the impact of gender based violence on the individual essay

Gender-Based Violence (Violence Against Women and Girls)

Photo: Simone D. McCourtie / World Bank

Gender-based violence (GBV) or violence against women and girls (VAWG), is a global pandemic that affects 1 in 3 women in their lifetime.

The numbers are staggering:

• 35% of women worldwide have experienced either physical and/or sexual intimate partner violence or non-partner sexual violence.
• Globally, 7% of women have been sexually assaulted by someone other than a partner.
• Globally, as many as 38% of murders of women are committed by an intimate partner.
• 200 million women have experienced female genital mutilation/cutting.

This issue is not only devastating for survivors of violence and their families, but also entails significant social and economic costs. In some countries, violence against women is estimated to cost countries up to 3.7% of their GDP – more than double what most governments spend on education.

Failure to address this issue also entails a significant cost for the future.  Numerous studies have shown that children growing up with violence are more likely to become survivors themselves or perpetrators of violence in the future.

One characteristic of gender-based violence is that it knows no social or economic boundaries and affects women and girls of all socio-economic backgrounds: this issue needs to be addressed in both developing and developed countries.

Decreasing violence against women and girls requires a community-based, multi-pronged approach, and sustained engagement with multiple stakeholders. The most effective initiatives address underlying risk factors for violence, including social norms regarding gender roles and the acceptability of violence.

The World Bank is committed to addressing gender-based violence through investment, research and learning, and collaboration with stakeholders around the world.

Since 2003, the World Bank has engaged with countries and partners to support projects and knowledge products aimed at preventing and addressing GBV. The Bank supports over $300 million in development projects aimed at addressing GBV in World Bank Group (WBG)-financed operations, both through standalone projects and through the integration of GBV components in sector-specific projects in areas such as transport, education, social protection, and forced displacement.  Recognizing the significance of the challenge, addressing GBV in operations has been highlighted as a World Bank priority, with key commitments articulated under both IDA 17 and 18, as well as within the World Bank Group Gender Strategy .

The World Bank conducts analytical work —including rigorous impact evaluation—with partners on gender-based violence to generate lessons on effective prevention and response interventions at the community and national levels.

The World Bank regularly  convenes a wide range of development stakeholders  to share knowledge and build evidence on what works to address violence against women and girls.

Over the last few years, the World Bank has ramped up its efforts to address more effectively GBV risks in its operations , including learning from other institutions.

Addressing GBV is a significant, long-term development challenge. Recognizing the scale of the challenge, the World Bank’s operational and analytical work has expanded substantially in recent years.   The Bank’s engagement is building on global partnerships, learning, and best practices to test and advance effective approaches both to prevent GBV—including interventions to address the social norms and behaviors that underpin violence—and to scale up and improve response when violence occurs.  

World Bank-supported initiatives are important steps on a rapidly evolving journey to bring successful interventions to scale, build government and local capacity, and to contribute to the knowledge base of what works and what doesn’t through continuous monitoring and evaluation.

Addressing the complex development challenge of gender-based violence requires significant learning and knowledge sharing through partnerships and long-term programs. The World Bank is committed to working with countries and partners to prevent and address GBV in its projects. 

Knowledge sharing and learning

Violence against Women and Girls: Lessons from South Asia is the first report of its kind to gather all available data and information on GBV in the region. In partnership with research institutions and other development organizations, the World Bank has also compiled a comprehensive review of the global evidence for effective interventions to prevent or reduce violence against women and girls. These lessons are now informing our work in several sectors, and are captured in sector-specific resources in the VAWG Resource Guide: www.vawgresourceguide.org .

The World Bank’s  Global Platform on Addressing GBV in Fragile and Conflict-Affected Settings  facilitated South-South knowledge sharing through workshops and yearly learning tours, building evidence on what works to prevent GBV, and providing quality services to women, men, and child survivors.  The Platform included a $13 million cross-regional and cross-practice initiative, establishing pilot projects in the Democratic Republic of Congo (DRC), Nepal, Papua New Guinea, and Georgia, focused on GBV prevention and mitigation, as well as knowledge and learning activities.

The World Bank regularly convenes a wide range of development stakeholders to address violence against women and girls. For example, former WBG President Jim Yong Kim committed to an annual  Development Marketplace  competition, together with the Sexual Violence Research Initiative (SVRI) , to encourage researchers from around the world to build the evidence base of what works to prevent GBV. In April 2019, the World Bank awarded $1.1 million to 11 research teams from nine countries as a result of the fourth annual competition.

Addressing GBV in World Bank Group-financed operations

The World Bank supports both standalone GBV operations, as well as the integration of GBV interventions into development projects across key sectors.

Standalone GBV operations include:

• In August 2018, the World Bank committed $100 million to help prevent GBV in the DRC . The Gender-Based Violence Prevention and Response Project will reach 795,000 direct beneficiaries over the course of four years. The project will provide help to survivors of GBV, and aim to shift social norms by promoting gender equality and behavioral change through strong partnerships with civil society organizations. 
• In the  Great Lakes Emergency Sexual and Gender Based Violence & Women's Health Project , the World Bank approved $107 million in financial grants to Burundi, the DRC, and Rwanda  to provide integrated health and counseling services, legal aid, and economic opportunities to survivors of – or those affected by – sexual and gender-based violence. In DRC alone, 40,000 people, including 29,000 women, have received these services and support.
• The World Bank is also piloting innovative uses of social media to change behaviors . For example, in the South Asia region, the pilot program WEvolve  used social media  to empower young women and men to challenge and break through prevailing norms that underpin gender violence.

Learning from the Uganda Transport Sector Development Project and following the Global GBV Task Force’s recommendations , the World Bank has developed and launched a rigorous approach to addressing GBV risks in infrastructure operations:

• Guided by the GBV Good Practice Note launched in October 2018, the Bank is applying new standards in GBV risk identification, mitigation and response to all new operations in sustainable development and infrastructure sectors.
• These standards are also being integrated into active operations; GBV risk management approaches are being applied to a selection of operations identified high risk in fiscal year (FY) 2019.
• In the East Asia and Pacific region , GBV prevention and response interventions – including a code of conduct on sexual exploitation and abuse – are embedded within the Vanuatu Aviation Investment Project .
• The Liberia Southeastern Corridor Road Asset Management Project , where sexual exploitation and abuse (SEA) awareness will be raised, among other strategies, as part of a pilot project to employ women in the use of heavy machinery. 
• The Bolivia Santa Cruz Road Corridor Project uses a three-pronged approach to address potential GBV, including a Code of Conduct for their workers; a Grievance Redress Mechanism (GRM) that includes a specific mandate to address any kinds gender-based violence; and concrete measures to empower women and to bolster their economic resilience by helping them learn new skills, improve the production and commercialization of traditional arts and crafts, and access more investment opportunities.
• The Mozambique Integrated Feeder Road Development Project identified SEA as a substantial risk during project preparation and takes a preemptive approach: a Code of Conduct; support to – and guidance for – the survivors in case any instances of SEA were to occur within the context of the project – establishing a “survivor-centered approach” that creates multiple entry points for anyone experiencing SEA to seek the help they need; and these measures are taken in close coordination with local community organizations, and an international NGO Jhpiego, which has extensive experience working in Mozambique.

Strengthening institutional efforts to address GBV  

In October 2016, the World Bank launched the  Global Gender-Based Violence Task Force  to strengthen the institution’s efforts to prevent and respond to risks of GBV, and particularly sexual exploitation and abuse (SEA) that may arise in World Bank-supported projects. It builds on existing work by the World Bank and other actors to tackle violence against women and girls through strengthened approaches to identifying and assessing key risks, and developing key mitigations measures to prevent and respond to sexual exploitation and abuse and other forms of GBV. 

In line with its commitments under IDA 18 , the World Bank developed an Action Plan for Implementation of the Task Force’s recommendations , consolidating key actions across institutional priorities linked to enhancing social risk management, strengthening operational systems to enhance accountability, and building staff and client capacity to address risks of GBV through training and guidance materials.

As part of implementation of the GBV Task Force recommendations, the World Bank has developed a GBV risk assessment tool and rigorous methodology to assess contextual and project-related risks. The tool is used by any project containing civil works.

The World Bank has developed a Good Practice Note (GPN) with recommendations to assist staff in identifying risks of GBV, particularly sexual exploitation and abuse and sexual harassment that can emerge in investment projects with major civil works contracts. Building on World Bank experience and good international industry practices, the note also advises staff on how to best manage such risks. A similar toolkit and resource note for Borrowers is under development, and the Bank is in the process of adapting the GPN for key sectors in human development.

The GPN provides good practice for staff on addressing GBV risks and impacts in the context of the Environmental and Social Framework (ESF) launched on October 1, 2018, including the following ESF standards, as well as the safeguards policies that pre-date the ESF: 

• ESS 1: Assessment and Management of Environmental and Social Risks and Impacts;
• ESS 2: Labor and Working Conditions;
• ESS 4: Community Health and Safety; and
• ESS 10: Stakeholder Engagement and Information Disclosure.

In addition to the Good Practice Note and GBV Risk Assessment Screening Tool, which enable improved GBV risk identification and management, the Bank has made important changes in its operational processes, including the integration of SEA/GBV provisions into its safeguard and procurement requirements as part of evolving Environmental, Social, Health and Safety (ESHS) standards, elaboration of GBV reporting and response measures in the Environmental and Social Incident Reporting Tool, and development of guidance on addressing GBV cases in our grievance redress mechanisms.

In line with recommendations by the Task Force to disseminate lessons learned from past projects, and to sensitize staff on the importance of addressing risks of GBV and SEA, the World Bank has developed of trainings for Bank staff to raise awareness of GBV risks and to familiarize staff with new GBV measures and requirements.  These trainings are further complemented by ongoing learning events and intensive sessions of GBV risk management.

Last Updated: Sep 25, 2019

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• Open access
• Published: 08 March 2019

Social norms and beliefs about gender based violence scale: a measure for use with gender based violence prevention programs in low-resource and humanitarian settings

• Nancy Perrin 1 ,
• Mendy Marsh 2 ,
• Amber Clough 1 ,
• Amelie Desgroppes 3 ,
• Clement Yope Phanuel 4 ,
• Ali Abdi 3 ,
• Francesco Kaburu 3 ,
• Silje Heitmann 5 ,
• Masumi Yamashina 6 ,
• Brendan Ross 7 ,
• Sophie Read-Hamilton 8 ,
• Rachael Turner 1 ,
• Lori Heise 1 , 9 &
• Nancy Glass 1  

Conflict and Health volume  13 , Article number:  6 ( 2019 ) Cite this article

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Gender-based violence (GBV) primary prevention programs seek to facilitate change by addressing the underlying causes and drivers of violence against women and girls at a population level. Social norms are contextually and socially derived collective expectations of appropriate behaviors. Harmful social norms that sustain GBV include women’s sexual purity, protecting family honor over women’s safety, and men’s authority to discipline women and children. To evaluate the impact of GBV prevention programs, our team sought to develop a brief, valid, and reliable measure to examine change over time in harmful social norms and personal beliefs that maintain and tolerate sexual violence and other forms of GBV against women and girls in low resource and complex humanitarian settings.

The development and testing of the scale was conducted in two phases: 1) formative phase of qualitative inquiry to identify social norms and personal beliefs that sustain and justify GBV perpetration against women and girls; and 2) testing phase using quantitative methods to conduct a psychometric evaluation of the new scale in targeted areas of Somalia and South Sudan.

The Social Norms and Beliefs about GBV Scale was administered to 602 randomly selected men ( N  = 301) and women (N = 301) community members age 15 years and older across Mogadishu, Somalia and Yei and Warrup, South Sudan. The psychometric properties of the 30-item scale are strong. Each of the three subscales, “Response to Sexual Violence,” “Protecting Family Honor,” and “Husband’s Right to Use Violence” within the two domains, personal beliefs and injunctive social norms, illustrate good factor structure, acceptable internal consistency, reliability, and are supported by the significance of the hypothesized group differences.

Conclusions

We encourage and recommend that researchers and practitioners apply the Social Norms and Beliefs about GBV Scale in different humanitarian and global LMIC settings and collect parallel data on a range of GBV outcomes. This will allow us to further validate the scale by triangulating its findings with GBV experiences and perpetration and assess its generalizability across diverse settings.

Introduction

Gender-based violence (GBV) remains one of the most prevalent and persistent issues facing women and girls globally [ 1 , 2 , 3 , 4 ]. Conflict and other humanitarian emergencies place women and girls at increased risk of many forms of GBV [ 5 , 6 , 7 ]. The Inter-Agency Standing Committee (IASC) 2015 Guidelines for Integrating GBV Interventions in Humanitarian Action defines GBV as any harmful act that is perpetrated against a person’s will and that is based on socially ascribed (i.e., gender) differences between females and males. It includes acts that inflict physical, sexual or mental harm or suffering, threats of such acts, coercion, and other deprivations of liberty. These harmful acts can occur in public and in private [ 8 ]. There continues to be limited global information on the burden of GBV in humanitarian emergencies. One systematic review found that approximately one in five refugees or displaced women in complex humanitarian settings experienced sexual violence, though this is likely an underestimation of the true prevalence given the many barriers to survivors’ disclosure of GBV [ 9 ]. A recent population-based survey on GBV across the three regions of Somalia examined typology and scope of GBV victimization with 2376 women (15 years and older). The study found that among women, 35.6% (95% CI 33.4 to 37.9) reported lifetime experiences of physical or sexual intimate partner violence (IPV) and 16.5% (95% CI 15.1 to 18.1) reported lifetime experience of physical or sexual non-partner violence (NPV) since the age of 15 years. Women at greatest risk of GBV (IPV and NPV) included membership in a minority clan, displacement from home because of conflict or natural disaster, husband/partner use of khat (e.g., leaves chewed or drunk as a stimulant), exposure to parental violence and violence during childhood. Women survivors of GBV consistently report negative impacts on physical, mental and reproductive health. Often negative health and social consequences are never addressed because women do not disclose GBV to providers or access health care or other services (e.g., protection, legal, traditional authorities) because of social norms that blame the woman for the assault (e.g., she was out alone after dark, she was not modestly dressed, she is working outside the home), norms that prioritize protecting family honor over safety of the survivor, and institutional acceptance of GBV as a normal and expected part of displacement and conflict [ 10 , 11 , 12 , 13 ].

