Forced Sexual Initiation and Early Sexual Debut and Associated Risk Factors and Health Problems Among Adolescent Girls and Young Women — Violence Against Children and Youth Surveys, Nine PEPFAR Countries, 2007–2018

Adolescent girls and young women aged 13–24 years are disproportionately affected by HIV in sub-Saharan Africa (1), resulting from biologic, behavioral, and structural* factors, including violence. Girls in sub-Saharan Africa also experience sexual violence at higher rates than do boys (2), and women who experience intimate partner violence have 1.3–2.0 times the odds of acquiring HIV infection, compared with those who do not (3). Violence Against Children and Youth Survey (VACS) data during 2007–2018 from nine countries funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) were analyzed to estimate prevalence and assess factors associated with early sexual debut and forced sexual initiation.^† Among adolescent girls and young women aged 13–24 years who ever had sex, the prevalence of lifetime sexual violence ranged from 12.5% to 49.3%, and forced sexual initiation ranged from 14.7% to 38.9%; early sexual debut among adolescent girls and young women aged 16–24 years ranged from 14.4% to 40.1%. In multiple logistic regression models, forced sexual initiation was associated with being unmarried, violence victimization, risky sexual behaviors, sexually transmitted infections (STIs), and poor mental health. Early sexual debut was associated with lower education, marriage, ever witnessing parental intimate partner violence during childhood, risky sexual behaviors, poor mental health, and less HIV testing. Comprehensive violence and HIV prevention programming is needed to delay sexual debut and protect adolescent girls and young women from forced sex.

VACS are nationally representative, multistage cluster household surveys of persons aged 13–24 years. All study protocols included oral informed consent, parental consent for minors, safeguards to protect privacy and confidentiality of participants, and referrals to postviolence care as needed.^§ CDC and in-country Institutional Review Boards approved study protocols.^⁋ This report examines lifetime experiences of sexual violence, early sexual debut, and forced sexual initiation among adolescent girls and young women aged 13–24 years in Eswatini,** Haiti, Kenya, Malawi, Nigeria, Tanzania, Uganda, Zambia, and Zimbabwe, using 2007–2018 data from VACS.^†† Lifetime sexual violence included ever experiencing 1) unwanted sexual touching, 2) unwanted attempted sex, 3) pressured or coerced sex, or 4) physically forced sex. Early sexual debut was defined as first sexual intercourse at or before age 15 years among adolescent girls and young women aged 16–24 years who had ever had sex with or without violence. Forced sexual initiation was defined as pressured, coerced, or physically forced first sex among adolescent girls or young women aged 13–24 years who had ever had sex. Orphan status was defined as having one or both parents deceased before the 18th birthday. Weighted prevalences of lifetime sexual violence, early sexual debut, and forced sexual initiation were estimated for each country using SAS (version 9.4; SAS Institute); prevalences were weighted to the most recent census or population projections to account for the multistage cluster design and nonresponse. Multiple logistic regression models were fit to the data combined across all countries to examine the odds of forced sexual initiation and early sexual debut by demographic characteristics and childhood experiences and health problems and behaviors. These models included a fixed effect for country and accounted for survey design, including stratification and clustering, and were adjusted to control for age and marital status.

Prevalence of lifetime sexual violence among adolescent girls and young women varied across countries, ranging from 12.5% (Zimbabwe) to 49.3% (Eswatini) (Table 1). Among those who had ever had sex, the prevalence of forced sexual initiation ranged from 14.7% (Zimbabwe) to 38.9% (Malawi) and early sexual debut ranged from 14.4% (Zimbabwe) to 40.1% (Nigeria). Among adolescent girls and young women who had ever had sex, the odds of having experienced forced sexual initiation were elevated among those aged 13–15 years (adjusted odds ratio [aOR] = 1.77), those who experienced nonpenetrative sexual violence during childhood (aOR = 2.38) and who experienced emotional violence during childhood (aOR = 1.44) (Table 2). Odds were lower among those who were ever married or cohabitating (aOR = 0.47) and those who never attended school (aOR = 0.56). The odds of early sexual debut were higher among adolescent girls and young women aged 16–19 years (aOR = 3.29), those who had no education (aOR = 5.16) or less than primary education (aOR = 2.19), were ever married or cohabitating (aOR = 3.03), or who had witnessed parental intimate partner violence before age 18 years (aOR = 1.31). The odds of forced sexual initiation or early sexual debut did not differ by orphan status, childhood physical violence, or witnessing violence in the community during childhood.

