responsibility for the consequences of sexual behaviour.."

Paragraph 7.34, Programme of Action of the International Conference on Population and Development, 1994



In addition to adequate health and the ability to determine the number and spacing of one’s children, the right to reproductive self-determination involves, among others, the right to marry voluntarily and to form a family, and the right to freedom from sexual violence
1  and coercion. This chapter addresses the sexual and reproductive health needs of adolescents, rights in marriage and childbearing, violence against women—in the home, in the streets, and in emergency situations—and trafficking in girls and women.

Adolescent Sexuality

At the ICPD, the international community for the first time recognized formally that adolescent reproductive and sexual health involves a specific set of needs distinct from adult needs. Previously, health services had largely ignored young people's needs. The Programme of Action emphasizes:

  • Young people of both sexes are typically poorly informed about how to protect themselves from unwanted pregnancies and sexually transmitted diseases, including HIV/AIDS. They need comprehensive information and access to services, and have the right to privacy, confidentiality, respect and informed consent.

  • Teenage mothers face a higher-than-average risk of maternal death, and their children have higher levels of morbidity and mortality. Early marriage and childbearing also impede young women's educational and employment opportunities.

  • High levels of adolescent pregnancy, childbearing and unsafe abortions reflect a lack of educational and economic opportunities. Young women and girls, particularly the poor, face considerable pressures to engage in sexual activity and are especially vulnerable to sexual abuse, violence and prostitution.

  • Young men need to be taught to respect women's self-determination and to share responsibility with women in matters of sexuality and reproduction.



Early Sexual Activity

The transitions to sexual activity, marriage and motherhood are major events in women’s lives, traditionally bringing changes in social status and responsibilities. The transformation in most societies over the last two or three generations has altered these social patterns and in some ways increased the risks to individuals, families and communities.

One very important change has been to separate the three events, sometimes by several years. Improvements in nutrition have been credited with lowering the age of sexual maturity in girls. While the decline may be levelling off, in some countries and particularly among higher socio-economic groups the result is that young women are at risk of pregnancy for an additional two years.2 At the same time, the age of marriage has gone up (see below).

Traditionally, premarital sex has been discouraged in most societies, though many condone it in some form, at least for boys. But this too is changing, and sex among unmarried teenagers is a problem most societies must learn to confront.

Information is difficult to collect systematically, but some broad patterns of adolescent sexual and reproductive behaviour have been identified.3 In most of Asia, including the Arab states of West Asia, marriage and childbearing start early. Premarital sexual activity is uncommon, as is pregnancy and childbirth out of wedlock, but adolescent pregnancy rates are high. Sub-Saharan Africa resembles the Asian pattern, with the exception that premarital sexual experience is more common.

In many industrialized countries, sexual activity starts in the middle to late teens and age at marriage is relatively late. Some have high rates of adolescent pregnancy, and increasing numbers of young, unmarried mothers raising children alone.4 Others have lower rates of adolescent pregnancy and abortion, and more widespread use of modern contraceptive methods. Adolescents in this group of countries also have more sex education.

In Latin America and the Caribbean, the proportion of women (married and unmarried) who are sexually active before age 20 appears to have fallen or remained stable in many countries.5 Households headed by young single mothers have increased, however, particularly in the Caribbean region.

In-depth studies reveal sobering implications for the health and safety of girls.6 Some studies have indicated that sexual initiation of girls often occurs even before menarche. In Malawi, 58 per cent of 300 female adolescents in villages sampled indicated that they had had sex before menarche. Very early ages of first intercourse have been reported among sexually active teenage girls in countries as diverse as Brazil and Papua New Guinea. While such early initiation is rare in many countries, interest in sex and sexual experimentation often starts before the beginning of traditional education (including ceremonies marking transitions to adulthood), school-based education and open discussion of sexuality within families.

On the other hand, in some countries sexual activity before age 16 may have declined or remained stable. Data from sub-Saharan Africa show a lower proportion of girls reporting intercourse by age 15 in Burundi, Ghana, Kenya and Zimbabwe and little change in Liberia, Malawi and Togo.7 Very different proportions of early sexual intercourse are apparent between and within countries, whether or not there has been change over time. The proportion of 15-24 year old women who report having been sexually active before age 15 varies in these countries from less than 2 per cent (Burundi) to more than one third (Liberia). In Latin America, trends also vary. The proportion of women who had their first sexual inter-course before age 20 appears to have declined over recent decades, reaching below half in Colombia, Mexico, and Peru, and nearing half in the Dominican Republic and Trinidad and Tobago. In Brazil and Ecuador, the proportions have been stable at about one half; in El Salvador and Guatemala, at over 60 per cent.

