Skip to main content
NCBI home page
HHS Author Manuscripts logoLink to HHS Author Manuscripts
. Author manuscript; available in PMC: 2023 Dec 1.
Published in final edited form as: Child Abuse Negl. 2022 Oct 7;134:105916. doi: 10.1016/j.chiabu.2022.105916

Association between lifetime sexual violence victimization and selected health conditions and risk behaviors among 13–24-year-olds in Lesotho: Results from the Violence Against Children and Youth Survey (VACS), 2018

Viani Picchetti a,*, Caroline Stamatakis a, Francis B Annor a, Greta M Massetti a, Jennifer Hegle b
PMCID: PMC9691579  NIHMSID: NIHMS1843176  PMID: 36215756

Abstract

Background:

Sexual violence is a serious public health concern worldwide. In Lesotho, one in seven women and one in twenty men aged 18 years and older experienced sexual violence during childhood. Sexual violence victimization may lead to long-term mental and physical health issues among victims, regardless of gender.

Objective:

To estimate the prevalence of lifetime sexual violence victimization (SV) among 13–24-year-olds in Lesotho and assess its association with selected health conditions and risk behaviors.

Participants and setting:

Data from 13 to 24-year-old participants (n = 8568) of the 2018 Lesotho Violence Against Children and Youth Survey were analyzed.

Methods:

SV was defined as reporting one or more types of sexual violence at any age. Logistic regression analyses measured associations between SV and selected health conditions (suicidal thoughts, self-harm behaviors, mental distress, STIs, and HIV), and risk behaviors (binge drinking in the past 30 days, drug use in the past 30 days, infrequent condom use in the past 12 months, multiple sex partners in the past 12 months, and transactional sex in the past 12 months).

Results:

After controlling for study covariates, SV was significantly associated with self-harm behaviors, suicidal thoughts, ever having an STI, binge drinking in the past 30 days, infrequent condom use in the past 12 months, and multiple sex partners in the past 12 months for both males and females; and mental distress and transactional sex in the past 12 months for females.

Conclusions:

Preventing SV against children and youth in Lesotho may improve their health and wellbeing.

Keywords: Sexual violence, Violence against children, STI, HIV, Risk behaviors, Lesotho

1. Introduction

Sexual violence is common and a serious public health concern worldwide (Abrahams et al., 2014; Barth et al., 2013; Borumandnia et al., 2020; Moody et al., 2018). An estimated 120 million females under 20 years of age (10 %) around the world have experienced some form of sexual violence in their lifetime (United Nations Children’s Fund, 2014). Males also experience sexual violence (Chynoweth et al., 2020; Sumner et al., 2016), although it is less commonly reported. In Lesotho, one in seven women and one in twenty men aged 18 years and older experienced sexual violence at least once in their childhood (Ministry of Social Development of Lesotho et al., 2020). In addition, 7.3 % of girls aged 13–17 years experienced sexual violence in the past year (Ministry of Social Development of Lesotho et al., 2020).

Sexual violence victimization may lead to long-term mental and physical health issues among victims, regardless of gender (Abajobir et al., 2017; Choudhary et al., 2012). For example, sexual violence is associated with mental distress, self-harm behaviors, suicidal ideation, and substance misuse throughout the victim’s life course (Choudhary et al., 2012; Khadr et al., 2018; Mgoqi-Mbalo et al., 2017; Nguyen, Padilla, Villaveces, Patel, Atuchukwu, Onotu, Apondi, Aluzimbi, Chipimo, Kancheya, and Kress, 2019b; Villalba et al., 2020). Experiencing sexual violence during childhood among males is also associated with intimate partner violence perpetration later in life (Cubellis et al., 2016; Teitelman et al., 2017; VanderEnde et al., 2016). Sexual violence is also associated with an increased risk for HIV and other sexually transmitted infections (STIs) (Hassen & Deyassa, 2013; Richter et al., 2014; Seña et al., 2015 For example, compared with nonvictims, children who are victims of sexual violence are more likely to engage in behaviors (e.g., alcohol misuse, drug use, and unprotected sex) that increase risk for HIV and STIs (Abajobir et al., 2017; Chiang et al., 2015; Chiang et al., 2021; Rogstad et al., 2016; VanderEnde et al., 2018). Forced sex with an infected person can also increase the likelihood of HIV acquisition in females due to vaginal tears and lacerations (Abbai et al., 2016; Hassen & Deyassa, 2013) and in males through forced anal sex (Hernandez et al., 2017).

With the high burden of HIV in Lesotho, a country with the second-highest HIV prevalence globally in 2019 (23.1 %) and an estimated 29,000 people aged 15–24 years living with HIV (The World Factbook, 2021; UNAIDS, 2021), it is crucial to understand the factors associated with sexual violence, which can directly and indirectly contribute to the HIV epidemic in the country. Current research on the associations between sexual violence victimization and health outcomes among children and youth in Lesotho is limited; most of the literature on the physical and mental health impacts of sexual violence reflects research conducted in Western high-income countries. The Lesotho VACS provides the first nationally representative data on sexual violence victimization and its association with HIV among children and youth in Lesotho, establishing a unique opportunity to examine the associations among sexual violence and health outcomes within this context. In this analysis, we aim to: (1) estimate the prevalence of lifetime sexual violence victimization among females and males aged 13–24 years in Lesotho, and (2) assess its association with selected health conditions (suicidal thoughts, self-harm behaviors, mental distress, STIs, and HIV) and risk behaviors (binge drinking in the past 30 days, drug use in the past 30 days, infrequent condom use in the past 12 months, multiple sex partners in the past 12 months, and transactional sex in the past 12 months). We hypothesize that lifetime sexual violence victimization is associated with selected health conditions and risk behaviors in males and females.

2. Methods

2.1. Data source

The 2018 Lesotho Violence Against Children and Youth Survey (VACS) was a nationally representative, cross-sectional household survey designed to assess the burden of violence against children and youth aged 13–24 years (Ministry of Social Development of Lesotho et al., 2020). The purpose of the Lesotho VACS was to measure the prevalence of sexual, physical, and emotional violence against children and youth, and to determine specific risk and protective factors for violence to help guide the development and implementation of HIV and violence prevention and response programs and policies (Ministry of Social Development of Lesotho et al.,2020).

The VACS was the first nationally representative survey of violence against children ever conducted in Lesotho and was led by the Lesotho Ministry of Social Development and implemented by ICAP at Columbia University with technical assistance from the United States Centers for Disease Control and Prevention (CDC) (Ministry of Social Development of Lesotho et al., 2020). A Multi-sectoral Task Force, including members of the National Orphans and Vulnerable Children (OVC) Coordinating Committee, representatives from key relevant ministries of the Government of Lesotho, and national and international agencies (e.g., UNICEF) coordinated the implementation of the survey and led the national action plan for responding to the study findings. The Lesotho VACS followed the World Health Organization’s ethical and safety recommendations for studies on violence against women (World Health Organization, 2001). The survey protocol was independently reviewed and approved by the Lesotho Ministry of Health’s Research and Ethics Committee, the Columbia University Medical Center Institutional Review Board (IRB), and the CDC IRB to ensure the rights and welfare of human research participants were appropriately protected (Ministry of Social Development of Lesotho et al., 2020). Data was collected via face-to-face computer assisted personal interviews conducted by trained interviewers (Centers for Disease Control and Prevention, 2017; Ministry of Social Development of Lesotho et al., 2020). HIV rapid tests were offered to participants who did not show proof of treatment or report previously testing positive for HIV (Ministry of Social Development of Lesotho et al., 2020). Participants in need for HIV treatment were identified by advising those who tested positive about the availability and benefits of starting HIV treatment early and offering them active linkage to a clinic for receiving antiretrovirals (ARVs), care, and support. In addition, participants who self-reported being HIV-positive and were not currently on treatment were also provided the same options. Those who declined active linkage to care received the standard Ministry of Health referral to care.

2.2. Sample

The Lesotho VACS used a three-stage cluster sampling design (Ministry of Social Development of Lesotho et al., 2020). Participants were stratified by sex and females were oversampled in two districts with high HIV burden, Berea and Maseru, which account for 39 % of Lesotho’s population (Bureau of Statistics, 2016). A split-sampling approach was used to ensure that females and males were interviewed in different enumeration areas (EAs) to increase confidentiality of participants and reduce the possibility that a male perpetrator and their female victim (and vice versa) living in the same community would both be interviewed (Nguyen, Kress, Villaveces, and Massetti, 2019a). During the first stage of sampling, 240 EAs (197 female EAs and 43 male EAs) were selected from the national sampling frame using a probability proportional to size sampling approach. In the second stage, 40 households with at least one eligible household member were randomly selected in each EA using equal probability systematic sampling. Finally, in the third stage, one eligible respondent was randomly selected per household, yielding 7101 completed female interviews (overall response rate was 96.2 %) and 1467 completed male interviews (overall response rate was 96.2 %). Eligibility criteria included being aged 13–24 years, residing in a household, and having the ability to speak one of two survey languages (English or Sesotho). Individuals residing in institutions, such as in prisons or hospitals, or who had cognitive disabilities or severe hearing or speech impairment were not eligible for inclusion. More detailed information on the methodology and design of the Lesotho VACS can be found elsewhere (Ministry of Social Development of Lesotho et al., 2020; Nguyen, Kress, Villaveces, and Massetti, 2019a).

