1. Safety and Sexual Violence against
Women and Girls with Disabilities in
Kumasi and the Ashanti Region
Nicole Huyser, 1738186
August, 2013
Master Health Sciences; International Public Health (30 EC)
VU Supervisor: Dr. W.H. van Brakel
On Site Supervisor: Dr. (Sr.) Frances Emily Owusu-Ansah
Center for Disability and Rehabilitation Studies, Kwame Nkrumah University of Science and
Technology
Word count: 9056

2. 1. Abstract
Objective To identify the factors that influence the safety and sexual health of women and girls with
disabilities in Kumasi and the Ashanti region. Background Although there is a lack of data in Ghana,
the vulnerability of women and girls with disabilities and with the worldwide underreporting of
sexual violence against women combined with evidence of sexual violence against women and girls
with disabilities in Malawi, suggests it may be taking place in Ghana as well. That leads to the
question: which factors influence the safety and sexual health of women and girls with disabilities in
Kumasi and the Ashanti region? Methods Purposive sampling and snowball sampling was used to
draw participants from the study population. Qualitative methods using interviews with a semi-structured
interview guide of women and girls with disabilities or their primary care taker. Data
analysis was conducted using a coding guide derived from the multifactorial model of violence.
Results Twenty-one women and girls with disabilities or their primary care taker were interviewed.
Eight of the twenty-one women experienced sexual violence. Knowledge of the rights of people with
disabilities is varied and access to justice is difficult. Conclusion Important risk factors influencing
sexual violence are a lack of access to justice and a lack of knowledge of their rights. The bond with
family members is a protective factor. In addition, membership of a DPO, age and the type of
disability also influence sexual violence victimization. More efforts and research is needed to
develop a suitable prevention program to reduce sexual violence and increase the level of knowledge
of sexual health rights for women and girls with disabilities.
2. Background
About 15% of the world’s population has some form of disability and this number is increasing (WHO,
2012). Persons with disabilities often have poorer health outcomes, lower education achievements,
less economic participation and higher rates of poverty than people without disabilities, but those
are not their only problems (WHO, 2011). Over the years is has become apparent that there is a
strong link between disability and abuse (Petersilia, 2001). Numerous studies have shown that
persons with disabilities have a higher risk of sexual abuse than persons without a disability (Kvam &
Braathen, 2006) (Martin, et al., 2006) (Calderbank, 2000). In Bangladesh, half of all disabled children
had been sexually abused and in a Canadian study, 30.5 percent of disabled women had experienced
sexual violence (Yoshida, DuMont, Odette, & Lysy, 2011) (The News Today, 2010). There is also
evidence of sexual violence against women and girls with disabilities in Malawi (Kvam & Braathen,
2008). Factors that contribute to the higher chance on sexual abuse include a lack of accessibility, a
lack of mobility and social isolation (Plummer & Findley, 2012).
2.1 Definitions
According to the United Nations (1994) the term "disability" summarizes a large number of different
functional limitations occurring in any population in any country of the world. People may be
disabled by physical, intellectual or sensory impairment, medical conditions or mental illness. Such
impairments, conditions or illnesses may be permanent or transitory in nature. According to the
International Classification of Functioning, Disability and Health (ICF), disability occurs in interaction
with contextual factors such as environmental and personal factors (WHO, 2012). The WHO defines
sexual violence as: “Any sexual act, attempt to obtain a sexual act, unwanted sexual comments or
advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any
person regardless of their relationship to the victim, in any setting, including but not limited to home
and work.” Sexual violence includes rape, defined as physically forced or otherwise coerced

3. penetration – even if slight – of the vulva or anus, using a penis, other body parts or an object. The
attempt to do so is known as attempted rape. Rape of a person by two or more perpetrators is
known as gang rape. Sexual violence can include other forms of assault involving a sexual organ,
including coerced contact between the mouth and penis, vulva or anus. A wide range of sexually
violent acts can take place in different circumstances and settings. These include, but are not limited
to:
 rape within marriage or dating relationships;
 rape by strangers;
 systematic rape during armed conflict;
 unwanted sexual advances or sexual harassment, including demanding sex in return for
favors;
 sexual abuse of mentally or physically disabled people;
 sexual abuse of children;
 forced marriage or cohabitation, including the marriage of children;
 denial of the right to use contraception or to adopt other measures to protect against
sexually transmitted diseases;
 forced abortion;
 violent acts against the sexual integrity of women, including female genital mutilation
and obligatory inspections for virginity (WHO, 2007).
2.2 Underreporting of sexual violence
Sexual violence is often underreported. A survey done in the United States revealed that only 19.1%
of women that were raped since their 18th birthday reported this (Tjaden & Thoennes, 2006). A
similar survey in Canada revealed that only 6% report the crime to the authorities (DuMont, Miller, &
Myhr, 2003). Fear of retaliation from the rapist, shame and embarrassment, the belief that it was a
minor incident and fears that the police and prosecutors would question their credibility were
reasons not to report the crime. Victims are more likely to report the crime when the offender is a
stranger than when the offender is an acquaintance and victims are more likely to report the crime if
they feel the probability on a conviction is high (Spohn & Tellis, 2012). For women with disabilities
there are even more reasons not to report sexual violence. One of which is that many services are
not accessible for people with disabilities. Also, the behavior of service providers and first responders
is often insensitive to people with disabilities (Plummer & Findley, 2012).
2.3 Vulnerability of women and girls with disabilities
Disabilities make women and girls more vulnerable to abuse because they often need help from
different caretakers (Sobsey & Mansell, 1994). Lower self-confidence and fewer friendships also
heighten their vulnerability (Armstrong, Rosenbaum, & King, 1992). They may also have
communication difficulties and reduced mental capacities which prevents them from reporting the
abuse and makes them attractive for offenders (Kvam & Braathen, 2008).
2.4 Convention on the Rights of Persons with Disabilities
The Convention on the Rights of Persons with Disabilities was adopted in 2006 to give extra attention
to the human rights of persons with disabilities and to provide an international legal framework for
action against rights abuses. The goal of the Convention is to change how the world sees persons

