ABSTRACT

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Refugees; Sex Offenses; Rape; Review; Prevalence

INTRODUCTION

The world is currently experiencing the biggest migratory crisis since World War II, with an increasing number of refugees. According to the United Nations High Commissioner for Refugees (UNHCR) report, 65.6 million people were forced to move because of persecution, conflict, widespread violence or human rights violations in 2016. Of these, 22.5 million were refugees; 2.8 million, asylum seekers; and 40.3 million, internally displaced persons within their own countries¹1. United Nations High Commissioner for Refugees. Global trends: forced displacement in 2016. Geneva: UNHCR; 2017..

Sexual violence (SV), defined as a sexual act or attempt to obtain a sexual act without the voluntary consent of the victim or with someone unable to consent or refuse²2. Basile KC, Smith SG, Breiding MJ, Black MC, Mahendra RR. Sexual violence surveillance: uniform definitions and recommended data elements. Version 2.0. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2014 [cited 2017 Jun 29]. Available from: https://www.cdc.gov/violenceprevention/pdf/sv_surveillance_definitionsl-2009-a.pdf
https://www.cdc.gov/violenceprevention/p... , is considered a present threat during forced displacement and the search for asylum³3. United Nations High Commissioner for Refugees. Working with men and boy survivors of sexual and gender-based violence in forced displacement. Geneva: UNHCR; 2012.,⁴4. Ward J, Vann B. Gender-based violence in refugee settings. Lancet. 2002 [cited 2017 Jun 29];360 Suppl:13-14. Available from: https://www.thelancet.com/pdfs/journals/lancet/PIIS0140673602118022.pdf
https://www.thelancet.com/pdfs/journals/... . In times of war, women and girls are more vulnerable to rape and are at greater risk for other forms of SV, such as early or forced marriage, intimate partner abuse, child sexual abuse, sexual exploitation and trafficking⁴4. Ward J, Vann B. Gender-based violence in refugee settings. Lancet. 2002 [cited 2017 Jun 29];360 Suppl:13-14. Available from: https://www.thelancet.com/pdfs/journals/lancet/PIIS0140673602118022.pdf
https://www.thelancet.com/pdfs/journals/... . SV has also been perpetrated against men and boys as a tactic of war or during detention and interrogation⁵5. United Nations. Sexual violence in conflict: General Assembly Security Council Report of the Secretary General. New York: UN; 2013.; they may suffer rape, sexual torture, mutilation, humiliation, enslavement, and forced incest⁶6. Women’s Refugee Commission. Mean streets: identifying and responding to urban refugees’ risks of gender-based violence male survivor and member of men of hope. New York: WRC; 2016.. This risk persists during the escape journey and after the reception in apparently safe destinations⁷7. Sheehy I. Sexual assault in refugee camps. Havard Political Review. 2016 Oct 17 [cited 2017 Jun 29]. Available from: http://harvardpolitics.com/hprgument-posts/sexual-assault-in-refugee-camps/
http://harvardpolitics.com/hprgument-pos... .

The consequences can be extremely serious. In women, it can lead to mental disorders, obstetric complications, sexual dysfunctions, unwanted pregnancies, unsafe abortions and sexually transmitted infections⁸8. World Health Organization. World report on violence and health. Geneva: WHO; 2002. Sexual violence; p.147-74.,⁹9. Jina R, Thomas LS. Health consequences of sexual violence against women. Best Pract Res Clin Obstet Gynaecol. 2013;27(1):15-26. https://doi.org/10.1016/j.bpobgyn.2012.08.012
https://doi.org/10.1016/j.bpobgyn.2012.0... . Among men, in addition to infections and mental disorders, sexual dysfunction, somatic complaints, sleep disorders, withdrawal from relationships, attempted suicide, alcohol and drug abuse, and violent behavior are common⁸8. World Health Organization. World report on violence and health. Geneva: WHO; 2002. Sexual violence; p.147-74.,¹⁰10. Tewksbudy R. Effects of sexual assaults on men: physical, mental and sexual consequences. Int J Mens Health. 2007;6(1):22-35. https://doi.org/10.3149/jmh.0601.22
https://doi.org/10.3149/jmh.0601.22... . In childhood, sexual abuse may also be accompanied by guilt, shame, eating disorders, cognitive distortions, mental disorders, sexual and relationship problems, and school absenteeism¹¹11. Haal M, Hall J. The long-term effects of childhood sexual abuse: counseling implications. Vistas Online. 2011 [cited 2017 Jun 29]: Article 19. Available from: https://www.counseling.org/docs/disaster-and-trauma_sexual-abuse/long-term-effects-of-childhood-sexual-abuse.pdf?sfvrsn=2
https://www.counseling.org/docs/disaster... .

