March 5, 2009
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Press ReleaseEmergency Medical Aid Vital for Victims of Rape
Through this report, MSF shares its experience in providing medical care, counseling, and other forms of support to thousands of victims of sexual violence in many countries around the world.
The report is partly born out of outrage about the inexcusable acts that these people have been subjected to and the damage inflicted upon their lives. It demonstrates why it is imperative to make immediate care available, and truly accessible, for those who have been sexually assaulted.
MSF hopes that this report will inform and inspire health officials, aid workers and others who should be involved in providing such support.
Sexual violence affects millions across the globe. It is a medical emergency, brutally shattering the lives of women, men, and children. It destroys families, damages communities. In many countries, the impact of sexual violence is further compounded by a dire absence of health care services for the victims.
In conflicts, rape and other forms of sexual violence are often widespread. This violence can be used to humiliate, punish, control, injure, inflict fear, and destroy communities. In times of stability, sexual violence is also a grave problem, devastating health and lives. In both settings, perpetrators are frequently those who are supposed to provide security, in their homes and in their societies at large.
In 2007, Médecins Sans Frontières (MSF) teams provided health care to 12,791 victims of sexual violence in 127 projects worldwide. However, any statistic on sexual violence paints an incomplete picture of the problem and its prevalence. The patients which MSF treats or who visit clinics or hospitals run by others are victims who seek help against all odds – overcoming shame, fear, stigmatization and many other obstacles to reach medical care. In too many places, however, people do not, or simply cannot, come forward to report their assault or seek treatment.
Finding immediate care is critically important after a sexual assault. The provision of medical care within days after rape is vital to limit serious consequences for the victims: treatment to prevent HIV infection has to start within three days, emergency contraception is possible within five. Yet, in many countries access to tailored health services is either severely limited or non-existent. It can be equally hard to find social support or seek justice. Thus, following incidents of sexual violence, many find that they are completely alone.
It should not, and need not, be this way. In this report, MSF describes some of the successes and the challenges of its work addressing rape and sexual violence. By sharing experiences of providing medical aid in Burundi, Colombia, Democratic Republic of Congo, Liberia, and South Africa, MSF shows that it is not only crucial, but also possible, to provide immediate health care for victims of sexual violence, even in difficult settings. MSF hopes that sharing these experiences will help ensure that more victims of sexual violence around the world get the care they desperately need and deserve.
Above all, MSF wants to put the millions of victims of sexual assault in the spotlight. Their horrible experiences should never have occurred and the acts of their perpetrators can never be excused. The damage done through rape and other forms of sexual violence can be dramatically limited through immediate assistance, but it will never be entirely repaired. Shattered lives can be rebuilt, but the scars will always remain.
What is sexual violence?1
© Bénédicte Kurzen
Sexual violence includes rape, sexual abuse and sexual exploitation.
Rape is an act of non-consensual sexual intercourse. This can include the invasion of any part of the body with a sexual organ or the invasion of the vaginal or anal opening with any object or body part. It involves the use of force, threat of force or coercion. Any penetration is considered rape. Efforts to rape that do not result in penetration are considered attempted rape.
Sexual abuse is the actual or threatened physical intrusion of a sexual nature, whether by force or under unequal or coercive conditions.
Sexual exploitation is the abuse of a position of vulnerability, differential power, or trust, for sexual purposes. it includes forced prostitution, sexual slavery, and transactional sex.
Transactional sex is the exchange of sex for favors, such as protection, food or money. It is a result of circumstances, an action resulting from a lack of choice.
Other forms of sexual violence include forced sterilization and female genital mutilation (FGM).
This report covers different forms of sexual violence. However, the most common form treated in MSF’s medical facilities, due to the medical response required, is rape.
Sexual Violence in Conflict
The rape of an estimated 20,000 to 50,000 women during the Bosnian war in the early 1990s was believed to be part of a deliberate strategy of ethnic cleansing. Following these horrific UN estimates, the International Criminal Tribunal for the former Yugoslavia, established in The Hague in 1993, recognized sexual violence as a crime against humanity. For the first time in history, a person was convicted of rape as a crime against humanity at the tribunal.
