Sexual violence is common and a serious public health concern worldwide (Abrahams et al., 2014; Barth et al., 2013; Borumandnia et al., 2020; Moody et al., 2018). An estimated 120 million females under 20 years of age (10 %) around the world have experienced some form of sexual violence in their lifetime (United Nations Children’s Fund, 2014). Males also experience sexual violence (Chynoweth et al., 2020; Sumner et al., 2016), although it is less commonly reported. In Lesotho, one in seven women and one in twenty men aged 18 years and older experienced sexual violence at least once in their childhood (Ministry of Social Development of Lesotho et al., 2020). In addition, 7.3 % of girls aged 13–17 years experienced sexual violence in the past year (Ministry of Social Development of Lesotho et al., 2020).

Sexual violence victimization may lead to long-term mental and physical health issues among victims, regardless of gender (Abajobir et al., 2017; Choudhary et al., 2012). For example, sexual violence is associated with mental distress, self-harm behaviors, suicidal ideation, and substance misuse throughout the victim’s life course (Choudhary et al., 2012; Khadr et al., 2018; Mgoqi-Mbalo et al., 2017; Nguyen, Padilla, Villaveces, Patel, Atuchukwu, Onotu, Apondi, Aluzimbi, Chipimo, Kancheya, and Kress, 2019b; Villalba et al., 2020). Experiencing sexual violence during childhood among males is also associated with intimate partner violence perpetration later in life (Cubellis et al., 2016; Teitelman et al., 2017; VanderEnde et al., 2016). Sexual violence is also associated with an increased risk for HIV and other sexually transmitted infections (STIs) (Hassen & Deyassa, 2013; Richter et al., 2014; Seña et al., 2015 For example, compared with nonvictims, children who are victims of sexual violence are more likely to engage in behaviors (e.g., alcohol misuse, drug use, and unprotected sex) that increase risk for HIV and STIs (Abajobir et al., 2017; Chiang et al., 2015; Chiang et al., 2021; Rogstad et al., 2016; VanderEnde et al., 2018). Forced sex with an infected person can also increase the likelihood of HIV acquisition in females due to vaginal tears and lacerations (Abbai et al., 2016; Hassen & Deyassa, 2013) and in males through forced anal sex (Hernandez et al., 2017).

With the high burden of HIV in Lesotho, a country with the second-highest HIV prevalence globally in 2019 (23.1 %) and an estimated 29,000 people aged 15–24 years living with HIV (The World Factbook, 2021; UNAIDS, 2021), it is crucial to understand the factors associated with sexual violence, which can directly and indirectly contribute to the HIV epidemic in the country. Current research on the associations between sexual violence victimization and health outcomes among children and youth in Lesotho is limited; most of the literature on the physical and mental health impacts of sexual violence reflects research conducted in Western high-income countries. The Lesotho VACS provides the first nationally representative data on sexual violence victimization and its association with HIV among children and youth in Lesotho, establishing a unique opportunity to examine the associations among sexual violence and health outcomes within this context. In this analysis, we aim to: (1) estimate the prevalence of lifetime sexual violence victimization among females and males aged 13–24 years in Lesotho, and (2) assess its association with selected health conditions (suicidal thoughts, self-harm behaviors, mental distress, STIs, and HIV) and risk behaviors (binge drinking in the past 30 days, drug use in the past 30 days, infrequent condom use in the past 12 months, multiple sex partners in the past 12 months, and transactional sex in the past 12 months). We hypothesize that lifetime sexual violence victimization is associated with selected health conditions and risk behaviors in males and females.

In this analysis, we estimated the association between SV and selected health conditions (suicidal thoughts, self-harm behaviors, mental distress, STIs, and HIV) and risk behaviors (binge drinking in the past 30 days, drug use in the past 30 days, infrequent condom use in the past 12 months, multiple sex partners in the past 12 months, and transactional sex in the past 12 months) among females and males aged 13–24 years in Lesotho. SV was more commonly reported among females than males. Among females, SV was significantly associated with almost all the health conditions and risk behaviors examined, except for HIV and drug use in the past 30 days. In males, SV was significantly associated with self-harm behaviors, suicidal thoughts, ever having an STI, binge drinking in the past 30 days, infrequent condom use in the past 12 months, and multiple sex partners in the past 12 months.

