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TRIPLE JEOPARDY:
FEMALE ADOLESCENCE, SEXUAL VIOLENCE, AND HIV/AID

Pervasive gender inequalities mean that girls especially face numerous violations to their sexual and reproductive health and rights, including sexual initiation before they are physically or emotionally ready.^1,2 Girls who live in extreme poverty, among marginalized populations, without family support, or in situations of conflict and displacement are particularly vulnerable to coerced sexual encounters and abuse.^3-7

HIV/AIDS AMONG YOUTH
Half of new HIV infections worldwide are in women,⁸ and in 2007, young people, ages 15–24, accounted for about 40 percent of new HIV infections among people age 15 and older. ⁹ Globally, there are 5.4 million young men and women who are living with HIV, and nearly 60 percent of them are female.¹⁰

• Unfortunately the 2007 published data from The Joint United Nations Programme on HIV/AIDS do not address the age group 15–19 specifically. The 2002 data indicated much higher rates of infection in girls than in boys in this age group in urban areas of southern and eastern Africa. ¹¹
• In sub-Saharan Africa, on average, three young women, ages 15–24, are infected with HIV for every young man; in some countries in the Caribbean, young women, ages 15–24, are more than twice as likely to be infected with HIV than young men.¹²
• In Cambodia, three times as many women and girls, ages 15–24, are living with HIV as their male counterparts.¹³
  
• In South Africa, an estimated 14 percent of young women and four percent of young men, ages 15–24, are living with HIV.¹⁴
  
• In Lesotho, fewer than ten percent of girls ages 18 and 19 are living with HIV, but by age 24 almost 40 percent of them will be HIV-positive.¹⁵

ADOLESCENT GIRLS’ EXPERIENCES OF SEXUAL COERCION AND VIOLENCE

Girls are highly vulnerable as children and adolescents to sexual abuse and violence in their homes, neighborhoods, schools, and communities.^1-7 Early sexual initiation is strongly associated with sexual coercion in many places.

• In Lima, Peru, 45 percent of women who first had intercourse before age 15 said they were coerced. Comparable figures for provincial Tanzania and Bangladesh are 43 percent and 36 percent, respectively (see table).¹⁶

• In South Africa, the most prevalent crime reported against children is rape. Forty percent of rapes or attempted rapes reported to the police are of girls under age 18.¹⁷
  
• Among primary school students in Malawi who reported having experienced forced sex, 71 percent said that it had happened at school. More than 80 percent of the students said they knew someone who had been sexually victimized by a teacher in return for good grades. Girls reported higher rates of sexual coercion than boys overall.¹⁸
  
• Among sexually experienced Kenyan boys and girls ages 10–19, 45 percent of girls and 17 percent of boys had been forced into non-consensual sex at least once. Boys who had been coerced themselves were four times more likely than those who hadn’t to admit to persuading or forcing girls to have sex against their will. ¹
  
• Sexual initiation within marriage may also be forced. Substantial proportions of Ethiopian and Bangladeshi women said their sexual initiation was forced (see table), and virtually all of these girls experienced sexual initiation within marriage.^1,2,16

SEXUAL VIOLENCE AND GIRLS’ VULNERABILITY TO HIV/AIDS
The use of physical force or emotional coercion during a sexual act greatly increases the risk of HIV transmission to the female if the male is infected. The female genital tract is highly susceptible to sexually transmitted infections (STIs), including HIV.¹⁹ Violence and rape can further increase HIV risk by causing abrasions, bleeding, and tearing, especially among young girls whose genital tracts are not yet fully mature.²⁰

Many girls and young women, especially the very young, cannot refuse unwanted sex or negotiate protection from pregnancy and STIs, including HIV, particularly when they fear retaliation. They can suffer multiple adverse physical, social, and emotional outcomes.^1,2,21  In situations of force or coercion, whether by strangers, acquaintances, family members, boyfriends, “sugar daddies,” or husbands, negotiating condom use is virtually impossible.