4. with disabilities and reaffirm that they have human rights and fundamental freedoms; that they can
make their own decisions and can be active members of society (UN Enable). Article 12, 13 and 16 of
the CRPD give attention to the equal recognition before the law, access to justice and freedom from
exploitation, violence and abuse. Article 23 and article 25 deal with the sexual and reproductive
rights of persons with disabilities and raising awareness for human rights (United Nations , 2008).
These rights should provide a legal foundation to take action to protect women and girls with
disabilities from sexual violence.
Article 12.3 States Parties shall take appropriate measures to provide access by persons with
disabilities to the support they may require in exercising their legal capacity.
Article 13.2 In order to help to ensure effective access to justice for persons with disabilities, States
Parties shall promote appropriate training for those working in the field of administration of
justice, including police and prison staff.
Article 16.2 States Parties shall also take all appropriate measures to prevent all forms of exploitation,
violence and abuse by ensuring, inter alia, appropriate forms of gender- and age-sensitive
assistance and support for persons with disabilities and their families and caregivers, including
through the provision of information and education on how to avoid, recognize and report
instances of exploitation, violence and abuse. States Parties shall ensure that protection
services are age-, gender- and disability-sensitive.
Article 23.1b The rights of persons with disabilities to decide freely and responsibly on the number and
spacing of their children and to have access to age-appropriate information, reproductive and
family planning education are recognized, and the means necessary to enable them to exercise
these rights are provided.
Article 25d Require health professionals to provide care of the same quality to persons with disabilities
as to others, including on the basis of free and informed consent by, inter alia, raising
awareness of the human rights, dignity, autonomy and needs of persons with disabilities
through training and the promulgation of ethical standards for public and private health care.
2.5 Models of disability in Ghana
There are a few models to enable an understanding of disability. In high-income countries the way
people understand disability often fits in a medical model, a social model or a combination of both.
The medical model defines people by their medical condition or illness. Someone with a disability has
a fault that needs to be fixed; they need to become as close to “normal” as possible. The social
model sees disability as imposed by society because of society’s conception of what is normal and
because of environmental barriers (Rothman, 2010) (Anthony, 2011). In the past and even still today
people in Ghana use a religious/magical worldview to understand disability (Avoke, 2002). In the
religious/magical worldview, disability is seen as a punishment from the gods. The way people with
disabilities are treated is justified by this belief. This view is still used in some communities and
although there is shift towards a more social model, the religious/magical worldview still influences
attitudes towards people with disabilities (Avoke, 2002).

5. 2.6 Problem description
According to estimations of the WHO, 7 to 9 percent of the Ghanaian population has a disability, in a
population of 21 million, this means 1.5 - 2.2 million persons. Because Ghana has ratified the CRPD
and has adopted the Disability Act, it would seem Ghana is well on its way to a life without abuse for
PWD’s (Human Rights Watch, 2012). However there are no legal mechanisms to enforce this and
prosecute the offenders (Kanter, 2003). On top of this, access to legal aid is generally unavailable and
corruption and unreasonable delays create a loss of confidence in the justice system (UNODC, 2011).
Even when legal aid schemes are available, people who earn a little more than US$ 50 per month do
not qualify for legal aid although they still cannot afford legal fees (UNODC, 2011). In addition there
is a geographical unbalance in court distribution; there are more courts in areas with a rising
economy than in areas with a high population density (AfriMAP, 2007).
In 2006, the Domestic Violence Victims Support Unit in Ghana recorded 345 cases of rape of children
and adolescents, 1427 cases of defilement (carnal knowledge of any child under the age of 16 (Ghana
Legal, 2013)), 52 cases of attempted rape and 4 cases of attempted defilement (Unicef, 2008). The
records do not specify the sex and age of the victims and there is no mention of them being disabled.
Furthermore, an estimated 27% of Ghanaian women have been sexually assaulted in their lifetime
and 1 in 3 women had been touched or fondled against their will according to a national study
performed by the Gender Studies and Human Rights Documentation Center (2013). Yet again there is
no mention of these women being disabled or not.
In a survey that was conducted in 1997 in Ghana, they found that women are most at risk for sexual
violence between the age of 10 and 18 years. There are certain reasons for Ghanaian women not to
report violence. In Ghanaian culture, any kind of violence against women is seen as a private matter
that should not be discussed with others. Therefore violence is often not reported and if it is
reported, it is not reported to state agencies. Another reason not to report violence is because it will
negatively affect the woman’s status in society. Also, most offenders were lovers, family members
and acquaintances, another reason not to report the violence, because of fear of abandonment. And
lastly, most offenders will not be held responsible for their actions. This makes women doubt the
effect of reporting violence (Ardayfio-Schandorf, 2005).
Although there is little research done in Ghana itself, research in other countries suggests that there
should be cases of abuse of disabled girls and women in Ghana as well. The absence of disabled
people in the research literature on abuse shows a lack of social awareness and concern, which in
turn perpetuates the resignation, acceptance and a reluctance of women with disabilities to take
action against the perpetrators.
3. Aim and objective, conceptual framework and research
questions
3.1 Aim and objective
The aim is to improve the mechanisms in place to protect women and girls with disabilities from
sexual violence. Therefor the objective is to identify the factors that influence the safety and sexual
health of women and girls with disabilities in Kumasi and the Ashanti region.

