Associations between climate change-related factors and sexual health: A scoping review

ABSTRACT

There is growing attention to the ways in which climate change may affect sexual health, yet key knowledge gaps remain across global contexts and climate issues. In response, we conducted a scoping review to examine the literature on associations between climate change and sexual health. We searched five databases (May 2021, September 2022). We reviewed 3,183 non-duplicate records for inclusion; n = 83 articles met inclusion criteria. Of these articles, n = 30 focused on HIV and other STIs, n = 52 focused on sexual and gender-based violence (GBV), and n = 1 focused on comprehensive sexuality education. Thematic analysis revealed that hurricanes, drought, temperature variation, flooding, and storms may influence HIV outcomes among people with HIV by constraining access to antiretroviral treatment and worsening mental health. Climate change was associated with HIV/STI testing barriers and worsened economic conditions that elevated HIV exposure (e.g. transactional sex). Findings varied regarding associations between GBV with storms and drought, yet most studies examining flooding, extreme temperatures, and bushfires reported positive associations with GBV. Future climate change research can examine understudied sexual health domains and a range of climate-related issues (e.g. heat waves, deforestation) for their relevance to sexual health. Climate-resilient sexual health approaches can integrate extreme weather events into programming.

KEYWORDS:

• Climate change
• sexual health
• HIV
• sexually transmitted infections
• violence

Background

Climate change has far-reaching environmental effects including alterations in climate patterns and increased extreme weather events such as storms, heatwaves, drought, fire, and heavy precipitation (Romanello et al., 2021). These extreme weather events harm human health and livelihoods through straining global food and water supplies (Phalkey et al., 2015; Stanke et al., 2013; Watts et al., 2019), in turn increasing food insecurity (Austin et al., 2021; Lobell et al., 2008; Zhao & Running, 2010) and migration (Dzomba et al., 2018; McMichael et al., 2012; Watts et al., 2019; Weine & Kashuba, 2012). In fact, climate change and related extreme weather events contribute to an array of direct and indirect health effects (Romanello et al., 2021; Watts et al., 2015), including malnutrition, infectious diseases, and mental health challenges (Lieber et al., 2021; Romanello et al., 2021; Singh et al., 2018; Whitmee et al., 2015; Women Deliver, 2021). Extreme weather events can also disrupt provision of, and access to, health services (Stanke et al., 2013). There is growing attention to how climate change and related extreme weather events may affect sexual health (Orievulu et al., 2022; Thurston et al., 2021; van Daalen et al., 2021).

Sexual health is a multifaceted concept, comprising comprehensive sexuality education and information; gender-based violence (GBV) prevention, support, and care; human immunodeficiency virus (HIV) and sexually transmitted infections (STI) prevention and control; and sexual function and psychosexual counselling (Stephenson et al., 2017; World Health Organization, 2017). Yet most climate change-related literature to date has focused on one or two of these sexual health dimensions – GBV and HIV/STI (Orievulu et al., 2022; Thurston et al., 2021; van Daalen et al., 2021). For instance, a systematic review found that GBV perpetrated by strangers and close relationships increased during and following extreme weather events, and this increase was attributed to a range of factors including exacerbated economic insecurity, food insecurity, mental health stressors, disruptions to health and legal infrastructure, and increased gender inequity (Van Daalen et al., 2022). The authors underscore that ‘extreme events do not cause GBV; rather, extreme events exacerbate drivers of violence or create enabling environments for this behaviour. The primary causes are systematic social and patriarchal structures enabling and normalising GBV’ (p. e519) (Van Daalen et al., 2022). In another systematic review, authors highlight complex linkages between drought and HIV treatment adherence in Africa, whereby economic and livelihoods related challenges were among the strongest determinants of antiretroviral therapy (ART) non-adherence (Orievulu et al., 2022). For instance, food and water insecurity may increase concerns about ART side effects, and drought can also result in human migration to seek employment or forage and water for livestock. In turn this migration can disrupt both connections to health systems and social support networks (Orievulu et al., 2022). These important reviews signal the need to better understand climate change, and a range of extreme weather events, and how they may affect multiple dimensions of sexual health.

There are three frameworks that are particularly relevant for conceptualising potential associations between climate change and sexual health. First, Women Deliver developed a framework examining linkages between climate change and GBV (Women Deliver, 2021). This framework posits that climate-related disasters and extreme weather events may increase mobility and migration that in turn elevate risks of trafficking and violence, and extreme weather events may also increase financial and other household stressors that can exacerbate existing violence and increase risks of child, early and forced marriage as a financial coping mechanism (Women Deliver, 2021). Second, Lieber et al.’s model of the linkages between climate change and HIV conceptualises that global changes in the environment, including temperature levels, natural disasters, floods and heat waves, may result in increased HIV acquisition risks and HIV morbidity and mortality through four pathways: migration, infectious disease, infrastructure erosion, and food insecurity (Lieber et al., 2021). For instance, changes in climate may alter the prevalence of vector-borne diseases such as malaria and leishmaniasis, and HIV co-infection with either malaria or leishmaniasis may worsen HIV outcomes (Lieber et al., 2021). Third, the ecosyndemics framework describes the interaction and synergistic associations between social (e.g. violence), health (e.g. mental health), and environmental (e.g. unstable environmental conditions) challenges (Tallman et al., 2022). For instance, migration, sex work, substance use, stress and violence are some of the mechanistic pathways connecting environmental disruption (e.g. construction of dams/highways in tropical forests) with increased STI acquisition risks (Tallman et al., 2022). Taken together, these conceptual frameworks offer a range of potential pathways to examine regarding the connections between climate change-related factors and sexual health outcomes that span social-ecological levels, including structural (e.g. livelihoods disruption), community (e.g. violence), interpersonal (e.g. transactional sex), and intrapersonal (e.g. stress).

Three key knowledge gaps remain regarding pathways from climate change-related factors, such as extreme weather events, and sexual health. First, most climate change and GBV reviews focus on displacement and disaster, and potential associations between other aspects of climate change (e.g. extreme heat, bushfires) and GBV are not well characterised. Specifically, identifying GBV risks that span multiple types of climate change-related issues and extreme weather events globally for all genders could inform climate-tailored GBV reduction approaches (IPCC, 2022). Second, there are knowledge gaps regarding a range of climate change-related effects and extreme weather events on HIV/STI prevention and care outcomes across global regions. A systematic review on drought and ART adherence among people living with HIV in Africa provided valuable regional insights (Orievulu et al., 2022), and could be complemented with a global review examining extreme weather events at large and both HIV prevention (Moorhouse et al., 2019) and care (Mugglin et al., 2021) cascades. Third, there is a dearth of literature exploring climate change and the other two pillars of sexual health, namely comprehensive sexuality education and sexual function and psychosexual counselling (Stephenson et al., 2017).

To address these knowledge gaps, we conducted a scoping review guided by the following research question: what is known in the literature about the associations and relationships between climate change and sexual health?

Methods

This scoping review explores the linkages between climate change and sexual health, with a focus on four dimensions of sexual health: comprehensive sexuality education; GBV; preventing and controlling HIV and STIs; and psychosexual counselling. Full methods for this review are outlined in the published study protocol (Logie et al., 2021) and summarised below.

Search strategy

Five databases (MEDLINE, EMBASE, PsycINFO, CINAHL and Web of Science) were searched for relevant articles in May 2021 and updated in September 2022 using a search strategy informed by the WHO’s definition of sexual health (Stephenson et al., 2017; World Health Organization, 2017), and previous work on climate change-related extreme weather events (Bell et al., 2018). Search terms included those related to sexual health, GBV, and climate change/EWE/natural disasters. Searches were not limited by language, date, or geographic location and all records were managed in EndNote, Covidence, and Excel. Reference lists from included studies and review articles looking at related topics were also hand searched for additional articles the database searches might have missed.

Study selection and analysis

After duplicates were removed, titles and abstracts of all identified reviewed for eligibility by two reviewers. Articles had to discuss at least one of the four dimensions noted above of sexual health (i.e. sex education, sexual health counselling, STIs/HIV, GBV) in the context of climate change or EWE. Articles focusing on infants or children or exploring sexual health separately from climate change or extreme weather events were excluded. We considered quantitative, qualitative, and mixed methods studies in this review. Differences were resolved through discussion; if consensus could not be reached, the article was moved to the full-text screen for further review. Full texts of articles passing the title/abstract screen were then reviewed by two reviewers based on the same inclusion and exclusion criteria. Additionally, conference abstracts, protocols, books, and studies conducted in animals were excluded. All differences in screening at the full-text stage were reviewed by a third reviewer and/or discussed with all reviewers. Data was extracted from all articles included in the review by one reviewer and peer reviewed by a second.

We used thematic analysis to narratively synthesise the articles and determine common themes. We grouped findings by type of climate change/EWE discussed and then stratified them into the four sexual health domains (comprehensive sexuality education; GBV; HIV and STI; psychosexual counselling). We aggregated and organised findings tabularly to explore overall common linkages between a climate-related factor and sexual health related outcomes, noting geographic regions and socio-demographic characteristics when provided (e.g. age, gender, sexual orientation, HIV serostatus etc.). We share these findings in narrative and tabular formats below. We then developed a summative joint display to illustrate the converge and divergence of areas of investigation and findings by qualitative and quantitative methods (McCrudden et al., 2021) to increase knowledge of the state of the research field on climate change and sexual health and inform recommendations for future research.

