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Revista de Saúde Pública

Print version ISSN 0034-8910On-line version ISSN 1518-8787

Rev. Saúde Pública vol.53  São Paulo  2019  Epub Sep 23, 2019

http://dx.doi.org/10.11606/s1518-8787.2019053001081 

Original Article

Prevalence of sexual violence among refugees: a systematic review

IUniversidade do Estado do Rio de Janeiro. Instituto de Medicina Social. Programa de Pós-Graduação em Saúde Coletiva. Rio de Janeiro, RJ, Brasil

IIUniversidade Federal do Rio de Janeiro. Faculdade de Medicina. Programa de pós-Graduação em Clínica médica. Rio de Janeiro, RJ, Brasil.

IIIMcGill University. Montreal, QC, Canadá.

IVUniversidade do Estado do Rio de Janeiro. Instituto de Medicina Social. Departamento de Epidemiologia. Rio de Janeiro, RJ, Brasil


ABSTRACT

OBJECTIVE

To synthesize data about the prevalence of sexual violence (SV) among refugees around the world.

METHODS

A systematic review was conducted from the search in seven bibliographic databases. Studies on the prevalence of SV among refugees and asylum seekers of any country, sex or age, whether in English, French, Spanish and Portuguese, were eligible.

RESULTS

Of the 2,906 titles found, 60 articles were selected. The reported prevalence of SV was largely variable (0% to 99.8%). Reports of SV were collected in all continents, with 42% of the articles mentioning it in refugees from Africa (prevalence from 1.3% to 100%). The rape was the most reported SV in 65% of the studies (prevalence from 0% to 90.9%). The main victims were women in 89% of the studies, all the way, especially when still in the countries of origin. The SV was perpetrated particularly by intimate partners, but also by agents of supposed protection. Few studies have reported SV in men and children; the prevalence reached up to 39.3% and 90.9%, respectively. Approximately one-third of the studies (32%) were carried out in refugee camps and more than half (52%) in health services using mental health assessment tools. No study has addressed the most recent migratory crisis. Meta-analysis was not performed due to the methodological heterogeneity of the studies.

CONCLUSIONS

SV is a prevalent problem affecting refugees of both sexes, of all ages, throughout the migratory journey, particularly those from Africa. Protection measures are urgently needed, and further studies, with more appropriate tools, may better measure the current magnitude of the problem.

Key words: Refugees; Sex Offenses; Rape; Review; Prevalence

RESUMO

OBJETIVO

Sintetizar dados da literatura sobre a prevalência de violência sexual em refugiados.

MÉTODOS

Conduzimos uma revisão sistemática a partir da busca em sete bases bibliográficas. Foram elegíveis estudos em inglês, francês, espanhol e português com dados sobre a prevalência de violência sexual em refugiados e requerentes de asilo, de qualquer país, sexo ou idade.

RESULTADOS

Dos 2.906 títulos encontrados, 60 artigos foram incluídos. A prevalência foi amplamente variável (0% a 99,8%). Houve relatos de violência sexual em todos os continentes, com 42% dos artigos mencionando-a em refugiados provenientes da África (prevalências de 1,3% a 100%). O estupro foi a ocorrência mais relatada em 65% dos estudos (prevalências de 0% a 90,9%). As principais vítimas foram mulheres em 89% dos estudos, em todo o trajeto, principalmente nos países de origem. A violência foi perpetrada particularmente por parceiros íntimos, mas também por agentes de suposta proteção. Poucos estudos relataram-na em homens e crianças, com prevalências atingindo até 39,3% e 90,9%, respectivamente. Cerca de 1/3 dos estudos (32%) foram realizados em campos de refugiados ou locais de acolhimento, e mais da metade (52%) em serviços de saúde, utilizando instrumentos de avaliação de saúde mental. Nenhum estudo abordou a crise migratória mais recente. Não foi realizada meta-análise devido à heterogeneidade metodológica dos estudos.

CONCLUSÕES

A violência sexual é um problema prevalente que atinge refugiados de ambos os sexos, de todas as idades, em particular aqueles provenientes da África, durante todo o percurso migratório. Medidas de proteção são urgentemente necessárias, e novos estudos, com instrumentos mais apropriados, poderão mensurar melhor a magnitude atual do problema.

Palavras-Chave: Refugiados; Delitos Sexuais; Estupro; Revisão; Prevalência

INTRODUCTION

The world is currently experiencing the biggest migratory crisis since World War II, with an increasing number of refugees. According to the United Nations High Commissioner for Refugees (UNHCR) report, 65.6 million people were forced to move because of persecution, conflict, widespread violence or human rights violations in 2016. Of these, 22.5 million were refugees; 2.8 million, asylum seekers; and 40.3 million, internally displaced persons within their own countries1.