2.3. Measures

2.3.1. Independent variable

2.3.1.1. Sexual violence.

Measured through four questions that asked whether the participant had ever: (1) been touched in a sexual way without their permission, (2) had someone try to force them to have sex without success, (3) been physically forced to have sex, or (4) been pressured in a non-physical way to have sex against their will. Lifetime sexual violence victimization (SV) was defined as reporting one or more of these types of sexual violence at any age.

2.3.2. Dependent variables

2.3.2.1. Health conditions
2.3.2.1.1. Self-harm behaviors.

Assessed by asking whether participants had ever tried to hurt themselves on purpose in any way (answer options were “yes” or “no”).

2.3.2.1.2. Suicidal thoughts.

Assessed by asking participants whether they had ever thought about killing themselves (answer options were “yes” or “no”).

2.3.2.1.3. Mental distress.

Assessed based on Kessler’s K6 scale of psychological distress (Kessler et al., 2002). Participants were asked how frequently in the past 30 days they felt (1) nervous, (2) hopeless, (3) restless, (4) so sad that nothing could cheer them up, (5) that everything was an effort, or (6) worthless. Responses to each question were scored ranging from 0 (‘none of the time’) to 4 (‘all of the time’) and responses were summed and categorized into serious (scores of 13–24), moderate (scores of 5–12), and no (scores of 0–4) mental distress (Kessler et al., 2002).

2.3.2.1.4. Sexually transmitted infections (STI).

Measured through two questions that asked whether the participants had ever: (1) been diagnosed with an STI or (2) had a genital sore or ulcer.

2.3.2.1.5. HIV status.

Ascertained through an HIV rapid test, showing proof of treatment, or self-reporting a prior HIV test. Participants who did not report previously testing positive for HIV were offered an HIV rapid test (Ministry of Social Development of Lesotho et al., 2020). In this analysis, being HIV-positive was defined as either testing positive for HIV or having a prior positive HIV test result.

2.3.2.2. Risk behaviors
2.3.2.2.1. Binge drinking in the past 30 days.

Assessed by asking how many days in the past 30 days participants had four or more drinks of alcohol in a row. Binge drinking was defined as having four or more drinks in a row on one or more days (Esser et al., 2017; National Institute of Alcohol Abuse and Alcoholism, 2004).

2.3.2.2.2. Drug use in the past 30 days.

Participants were asked whether they had used drugs such as dagga, prescription pills, injection drugs, ecstasy, or sniffed any chemical such as petrol or glue in the past 30 days. Drug use was defined as responding ‘yes’ to this question.

2.3.2.2.3. Infrequent condom use in the past 12 months.

Defined as responding ‘sometimes’ or ‘never’ to a question about how often participants had used a condom when they had sex in the past 12 months, among those who ever had sex and had at least one sex partner in the past 12 months. In addition, participants who reported (1) ‘sometimes’ or ‘never’ using condoms, (2) being married or living with someone as if married, and (3) having only one sex partner in the past 12 months were coded as no infrequent condom use. Those who reported having zero sex partners in the past 12 months were coded as missing and excluded from analyses.

2.3.2.2.4. Multiple sex partners in the past 12 months.

Defined as reporting two or more sex partners in the past 12 months, among those who ever had sex. Those who reported only one sex partner were defined as no multiple sex partners in the past 12 months. Those who reported having zero sex partners in the past 12 months were coded as missing and excluded from analyses.

2.3.2.2.5. Transactional sex in the past 12 months.

Participants were asked three questions about whether they had sex with a person to get things like money, gifts, or other things in the past 12 months. An additional question asked how many times in the past 12 months they had done this. Transactional sex in the past 12 months was defined as responding ‘yes’ to one or more of the three questions or responding they had done this at least one time in the past 12 months, among those who ever had sex. Those who reported having zero sex partners in the past 12 months were coded as missing and excluded from analyses.

2.3.3. Covariates

Demographics such as age (13–17 years; 18–24 years), educational level (currently attending or completed less than secondary education; currently attending or completed secondary education or more), marital status (ever married or living with a partner; never married or lived with a partner), and food insecurity (living in a household that did not have enough money for food) were included as covariates.

2.3.4. Missing data

For all variables included in this analysis, participants who (1) had a combination of Don’t know and declined responses in all questions, (2) answered Don’t know to all questions, or (3) declined responding to all questions were coded as missing and excluded from analyses.

2.4. Data analysis

2.4.1. Descriptive analysis

We calculated weighted prevalence and 95 % confidence intervals (CI) to summarize demographic characteristics (i.e., age, educational level, marital status, and food insecurity), SV, selected health conditions, and risk behaviors of males and females in the sample.

2.4.2. Inferential analysis

We conducted chi-square tests of independence to determine the association between SV and each demographic characteristic, selected health condition, and risk behavior stratified by sex. We also conducted logistic regression analyses to measure unadjusted and adjusted associations between SV and each selected health condition and risk behavior. For this, two models were built for each selected health condition and risk behavior based on the literature or statistically significant results from the chi-square analyses. The first model (unadjusted) did not control for any covariate. The second model (adjusted) controlled for demographics variables (age, educational level, marital status, and food insecurity). Unadjusted and adjusted odds ratios (aOR), 95 % CI, and p-values were calculated. Both the p-value (p < 0.05) and the 95 % CI were considered in determining statistical significance of each association. We performed all statistical analyses using SAS version 9.4 software while considering the complex survey design of the Lesotho VACS.

3. Results

3.1. Descriptive analysis results

A total of 7101 females and 1467 males participated in the 2018 Lesotho VACS (Table 1). Most children and youth were aged 18–24 years old (females, 57.3 %; males, 56.8 %), were currently attending or completed a secondary education or more (females, 73.2 %; males, 60.4 %) and had never been married or lived with a partner (females, 76.3 %; males, 94.2 %). About one-third of females (33.6 %) and males (31.0 %) experienced food insecurity. One in five females (19.0 %) and 7.3 % of males experienced SV. Females more frequently reported suicidal thoughts (females, 8.2 %; males, 2.9 %), experienced severe mental distress (females, 4.0 %; males, 1.3 %), were HIV-positive (females, 6.6 %; males, 2.1 %), and engaged in transactional sex in the past 12 months (females, 5.0 %; males, 1.6 %). Males more frequently reported binge drinking in the past 30 days (males, 16.1 %; females, 4.8 %), drug use in the past 30 days (males, 8.1 %; females, 1.1 %), and multiple sex partners in the past 12 months (males, 37.4 %; females, 10.8 %).

Table 1.

Characteristics of 13–24-year-old females and males in Lesotho — Violence Against Children and Youth Survey (VACS), 2018.

Characteristics Females Males
Unweighted na bWeighted % (95 % CI) Unweighted na bWeighted % (95 % CI)
Age
 13–17 years 7101 42.7 (41.1–44.2) 1467 43.2 (40.0–46.3)
 18–24 years 57.3 (55.8–58.9) 56.8 (53.7–60.0)
Educational level
 Currently attending or less than secondary education 7101 26.8 (24.0–29.6) 1467 39.6 (32.5–46.8)
 Currently attending or secondary education or more 73.2 (70.4–76.0) 60.4 (53.2–67.5)
Marital status
 Married or cohabitatedc 7101 23.7 (21.7–25.7) 1467 5.8 (4.2–7.4)
 Never married 76.3 (74.3–78.3) 94.2 (92.6–95.8)
Food insecured 7101 33.6 (31.5–35.8) 1467 31.0 (25.8–36.2)
Lifetime sexual violence 7101 19.0 (17.2–20.9) 1467 7.3 (5.2–9.4)
Ever had suicidal thoughts 7100 8.2 (7.3–9.1) 1466 2.9 (1.7–4.1)
Ever had self-harm behaviorse 7101 2.2 (1.8–2.7) 1467 2.4 (1.2–3.6)
Experienced mental distress in the past 30 daysf
 Severe mental distress 7101 4.0 (3.3–4.8) 1467 1.3 (0.6–1.9)
 Moderate mental distress 22.5 (20.5–24.5) 27.2 (21.6–32.9)
 No mental distress 73.5 (71.2–75.7) 71.5 (65.9–77.1)
Ever had an STIl 7087 9.7 (8.7–10.7) 1467 7.7 (5.6–9.8)
HIV-positive 7010 6.6 (5.7–7.5) 1457 2.1 (1.3–3.0)
Binge drinking in the past 30 daysg 6970 4.8 (3.9–5.6) 1426 16.1 (13.1–19.1)
Drug use in the past 30 daysh 7101 1.1 (0.7–1.5) 1467 8.1 (6.0–10.2)
Infrequent condom use in the past 12 monthsi 3011 26.6 (24.2–29.0) 639 32.8 (26.6–39.0)
Multiple sex partners in the past 12 monthsj 3024 10.8 (9.3–12.4) 643 37.4 (31.3–43.6)
Transactional sex in the past 12 monthsk 3024 5.0 (4.0–6.0) 642 1.6 (0.4–2.8)
Open in a new tab

Acronyms: CI = Confidence interval; STI = Sexually transmitted infection.

