International Activity Report 2003
Enough is Enough: Why Sexual Violence Demands a Humanitarian Response

by Tine Dusauchoit, MD, General Director, MSF Operational Center Brussels

Women meet together in Shabunda, Democratic Republic of the Congo. Unfortunately, they are bound together by a terrible violence: many of them have been raped. MSF provides medical care for rape survivors and works closely with the local woman's association where these women are meeting.

For a long time we have insulated ourselves from understanding what sexual violence is really about. Cold terms and their abbreviations – sexual and gender-based violence (SGBV), or just gender-based violence, or even just assault – are ways of taking a detour around the reality underneath, a reality that contains so much deep and lasting suffering that it is hard to face.

The kind of violence we are talking about intentionally inflicts harm on (mainly) women and girls. It often means rape or attempted rape, sometimes gang rape and very often rape remaining unpunished. In the humanitarian crises where MSF works, it means women and girls (as young as four or as old as eighty) in eastern Democratic Republic of the Congo (DRC) kidnapped to become sexual slaves in military camps; the 12-year-old in the Philippines whose main concern is "how to get on to the next day after being abused all night"; the young woman in Chechnya raped and murdered by a Russian soldier; the adolescent on the Liberian border "borrowed by soldiers for a night" to ensure her displaced family's safe passage to Guinea; the five-year old girl trembling and screaming in a clinic in Monrovia, raped. So let's not use cold terms that jump over the fact that the physical and emotional reality of a real person may be changed forever. Let's use straightforward words: violence against women and girls. Rape.

Sexual violence is of all times, societies and social classes. It is directed at women (and sometimes men) of all ages, but younger women and girls are more at risk. Difficult enough to identify and address in its "ordinary" and often hidden occurrence around the world, how can a humanitarian organization like MSF respond to sexual violence in the emergency situations where we work?

A humanitarian response to very human suffering

Humanitarian agencies must deal with the problems and suffering they are faced with. MSF actively seeks to respond to the needs of those who are the most vulnerable, have the greatest needs and suffer most. Women and girls, in many of the places where we work, are the most vulnerable of the most vulnerable.

As a humanitarian medical organization, we have to act in the face of sexual violence, because it is a major problem of many of our patients in the most forgotten places. To respond effectively and with compassion, we have to understand the causes of sexual violence, we have to be aware of its magnitude, we have to know what kind of medical and psychological care is best in different situations. We need to be convinced that we can do something significant and meaningful. We must realize that we have to deal with sexual violence. Unfortunately, this realization has been a long time coming.

Awakening

MSF and other humanitarian agencies have been late in recognizing sexual violence as a serious problem. We underestimated both the extent and seriousness of the problem; our response did not match the needs. We also failed to understand whose responsibility it was to act – ours. Before the 1990s, MSF considered sexual violence to be more of a human rights issue. We were unable to identify the added medical value an organization like ours could bring in treating victims of sexual violence. Rooted in emergency work, with its imperative of quick, mass action often geared toward public health (think of cholera tents for hundreds of people or the triage of thousands of refugees arriving in a new camp), humanitarian medical action – in its purest caricature – was not predisposed to see people as specific individuals. Treating the physical effects of rape (not to mention the psychological scars, when they were even addressed) had to compete with other activities, often losing out on the grand scale of priorities to work which favored whole populations rather than the individual.

Our underestimation of the extent of sexual violence in war and conflict, in refugee camps and in other situations of displacement is illustrated by the fact that MSF's widely known and used handbook, Refugee Health, devotes 13 pages to specific nutritional deficiencies compared to just over half a page to sexual violence. As is often the case, more attention was given to prenatal care, delivery and postnatal care than to rape – as if women only mattered to us if they were mothers or future mothers. In this handbook we wrote about what can or could be done, not about what should be done. We simply did not truly consider that, when faced with sexual violence, we had to act.

Awakening for MSF, and for many other NGOs and international agencies, was a long time coming but began to occur in the 1990s. In the early 1990s, systematic rape was used as a weapon of war first in Bosnia (women were raped and then sequestered so they could give birth to a "Serbian baby") and then in Rwanda (with the systematic rape of Tutsi women – between 300,000 and 500,000 female survivors of the genocide are thought to have been raped). MSF was active in both these crises and this is when our awareness really began. At the same time, with the AIDS pandemic fully upon us, rape and immediate follow-up medical care for victims became matters of life and death. The consequences of rape were "medicalized." It was becoming clear that much more could – and had to – be done to prevent sexual violence but also in terms of educating and training our staff and providing medical and psychological care for victims. What happens in times of conflict and displacement In armed conflict and subsequent displacement, sexual violence is widespread.