6. 3.2 Main research question
Which factors influence the safety and sexual health of women and girls with disabilities in Kumasi
and the Ashanti region?
3.3 Conceptual framework
To explain all the factors that influence sexual abuse of women and girls with disabilities, the
multifactorial model of violence is used (Sobsey & Calder, 1999). The model combines other models
and theories such as the routine activity theory and Skinner’s model of counter-control (Skinner,
1953). It is the most comprehensive model considering factors that increase victimization of persons
with disabilities (Petersilia, 2001).
Environmental Factors
Person A Person B
Offender-Related Factors
Perceived Vulnerability
Profiles of offenders
Victim-Related Factors
Direct effects of
vulnerability
Socially mediated effects
of disability
Victim Precipitation
Easy Victims
Relationship Factors
Fig. 1 Multifactorial model of violence
In an equal relationship the power between person A and person B would be equally distributed. In
the case of a victim (A) and an offender (B), the offender has more power than the victim, hence the
thick arrow in the model in figure 1 (ICAD, 2008). There are certain factors that influence the
victimization.
3.3.1 Victim-related factors
Victim-related factors are the factors that make a disabled person a probable victim. These factors
are the direct effects of disability, socially mediated effects, victim precipitation, and victims that are
easy for offenders. The direct effects of disability are the effects that are forced upon a disabled
person because of their disability. This can be the dependency on a caregiver; the inability to escape
or avoid the offender and the inability to seek help, but also the type of disability (Petersilia, 2001). A
study in Taiwan points out that intellectually disabled people make out more than 50 percent of the
sexual assault cases reported by PWD (Lin, Yen, Kuo, Wu, & Lin, 2009). Socially mediated effects are
the effects that come from what they have learned or not learned. People with disabilities are often

7. not taught their human rights, they do not get sexual education and they are often taught to obey all
the time and not taught assertiveness or to make their own choices (Groce, 2004).
Victim precipitation is when a disabled person displays behavior that elicits a reaction from an
offender. For example when an intellectually disabled person cannot recognize a dangerous situation
and will therefore do nothing to avoid that situation, which creates an opportunity for an offender.
Lastly, victims that are attractive for offenders have characteristics that motivate the offender to
abuse the victim, as vulnerability alone is not enough for abuse. These motivating factors are:
- Control over the victim: the offender wants control over the victim and uses abuse to get
that control (Gilson, DePoy, & Cramer, 2001).
- Sex: the offender is sexually attracted to people with specific disabilities.
- Money: the victim receives money and the offender wants that money and will abuse the
victim to get it.
- Few alternatives to exploitation: the victim remains in the situation in which the abuse is
taking place because the victim has few alternatives (Petersilia, 2001). For example, lack of
access to justice will keep the offender out of jail and in the proximity of the victim.
3.3.2 The offender-related factors
The offender-related factors are the perceived vulnerability and the profiles of the offenders.
Perceived vulnerability is the way the offender sees the victim as vulnerable; because the victim has
a mental disability the crime will not be reported and the offender can get away with it or the victim
is paralyzed and will not be able to fight the offender off. This may not be reality, but it adds to the
risk of victimization (Petersilia, 2001). The media adds to this perceived vulnerability by portraying
people with disabilities as helpless.
Some of the offenders fit certain profiles of offenders. For caregivers, who make up a large part of all
offenders, there are two types of offenders, the predatory caregiver and the corrupted caregiver
(Sobsey & Calder, 1999). The predatory caregivers usually have feelings of inadequacy, a lack of
control and the need to have control over vulnerable people (Crossmaker, 1991). They seek to be in
the proximity of disabled people and they often plan their offenses. The corrupted caregiver can be a
good caregiver but a lack of training, supervision or policy can result in abusive behavior. Often the
abusive behavior starts gradually and without planning. However, not all abuse is committed by
caregivers. Abuse can also be committed by other people with disabilities. This can be explained by
the lifestyles exposure model. A lot of people with disabilities live in groups. This increases the
exposure of potential victims to offenders with disabilities (Petersilia, 2001). These offenders with
disabilities can be abused by caregivers and therefor start abusing other people; some may have
brain damage that leads to reduced control over impulsive behavior and a lack of inhibition.
3.3.3 Relationship Factors
The relationships that persons with disabilities have influence the risk of abuse. Dependency on
others, such as caregivers, increases the risk of abuse because of power inequities (Crossmaker,
1991). When there are more contacts with caregivers, the risk that one of them will be abusive
increases. A good connection with family members decreases the risk of abuse.