Sexual violence (SV), defined as a sexual act or attempt to obtain a sexual act without the voluntary consent of the victim or with someone unable to consent or refuse2, is considered a present threat during forced displacement and the search for asylum3,4. In times of war, women and girls are more vulnerable to rape and are at greater risk for other forms of SV, such as early or forced marriage, intimate partner abuse, child sexual abuse, sexual exploitation and trafficking4. SV has also been perpetrated against men and boys as a tactic of war or during detention and interrogation5; they may suffer rape, sexual torture, mutilation, humiliation, enslavement, and forced incest6. This risk persists during the escape journey and after the reception in apparently safe destinations7.

The consequences can be extremely serious. In women, it can lead to mental disorders, obstetric complications, sexual dysfunctions, unwanted pregnancies, unsafe abortions and sexually transmitted infections8,9. Among men, in addition to infections and mental disorders, sexual dysfunction, somatic complaints, sleep disorders, withdrawal from relationships, attempted suicide, alcohol and drug abuse, and violent behavior are common8,10. In childhood, sexual abuse may also be accompanied by guilt, shame, eating disorders, cognitive distortions, mental disorders, sexual and relationship problems, and school absenteeism11.

Two previous systematic reviews have portrayed SV in refugees and internally displaced persons in emergency humanitarian complexes12,13: a meta-analysis aimed at estimating its prevalence in women only12, and other aimed at quantifying gender-based violence in three categories: physical violence, by intimate and sexual partner13. Neither analyzed the different types, profile of perpetrators and the moment of occurrence of SV in the migratory process. No studies have been conducted on the prevalence of this violence in the total refugee population (children, adults and older adults of both sexes) in different scenarios and moments of their trajectory, for a more comprehensive understanding of the magnitude of the problem.

Thus, we aim to synthesize the literature on the prevalence of SV in refugees around the world through a systematic review, regardless of sex, age and location. With this knowledge, one may better identify the profile of refugees who are victims of SV, contributing to specific prevention, approach, treatment and monitoring strategies in the countries of origin, during migration and in the host countries.

METHODS

The bibliographic search was carried out in January 2018, using the MEDLINE (via Ovid), Embase (via Ovid), PsycINFO (via Ovid), Scopus, Web of Science, Sociological Abstracts (via ProQuest) and LILACS (via VHL) databases. No date limits or language restrictions were applied. Search strategies have involved the following MeSH and free terms: “refugee,” “asylum seek,” “exiled,” “refugee camps,” “sexual violence,” “sexual harassment,” “child abuse,” “sexual offense,” “sexual abuse,” “sexual crime,” “rape,” “sexual coercion,” “sexual assault.” Articles addressing any form of SV were included, using the connector “OR.” For the calculation by type of SV, we use the definition described in each of the articles. The search strategy is detailed in Appendix A. Articles within the bibliographic reference lists of the review studies and those included in this study were added where applicable.

Studies with data available for calculating the prevalence of SV in refugees or asylum seekers (considered as single population) in any country, sex or age, and published in English, French, Spanish and Portuguese were eligible. Chapters of books, dissertations, annals of congresses, editorials, letters, notes and comments were not included.

The selection of studies was initially conducted through the search of titles and abstracts; then by reading the full texts. Decisions on study eligibility and data extraction were performed by two independent reviewers on electronic forms constructed in EpiData 3.1 (EpiData Association, Odense, Denmark), and the differences were resolved by consensus or by a third reviewer. References were managed in EndNote Web software [Thomson Reuters (SCIENTIFIC), NY, USA].

Information was collected on: (1) study methods and population; (2) prevalence of SV according to sex, age, type of SV, continent/region/country of origin, host country/region, period of occurrence and profile of perpetrators.

In studies that presented additional categories of migrants (e.g. economic migrants), only information on refugees and asylum seekers was used. Likewise, in studies that reported psychological, physical and sexual violence, only SV data were used.

The calculation of global prevalence was estimated from the information on the total cases of the studies. For the calculation of specific prevalence, the following types of SV reported by the articles were considered: rape, attempted rape, unwanted sexual contact, non-contact unwanted sexual experience, sexual harassment, sexual abuse, sexual torture, sexual assault, sexual exploitation, including enforced prostitution and sex for survival, genital mutilation, forced marriage and abortion. When only the prevalence by type were informed and more than one of these forms was inflicted on the same victims, it was not possible to estimate the overall prevalence.

