Epidemiological Profile of Intimate Partner Homicides of Sexual and Gender Minority Women in the United States, 2003 to 2017.

Sexual and gender minority (SGM) women are among the many victims killed by intimate partner homicide (IPH) each year, though the differences between different SGM groups (and how these groups compare to non-SGM IPH) have not been well established. The objective of this article was to identify practicable, correlated risk factors of IPH of SGM women that may have utility in prevention of future IPH among these populations in the U.S. Homicide data from the National Violent Death Reporting System spanning 2003 to 2017 were used to identify a profile of IPH specific to SGM women compared to women who were neither sexual nor gender minorities. Situational and individual characteristics significantly differentiated sexual minority (SM) women from non-SGM women victims of IPH, including substance abuse history (adjusted odds ratio [AOR] = 4.80 [2.42, 9.51]), having themselves used a weapon during the incident (AOR = 3.63 [1.44, 9.16]), and the type of weapon(s) used, such as firearms (AOR = 0.61 [0.40, 0.91]), with notably different differentiating characteristics for gender minority (GM) women (vs. non-SGM women) such as the likelihood that the victim was known to have experienced interpersonal violence victimization in the previous month (AOR = 0.50 [0.07, 3.67]). Lesbian and bisexual women homicide victims were far more likely to have been killed via IPH than non-SGM women (AOR for Black SM women = 7.84 [3.65, 16.88], AOR for White SM women = 2.30 [1.03, 5.17]). There was no corresponding difference for GM women victims, whose likelihood of being killed by an intimate partner was similar to that of non-SGM women. Based on these findings, actionable public health recommendations-centered around evidence that neither "all women" nor "all LGBTQ people" are appropriate intimate partner violence prevention umbrellas-are proposed.

How, when and where? A systematic review on abortion decision making in legally restricted settings in sub-Saharan Africa, Latin America, and the Caribbean.

BACKGROUND: With increasing global availability of medication abortion drugs, a safer option exists for many women to terminate a pregnancy even in legally restrictive settings. However, more than 22,000 women die each year from unsafe abortion, most often in developing countries where abortion is highly legally restricted. We conducted a systematic review to compile existing evidence regarding factors that influence women's abortion-related decision making in countries where abortion is highly legally restricted. METHODS: We searched ten databases in two languages (English and Spanish) for relevant literature published between 2000 and 2019 that address women's decision-making regarding when, where and how to terminate a pregnancy in sub-Saharan African, Latin American and the Caribbean countries where abortion is highly legally restricted. RESULTS: We identified 46 articles that met the review's inclusion criteria. We found four primary factors that influenced women's abortion-related decision-making processes: (1) the role of knowledge, including of laws, methods and sources; (2) the role of safety, including medical, legal and social safety; (3) the role of social networks and the internet, and; (4) cost affordability and convenience. CONCLUSIONS: The choices women make after deciding to terminate a pregnancy are shaped by myriad factors, particularly in contexts where abortion is highly legally restricted. Our review catalogued the predominant influences on these decisions of when, where and how to abort. More research is needed to better understand how these factors work in concert to best meet women's abortion needs to the full limit of the law and within a harm reduction framework for abortions outside of legal indications.

Identifying and addressing barriers to contraception uptake among adolescent girls in urban Burkina Faso: Evidence from a qualitative study.

Several barriers drive low uptake of contseraception among adolescents. This study investigates the effectiveness of (re)solve, a school-based program in Burka Faso, to overcome barriers to contraception uptake and facilitate the development of intention to use it. This paper presents qualitative endline findings from a mixed-methods longitudinal study conducted between 2019 and 2020 in two urban sites using in-depth interviews with girl participants and implementers, and key informant interviews with local stakeholders. We found that adolescent girls in the target group are likely to soon become sexually active but may be underestimating this risk. We also identified three key barriers to access to contraception in the study sites: misinformation and fear of side effects of contraception, stigma and negative attitudes, and a lack of youth-friendly sexual and reproductive health services. We conclude that the school-based (re)solve program was able to address barriers and spark contraceptive interest among participant girls.

Strengthening local capacity for abortion-related research in contexts with highly restrictive abortion laws: The case of STARS in Mali.

