Grose, Et. Al. (2020) - Sexual and Reproductive Health Outcomes

The Journal of Sex Research
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Sexual and Reproductive Health Outcomes of

Violence Against Women and Girls in Lower-
Income Countries: A Review of Reviews
Rose Grace Grose, Julia S. Chen, Katherine A. Roof, Sharon Rachel & Kathryn
M. Yount
To cite this article: Rose Grace Grose, Julia S. Chen, Katherine A. Roof, Sharon Rachel &
Kathryn M. Yount (2021) Sexual and Reproductive Health Outcomes of Violence Against Women
and Girls in Lower-Income Countries: A Review of Reviews, The Journal of Sex Research, 58:1,
1-20, DOI: 10.1080/00224499.2019.1707466
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THE JOURNAL OF SEX RESEARCH
2021, VOL. 58, NO. 1, 1–20
https://doi.org/10.1080/00224499.2019.1707466
Sexual and Reproductive Health Outcomes of Violence Against Women and Girls in
Lower-Income Countries: A Review of Reviews
Rose Grace Grosea, Julia S. Chenb, Katherine A. Roofb, Sharon Rachelc, and Kathryn M. Yountd
a
Department of Community Health Education, Colorado School of Public Health, University of Northern Colorado; bHubert Department of Global
Health, Rollins School of Public Health, Emory University; cKennedy-Satcher Center for Mental Health Equity, Satcher Health Leadership Institute,
Morehouse School of Medicine; dAsa Griggs Candler Chair of Global Health | Professor of Global Health and Sociology, Hubert Department of Global
Health and Department of Sociology, Emory University
ABSTRACT
Gender-based violence (GBV) against women and girls is pervasive and has negative consequences for
sexual and reproductive health (SRH). In this systematic review of reviews, we aimed to synthesize
research about the SRH outcomes of GBV for adolescent girls and young women in low- and middle-
income countries (LMICs). GBV exposures were child abuse, female genital mutilation/cutting, child
marriage, intimate partner violence (IPV), and non-partner sexual violence. PsycINFO, PubMed, and
Scopus searches were supplemented with expert consultations, reference-list searches, and targeted
organizational website searches. Reviews had to contain samples of girls and young women ages 10–24,
although inclusion criteria were expanded post-hoc to capture adolescent-adult combined samples.
Twenty-seven reviews were quality-rated. Study-level data were extracted from the 10 highest quality
reviews (62 unique studies, 100 samples). Reviews were mostly from Africa and Asia and published
between 2011 and 2015. We found consistent associations between GBV and number of sexual partners,
gynecological conditions (e.g., sexually transmitted infections [STIs]), unwanted/unplanned pregnancy,
and abortion. Some types of IPV also were associated with greater use of contraception/STI prevention.
Addressing GBV is essential to improve SRH for girls and women in LMICs.
Gender-based violence (GBV) against women and girls is Population Fund [UNFPA], 2016; World Health
a prevalent global health problem and human rights violation, Organization [WHO], 2006). Sexual health goes beyond dis-
with detrimental health, social, and economic consequences ease, dysfunction, or infirmity, requiring respectful relation-
(Decker et al., 2014; Yount, DiGirolamo, & Ramakrishnan, ships and the possibility of pleasurable and safe sex (WHO,
2011). GBV against women and girls includes any act of violence 2006). To attain SRH, sexual empowerment may be necessary.
that “results in, or is likely to result in, physical, sexual or Sexual empowerment is a psychosocial process whereby less
psychological harm or suffering to women, including threats of powerful individuals gain more power and control over their
such acts, coercion or arbitrary deprivation of liberty” (United sexuality through healthy sexual experiences and more claim
Nations [UN] General Assembly, Resolution 48/104 1993, p. 3, to resources (Peterson, 2010; Zimmerman, 1995). Aspects of
art. 1, para.1). Polyvictimization, or experiencing multiple forms sexual empowerment include the ability to make decisions
of GBV in one’s lifetime, may intensify the negative effects about sexual health and the ability to refuse unwanted beha-
(Finkelhor, Ormrod, & Turner, 2007). Ending all forms of GBV vior and to advocate for one’s sexual desires and interests
against women is a UN priority and a means to achieve global (Peterson, 2010).
gender equality (United Nations Development Programme
[UNDP], 2016). Eliminating GBV as a sustainable development
GBV and Adolescence in the Context of LMICs
goal also is tied to the achievement of other goals, such as
improving women’s health (United Nations Women, 2018). Despite increased attention to GBV, research on the subject
In this systematic review of reviews, we set out to synthe- has come disproportionately from higher-income countries.
size the literature on GBV exposures and sexual and repro- Existing research may perpetuate biases and lack relevance to
ductive health (SRH) outcomes for adolescent girls and young cultural and economic environments in LMICs, where 89% of
women in low- and middle-income countries (LMICs), with the world’s 600 million adolescent girls and young-adult
the goal of informing policy and prevention. SRH is defined women live (UNFPA, 2014a). Predominantly, research on
as physical, emotional, mental, and social well-being regard- GBV in LMICs has focused on adult women in urban envir-
ing sexuality and the reproductive system (United Nations onments (e.g., Chacham, Simao, & Caetano, 2016; Decker
CONTACT Kathryn M. Yount [email protected] Asa Griggs Candler Chair of Global Health | Professor of Global Health and Sociology, Hubert Department
of Global Health and Department of Sociology, Emory University, 1518 Clifton Road, NE, Atlanta, GA 30322
Supplemental data for this article can be accessed here.
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2 R. G. GROSE ET AL.
et al., 2014), leaving the experiences of adolescent girls and above (WHO, 2013). Globally, between 178 and 312 million
young women in LMICs underexplored, especially in rural women have experienced sexual violence in their lifetime
areas (Yount, Krause, & Miedema, 2017). During adolescence (Abrahams et al., 2014). Across 30 LMICs, 15% of sexually
and young adulthood (approximately ages 10–24), young experienced adolescents and over 11% of young adult women
people form intimate relationships and an understanding of report that their first sexual experience was forced or coerced
their sexuality (Fatusi & Hindin, 2010). Early exposure to (Decker et al., 2014).
GBV may negatively influence well-being, with lifelong con- GBV against women and girls can be attributed to an
sequences for SRH. Some evidence suggests that experiencing interplay of personal, situational, and sociocultural factors
GBV during one’s formative years may increase one’s chances (Heise, 1998). Globally, men have disproportionate social,
of revictimization or polyvictimization (Dunkle, Jewkes, political, and economic power, which is reinforced through
Brown, Yoshihama, et al., 2004; Finkelhor et al., 2007). For sexist norms and policies (Connell, 2009; Heise, 1998).
women, adolescence and young adulthood introduce biologi- Although men may experience violence linked to their gender,
cal vulnerabilities (e.g., unique cellular formation of the cer- unequal power places the burden of GBV on women and girls
vix) that make them disproportionately susceptible to the (Connell, 2009; Yount, James-Hawkins, Cheong, & Naved,
negative consequences of GBV compared to older women, 2018). In general, masculinity norms support men’s use of
such as Human Immunodeficiency Virus (HIV; Kleppa violence to discipline and dominate women and children,
et al., 2015) and other sexually transmitted infections (STIs; whereas norms of femininity encourage women to exert emo-
Andersson, Cockcroft, & Shea, 2008). Adolescents in LMICs tional labor by attending to others’ needs and not their own
face the largest global SRH burden, including STIs, early (Fahs & Swank, 2017; James-Hawkins, Salazar, Hennink, Ha,
pregnancy, and unsafe abortions (Bearinger, Sieving, & Yount, 2016; Wingood & DiClemente, 2000). In addi-
Ferguson, & Sharma, 2007). For instance, of the estimated tion, men may feel entitled to use coercion and aggression to
10 million people ages 15–24 living with HIV, 84% are in meet their sexual needs. Harmful practices such as child
Africa and Asia (Bearinger et al., 2007), while the average marriage and FGMC reinforce the notion that girls’ and
birth rate for girls ages 15–19 in sub-Saharan Africa is 100/ women’s sexuality is mainly for producing children–particu-
1000, compared to the global average of 44/1000 (The World larly sons–and for men’s pleasure (Andro & Lesclingand,
Bank, 2019). 2016). With global inequities that render women and girls
Forms of GBV relevant for adolescent girls and young vulnerable to GBV and poor SRH, understanding how GBV
women in LMICs include child abuse, female genital mutila- experiences are associated with SRH across the life course is