Note: All statistical analyses took into account the complex survey design of the Lesotho VACS, 2018.

a

Unweighted denominators. Denominators may differ due to skip patterns in the questionnaire.

b

Weighted percentages. Weighted percentages may not total due to rounding.

c

Includes ever married or lived with a partner.

d

Includes respondents who did not think their household had enough money for food.

e

Ever tried to hurt themselves on purpose in any way.

f

Measured using the Kessler K6 scale by asking respondents series of questions about their mental health during the past 30 days. Moderate mental distress was defined as scoring 5 ≤ K6 scale <13. Serious mental distress was defined as scoring ≥13 on the K6 scale.

g

Drinking ≥4 drinks of alcohol in a row on one or more days in the past 30 days.

h

Used drugs such as dagga, prescription pills, injection drugs, ecstasy, or sniffed any chemical such as petrol or glue in the past 30 days.

i

Sometimes or never using condoms when having sex with someone in the past 12 months (among those who ever had sex and had at least 1 sex partner in the past 12 months).

j

Having sex with more than one person in the past 12 months (among those who ever had sex).

k

Having sex with a person mainly in order to get money, gifts, or other things in the past 12 months (among those who ever had sex and had at least 1 sex partner in the past 12 months).

l

Includes respondents who were ever diagnosed with an STI or ever had a genital sore or ulcer.

3.2. Inferential analysis results

3.2.1. Chi square analysis

Females who experienced SV were significantly more likely to be older, currently attending or completed a secondary education or higher, and to have ever been married or lived with a partner compared with females who did not experience SV (Table 2). All health conditions (except no mental distress and being HIV-positive) and all risk behaviors (except drug use in the past 30 days) were significantly more frequent among females who experienced SV than among those who did not.

Table 2.

Prevalence of health conditions and risk behaviors among 13–24-year-old females and males in Lesotho who did and did not experience lifetime sexual violence victimization in Lesotho — Violence Against Children and Youth Survey (VACS), 2018.

Characteristics Females Males
SVa No SVa p value SVa No SVa
nb cWeighted % (95 % CI) nb cWeighted % (95 % CI) nb cWeighted % (95 % CI) nb cWeighted % (95 % CI) p value
Age
 13–17 years 1210 24.4 (22.0–26.8) 5891 47.0 (45.2–48.7) <0.0001 89 16.7 (7.9–25.5) 1378 45.2 (42.1–48.4) <0.0001
 18–24 years 1210 75.6 (73.2–78.0) 5891 53.0 (51.3–54.8) 89 83.3 (74.5–92.1) 1378 54.8 (51.6–57.9)
Educational level
 Currently attending or less than secondary education 1210 19.1 (16.1–22.0) 5891 28.7 (25.6–31.7) <0.0001 89 16.7 (7.6–25.9) 1378 41.5 (34.3–48.6) <0.0001
 Currently attending or secondary education or more 1210 80.9 (78.0–83.9) 5891 71.3 (68.3–74.4) 89 83.3 (74.1–92.4) 1378 58.5 (51.4–65.7)
Marital status
 Married or cohabitatinge 1210 31.9 (28.4–35.4) 5891 21.8 (19.7–23.9) <0.0001 89 9.5 (1.8–17.2) 1378 5.5 (3.9–7.1) 0.224
 Never married 1210 68.1 (64.6–71.6) 5891 78.2 (76.1–80.3) 89 90.5 (82.8–98.2) 1378 94.5 (92.9–96.1)
 Food insecuref 1210 31.8 (28.4–35.2) 5891 34.1 (31.8–36.4) 0.195 89 24.2 (12.4–36.0) 1378 31.6 (26.2–37.0) 0.261
Health conditions
 Ever had suicidal thoughts 1210 20.2 (17.3–23.1) 5890 5.3 (4.6–6.1) <0.0001 89 7.3 (2.0–12.6) 1377 2.5 (1.4–3.7) 0.005
 Ever had self-harm behaviorsg 1210 7.2 (5.4–9.1) 5891 1.0 (0.8–1.3) <0.0001 89 8.9 (0.0–19.4) 1378 1.9 (0.9–2.9) 0.013
Experienced mental distress in the past 30 daysh
 Serious mental distress 1210 10.1 (7.8–12.4) 5891 2.6 (2.0–3.2) <0.0001 89 1.1 (0.0–3.4) 1378 1.3 (0.6–1.9) 0.126
 Moderate mental distress 1210 33.9 (30.5–37.3) 5891 19.8 (17.7–21.9) 89 38.3 (26.3–50.3) 1378 26.4 (20.3–32.4)
 No mental distress 1210 56.0 (52.1–59.9) 5891 77.6 (75.3–79.8) 89 60.6 (48.6–72.5) 1378 72.4 (66.3–78.4)
Ever had an STIi 1210 15.9 (13.4–18.4) 5877 8.2 (7.2–9.3) <0.0001 89 31.1 (15.0–47.2) 1378 5.9 (4.2–7.6) <0.0001
HIV-positive 1197 8.1 (5.9–10.3) 5813 6.2 (5.3–7.1) 0.050 89 1.5 (0.0–3.7) 1368 2.2 (1.3–3.1) 0.613
Risk behaviors
 Binge drinking in the past 30 daysj 1183 9.0 (6.3–11.6) 5787 3.8 (3.1–4.5) <0.0001 85 36.4 (21.5–51.2) 1341 14.5 (11.6–17.5) 0.0002
Drug use in the past 30 daysk 1210 1.4 (0.6–2.2) 5891 1.0 (0.6–1.4) 0.343 89 17.2 (6.5–28.0) 1378 7.4 (5.4–9.3) 0.009
 Infrequent condom use in the past 12 monthsl 794 32.1 (27.1–37.2) 2217 24.4 (22.1–26.8) 0.002 68 55.2 (40.6–69.8) 571 29.8 (23.2–36.4) 0.001
 Multiple sex partnersm in the past 12 months 800 15.0 (12.5–17.5) 2224 9.2 (7.7–10.8) <0.0001 68 55.6 (40.9–70.4) 575 35.0 (29.2–40.8) 0.001
 Transactional sexn in the past 12 months 800 7.5 (5.7–9.2) 2224 4.0 (2.8–5.2) 0.002 68 2.2 (0.0–5.3) 574 1.5 (0.3–2.7) 0.576
Open in a new tab

Bold font indicates statistical significance.

Acronyms: CI = Confidence interval; STI = Sexually transmitted infection; SV = lifetime sexual violence.

Note: All statistical analyses took into account the complex survey design of the Lesotho VACS, 2018.

a

Prevalence estimates and unweighted denominators shown are among those who experienced SV and those who did not experience SV.

b

Unweighted denominators. Denominators may differ due to skip patterns in the questionnaire.

c

Weighted percentages. Weighted percentages may not total due to rounding.

e

Includes ever married or lived with a partner.

f

Includes respondents who did not think their household had enough money for food.

g

Ever tried to hurt themselves on purpose in any way.

h

Measured using the Kessler K6 scale by asking respondents series of questions about their mental health during the past 30 days. Moderate mental distress was defined as scoring 5 ≤ K6 scale <13. Serious mental distress was defined as scoring ≥13 on the K6 scale.

i

Includes respondents who were ever diagnosed with an STI or ever had a genital sore or ulcer.

j

Drinking ≥4 drinks of alcohol in a row on one or more days in the past 30 days.

k

Used drugs such as dagga, prescription pills, injection drugs, ecstasy, or sniffed any chemical such as petrol or glue in the past 30 days.

l

Sometimes or never using condoms when having sex with someone in the past 12 months (among those who ever had sex and had at least 1 sex partner in the past 12 months).

m

Having sex with more than one person in the past 12 months (among those who ever had sex).

n

Having sex with a person mainly in order to get money, gifts, or other things in the past 12 months (among those who ever had sex and had at least 1 sex partner in the past 12 months).

Males who experienced SV were significantly more likely to be older and to currently be attending or have completed a secondary education or more (Table 2). Suicidal thoughts, self-harm behaviors, ever having an STI, and all risk behaviors (except transactional sex in the past 12 months) were significantly more frequent among males who experienced SV when compared with those who did not experience SV.

3.2.2. Logistic regression analysis

Results from the logistic regression are presented in Table 3. Although chi-square test results indicated there were no statistically significant associations between SV and HIV among females or males, we still included HIV in the adjusted model because previous researchers have found significant associations between SV and increased risk for HIV (Baral et al., 2012; Hassen & Deyassa, 2013; Henny et al., 2012; Machtinger et al., 2012; Reisner et al., 2011). Among females, in the final adjusted model, SV was significantly associated with all health conditions, except for being HIV-positive. Compared to females who did not experience SV, females who experienced SV had significantly higher odds of reporting serious or moderate mental distress (serious: aOR = 4.8; 95 % CI = 3.5–6.7; moderate: aOR = 2.2; 95 % CI = 1.8–2.7), self-harm behaviors (aOR = 7.8; 95 % CI = 5.2–11.6), suicidal thoughts (aOR = 3.9; 95 % CI = 3.1–4.9), ever having an STI (aOR = 1.7; 95 % CI = 1.3–2.2), binge drinking in the past 30 days (aOR = 1.8; 95 % CI = 1.3–2.7), infrequent condom use in the past 12 months (aOR = 1.4; 95 % CI = 1.1–1.9), multiple sex partners in the past 12 months (aOR = 1.7; 95 % CI = 1.3–2.1), and transactional sex in the past 12 months (aOR = 2.0; 95 % CI = 1.3–3.1). No statistically significant associations were found between SV and HIV or drug use in the past 30 days among females.

