Gender and Health

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Submission presented by: Dr Rachel Jewkes,

Director, Gender & Health Group,
Medical Research Council

Date of submission: 13 March 2002


Over the last seven years Medical Research Council researchers have been
undertaking research on child rape. The research has investigated the magnitude
and nature of the problem, its health consequences and its causes.

Magnitude of the problem

The 1998 South Africa Demographic & Health Survey interviewed a nationally
representative sample of women aged 15-49 years. These were recruited from all
provinces and all social groups in the country. This study found that 1.6% of
women had been raped in childhood before the age of 15 years. [1]

Statistics from the South African Police Services indicate that approximately 20
000 children aged 0-17 years report rape to the police each year. This f
igure did not increase or decrease between 1996-2000. [2]

Amongst 14-18 year olds, rape is very common. The Medical Research Council
undertook a study in Cape Town to investigate factors associated with teenage
pregnancy, 191 pregnant teenagers were interviewed and compared with 353 who had never been pregnant. 30% of the pregnant teenagers and 18% of the
comparison group had been forced to have sex the first time. 72% of pregnant
teenagers and 60% of the comparison group had been forced to have sex against

their wishes at some time [3].

Perpetrators of rape

The 1998 South Africa Demographic & Health Survey found that 33% of rapes
of under 15 year olds were perpetrated by school teachers - in other words
approximately 1 in 200 South African women aged 15-49 years have been raped
by a teacher. Family members were responsible for 21%, strangers and recent

acquaintances for 21% and boyfriends for 10%. [1]

Rape by multiple perpetrators, often known as gang rape or Streamline, is very
common. One third of cases of rape in two medico-legal surveillance series were
gang rapes. [4,5] Teenager girls are predominantly the victims.

Health consequences

Immediate health consequences of child rape include pregnancy [3, 6], HIV infection [7], sexually transmitted diseases, psychological distress, depression, post-traumatic stress, injury, including very severe genital injury, and death through murder or suicide. Children who are raped are also at risk of long term problems including subsequent HIV infection, unwanted pregnancy, infertility resulting from untreated sexual transmitted diseases, post- traumatic stress disorder, depression, alcohol abuse, drug abuse and high risk sexual practices [8-13].

Social consequences

Children who are raped are often blamed for having brought it on themselves. They may experience stigma which stems from ideas that they are morally suspect or polluted and may be shunned. If rape occurs in school, girls are very likely to drop out which may have severe implications for their options as adults. Some girls who become pregnant after rape may be thrown out of their home and they are at much higher risk of involvement in sex work. Since sexual abuse survivors often have long term mental health problems, this negatively impacts on their parenting as adults and therefore has consequences for their children.

Links to the HIV epidemic

There is an immediate risk of transmission during rape. This is higher for children than adult women as their bodies are smaller and so perineal tears are more likely. There is also a long term risk as girls who have been sexually abused are more likely to have sex with a boyfriend at an earlier age, have more partners, abuse drugs and alcohol, trade sex for money and not use condoms. All of these factors increase the risk of acquiring HIV in later years. [7,9,10,13]

Child sexual abuse and teenage pregnancy

The MRC case control study of factor associated with teenage pregnancy [3] found that forced sexual initiation was more strongly associated with risk of teenage pregnancy than any other risk factor except determinants of biological risk such as use (or non-use) of the highly effective injectable contraceptives and frequency of having sexual intercourse. It was more important than education, socio-economic status, parenting, information and home environment factors.

Causes of girl child rape

Gender inequality

The most important cause of girl child rape is gender inequality. This operates at several levels and has many manifestations. In our society, girls and women are expected to control their sexuality, prevent rape and, if they are raped, they are often blamed for it. This is an example of a profound double standard as society does not expect men to control themselves in the same way, and sexual aggression by boys is often regarded as inevitable, 'normal boyish behaviour' [14]. The process of blaming the victim for 'bringing rape on themselves' legitimates rape as a way of controlling the behaviour of women and girls and in particular discouraging certain types of behaviour such as drinking alcohol, infidelity or dressing in a particular way [14]. Not only do many men feel they are expected to control women, but they may also perceive that they own their wives and children. Some men rape their children and justify it in terms of the fact that she is 'his' and he is therefore entitled to 'have' her. There is very little social pressure focused by parents, families and society overall on discouraging men & boys from raping. Punishments are very ineffectual and often completely lacking. Police are often slow to respond to rape complaints, slow to arrest perpetrators and highly open to corruption [15]. Conviction rates are very low (10%) [2] and sentences are often very lenient despite mandatory sentencing. The message from the courts is often one that men are valued more than women, for example in the not infrequent judicial decisions to be lenient on men because they have a promising future ahead of them. In this way rape is trivialised

Childhood environments

Men who are raised in harsh childhood environments without love, nurturing and support are more likely to rape. This is related to their greater likelihood of difficulties with close emotional relationships in adult life, as shown in preferences for impersonal sex [16]. Men who are sexually abused in childhood are much more likely to rape as adults [17].


