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Sexual violence against women by so-called Islamic state of Iraq and Syria (ISIS): protocol for a systematic review

Background Violence against women and girls (VAWG) has been significantly increased by the rise of conflict and insecurity in the territories under controlling so-called Islamic State of Iraq and Syria (ISIS). This review aims to provide an understanding of the consequences of ISIS sexual violence against women. Methods Electronic databases including MEDLINE, Cochrane Central Register of Controlled Trials, JSTOR, Web of Science, Scopus, Science Direct, ProQuest, and Google Scholar are searched for the articles published from 2014 to 2020. Then, two reviewers will systematically identify the articles which will meet the inclusion criteria. Using a standard checklist, methodological quality of articles is assessed. The findings will be summarized, and a narrative synthesis of data will be reported. Discussion This systematic review with a narrative synthesis approach will provide the important information about the gap in knowledge and detailed summary of the existing evidence on consequences of ISIS's systematic sexual violence against women. The evidence is useful for the international health organizations to plan and develop clinical guidelines with interest to reduce the consequences of sexual violence in the armed conflict territories. Systematic review registration PROSPERO CRD42019124215


Background
The term sexual violence can include many different crimes ranging from sexual humiliation to multiple or gang rape and forced prostitution [1,2]. It was defined with World Health Organization as "any sexual act attempts 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" [3]. Sexual violence during wars and conflicts is not a new phenomenon [2]. It occurred all over the world which affected men and women for a long time [4]. However, until recently, it was a neglected issue [5]. Due to the global statistics, more civilian women were the target of violence in modern armed conflicts than civilian men for several reasons in the brutal way [1][2][3][6][7][8].
Studies about conflicts usually staged the conflicts to "pre-conflict," "the conflict itself," "peace process," and "reconstruction or reintegration" where at any stage, different consequences on victims are expected [9]. Women experience the conflict differently than men, so their challenges and needs are different during and after the conflict. The conflicts may have direct or indirect impacts on women. Direct impacts include sexual assault and rape, forced marriage, sexual slavery, disability, and the difficulty of accessing health care. Indirect impact includes honor killings, prostitution, rape, abduction, and trafficking [10].
Sexual violence, itself, has many physical and psychological consequences (e.g., homicide, suicide, serious injuries, pregnancy, sexually transmitted infections including HIV, suicide, and mental health problems), and it has negative impacts on society (e.g., influencing productivity and employment) [1].
The Middle East and North Africa region (MENA) faced the persistent violent conflicts and instability since late 2010 due to "Arab Spring." When the conflict in Syria began in 2011, the Islamic State of Iraq (ISI) started the war in Syria, and ISIS which stands for "Islamic State of Iraq and Syria" was formed in April 2013 [11,12].
The incident of violence against women and girls (VAWG) has been significantly increased with the rise of conflict and insecurity in the territories under controlling ISIS [13], especially among Yazidi, Christian, Turkomen, and Shabak women and girls aged between 8 and 35 years [11]. The United Nations Assistance Mission for Iraq (UNAMI) estimated that 1500 women and girls may be forced into sexual slavery. Studies showed that approximately 70% of women and girls who survived from ISIS captivity in Iraq were raped [13].
As stated, ISIS uses sexual violence widely, and few studies report on the sexual consequences of ISIS systematic sexual violence against women. ISIS is still a new phenomenon, and their use of sexual violence and its consequences have not been properly investigated. Thus, compiling evidence on the topic might help recognize the problem and perhaps provide the evidence for possible interventions. Currently, there is no systematic review addressing this phenomenon.

Objectives
This review aims to provide an understanding of the consequences of ISIS's sexual violence against women. We used the PICO tool (Table 1)

Search strategy
Peer-reviewed journal articles and conference presentations with the qualitative or quantitative design will be sought. We will exclude the duplicates, narratives, expert opinions, and review articles. Our search terms will be the following:  Table 2. A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow chart ( Fig. 1) will present the review process's steps. The search will be continued toward the end of study.

Eligibility criteria
The present review will include all types of articles on sexual valence against women and girls which are published in English, German, French, and Arabic-languages from 2014 to 2020. The year 2014 was chosen, because ISIS was established. There will be no limitation by setting, and we will include all studies about sexual violence against women in ISIS territories.

Study records
The results obtained from the literature search will be exported to Mendeley-Reference Management Software and Researcher Network. This Internet-based program simplifies the research team's participation during the process of study selection. The research team will create a folder for the studies under review and develop subfolders to insert the databases' results. The folder and subfolders will be shared with other research teams online to be assessed due to inclusion and exclusion criteria.

Selection process
Two authors will screen the studies' titles and abstracts using a designed screening tool, as shown in Table 3. After categorizing the studies, the full texts will be reviewed to finalize the categorization by employing independent double screening. Also, gray literature will be screened and categorized by the National Information Centre on Health Services Research and Health Care Technology at the National Library of Medicine (NICH SR) [14]. Finally, relevant documents will be examined and included.

Assessment of methodological quality and risk of bias individual studies
For quality assessment, Mixed Methods Appraisal Tool (MMAT) and scoring system will be used (Additional file 1) [15,16]. The MMAT was adapted to check robustness of both qualitative and quantitative and for minimizing the risk of bias. In addition, if needed, we will contact the authors of papers for any possible issues which require clarification during data extraction and the double-check validation process.

Data items
The data will be extracted as follows: psychological consequences, mental consequences, cultural consequences, economic consequences, spiritual consequences, physical consequences, and health-related consequences of ISIS's systematic sexual violence against women, sample size, age, and type of violence, follow-up, outcome indicators, and the results.

Outcomes
The outcome includes frequency and severity of sexual violence and its direct (physical) and indirect (psychological) consequences against women by ISIS. Physical or health-related consequences will include trauma, somatic problems, pregnancy, sexually transmitted infections, social isolation behavior, and sexual revictimization. Psychological or mental consequences will include the measures of suicidal thoughts or attempted suicide, depression, post-traumatic stress disorder (PTSD), stress, anxiety, sleep disorders, eating disorders, substance abuse, selfharm, panic attacks, quality of life, and self-esteem.

Data synthesis (narrative synthesis)
We follow Popay et al.'s methodology for data synthesis, which involves four steps: "developing a theory of how the intervention works, why and for whom," "developing a preliminary synthesis of findings," "exploring relationships in data," and "assessing the robustness of synthesis" [17].
1. Developing a theory of how the intervention works, why and whom for: Because of the exploratory nature of this review, the theory will not be developed. 2. Developing a preliminary synthesis of the findings of included studies: The studies' descriptive characteristics will be tabulated. Then, the topics of interest will be checked to find out how the data can provide appropriate answers to the study questions. 3. Exploring relationships in the data. Exploring the relationships between and within studies will be carried out, and emerging strategies and characteristics patterns of studies will be rigorously evaluated. 4. Assessing the robustness of the synthesis: We will assess the strength of the evidence for concluding the consequences of sexual violence on the women and girls and assess our findings' transferability to different contexts

Discussion
This systematic review with a narrative synthesis approach will provide important information about the gap in knowledge and a detailed summary of the existing evidence on consequences of the ISIS's systematic sexual violence against women. This evidence will help international health organizations plan and develop clinical guidelines with interest in reducing the consequences of sexual violence in the armed conflict territories. Our study's strength is the use of validated and efficient tools for quality appraisal of reviews and study selection process. Our study's limitations are that we will not use meta-analysis because studies are not reporting homogenous outcomes, and that too few studies exist to perform the statistical meta-analysis.
Additional file 1:. The Mixed Methods Appraisal Tool