The proportion of adolescents who are sexually active before age 16 is steadily rising in industrial countries.8 For example, in Great Britain and Northern Ireland less than 2 per cent of women and 10 per cent of men now over 50 report having had first intercourse by age 16; of respondents under age 20, 18.7 per cent of women and 27.6 per cent of men report first intercourse before age 16. Similar findings of declining ages at first intercourse have been reported in the United States, the Netherlands, and Sweden.9

Most unmarried adolescents are not engaging in sexual relations. Increased sexual activity has been reported in recent surveys in Latin America, Africa and in Asia, however.10 Early sexual activity usually exposes adolescents to risks of pregnancy and of disease. Contraception is rarely used; taking such precautions is often felt to reflect premeditation rather than spontaneity. Young men report starting sexual activity at younger ages and having more partners and more casual relationships, thus exposing themselves and their partners to greater risks. Curiosity and peer approval is a significant part of their motivation. Young women usually report their experiences are based on love and a desire to please their partner; they may take greater risks out of fear of hurting their relationships.

Many first sexual experiences are the result of force or coercion by older partners. Inducements to sex offered to young girls from poor families may be difficult to resist.

Knowledge about Sexuality and Contraception

Adolescents around the world report a lack of adequate information about reproduction, sexuality, family planning and health.11 Exposure to the health risks of early pregnancy is increased where young people and their parents are under-educated about sexuality and about contraception, as they are in many parts of the world. Parents are not comfortable talking to their children about sexual matters, and information (much of it incorrect) is transmitted to young girls and boys by their peers.12 Low levels of general education can also restrict young people’s access to information about health practices and risks in all aspects of their lives.

Young people of both sexes are typically poorly informed about how to protect themselves from unwanted pregnancies and sexually transmitted diseases, including HIV/AIDS.

Advocates of family life and sex education are confronted with the persistent myth that sex education leads to promiscuity. Research indicates that sex education encourages responsible sexual behaviour including higher levels of abstinence, later start of sexual activity, higher use of contraception and fewer sexual partners. These effects are greater where there is a close relationship with parents who frankly discuss sex and reproduction with their children. However, this sort of discussion is frequently difficult and research shows that only a minority undertake it.

In the United States, fewer than one in three girls and one in six boys discuss these concerns with either parent. Even so, parents are themselves often incompletely informed about many important facts about sex and reproduction. Information and misinformation is most likely to come from peers.

Surveys show that even in couples practising periodic abstinence for family planning, a majority do not know when they are most fertile.13 Even where information is available, adolescent girls, married or not, may be hampered by their partners’ ignorance, their families’ expectations and their societies from gaining access to sexual and reproductive health information and services. (See section on contraceptive barriers and use.)

UNFPA has funded the development and inclusion of family life education (FLE) in school curricula in 79 countries over the past three decades, with technical assistance from UNESCO. Today’s curricula are more likely to add reproductive health and physiology, family planning information and training for responsible parenthood (including planning and decision-making skills), encouragement of sexual abstinence, STD/HIV prevention and training in gender equality to concerns with population and development relations. Teachers’ discomfort with some subjects, opposition from traditionalists and some religious groups, fear of parents’ criticism (even when parents have been involved in designing the programmes), and difficulties in setting priorities can all raise problems. Proper consultation, training and continued support help to overcome these obstacles. Curricula need to be adapted to ensure that they are appropriate to the age, gender and experience of the audiences, and ways are needed to reach out to young people out of school, including the homeless, young parents and commercial sex workers.

FLE can be effective in changing the behaviour of young people, for example in delaying the start of sexual activity or increasing contraceptive use. Better negotiating skills have been an important contributor to these improvements. Perhaps even more important, however, is the effect of bringing hitherto forbidden subjects into public discussion. Myths and misperceptions are dispelled; discussion is possible within the family and the community, and population issues such as reproductive health become part of the wider debate on national policy.14



Rights of Adolescents and Parents

International agreements on adolescents’ reproductive and sexual health have sought to define a delicate balance that recognizes both the rights of adolescents to information and services and parents’ right to provide guidance. Cultural definitions, expectations and practices related to adolescents and their sexuality (age of marriage, acceptance of pre-marital sexuality, the independence of youth, family structure, etc.) vary significantly and are changing over time. Consequently, the accepted principles have evolved gradually.