In 1998, the Rome Statute that established the International Criminal Court determined that rape, sexual slavery, forced prostitution, forced pregnancy and forced sterilization, among other forms of sexual violence, were crimes against humanity, a war crime, and could constitute an element of genocide. In June 2008, the UN adopted a resolution to ensure the protection and care of victims of sexual violence. Resolution 1820 states that sexual violence, when used as a tactic of war or to target civilians, can exacerbate conflict, and demands parties to conflict to protect civilians from it.
Sexual violence in conflict has long been seen as the collateral damage of fighting, practiced and accepted by different warring parties. The disruption of society and generalized violence help create an environment where sexual violence thrives. Increasing numbers of female-headed households and displacement, common phenomena in situations of conflict, leave civilians exposed to various forms of sexual violence. Sometimes, it is practiced by those with the mandate to protect the population. Sexual violence can also be used as a weapon of war, part of a military strategy to humiliate the enemy and destroy communities2. According to the United Nations (UN), between 250,000 and 500,000 women were raped during the 1994 genocide in Rwanda.
In more recent conflicts, sexual violence continues to be perpetrated on a large and brutal scale. “Sexual violence during war can have several objectives”, explained Françoise Duroch, MSF’s expert on violence. “Rape can be used as a weapon, meaning it is carried out with martial reasoning and used for political ends. It can be used to reward soldiers, or remunerate them, to motivate the troops. It can also be used as a means of torture, sometimes to humiliate the men of a certain community. Systematic rape can be used to force a population to move. Rape can also be used as a biological weapon to deliberately transmit the AIDS virus. In war, we also find the phenomenon of sexual exploitation, forced prostitution or even sexual slavery”.
For many years, MSF has been confronted with large-scale sexual violence perpetrated in war contexts. In 1998, during the conflict in Congo Brazzaville, more than 1,300 victims of sexual violence were treated in Makelekele hospital in the capital. In Ituri, Democratic Republic of Congo (DRC), 7,482 rape victims were admitted to MSF health centers between 2003 and 2007. Victims reported that attacks occurred during everyday activities, as well as during widespread offensives and forced displacement3. In North and South Kivu, eastern DRC, MSF teams treated 6,700 victims of sexual violence in 2008 alone.
Sexual Violence in Stable Contexts
Although sexual violence is exacerbated in war, it also affects millions of people living in post-conflict or stable contexts. In these situations, the perpetrators are often civilians known to the victims. They are neighbors, landlords, servants or family members. In many cases, they are heads of household or other males expected to protect the victim. In Burundi, when MSF first opened its clinic for rape victims towards the end of the country’s civil war in 2003, less than half of the rapes were committed by someone known to the victim. Today, this figure has risen to 67 percent. MSF also observes that, in post-conflict and stable contexts, a large proportion of the victims are children. More than 60 percent of the rape victims who visit the clinic in Burundi are under 19 years old. Thirteen percent are under five years old.
A less recognized but equally grave form of rape is that practiced within a couple. According to the World Health Organization (WHO), most cases of violence against women occur in their home and are committed by their partners4. Many times, they include both physical and sexual aggression. A WHO study on domestic violence carried out in 10 countries not at war shows that in the majority of settings, more than 75 percent of women who had been physically or sexually abused since the age of 15 years had been abused by a partner. In most countries, rape by a husband or partner is not considered a crime, despite the consequences these acts of violence may have on a woman’s physical and mental health5.
In stable contexts, sexual violence can sometimes also be an activity condoned by governments, as in cases of forced sterilization, or in rape in state prisons or psychiatric institutions. In 2007, an MSF emergency team in DRC provided medical and psychological care to Congolese women deported from Angola by the Angolan military for working illegally. While being deported, women were systematically beaten and raped. MSF collected 100 testimonies reporting the abuse.
Men and Boys: Unrecognized and Untreated
Liberia 2009 © Alessandra Vilasboas
Although women and girls are the primary targets of sexual violence, men and boys can also be victims of rape. However, this minority is often unrecognized and receives little care or protection.
