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Introduction
Violence against children is a pervasive global public health and human rights issue, with 1 billion children experiencing at least one form of violence annually.1 Extensive scientific literature shows childhood adversity, including sexual violence, to be directly and indirectly associated with a host of health and social consequences with a dose–response effect, consequential intergenerational impacts, and sizeable economic ramifications.2 There is a dearth of population data on the prevalence of childhood sexual violence as well as its antecedents and health and social outcomes, which has hampered violence prevention and child protection efforts globally and locally. Population data are critical, alongside administrative data systems and statistical definitions and classification schemes,3 for governments to adequately begin addressing violence against children. The absence of national prevalence data has resulted in limited information to guide national policies and prevention strategies, monitor trends, and evaluate prevention efforts. Globally, lack of data on the epidemiological patterns of violence against children has resulted in deficient prioritisation for preventing and responding to this critical problem.
Violence Against Children and Youth Surveys (VACS) collect comprehensive data on violence and have been implemented in over 23 countries in Africa, Asia, the Caribbean, Europe and Latin America since 2007. VACS have also been repeated in three countries: Zimbabwe (2011; 2017), Kenya (2010; 2019) and Eswatini (2007; 2022). VACS provide extensive data on the prevalence and contexts of all forms of violence, including sexual violence, therefore allowing for targeted prevention and response efforts. VACS further provide the global research community with data to examine the epidemiological patterns of childhood sexual violence across countries and regions. VACS data have raised awareness and improved understanding of childhood sexual violence in many countries worldwide, and thereby catalysed action.
This article draws on VACS reports and empirical publications, to summarise and describe patterns in childhood sexual violence across countries that have completed VACS and shed light on the global prevalence of childhood sexual violence.
Methods
VACS data from 20 countries was used to summarise the prevalence of childhood sexual violence from diverse regions of the world. Both estimates for countries that have repeated VACS are represented in this summary. VACS use a three-stage cluster randomised household sampling design to generate nationally representative estimates of violence against children.4 Interviewer-administered surveys are conducted with male and female youth aged 13–24 years, who provide retrospective reports of lifetime experiences. A standard protocol ensures data comparability across countries and protections for participant safety and confidentiality. Participants in need of help with violence or other adversity are offered services and support.
VACS collects data on physical, emotional and sexual violence, but this discussion is focused on sexual violence. VACS collect data on four types of sexual violence: (1) unwanted sexual touching; (2) attempted forced sex; (3) forced sex; and (4) pressured sex. Experiences of one or more of these types of sexual violence prior to the age of 18 is defined as any childhood sexual violence.
Results
Data from 20 countries across four continents highlight that childhood sexual violence is a sizeable problem, with lifetime prevalence estimates ranging from 4.4% in Cambodia to 37.2% in Eswatini (2007) for females and from 1.1% in Zimbabwe (2017) to 21.2% in Haiti for males (online supplemental table S1 and figure S1). The prevalence of childhood sexual violence declined in the three countries where the VACS was repeated. In Eswatini, data were only collected from females in the first VACS therefore a prevalence comparison was only allowable for the female population. The Eswatini results showed that childhood sexual violence reduced from 37.2% in 2007 to 5.5% in 2022 (online supplemental table S1 and figure S1). In Zimbabwe, childhood sexual violence reduced from 32.5% in 2011 to 9.1% in 2017 among girls; and reduced from 8.9% in 2011 to 1.1% in 2017 among boys (online supplemental table S1). In Kenya, the rate of childhood sexual violence reduced from 31.9% in 2010 to 15.6% in 2018 among girls and reduced from 17.5% in 2010 to 6.4% in 2018 among boys (online supplemental table S1 and figure S1).
Supplemental material
Supplemental material
Certain patterns also emerged with respect to contexts for childhood sexual violence. Common perpetrators of childhood sexual violence are people known to the child: intimate partners, friends and classmates, family, and neighbours (results available on request). Further, childhood sexual violence most often takes place in homes or school (results available on request). Across all countries, VACS find that many victims of childhood sexual violence do not disclose their experiences to anyone. Disclosure of childhood sexual violence to anyone ranged from 13.8% (Lao PDR) to 72.9% (El Salvador) among females, and from 17.3% (Zimbabwe 2017) to 64.7% (Malawi) among males. A smaller minority of victims try to seek professional services (<0.1%–25.7% among females; <0.1%–32.6% among males) and very few successfully receive any services for their experience/s (less than 5% in most of the countries).