tion/cutting (FGMC), child marriage, intimate partner violence critical.
(IPV), and non-partner perpetrated sexual violence (NPSV; GBV is linked to negative SRH outcomes for women and
Yount et al., 2017). Child abuse includes physical, emotional, girls. GBV has been associated with pain during sex, arousal
and sexual abuse, neglect, exploitation, and other ill treatment problems, risky sexual behaviors (Alsibiani & Rouzi, 2010;
(United Nations Children’s Fund [UNICEF], 2014) and dis- Biglu, Farnam, Abotalebi, Biglu, & Ghavami, 2016), genital
proportionately affects girls (UNFPA, 2014a). Estimates of and reproductive tract infections (Diouf & Nour, 2013;
child abuse range from 30% to 50% across geographic regions Iavazzo, Sardi, & Gkegkes, 2013), and unintended pregnancies
(Hillis, Mercy, Amobi, & Kress, 2016). FGMC involves the and pregnancy complications (Anand, Unisa, & Singh, 2017;
partial or total removal of external female genitalia, or other Berg & Underland, 2013). Conceivably, although beyond the
injury to the female genital organs for non-medical reasons scope of the current study, some SRH behaviors or statuses
(UNICEF, 2016b; WHO, 1997). FGMC affects at least may precede GBV in instances where sociocultural factors
200 million girls, of whom 44 million are under age 15 engender intolerance of women’s sexual and reproductive
(UNICEF, 2016a). Child marriage, meaning formal marriage agency (Anderson, 2005). Further, the relationship of any
or informal union of a child before the age of 18, affects 44% of one form of GBV with a specific SRH outcome may be
young women in South Asia and 39% in sub-Saharan Africa, confounded by prior or co-occurring forms of GBV (i.e.,
with approximately 8% of these young women married before polyvictimization; Ellsberg & Heise, 2005; Santhya et al.,
age 15 (Santhya & Jejeebhoy, 2015; UNICEF, 2016b). IPV refers 2010).
to behaviors committed by a current or former intimate part- We aimed originally to synthesize the literature on SRH
ner that causes physical, emotional, or sexual harm (WHO, outcomes associated with GBV exposures for adolescent girls
2006). Across 81 LMIC settings, an estimated 30% of women and young women in LMICs (ages 10–24). However, too few
ages 15 and over have experienced physical and/or sexual IPV reviews focused exclusively on this group. Therefore, we
(Devries et al., 2013). Moreover, an estimated 20–75% of expanded our eligibility criteria to allow reviews including
women ages 15 and over have experienced emotional abuse, our target group (ages 10–24) as well as girls and women of
which includes insults, humiliation, intimidation, and use of other ages. A recent review highlighted the lack of sexuality
threats (WHO, 2005). Finally, NPSV includes attempted or studies focused on the Global South, especially research on
completed unwanted sexual acts or advances using coercion, sexual violence (Dworkin, Lerum, & Zakaras, 2016). This
intimidation, or force (WHO, 2013). Although sexual violence systematic review of reviews provides a synthesis of the global
before age 18 often is counted as a sub-type of child abuse, research in this area by assessing the methodological quality
estimates in adulthood sometimes include women ages 15 and of systematic reviews and compiling the results of studies
THE JOURNAL OF SEX RESEARCH 3
included in the highest-quality reviews. It also allowed us to double-screened by title and abstract, yielding 22 eligible
synthesize findings across a range of exposures and outcomes, reviews. After full-text screening, 10 reviews met eligibility
identifying implications of observed patterns for future criteria. Additional reviews were found through a reference-
research and prevention efforts. list search (n = 7), expert consultations (n = 5), and a gray-
literature search (n = 6, including one duplicate). A list of
Method included and excluded reviews is available upon request.
We followed the Assessment of Multiple Systematic Reviews
(AMSTAR) guidelines for systematic review of reviews (Shea Quality Assessment
et al., 2007). AMSTAR is an 11-item tool to assess the meth-
odological quality of systematic reviews. Our protocol is based All 27 reviews were duplicate-rated for quality using
on two other reviews from our research group (Grose, Roof, AMSTAR criteria (Shea et al., 2007). AMSTAR denotes cri-
Semenza, Leroux, & Yount, 2019; Yount et al., 2017). teria to evaluate review designs, search strategies, inclusion
criteria, quality assessment of included studies, methods for
synthesizing studies, publication bias, and conflicts of interest
Search Strategy (Online Supplement 2). Scores ranged from 1 to 8 (M = 4.04,
We used a comprehensive list of search strings on PubMed SD = 2.38) on the 11-point scale. Seventeen reviews were low
and PsycINFO (November 1, 2016) and Scopus (November 6, quality (scored 0–4), 10 were moderate quality (scored 5–8)
2016) online databases. Search strings included keywords on and zero were high quality (scored 9–11). We included
violence (e.g., domestic violence), SRH (e.g., vaginismus, sex- reviews scoring 5 or higher (moderate quality) in our sum-
ual arousal), and LMICs (e.g., third world nation, under- mary of study-level results, for a total of 10 eligible reviews.
developed country), including specific names (e.g., Latin
America, Haiti). A complete list of search strings is available
in Online Supplement 1. We searched the reference lists of Data Extraction and Analysis
eligible reviews from the database search and emailed the We used a systematic approach to extract review- and study-
corresponding author(s) for additional reviews. Finally, we level data. One author and one research assistant extracted
conducted a gray-literature search for non-peer reviewed review data. Three authors extracted study data. Original,
and unpublished work from targeted organizational websites empirical studies (N = 62) included in the data extraction
(Figure 1). must have met the same exposure, outcome, gender, age,
and language inclusion criteria applied at the review level.
Eligibility Criteria Data were extracted only once from studies reported in multi-
ple reviews. There was no restriction on publication date for
This systematic review of reviews included original, English- studies within the reviews. Information from reviews and
language systematic reviews and meta-analyses of primary studies was extracted in duplicate.
studies published between January 1, 2000 and November 6,
2016. We included reviews that were not labeled “systematic”
if they discussed search terms and use of electronic databases. Results
Included were reviews that addressed at least one quantitative
association between a GBV exposure and SRH outcome of Review Characteristics
interest; reviews that explicitly examined only SRH exposures Table 1 summarizes characteristics of the 10 moderate-quality
predicting GBV outcomes were excluded. The principal GBV reviews, all published between 2011 and 2015. Sums in Table
exposures of interest were child abuse, FGMC, child marriage, 1 account for instances of study duplication across reviews.
IPV, and NPSV. Outcomes were sexual function, behavior, Ten reviews yielded 362 studies (M = 36.2; range 10–124), of
and empowerment; contraception/STI prevention; gynecolo- which two-thirds (n = 239) focused on LMICs. LMIC geo-
gical conditions; and pregnancy and birth-related outcomes. graphic representation in reviews included North, South, East,
Our current focus on SRH complements prior reviews of GBV West, and Central Africa (n = 8); East, South, and Southeast
interventions (Yount et al., 2017) and mental health and Asia (n = 4); South and Central America (n = 3); Eastern
psychological empowerment outcomes (Grose et al., 2019). Europe (n = 2); Polynesia (n = 2), and the Caribbean (n = 1).
Reviews must have included at least one sample with adoles- Of the studies from LMICs, 88% were written in English (n =
cent girls and young women ages 10–24 from an LMIC, based 210). The percentage of English-language studies contained in
on the 2016 World Bank classifications of country incomes the LMIC-inclusive reviews ranged from 79% to 100%. Only
(The World Bank, 2018). 53% (n = 189) of all studies were in English and analyzed
women and girls only or analyzed girls’ and women’s data
separately from boys’ and men’s data. Of those studies strati-
Review Selection
fied by gender, 40% examined exposures and outcomes of
The search, screening, review, and selection processes are interest to this review (21% of all studies). Ultimately, 3%
summarized in Figure 1. The PsycINFO search revealed no (n = 12) of studies met all criteria by examining our exposures
eligible reviews. After excluding duplicate results from the and outcomes with adolescent girls and young women ages
PubMed and Scopus database searches, all 214 reviews were 10–24 years in LMICs.
(1) Records identified through
Identification
(2) Duplicate records across
PUBMED PsycINFO, and
search engines excluded
Scopus searches
(n = 6)
(n = 220)
Title/Abstract Screening
(3) Records with title/abstract

