Reproductive health and HIV prevention programmes for youth rarely address the reality of coercive sex that many youth face. Such coercion is a violation of a person's rights and can have severe physical, mental, and reproductive health consequences. Sexual abuse can occur in premarital, extramarital, and marital situations. Perpetrators are usually people with whom the victim is familiar, including intimate partners, peers, family members, teachers, and other youth and adult acquaintances. Coercion often occurs in the course of routine activities in the home, neighbourhood, community, and school. Perpetrators are generally, but not always, males.

Data on sexual coercion among youth in developing countries are limited; most studies are small with findings that may not be representative. A review of thirteen studies found that between 2 and 20% of girls and fewer than 15% of boys reported ever experiencing sexual coercion. The youth surveyed were generally aged 15 to 19; of these thirteen studies, six included males. In a review of fourteen studies that asked about forced first sexual experience, about 15 to 30% of sexually active girls reported coercion; and fewer than 10% of boys. Of these fourteen studies, five included males.¹

Gender norms

Deeply rooted gender norms can contribute to sexual coercion. Many cultures condone sex for boys while girls face social sanctions if they appear to be sexually active or get pregnant. In a Nigerian study, for example, 57% of male students and 74% of out-of-school male apprentices agreed with the statement, "A man has the right to have sex with a woman on whom he has spent a lot of money". Also agreeing were 37% of female students and 43% of female apprentices.²

At an international meeting held in New Delhi, India in September 2003, a panel of local youth emphasized how gender roles condoned coercion of young females. One youth described teachers who touched girls, but when complaints were made, no action was taken against the teacher. Another described the sexual harassment girls encountered walking to school. Gender norms appeared so entrenched that "many girls were shocked because they realized they have a right to say ‘no', that going out with a boy does not give consent for sex", explained another panellist.

In areas where girls continue to marry at a young age, such as South Asia and West Africa, lack of decision-making authority, lack of familiarity with the husband-to-be, and a lack of information on sexual matters can contribute to forced sex in marriage.³

Health consequences

Sexual coercion in childhood and adolescence has long-term consequences in terms of reproductive health/HIV, violence, and mental health problems.

Reproductive health/HIV – A review of evidence in Latin America found that young women who had been sexually abused had significantly earlier sexual initiation and more lifetime partners than non-abused women.⁴ A Ugandan study of 575 sexually active girls aged 15 to 19 found that those who had experienced sexual coercion were significantly more likely to be non-users of contraception, to have unintended pregnancies, and not use condoms at last intercourse. The study also found that after controlling for other risk factors, girls who had experienced coercive first sex were more likely to be HIV infected.⁵

Violence – Studies have found that women who experience sexual violence are more likely to suffer severe physical violence and violence in pregnancy.⁴ A study in Thailand found that of women who had first sex by force, 65% had later experienced intimate spousal violence, compared to 37% of those with a first sex experience where the degree of force was ambiguous, and 25% of those who did not have first sex by force.⁶

Mental health problems – Sexually abused women and men have significantly higher risks for suicidal thoughts and behaviour than those who were not abused.⁴ A qualitative study in India among 33 female survivors of incest, which occurred between the ages of 10 and 24, found that these women experienced a wide range of mental health issues that needed to be addressed in order to help them overcome their fear of intimacy and sexuality, and their isolation.⁷

Emerging programme approaches

From these and other studies several programmatic lessons can be learned. First, reproductive health and HIV prevention programmes need to understand and address the full context of young people's lives, including social and economic factors leading to coercion. By emphasizing abstinence, partner reduction, and condom promotion, programmes may overlook the reality of the lives of many youth, including factors underlying their ability to choose whether or not to engage in sex. A more holistic and realistic approach would include preventing sexual coercion, providing support to victims, strengthening the legal and advocacy environment, and training providers.⁸

Second, programmes need to help improve provider attitudes about, and clinical services for, youth who may have experienced sexual coercion. In a two-year intervention, the International Planned Parenthood Federation (IPPF)/Western Hemisphere Region, in coordination with IPPF affiliates in the Dominican Republic, Peru, and Venezuela, trained all staff on the sensitivity of this issue and how to provide appropriate services. Staff learned to recognize how sexual coercion affects clients and the importance of maintaining confidentiality and privacy. The initiative introduced new clinical history forms, policies and procedures, and in-house services and referrals.⁹

Third, programmes must focus on supporting young people's rights, changing gender norms, and improving communication and negotiation skills. Programmes such as the PROMUNDO ‘Program H' effort in Brazil and the Young Men as Equal Partners project in several African countries have begun to address gender norms, including associations of sexual violence with masculinity, and to offer alternative models for male behaviour. These experiences should be documented and studied so that these models can be adapted and replicated.

Fourth, actions at the community, institutional, and policy levels need to sensitize policy-makers, religious leaders, and other gatekeepers to the reality and impact of sexual coercion and the need to provide a supportive and non-judgemental environment. Programmes need to work more closely with the media, police, and other authorities to enforce existing laws and to develop community-based councils and other approaches that can help instil a safe environment for young people.

Finally, more research and innovative interventions are needed to guide programmes to help prevent coercion, support youth in making safe and appropriate sexual decisions, and provide counselling and treatment to those who are victims of coercion.

William Finger, Information Dissemination Coordinator YouthNet, Family Health International; P.O. Box 13950, Research Triangle Park, NC 27709, USA; tel.: +1-919-544.70.40 ext. 468, fax: +1-919-544.72.61, e-mail: bfinger@fhi.org, web: www.fhi.org/youthnet

2. Ajuwon A. Research in sexual coercion in young persons: the experiences and lessons learnt from Ibadan, Nigeria. Presentation Global Consultative Meeting on Nonconsensual Sex among Young People in Developing Countries, New Delhi, India, September 2003.

4. Ellsberg M. Coerced sex among adolescents in Latin America and the Caribbean. Presentation Global Consultative Meeting, New Delhi, 2003.

5. Koenig M, Lutalo T, Zablotska I, et al. The sequelae of adolescent coercive sex: evidence from Rakai, Uganda. Presentation Global Consultative Meeting, New Delhi, 2003.

6. Im-em W. Sexual coercion among women in Thailand: results from the WHO multi-country study on women's health and life experiences. Presentation Global Consultative Meeting, New Delhi, 2003.

7. Gupta A, Ailawadi A. Incest in Indian families: learnings from a support centre for women survivors. Presentation Global Consultative Meeting, New Delhi, 2003.

8. Erulkar AS. Sexual and reproductive health research and programming for youth. Presentation Global Consultative Meeting, New Delhi, 2003.

9. Bott S, Guedes A, Guezmes A. The health service response to sexual coercion/violence: lessons from IPPF/WHR associations in Latin America. Presentation Global Consultative Meeting, New Delhi, 2003.