Sexual violence against men includes rape, sexual torture, sexual humiliation, and sexual slavery. A form of violence specifically perpetrated against males is forcing them to rape family members, a practice known as forced incest, where both the rapist and the victim suffer the violence. Men in custody are at particular risk of sexual abuse, as rape is used to establish hierarchies of control and respect. A 2008 crackdown by Kenyan authorities against a rebel militia in the western part of the country led to many men, including male teenagers, being beaten, humiliated, and tortured. Most of them had their testicles pulled out or beaten7.
Men and boys are even less likely to report sexual abuse than women8. Fear of stigmatization, but also lack of care and protection under the law prevent them from reporting a case of rape. In MSF projects, only a small proportion of rape cases seen are men and boys. In MSF projects in Khayelitsha, South Africa, and in Masisi, DRC, approximately 6 percent of the rape victims who visit MSF clinics are male.
Some countries, like DRC, do not include male victims in their legal definitions of sexual violence. Male rape survivors also find a lack of male-friendly resources in services for victims of sexual violence. Not seeing themselves represented in leaflets, billboards or other material for rape survivors increases their fear of isolation and discourages them from seeking support.
While men can be victims of sexual violence, women can also be perpetrators. Male rape survivors attending MSF clinics in Ituri reported being forced to have intercourse with female fighters or guards while in detention. Most of these assaults were committed publicly, to cause humiliation. Even if not involved directly in forced sex, women may play a role as accomplices, facilitating repeated aggression or preventing the violation from being reported.
Far-Reaching and Long-Lasting Damage
For men and women, boys and girls, the consequences of sexual violence are physical, psychological, social, and economic. They affect not only the victims, but also their families and communities, leaving scars for life.
A violent case of sexual aggression may result in physical injuries, such as bruises, lacerations, stabbing, and fractures. Forced sex also causes vaginal or anal tearing, bleeding or infection, and chronic pelvic pain. In extremely brutal cases, such as gang rape or when an object is forced into a woman’s vagina, the physical harm can be so severe that it leads to the opening of an orifice between the vagina and the bladder, or the vagina and the rectum. This is known as vaginal fistula, a condition of devastating consequences which more commonly occurs after prolonged labor. Women with vaginal fistula have urinary or faecal incontinence, or sometimes both. Besides being painful, fistula leads to stigmatization and isolation.
HIV and other sexually transmitted infections
Sexually transmitted infections (STIs), including HIV/AIDS, are a serious health concern for victims of sexual violence. A woman is more likely to contract HIV/AIDS from rape than during regular sexual relations, as tearing and cuts in the vagina often caused by forced sex facilitate the entry of the virus in the mucosa. The risk is even higher amongst adolescent girls, as their reproductive tract is not yet fully developed, making it more susceptible to tearing. STIs like gonorrhea, syphilis, chlamydia, trichomoniasis, and urinary tract infections can also be a result of rape. Though some of these do not present any symptoms in women, if left untreated, they can lead to pelvic inflammatory disease and cause infertility.
Rape may result in unwanted pregnancies. Where abortion services do not exist or are unaffordable, women who feel unable to give birth to a child conceived during rape are exposed to the risks of an unsafe abortion.
Every year, about 18 million unsafe abortions are carried out in developing countries for different reasons, resulting in 70,000 maternal deaths9. Of those who survive complications from these abortions, many suffer serious consequences such as infertility or difficulties with future pregnancies.
The psychological impact of sexual violence can be devastating. According to the WHO, it often outlasts the physical injuries. Even with counseling, up to 50 percent of women retain symptoms of stress10.
Immediately after a sexual attack, victims are often in a state of shock. It is also common to feel guilty and believe that they could have avoided the rape. They may feel that they have lost control of their lives, be unable to perform everyday tasks or have nightmares and disturbing flashbacks. Rape victims also fear for their safety. Where impunity is rife, victims may still come across their perpetrators and fear further attacks. A case of sexual violence may hinder a person’s ability to form relationships and trust others. Their sex life may also be affected, as they often associate sexuality with violence and pain. In the longer term, many women will go on to develop depression, anxiety, and psychotic episodes. Rape survivors can also develop depression and post-traumatic stress disorder (PTSD), especially when there is a physical injury during the assault. Women and men who have been raped may also attempt suicide.