screened (4) Ineligible records
excluded
(n = 214)
(n = 192)
(5) Full-text records assessed for (6) Full-text records excluded,

with reasons (e.g., no GBV,
Eligibility
eligibility
no outcomes/GBV
(n = 22) relationship, not systematic,
no LMIC)
(n = 11)
(8) Eligible reviews identified from

reference list search added
(7) Reviews included in qualitative (n = 7)
synthesis from PUBMED and Scopus
search
Included Reviews
(9) Eligible reviews identified by

(n = 11) expert consults and grey
literature search1 added
(n = 10)
(10) Removed low quality reviews

(11) Total number reviews included in rated with AMSTAR tool
review excluded (n = 17), and review
where no studies within were
(n = 10) eligible (n = 1)
Figure 1. Study selection flow diagram.

1
Websites: https://www.unicef.org/, https://www.unicef-irc.org/, http://www.who.int/en/, http://www.unwomen.org/en, http://www.savethechildren.org/, http://
www.care.org/, https://www.campbellcollaboration.org/, http://www.bettercarenetwork.org/, https://plan-international.org/, http://www.endcorporalpunishment.
org/, http://www.childtrafficking.com/, http://www.ecpat.org/, http://www.unfpa.org/, http://www.worldsexology.org/, http://www.svri.org/, https://www.globalfund
forwomen.org/, https://www.fordfoundation.org/, http://www.icrw.org/, http://www.popcouncil.org/, http://www.pathfinder.org/, https://www.engenderhealth.org/
index-main.php, http://whatworks.co.za/
Our original intent was to synthesize evidence from ado- physical, and/or sexual child abuse or IPV into “any child
lescent and young-adult samples (ages 10–24). However, too abuse” or “any IPV” in one’s life to accommodate studies that
few reviews focused exclusively on this group in LMICs to utilized composite measures. Composites included various
provide a thorough review. Therefore, we widened the scope combinations of emotional, physical, and/or sexual violence
to incorporate any review that included samples of adolescent (e.g., physical and sexual, physical only, or all three). The
and young-adult respondents, even those that included adult largest number of reviews addressed any IPV experience
women, expanding the age range to 9–70 years. We included (Hall, Chappell, Parnell, Seed, & Bewley, 2014; Li et al., 2014;
additional four reviews and 11 studies, ultimately producing Maxwell, Devries, Zionts, Alhusen, & Campbell, 2015; Shamu,
another 88 samples. Abrahams, Temmerman, Musekiwa, & Zarowsky, 2011;
In terms of exposures and outcomes, reviews covered all five UNICEF, 2012), or NPSV (Hall et al., 2014; Li et al., 2014;
forms of GBV: IPV (50%, n = 5), NPSV (50%, n = 5), child Shamu et al., 2011; Thornton & Veenema, 2015; UNICEF,
abuse (40%, n = 4), FGMC (30%, n = 3), and child marriage 2012). Only one review each addressed emotional child abuse
(10%, n = 1). Sixty percent of reviews examined only one GBV (Norman et al., 2012), child neglect (Norman et al., 2012), any
outcome (range 1–4). Reviews tended to collapse emotional, child abuse (Li et al., 2014), or child marriage (Li et al., 2014).
Table 1. Systematic review of summary characteristics.1

