Reviewer's report
Title:Forced Sex and Health Outcomes among Southern African Lesbian and
Bisexual Women: A cross-sectional study
Version:2Date:2 October 2014
Reviewer: Kerith Conron
Reviewer's report:
Forced Sex and Health Outcomes among Southern African Lesbian and Bisexual
Women: A Cross-sectional Study
- Major Compulsory Revisions
The manuscript addresses and important and understudied issue; however, the
manuscript would be strengthened by 1) further contextualization of violence
against LB women within the larger literatures on a) sexual violence against
women and b) IPV. Stated differently, the authors have gone to great trouble to
collect data about a very important issue and could make a significant
contribution to the field if the manuscript were developed. Additional discussion
of relevant literature and 3) greater attention to implications for public health and
medical practice, policy, and research are warranted.
Although I am not well-versed in the literature on sexual violence in sub-Saharan
Africa, a quick PubMed search identified over 100 articles. For example:
Afr J Reprod Health. 2011 Dec;15(4):87-97.
Prevalence of forced sex and associated factors among women and men in
Kisumu, Kenya.
Adudans MK1, Montandon M, Kwena Z, Bukusi EA, Cohen CR.
Sexual violence is a well-recognized global health problem, albeit with limited
population-based data available from sub-Saharan Africa. We sought to measure
the prevalence of forced sex in Kisumu, Kenya, and identify its associated
factors. The data were drawn from a population-based cross-sectional survey. A
two-stage sampling design was used: 40 clusters within Kisumu municipality
were enumerated and households within each cluster selected by systematic
random sampling. Demographic and sexual histories, including questions on
forced sex, were collected privately using a structured questionnaire. The
prevalence of forced sex was 13% (women) and 4.5% (men). After adjusting for
age and cluster, forced sex among women was associated with transactional sex
(OR 2.33; 95%CI 1.38-3.95), having more than two lifetime partners (OR 1.9;
95%CI 1.20-3.30), having postprimary education (OR 1.49; 95%CI 1.04-2.14)
and a high economic status (OR 1.87; 95%CI 1.2-2.9). No factors were
significantly associated with forced sex among the male respondents. Intimate
partners were the most common perpetrators of forced sex among both women
(50%) and men (62.1%). Forced sex prevention programs need to target the
identified associated factors, and educate the public on the high rate of forced
sex perpetrated by intimate partners.
- Minor Essential Revisions
Background:
1) The epidemiological review is unclear regarding the prevalence of sexual
violence victimization among women in the region. In addition, the argument for
why sexual violence victimization against LB women may be higher could be
strengthened.
a. How prevalent is sexual violence victimization or forced sex (or rape) among
women in the region (or from relevant countries)?
b. How common is corrective rape? (Estimates by advocacy organizations are
fine an…. In YEAR, 1/20, 1/10, 1/100 lesbians were estimated to experience
corrective rape in XX country in their lifetime.)
2) Why is it important to study sexual perpetration by sexual minority women?
(What are the implications of studying violence perpetration and victimization in
terms of a) prevention b) treatment of victim and perpetrator? Are systems in
each country ready to address the needs of LB women when the perpetrator is
male? Female?)
3) How does the issue of reciprocal violence relate to violence perpetration by
women against intimate partners?
4) Please add justifications for collecting data on community
connectedness/LGBT belonging and gender expression to the introduction.
Methods:
5) From how many organizations were women recruited (total and per country)?
6) Were all interviews conducted in the same language? If not, how was
translation handled?
7) Were surveys self-administered or interviewer-administered?
8) What information can be added regarding the validity of the study measures in
the target population?
9) Please add a description of the analytic approach. How was clustering within
recruitment organizations addressed? Missing data? Statistical software?
10) The multivariable regression model should adjust for relationship to
perpetrator as this is imbalanced across perpetrator types.
Discussion:
11) The authors may wish to consider unplanned pregnancy and HIV infection
and elevated risk of other STI as additional consequences of male-perpetrated
violence.
12) Better cross-sectional research, representative and inclusive of sexual
majority women, is needed before longitudinal studies are warranted.
13) Limitations. Temporality regarding LB identity and outness and sexual
violence victimization is also important to know (and was probably not collected).
Temporality regarding substance abuse and serious mental health problems and
violence victimization is also unclear.
14) Please consider the discussion section an opportunity to outline priorities for
prevention and intervention related to violence victimization and perpetrators.
What is most important to address?
Level of interest: An article of importance in its field
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
'I declare that I have no competing interests'