Table 3.

Associations between lifetime sexual violence victimization and specific health conditions and risk behaviors among 13–24-year-old females and males in Lesotho — Violence Against Children and Youth Survey (VACS), 2018.

Characteristics of interest Females Males
Unadjusted Adjusted Unadjusted Adjusted
OR (95 % CI) p value aOR (95 % CI) p value OR (95 % CI) p value aOR (95 % CI) p value
Health conditions
 Experienced mental distress in the past 30 daysa
  Serious mental distress (Ref. no mental distress) 5.3 (3.8–7.3) <0.0001 4.8 (3.5–6.7) <0.0001 1.1 (0.1–8.2) 0.941 0.8 (0.1–6.8) 0.872
  Moderate mental distress (Ref. no mental distress) 2.3 (2.0–2.8) <0.0001 2.2 (1.8–2.7) <0.0001 1.7 (1.0–3.1) 0.068 1.5 (0.9–2.7) 0.134
 Ever had self-harm behaviorsb (Ref. no self-harm behaviors) 7.3 (5.0–10.8) <0.0001 7.8 (5.2–11.6) <0.0001 5.2 (1.2–22.7) 0.030 4.4 (1.1–17.8) 0.039
 Ever had suicidal thoughts (Ref. no suicidal thoughts) 4.5 (3.5–5.7) <0.0001 3.9 (3.1–4.9) <0.0001 3.0 (1.3–6.9) 0.008 2.5 (1.0–6.3) 0.046
 Ever had an STIc (Ref. never had an STI) 2.1 (1.7–2.7) <0.0001 1.7 (1.3–2.2) <0.0001 7.2 (3.2–16.3) <0.0001 5.7 (2.5–12.9) <0.0001
 HIV-positive (Ref. not HIV-positive) 1.5 (1.1–2.0) 0.025 1.2 (0.9–1.6) 0.323 0.9 (0.2–3.7) 0.981 1.2 (0.3–4.6) 0.808
Risk behaviors
 Binge drinking in the past 30 daysd (Ref. no binge drinking) 2.5 (1.7–3.6) <0.0001 1.8 (1.3–2.7) 0.001 3.4 (1.7–6.8) 0.001 2.2 (1.1–4.5) 0.030
 Drug use in the past 30 dayse (Ref. no drug use) 1.4 (0.7–2.6) 0.346 1.1 (0.5–2.1) 0.814 2.6 (1.2–5.7) 0.015 2.0 (0.9–4.4) 0.099
 Infrequent condom use in the past 12 monthsf (Ref. frequent condom use) 1.5 (1.1–1.9) 0.003 1.4 (1.1–1.9) 0.014 2.9 (1.5–5.6) 0.001 2.9 (1.5–5.5) 0.002
 Multiple sex partnersg in the past 12 months (Ref. no multiple sex partners) 1.7 (1.4–2.2) <0.0001 1.7 (1.3–2.1) <0.0001 2.3 (1.3–4.2) 0.006 2.0 (1.1–3.7) 0.025
 Transactional sexh in the past 12 months (Ref. no transactional sex) 1.9 (1.3–2.9) 0.002 2.0 (1.3–3.1) 0.001 1.5 (0.3–6.5) 0.581 1.5 (0.3–6.3) 0.594
Open in a new tab

Bold font indicates statistical significance.

Acronyms: aOR = Adjusted odds ratio; CI = Confidence interval; STI = Sexually transmitted infection.

Note: All statistical analyses took into account the complex survey design of the Lesotho VACS, 2018.

Unadjusted model = Unadjusted association between lifetime sexual violence and outcome of interest.

Adjusted model = Controlled for age group, educational level, marital status, and food insecurity.

a

Measured using the Kessler K6 scale by asking respondents series of questions about their mental health during the past 30 days. Moderate mental distress was defined as scoring 5 ≤ K6 scale <13. Serious mental distress was defined as scoring ≥13 on the K6 scale.

b

Ever tried to hurt themselves on purpose in any way.

c

Includes respondents who were ever diagnosed with an STI or ever had a genital sore or ulcer.

d

Drinking ≥4 drinks of alcohol in a row on one or more days in the in the past 30 days.

e

Used drugs such as dagga, prescription pills, injection drugs, ecstasy, or sniffed any chemical such as petrol or glue in the past 30 days.

f

Sometimes or never using condoms when having sex with someone in the past 12 months (among those who ever had sex and had at least 1 sex partner in the past 12 months).

g

Having sex with more than one person in the past 12 months (among those who ever had sex).

h

Having sex with a person mainly in order to get money, gifts, or other things in the past 12 months (among those who ever had sex and had at least 1 sex partner in the past 12 months).

Among males, in the final adjusted model, SV was significantly associated with self-harm behaviors (aOR = 4.4; 95 % CI = 1.1–17.8), suicidal thoughts (aOR = 2.5; 95 % CI = 1.0–6.3), ever having an STI (aOR = 5.7; 95 % CI = 2.5–12.9), binge drinking in the past 30 days (aOR = 2.2; 95 % CI = 1.1–4.5), infrequent condom use in the past 12 months (aOR = 2.9; 95 % CI = 1.5–5.5), and multiple sex partners in the past 12 months (aOR = 2.0; 95 % CI = 1.1–3.7). No statistically significant associations were found between SV and other health conditions or risk behaviors in males, including HIV.

4. Discussion

In this analysis, we estimated the association between SV and selected health conditions (suicidal thoughts, self-harm behaviors, mental distress, STIs, and HIV) and risk behaviors (binge drinking in the past 30 days, drug use in the past 30 days, infrequent condom use in the past 12 months, multiple sex partners in the past 12 months, and transactional sex in the past 12 months) among females and males aged 13–24 years in Lesotho. SV was more commonly reported among females than males. Among females, SV was significantly associated with almost all the health conditions and risk behaviors examined, except for HIV and drug use in the past 30 days. In males, SV was significantly associated with self-harm behaviors, suicidal thoughts, ever having an STI, binge drinking in the past 30 days, infrequent condom use in the past 12 months, and multiple sex partners in the past 12 months.

Our findings that SV was more commonly reported by females than males is consistent with previous reports from other African countries (i.e., Malawi, South Africa, Kenya, and Tanzania), Cambodia, and Haiti (Mwangi et al., 2015; Stark et al., 2019; Vagi et al., 2016; VanderEnde et al., 2018; Ward et al., 2018). SV is considered one of the most prevalent traumas worldwide, with girls and women being disproportionately affected. Until relatively recently, there has been a dearth of research on the epidemiology of sexual violence among boys and men (Forde & Duvvury, 2017). Further, there is growing evidence that experiences of SV as well as disclosure and help-seeking behavior is highly gendered (Easton et al., 2014; Lomans et al., 2022; Pereira et al., 2020). As such, inclusion of males in our analysis represents an important contribution to the field. The higher prevalence of SV in young females may be due to factors like social and gender norms that prescribe male dominance and right to control females. For example, some have proposed that SV against females is a demonstration of patriarchal dominance over females by males based on gender and power inequality (Lawson, 2012). Norms related to gender and masculinity contribute to patriarchal social contexts in some African countries (Adegoke & David, 2007; Amoakohene, 2004; Ilika, 2005; Jewkes et al., 2005). The present study found similarities in patterns of associations between SV and health outcomes for males and females, with few differences in adjusted analyses: the associations between SV and mental distress and transactional sex were not significant for males, but significant for females. For all other outcomes examined, similar patterns emerged for females and males. This underscores the substantial and enduring impacts of SV and suggests that these impacts do not vary by sex, on the whole.

Gender transformative programming to shift gender norms should be a component of violence prevention initiatives (Abramsky et al., 2014; Kerr-Wilson et al., 2020; Levtov et al., 2014; Pulerwitz et al., 2019).

Females who experienced SV had significantly greater odds of experiencing serious or moderate mental distress, suicidal thoughts, and self-harm behaviors than those who did not experience SV. We also found statistically significant associations between SV and these health conditions, except for serious or moderate mental distress, in males. Consistent with these findings, in a study among adolescents in Brazil, Schäfer et al. (2017) found that females who experienced SV were three times more likely to have suicidal thoughts than those who did not experience SV. In Nigeria, Omigbodun et al. (2008) reported that SV was a significant predictor of suicidal thoughts among females attending secondary school. SV was found to be significantly associated with self-harm behaviors in adolescents and youth in Nigeria, Zambia, and Uganda (Nguyen, Padilla, Villaveces, Patel, Atuchukwu, Onotu, Apondi, Aluzimbi, Chipimo, Kancheya, and Kress, 2019b). Experiences of SV can negatively impact an individual’s mental health throughout their life course (Choudhary et al., 2012). For example, serious mental distress has been associated with risky behaviors, including drug use (Substance Abuse and Mental Health Services Administration, 2013), lower income (Davison et al., 2020; Leary et al., 2021), unemployment, poor physical health, and chronic illness (Davison et al., 2020). Though SV was associated with increased odds for mental distress in females, this association was not statistically significant for males. Additional research on mental health consequences of SV among males in Lesotho is needed to refine measurement among this population and understand impacts of SV and implications for prevention.