Review n Exposure- Age
(1st author, AMSTAR n GW Outcome n 10–24-year Range
date) (out of 11) Regions N Studies n LMICs n English Analyzed Analyzed -olds Only (years) GBV SRH
Shamu et al., 5 S Africa 19 19 19 18 1 0 16–44 CA Contra, SB, STI
2011 IPV
SV
Thornton & 5 S America 14 14 11 9 1 0 16–30 SV Emp, Preg, SB, STI
Veenema,
2015
Berg et al., 2014 6 E/N/W 54 45 41 38 16 1 15–70 FGMC Contra, Gyn, Preg,
Africa SB, SFxn, STI
2
UNICEF, 2012 6 E/S/SE 89 79 63 53 8 5 9–64 CA Contra, Emp,
Asia IPV Preg, SB, SFxn, STI
E Europe SV
Polynesia
Berg & 7 E/N/W 27 19 15 15 6 0 15–55 FGMC Contra, Gyn, Preg,
Underland, Africa SB, SFxn, STI
2013
Norman et al., 7 S Africa 124 6 6 2 1 1 16–26 CA STI
2012
Berg & Denison, 8 C//N/W 15 14 14 14 6 1 15–54 FGMC Emp, Gyn, Preg,
2012 Africa SB, SFxn, STI
Hall et al., 2014 8 C/E/W 73 21 19 18 13 1 13–69 IPV Contra, Preg
Africa SV
E/S/SE
Asia
E Europe
Polynesia
Li et al., 2014 8 E/S Africa 26 18 18 18 18 3 14–59 CA Contra, Emp,
S Asia CM Preg, SB, STI
Caribbean IPV
S America SV
Maxwell et al., 8 E/S Africa 10 4 4 4 3 0 15–49 IPV Contra, SB, STI
2015 S Asia
C America
Totals - - 362 239 210 189 73 12 9–70 - -
Columns: AMSTAR = AMSTAR quality assessment rating; range 0–11; low = 0–4, moderate = 5–8, high = 9–11. Regions = geographic areas represented in the
reviews. N Studies = total # of articles included in the reviews. n LMICs = total # of articles in the reviews that were from low- or middle-income countries.
n English = total # of articles in the reviews written in English. n GW analyzed = # of articles in the reviews in which there was a separate analysis for women.
n Exposure-Outcome Analyzed = # of articles in the reviews that analyzed a relationship of interest with a sample that included adolescents. n Adolescent Only = #
of articles in the review analyzed data for adolescent girls and young women separately. Age Range = the age range of women and girls, in years, across the
articles in the reviews. GBV = gender-based violence exposures. SRH = sexual and reproductive health outcomes.
Note: CA = childhood abuse; CM = child marriage; Contra = contraception; Emp = empowerment; FGMC = female genital cutting/mutilation; Gyn = gynecological
conditions other than STIs; IPV = intimate partner violence; Preg = pregnancy, abortion outcomes; SB = sexual behavior; SFxn = sexual function/dysfunction; STI =
sexually transmitted infections; SV = non-partner sexual violence.
1
Includes duplicates studies across reviews. Studies are counted once, even if they analyzed multiple samples.
2
Total studies for UNICEF (2012) are the number of studies analyzing “consequences,” and does not include prevalence studies.
Nearly all reviews (n = 9) focused on more than one SRH Berg & Underland, 2013; Berg et al., 2014; UNICEF, 2012) or
outcome. Considered by broad SRH category, most reviews gynecological conditions other than STIs (Berg & Denison, 2012;
(90%) addressed STIs/HIV (Berg & Denison, 2012; Berg & Berg & Underland, 2013; Berg et al., 2014). Further, reviews that
Underland, 2013; Berg, Underland, Odgaard-Jensen, Fretheim, focused on sexual empowerment were less common, with only
& Vist, 2014; Li et al., 2014; Maxwell et al., 2015; Norman et al., one or two covering sexual communication (Li et al., 2014;
2012; Shamu et al., 2011; Thornton & Veenema, 2015; UNICEF, UNICEF, 2012), refusing unwanted sexual behavior (Li et al.,
2012). Sexual behaviors were included in eight reviews (80%), 2014; UNICEF, 2012), relationship equity (Li et al., 2014), or
with most focusing on extramarital sex (Berg & Denison, 2012; sexual knowledge (Berg & Denison, 2012; Thornton & Veenema,
Berg & Underland, 2013; Berg et al., 2014; Li et al., 2014; Shamu 2015).
et al., 2011; UNICEF, 2012) and number of sexual partners (Berg
et al., 2014; Li et al., 2014; Maxwell et al., 2015; Shamu et al.,
2011; Thornton & Veenema, 2015; UNICEF, 2012). Seven (70%)
Characteristics of Extracted Studies
addressed contraception/STI prevention (Berg & Underland,
2013; Berg et al., 2014; Hall et al., 2014; Li et al., 2014; Maxwell Sixty-two unique studies from the moderate-quality reviews
et al., 2015; Shamu et al., 2011; UNICEF, 2012). Reviews of assessed GBV exposures and SRH outcomes for women and
pregnancy and birth-related outcomes also were common girls in LMICs (see Online Supplement 3 for extensive study
(70%, n = 7), especially reviews of miscarriage and/or stillbirth information). Twelve (19%) were studies of adolescent and
(Berg & Denison, 2012; Berg & Underland, 2013; Berg et al., young-adult women ages 10–24. Several studies included dis-
2014; Hall et al., 2014; Li et al., 2014; UNICEF, 2012). Limited tinct samples from multiple LMIC study sites, so we synthe-
attention was given to sexual function (Berg & Denison, 2012; sized information from all 100 separate samples from the 62
studies and report sample percentages in this section. Designs associated with induced abortion (86% of analyses).
for the samples were mostly cross-sectional (87%) and rarely Emotional IPV and physical IPV were (counterintuitively)
longitudinal (6%). The majority (75%) used probability (e.g., related to greater use of contraception/STI prevention (56%
multi-stage cluster) sampling, whereas 25% relied on non- and 50% of analyses, respectively). Finally, sexual IPV was
probability (convenience) sampling. Most samples (78%) positively associated with induced abortions (57% of ana-
were community- or population-based, and 20% were clinical. lyses), and FGMC was related to genital symptoms other
Most studies were published between 2000–2010 (62%) or than STIs (41% of analyses). Below we summarize results for
2011–2016 (31%). Over half (56%) were undertaken in Africa, each SRH outcome organized by broad category. We provide
and more than one quarter (27%) in Asia. Samples were split country designations in parentheses the first time a citation
on urbanicity, with 34% comprised of urban sites/participants, appears in each sub-section (see Online Supplement 4 for
39% mixed urban/rural, and 27% rural. Sample sizes ranged detailed study information).
from 80 to 37,781, with most between 500 and 1,499 (45%) or
1,500 and 4,999 (28%) women and girls. Most samples (84%) Sexual Function
included only married/partnered adolescent girls and women. GBV and sexual function were examined in seven samples from
However, only 8% of the adolescent/young adult-only samples seven studies. Sexual function included measures of general
were comprised of married/partnered participants (58% sexual dysfunction, sexual pleasure (desire, arousal, orgasm, or
unmarried, 34% unknown). Our results revealed a shortage satisfaction), and pain during sex. Child sexual abuse (CSA) was
of research that was longitudinal, from LMICs outside Africa positively associated with general sexual dysfunction in 40%
and Asia, inclusive of married adolescents and young adults, (n = 2) of analyses from one 9–18-year-old sample (Fahrudin
or focused only on adolescent girls and young-adult women. & Edward, 2009 [Malaysia]) and one combined adolescent-adult
sample (Luo, Parish, & Laumann, 2008 [China]), and was not
associated in the other 60% (n = 3). FGMC analyses (n = 2)
Synthesis of Results for Sexual and Reproductive Health
revealed mixed results, with half finding positive associations
Table 2 summarizes the GBV exposures and SRH outcomes and half finding no association with pain during sex (Elnashar &
addressed in the 10 moderate-quality reviews and their 62 unique Abdelhady, 2007 [Egypt]). Similarly, FGMC was negatively asso-
studies (12 adolescent-only). For exposure-outcome combina- ciated with pleasure in 44% (n = 8) of analyses (Adinma, 1997
tions, we report the number of reviews (out of 10), samples (out of [Nigeria]; Elnashar & Abdelhady, 2007; Megafu, 1983 [Nigeria]),
100), and analyses (out of 542). Recall that some studies exam- including results from one 18–28-year-old sample (Thabet &
ined GBV and SRH across multiple sites or countries, yielding Thabet, 2003 [Egypt]), but was not associated in the other 56%
multiple samples. Many of these samples included several assess- (n = 10). Thus, there was some evidence that CSA and FGMC are
ments of the same type of GBV exposures and/or SRH outcomes, detrimental to sexual function for this population. Yet, research
yielding multiple analyses. In Table 2, we report the percentage of on non-sexual child abuse, child marriage, IPV, and NPSV was
positive, negative, and null associations for each exposure–out- absent, and few studies examined only adolescents or young
come relationship studied. The denominators vary because they adults.
are the total number of analyses for the specific exposure–out-
come relationships (see Online Supplement 4 for detailed results Sexual Behavior
by sample). Positive associations indicated that a GBV exposure The relationship between GBV and women’s sexual behavior
was associated with a higher likelihood of experiencing an SRH was examined in 19 samples from 19 studies. Four forms of
outcome (e.g., IPV associated with a higher likelihood of contra- GBV exposure (all except child marriage) were assessed in
ception use). We did not attempt to predict all possible exposure- relationship to sexual behavior. Sexual behaviors included age
outcome combinations a priori, rather, outcomes emerged from of sexual debut, frequency of sex, number of sexual partners,
the systematic search strategy. The following summary statistics extramarital sex, drug and/or alcohol use before or during sex,
provide a cursory understanding of the gaps in the literature on transactional sex, and “other” behaviors.
the direct connections between GBV exposures and SRH
outcomes. Timing and Frequency. All five analyses indicated that
The reviews addressed 28% of all possible exposure–out- FGMC, physical IPV, and NPSV were associated with
come relationships. Only 7% (n = 23) of exposure-outcome a younger age of sexual debut (Caceres, Vanoss Marin, &
combinations were examined in five or more samples, with Sid Hudes, 2000 [Peru]; Fonck, Leye, Kidula, Ndinya-
most associations examined in only one or two. Several expo- Achola, & Temmerman, 2005 [Kenya]; Yount & Abraham,
sure–outcome relationships stand out because they were 2007 [Kenya]). Results from one less-than-22-year-old sample
assessed in numerous samples (>5) and resulted in a high supported this overall finding with NPSV (Cheng et al., 2001
percentage of significant associations (>40%). Any IPV was [China]). In contrast, FGMC, physical IPV, sexual IPV, any
positively associated with number of sexual partners (100% of IPV, and NPSV were not associated with coital frequency in
analyses), STIs other than HIV (86% of analyses), induced 90% (n = 9) of analyses (Caceres et al., 2000; Stewart,
abortion (78% of analyses), combined measures of pregnancy Morison, & White, 2002 [Central African Republic]; van der
termination (78% of analyses), and unwanted/unplanned Straten et al., 1998 [Rwanda]). Results from one 15–26-year-
pregnancy (64% of analyses). Emotional IPV was positively old sample were consistent with these null results for any IPV
associated with HIV (67% of analyses), and induced abortion and coital frequency (Jewkes et al., 2006 [South Africa]).
(50% of analyses). Similarly, physical IPV was positively Although research was missing on child abuse, results
Table 2. Summary of results (% positive, negative, and null analyses).
Exposures
Child Abuse IPV
Outcomes Emo Neg Phys Sex Wit Any CM FGMC Emo Phys Sex Any 2+ SV Total
Sexual Function
General
n reviews, samples, analyses 0,0,0 0,0,0 0,0,0 1,2,5 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 0,0,0 1,2,6
% positive analyses 40 40
% negative analyses 0 0
% null analyses 60 60
Desire/Arousal/Orgasm/Satisfaction
Pain During Sex
Sexual Behavior
Age of Sexual Debut
% positive analyses 0 0 0 0
% negative analyses 100 100 100 100
% null analyses 0 0 0 0
Coital Frequency
% positive analyses 0 0 25 0 0 10
% negative analyses 0 0 0 0 0 0
% null analyses 100 100 75 100 100 90
Number of Sexual Partners
% positive analyses 33 100 0 0 100 80 52
% negative analyses 0 0 0 0 0 0 0
% null analyses 67 0 100 100 0 20 48
Extramarital Sex
% positive analyses 67 0 67 100 64
% negative analyses 0 0 0 0 0
% null analyses 33 100 33 0 36
Transactional Sex
Other Sexual Behaviors
% null analyses 100 25 100 0 50 44
Sexual Empowerment
Communication
(Continued )
7
8
Table 2. (Continued).
Exposures
Child Abuse IPV
Refusing Unwanted Behavior
R. G. GROSE ET AL.

