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Shattered Lives: Liberia
Ensuring Care for Rape Survivors in Health Facilities
March 4, 2009
DRC 2008 © Pascale Zintzen
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MSF is providing care for victims of sexual violence in two hospitals and two clinics in Liberia’s capital, Monrovia. A drama group helps raise awareness of rape, social workers provide psychosocial support to patients and medical-legal certificates are issued for everyone. Coordinated lobbying efforts resulted in the adoption of a new medical-legal certificate, which is now being implemented at a national level.
The 14-year civil war left a trail of destruction in Liberia. Violence committed during the conflict included many forms of sexual violence, such as gang rape and sexual slavery15, affecting mostly women and girls. Combatants, whether male or female, were also frequently targeted.
A study carried out in 2008 found that more than 40% of women combatants, and 32% of men who fought in the war, suffered sexual violence during the conflict16. Its impact outlived the conflict. The same study revealed that 74% of female combatants who suffered sexual violence during the war had symptoms of post traumatic stress disorder (PTSD), compared to 44% amongst combatants who did not suffer such violence. Prevalence of PTSD among sexually abused male combatants is as high as 81%.
Despite the end of the conflict in 2003, rates of sexual violence in Liberia remain high. In 2006, the government launched a national action plan to prevent and respond to violence against women. Strengthening the justice system and facilitating health care for survivors of sexual violence are some of the objectives spelled out in the plan, but implementation takes time.
Significant changes were made to legislation, which expanded the definition of rape. any form of sexual penetration, whether with a penis, a finger, or an object, is now considered rape under Liberian law. The age of consent has also been raised to 18 years old, which means that any sexual relation with a person younger than 18 is interpreted as rape. The new laws have also established harsher punishment for perpetrators and abolished bail for rape cases. Despite these important first steps, the judicial system has yet to adapt these changes so the new laws have not yet made a difference in the society. Perpetrators are still hardly ever convicted. Rape still tends to be considered an act of aggression that should be dealt with privately. Most victims never seek health care or press charges. according to the association of Female Lawyers of Liberia, there is a conspiracy of silence and denial within the community and within the families involved.
If justice does not redress the plight of victims, the health system is also far from able to cope with their needs. Damaged by years of war, the weak health sector is unable to provide adequate health care. In Monrovia, for example, MSF provides 79% of all the pediatric beds available, in other words, the majority of health care for children. Victims of sexual violence struggle to get the care they need.
Treating Victims of Sexual Violence in Hospitals and Clinics in Monrovia
Since 2005, MSF has been providing health care to victims of sexual violence in two health centers and one pediatric hospital in Bushrod Island, an overcrowded area in Monrovia, home to more than 500,000 people. Clara town and New Kru town health centers, run by the Ministry of health, offer primary health care, including a range of services for mothers and children such as anteand post-natal care, vaccinations and prevention of mother-to-child-transmission of HIV. Together, they provide 20,000 consultations each month, including deliveries. island hospital is a pediatric emergency medical facility with 187 beds, which also provides antiretrovirals for children and families living with hiv, treatment for tuberculosis and medical care and food for malnourished children. Both clinics and the hospital offer medical care and psychosocial support to victims of sexual violence. victims younger than 16 years old are treated at the hospital. In 2008, MSF teams in Bushrod Island treated 771 survivors of sexual violence.
In Benson, a 106-bed hospital in Paynesville, a suburb of Monrovia, MSF offers medical care for children and gynecological and obstetrical emergency services for women. Health care for victims of sexual violence was also provided in the hospital until July 2008, when it was handed over to think, a local nongovernmental organization. MSF continues to provide technical and material support. In 2008, 886 rape survivors were treated by MSF in Paynesville.
In Bushrod Island, each facility is equipped to provide comprehensive care for rape survivors. Besides the care provided by a medical practitioner, a social worker provides psychosocial support, welcoming the patients and accompanying them to consultations. “Before the examination, the social worker counsels the patient to stabilize the symptoms and prepare her for the medical examination”, Theresa Saday, an MSF social worker in Monrovia, explained. “after the examination, another counseling session is conducted to find out about the patient’s family and whether they need protection. If they need it, we liaise with another organisation who can provide it”.
Medical-legal certificates are issued for every rape survivor who visits the health facilities. however, few patients decide to pursue legal action. “Many of our patients are illiterate, so it is very difficult for them to follow all the necessary steps”, Saday said. “Many times, they don’t know what they need to do to press charges, or they can’t afford it, as it is an expensive process”. In 2008, only four out of the total 771 victims MSF treated took their perpetrators to court.
The judicial system is an ongoing source of frustration to the team. although seeking justice goes beyond MSF’s medical mandate, health workers acknowledge that impunity may affect the way a rape victim deals with trauma after a sexual attack. “If they know the perpetrator and justice is not done, they feel afraid and powerless”, said Huyskens, the MSF psychologist who worked in Liberia. “Justice is also a way of telling the victims that it is not their fault”. As most rapes are committed by people known by the victim, impunity also means that they may be at risk of repeated attacks.
Raped? Get Treatment Now!
To raise awareness of rape and other health concerns in Bushrod Island, a drama group performs plays in the health facilities and in the community. in street markets and other popular locations, large groups of people gather to watch the performance and hear about the consequences of rape and the need to seek medical care. “We also do daily talks about sexual violence in the health facilities. What to do when a rape occurs? Most people in Liberia don’t know what to do, where to go”, said Saday. Billboards and t-shirts with the slogan ‘Raped? Get treatment now’! also help to spread the message.
After health promotion activities were expanded, the number of victims coming for care increased from an average of 26 to 60 per month. However, less than one-third arrived within 72 hours. “They feel ashamed, shocked. Disclosing the rape often leads to rejection from the husband, family or even community”, said Jill Huberty, MSF psychologist in charge of the sexual violence program in Liberia. “So they are afraid. Normally an adult woman would only come for medical care when she has physical symptoms related to the rape”. Many times, sexual violence is perpetrated by their own husbands, making it even harder to disclose. “Revealing that her own husband is forcing her to have sex is like speaking against the husband and covers her with shame”, said Huberty. Sexual violence against children, however, triggers a different reaction. “Rape of children, especially young children, is more recognized as an immoral act by the population”, Huberty said. ‘In most cases, it is a relative, a neighbor or a friend who discovers the rape because the child is bleeding, walking differently or changing behavior. And it is this person who makes a decision to take the child to the health structure”. In 2008, more than 70% of the survivors of sexual violence treated by MSF in Liberia were children.
MSF has also influenced how medical-legal certificates are accepted in the country. Before, they could only be signed by doctors. MSF lobbied so that other health workers would also be allowed to issue the certificate, therefore ensuring that a shortage of doctors in medical facilities would not prevent medical certificates from being issued. today, courts in Liberia recognize a medical-legal certificate signed by any medical practitioner. In addition, by creating a model that works both as a legal certificate and an examination record, the teams in Liberia have simplified the process and avoided duplication. “We record the history with the patients’ own words, what the medical person sees, like bruises, scars, and lacerations and mark everything on a picture”, Huyskens said. ‘It is objective and doesn’t leave much room for mistakes, which made the team much more comfortable in working with it”. As a result of lobbying efforts, the MSF medical-legal certificate was used as the basis for a new government-issued national medical certificate - called the national medical report - which is recognized throughout the country by Liberian law. Since October 2008, the new medical certificate has been used in all public health facilities that treat survivors of sexual violence.
Read the full report: Shattered Lives