Stigma and Rejection
The damage caused by sexual violence goes far beyond physical and mental health. Victims of sexual violence are often rejected by their partners and family. They may be chased out of their homes, having nowhere to live. In many countries, a woman who is abandoned by her husband has no place in society. Rape survivors are often stigmatized and humiliated in their communities and many times blamed for the assault. In cases where the aggressor is the main bread winner in the family, the victim may feel forced to keep silent and endure further assaults to guarantee the family’s survival. In some cultures, due to the association of virginity and honor, the rapist may be forced to marry the victim, or the victim may be killed by male family members in an attempt to restore the honor of the family.
For all these reasons, revealing an episode of rape takes courage. When treatment is available, rape survivors must face an excruciating choice: seeking treatment means disclosing information and facing rejection and stigmatization; keeping it secret may affect their health or cost them their lives.
Sexual Violence As a Medical Humanitarian Emergency: MSF's Approach
© Bénédicte Kurzen
In 2007, MSF teams saw 12,791 victims of sexual violence in 127 projects throughout the world. In some countries, like Burundi and South Africa, MSF runs projects that provide care exclusively to victims of sexual violence. “Having a team that is specialized and well trained enables us to give the best care possible, therefore it is not long before the clinic becomes a reference”, said Thilde Knudsen, MSF women’s health expert. “It is also easier to raise awareness, as care for rape victims is not mixed with a range of other services nor hidden behind them”. In other contexts, a more suitable way of providing care for victims of sexual violence may be to integrate it into mobile clinics, health centers or hospitals. “If we work in every clinic, we will have a better chance of training a lot of people under good supervision, and when MSF leaves they will have experience and training so they won’t be afraid of dealing with it”, said Angie Huyskens, an MSF psychologist who worked in Liberia. Whatever the approach, an optimum package of services should include medical care, psychological support, medical-legal certificates which can be used as evidence in court, and information to help people understand why, how and when to seek care. MSF may also speak out against rape.
Prevention of HIV infection:
If the victim has been exposed to HIV, a course of treatment with antiretrovirals (ARVs) known as PEP (post-exposure prophylaxis) can prevent HIV infection. The PEP only works if started within 72 hours of the rape, though the sooner the treatment starts, the more likely it is to be effective. It must be taken for 28 consecutive days. If a patient arrives later than three days after the rape, it is too late to prevent HIV infection.
Prevention of hepatitis B:
The hepatitis B virus can also be transmitted through sexual intercourse and is more contagious than HIV. The hepatitis B vaccine is effective in preventing infection if the first dose is given within three months of the rape.
Prevention and treatment of other STIs:
Sexually transmitted infections can be prevented and treated with antibiotics. Whenever the risk is identified, a victim of rape will receive antibiotics that can prevent the development of infections like chlamydia, syphilis and gonorrhea – or treat them if they have already been infected.
Prevention of tetanus:
Depending on the nature of the violence, the victim may be at risk of contracting tetanus. When the patient has not been previously immunized or when the immunization status is unknown, a rape victim must receive a tetanus vaccination.
If the victim seeks medical care within 120 hours of the assault, it is possible to prevent an unwanted pregnancy with the morning after pill. The pill stops ovulation and inhibits implantation of a fertilized egg in the womb.
Treatment of injuries:
The presence of injuries related to rape depends on the level of violence used during the assault. injuries need immediate medical attention and extreme cases, such as fistula, require surgery.
During follow-up consultations, patients receive subsequent doses of the tetanus and hepatitis B vaccinations and are offered an HIV test. Even if the PEP has been taken, there is still a chance that the victim has been infected. Due to the virus incubation period, rape victims must wait at least three months to find out whether they have been infected with HIV as a result of the rape.
© Francesco Zizola
The first objective of psychosocial care for victims of sexual violence is to help them restore their ability to carry on with their lives after the traumatic event. In some cases, when patients arrive in a state of shock, initial counseling helps stabilize their symptoms and prepare them for the medical consultation. Timely counseling can also prevent the development of post-traumatic stress disorder at a later stage. “We have to find a balance between treating and preventing symptoms and at the same time helping the patient deal with some very practical problems that arise from being raped”, said Joel Montanez, MSF psychologist in Burundi. “For example: ‘the nurse told me that my husband has to wear a condom for six months, but I don’t want to tell him that I was raped, so what can I do ?’ There are many very practical problems that they have to deal with”.