Relationship Equity
% null analyses 0 0
Sexual Knowledge
% positive analyses 0 0 0
% negative analyses 0 0 0
% null analyses 100 100 100
Contraception/STI Prevention
% positive analyses 0 0 56 50 8 22 0 27
% negative analyses 100 100 33 14 25 22 67 27
% null analyses 0 0 11 36 67 56 33 45
Gynecological Conditions
HIV
% positive analyses 100 0 50 25 100 0 0 13 67 36 19 33 9 0 27
% negative analyses 0 0 0 0 0 0 0 13 0 0 0 0 0 0 1
% null analyses 0 100 50 75 0 100 100 75 33 64 81 67 91 100 72
Other STIs
% positive analyses 0 25 0 50 7 50 100 50 86 100 39
% negative analyses 0 0 0 0 7 0 0 0 0 0 2
% null analyses 100 75 100 50 86 50 0 50 14 0 59
Other Genital Symptoms
Pregnancy-Related Outcomes
Unplanned/Unwanted Pregnancy
% null analyses 0 0 40 36 100 100 35
Miscarriage, Stillbirth
% null analyses 88 33 100 63 100 71
Abortion: Induced
% null analyses 50 14 43 22 50 0 28
Abortion: Induced w/Stillbirth &/or Spontaneous
(Continued )
Table 2. (Continued).
Exposures
Child Abuse IPV
% null analyses 0 33 100 21 50 35
Birth Complications
Total
n reviews, samples, analyses 1,1,4 1,1,8 2,2,5 4,6,27 2,2,2 1,1,2 1,1,1 3,20,141 3,13,27 3,20,55 4,28,59 5,57, 161 2,13,19 5,8,31 10,100, 542
% positive analyses 50 13 20 42 50 50 0 17 63 55 28 50 16 35 37
% negative analyses 0 0 0 4 0 0 0 10 11 5 7 4 0 16 7
% null analyses 50 88 80 54 50 50 100 73 26 40 65 45 84 48 56
We include the number of systematic reviews (out of 10), unique samples from the extracted studies (out of 100), and the number of analyses exploring a particular exposure–outcome relationship (out of 542). Percent
positive, negative, and null analyses are calculated out of the number of analyses exploring a particular exposure–outcome relationship so the denominator changes. Shaded cells denote combinations analyzed in ≥5
samples. Emo = emotional, Neg = neglect, Phys = physical, Sex = sexual, Wit = witnessing parental abuse, Any = any type, CM = child marriage, FGMC = Female Genital Mutilation/Cutting, IPV = Intimate partner violence, 2+
= two or more forms of IPV, SV = non-partner sexual violence
9
consistently suggested that GBV was related to earlier first sex Other Sexual Behavior. The relationships between GBV and
but not to coital frequency. other sexual behaviors (e.g., drug or alcohol use before sex,
pornography use) were also examined, though most were
Number of Sexual Partners. CSA was unrelated to number of assessed in only one study each. In all analyses, physical
sexual partners in most analyses (67%, n = 2; Luo et al., 2008 child abuse (n = 1) and witnessing parental abuse (n = 1)
[China]). All analyses indicated that any child abuse (n = 1; were unrelated to a measure of “risky sexual behavior” for
Jewkes et al., 2006 [South Africa]) and any IPV (n = 5; Decker 14–20-year-olds (Yi et al., 2010 [Cambodia]). In one analysis
et al., 2009 [India]; Dunkle, Jewkes, Brown, Gray, et al., 2004 each, CSA was unrelated to “thinking about sex often,” but
[South Africa]; Jewkes et al., 2006; Kacanek et al., 2013 [South was positively related to reporting masturbation and a greater
Africa/Zimbabwe, combined]; Silverman, Decker, Saggurti, variety of sexual practices (Luo et al., 2008 [China]), and to
Balaiah, & Raj, 2008 [India]) were associated with reporting watching pornography in an 18–24-year-old sample (Niu
more sexual partners. Further, in 80% of analyses (n = 4), et al., 2010 [China]). Any IPV was related to recent anal sex
NPSV was associated with reporting more sexual partners for women in sex work in all analyses (n= 1; Decker et al.,
(Cheng et al., 2001 [China]; Dunkle, Jewkes, Brown, 2010 [Thailand]). Sexual coercion was related to a higher
Gray, et al., 2004). In all analyses, FGMC (n = 6; Klouman, likelihood of sex following excessive drinking for less-than
Manongi, & Klepp, 2005 [Tanzania]) and physical IPV (n = 1; -22-year-old abortion seekers in all analyses (n= 1; Cheng
Fonck et al., 2005 [Kenya]) were unrelated to the number of et al., 2001 [China]). However, coercion at first sex was
sexual partners. Results from one less-than-22-year-old unrelated to sex under the influence of drugs or alcohol for
(Cheng et al., 2001) and one 15–26-year-old sample (Jewkes all analyses in a probability sample of 16–30-year-olds (n= 1;
et al., 2006) were consistent with those from combined ado- Caceres et al., 2000 [Peru]). Although some studies used
lescent-adult samples, showing GBV was related to reporting rigorous methods, the limited number of analyses across
more sexual partners. Overall, some forms of GBV – espe- varied behaviors made it difficult to draw broad conclusions.
cially any child abuse, any IPV, and NPSV – were associated
with reporting more sexual partners. Sexual Empowerment
Twenty samples from seven studies assessed the relationship
between GBV and sexual empowerment. All GBV exposures
Extramarital Sex. In 67% of analyses, CSA (n = 2; Dunkle, except child marriage were examined in relationship to sexual
Jewkes, Brown, Gray, et al., 2004 [South Africa]; Niu, Lou, empowerment outcomes, which included sexual communica-
Gao, Zuo, & Shah, 2010 [China]) and any IPV (n = 2; Dunkle, tion, refusing unwanted sexual behavior, relationship equity,
Jewkes, Brown, Gray, et al., 2004; Jewkes et al., 2006 [South and sexual knowledge. Physical IPV and any IPV were unre-
Africa]) were related to a higher likelihood of reporting extra- lated to sexual communication in 100% (n = 1) and 80% (n =
marital sex. All three analyses of NPSV showed a positive 12) of analyses, respectively (van der Straten et al., 1998
association with extramarital sex (Dunkle, Jewkes, Brown, [Rwanda]; Kiarie et al., 2006 [Kenya]; WHO, 2005
Gray, et al., 2004; Le & Blum, 2009 [Vietnam]). FGMC was [American Samoa, Bangladesh, Brazil, Ethiopia, Peru, Serbia
not associated with extramarital sex in any analysis (n = 2; and Montenegro, Tanzania, and Thailand]). In contrast, sex-
Megafu, 1983 [Nigeria]; Yount & Abraham, 2007 [Kenya]). ual IPV was associated with more condom negotiation in all
Results from 15–26-year-old (Jewkes et al., 2006), 15–24-year- analyses (n = 2; van der Straten et al., 1998). A partner’s
old (Le & Blum, 2009) and 18–24-year-old samples (Niu et al., insistence on sex was related to higher likelihood of refusing
2010) were consistent with those of combined adolescent- sex in all analyses (n = 1; van der Straten et al., 1998).
adult samples. Overall, CSA, any IPV, and NPSV were con- However, no associations were observed between CSA and
sistently related to a higher likelihood of reporting extramar- sex just to please one’s partner (n = 1; Luo et al., 2008
ital sex. [China]) or between physical IPV and refusing sex (n = 1;
van der Straten et al., 1998). Results from one 15–26-year-old
Transactional Sex. Transactional sex measures included sample found a negative relationship between any IPV and
exchanging sex for resources such as food, clothes, transpor- relationship equity in all analyses (n = 1; Jewkes, Dunkle,
tation, school fees, housing, or money. None of the analyses Nduna, & Shai, 2010 [South Africa]). In all analyses, neither
(n = 1) suggested a relationship between CSA and transac- coercion at sexual initiation for 16–30-year-olds (n = 1;
tional sex (Dunkle, Jewkes, Brown, Gray, et al., 2004 [South Caceres et al., 2000 [Peru]) nor FGMC for 18–28-year-olds
Africa]). In 33% of analyses (n = 1), NPSV was positively (n= 3; Thabet & Thabet, 2003 [Egypt]) were related to sexual
associated with transactional sex (Dunkle, Jewkes, Brown, knowledge. Thus, available evidence suggested IPV was asso-
Gray, et al., 2004). In all four analyses, including a 15–26- ciated with lower power in sexual relationships and that sex-
year-old sample (Jewkes et al., 2006 [South Africa]), any IPV ual violence (IPV and NPSV) was related to more refusal and
was related to a higher likelihood of participating in transac- negotiation.
tional sex (Dunkle, Jewkes, Brown, Gray, et al., 2004;
Kacanek et al., 2013 [South Africa/Zimbabwe, combined]). Contraception/STI Prevention
Overall, results suggested NPSV and any IPV were related to Thirty-six samples from 21 studies analyzed the relationship
a higher likelihood of transactional sex, although research on between GBV and using contraception or STI-prevention
non-sexual child abuse was missing and only one 15–26- methods (e.g., condoms, hormonal pills, sterilization, etc.).
year-old sample was found. All GBV exposures except child marriage were examined in
relation to contraception/STI prevention. Of childhood GBV conditions included STIs and other genital symptoms that
exposures, CSA (Dunkle, Jewkes, Brown, Gray, et al., 2004 were not clearly sexually transmitted (e.g., abnormal dis-
[South Africa]) and FGMC (Jackson, Adongo, Bawah, charge, urination difficulties, reproductive tract infections,
Feinglass, & Phillips, 2005 [Ghana]; Yount & Abraham, and menstrual problems). All GBV exposures were examined
2007 [Kenya]) were associated with less use of contracep- in relationship to STIs. However, only FGMC was assessed in
tion/STI prevention in all three analyses. No other forms of relation to other genital symptoms. The lack of studies of
childhood abuse were explored. other GBV exposures in relationship to gynecological condi-
Results for IPV were mixed and varied by form of abuse. In tions beyond STI diagnoses and symptoms was a notable
56% of analyses (n = 5), emotional IPV was associated with evidence gap.
more use of contraception/STI prevention (Emenike, Lawoko,
& Dalal, 2008 [Kenya]; Nguyen et al., 2012 [Vietnam]; Salazar, STIs. HIV was the most common STI outcome analyzed,
Valladares, & Hogberg, 2012 [Nicaragua]), but was related to although most studies analyzed HIV and other STIs. Other
less use in 33% (n = 4; Antai & Adaji, 2012 [Nigeria]; Kacanek STI symptoms (e.g., genital lesions, warts, sores) and diag-
et al., 2013 [South Africa/Zimbabwe, combined]). In 50% of noses (e.g., chlamydia, gonorrhea, syphilis) were grouped to
analyses (n = 7), physical IPV was associated with more use of facilitate interpretation. Across exposures, GBV was positively
contraception/STI prevention (Emenike et al., 2008; Fonck associated with HIV in 27% of analyses (n= 28) and with
et al., 2005 [Kenya]; Nguyen et al., 2012; Okenwa, Lawoko, & other STIs in 39% of analyses (n = 16).
Jansson, 2011 [Nigeria]; Salazar et al., 2012; Stephenson, Emotional child abuse and witnessing parental abuse were
Jadhav, & Hindin, 2013 [India]), but with less use in 14% consistently associated with a higher likelihood of HIV ser-
(n = 2; Antai & Adaji, 2012; Kacanek et al., 2013). Examples opositivity (Jewkes, Dunkle, Nduna, Jama, & Puren, 2010
of positive, negative, and null associations with physical IPV [South Africa]; Kayibanda, Bitera, & Alary, 2012 [Rwanda]);
were found with longitudinal study designs (Kacanek et al., however, in most (75–100%) analyses, HIV was not associated
2013; Stephenson et al., 2013). In 56% of analyses (n= 18), with childhood neglect (n= 4; Jewkes, Dunkle, Nduna,
any IPV was not associated with contraception/STI prevention Jama, et al., 2010), CSA (n= 3; Dunkle, Jewkes, Brown,
use (Decker et al., 2010 [Thailand]; Dunkle, Jewkes, Brown, Gray, et al., 2004 [South Africa]; Jewkes, Dunkle, Nduna,
Gray, et al., 2004 [South Africa]; Jewkes et al., 2006 [South Jama, et al., 2010; Maman et al., 2002 [Tanzania]), any child