• A study in South Africa which included young women ages 16 and over found that women who are in relationships with violent or domineering men are 50 percent more likely to contract HIV than women not involved in abusive relationships.²²
• For girls who marry young, physiological vulnerability is compounded by exposure to frequent, unprotected, and also forced sexual intercourse within marriage. Young girls married to older men are at especially high risk because their husbands are more likely than younger men to have had other partners and to be HIV-positive.^{23, 24} In Uganda, the risk of HIV infection doubles for girls ages 15–19 who have male partners ten or more years older.²⁵
• Some abusive men control their female partners by forbidding them to leave the house, contact friends or family members, or attend health clinics or other community services.¹⁶ Young married girls are often particularly isolated,²⁶ but most adolescent girls who experience sexually abusive relationships or encounters have difficulty accessing services.
• Violence can be both a cause and a consequence of HIV infection.^{27, 28} Women in some studies report fear of being beaten or abandoned by their partners as their main reason for not obtaining an HIV test, not disclosing the results, or not requesting that their partner be tested, use condoms, or be faithful.²⁹

POLICY AND PROGRAM RESPONSES
Effective strategies, policies, and programs are urgently needed at national, provincial, and local levels to protect young people, especially girls and young women, from sexual abuse or coerced sex and its consequences, including HIV infection.^1,2,30-33   Continuous advocacy, strategic investment, and committed leadership are essential to addressing the triple jeopardy of sexual violence, HIV/AIDS, and adolescence.

• ESTABLISH LAWS AND POLICIES FOR ZERO-TOLERANCE OF ABUSE AND VIOLENCE. Political, civic, and religious leaders should publicly condemn all forms of sexual harassment, abuse, and violence and initiate and implement laws that emphasize the human rights of girls and young women. Police officers and other law enforcement officials should be trained to recognize and respond to violence against adolescents, particularly to understand how gender inequalities often lead to and perpetuate abuse.
  
• PROVIDE UNIVERSAL ACCESS TO COMPREHENSIVE SEXUALITY EDUCATION. Comprehensive sexuality education in schools should be available to all students, beginning in the primary levels.³⁴ Such education gives young people information about their bodies, their health, and health care. It teaches young people about communication and decision-making. It helps them learn how to establish equality in relationships, respect the right to consent in both sex and marriage, and end violence and sexual coercion.
  
• EMPLOY POPULAR MEDIA IN AWARENESS AND EDUCATION CAMPAIGNS.   Awareness and prevention messages about sexual violence, equality, and human rights can be effectively promoted among adolescents through popular media such as radio, video, and the Internet.
  
  
• CREATE SAFE PLACES FOR GIRLS INSIDE SCHOOLS AND IN THE COMMUNITY.  Schools, youth programs, and communities must have clear policies and interventions to prevent and punish sexual harassment and abuse, as well as gender discrimination in these settings. They should ensure physical security on the premises, including in lavatories and girls' travel to and from school. Girls-only programs, facilities, and spaces can be considered depending on local circumstances.⁷ All professional personnel should be trained to recognize symptoms of abuse or violence, to refer girls for support and care, and treat their students in a non-discriminatory manner.
  
• MAKE HEALTH SERVICES ATTRACTIVE TO YOUNG PEOPLE. Sexual and reproductive health services should be offered to all adolescents and encompass information and services for the prevention, diagnosis, and treatment of sexual violence, unwanted pregnancy, and STIs, including HIV. ^{36, 37} To ensure that these services appeal to young people, they must be affordable, non-judgmental, confidential, available outside of school hours, and accessible without parental consent requirements.
  
  
• TRAIN HEALTH CARE PROVIDERS. Health care providers should be trained to recognize and treat emotional, physical, and sexual abuse among youth, including providing referrals and confidential, non-judgmental counseling. Health care providers should routinely offer youth, who have been sexually assaulted, STI and HIV counseling and testing, emergency contraception, and post-exposure prophylaxis to prevent HIV infection. Young women should also receive pregnancy counseling and testing, and safe abortion services if desired. In addition, health care providers should be trained to refer offenders to social services and to call on the criminal justice system for support.^{38, 39}
  
• UNDERTAKE PROGRAMS FOR MEN AND BOYS. Programs for men and boys are also urgently needed to help change social norms of how men and women interact and to encourage relationships based on gender equality. These programs should emphasize men’s obligation to respect and protect the human rights of women as well as men’s responsibility for their own sexual behaviors and their consequences.

Acknowledgements
We are grateful to reviewer Lucy Stackpool-Moore.

For more information on adolescents, including additional policy and program recommendations, please visit www.iwhc.org/resources/youngadolescents/index.cfm.