RESULTS

We found 2,906 studies in the databases searched and 10 in the lists of bibliographic references (Figure 1). After the duplicates were removed (n = 1,111), 1,805 studies were selected for the reading of titles and abstracts. Of these, 1,498 were excluded by the following criteria: language (n = 29), type of publication (comments, letters, books, notes, editorials, abstracts of lectures and dissertations, n = 361), study design (most qualitative or review studies, n = 521), population not composed of refugees or asylum seekers (n = 176), out of scope (did not address SV, n = 131) or both (population and scope, n = 280).

Figure 1 Flowchart for the selection of studies included in the systematic review. 

Three hundred and seven studies were selected for the reading of full texts. After the application of the eligibility criteria, 60 studies were included for data extraction. Of the excluded ones, 15 were not original articles, 121 were review studies or with qualitative design and in 27 studies the population was not formed by refugees or asylum seekers.

Characteristics of the Studies and their Populations

The 60 articles selected were all published in English between 1990 and 2017 (45% between 2000 and 2010) and from 31 different countries (14 from the USA). Studies were of cross-sectional design (Table 1), except for two cohort studies48,73.

Table 1 Characteristics of the studies included in the systematic review and prevalence of sexual violence. (n = 60) 

First author and year of study Country(ies)/ host region Data collection location Period of data collection Instrument of study Sampling (n) Mean age of sample (years) Female proportion (%) Global SV prevalence (%)* Prevalence of SV by sex