Our findings that SV was more commonly reported by females than males is consistent with previous reports from other African countries (i.e., Malawi, South Africa, Kenya, and Tanzania), Cambodia, and Haiti (Mwangi et al., 2015; Stark et al., 2019; Vagi et al., 2016; VanderEnde et al., 2018; Ward et al., 2018). SV is considered one of the most prevalent traumas worldwide, with girls and women being disproportionately affected. Until relatively recently, there has been a dearth of research on the epidemiology of sexual violence among boys and men (Forde & Duvvury, 2017). Further, there is growing evidence that experiences of SV as well as disclosure and help-seeking behavior is highly gendered (Easton et al., 2014; Lomans et al., 2022; Pereira et al., 2020). As such, inclusion of males in our analysis represents an important contribution to the field. The higher prevalence of SV in young females may be due to factors like social and gender norms that prescribe male dominance and right to control females. For example, some have proposed that SV against females is a demonstration of patriarchal dominance over females by males based on gender and power inequality (Lawson, 2012). Norms related to gender and masculinity contribute to patriarchal social contexts in some African countries (Adegoke & David, 2007; Amoakohene, 2004; Ilika, 2005; Jewkes et al., 2005). The present study found similarities in patterns of associations between SV and health outcomes for males and females, with few differences in adjusted analyses: the associations between SV and mental distress and transactional sex were not significant for males, but significant for females. For all other outcomes examined, similar patterns emerged for females and males. This underscores the substantial and enduring impacts of SV and suggests that these impacts do not vary by sex, on the whole.

Gender transformative programming to shift gender norms should be a component of violence prevention initiatives (Abramsky et al., 2014; Kerr-Wilson et al., 2020; Levtov et al., 2014; Pulerwitz et al., 2019).

Females who experienced SV had significantly greater odds of experiencing serious or moderate mental distress, suicidal thoughts, and self-harm behaviors than those who did not experience SV. We also found statistically significant associations between SV and these health conditions, except for serious or moderate mental distress, in males. Consistent with these findings, in a study among adolescents in Brazil, Schäfer et al. (2017) found that females who experienced SV were three times more likely to have suicidal thoughts than those who did not experience SV. In Nigeria, Omigbodun et al. (2008) reported that SV was a significant predictor of suicidal thoughts among females attending secondary school. SV was found to be significantly associated with self-harm behaviors in adolescents and youth in Nigeria, Zambia, and Uganda (Nguyen, Padilla, Villaveces, Patel, Atuchukwu, Onotu, Apondi, Aluzimbi, Chipimo, Kancheya, and Kress, 2019b). Experiences of SV can negatively impact an individual’s mental health throughout their life course (Choudhary et al., 2012). For example, serious mental distress has been associated with risky behaviors, including drug use (Substance Abuse and Mental Health Services Administration, 2013), lower income (Davison et al., 2020; Leary et al., 2021), unemployment, poor physical health, and chronic illness (Davison et al., 2020). Though SV was associated with increased odds for mental distress in females, this association was not statistically significant for males. Additional research on mental health consequences of SV among males in Lesotho is needed to refine measurement among this population and understand impacts of SV and implications for prevention.

Participants who experienced SV had twice the odds of binge drinking in the past 30 days than those who did not experience SV, consistent with research on SV and alcohol misuse among adolescents (Kirk-Provencher et al., 2020) and between childhood sexual violence and hazardous drinking among adults (Bello et al., 2017; Lown et al., 2011; Tonmyr & Shields, 2017). This association may be explained in part by the self-medication theory, which states that individuals use substances (e.g., alcohol or drugs) to relieve painful feelings or memories (Khantzian, 1997).

Participants who experienced SV had significantly higher odds of reporting infrequent condom use in the past 12 months than those who did not experience SV. Females who experienced SV had 1.4 times the odds of engaging in infrequent condom use in the past 12 months, while males who experienced SV had almost three times the odds of engaging in infrequent condom use in the past 12 months when compared with those who did not experience SV. This association suggests that primary prevention of SV may be an opportunity to prevent the occurrence of STI/HIV risk behaviors, as a pathway to interrupting spread of STIs and HIV in Lesotho. Similarly, SV was significantly associated with infrequent condom use in a cohort study of HIV-infected individuals in the United States (Chuang et al., 2006). SV increases risk for HIV both directly through forced genital or anal intercourse, as well as indirectly through high-risk sexual behaviors (e.g., no or infrequent condom use; (Chuang et al., 2006).

