The global statistics on sexual assault against women are shocking. At least one in every five women experiences rape or attempted rape during her lifetime.1 The recently published report from the United Nations Population Fund on the State of the World Population 2000 is the latest of many official reports that have documented the size of the problem.2 Yet despite clear documentation and the fact that much attention has been paid to the issue of sexual violence against women at international level, the problem is getting worse.
The UN report and other data make it clear that the incidence of rape and other forms of sexual violence is increasing worldwide.3 Yet even official figures underestimate the scale of the problem because the proportion of rapes reported to the authorities varies from 16% in the United States to 3% in South Africa (where even 3% amounted to 49 280 rapes in 19984). The fourth world conference on women in 1995 in Beijing considered violence against women to be one of the 12 critical areas of concern, and a “platform for action” was agreed by the 189 governments present.5 Yet the follow up conference in New York in 2000 agreed that the action had been woefully ineffective,6 and a Human Rights Watch report on six countries—Jordan, Pakistan, Peru, Russia, South Africa, and the United States—concluded that women were actually worse off.4 These six countries are not extreme cases; they reflect the situation for women in most countries.
Perhaps it is not surprising that international action to prevent sexual violence has failed when the judicial system is so often stacked against women who complain of sexual violence. In the United States, for example, some states do not treat sexual misconduct by guards on women prisoners as a criminal offence. In Peru some women have had to deliver police summonses to their abusers, and in Pakistan police often refuse to register a complaint. Forensic examination in some countries focuses solely on whether or not the victim was a virgin. In Jordan officials place women victims in prison, apparently for protective custody, and in most countries the moral standing of the victim is taken into account in the judicial system. One judge in Pakistan allegedly dismissed a case because he felt that the victim had not struggled enough.4
Human Right Watch has identified the high level issues that need to be addressed to counter these problems. They include repealing laws that discriminate against women; eliminating police bias against female victims of sexual assault; ensuring medicolegal systems provide women with appropriate treatment and diagnosis, providing protection from further violence; ensuring that perpetrators are brought to justice; and eliminating judicial bias against women. But some of these measures are hard to implement, because they involve changing attitudes and power relationships, and governments need encouragement to implement them: women need advocates.
The international medical advisory panel of the Planned Parenthood Foundation recommends that healthcare professionals should provide that advocacy, alongside increasing their awareness of sexual violence and their skills in managing victims, providing support and care for the victims, and implementing preventive actions.1 Providing physical care and attention and doing so with sensitivity and understanding obviously fall within the remit of clinicians, but even these are often done badly. Even if the physical consequences of rape—injury, sexually transmitted diseases, and unwanted pregnancy—are dealt with adequately, the psychological consequences are often neglected, with victims rarely being followed up or routinely referred for counselling.7 There are often no standard procedures for dealing with rape victims, and doctors are often ignorant of the sampling techniques and legislative procedures required or where to refer for counselling services even if they do know about the need to investigate and treat sexually transmitted diseases.8,9
Doctors also need to advocate for action as influential members of society. There needs to be a strong, coordinated, bottom up approach to the problem of sexual violence as well as a top down one. Sexual assault is still talked about only in hushed whispers, making it even harder for victims to come to terms with their ordeal and seek the help they need. We need to brush aside the taboos and talk more openly about this huge problem and the practical ways of tackling it. As well as being an individual, every rape victim is also someone's daughter, sister, or mother. It is our responsibility to become involved and take action before these cold statistics become personal.