Results

Study characteristics

The combined searches (May 2021 and September 2022) returned 4,534 citations across the five databases. After removal of duplicates, 3,183 records were assessed for inclusion, with reference lists of all included articles and relevant commentaries or reviews hand searched for additional articles. A total of 83 articles met inclusion criteria and were included in this review, 52 focusing on GBV, 30 on HIV/STIs, and one on comprehensive sexuality education (Figure 1; Table 1). Table 1 reports general characteristics of included studies.

Figure 1. PRISMA flow diagram.

Table 1. Summary of included article (n = 83) characteristics in scoping review on climate change-related factors and sexual health.

	Gender-Based Violence		HIV/Sexually Transmitted Infections		Total
	n	%	n	%	n	%
Total	52	100%	30	100%	83	100%
Type of Disaster
Storms	23	44%	17	57%	41	49%
Drought	8	15%	7	23%	15	18%
Flooding & Precipitation	13	25%	5	17%	18	22%
Temperature	7	13%	3	10%	10	12%
Fire	3	6%	0	0%	3	4%
General	4	8%	1	3%	5	6%
Methodology
Quantitative	26	50%	20	67%	46	55%
Qualitative	17	33%	5	17%	23	28%
Mixed/multi method	9	17%	5	17%	14	17%
Continent
Africa	7	13%	9	30%	16	19%
Asia	17	33%	2	7%	19	23%
Europe	2	4%	0	0%	2	2%
North America	19	37%	17	57%	37	45%
Oceania	5	10%	0	0%	5	6%
South America	1	2%	0	0%	1	1%
Global/Multiple	1	2%	2	7%	3	4%

Included studies were published between 1997 and 2022 (50% published in 2018 or later), presenting data from 108 countries across all continents except Antarctica (Figure 2). The countries are reflected in Figure 2, and a full list of the number of studies included from each country is listed in Supplementary Table 1.

Figure 2. Map of countries of included studies in this scoping review. Included countries are represented with colours reflecting the number of studies from each country reported in the figure legend.

Sexual health issues

Among the 30 studies focusing on HIV/STIs, 25 focused only on HIV, four studies examined both HIV and STIs, and one focused on gonorrhea. Most studies assessed HIV prevention (n = 6) and care (n = 9) cascades. Articles also explored psychological (n = 3) (distress, depression, optimism) and socioeconomic (food, income insecurity) (n = 2) aspects of HIV. One article addressed HIV/STI transmission and prevention knowledge. Lastly, three articles examined prevalence (n = 2), and outreach, education, and support (n = 1) for STIs other than HIV. HIV/STI articles were predominantly quantitative (n = 20), with a minority using qualitative (n = 5) or mixed/multi (n = 5) methods. We provide an overview of sub-regional study characteristics of included articles in Table 2.

Table 2. Sub-regional study characteristics of articles (n = 83) included in scoping review on climate change-related factors and sexual health.

	Sub-Saharan Africa
	East Africa		West Africa		Southern Africa		Central Africa
	SGBV	HIV/STI	SGBV	HIV/STI	SGBV	HIV/STI	SGBV	HIV/STI
Storms
Drought	4	1	3	1	3	5	4	1
Flooding & Precipitation	1	1		1		2	1	1
Temperature		1		1	2	1		1
Fire
General	1			1
	Americas
	North America		Central America		Caribbean		South America
	SGBV	HIV/STI	SGBV	HIV/STI	SGBV	HIV/STI	SGBV	HIV/STI
Storms	11	15		1	3	1
Drought							1
Flooding & Precipitation	3	1					1
Temperature	3	1
Fire
General	1
	Asia						Europe
	South Asia		Southeast Asia		East Asia		Southern Europe
	SGBV	HIV/STI	SGBV	HIV/STI	SGBV	HIV/STI	SGBV	HIV/STI
Storms	3		4
Drought	1
Flooding & Precipitation	7			1		1
Temperature	1					1		1
Fire
General	2
	Pacific				Global
	Pacific Islands		Australia and New Zealand
	SGBV	HIV/STI	SGBV	HIV/STI	SGBV	HIV/STI
Storms	1		1			1
Drought						1
Flooding & Precipitation
Temperature
Fire			3
General

Most of the 52 articles examining GBV focused on violence between partners (n = 19) (including domestic violence, intimate partner violence (IPV), and dating violence), sexual violence (n = 19), or explored broad constructs of GBV or violence against women (VAW; n = 17), with several discussing multiple themes. Half of included articles (n = 26) were quantitative, 33% (n = 17) were qualitative, and 17% (n = 9) used mixed or multiple methods.

Articles are discussed below, categorised by type of extreme weather event. Several articles dealt with multiple disasters (e.g. flooding and drought) (Díaz & Saldarriaga, 2023; Masson et al., 2019), extreme temperatures and precipitation (Li et al., 2010; Samano et al., 2021), flooding and hurricanes (Enarson, 1999), and droughts and cyclones (Rai et al., 2021), and are represented in multiple sections. Table 3 provides an overview of study site, methodology, and outcomes.

Table 3. Overview of articles (n = 83) included in scoping review on climate change-related factors and sexual health.