Strong local abortion research capacity is missing in many African countries. We report on the Strengthening Abortion Research Capacity in sub-Saharan Africa (STARS) program, an ongoing initiative to strengthen local capacity for abortion research in Mali, West Africa. We highlight the background, context, and methodology of the initiative as well as its achievements, challenges, and emerging lessons. Within a short time, STARS has initiated some key studies on abortion in Mali and created a much-needed platform for nurturing the country's next generation of abortion researchers, institutionalizing abortion research, increasing the quantity and quality of locally generated evidence on abortion, and facilitating evidence-informed abortion policy and programmatic action. The program's learning-by-doing approach has boosted the skills of individual researchers while also enhancing institution-based abortion and sexual and reproductive health and rights (SRHR) research expertise in Mali. Although STARS' capacity to deliver its mandate over time is evident, ultimate results will depend on the sustained commitment of funders to the program in the full realization that capacity building requires long-term investment and support for it to fully bear fruits.

Women's empowerment and attitudes towards female genital mutilation abandonment in Nigeria: A cross-sectional analysis of the Nigeria demographic health survey.

Female genital mutilation (FGM) is a human rights violation that impacts the social, physical, psychological, sexual, and gynecological wellbeing of women and girls. Even so, FGM persists in many Nigerian communities. Using data from the 2018 Nigeria Demographic and Health Survey, we investigated the association between women's empowerment and attitudes towards FGM abandonment. A weighted logistic regression adjusting for demographic factors, contraceptive use, contraceptive decision-making power, and severity of FGM was used to assess the influence of the validated African Women's Empowerment Index-West on women's favorability to abandoning FGM as a practice. This study found that higher education level, zero acceptance of violence against women, and higher access to healthcare as indicators of empowerment were associated with support for FGM abandonment. Additional research is needed to understand further the influences on decision making and to further research the various empowerment scales and their impact on FGM abandonment.

Contraceptive use, menstrual resumption, and experience of pregnancy and birth among girls and young women in an internally displaced persons camp in Northeastern Nigeria.

In Northeastern Nigeria 600,000 internally displaced girls and women need sexual and reproductive health and rights (SRHR) services. We examined the relationships between contraceptive use, menstrual resumption, and pregnancy and birth experiences among girls (ages 15-19) and young women (ages 20-24) in an IDP camp. Data are from a cross-sectional survey collected using three-stage cluster sampling; the analytic sample is 480. Data were analyzed in Stata 14 using logistic regression models. Sixty-three percent of respondents had ever had sex and over half were currently sexually active. Current contraceptive use was 8% and 47% had ever been pregnant. Older respondents and those who had ever had sex were more likely to have heard of a contraceptive method and current use was higher for women with 5 or more births. These findings indicate a need for better contraceptive education for girls before sexual activity and promotion of contraception that accounts for fertility preferences in this setting.

Provision and uptake of sexual and reproductive health services during the COVID-19 pandemic: The case of Mali.

A qualitative study assessed the effects of the COVID-19 epidemic on Malian sexual and reproductive health services. Sexual and reproductive health (SRHR) providers in 25 purposively selected public health facilities in urban Bamako, rural Kita (western Mali) and Koutiala (southeast Mali) were interviewed. Disruptions within SRH supply, staffing, the prioritization of SRHR services, and patients' ability to seek, obtain and pay for services were reported across urban and rural settings at all levels of public health care, and by all cadres of SRHR providers. Most facilities in the study areas sustained some SRHR services at the height of the COVID-19 epidemic through innovative outreach and phone-based consultations. This study offers critical lessons for SRHR service provision during future waves of the pandemic or during periods of comparable emergency.

Development of an international sexual and reproductive health survey instrument: results from a pilot WHO/HRP consultative Delphi process.

Population health surveys are rarely comprehensive in addressing sexual health, and population-representative surveys often lack standardised measures for collecting comparable data across countries. We present a sexual health survey instrument and implementation considerations for population-level sexual health research. The brief, comprehensive sexual health survey and consensus statement was developed via a multi-step process (an open call, a hackathon, and a modified Delphi process). The survey items, domains, entire instruments, and implementation considerations to develop a sexual health survey were solicited via a global crowdsourcing open call. The open call received 175 contributions from 49 countries. Following review of submissions from the open call, 18 finalists and eight facilitators with expertise in sexual health research, especially in low- and middle-income countries (LMICs), were invited to a 3-day hackathon to harmonise a survey instrument. Consensus was achieved through an iterative, modified Delphi process that included three rounds of online surveys. The entire process resulted in a 19-item consensus statement and a brief sexual health survey instrument. This is the first global consensus on a sexual and reproductive health survey instrument that can be used to generate cross-national comparative data in both high-income and LMICs. The inclusive process identified priority domains for improvement and can inform the design of sexual and reproductive health programs and contextually relevant data for comparable research across countries.

