a. Review of the evidence on violence and WASH
The existing evidence in the peer reviewed and grey literature highlights a range of situations in which vulnerability to violence is increased in accessing water and sanitation. Multiple reports emerged subsequent to the Haitian earthquake emergency response, with one study reviewing the risks of sexual violence in the internally displaced person (IDP) camps in urban Port-au-Prince. Findings suggested open-air sanitary facilities, insufficient bathing areas, and lack of lighting at night intensified the risks of sexual violence for those using the facilities. This report recommended that women-only latrine and bathing areas should be considered in IDP camps, with additional security put into place to assure that the usage is limited to women, and funding allocated to support security.(9)
Another study explored the risks of violence to girls and women specifically, discussing how latrines were frequently not built where recommended by camp residents due to practical and engineering concerns. Latrines were also poorly maintained and rarely used, with 33 per cent of women reporting never feeling safe when utilizing them. A further 6 per cent reported feeling safe only during daylight hours.(10)
A UNICEF study of girls’ and women’s WASH-related needs in IDP or refugee camps in Haiti, Somalia and the Philippines similarly identified communal latrines, along with bathing in the bush, as dangerous at nighttime for meeting girls’ and women’s water- and sanitation-related needs.(11)
There has also been documentation by the United Nations High Commissioner for Refugees (UNHCR) of increased vulnerability to violence in the context of accessing WASH services in refugee camps.(12)
A series of case studies describes, for example, both boys and girls being frightened of rape in school toilets in South Africa; girls in particular experiencing rape when using the toilets or fetching water in Zambia; and women fighting with girls when queuing for water in Malawian refugee camps. These reports demonstrate the varied nature of the violence that exists in relation to WASH, ranging from sexual violence to violence over access to water or competition for resources. Similar scenarios are described in Botswana and Mozambique, with additional stories describing experiences of rape in toilets in Mozambique. Although this series of case studies has its methodological limitations (e.g. less rigorous research methods), such documentation still forms an important part of the existing evidence base. Another report from UNCHR and Save the Children(13)
documented experiences of refugee children in camps in Guinea, Liberia and Sierra Leone, with children reporting experiences of rape mostly when using the toilets or taking a bath, and describing men lying in wait for them to enter toilets. Similar stories are described from rural villages in the Democratic Republic of the Congo, where a non-governmental organization focused on improving sanitation after reports of women and children being at increased risk of sexual violence when walking outside of the village at night in order to defecate.(14)
In refugee camps in Dadaab, Kenya (which is equivalent in population size to one of the largest cities in Kenya), researchers found that women were particularly vulnerable to sexual violence around latrine use. The latrines in the camps were not separated by gender, were poorly lit, and had no locking mechanisms.(15)
Although these are primarily examples from refugee or IDP camps and not “urban” contexts per se, there are similarities in terms of the often closely packed living conditions in camps and urban settlements that also lack adequate water and sanitation systems.
Violence in relation to WASH is similarly documented in the development literature. In rural Ethiopia, findings from an ethnographic study that explored local experiences of water insecurity documented multiple situations of violence that emerged in relation to water. A range of experiences was revealed, including women experiencing tension with husbands over the amount of water they brought home; women experiencing domestic violence over water; women experiencing the risk of rape while fetching water daily from distant water sources; and experiences of violence while standing in water queues.(16)
Sorenson et al. also explored safe access to water in low-income countries,(17)
although their analysis focused more on the burden of water access for women. Their conclusions pointed to the need for better documentation of the assault and attack risks to women when they collect water. In the semi-urban town of Buea, Cameroon, girls described fears around having to fetch water at night, reporting how the lack of water forces them to travel farther away and later into the evening hours to meet their families’ daily water requirements. This in turn places them at increased risk of sexual harassment, abuse and rape. In addition, the girls described how vulnerability to violence while accessing water creates feelings of fear, anxiety and stress.(18)
Similar findings were reported from rural Uganda and urban Afghanistan, where children reported experiencing verbal attacks and physical fights at water collection points.(19)
Another study from Kabul, Afghanistan documented the dangers boys and girls, primarily of pre-pubescent age, face in fetching water for their families. Children were asked to map the most dangerous places they faced, and out of 37 places identified, five related to water points and one to toilets.(20)
In Afghanistan, it can be more common for boys to be asked to collect water than girls, as the movement of girls tends to be more restricted.