Two previous systematic reviews have portrayed SV in refugees and internally displaced persons in emergency humanitarian complexes¹²12. Vu A, Adam A, Wirtz A, Pham K, Rubenstein L, Glass N, et al. The prevalence of sexual violence among female refugees in complex humanitarian emergencies: a systematic review and meta-analysis. PLoS Curr. 2014;6. https://doi.org/10.1371/currents.dis.835f10778fd80ae031aac12d3b533ca7
https://doi.org/10.1371/currents.dis.835... ,¹³13. Stark L, Ager A. A systematic review of prevalence studies of gender-based violence in complex emergencies. Trauma Violence Abuse. 2011;12(3):127-34. https://doi.org/10.1177/1524838011404252
https://doi.org/10.1177/1524838011404252... : a meta-analysis aimed at estimating its prevalence in women only¹²12. Vu A, Adam A, Wirtz A, Pham K, Rubenstein L, Glass N, et al. The prevalence of sexual violence among female refugees in complex humanitarian emergencies: a systematic review and meta-analysis. PLoS Curr. 2014;6. https://doi.org/10.1371/currents.dis.835f10778fd80ae031aac12d3b533ca7
https://doi.org/10.1371/currents.dis.835... , and other aimed at quantifying gender-based violence in three categories: physical violence, by intimate and sexual partner¹³13. Stark L, Ager A. A systematic review of prevalence studies of gender-based violence in complex emergencies. Trauma Violence Abuse. 2011;12(3):127-34. https://doi.org/10.1177/1524838011404252
https://doi.org/10.1177/1524838011404252... . Neither analyzed the different types, profile of perpetrators and the moment of occurrence of SV in the migratory process. No studies have been conducted on the prevalence of this violence in the total refugee population (children, adults and older adults of both sexes) in different scenarios and moments of their trajectory, for a more comprehensive understanding of the magnitude of the problem.

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

METHODS

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

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

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

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

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

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

RESULTS

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

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

Characteristics of the Studies and their Populations

The 60 articles selected were all published in English between 1990 and 2017 (45% between 2000 and 2010) and from 31 different countries (14 from the USA). Studies were of cross-sectional design (Table 1), except for two cohort studies⁴⁸48. Williams ACC, Peña CR, Rice ASC. Persistent pain in survivors of torture: a cohort study. J Pain Symptom Manage. 2010;40(5):715-22. https://doi.org/10.1016/j.jpainsymman.2010.02.018
https://doi.org/10.1016/j.jpainsymman.20... ,⁷³73. Wright AM, Talia YR, Aldhalimi A, Broadbridge CL, Jamil H, Lumley MA, et al. Kidnapping and mental health in Iraqi refugees: the role of resilience. J Immigr Minor Health. 2017;19(1):98-107. https://doi.org/10.1007/s10903-015-0340-8
https://doi.org/10.1007/s10903-015-0340-... .