The Sexual and Reproductive Health Context of an Internally Displaced Persons' Camp in Northeastern Nigeria: Narratives of Girls and Young Women.

In humanitarian settings, ~35 million girls and young women of reproductive age (15-24) are in urgent need of sexual and reproductive health (SRH) information and services. Young women and girls in humanitarian contexts are particularly vulnerable to unwanted pregnancies, unsafe abortion, gender-based violence, and early and forced marriage. We sought to understand girls' and young women's experiences with unwanted pregnancy, abortion, contraception, sexually transmitted infections (STIs), gender-based violence (GBV), and forced marriage in an IDP camp in Northeastern Nigeria. We conducted 25 in-depth interviews with girls aged 15-19 (N = 13; 8 single and 5 married) and young women aged 20-24 (N = 12; 3 single and 9 married). All interviews were audiotaped, transcribed, translated, computer recorded and coded for analysis. The participants in our study fled from and witnessed violence to arrive in the IDP camp with little material support. Lack of necessities, especially food, has driven many to sex in exchange for goods or into forced marriages. This, in turn, leads to increased unwanted pregnancies and unsafe abortions. Participants had limited knowledge about contraception, and some information about SRH services available in the camp, but overall, knowledge and utilization of SRH services was low.

Challenges in Supporting Survivors of Child Sexual Abuse in Kenya: A Qualitative Study of Government and Non-governmental Organizations.

Child sexual abuse (CSA) is a global, social, and health challenge. Existing literature on post-sexual assault care has focused largely on health providers' skills and capacity to offer quality clinical, medicolegal, and psychosocial care. Services other than medical and psychosocial care provided to survivors of CSA remain poorly studied, particularly in the global south. The study aimed to explore challenges facing service providers supporting children who have experienced sexual abuse and make suitable recommendations. We triangulated different qualitative methods: in-depth interviews with 61 key informants, three focus group discussions with community leaders, and unstructured observations for data collection. Findings indicate that service providers supporting children who had experienced sexual abuse play a vital role in ensuring that survivors receive clinical and medicolegal care, psychosocial support, have access to justice, and are protected from further victimization. However, these service providers face several challenges, including poor infrastructure, the lack of effective coordination and linkage among the service providers in the continuum of care, corruption among officials, and harmful patriarchal norms that hinder reporting of abuse. To effectively support and care for survivors, we recommend government commitment to, and investments in, safe spaces, supervision, and professional development of providers. Working with community leaders and gatekeepers of all genders is critical to address harmful practices that perpetuate CSA and make it difficult to care for and obtain justice for CSA survivors.

Gender-based violence and its association with mental health among Somali women in a Kenyan refugee camp: a latent class analysis.

BACKGROUND: In conflict-affected settings, women and girls are vulnerable to gender-based violence (GBV). GBV is associated with poor long-term mental health such as anxiety, depression and post-traumatic stress disorder (PTSD). Understanding the interaction between current violence and past conflict-related violence with ongoing mental health is essential for improving mental health service provision in refugee camps. METHODS: Using data collected from 209 women attending GBV case management centres in the Dadaab refugee camps, Kenya, we grouped women by recent experience of GBV using latent class analysis and modelled the relationship between the groups and symptomatic scores for anxiety, depression and PTSD using linear regression. RESULTS: Women with past-year experience of intimate partner violence alone may have a higher risk of depression than women with past-year experience of non-partner violence alone (Coef. 1.68, 95% CI 0.25 to 3.11). Conflict-related violence was an important risk factor for poor mental health among women who accessed GBV services, despite time since occurrence (average time in camp was 11.5 years) and even for those with a past-year experience of GBV (Anxiety: 3.48, 1.85-5.10; Depression: 2.26, 0.51-4.02; PTSD: 6.83, 4.21-9.44). CONCLUSION: Refugee women who experienced past-year intimate partner violence or conflict-related violence may be at increased risk of depression, anxiety or PTSD. Service providers should be aware that compared to the general refugee population, women who have experienced violence may require additional psychological support and recognise the enduring impact of violence that occurred before, during and after periods of conflict and tailor outreach and treatment services accordingly.