There is increasing agreement that adolescents need unrestricted access to information about sexuality, and the risks of early pregnancy and sexually transmitted diseases. Age-appropriate education efforts should be undertaken, with the participation of parents and the community. Both young men and young women must be encouraged to be responsible in their sexuality. Young people also need private and confidential services to protect them from health risks. Sexual exploitation and abuse of adolescents must be strongly proscribed.

The ICPD Programme of Action states that conflicts between parental rights and adolescent rights must be resolved in ways which take into account both the children’s needs and capacities and parents’ responsibilities to prepare a better life for future generations.

Most international agreements leave the resolution of potential conflicts between parental and adolescent rights to local decision, in accordance with local custom and practice, while emphasizing the needs of adolescents. The only instrument that explicitly assigns priority in resolving conflicts is the Convention on the Rights of the Child. It recognizes the primacy of children’s interests in decisions by families, legal systems and other state action.15 Nearly all nations have ratified the convention, which applies to individuals below age 18.

Voluntarism and Marriage

Patterns of family formation are intricately related to the social and cultural norms and practices of societies. Marriage is the result of an often extended social process 16 involving the couple, their families and the wider community. Generalizations based on the quantifiable aspects of family life cannot do justice to the diverse meanings of family around the world. However, it is possible to examine the diversity of global practices with an eye to their implications for sexual and reproductive rights.

The right to found a family is paralleled by the right not to be coerced in marriage. Although information is not readily available about the degree to which these rights are realized in practice, questions arise in relation to child marriage, timing and frequency of pregnancy, dowry and bride price arrangements, consanguineous marriage17 , women’s inheritance rights and polygyny.18

Changes in Age at Marriage

Overall, the age of first marriage for both men and women has been rising in many parts of the world.19 The age of marriage has risen most rapidly in Asia (including Western Asia) and in North Africa. For example, when the experience of women aged 20-24 is compared with that of women currently 40-44 there is a decrease in the proportions who were married by age 20 and a corresponding increase in the median age at marriage.

Regional patterns differ. Among the eight Asian countries with recent data, 57 per cent of the older women were married by age 20 while only 37 per cent of the younger women were. In Northern Africa, the corresponding reduction has been from 66 to 34 per cent. In sub-Saharan Africa, where the prevalence of teenage marriage remains high, the decline has been from 73 to 59 per cent.

The proportion married by age 20 has remained comparatively stable in Latin America and the Caribbean, changing only from 50 to 42 per cent. In some countries of the region (Costa Rica, Guatemala, Jamaica and Trinidad and Tobago) the pro-portion marrying (or forming consensual unions) young has increased. Western Europe and Northern America have also seen steady rises in age at marriage, increasing from the early to the mid- or late twenties.20 Eastern and Southern Europe have shown more stability, Eastern Europe at a relatively low age (on average between 21 and 22), Southern Europe at a higher (on average between 24 and 25).

In all regions, less-educated women are more likely to marry young. Among 20-24 year-old women married before age 20 in Zambia, 44 per cent had completed primary school; among those married at age 20 or higher, 83 per cent had. Corresponding figures for other countries are: Uganda, 20 and 43; Cameroon, 27 and 77; Kenya, 54 and 84; Indonesia, 18 and 58; the Philippines, 61 and 84; Colombia, 39 and 66; Mexico, 32 and 72; Peru, 53 and 88; Egypt, 25 and 60; Morocco, 9 and 31.21

Though the age of the woman at marriage has been more commonly studied in demographic surveys, the age of the man, and the difference between the ages of the spouses, also reflect social expectations and affect marital and other social relationships. Larger age differences between husbands and wives reinforce gender stereotypes of wifely dependency and powerlessness. In the past, age differences between spouses were more pronounced in many parts of the world. Differences have begun to narrow, notably in North Africa, many countries of Latin America and the Caribbean and in Asia. In sub-Saharan Africa, age differences persist. These tend to be highest in West Africa (commonly six to nine years) and lowest in South Africa (more than two years).22 The contraction of age differences between spouses over time does not indicate a convergence on any particular model of family structure (erroneously forecast by some social scientists).