“In many places where we work, seeing a psychologist can be stigmatizing, which doesn’t facilitate the healing process”, said Luk van Baelen, MSF project coordinator in Burundi. Psychosocial support to victims of sexual violence can be provided through psychologists or social workers, or incorporated into the health care offered by doctors, nurses, and other health personnel. Being compassionate to the patients’ feelings, listening actively and being non-judgmental is essential when dealing with rape survivors. It is also important to give them information about the common psychological consequences of sexual violence.
© Bénédicte Kurzen
As a medical organization, MSF has a clear role in issuing medical-legal certificates to victims of sexual violence. When a patient wishes to press charges against a perpetrator, the medical-legal certificate can constitute important evidence in court – sometimes the only evidence beyond the victim’s own words.
The certificate must contain a description of what the health worker has observed during the clinical examination and the patient’s own account of the sexual violence. A health worker cannot and should not determine whether a rape occurred.
The medical-legal certificate is a confidential document. A copy must be kept in the medical archives for as long as the victim is allowed to press charges – depending on the local legislation, this can be as long as 20 years.
In many countries, medical-legal certificates issued by MSF are accepted in court and have been submitted by victims. Even in conflict situations, where immediate legal action is impossible due to the collapse of judicial systems, patients still have the right to medical-legal certificates, as they may decide to pursue legal action once the conflict is over.
Raising Awareness of Services
© Alessandra Vilasboas/MSF
A crucial element of any project providing health care to victims of sexual violence is ensuring that they know about the services available, and about the importance of seeking care and of doing so as quickly as possible. Talking to people door-to-door, using theatre, radio announcements, and billboard advertisements are among the tools that can be used to communicate about sexual violence and encourage victims to seek help. While awareness raising focuses mostly on health care, it often touches on cultural issues and prevailing myths in a society. Therefore, it can help facilitate disclosure and challenge the guilt often felt by rape survivors.
Speaking Out Against Rape
Speaking out and involving other organizations and the community in addressing sexual violence help ensure that it is no longer hidden. “By making the projects visible, we are bringing the problem to the surface. By giving victims a voice, by talking about it, we are breaking through the taboo”, said Meinie Nicolai, MSF operational director.
In some cases, MSF may also engage in efforts to end rape. In 2007, as Congolese women deported from Angola were subjected to systematic rape by Angolan soldiers, MSF collected testimonies from one hundred women describing the appalling abuse they had suffered. By raising awareness of the violations and directly addressing Angolan authorities and the international community, MSF pushed for action to stop the abuse. “If systematic rape is being practiced by certain groups, we will address it directly and push for it to end”, Nicolai said.
Beyond Medical Intervention: Legal, Social and Economic Support
Many rape victims need more than medical care, psychological support, and a medical-legal certificate. When victims face rejection by the community or are at risk of repeated attacks, they may need protection and additional support. If they are no longer able to work as a result of rape, they need alternative means of generating income. If they wish to press charges, they may need legal assistance.
MSF’s role in providing legal, social, and economic support is limited due to the nature of its mandate as a medical humanitarian agency. Coordination amongst medical and other sectors is essential to guarantee comprehensive assistance to victims that addresses needs beyond medical care. Therefore, MSF often works in collaboration with other parties that should play a role.
MSF strives to make comprehensive health care for victims of sexual violence available in all its projects. Services should be provided in a way to ensure privacy and confidentiality, by same-sex health workers who receive ongoing training, and are respectful of the victim and non-judgmental. Teams often engage in extensive awareness raising activities to sensitize communities about the need to seek care as soon as possible.
Many times, however, volatile security, cultural myths and taboos, customs, poor conditions, and other external factors affect the ability to offer optimal care. In many settings where health facilities have few resources, ensuring safe spaces for treatment and counseling for victims of sexual violence is a challenge. The scarcity of qualified female workers in some countries may mean that having same-sex health workers is impossible. Outreach activities may be limited by security. A medical-legal certificate may be of no immediate value if the justice system has collapsed.
