September 27, 2004
While working in their clinics and feeding centers in Sudan's western Darfur region, Doctors Without Borders/Médecins Sans Frontières (MSF) volunteers regularly come across women and girls who have been raped or sexually assaulted. The sexual violence generally happened when their village was attacked, or when, after having fled to displaced settlements, the women had to go out looking for firewood. Joop Hegeman, an MSF nurse and therapist, is helping to set up a response within MSF's South Darfur programs for women seeking treatment and a system to identify girls and women who need help, but are not necessarily coming forward. MSF teams in other parts of Darfur are organizing similar responses.
What are you doing to assist women and girls who have been the victim of rape or other forms of sexual violence?
We started to train our community health workers (CHWs) in Kass [internally displaced people (IDP) camp] and Kalma [IDP camp]. During their weekly visits in the camp and the community, they engage in active case-finding, social support, and psycho-education, which is explaining the psychological process women are likely to go through. The CHWs initially started visiting the mothers of malnourished children who were discharged from our day-care feeding program. But they soon came across women who had been raped, sometimes even twice: you see, after the first rape, they still needed to go out and fetch firewood to be able to cook for their families. They also met women who had been gang raped by up to forty men or taken to the camps of their attackers where they were assaulted. Our CHWs find out what type of complaints the women and girls have, whether they received medical treatment, what they need the most.
We refer the women and girls to our primary health-care clinic. We give them referral cards, on the basis of which our doctor immediately recognizes why they are coming. We try to be as discrete as possible and if necessary, get them in through the back door. The doctor examines them, gives them antibiotics against sexually transmitted infections (STI), emergency contraception, and post-exposure prophylaxis to prevent HIV infection. Listening to their story and giving them information during the consultation is as important for them, but also for their husband who is equally at risk of contracting a STI.
How do you organize the social and psychological support?
In Kass, where we came across rape survivors as young as 11 years old, we organized for them to meet each week in the presence of a community health worker. For adult women it is generally easier to talk about a traumatic experience. We have to be careful not to force the girls to talk. We asked them to make a drawing of a house. The girls drew houses with very thick walls or large fences around them illustrating their need to feel protected. There is also the fear that because they are no longer virgins, they risk being taken as a third or fourth wife. With the group they try to find out what the rape will mean for their future.
The CHWs help them put their complaints into context, they reassure them that their fears are normal, that it is okay for them to look for what is healthy and safe for them. These are healthy coping mechanisms, and they generally fade after three months. It is the women who suffer from post-traumatic stress disorder who can't pick up the pieces of their lives. It is clear that more specialized help is needed for them, but this is unfortunately still lacking.
We are also considering creating groups in the feeding centers to offer mothers some kind of activity and an opportunity to talk about their experiences. Now, the women are just sitting there the whole day with their malnourished children.
Do many women seek help?
The day after I informed our CHWs in Kass of our future plans, in quite general terms actually, twenty women and girls presented themselves. So we looked for a private location, and I did a brief consultation with each. In one sense, you feel powerless, but one shouldn't underestimate the importance of giving information and a possibility to get treatment, but also of listening to their story and trying to give them the power to go on. Another factor is that the community leaders among the displaced regard treatment and support as a necessity. The men feel very responsible for what has happened to the women. There is a real social coherence-in Kalma they even named their "sector" in the camp after their village. These are all supportive factors. In Kass and Kalma about 40 women and girls are participating in each program.
The community here is very well aware that this has been happening, community leaders point out women or girls who have been victims. We chose a very select group among the CHWs-six in Kass and eight in Kalma. We ask them to treat these cases with the utmost discretion and confidentiality. If they come across a rape survivor, they first have to report back to the group and they cannot talk to anyone else about it. It is also important for them to share their experiences in group, which is being coached by an MSF volunteer, for the sake of their own mental health and to receive suggestions on how to deal with each specific situation.
Do women present themselves easily?
Not necessarily, the CHWs actively look for girls who are depressed and don't want to come forward. They pay extra attention to these cases, and visit them more regularly. They try to involve them in practical activities, for instance the making of baskets. You don't have to imagine extraordinary treatment techniques. We rather try to restore basic traditional village patterns so that women find a sense to their life again and take up the care for their children again. So many people have suffered traumatic experiences. A 15-year-old girl got pregnant as a result of being raped. Her father was shot dead and she fled with the rest of her family. She gave birth to the baby, but it died soon after. A few days later, her two-year-old little brother died of malnourishment and disease. The other day we saw her playing outside. It is difficult to grasp that a 15-year-old life can hold so many consecutive traumas, and see that despite everything, life has to continue.
© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)