GBV primary prevention in humanitarian settings

GBV primary prevention programs seek to facilitate change by addressing the underlying causes and drivers of GBV at a population level. Such programs have traditionally included initiatives to economically empower girls and women, enhanced legal protections for GBV, enshrining women’s rights and gender equality within national legislation and policy, and other measures to promote gender equality. Increasingly, programs are also targeting transformation of social norms that justify and sustain acceptance of GBV. Social norms are contextually and socially derived collective expectations of appropriate behaviors [ 14 ]. Families and communities have shared beliefs and unspoken rules that both proscribe and prescribe behaviors that implicitly convey that GBV against women is acceptable, even normal [ 15 , 16 ]. This includes social norms pertaining to sexual purity, family honor, and men’s authority over women and children in the family. Community leaders, institutions, and service providers, such as health care, education and law enforcement, can reinforce harmful social norms by, for example, blaming women and girls for the sexual assault they experience, or by justifying a husband’s use of physical violence as a means to discipline his wife. Both behaviors are viewed as essential to protect the family’s reputation in the larger community [ 16 ].

Diverse academic disciplines have developed different theories to explain the complexity of social norms and their influence on behavior. We use social norms theory as elaborated in social psychology [ 17 ]. This theory conceptualizes social norms as beliefs of two types: 1) an individual’s beliefs about what others typically do in a given situation (i.e., descriptive norm); and 2) their beliefs about what others expect them to do in a given situation (i.e., injunctive norm) [ 18 , 19 , 20 ]. For this study, we focus on developing a measure of injunctive norms—defined in this case as beliefs about what influential others (e.g., parents, siblings, peers, religious leaders, teachers) expect individuals to do in the case of GBV.

Even with the multiple challenges of humanitarian settings (e.g., separation of families, insecurity and limited resources), there is an opportunity to develop, implement, and evaluate innovations in GBV programming. In such settings, displacement and conflict have created situations where social rules about who can do what necessarily bend to accommodate new realities [ 16 ]. Women, for example, may be forced to assume new roles in the family and community, such as having decision-making power and control over household financial resources and assets and working outside the home to help support the family. These changing roles then lead to shifts in behavior and potentially power relations in the family and community that challenge traditional norms around male authority and women’s relegation to the domestic sphere. These circumstances can provide an opportunity to initiate GBV primary prevention efforts, such as those that engage community leaders and members in critical reflection on norms that legitimate gender inequality and what actions can be taken by the individual, family, and community to change norms that cause harm [ 15 , 16 ]. Acknowledging the potential of the humanitarian setting as an opportunity for primary prevention programming and recognizing the need to strengthen GBV response systems, the United Nations Children’s Fund (UNICEF) built on their work to end female genital mutilation using social norms theory [ 19 ] to develop the Communities Care Program: Transforming Lives and Preventing Violence Program (Communities Care) [ 21 ]. The goal of Communities Care is to create safer communities for women and girls by challenging social norms that sustain GBV and catalyzing new norms that uphold women and girls’ equality, safety, and dignity [ 15 , 21 ]. The description of the Communities Care program is published elsewhere [ 15 , 16 , 21 ].

However, a significant limitation for evaluating the effectiveness of GBV prevention programs such as Communities Care is the lack of validated instruments to measure change in norms supporting GBV. Therefore, our goal was to create a brief, valid, and reliable measure to examine change over time in harmful social norms and personal beliefs that maintain and tolerate sexual violence and other forms of GBV in low resource and complex humanitarian settings.

While validated instruments exist to measure attitudes towards gender roles and some types of GBV [ 22 , 23 ], social norms are different from individual attitudes. For nearly two decades, the Demographic and Health Surveys (DHS), which are nationally representative surveys conducted in low and middle-income countries (LMIC), have provided information on attitudes about the acceptability of IPV or wife beating. Respondents are asked whether a man is justified in beating his wife in five different situations: a wife goes out without her husband’s permission; she neglects to keep the children well fed; she argues with her husband in public; she refuses to have sexual intercourse with her husband; and she does not prepare her husband’s meal on time. Response options for these questions are as follows: “agree,” “disagree,” “refuse to answer,” and “don’t know.” These questions are designed specifically to elicit personal beliefs (attitudes) about IPV; they have generally functioned well in that they capture various levels of endorsement of IPV both within and among settings, and respondents routinely vary their answers based on the transgression mentioned.

Investigators, however, have raised questions about whether the DHS questions reflect respondents’ own personal beliefs on the acceptability of beating or women’s perception of the social norm operative in their setting. Cognitive interviews with women in Bangladesh, for example, suggested that women’s interpretation of the attitude questions switched between personal and normative beliefs, although it is difficult to know whether this happens routinely in other settings, or whether it was a function of the especially low literacy and female mobility of rural Bangladesh [ 24 , 25 ].

Scientists have also warned that changing key features of a scenario (e.g., setting, perpetrator, infraction committed, perceived intentionality) can influence measured attitudes and perceived norms on the acceptability of GBV. For example, in Uganda, researchers randomly assigned participants to answer attitude and norm questions on wife beating using three separate wordings [ 26 ]. The attitude questions compared the traditional wording of the DHS (whether a man is justified in beating his wife for 5 different infractions) to more contextualized scenarios that depicted the wife’s transgression as either willful or beyond her control. To elicit norms related to wife beating, participants were asked about the extent to which they thought other people in their village (reference group) would think the behavior described was justified. Response options for the five questions followed a four-point Likert-type scale: “all or almost all, for example, at least 90% of people in your village,” “more than half but fewer than 90% of people in your village,” “fewer than half but more than 10% of people in your village,” and “very few or none, for example, less than 10% of people in your village.”

The findings demonstrated that when measuring both attitudes and social norms, adding contextual details about the intentionality of a wife’s transgression changed participants’ perception of the acceptability of IPV. In the vignettes, wives who intentionally violated norms about acceptable wifely behavior had a “large” effect [ 27 ] on increasing the number of items for which wife beating was viewed as acceptable. In contrast, the vignette that depicted the wife as unintentionally violating norms of behavior had a “small” effect in decreasing the number of items where IPV was considered acceptable. The study authors interpreted this difference as measurement error, arguing that question wordings without context may mis-represent attitudes and norms on violence. While context does matter, the specific details added in this study were likely critical to its findings. Qualitative studies have repeatedly shown that wife beating in LMIC is understood as “discipline” and its acceptability varies depending on the nature of the transgression (whether it is perceived as for “just cause”), who is doing the “correction,” and whether the beating stays within acceptable bounds of severity [ 24 , 25 , 28 , 29 , 30 ].

In this paper, we describe the formative research and psychometric testing of the Social Norms and Beliefs about Gender Based Violence (GBV) Scale . The Scale is designed to measure change over time in harmful social norms and personal beliefs associated with violence against women and girls among men and women community members in low resource and complex humanitarian settings. The development and validation of the scale was essential for use in measuring change in harmful social norms and beliefs among community members in districts and regions implementing the Communities Care program in two countries with ongoing humanitarian crises, Somalia and South Sudan. The development and testing of the scale was conducted in two phases: 1) formative phase of qualitative inquiry to identify social norms and personal beliefs that sustain and justify GBV perpetration against women and girls across the lifespan in low-resource and humanitarian contexts; and 2) testing phase using quantitative methods to conduct a psychometric evaluation of the new scale in targeted areas of Somalia and South Sudan.

Study settings

The formative and testing phases of the psychometric evaluation was conducted in two countries, Somalia and South Sudan. In Southern Central Somalia, we worked in four districts (Bondhere, Karaan, Wadajir, Yaqshid ) in Mogadishu and in South Sudan, we worked in two regions (Yei and Warrap). Somalia has experienced more than two decades of conflict as well as ongoing emergencies including drought, famine, and a large number of internally displaced people (IDPs). Yei is located in southwestern South Sudan and was the re-entry point for South Sudanese who fled to the Democratic Republic of Congo (DRC) and Uganda during the Second Sudanese Civil War. Since many people stayed in Yei upon returning, there is conflict between those native to Yei and IDPs from other regions of South Sudan. Warrap is in the northern region of South Sudan and is a gateway between South Sudan and Sudan. Militia activity, cattle-raiding, and conflict over oil, along with the influx of people returning to South Sudan, has caused significant challenges for access to and use of limited resources. The districts and regions in each country were selected based on multiple factors. We focused efforts on districts and regions where GBV reporting systems existed and could be accessed to generate data on case reports and referrals. When engaging GBV survivors and other community members in research on sensitive issues it is essential to have partnerships with diverse service sectors (e.g., health, protection, legal, advocacy) for participants that disclose GBV and request referrals. The evaluation also required safe access to the sites and security while doing the study for both participants and local researchers, therefore this required establishing relationships and obtaining permission from national, regional, and district governmental authorities and ministries as well as traditional leaders in the communities.

Phase 1: Formative phase methods

For the formative phase, we worked with local partners to identify male and female key stakeholders (e.g., religious leaders, youth and women’s group leaders, advocates for GBV survivors, health providers, child protection staff, police officers, traditional leaders, elders, and teachers) to advance our understanding of and identify harmful and protective social norms associated with GBV within and across settings. The focus group guide was developed and translated to the local language in partnership with team members in each setting. Johns Hopkins provided in-depth training to local staff on facilitating focus groups, data collection, human subjects’ protections, working with distressed participants, and providing referrals to services as appropriate. The focus group guide focused on identification of social norms that protect women and girls from sexual violence and other forms of GBV, norms that are harmful (e.g., hide, sustain, or encourage), norms about disclosing and reporting sexual violence and other forms of GBV to authorities, and who are the people in the family or larger community that are influential in maintaining and changing social norms. For example, the team used scenarios created from aggregating GBV experiences in each setting to explore social norms about the situations and the survivor-perpetrator relationship. We varied the perpetrator and circumstances in each scenario from the perpetrator being a family member, a known person to the family but not part of the family, and an unknown person. For each scenario, focus group participants were asked about their beliefs and norms about how the family and community would respond to victims of the sexual assault or other forms of GBV, if the assault would be reported to authorities, and reasons for reporting or not reporting the assault.

Qualitative analysis

A qualitative descriptive approach was used to identify themes related to harmful and protective social norms within and across settings. The transcripts were read by three research team members to identify thematic codes. Themes with sub-themes were identified and defined by exemplars or quotes from the transcripts. The three researchers independently assigned codes and discrepancies in coding were discussed in weekly meetings. The codes and corresponding quotes were used to write items for the scale representing each of the identified themes. The themes, sub-themes, and items were then shared with the in-country teams in a joint Somalia/South Sudan meeting. The relevance of the themes and their interpretation for each context was discussed leading to a refinement of the items. Meeting participants from each country rated the importance of each item and offered suggestions on wording of the items to ensure they were capturing the relevant aspects of the different contexts and cultures.

Results of phase 1: Formative phase

A total of 42 focus groups (22 in Somalia and 20 in South Sudan) with a total of 215 participants (111 in Somalia and 104 in South Sudan) were conducted. The composition of the focus groups varied by stakeholders (e.g., religious leaders, service providers, teachers, police, youth, elders), age (under 30, 31–45, and 46+), marital status, and sex. Themes identified for social norms that are protective against GBV included parents teaching/guiding children, marriage, and respect for female members of the family. Themes identified as harmful social norms included men’s responsibility/right to correct female behavior and the social expectation that a woman will obey her husband and fulfill her gender prescribed duties to his satisfaction, protecting the family’s dignity by not reporting violence/assault to avoid stigma associated with being a victim, husband’s right to force his wife to have sex, lack of status for women, and forced marriage. Mothers, fathers, parents, community and religious leaders, and male relatives were seen as people that influenced behavior and protected women and girls from GBV. Men and women’s behavior also emerged as subthemes associated with harmful social norms, such as indecent dressing, being out in public alone, and drug/alcohol use. Stigma associated with being a GBV victim, blaming women and girls for the violence/assault, and the importance of family honor and respect were identified as norms that prevent victims and families from reporting sexual violence and other forms of GBV to authorities. Items for the new scale were written for each of the themes and sub-themes relevant to harmful social norms and after elimination of redundant items, 30 items remained and were presented to the in-country teams. After discussion about the focus group themes and the items with the in-country teams, a total of 18 items remained. The team then collaborated to develop introductory statements and response scales for each of two domains of the scale, personal beliefs and injunctive social norms. The final scale to be tested in the evaluation phase had two sets of the 18 items, one for each domain.

Methods for phase 2: Psychometric testing

At each of the three sites in the two countries detailed above, trained local research assistants (RAs) recruited and consented 200 community members (15 years and older) to complete the Social Norms and Beliefs about Gender Based Violence Scale. The sampling frame was stratified by age group (15–18, 19–24, 25–45, 46+ years) and sex with a target of 25 people per age group/sex combination. As suggested by the in-country teams, male RAs recruited and interviewed male community members and female RAs recruited and interviewed female community members. Each RA recruited participants across age groups. The RA started from a central point determined by the research coordinator each morning. The RA would contact every 3rd house/dwelling counting on both sides of the street/pathway. If nobody was home, the person was not willing to participate, or the person did not match the sampling target for sex/age, the RA went to the next house/dwelling. Once a RA identified and consented an eligible participant in the household and completed the scale, the RA started the process to identify the next eligible participant by going to the next 3rd house/dwelling on the street/pathway. Only one eligible household member completed the scale.

Field procedures

RAs received detailed training on protocols for maintaining participant confidentiality and safety as well as protocols designed to ensure safety and security for the team members. In the field, when a RA identified an adult at a house/dwelling, he/she introduced the study. If that person met the eligibility criteria and agreed to participate, the RA worked with the participant to find a private and comfortable place to provide informed consent and administer the scale. If that person did not meet eligibility, he/she was asked if there was someone living in the household that did meet the eligibility. The RA provided each potential participant with informed consent information using the script provided on the study tablet and approved by the in-country team and the Johns Hopkins Medical Institution Institutional Review Board (IRB). If the eligible participant provided verbal consent the RA continued and administered the scale with brief demographic questions, including marital status, employment, and children in the household. The responses were entered by the RA directly on the tablet. Once finished, the RA thanked the participant for their time and answered any questions prior to moving on.

The 18 items generated from the formative phase were asked in two sets to capture the two domains, personal beliefs and injunctive norms. The injunctive social norms items started with “How many of the people whose opinion matters most to you….” with the response scale of: 1 – None of them, 2 – A few of them, 3 – About half of them, 4 – Most of them, and 5 – All of them. The personal beliefs items started with “We would like to know if you think any of the following statements are wrong and should be changed in your community. We also would like to understand how ready or willing you are to take action by speaking out on the issues you think are wrong” and used the response scale: 1 – Agree with this statement, 2 – I am not sure if I agree or disagree with this statement, 3 – I disagree with the statement but am not ready to tell others, and 4 – I disagree with the statement and I am telling others that this is wrong. The scale was translated into Somali and the translation was reviewed by the Somalia team and revised before it was programmed into the study tablet. In South Sudan, the scale was administered in the Kakwa language in Yei and Dinka language in Warrap. As these are not commonly written languages in South Sudan, the team preferred using the English version of the scale programmed on the tablet and translated into the local language at time of administration. The South Sudan team training included discussions and decisions on correct translation of items in the two languages and then the team practiced administering with volunteers not participating in the study to ensure consistency in real-time translation across RAs and sites.