Start End Female Male
Allodi14 (1990) Canada USS 1979 1985 NI 56 NI 50.0 NI 64.3 39.3
Fornazzari15 (1990) Canada USS NI NI Collection in records 36 37 100.0 22.2 22.2 NA
Mckelvey16 (1995) Philippines USS NI NI RQ 102 NI 33.3 9.8 8.8 10.3
Peel17 (1996) United Kingdom USS and detention centers 1993 1994 Collection in records 92 NI 21.7 33.7 80 20.8
Frljak18 (1997) Bosnia and Herzegovina USS 1993 1994 Collection in records 241 NI 100.0 3.3 3.3 NA
Silove19 (1998) Australia NI NI NI HTQ 96 NI NI 0.0 0.0 0.0
Gorst-Unsworth20 (1998) United Kingdom USS NI NI HTQ 84 39 0.0 14.3 NA 14.3
Loutan21 (1999) Switzerland USS 1993 1994 HTQ 573 27 36.3 2.3 NI NI
Blair22 (2000) USA USS and households 1991 1991 WTS 124 37 60.5 5.6 NI NI
Hondius23 (2000) Netherlands USS NI NI NI 156 NI 34 23.1 26.4 21.4
Petersen24 (2000) Thailand RC 1999 1999 RQ 129 36 37.2 NI 6.3 NI
Iacopino25 (2001) Macedonia and Albania RC 1999 1999 RQ 11,458 NI NI 0.03 NI NI
Tang26 (2001) Gambia RC 1999 1999 HTQ 80 41.3 48.8 1.3 NI NI
Crescenzi27 (2002) India Villages 1995 1995 HTQ 150 NI 37.3 NI NI NI
Sabin28 (2003) Mexico RC 2000 2000 HTQ 170 37.9 58.2 3.5 NI NI
Cardozo29 (2004) Thailand RC 2001 2001 HTQ 495 NI 57.4 NI 2.8 2.9
Sesay30 (2004) Sierra Leone RC and villages 2001 2011 RQ 400 NI 100.0 11.3 11.3 NA
Thomas31 (2004) United Kingdom NI NI NI NI 100 16 41 32 63.4 10.2
Asgary32 (2006) USA USS 1998 2002 Istanbul Protocol 89 34 13.5 NI NI NI
Avdibegovic33 (2006) Bosnia and Herzegovina USS and RC 2000 2002 Modified DVI 50 NI 100.0 30.0 30.0 NA
Bradley34 (2006) United Kingdom USS NI NI NI 97 30 14.4 8.2 28.6 2.4
Schweitzer35 (2006) Australia Community 2003 2003 HTQ 63 34.2 33.3 11.1 19 7.1
Olsen36 (2006) Denmark USS 1991 1994 RQ 221 35.6 12.7 11.3 NI NI
Bogner37 (2007) England USS 2004 2005 RQ 27 NI 59.3 55.6 68.8 36.4
Edston38 (2007) Sweden USS 1993 2005 NI 63 28 100.0 76.2 76.2 NA
Hammoury39 (2007) Lebanon USS 2005 2005 AAS 349 28 100.0 26.4 26.4 NA
Hooberman40 (2007) USA USS 2000 2003 HTQ 325 33.5 38.8 28.9 NI NI
John-Langba41 (2007) Botswana RC NI NI SGBV 402 29.2 100.0 99.8 99.8 NA
Kira42 (2007) USA NI NI NI CTS 501 35.7 45.3 1.2 NI NI
Piwowarczyk43 (2007) USA USS 1999 2002 NI 134 34 65.7 50.0 NI NI
Chang44 (2008) USA USS 2001 2001 NI 243 10.6 51.9 4.9 NI NI
Nagai45 (2008) Uganda RC and villages 1999 2000 RQ 1,216 NI 78.0 NI 18.1 16.9
Harrison46 (2009) Uganda RC and villages 2006 2006 BSS 1,158 NI 52.4 NI 3.8 NI
Mitike47 (2009) Ethiopia RC 2004 2004 RQ 288 NI 100.0 42.4 42.4 NA
Williams48 (2010) United Kingdom USS 2005 2005 NI 178 30.4 35.4 25.8 54.0 10.4
Schubert49 (2011) Finland USS NI NI HTQ 78 37.6 37.2 NI NI NI
Tamblym50 (2011) USA USS 2004 2007 HTQ modified 58 34.7 29.3 20.7 NI NI
Bogic51 (2012) Germany, Italy and United Kingdom Households and communities 2005 2006 LSC 854 41.6 51.3 5.2 NI NI
Kira52 (2012) USA NI 2006 2006 CTS 209 NI 0.0 90.9 NI NI
Parmar53 (2012) Republic of Cameroon Villages 2010 2010 NI 191 35.1 100.0 40.8 40.8 NA
Black54 (2013) USA USS and Community 2004 2004 CREV SECV 196 13.8 45.9 4.6 NI NI
Falb55 (2013) Thailand RC 2008 2008 RHA 861 30.1 100.0 NI NI NA
Tufan56 (2013) Turkey USS 2005 2007 SLESQ 67 30.6 41.8 20.9 46.4 2,6
Gibson-Helm57 (2014) Australia USS 2002 2011 NI 1,279 NI 100.0 5.7 5.7 NA
Idemudia58 (2014) Polokwane, South Africa City NI NI RQ 125 28.3 42.3 NI NI NI
Morof59 (2014) Uganda NI 2010 2010 HTQ RQ 117 31.6 100.0 71.8 71.8 NA
Bell60 (2015) Ruanda RC 2008 2008 RHA toolkit 810 29 100.0 8.0 8.0 NA
Connor61 (2015) USA Community NI NI RQ 30 31.8 100.0 93.3 93.3 NA
Sipsma62 (2015) Ruanda RC NI NI RHA toolkit 548 32 100.0 38.1 38.1 NA
Al-Modallal63 (2016) Jordan RC NI NI AAS 238 32.7 100.0 21.0 21.0 NA
Chu64 (2016) USA Communities and households 2014 2014 RQ 15 NI 100.0 60.0 60.0 NA
Lerner65 (2016) USA USS 2010 2013 RQ 267 34 33.0 33.3 NI NI
Um66 (2016) South Korea NI 2010 2010 CTS2 180 39.8 100.0 25.6 25.6 NA
Wirtz67 (2016) Ethiopia RC 2012 2012 ASIST-GBV 487 NI 100.0 NI NI NA
Gušić68 (2017) Sweden Schools USS NI NI WRGTI 77 NI 35.0 12.0 NI NI
Hopkinson69 (2017) USA USS 2008 2013 HTQ RQ 61 28.8 37.7 62.3 NI NI
Logie70 (2017) Canada Communities and social networks 2013 2015 RQ 42 NI 100.0 52.0 52.0 NA
Riley71 (2017) Bangladesh RC NI NI HTQ 148 34 52.8 13.0 NI NI
Stark72 (2017) Ethiopia RC 2015 2015 NI 919 14.6 100.0 65.3 65.3 NA
Wright73 (2017) USA Agencies of settlement 2011 2012 HTQ 298 NI 45.0 NI 1.5 NI

SV: sexual violence; NA: not applicable; NI: not informed; RC: refugee camps; USA: Unites States of America; USS: health services units; RQ: research questionnaire; HTQ: Harvard Trauma Questionnaire; STAR: Resettlement Stressor Scale; WTS: War Trauma Scale; DVI: Domestic Violence Inventory; AAS: Abuse Assessment Screen; SBGV: Sexual and Gender-based Violence Scale; CTS: Revised Conflict Tactics Scales; CREV: Children’s Report of Exposure to Violence; SECV: Survey of Exposure to Community Violence; BSS: Behavioral Surveillance Surveys Questionnaire; SLESQ: Stressful Life Events Screening Questionnaire; LEC: Life Events Checklist; ASIST-GBV: Assessment Screen to Identify Survivors Toolkit for Gender Based Violence; LSC: Life Stressor Checklist; RHA: Reproductive Health Assessment; WRGTI: War/refugee and general trauma inventory