In armed conflict women and girls – even the very young – are raped, abducted by warring parties and forced into sexual slavery. Rape may be followed by murder. During ensuing displacement, both while fleeing and even when settled in camps, women and girls may be forced to trade sex for protection, a way out or simply food or shelter. Violence against women increases in refugee settings. A report by UNHCR and Save the Children in January 2002 (Sexual exploitation: The experience of refugee children in Liberia, Guinea and Sierra Leone) highlighted the problem of sexual abuse in refugee and displaced camps in many parts of West Africa. Accusations were leveled at almost every actor in the refugee's lives: soldiers, peacekeepers, civilians and aid workers, including some from MSF. Although none of the cases against MSF could be substantiated, such cases have occurred in the past, leading to disciplinary action. And our medical teams are confronted on a daily basis, in refugee and displaced camps all over the world, with women and children who have been abused. This only underlines what we has been feeling for many years now: how vulnerable those who are forced to flee really are, and how little protection they receive.

Sexual violence is so widespread in contexts of conflict and displacement because the vulnerability of women and girls increases. They have fewer options, fewer resources and even less power than before. This is often linked to the fact that they have lost or been separated from their relatives, who may have been killed. The likelihood of men taking part in sexual violence also increases. It is not hard to understand why that is so. Severe economic and social disruption leads to the reduction and loss of the normal restraints on all forms of violence, including sexual violence. Physical and environmental factors related to displacement and flight may contribute to increased sexual violence. Refugee camps are often overcrowded, and there is little or no private space available. Camp design (lack of lighting, men's and women's latrines together) further increases the likelihood of sexual violence both from within and outside the camp. Lack of the basic necessities (food, soap, medicine) can create an unbalanced economic dynamic inside a camp. Refugees may also become victims of acts of hostility from local residents, if their living conditions are worse than for inhabitants of the camps, which is sometimes the case. In Boreah and Sambakounya refugee camps in Guinea, where MSF works, young girls have been regularly kidnapped from the camps on Friday by a neo-mafia network to serve as prostitutes in the neighboring city of Dabola and returned to the camps on Monday.

To address this and contribute to preventing acts of sexual violence, MSF is working to improve the design of refugee camps and other structures and facilities, such as feeding centers, in such a way to reduce the risk of sexual violence.

Rape as a weapon of war

It is totally wrong to think of sexual violence solely as a consequence or accident of war and displacement. Sexual violence is also a weapon of war, a weapon often used to destabilize or even break a particular ethnic, national or religious group or to ethnically "cleanse" a whole society. Women and girls are singled out because they belong to a certain group and because the harm and humiliation inflicted on them deeply harms and humiliates their communities. That is why rape is systematic in many armed conflicts. MSF was and is witness to this in the former Yugoslavia, Rwanda, Congo, Liberia, Sierra Leone and so many other places.

Women and girls scarred

The consequences of sexual violence are devastating: it profoundly and deeply affects the health and well-being of the victims. The physical injury can be very serious, especially in young girls. Many rape victims also contract sexually transmitted diseases, including HIV, and develop AIDS. The risk of HIV/AIDS infection significantly increases because forced sexual intercourse is accompanied by injuries and bleeding, which enhance transmission of the virus. Being raped may lead to long-lasting trauma and suffering. Being raped and becoming HIV-positive as a consequence means that still more trauma is added.

Raped women may become pregnant and have to bear and bring up unwanted children. In Rwanda, babies born of rape are called the "enfants du mauvais souvenir" (children of bad memories). Raped women and girls are often stigmatized and ostracized. In the Republic of Congo, women have told MSF of being urged by people in their communities to throw their babies into the river. In Albania, women who have been raped say they are dead, because they consider themselves to have been completely desecrated.

Rape victims are at greater risk of mental health problems, from pervasive fear to suicide. One woman, 30, from Bunia, DRC, tells her story: "I was sleeping with my children. They shot outside our door. I opened... They ordered me to remove the child from my back with threats to kill me. I obeyed and they raped me... I never went to the hospital. I have been so depressed, life seems to have stopped for me. I am so lost for words..." Says Clotilde, a 15-year-old girl from Bujumbura, Burundi who was treated by MSF in July 2003: "I think about committing suicide, but my heart tells me not to. I am ashamed. I am not myself."