Participants who experienced SV had significantly greater odds of reporting multiple sex partners in the past 12 months than those who did not experience SV. This aligns with results from prior studies. For example, in Tanzania, females who experienced childhood sexual violence were over two times more likely to report multiple sex partners in the past 12 months than nonvictims of childhood sexual violence (Chiang et al., 2015). In Quebec, Thibodeau et al. (2017) found a direct association between SV and having multiple sex partners among 13–17-year-old adolescents. This association could be mediated by traumatic sexualization, in which an individual’s sexuality (e.g., sexual feelings and attitudes) is developed inappropriately during experiences of sexual violence, resulting in them learning to use sexual behavior to receive rewards or affection (Finkelhor & Browne, 1985; Thibodeau et al., 2017). Thus, adolescents who experience SV may have multiple sex partners in an effort to receive affection and rewards (Thibodeau et al., 2017). This was observed in a study where women who experienced childhood sexual violence reported more traumatic sexualization and higher number of sex partners than those who did not experience childhood sexual violence (Senn et al., 2011).

Females who experienced SV had significantly greater odds of engaging in transactional sex in the past 12 months than those who did not experience SV. Similar findings were reported from the Uganda VACS, where young girls who experienced SV were more likely to engage in transactional sex in the past 12 months than those who did not experience SV (Stamatakis et al., 2021). Among South African adults, experiencing childhood sexual violence was associated with transactional sex in adulthood (Gibbs et al., 2018). Transactional sex is motivated by various factors, such as poverty and the desire for material acquisition (Leclerc-Madlala, 2008; McCloskey et al., 2021; Stoebenau et al., 2011), and is widely accepted by both parents and youth in some countries (Deane & Wamoyi, 2015; Kamndaya et al., 2016; Wamoyi et al., 2011). Transactional sex increases the risk for HIV in young women (Kilburn et al., 2018; Wamoyi et al., 2016) because they may have more sexual partners (Choudhry et al., 2015), use condoms less frequently (Luke, 2006), and report more alcohol misuse (Bello et al., 2017).

Our finding that females who experienced SV had greater odds of engaging in transactional sex in the past 12 months aligns with our finding that females who experienced SV had greater odds of reporting multiple sex partners in the past 12 months. Similarly, results from an analysis of Uganda VACS data indicated that childhood transactional sex was significantly associated with having multiple sex partners in the past 12 months among 18–24-year-old females (Chiang et al., 2021). In a different study, transactional sex was significantly associated with having multiple concurrent sex partners among 15–24-year-old Ugandan females (Choudhry et al., 2015). Food deprivation has been associated with both transactional sex and having multiple sex partners among out-of-school girls in Nigeria (Kunnuji, 2014). Over one-third of females in our sample who experienced SV also experienced food insecurity, which may have contributed to the association observed between SV and transactional sex in the past 12 months.

Females who experienced SV had significantly greater odds of ever having an STI than those who did not experience SV. This aligns with other studies where adolescent and young females who experienced SV were two times more likely to have an STI than those who did not experience SV in Tanzania (Vagi et al., 2016), Kenya, and Zambia (Mathur et al., 2018). This increased risk for STIs among female victims of SV reflects risk through both direct and indirect transmission among female victims of SV (Burgueño et al., 2017; Davis et al., 2018; Silverman et al., 2011). Males who experienced SV were almost six times more likely to ever have had an STI when compared with those who did not experience SV. These findings align with results from previously published studies. For example, Vagi et al. (2016) found that 13–24-year-old males in Tanzania who experienced SV were over two times more likely to have an STI as compared with those who did not experience SV. If used properly, condoms can prevent STIs and HIV (Beksinska et al., 2020). However, individuals may not use condoms consistently during sex because of poor access, gender norms, religious norms, and stigma (Beksinska et al., 2020).