* The global prevalence of SV was calculated from the total number of cases reported by the studies or, when there was no such information, by the total sum of the specific cases reported (e.g. cases of rape, sexual harassment, etc.). However, in five studies32,49,55,58,67, the global prevalence could not be estimated since the authors did not report the total number of cases. It was not possible to calculate it from the sum of the typified prevalence because there were victims who suffered more than one type of SV, which would overestimate the calculation of the global prevalence.

The most frequent sites of data collection, according to the 54 articles that contained this information, were health services (n = 28.52%) and refugee camps (n = 17.32%). Most studies (87%) were conducted to evaluate outcomes in mental health, without the main objective of measuring the prevalence of SV cases. Among the 49 studies that informed the instrument used, the Harvard Trauma Questionnaire (HTQ) was the most frequently validated instrument (n = 15, corresponding to 31%), while 29% (n = 14) used questionnaires designed specifically for the research.

Studies involved 28,101 refugees and asylum seekers. The population of each study varied between 15 and 11,458 individuals. In 33% (n = 20) of the studies, the sample included less than 100 people, and in 18% (n = 11), more than 500 people. The mean age of participants ranged from 10.6 to 41.6 years old; 42% (n = 25) of the studies included those younger than 18 years. There was a general predominance of women; in 37% (n = 21) of the studies, the sample was exclusively female. The predominant religion was Muslim, in 12 (63%) of the 19 studies with data about it.

Prevalence of Sexual Violence

The global prevalence variation presented a large amplitude, regardless of the sample size: from 0% to 99.8%, with a total of 2,859 cases of SV. In 15 studies (31%), the prevalence was less than 10% (samples from 80 to 11,458 people), and in 11 (23%), more than 50% (samples from 15 to 919 people), as shown in Table 1. This wide variation occurred independently of the data collection scenario – in refugee camps (n = 12, 0.03% to 99.8%), health units (n = 25, 2.3% to 76.2%) and communities/villages (n = 6, 5.2% to 93.3%) – and assessing form – validated instruments (n = 25%; 0.0% to 99.8%) or questionnaires of the own research (n = 14; 0.03% to 93.3%).

Six studies reported SV in children and adolescents, with prevalence varying between 4.6% and 90.9%16,44,47,52,54,72. In 32 of the 36 (89%) studies that showed prevalence by sex, the main victims were women. Of these, 12 studies reported SV in both sexes, with a difference of up to 59.2% more of prevalence in women17. Two studies reported the opposite, but with disparities less than 2%16,29. In men, the prevalence reached 39.3%14.

Africa was the most frequent continent of origin in 13 (42%) of the 31 studies with information about it (Table 2). As to the moment of occurrence, approached by 18 studies, 17 (94%) reported that SV occurred in the country of origin (prevalence between 1% and 92%); in two studies (11%), it occurred during the course (prevalence of 5.2% in both)53,68; and two (11%) reported SV at the host site (prevalence of 39% in Cameroon53 and 46.1% in Uganda59).

Table 2 Prevalence of sexual violence in refugees according to place of origin. (n = 31) 