REFERENCES
¹ Shireen J. Jejeebhoy, Iqbal Shah and Shyam Thapa. 2005. Sex Without Consent: Young People in Developing Countries. New York and London: Zed Books.
²   Shireen J. Jejeebhoy and Sarah Bott. 2003. Non-consensual sexual experiences of young people: A review of evidence from developing countries. New Delhi: Population Council. http://www.popcouncil/pdfs/wp/seasia/seawp16.pdf.
³ UNICEF, UNAIDS and WHO. 2002. Young People and HIV/AIDS: Opportunity in Crisis. New York: UNICEF.
⁴ Judith Bruce and Amy Joyce (eds.). 2006. The Girls Left Behind: The Failed Reach of Current Schooling, Child Health, Youth-serving and Livelihoods Programs for Girls Living in the Path of HIV. New York: The Population Council.
⁵ Global Coalition on Women and AIDS, WHO. November 2004. “Sexual violence in conflict settings and the risk of HIV,”  Violence Against Women and HIV/AIDS: Critical Intersections. Information Bulletin Series, no. 2.   Geneva: World Health Organization. http://www.who.int/gender/en/infobulletinconflict.pdf
⁶ Global Coalition on Women and AIDS. 2005. “Violence against sex workers and HIV prevention.”  Violence Against Women and HIV/AIDS: Critical Intersections. Information Bulletin Series, no. 3. Geneva: World Health Organization. http://www.who.int/gender/documents/sexworkers.pdf
⁷ Global Health Council. 2007. Girls and HIV: A New Epidemic in the Women of Tomorrow?  Thematic issue of Global AIDS Link, No. 101. Washington DC: Global Health Council.
http://www.ungei.org/resources/files/globalhealthcouncil_Aidslink101.pdf.
⁸UNAIDS. 2007. AIDS epidemic update December 2007. Geneva: UNAIDS/WHO, . http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2007/default.asp
⁹ UNICEF. January 2007. Children and AIDS: A Stocktaking Report. New York: UNICEF. http://www.unicef.org/publications/index_38048.html
¹⁰ WHO, Children and AIDS: Second stocktaking report Fast Facts. http://www.who.int/hiv/mediacentre/Stocktaking_FastFacts.pdf
¹¹ “In Ethiopia, Malawi, United Republic of Tanzania, Zambia and Zimbabwe, for every 15- to 19-year-old boy who is infected, there are five to six girls infected in the same age group… In major urban areas of eastern and southern Africa, epidemiological studies have shown that 17 to 22 per cent of girls aged 15 to 19 are already HIV infected compared with 3 to 7 per cent of boys of similar age.” Taken from: UNICEF. July 2002. Young people and HIV/AIDS opportunity in crisis. http://www.unicef.org/newsline/HIV_10REV67.pdf
¹² The Kaiser Family Foundation. November 2007. The global HIV/AIDS epidemic. Washington DC: The Kaiser Family Foundation. http://www.kff.org/hivaids/upload/3030-103.pdf.
¹³UNICEF. The State of the World’s Children, 2008. Table 4, HIV/AIDS. New York: UNICEF. http://www.unicef.org/sowc08/statistics/tables.php
¹⁴ UNAIDS. 2006.   Report on the Global AIDS Epidemic, 2006. Geneva: UNAIDS/WHO, cited by Kaiser Family Foundation, “The HIV/AIDS Epidemic in South Africa,” January 2008.  http://kff.org/hivaids/upload/7365_04.pdf
¹⁵ UNAIDS. 2006.   Report on the Global AIDS Epidemic, 2006. Geneva: UNAIDS/WHO. http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/Default.asp
¹⁶ World Health Organization. WHO Multi-country Study on Women’s Health and Domestic Violence Against Women. Summary Report. Geneva: WHO http://www.who.int/gender/violence/who_multicountry_study/en/index.html
¹⁷ Julia C. Kim, Lorna J. Martin and Lynette Denny. “Rape and HIV post-exposure prophylaxis: addressing the dual epidemics in South Africa.” Reproductive Health Matters, no. 11(22) 2003:101-112.
¹⁸ Patrick Burton. 2005. Suffering at School: Results of the Malawi Gender-based Violence in Schools Survey. Malawi: National Statistical Office.
¹⁹ World Health Organization. 2005. Sexually Transmitted and Other Reproductive Tract Infections: A Guide to Essential Practice. Geneva: WHO.
