Protecting female migrants from forced sex and HIV infection
Authors: Nyovani Janet Madise, Bernard Onyango
Journal: The Lancet Public Health (2017)

Worldwide, more than one-third of women have experienced either sexual or physical violence, often perpetrated by an intimate partner, while about 7% have been sexually assaulted by a non-partner.1WHOGlobal and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence.http://www.who.int/reproductivehealth/publications/violence/9789241564625/en/Date: 2013Google Scholar Such violence is not only a crime, but also a public health concern since it is associated with ill-health including depression, low birthweight babies, and infection from HIV.1WHOGlobal and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence.http://www.who.int/reproductivehealth/publications/violence/9789241564625/en/Date: 2013Google Scholar The study by Julie Pannetier and colleagues2Pannetier P Ravalihasy A Lydié N Lert F Desgrées du Loû A on behalf of the Parcours study groupPrevalence 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. 2017; (published online Nov 22.)http://dx.doi.org/10.1016/S2468-2667(17)30211-6Summary Full Text Full Text PDF PubMed Scopus (29) Google Scholar in The Lancet Public Health provides evidence of forced sex and HIV infection in female migrants in Europe. Forced sex and other forms of sexual harassment against women are under-reported in mainstream society, but the situation is worse for migrants who might be reluctant to report such experiences for fear of being removed from the host country or because they lack knowledge of where to go to complain and how.3Ibrahim A Devakumar D Madise N et al.UCL-Lancet Commission on Migration and Health.Lancet. 2016; 388: 1141-1142Summary Full Text Full Text PDF PubMed Scopus (14) Google Scholar Gender-based violence can also be perpetrated by family friends and relatives, as Pannetier and colleagues report,2Pannetier P Ravalihasy A Lydié N Lert F Desgrées du Loû A on behalf of the Parcours study groupPrevalence 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. 2017; (published online Nov 22.)http://dx.doi.org/10.1016/S2468-2667(17)30211-6Summary Full Text Full Text PDF PubMed Scopus (29) Google Scholar and in such cases under-reporting is severe because survivors of violence can face stigma and blame.4Klugman J Gender based violence and the law. Background paper to the World Development report. The World Bank, Washington DC2017Google Scholar Most women who migrate are labour migrants but there are some who are escaping sexual violence from their places of origin. Such women can also face violence during transit and at their destinations. High profile examples include atrocities against Rohingya women who are being subjected to rape in their countries and in refugee camps or African female migrants who are forced to have sex in detention camps in Libya.5United Nations Office for Coordination of Humanitarian Affairs (OCHA)Rohingya Refugee Crisis.https://www.unocha.org/rohingya-refugee-crisisDate: 2017Google Scholar, 6UNICEFA deadly journey for children. The Central Mediterranean Migration Route.https://www.unicef.org/publications/files/EN_UNICEF_Central_Mediterranean_Migration.pdfDate: 2017Google Scholar A UNHCR report7United Nations Refugee Agency (UNHCR)United Nations Population Fund (UNFPA)Women's Refugee CommissionInitial Assessment Report: Protection Risks for Women and Girls in the European Refugee and Migrant Crisis, Greece and former Yugoslav Republic of Macedonia.http://www.unhcr.org/569f8f419.pdfDate: 2016Google Scholar that assessed gender-based violence among refugees and migrants into Europe in 2016 documented evidence of women and girls forced to have sex in transit to pay for transportation or papers. On arriving in Europe, they were not given adequate shelter and protection from sexual harassment and forced sex. Furthermore, most European member states did not record reports of such violations. The study by Pannetier and colleagues2Pannetier P Ravalihasy A Lydié N Lert F Desgrées du Loû A on behalf of the Parcours study groupPrevalence 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. 2017; (published online Nov 22.)http://dx.doi.org/10.1016/S2468-2667(17)30211-6Summary Full Text Full Text PDF PubMed Scopus (29) Google Scholar provides evidence that female migrants who lack residence permits and housing are most vulnerable to being forced to have sex. Irregular migration status makes it harder for women to confront and report sexual violence and as a result, such women can be exploited even by officials, friends, and relatives. Vulnerable employment also exposes female migrants to risk. In 2010, Waugh8Waugh I Examining the sexual harassment experiences of Mexican immigrant farm working women.Violence against Women. 2010; 16: 237-261Crossref PubMed Scopus (49) Google Scholar documented the high risks of sexual harassment and forced sex among migrants in Mexico who were in low skilled and exploitative occupations such as farm work and domestic service. One of the strengths of the Pannetier and colleagues' study is the identification of women who were infected with HIV after migrating to France.2Pannetier P Ravalihasy A Lydié N Lert F Desgrées du Loû A on behalf of the Parcours study groupPrevalence 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. 2017; (published online Nov 22.)http://dx.doi.org/10.1016/S2468-2667(17)30211-6Summary Full Text Full Text PDF PubMed Scopus (29) Google Scholar The investigators used women's reports of life events and clinical data to model the decrease of CD4-positive T cell counts, thus establishing cases in which HIV infection most likely occurred after women had migrated. In so doing, the report2Pannetier P Ravalihasy A Lydié N Lert F Desgrées du Loû A on behalf of the Parcours study groupPrevalence 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. 