8. 3.3.4 Environmental factors
There are certain environmental factors that influence the risk of abuse. This can be living in
institutions or group homes, being born in an abusive family or exposure to high risk environment,
because the disability affects the routine activities, for example because of the disability the victim
has to take a different route from home to work (Petersilia, 2001) (Crossmaker, 1991).
3.4 Specific research questions
Based on the conceptual model and the main research question, specific research questions were
formulated:
1. What do women and girls know of their rights in relation to safety and sexual health?
2. What are the experiences of WWD in urban and rural areas with access to legal justice
systems?
3. What experiences do the WWD in the Ashanti region have with sexual exploitation and
abuse?
4. What factors of the multifactorial model of violence are influencing sexual violence against
women and girls with disabilities?
4. Methods
4.1 Study design
An exploratory study was conducted because the perspective of the women and girls with disabilities
on the vulnerability for sexual violence is important to raise more awareness for this important and
undervalued subject.
4.2 Study Population and study sample
The study took place in Kumasi and the Ashanti region. The Ashanti region is the biggest region in
Ghana in terms of population and has the least equal allocation of health funds between the regions
(Asante, Zwi, & Ho, 2006). All women and girls with disabilities in Kumasi and the Ashanti region were
the study population; to select participants from the study population, the following inclusion and
exclusion criteria were used.
4.2.1 Inclusion criteria
The inclusion criteria include:
 Women and girls with disabilities (from the age of 10);
 Primary care takers of women and girls with disabilities who are not able to communicate.
4.2.2 Exclusion criteria
The exclusion criteria include:
 Women and girls with a disability that is not permanent;
 Women and girls refusing informed consent;
 Women and girls that offer communication difficulties and who do not have a primary care
taker present.

9. 4.3 Sample size and sampling method
Purposive sampling and snowball sampling was used to draw participants from the study population.
With the assistance of the Ghana Society for the Physically Disabled and members of the Ghana Blind
Union, women were contacted by phone and asked if they were willing to participate. Some of the
women knew other disabled women that would also want to participate. Also, the Ashanti School for
the Deaf in Jamasi was contacted and a few students agreed to participate. In total 21 interviews
were conducted. The age ranged from 15 to 65. Six of the interviewees were with primary care takers
because the woman or girl in question was not able to respond to questions. Of the 21 respondents,
ten were members of a DPO and eleven were not.
4.4 Method of measurement
In order to obtain the valuable information needed to get insight in the safety and sexual health of
women and girls with disabilities, semi-structured interviews were conducted. Because of the
sensitive nature face-to-face interviews were held instead of focus group discussion. The interviews
were conducted using an interview guide with questions based on the concepts mentioned in the
conceptual framework. The interviews were mostly conducted at the homes of the participants or a
place near their work and at the Ashanti School for the Deaf. With consent of the participants the
interviews were audio-recorded. The recorded interviews have been deleted after transcription and
analysis of the interviews.
4.5 Method of analysis
The audio-recorded interviews were transcribed verbatim. The analysis of the interviews was done
using Weft QDA. Weft QDA is a free qualitative data analysis program. The data was analyzed by
performing a directed content analysis. Before starting data analysis a coding guide was constructed
based on the concepts of the conceptual framework. With the coding guide fragments were coded
accordingly. Any fragments that could not be categorized using the coding guide were given new
codes (Hsieh & Shannon, 2005).
5. Results
The study sample consisted of 21 women and girls, of which six had a physical disability, five had an
intellectual disability, three were visually impaired and another three were hearing impaired. Their
age ranged from 15 to 64 and, except for four respondents, lived in an urban area. Nearly half (48%)
of the respondents were members of a DPO. Eight of the 21 women and girls experienced sexual
violence; three were intellectually disabled, one was visually impaired and four were hearing
impaired. None of the women and girls that were members of a DPO experienced sexual violence.
The themes the respondents were questioned about were their experience and knowledge of the
rights of PWD, their experiences with and knowledge of the legal justice system and their
experiences with sexual exploitation and abuse and other factors that might influence sexual
exploitation and abuse of WWD.
5.1 Rights
All the women were questioned about reproductive health and family planning education, the legal
justice system, the treatment of women with disabilities by the health care system and about equal
rights in general.

10. 5.1.1 Equal rights
Almost all of the women participating in this study felt they do not have the same rights as women
without disabilities because they cannot do the same things women without disabilities can do. A
physically disabled woman (A.M.) mentions,
“Because of their level of education it doesn’t allow them to enjoy the same rights as those without
disabilities. And even in the family, those with disabilities aren’t allowed to go, because they question
the relevance of education for them. That’s why it is not the same.”
Another physically disabled woman (R.A.) feels disabled women cannot be compared to persons
without disabilities. Two women felt they have the same rights as women without disabilities, on this
a physically disabled woman (A.A.) said, “I have given birth because of that. I am aware of the rights. I
know those rights exist; I have given birth because of that.”
5.1.2 Treatment by the health care system
The opinions on the treatment by the health care system are varied. Some women feel they are
treated the same as persons without disabilities. A physically disabled woman said, “It is the same.
But the problem is that when I go to the hospital, I have to stand in the cue for a long time just like
any other person. But normally the treatment is the same.” Other women, however, feel they are
treated different because of their disability. One visually impaired woman (M.O.) mentioned that she
was being shouted at by a nurse when she came in to deliver. The deaf women and girls said that
they are treated differently because in in the hospital there are no sign language interpreters so they
cannot communicate with the hospital staff.
5.1.3 Family planning education
Most women see reproductive and family planning education as a means to space up the number of
children. The women below the age of 30 received some reproductive and family planning education
at school; some of the older women received family planning education at meetings with their DPO
and some were given information about spacing up the pregnancies at the hospital when going in for
labor or at church. But most didn’t get any education about the reproductive system and family
planning. According to a physically disabled woman (S.O.), “At the hospital that is the only place
where they normally give family planning education. Apart from that there is no other place.” When
asked about whether or not women and girls with disabilities should receive such education a deaf
woman (A.A.) said, “When you are young and you are taught… given such education, some will be
tempted to practice some of that. That is why it is very bad when you are young.”
5.1.4 Access to justice
There are certain problems the women mention when it comes to accessing the legal system.
Transport to and from the police station is a problem because taxi drivers are reluctant to pick up
physically disabled women: “They normally prefer picking others than those that are disabled” (S.O.).
There also need to be ramps to get physical access to the police station. Some know about the
Disability Act but feel the laws are often not enacted. Money is also a problem, ‘you have to have
money or find someone else who is willing to assist you to get justice’ or as R.A. puts it, “Unless you
get a respectable person who can help you when you get problems, that can lead you. Without that