²⁰ Global Coalition on Women and AIDS, WHO. 2004.“Intimate partner violence and HIV/AIDS.” Violence Against Women and HIV/AIDS: Critical Intersections. Information Bulletin Series, no. 1. Geneva: WHO. http://www.who.int/gender/violence/en/vawinformationbrief.pdf
²¹ Population Council. “The adverse health and social outcomes of sexual coercion: Experiences of young women in developing countries.”  Research Brief. New York: Population Council.http://www.popcouncil.org/pdfs/popsyn/PopulationSynthesis3.pdf.
²² Kristin L. Dunkle, Rachel K. Jewkes, Heather C. Brown et al. 2004. "Gender-based violence, relationship power and risk of HIV infection in women attending antenatal clinics in South Africa." Lancet 363(9419):1415-1421.
²³ Shelley Clark, Judith Bruce, and Annie Dude. 2006. “Protecting young women from HIV/AIDS: the case against child and adolescent marriage.”  International Family Planning Perspectives 32(2):79-88.
²⁴ Shelley Clark. 2004. “Early marriage and HIV risks in Sub-Saharan Africa.” Studies in Family Planning 35(3):149-160.
²⁵ International Center for Research on Women. 2003. Cross Generational Sex Fueling the HIV/AIDS Epidemic in sub-Saharan Africa. Washington, DC: ICRW.
²⁶ Nicole Haberland, Erica L. Chong and Hillary J. Bracken. 2004. “A world apart: the disadvantage and social isolation of married adolescent girls.”  Brief based on background paper prepared for the WHO/UNFPA/Population Council Technical Consultation on Married Adolescents. New York: Population Council.
²⁷ Claudia Garcia-Moreno and Charlotte Watts. 2000. “Violence against women: its importance for HIV/AIDS.”  AIDS 14 (Suppl. 3):S 253-265.
²⁸ UNAIDS, Global Coalition on Women and AIDS, Stop Violence Against Women, Fight AIDS, Issue 2 (2005). http://womenandaids.unaids.org/themes/docs/UNAIDS%20VAW%20Brief.pdf.
²⁹ World Health Organization. 2004. Gender Dimensions of HIV Status Disclosure to Sexual Partners: Rates, Barriers and Outcomes. A Review Paper. Geneva: WHO.
³⁰ WHO. 2003. Integrating Gender into HIV/AIDS Programmes. A Review Paper. Geneva: WHO.
³¹ Sarah Bott, Andrew Morrison and Mary Ellsberg. 2005. Preventing and Responding to Gender-based Violence in Middle- and Low-income Countries: A Global Review and Analysis. World Bank Policy Research Working Paper 3618. Washington, DC: World Bank.
³² David A. Ross, Bruce Dick and Jane Ferguson (eds.). 2006. Preventing HIV/AIDS in Young People: A Systematic Review of the Evidence from Developing Countries. UNAIDS Inter-agency Task Team on Young People. Geneva: World Health Organization.
³³ Judith Mirsky. 2003. Beyond Victims and Villains: Addressing Sexual Violence in the Education Sector. London: The Panos Institute.
³⁴ Deborah Rogow and Nicole Haberland. 2005. “Sexuality and relationships education: toward a social studies approach.”  Sex Education 5(4):333-344.
³⁵ Fiona Leach. 2006. “Gender Violence in Schools: What’s New?” Brighton, United Kingdom: Centre for International Education, University of Sussex.
³⁶ Karl L. Dehne and Gabriele Riedner. 2005. Sexually Transmitted Infections Among Adolescents: The Need for Adequate Health Services. Geneva: World Health Organization.
³⁷ World Health Organization. 2005. Sexual and Reproductive Health and HIV/AIDS: A Framework for Priority Linkages. Geneva: WHO, UNAIDS; London: IPPF; New York: UNFPA.
³⁸ Rachel Goldberg. 2006. Living Up to their Name: Profamilia Takes on Gender-based Violence. Quality/Calidad/Qualité No. 18. New York: The Population Council.
³⁹ World Health Organization. 2004. Clinical Management of Rape Survivors: Developing Protocols for Use with Refugees and Internally Displaced Persons (revised ed.). Geneva: WHO.

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