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July 2003, Vol 93, No. 7 | American Journal of Public Health 1067-1070
© 2003 American Public Health Association

RESEARCH AND PRACTICE

High Prevalence of Self-Reported Forced Sexual Intercourse Among Internally Displaced Women in Azerbaijan

Jamila Kerimova, MD, Samuel F. Posner, PhD, Y. Teresa Brown, MPH, Susan Hillis, PhD, Susan Meikle, MD and Ann Duerr, MD, PhD, MPH

At the time of the study, Jamila Kerimova was with Relief International, Baku, Azerbaijan. Samuel F. Posner, Y. Teresa Brown, Susan Hillis, Susan Meikle, and Ann Duerr are with the Centers for Disease Control and Prevention, Atlanta, Ga.

Correspondence: Requests for reprints should be sent to Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 4770 Buford Highway Mail Stop K-34, Atlanta, GA 30341–3724 (e-mail: shp5{at}cdc.gov).


   INTRODUCTION
TOP
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 References
 
Previous reports have shown that forced sexual intercourse and other forms of gender-based violence are a persistent public health problem for refugee or internally displaced women.1–6 (Internal displacement is defined as forced relocation within a person’s country of citizenship because of some catastrophic event.) In some settings, the proportion of refugee or internally displaced women reporting some type of gender-based violence exceeds 60%.7,8 Sexual violence against refugee or internally displaced women can cause women to flee their homelands.9–14 Unfortunately, these women are not always safe from harm after their relocation or after resettlement.4,12,15–18 Investigation of sexual violence affecting these women, its incidence, prevalence, and correlates is critical to the development of effective treatment and prevention strategies.


   METHODS
TOP
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 References
 
Setting
This investigation was conducted in nongovernmental organization–operated reproductive health clinics in the Barda, Yevlack, and Terter districts in Azerbaijan between May and August 2000. It was part of a larger study of reproductive tract infections and pregnancy among displaced women.19 The study included a gynecologic examination, laboratory testing for sexually transmitted disease, and an interviewer-administered survey that took approximately 45 minutes to complete.

Study Design and Procedure
Women attending the clinics were approached by female clinical staff and asked to participate in a study of reproductive health. Informed consent was obtained from nonpregnant, 18- to 48-year-old, sexually active volunteers. Nearly all (greater than 90%) women approached agreed to participate in the study. Women were excluded if they had had a hysterectomy, were in menopause, or had used antibiotics in the past 30 days.

Data Analysis
Analysis was conducted to characterize the study group and the prevalence of forced sexual intercourse. Women were first asked, "At any time in your life, have ever been forced by a man to have sexual intercourse against your will?" If a woman responded affirmatively, she was then asked, "How old were you the last time you were forced by a man to have sexual intercourse against your will?"

Logistic regression analyses were conducted to identify correlates of self-reported forced sexual intercourse. This analysis evaluated 16 potential correlates of forced sexual intercourse that can be assessed during brief clinical encounters. These variables were grouped into 4 broad domains: (1) demographics, (2) living situation, (3) sexual behavior and reproductive history, and (4) gynecologic conditions diagnosed syndromically.


   RESULTS
TOP
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 References
 
Approximately 30% of the 457 women reported being forced to have sexual intercourse at least once in their life. Of those, 120 (26%) reported they had been forced to have sexual intercourse in the last 6 years. Twenty-one percent of the women reported that they had been forced to have sexual intercourse in the past year (Table 1Go).


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  		TABLE 1— Study Group Characteristics (n = 457): Azerbaijan, May to August 2000
 
The regression analysis was limited to women (n = 95) who reported forced sexual intercourse in the past year and those who reported never being forced to have sexual intercourse (n = 302) to identify correlates of recent forced sexual intercourse. Initial analysis found that 8 of the 16 correlates were significantly associated with self-reported forced sexual intercourse in the past year (Table 2Go) compared with those who had never experienced forced sexual intercourse. Positive associations were found with being employed, partner’s being employed, increasing income, and being physically attacked at least once in the past 3 months. Not having enough money for basic necessities in the past 3 months was negatively associated with forced sexual intercourse. Abortion, genital ulcers, and lower abdominal pain were positively associated with forced sexual intercourse.


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  		TABLE 2— Associations of Demographics, Living Situation, and Sexual Behavior/Reproductive Health and Syndromic Diagnoses With Recent Forced Sexual Relations (n = 95 Recent Forced Sexual Relations; n = 302 Never Forced Sexual Relations)a: Azerbaijan, May to August 2000
 
Seven of the 8 variables were included in the final logistic regression model (Table 2Go). Partner’s employment status was excluded because of the high correlation with respondent’s employment status. Four variables remained significant in the multivariate model including (1) being physically attacked in the past 3 months (odds ratio [OR] = 3.7, 95% confidence interval [CI] = 1.2, 11.5), (2) abortion (1 or 2, OR = 2.2, 95% CI = 1.0, 4.7; 3 or more, OR = 2.7 95% CI = 1.4, 5.3), (3) syndromic diagnosis of genital ulcers (OR = 2.6, 95% CI = 1.3, 5.0), and (4) lower abdominal pain (OR = 3.5, 95% CI = 1.8, 6.4).


   DISCUSSION
TOP
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
References
 
One of every 5 women in this study reported being forced to have sexual intercourse in the past year. Women who had been physically attacked, had had at least 1 abortion, and had syndromic diagnoses of genital ulcers or lower abdominal pain were more likely to have recently experienced forced sexual intercourse.