Psychometric analyses

For each of the two domains of the scale, we examined construct validity with factor analysis using the common factor model with oblique rotation. Factor loadings of .40 or above were considered as loading on a given factor [ 31 ]. Items that did not load on any factor were considered for revision or elimination from the scale. Reliability was estimated with Cronbach’s alpha for each factor subscale. Known groups validity was examined by testing two a priori hypotheses: H 1 : The sites (Somalia, Yei, South Sudan, and Warrup, South Sudan) differ on social norms and personal beliefs due to differences in the extent of GBV programming within the districts of Mogadishu and regions of South Sudan; and H 2 : Men and women participants will differ on social norms and personal beliefs related to GBV. The first hypothesis was tested with analysis of variance and the second with t-tests.

Results of psychometric testing

The team administered the Social Norms and Beliefs about GBV Scale to 602 community members across Mogadishu, Somalia and Yei and Warrup, South Sudan. The sampling frame was successfully implemented by the research team with 50.0% of participants across the settings being female and 50.0% male with an equal distribution across age groups except in Yei, South Sudan. The team in Yei reported having difficulty finding community members in the region over 60 years of age. The lack of older community members could be related to deaths in the Second Civil War from 1983 to 2005. Over half (58.6%) of the participants were married and had children in the home (67.4%). One third (34%) reported working outside the home, 10.1% were looking for work, 21.4% were students, 29.4% were housewives, and 4.7% were too old to work. Table  1 summarizes the characteristics of the participants by country and site.

Factor analysis

The factor analysis for the items in the injunctive norms domain of the scale was based on responses from participants that completed all items ( N  = 587, 97.5%). There were 3 of the 18 items on the injunctive social norms scales that did not load on any factor and were thus removed from the scale. The first item “expect daughters to be married before 15 years of age” likely did not correlate with the other items on the scale because early marriage is seen as a different concept than sexual violence. The second item “think that if an unmarried woman/girl is raped by a man, she should marry him rather than not being married at all” captures two different concepts—marrying the man who raped her and that being better than not being married at all. This complexity likely made the question difficult to answer. The third item “expect a woman not to report her husband for forcing her to have sexual intercourse” did not reflect a consistent social norm. Discussions with the in-country teams revealed that there was considerable debate on this item even among people who agreed on other items. Based on the eigenvalues (first 5 eigenvalues were 4.27, 1.82, 1.23, 0.94, 0.81), the remaining 15 items formed three factors (Table  2 presents the factor loadings for each item on each of the three factors) with each item loading above 0.40 on only one factor. The following titles were given to represent the three factors, later describes as subscales: “Response to Sexual Violence” has 5 items, “Protecting Family Honor” has 6 items, and “Husband’s Right to Use Violence” has 4 items. The “Response to Sexual Violence” and “Husbands’ Right to Use Violence” subscales had the highest inter-factor correlation (0.46) followed by “Response to Sexual Violence” and “Protecting Family Honor” (0.34), then “Protecting Family Honor” and “Husbands’ Right to Use Violence” (0.30). Importantly, these 3 factors were consistent with and reflected the themes identified from the qualitative analyses of the focus groups in Phase 1. A very similar factor structure was found for the personal beliefs domain ( N  = 588, 97.7%). Eigenvalues (first 5 eigenvalues were 4.46, 1.76, 1.46, 0.90, 0.88) suggested 3 factors as illustrated in Table  3 . All items loaded at 0.45 or greater on only one of the three factors. One item, “a woman/girl would be stigmatized if she were to report rape” loaded on the “Response to Sexual Violence” in the personal beliefs domain whereas the corresponding item, “women/girls fear stigma if they were to report sexual violence”, loaded on the “Protecting Family Honor” subscale for the social norms domain. The inter-factor correlations on the personal beliefs domain were also very similar to the injunctive social norms domain scale: “Response to Sexual Violence” and “Husbands’ Right to Use Violence” had the highest correlation (0.43) followed by “Response to Sexual Violence” and “Protecting Family Honor” (0.32), then “Protecting Family Honor” and “Husbands’ Right to Use Violence” (0.26).

Reliability

Cronbach alpha reliabilities, a measure of internal consistency of the scale, were in an acceptable range for all factors/subscales within each domain. Cronbach alphas ranged from 0.69 to 0.75 for the injunctive norms domain and 0.71 to 0.77 for the personal beliefs domain (the last row of Tables  2 and 3 present the Cronbach alphas for each scale).

Descriptive statistics

Scores for each of the factors (subscales) were computed by taking the average of the items within the subscales. The injunctive social norms domain subscales scores range from 1 to 5 with higher scores reflecting more negative responses to sexual violence and GBV, stronger support for social norms that prioritize protecting family honor by not reporting sexual violence or other forms of GBV, and stronger support for norms endorsing a husband’s right to use violence. Personal beliefs subscales can range from 1 to 4 with higher scores reflecting a more positive response to survivors of sexual violence, that protecting family honor and not reporting sexual violence is wrong, and that a husband should not have the right to use violence against his wife. The means, standard deviations, minimum, and maximum observed score for each of the subscales in each domain are presented in Table  4 . In general, the mean for the injunctive social norms subscales reflect participants’ views that “few to about half” of the people who are important/influential to them endorse harmful social norms about GBV with “Protecting Family Honor” being the strongest norm (means range from 2.00 to 2.77). The mean for the personal beliefs subscales reflects that participant beliefs range between “not being sure if they disagree” with the norms to “disagreeing but not being ready to speak out against them.” Specifically, participants’ beliefs ranged between not being sure if they disagree to disagreeing but not ready to speak out against protecting family honor (mean = 2.61) and husband’s right to use violence (mean = 2.90). Participants indicated that they were between disagreeing but not being ready to tell others to telling others that negative responses to sexual violence survivors are wrong (mean = 3.29). Cross domain correlations were − .318 (p < .001) for “Response to Sexual Violence”, −.512 (p < .001) for “Protecting Family Honor”, and − .427 (p < .001) for “Husband’s Right to Use Violence.”

Known groups validity

Analysis of variance with Bonferroni post-hoc tests revealed that the three sites differed significantly on all subscales for the injunctive social norms domain (i.e., “Response to Sexual Violence,” p < .001; “Protecting Family Honor,” p = .039; “Husband’s Right to Use Violence,” p < .001). Women and men participants in Yei, South Sudan, where there are few GBV programs and services, reported social norms that are significantly more accepting of sexual violence and other forms of GBV than Warrap, South Sudan and Mogadishu, Somalia. In terms of personal beliefs, women and men in Yei were also significantly less likely to speak out against harmful responses to sexual violence and other GBV (p < .001). In Mogadishu, Somalia, men and women were significantly less likely to speak out against “Protecting Family Honor” (p < .001) and “Husband’s Right to Use Violence” (p < .001) than the sites in South Sudan. Table  5 summarizes the t-test results examining differences in the subscales for both domains between men and women. Women participants had significantly higher scores on all of the subscales for the injunctive social norms, indicating women were more likely to endorse harmful norms related to “Response to Sexual Violence”, “Protecting Family Honor”, and “Husband’s Right to Use Violence” than men. Men and women did not differ on personal beliefs about “Response to Sexual Violence”, however, men reported that they are more ready to speak out against harmful social norms of “Protecting Family Honor” and “Husband’s Right to Use Violence” than women.

The psychometric properties of the Social Norms and Beliefs about GBV Scale (final scale is presented in Additional file  1 ) are strong. Each of the three subscales, “Response to Sexual Violence,” “Protecting Family Honor,” and “Husband’s Right to Use Violence” within the two domains of the scale illustrate good factor structure, acceptable internal consistency, reliability, and are supported by the significance of the hypothesized group differences. These three factors represent social norms that are known from previous research to maintain the high rates of GBV in many global settings [ 28 ]. The “Response to Sexual Violence” subscale captures the individual, family, and community response of blaming the victim for GBV. Most often a woman or girl is blamed for the sexual assault or other form of GBV and the family and larger community can respond with rejection and judgement of her behavior, which can result in the family not supporting or abandoning the victim. It reflects the acceptance of sexual violence and other forms of GBV as expected or even normal and that women and girls need to limit their movement and actions to prevent men from assaulting them, as men are not able to control their behavior if they are “tempted” by women. High scores on the injunctive norms domain of this subscale represent that the respondents believe that their influential others expect people to endorse victim blaming responses to sexual violence and other forms of GBV. The “Protecting Family Honor” subscale identifies the stigma associated with being a member of a family/clan where a women/girl experiences GBV and the importance placed on addressing the violence within the family/clan rather than reporting it to authorities. The priority is to protect the family and victim’s reputations rather than the safety and well-being of the woman or girl. High scores on the injunctive domain of this subscale represent that the respondent believes their influential other expects people to prioritize protecting family honor over safety and well-being of victims. The “Husband’s Right to Use Violence” subscale reflects social norms that support a husband’s use of violence to discipline his wife and to have sex with her even when she does not want to. It also reflects a norm that associates a man’s use of violence against his wife with illustrating his love for her. High scores on the injunctive norms domain for this subscale indicates that the respondents believe their influential others expect people to endorse a husband’s right to use violence against his wife. High scores on the personal beliefs domains for each of the subscales reflect a greater willingness to speak out against social norms that endorse GBV.

Validity of the injunctive norms subscales was supported by significant relationships with other variables (i.e., site and sex) as hypothesized during the development of the scale. The three sites were significantly different on the injunctive norms domain of the scale. Although all three sites experienced a high degree of conflict, the amount of humanitarian services to support GBV survivors and programming to raise awareness and change harmful social norms towards GBV varied. Mogadishu districts participating in the study had relatively active programming, with Warrap and Yei reporting few international and local NGOs with capacity to provide diverse GBV services and programs. Yei, South Sudan was found to have significantly stronger norms that endorse negative “Response to Sexual Violence” and other forms of GBV than other sites. The beliefs of participants from Yei also indicated less support for changing harmful social norms about GBV than other sites in the study. Participants in the four districts of Mogadishu scored the lowest on the personal beliefs subscales of “Husband’s Right to Use Violence” and “Protecting Family Honor.” This finding indicates that participants were less willing to speak out against social norms that support husbands’ rights to use violence against their wives or norms that support not reporting sexual violence to protect family honor than the South Sudan sites. Important to interpreting the findings are the differences in context, culture, and religion across the sites which inform social norms and personal beliefs.

Generalizability is one of the indicators of trustworthiness of the Social Norms and Beliefs about GBV scale  – the ability to interpret and apply the scale in a broader context to make it relevant and meaningful to GBV prevention programs being implemented and evaluated in diverse low-resource and humanitarian settings. Importantly, the 36-item two domain scaled applied with community members by local teams in diverse districts and regions within Somalia and South Sudan resulted in a valid and reliable 30-item scale to measure personal beliefs and injunctive social norms. The psychometric phase included randomly selected women and men across multiple age groups (15 years and older), living in both urban and rural communities, and included community members living in settlements and camps for displaced persons. Thus, the scale has the potential to be used in not only humanitarian settings, but also GBV prevention programs in other low-resource and fragile settings.

Although this psychometric evaluation has several strengths, including a mixed methods design to develop the scale and a large sample size to test the scale across diverse sites, it has limitations. The study does not include a separate validation sample to conduct a confirmatory factor analysis. Further, we did not test the relationship between the Social Norms and Beliefs about GBV Scale and community members’ reports on experience, perpetration, or witnessing of GBV in the participating communities. The research team decided in collaboration with local partners not to ask participants in the evaluation phase about personal experiences with GBV for either the scale development or testing. The local colleagues felt community members would be more comfortable and likely to participate in the scale development and testing if they were not asked about their own experiences and thus also increasing generalizability.

The study presents a mixed methods approach to developing a brief scale with strong psychometric properties to measure change in harmful social norms associated with GBV. The Social Norms and Beliefs About GBV Scale is a 30-item scale with three subscales, “Response to Sexual Violence,” “Protecting Family Honor,” and “Husband’s Right to Use Violence” in each of the two domains, personal beliefs and injunctive social norms. The scale to our knowledge is one of the first to demonstrate good factor structure, acceptable internal consistency, and reliability, and be supported by the significance of the hypothesized group differences by setting and sex. We encourage and recommend that researchers apply the Social Norms and Beliefs about GBV Scale in different humanitarian and global LMIC settings and collect parallel data on a range of GBV outcomes. This will allow us to further validate the scale by triangulating its findings with GBV experiences and perpetration and assess its generalizability across diverse settings.

Abbreviations

Demographic and Health Surveys

Democratic Republic of Congo

• Gender-based violence

Inter-Agency Standing Committee

Internally displaced persons

Intimate partner violence

Institutional Review Board

Low and middle-income countries

Non-partner violence

Research assistant

United Nations Children’s Fund

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Acknowledgements

We acknowledge our committed and talented implementing partners in South Sudan, two national NGOs, Voice for Change in Central Equatoria State and The Organization for Children Harmony in Warrup State. In Somalia, the Italian NGO, Comitato Internazionale per LoSviluppo dei Popoli (CISP) Mogadishu and other regions of the country.

United Nations Children’s Fund (UNICEF) provided the funding for the Communities Care program.

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The Communities Care program toolkit is available through United Nations Children’s Fund (UNICEF). Requests for research data and materials can be obtained by contacting UNICEF.

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NP, NG, MM, AC, SRH, SH, FK, AD, MY designed the study. MM, SRH, NP, RT, LH, NG and AC identified the theoretical framework for the formative and psychometric phases of the study. NG, NP, and LH conducted the psychometric analysis. MY, CYP, AA, AC, NP and NG implemented and interpretation the study findings in South Sudan and SH, BR, AD, AA, FK, AC, NG and NP implemented and interpretation of the study findings in Somalia. NP, NG, RT, AC and LH finalized the manuscript.

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Perrin, N., Marsh, M., Clough, A. et al. Social norms and beliefs about gender based violence scale: a measure for use with gender based violence prevention programs in low-resource and humanitarian settings. Confl Health 13 , 6 (2019). https://doi.org/10.1186/s13031-019-0189-x

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Combating Gender-based Violence

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Definition and types of gender-based violence, causes of gender-based violence, effects of gender-based violence, existing strategies and interventions to address gender-based violence, challenges in addressing gender-based violence, recommendations and conclusion.

• World Health Organization. (2021). Violence against women. https://www.who.int/news-room/fact-sheets/detail/violence-against-women
• European Parliament. (2012). Istanbul Convention on preventing and combating violence against women and domestic violence. https://www.europarl.europa.eu/RegData/etudes/BRIE/2014/536291/EPRS_BRI(2014)536291_EN.pdf
• UN Women. (2020). Men and boys are called to action to end gender-based violence. https://www.unwomen.org/en/news/stories/2020/11/feature-men-and-boys-are-called-to-action-to-end-gender-based-violence

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Gender-Based Violence

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Introduction

Gender-based violence (GBV) refers to violence directed towards an individual or group on the basis of their gender. Gender-based violence was traditionally conceptualized as violence by men against women but is now increasingly taken to include a wider range of hostilities based on sexual identity and sexual orientation, including certain forms of violence against men who do not embody the dominant forms of masculinity.