2017; (published online Nov 22.)http://dx.doi.org/10.1016/S2468-2667(17)30211-6Summary Full Text Full Text PDF PubMed Scopus (29) Google Scholar improves on studies based only on self-reports that can suffer from recall and social desirability biases. This evidence provides some support to counter populist perceptions that sub-Saharan people coming to Europe are all infected with HIV; this view has done much harm to migration policies and the humane treatment of migrants from Africa. Alvarez-Del Arco and colleagues9Alvarez-Del Arco D Fakoya I Thomadakis C et al.High levels of post-migration HIV acquisition within nine European countries.AIDS. 2017; 31: 1979-1988Crossref PubMed Scopus (78) Google Scholar provide further evidence that post-migration HIV infection among women in nine European countries might be as high as 51%. Some of the explanations for higher HIV infection post-migration for sub-Saharan Africa women are poverty, assortative sexual mixing, and poor access to antiretroviral therapy among irregular migrants.10Fakoya I Álvarez-del Arco D Woode-Owusu M et al.A systematic review of post-migration acquisition of HIV among migrants from countries with generalised HIV epidemics living in Europe: implications for effectively managing HIV prevention programmes and policy.BMC Public Health. 2015; 15: 561Crossref PubMed Scopus (85) Google Scholar The issue of poverty as an underlying cause is mentioned by Pannetier and colleagues but not in sufficient detail. Poverty disempowers and creates unequal status between the poor and less poor, leading to the exploitation of the poor. Poverty erodes human dignity and can compel women to accept or offer transactional or survival sex. Poverty, when accompanied by isolation and lack of social support systems as is often the case with migrants, exposes women to very high risks of experiencing forced sex, domestic violence, and HIV infection—infringement of their rights to lives free from violence. The report2Pannetier P Ravalihasy A Lydié N Lert F Desgrées du Loû A on behalf of the Parcours study groupPrevalence 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. 2017; (published online Nov 22.)http://dx.doi.org/10.1016/S2468-2667(17)30211-6Summary Full Text Full Text PDF PubMed Scopus (29) Google Scholar does not provide a strong framing of the link between gender and HIV. That is, it does not discuss the biological, social, and cultural vulnerabilities of women to HIV infection in general.11Türmen T Gender and HIV/aids.Int J Gynaecol Obstet. 2003; 82: 411-418Crossref PubMed Scopus (131) Google Scholar Some of the Article's understated powerful messages are: a need for proper healthcare for migrants, whether regular or irregular, if countries are to stop the spread of infections such as HIV; that failure to provide housing and safe shelter for women is more than a denial of their rights to adequate standards of living—it is also a denial of women's rights to lives free from violence and to choose who they have sex with. The messages should inform the discussions of gender and migration in the United Nations Global Compact for Migration that will be signed in September 2018. Female migrants form a substantial proportion of all migrants and so there is need to think about gender when designing policies and programmes on migration. For more on the UN Global Compact for Migration see https://www.iom.int/globalcompact-migration For more on the UN Global Compact for Migration see https://www.iom.int/globalcompact-migration This online publication has been corrected. The corrected version first appeared at thelancet.com/public-health on December 5, 2017 This online publication has been corrected. The corrected version first appeared at thelancet.com/public-health on December 5, 2017 We declare no competing interests. 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 studyThe social hardships faced by sub-Saharan African migrant women after migration, especially a lack of housing or lack of a residence permit, increases their exposure to sexual violence and to HIV infection. Full-Text PDF Open AccessProtecting migrant womenEurope is facing massive movements of refugees and migrants—women, girls, men, and boys of all ages. The journey to Europe is perilous; migrants often face high levels of violence, extortion, and exploitation along the way, reaching a paroxysm with recent reports of slave auctions in Libya. Full-Text PDF Open AccessCorrection to Lancet Public Health 2018; 3: e2–3Madise NJ, Onyango B. Protecting female migrants from forced sex and HIV infection. Lancet Public Health 2018; 3: e2–3—In this Comment, the affiliation for Bernard Onyango has been corrected. This correction has been made to the online version as of Dec 5, 2017. Full-Text PDF Open AccessProtecting female migrants from forced sex and HIV infectionWe thank Nyovani Janet Madise and Bernard Onyango for their comments1 on our Article.2 They question our insufficient elaboration on poverty as an underlying cause of forced sex in relation to HIV for migrant women. However, our study characterised, with an innovative life-course approach, the adverse living conditions faced by migrant women when they are subjected to forced sex after migration. We showed that administrative and housing insecurity are specific forms of poverty faced by migrant women. Full-Text PDF Open Access