The prevalence of forced sexual intercourse in this study group is similar to that cited in reports from other refugee settings.1–6 Our clinical and sexual/reproductive health findings are similar to those in other reports: women who have experienced forced sexual intercourse are at increased risk for sexually transmitted diseases, genital irritation, pelvic pain, urinary tract infections, physical abuse, mistimed/unwanted pregnancies, and abortions.3,5–7,8,18,22–27

Gender-based violence is a universal public health problem. Both the scientific and the popular literature have reported that around the world women are being victimized. The high prevalence of forced sexual intercourse calls for vigilance among providers to ensure appropriate treatment and referral of victims of sexual violence. Further study of sexual violence toward women is needed to elucidate the problem and to lay the foundation for eliminating it.


   Acknowledgments
 
This project was carried out in part under a cooperative agreement with the Contraceptive Research Development Program. The Division of Reproductive Health at the Centers for Disease Control and Prevention provided technical assistance.

Human Participant Protection

Local and Centers for Disease Control and Prevention human subjects protection review panels approved the study protocol.


   Footnotes
 
Note: The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services or the Contraceptive Research Development Program, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government.

Peer Reviewed

Accepted for publication November 14, 2002.


   References
TOP
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 
1. Nduna S, Goodyear L. Pain Too Deep for Tears: Assessing the Prevalence of Sexual and Gender Violence Among Burundian Refugees in Tanzania. New York, NY: International Rescue Committee; 1997:1–27.

2. Mollica RF, Donelan K, Tor S, et al. The effect of trauma and confinement on functional health and mental health status of Cambodians living in Thailand-Cambodia border camps. JAMA. 1993;270:581–585.[Abstract]

3. Cossa HA, Gloyd S, Vaz RG, et al. Syphilis and HIV infection among displaced pregnant women in rural Mozambique. Int J STD AIDS.1994;5:117–123.[ISI][Medline]

4. Arcel LT. Deliberate sexual torture of women in war: the case of Bosnia-Herzegovina. In: Shalev AY, Yehuda R, McFarlane AC, eds. International Handbook of Human Response to Trauma. New York, NY. Kluwer Academic Plenum Press; 2000:173–193. The Plenum Series on Stress and Coping.

5. Campbell JC, Soeken KL. Forced sex and intimate partner violence: effects on women’s risk and women’s health. Violence Against Women.1999;5:1017–1035.[Abstract/Free Full Text]

6. Golding JM. Sexual assault history and women’s reproductive and sexual health. Psychol Women Q.1996;20:101–121.[ISI][Medline]

7. Heise LL, Pitanguy J, Germain A. Violence against women: the hidden health burden. Washington DC: World Bank; 1994. World Bank Discussion Papers 255.

8. Center for Health and Gender Equality. Ending violence against women. Popul Rep L.1999;11:1–43.

9. Peel MR. Effects on asylum seekers of ill treatment in Zaire. BMJ.1996;312:293–294.[Free Full Text]

10. Kozaric-Kovacic D, Folnegovic-Smalc V, Skrinjaric J, Szajnberg NM, Marusic A. Rape, torture, and traumatization of Bosnian and Croatian women: psychological sequelae. Am J Orthopsychiatry. 1995;65:428–433.[ISI][Medline]

11. Stevanovic I. Violence against women in the Yugoslav war as told by women refugees. Int Rev Victimology.1998;6:63–76.

12. Kelly N. Political rape as persecution: a legal perspective. J Am Med Womens Assoc.1997;52:188–190, 198.

13. Mezey G. Rape in war. J Forensic Psychiatry.1994;5:583–597.

14. Swiss S, Giller JE. Rape as a crime of war: a medical perspective. JAMA.1993;270:612–615.[Abstract]

15. Friedman AR. Rape and domestic violence: the experience of refugee women. Women Ther Q.1992;13:65–78.

16. Palmer CA, Zwi AB. Women, health and humanitarian aid in conflict. Disasters.1998;22:236–249.[ISI][Medline]

17. Dahl S, Mutapcic A, Schei B. Traumatic events and predictive factors for posttraumatic symptoms in displaced Bosnian women in a war zone. J Trauma Stress.1998;11:137–145.[ISI][Medline]

18. Coker AL, Richter DL. Violence against women in Sierra Leone: frequency and correlates of intimate partner violence and forced sexual intercourse. Afr J Reprod Health.1998;2:61–72.[Medline]

19. Relief International Annual Report 1996/1997. Los Angeles, Calif: Relief International; 1998.

20. Management of Patients With Sexually Transmitted Disease. Geneva, Switzerland: World Health Organization; 1991. WHO Technical Report Series 810.

21. Global Programme on AIDS. Management of Sexually Transmitted Diseases. Geneva, Switzerland: World Health Organization; 1994. WHO/GPA/TEM/94.1.

22. Golding JM, Cooper ML, George LK. Sexual assault history and health perceptions: seven general population studies. Health Psychol.1997;16:417–425.[ISI][Medline]

23. Rasekh Z, Bauer HM, Manos MM, Iacopino VV. Women’s health and human rights in Afganistan. JAMA.1998;280:449–455.[Abstract/Free Full Text]

24. Ekblad S, Klefbeck EL, Wennstrom C, Pietkainen AL. Help for refugees. World Health Forum.1997;18:305–310.[ISI][Medline]

25. Mollica RF, Son L. Cultural dimensions in the evaluation and treatment of sexual trauma. Psychiatr Clin North Am.1989;12:363–379.[ISI][Medline]

26. Van Willigen LHM. Incidence and consequences of sexual violence in refugees: considerations for general health care. Nord Sexologi.1992;10:85–91.

27. Sveaass N, Axelsen E. Psychotherapeutic interventions with women exposed to sexual violence in political detention: a presentation of two therapies. Nord Sexologi.1994;12:13–28.




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