While most earlier sources take gender-based violence as synonymous with violence against women (United Nations General Assembly, 1993 ), O’Toole and Schiffman ( 1997 ) offer a broad definition to include “any interpersonal, organisational or politically orientated violation perpetrated against people due to their gender identity, sexual orientation, or location in the hierarchy of male-dominated social systems such as family, military, organisations, or the labour force” (p. xii). This definition is useful in that it potentially includes not only...

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Vetten, L. (2000). Gender, race and power dynamics in the face of social change: Deconstructing violence against women in South Africa. In J. Y. Park, J. Fedler, & Z. Dangor (Eds.), Reclaiming women’s spaces: New perspectives on violence against women and sheltering in South Africa (pp. 47–80). Johannesburg, South Africa: Nisaa Institute for Women’s Development.

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Online Resources

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www.apa.org/about/division/activities/abuse.aspx

www.genderlinks.org.za/page/gender-justice-mapping-violence-prevention-models

www.unfpa.org/gender/violence.htm ; www.who.int/topics/gender_based_violence/en/

www.who.int/topics/gender/violence/gbv/en/index1.html

www.un.org/womenwatch/directory/gender_training_90.htm

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Anthony Collins

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Causes and Effects of Gender-Based Violence

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Psychosocial effects of gender-based violence among women in Vhembe district: A qualitative study

Rodney rikhotso.

1 Department of Social Work, Faculty of Human Sciences, University of South Africa, Pretoria, South Africa

Thinavhuyo R. Netangaheni

2 Department of Health Studies, Faculty of Human Sciences, University of South Africa, Pretoria, South Africa

Nongiwe L. Mhlanga

Associated data.

Data for the study are available from the first author, R.R.

The phenomenon of gender-based violence is a pertinent social problem in South Africa. The fear of reporting gender-based violence contributes to its continuation, marginalisation and silencing of victims.

The study sought to explore the psychosocial effects of gender-based violence among women in Vhembe district.

An exploratory phenomenological research design was used and sampling was performed purposively from a population of women who experienced gender-based violence in a low-resource, rural setting of Vhembe district. Semi-structured telephonic interviews were used as the main method of data collection after permissions and informed consent were sought for conducting the study. Thematic content analysis was applied to convert the participants’ statements into a meaningful framework to derive the findings.

A total of 15 participants aged from 19 to 35 years participated in the study. Their psychosocial experiences of gender-based violence were depression, worthlessness, social isolation and anger directed towards children.

This research confirms that gender-based violence remains one of the most challenging problems associated with mental health problems in Vhembe district. It affirms the need to focus on awareness in rural areas afflicted by patriarchal attitudes, norms and stereotypes. Gender-based violence should to be viewed as human rights violation for victims’ protection.

Contribution

The study contributes to the body of knowledge on the experiences of gender-based violence among marginalised women from rural areas.

Introduction

Gender-based violence (GBV) is violence directed towards other people and is subject to various conceptual interpretations and contextual applications. 1 Gender-based violence is founded on gender inequality with most victims being women. 2 It is a serious public health and human rights issue, and its manifestations are classified according to emotional, physical, social, psychological, sexual, economic and domestic forms. 3 It encompasses intimate partner violence (IPV), which is sexual or physical violence committed by a current or previous partner after the age of 15 years. 3

The World Health Organization (WHO) states that males are more likely to perpetrate GBV while women and girls of all ages are victims. 3 Globally, by the end of 2021, IPV resulted in at least 137 femicides daily. 4 In 2019, at least ‘243 million women and girls aged 15–49 across the world’ were victims of GBV and suffered from the mental, physical, spiritual, sexual and/or reproductive health aftermaths. 5 In the South African context, there was a total number of 224 912 general crimes against children and women (179 683 against women and 45 229 against children), during the 2018 and 2019 periods alone. These statistics were the highest in the world, characterising South Africa as ‘the rape capital of the world’. 6 In Limpopo province, studies by the Thohoyandou Victim Empowerment Programme (TVEP) have established that the Vhembe District Municipality (VDM) has the highest reported cases of domestic violence in Limpopo province. 7 , 8 Statistics on GBV in South Africa illustrate its high prevalence with the general public calling incessantly for interventions to prevent and mitigate GBV. As such, this study is based on the problem of GBV and is founded on the effects of GBV in the VDM.

Several factors have been alluded to the perpetration of GBV. In a study conducted in 12 African countries, the authors concluded that absence of laws on GBV, alcohol consumption, male dominance, women’s attitudes after the perpetration of GBV and their empowerment predict GBV. 9 In a systematic review, Van Daalen et al. concluded that GBV was related to food insecurity, economic hardship and disruption of infrastructure because of extreme weather conditions. 10 The review by Van Daalen et al. further observed that GBV is related to harmful cultural or traditional practices against women such as early marriages. 10 The authors notice the cyclical effects of GBV by highlighting that GBV results in women transferring the violence and anger towards children. 10

Several studies explored the mental health issues and behavioural disturbances among victims of GBV. A survey with 273 respondents, conducted in Australia, concluded that GBV results in a complexity of mental health challenges that include social isolation which worsens the effects of GBV, as victims are unable to seek help and reduce occurrence of GBV. 11 In a narrative review of literature, in the United States, GBV was also associated with increased childhood exposure to trauma. 12 In Africa, a survey with 209 women in Kenya concluded that GBV resulted in anxiety, depression and post-traumatic stress disorder in women and girls. 13 In another survey with 283 respondents conducted in Kenya, the authors found that GBV was associated with poor mental health, high-risk sexual behaviour and sexually transmitted infections. 14 In addition, GBV resulted in disordered alcohol usage among women. 14 A Nigerian study revealed that 31% of the participants agreed that women suffered GBV because they were viewed as ‘inferior to males, incompetent and worthless’. 15 This Nigerian study further concluded that women were not allowed to associate with male relatives or male friends. 15 On this issue of social isolation, South African statistics reveal that most women (60%) did not report GBV while 40% reported to law enforcement. 16 Also, in South Africa, a longitudinal study with a sample size of 415 participants found that GBV results in depression and suicidal ideation. 17 These issues highlight the seriousness of GBV, should prompt society to respond to these victims and increase awareness on the need to prevent GBV. Therefore, the purpose of the study is to explore the psychosocial effects of GBV among women in Vhembe district.

Research methods and design

This study used a qualitative approach to explore the psychosocial effects of GBV among marginalised women in Vhembe district, Limpopo province.

Study design

This study opted for the phenomenological research design to understand the phenomenon of GBV as constructed by the participants themselves in their own familiar ecological surroundings. 18 Phenomenological designs enable the search and establishment of knowledge, truth or reality of a phenomenon as socially constructed products of the affected individuals’ experiences and perspectives concerning that very phenomenon. 19 The study utilised an interpretivist paradigm that acknowledges that the culture and context are different among research participants and seeks to interpret such subjective experiences among women experiencing GBV in Vhembe district. 18

The researchers conveniently selected to undertake the study in the N’wamatatani and Hlanganani rural informal settlements located in the VDM, one of the five districts in Limpopo province. The VDM has a population of about 1.385 million residents. 20 The district is largely populated by the Venda, Tsonga, Bapedi and Afrikaners. 20 The dominant Vhembe district languages are Tshivenda and Xitsonga, followed by Sepedi, Afrikaans and other minority languages of migrants Zimbabwe and Mozambique. 20

Study population and sampling strategy

The study population consisted of women victims of GBV in the study setting. Purposive sampling was conducted whereby participants known to the Department of Social Development Area Social Worker who worked with female GBV victims were invited to participate. The inclusion criteria included all females aged 19–35 years who directly experienced GBV; women experiencing GBV who were residents of N’wamatatani and/or Hlanganani informal settlement in the VDM; and women who were willing to participate voluntarily and be audio-recorded through telephonic interviews. The study included all women till data saturation, whereby no additional new information could be solicited from participants upon further interviewing more participants (data saturation was reached at 15 participants).

Data collection

The principal investigator (RR) conducted the 15 semi-structured, in-depth interviews telephonically, each lasting 30 min–45 min. Open-ended questions were used during data collection, which enabled the researcher to implement probing questions and to elicit participants’ spontaneous or unhindered responses on GBV. The principal researcher (RR) asked the participants questions and probed for clarity in cases of misunderstanding and for more insight, despite the telephonic interviews that were performed in adherence to affiliated institutions’ coronavirus disease 2019 (COVID-19) guidelines at the time of the study. For all these telephonic interviews, the participants were requested to ensure that they were at a quiet place that would not cause distractions to them. They were informed that arrangements had been made with the Area Social Worker in case they needed further interventions or assistance during the interviews because of questions that could disturb them emotionally and/or psychologically. All 15 participants were interviewed within a space of 5 days between 15 March 2021 and 19 March 2021. Three participants were interviewed on each day. The researcher sought clarity from the participants concerning responses that the researcher did not understand. The interviews were conducted in Xitsonga and English, as it was easy for the participants to freely express themselves.

Data analysis

Thematic analysis was applied in this study, founded on the procedure proposed by Braun and Clark in 2006. 19 This involved all English interviews being transcribed, with the Xitsonga interviews firstly being translated and then transcribed to English. To ensure rigour of the translated data, the researcher checked the correctness of the transcriptions by asking a participant who could speak both Xitsonga and English to verify the correctness of the transcripts. The transcripts were examined for themes, using Braun and Clark’s six steps for thematic analysis. 19 These steps included generating codes from the initial data collected, searching for themes in the transcribed data, reviewing the themes which had been found, and finally defining and naming the themes. 19 The themes generated from the analysis were corroborated by the participants to ensure trustworthiness. Following this corroboration, the themes were presented in a narrative format.

The researcher ensured the study’s trustworthiness by accurately recording all procedures taken during the study to enable auditing and verifying the results of the study with the study participants. 19 The researcher reflected on their role as a social worker who works with women victims of GBV and maintained objectivity as participants shared their experiences through use of an interview guide to ensure that questions asked were related to the research, thus minimising the researcher imposing their beliefs.

Ethical considerations

Ethical clearance for this study was approved by the College of Human Sciences Research Ethics Review Committee at the University of South Africa. Prior to the commencement of data collection, all the participants signed the consent forms with the assistance of the Area Social Worker. Participants were notified about their right to participate or decline before any involvement in the study. The researcher further explained that their involvement would be in the form of answering the researcher’s questions orally. Prior to the commencement of the interviews, the researcher fully disclosed what the study entails and the rights of the participants (2020-PsyREC-56712618).

Participants’ biographical profiles

Fifteen female participants formed part of the study, all of whom were black, with 14 South African nationals and 1 Mozambiquan expatriate. They were all aged from 19 to 35 years and Xitsonga speaking and had experienced GBV in the form of IPV. Eight of the participants were married, five were single, one was divorced and one was widowed. Eight of the participants still lived with their partners while seven no longer lived with their partners. All participants resided in informal housing of Hlanganani and N’wamatatani settlements in the VDM where the study was undertaken.

Key findings

From the phenomenological analysis, four main themes emerged that described the psychosocial effects of GBV on women in the Vhembe district. The first main theme was an effect of ‘worthlessness’ as a result of GBV. The second effect of GBV among women in Vhembe district was ‘social isolation’. The third was ‘depression’ as a consequence of GBV. The last theme was that GBV had a psychosocial effect of causing ‘anger towards children’ among women in the Vhembe district.

The first theme was the issue of ‘experience of worthlessness’ associated with GBV. The issue of experiencing worthlessness among victims of GBV was expressed by five participants. This response was elicited from the discussion on the topic, GBV, and its emotional effects. The participants described their experiences of feeling worthless without their husbands. From these shared experiences, participants highlighted they felt worthlessness because a bride price had been paid for them or they came from a poor background. Excerpts from participants C and I are as follows:

‘First it was emotional and then it escalated to physical violence. I was told that I am nothing without him and there are a lot of things I cannot achieve without him because I am from a poor family. Today I know how to wear a night dress because of him and that I came with nothing to the marriage … I most of the time feel worthless as a woman.’ (Participant C, 26 year old, female, single) ‘I think it is the reason that I stayed in the relationship for too long to a point where my husband realized that I will not leave him. Again, I think he ended up viewing me as his property because he paid lobola or dowry for me … The violence I suffered killed my self-esteem because of being told that I am useless.’ (Participant I, 27 year old, female, married)

The second theme to emerge was ‘experiencing social isolation’ as a consequence of GBV. This theme was elicited in response to the topic on family/friends being aware of the GBV. Participants A, G, K, L and M expressed that the social isolation was related to insecurities of their partners who suspected infidelity of the women. Participant N similarly revealed she feared her spouse who was insecure and obsessive to the extent of following to her place of work for the purpose of taking her home after work. The following excerpts from participants A and G illustrate the experiences of social isolation:

‘My husband was very insecure. He did not want me to associate with other people because of his jealous … That man isolated me from people that I cared about. He made me see no value in interacting with other people with the fear of being judged even though they did not know. I actually, lost interest in socialising with other people.’ (Participant A, 35 year old, female, divorced) ‘He is insecure due to his past relationships and very jealous. He does not allow me to interact with my friends freely over the phone. He assaults me when I am using my phone thinking that I am talking to other men. Alcohol abuse and trust issues are also the contributing factors.’ (Participant G, 23 year old, female, single)

The third theme to emerge was ‘depression was associated with GBV’. This theme was also elicited when discussing the topic on emotional consequences of GBV. The participants described how the effects of GBV became the source of their depression. Participant B noticed they became depressed after the GBV and when their partner took away their child. Participant K who was subjected to GBV similarly observed they had become depressed after they found out their daughter had been sexually abused. The theme is evidenced from the following excerpts from participants:

‘It destroyed me. I lost myself. There was a time where I felt that I was done with him. However, he spent more time with my family members drinking alcohol even after I left him. My family looked at me as the source of the problems we encountered and view him as an angel. I ended up being depressed after he took custody of my last-born baby. At work it affected me a lot because I would even see case dockets of women who were killed by their partners. I would cry before I go to work.’ (Participant B, 27 year old, female, married) ‘That abuse affected me so much because I always went back to work on with bruises and pain but what shattered me the most was that after the death of my husband my daughter told me that he used to rape her in my absence. I don’t know whether it was because she was his step-daughter or what. I was depressed for more than three years because of what he did given the fact that after his death I found out that I was HIV positive.’ (Participant K, 34 year old, female, widowed)

The fourth theme was that GBV is experienced through ‘anger towards children’. This is evidenced by responses from participants A, D and E. The issue of anger and irritability towards children emanated on discussing the topic, on whether participants had children and if the GBV occurs in the presence of the children; if the response was yes, a follow-up question on how the GBV affected the children was asked. Participants described how the GBV resulted in them becoming angry towards their children and would easily shout at them. Participants A and D elaborated that they would shout at the children for no apparent reasons. The excerpts from their responses are as follows:

‘The abuse I endured has changed me a lot. I have trust issues and I always snap at people every now and then. What pains me the most is that I even shout at my children for unnecessary things. Even in my current relationship I had to go for counselling with my boyfriend because I am always ready to defend myself.’ (Participant A, 35 year old, female, divorced) ‘This thing is really affecting me because you can find that sometimes I fight with children, taking my frustrations, my anger to the children. Like I told you that I fight back and I started to be somebody I don’t know. I also don’t understand myself. My children are suffering for what they don’t even know [ crying ].’ (Participant D 30 year old, female, married) ‘I am always unhappy and the way I treat my children shows that I am releasing that anger. I display a lot of anger towards other people. The abuse I suffered has changed me completely.’ (Participant E, 21 year old, female, married)

Notably, the GBV and anger resulted in children displaying disturbing behaviours towards other children as observed by Participant G who related that she had been asked to go to her child’s school following reports of bullying other children. The quotation to support this is as follows:

‘I am not allowed to go out with my friends and that affects me because I end up sitting at home with my son or with him when he is around and my sons sees all the violence and bullies other children at school, I was called to the school once because of the bullying.’ (Participant G, 23 year old, female, single)

Four themes were discussed, two of which formed part of the modus operandi of the abusive partner (worthlessness and social isolation) and two appeared to be effects of the violence (depression, irritability, anger towards their children). One participant also expressed concern over anger and abusive behaviour evident in her child, behaviour that she thought was a consequence of witnessing violence against her.