Discussion
Results in this summary provide data from 24 published VACS reports from 20 countries, including three countries that have repeated VACS. This summary provides insight into the global prevalence and patterns of childhood sexual violence. VACS have raised awareness and improved understanding of childhood sexual violence in many countries worldwide, and thereby catalysed action. After data collection and analysis, findings are disseminated to multi-sectoral partners within countries, including relevant government ministries, civil society and multi-lateral institutions. These partners provide interpretive context to the results and identify prioritised actions to prevent and respond to childhood sexual violence in a data to action process. Since 2016, INSPIRE: Seven Strategies to End Violence Against Children (https://www.who.int/publications/i/item/9789241565356) has guided the interpretation of VACS results and their use in guiding data-driven efforts to address all forms of violence against children, including sexual violence. INSPIRE has served as a framework to link prioritised indicators from VACS to evidence-based prevention and response programmes and policies for countries to consider introducing, scaling up or evaluating, depending on their current national strategy.
While VACS cannot tell us why childhood sexual violence declined in all three sub-Saharan African countries that repeated the survey, we do know governments and stakeholders used survey results to guide violence prevention programming and policy. For example, after the 2010 Kenya VACS, the government instituted a new constitution which included articles explicitly protecting children from violence and shortly after passed the Children’s Act (2012) and Marriage Act (2014), both of which further expanded legal protections.5 In addition, PEPFAR (The President’s Emergency Plan for AIDS Relief) and the Global Fund have made sizeable contributions through HIV prevention programming in each of these three countries and integrates violence prevention interventions and post-violence care clinical services. A notable example is the DREAMS initiative that delivers a package of evidence-based programmes on key risk factors of HIV among adolescent girls and young women, including sexual violence, and reaches approximately 2.9 million girls and young women each year.6 VACS data have also informed PEPFAR’s investments in strengthening child protection systems through its Orphans and Vulnerable Children programming. VACS results informed the establishment of a national child protection management system in Kenya, the introduction of a child-friendly courtroom in Eswatini, and the scale up of an evidence-based parenting intervention focused on reducing harsh discipline throughout East and Southern Africa.7
It is important to consider the impact of UNICEF and WHO as key global health and child protection leaders as they have expanded their attention to violence, as well as the targeted work of partners such as Together for Girls who take a data driven focus specifically on childhood sexual violence elimination. As VACS continue to be implemented globally, and particularly as it is repeated in countries, a clearer picture may emerge on global trends in childhood sexual violence. Current results show: a pattern of high prevalence; people who perpetrate are typically known and often trusted by their child victims; and sexual violence frequently occurs in homes and schools where children should be safest. Further, few victims of childhood sexual violence receive professional services. Patterns of VACS results continue to demonstrate the gendered nature of sexual violence against girls and boys and highlight the need for gender-informed interventions to reduce the risk and mitigate the consequences of childhood sexual violence for all youth. Continued and regular population-level data collection, such as through VACS, is critically important for countries to understand the burden, contexts and consequences of violence against children and youth and to galvanise action.
This summary is subject to several limitations. First, VACS provide cross-sectional data or in countries that have repeated VACS, serial cross-sectional data. The surveys cannot provide information on why childhood sexual violence declined in those three countries where it has been repeated. Second, the VACS are adapted by key partners in each country and there is some variation in wording of questions between countries. Third, VACS are household surveys and do not collect data on children who are institutionalised or otherwise living outside family care. Complimentary research is needed globally and VACS countries to better understand and interpret patterns of childhood sexual violence, what is contributing to the observed reduction in prevalence and conduct research with youth not captured in a household survey who may be even more vulnerable to violence.
Conclusion
Sexual violence in childhood is a public health and human rights issue with long-term consequences across the lifetime of the affected individuals as well as consequential societal and economic impacts. VACS have documented the prevalence and epidemiological patterns across more than 24 countries, providing governments and key child protection partners with critical data that can catalyse multi-sectoral action. The countries that have repeated VACS have seen marked improvement in prevalence of violence, demonstrating that violence is preventable, not inevitable. VACS have provided countries with baseline data and in so doing, the survey has led to concerted action to improve this public health challenge, as demonstrated by the repeat VACS in Zimbabwe, Kenya and Eswatini. However, much more work remains, given the high prevalence rates still seen in many countries and to understand the reasons for the declining prevalence of childhood sexual violence that has been observed. Population level surveys repeated regularly and with close attention to ethical and methodological rigour, such as VACS, are a critical tool to elucidate the problem and ignite action.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants these studies were all approved by the CDC Institutional Review Board with the IRB ID of IORG0000112. Each country was also reviewed and approved by required local Institutional Review Boards or Ethical Review Committees as required and appropriate for each country. Participants gave informed consent to participate in the study before taking part.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors All of the coauthors have substantially contributed to this viewpoint article. LC led in the conceptualisation, writing and editing and is the guarantor of the manuscript. SM led in writing, data preparation and editing. JS, JM, GB, ABrooks, AButchart, JH, DL and JL contributed to writing and review. GM led in conceptualisation, writing and editing. All coauthors have substantially contributed to the drafting and final approval of the submitted document and agree to be accountable for all aspects of the work.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Disclaimer The views of the authors do not necessarily reflect those of the US Government or Bureau of Global Health Security and Diplomacy/PEPFAR, the United States Agency for International Development or the US Centers for Disease Control and Prevention.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.