Author (Year) Region	Study Design (Population)	Objective	Key Findings	Extreme Weather Event (EWE)	Type of Sexual Health
Abah and Petja (2016); Nigeria	Quantitative (Quant); (n = 281)	Assess the climatic and population-based threats to agricultural development.	Climate change and population growth could lead to the proliferation of infectious diseases including HIV.	General EWE	HIV
Ahmed et al. (2019); Bangladesh	Mixed Methods (MM); (quant n = 120; qualitative [qual] n = 40)	Explore associations between EWE, sexual violence (SV), and early marriage.	Early marriage was a coping strategy following EWE events to: (1) reduce the economic burden of children; (2) manage the threat of SV to reputation and future marriage during a crisis.	General EWE	GBV^1
Alam and Rahman (2014); Bangladesh	MM; (quant n = 105; qual n = 10, n = 10 key informants [KI])	Explore women's preparedness, risk and loss, adaptability and recovery capacity from natural disasters.	Harassment of pregnant and adolescent girls (60%) reported in the cyclone shelter. Adverse effects of disaster included sexual harassment (51.43%).	General EWE	GBV
Alburo-Cañete (2014); Philippines	MM; (quant n = 494 refugees)	Explore practices and gender/sexual power relations in the process of managing disasters (tropical storm).	Rampant sexual abuse of women attributed to a lack of privacy in camps resulting from overcrowding. Service providers receiving referrals of violence survivors lacked sensitivity.	Storms (Tropical storm)	GBV
Allen et al. (2021); Kenya	Quant; (n = 9415 women aged 15–49)	Explore relationship between flooding for 10+ days and IPV.	Counties that experienced flooding were 60% more likely to experience IPV than counties that did not experience flooding.	Flooding	GBV
Anastario et al. (2008); United States (US)	Quant; (n = 366 trailer park residents)	Examine post-disaster GBV likelihood and prevalence among women displaced by Hurricanes Katrina & Rita.	17.5% of women surveyed experienced post-disaster GBV. Socio-demographic and mental health challenges (e.g. sleep issues) associated with higher odds of post-disaster GBV.	Storms (Hurricane)	GBV
Anastario et al. (2009); US	Quant; (n = 420 women)	Assess change in rates of GBV (SV, IPV) in the 2 years after Hurricane Katrina among displaced people.	IPV increased from 2006 to 2007, and SV decreased from 2006 to 2007.	Storms (Hurricane)	GBV
Anthonj et al. (2015); Namibia	Qual; (n = 7 women with HIV [WHIV], n = 5 KI, n = 16 civil society & public sector)	Understand experiences of flooding on people living with HIV (PLHIV) and HIV service providers in the Ohangewa region.	Flooding negatively affected livelihoods (loss of work and income) and living conditions (poor sanitation and hygiene) of PLHIV. Flooding caused healthcare infrastructural damage, which made HIV care services less accessible for PLHIV.	Flooding	HIV
Asadullah et al. (2021); Bangladesh	MM; (qual: n = 8 FGD, n = 75 CEFM^2 survivors; quant: n = 353 households)	Examine the associations between natural disasters and child, early, and forced marriage (CEFM).	More than two-thirds (72%) of respondents had experienced a natural disaster at least once before marriage. A large proportion of respondents married shortly after major floods and cyclones.	Storms (cyclones) and flooding	GBV
Austin et al. (2021); 91 World Bank LDC^3	Quant; (n = not reported; WHIV aged 15+)	Investigate how food insecurity resulting from drought is associated with women's likelihood of acquiring HIV.	Drought increases risk of acquiring HIV among women in LMIC through pathways linked with increased food insecurity.	Drought	HIV
Azad et al. (2013); Bangladesh	MM; (qual n = 5 KI; n = 5 FGD; quantitative n = 185 flood-affected women)	Examine vulnerability for women in households and major difficulties women face because of flooding in northern Bangladesh.	In a crisis, such as a flood, women are more susceptible to sexual, mental, and verbal abuse, and IPV. Around 35% of women reported being harassed by a man during the social disruption caused by flooding, and 58% were harassed by husbands.	Flooding	GBV
Baker (2020); 25 countries in SSA^4	Quant; (n = 400,000 adults aged 15+)	Modelling study to test the effect of temperature changes on HIV prevalence.	Warmer periods will lead to 11.6–16.0 million additional cases of HIV by 2050, notabily in rural areas and with younger ages.	Extreme temperatures	HIV
Beek et al. (2021); Fiji and Tonga	Qual; (n = 8 key informants)	Identify capacity development activities and how these enabled SRH responses to tropical Cyclones Winston and Gita.	Participants highlighted the importance of personal relationships, individual and organisational motivation to respond, and strong rapport with the community to deliver SRH.	Storms (Cyclones)	General SRH
Bermudez et al. (2019); Haiti	Qual; (n = 18 adults aged 25–66, n = 18 youth aged 13–17)	Investigate intersecting drivers of GBV in Côteaux, Haiti, and how these drivers may be influenced by Hurricane Matthew.	Drivers of GBV post-hurricane include intersecting experiences of economic adversity, food insecurity, and unemployment.	Storms (Hurricane)	GBV
Berndt and Austin (2021); 69 World Bank LDC	Quant; (n = not reported [NR]; people at risk of HIV aged 15–49)	Compare the impact of drought on vulnerability to HIV among women and men.	Drought was not a robust predictor of differences in total HIV prevalence across LMIC. In contrast, drought was positively associated with a higher proportion of HIV cases among women relative to men in LMIC.	Drought	HIV
Bradley et al. (2023); Nepal	MM; (qual n = 73 adults, n = 20 KI; quant n = 880 adults)	Examine the impact of natural disasters on violence against women during post-disaster reconstruction of the 2015 earthquake and the 2017 floods in Nepal.	36% of women participants experienced IPV. Displacement, housing conditions, alcohol use and multifactorial social vulnerability post-disaster were factors associated with IPV 0–11 months after natural disasters occurred.	Flooding	GBV
Burke et al. (2015); 19 SSA countries	Quant; (n = 200,000 women aged 15–49 and men aged 15–64)	Explore linkages between income decline caused by drought on HIV epidemiology in Africa.	For every recent drought experienced in Africa, HIV prevalence increased by 11%. Income shocks resulting from drought may account for up to 20% of the variation in HIV prevalence.	Drought	HIV
Carrico et al. (2020); Bangladesh	Quant; (n = 3636 female head of household or female spouse of household head)	Test the theory that climate change may exacerbate conditions that contribute to CEFM^2 among girls and women, and acceptance of less desirable marriage proposals for daughters of all ages.	The more intense a heat wave, the greater the probability that a woman enters a first marriage. Heat waves >25 days were associated with a 23% probability that a woman marries that year. A significant relationship was found between dry spells and the risk of marrying a man who supports IPV.	Extreme temperatures	SGBV
Clark (2006); US	Brief Report (n = N/A)	Examine how Hurricane Katrina effected the research activities of one HIV clinic.	Clinical services closed post hurricane. Research projects were halted. Research personal downsized due to reduced financial support and patient population post- hurricane.	Storms (Hurricane Katrina)	HIV
Clark et al. (2006); US	Case Study (n = N/A)	Lessons learned from an HIV clinic's response 6-months post-hurricane Katrina.	After Hurricane Katrina, the HIV clinic had difficulty filling prescriptions and was unable to provide laboratory monitoring for patients for six months.	Storms (Hurricane Katrina)	HIV
Clark et al. (2007); US	Quant; (n = 2,588 people living with HIV [PLHIV] aged 12+)	Examine differences between HIV clinic patients pre/post- Hurricane Katrina, and factors associated with returning to care.	Post-hurricane, fewer participants attended the HIV clinic. Patients were less likely to return to care if they were incarcerated during Katrina, lived in very damaged areas, were women or Black men.	Storms (Hurricane Katrina)	HIV
Clark et al. (2007); United States	Quant; (n = 175 adult patients at HIV outpatient clinic)	Understand access to healthcare and medication in the HIV outpatient program during and after Hurricane Katrina.	Half (53%) of PLHIV on ART had a treatment interruption of >1 week post-storm, attributed to: running out of ART and/or no provider/pharmacy available. Delays returning to care were associated with: no place to live, health access barriers, no school for children, and no job.	Storms (Hurricane Katrina)	HIV/STI
Cools et al. (2020); 17 SSA countries	Quant; (n = 149,032 females experiencing violence 15–49)	Study the effect of rainfall shocks on IPV in sub-Saharan Africa.	No robust evidence documented that droughts were associated with IPV and no general associations found between drought and IPV.	Drought	GBV
Corno et al. (2020); 31 countries in SSA and India	Quant (n = ∼400,000 women aged 12–24)	Examine effect of rainfall shocks –a source of income variability– on the hazard of early marriage among women in Sub-Saharan Africa and India.	Findings indicate droughts may have opposite effects on early marriage in SSA and in India. A drought raises the annual hazard of marriage between ages 12 and 17 by 3% in Sub-Saharan Africa, and it decreases it by 4% in India.	Drought	GBV
Cruess et al. (2000); US	Quant; (n = 40 gay men PLHIV aged 21–57)	Examine links between optimism, distress, distress and HSV control among gay PLHIV after Hurricane Andrew.	After Hurricane Andrew, high optimism among participants was associated with lower levels of hurricane-related distress, depression and circulating antibodies for HSV.	Storms (Hurricane)	HIV
Díaz and Saldarriaga (2023); Peru	Quant; (n = 15,110 women aged 15–49)	Examine the link between rainfall shocks and physical IPV in rural areas of the Peruvian Andes.	Exposure to an event of drought, but not flood, during the cropping season increases women’s experience of physical IPV by 65%.	Drought and Flooding	GBV
Dwyer and Woolf (2018); Fiji	Qual; (n = NR; sexual and gender minorities in Fiji)	To explore inclusion of sexual and gender minorities in disaster risk reduction and humanitarian response efforts in Fiji.	Violence/harassment pre-disaster increased vulnerability and reduced coping capacity post-cyclone. Gender minorities were blamed for the storm and persons were punished for LGBTQ identities.	Storms (Cyclone)	GBV