Participants who experienced SV had twice the odds of binge drinking in the past 30 days than those who did not experience SV, consistent with research on SV and alcohol misuse among adolescents (Kirk-Provencher et al., 2020) and between childhood sexual violence and hazardous drinking among adults (Bello et al., 2017; Lown et al., 2011; Tonmyr & Shields, 2017). This association may be explained in part by the self-medication theory, which states that individuals use substances (e.g., alcohol or drugs) to relieve painful feelings or memories (Khantzian, 1997).

Participants who experienced SV had significantly higher odds of reporting infrequent condom use in the past 12 months than those who did not experience SV. Females who experienced SV had 1.4 times the odds of engaging in infrequent condom use in the past 12 months, while males who experienced SV had almost three times the odds of engaging in infrequent condom use in the past 12 months when compared with those who did not experience SV. This association suggests that primary prevention of SV may be an opportunity to prevent the occurrence of STI/HIV risk behaviors, as a pathway to interrupting spread of STIs and HIV in Lesotho. Similarly, SV was significantly associated with infrequent condom use in a cohort study of HIV-infected individuals in the United States (Chuang et al., 2006). SV increases risk for HIV both directly through forced genital or anal intercourse, as well as indirectly through high-risk sexual behaviors (e.g., no or infrequent condom use; (Chuang et al., 2006).

Participants who experienced SV had significantly greater odds of reporting multiple sex partners in the past 12 months than those who did not experience SV. This aligns with results from prior studies. For example, in Tanzania, females who experienced childhood sexual violence were over two times more likely to report multiple sex partners in the past 12 months than nonvictims of childhood sexual violence (Chiang et al., 2015). In Quebec, Thibodeau et al. (2017) found a direct association between SV and having multiple sex partners among 13–17-year-old adolescents. This association could be mediated by traumatic sexualization, in which an individual’s sexuality (e.g., sexual feelings and attitudes) is developed inappropriately during experiences of sexual violence, resulting in them learning to use sexual behavior to receive rewards or affection (Finkelhor & Browne, 1985; Thibodeau et al., 2017). Thus, adolescents who experience SV may have multiple sex partners in an effort to receive affection and rewards (Thibodeau et al., 2017). This was observed in a study where women who experienced childhood sexual violence reported more traumatic sexualization and higher number of sex partners than those who did not experience childhood sexual violence (Senn et al., 2011).

Females who experienced SV had significantly greater odds of engaging in transactional sex in the past 12 months than those who did not experience SV. Similar findings were reported from the Uganda VACS, where young girls who experienced SV were more likely to engage in transactional sex in the past 12 months than those who did not experience SV (Stamatakis et al., 2021). Among South African adults, experiencing childhood sexual violence was associated with transactional sex in adulthood (Gibbs et al., 2018). Transactional sex is motivated by various factors, such as poverty and the desire for material acquisition (Leclerc-Madlala, 2008; McCloskey et al., 2021; Stoebenau et al., 2011), and is widely accepted by both parents and youth in some countries (Deane & Wamoyi, 2015; Kamndaya et al., 2016; Wamoyi et al., 2011). Transactional sex increases the risk for HIV in young women (Kilburn et al., 2018; Wamoyi et al., 2016) because they may have more sexual partners (Choudhry et al., 2015), use condoms less frequently (Luke, 2006), and report more alcohol misuse (Bello et al., 2017).

Our finding that females who experienced SV had greater odds of engaging in transactional sex in the past 12 months aligns with our finding that females who experienced SV had greater odds of reporting multiple sex partners in the past 12 months. Similarly, results from an analysis of Uganda VACS data indicated that childhood transactional sex was significantly associated with having multiple sex partners in the past 12 months among 18–24-year-old females (Chiang et al., 2021). In a different study, transactional sex was significantly associated with having multiple concurrent sex partners among 15–24-year-old Ugandan females (Choudhry et al., 2015). Food deprivation has been associated with both transactional sex and having multiple sex partners among out-of-school girls in Nigeria (Kunnuji, 2014). Over one-third of females in our sample who experienced SV also experienced food insecurity, which may have contributed to the association observed between SV and transactional sex in the past 12 months.

Females who experienced SV had significantly greater odds of ever having an STI than those who did not experience SV. This aligns with other studies where adolescent and young females who experienced SV were two times more likely to have an STI than those who did not experience SV in Tanzania (Vagi et al., 2016), Kenya, and Zambia (Mathur et al., 2018). This increased risk for STIs among female victims of SV reflects risk through both direct and indirect transmission among female victims of SV (Burgueño et al., 2017; Davis et al., 2018; Silverman et al., 2011). Males who experienced SV were almost six times more likely to ever have had an STI when compared with those who did not experience SV. These findings align with results from previously published studies. For example, Vagi et al. (2016) found that 13–24-year-old males in Tanzania who experienced SV were over two times more likely to have an STI as compared with those who did not experience SV. If used properly, condoms can prevent STIs and HIV (Beksinska et al., 2020). However, individuals may not use condoms consistently during sex because of poor access, gender norms, religious norms, and stigma (Beksinska et al., 2020).

The higher odds of having an STI among participants who experienced SV in our analysis were consistent with our findings that those who experienced SV were more likely to report infrequent condom use in the past 12 months, multiple sex partners in the past 12 months, transactional sex in the past 12 months (for females only), and binge drinking in the past 30 days than those who did not experience SV. Each of these factors, as well as SV, is associated with an increased risk for HIV (Andersson et al., 2012; Bello et al., 2017; Burgueño et al., 2017; Chiang et al., 2015; Choudhry et al., 2015; Hassen & Deyassa, 2013; Kilburn et al., 2018; McCloskey et al., 2021). In our study, we did not find a statistically significant association between SV and HIV for males, and found a marginally significant association for females. While SV and HIV were not significantly associated, several HIV risk factors were, including infrequent condom use, multiple sex partners, and binge drinking. Due to the age criteria of the study (13–24 years), it is possible that exposure to SV leads to increased risk for HIV, which then can lead to HIV acquisition later in adulthood. The most current HIV incidence data indicates that the 25–35-year age group has the highest incidence compared to any other age group (0.55 for males and 1.55 for females; Lesotho Ministry of Health (MOH), 2022).

As Lesotho aims to sustain HIV epidemic control and prevent new infections, HIV programs should consider expanding sexual violence prevention programming. SV prevention programming, such as that delivered through the United States President’s Emergency Plan for AIDS Relief (PEPFAR) Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) program (Saul et al., 2018) and other HIV prevention programs can leverage data-driven efforts to target HIV risk-reducing interventions to prevent violence in the context of HIV epidemic control efforts. Reducing sexual violence against children and adolescents could result in healthier individuals and stronger communities.

The findings from our analysis were subject to some limitations. First, the Lesotho VACS did not include 13–24-year-olds who were institutionalized, could not speak the languages of the survey, or had certain disabilities. Therefore, results are not generalizable to these populations. Second, the data used in this analysis were self-reported, which are subject to self-report bias, especially recall and social desirability bias. This may have resulted in underreporting of important variables in this analysis. Finally, the Lesotho VACS was a cross-sectional survey, which did not allow us to establish causality in our analysis and we were not able to determine whether the SV occurred before or after engagement in sexual risk behaviors or the emergence of the selected health conditions. However, we were able to determine associations between SV and the sexual risk behaviors and selected health conditions.

Strengths of the study include a robust methodology with a nationally representative survey with high response rates (>90 %) (Ministry of Social Development of Lesotho et al., 2020). To the best of our knowledge, this is the first analysis of SV and related health conditions and risk behaviors conducted using nationally representative data on violence against children and young adults in Lesotho. Most importantly, to our knowledge, this is the first time this type of analysis has been conducted among adolescent and young males in Lesotho. Our results indicate that violence prevention and response efforts in Lesotho should include targeting and supporting boys and young men in addition to strengthening supports for girls and young women, including implementing community mobilization programs, teaching about positive masculinity and healthy gender norms, and conducting bystander support interventions (Ward et al., 2018). INSPIRE: Seven Strategies to End Violence Against Children (World Health Organization, 2016) provides a framework of evidence-based policies, interventions, and programs to prevent and respond to violence. The strategies in INSPIRE include implementation and enforcement of laws, norms and values change, safe environments, parenting and caregiver support, income and economic strengthening, response and support services, and education and life skills. The programs and interventions reflect the bestavailable evidence to prevent violence and avert its negative impacts, with particular emphasis on approaches with proven success in low-resource settings. Based on the results of the present study, evidence-based interventions like those represented in INSPIRE, implemented through multi-sectoral action, can create safe and supportive environments for youth to reduce risk of sexual violence in the schools and community settings where young people live as well as in their homes. In addition, sexual violence victims should be provided linkage to supportive and high quality services including mental health support and other post violence care services such as HIV testing, STI testing and treatment, post-exposure prophylaxis, emergency contraceptives, and any other necessary clinical care. HIV prevention programming can also be leveraged to incorporate violence prevention and reduce risky sexual behavior. Prevention programming through the President’s Emergency Plan for AIDS Relief (PEPFAR) focuses on conducting community mobilization campaigns to support healthy gender norms changes and building adolescent-parent relationships as a strategy to reduce adolescent girls’ risk of violence and risky sexual behavior (Saul et al., 2018). HIV prevention programs can further integrate violence prevention efforts to promote upstream prevention efforts, and incorporate programming for boys and young men, given the similar patterns between males and females of impacts of sexual violence in the present study. VACS data can help guide the development and adaptation of violence and HIV prevention and response programs to meet the unique needs of children and young adults in Lesotho.

