MSF Briefing paper for March 8, 2004, International Women's Day
Rape as a weapon of war
Wars leave women and girls particularly vulnerable. Women, girls and even young children are all too often raped, abducted and forced into sexual slavery as social and economic structures fall apart. When forced to flee their homes, women and girls frequently become separated from their families and are left open to attack. They may be forced to trade sex for protection, or simply food or shelter.
The incidence of rape and sexual violence in these situations not only increases but often becomes systematic. Rape becomes a weapon of war with women and girls the targets.
Seen this way, sexual violence is not "only" a consequence or side effect of war and displacement. It is, instead, a deliberate tool of war, used to destabilize and threaten a part of the civilian population, often a particular group. Women and girls are singled out because the harm and humiliation inflicted on them not only hurts them but also deeply harms and humiliates their families and often the entire community. Unfortunately, too often when even the war might have finished, rape hasn't.
MSF was first confronted with this in their programs in the 1990s. In Bosnia, systematic rape was used as part of the strategy of ethnic cleansing. Women were raped so they could give birth to a Serbian baby. In Rwanda, systematic rape of Tutsi women took place during the genocide. Between 300,000 and 500,000 women survivors of the genocide are estimated to have been raped.
With the aids pandemic, rape has now become a lethal weapon. Immediate medical care, including the availability of Post Exposure Prophylaxis (PEP), is now a matter of life and death. More must be done to treat and support the victims of sexual violence and to prevent it from happening in the future. Silence, indifference and inaction have been the answer for too long. Enough is enough.
Impunity has to stop
Unfortunately, impunity is often the norm. While some progress has been made in recognizing rape and other acts of sexual violence as war crimes (rape is now specifically mentioned in the Statute of the International Criminal Court ), the international and national response so far remains unclear and inadequate.
Local, national and international actors must take all necessary measures to address impunity and help prevent such acts. Counseling sessions with rape survivors have also highlighted the importance to the healing process of having rape declared a punishable crime, even in international law. The present lack of justice remains unacceptable and sexual violence will continue unless political and military decision-makers finally decide to act.
Consequences of rape: women and girls are scarred
The medical consequences of sexual violence are devastating. The physical injuries can be life threatening and many rape victims are at risk of contracting sexually transmitted diseases, including HIV/Aids. This risk is significantly increased during rape because forced sexual intercourse results in injuries and bleeding, thereby facilitating transmission of the virus.
Unwanted pregnancies as a result of rape can force women to seek medically unsupervised abortions. MSF has seen cases of pelvic inflammatory infections and septicemia arising from such procedures. Other reproductive health problems include interruptions or abnormalities to the menstrual cycle or delayed conception.
Being raped leads to long-lasting trauma and suffering. Sometimes this takes the shape of mental health disorders whereas at other times it surfaces in less obvious ways such as shame, guilt, sleeping problems, difficulties in daily functioning and withdrawal. Many women report ongoing fear, anxiety, intrusive memories and flashbacks, which are rooted in their experience of the fear of being killed or mutilated. Other patients have complained about a constant feeling of being ill, low appetite and disappearance of sexual desire. Decreased sexual desire or pain during sex is particularly common and very damaging to family life and relationships. Acute heart palpitations are symptoms of anxiety and daily functioning is often disrupted by the fatigue caused by nightmares and other sleeping disorders.
On top of the physical and psychological trauma caused by sexual violence, the raped woman is often stigmatized by the community and sometimes even rejected by her husband. These women, isolated and ashamed, are then forced to find their own way and live in poverty. It is imperative that the stigma of rape is removed so that they can regain their livelihoods and their full place society.
Dealing with sexual violence is difficult and there are many obstacles, including cultural, to treating and supporting the victims appropriately. Working in emergency or semi-emergency settings where there may not be even basic health care, let alone a private space for treatment and counseling, only adds to these. But we have a responsibility to provide care.