A compassionate medical response

There is no denying that dealing with sexual violence is difficult (examining a rape victim is extremely stressful for the woman concerned and often for the examiner as well) and that that the obstacles to appropriate response can be multiplied in emergency or semi-emergency settings (where, for example, there may be no private clinic space for an exam). But we have a responsibility to provide care and support to persons in need; receiving and caring for victims of sexual violence can be done in a way that is both humane and effective.

MSF is educating and training staff to identify sexual violence and respond to it. In more and more projects, special training is offered on how to receive victims of sexual violence, how to talk to patients, which medical protocol to follow, preparations of medical-legal certificates, and referral of patients to appropriate follow-up care and support. Training also emphasizes empathetic listening to victims. Confidentiality is of the utmost importance. MSF tries to set up private spaces to receive and treat victims of sexual violence – exactly what is lacking in makeshift hospitals or crowded clinics in many of the places where we work. To cope with this, especially in extreme emergencies, MSF staff sometimes work logistical miracles: in Bunia, DRC, logisticians organized a "wing" in an overcrowded warehouse-turned-hospital where victims of sexual violence could be seen privately. Reception and treatment by female medical personnel can also be extremely important; yet in many contexts where we work, education of girls and women is not deemed a priority, and it can be hard to find qualified female staff. To overcome this, MSF makes extra efforts to find qualified personnel among the refugees themselves.

Medical care must include treating physical injuries and lesions. Patients are voluntarily tested and treated for sexually transmitted diseases, including HIV, and provided antiretroviral drugs to prevent post-rape HIV infection (which must be taken within 72 hours of the rape, one reason why immediate medical assistance for rape victims is so important). MSF also provides emergency contraception, counseling and referral for abortion. Medical care is complemented by psychological assistance, either provided by MSF directly or through another source.

It is not easy for victims of rape to come to health centers and seek help. As MSF has set up specific medical services for rape victims, work has also gone into getting word of the possibility for care into the community, because if there is no care to be expected, women and girls will not come at all. MSF has begun or is planning special programs on sexual violence, including addition of sexual violence awareness training and protocols to preexisting projects, in countries around the world.

Out of the usual and customary place

Once treated, both physically and psychologically, it would be nice to think that women and girls could obtain legal redress for crimes of sexual violence committed against them. Unfortunately, this is rare in many of the places where we work. Providing medical-legal certificates moves the humanitarian worker toward the legal sphere, not our customary place to act. Documenting cases, collecting forensic evidence and issuing medical-legal certificates are essential for breaking the cycle of acceptance of sexual violence and impunity of its perpetrators. It should always be considered, even if the potential for use is often very limited in many contexts with near complete breakdown of the judicial system.

Unfortunately, impunity is often the norm. In Chechnya, a young woman was raped and murdered by a Russian colonel in March 2000. While the officer was arrested and the crime investigated (the first – and only – investigation for such crimes by Russian officers in Chechnya), rape was dropped from the final accusation, despite the physical evidence of rape revealed by the autopsy. The soldier, first judged temporarily insane and acquitted, was eventually convicted on appeal and sentenced to ten years in prison – for murder, not rape.

While the first point of legal reference for such crimes remains national law, rape and other forms of sexual violence can also be serious violations of international humanitarian law. However, while there has been progress in international recognition of rape and other crimes of sexual violence (eg, in the new International Criminal Court), until now there has not been a clear and sufficient international response. These crimes have not often been investigated. These crimes remain largely unpunished.

If not a humanitarian response, then who will respond? As a medical organization our medical role is clear: we have to provide adequate care to women and girls. As a humanitarian organization our responsibility goes beyond that. We have to expose the pervasiveness of sexual violence and its devastating consequences. We have to talk about sexual violence being used as a weapon. We have to point to those who allow sexual violence to continue. We have to address the responsibility of those who do not provide adequate protection, fail to see vulnerability or do not take it seriously.

Silence, indifference and inaction have been the answer to sexual violence for too long. Enough is enough. In the emergency situations where we work, among some of our planet's most vulnerable people, we can, and must, respond to rape and other forms of sexual violence in a humanitarian – and thus truly human – way. If we do not do this, who will?