Acknowledgments

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Footnotes

Disclaimer

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Declaration of competing interest

No authors have any conflicts of interest to declare.

Data availability

Lesotho VACS data are publicly available and access can be requested through the Together for Girls website: https://www.togetherforgirls.org/request-access-vacs/

References

  1. Abajobir AA, Kisely S, Maravilla JC, Williams G, & Najman JM (2017). Gender differences in the association between childhood sexual abuse and risky sexual behaviours: A systematic review and meta-analysis. Child Abuse & Neglect, 63, 249–260. [DOI] [PubMed] [Google Scholar]
  2. Abbai NS, Wand H, & Ramjee G (2016). Biological factors that place women at risk for HIV: Evidence from a large-scale clinical trial in Durban. BMC Women’s Health, 16, 19. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Abrahams N, Devries K, Watts C, Pallitto C, Petzold M, Shamu S, & García-Moreno C (2014). Worldwide prevalence of non-partner sexual violence: A systematic review. The Lancet, 383(9929), 1648–1654. [DOI] [PubMed] [Google Scholar]
  4. Abramsky T, Devries K, Kiss L, Nakuti J, Kyegombe N, Starmann E, Cundill B, Francisco L, Kaye D, Musuya T, Michau L, & Watts C (2014). Findings from the SASA! Study: A cluster randomized controlled trial to assess the impact of a community mobilization intervention to prevent violence against women and reduce HIV risk in Kampala, Uganda. BMC Medicine, 12(1), 122. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Adegoke TG, & David O (2007). Community norms and cultural attitudes and beliefs factors influencing violence against women of reproductive age in Nigeria. Pakistan Journal of Social Sciences, 4(4), 490–495. [Google Scholar]
  6. Amoakohene MI (2004). Violence against women in Ghana: A look at women’s perceptions and review of policy and social responses. Social Science & Medicine, 59 (11), 2373–2385. [DOI] [PubMed] [Google Scholar]
  7. Andersson N, Paredes-Solís S, Milne D, Omer K, Marokoane N, Laetsang D, & Cockcroft A (2012). Prevalence and risk factors for forced or coerced sex among school-going youth: National cross-sectional studies in 10 southern African countries in 2003 and 2007. BMJ Open, 2(2), Article e000754. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Baral S, Beyrer C, Muessig K, Poteat T, Wirtz AL, Decker MR, Sherman SG, & Kerrigan D (2012). Burden of HIV among female sex workers in low-income and middle-income countries: A systematic review and meta-analysis. The Lancet Infectious Diseases, 12(7), 538–549. [DOI] [PubMed] [Google Scholar]
  9. Barth J, Bermetz L, Heim E, Trelle S, & Tonia T (2013). The current prevalence of child sexual abuse worldwide: A systematic review and meta-analysis. International Journal of Public Health, 58(3), 469–483. [DOI] [PubMed] [Google Scholar]
  10. Beksinska M, Wong R, & Smit J (2020). Male and female condoms: Their key role in pregnancy and STI/HIV prevention. Best Practice & Research Clinical Obstetrics & Gynaecology, 66, 55–67. [DOI] [PubMed] [Google Scholar]
  11. Bello B, Moultrie H, Somji A, Chersich MF, Watts C, & Delany-Moretlwe S (2017). Alcohol use and sexual risk behaviour among men and women in inner-city Johannesburg, South Africa. BMC Public Health, 17(Suppl. 3), 548. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Borumandnia N, Khadembashi N, Tabatabaei M, & Alavi Majd H (2020). The prevalence rate of sexual violence worldwide: A trend analysis. BMC Public Health, 20(1), 1835. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Bureau of Statistics. (2016). 2016 Lesotho population and housing census analytical report: Volume IIIA population dynamics. Retrieved May 3, 2021, from http://www.bos.gov.ls/microdata/index.php/home.
  14. Burgueño E, Carlos S, Lopez-Del Burgo C, Osorio A, Stozek M, Ndarabu A, Muamba P, Tshisuaka P, & De Irala J (2017). Forced sexual intercourse and its association with HIV status among people attending HIV voluntary counseling and testing in a healthcare center in Kinshasa (DRC). PLoS One, 12(12), Article e0189632. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Centers for Disease Control and Prevention. (2017). Critical elements of interviewer training for engaging children and adolescents in global violence research: Best practices and lessons learned from the Violence Against Children Survey. Retrieved October 20, 2021, from https://www.cdc.gov/violenceprevention/pdf/vacs/VACS-trainingwhitepaper.pdf.
  16. Chiang LF, Chen J, Gladden MR, Mercy JA, Kwesigabo G, Mrisho F, Dahlberg LL, Nyunt MZ, Brookmeyer KA, & Vagi K (2015). HIV and childhood sexual violence: Implications for sexual risk behaviors and HIV testing in Tanzania. AIDS Education and Prevention, 27(5), 474–487. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Chiang LF, Howard A, Stoebenau K, Massetti GM, Apondi R, Hegle J, Kyatekka M, Stamatakis C, Wasula L, & Aluzimbi G (2021). Sexual risk behaviors, mental health outcomes and attitudes supportive of wife-beating associated with childhood transactional sex among adolescent girls and young women: Findings from the Uganda Violence Against Children Survey. PLoS One, 16(3), Article e0249064. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Choudhary E, Smith M, & Bossarte RM (2012). Depression, anxiety, and symptom profiles among female and male victims of sexual violence. American Journal of Men’s Health, 6(1), 28–36. [DOI] [PubMed] [Google Scholar]
  19. Choudhry V, Ambresin A-E, Nyakato VN, & Agardh A (2015). Transactional sex and HIV risks - Evidence from a cross-sectional national survey among young people in Uganda. Global Health Action, 8, 27249. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Chuang CH, Liebschutz JM, Horton NJ, & Samet JH (2006). Association of violence victimization with inconsistent condom use in HIV-infected persons. AIDS and Behavior, 10(2), 201–207. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Chynoweth SK, Buscher D, Martin S, & Zwi AB (2020). Characteristics and impacts of sexual violence against men and boys in conflict and displacement: A multicountry exploratory study. Journal of Interpersonal Violence, 0(0), 0886260520967132. [DOI] [PubMed] [Google Scholar]
  22. Cubellis MA, Peterson BE, Henninger AM, & Lee D (2016). Childhood sexual abuse and antisocial traits and behaviors: A gendered examination of the factors associated with perpetration of intimate partner violence. Journal of Interpersonal Violence, 33(20), 3125–3161. [DOI] [PubMed] [Google Scholar]
  23. Davis KC, Neilson EC, Wegner R, & Danube CL (2018). The intersection of men’s sexual violence perpetration and sexual risk behavior: A literature review. Aggression and Violent Behavior, 40, 83–90. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Davison KM, Lung Y, Lin SL, Tong H, Kobayashi KM, & Fuller-Thomson E (2020). Psychological distress in older adults linked to immigrant status, dietary intake, and physical health conditions in the Canadian longitudinal study on aging (CLSA). Journal of Affective Disorders, 265, 526–537. [DOI] [PubMed] [Google Scholar]
  25. Deane K, & Wamoyi J (2015). Revisiting the economics of transactional sex: Evidence from Tanzania. Review of African Political Economy, 42(145), 437–454. [Google Scholar]
  26. Easton SD, Saltzman LY, & Willis DG (2014). “Would you tell under circumstances like that?”: Barriers to disclosure of child sexual abuse for men. Psychology of Men & Masculinity, 15, 460–469. [Google Scholar]
  27. Esser M, Clayton H, Demissie Z, Kanny D, & Brewer R (2017). Current and binge drinking among high school students — United States, 1991–2015. MMWR. Morbidity and Mortality Weekly Report, 66, 474–478. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Finkelhor D, & Browne A (1985). The traumatic impact of child sexual abuse: A conceptualization. American Journal of Orthopsychiatry, 55(4), 530–541. [DOI] [PubMed] [Google Scholar]
  29. Forde C, & Duvvury N (2017). Sexual violence, masculinity, and the journey of recovery. Psychology of Men & Masculinity, 18, 301. [Google Scholar]