Compared with adolescent girls and young women who did not experience forced sexual initiation, those who did had elevated odds of engaging in transactional sex^§§ during the past 12 months (aOR = 1.6), infrequent condom use during the past 12 months (among those who were never married) (aOR = 1.7), ever having had an STI (aOR = 1.6), experiencing one or more (aOR = 2.8) and two or more (aOR = 2.6) types of violence during the past 12 months, having recent moderate or severe mental distress (aOR = 1.6), and ever having suicidal thoughts (aOR = 2.1) (Table 3). Compared with those who did not experience early sexual debut, those who did had increased odds of having multiple sexual partners during the past 12 months (aOR = 1.7), infrequent condom use among those who were ever married (aOR = 2.1) or never married (aOR = 1.9), having recent moderate or severe mental distress (aOR = 1.5), and ever having attempted suicide (among those who ever thought of suicide) (aOR = 2.1). The odds were lower for ever having been tested for HIV (aOR = 0.4) and having been tested during the past year (aOR = 0.5). The odds of alcohol abuse did not differ among those who did and did not experience forced sexual initiation or early sexual debut.

Acknowledgments

Governments and VACS Multisector Taskforce/Steering Committees of Eswatini, Haiti, Kenya, Malawi, Nigeria, Tanzania, Uganda, Zambia, Zimbabwe; PEPFAR; U.S. Agency for International Development; UNICEF; Together for Girls; the implementing partners; Division of Global HIV and TB, Center for Global Health, CDC; CDC staff members at headquarters and in each country.

Corresponding author: Pragna Patel, plp3@cdc.gov, 404-639-6132.

¹Strategic Innovative Solutions, LLC, Clearwater, Florida; ²Division of Global HIV and TB, Center for Global Health, CDC; ³Division of Violence Prevention, National Center for Injury Prevention and Control, CDC; ⁴CDC Kenya; ⁵CDC Nigeria; ⁶University of Miami, Coral Gables, Florida; ⁷Interuniversity Institute for Research and Development, Port-au-Prince, Haiti; ⁸Department of Population Studies, University of Zambia, Harare, Zimbabwe; ⁹CDC Zimbabwe; ¹⁰CDC Malawi; ¹¹CDC Tanzania; ¹²Walter Reed Army Institute of Research, U.S. Department of Defense, Tanzania; ¹³CDC Eswatini; ¹⁴CDC Uganda; ¹⁵Uganda Ministry of Gender, Labour and Social Development, Kampala, Uganda; ¹⁶Zimbabwe Ministry of Health and Child Care, Harare, Zimbabwe; ¹⁷Zambia Central Statistics Office, Lusaka, Zambia; ¹⁸Malawi Ministry of Gender, Children, Disability and Social Welfare, Lilongwe, Malawi; ¹⁹Tanzania Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania; ²⁰Eswatini Ministry of Health, Mbabane, Eswatini; ²¹Office of the Global AIDS Coordinator, U.S. Department of State.

References

1. Joint United Nations Programme on HIV/AIDS. UNAIDS data 2019. Geneva, Switzerland: UNAIDS; 2019. https://rstesa.unaids.org/publications/global-publications/item/208-unaids-data-2019external icon
2. Sumner SA, Mercy AA, Saul J, et al. ; CDC. Prevalence of sexual violence against children and use of social services—seven countries, 2007-2013. MMWR Morb Mortal Wkly Rep 2015;64:565–9. PMID:26042646external icon
3. Li Y, Marshall CM, Rees HC, Nunez A, Ezeanolue EE, Ehiri JE. Intimate partner violence and HIV infection among women: a systematic review and meta-analysis. J Int AIDS Soc 2014;17:18845. https://doi.org/10.7448/IAS.17.1.18845external icon PMID:24560342external icon
4. Stöckl H, Kalra N, Jacobi J, Watts C. Is early sexual debut a risk factor for HIV infection among women in sub-Saharan Africa? A systematic review. Am J Reprod Immunol 2013;69(Suppl 1):27–40. https://doi.org/10.1111/aji.12043external icon PMID:23176109external icon
5. Stockman JK, Lucea MB, Campbell JC. Forced sexual initiation, sexual intimate partner violence and HIV risk in women: a global review of the literature. AIDS Behav 2013;17:832–47. https://doi.org/10.1007/s10461-012-0361-4external icon PMID:23143750external icon
6. Wellings K, Collumbien M, Slaymaker E, et al. Sexual behaviour in context: a global perspective. Lancet 2006;368:1706–28. https://doi.org/10.1016/S0140-6736(06)69479-8external icon PMID:17098090external icon
7. Mitchell J, Wight M, Van Heerden A, Rochat TJ. Intimate partner violence, HIV, and mental health: a triple epidemic of global proportions. Int Rev Psychiatry 2016;28:452–63. https://doi.org/10.1080/09540261.2016.1217829external icon PMID:27599188external icon
8. U.S. President’s Emergency Plan for AIDS Relief. PEPFAR 2020 country operational plan guidance for all PEPFAR countries. Washington, DC: PEPFAR; 2020. https://www.state.gov/wp-content/uploads/2020/01/COP20-Guidance_Final-1-15-2020.pdfpdf iconexternal icon
9. World Health Organization. INSPIRE: seven strategies for ending violence against children. Geneva, Switzerland: World Health Organization; 2016. https://www.who.int/publications/inspire-seven-strategies-for-ending-violence-against-childrenexternal icon
10. Saul J, Bachman G, Allen S, Toiv NF, Cooney C, Beamon T. The DREAMS core package of interventions: a comprehensive approach to preventing HIV among adolescent girls and young women. PLoS One 2018;13:e0208167. https://doi.org/10.1371/journal.pone.0208167external icon PMID:30532210external icon