11. there is nothing that you can do.” None of the deaf women and girls had any knowledge of laws
being in place: “We do not have anything like that for disabled in Ghana” (J.K.).
5.2 Safety
Also included in the interview guide were questions about if they feel they are well protected from
violence and abuse, about the vulnerability of women and girls with disabilities, the influence of the
community views and what they think could be done to improve the safety of women and girls with
disabilities.
5.2.1 Protection from violence and abuse
When questioned if women and girls with disabilities are sufficiently protected from sexual violence
and abuse, almost all of the women feel that they are not well protected. They say they are being
discriminated against, verbally abused and submitted to beatings. One physically disabled woman
(A.A.) said, “I may be alone in the house and someone comes in when the place is very quiet. We are
protected by law but these situations make us prone to sexual violence.” Some mention DPOs as a
protective factor because when something happens, their organization makes sure justice is done
but it is also mentioned that in the villages it is harder to reach the organizations. They also say that
they know there are laws that should protect them, but the laws are not enacted and that is why
they feel they are not well protected, “We are not much protected by law. Although there are laws
taking care of all of us but we are not well taken care of” (A.M.).
5.2.2 Vulnerability
The women that reported not to have been a victim of sexual violence were asked about the
vulnerability of WWD with respect to sexual violence. Money has come up as an influence; most of
the disabled women are not working so they can easily be influenced by men offering money or gifts.
And one visually impaired woman (M.O.) told us,
“There was a deaf person who lives in a compound house and because she was sleeping alone in the
room, at dawn some people were sneaking in to go having an affair with her. Although they knew her
condition and she was alone and cannot report. That was what they used to do on a daily basis.
When she became pregnant, they will not see anybody who will come and take responsibility for it.”
Although not all women see the same dangers as described in the previous quote; one visually
impaired woman (A.O.) brings up that the disabled are not the most vulnerable because:
“In our society people wouldn’t even think of going to a person with a disability because they think it
is an abomination. Secondly, when the person is pregnant you may give birth to a child with a
disability as well, so that scares them and prevents them from trying to abuse people sexually.”
5.2.3 Community views on disabled people
The mother of an intellectually disabled woman (A.M.) said that her daughter gets teased a lot
because of her condition. Some people are afraid of coming to people with a disability and they look
at them strangely and some of the women feel the community does not regard them as human
beings: “Because people see us as if we are sick, so if there is something, they do not regard us as
humans”(E.O). A feeling of neglect by the community is also present:

12. “Before I came blind, they used to involve me in community activities but since I became blind they
have not even called me. It seems they don’t even know me. They neglect me and don’t tell me
anything.”(S.J.)
5.2.4 Improvements for safety
The opinions of what can be done to improve the safety of women and girls with disabilities varied. It
was mentioned that the family should take better care of them. Also, for disabled women to be
working would make them less vulnerable for sexual exploitation, according to V.O. a physically
disabled woman,
“When they see that you are weak, like you are poor and do not have the necessary finances, they can
make approaches. But if you are working and you have the means of life, you are very well protected
against such things.”
Raising more awareness and educating the community and disabled persons is also mentioned by
multiple women as a means to improve safety.
5.3 Sexual violence
All women and primary care takers were asked if they or the woman they are responsible for ever
experienced any kind of sexual exploitation or abuse. Nine women said they never heard about
things like that happening, four women said they heard about it and eight of the woman and girls
were victims of sexual violence. Half of these women and girls had an intellectual disability and the
other half was hearing impaired. One visually impaired woman was approached by four different
men to have an affair but according to her nothing happened. A deaf woman (A.A.) said,
“When I was in primary 4, we were staying in a village. So my grandmother went to farm and she
asked me to prepare food and bring it to her. So when I was going on the way a man met me, a man
forced me and had sex with me. That was the first one. Also another one, another boy tried to rape
me but then I was able to… by that time I was taught to protect myself. So I bite the boy and he left
running.”
The frequency of the sexual violence ranged from one to four times. The age of the seven women
when it started ranges from 9 to 20 years old. Except for one deaf woman who cannot explain why
she feels that way, all of the other women and girls feel the disability influenced the victimization.
One deaf girl (B.A.) said, “There were so many girls of my age but none of them went into that
problem. But I am disabled, that is why the boy called me to the bush.” And C.Y. the aunt of an
intellectually disabled woman mentioned that her niece was taken for granted by the man, but that
she had not seen it only heard others talk about it. If she had seen it, the offender would have to pay
money for compensation.
5.3.1 Offender
None of the women were assaulted by family members, but most of the time it was someone in their
close proximity; living in the same house or the same village. One girl was raped at school by another
student and at the home of a teacher. The mother of an intellectually disabled woman (T.A.) said
about the offender: “It is a drunkard who has been doing that. He has not been taking care of her. He
didn’t give her anything. It is just a drunkard who is staying in the community.” One intellectually