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

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

Prevalence of Sexual Violence

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

Six studies reported SV in children and adolescents, with prevalence varying between 4.6% and 90.9%¹⁶16. McKelvey RS, Webb JA. A pilot study of abuse among Vietnamese Amerasians. Child Abuse Negl. 1995;19(5):545-53. https://doi.org/10.1016/0145-2134(95)00014-Y
https://doi.org/10.1016/0145-2134(95)000... ,⁴⁴44. Chang J, Rhee S, Berthold SM. Child abuse and neglect in Cambodian refugee families: characteristics and implications for practice. Child Welfare. 2008;87(1):141-60.,⁴⁷47. Mitike G, Deressa W. Prevalence and associated factors of female genital mutilation among Somali refugees in eastern Ethiopia: a cross-sectional study. BMC Public Health. 2009;9:264. https://doi.org/10.1186/1471-2458-9-264
https://doi.org/10.1186/1471-2458-9-264... ,⁵²52. Kira I, Lewandowski L, Somers CL, Yoon JS, Chiodo L. The effects of trauma types, cumulative trauma, and PTSD on IQ in two highly traumatized adolescent groups. Psychol Trauma. 2012; 4(1):128-139.,⁵⁴54. Black BM, Chiodo LM, Weisz NA, Elias-Lambert N, Kernsmit PD, Yoon JS, et al. Iraqi American refugee youths’ exposure to violence: relationship to attitudes and peers’ perpetration of dating violence. Violence Against Women. 2013;19(2):202-21. https://doi.org/10.1177/1077801213476456
https://doi.org/10.1177/1077801213476456... ,⁷²72. Stark l, Sommer M, Davis K, Asghar K, Assazenew Baysa A, Abdela G, et al. Disclosure bias for group versus individual reporting of violence amongst conflict affected adolescent girls in DRC and Ethiopia. PLoS One. 2017;12(4):e0174741. https://doi.org/10.1371/journal.pone.0174741
https://doi.org/10.1371/journal.pone.017... . In 32 of the 36 (89%) studies that showed prevalence by sex, the main victims were women. Of these, 12 studies reported SV in both sexes, with a difference of up to 59.2% more of prevalence in women¹⁷17. Peel MR. Effects on asylum seekers of ill treatment in Zaire. Br Med J. 1996;312(7026):293-4. https://doi.org/10.10.1136/bmj.312.7026.293
https://doi.org/10.10.1136/bmj.312.7026.... . Two studies reported the opposite, but with disparities less than 2%¹⁶16. McKelvey RS, Webb JA. A pilot study of abuse among Vietnamese Amerasians. Child Abuse Negl. 1995;19(5):545-53. https://doi.org/10.1016/0145-2134(95)00014-Y
https://doi.org/10.1016/0145-2134(95)000... ,²⁹29. Cardozo BL, Talley L, Burton A, Crawford C. Karenni refugees living in Thai–Burmese border camps: traumatic experiences, mental health outcomes, and social functioning. Soc Sci Med. 2004;58(12):2637-44. https://doi.org/10.1016/j.socscimed.2003.09.024
https://doi.org/10.1016/j.socscimed.2003... . In men, the prevalence reached 39.3%¹⁴14. Allodi F, Stiasny S. Women as torture victims. Can J Psychiatry. 1990;35(2):144-8. https://doi.org/10.1177/070674379003500207
https://doi.org/10.1177/0706743790035002... .

Africa was the most frequent continent of origin in 13 (42%) of the 31 studies with information about it (Table 2). As to the moment of occurrence, approached by 18 studies, 17 (94%) reported that SV occurred in the country of origin (prevalence between 1% and 92%); in two studies (11%), it occurred during the course (prevalence of 5.2% in both)⁵³53. Parmar P, Agrawal P, Greenough PG, Goyal R, Kayden S. Sexual violence among host and refugee population in Djohong District, Eastern Cameroon. Glob Public Health. 2012;7(9):974-94. https://doi.org/10.1080/17441692.2012.688061
https://doi.org/10.1080/17441692.2012.68... ,⁶⁸68. Gušić S, Cardeña E, Bengtsson H, Søndergaard HP. Dissociative experiences and trauma exposure among newly arrived and settled young war refugees. J Aggress Maltreat Trauma. 2017;26(10):1132-49. https://doi.org/10.1080/10926771.2017.1365792
https://doi.org/10.1080/10926771.2017.13... ; and two (11%) reported SV at the host site (prevalence of 39% in Cameroon⁵³53. Parmar P, Agrawal P, Greenough PG, Goyal R, Kayden S. Sexual violence among host and refugee population in Djohong District, Eastern Cameroon. Glob Public Health. 2012;7(9):974-94. https://doi.org/10.1080/17441692.2012.688061
https://doi.org/10.1080/17441692.2012.68... and 46.1% in Uganda⁵⁹59. Morof DF, Sami S, Mangeni M, Blanton C, Cardozo BL, Tomczyk B. A cross-sectional survey on gender-based violence and mental health among female urban refugees and asylum seekers in Kampala, Uganda. Int J Gynecol Obstet. 2014;127(2):138-43. https://doi.org/10.1016/j.ijgo.2014.05.014
https://doi.org/10.1016/j.ijgo.2014.05.0... ).