Adolescents' narratives of coping with unintended pregnancy in Nairobi's informal settlements.

AIM: This study explored adolescent experiences and coping strategies for unintended pregnancy in two informal settlements-Viwandani and Korogocho-in Nairobi, Kenya. METHODS: Forty-nine in-depth-interviews and eight focus group discussions were conducted with male and female adolescents aged 15-19 years from households in two informal settlements. Participants were purposively selected to include adolescents of varying socio-demographic characteristics, including the married and unmarried, and adolescents who had never/ever been pregnant. Data were transcribed, translated verbatim and analyzed thematically. RESULTS: Adolescents attributed unintended pregnancy to poverty, sexual violence and inconsistent contraceptive use. Lack of parental support and guidance, as well as household conflicts also exposed girls to early sexual debut and risky sexual behavior. Decisions about pregnancy management centered on carrying the pregnancy to term or terminating it. Deciding to terminate a pregnancy was not always straightforward and was motivated by concerns about stigma or shame, and school disruption. Participants reiterated that carrying an unintended pregnancy to term disrupts adolescents' schooling, with few girls returning to school after childbirth. Upon deciding to carry a pregnancy to term, adolescents used several coping strategies such as relocating from usual residence, hiding until delivery and planning to put up the child for adoption upon delivery. CONCLUSIONS: Early interventions to provide adolescents with comprehensive pregnancy prevention information and to address sexual violence and poverty can prevent unintended pregnancy in adolescents. Efforts to support adolescents to positively cope with unintended pregnancy and facilitate re-entry to school are also warranted.

Research challenges in evaluating gender-based violence response services in a refugee camp.

This article presents a case study of research in Dadaab, Kenya to highlight some of the relevant challenges encountered while conducting gender-based violence research in humanitarian settings. A longitudinal mixed-methods design was used to evaluate a comprehensive case-management intervention in the refugee complex near the border of Kenya and Somalia. We present an overview of both expected and unexpected challenges during preparation and implementation of the research, adaptations made to the research design, and lessons learned for future research in similar contexts. Some of the key challenges were attributed to the highly securitized and remote environment of Dadaab refugee camp, like many refugee camp settings, which created limitations for sampling designs, interview locations, and also created particular burdens for the research team members conducting interviews. In addition to the camp environment, the dynamic nature of events and trends in the camp setting created barriers to follow-up with longitudinal cohort participants as well as uncertainty on how to plan for future implementation of research design phases in response to camp changes. Conducting research in humanitarian settings requires a flexible approach to accommodate the challenges that can impact both service delivery and research activities. The discussion presented in this article contributes to the evolving practical guidance on conducting research in humanitarian settings.

Correlates of intimate partner violence among urban women in sub-Saharan Africa.