More recent research was conducted with women in the urban slums of Kampala, Uganda and New Delhi, India, with the aim of understanding how lack of adequate sanitation impacted on their lives. In three slum communities of Kampala (Jambula, Kiganda and Kifumbira), qualitative methods were utilized to elicit women’s experiences, and identified flawed sanitation facilities, fear of attack when using the facilities at night, and feelings of shame and helplessness over the daily struggle to practise sanitation in an environment that lacked clean, private and safe facilities.(21)
In three slums in the northeast district of Delhi (Bhalswa, New Seemapuri and Sunder Nagri), a participatory mapping exercise was conducted with women in order to identify the dangerous spaces where they felt at risk of sexual violence. Women shared feelings of fear, heightened at night, that they would experience sexual violence when using public toilets, and when defecating in the open and in other public spaces. They also expressed feelings of anger and disgust, as did the Ugandan women, at the daily struggle to manage sanitation-related needs with dignity and safety.(22)
The routes to the toilets in Uganda, India and other countries have been described as dangerous in various studies, and not just the facilities themselves.(23)
Although studies and reports have cited dangers related to walking to toilets in both rural and urban localities, pathways in urban slum areas in particular have been described as increasing girls’ and women’s vulnerability to experiencing sexual violence.
A range of articles and reports highlights the particularly gendered nature of vulnerability to violence. A 2012 editorial in Geoforum(24)
focused in particular on the ways in which urban sanitation and water inequality are gendered, with men being able to relieve themselves in relatively public spaces, but women being much more restricted due to sociocultural taboos. Girls and women are also constricted by their need to squat (a challenge especially for girls and women with disabilities), the heightened social attributions of shame related to women being seen to defecate or urinate, and their actual vulnerability to sexual violence in such situations. In addition, women’s added need for privacy during menstruation adds to the complexity of their burden. Although the Geoforum
editorial itself does not highlight explicit experiences of violence, the gendered nature of sanitation creates a vulnerability that is further delineated by an editorial in The Lancet Infectious Diseases(25)
that emphasizes the continuing challenge of failing to meet the global demand for clean water and sanitation. This editorial highlights the dangers that women and girls face when waiting to defecate under cover of darkness in numerous low- and middle-income contexts around the world. This was exemplified by a study of 10,000 Dalit households across five states in India that revealed how Dalit women (perceived as lower caste in India and hence frequently excluded from facilities being used by other castes) in particular face significant challenges by not having toilets in their household premises. These included sexual harassment when using communal latrines or defecating in open areas, painful situations during illness (particularly for stomach-related diseases), risks of accidents when defecating on roads or railway tracks, risks of snake and insect bites, and difficulties and pain during their menstrual cycle.(26)
Urban sanitation presents particular challenges for girls and women, as was documented in slum settlements of Mumbai and Pune in India.(27)
Women describe having no place to defecate but the side of the road, with men hiding in nearby bushes so they can watch as women squat. When women are alone, they are more likely to be molested by men in such scenarios. There are no toilets available for women, so they would not venture out to defecate after 6 am and before darkness falls due to the shame of being seen defecating. As with the Dalit study, some participants describe a nearby train track as the commonly used site for defecation, with great risk to girls and women using the tracks under cover of darkness. In Kenya, Amnesty International identified the inadequate availability of sanitation in Nairobi slums as having an adverse effect on women’s security, with violence against women occurring when they use latrines.(28)
Research from the outskirts of Phnom Penh, Cambodia documented the specific WASH-related challenges faced by women who work in garment factories in urban contexts. Women said the distance between their rental rooms and the available toilets was too far and too poorly lit to use the facilities at night, given the risk of sexual violence. Pregnant women were reported as struggling the most with the distance to the WASH facilities.(29)
Another gendered aspect of the connection between violence and latrines emerges from the literature on schoolgirls and educational environments. Researchers have applied different methodologies, such as safety audits and safety mapping, in an effort to better identify and map this vulnerability to violence. Mitchell describes the findings from the utilization of photo-voice (a technique that includes providing participants with cameras to document and then describe their own lived experiences) and other participatory visual methodology approaches with schoolgirls in townships in South Africa, just outside of Butare, Rwanda and in Mbabane, Swaziland, where girls were asked to identify safe and unsafe spaces in their school environments.(30)
Girls in all three contexts identified toilets as sites of anxiety and fear, and locations where boys and men might bully them, or harass and attack them sexually. One suggestion was that schools undertake “toilet audits”(31)
to better understand whether their sanitation facilities were potential sites of violence for girls. Brookes and Higson-Smith examined potential solutions in South Africa, finding that in schools where teachers monitored toilet blocks even from a distance, the instances of reported gendered violence decreased.(32)
Another study explored the intersections of sanitation, sexual coercion and girls’ safety in schools in South Africa. Researchers calculated that, based on the school population, around 80–100 girls would be menstruating on any school day – thus representing a large need for adequate toilet facilities. However, girls also reported that toilets were unsafe during class time because of boys and gangs that hid out in them and hence attention was needed to reduce these opportunities for harassment.(33)
c. Gaps in the violence and WASH evidence base
Although the existing peer reviewed and grey literature on the topic of violence and WASH provides very useful insights into the challenges facing girls, boys, women and men in various contexts, a number of important gaps remain in the current evidence. The priority areas for research include, first, an improved understanding of the scope of the violence and WASH vulnerabilities and challenges facing girls, boys, women and men in a range of contexts (i.e. urban slums, refugee camps, rural communities). This includes an exploration of the range of violence and WASH-related scenarios, such as the risk of fetching water from great distances, of accessing sanitation for girls and women living in peri-urban slums, and the disputes that arise at water collection points. There is also a particular need to examine the added vulnerability to violence anecdotally reported by marginalized groups, such as those from lower castes and/or people who have a disability.