The most frequent type of SV was rape (65%) (Table 3). The perpetrators were identified in 18 studies: 10 (55%) reported the occurrence of SV by intimate partner (prevalence from 4.3% to 30%)³³33. Avdibegovic E, Sinanovic O. Consequences of domestic violence on women’s mental health in Bosnia and Herzegovina. Croat Med J. 2006;47(5):730-41.,³⁹39. Hammoury N, Khawaja M. Screening for domestic violence during pregnancy in an antenatal clinic in Lebanon. Eur J Public Health. 2007;17(6):605-6. https://doi.org/10.1093/eurpub/ckm009
https://doi.org/10.1093/eurpub/ckm009... ,⁴⁵45. Nagai M, Karunakara U, Rowley E, Burnham G. Violence against refugees, non-refugees and host populations in southern Sudan and northern Uganda. Glob Public Health. 2008;3(3):249-70. https://doi.org/10.1080/17441690701768904
https://doi.org/10.1080/1744169070176890... ,⁵³53. Parmar P, Agrawal P, Greenough PG, Goyal R, Kayden S. Sexual violence among host and refugee population in Djohong District, Eastern Cameroon. Glob Public Health. 2012;7(9):974-94. https://doi.org/10.1080/17441692.2012.688061
https://doi.org/10.1080/17441692.2012.68... ,⁵⁵55. Falb KL, McCormick MC, Hemenway D, Anfinson K, Silverman JG. Suicide ideation and victimization among refugee women along the Thai-Burma border. J Trauma Stress. 2013;26(5) 631-5. https://doi.org/10.1002/jts.21846
https://doi.org/10.1002/jts.21846... ,⁵⁹59. Morof DF, Sami S, Mangeni M, Blanton C, Cardozo BL, Tomczyk B. A cross-sectional survey on gender-based violence and mental health among female urban refugees and asylum seekers in Kampala, Uganda. Int J Gynecol Obstet. 2014;127(2):138-43. https://doi.org/10.1016/j.ijgo.2014.05.014
https://doi.org/10.1016/j.ijgo.2014.05.0... ,⁶²62. Sipsma HL, Falb KL, Willie T, Bradley EH, Bienkowski L, Meerdink N, et al. Violence against Congolese refugee women in Rwanda and mental health: a cross-sectional study using latent class analysis. BMJ Open. 2015;5(4):e006299. https://doi.org/10.1136/bmjopen-2014-006299
https://doi.org/10.1136/bmjopen-2014-006... ,⁶³63. Al-Modallal H, Abu-Zayed I, Abujilban S, Shehab T, Atoum M. Prevalence of Intimate partner violence among women visiting health care centers in Palestine refugee camps in Jordan. Health Care Women Int. 2015;36(2):137-48. https://doi.org/10.1080/07399332.2014.948626
https://doi.org/10.1080/07399332.2014.94... ,⁶⁶66. Um M, Kim H, Palinkas LA. Correlates of domestic violence victimization among North Korean refugee women in South Korea. J Interpers Violence. 2018;33(13):2037-58. https://doi.org/10.1177/0886260515622297
https://doi.org/10.1177/0886260515622297... ,⁷²72. Stark l, Sommer M, Davis K, Asghar K, Assazenew Baysa A, Abdela G, et al. Disclosure bias for group versus individual reporting of violence amongst conflict affected adolescent girls in DRC and Ethiopia. PLoS One. 2017;12(4):e0174741. https://doi.org/10.1371/journal.pone.0174741
https://doi.org/10.1371/journal.pone.017... , five by military personnel (prevalence from 1% to 74.6%)³⁸38. Edston E, Olsson C. Female victims of torture. J Forensic Leg Med. 2007;14(6):368-73. https://doi.org/10.1016/j.jflm.2006.12.014
https://doi.org/10.1016/j.jflm.2006.12.0... ,⁴⁵45. Nagai M, Karunakara U, Rowley E, Burnham G. Violence against refugees, non-refugees and host populations in southern Sudan and northern Uganda. Glob Public Health. 2008;3(3):249-70. https://doi.org/10.1080/17441690701768904
https://doi.org/10.1080/1744169070176890... ,⁵⁵55. Falb KL, McCormick MC, Hemenway D, Anfinson K, Silverman JG. Suicide ideation and victimization among refugee women along the Thai-Burma border. J Trauma Stress. 2013;26(5) 631-5. https://doi.org/10.1002/jts.21846
https://doi.org/10.1002/jts.21846... ,⁵⁸58. Idemudia ES. Displaced, homeless and abused: the dynamics of gender-based sexual and physical abuses of homeless Zimbabweans in South Africa. Gender Behav. 2014;12(2):6312-6.,⁷²72. Stark l, Sommer M, Davis K, Asghar K, Assazenew Baysa A, Abdela G, et al. Disclosure bias for group versus individual reporting of violence amongst conflict affected adolescent girls in DRC and Ethiopia. PLoS One. 2017;12(4):e0174741. https://doi.org/10.1371/journal.pone.0174741