Continent(s) of origin Region of origin Country of origin First author and year of study Sampling (n) Prevalence of SV
Africa (n = 13) NI NI Thomas31 (2004) 65 24.6
NI NI Chu64 (2016) 15 60.0
Central Africa RDC Peel17 (1996) 92 33.7
RDC Edston38 (2007) 3 100.0
Central African Republic Parmar53 (2012) 77 57.1
RDC Bell60 (2015) 810 8.0
RDC Sipsma62 (2015) 548 38.1
West Africa Senegal Tang26 (2001) 80 1.3
Sierra Leone Sesay30 (2004) 400 11.3
NI Gibson-Helm57 (2014) 45 6.7
North Africa Sudan Schweitzer35 (2006) 63 11.1
Sudan and South Sudan Stark72 (2017) 919 65.3
NI Gibson-Helm57 (2014) 1,147 5.1
East Africa Uganda Edston38 (2007) 9 66.7
Somalia Mitike47 (2009) 248 49.2
NI Gibson-Helm57 (2014) 87 13.8
Asia (n = 8) Southern Asia Sri Lanka Silove19 (1998) 92 0.0
Bangladesh Edston28 (2007) 13 84.6
South Asia Myanmar Petersen24 (2000) 129 2.3
Myanmar Riley71 (2017) 148 13.0
Southeastern Asia Vietnam McKelvey16 (1995) 102 9.8
Cambogia Blair22 (2000) 124 5.6
Cambogia Chang44 (2008) 243 4.9
East Asia North Korea Um66 (2016) 180 25.6
Europe Asia Africa (n = 8) Middle East NI Olsen36 (2006) 221 11.3
NI Wright73 (2017) 133 1.5
Europe Asia Africa (n = 8) Middle East Iraq Gorst-Unsworth20 (1998) 84 14.3
Iraq Kira42 (2007) 501 1.2
Iraq Kira52 (2012) 209 90.9
Iraq Black54 (2013) 196 4.6
Iran Edston38 (2007) 11 45.5
Syria Edston38 (2007) 3 66.7
Turkey Bradley34 (2006) 97 8.2
Turkey Edston38 (2007) 3 100.0
NA (n = 2) Palestine NA Hammoury39 (2007) 349 26.4
NA Al-Modallal63 (2016) 238 21.0
America (n = 1) Central America Guatemala Sabin28 (2003) 170 3.5
Europe (n = 1) Bosnia Frljak18 (1997) 241 3.3

SV: sexual violence; NI: not informed; NA: not applicable; DRC: Democratic Republic of the Congo

The most frequent type of SV was rape (65%) (Table 3). The perpetrators were identified in 18 studies: 10 (55%) reported the occurrence of SV by intimate partner (prevalence from 4.3% to 30%)33,39,45,53,55,59,62,63,66,72, five by military personnel (prevalence from 1% to 74.6%)38,45,55,58,72, four by acquaintances51,53,55,72, four by relatives45,54,58,72, two by unknowns 51,53, two by rebel soldiers 31,53, one by police officers58, one by armed groups72, and one by guards in prison17.

Table 3 Prevalence according to the type of sexual violence in refugees. (n = 51) 