Readiness to marry has traditionally been defined for women by physical development (e.g., the onset of menses). In other settings, availability of a dowry and other social exchanges play a role. Men are more likely to be free to marry when they demonstrate an ability to support a wife and family. Such social rules reinforce male power and the pre-dominance of women’s domestic roles.

Educational disparities between spouses can also limit women’s opportunities and negotiating positions in household decision-making. Increasing education for women will contribute to raising the age at which they marry, empower them for more active economic and social participation and foster more equitable participation in family decision-making.

Child Marriage

Parents are vitally concerned with the marital plans and activities of their children. The vast majority of marriages and unions take place with the approval and participation of the spouses’ families. In a wide variety of societies in Asia, Latin America and Africa, marriages are arranged by parents during childhood or early adolescence.23 In some societies, the young couple have the opportunity to accept or reject the arrangement once they have met; in others family contracts are final, especially when the marriage has already taken place.

The legal situation with regard to age at marriage is complex. Marriage is legally regulated in all countries. Human rights instruments have called for establishment and enforcement of minimum ages of marriage for over three decades. In most countries, however, laws concerning age at marriage are applicable only in cases where parental consent is lacking. They indicate minimum ages for consent to marriage where parents disapprove, usually with different ages for young women and men.

However, marriage laws are not always applicable or enforced. In many countries, formal legal systems based in courts operate alongside customary and traditional systems based in local institutions or families.24 In many countries formal legal systems cede priority to customary systems in matters related to families. In such cases legal protection of marital choice for adolescents may be subordinated to family desires. Since most marriages take place with the knowledge, consent and active involvement of parents and the extended family, it is likely that, on balance, parental wishes are either respected or imposed.

Young couples often face strong pressure to begin childbearing immediately after marriage.

Information from consent laws does not indicate the ages that parents can and do marry off their children in practice. A complex social calculus determines parental behaviours regarding their children’s marriages. Custom can override practical considerations, including the best interests and wishes of the partners, to dictate early marriage decisions. Where girls are seen as burdens on their families or, at worst, unprofitable investments, there are strong incentives to marry them off. Where economic gains can be made, for example from dowries or bride price, parents, particularly poor parents, can be tempted into making arrangements for the very young.

In the area of family formation, laws often do not protect young people from forced marriages. In some settings, families may legally infringe on the rights of sons and daughters over the age of legal consent. In Pakistan, for example, after a college-educated couple in their mid-20s married against the wishes of the woman’s family, police arrested the husband on charges of kidnapping for immoral purposes.

Early Childbearing

Young married couples often face strong pressure to begin childbearing immediately after marriage. In cultures where there is an expectation that newlyweds will start a family immediately, a marriage can be made more secure by an early arrival. Equally, it can be wrecked by lack of a pregnancy, or in some cases lack of a male firstborn. From a health standpoint, the younger the bride, the longer she should wait before starting her family; the risk of maternal death among pregnant women aged 15-19 is four times higher than among 25-29 year-olds. Unfortunately it is often where marriage age is lowest that pressures from parents and husbands are strongest. A young woman feels she has only one thing to prove—that she can bear sons.



Polygyny

Polygyny (the custom of taking more than one wife) used to be widespread in Africa, parts of the Muslim world and in parts of Asia. It is now less common under the influence of other social changes, notably the move from rural to urban life and from a subsistence to a cash economy.

Defenders of the practice and some of the few studies in the area claim that women in polygynous marriages appreciate additional help with household chores, that it confers status upon the senior wife, and that it offers security to the younger ones who might otherwise be left without male “protection.” It has also been claimed that polygyny has the effect of reducing fertility per woman, since the strict rules governing sexual contact during pregnancy and breast-feeding are more likely to be observed in a polygynous marriage.

The extent to which such status and protection is needed in today’s world is in doubt, however, as is the strength of traditional customs about abstinence. It seems more likely that these rules are breaking down under the same pressures which are changing other marital customs, including the practice of polygyny itself.

Studies have found that women strongly disapprove of polygynous unions. Such marriages often result in conflicts between co-wives, or between a wife and her husband, and in competition for resources, particularly when the husband is perceived as favouring one wife and her children over the others.