INTRODUCTION: The dynamics of intimate partner violence (IPV)-one of the world's leading public health problems-in urban Africa remain poorly understood. Yet, urban areas are key to the future of women's health in Africa. STUDY OBJECTIVES: We explored survivor-, partner-, and household-level correlates of prevalence rates for types of IPV in urban SSA women. METHOD: The study uses DHS data from 42,143 urban women aged 15-49 in 27 SSA countries. Associations at the bivariate level were examined using the Pearson Chi-square test. The modified Poisson regression test estimated the relative prevalence of IPV subtypes in the study population at the multivariate level. RESULTS: Approximately 36% of women in urban SSA experienced at least one form of IPV; 12.8% experienced two types; and 4.6% experienced all three types. SSA urban women who had only primary-level education, had 3 or more living children, were informally employed, were in polygynous unions, or who approved of wife-beating similarly displayed higher adjusted prevalence rates for all three forms of IPV compared respectively to their counterparts without formal education, without a living child, were unemployed, in monogamous unions, or who do not approve of wife-beating. On the other hand, the region's urban women who began cohabiting between ages 25 and 35 years or who lived in higher wealth households showed consistently lower adjusted prevalence rates for all three forms of IPV relative to their counterparts who began cohabiting before 18 years or who lived in lower wealth households. Compared to their counterparts without formal education, without a living child, or whose partners did not have formal education, women with secondary and higher education, with 1-2 living children, or whose partners had only primary level schooling displayed higher adjusted prevalence rates for both IPEV and IPPV, but not for IPSV. However, relative to their counterparts whose partners were aged 25 years or below, living with a partner aged 40 years and above was associated with statistically significant reduced prevalence rates for IPPV and IPSV, but not for IPEV. Only for IPPV did women with partners educated at secondary and above levels display statistically significant higher adjusted prevalence rates relative to their counterparts with uneducated partners. Also, solely for IPPV did women who began cohabiting between ages 18 and 24 years or whose partners were employed (whether formally or informally) show decreased adjusted prevalence rates relative to their counterparts who started cohabiting before 18 years or whose partners were unemployed. In addition, only for IPSV did women aged 40 years and above or living in middle wealth households show statistically significant reduced adjusted prevalence rates relative to their counterparts aged less than 25 years or living in lower wealth households. DISCUSSION AND CONCLUSION: By 2030, the majority of SSA women will be urban dwellers. Complexities surround IPV in urban SSA, highlighting the unique dynamics of the problem in this setting. While affirming the link between IPV and marital power inequities and dynamics, findings suggest that the specific correlates of prevalence rates for different IPV sub-types in urban SSA women can, at once, be both similar and unique. The contextual drivers of the differences and similarities in the correlates of the prevalence rates of IPV sub-types among the region's urban women need further interrogation.

Barriers and facilitators to care-seeking among survivors of gender-based violence in the Dadaab refugee complex.

In humanitarian settings, timely access to care is essential for survivors of gender-based violence (GBV). Despite the existence of GBV support services, challenges still exist in maximising benefits for survivors. This study aimed to understand the characteristics of violence against women and explore barriers and facilitators to care-seeking for GBV by women in two camps within the Dadaab refugee complex in Kenya. A mixed-methods design was used to study women accessing comprehensive GBV services between February 2016 and February 2017. Women were recruited into a cohort study (n = 209) and some purposively selected for qualitative in-depth interviews (n = 34). Survivor characteristics were descriptively analysed from baseline measures, and interview data thematically assessed. A majority of women were Muslim, of Somali origin, had been residents in the camp for more than five years, with little or no formal education, and meagre or no monthly income. From the survey, 60.3% and 66.7% of women had experienced non-partner violence or intimate partner violence in their lifetime respectively. Facilitators to accessing GBV services by survivors included awareness of GBV services and self-perceived high severity of acts of violence. Barriers included stigma by family and the community, fear of further violence from perpetrators, feelings of helplessness and insecurity, and being denied entry to service provision premises by guards. Women in the Dadaab refugee camps face violence from intimate partners, family, and other refugees. There is an urgent need to address drivers of GBV and the barriers to disclosure and access to services for all survivors of GBV.

Regional legal and policy instruments for addressing LGBT exclusion in Africa.

The vulnerability of lesbian, gay, bisexual and transgender (LGBT) persons in Africa to public health and other risks is heightened by their exclusion from socio-economic opportunities and services. We analysed existing regional-level legal and policy instruments and treaties for the opportunities they offer to tackle the exclusion of LGBT persons in Africa. We identified seven key living legal and policy instruments, formulated and adopted between 1981 and 2018, by the African Union (AU) or its precursor, the Organization of African Unity. These treaties and instruments do not only highlight the region's challenges related to inclusion, most of them are binding and enforceable, and all enshrine the responsibility of AU member-states to safeguard and ensure the inclusion and protection of citizens, their gender or sexual orientation notwithstanding. The instruments set forth strong and ambitious agendas of inclusion and recognise and affirm the rights of the region's citizens to sexual and reproductive health (SRH), equality, freedom and opportunities, regardless of their sexual orientation. Their language is generally universalist and their rejection of discrimination, criminalisation, and denial of socio-economic opportunities and services to the region's sexual minorities is forthright. However, the instruments do not explicitly mention LGBT persons and lack clear and effective mechanisms for answerability among member-states. Accountability and commitment among member-states towards these instruments and policies will improve national legal and policy environments and propel forward the agenda of LGBT inclusion, SRH and wellbeing in the region.