These findings are of particular interest as they present the effects of GBV in Vhembe district, which is a population underrepresented in literature on GBV, as well as confirm findings from other studies conducted in other parts of the world.

Worthlessness described by the participants may have been part of the abuse as the women were reminded by their abusers that they were nothing, and in some instances, the worthlessness was a sequela to the GBV. These feelings of worthlessness are also supported by a review conducted in 12 African countries, which found that women’s attitudes on GBV perpetuate GBV through feelings of worthlessness. 9 Such feelings of worthlessness associated with GBV could also be a symptom of post-traumatic stress disorder described by a narrative literature review in the United States. 15

The participants experienced social isolation that was imposed on them as part of the controlling or abusive behaviour of their partners or as a symptom of depression as they felt they were cut off from social contact. This social isolation is described by Fernández-Fillol et al. 21 who observed that women who experience GBV exhibit signs of post-traumatic stress disorder, which manifests through social isolation. These findings are confirmed by a study conducted in Australia where the authors found that GBV results in social isolation. 11 Similar findings were noticed from a study conducted in Nigeria, where GBV experiences included prohibition from socialisation with family and friends, as women were viewed as worthless. 15 The authors from the Australian study further found that the social isolation made it difficult to provide help to GBV victims. 11 This implication is drawn from the different characterisations of GBV such as financial, emotional, psychological and sexual, which may not be easily visible. 1 Furthermore, the social isolation and consequential silence on GBV victims were evident in South Africa, where only 40% of cases are reported, warrants further studies on interventions that empower women and children to speak up and access psychosocial assistance. 16

The participants shared their experiences of anger that they would direct towards the children. The issue of anger was also confirmed in a systematic mixed-methods review that GBV has negative ramifications for children. 10 The anger towards children concluded in this study necessitates a holistic approach in low- to middle-income countries in the management of GBV, which provides for children of women who are victims of GBV to be cared for. The negative consequences of GBV affecting children could be as a result of difficulty in parenting or poor emotion regulation, which could be asked about in the International Trauma Questionnaire. With regard to social isolation, the finding implies that service providers may experience difficulty in recognising and providing women in need of healthcare or psychosocial support because of the GBV.

Limitations

Despite the research objective being achieved, the study was limited by the methodological approach. The researchers used a qualitative approach with a small sample size, as such results cannot be generalised to all victims of GBV.

The study sought to explore psychosocial effects of GBV among women in the VDM in Limpopo province. The study recognises that GBV is a global psychosocial problem that infringes on the rights of women and relegates women to inferior status in society. The determinants of GBV are varied, and as a consequence, the experiences of women vary across different cultures and communities. The study concluded that in VDM, women experienced psychosocial effects of depression, anger towards children, social isolation and worthlessness because of GBV. From these findings, a holistic approach to prevent and manage GBV is recommended. This approach should empower women to seek assistance mitigating the experiences of social isolation that results in depression and anger towards children, who also need assistance to manage effects of GBV. The study further corroborated several studies that empowerment through women’s employment together with a change in norms, attitudes and roles are critical interventions among marginalised women. Further studies in treatment approaches for GBV in rural communities are recommended.

Acknowledgements

The authors would like to express gratitude to all faculty staff at the affiliated institutions for intellectual support in conducting the study.

Competing interests

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

Authors’ contributions

The authors R.R., R.N. and N.M. contributed to the design and implementation of the research, to the analysis of the results and to the writing of the manuscript.

Funding information

The authors received no financial support for the research, authorship, and/or publication of this article.

Data availability

The views expressed in this article are of the authors in their individual capacity and do not express the views or opinions of the affiliated institution.

Research Project Registration:

Project Number: Rec-240816-052

How to cite this article: Rikhotso R, Netangaheni TR, Mhlanga NL. Psychosocial effects of gender-based violence among women in Vhembe district: A qualitative study. S Afr J Psychiat. 2023;29(0), a2012. https://doi.org/10.4102/sajpsychiatry.v29i0.2012

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Call the OWH HELPLINE: 1-800-994-9662 9 a.m. — 6 p.m. ET, Monday — Friday OWH and the OWH helpline do not see patients and are unable to: diagnose your medical condition; provide treatment; prescribe medication; or refer you to specialists. The OWH helpline is a resource line. The OWH helpline does not provide medical advice.

Please call 911 or go to the nearest emergency room if you are experiencing a medical emergency.

Effects of violence against women

Violence against women can cause long-term physical and mental health problems. Violence and abuse affect not just the women involved but also their children, families, and communities. These effects include harm to an individual's health, possibly long-term harm to children, and harm to communities such as lost work and homelessness.

What are the short-term physical effects of violence against women?

The short-term physical effects of violence can include minor injuries or serious conditions. They can include bruises, cuts, broken bones, or injuries to organs and other parts inside of your body. Some physical injuries are difficult or impossible to see without scans, x-rays, or other tests done by a doctor or nurse.

Short-term physical effects of sexual violence can include:

• Vaginal bleeding or pelvic pain
• Unwanted pregnancy
• Sexually transmitted infections (STIs ), including HIV
• Trouble sleeping or nightmares

If you are pregnant, a physical injury can hurt you and the unborn child. This is also true in some cases of sexual assault.

If you are sexually assaulted by the person you live with, and you have children in the home, think about your children’s safety also. Violence in the home often includes child abuse. 1 Many children who witness violence in the home are also victims of physical abuse. 2 Learn more about the effects of domestic violence on children.

If you are injured in a physical or sexual assault, call 911.

What are the long-term physical effects of violence against women?

Violence against women, including sexual or physical violence, is linked to many long-term health problems. These can include: 3

• Chronic pain
• Digestive problems such as stomach ulcers
• Heart problems
• Irritable bowel syndrome
• Nightmares and problems sleeping
• Migraine  headaches
• Sexual problems such as pain during sex
• Problems with the immune system

Many women also have mental health problems after violence . To cope with the effects of the violence, some women start misusing alcohol or drugs or engage in risky behaviors, such as having unprotected sex. Sexual violence can also affect someone’s perception of their own bodies, leading to unhealthy eating patterns or eating disorders. If you are experiencing these problems, know that you are not alone. There are resources that can help you cope with these challenges.

How is traumatic brain injury related to domestic violence?

A serious risk of physical abuse is concussion and traumatic brain injury (TBI) from being hit on the head or falling and hitting your head. TBI can cause: 4

• Headache or a feeling of pressure
• Loss of consciousness
• Nausea and vomiting
• Slurred speech
• Memory loss
• Trouble concentrating

Some symptoms of TBI may take a few days to show up. Over a longer time, TBI can cause depression and anxiety . TBI can also cause problems with your thoughts, including the ability to make a plan and carry it out. This can make it more difficult for a woman in an abusive relationship to leave. Even if you think you are OK after hitting your head, talk to you doctor or nurse if you have any of these symptoms. Treatment for TBI can help.

What are the mental health effects of violence against women?

If you have experienced a physical or sexual assault, you may feel many emotions — fear, confusion, anger, or even being numb and not feeling much of anything. You may feel guilt or shame over being assaulted. Some people try to minimize the abuse or hide it by covering bruises and making excuses for the abuser.

If you’ve been physically or sexually assaulted or abused, know that it is not your fault. Getting help for assault or abuse can help prevent long-term mental health effects and other health problems.

Long-term mental health effects of violence against women can include: 5

• Post-traumatic stress disorder (PTSD) . This can be a result of experiencing trauma or having a shocking or scary experience, such as sexual assault or physical abuse. 6 You may be easily startled, feel tense or on edge, have difficulty sleeping, or have angry outbursts. You may also have trouble remembering things or have negative thoughts about yourself or others. If you think you have PTSD, talk to a mental health professional.
• Depression . Depression is a serious illness, but you can get help to feel better. If you are feeling depressed, talk to a mental health professional.
• Anxiety . This can be general anxiety about everything, or it can be a sudden attack of intense fear. Anxiety can get worse over time and interfere with your daily life. If you are experiencing anxiety, you can get help from a mental health professional.

Other effects can include shutting people out, not wanting to do things you once enjoyed, not being able to trust others, and having low-esteem. 1

Many women who have experienced violence cope with this trauma by using drugs, drinking alcohol, smoking, or overeating. Research shows that about 90% of women with substance use problems had experienced physical or sexual violence. 7

Substance use may make you feel better in the moment, but it ends up making you feel worse in the long-term. Drugs, alcohol, tobacco, or overeating will not help you forget or overcome the experience. Get help  if you’re thinking about or have been using alcohol or drugs to cope.

Who can help women who have been abused or assaulted?

After you get help for physical injuries, a mental health professional can help you cope with emotional concerns. A counselor or therapist can work with you to deal with your emotions in healthy ways, build your self-esteem, and help you develop coping skills. You can ask your doctor for the name of a therapist, or you can search an online list of mental health services . Learn more about getting help for your mental health .

Victims of sexual assault can also talk for free with someone who is trained to help through the National Sexual Assault Hotline over the phone at 800-656-HOPE (4673) or online .

What are some other effects of violence against women?

Violence against women has physical and mental health effects, but it can also affect the lives of women who are abused in other ways:

• Work. Experiencing a trauma like sexual violence may interfere with someone’s ability to work. Half of women who experienced sexual assault had to quit or were forced to leave their jobs in the first year after the assault. Total lifetime income loss for these women is nearly $250,000 each. 8
• Home. Many women are forced to leave their homes to find safety because of violence. Research shows that half of all homeless women and children became homeless while trying to escape intimate partner violence. 9
• School. Women in college who are sexually assaulted may be afraid to report the assault and continue their education. But Title IX laws require schools to provide extra support for sexual assault victims in college. Schools can help enforce no-contact orders with an abuser and provide mental health counseling and school tutoring.
• Children . Women with children may stay with an abusive partner because they fear losing custody or contact with their children.

Sometimes, violence against women ends in death. More than half of women who are murdered each year are killed by an intimate partner. 10 One in 10 of these women experienced violence in the month before their death. If you have experienced abuse, contact a hotline  at 800-799-SAFE (800-799-7233) , or learn more ways to get help .

Did we answer your question about the effects of violence against women?

For more information about the effects of violence against women, call the OWH Helpline at 1-800-994-9662 or check out the following resources from other organizations:

• A Head for the Future — Information on traumatic brain injury from the Defense and Veterans Brain Injury Center.
• The Costs and Consequences of Sexual Violence and Cost-Effective Solutions (PDF, 220 KB) — Publication from the National Alliance to End Sexual Violence.
• Effects of Sexual Violence — Information from the Rape, Abuse & Incest National Network (RAINN).
• Behavioral Health Treatment Services Locator  — Links to mental health services from the Substance Abuse and Mental Health Services Administration (SAMHSA).
• Post-Traumatic Stress Disorder — Information from the National Institute of Mental Health.
• Tips for Survivors of a Disaster or Traumatic Event: What to Expect in Your Personal, Family, Work, and Financial Life — Publication from SAMHSA.
• Centers for Disease Control and Prevention. (2015). Intimate Partner Violence: Consequences.
• Modi, M.N., Palmer, S., Armstrong, A. (2014). The Role of Violence Against Women Act in Addressing Intimate Partner Violence: A Public Health Issue. Journal of Women’s Health; 23(3): 253-259.
• Smith, S.G., Chen, J., Basile, K.C., Gilbert, L.K., Merrick, M.T., Patel, N., et al. (2017). The National Intimate Partner and Sexual Violence Survey: 2010-2012 State Report . Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.
• Defense and Veterans Brain Injury Center. (2016). Recognize TBI and Concussion .
• Delara, M. (2016). Mental Health Consequences and Risk Factors of Physical Intimate Partner Violence . Mental Health in Family Medicine; 12: 119-125.
• Jina, R., Thomas, L.S. (2013). Health consequences of sexual violence against women . Best Practice and Research: Clinical Obstetrics and Gynaecology; 27: 15-26.
• Beijer, U., Scheffel Birath, C., DeMartinis, V., Af Klinteberg, B. (2015). Facets of Male Violence Against Women With Substance Abuse Problems: Women With a Residence and Homeless Women. Journal of Interpersonal Violence; Dec 4. pii: 0886260515618211.
• National Alliance to End Sexual Violence. (2011). The Costs and Consequences of Sexual Violence and Cost-Effective Solutions.
• Goodman, L.A., Fels, K., Glenn, C., Benitez, J. (2011). No Safe Place: Sexual Assault in the Lives of Homeless Women . National Resource Center on Domestic Violence.
• Petrosky, E., Blair, J.M., Betz, C.J., Fowler, K.A., Jack, S.P.D., Lyons, B.H. (2017). Racial and Ethnic Differences in Homicides of Adult Women and the Role of Intimate Partner Violence – United States, 2003-2014 . MMWR; 66: 741-746.
• Kathleen C. Basile, Ph.D., Lead Behavioral Scientist, Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC)
• Kathryn Jones, M.S.W., Public Health Advisor, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC)
• Sharon G. Smith, Ph.D., Behavioral Scientist, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC)
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Ending Gender-Based Violence

CDC affirms its commitment to preventing and responding to violence during the 16 Days of Activism Against Gender-Based Violence campaign. The campaign is observed annually from November 25 to December 10.