Type of sexual violence First author and year of study Continent/region/country of origin Host country/region Prevalence (%)
Rape (n = 33) Allodi14 (1990) Latin America Canada 30.4
Fornazzari15 (1990) Latin America Canada 22.2
Peel17 (1996) RDC United Kingdom 33.7
Frljak18 (1997) Bosnia Bosnia 3.3
Silove19 (1998) Sri Lanka Australia 0.0
Loutan21 (1999) Africa, Asia and Europe Switzerland 2.3
Petersen24 (2000) Myanmar Thailand 2.3
Tang26 (2001) Senegal Gambia 1.3
Crescenzi27 (2002) Tibet India 0.7
Cardozo29 (2004) Myanmar Thailand 2.8
Sesay30 (2004) Sierra Leone Sierra Leone 11.3
Thomas31 (2004) Africa, Middle East, Western Europe and Asia United Kingdom 32.0
Asgary32 (2006) Africa and Asia USA 6.7
Bradley34 (2006) Turkey United Kingdom 1.0
Schweitzer35 (2006) Sudan Australia 11.1
Avdibegovic33 (2006) NI Bosnia 34.0
Bogner37 (2007) Middle East, Europe, Africa and Latin America England 44.4
Edston38 (2007) Africa, Asia and Middle East Sweden 76.2
Hammoury39 (2007) Palestine Lebanon 26.4
Hooberman40 (2007) Africa, Asia, Europe and Central and South America USA 18.2
Harrison46 (2009) Africa Uganda 2.0
Williams48 (2010) Africa and Middle East United Kingdom 16.3
Rape (n = 33) Schubert49 (2011) Middle East, Southeast Europe, South Asia and Central Africa Finland 21.8
Kira52 (2012) Iraq USA 90.9
Falb55 (2013) Myanmar Thailand 0.3
Morof59 (2014) Somalia and DRC Uganda 54.7
Idemudia58 (2014) Zimbabwe Polokwane, South Africa 56.8
Bell60 (2015) RDC Ruanda 8.0
Lerner65 (2016) Africa, America and Western Europe USA 33.3
Wirtz67 (2016) Somalia Ethiopia 20.1
Hopkinson69 (2017) Africa, Asia, America and Eastern Europe USA 42.6
Logie70 (2017) NI Canada 52.0
Stark72 (2017) Sudan and South Sudan Ethiopia 16.1
Unwanted sexual contact (n = 7) Asgary32 (2006) Africa and Asia USA 6.7
Avdibegovic33 (2006) NI Bosnia 2.0
Schubert48 (2011) Middle East, Southeast Europe, South Asia and Central Africa Finland 46.2
Falb55 (2013) Southeastern Asia Thailand 0.7
Idemudia58 (2014) Zimbabwe Polokwane, South Africa 63.2
Hopkinson69 (2017) Africa, Asia, America and Eastern Europe USA 24.6
Stark72 (2017) Sudan and South Sudan Ethiopia 22.0
Sexual coercion (n = 1) Stark72 (2017) Sudan and South Sudan Ethiopia 27.3
Attempted rape (n = 2) Idemudia58 (2014) Zimbabwe Polokwane, South Africa 44.8
Morof59 (2014) Somalia and DRC Uganda 64.1
Forced pregnancy (n = 1) Wirtz67 (2016) East Africa Ethiopia 15.6
Sexual torture (n = 6) Hondius23 (2000) Turkey and Iran Netherlands 23.1
Asgary32 (2006) Africa and Asia USA 9.0
Bradley34 (2006) Turkey United Kingdom 2.1
Olsen36 (2006) Middle East Denmark 11.3
Bogner37 (2007) Middle East, Europe, Africa and Latin America England 11.1
Tamblyn50 (2011) Africa USA 20.7
Sexual Assault (n = 5) Gorst-Unsworth20 (1998) Iraq United Kingdom 14.3
Iacopino25 (2001) Kosovo Macedonia 0.03
Bradley34 (2006) Turkey United Kingdom 8.2
Hooberman40 (2007) Africa, Asia, Central and South America and Europe USA 10.8
Williams48 (2010) Africa and Middle East United Kingdom 12.9
Genital mutilation (n = 6) Asgary32 (2006) Africa and Asia USA 2.2
Bradley34 (2006) Turkey United Kingdom 1.0
Mitike47 (2009) Somalia Ethiopia 42.4
Gibson-Helm57 (2014) Africa and Middle East Australia 5.7
Connor61 (2015) Somalia and Ethiopia USA 93.3
Chu64 (2016) Africa USA 60.0
Sexual exploitation (n = 4) Cardozo29 (2004) Myanmar Thailand 1.0
Nagai45 (2008) Sudan Uganda 82.0
Idemudia58 (2014) Zimbabwe South Africa 44.0
Wirtz67 (2016) Somalia Ethiopia 27.3
Non-contact unwanted sexual experiences (n = 5) Crescenzi27 (2002) Tibet India 24.6
Asgary32 (2006) Africa and Asia USA 4.5
Avdibegovic33 (2006) NI Bosnia 2.0
Falb55 (2013) Myanmar Thailand 1.5
Hopkinson69 (2017) Africa, Asia, America and Eastern Europe USA 29.8
Sexual Abuse (n = 8) Allodi14 (1990) Latin America Canada 21.4
McKelvey16 (1995) Vietnam Philippines 9.8
Blair22 (2000) Cambodia USA 5.6
Kira42 (2007) Iraq USA 1.2
Chang44 (2008) Cambodia USA 4.9
Nagai45 (2008) Sudan Uganda 85.0
Black54 (2013) Iraq USA 4.6
Riley71 (2017) Myanmar Bangladesh 13.0
Forced marriage (n = 2) Asgary32 (2006) Africa and Asia USA 2.2
Wirtz67 (2016) Somalia Ethiopia 19.5
Sexual Harassment (n = 4) Asgary32 (2006) Africa and Asia USA 12.4
Bogic51 (2012) Bosnia Germany, Italy and United Kingdom 5.2
Idemudia58 (2014) Zimbabwe Polokwane, South Africa 52.8
Wright73 (2017) Middle East USA 1.5

NI: not informed; USA: United States of America; DRC: Democratic Republic of the Congo

In five studies32,49,55,58,67, the authors did not report the number of victims, and it was not possible to estimate the overall prevalence. Estimating the sum of prevalence by specific type would overestimate the overall prevalence due to cases that suffered more than one type of SV.

DISCUSSION

Previous studies have shown that SV is a constant threat throughout the refugee migration pathway3,12,13, which has been confirmed in the present review. Although most of the studies identified here revealed a higher prevalence among adult women, SV was also a serious problem in men and children. In addition, we observed the SV is perpetrated mainly by intimate partners, but also by military, guards and police. Most cases occur in the country of origin, in the form of rape and in refugees from Africa. In some refugee camps, such as Uganda and Cameroon, the frequency was alarming.