Ekperi et al. (2018); US	Quant (n = NR; people at risk for HIV)	Examine Hurricane Sandy’s impact on HIV testing and disruption in HIV testing.	HIV testing rates declined across hurricane affected areas, and recovered after: 6 weeks in low; 15 weeks in moderate; and 17 weeks in high, impact areas.	Storms (Hurricane)	HIV
Enarson (1999); US and Canada	MM; (n = 77 IPV shelters, transition houses, and coalition offices)	Investigate first responders in grassroots organisations serving women at risk of violence regarding the social impacts of disaster (including flooding & hurricane).	Crisis calls increased by 21% and counselling of ongoing clients by 59% in timeframe preceding and following the flood; there was a 15–18% increase in protection orders post-flood; more calls from known vs. first-time callers indicate that prior IPV was a risk factor.	Storms (Hurricanes) and flooding	GBV
Epstein et al. (2020); 19 SSA countries	Quant; (n = 83,990 partnered women aged 15–49)	Evaluate the relationship between drought and IPV, and assess heterogeneity between subgroups.	Mild/moderate and severe drought positively associated with IPV, physical violence, and SV. Severe drought associated with reporting a controlling partner.	Drought	SGBV
Esho et al. (2021); Kenya	Qual; (n = 12 KI, n = 12 women aged 18–25, n = 8 women vocational program participants)	Elucidate the impact of climate change on gender inequalities and practices of female genital cutting (FGC) among the Maasai of Kajiado County in Kenya.	Climate change-related impacts negatively affect Maasai livelihoods from livestock, in turn increasing poverty. Increases in FGC and CEFM may be driven by the intersections between climate change and widening gender inequalities, harming girls and women.	Drought and general climate change	GBV
Fagen et al. (2011); US	Quant; (n = 237 pre-Katrina and n = 215 post-Katrina women undergrad students)	Examine the prevalence of SV experienced by women undergrad students at the University of New Orleans before and after Hurricane Katrina.	No significant associations were found between SV and Hurricane Katrina when comparing the pre-Katrina sample with the post-Katrina sample (pre to post-test).	Storms (Hurricane)	GBV
Fothergill (1999); US	Qual; (n = 2 women experiencing IPV)	Enhance understanding of IPV among women experiencing a flood.	There was increased demand for women GBV survivor services post-flood, yet there was a decrease in availability of services.	Flooding	GBV
Frasier et al. (2004); US	Quant; (n = 785 women aged 18+)	Investigate the relationship between IPV and the flood experience.	No significant IPV increase post- flood. Women who ever experienced physical IPV vs. never were 25% more likely to report being affected by the hurricane and flood.	Flooding	GBV
Gamble and Hess (2012); US	Quant; (calls for: assault n = 283,916; murder n = 1,731; rape/attempted rape: n = 5,294)	Relationship between ambient temperature and violent crimes (including sexual assault).	Rape and sexual assault were positively correlated with increased temperature.	Extreme temperatures	GBV
Geyer et al. (2018); US	Quant; (n = 13,045 adults aged 18+)	Examine the factors linked with HIV screening post-Hurricane Sandy.	HIV screening was positively associated with participant-reported need for access to medical care post-Hurricane Sandy.	Storms (Hurricane)	HIV
Gwatirisa and Manderson (2012); Zimbabwe	Qual; (n = 25 low-income households, n = 40 PLHIV)	Examine intersections between HIV, drought, and food insecurity during a period of political instability in Zimbabwe.	The effects of drought (declining food production and availability) were greatest in households affected by HIV, where the cost of caring for people with HIV exacerbated household food shortage.	Drought	HIV
Hammett et al. (2022); US	Quant; (n = 151 heterosexual couples)	Examine effects of Hurricane Harvey on conflict among low-income newlyweds.	There was no evidence of an increase in newlywed conflict post-hurricane Harvey.	Storms (Hurricane)	GBV
Harville et al. (2011); US	Quant; (n = 123 postpartum women)	Examine relationship between experiences of Hurricane Katrina and IPV in a cohort of postpartum women.	Strong relative risks were seen for the relationship between damage due to the storm and physical violence. Injury during the storm was associated with increased emotional violence.	Storms (Hurricane)	GBV
Hossen et al. (2021); Bangladesh	Qual; (n = 47 women aged 40+)	Analyze how drought impacts women’s vulnerabilities to GBV.	Participants described that effects of drought cause increased violence against women. Poverty forces local poor people to accept early marriage to cope with climatic vulnerabilities.	Drought	GBV
Louisiana State University Health Science Center (2006); US	Case Study (n = N/A)	Outline post-Katrina response of the university health science system to maintain existing HIV and infectious diseases programs.	Hurricane Katrina made it difficult to staff hospitals, resulted in decreases in hospital operations, and led to disruptions of HIV treatment.	Storms (Hurricane)	HIV
Khawcharoenporn et al. (2013); Thailand	Quant; (n = 217 PLHIV aged 15+)	Evaluate antiretroviral treatment access among people living with HIV during black-water floods in Thailand.	After the floods, 3% of participants reported un-sustained ART access, suggesting that the floods disrupted treatment access for people living with HIV.	Flooding	HIV
Kilbourn (1997); US	Quant; (n = NR; adult gay men PLHIV)	Examine the effects of Hurricane Andrew on mental health and HIV infection.	Gay men living with HIV participants reported greater levels of HIV-specific distress than hurricane-specific distress.	Storms (Hurricane)	HIV
Li et al. (2010); China	Quant; (n = not reported)	Understand associations between STI incidence, socioeconomic change, and climate change (precipitation and temperature) from 1950 to 1998	There was a significant positive correlation between precipitation and prevalence of blood-borne and sexually transmitted infections, including syphilis, HIV, hepatitis B, hepatitis C and epidemic hemorrhagic fever.	Extreme temperatures and precipitation	HIV/STI
Low et al. (2019); Lesotho	Quant; (n = 12,887 adults and children aged 0–59)	Assess HIV prevalence, risk behaviours, and the HIV care continuum among people living in drought-affected areas.	Young women in rural drought-affected areas had high sexual risks. Living in a drought-affected area was associated with HIV prevalence that was higher in young women and lower in young men. Migration was linked with higher HIV prevalence.	Drought	HIV
Luetke et al. (2020); Haiti	Quant; (n = 304 female microfinance clients aged 18–49)	Evaluate whether severity of impact from 2016 Hurricane Matthew was associated with engaging in transactional sex.	Among food insecure and poor women, those impacted by the hurricane were 58% more likely to have engaged in transactional sex than those not impacted by the hurricane.	Storms (Hurricane)	GBV
Madhuri (2016); India	Qual; (n = 150 women survivors, n = 10 women household heads)	Examine problems faced by women in the flood aftermath, including GBV, vulnerabilities, and health impacts.	Sexual harassment was common in relief camps and shelters, especially for lower caste women. Family and community stress and trauma was aggravated by flooding. Men IPV perpetrators were stressed at not providing for their families and/or used substances.	Flooding	GBV
Madkour et al. (2011); US	Quant; (n = 5,267 youth aged 12–18)	Assess Hurricane Katrina changes in violence among high school youth.	There was no significant changes in violence-related behaviours among high school youth in New Orleans post-Katrina.	Storms (Hurricane)	GBV
Masson et al. (2019); Chad	MM; (qual n = 162 men and women, n = 38 KI; quant n = NR)	Examine linkages between GBV and resilience capacities to survive and adapt to drought or flooding.	Violence negatively affects resilience-building. Gender inequalities contribute to many issues (poor reproductive health, low literacy, limited livelihoods) that increase GBV vulnerability.	Drought and Flooding	GBV
Mazzeo (2008); Zimbabwe	MM (qual n = 30 households, n = 173 FGD, n = 10 KI; quant n = 3,045 households)	Understand how drought and HIV interact to affect the livelihoods of people in an arid region of Southeastern Zimbabwe.	The combination of HIV and drought increases livelihood insecurity by lowering food production and monetary income.	Drought	HIV
Molyneaux et al. (2020); Australia	Quant; (n = 967 adults)	Examining assault/violence experiences after 2009 Black Saturday bushfires.	Regions with a high vs. low bushfire impact reported among women (a) significantly higher violence and (b) associations between reduced income and increased likelihood of violence.	Fires (Bush Fire)	SGBV
Nagata et al. (2022); 21 SSA countries	Quant; (n = 288,333 women and men aged 15–59)	Investigate association between heavy rainfall, HIV prevalence, and HIV transmission risk over a 12-year period.	Heavy rainfall associated with 14% greater odds of HIV infection, 11% greater odds of STIs, and 12% greater odds of reporting a higher number of sex partners. Heavy rainfall’s impact on HIV infection was highest among >20 years and in rural areas.	Extreme precipitation	HIV/STI
Nguyen (2019) Philippines	Qual; (n = 21 sexually abused women and girls, n = 21 NGO and government officials)	Examine cause of gender inequities to prevent post disaster (Typhoon Haiyan) GBV.	The typhoon exacerbated existing tensions, triggering violence, and disrupted law and social order. Damage to the prison led to prisoners escaping and coming back to their communities, some of whom were incarcerated for perpetration of GBV.	Storms (Typhoon)	GBV
Nguyen and Rydstrom (2018) Vietnam; Philippines	Qual; (n = 89; n = 100 men and women aged 20–65)	Understand how to prevent and combat GBV prior to and during climate disasters (Typhoons Haiyan and Nari).	Increased VAW was reported during and after super Typhoon Haiyan in the Philippines. Governmental pre-typhoon strategies aimed at preventing and combatting GBV in Vietnam had a pre-emptive effect on gender-specific disaster related violence.	Storms (Typhoon)	SGBV