  30. Gibbs A, Dunkle K, Washington L, Willan S, Shai N, & Jewkes R (2018). Childhood traumas as a risk factor for HIV-risk behaviours amongst young women and men living in urban informal settlements in South Africa: A cross-sectional study. PLoS One, 13(4), Article e0195369. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Hassen F, & Deyassa N (2013). The relationship between sexual violence and human immunodeficiency virus (HIV) infection among women using voluntary counseling and testing services in South Wollo Zone, Ethiopia. BMC Research Notes, 6, 271. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Henny KD, Crepaz N, Lyles CM, Marshall KJ, Aupont LW, Jacobs ED, Liau A, Rama S, Kay LS, Willis LA, & Charania MR (2012). Efficacy of HIV/STI behavioral interventions for heterosexual African American men in the United States: A meta-analysis. AIDS and Behavior, 16(5), 1092–1114. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Hernandez I, Reina-Ortiz M, Johnson A, Rosas C, Sharma V, Teran S, Naik E, Salihu HM, Teran E, & Izurieta R (2017). Risk factors associated with HIV among men who have sex with men (MSM) in Ecuador. American Journal of Men’s Health, 11(5), 1331–1341. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Ilika AL (2005). Women’s perception of partner violence in a rural Igbo community. African Journal of Reproductive Health, 9(3), 77–88. [PubMed] [Google Scholar]
  35. Jewkes R, Penn-Kekana L, & Rose-Junius H (2005). “If they rape me, I can’t blame them”: Reflections on gender in the social context of child rape in South Africa and Namibia. Social Science and Medicine, 61(8), 1809–1820. [DOI] [PubMed] [Google Scholar]
  36. Kamndaya M, Vearey J, Thomas L, Kabiru CW, & Kazembe LN (2016). The role of material deprivation and consumerism in the decisions to engage in transactional sex among young people in the urban slums of Blantyre, Malawi. Global Public Health, 11(3), 295–308. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Kerr-Wilson A, Gibbs A, McAslan Fraser E, Ramsoomar L, Parke A, Khuwaja H, & Jewkes R (2020). A rigorous global evidence review of interventions to prevent violence against women and girls, What Works to Prevent Violence Against Women and Girls Global Programme. Retrieved July 22, 2021, from https://www.whatworks.co.za/documents/publications/374-evidence-reviewfweb/file. [DOI] [PMC free article] [PubMed]
  38. Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand SL, Walters EE, & Zaslavsky AM (2002). Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological Medicine, 32(6), 959–976. [DOI] [PubMed] [Google Scholar]
  39. Khadr S, Clarke V, Wellings K, Villalta L, Goddard A, Welch J, Bewley S, Kramer T, & Viner R (2018). Mental and sexual health outcomes following sexual assault in adolescents: A prospective cohort study. Lancet Child and Adolescent Health, 2(9), 654–665. [DOI] [PubMed] [Google Scholar]
  40. Khantzian EJ (1997). The self-medication hypothesis of substance use disorders: A reconsideration and recent applications. Harvard Review of Psychiatry, 4(5). [DOI] [PubMed] [Google Scholar]
  41. Kilburn K, Ranganathan M, Stoner MCD, Hughes JP, MacPhail C, Agyei Y, Gómez-Olivé FX, Kahn K, & Pettifor A (2018). Transactional sex and incident HIV infection in a cohort of young women from rural South Africa. AIDS, 32(12), 1669–1677. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Kirk-Provencher KT, Schick MR, Spillane NS, & Tobar-Santamaria A (2020). History of sexual assault, past-year alcohol use, and alcohol-related problems in American Indian adolescents. Addictive Behaviors, 108, 106441. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Kunnuji M (2014). Basic deprivation and involvement in risky sexual behaviour among out-of-school young people in a Lagos slum. Culture, Health & Sexuality, 16 (7), 727–740. [DOI] [PubMed] [Google Scholar]
  44. Lawson J (2012). Sociological theories of intimate partner violence. Journal of Human Behavior in the Social Environment, 22(5), 572–590. [Google Scholar]
  45. Leary E, Zachary I, & Kyeong NY (2021). Regional differences in serious psychological distress and overall physical and mental health. Community Mental Health Journal, 1–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Leclerc-Madlala S (2008). Age-disparate and intergenerational sex in southern Africa: The dynamics of hypervulnerability. AIDS, 22, S17–S25. [DOI] [PubMed] [Google Scholar]
  47. Lesotho Ministry of Health (MOH). (2022). Lesotho population-based HIV impact assessment 2020 (LePHIA 2020): Final report. Maseru. [Google Scholar]
  48. Levtov RG, Barker G, Contreras-Urbina M, Heilman B, & Verma R (2014). Pathways to gender-equitable men: Findings from the international men and gender equality survey in eight countries. Men and Masculinities, 17(5), 467–501. [Google Scholar]
  49. Lomans AM, Uijen AA, Akkermans RP, Lagro-Janssen T, & Teunissen DAM (2022). Help-seeking behaviour in primary care of men and women with a history of abuse: A dutch cohort study. The European Journal of General Practice, 28(1), 40–47. [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Lown EA, Nayak MB, Korcha RA, & Greenfield TK (2011). Child physical and sexual abuse: A comprehensive look at alcohol consumption patterns, consequences, and dependence from the National Alcohol Survey. Alcoholism, Clinical and Experimental Research, 35(2), 317–325. [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Luke N (2006). Exchange and condom use in informal sexual relationships in urban Kenya. Economic Development and Cultural Change, 54, 319–348. [Google Scholar]
  52. Machtinger EL, Wilson TC, Haberer JE, & Weiss DS (2012). Psychological trauma and PTSD in HIV-positive women: A meta-analysis. AIDS and Behavior, 16 (8), 2091–2100. [DOI] [PubMed] [Google Scholar]
  53. Mathur S, Okal J, Musheke M, Pilgrim N, Kishor Patel S, Bhattacharya R, Jani N, Matheka J, Banda L, Mulenga D, & Pulerwitz J (2018). High rates of sexual violence by both intimate and non-intimate partners experienced by adolescent girls and young women in Kenya and Zambia: Findings around violence and other negative health outcomes. PLoS One, 13(9), 1–13. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. McCloskey LA, Eloff I, & Doran K (2021). Determinants of intergenerational sexual relationships and HIV risk among South African women outpatients in Gauteng. AIDS Care, 33(5), 654–662. [DOI] [PubMed] [Google Scholar]
  55. Mgoqi-Mbalo N, Zhang M, & Ntuli S (2017). Risk factors for PTSD and depression in female survivors of rape. Psychological trauma : theory, research, practice and policy, 9(3), 301–308. [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Ministry of Social Development of Lesotho, ICAP, & Centers for Disease Control and Prevention.. (2020). Violence against children and youth survey, 2018. Retrieved May 3, 2021, from https://www.togetherforgirls.org/wp-content/uploads/2020/09/Lesotho-VACS-2019_Final-Report-1.pdf.
  57. Moody G, Cannings-John R, Hood K, Kemp A, & Robling M (2018). Establishing the international prevalence of self-reported child maltreatment: A systematic review by maltreatment type and gender. BMC Public Health, 18(1), 1164. [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. Mwangi MW, Kellogg TA, Brookmeyer K, Buluma R, Chiang L, Otieno-Nyunya B, & Chesang K (2015). Perpetrators and context of child sexual abuse in Kenya. Child Abuse & Neglect, 44, 46–55. [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. National Institute of Alcohol Abuse and Alcoholism. (2004). NIAAA council approves definition of binge drinking. NIAAA Newsletter. Retrieved May 24, 2021, from https://pubs.niaaa.nih.gov/publications/Newsletter/winter2004/Newsletter_Number3.pdf.
  60. Nguyen KH, Kress H, Villaveces A, & Massetti GM (2019). Sampling design and methodology of the violence against children and youth surveys. Injury Prevention, 25(4), 321–327. [DOI] [PMC free article] [PubMed] [Google Scholar]
  61. Nguyen KH, Padilla M, Villaveces A, Patel P, Atuchukwu V, Onotu D, Apondi R, Aluzimbi G, Chipimo P, Kancheya N, & Kress H (2019). Coerced and forced sexual initiation and its association with negative health outcomes among youth: Results from the Nigeria, Uganda, and Zambia violence against children surveys. Child Abuse & Neglect, 96, 104074. [DOI] [PMC free article] [PubMed] [Google Scholar]
  62. Omigbodun O, Dogra N, Esan O, & Adedokun B (2008). Prevalence and correlates of suicidal behaviour among adolescents in southwest Nigeria. International Journal of Social Psychiatry, 54, 34–46. [DOI] [PubMed] [Google Scholar]