With support from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), CDC works with partners in 46 countries to achieve global targets to end the HIV epidemic. Although progress is being made, some people, including adolescent girls and young women, bear a disproportionate burden of HIV.

Women with a history of physical and/or sexual abuse are more likely to be living with HIV, especially if that abuse started during childhood. HIV-related stigma, discrimination, and violence restrict access to prevention and treatment services for those most at risk. These challenges serve as persistent barriers to ending the HIV epidemic.

Violence against youth is also a global public health problem. One in eight young people reported having experienced sexual abuse. The results can be devastating—leading to long-term psychological, social, and physical harm.

Violence prevention and response for youth is a global priority . It is complementary to efforts to eliminate all barriers to HIV treatment and prevention and accelerate progress toward ending the HIV epidemic.

What is gender-based violence?‎

The 2023 campaign highlighted the urgent call to " End inequalities. End HIV ." by breaking down barriers posed by gender disparities and violence. Stories featured had a keen focus on:

• Engaging young people for youth-led solutions to address stigma
• Strengthening youth's skills and economic empowerment
• Using Violence Against Children and Youth data to create actions that measurably reduce violence
• Focusing on health equity by putting people at the center of our efforts

Starting with the 16 Days of Activism, we invite you to explore the stories and learn how CDC works with our local partners to and respond to gender-based violence as part of our commitment to end inequalities and end AIDS. By amplifying voices worldwide, CDC aims to continue to increase awareness of gender-based violence—and ultimately save lives.

Empowering Young People in Mozambique and Zambia

Empowering Women through Visual Storytelling

Additional resources

Renewed Focus on Ending Gender-Based Violence to End HIV/AIDS

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Gender-based violence in South Africa

Gender-based violence in south africa – understand.

Civil society organisations across the country formed the National Strategic Plan on Gender-Based Violence campaign, demanding a fully-costed, evidence-based, multi-sectoral, inclusive and comprehensive NSP to end GBV. [Photo: Alexa Sedgwick, Sonke Gender Justice]

Introduction

Gender-based violence (GBV) is a profound and widespread problem in South Africa, impacting on almost every aspect of life. GBV (which disproportionately affects women and girls) is systemic, and deeply entrenched in institutions, cultures and traditions in South Africa.

This introduction will explore what GBV is and some of the forms it takes, examine GBV in South Africa, and begin to explore what different actors are doing to respond to GBV.

What is gender-based violence?

GBV occurs as a result of normative role expectations and unequal power relationships between genders in a society.

There are many different definitions of GBV, but it can be broadly defined as “the general term used to capture violence that occurs as a result of the normative role expectations associated with each gender, along with the unequal power relationships between […] genders, within the context of a specific society.” [1]

The expectations associated with different genders vary from society to society and over time. Patriarchal power structures dominate in many societies, in which male leadership is seen as the norm, and men hold the majority of power. Patriarchy is a social and political system that treats men as superior to women – where women cannot protect their bodies, meet their basic needs, participate fully in society and men perpetrate violence against women with impunity [2].

Forms of gender-based violence

There are many different forms of violence, which you can read more about here . All these types of violence can be – and almost always are – gendered in nature, because of how gendered power inequalities are entrenched in our society.

GBV can be physical, sexual, emotional, financial or structural, and can be perpetrated by intimate partners, acquaintances, strangers and institutions. Most acts of interpersonal gender-based violence are committed by men against women, and the man perpetrating the violence is often known by the woman, such as a partner or family member [3].

Violence against women and girls (VAWG)

GBV is disproportionately directed against women and girls [4]. For this reason, you may find that some definitions use GBV and VAWG interchangeably, and in this article, we focus mainly on VAWG.

Violence against LGBTI people

However, it is possible for people of all genders to be subject to GBV. For example, GBV is often experienced by people who are seen as not conforming to their assigned gender roles, such as lesbian, gay, bisexual, transgender and/or intersex people.

More information

For more information on intimate partner violence and domestic violence, read this WHO brief

Intimate partner violence (IPV)

IPV is the most common form of GBV and includes physical, sexual, and emotional abuse and controlling behaviours by a current or former intimate partner or spouse, and can occur in heterosexual or same-sex couples [5].

Domestic violence (DV)

Domestic violence refers to violence which is carried out by partners or family members. As such, DV can include IPV, but also encompasses violence against children or other family members.

Sexual violence (SV)

Sexual violence is “any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work.” [6]

What is violence?

For more information on forms of violence, read our introduction on " What is violence? "

Indirect (structural) violence

Structural violence is “where violence is built into structures, appearing as unequal power relations and, consequently, as unequal opportunities.

Structural violence exists when certain groups, classes, genders or nationalities have privileged access to goods, resources and opportunities over others, and when this unequal advantage is built into the social, political and economic systems that govern their lives.”

Because of the ways in which this violence is built into systems, political and social change is needed over time to identify and address structural violence.

GBV in South Africa

Societies free of GBV do not exist, and South Africa is no exception [7].

Although accurate statistics are difficult to obtain for many reasons (including the fact that most incidents of GBV are not reported [10] ), it is evident South Africa has particularly high rates of GBV, including VAWG and violence against LGBT people.

Population-based surveys show very high levels of intimate partner violence (IPV) and non-partner sexual violence (SV) in particular, with IPV being the most common form of violence against women.

• Whilst people of all genders perpetrate and experience intimate partner and or sexual violence, men are most often the perpetrators and women and children the victims [7].
• More than half of all the women murdered (56%) in 2009 were killed by an intimate male partner [8].
• Between 25% and 40% of South African women have experienced sexual and/or physical IPV in their lifetime [9, 10].
• Just under 50% of women report having ever experienced emotional or economic abuse at the hands of their intimate partners in their lifetime [10].
• Prevalence estimates of rape in South Africa range between 12% and 28% of women ever reporting being raped in their lifetime [10-12].
• Between 28 and 37% of adult men report having raped a women [10, 13].
• Non-partner SV is particularly common, but reporting to police is very low. One study found that one in 13 women in Gauteng had reported non-partner rape, and only one in 25  rapes had been reported to the police [10].
• South Africa also faces a high prevalence of gang rape [14].
• Most men who rape do so for the first time as teenagers and almost all men who ever rape do so by their mid-20s [15].
• There is limited research into rape targeting women who have sex with women. One study across four Southern African countries, including South Africa, found that 31.1% of women reported having experienced forced sex [16].
• Male victims of rape are another under-studied group. One survey in KwaZulu-Natal and the Eastern Cape found that 9.6% of men reported having experienced sexual victimisation by another man [17].

Drivers of GBV

Drivers of GBV are the factors which lead to and perpetuate GBV. Ultimately, gendered power inequality rooted in patriarchy is the primary driver of GBV.

GBV (and IPV in particular) is more prevalent in societies where there is a culture of violence, and where male superiority is treated as the norm [18]. A belief in male superiority can manifest in men feeling entitled to sex with women, strict reinforcement of gender roles and hierarchy (and punishment of transgressions), women having low social value and power, and associating masculinity with control of women [18].

These factors interact with a number of drivers, such as social norms (which may be cultural or religious), low levels of women’s empowerment, lack of social support, socio-economic inequality, and substance abuse.

In many cultures, men’s violence against women is considered acceptable within certain settings or situations [18] - this social acceptability of violence makes it particularly challenging to address GBV effectively.

In South Africa in particular, GBV “pervades the political, economic and social structures of society and is driven by strongly patriarchal social norms and complex and intersectional power inequalities, including those of gender, race, class and sexuality.” [19].

Impact of gender-based violence

GBV is a profound human rights violation with major social and developmental impacts for survivors of violence, as well as their families, communities and society more broadly.

On an individual level, GBV leads to psychological trauma, and can have psychological, behavioural and physical consequences for survivors. In many parts of the country, there is poor access to formal psychosocial or even medical support, which means that many survivors are unable to access the help they need. Families and loved ones of survivors can also experience indirect trauma, and many do not know how to provide effective support.

Jewkes and colleagues outline the following impacts of GBV and violence for South Africa as a society more broadly [20]:

• South African health care facilities – an estimated 1.75 million people annually seek health care for injuries resulting from violence
• HIV – an estimated 16% of all HIV infections in women could be prevented if women did not experience domestic violence from their partners. Men who have been raped have a long term increased risk of acquiring HIV and are at risk of alcohol abuse, depression and suicide.
• Reproductive health - women who have been raped are at risk of unwanted pregnancy, HIV and other sexually transmitted infections.
• Mental health - over a third of women who have been raped develop post-traumatic stress disorder (PTSD), which if untreated persists in the long term and depression, suicidality and substance abuse are common. Men who have been raped are at risk of alcohol abuse, depression and suicide.

Violence also has significant economic consequences. The high rate of GBV places a heavy burden on the health and criminal justice systems, as well as rendering many survivors unable to work or otherwise move freely in society.

A 2014 study by KPMG also estimated that GBV, and in particular violence against women, cost the South African economy a minimum of between R28.4 billion and R42.4 billion, or between 0.9% and 1.3% of gross domestic product (GDP) in the year 2012/2013. [21]

What do we do?

South Africa is a signatory to a number of international treaties on GBV, and strong legislative framework, for example the Domestic Violence Act (DVA) (1998), the Sexual Offences Act (2007) and the Prevention and Combatting of Trafficking in Human Persons (2013) Act” [22].

Response services aim to support and help survivors of violence in a variety of ways. Prevention initiatives look at how GBV can be prevented from happening.

Whilst international treaties and legislation is important it is not enough to end GBV and strengthen responses.

Addressing GBV is a complex issue requiring multi-faceted responses and commitment from all stakeholders, including government, civil society and other citizens. There is growing recognition in South Africa of the magnitude and impact of GBV and of the need to strengthen the response across sectors.

Prevention and Response

For more information, check the page What Works in preventing GBV

Broadly speaking, approaches to addressing GBV can be divided into response and prevention . Response services aim to support and help survivors of violence in a variety of ways (for instance medical help, psychosocial support, and shelter). Prevention initiatives look at how GBV can be prevented from happening. Response services can in turn contribute towards preventing violence from occurring or reoccurring.

Responses are important. Major strides are being made internationally on how to best respond and provide services for survivors of violence. WHO guidelines describe an appropriate health sector response to VAW – including providing post-rape care and training health professionals to provide these services [32].

WHO does not recommend routine case identification (or screening) in health services for VAW exposure, but stresses the importance of mental health services for victims of trauma.

Need to address underlying causes

Much of our effort in South Africa has been focused on response. However – our response efforts need to be supported and complemented by prevention programming and policy development. By addressing the underlying, interlinked causes of GBV, we can work towards preventing it from happening in the first place.

SACQ: Primary prevention

For more information on prevention programmes that work, have a look at the South African Crime Quarterly 54 on evidence-based primary prevention.

Violence prevention policies and programmes should be informed by the best evidence we have available. Programmes that are evidence based are [35]:

• built on what has been done before and has been found to be effective;
• informed by a theoretical model;
• guided by formative research and successful pilots; and
• multi-faceted and address several causal factors.

Several GBV prevention programmes which have support for effectiveness have been implemented in South Africa. A summary of the prevention programmes mentioned below can be found in the South African Crime Quarterly 51: Primary prevention (see table on pgs. 35-38):

• Thula Sana: Promote mothers’ engagement in sensitive, responsive interactions with their infants
• The Sinovuyo Caring Families Programme: Improve the parent–child relationship, emotional regulation, and positive behaviour management approaches
• Prepare: Reduce sexual risk behaviour and intimate partner violence, which contribute to the spread of sexually transmitted diseases (STIs)
• Skhokho Supporting Success: Prevent IPV among young teenagers
• Stepping Stones: Promote sexual health, improve psychological wellbeing and prevent HIV
• Stepping Stones / Creating Futures: Reduce HIV risk behaviour and victimisation and perpetration of different forms of IPV and strengthen livelihoods
• IMAGE (Intervention with Microfinance for AIDS and Gender Equity): Improve household economic wellbeing, social capital and empowerment and thus reduce vulnerability to IPV and HIV infection

Importance to develop evidence base

At the same time, it is important to develop the evidence base further by exploring a range of other interventions that have the potential to be effective in a South African context. Many actors, including government, civil society and funders, as well as community members, are working in creative and innovative ways every day to address GBV.

For example, several civil society organisations are working with women’s groups to build their agency and empower them to address the issues that impact their lives, such as structural and interpersonal violence. Others are tackling specific drivers of GBV, such as substance abuse and gangsterism. Still others take a “whole community” approach to dealing with GBV, involving community members and leaders in the fight against violence in their communities.

Many of these interventions have not yet been formally documented, but they are nevertheless promising models which play an important role in the overall fight against GBV.

While South Africa has high levels of GBV, we are also a leader in the field of prevention interventions in low and middle income countries [36].

We are identifying models which work to respond to and prevent violence, and we can work on scaling those up to reach more people. At the same time, as a society, we can work together to find new ways to address GBV, building the current evidence base and responding to this national crisis.

[1] Bloom, Shelah S. 2008. “Violence Against Women and Girls: A Compendium of Monitoring and Evaluation Indicators.” Carolina Population Center, MEASURE Evaluation, Chapel Hill, North Carolina. https://www.measureevaluation.org/resources/publications/ms-08-30

[2] Sultana, Abeda, Patriarchy and Women’s Subordination: A Theoretical Analysis, The Arts Faculty Journal, July 2010-June 2011 http://www.bdresearch.org/home/attachments/article/nArt/A5_12929-47213-1-PB.pdf

[3] World Health Organisation, 2005, WHO multi-country study on women's health and domestic violence against women. REPORT - Initial results on prevalence, health outcomes and women's responses http://www.who.int/reproductivehealth/publications/violence/24159358X/en/

[4] Decker MR et al., Gender-based violence against adolescent and young adult women in low- and middle-income countries , The Journal of Adolescent Health, 2015. 56(2): p. 188-96.

[5] 1 Garcia-Moreno, C., Responding to intimate partner violence and sexual violence against women. WHO clinical and policy guidelines - what’s new?, in SVRI Forum 2013: Evidence into Action, 14 – 17 October 2013. 2013, Sexual Violence Research Initiative: Bangkok, Thailand.

[6] 2 Jewkes, R., P. Sen, and C. Garcia-Moreno, Sexual Violence in World Report on Violence and Health, E. Krug, et al., Editors. 2002, World Health Organization: Geneva.

[7] 3 Dartnall, E. and R. Jewkes, Sexual Violence against Women: The scope of the problem. Best Practice & Research Clinical Obstetrics & Gynaecology, 2012. Special Issue.

[8] 4 Abrahams, N., et al., Intimate Partner Femicide in South Africa in 1999 and 2009. PLoS medicine, 2013. 10(4).