A study of the Kaguru people of Tanzania 25 found a widespread rejection of polygyny among women. Some respondents were fatalistic, suggesting that they had little power to prevent their husbands from taking another wife. Other responses indicated that women threaten to, and sometimes do, divorce their husbands in such cases. Although Kaguru women have a substantially heavier workload than men, the study found no indication that women perceive polygyny as offering a means of reducing their workload by sharing it with co-wives.

Pregnancy and Childbirth: Intention and Reality

In most of the world the initiation, timing and final level of fertility are now recognized as a matter of conscious choice. When asked in surveys, men and women are increasingly able to indicate how many children they would like to have, what their ideal number of children is, how many children they would want to have if they were starting their reproductive life now, and whether or not their last birth was wanted or timed as they would have preferred. This is in marked contrast to three decades ago, in the infancy of national population programmes, when fatalistic answers (“What-ever happens, happens,” “It’s up to God”) accounted for a significant minority of responses.

Husband and Wife Communication

Spouses tend to agree to a large extent about family size and family planning but, under close discussion with individuals or in sympathetic groups, they reveal significantly different understandings.

It is well established that discussion of family size desires and family planning between husbands and wives is associated with higher levels of use of modern contraceptives. In the region with the lowest prevalence of family planning use, sub-Saharan Africa, there have been substantial increases in knowledge of particular methods and where to find them. However, as a rule there is little discussion of family planning or sexuality within families,26 so the desire to space or limit births on the part of one or both partners may go unspoken, unless some other force intervenes. Discussion in the media often brings the subject into the open, allowing discussion in the family and perhaps the discovery of hidden agreement between spouses.

Son Preference27

Unusual patterns of child death and distorted sex ratios at birth in some countries reflect the low status accorded to girls. Explicit preference for sons is readily expressed in these countries. When fertility levels are high, couples may have more children than they want as they continue to try to produce a desired number of sons. As the average number of children desired declines, the continued desire for sons reduces tolerance for girl children.

In most of the world, life expectancy at birth for women exceeds that for men. This is believed to have biological causes: male children are at comparatively higher risk in the early years of life; men mature slower than women and die earlier (even though spared the risk of death in childbearing). However, in South Asia, where son preference is strong, mortality of girls in the second to fifth year of life is higher than for boys. This is the result of different treatment of girl and boy children. Boys are often fed better and receive medical attention earlier in illness and other favourable attention. While deliberate infanticide probably contributes to only a very small portion of the observed mortality,28 pervasive comparative neglect can take a serious toll in death and illness.

In several countries of Eastern Asia, where son preference is strong and fertility is low, sex ratios at birth have shifted to unusual levels. Sex selective abortion is substantially responsible for this development. Normally, 104-107 boys are born for every 100 girls. In China and the Republic of Korea, ratios over 110 have been observed. The excess of boys over girls is even more striking at higher parities—after the first birth—and varies for different sex compositions of children in the family. While information is sparse, studies suggest a higher pro-portion of girl fetuses are aborted when sex detection has been performed, particularly after the first birth.

While the exact number is difficult to determine, conservatively, at least 60 million girls who would otherwise be expected to be alive are “missing” in various Asian populations as a result of sex-selective abortions or relative neglect.29

Laws in India and China ban sex-determination testing. In Taiwan (Province of China) a culturally sensitive public education campaign against the practice also informs people of the risks and potential unreliability of some forms of testing. This appears to have started a decline in the number of sex-selective abortions. Eliminating sex selective abortion will require public education, action to increase the status of women and girls, appropriate legislative frameworks and continued monitoring and enforcement of prohibitions.

The Principle of Non-coercion

The ICPD and the FWCW recognized the principle of non-coercion as fundamental to population and reproductive health programmes. This principle recognizes that population programmes must fully respect the right to reproductive self-determination. Coercion in any form is unacceptable.

Individuals’ decisions can sometimes harm community interests—but this does not justify coercion or methods of persuasion that do not respect individual decisions and responsibility. For countries, population growth targets are ineffective and may lead to coercive practices.

Service providers should give clients information about reproductive health services so that they can make informed choices about how best to address their needs; they should not force decisions on clients, whether by withholding information or options, misinforming them about benefits to be obtained, or performing procedures without informed consent. A full range of services should be available to ensure informed choice.