  63. Pereira A, Peterman A, Neijhoft AN, Buluma R, Daban RA, Islam A, Kainja ETV, Kaloga IF, Kheam T, Johnson AK, Maternowska MC, Potts A, Rottanak C, Samnang C, Shawa M, Yoshikawa M, & Palermo T (2020). Disclosure, reporting and help seeking among child survivors of violence: A crosscountry analysis. BMC Public Health, 20(1), 1051. [DOI] [PMC free article] [PubMed] [Google Scholar]
  64. Pulerwitz J, Gottert A, Betron M, & Shattuck D (2019). Do’s and don’ts for engaging men & boys. Retrieved December 3, 2021, from https://www.igwg.org/wpcontent/uploads/2021/03/Male-Engagement-DosDonts-Final-ENGLISH.pdf.
  65. Reisner SL, Falb KL, & Mimiaga MJ (2011). Early life traumatic stressors and the mediating role of PTSD in incident HIV infection among US men, comparisons by sexual orientation and eace/ethnicity: Results from the NESARC, 2004–2005. Journal of Acquired Immune Deficiency Syndromes, 57(4). [DOI] [PubMed] [Google Scholar]
  66. Richter L, Komárek A, Desmond C, Celentano D, Morin S, Sweat M, Chariyalertsak S, Chingono A, Gray G, Mbwambo J, & Coates T (2014). Reported physical and sexual abuse in childhood and adult HIV risk behaviour in three African countries: Findings from project accept (HPTN-043). AIDS and Behavior, 18 (2), 381–389. [DOI] [PMC free article] [PubMed] [Google Scholar]
  67. Rogstad KE, Wilkinson D, & Robinson A (2016). Sexually transmitted infections in children as a marker of child sexual abuse and direction of future research. Current Opinion in Infectious Diseases, 29(1), 41–44. [DOI] [PubMed] [Google Scholar]
  68. Saul J, Bachman G, Allen S, Toiv NF, Cooney C, & Beamon TA (2018). The DREAMS core package of interventions: A comprehensive approach to preventing HIV among adolescent girls and young women. PLoS One, 13(12), Article e0208167. [DOI] [PMC free article] [PubMed] [Google Scholar]
  69. Schäfer JL, Texeira VA, Prado da Fontoura L, de Castro LC, & Horta RL (2017). Exposure to physical and sexual violence and suicidal ideation among schoolchildren. Jornal Brasileiro de Psiquiatria, 66(2), 96–103. [Google Scholar]
  70. Seña AC, Hsu KK, Kellogg N, Girardet R, Christian CW, Linden J, Griffith W, Marchant A, Jenny C, & Hammerschlag MR (2015). Sexual assault and sexually transmitted infections in adults, adolescents, and children. Clinical Infectious Diseases, 61(suppl_8), S856–S864. [DOI] [PubMed] [Google Scholar]
  71. Senn TE, Carey MP, & Coury-Doniger P (2011). Self-defining as sexually abused and adult sexual risk behavior: Results from a cross-sectional survey of women attending an STD clinic. Child Abuse & Neglect, 35(5), 353–362. [DOI] [PMC free article] [PubMed] [Google Scholar]
  72. Silverman JG, McCauley HL, Decker MR, Miller E, Reed E, & Raj A (2011). Coercive forms of sexual risk and associated violence perpetrated by male partners of female adolescents. Perspectives on Sexual & Reproductive Health, 43(1), 60–65. [DOI] [PubMed] [Google Scholar]
  73. Stamatakis C, Howard A, Chiang L, Massetti GM, Apondi R, Stoebenau K, Hegle J, Wasula L, & Patel P (2021). Regional heterogeneity in violence and individual characteristics associated with recent transactional sex among Ugandan girls and young women: A national and regional analysis of data from the violence against children and youth survey. PLoS One, 16(9), Article e0257030. [DOI] [PMC free article] [PubMed] [Google Scholar]
  74. Stark L, Seff I, Hoover A, Gordon R, Ligiero D, & Massetti G (2019). Sex and age effects in past-year experiences of violence amongst adolescents in five countries. PLoS One, 14(7), Article e0219073. [DOI] [PMC free article] [PubMed] [Google Scholar]
  75. Stoebenau K, Nixon SA, Rubincam C, Willan S, Zembe YZN, Tsikoane T, Tanga PT, Bello HM, Caceres CF, Townsend L, Rakotoarison PG, & Razafintsalama V (2011). More than just talk: The framing of transactional sex and its implications for vulnerability to HIV in Lesotho, Madagascar and South Africa. Globalization and Health, 7(1), 34. [DOI] [PMC free article] [PubMed] [Google Scholar]
  76. Substance Abuse and Mental Health Services Administration. (2013). Results from the 2012 National Survey on drug use and health: Summary of national findings. Retrieved May 3, 2021, from https://www.samhsa.gov/data/sites/default/files/NSDUHresults2012/NSDUHresults2012.pdf. [PubMed]
  77. Sumner SA, Mercy JA, Buluma R, Mwangi MW, Marcelin LH, Kheam T, Lea V, Brookmeyer K, Kress H, & Hillis SD (2016). Childhood sexual violence against boys: A study in 3 countries. Pediatrics, 137(5), Article e20153386. [DOI] [PMC free article] [PubMed] [Google Scholar]
  78. Teitelman AM, Bellamy SL, Jemmott JB 3rd, Icard L, O’Leary A, Ali S, Ngwane Z, & Makiwane M (2017). Childhood sexual abuse and sociodemographic factors prospectively associated with intimate partner violence perpetration among South African heterosexual men. Annals of Behavioral Medicine, 51(2), 170–178. [DOI] [PMC free article] [PubMed] [Google Scholar]
  79. The World Factbook. (2021). HIV/AIDS – adult prevalence rate. Retrieved June 7, 2021, from https://www.cia.gov/the-world-factbook/field/hiv-aids-adultprevalence-rate/country-comparison.
  80. Thibodeau M-E, Lavoie F, Hébert M, & Blais M (2017). Pathways linking childhood maltreatment and adolescent sexual risk behaviors: The role of attachment security. Journal of Sex Research, 54(8), 994–1005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  81. Tonmyr L, & Shields M (2017). Childhood sexual abuse and substance abuse: A gender paradox? Child Abuse & Neglect, 63, 284–294. [DOI] [PubMed] [Google Scholar]
  82. UNAIDS. (2021). People living with HIV - Young people (15–24). AIDSinfo. Retrieved June 5, 2021, from https://aidsinfo.unaids.org/.
  83. United Nations Children’s Fund. (2014). Hidden in plain sight: A statistical analysis of violence against children. New York. [Google Scholar]
  84. Vagi KJ, Brookmeyer KA, Gladden RM, Chiang LF, Brooks A, Nyunt M-Z, Kwesigabo G, Mercy JA, & Dahlberg LL (2016). Sexual violence against female and male children in the United Republic of Tanzania. Violence Against Women, 22(14), 1788–1807. [DOI] [PubMed] [Google Scholar]
  85. VanderEnde K, Chiang L, Mercy J, Shawa M, Hamela J, Maksud N, Gupta S, Wadonda-Kabondo N, Saul J, Gleckel J, Kress H, & Hillis S (2018). Adverse childhood experiences and HIV sexual risk-taking behaviors among young adults in Malawi. Journal of Interpersonal Violence, 33(11), 1710–1730. [DOI] [PMC free article] [PubMed] [Google Scholar]
  86. VanderEnde K, Mercy J, Shawa M, Kalanda M, Hamela J, Maksud N, Ross B, Gupta S, Wadonda-Kabondo N, & Hillis S (2016). Violent experiences in childhood are associated with men’s perpetration of intimate partner violence as a young adult: A multistage cluster survey in Malawi. Annals of Epidemiology, 26 (10), 723–728. [DOI] [PMC free article] [PubMed] [Google Scholar]
  87. Villalba K, Attonito J, Jean-Gilles M, Rosenberg R, & Dévieux JG (2020). Gender differences in the association between childhood sexual abuse and risk behaviors among people living with HIV in Haiti. AIDS Care, 32(11), 1438–1444. [DOI] [PMC free article] [PubMed] [Google Scholar]
  88. Wamoyi J, Fenwick A, Urassa M, Zaba B, & Stones W (2011). “Women’s bodies are shops”: Beliefs about transactional sex and implications for understanding gender power and HIV prevention in Tanzania. Archives of Sexual Behavior, 40(1), 5–15. [DOI] [PubMed] [Google Scholar]
  89. Wamoyi J, Stobeanau K, Bobrova N, Abramsky T, & Watts C (2016). Transactional sex and risk for HIV infection in sub-Saharan Africa: A systematic review and meta-analysis. Journal of the International AIDS Society, 19(1), 20992. [DOI] [PMC free article] [PubMed] [Google Scholar]
  90. Ward CL, Artz L, Leoschut L, Kassanjee R, & Burton P (2018). Sexual violence against children in South Africa: A nationally representative cross-sectional study of prevalence and correlates. Lancet Global Health, 6(4), e460–e468. [DOI] [PubMed] [Google Scholar]
  91. World Health Organization. (2001). Ethical and safety recommendations for research on domestic violence against women. Retrieved August 21, 2021, from https://www.who.int/gender/violence/womenfirtseng.pdf.
  92. World Health Organization. (2016). INSPIRE: Seven strategies for ending violence against children. Retrieved September 15, 2022, from https://www.who.int/publications/i/item/inspire-seven-strategies-for-ending-violence-against-children.

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Lesotho VACS data are publicly available and access can be requested through the Together for Girls website: https://www.togetherforgirls.org/request-access-vacs/

RESOURCES