[9] 5 Jewkes, R., J. Levin, and L. Penn-Kekana, Risk factors for domestic violence: findings from a South African cross-sectional study. Social science & medicine, 2002. 55(9): p. 1603-17.

[10] 6 Machisa, M., et al., The War at Home. 2011, Genderlinks, and Gender and Health Research Unit, South African Medical Research Council (MRC) Johannesburg.

[11] 7 Dunkle, K.L., et al., Prevalence and patterns of gender-based violence and revictimization among women attending antenatal clinics in Soweto, South Africa. American journal of epidemiology, 2004. 160(3): p. 230-9.

[12] 8 Jewkes, R., et al., Understanding Men's Health and Use of Violence: Interface of rape and HIV in South Africa. 2009.

[13] 9 Jewkes, R., et al., Gender inequitable masculinity and sexual entitlement in rape perpetration South Africa: findings of a cross-sectional study. PloS One, 2011. 6(12).

[14] 10 Jewkes, R., Streamlining: understanding gang rape in South Africa. 2012: Forensic Psychological Services, Middlesex University.

[15] 11 Jewkes, R., et al., Why, when and how men rape? Understanding rape perpetration in South Africa. South African Crime Quarterly, 2010. 34(December).

[16] Sandfort, TGM, et al, Forced sexual experiences as risk factor for self-reported HIV Infection among Southern African lesbian and bisexual women, PLoS ONE, 8:1, 2013.

[17] Dunkle, K, et al, Prevalence of consensual male–male sex and sexual violence, and associations with HIV in South Africa: a population-based cross-sectional study, PLoS Medicine, 10:6, 2013.

[18] Jewkes, R, Intimate partner violence: causes and prevention. Lancet, 2002. 359: 1423–29.

[19] Cornelius R., T. Shahrokh and E. Mills. Coming Together to End Gender Violence: Report of Deliberative Engagements with Stakeholders on the Issue of Collective Action to Address Sexual and Gender-based Violence, and the Role of Men and Boys . Evidence Report, 2014. 12 (February), Institute of Development Studies.

[20] 12 Jewkes, R., et al. Preventing Rape and Violence in South Africa: Call for Leadership in A New Agenda For Action. MRC Policy Brief, 2009.

[21] Muller R, Gahan L & Brooks L (2014). Too costly to ignore – the economic impact of gender-based violence in South Africa. Available online . Accessed 16 July 2015.

[22] Moolman, B. Human Sciences Research Council (HRSC) (2016). Research Report on the Status of Gender-based Violence Civil Society Funding in South Africa.

[23] Van Dorn, R., J. Volavka, and N. Johnson, Mental disorder and violence: is there a relationship beyond substance use? Soc Psychiatry Psychiatr Epidemiol, 2012. Mar(47(3)): p. 487-503.

[24] Eckenrode, J., M. Laird, and D. J., School performance and disciplinary problems among abused and neglected children. Dev Psychol., 1993. 29: p. 53-62.

[25] Anda, R.F. and V.J. Felliti, The Relationship of Adverse Childhood Experiences to Adult Medical Disease, Psychiatric Disorders, and Sexual Behavior: Implications for Healthcare., in The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease., L.R.a.V. E, Editor. 2009, Cambridge University Press: Cambridge.

[26] Anda RF, et al., The enduring effects of abuse and related adverse experiences in childhood. Eur Arch Psychiatry Clin Neurosci, 2006. 256: p. 174-186.

[27] Westad, C. and D. McConnell, Child welfare involvement of mothers with mental health issues. . Community Mental Health Journal, 2012. 48: p. 29-37.

[28] Committee on Child Maltreatment Research, Policy, and Practice for the Next Decade: Phase II; , A.C. Petersen, J. Joseph, and M. Feit, Editors. 2014 Board on Children, Youth, and Families; Committee on Law and Justice; Institute of Medicine; National Research Council: Washington (DC).

[29] Messman-Moore, T.L. and P.J. Long, The role of childhood sexual abuse sequelae in the sexual revictimization of women. Clinical psychology review, 2003. 23(4): p. 537-571.

[30] Millett, L.S., et al., Child maltreatment victimization and subsequent perpetration of young adult intimate partner violence: an exploration of mediating factors. Child Maltreat. , 2013. 18(2)(May): p. 71-84.

[31] Jewkes, R., Rape Perpetration: A review. 2012, Sexual Violence Research Initiative, hosted by the South African Medical Research Council: Pretoria.

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[34] Jewkes, R., Intimate partner violence: causes and prevention. Lancet, 2002. 359(9315): p. 1423-9.

[35] Dartnall, E. and A. Gevers, Editorial. South African Crime Quarterly, 2015. In press.

[36] Shai NJ and Y. Sikweyiya, Programmes for change: Addressing sexual and intimate partner violence in South Africa. South African Crime Quarterly, 2015. 51(March) .

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A systematic review of the literature: Gender-based violence in the construction and natural resources industry

• Joyce Lo 1 , 
• Sharan Jaswal 1 , 
• Matthew Yeung 1 , 
• Vijay Kumar Chattu 1,2,3 , 
• Ali Bani-Fatemi 1 , 
• Aaron Howe 1 , 
• Amin Yazdani 4 , 
• Basem Gohar 5,6 , 
• Douglas P. Gross 7 , 
• Behdin Nowrouzi-Kia 1,6 ,  , 
• 1. Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON M5G 1V7, Canada
• 2. Center for Global Health Research, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha University, Chennai 600077, India
• 3. Department of Community Medicine, Faculty of Medicine, Datta Meghe Institute of Medical Sciences, Wardha 442107, India
• 4. Canadian Institute for Safety, Wellness & Performance, School of Business, Conestoga College Institute of Technology and Advanced Learning, Kitchener, ON N2G 4M4, Canada
• 5. Department of Population Medicine, University of Guelph, Guelph, ON N1G 2W1, Canada
• 6. Centre for Research in Occupational Safety & Health, Laurentian University, Sudbury, ON P3E 2C6, Canada
• 7. Department of Physical Therapy, University of Alberta, Edmonton, AB, T6G 2G4, Canada
• Received: 08 February 2024 Revised: 09 April 2024 Accepted: 12 April 2024 Published: 08 May 2024
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Gender-based violence (GBV) poses a significant concern in the construction and natural resources industries, where women, due to lower social status and integration, are at heightened risk. This systematic review aimed to identify the prevalence and experience of GBV in the construction and natural resources industries. A systematic search across databases including PubMed, OVID, Scopus, Web of Science, and CINAHL was conducted. The Risk of Bias Instrument for Cross-sectional Surveys of Attitudes and Practices by McMaster University and the Critical Appraisal of Qualitative Studies by the Center for Evidence Based Medicine at the University of Oxford were used to assess the studies included in the review. Six articles were included after full-text analysis. GBV was reported in the construction, mining, urban forestry, and arboriculture sectors. Workplace GBV was measured differently across the studies, and all studies examined more than one form of GBV. The main forms of GBV discussed in these studies were discrimination, sexual harassment, and sexism. The studies provided some insight for demographic factors that may or may not be associated with GBV, such as age, region of work, and number of years working in the industry. The review also suggests that workplace GBV has a negative impact on mental health and well-being outcomes, such as higher levels of stress and lower job satisfaction. The current research has not established the effectiveness of interventions, tools, or policies in these workplaces. Thus, additional research should include intervention studies that aim to minimize or prevent GBV in male-dominated workplaces. The current study can bring awareness and acknowledgement towards GBV in the workplace and highlight the importance of addressing it as this review outlines the negative consequences of GBV on mental health and well-being in these male-dominated industries.

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• gender-based violence ,
• natural resources ,
• systematic review ,

Citation: Joyce Lo, Sharan Jaswal, Matthew Yeung, Vijay Kumar Chattu, Ali Bani-Fatemi, Aaron Howe, Amin Yazdani, Basem Gohar, Douglas P. Gross, Behdin Nowrouzi-Kia. A systematic review of the literature: Gender-based violence in the construction and natural resources industry[J]. AIMS Public Health, 2024, 11(2): 654-666. doi: 10.3934/publichealth.2024033

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Injuries and /or trauma due to sexual gender-based violence among survivors in sub-Saharan Africa: a systematic scoping review of research evidence

• Desmond Kuupiel 1 , 2 ,
• Monsurat A. Lateef 1 ,
• Patience Adzordor 3 , 4 ,
• Gugu G. Mchunu 1 &
• Julian D. Pillay 1  

Archives of Public Health volume  82 , Article number:  78 ( 2024 ) Cite this article

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Sexual and gender-based violence (SGBV) is a prevalent issue in sub-Saharan Africa (SSA), causing injuries and trauma with severe consequences for survivors. This scoping review aimed to explore the range of research evidence on injuries and trauma resulting from SGBV among survivors in SSA and identify research gaps.

The review employed the Arksey and O’Malley methodological framework, conducting extensive literature searches across multiple electronic databases using keywords, Boolean operators, medical subject heading terms and manual searches of reference lists. It included studies focusing on injuries and trauma from SGBV, regardless of gender or age, published between 2012 and 2023, and involved an SSA countries. Two authors independently screened articles, performed data extraction and quality appraisal, with discrepancies resolved through discussions or a third author. Descriptive analysis and narrative synthesis were used to report the findings.

After screening 569 potentially eligible articles, 20 studies were included for data extraction and analysis. Of the 20 included studies, most were cross-sectional studies ( n  = 15; 75%) from South Africa ( n  = 11; 55%), and involved women ( n  = 15; 75%). The included studies reported significant burden of injuries and trauma resulting from SGBV, affecting various populations, including sexually abused children, married women, visually impaired women, refugees, and female students. Factors associated with injuries and trauma included the duration of abuse, severity of injuries sustained, marital status, family dynamics, and timing of incidents. SGBV had a significant impact on mental health, leading to post-traumatic stress disorder, depression, anxiety, suicidal ideations, and psychological trauma. Survivors faced challenges in accessing healthcare and support services, particularly in rural areas, with traditional healers sometimes providing the only mental health care available. Disparities were observed between urban and rural areas in the prevalence and patterns of SGBV, with rural women experiencing more repeated sexual assaults and non-genital injuries.

This scoping review highlights the need for targeted interventions to address SGBV and its consequences, improve access to healthcare and support services, and enhance mental health support for survivors. Further research is required to fill existing gaps and develop evidence-based strategies to mitigate the impact of SGBV on survivors in SSA.

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The World Health Organization (WHO) reports that injuries are a growing global public health problem [ 1 ]. In 2021, unintentional and violence-related injuries were estimated to cause over 4 million deaths worldwide, accounting for nearly 8% of all deaths [ 1 ]. Additionally, injuries are responsible for approximately 10% of all years lived with disability each year [ 1 ]. While injuries can result from various causes such as road traffic accidents, falls, drowning, burns, poisoning, and acts of violence, including sexual and gender-based violence (SGBV) [ 1 , 2 ], SGBV remains a neglected cause of injuries that silently affects the lives of many, especially women [ 3 , 4 ]. Injuries due to SGBV refer to physical harm or trauma resulting from acts of violence perpetrated based on an individual’s sex or gender. These injuries can encompass a range of physical harm, including but not limited to bruises, cuts, fractures, internal injuries, and sexual trauma (psychological or emotional) [ 5 ].

Sexual and gender-based violence is a pervasive issue [ 6 , 7 , 8 , 9 , 10 ] with alarming rates globally, particularly in the WHO Africa and South-East Asia regions with 33% each compared to 20% in the Western Pacific, 22% in high-income countries and Europe, and 31% in the WHO Eastern Mediterranean region [ 8 ]. However, this statistic includes only physical and/or sexual violence by an intimate partner alone and does not include other forms of violence [ 8 ]. Sexual and gender-based violence encompasses various acts such as sexual assault, rape, intimate partner violence, and harmful traditional practices, all of which have severe physical and psychological consequences for women [ 9 , 11 , 12 ]. The sub-Saharan Africa region has witnessed numerous cases of SGBV perpetrated against vulnerable populations, such as women, children, refugees, and individuals with disabilities, with devastating impacts on their well-being and overall quality of life [ 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ].

Understanding the extent and nature of injuries and trauma resulting from SGBV among survivors is crucial in formulating effective interventions, policies, and support systems. Research evidence plays a fundamental role in shaping responses to this pressing public health concern, guiding the development of targeted interventions and preventive measures. However, the available research on injuries and trauma related to SGBV in sub-Saharan Africa remains scattered and diverse, necessitating a comprehensive and systematic review to consolidate and analyse existing knowledge.

A scoping review study would support a valuable research approach to systematically map and describe the existing evidence on injuries and trauma related to SGBV against women in sub-Saharan Africa. In so doing, the scoping review would provide a broader overview of the literature to identify knowledge gaps, key concepts, and various study designs employed in the field, and inform more specific research questions that can be unpacked by way of a systematic review and /or meta-analysis quantitative studies or meta-synthesis of qualitative studies [ 33 , 34 ]. To our knowledge, current literature shows no evidence of any previous scoping review that has focused on injuries and trauma due SGBV. This study, therefore, conducted a systematic scoping review to explore the scope of research evidence regarding injuries and trauma stemming from SGBV among survivors in sub-Saharan Africa. This research sheds light on the prevalence, patterns, and factors associated with injuries and trauma resulting from SGBV in the region and their impact on survivors.

To achieve the objective of this scoping review, we utilised the Arksey and O’Malley methodological framework [ 35 ] as a guiding framework for mapping and examining the literature on injuries and trauma associated with SGBV in the context of sub-Saharan Africa. This framework comprises several key steps, including identifying the research question, identifying relevant studies, study selection, data charting and collation, and summarizing and reporting the results [ 33 , 34 ].

Identifying the research question

The primary research question guiding this scoping review is as follows: What is the scope of research evidence regarding injuries and trauma resulting from sexual and gender-based violence among survivors in sub-Saharan Africa in the last decade? To ensure the appropriateness and relevance of this question, we employed the Population, Concept, and Context (PCC) framework [ 36 ] as part of the study eligibility criteria, which is detailed in Table  1 . To comprehensively address the research objective, the scoping review explored the following sub-questions:

Literature searches

The purpose of our search was to identify relevant peer-reviewed papers that address the review questions. To accomplish this, a comprehensive search was conducted across several electronic databases, including PubMed, EBSCOhost (CINAHL, PsycInfo, and Health Source: Nursing/Academic Edition), SCOPUS, and Web of Science for original articles published within between 2012 and 2023. Additionally, a search using the Google Scholar search engine was performed to identify additional literature of relevance. For the database searches, we developed a search strategy in collaboration with an information scientist, ensuring the inclusion of relevant keywords such as “survivor,” “gender-based violence,” “sexual violence,” “injuries,” and “trauma.” We employed Boolean operators (AND/OR) and Medical Subject Heading (MeSH) terms to refine the search string (Please refer to Supplementary File 1 for the detailed search strategy). Adjustments were made to the syntax based on the specific requirements of each database. The information scientist also played a role in conducting website searches. In addition to electronic searches, we manually explored the reference lists of included sources to identify any additional relevant literature. At this stage, no search filters based on language or publication type were applied, however, the search results will be limited to publications from 2012 to 2023. This date limitation was to enable as captured recent and relevant studies to understand the current trend. All search results were imported into an EndNote Library X20 for efficient citation management.