It is possible that prevalence may be underestimated in some studies, since many victims – especially men – do not report SV because of shame, threats by perpetrators, fear of being found guilty or suffering from stigma and exclusion from family and community6,74, with consequent low demand for health care and case records75. In addition, the humanitarian crisis caused by armed conflicts in the refugees’ countries of origin leads to large displacements of people and demands incompatible with the availability of health services and resources76, which may further reduce the chances of case identification. On the other hand, studies focused on the evaluation of mental trauma in health services may overestimate the prevalence.

In the meta-analysis of SV prevalence in women in emergency humanitarian complex scenarios, which also included internally displaced persons and excluded genital mutilation, the mean prevalence was 21.4% and higher in refugees from Africa12. In our review, we found several studies with a much higher prevalence. Regardless of the actual prevalence, SV was frequent in the populations studied, and deserves special attention in the health services and the reception of this population already weakened by traumas of war and persecution.

Young women are the main victims of SV, but men, children and adolescents are also victims, a reality little discussed in the literature. Men and unaccompanied minors are also exposed to the risk of sexual exploitation and abuse during migration and arrival in destination countries3. Nevertheless, the predominance in women is not surprising. The immigration process is accompanied by difficulties such as economic insecurity, language barriers and acculturation, which lead to the imbalance of power between women and partners, leading to increased tensions77. Because of economic, political, and social changes during wars and postwar periods, many men use violence to control women and reestablish their status of power78. Such conditions may explain the higher frequency of SV perpetrated by intimate partners.

SV occurs mainly before migration, in the countries of origin of the refugees. This suggests a relation with the conditions generated by the armed conflicts, which potentiate cultural norms of superiority of the masculine power present in these places, even before the condition of search of refuge. High prevalence in Africa supports this view. The Democratic Republic of Congo, where armed conflicts over natural resource reserves have lasted since independence in 196079, is marked by atrocities including group rape, sexual slavery, forced family involvement in rape, genital mutilation, among others80. More shocking is the fact that, even when hosted in refugee camps, this already fragile population still faces insecurity and suffers SV perpetrated by those from whom they expect protection, such as officers and police.

Rape was the most mentioned form of this violence. This can be explained by the more concrete definition, by the most remarkable experience, and because most studies have used the HTQ instrument, which has a specific question about rape and sexual abuse, but not about other forms of SV. Rape is considered the cruelest type because it brings serious and severe consequences to the health of the victims. War survivors diagnosed with posttraumatic stress disorder and rape victims report more somatic symptoms than those without a rape experience81. Rape also increases the chances of acquiring HIV infection, as reported in sub-Saharan African refugee women in Paris, and is related to social difficulties and lack of fixed residence due to the risk of transactional sex or sexual harassment during lodging by relatives or acquaintances82.

Several studies included in this review had many limitations, such as lack of detail on the population, outcome of interest, timing of the occurrence, profile of the perpetrators, gender and age of the victims. In addition, the studies did not include victims of the most recent migratory crisis, which began in 2015.

Our review also has limitations. The literature search did not include the terms “sexual torture” and “genital mutilation,” which may have resulted in low sensitivity and explained the number of articles found in reference lists. We did not include the gray literature and no methodological quality evaluation of the selected studies was performed. In addition, we did not restrict the sample size of the articles, which resulted in imprecise estimates in studies with few individuals38. Finally, methodological differences between the studies (different data collection sites, such as mental health services and refugee camps; different data collection instruments; studies focusing on mental disorders rather than SV prevalence; and unequal sampling) have contributed to the diversity of the rates found and heterogeneity between the studies, which prevented a meta-analysis to summarize the information.

In summary, results of this review show that SV is a frequent problem among refugees, both women and men, mainly those from Africa, and occurs at all times in the migratory process, including in places of supposed reception and protection. The SV problem among refugees from the most recent migratory crisis must be investigated in unselected scenarios and with more appropriate methods to better guide the necessary protection measures.

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Received: September 9, 2018; Accepted: December 4, 2018

Correspondence: Eduardo Faerstein Rua Sacopã,191 apto 201 22471-180 Rio de Janeiro, RJ, Brasil E-mail: efaerstein@gmail.com

Authors’ Contributions: Design and planning of the study: JOA, FMS, RP, AT, EF. Data collection, analysis and interpretation: JOA, FMS, RP, MLB, AT, EF. Elaboration or revision of the manuscript: JOA, FMS, AT, EF. Approval of the final version: JOA, FMS, RP, MLB, AT, EF. Public responsibility for the content of the article: JOA, FMS, PR, MLB, AT, EF.

Conflict of Interest: The authors declare no conflicts of interest.

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