Incentives

There has been extensive discussion of the place of incentives in national family planning programmes. The resulting consensus, reflected in the ICPD Programme of Action, sharply delimits their use. Specifically, incentive systems should not directly or indirectly encourage service providers to interfere with informed individual choice, for example by rewarding new acceptors of certain contraceptive methods but not others. Programmes should avoid giving excessive priority to new acceptors, so as to maintain attention to the health needs, complications and changing preferences of continuing clients.

Incentives to providers to promote selected methods of contraception may lead them to ignore counter-indications, with-hold information about more appropriate methods, or neglect returning clients.

Programmes may offer incentives to individuals and couples. However, even small incentives may interfere with discussion and informed choice for the very poor; equally, rewarding people for decisions they would have made anyway simply wastes resources. Incentives, if offered, should be modest and proportional and not infringe on informed choice.30

Twenty-nine countries used some combination of client incentives in their national family planning programmes in 1994.31



UNFPA is committed to informed, voluntary choice in population and reproductive health programmes, and supports training and management reforms to ensure this. The Fund only assists service delivery projects that rely on informed consent and offer quality care. In its programme of assistance to China which ended in 1995, for example, UNFPA aimed to improve contraceptive safety and reliability, raise women’s status, train family planning workers in counselling, extend maternal and child health and family planning services in the country’s 300 poorest counties, and improve national capacity for contraceptive and demographic research. Special emphasis was placed on informing programme experts and managers about the necessity of voluntary family planning programmes instead of policies limiting family size, based on quotas and targets.

Pronatalist Pressures

Discussion about coercion usually centres on efforts to prevent people having children. Less attention has been paid to strong pressures in many societies for women to marry young, to have children early in marriage and to go on having children when they would prefer to stop, for example to “try for a boy”. The effect of this pressure can amount to coercion, even or perhaps especially when it comes from within the family. Equating large numbers of children with personal power—“being a real man” (or woman)—can coerce women to make reproductive choices which they know to be counter to their interests. Studies in some countries in some show that between a third and half of all births are unwanted.32

Violence Against Women

The Vienna Human Rights Conference and the Fourth World Conference on Women gave priority attention to violence against women which has been characterized as “the most pervasive yet least recognized human rights abuse in the world”.33 Gender violence includes a variety of different acts which jeopardize the life, body, psychological integrity or freedom of women, and which generally serve by intention or effect to perpetuate male power and control.34

Men have a key role to play in eliminating coercion and violence against women. As legislators, judges, police officers, health and family planning service providers, teachers, husbands and fathers, they must participate in efforts to change the deeply rooted cultural causes of the problem. This includes fundamental changes in the way they view themselves as men—and the way they view women. It is essential to help men develop a self-image as nurturing people who can care for their partners. There is growing evidence that the creation of this kind of self-image may lead to a reduction in violence against women.35

Until they are able to live in a world where they are free from the fear of violence, women will never be truly empowered.

Domestic Violence

One of the most persistent risks to the physical security of women is domestic violence, the physical or emotional abuse of women by their intimate male partners. Abuse of women has been documented in most societies in which the question has been examined.36 A national study in the United States estimated that between 21 and 30 per cent of women are beaten by a partner at least once in their lives. At least half of these women are beaten more than three times each year. Men who are violent towards their wives show a tendency to act this way with increasing frequency and intensity over time.

Not many national studies have been undertaken, but wherever they have, a pattern of widespread violence is discovered. In Colombia, about 20 per cent of women have been beaten by a partner; one out of every three has been emotionally or verbally abused. In Papua New Guinea, 67 per cent of rural women and 56 per cent of urban women have been physically abused. In Norway, 25 per cent of gynaecological patients have been physically or sexually abused by their mates. In a local study in one district in Kenya, 42 per cent of women said that they were regularly beaten by their husbands. In Santiago, Chile, nearly four fifths of women reported ever having been physically, emotionally or sexually abused by a male partner or relative and 63 per cent reported current abuse. The relative paucity of data does not allow comparison of different regions or assessment of overall levels. However, violence in families, overwhelmingly male violence directed towards women, is clearly common.

Other indirect evidence also supports the expectation of substantial domestic violence against women. Suicide is an extreme response to what individuals perceive as an intolerable situation. Studies in Oceania (which are mirrored by results elsewhere) suggest a substantial involvement of marital violence in female suicides. In a study of Fijian Indian families (where suicide is culturally recognized as revenge against those who have made one’s life intolerable), 41 per cent cited marital violence as a cause of their loved one’s suicide.