Articles selection process

A study selection tool was developed using Google Forms based on the items outlined in the inclusion criteria (Table  1 ) and was subsequently pilot tested. The EndNote library was then examined for duplicates using the “Find Duplicate” function. Two authors (DK and ML) independently utilised the study screening tool to categorise titles and abstracts into two groups: “include” and “exclude.” Any discrepancies in their responses during this phase were resolved through discussion and consensus. The full-text articles of all titles and abstracts that met the inclusion criteria during the initial screening phase were obtained from using the Durban University of Technology Library Services, and independently screened by DK and ML following the eligibility criteria as a guide. In cases where there was a lack of consensus between DK and ML, a third author (PA) was consulted to resolve any discrepancies. The PRISMA flow diagram was utilised to document the article selection process, ensuring transparency and accountability.

Quality appraisal

The Mixed Method Quality Appraisal Tool (MMAT) Version 2018 [ 37 ] was utilised to assess the methodological quality and potential risk of bias in the included studies. This tool was employed to evaluate the appropriateness of the study’s objective, the suitability of the study design, participant recruitment methods, data collection procedures, data analysis techniques, and the presentation of results/findings. To determine the quality of the studies, a quality score based on established criteria was applied, where a score of 50% indicated low quality, 51–75% indicated average quality, and 76–100% indicated high quality. The total percentage score was calculated by adding all the items rated, divided by seven, and multiply by a hundred. This rigorous assessment is crucial for identifying any research gaps. Two authors (DK and ML) independently conducted the quality appraisal, and any disagreements were resolved by involving a third author (PA).

Data charting

Data extraction was conducted using a spreadsheet, which underwent a pilot test with 15% (3) of the included evidence sources to ensure its efficacy in capturing all relevant data for addressing the review question. Feedback from the pilot test was carefully considered, and necessary adjustments were made to the form. Upon a comprehensive examination of the full texts, two independent reviewers (DK and ML) extracted all pertinent data from the included studies. The data extraction process employed a hybrid approach, incorporating both inductive and deductive reasoning [ 38 ]. The process involved a thorough analysis of the extracted information to identify patterns, themes, and trends in the existing research evidence regarding injuries and trauma resulting from SGBV among survivors in sub-Saharan Africa. Key study characteristics, including author(s), publication year, study title, aim/objective, geographical location (country), study design and study population, were extracted. Additionally, the study findings pertaining to injuries and/or trauma resulting from SGBV were recorded.

Collating, summarising, and reporting the results

The results of the data extraction were collated and summarised in a narrative format. Descriptive analysis and narrative synthesis were utilised to present the findings in a comprehensive manner. The study outcomes included a comprehensive overview of the scope of research evidence on injuries and trauma due to SGBV among survivors in the region. This study was be reported in keeping with the Preferred Reporting Items for Systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) checklist [ 39 ].

Study selection

A total of 569 potentially eligible titles and abstracts across databases were screened and after excluding duplicates and those that did not meet this eligibility criteria, included 20 [ 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ] studies for data extraction and analysis (Fig.  1 ).

PRISMA 2020 flow diagram

Characteristics and quality appraisal of the included studies

Of the 20 included studies, the majority ( n  = 4; 20%) were from South Africa, and mostly ( n  = 11; 55%) published between 2012 and 2022. The majority ( n  = 9, 45%) were cross-sectional studies, and mostly ( n  = 15; 75%) involved women. The mean quality score ± SD of the 20 included studies was 87% ± 13. All details on the characteristics and quality appraisal of the included studies are provided in Table  2 .

Study findings

Theme 1: physical injuries/trauma due to sgbv occurrence/prevalence, pattern, and associated factors.

Several studies have explored the prevalence and factors associated with injuries/trauma due to SGBV (Table  3 ). Ssewanyana et al. highlighted the occurrence of genital trauma among adolescent girls resulting from sexual assault [ 14 ]. Apatinga et al. demonstrated that sexual violence was accompanied by physical abuse, leading to physical injuries among women [ 15 ]. Azumah et al. reported that visually impaired women who experienced gender-based violence faced a higher risk of injuries including genital injuries [ 16 ]. Amashnee et al. identified specific patterns in the occurrence of sexual assault injuries, with higher prevalence on Mondays (28%) and Fridays (27.3%), during specific months, and predominantly during working hours [ 17 ]. Abubeker et al. examined the impact of physical violence on female students, with findings indicating various injuries such as bruising, cuts, scratches, and fractures, leading to missed classes and fear of walking alone [ 19 ]. Biribawa et al. investigated the burden of GBV-related injuries and found a significant number of hospital visits in Uganda, with slightly declining injury rates (from 13.6 to 13.5 per 10,000 population) from 2012 to 2016 [ 18 ]. Umana et al. documented that 6.6% of undergraduate and postgraduate female students experienced sexual intimate partner violence, leading to injuries such as cuts, bruises, and sprains [ 20 ]. Mukanangana et al. reported the prevalence of virginal bleeding, genital irritation and urinary tract infection among women in reproductive age in Zimbabwe [ 21 ]. These findings collectively underscore the occurrence/prevalence physical injuries/trauma, pattern and specific associated factors associated resulting from SGBV.

Theme 2: consequences and impact on mental health

Several studies highlighted the significant consequences and impact of SGBV on mental health (Table  4 ). Ombok et al. found that sexually abused children had a high prevalence (49%) of post-traumatic stress disorder (PTSD), which was associated with the duration of abuse, severity of injuries sustained, parents’ marital status, and family dynamics [ 13 ]. Apatinga et al. demonstrated that sexual violence was accompanied by emotional abuse, leading to psychological problems, sexual and reproductive health issues, and suicidal ideations among women [ 15 ]. Azumah et al. reported that visually impaired women who experienced gender-based violence faced a higher risk of suicide attempts, and marital breakdown [ 16 ]. Liebling et al. found that women and girls who experienced SGBV frequently became pregnant and suffered from injuries, disability, and psychological trauma [ 22 ]. Morof et al. highlighted the high prevalence of violence and its association with PTSD symptoms and depression among women [ 23 ]. Nguyen et al. demonstrated that exposure to various forms of gender-based violence, including intimate partner violence and sexual harassment, was significantly associated with hypertension, mediated by depression, post-traumatic stress symptoms, and alcohol binge-drinking [ 24 ]. Abrahams et al. reported that women raped by intimate partners had higher levels of depressive symptoms compared to those raped by strangers [ 25 ]. Pitpitan et al. found a significant association between gender-based violence and increased alcohol use, as well as heightened levels of depressive symptoms and PTSD symptoms [ 26 ]. Okunola et al. revealed the complications experienced by survivors of sexual assault, including sexually transmitted infections, depression, and post-traumatic stress disorder [ 27 ]. Umana et al. identified the negative impact of violence on academic performance, with victims experiencing loss of concentration, self-confidence, and school absenteeism [ 20 ]. Roberts et al. highlighted the association between severe GBV and higher depressive symptoms, PTSD symptoms, disordered alcohol use, and more sex partners [ 29 ]. Tantu et al. emphasized the wide range of social, health-related, and psychological consequences resulting from gender-based violence [ 28 ]. Finally, Mukanangana et al. revealed that the majority of respondents who experienced rape suffered from psychological trauma, exposure to sexually transmitted infections, unwanted pregnancies, loss of libido, and illegal abortions [ 21 ]. These findings collectively demonstrate the significant impact of SGBV on mental health, including psychological trauma, depression, PTSD symptoms, and various adverse outcomes.

Theme 3: healthcare access and support services

The findings from the studies conducted in the Democratic Republic of the Congo and Togo highlight significant barriers and challenges faced by survivors of SGBV in accessing healthcare and receiving proper psychological care. In the Democratic Republic of the Congo, Scott et al. reported that SGBV survivors faced barriers to accessing healthcare, such as availability and affordability, in their study to evaluate community attitudes of SGBV and health facility capacity to address SGBV in the eastern part of the country [ 30 ]. Access to mental health care was difficult [ 30 ]. Witch doctors and other traditional healers provided mental health services to some survivors [ 30 ]. Burgos-Soto et al.‘s study in Togo, which sought to estimate the prevalence and contributing factors of intimate partner physical and sexual violence among HIV-infected and -uninfected women, found that lifetime prevalence rates of physical and sexual violence were significantly higher among HIV-infected women compared to uninfected women [ 31 ]. 42% of the women admitted to ever suffering physical harm as a result of intimate partner abuse [ 31 ]. Only one-third of the injured women had ever told the medical professionals the true nature of their injuries, and none had been directed to neighbourhood organizations for the proper psychological care [ 31 ].

Theme 4: rural vs. urban disparities

According to a study conducted in Nigeria by Na et al. to identify the trends in sexual assault against women in urban and rural areas of Osun State, completed rapes occurred 10.0% of the time in urban areas and 9.2% of the time in rural areas, while attempted rapes occurred 31.4% of the time in urban areas and 20.0% of the time in rural areas [ 32 ]. Rural women were more likely than urban women to endure repeated sexual assault and non-genital injuries [ 32 ]. This study findings suggest that sexual assault against women occurs in both urban and rural areas, with notable differences in the patterns and outcomes.

This scoping review study on injuries and trauma resulting from sexual and SGBV) in sub-Saharan Africa revealed key findings that shed light on this critical issue. The majority (15%) of the included studies were conducted in South Africa. Most (75%) of these studies adopted a cross-sectional design and focused on women as the population of interest. The overall mean quality score of the included studies was high, indicating robustness and reliability in the research.

The findings from the included studies collectively highlighted the prevalence of physical injuries and trauma resulting from SGBV in sub-Saharan Africa such as genital injuries, cuts, bites, scratches, abrasions, bruises, sprains, dislocations, fractures, vaginal bleeding, and genital trauma. The included studies provided insights into the consequences and specific factors associated with such violence, emphasising the urgent need for effective interventions and support services. Notably, the impact of SGBV on mental health was a recurring theme in the literature, with evidence pointing to psychological trauma, depression, PTSD symptoms, and other adverse outcomes experienced by survivors.

While the review identified limited research on healthcare access and support services for SGBV survivors, the available studies underscored significant barriers in accessing healthcare and receiving proper psychological care [ 30 , 31 ]. Challenges included limited availability and affordability of services, as well as survivors’ hesitancy to disclose abuse to medical professionals. These findings highlight importance healthcare gaps requiring interventions to ensure comprehensive support for survivors in sub-Saharan Africa.

Policymakers in sub-Saharan Africa should prioritise the implementation of comprehensive and evidence-based interventions to address injuries and trauma resulting from SGBV. The concentration of included studies from South Africa indicates the need to expand research efforts to include other countries in the region, ensuring that policies are tailored to meet the diverse needs and contexts of different nations. The limited research on healthcare access and support services for SGBV survivors underscores the urgency of improving healthcare systems and strengthening support services for survivors. Policymakers should consider investing in accessible and affordable healthcare services that provide specialised care for SGBV survivors, including mental health support. Additionally, addressing publication language bias by promoting research in multiple languages (e.g., French and Portuguese) can ensure that relevant findings reach policymakers across the sub-Saharan African region. Furthermore, this scoping review’s potentially can inform the development of targeted policies that address the specific risk factors, consequences, and contributing factors associated with injuries and trauma resulting from SGBV.

The scoping review findings highlight several avenues for future research on injuries and trauma as a result of SGBV in sub-Saharan Africa. Researchers should focus on conducting studies in countries with limited representation in the current literature to enhance the breadth and diversity of evidence available. Investigating the barriers and challenges faced by survivors in accessing healthcare and support services should be a priority to identify gaps and improve service delivery. Moreover, longitudinal studies could provide valuable insights into the long-term consequences of SGBV on survivors’ mental health and well-being. Researchers should also explore the effectiveness of various interventions, including those involving community-based support systems, to address SGBV-related injuries and trauma. Furthermore, incorporating qualitative research approaches could deepen the understanding of survivors’ experiences and help in tailoring interventions to their specific needs. Future research should also consider the perspectives of various stakeholders, including healthcare providers, community leaders, and policymakers, to develop comprehensive and context-specific strategies to prevent and respond to SGBV and its consequences. Overall, conducting rigorous research that spans diverse contexts and populations will contribute to a more comprehensive understanding of the multifaceted challenges posed by SGBV and inform evidence-based interventions that promote survivor support and well-being.

The scoping review’s strength lies in its comprehensive approach, encompassing a wide range of literature on injuries and trauma resulting from SGBV in sub-Saharan Africa. By considering various study designs and sources of evidence, the review offers a holistic view of the topic. Additionally, the study effectively identifies key themes and trends in the literature, leading to a deeper understanding of the prevalence, consequences, and specific factors associated with injuries and trauma resulting from SGBV in the region. The mapping of research evidence within the review proves to be a valuable resource for researchers, policymakers, and practitioners working in the field of SGBV. Furthermore, the review’s emphasis on studies with an overall high mean quality score (87% ± 13%) enhances the credibility and reliability of the findings, ensuring that the evidence presented is robust and trustworthy.

Despite these strengths, this scoping review has several limitations. The concentration of included studies from South Africa introduces a geographic bias, potentially limiting the generalizability of findings to other countries within sub-Saharan Africa. To enhance the review’s applicability, a more diverse representation of research from different regions in the area would be beneficial. Additionally, the paucity of studies investigating healthcare access and support services for SGBV survivors may restrict the review’s ability to provide comprehensive insights into this critical aspect of the topic. Despite these limitations, this scoping review provides a valuable overview of the available research evidence on injuries and trauma related to SGBV in sub-Saharan Africa, paving the way for further research and targeted interventions to address this critical issue. Researchers should acknowledge and consider these limitations when interpreting and applying the review’s findings.

In conclusion, this scoping review provides a comprehensive overview of the research evidence on injuries/trauma resulting from SGBV in the sub-Saharan African region. It underscores the urgent need for further research and targeted interventions to address this pervasive issue and support the well-being of survivors.

Data availability

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Desmond Kuupiel, Monsurat A. Lateef, Gugu G. Mchunu & Julian D. Pillay

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Kuupiel, D., Lateef, M.A., Adzordor, P. et al. Injuries and /or trauma due to sexual gender-based violence among survivors in sub-Saharan Africa: a systematic scoping review of research evidence. Arch Public Health 82 , 78 (2024). https://doi.org/10.1186/s13690-024-01307-3

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Received : 08 August 2023

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Published : 21 May 2024

DOI : https://doi.org/10.1186/s13690-024-01307-3

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