Africa]; Kiarie et al., 2006 [Kenya]; Nguyen et al., 2012 abuse (n= 1; Jewkes et al., 2006 [South Africa]), child marriage
[Vietnam]; Salazar et al., 2012; Were et al., 2011 [Botswana/ (n= 1; Ghosh et al., 2011 [India]), and FGMC (n= 6; Brewer,
Kenya/Rwanda/South Africa/Tanzania/Uganda/Zambia, com- Potterat, Roberts, & Brody, 2007 [Kenya]; Jewkes, Dunkle,
bined]; WHO, 2005 [American Samoa, Bangladesh, Brazil, Nduna, Jama, et al., 2010; Klouman et al., 2005 [Tanzania];
Ethiopia, Namibia, Peru, Serbia, and Montenegro]), was posi- Pépin et al., 1991 [The Gambia]). There were two exceptions
tively associated in 22% of analyses (n = 7; Nguyen et al., 2012; for FGMC, with one study finding a negative association with
Salazar et al., 2012; WHO, 2005 [Tanzania and Thailand]), and HIV in a clinical convenience sample of sex workers (Kanki
was negatively associated in 22% of analyses (n = 7; Antai & et al., 1992 [Senegal]), and one study finding a positive asso-
Adaji, 2012; Decker et al., 2009 [India], 2010; Kacanek et al., ciation in a nationally representative Kenyan sample
2013; Silverman et al., 2008 [India]; Were et al., 2011). Results (Maslovskaya, Brown, & Padmadas, 2009). Similarly, in most
for sexual violence exposures also varied. In 67% of analyses (75–100%) analyses, STIs were not associated with emotional
(n= 8), sexual IPV was not associated with contraception/STI child abuse (n= 2), neglect (n= 3), physical child abuse (n= 2;
prevention use (Le & Blum, 2009 [Vietnam]; Nguyen et al., Jewkes, Dunkle, Nduna, Jama, et al., 2010) or FGMC (n= 12;
2012 [Vietnam]; Okenwa et al., 2011 [Nigeria]; Salazar et al., Elmusharaf, Elkhidir, Hoffmann, & Almroth, 2006 [Sudan];
2012 [Nicaragua]; van der Straten et al., 1998 [Rwanda]), with Klouman et al., 2005; Msuya et al., 2002 [Tanzania]; Yount &
less use in 25% (n = 3; Antai & Adaji, 2012 [Nigeria]; Kacanek Abraham, 2007 [Kenya]). Mixed results in 25–50% of analyses
et al., 2013 [South Africa/Zimbabwe, combined]), and with from one study of 16–26-year-olds indicated a positive asso-
more use in 8% (n= 1; Emenike et al., 2008 [Kenya]). Null ciation between physical child abuse and HIV (n = 1), CSA
findings were confirmed in samples examining sexual IPV with and HIV (n = 1), and neglect and other STIs (n= 1; Jewkes,
15–24-year-olds (Le & Blum, 2009) and any IPV with 15–26- Dunkle, Nduna, Jama, et al., 2010). The mixed results found
year-olds (Jewkes et al., 2006 [South Africa]). Negative associa- with combined adolescent-adult samples also were evident
tions and null findings with sexual IPV and any IPV were with adolescents and young women of median age 17
found in longitudinal analyses (Kacanek et al., 2013). Finally, (Brewer et al., 2007), ages 15–26 (Jewkes et al., 2006), or
in 67% of analyses (n= 2), NPSV was associated with less use of ages 16–26 (Jewkes, Dunkle, Nduna, Jama, et al., 2010).
contraception/STI prevention (Dunkle, Jewkes, Brown, Overall, childhood GBV was not associated with HIV or
Gray, et al., 2004 [South Africa]), including one 15–24-year- other STIs, although emotional child abuse, physical child
old sample (Speizer et al., 2009 [South Africa]). In sum, NPSV abuse, and witnessing parental abuse may be HIV risk factors,
and sexual IPV tended to be either unassociated with contra- and CSA may be a risk factor for other STIs.
ception/STI prevention use or associated with less use. Associations between adult GBV exposures and STIs were
mixed and dependent on the form of abuse. In 67% of ana-
Gynecological Conditions lyses (n = 4), emotional IPV was associated with a greater
The relationship between GBV and gynecological conditions likelihood of HIV (Dude, 2011 [Rwanda]; Kayibanda et al.,
was assessed in 45 samples across 35 studies. Gynecological 2012; Kouyoumdjian et al., 2013 [Uganda]), and in 50% with
a greater likelihood of other STIs (n = 1; Dude, 2011). Physical Unplanned/unwanted Pregnancy. In all analyses, emotional
IPV was related to a greater likelihood of HIV in 36% of IPV (n = 3; Nguyen et al., 2012 [Vietnam]; Okenwa et al., 2011
analyses (n = 5; Fonck et al., 2005 [Kenya]; Kouyoumdjian [Nigeria]) and physical IPV (n = 5; Nguyen et al., 2012; Okenwa
et al., 2013; Maman et al., 2002), and was associated with et al., 2011; Silverman, Gupta, Decker, Kapur, & Raj, 2007
a greater likelihood of other STIs in all three analyses (Barros, [Bangladesh]) were positively associated with unplanned/
Schraiber, & Franca-Junior, 2011 [Brazil]; Dude, 2011; Fonck unwanted pregnancy. Most analyses of sexual IPV (60%, n =4;
et al., 2005). In 19% of analyses (n = 4), sexual IPV was Nguyen et al., 2012; Okenwa et al., 2011) and any IPV (64%, n= 9;
positively associated with HIV (Kouyoumdjian et al., 2013; Nguyen et al., 2012; Pallitto et al., 2013 [Bangladesh, Brazil,
Maman et al., 2002; Quigley et al., 2000 [Uganda]; van der Ethiopia, Namibia, Peru, Tanzania, and Thailand]) also found
Straten et al., 1998 [Rwanda]), and in 50% was positively positive associations with unplanned/unwanted pregnancy. Yet,
associated with other STIs (n = 1; Dude, 2011). In 33% of in all analyses, two or more forms of IPV (n = 2; Silverman et al.,
analyses (n = 8), any IPV was positively associated with HIV 2007) and NPSV (n = 2; Caceres et al., 2000 [Peru]) were unrelated
(Barros et al., 2011; Decker et al., 2009 [India]; Dude, 2011; to unplanned/unwanted pregnancy. One 15–24-year-old study
Dunkle, Jewkes, Brown, Gray, et al., 2004; Jewkes, Dunkle, supported the null findings for NPSV (Speizer et al., 2009 [South
Nduna, & Shai, 2010; Kouyoumdjian et al., 2013; Were et al., Africa]). In sum, IPV (emotional, physical, sexual) was consis-
2011 [Botswana/Kenya/Rwanda/South Africa/Tanzania/ tently associated with unwanted/unintended pregnancy.
Uganda/Zambia, combined]), and in 86% was positively asso-
ciated with other STIs (n = 6; Barros et al., 2011; Decker et al., Miscarriage/stillbirth. FGMC was unrelated to miscarriage/
2010 [Thailand]; Dude, 2011; Jewkes, Dunkle, Nduna, & Shai, stillbirth in 88% of analyses (n = 7; Larsen & Okonofua, 2002
2010). When two or more forms of IPV were combined, [Nigeria]; Morison et al., 2001 [The Gambia]). In all analyses,
nearly all analyses (91%; n = 10) found null results for HIV sexual IPV (n = 2) and experiencing two or more forms of IPV
(Harling, Msisha, & Subramanian, 2010 [Dominican Republic, (n = 2) were unrelated to miscarriage/stillbirth (Silverman et al.,
Haiti, India, Kenya, Liberia, Malawi, and Mali]; see; Silverman 2007 [Bangladesh]). However, physical IPV was related to higher
et al., 2008 [India] for an exception). Finally, no analyses likelihood of miscarriage/stillbirth in 67% of analyses (n = 2;
(n = 6) found a relationship between NPSV and HIV, Fonck et al., 2005 [Kenya]; Silverman et al., 2007). Also, experi-
although in all analyses (n = 1) NPSV was positively asso- encing any IPV was related to a higher likelihood of miscarriage/
ciated with other STIs (Caceres et al., 2000 [Peru]). Studies stillbirth in 37% of analyses (n = 6; Stöckl, Filippi, Watts, &
with 15–26-year-olds (Jewkes et al., 2006) and 15–24-year- Mbwambo, 2012 [Tanzania]; WHO, 2005 [American Samoa,
olds (Speizer et al., 2009 [South Africa]) supported the overall Brazil, and Peru]), although unrelated in 63% (n = 10; Nair
results, including one longitudinal study assessing incident et al., 2013 [India]; WHO, 2005 [Bangladesh, Ethiopia,
HIV with 15–26-year-olds (Jewkes, Dunkle, Nduna, & Shai, Namibia, Serbia and Montenegro, Tanzania, and Thailand]). In
2010). In sum, emotional child abuse and IPV, physical child sum, physical IPV and any IPV were concerning potential risk
abuse and IPV, witnessing abuse, and any IPV were of con- factors for miscarriage/stillbirth.
cern for HIV, while CSA, all forms of IPV, and NPSV were of
concern for other STIs. Abortion. Studies assessed elective-induced abortion and
measures of induced abortion combined with stillbirth and/
Other Genital Symptoms. FGMC was assessed in relationship or spontaneous abortion. In the latter case, it was not possible
to several genital symptoms, including abnormal vaginal dis- to disaggregate which pregnancy terminations were stillbirth,
charge, bacterial vaginosis, pelvic inflammatory disease, geni- spontaneous abortion, or induced abortion. Physical IPV (n =
tal sores, irregular menses, and dysmenorrhea. There were no 6; Alio et al., 2011 [Cameroon]; Antai & Adaji, 2012 [Nigeria];
studies with only adolescents or young adults in this category. Emenike et al., 2008 [Kenya]; Kaye, Mirembe, Bantebya,
In 35% of analyses (n = 9), FGMC was associated with more Johansson, & Ekstrom, 2006 [Uganda]; Nguyen et al., 2012
genital symptoms (Elnashar & Abdelhady, 2007 [Egypt]; Fillo [Vietnam]) and any IPV (n = 18; Antai & Adaji, 2012; Kaye
& Leone, 2007 [Burkina Faso]; Jones, Diop, Askew, & Kabore, et al., 2006; Nguyen et al., 2012; Stöckl et al., 2012 [Tanzania];
1999 [Burkina Faso and Mali]; Morison et al., 2001 [The WHO, 2005 [Bangladesh, Brazil, Ethiopia, Peru, Serbia and
Gambia]). Although results were sparse, and none focused Montenegro, Tanzania, and Thailand]; Wu, Guo, & Qu, 2005
only on adolescents, there was some evidence that FGMC [China]) were positively associated with induced abortion in
may be a risk factor for gynecological and menstrual 86% and 78% of analyses, respectively. Similarly, physical IPV
problems. (n = 2; Silverman et al., 2007 [Bangladesh]) and any IPV (n =
11; Pallitto et al., 2013 [Bangladesh, Brazil, Ethiopia, Namibia,
Pregnancy and Birth-related Outcomes Peru, Serbia and Montenegro, Tanzania, and Thailand]) were
Forty-nine samples from 22 studies examined the relationship positively related to other measures of pregnancy termination
between GBV and pregnancy- or birth-related outcomes. in 67% and 79% of analyses, respectively. In one 15–24-year-
Pregnancy-related outcomes included unplanned/unwanted old sample, NPSV was related to a higher likelihood of
pregnancy, miscarriage and/or stillbirth, and abortion. Birth- induced abortion (Kalyanwala, Zavier, Jejeebhoy, & Kumar,
related outcomes included complications during delivery (e.g., 2010 [India]).
episiotomy, cesarean delivery, obstructed labor, hemorrhage). Results were also mixed for emotional IPV, sexual IPV,
Only studies of FGMC, IPV, and NPSV with pregnancy and and combined measures of two or more forms of IPV.
birth-related outcomes were found. Emotional IPV was positively associated with induced
abortion in 50% of analyses (n = 3; Emenike et al., 2008; Kaye 10–24-year-olds were scarce. This finding corroborates our
et al., 2006; Nguyen et al., 2012), and with other termination team’s prior systematic reviews of reviews identifying
measures in 100% (n = 1; Okenwa et al., 2011 [Nigeria]). a dearth of evidence regarding interventions to prevent GBV
Positive associations between sexual IPV and induced abor- (Yount et al., 2017) and about the relationship between GBV
tion were found in 57% of analyses (n = 4; Alio et al., 2011; and mental-health outcomes in the same population groups in
Antai & Adaji, 2012; Kaye et al., 2006; Nguyen et al., 2012), LMICs (Grose et al., 2019). Therefore, we expanded the inclu-
but only null results (n = 3) were reported for other termina- sion criteria post-hoc for the present study to capture com-
tion measures (Okenwa et al., 2011). In 50% of analyses, two bined samples of adolescent girls, young women, and adult