Secondly, the identification of effective interventions aimed at reducing vulnerability to violence for various populations when they are accessing WASH (i.e. water collection, sanitation facilities) is a priority. While not documented here, there were numerous recommended improved practices for reducing vulnerabilities to violence in relation to WASH. These are greatly expanded upon in the toolkit, but include, for example, engaging girls and women in sanitation facility design in schools and other locations (e.g. refugee camps) in order to assure they feel safe using the end product; assuring that gender specific latrines and bathing facilities are located at a distance from each other as agreed with the users, to increase the safety of their usage; adding strong doors and locks; improving the lighting in latrines; and where possible building family latrines or latrines shared among a few families to reduce the vulnerability to violence in using communal latrines, while also assuring that even family latrines are safe. More complex situations in need of improved interventions include the physical or verbal fighting that occurs at water collection points, particularly for children fetching water for their families, or domestic violence women face if they do not adequately meet the household water needs expected by their husbands. Although only the latter is a gendered experience, the vulnerability of various subgroups within a given population, due to the cultural expectations around chores, is important to highlight and address. The evidence on solutions remains insufficient, both for the documentation of different approaches and for the monitoring and evaluation of their effectiveness. Much learning and innovation remain to be done to meet these needs. Increased documentation must, however, be undertaken carefully given the unique challenges of conducting research on a topic that has dual sensitivities (that of violence and that of sanitation practices) as discussed below.
d. Challenges in conducting research on violence and WASH
A number of methodological challenges arise when research is undertaken on the sensitive topics of vulnerability to and experiences of violence, and also sanitation practices and behaviours. Parkes et al. highlighted the ethical and methodological challenges of researching GBV through insights that were gained from studies conducted in schools and communities in Kenya, Ghana and Mozambique.(35)
Although there is a body of literature on the ethics of conducting research on violence and on GBV in particular, some useful insights on conducting violence and WASH-related research with girls and boys emerged from Mitchell’s use of participatory visual methodologies(36)
and from other participatory methodologies described by Leach on utilizing mapping and other techniques for identifying toilets as sites of violence.(37)
Joshi suggests that, as a result of the sensitivities around these topics, there is likely significant under-reporting of sexual violence as linked to sanitation and that women, needing privacy both for regular sanitation and for monthly menstrual management, are both uniquely vulnerable and less likely to report their experiences of sexual violence.(38)
The nature of such sensitivities should be carefully considered when designing future research on this topic.
The vast majority of the documentation identified in this review and learning process did not use extensive quantitative surveys or randomized controlled trials. The reasons for this may be the methodological and ethical challenges of conducting research on this sensitive topic, one that can bring shame and stigma to the individual who experiences violence (particularly sexual violence) or that could lead to further violence towards that individual if not undertaken appropriately. Not only would reporting of violence and/or sanitation behaviours pose potential challenges, but ethical issues around assuring that all individuals have safe and adequate sanitation facilities also hinder the use of randomized trials for testing of interventions. Because of these challenges, qualitative research is likely to remain a more appropriate methodology in many circumstances. That being said, the global health community (including but not limited to WASH) is in great need of a larger body of empirical evidence (both qualitative and quantitative where possible) documenting the ways in which accessing water and sanitation may increase individuals’ vulnerabilities to violence, in order to determine more effective programming and policy.