In the United States, one out of four suicide attempts has been preceded by abuse; higher rates are suggested for African-American women. In Sri Lanka, studies in the mid-1980s suggested that suicide among women aged 15-24 was five times the death rate from infectious diseases and 55 times the rate of obstetric deaths. Other studies in Africa and Peru also link violence with women’s suicide.

Domestic violence can end in murder. In Bangladesh, up to 50 per cent of all murders have at times been attributed to husbands’ violence against women. In Canada, 62 per cent of women murdered in 1987 died from domestic violence. In Papua New Guinea at that time, nearly three quarters of murdered women were killed by their husbands. Murder of husbands by women is often in response to persistent and escalating abuse.

Most domestic violence everywhere is male violence directed at their women partners.37 This gender difference appears to be due primarily to the way boys and men are socialized. The search for biological factors underlying male and female differences in cognitive abilities or temperament that might contribute to violence has identified only small differences which cannot account for the dramatic behavioural disparity.

Studies of young boys and girls (before socialization differences become pronounced) indicate only that boys have a lower tolerance for frustration, greater irritability and impulsiveness and a tendency towards rough and tumble play. Though they are a factor, these tendencies are dwarfed by the importance of male socialization and peer pressure into gender roles. This is particularly clear since cross-cultural studies of wife abuse have found that nearly a fifth of peasant and small-scale societies are “essentially untroubled by family violence.” The existence of such cultures proves that male violence against women is not the inevitable result of male biology or sexuality.

Male aggression can be sparked by a wide variety of frustrations, disagreements and disappointments, over matters consequential or trivial. The prevalence of violence in a domestic setting is the result of tacit acceptance: where domestic violence is clearly unacceptable, abused women will come forward rather than hiding their shame. The threat of physical violence may be a consideration when women seek to discuss family planning, request resources for or act on decisions concerning their reproductive health needs.

Throughout the world, there is a growing volume of legislation protecting women against domestic violence. Enforcement can be problematic, however, even where such legislation is well established. Police are often reluctant to interfere in family disputes of either the privileged or the poor (for different reasons).

Rape

Forced sexual attacks occur in a wide variety of circumstances. This violation of the liberty and security of the person varies enormously in its meaning and impact depending on the circumstances under which it occurs. Eighty per cent of women assaulted already know their attackers— friends, acquaintances, intimates or family members.38 Rape by employers, supervisors or spouses needs to be recognized as such, rather than condoned or treated as merely a serious form of sexual harassment.

Women subjected to rape and assault suffer health risks from a myriad of health consequences.39 These include: severe injuries, unconsciousness and mental illness (including depression, alcohol abuse, post-traumatic stress disorder, drug abuse, guilt, obsessive-compulsive disorders, generalized anxiety, humiliation and embarrassment, self-blame, avoidance of previously pleasurable activities, avoidance of the place or circumstance in which the rape occurred, impaired memory, sexual dysfunction, eating disorders and multiple personality syndrome). Sexual violence also puts women at risk of STDs and unwanted pregnancy. Survivors have significantly higher future health needs for a wide variety of disorders, and their experience of stigmatization and abuse can contribute to attempted suicides. Their families and friends are also affected, as survivors often avoid intimate relationships or become regressively fearful, clinging and needy.

In all cultures the rape survivor is suspected or treated as if there were suspicion of collusion with the rapist. Since women are traumatized and stigmatized by the experience, only a small portion of rapes are reported.

In the United States, only 16 per cent are reported, according to victim surveys. Seven hundred thousand women are raped or sexually assaulted annually—one woman is physically abused every eight seconds and one is raped every six minutes; this amounts to 118 rapes per 100,000 women aged 15- 59.
40 This level is significantly higher than in other developed countries in Europe (the next three: Sweden, 43; Denmark, 35; and Hungary, 31).

Statistics on the incidence of rape in other societies are regularly reported by many countries to the United Nations. However, the quality of these data is often questionable. The greater the stigma attached to rape and the lower the public sympathy for victims, the less likely that rapes will be reported to formal authorities. In any event, substantial evidence exists of forced sexual attacks, especially on young women and girls, in Latin America and sub-Saharan Africa.

