According to one estimate, one in three women worldwide are physically assaulted, sexually coerced or otherwise abused in their lifetime, in most cases by an intimate partner. The accuracy of this estimate is unclear; efforts to collect reliable data on the prevalence and consequences of violence—especially in developing countries—have been hampered by such problems as a lack of representative samples, variations in interview techniques and in the wording of questions, differing cultural definitions of and attitudes toward violence, and unknown levels of underreporting. Given this situation, it is not surprising that so little is known about the sexual and reproductive health consequences of violence. This issue of International Family Planning Perspectives is dedicated to the examination of how abuse affects risk behaviors and health outcomes, and what reproductive health care providers can do to reduce the prevalence of gender-based violence and alleviate its consequences.
In the lead article, Michael Koenig and colleagues examine the impact of coerced first intercourse on the reproductive health of adolescent women in Rakai, Uganda [see article]. Of 575 sexually experienced young women, 14% reported that their first intercourse had been coerced. After the effects of other factors were accounted for, adolescents who had been coerced were significantly less likely than those who had not to be using modern contraceptives, to have used a condom at last intercourse or to have used condoms consistently over the previous six months; they were significantly more likely to say that their current or most recent pregnancy was unintended and to report one or more genital tract symptoms. In addition, the proportion of respondents who had experienced recent coercion was significantly higher among those who had been coerced at first intercourse than among those who had not.
Using data from the 2000 Colombia Demographic and Health Survey, Christina Pallitto and Patricia O'Campo look specifically at links between domestic violence and unintended pregnancy [see article]. In their sample of ever-married women who were currently pregnant or had given birth in the previous five years, 55% had had at least one unintended pregnancy and 38% had been physically or sexually abused by their current partner. In a multivariate analysis, the odds of unintended pregnancy were 40% higher among women who had been abused than among those who had not.
William Parish and colleagues provide the first national estimates of intimate partner violence in China—including violence perpetrated by the man, the woman or both partners—and look at risk factors and associated health problems [see article]. In their representative sample of adults aged 20–64 who had a spouse or other steady partner, 34% of women and 18% of men had ever been hit by their current partner; for 12% and 5%, respectively, the hitting had resulted in injury. After the effects of individual characteristics were controlled, risk factors associated with hitting included sexual jealousy, low female contribution to household income, low male socioeconomic status, female alcohol consumption and male inebriation. Hard hitting was linked to self-reported sexual health problems such as sexual dysfunction, sexual dissatisfaction and unwanted sex, as well as to negative general health conditions.
Annabel Erulkar, who examines young people's experiences of sexual coercion, also looks at the experiences of both females and males [see article]. In a large, population-based sample of 10–24-year-olds, 21% of young women and 11% of young men said they had experienced sexual coercion. The great majority of coerced respondents said the perpetrator was an intimate partner (for 28% of young women, it was their husband), but a sizeable minority identified an acquaintance. Young women who had been coerced had elevated odds of having had three or more sex partners and of having experienced symptoms of reproductive tract infections. Young men who had been coerced were more likely than those who had not to have had a first partner who was five or more years older.
Lisa Bates and colleagues use qualitative and quantitative methods to examine the prevalence of abuse and its association with the status of women in rural Bangladesh [see article]. Of more than 1,200 married women in six villages, 67% had ever experienced intimate partner violence, including 33% who had been kicked, burned or had a weapon used against them. Eighteen percent had been mistreated while pregnant. Women who were members of a microcredit program and those with a higher-than-average level of education (six years or more) were less likely than other women to have been abused in the last year, while women who contributed more than nominally to household expenses and those who had outstanding unpaid dowry were more likely to have been abused.
Heidi Lary and colleagues use qualitative data to explore an association between intimate partner violence and HIV found in earlier quantitative research in Tanzania [see article]. Interviews with 40 men and 20 women aged 16–24 who lived in Dar es Salaam indicate that infidelity and forced sex were widespread in youth's intimate relationships. Young men who had multiple concurrent sexual relationships reported abusing their female partners when confronted about their infidelity, and forcing partners to have sex if they initially refused. In contrast, young people who felt that violence and forced sex could not be justified under any circumstances were usually in monogamous partnerships or had not yet had sex.
Finally, a Comment by Charlotte Watts and Susannah Mayhew examines ways in which responses to violence can be integrated into reproductive health services [see article]. The authors recommend that clinics that have adequate private space provide violence screening and counseling during reproductive health consultations; train and support staff interested in helping abused women; document abuse and its medical consequences; provide appropriate clinical care; and offer women information and referrals to other services. In addition, they suggest that ministries of health issue statements condemning violence and incorporate specialized modules on violence into health worker training. Above all, they stress that a "considered, sustainable and context-specific approach" to integration of violence interventions be used to avoid further jeopardizing women's safety.