https://doi.org/10.1371/journal.pone.017... , four by acquaintances⁵¹51. Bogic M, Ajdukovic D, Bremner S, Franciskovic T, Galeazzi GM, Kucukalic A, et al. Factors associated with mental disorders in long-settled war refugees: refugees from the former Yugoslavia in Germany, Italy and the UK. Br J Psychiatry. 2012;200(3):216-23. https://doi.org/10.1192/bjp.bp.110.084764
https://doi.org/10.1192/bjp.bp.110.08476... ,⁵³53. Parmar P, Agrawal P, Greenough PG, Goyal R, Kayden S. Sexual violence among host and refugee population in Djohong District, Eastern Cameroon. Glob Public Health. 2012;7(9):974-94. https://doi.org/10.1080/17441692.2012.688061
https://doi.org/10.1080/17441692.2012.68... ,⁵⁵55. Falb KL, McCormick MC, Hemenway D, Anfinson K, Silverman JG. Suicide ideation and victimization among refugee women along the Thai-Burma border. J Trauma Stress. 2013;26(5) 631-5. https://doi.org/10.1002/jts.21846
https://doi.org/10.1002/jts.21846... ,⁷²72. Stark l, Sommer M, Davis K, Asghar K, Assazenew Baysa A, Abdela G, et al. Disclosure bias for group versus individual reporting of violence amongst conflict affected adolescent girls in DRC and Ethiopia. PLoS One. 2017;12(4):e0174741. https://doi.org/10.1371/journal.pone.0174741
https://doi.org/10.1371/journal.pone.017... , four by relatives⁴⁵45. Nagai M, Karunakara U, Rowley E, Burnham G. Violence against refugees, non-refugees and host populations in southern Sudan and northern Uganda. Glob Public Health. 2008;3(3):249-70. https://doi.org/10.1080/17441690701768904
https://doi.org/10.1080/1744169070176890... ,⁵⁴54. Black BM, Chiodo LM, Weisz NA, Elias-Lambert N, Kernsmit PD, Yoon JS, et al. Iraqi American refugee youths’ exposure to violence: relationship to attitudes and peers’ perpetration of dating violence. Violence Against Women. 2013;19(2):202-21. https://doi.org/10.1177/1077801213476456
https://doi.org/10.1177/1077801213476456... ,⁵⁸58. Idemudia ES. Displaced, homeless and abused: the dynamics of gender-based sexual and physical abuses of homeless Zimbabweans in South Africa. Gender Behav. 2014;12(2):6312-6.,⁷²72. Stark l, Sommer M, Davis K, Asghar K, Assazenew Baysa A, Abdela G, et al. Disclosure bias for group versus individual reporting of violence amongst conflict affected adolescent girls in DRC and Ethiopia. PLoS One. 2017;12(4):e0174741. https://doi.org/10.1371/journal.pone.0174741
https://doi.org/10.1371/journal.pone.017... , two by unknowns ⁵¹51. Bogic M, Ajdukovic D, Bremner S, Franciskovic T, Galeazzi GM, Kucukalic A, et al. Factors associated with mental disorders in long-settled war refugees: refugees from the former Yugoslavia in Germany, Italy and the UK. Br J Psychiatry. 2012;200(3):216-23. https://doi.org/10.1192/bjp.bp.110.084764
https://doi.org/10.1192/bjp.bp.110.08476... ,⁵³53. Parmar P, Agrawal P, Greenough PG, Goyal R, Kayden S. Sexual violence among host and refugee population in Djohong District, Eastern Cameroon. Glob Public Health. 2012;7(9):974-94. https://doi.org/10.1080/17441692.2012.688061
https://doi.org/10.1080/17441692.2012.68... , two by rebel soldiers ³¹31. Thomas S, Thomas S, Nafees B, Bhugra D. ‘I was running away from death’: the pre-flight experiences of unaccompanied asylum seeking children in the UK. Child Care Health Dev. 2004;30(2):113-22. https://doi.org/10.1111/j.1365-2214.2003.00404.x
https://doi.org/10.1111/j.1365-2214.2003... ,⁵³53. Parmar P, Agrawal P, Greenough PG, Goyal R, Kayden S. Sexual violence among host and refugee population in Djohong District, Eastern Cameroon. Glob Public Health. 2012;7(9):974-94. https://doi.org/10.1080/17441692.2012.688061
https://doi.org/10.1080/17441692.2012.68... , one by police officers⁵⁸58. Idemudia ES. Displaced, homeless and abused: the dynamics of gender-based sexual and physical abuses of homeless Zimbabweans in South Africa. Gender Behav. 2014;12(2):6312-6., one by armed groups⁷²72. Stark l, Sommer M, Davis K, Asghar K, Assazenew Baysa A, Abdela G, et al. Disclosure bias for group versus individual reporting of violence amongst conflict affected adolescent girls in DRC and Ethiopia. PLoS One. 2017;12(4):e0174741. https://doi.org/10.1371/journal.pone.0174741
https://doi.org/10.1371/journal.pone.017... , and one by guards in prison¹⁷17. Peel MR. Effects on asylum seekers of ill treatment in Zaire. Br Med J. 1996;312(7026):293-4. https://doi.org/10.10.1136/bmj.312.7026.293
https://doi.org/10.10.1136/bmj.312.7026.... .