The higher odds of having an STI among participants who experienced SV in our analysis were consistent with our findings that those who experienced SV were more likely to report infrequent condom use in the past 12 months, multiple sex partners in the past 12 months, transactional sex in the past 12 months (for females only), and binge drinking in the past 30 days than those who did not experience SV. Each of these factors, as well as SV, is associated with an increased risk for HIV (Andersson et al., 2012; Bello et al., 2017; Burgueño et al., 2017; Chiang et al., 2015; Choudhry et al., 2015; Hassen & Deyassa, 2013; Kilburn et al., 2018; McCloskey et al., 2021). In our study, we did not find a statistically significant association between SV and HIV for males, and found a marginally significant association for females. While SV and HIV were not significantly associated, several HIV risk factors were, including infrequent condom use, multiple sex partners, and binge drinking. Due to the age criteria of the study (13–24 years), it is possible that exposure to SV leads to increased risk for HIV, which then can lead to HIV acquisition later in adulthood. The most current HIV incidence data indicates that the 25–35-year age group has the highest incidence compared to any other age group (0.55 for males and 1.55 for females; Lesotho Ministry of Health (MOH), 2022).

As Lesotho aims to sustain HIV epidemic control and prevent new infections, HIV programs should consider expanding sexual violence prevention programming. SV prevention programming, such as that delivered through the United States President’s Emergency Plan for AIDS Relief (PEPFAR) Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) program (Saul et al., 2018) and other HIV prevention programs can leverage data-driven efforts to target HIV risk-reducing interventions to prevent violence in the context of HIV epidemic control efforts. Reducing sexual violence against children and adolescents could result in healthier individuals and stronger communities.

The findings from our analysis were subject to some limitations. First, the Lesotho VACS did not include 13–24-year-olds who were institutionalized, could not speak the languages of the survey, or had certain disabilities. Therefore, results are not generalizable to these populations. Second, the data used in this analysis were self-reported, which are subject to self-report bias, especially recall and social desirability bias. This may have resulted in underreporting of important variables in this analysis. Finally, the Lesotho VACS was a cross-sectional survey, which did not allow us to establish causality in our analysis and we were not able to determine whether the SV occurred before or after engagement in sexual risk behaviors or the emergence of the selected health conditions. However, we were able to determine associations between SV and the sexual risk behaviors and selected health conditions.

Strengths of the study include a robust methodology with a nationally representative survey with high response rates (>90 %) (Ministry of Social Development of Lesotho et al., 2020). To the best of our knowledge, this is the first analysis of SV and related health conditions and risk behaviors conducted using nationally representative data on violence against children and young adults in Lesotho. Most importantly, to our knowledge, this is the first time this type of analysis has been conducted among adolescent and young males in Lesotho. Our results indicate that violence prevention and response efforts in Lesotho should include targeting and supporting boys and young men in addition to strengthening supports for girls and young women, including implementing community mobilization programs, teaching about positive masculinity and healthy gender norms, and conducting bystander support interventions (Ward et al., 2018). INSPIRE: Seven Strategies to End Violence Against Children (World Health Organization, 2016) provides a framework of evidence-based policies, interventions, and programs to prevent and respond to violence. The strategies in INSPIRE include implementation and enforcement of laws, norms and values change, safe environments, parenting and caregiver support, income and economic strengthening, response and support services, and education and life skills. The programs and interventions reflect the bestavailable evidence to prevent violence and avert its negative impacts, with particular emphasis on approaches with proven success in low-resource settings. Based on the results of the present study, evidence-based interventions like those represented in INSPIRE, implemented through multi-sectoral action, can create safe and supportive environments for youth to reduce risk of sexual violence in the schools and community settings where young people live as well as in their homes. In addition, sexual violence victims should be provided linkage to supportive and high quality services including mental health support and other post violence care services such as HIV testing, STI testing and treatment, post-exposure prophylaxis, emergency contraceptives, and any other necessary clinical care. HIV prevention programming can also be leveraged to incorporate violence prevention and reduce risky sexual behavior. Prevention programming through the President’s Emergency Plan for AIDS Relief (PEPFAR) focuses on conducting community mobilization campaigns to support healthy gender norms changes and building adolescent-parent relationships as a strategy to reduce adolescent girls’ risk of violence and risky sexual behavior (Saul et al., 2018). HIV prevention programs can further integrate violence prevention efforts to promote upstream prevention efforts, and incorporate programming for boys and young men, given the similar patterns between males and females of impacts of sexual violence in the present study. VACS data can help guide the development and adaptation of violence and HIV prevention and response programs to meet the unique needs of children and young adults in Lesotho.