Poverty has a complex interrelationship with child rape. Poor girls are much more vulnerable in the course of daily activities, for example they are more likely to walk long distances to school and may have less parental supervision if parents are away working as after school child care is less affordable. They may be more vulnerable to abuse of power, for example in the form of demands for sex with a school teacher in the face of threats of school failure, as they may be more concerned that their families could not afford school fees if they must repeat the year. They are also more likely to become involved in transactional sexual relationships and sex work, which carry an increased risk of rape. [15] Poor men lack opportunities in which they may excel, which reduce their ability to feel they are successful men. In this situation they are more likely to become involved in crime and associate with sexually aggressive peers and perpetrate rape as a demonstration of 'success' in controlling women. [14]

Alcohol & drug use

On its own alcohol use does not cause men to rape, men's behaviour after drinking alcohol is substantially socially learnt. [18] However, women who drink are more vulnerable. Alcohol clouds judgement and reduces inhibitions [19]. Men often drink in groups and engage in male bonding using alcohol and building on these effects. Rape may be an act performed in the course of male bonding activities. [15] Alcohol is often regarded as providing a cultural excuse for otherwise unacceptable behaviour.

Action to stop child rape

Action must address the risk factors. Efforts to promote gender equality, reduce poverty and alcohol use are necessary. A climate must be created in which rapists are likely to be apprehended and effectively punished, this requires much greater resources for police and the criminal justice system. Victim support services need to be made much more accessible so that the impact of rape on victims can be lessened. Health services for sexual violence need to be improved with greater emphasis on care of victims and training staff in performing sexual assault examination. Anti-retroviral medicines should be provided for women who have been raped in cases where they will be effective. The new sexual offences legislation proposed by the South Africa Law Commission needs to be speedily introduced, as it will greatly assist protection of girl children. Effective and rapid disciplinary action is needed against teachers who rape and sexually harass school girls.


1. Jewkes R, Levin J, Mbananga N, Bradshaw D. Rape of girls in South Africa. The Lancet 2002

2. CIAC, December 2001.

3. Jewkes R, Vundule C, Maforah F, Jordaan E.(2001) Relationship dynamics and adolescent pregnancy in South Africa. Social Science and Medicine 5, 733-744.

4. Martin L (1999) Violence against women: an analysis of the epidemiology and patterns of injury in rape homicide in Cape Town and in rape in Johannesburg. Unpublished MMed Forensic Pathology Thesis, University of Cape Town.

5. Swart L, Gilchrist A, Butchard A, Seedat M, Martin L. (1999). Rape Surveillance trough district surgeons offices in Johannesburg, 1996-1998: Evaluation and prevention Implications. Institute of Social and Health Sciences. University of South Africa.

6. Beitchman, J.H., Zucker, K.J., Hood, J.E. A review of the short-term effects of child sexual abuse. Child Abuse and Neglect 15: 537-556. 1991.

7. Miller M (1999) A model to explain the relationship between sexual abuse and HIV risk among women. AIDS Care 11, 3-20

8. Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., K-oss, M.P., Marks, J.S. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine 14(4): 245-258. 1998.

9. Fergusson, D.M., Horwood L.J., Lynskey, M.T. Childhood sexual abuse, adolescent behaviours and sexual revictimization. Child Abuse and Neglect 21(8): 789-803. 1997.

10. Handwerker, W. Gender power differences between parents and high-risk sexual behaviour by their children: AIDS/STD risk factors extend to a prior generation. Journal of Women's Health 2 (3): 301-316. 1993.

11. Mccauley, J., Kem, D.E., Kolodner, K., Dill, L., Schroeder, A.F., Dechant, H.K., Ryden, J., Derogatis, L.R., Bass, E.B. Clinical characteristics of women with a history of childhood abuse: Unhealed wounds. Journal of the American Medical Association 277(17): 1362-1368.1997

12. Walker, E., Gelfand, A., Katon, W., Koss, M., Korff, M.V., Bernstein, D., Russo, J. Adult health status of women HMO members with histories of childhood abuse and neglect. American Journal of Medicine 107(4): 332-339. 1999.

13. Zierler, S., Feingold, L., Lufer, D., Velentgas, P., Kantrowitz-Gordon, I., Mayer, K. Adult survivors of childhood sexual abuse and subsequent risk of HIV infection. American Journal of Public Health 81 (5): 572-575. 1991.

14. Wood K, Jewkes R (2001) Dangerous love: reflections on violence among Xhosa township youth. In: Morrell R (ed) Changing men in Southern Africa. University of Natal Press, Pietermaritzburg.

15. Jewkes R, Abrahams N (forthcoming) The epidemiology of rape and sexual coercion in South Africa: an overview. Social science and Medicine.

16. Malamuth NM (1988) A multidimensional approach to sexual aggression: combining measures of past behaviour and present likelihood. Human Sexual Aggression: Current Perspectives, Annals of the New York Academy of Science 528, 113-146.

17. Watkins B, Bentovim A (1992) The sexual abuse of male children and adolescents: a review of current research. Journal of Child Psychology and Psychiatry 33, 197-248.

18. McDonald M (eds) 1994 Gender, drink and drugs. Berg Publishers, Oxford.

19. Abby A, Ross LT, McDuffie D 1995 Alcohol's role in sexual assault. In RR Watson. Drug and Alcohol Reviews, Vol 5: Addictive Behaviours in Women. Totowa, NJ: Humana Press.