Nsuami et al. (2009); US	Quant; (n = 646 adolescents)	Determine prevalence of gonorrhoeae among high school students pre/post Hurricane Katrina.	Prevalence of gonorrhea increased from 2.3% to 5.1% pre-post Hurricane Katrina. Findings indicate a 2-time greater likelihood of testing positive for gonorrhea after the hurricane.	Storms (Hurricane)	STI
Orievulu and Iwuji (2021); South Africa	Qual; (n = 27 PLHIV, n = 14 key informants)	Examine effects of the 2015 drought in a high HIV prevalence region to inform institutional solutions to future droughts.	The 2015 drought had negative impacts on PLHIV including: food insecurity, crop failure, water insecurity, forced relocations, and less engagement with HIV care due to economic losses.	Drought	HIV
Padilla et al. (2022); Puerto Rico	Qual; (n = 8 health institutions; n = 20 chronic disease patients; n = 42 health care providers; n = 5 policy makers)	Explore how persons with chronic conditions who were in critical need of life-sustaining treatments and care in the aftermath of Hurricane María, and health-sector representatives, sought aid from a variety of sources	Effects of the storm were experienced most among persons living with chronic conditions, such as renal disease, substance use addiction, and HIV and AIDS. After the storm, clinical services, such as HIV testing and treatment, were non-functional for 2 weeks. All clinical services resumed 3 months after the storm.	Storms (Hurricane)	HIV
Parkinson (2019); Australia	Qual; (n = 30 women aged 20–70)	Examine any increased IPV after disasters (Black Saturday bushfires).	Fires were described as a catalyst for new or increased relationship violence.	Fires (Bush Fire)	GBV
Parkinson and Zara (2013); Australia	Qual; (n = 30 women; n = 47 health/ service provider)	Explore IPV after Black Saturday bushfires.	Most health/social service providers and all 30 women spoke of increased community or domestic violence.	Fires (Bush Fire)	GBV
Picardo et al. (2010); US	Quant; (n = 66 women in public housing)	Examine prevalence of abuse among women displaced by Hurricane Katrina.	Since Hurricane Katrina, abuse increased for 33%, was the same for 20%, and decreased for 13% of women.	Storms (Hurricane)	GBV
Potgieter et al. (2022); South Africa	Quant; (n = 29,924 crimes)	Identify temporal relationships between temperature, relative humidity and rainfall, and violent, property and sexual crime over a 10-year period (2006–2016).	Findings for sexual violence were largely insignificant. Significant associations were found among other crime-weather pairings, including violent crime with a rise in daily temperature, and property crime with both very cold temperatures and rainfall.	Extreme temperatures	GBV
Pouget (2015); US	Qual; (n = 300 men and women who inject drugs aged 19–62)	Assess HIV transmission and access to treatment among people who inject drugs (PID) after Hurricane Sandy.	After Hurricane Sandy, 27% of participants reported sharing needles with people they normally wouldn't, and 43% of PLHIV missed treatment doses during the week of Hurricane Sandy.	Storms (Hurricane)	HIV
Rai et al. (2021); India	Quant; (ever-married women n = 8,469 exposed to cyclone, n = 31,045 exposed to drought)	Examine associations of drought exposure and cyclone exposure with self-reported emotional, physical, and sexual IPV against women.	Exposure to a cyclone was positively and statistically significantly associated with emotional IPV. There was no significant association between IPV and drought.	Storms (Cyclones) and Droughts	GBV
Ranson (2014); US	Quant; (n = 2,997 counties)	Estimate impact of high temperatures on US crime rates (including rape).	Higher numbers of rape cases were reported on hotter days than cooler days.	Extreme temperatures	GBV
Rashid and Michaud (2000); Bangladesh	Qual; (n = 9 girls aged 15–19)	Explore experiences of adolescent girls during 1998 Bangladesh floods.	A common concern among girls was fear of harassment caused by the presence of strange males roaming the neighbourhood. Floods exacerbated harassment of girls.	Flooding	GBV
Reilly et al. (2009); US	Quant; (n = 145 PLHIV aged 18+)	Examine the effects of post-traumatic stress disorder on disease progression among PLHIV post-Hurricane Katrina.	Post-hurricane, people with vs. without post-traumatic stress disorder were more likely to: (1) have detectable viral loads; and (2) experience HIV treatment interruptions.	Storms (Hurricane)	HIV
Rezwana and Pain (2021); Bangladesh	Qual; (n = 8 KI; n = 29 women SGBV survivors aged 17–50; n = 8 men)	Observe the relationship between cyclones (primarily Cyclone Roanu) and GBV in Barguna.	GBV increased from when a severe weather warning was issued. Participants discussed abuse by family, strangers, and/or acquaintances before, during, and after cyclones that was exacerbated by existing poverty and gender inequity.	Storms (Cyclone)	GBV
Robinson et al. (2011); US	Quant; (n = 7,315 PLHIV)	Examine disease progression among PLHIV in Louisiana pre- and post-Hurricane Katrina.	Non-returning evacuees had lower CD4 counts and a greater CD4 count decrease pre- to post-Hurricane Katrina than did evacuees who returned or non-residents of New Orleans.	Storms (Hurricane)	HIV
Samano et al. (2021); US	Quant; (n = NRPLHIV)	Identify associations between heat and precipitation and HIV clinic attendance across Miami.	There were more no shows in HIV clinics on days when the heat index was extreme. There were 10% more no shows at HIV clinics on days with extreme precipitation.	Extreme temperatures & precipitation	HIV
Sanz-Barbero et al. (2018); Spain	Quant; (n = 38,088 IPV reports, n = 23 intimate partner femicides reports)	Analyze the effect of daily maximum temperatures during heat waves on the risk of intimate partner femicides.	Intimate partner femicides increased by 28.8% for every 1 degree in daily maximum temperature above 34°C three days after the increased temperature. IPV increased by 1.7% for each degree above 34°C the day after the increased temperature.	Extreme temperatures	GBV
Schumacher et al. (2010); US	Quant; (n = 251 adult women, n = 194 men)	Establish the prevalence and correlates of IPV victimisation pre-post hurricane.	Psychological victimisation increased for women and men pre- to post-Katrina. Physical victimisation increased for women.	Storms (Hurricane)	GBV
Schutte and Breetzke (2018); South Africa	Quant; (n = 1,361,220 crimes reported from 2001–2006)	Examine the effect of temperature and weather extremes on the magnitude and spatial distribution of violence (rape, attempted rape, and indecent assault).	Overall, mean crime rates were highest on high-temperature days. Sexual crime rates were higher on high temperature days than low temperature days. Crimes increased across all categories (violent, sexual) on higher temperature days.	Extreme temperatures	GBV
Sharpe (2019); US	Quant; (n = NR PLHIV aged 13+)	Assess spatial correlation between Hurricanes and HIV prevalence in the US.	States that experienced a higher-than-average number of hurricanes also had higher HIV prevalence.	Storms (Hurricanes)	HIV
Singh (2020); India	Qual; (n = 15 women aged 12–68)	Understand how the nexus of urban geography and gender inequality shapes women's vulnerabilities.	Many women described feeling unsafe on the streets and this increased during floods. Women reported family and economic stressors during floods, including higher familial conflict and IPV.	Flooding	SGBV
Sohrabizadeh (2016); Azerbaijan and Iran	Qual; (n = 8 women aged 17–55, n = 7 KI)	Exploring the manifestations of GBV after natural disasters (including floods between 2012 and 2013) in Iran.	Women experienced increased physical, psychological, and SV from family members after disasters, and community psychological violence, which negatively influenced coping.	Flooding	GBV
Spencer and Strobl (2019); Jamaica	Quant; (n = 66,712 crime observations)	Investigate the relationship between hurricane strikes and crime in Jamaica.	Hurricanes were linked with decreased rape reports; yet hurricane storm warnings were linked with higher rape reports.	Storms (Hurricanes)	GBV
Tanyag (2018) Philippines	Qual; (n = 26 KI)	Examine women’s and girls’ experiences of displacement and recovery in disaster contexts (super Typhoon Haiyan).	Participants reported increased GBV possibly caused by post-disaster economic strain. High rates of teen pregnancies were seen as an indicator of SV and GBV in displacement camps. Transactional sex was an economic coping strategy.	Storms (Typhoon)	GBV
Temple et al. (2011); US	Quant; (n = 1,048 low-income public high-school students)	Examine substance use and physical and sexual teen dating violence between youth who did and did not evacuate.	Non-evacuating boys had 3 times higher odds of reporting physical and sexual violence perpetration compared to evacuated boys.	Storms (Hurricane)	GBV
True (2013); US and New Zealand	MM	Examine how social and gender structures shape GBV during disasters.	The social and economic status of women prior to a disaster impacts their vulnerability to violence during and after.	Storms	GBV
Vacca et al (2021); US	MM; (HIV service providers: qual n = 6; quant = 31)	Document the challenges and strengths reported by HIV and STI service providers during Hurricane Sandy.	HIV/STI outreach and education, support and testing were interrupted during Hurricane Sandy. HIV providers benefited with emergency plans to resume work within 1 week post hurricane.	Storms (Hurricane)	HIV/STI
Van Voorst (2009) Greenland	Qual; (n = 79)	Examine impact of climate change-related policies on GBV.	Climate change policies impact men’s livelihood as hunters, impacting self-esteem and identity, and may increase IPV.	General EWE	GBV
Westhoff et al. (2008); Belize	Qual; (n = 202 refugees and displaced people)	Assess knowledge of HIV among refugees and displaced persons after Hurricane Mitch in southern Belize.	Participants reported various misconceptions about HIV; <50% believed HIV could be transmitted through needle sharing, and 50% believed condoms were an HIV prevention method.	Storms (Hurricane)	HIV/STI
Xu et al. (2021); US	Quant; (n = 97,100 sex offenses)	Short-term effect of daily ambient temperature on sex offenses.	For every 5°C increase in mean daily temperature, a 4.5% increase in sex offenses was reported in the following week.	Extreme temperatures	GBV