In five studies³²32. Asgary R, Metalios EE, Smith CL, Paccione GA. Evaluating asylum seekers/torture survivors in urban primary care: a collaborative approach at the Bronx Human Rights Clinic. Health Hum Rights. 2006;9(2):164-79. https://doi.org/10.2307/4065406
https://doi.org/10.2307/4065406... ,⁴⁹49. Schubert CC, Punamäki RL. Mental health among torture survivors: cultural background, refugee status and gender. Nord J Psychiatry. 2011;65(3):175-82. https://di.org/10.3109/08039488.2010.514943
https://di.org/10.3109/08039488.2010.514... ,⁵⁵55. Falb KL, McCormick MC, Hemenway D, Anfinson K, Silverman JG. Suicide ideation and victimization among refugee women along the Thai-Burma border. J Trauma Stress. 2013;26(5) 631-5. https://doi.org/10.1002/jts.21846
https://doi.org/10.1002/jts.21846... ,⁵⁸58. Idemudia ES. Displaced, homeless and abused: the dynamics of gender-based sexual and physical abuses of homeless Zimbabweans in South Africa. Gender Behav. 2014;12(2):6312-6.,⁶⁷67. Wirtz, A, Glass N, Pham K, Perrin N, Rubenstein LS, Singh S, et al. Comprehensive development and testing of the ASIST-GBV, a screening tool for responding to gender-based violence among women in humanitarian settings. Confl Health. 2016;10:7. https://doi.org/10.1186/s13031-016-0071-z
https://doi.org/10.1186/s13031-016-0071-... , the authors did not report the number of victims, and it was not possible to estimate the overall prevalence. Estimating the sum of prevalence by specific type would overestimate the overall prevalence due to cases that suffered more than one type of SV.