Throughout the world, MSF teams must overcome daily challenges in providing quality emergency care to victims of sexual violence. In some places, they have found innovative ways of offering emergency relief to those who experienced the trauma of rape. In others, reaching victims and providing care remains a challenge. MSF projects in Burundi, Colombia, DRC, Liberia and South africa show that the provision of health care to victims of sexual violence is possible and urgently needed.
Learning from MSF’S experience in Burundi, Colombia, DRC, Liberia and South Africa
Sexual violence happens everywhere. It can affect anybody. In conflict, it affects civilians and combatants, displaced and refugee populations, women, men,and children. It may be a consequence of widespread violence or deliberately used as weapon of war.
In stable situations, sexual violence is also pervasive. in MSF’s experience, it often happens within communities and even families, perpetrated by people known to the victim. It frequently involves children.
The impact of rape is devastating. A victim of rape is at risk of HIV/AIDS and other infections. Particularly brutal cases of rape may result in injuries including vaginal fistula, a painful and stigmatizing condition. Where safe abortion services are not available or are unaffordable, women who feel they need to end a pregnancy resulting from rape are at risk of serious complications and even death.
The psychological trauma of sexual violence can be equally devastating and may last even longer. Women, men, and children who have been raped may suffer from post-traumatic stress disorder. They may have low-self esteem and be unable to trust others or form relationships. They may also not be able to seek and find justice.
Sexual Violence: A Medical Emergency
Victims of sexual violence face serious health risks. However, with adequate and timely medical care, it is possible to minimize the physical and psychological consequences.
Even after exposure to HIV, infection can be halted through a course of post-exposure prophylaxis (PEP), a 28-day treatment with ARVs (antiretrovirals). This treatment is only effective if initiated within 72 hours of the rape. Within 120 hours of forced sexual intercourse, it is also possible to prevent an unwanted pregnancy. Sexually transmitted infections (STIs) can be prevented and treated with antibiotics. Infection with hepatitis B and tetanus can be avoided with a vaccine, which may be given after the rape.
Counseling can help patients restore their ability to carry on with their lives after surviving rape. An early offer of trauma counseling can also prevent anxiety, post-traumatic stress disorder, and other psychological conditions.
In many countries, however, health services for rape survivors are simply not available. Where they exist, lack of awareness, stigmatization and the inability to reach a health center are some of the obstacles that prevent victims from receiving care.
MSF’s experience shows that establishing services for victims of sexual violence in an environment where rape rates are high does not guarantee that rape survivors will come forward for care. Many times, victims of sexual violence are not aware that rape requires a medical response. In cultures where victims themselves are often blamed for being sexually assaulted, they may want to keep the rape a secret. Where they are uncertain about confidentiality and privacy of services, they may choose to stay away from medical facilities.
Sensitization activities are crucial to ensuring that victims of sexual violence are aware of the services available and of the benefits of seeking care swiftly. Through awareness raising efforts, people must also be reassured that health services will be provided confidentially and independently from other institutions, such as courts or police forces.
Speaking out about sexual violence can also help dispel myths and challenge long-established cultural beliefs, which influence the way rape is perceived and determine what is socially and legally accepted. By making the problem visible in the society, it is possible to stimulate public debate and contribute to efforts to prevent and address sexual violence.
The needs of rape survivors go beyond medical care. When livelihoods are lost as a result of the stigma that often follows rape, survivors need economic assistance. Where rape survivors are still exposed to their aggressors, protective measures must be put in place. Where the possibility to prosecute perpetrators exists, rape survivors should have access to legal support. When judicial systems offer little recourse for victims, lobbying and advocacy efforts may help improve legislation and ensure its implementation. In some cases, different organizations may join together in an effort to stop rape.
A truly comprehensive response to the plight of survivors of sexual violence can only be provided by a range of different actors. A coordinated approach between organizations involved in medical, legal and social support can best bring relief to those who experience the trauma of rape and other sexual violence.
MSF helps survivors of sexual violence in more than 120 projects worldwide - those who seek care despite many obstacles. For too many others, rape is left unaddressed and the physical and psychological wounds may never heal. To help these invisible victims, sexual violence must be recognised by more communities and governments as the medical emergency it is and addressed accordingly. It is only in this way that the untold numbers of hidden survivors can be helped and their lives rebuilt, and that future victims will be saved from the trauma that can shatter their lives.
© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)