Note: 1: GBV: gender-based violence. 2: CEFM: child, early and forced marriage. 3: LDC: World Bank definition of Less Developed Countries. 4: SSA: Sub-Saharan Africa; 5: ART: antiretroviral therapy; 6: NGO: non government organisations.

Hurricanes, cyclones, typhoons, and tropical storms

Almost half of included studies (n = 40) focused on storms including hurricanes (n = 31), typhoons (n = 3), cyclones (n = 5), and tropical storms (n = 1). Over half of the storm-focused studies were quantitative (n = 22), just over a quarter were qualitative (n = 10) and the remainder were mixed/multi method (n = 8). Studies focusing on hurricanes predominantly originated from the United States of America (USA, n = 26) and investigated HIV/STIs (n = 17) and GBV (n = 14). Hurricane Katrina (n = 15) was the most frequently investigated individual storm. Among studies discussing other types of storms, four explored typhoons and tropical storms in the Philippines and the remainder explored cyclones in Bangladesh, Fiji and Tonga (Beek et al., 2021), and India (Rai et al., 2021). All studies exploring non-hurricane storms (i.e. cyclones, typhoons) focused on GBV.

HIV and hurricanes

Of the 40 studies focussed on storms, nearly half (n = 18) investigated HIV/STIs and hurricanes. Most studies were quantitative (n = 10), and the remainder were qualitative (n = 4) and mixed/multi method (n = 4). Among the literature found, no other storm types were investigated alongside HIV/STIs. Studies identified disruptions in HIV prevention and care outcomes and mental health following hurricanes. These disruptions may be attributed to staffing difficulties affecting HIV treatment provision, displacement to shelters far from HIV clinics, and challenges accessing treatment and testing due to power outages and structural damage. For instance, authors reported decreases in HIV clinic attendance following hurricanes, with one quantitative study noting poorer HIV clinical outcomes in the 18 months following Hurricane Katrina (Robinson et al., 2011). Additionally, African Americans, men, and older individuals were most likely to have lower CD4 counts after the hurricane, suggesting that impacts of treatment disruptions were not experienced equally across race, gender, and age. The duration of care disruption varied, ranging from two to 17 weeks across two studies (Ekperi et al., 2018; Padilla et al., 2022). Some studies suggested testing rates for HIV (Geyer et al., 2018) and STIs (Nsuami et al., 2009) increased following hurricanes.

Three quantitative studies examined the intersections of hurricanes, HIV, and mental health (Cruess et al., 2000; Kilbourn, 1997; Reilly et al., 2009). One reported that people living with HIV with post-traumatic stress disorder were more likely than those without to have detectable viral loads, lower CD4 counts, and HIV treatment interruptions after Hurricane Katrina (Reilly et al., 2009). Another study, using self-reported data, found that gay men reported higher stress levels associated with living with HIV than from Hurricane Andrew and noted the importance of adaptive coping mechanisms for adapting to major stressors (Kilbourn, 1997). For instance, higher optimism levels among gay men living with HIV following Hurricane Andrew were significantly associated with lower hurricane-related distress and depression (Cruess et al., 2000).

Other hurricane-related studies documented practices that elevate HIV exposure and HIV prevalence. Among people who inject drugs, a mixed-methods study found that participants shared needles (28%) and preparation equipment (36%) with people they normally would not have during Hurricane Sandy, which was attributed to the hurricane-related closure of the needle exchange facility (Pouget et al., 2015). A spatial correlation study in the USA examined HIV infection rates in relation to hurricane events between 1851 and 2017, finding higher HIV infection rates in states with ≥5 (421 per 100,000) and ≥20 (453 per 100,000) hurricanes compared to the national average (365 per 100,000) (Sharpe, 2019). No explanation was offered for this observed geographical overlap between hurricanes and HIV infection.

One qualitative study addressed HIV/STI knowledge among forcibly displaced youth in Belize following Hurricane Mitch, reflecting a dimension of comprehensive sexuality education. Among the youth, HIV transmission and prevention misconceptions were reported, with just 45.5% believing needle-sharing was a means of HIV transmission and only 50% believing condoms could be used for HIV prevention (Westhoff et al., 2008). The authors stressed the importance of prioritising HIV/STI education, particularly after the immediate emergency phase, as refugee and IDP (internally displaced persons) settings often carry an increased risk of violence and potential exposure to HIV (Westhoff et al., 2008)

GBV and storms

The largest proportion of the 52 studies reporting on GBV focused on the impact of storms (n = 22). Most explored impacts on GBV broadly (n = 12), on IPV/DV (n = 8), and/or on sexual violence (n = 9), with overlap between the three groups. Notably, the one included study that investigated transactional sex and GBV focused on the impact of storms (Luetke et al., 2020). Most of the studies were quantitative (n = 12), with the remaining being qualitative (n = 6) and mixed/multi method (n = 4). The most common storm type examined was hurricanes (n = 14), predominantly Hurricane Katrina (n = 7).

Two quantitative studies conducted with student populations in the aftermath of Hurricane Katrina found no statistically significant increase in sexual violence following the disaster (Fagen et al., 2011; Madkour et al., 2011). Authors suggest social cohesion, the physical buffer between the university campus and downtown New Orleans (Fagen et al., 2011), and increased mental health services in secondary schools post-Katrina (Madkour et al., 2011), might account for this non-significant change in sexual violence. Four additional quantitative studies, examining the general population rather than student populations, revealed statistically significant increases in the prevalence and/or risk of IPV following Hurricane Katrina (Anastario et al., 2009; Harville et al., 2011; Picardo et al., 2010; Schumacher et al., 2010). Finally, a quantitative study of high school students after Hurricane Ike found boys who did not evacuate during the storm had significantly higher odds of both perpetrating and experiencing sexual violence (Temple et al., 2011).

Several studies noted that storms increased community and/or household stress or exacerbated existing tensions, and this contributed to increased violence both generally (Bermudez et al., 2019; Nguyen, 2019), and specifically related to stressors of food insecurity (Bermudez et al., 2019; Luetke et al., 2020), poverty or financial insecurity (Bermudez et al., 2019; Luetke et al., 2020; Tanyag, 2018; True, 2013), and disruption of law and social order (Nguyen, 2019). GBV and poverty are interlinked, heightening women’s vulnerability to GBV before, during, and after disasters (Rezwana & Pain, 2021). Increased violence among displaced persons was attributed to lack of privacy and security in displacement camps (Ahmed et al., 2019; Alburo-Cañete, 2014; Tanyag, 2018). Finally, storms, GBV, physical health, and mental health concerns were interconnected. In one quantitative study, IPV and storm exposure significantly increased the risk of depression and PTSD (Schumacher et al., 2010), while another reported that sleeping problems, appetite dysregulation, low self-esteem, suicidal ideation, and depressive symptoms were associated with significantly increased odds of experiencing GBV after the storm (Anastario et al., 2008).

Drought

Drought was the focus of 15 included studies, most focused on low-and-middle-income countries (LMIC): multiple Sub-Saharan African (SSA) countries together (n = 4), World Bank’s less developed countries (LDC), Zimbabwe (n = 2), and India (n = 2). Most studies were quantitative (n = 9), four were qualitative, and 2 were mixed/multi method. Seven drought-focused studies examined HIV and eight assessed GBV.

HIV and drought

Of the 15 studies in which drought was examined, four quantitative studies assessed associations between drought and HIV prevalence (Austin et al., 2021; Berndt & Austin, 2021; Burke et al., 2015; Low et al., 2019), finding a positive association between the two. Three of those studies (Austin et al., 2021; Berndt & Austin, 2021; Low et al., 2019) also reported a gendered relationship between drought and HIV, with drought positively associated with HIV prevalence in women and not men. Three studies, two in rural Zimbabwe (Gwatirisa & Manderson, 2012; Mazzeo, 2008) and one in South Africa (Orievulu & Iwuji, 2021), explored experiences of drought among people living with HIV. The authors indicated drought-related food and income insecurity might be exacerbated among people living with HIV, for example when agricultural labourers living with HIV are not healthy enough to work or if households prioritise paying for HIV-related healthcare over buying food (Gwatirisa & Manderson, 2012; Mazzeo, 2008). In these situations, food and/or income insecurity could extend beyond people living with HIV to their households.

One quantitative study reported an association between drought and higher HIV prevalence among adolescent girls aged 15–19 living in rural Lesotho (Low et al., 2019). The same study also found that living in a rural drought area was associated with lower educational attainment and an increase in high-risk sexual practices among adolescent girls and young women aged 15–24 (Low et al., 2019). Authors suggest that drought elevated HIV acquisition risks via reduced educational access and changes in sexual practices, and drought-related migration was also linked with HIV risk among men and women (Low et al., 2019). The effect was modified by sex and age for HIV testing, whereby the negative association was highest for men and adolescents.

GBV and drought

Eight studies, including five quantitative, two qualitative, and one mixed/multi method, explored the relationship between drought and GBV, including IPV (n = 4), violence against women (VAW) (n = 2), and child marriage (n = 3), predominantly in SSA (n = 5).

Four quantitative studies investigated associations between IPV and drought and had differing findings: two reported significantly higher IPV among women experiencing drought (Peru (Díaz & Saldarriaga, 2023) and SSA (Epstein et al., 2020)) whereas the other two reported no significant associations (India (Rai et al., 2021) and SSA (Cools et al., 2020)). However, Rai and colleagues found a non-significant positive association between drought and physical IPV that was not further elaborated on (Rai et al., 2021). Findings on child marriage were similarly conflicting, most notably in comparison of early marriage in SSA and India (Corno et al., 2020). The authors of this quantitative study reported opposite associations in the two regions, with drought significantly associated with increased risk of early marriage in SSA and significantly associated with reduced risk of early marriage in India, despite drought having similar negative effects on crop yields. The other two studies investigating early marriage were qualitative and discussed how the economic harms brought about by drought increased risks of child and early marriage as a financial stress coping strategy (Esho et al., 2021; Hossen et al., 2021).

One quantitative study discussed potential mechanisms linking drought and IPV, suggesting the loss of crops or food supply may cause or exacerbate existing poverty and food insecurity which are both recognised IPV risk factors (Epstein et al., 2020). Lastly, the sole mixed/multi method study reported that violence may constrain women’s resilience following a natural disaster, potentially exacerbating power inequalities and preventing women from proactively managing emergent challenges (Masson et al., 2019).