13. disabled woman (A.S.) said that the offender gave her gifts and she felt it got to a point where she
felt obliged to have sex with him.
5.3.2 Bond with family members and friends
Most women feel that if disabled women and girls have a good relationship with their family it will
protect them from sexual violence. The mother of a disabled woman (A.M.) never lets her daughter
out of her sight,
“Looking at how I take care of my daughter, I don’t let her roam about. There are some people… the
family has abandoned them, so they just roam about. They become… the people can easily get to
them. In my case, I don’t allow that. We are always together, so it is not easy for people to come up
to her.”
If there is a problem it can be discussed within the family and the family will solve the problem and
the family can give support financially. This is not sufficient protection according to physically
disabled S.O., “regardless of whether you have a good relation with your family or not, the men will
come around and maltreat you.” The deaf women and girls do not have a good relationship with
their family because their families do not know sign language, as A.A. brought up: “I explained it to
my grandmother but she did not understand. She doesn’t know sign language.”
5.3.3 Reporting sexual exploitation and abuse
The women that were victimized were asked if their cases were reported but none of them did. They
had various reasons not to report their cases. One of the deaf women (A.A.) lived in a village where
there is no police station present. The mother of intellectually disabled T.A. reports not having the
money to pay the police and the transportation to go to the police station to report, “I am not having
money so to be able to get to the police station, the means of transport and also… when you go to the
police station they ask you to get proof of that and all of this involves money.” Two of the care takers
told us that they did not report the sexual violence because they heard about it from other tenants
living in the same house. One of them said: “It is not necessary to report since we have not seen it
ourselves.” The woman that was approached by four different men responded when asked if she
went to the police to report: “I do not think it is serious that is why I did not report it.”
The women that were not victimized said they would go to the police station, to the family, to their
DPO or to the village leaders to report if they were victims of sexual violence. As reasons why others
might not report sexual violence, transportation is mentioned again. In addition, they find the case
not serious enough when there is no visible injury, they do not like talking about their personal issues
and they think that the police would not take them seriously. The mother of an intellectually disabled
woman (A.T.) said about this, “Such people with such conditions, they can’t talk. So based on that,
even if you go and report… they will treat it like… they will not follow up and just throw the case out.”

14. 6. Discussion and conclusion
6.1 What do women and girls know of their rights in relation to safety
and sexual health?
Most women interviewed did not experience the same rights as women and girls without disabilities.
Some know that there are rights, especially the women that are a member of a DPO. However the
intellectually disabled do not have any knowledge on their rights on safety and sexual health. At the
DPOs they get education about their rights and some reproductive and family planning education
and it is the place where they have their social contacts, where they can discuss these kinds of issues
with their peers. However, the women who are not a member of DPO display a lower level of
education and have less knowledge about their rights in relation to safety and sexual health and for
most women the only reproductive and family planning education they received was when going to
the hospital to deliver. This is in compliance with the findings from multiple other studies (Groce,
2004) (Calderbank, 2000) (Isler, Beytut, Tas, & Conk, 2009) (McKenzie, 2013) (Rohleder & Swartz,
2009). McKenzie (2013) feels that health services should be responsible for educating disabled
people about their sexual rights. According to Isler et al. (2009) the responsibility of educating
intellectually disabled about sexual health lies with the parents and the parents should be guided in
their efforts to educate their intellectually disabled children. While Rohleder & Swartz (2009) feel
that education for intellectually disabled about sexual health and HIV should be incorporated into the
main stream campaigns and in schools. In Ghana most sexual health education focuses on HIV/AIDS
prevention and education about sexual rights is not being taught at schools because of objections as
a result of cultural and religious beliefs from parents and churches (Owusu, 2012). It is important to
teach disabled women and girls with disabilities about their rights in relation to safety and sexual
health because it teaches them to recognize which practices are normal and which are abnormal and
empowers them to make decisions in difficult situations (Barger, Wacker, Macy, & Parish, 2009).
6.2 What are the experiences of WWD in urban and rural areas with
access to legal justice systems?
Although Ghana has a special unit to deal with sexual violence, the Domestic Violence Victims
Support Unit, none of the victimized women reported the abuse they experienced to official
agencies, which support the findings from a survey done in 1998 (Boakye, 2009). One of the women
even said that in her village there is no police present. This is the only difference between rural and
urban in relation to access to justice found in this study. The women living in rural and urban areas
face the same obstacles in their access to the legal justice system; the need for money to pay the
police, the need for transportation; the fear of not being taken seriously. This is in line with what was
found about police corruption and unequal court distributions in a review (AfriMAP, 2007).
6.3 What experiences do the WWD in the Ashanti region have with
sexual exploitation and abuse?
As expected, sexual violence against women and girls with disabilities is taking place in the Ashanti
region. Although Ardayfio-Schandorf (2005) finds in her research in Ghana that most women are
victimized by people close to them, often family members, none of the women that were victims in
this study reported the offender to be family members or spouses. The offenders were mostly
people living in the same community. Some of the primary care takers mentioned that if the offender
would give something in return or apologize, the case would be solved and also if the woman does