Abbreviation: VACS = Violence Against Children and Youth Surveys.
* Lifetime sexual violence is defined as unwanted touching, unwanted attempted sex, pressured or coerced sex, or physically forced sex. For this analysis, lifetime sexual violence was examined for adolescent girls and young women aged ≤24 years.
^† Forced sexual initiation defined as first sexual intercourse was physically forced, pressured, or coerced, among adolescent girls and young women aged 13–24 years who had ever had sex. Definitions of pressured sex varied among countries.
^§ Early sexual debut defined as first sex at aged ≤15 years among adolescent girls and young women aged 16–24 years who had ever had sex.
^¶ Weights accounted for the multistage cluster sampling design (e.g., enumeration area, household, and household member), nonresponse, and calibration to a known population (i.e., the most recent census for Eswatini, Kenya, Tanzania, Uganda, and Zimbabwe; for the remaining countries, the country’s population projections for the year of VACS data used).
** Formerly Swaziland.

Abbreviation: aOR = adjusted odds ratio.
* Sex was defined as ever experiencing vaginal, oral, or anal sex (Kenya, Malawi, Nigeria, Uganda, Zambia, and Zimbabwe); vaginal or anal intercourse (Haiti); or sexual intercourse (Eswatini and Tanzania).
^† Forced sexual initiation was defined as having sexual intercourse at first sexual encounter through physical force, pressure, or coercion, among adolescent girls and young women aged 13–24 years who had ever had sex. Definitions of pressured sex varied among countries.
^§ Early sexual debut was defined as first sex at age ≤15 years among adolescent girls and young women aged 16–24 years who had ever had sex. Participants aged 13–15 years were excluded from this analysis because they are still in the period during which early sexual debut could occur.
^¶ Prevalence is weighted to the population of each of the nine included countries (except where fewer countries are included, as noted).
** Statistically significant (p<0.05).
^†† Orphan status was defined as having one or both parents deceased before the 18th birthday.
^§§ Nonpenetrative sexual violence was defined as unwanted sexual touching or unwanted attempted sex.
^¶¶ Physical violence included being “punched, kicked, whipped, or beat with an object,” “choked, smothered, drowned, or burned,” or “threatened with a weapon” by an intimate/romantic partner, peer, family member or caregiver, or adult in community before age 18 years.
*** Emotional violence included having a parent, caregiver, or other adult telling child they were not loved, do not deserve to be loved, that they wished the child was dead or never born, or if they ever ridiculed or put down the child before age 18 years.
^††† Ever witnessed parental intimate partner violence included seeing or hearing a parent punched, kicked, or beaten by their partner. Data from Eswatini, Haiti, Tanzania, and Zimbabwe were not included.
^§§§ Ever witnessed violence in the community included seeing anyone get attacked outside of home or family environment. Data from Eswatini, Haiti, Tanzania, and Zimbabwe were not included.

Abbreviations: aOR = adjusted odds ratio; STI = sexually transmitted infection.
* Sex was defined as ever experiencing vaginal, oral, or anal sex (Kenya, Malawi, Nigeria, Uganda, Zambia, and Zimbabwe); vaginal or anal intercourse (Haiti); or sexual intercourse (Eswatini and Tanzania).
^† Forced sexual initiation was defined as having sexual intercourse at first sexual encounter through physical force, pressure, or coercion, among women and girls aged 13–24 years who had ever had sex. Definitions of pressured sex varied among countries.
^§ Early sexual debut was defined as first sex at age ≤15 years among adolescent girls and young women aged 16–24 years who had ever had sex.
^¶ Prevalence is weighted to the population of each of the nine included countries (except where fewer countries are included, as noted).
** Among adolescent girls and young women who had sex in the past 12 months. Data for Eswatini (risky sexual behavior) and Tanzania (multiple sex partners) were not included. Models for transactional sex and infrequent condom use did not include a fixed effect for country as it made the model unstable.
^†† Statistically significant (p<0.05).
^§§ STI was defined as ever having symptoms or a diagnosis of an STI. Data for Tanzania were not included. Model does not include a fixed effect for country because it made the model unstable.
^¶¶ Data for Eswatini were not included.
*** Mental distress was defined as a score of five or higher on the Kessler 6 scale (https://onlinelibrary.wiley.com/doi/10.1002/mpr.310external icon). Data for Eswatini and Tanzania were not included.
^††† Data for Eswatini and Tanzania were not included.