MSF is striving to provide comprehensive and quality care to victims of sexual violence in confidential settings. We treat the victims' wounds, offer emergency contraception and provide treatment for the prevention of sexually transmittable diseases. This includes HIV, for which we administer antiretroviral drugs to prevent post-rape infections. These drugs are effective only when taken within 72 hours after of the rape, one reason why immediate medical assistance is so vital.
Given the fact that sexual violence is often a taboo, it is as important to have education activities in place to raise awareness about the issue and the fact that medical treatment is available. In some projects, MSF also organizes the psychosocial counseling. Here, women are enabled to talk about - often for the first time - what they endured. They share their beliefs and receive acknowledgement for their suffering. The objective of the psychosocial interventions is to reinforce or restore coping mechanisms and self-control.
Overview of countries
MSF is providing care and support to victims of sexual violence in a number of countries where we work. Below is a selection of 4 projects where MSF has been providing assistance to victims of sexual violence. The dominance of African countries does not mean that sexual violence does not happen elsewhere. It does, however, reflect the fact that it is extremely difficult to support victims of sexual violence in countries like Chechnya, Pakistan and Afghanistan where the taboo and stigma is even greater and where women risk being expelled or possibly killed once the family finds out.
The war in the eastern Democratic Republic of Congo has been raging since 1998 and has resulted in untold casualties. In Bunia, a once lively town, violent clashes between two rebel groups erupted from May 6-12, 2003, killing hundreds and causing tens of thousands to flee. The people left behind sought refuge in two camps where living conditions soon became gruesome.
In Bunia, sexual violence was used systematically as a weapon of war against women. The highest numbers were reached not only in May, during the clashes, but also in December, when the city was more or less calm but still dangerous due to 'ordinary' crime. In May, MSF set up its own clinic in Bunia and had started treating victims of sexual violence by the end of June. More and more women began to arrive at the clinic. Between July and December 2003 MSF treated more than 820 patients.
During consultations, women slowly open up and begin to tell their horrifying stories. The majority of victims are between 13 and 25 years old. About 27% of victims have been held for anywhere between two days and several months and abused as sexual or domestic slaves. 45 % of the women have endured group rape and 53 % have been raped more than once. 7 % of the women have subsequently been rejected by their husbands or families.
What these women have suffered and still endure severely affects their physical and mental health and both must be treated. At the MSF clinic the victims receive first aid and medical care and can talk for the first time about their experience. For further psychological treatment they are referred to the Centre d'Intervention Psychologique (CIP), an organization who provides therapeutic follow-up.
Sexual violence is widespread in Burundi. Although the exact scale remains unknown, it frequently takes place when armed combatants invade villages. MSF started a program for rape victims in the Ruyigi hospital in February 2003, and sees an average number of 10-15 patients a month. Fortunately, almost all the victims arrive within 72 hours in the hospital, some after walking 25 kilometers. This quick arrival allows them to be treated by MSF's Post-Exposure-Protocol, which includes the administration of the morning after pill and the systematic treatment for sexually transmitted diseases (STD's). If requested, women are also tested for HIV/aids.
Counseling is offered alongside medical treatment, and an international staff member records each woman's story. In November, MSF started treating raped women in the Kinyinya hospital in the rural Moso area and two months earlier also opened a health center for women in Bujumbura-Mairie dealing with sexual violence, as well as family planning and sexually transmitted infections. Providing medical and psychological care in addition to working in collaboration with Avocats Sans Frontières to ensure the possibility of a legal follow-up, the center has received an increasing volume of patients since opening, with the number of cases rising from 40 in September to 92 in January. It also works in close contact with local associations who orient women to MSF and tries to raise awareness about sexual violence.
Raising awareness about this delicate issue is very important in order to remove victims' stigma and ensure as many of them as possible get treatment in time. The message is twofold: stating explicitly that rape is a violation of human rights and it is not the victim who is responsible, and informing (potential) victims about the importance of seeing a doctor within 72 hours to get free and confidential treatment. This message is disseminated via daily national radiobroadcasts, banners and posters in the health centers, along with presentations held for the women and men in the waiting rooms of the health centers. "Communicating on this delicate issue is certainly not easy," says Maria Mora, assistant Head of Mission. "The word 'rape' does not exist in the local language Kirundi here. After many discussions, we came to the translation 'sexual relation outside the couple by force'."