15. not get pregnant it is not very important. In Ghana, receiving gifts in return for sex is socially
accepted and sometimes even encouraged (Baba-Djara, et al., 2013). After conversations with the
women and girls that have participated in this study, I feel that accepting a gift or an apology after
having experienced sexual violence does not make it any less traumatic. The emotions on their faces
show that, even if the violence happened years ago, it is still difficult for them, especially when still
living in close proximity to the offender.
6.4 What factors of the multifactorial model of violence are influencing
sexual violence against women and girls with disabilities?
6.4.1 Victim related factors
The victim related factors are elements that cause the disabled woman or girl to be at risk of sexual
violence. This can be the age, gender, lifestyle, the socioeconomic status or the disability. As
mentioned before the knowledge of their rights in relation to safety and sexual health is an
important factor influencing sexual violence. The women and girls that experienced sexual violence
were between the ages of nine and twenty-one when the sexual abuse or exploitation took place.
This gives an average age of almost fifteen years which concurs with the survey done in 1997 that
revealed that women in Ghana were most at risk for sexual violence between the ages of ten and
eighteen (Ardayfio-Schandorf, 2005). In South-Africa Dickman and Roux (2005) assessed 100 sexual
violence cases reported by people with an intellectual disability. They found that the average age of
the sexual violence was 18 years and 5 months and 40,4 percent was under the age of 16. Another
study in South Africa by Human Rights Watch (2001) found that women in general were most at risk
for sexual violence between the age of 12-17. In a study carried out in Swaziland in women age 13-
24, they found that 33 percent experienced some form of sexual violence before reaching the age of
18 (WHO Regional Office for Africa, 2012). This suggests that age is also a factor influencing sexual
violence that should be taken into account when developing a prevention program. The nature of the
disability is also an important factor. The deaf women are not able to communicate with their family
and the people in the community; this makes them easy victims for offenders. The primary care
takers of the intellectually disabled women that experienced sexual violence mention that they have
little control over what their protégés do and that they walk around alone often, which makes them
easy victims. Also, because there is a lack of access to justice the offenders can stay in the proximity
of the victims.
6.4.2 Offender-related factors
One offender-related factor is the relationship of the offender with the victim. As mentioned earlier,
the offenders were not family members, spouses or care takers. Another offender related factor is
the perceived vulnerability. An important influence on the perceived vulnerability is how the
community sees women and girls with disabilities (Boakye, 2009). The women report that the
community does not see them as human beings. They see them as sick and weak. According to a
study by Bones (2013) disabled women with a visible sign of impairment are seen as very easy victims
because they are viewed as less capable of engaging in self-guardianship. In the same study Bones
(2013) argues that: “What constitutes a good victim is determined by societal beliefs about certain
attributes and behaviors, many of which are uncontrollable and permanent.” The perceived

16. vulnerability of women in general is ingrained in society (Hollander, 2001). It is nearly impossible to
change this perception in a few years. I believe it will take another decade to change this perception.
This will make it even harder to change the perceived vulnerability of disabled women and girls
because that will take an extra step.
6.4.3 Relationship factors
This study confirms the theory of Sobsey and Calder (1999) that the bond with family members and
friends is an important influencing factor on the victimization of the disabled. The deaf women and
girls did not have a good bond with their family members because they could not communicate with
them. With the intellectually disabled women there was a clear distinction between primary care
takers that had a good bond with their protégé and the primary care takers that did not have a good
bond with their protégé. The intellectually disabled women that experienced sexual violence were
not kept in sight and were able to walk around alone, while the intellectually disabled women who
did not experience sexual violence were kept in constant sight of their primary care taker. Also, some
of the women had heard stories of other disabled women who were abandoned by their families and
therefore taken advantage of. According to Bones (2013)being isolated from others increases the risk
of victimization by 54%. The offender feels that the possible victim is going to tell family members or
friends about what happened and he could get into trouble because of that, he will not approach the
possible victim. Therefor the bond with family members and friends is a protective factor.
6.4.4 Environmental factors
In Ghana religion is very important. Often, legal action against offenders is not taken because they
feel everything is in the hands of God. This will keep the offenders in the proximity of the victims and
the victims unable to escape the sexual violence. Also, one woman feels her daughter does not need
reproductive and family planning education because she leaves it in the hands of God and will accept
anything that happens. According to the Bible sexual violence is wrong: “But fornication, and all
uncleanness, or covetousness, let it not be once named among you, as becometh saints; Neither
filthiness, nor foolish talking, nor jesting, which are not convenient: but rather giving of thanks. For
this ye know, that no whoremonger, nor unclean person, nor covetous man, who is an idolater, hath
any inheritance in the kingdom of Christ and of God” (Hidden Hurt, 2012). Also, according to the
Quran rape is forbidden and punishable by death (Huda, 2013). In theory these religions should
prevent possible offenders from committing sexual violence and should encourage women and girls
with disabilities to report sexual violence. However, according to Franiuk & Shain (2011) religion
endorses rape myth acceptance. In the Muslim culture, for example, family honor is very important.
Sexual violence brings dishonor to a family. Boakye (2009) uses the following definition for rape
myths: prejudicial, stereotyped, or false beliefs about rape, rape victims, and rapists, which serve to
create a climate hostile to rape victims. This will prevent victims from reporting sexual violence. Rape
myth acceptance is present in Ghana, but unlike the findings from Franiuk & Shain (2011) religion is
not associated with rape myth acceptance but with gender, education and age. Males and older
people have a higher level of rape myth acceptance. Education lowers the level of rape myth
acceptance (Boakye, 2009).
6.5 Strengths and limitations
One limitation was that the interpreter and the sign language interpreter were both males. Although
eight cases of sexual violence were found and most of the women appeared to be very open and
honest about themselves, the male interpreters could have held back some of the women. The