DISCUSSION

Previous studies have shown that SV is a constant threat throughout the refugee migration pathway³3. United Nations High Commissioner for Refugees. Working with men and boy survivors of sexual and gender-based violence in forced displacement. Geneva: UNHCR; 2012.,¹²12. Vu A, Adam A, Wirtz A, Pham K, Rubenstein L, Glass N, et al. The prevalence of sexual violence among female refugees in complex humanitarian emergencies: a systematic review and meta-analysis. PLoS Curr. 2014;6. https://doi.org/10.1371/currents.dis.835f10778fd80ae031aac12d3b533ca7
https://doi.org/10.1371/currents.dis.835... ,¹³13. Stark L, Ager A. A systematic review of prevalence studies of gender-based violence in complex emergencies. Trauma Violence Abuse. 2011;12(3):127-34. https://doi.org/10.1177/1524838011404252
https://doi.org/10.1177/1524838011404252... , which has been confirmed in the present review. Although most of the studies identified here revealed a higher prevalence among adult women, SV was also a serious problem in men and children. In addition, we observed the SV is perpetrated mainly by intimate partners, but also by military, guards and police. Most cases occur in the country of origin, in the form of rape and in refugees from Africa. In some refugee camps, such as Uganda and Cameroon, the frequency was alarming.

It is possible that prevalence may be underestimated in some studies, since many victims – especially men – do not report SV because of shame, threats by perpetrators, fear of being found guilty or suffering from stigma and exclusion from family and community⁶6. Women’s Refugee Commission. Mean streets: identifying and responding to urban refugees’ risks of gender-based violence male survivor and member of men of hope. New York: WRC; 2016.,⁷⁴74. Hynes M, Cardozo BL. Sexual violence against refugee women. J Womens Health Gend Based Med. 2000;9(8):819-23. https://doi.og/10.1089/152460900750020847
https://doi.og/10.1089/15246090075002084... , with consequent low demand for health care and case records⁷⁵75. Alcorn T. Responding to sexual violence in armed conflict. Lancet. 2014;383(9934):2034-7. https://doi.org/10.1016/S0140-6736(14)60970-3
https://doi.org/10.1016/S0140-6736(14)60... . In addition, the humanitarian crisis caused by armed conflicts in the refugees’ countries of origin leads to large displacements of people and demands incompatible with the availability of health services and resources⁷⁶76. Checci F, Warsame A, Treacy-Wong V, Polonsky J, Ommerem M, Prudhon C. Public health information in crisis-affected populations: a review of methods and their use for advocacy and action. Lancet. 2017;390(10109):2297-313. https://doi.org/10.1016/S0140-6736(17)30702-X
https://doi.org/10.1016/S0140-6736(17)30... , which may further reduce the chances of case identification. On the other hand, studies focused on the evaluation of mental trauma in health services may overestimate the prevalence.

In the meta-analysis of SV prevalence in women in emergency humanitarian complex scenarios, which also included internally displaced persons and excluded genital mutilation, the mean prevalence was 21.4% and higher in refugees from Africa¹²12. Vu A, Adam A, Wirtz A, Pham K, Rubenstein L, Glass N, et al. The prevalence of sexual violence among female refugees in complex humanitarian emergencies: a systematic review and meta-analysis. PLoS Curr. 2014;6. https://doi.org/10.1371/currents.dis.835f10778fd80ae031aac12d3b533ca7
https://doi.org/10.1371/currents.dis.835... . In our review, we found several studies with a much higher prevalence. Regardless of the actual prevalence, SV was frequent in the populations studied, and deserves special attention in the health services and the reception of this population already weakened by traumas of war and persecution.

Young women are the main victims of SV, but men, children and adolescents are also victims, a reality little discussed in the literature. Men and unaccompanied minors are also exposed to the risk of sexual exploitation and abuse during migration and arrival in destination countries³3. United Nations High Commissioner for Refugees. Working with men and boy survivors of sexual and gender-based violence in forced displacement. Geneva: UNHCR; 2012.. Nevertheless, the predominance in women is not surprising. The immigration process is accompanied by difficulties such as economic insecurity, language barriers and acculturation, which lead to the imbalance of power between women and partners, leading to increased tensions⁷⁷77. Hilsdon AM, Rozario S. Special issue on Islam, gender and human rights. Women’s Stud Int Forum. 2006 29(4):331-8. https://doi.org/10.1016/j.wsif.2006.05.009
https://doi.org/10.1016/j.wsif.2006.05.0... . Because of economic, political, and social changes during wars and postwar periods, many men use violence to control women and reestablish their status of power⁷⁸78. Guruge S, Ford-Gilboe M, Varcoe C, Jayasuriya-Illesingh V, Ganesan M, Sivayogan S, et al. Intimate partner violence in the post-war context: women’s experiences and community leaders’ perceptions in the Eastern Province of Sri Lanka. PLoS One. 2017;12(3):e0174801. https://doi.org/10.1371/journal.pone.0174801
https://doi.org/10.1371/journal.pone.017... . Such conditions may explain the higher frequency of SV perpetrated by intimate partners.