During the Congolese conflict (1998-2000), rape was used as a weapon of war. At that time, more than 1 300 women victims of rape were treated in the Makelekele hospital in Brazzaville. Today, while the country is at peace and on the way to reconstruction, these crimes continue, perpetrated both by civilians and military.
Since 2000, MSF treats victims of sexual violence in Makelekele hospital in the capital, Brazzaville. Since January 2003, a similar program was set up in TalangaÃ¯ Hospital, in another area of the capital. Patients receive free and anonymous medical care which includes the morning after pill, STD treatment, HIV testing and prophylaxis as well as psychological counseling. As victims are isolated and often excluded, social support is also provided to help them register and obtain necessary documents in order to access basic services. Also, women who, as a result of rape, are pregnant as well as children born from rapes receive free medical care during and after pregnancy.
Overall, more than 900 women have been treated in the MSF clinics. Victims are between 6 months to 69 years old, and more than 55% of them are between 13 to 25 years old.
On the 8 March 2003, on International Women's Day, MSF teams in Brazzaville decided to break silence surrounding rape and set up a public education campaign "Tika/Bika Viol, Je dis non! Say no to rape!" The aim was to make people aware of the important problem of rape in the Congo and to inform about the two programs and about the necessity to come to consultations within the necessary 72 hours time-span following the rape.
In October 2003, MSF set up a project to treat the victims of rape and sexual violence near Liberia's capital, Monrovia. The move followed a summer of intense fighting around the city, when violent clashes between the LURD rebel group and troops loyal to President Charles Taylor wrought destruction and terrorized civilians. The three rebel attacks on Monrovia - known locally as "World Wars I, II and III" - followed 14 years of civil war which have left Liberia decimated. Despite Charles Taylor's flight from the country in August and the installation of a transitional government, the country remains unstable and the humanitarian situation is precarious.
It is feared that a high proportion of woman and children suffered brutal sexual abuse or attack during the course of the conflict, with women and girls being taken from their families and used as "sex slaves" by fighters from both sides. Extremely young children were also assaulted. One woman, a 27 year old living in a camp for displaced people, told an MSF worker her story: "The day before yesterday - 21st June 2003 - I went to the bush to look for wood. There were three government soldiers with guns. One of them saw me and asked, "Where are you going?" I said I was looking for wood. Then he told me "You are assigned to me for the day." I was very afraid. He forced me to go far into the bush and he undressed me. Then he raped me. When I got dressed afterwards he took 50 Liberian dollars from me. I came back to the camp and yesterday I felt very sick. My stomach is very painful, but I don't have any money to go for treatment." She had been raped twice before, once in 1990 when she was a 14-year-old girl, and again in 1994, when she was gang-raped by three different men.
The MSF project is based in three camps north of Monrovia which shelter displaced people who fled their homes during the war. Liberian MSF staff, many of whom have been victims of the war themselves, work in the camps to spread the message that free medical care is available and give rape survivors the confidence to come for treatment. Since the program started, more and more women and girls have been coming forward, and the project is now caring for about 300 patients. The program provides treatment for sexually transmitted illnesses such as gonorrhea, chlamydia and syphilis and gives vaccinations against hepatitis B. Patients who come within three days of a sexual attack can be given a prophylaxis to prevent pregnancy. Those who come within three days can also be given "PEP" - a prophylaxis that reduces the risk of contracting HIV/AIDS. Unfortunately, many women only come forward for treatment long after the rape or attack took place, and so are too late to benefit from this. Patients who are suffering from psychological trauma following the attack - of which there are sadly many - are referred on to the International Rescue Committee or Save the Children for psychosocial care.