The majority of sexual assault victims are young. In the United States, a 1992 report estimated that 61 per cent of victims of sexual assault are under age 18. The information on initiation into sexual activity reviewed elsewhere in this report also reveals a global pattern of high victimization of the young. In Canada, a 1993 study based on randomly selected women found that more than 54 per cent had experienced some form of unwanted or intrusive sexual experience before reaching age 16; 51 per cent reported being victims of rape or attempted rape. In Peru, a study found 90 per cent of young mothers aged 12 to 16 in a hospital to be victims of rape, often by a family member. Mid-teen pregnant women in a hospital in Costa Rica were also found to be largely incest victims.

Rapes of males, most often by other males, are estimated to comprise about 5 per cent of attacks in the United States. Little is known, however, of the level, distribution and characteristics of rapes perpetrated against men in other societies.

In most societies, reports of rape do not guarantee redress or punishment of the offenders. Sexual socialization perpetuates powerful mythologies—incorporated in law or juror understandings—which make it difficult to prosecute sexual criminals in diverse settings without evidence of physical injury from assault, collaborating eye-witnesses or other difficult evidence. The belief that women somehow invite their rapes persists even in circumstances clearly belying it.

In many societies there is a persistent myth that rape cannot occur among people who know each other. Forced or coerced sexual relations without the willing consent of one participant can happen whatever the prior relationship between the couple. Rape by friends, associates and spouses can be particularly traumatic. Such experiences, particularly forced by those in a continuing relationship, can undermine self-esteem by subverting feelings of trust and affection and reinforcing feelings of helplessness and loss of control. The right to security and dignity of the person requires at a minimum that there be no coercion in sexual relationships.

Women in conditions of abject dependency on male authorities—prisoners, workers without special skills or tenure, military recruits, refugees, civilians in war— are also particularly subject to unwanted sexual coercion. Such reports are available from around the world. The linking of gender violence and sexual attack is a dangerous and insidious common violation of women’s basic rights.

Violation of Reproductive Rights in Emergency Situations

Rape in time of war is still common. It has been extensively documented in recent conflicts including in the former Yugoslavia, Rwanda, Cambodia, Liberia, Peru, Somalia and Uganda. In time of war, population displacement or other break-downs of social order it has been used systematically as an instrument of torture or ethnic domination.

Women who have been raped have difficulty returning to normal life, often finding that family and friends reject them for “consorting with the enemy.” At the same time, the capacity and mechanisms of response by the international community have improved.



Trafficking in Girls and Women

Sexual exploitation and trafficking in children is a global problem. Tens of millions of children are already in the sex market, and each year 2 million girls between ages 5 and 15 are introduced to the commercial sex market.41 In developing countries, commercial demand for young women brings children from poor families in the country to cities where the sex industry supplies the wealthy, including some tourists.

Commercial sex is increasing in Asia: in poor countries and regions because of high unemployment and rural poverty, in expanding economies because of growing inequalities in wealth and increased demand. It is estimated that 300,000 Nepalese women have been sent or sold to brothels in India. Concerned political figures report the complicity of police and local authorities in some of this trafficking.

Poverty also fuels the sex trade in Latin America and Africa. News reports tell of kidnappings of Chinese women who are sold into forced marriages in parts of the country where unbalanced sex ratios and underdevelopment mean few potential wives are available.42

The European Union is concerned about what Justice Commissioner Anita Gradin calls “a slave trade in women”—an estimated 500,000 women, largely from Eastern Europe, who have been forced into commercial sex. Many are lured by hopes of other job opportunities and then forced into prostitution to pay off inflated debts for food, accommodation and travel to those who recruited them. In several EU member states, commercial sex workers are predominantly foreign: in Germany, an estimated three quarters of prostitutes are foreign born, in Milan, 80 per cent of street prostitutes, in Vienna, 80 per cent of women working as dancers and hostesses in sex clubs.43

Sex workers are much more exposed to STD/HIV infection than most women, and suffer disproportionately from RTIs. In some studies up to 80 per cent have been found to be HIV-positive. As such they are not only in danger themselves but they and their clients are carriers and spreaders of disease. Studies of patterns of HIV infection in Nigeria and India have shown how it spreads along trucking routes, where drivers have frequent recourse to commercial sex.

Checking the spread of the infection demands not only some sense of urgency and responsibility among the men involved but some control of the sex trade including better law enforcement, elimination of corruption, better legal redress, and health and social programmes for sex workers. The latter have had some success in Thailand and the Philippines, where sex workers now often require their clients to use condoms.