or more forms of IPV were positively associated with induced women. Overall, out of 62 unique studies, only 12 (19%)
abortion (n = 1) and with other termination measures (n = 1; focused solely on adolescent girls and young women, and
Alio et al., 2011; Silverman et al., 2007). Overall, GBV – only one sample included early adolescents (age 9–18). As
especially emotional IPV, physical IPV, and any IPV – was such, we were only partially able to synthesize developmen-
consistently related to induced abortion and other measures tally nuanced GBV consequences. Although findings from
of pregnancy termination. adolescent-only studies still corroborated with those for com-
bined samples including adults, it is possible that the
Birth Complications. FGMC was unrelated to birth compli- expanded age range may have diluted the results specifically
cations in 82% of analyses (n = 40; Adinma, 1997 [Nigeria]; for the 10–24-year-old age group of interest. That is, if
Browning, Allsworth, & Wall, 2010 [Ethiopia]; Elnashar & a woman experienced GBV early in life and then experienced
Abdelhady, 2007 [Egypt]; Jones et al., 1999 [Burkina Faso negative SRH outcome(s) later in life, the influence of time-
and Mali]; Larsen & Okonofua, 2002 [Nigeria]). FGMC was varying confounders may grow with the increasing time
positively associated with birth complications like episio- between the exposure and the outcome.
tomies and perineal tears in the other 18% (n = 9; Elnashar Several other gaps in the literature were notable. Our
& Abdelhady, 2007; Jones et al., 1999 [Mali]; Larsen & findings were limited in geographic scope, with most studies
Okonofua, 2002). Overall, FGMC was not associated with occurring in Africa or Asia and evidence substantially lacking
birth complications, but no analyses focused solely on adoles- for Latin America, the Caribbean, and the Middle East. To
cents and young adults and no other GBV exposures were some extent, the geographic focus on Africa and Asia is
assessed. justified by the large numbers of adolescent girls in these
regions and relatively high rates of GBV and poor SRH out-
comes (Woog & Kågesten, 2017). That said, this synthesis is
Discussion
not necessarily generalizable to the experiences of women and
This systematic review of reviews is the first synthesis of the girls living in underrepresented regions. Although married/
evidence from the highest-quality reviews about the relation- partnered individuals were recruited in most studies, only one
ship between GBV and SRH for women and girls in LMICs. study explicitly analyzed results from married adolescents
The reviews were published between 2011 and 2015, suggest- separate from adults. Attention must be paid to adolescents’
ing a literature in its early stages. Our analysis confirmed entry into more diverse relationship types, given changing
relationships between GBV and SRH across multiple expo- patterns of marriage worldwide (e.g., marrying at later ages,
sures and outcomes and identified evidence gaps, offering entering consensual non-marital unions; United Nations
a roadmap for future research. We examined five common Department of Economic and Social Affairs, Population
forms of GBV in adolescents and young adults: child abuse, Division, 2016). Further, we focused on IPV and NPSV per-
FGMC, child marriage, IPV, and NPSV. This review revealed petrated by men against women and girls. Our search strategy
that GBV exposure was a risk factor for more sexual partners, did not focus on gay, lesbian, bisexual, transgender, or queer
gynecological conditions (HIV, other STIs, and genital symp- (LGBTQ) populations, and stratifying by gender identity was
toms other than STIs), unwanted/unplanned pregnancy, and neither feasible nor a focus of this review of reviews. Future
abortion. Emotional and physical IPV were associated with efforts to synthesize the literature on relationships between
higher use of contraception/STI prevention, which may GBV and SRH should focus on LGBTQ populations.
(depending on timing) be a self-protective response to IPV Synthesizing research on GBV and SRH also was difficult
exposure. We conclude that GBV may have negative implica- due to variations in the measurement of exposures and out-
tions for the sexual health and well-being of women and girls comes. Few studies used validated measures of SRH (except
in LMICs. Our work contributes an important synthesis of for STI/HIV tests). More often, measures of GBV were stan-
evidence from LMICs showing a relationship between GBV dardized because studies used comparative survey modules
and aspects of SRH. Below, we summarize the scope of for child marriage, FGMC, IPV, and NPSV available from
reviews and studies and offer guidance for future research. the WHO (2005) or the Demographic and Health Surveys
(DHS; Kishor & Johnson, 2004). Many studies did not have
enough participants to analyze separate forms of IPV or sub-
Review and Study Characteristics
types of FGMC, so IPV often was consolidated into “any IPV”
We identified several important gaps in research on the asso- or “two or more forms,” and FGMC was coded as “cut” or
ciation between GBV and SRH outcomes for adolescent girls “uncut.” Although combined prevalence measures allowed
and young women in LMICs. We originally aimed to focus on analysis of some rare exposures, some GBV exposures were
adolescent girls and young women only, but data targeting common, and aggregation across type may have masked
relationships between more severe forms of GBV and SRH sing parental abuse both were addressed in just two studies.
(Battle, Hennink, & Yount, 2017; Godha, Hotchkiss, & Gage, The shortage of adolescent-only studies may be related to this
2013) and between poly-victimization and SRH (Aho, oversight of childhood exposures. The limited research on
Proczkowska-Björklund, & Svedin, 2016). For instance, com- child marriage was particularly concerning because girls mar-
bining FGMC types that vary greatly in severity may explain ried in childhood also are more likely than those married later
the mixed and contradictory findings for outcomes like pain to experience physical and/or sexual IPV (Santhya et al., 2010;
during sex, genital symptoms, and birth complications. Yount, Crandall, et al., 2016). Moreover, we found no adoles-
Sometimes there were contradictions between composite mea- cent-only studies of emotional or physical IPV. Because of
sures and their components, precluding clear guidance on these gaps, our results provide a limited understanding of
tailoring interventions and policies to reduce specific types dating violence and violence within marriages for young
of GBV to improve SRH outcomes. Using validated instru- women in LMICs.
ments and standardized protocols in adequately sized samples Consistent with findings from other systematic review of
would help ensure comparability across regions and inform reviews (Grose et al., 2019; Yount et al., 2017), the implica-
interventions to best serve vulnerable groups. tions of polyvictimization for SRH were underexplored for
Cross-sectional research was pronounced in the studies girls and women in LMICs. Fewer than half of the reviews in
included here. Although many included studies reported this synthesis examined multiple forms of GBV (Hall et al.,
adjusted statistics accounting for relevant covariates, cross- 2014; Li et al., 2014; Shamu et al., 2011; UNICEF, 2012). The
sectional findings are subject to the possibility of spurious original studies comprising these reviews also rarely analyzed
and confounding relationships. The only SRH outcomes the unique experiences of those who have endured several
explored with longitudinal research designs were HIV sero- GBV exposures over their lifetimes. Although some studies
conversion, Herpes seroconversion, and adoption of contra- combined measures of IPV to assess two or more forms, they
ception (Jewkes, Dunkle, Nduna, Jama, et al., 2010; Jewkes, did not examine the combined relationship of IPV with child
Dunkle, Nduna, & Shai, 2010; Kacanek et al., 2013; abuse, FGMC, child marriage, or NPSV. This oversight is
Stephenson et al., 2013). Interpreting limited longitudinal a missed opportunity to understand women’s lived experi-
results alongside cross-sectional findings was difficult because ences, which may include the sequential or co-occurrence of
mixed results were typical for these three outcomes. various forms of GBV by age 24 years. The impact of sequen-
Such cross-sectional research is particularly problematic in tial and/or concurrent GBV may differ than that of single
the context of GBV and SRH because male-perpetrated vio- GBV exposures (Alexander, Amerigo, & Harrelson, 2018).
lence may be used to discipline girls and women for insubor- The timing of exposure also may matter; for instance, the
dination or violation of gender roles (Anderson, 2005; Hynes SRH effects of IPV before versus during pregnancy may differ
et al., 2016; Wingood & DiClemente, 2000). Some male part- (Islam, Broidy, Mazerolle, Baird, & Mazumder, 2018). To
ners could consider STIs/HIV, gynecological conditions, and create interventions, a better understanding of polyvictimiza-
sexual dysfunction to be evidence of a woman’s violation of tion against girls and women in LMICs will be essential
chaste, maternal gender roles. In this review, although we (Grose et al., 2019; Le, Holton, Romero, & Fisher, 2018;
excluded studies that explicitly assessed SRH exposures, it Yount et al., 2017).
was not always possible to unravel whether GBV caused
women to pursue contraception use, extra-marital sex,
a higher number of sexual partners, transactional sex, or Scope of SRH Outcomes
abortion, or whether those behaviors put women at risk of
experiencing violent retaliation. Resource instability also may This systematic review of reviews makes a significant contri-
heighten the reproductive imperative in some LMICs, creating bution in that we defined SRH broadly to include emotional,
a social milieu intolerant of certain SRH behaviors or statuses mental, and social aspects and identify neglected SRH out-
(Stellar, Garcia-Moreno, Temmerman, & van der Poel, 2016). comes in this corpus of research. Contraception, STIs/HIV,
Our search strategy excluded studies examining SRH expo- sexual risk behaviors, and pregnancy-related outcomes have
sures relative to GBV outcomes; other relationships are pos- been studied to a much greater extent in research on GBV in
sible and should be considered when interpreting the results. LMICs. This emphasis was not surprising given the severity of
the HIV/AIDS pandemic in many LMIC contexts (Joint
United Nations Programme on HIV/AIDS (UNAIDS), 2010)
and social expectations of virginity and pressure to bear
Scope of GBV Exposures
children once married (Andro & Lesclingand, 2016; Santhya
Based on this body of evidence, several forms of GBV may & Jejeebhoy, 2010). In contrast, research was scarce on the
have important consequences for the SRH of girls and women relationship between GBV and sexual function, gynecological
in LMICs. IPV and NPSV were studied most often, with IPV conditions other than STIs, and sexual empowerment.
showing the most consistent adverse relationships with SRH Although organizations like UNFPA and WHO define SRH