17. decision to stick to the male interpreters was because they were volunteers and money was an issue,
they were knowledgeable on the subject and the sign language interpreter was trusted by the deaf
women and girls and knew about their situation already. A comparison of sexual violence and access
to justice between rural and urban areas is difficult to make as there were only four women from
rural areas included in this study. As with the problem with access to justice in rural areas, reaching
DPOs is also difficult which makes it harder to find participants in rural areas. Also, the sample size is
small, which makes the findings not generalizable to the whole of Ghana and even the Ashanti
region. This notwithstanding, the strength of this study is that it includes women and girls with
intellectual disabilities, visual impairments, hearing impairments and physical disabilities. This makes
the differences in the experience of sexual violence between the different disabilities identifiable.
Also, this study is important because there is little research done on sexual violence against women
and girls with disabilities in Ghana and this study provides recommendations to improve the safety
situation of the disabled women and girls.
6.6 Conclusions and Recommendations
6.6.1 Conclusion
There are a lot of factors that influence the safety and sexual health of women and girls with
disabilities in Kumasi and the Ashanti Region. There are protective factors and risk factors. Factors
that can be changed and factors that cannot be changed. DPO membership and a good bond with
family members and friends are protective factors and these can be influenced by an intervention
program. Risk factors are a lack of knowledge of the rights of women and girls with disabilities in
relation to safety and sexual health, a lack of access to the legal justice system and the perceived
vulnerability. A lack of knowledge and a lack of access to the legal justice system can be changed. The
perceived vulnerability, however, cannot be changed that easily. Other factors that influence sexual
violence against women and girls with disabilities are age and the type of disability a person has. The
women and girls that experienced sexual violence were between the 9 and 21 years old when the
sexual violence took place. Also, women and girls with a hearing impairment or who are intellectually
disabled are more vulnerable for sexual violence than women that are visually impaired or physically
disabled.
6.6.2 What do women and girls know of their rights in relation to safety and
sexual health?
The overall knowledge of the women and girls with disabilities or their primary care taker is low.
Most information about sexual health the women get is at the hospital when going in to give birth or
at meetings from their DPOs. It is evident that DPOs educate women on sexual health and human
rights, which will increase the level of knowledge of women and girls with disabilities and makes
them less prone to sexual violence. Information about their rights in relation to safety and sexual
health should also be taught at school and by the parents. When teaching the disabled girls about
safety and sexual health rights in school the right age group can be reached. In a review by Barger,
Wacker, Macy & Parish (2009) only four sexual violence intervention programs for women with
intellectual disabilities were found. These four programs were assessed. Although none of the
programs was able to evaluate if the programs actually reduced sexual violence victimization. The
most promising intervention program was a program called ESCAPE by Khemka, Hickson & Reynolds
(2005) that empowered the women with a self-directed decision making training so they were able

18. to recognize the difference between healthy and abusive interaction and make decisions accordingly.
Barger, Wacker, Macy & Parish (2009) found the program promising but concluded that more
research into intervention programs and their effectiveness was needed. Interventions for women
against sexual violence are not directed at WWD. These intervention programs are mostly directed at
university students in the United States and often consist of self-defense training. Of these
intervention programs the effectiveness is not proven. Overall there is a lack of effective intervention
programs for WWD dealing with sexual violence. More research is needed to develop suitable
intervention programs for women and girls with disabilities.
6.6.3 What are the experiences of WWD in urban and rural areas with access to
legal justice systems?
Most of the women have no experience with the legal justice system. Reaching legal justice systems
is hard and money is needed. They would rather solve problems within their community than going
to the police station. To get offenders prosecuted and to get the law enacted and work as a deterrent
for offenders, transparent and easy to access information should become available for the women
and girls with disabilities. DPOs could play an important role in getting this information to the women
and girls. In addition, the government should take responsibility to ensure the law is enforced and
people with disabilities can make use of their rights.
6.6.4 What experiences do the WWD in the Ashanti region have with sexual
exploitation and abuse?
The deaf and intellectually disabled women and girls have experience with sexual exploitation and
abuse. The visually impaired and physically disabled do not have any experience with sexual
exploitation and abuse. It is noteworthy to mention that none of the women that experienced sexual
violence were members of any DPO. An increased effort from the DPOs is needed to reach the
women and girls in the more secluded areas to teach them the necessary tools to be able to avoid or
escape sexual violence such as taught in the ESCAPE program. Special attention should be given to
the intellectually disabled and their caretakers and the hearing impaired. These groups appear to be
more vulnerable than the physically disabled and the visually impaired because they often encounter
communication difficulties. Additionally the women and girls with disabilities and their caretakers
should be made aware that transactional sex is not acceptable and that sexual violence should be
reported to the official agencies.
6.6.5 What factors of the multifactorial model of violence are influencing sexual
violence against women and girls with disabilities?
Most of the factors described in the multifactorial model of violence also apply in the Ashanti region.
Some of the factors of the multifactorial model of violence are factors that can be influenced and
changed; other factors are impossible or nearly impossible to change. The victim related factors that
influence sexual violence are age, the type of disability, level of knowledge of their sexual health
rights and a lack of access to the legal justice system. Interventions are not able to change someone’s
age or the type of disability someone has, focus should lie on increasing the level of knowledge and
ensuring the legal justice system is physically accessible and financially accessible. An offender
related factor that influences sexual violence is the perceived vulnerability. This is a factor that is
nearly impossible to change. To change the relationship factors, to improve the relationship with
family members and friends, the views of the family members on their disabled family members

19. need to be changed. They need to be informed about the value of disabled people, that disabled can
contribute something to the family and the community. In addition to the multifactorial model, being
a member of a DPO also seems to be a protective factor as none of the women that were a member
of a DPO experienced sexual violence. Ghana is a very religious country, Christianity and the Islam are
against sexual violence. However, at this moment it does not stimulate the women and girls with
disabilities or their caretakers to take action against sexual violence. There is an opportunity for an
intervention to educate spiritual leaders so they can encourage women and girls with disabilities to
report sexual violence.
It is important to realize that one intervention that is appropriate for all types of disabilities is not
possible as every disability and every individual has different needs.

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