SV occurs mainly before migration, in the countries of origin of the refugees. This suggests a relation with the conditions generated by the armed conflicts, which potentiate cultural norms of superiority of the masculine power present in these places, even before the condition of search of refuge. High prevalence in Africa supports this view. The Democratic Republic of Congo, where armed conflicts over natural resource reserves have lasted since independence in 1960⁷⁹79. Bastik M, Grimm K, Kunz R. Sexual violence in armed conflict: global overview and implications for the security sector. Geneva: Centre for the Democratic Control of Armed Forces; 2007., is marked by atrocities including group rape, sexual slavery, forced family involvement in rape, genital mutilation, among others⁸⁰80. Peterman A, Palermo T, Bredenkamp C. Estimates and determinants of sexual violence against women in the Democratic Republic of Congo. Am J Public Health. 2011;101(6):1060-7. https://doi.org/10.2105/AJPH.2010.300070
https://doi.org/10.2105/AJPH.2010.300070... . More shocking is the fact that, even when hosted in refugee camps, this already fragile population still faces insecurity and suffers SV perpetrated by those from whom they expect protection, such as officers and police.

Rape was the most mentioned form of this violence. This can be explained by the more concrete definition, by the most remarkable experience, and because most studies have used the HTQ instrument, which has a specific question about rape and sexual abuse, but not about other forms of SV. Rape is considered the cruelest type because it brings serious and severe consequences to the health of the victims. War survivors diagnosed with posttraumatic stress disorder and rape victims report more somatic symptoms than those without a rape experience⁸¹81. Gola H, Engler H, Schauer M, Adenauer H, Riether C, Kolassa S, et al. Victims of rape show increased cortisol responses to trauma reminders: a study in individuals with war- and torture-related PTSD. Psychoneuroendocrinology. 2012;37(2):213-20. https://doi.org/10.1016/j.psyneuen.2011.06.005
https://doi.org/10.1016/j.psyneuen.2011.... . Rape also increases the chances of acquiring HIV infection, as reported in sub-Saharan African refugee women in Paris, and is related to social difficulties and lack of fixed residence due to the risk of transactional sex or sexual harassment during lodging by relatives or acquaintances⁸²82. Pannetier J, Ravalihasy A, Lydié N, Lert F, Desgrées du Loû A. Prevalence and circumstances of forced sex and post-migration HIV acquisition in sub-Saharan African migrant women in France: an analysis of the ANRS-PARCOURS retrospective population-based study. Lancet Public Health. 2018;3(1):e16-23. https://doi.org/10.1016/S2468-2667(17)30211-6
https://doi.org/10.1016/S2468-2667(17)30... .

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

Our review also has limitations. The literature search did not include the terms “sexual torture” and “genital mutilation,” which may have resulted in low sensitivity and explained the number of articles found in reference lists. We did not include the gray literature and no methodological quality evaluation of the selected studies was performed. In addition, we did not restrict the sample size of the articles, which resulted in imprecise estimates in studies with few individuals³⁸38. Edston E, Olsson C. Female victims of torture. J Forensic Leg Med. 2007;14(6):368-73. https://doi.org/10.1016/j.jflm.2006.12.014
https://doi.org/10.1016/j.jflm.2006.12.0... . Finally, methodological differences between the studies (different data collection sites, such as mental health services and refugee camps; different data collection instruments; studies focusing on mental disorders rather than SV prevalence; and unequal sampling) have contributed to the diversity of the rates found and heterogeneity between the studies, which prevented a meta-analysis to summarize the information.

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

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