measures. In contrast, little research linked childhood GBV broadly, the shortage of sexual empowerment outcomes
experiences with SRH outcomes. Emotional child abuse, reveals unequal attention to emotional, mental, and social
neglect, any child abuse, and child marriage were addressed aspects of SRH. Given these gaps and the predominantly
only in one study each, while physical child abuse and witnes- cross-sectional nature of the research reviewed here, it may
be too early to make extensive inferences about these Results and their implications should be interpreted in this
outcomes. context.
One explanation for this gap is that sexuality research We were also unable to examine all forms of GBV, such as
globally tends to focus on negative aspects of sex and sexuality forced prostitution or trafficking, and their possible relation-
(Higgins & Hirsch, 2007); the research synthesized here was ships with SRH. Further, this review examined direct relation-
no exception. The attention to harmful biological outcomes ships between GBV and SRH, although indirect relationships
such as STIs/HIV, other gynecological conditions, and preg- are possible (Yount & Abraham, 2007). For instance, GBV
nancy complications highlights this concentration. This pat- may be related to HIV/STIs indirectly through mental disor-
tern was most noticeable for adolescent-only studies. For ders, with symptom-expression of high-risk sexual behaviors.
example, the adolescent-only samples assessed general sexual The evidence gaps we observed may reflect a nascent under-
function or pain during sex, neglecting positive aspects of standing of indirect relationships and SRH across the lifespan.
sexual functioning like pleasure and orgasm (see Online It also is possible that researchers did not assess some direct
Supplement 3). Further, authors defined sexual behaviors GBV-SRH relationships because the researchers viewed these
(e.g., masturbation, pornography use) as overtly “risky” and relationships as implausible (e.g., child abuse and sexual
sometimes risky-by-omission by neglecting discussion of posi- empowerment) or prioritized other physical or mental-
tive sexual health outcomes. Many of these behaviors are not health outcomes.
fundamentally unhealthy. For instance, having a greater num- Another limitation is that this research focused exclusively
ber of sexual partners may not be harmful or risky if a woman on girls and women, and GBV as a risk factor for SRH out-
is free from coercion, practices safer sex, and is otherwise comes in adolescent boys and young men were not addressed.
content with her partners. As such, more research is needed Their experiences may include overlapping and distinct forms
on positive SRH outcomes – such as sexual communication, of GBV, and a different set of SRH outcomes may be indi-
sexual knowledge, relationship power, and sexual pleasure – cated. Although most forms of GBV against adolescent girls
especially among adolescent girls and young women in and young women are perpetrated by boys and men, the
LMICs. pursuit of gender equity across all markers (UNDP, 2016)
Future research should examine the possible reciprocal necessitates the study of GBV’s association with the sexual
relationships between experiences of GBV and sexual empow- well-being of boys and men. A separate systematic review of
erment in LMICs. The UN and other international agencies reviews is warranted for this population. The current analysis
have discussed the importance of empowerment to achieve also assumes sex-gender congruence among the participants.
gender equity and to ensure equal participation in society free Yet, transgender, non-binary, and gender non-conforming
from violence (UNFPA, 2014b). Our review revealed that SRH people are at increased risk for violence, harassment, and
research has not yet incorporated the global empowerment discrimination (Institute of Medicine, 2011). Understanding
discourse. This gap is worrisome because, empirically, GBV the SRH sequelae of GBV in these populations within LMICs
may reduce one’s decision-making power and control within will be necessary for achieving gender equity.
relationships (Grose & Grabe, 2014; Santhya et al., 2010).
Indeed, one study reviewed here indicated that IPV was
associated with reduced power in sexual relationships for Recommendations and Conclusions
a sample of adolescents (Jewkes, Dunkle, Nduna, & Shai,
2010). It also is possible that low sexual empowerment may We have highlighted an ongoing need for research on GBV
increase the risk of IPV, although we did not assess those and SRH in LMICs. More research is needed to verify whether
relationships in the current review. A systematic review on GBV has similar SRH ramifications for adolescent girls, young
GBV and sexual empowerment would aid our understanding women, and adult women, and whether consequences vary
of the reciprocal relationships between GBV and empowered based on timing, severity, and frequency. Future systematic
participation in healthy sexual relationships. reviews on these topics should feature adolescent-specific
inquiries. Research should address the unique experiences of
adolescent girls and young women to develop age/develop-
mentally/culturally appropriate, evidence-based interventions
Review Limitations
(Yount et al., 2017). Longitudinal research is needed to fill this
Our study was limited by the inclusion of only English- gap because, although GBV may impact SRH, a reciprocal
language reviews and studies published between January 1, causal relationship also may exist. Indeed, other factors like
2000 and November 6, 2016. Although we identified reviews limited access to resources and gender inequity may influence
from three electronic databases, complementary expert con- both GBV and SRH. Understanding the temporal relationship
sultation, and gray literature searches, we may have missed between GBV and SRH could facilitate the development of
reviews. We extracted studies from the highest quality reviews policies and interventions that reflect girls’ and women’s lived
using AMSTAR criteria (Shea et al., 2007), thus, we did not experiences.
include studies contained in low-quality reviews. There also The synthesis presented here suggests that efforts to
was an imbalance of study source. WHO and DHS data were improve SRH for women and girls in LMICs may benefit
overrepresented, with two-fifths of the samples derived from from a focus on their early risks of exposure to multiple and
the WHO multi-country study (18%) and the DHS (24%). diverse forms of GBV. Advocates and practitioners must
consider and address the structural, community, and relation- Anand, E., Unisa, S., & Singh, J. (2017). Intimate partner violence and
ship contexts that influence SRH (Sommer & Mmari, 2015). unintended pregnancy among adolescent and young adult married
women in South Asia. Journal of Biosocial Science, 49, 206–221.
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changing social norms are vital and must be coupled with Anderson, K. L. (2005). Theorizing gender in intimate partner violence
enhanced individual-level resource investments, community research. Sex Roles, 52, 853–865. doi:10.1007/s11199-005-4204-x
engagement, and community infrastructure improvements Andersson, N., Cockcroft, A., & Shea, B. (2008). Gender-based violence and
(Yount et al., 2017). Evidence-based sexual education also is HIV: Relevance for HIV prevention in hyperendemic countries of southern
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& Hindin, 2016). Moreover, increased access to STI screen- +Antai, D., & Adaji, S. (2012). Community-level influences on women’s
ings, contraception, age/developmentally/culturally appropri- experience of intimate partner violence and terminated pregnancy in
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opportunities are needed in LMICs (Bearinger et al., 2007).
+Barros, C., Schraiber, L. B., & Franca-Junior, I. (2011). Association between
Policy and structural changes must be prioritized to combat intimate partner violence against women and HIV infection. Revista De
GBV and move closer to the goal of ensuring universal access Saúde Pública, 45, 365–372. doi:10.1590/S0034-89102011005000008
to SRH and rights for all. Battle, J., Hennink, M., & Yount, K. (2017). Influence of female genital cutting
on sexual experiences in southern Ethiopia. International Journal of Sexual
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Acknowledgments perspectives on the sexual and reproductive health of adolescents:
The team thanks the experts who responded to our email inquiries, the Patterns, prevention, and potential. The Lancet, 369, 1220–1231.
intellectual contributions of Kathleen Krause, Ximena Leroux, Stephanie doi:10.1016/S0140-6736(07)60367-5
Miedema, and Daniel Semenza, and the research assistance of Amanda *Berg, R. C., & Denison, E. (2012). Does female genital mutilation/
Chahine and Brittany McDermott. cutting (FGM/C) affect women’s sexual functioning? A systematic
review of the sexual consequences of FGM/C. Sexuality Research
and Social Policy, 9, 41–56. doi:10.1007/s13178-011-0048-z
*Berg, R. C., & Underland, V. (2013). The obstetric consequences of
Declaration of Interests female genital mutilation/cutting: A systematic review and
meta-analysis. Obstetrics and Gynecology International, 2013, 1–15.
The authors have no conflicts of interest to disclose.
doi:10.1155/2013/496564
*Berg, R. C., Underland, V., Odgaard-Jensen, J., Fretheim, A., &
Vist, G. E. (2014). Effects of female genital cutting on physical health
Funding outcomes: A systematic review and meta-analysis. BMJ Open, 4,
e006316. doi:10.1136/bmjopen-2014-006316
This work was supported with internal funding from Emory University Biglu, M. H., Farnam, A., Abotalebi, P., Biglu, S., & Ghavami, M. (2016).
and Morehouse School of Medicine. Funding was received from the Effect of female genital mutilation/cutting on sexual functions. Sexual
Centers for Disease Control and Prevention National Center on HIV/ & Reproductive Healthcare, 10, 3–8. doi:10.1016/j.srhc.2016.07.002
AIDS, Viral Hepatitis, STD, and TB Prevention and Health Resources
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at Morehouse School of Medicine.
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Grose, Et. Al. (2020) - Sexual and Reproductive Health Outcomes

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Grose, Et. Al. (2020) - Sexual and Reproductive Health Outcomes

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The Journal of Sex Research

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/hjsr20

Sexual and Reproductive Health Outcomes of

To link to this article: https://doi.org/10.1080/00224499.2019.1707466

© 2020 The Author(s). Published with View supplementary material

Published online: 04 Jan 2020. Submit your article to this journal

Article views: 10719 View related articles

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(1) Records identified through

(3) Records with title/abstract

(5) Full-text records assessed for (6) Full-text records excluded,

(8) Eligible reviews identified from

(9) Eligible reviews identified by

(10) Removed low quality reviews

Figure 1. Study selection flow diagram.

Table 1. Systematic review of summary characteristics.1

% null analyses 100 100 0 67

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