Flooding

Almost 20% of studies (n = 15) focused on the impacts of flooding on sexual health, predominantly in LMIC, most commonly Bangladesh (n = 3) and India (n = 2); three additional studies originated in the USA and/or Canada. Six of the flooding-focused studies were qualitative, five were mixed/multi method, and four were quantitative. Most studies explored the impact on GBV (n = 13), largely focusing on IPV and/or sexual harassment. Two studies examined the impacts of flooding on people living with HIV, one in Thailand (Khawcharoenporn et al., 2013) and one in Namibia (Anthonj et al., 2015).

HIV and floods

Only two studies focused on flooding examined HIV as an outcome. In a quantitative study in Thailand, 3% (n = 7) of 217 people living with HIV self-reported missing their ART appointments due to flood-related HIV clinic closures (Khawcharoenporn et al., 2013). A qualitative study in a rural, flood-prone region of Namibia found that flooding led to a loss of work and income, poor household hygiene and sanitation, and an inability to access HIV services due to infrastructural damage to health facilities (Anthonj et al., 2015). These two studies highlight the interlinked effects of floods on healthcare and household infrastructure alongside livelihoods disruption that hold the potential to constrain HIV care access.

GBV and floods

Most studies examining floods focused on GBV (n = 13), n = 5 were qualitative, n = 5 mixed/multi method (n = 5), and n = 3 three quantitative. Eight studies across six countries reported increases in violence post-disaster. Displacement (Bradley et al. 2023; Madhuri, 2016), the influx of ‘strange men’ in their communities in Dhaka and Mumbai (Rashid & Michaud, 2000; Singh et al., 2018), and mental health challenges were noted as potential factors contributing to increased GBV following floods. Articles largely did not delineate mechanisms connecting GBV and floods, though one specifically noted disaster-related mental health problems could contribute to increased violence (Sohrabizadeh, 2016). A quantitative study reported that post-hurricane flooding was not significantly associated with IPV rates; noting that experiences of IPV pre-flooding were significantly associated with post-flooding IPV (Frasier et al., 2004). In another qualitative example from the United States, an IPV survivor reported that surviving the flood without her abusive partner allowed her to recognise she was ‘strong and competent enough to survive without him’ (Fothergill, 1999).

Extreme precipitation

Three quantitative studies included in this review examined the associations between extreme precipitation and HIV/STI prevalence, acquisition risks, and care outcomes (Li et al., 2010; Nagata et al., 2022; Samano et al., 2021). A study in Xiamen, China found higher prevalence of HIV and syphilis during periods of high precipitation, though no causal pathway was suggested (Li et al., 2010). Similarly, a cross-sectional population-based study from 21 countries in SSA found that heavy rainfall (≥1.5 deviation from the average precipitation index) was associated with 14% greater odds of HIV infection, 11% greater odds of STIs, and 12% greater odds of reporting a higher number of sexual partners (Nagata et al., 2022). Lastly, an ecological study in Miami, USA reported that HIV clinic attendance was 13% lower on days of extreme precipitation, hypothesising that periods of high rainfall may disrupt access to healthcare services (Samano et al., 2021). These three studies suggest that extreme precipitation may be linked with increased risk and prevalence of HIV/STI infections, along with hindered access to care.

Extreme temperature

Ten studies in our review discussed extreme temperature, most (n = 7) focusing on GBV. These studies were split between higher income countries (predominantly the USA) and LMIC. All studies focused on extreme temperature were quantitative.

HIV/STI and extreme temperature

Three of the ten extreme-temperature focused studies assessed links between temperature and HIV and STIs, with mixed results. One study modelled data from 400,000 individuals in 25 countries across SSA, predicting that rising temperatures resulting from climate change will account for up to a 2% increase in HIV prevalence (16 million additional HIV infections) by the year 2050 (Baker, 2020). The author posits that the pathways from rising temperatures to HIV acquisition risks include increased men’s migration and increased demand among men for transactional sex – both factors are more prevalent in warmer temperatures. An ecological study in Miami, USA showed that on days of extreme heat, HIV clinic attendance dropped by 14% (Samano et al., 2021). However, causality between extreme heat and HIV clinic attendance could not be determined as findings used population-level versus individual-level data. In contrast, an ecological study spanning a 50-year period in China found no correlations between temperature changes and HIV or syphilis incidence (Li et al., 2010).

GBV and temperature

Seven studies explored the impact of temperature on rates of GBV, six of which found a positive correlation between the two, with higher rates of GBV reported at higher temperatures. Almost all articles investigated sexual assault or violence (n = 5), with two investigating IPV or intimate partner femicides. The increases in violence were generally seen in the days following the temperature spike. A study in Dallas, USA found a statistically significant U-shaped relationship, with violence increasing with temperatures up to 90 degrees Fahrenheit and dropping off at higher temperatures, a pattern they suggest is due to people finding shelter in cooler spaces, thus reducing the amount of street crime (Gamble & Hess, 2012). Conversely, a study on climate data across the USA found a strictly linear relationship between rape and temperature ranging from 0 to 100 degrees Fahrenheit, despite noting a U-shaped relationship in other types of violent crime (Ranson, 2014). Studies conducted in Tshwane, South Africa (Schutte & Breetzke, 2018), Madrid, Spain (Sanz-Barbero et al., 2018), and across seven large US cities (Xu et al., 2021) all showed linear relationships between GBV and temperature. Generally, with regard to linear relationships, researchers posit that elevated temperature may increase socialisation, frustration, discomfort, and in turn raise the likelihood of aggression. With U-shaped relationships, researchers posit that above certain temperatures, individuals may be more likely to seek refuge in cooler spaces, reducing social interactions and related crimes.

Fires

In our review, all three studies investigating fires examined GBV outcomes following the Black Saturday bushfires in Australia. Each study revealed perceptions of a surge in violence against women post-disaster, with two qualitative studies noting perceived increases in domestic violence (Parkinson, 2019; Parkinson & Zara, 2013). One of these qualitative studies noted half of women participants reported IPV – most of whom had not experienced IPV prior to the fires. Those who had experienced IPV prior to the fires reported experiencing escalated post-disaster violence (Parkinson, 2019). The one quantitative study found reduced income was most strongly associated with woman reporting violence in areas highly impacted by the fires (Molyneaux et al., 2020).

GBV and warning systems

Among the studies focused on GBV, four investigated the relationship between advanced warning systems or strategies and the prevalence of GBV. These warning systems predominantly aimed at addressing three critical areas: (1) enhancing emergency preparedness, which encompassed measures like structural protection, emergency food stockpiles, and evacuation plans; (2) improving knowledge, often through government or local non-profit campaigns or interventions on gender-based violence prevention; and (3) alleviating individual stress associated with the disaster. Advanced warning of a disaster appeared to be protective against GBV in some circumstances, allowing sufficient time for individuals and support organisations to prepare. For example, a mixed-methods study found an association between sandbagging and evacuation in preparation for flooding and no reported increases in domestic violence service demand in Winnipeg, Canada (Enarson, 1999). Conversely, one qualitative and one quantitative study found linkages between an advanced warning and increased violence (Rezwana & Pain, 2021; Spencer & Strobl, 2019). For example, a study using constabulary force databases investigating the relationship between hurricanes and rape reports over a 13 year period in Jamaica found that reports of rape significantly decreased during hurricanes, while storm warning issuance for hurricanes was associated with significantly increased rape reports (Spencer & Strobl, 2019). In another example, qualitative respondents in Barguna, Bangladesh widely believed GBV increased before, during, and after cyclones, starting from the time a severe weather warning was issued (Rezwana & Pain, 2021). Strategies aimed at preventing and combatting GBV implemented before a typhoon hit in Vietnam were believed by researchers to have had a pre-emptive effect on violence (Nguyen & Rydstrom, 2018).

Discussion

Findings from this scoping review of 83 studies exploring the associations between climate change-related factors and sexual health reveal potential multi-level pathways from EWE to poorer HIV/STI outcomes and increased GBV risks. These pathways span structural (e.g. health infrastructure damage), community (e.g. forced relocation), interpersonal (e.g. transactional sex), and intrapersonal (e.g. psychological distress) levels. Several global regions (South America, South Asia, Asia Pacific, Australasia, Europe), sexual health dimensions (comprehensive sexuality education, psychosexual counselling), and EWE (e.g. dust storms, wildfires) were underrepresented in this review, as illustrated in Figure 2 and Table 2. Findings can inform future climate-informed sexual health research, intervention, and policy.

Our findings underscore the utility of applying an ecosocial approach (Krieger, 1994, 2001) to conceptualise pathways from EWE to sexual health. Ecosocial approaches explore the interacting and diverse pathways that shape adverse exposure to exogenous hazards (such as extreme weather), social and economic challenges, and health care barriers that ultimately shape the patterning of health and disease (Krieger, 1994, 2001). We applied an ecosocial approach to develop a conceptual framework illustrating mechanistic pathways we identified between EWE and HIV/STI and GBV (Figure 3). As illustrated in Figure 3, this conceptual framework details the interconnected pathways connecting EWE to HIV/STI and GBV spanning ecosocial levels. For instance, EWE may influence HIV clinical outcomes among people living with HIV by constraining access to ART via structural (e.g. medication stockout) and intrapersonal (e.g. increased depression) pathways. HIV/STI testing access may be reduced during EWE via structural (e.g. infrastructure damage) factors. EWE may contribute to increased HIV/STI exposure through structural (e.g. increased poverty), community (e.g. migration), and interpersonal (e.g. transactional sex) pathways. While findings varied regarding associations between storms and drought with GBV, most studies that examined flooding, extreme temperatures, and bushfires reported associations with increased GBV. These pathways from EWE to GBV similarly span social-ecological levels including institutional (e.g. disrupted law/social order), community (e.g. exacerbation of inequitable gender norms), interpersonal (e.g. increased household stress), and individual (e.g. increased psychological stress). Importantly, we include intersecting stigma (Berger, 2004; Logie et al., 2021) as a factor to consider when exploring GBV: our review noted that LGBTQ persons, persons of a lower caste, women (vs. men), and younger persons may experience exacerbated stigma linked with GBV risks after EWE. Our framework aligns with past research on social ecological drivers of GBV (Michau et al., 2015) and HIV (Baral et al., 2013) to highlight how the mechanistic pathways connecting EWE to sexual health are also multi-level and interacting and thus can inform multi-pronged interventions.

Figure 3. Conceptual framework of pathways between extreme weather events and HIV/STI outcomes and gender-based violence.

Our findings expand the evidence-base regarding climate change and HIV and STI outcomes (Lieber et al., 2021). The HIV treatment (Kay et al., 2016) and prevention (Moorhouse et al., 2019) cascades may be useful frameworks for future EWE research. For instance, the HIV treatment cascade includes: HIV testing as key to diagnosis, yet EWE can damage health infrastructure and subsequently pose testing barriers; engagement and retention in care, which can be disrupted with medication stockouts during EWE; and adherence and viral suppression, whereby EWE such as floods can disrupt access to HIV clinics. Others discussed drought-related food insecurity and livelihoods challenges worsened general health outcomes among PLHIV (Gwatirisa & Manderson, 2012; Mazzeo, 2008; Orievulu & Iwuji, 2021). Less studies have examined pathways connecting EWE to HIV prevention, particularly pathways from EWE to multiple dimensions of HIV prevention cascade (Moorhouse et al., 2019), including motivation (e.g. risk perception), access (e.g. availability, affordability), and effective use (e.g. sex efficacy). Our findings that higher HIV prevalence was documented in contexts of drought aligns with prior research that documents drought-related changes in sexual practices and migration contribute to HIV acquisition risk (Low et al., 2019). Our findings also corroborate systematic review findings on drought and poorer ART adherence among people living with HIV in SSA (Orievulu et al., 2022) and signals the benefit of also examining drought and pathways to HIV prevention. For instance, a recent study of 10 high prevalence SSA countries reported drought was associated with reduced HIV testing and increased condomless sex (Epstein et al., 2023). Future studies could thus examine a wider range of EWE and HIV/STI prevention modalities (e.g. pre-exposure prophylaxis uptake).

Our findings build on past reviews of linkages between EWE and higher GBV (Rezaeian, 2013; Thurston et al., 2021; Van Daalen et al., 2022). Our review notes variability in pathways to GBV by EWE, for instance drought may elevate drivers of food insecurity (structural level) while storm-related forced relocation can increase exposure to sexual harassment (community level) (see Table 2). Our findings corroborate disaster-related GBV drivers identified in other reviews (e.g. stress, economic insecurity, gender inequity) (Rezaeian, 2013; Thurston et al., 2021; van Daalen et al., 2021) and expand this evidence base by illustrating how these drivers can vary by EWE across ecosocial levels. Notably, climate change-related factors do not cause GBV, rather they exacerbate existing social inequities (e.g. gender inequity, LGBTQ marginalisation) that in turn create enabling environments for GBV to occur.

Revisiting the conceptual frameworks guiding this review, our findings align with Lieber’s hypothesised impacts of EWE – particularly droughts and hurricanes – on migration, infrastructure erosion, and food insecurity in ways that can increase HIV/STI acquisition and worsen HIV/STI outcomes. This conceptual model (Lieber et al., 2021) also posited that climate change would result in higher infectious disease prevalence that could worsen health outcomes among PLHIV – this was an understudied area in studies included in our review. STIs are also largely understudied, with only syphilis and gonorrhea examined. While ecosydemic interactions (Tallman et al., 2022) were not discussed in included studies, our findings suggest the promise of empirically testing bio-social (e.g. GBV and HIV/STI acquisition) and bio-bio (e.g. schistosomiasis and viral suppression) interactions. Our review also corroborates Women Deliver’s (2021) framework where climate-change related household stress can worsen GBV, including child, early and forced marriage; their hypothesised pathway from mobility and migration to trafficking remains understudied and warrants further empirical investigation.

This review identified several persisting research gaps. Firstly, there was a lack of attention to key populations who experience sexual health disparities, including sex workers, LGBTQ persons, people who use drugs, and individuals living with a disability – particularly in LMIC. There was a dearth of studies reporting on participants’ ethno-racial identity and a lack of investigation into the intersection of EWE with racial discrimination. As climate change most impacts socially marginalised communities (IPCC, 2022; Romanello et al., 2021), and can exacerbate existing social and health disparities (Lieber et al., 2021; Romanello et al., 2021; Singh et al., 2018; Whitmee et al., 2015; Women Deliver, 2021), including key populations affected by sexual health disparities in climate change sexual health research is essential to advance health equity. Without adequate research representation, the unique needs of these groups may remain invisible, reproducing policy exclusion that can re/produce existing inequities. Additionally, a recent climate migration and sexual and reproductive health (SRH) review noted a lack of primary data collection and called for research with all genders on diverse SRH health outcomes among climate migrants (van Daalen et al., 2021). Some topics, such as extreme temperature and linkages with GBV and HIV/STI, and extreme precipitation and linkages with HIV/STI, were only examined in quantitative studies (Figure 4) and in some regions (Table 2), reflecting the need for qualitative and mixed-methods studies on additional EWE across geographies to gain in-depth insight into vulnerabilities and protective factors. There is also a need for more longitudinal mixed-methods studies to examine EWE to better identify mechanistic pathways and understand trajectories of sexual health risks and resiliency for a diversity of populations and contexts. This can in turn inform intervention research – there is a dearth of climate-informed sexual health interventions. Together, findings signal that climate change and sexual health research may be strengthened by examining multi-faceted sexual health dimensions globally using mixed-method approaches across a range of climate change issues.

Figure 4. Joint display of qualitative and quantitative scoping review findings on associations between climate change and sexual health.

Strengths and limitations

Our review of climate change and sexual health builds on previous reviews focused on one dimension of sexual health (e.g. ART adherence, GBV) and/or singular climate event (e.g. drought) or response (e.g. climate migration) by comprehensively examining sexual health. We identify knowledge gaps, particularly regarding EWE with comprehensive sexuality education and sexual function and psychosexual counselling. This review also has limitations. As the focus was on climate change-related events, other natural and human-made disasters that might impact sexual health, such as earthquakes and oil spills, were not captured. Though we did not limit studies by language, our search terms were in English, which may have limited our identification of articles published in other languages and might contribute to the overrepresentation of articles from North America. In keeping with standard scoping review approaches, study quality was not assessed, which might also be considered a limitation.

Conclusions

Our scoping review findings can support theoretically informed research exploring a range of climate-related issues potentially relevant to sexual health including greenhouse gases, temperature, sea levels, natural disasters, dust storms, floods, heat waves, deforestation, land degradation, and a loss of biodiversity. Future studies can examine a range of climate change-related sexual health outcomes. Examining climate resilience – the ability of individuals and their communities to anticipate, cope with, and adapt to climatic events and environmental changes (Masson et al., 2019) – is urgently needed in the context of sexual health. Creative climate-informed sexual health strategies can be co-developed with affected communities building on existing early warning systems (Lowe et al., 2011). For instance, contextually, gender and age tailored GBV prevention strategies can be integrated within early warning systems. Self-care SRH strategies (Narasimhan et al., 2019) could be also integrated into early warning systems; for instance, if droughts are linked with increased migration, mobile health could be used to inform community members of upcoming drought, related sexual health issues, and action planning (e.g. securing sufficient ART prior to migration). Similar to humanitarian settings, when storms, flooding or other health infrastructure disruptions are expected, self-care SRH strategies such as HIV self-testing could be distributed in advance to increase access (Logie et al., 2019). Identifying social ecological protective resources can inform multi-level strategies that leverage community strengths, resilience, and cohesion to ensure contextual relevance and long-term sustainability. Global health research can consider the effects of climate change and EWE to ensure that the changing, multi-level drivers of sexual health and wellbeing are centred and addressed.

Author’s contributions

CHL conceptualised the study and led the writing. DT led the scoping review search and extraction process and substantially contributed to writing the manuscript. HD, NL, KM conducted the search and extraction. KM also substantially contributed to writing the manuscript. FM, AH, and MN contributed substantially to the revision process and to editing. All authors approved the final version of the manuscript.

Acknowledgements

The authors wish to acknowledge the assistance of the University of Toronto librarians.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Additional information

Funding

This work was supported by Canada Research Chairs [Logie CRC Tier 2]; University of Toronto [Provost Postdoctoral Fellowship Award]; and Social Sciences and Humanities Research Council of Canada (SSHRC) [Insight Grant].