March 4, 2009
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In Colombia, few victims of sexual violence seek medical care immediately after being raped. Fear of stigmatization and safety concerns are some of the reasons that prevent them from doing so. MSF provides comprehensive health care for victims of rape and tries to reduce the barriers they face in accessing services.
A national demographic and health survey carried out in Colombia in 200512 found that 17.5% of women of child-bearing age had been raped at least once in their lives. In 2008, MSF conducted a survey in five provinces where medical teams were providing health care and the results in these specific areas were alarming: 35% of the women attending mobile clinics and 22% of those seeking care at the health centers and hospitals had been raped at least once. Almost 90% of the victims were between 13 and 49 years old. The MSF survey also revealed the many obstacles women face when seeking health care after being raped and the lack of adequate care.
In order to access health care, women have to overcome shame and fear for their safety. Among those who had suffered sexual violence eighty-one percent of women interviewed in mobile clinics and 95% in health centers and hospitals said that shame was the main reason they did not seek care. As most of the rapes are committed by people known to the victims, the proximity to the perpetrator generates fear of reprisal. According to 84% of victims interviewed in non-mobile health facilities, fear for their safety or that of their family prevented them from seeking health care. Doubts about whether the services would be provided confidentially also prevented women from seeking medical care.
Colombia 2007 © © Francesco Zizola
For those who overcome the initial obstacles, access to medical care is often not guaranteed. Although care for victims of sexual violence is established by Colombian law, the system does not ensure that medical or psychological care is available for those who need it. The health system in Colombia has been privatized and is run by the aseguradoras de salud, private health insurance companies paid by the government. Health care providers are concentrated in densely populated areas, leaving rural and remote areas with virtually no access to medical care. For victims of sexual violence, a lack of clarity about protocols and procedures hampers their access to care even more. “As each individual treatment has to be authorized by the aseguradoras, it can take a long time before the patient can receive care”, said Dr. Oscar Bernal, MSF medical coordinator in Colombia. inadequate human resources, insufficient supplies, lack of training of staff and administrative and logistical barriers also hinder the provision of care to victims of rape.
Many times, the medical or legal personnel who are supposed to offer assistance are judgmental, an attitude often rooted in prejudice and shaped by cultural myths. “The doctor told me that it was my fault, that I was the one to blame for what had happened, because I should not have been out in the street at that time”, said a victim of sexual violence interviewed in the MSF survey. “Such a beautiful woman should not be out in the street so late. But if i do not go out to work, who is going to support me? I work night shifts so if I do not go out…if I do not work, what then?”
Offering Health Care For Victims of Sexual Violence In a Hospital and Mobile Clinics
In Chocó department, one of the poorest regions in Colombia, MSF provides medical and psychological care to victims of sexual violence as part of the sexual and reproductive health care program. In Quibdo, the main city, a mobile medical team comprising a nurse, a doctor and a psychologist visit the most vulnerable areas every week, providing services like antenatal care, family planning, treatment of sexually transmitted infections and psychological care. Another MSF mobile team travels by boat to reach remote and isolated villages on the banks of the San Juan river, where the population has no other means of accessing health care. MSF also supports the maternity ward in the main hospital of Quibdo, where at-risk deliveries are referred.
Services for victims of sexual violence are provided at the hospital and in mobile clinics. Most of the patients who arrive within 72 hours go directly to the hospital, where care is given by the maternity team. Every woman is also offered at least one consultation with the psychologist. “Psychological care is very important in the early stages. It helps women to carry on with their activities, to continue with their lives”, explained MSF psychologist Magaly Manco. In Quibdo, it is also the psychologists’ role to tell patients about the steps they should take if they want to press charges. “Many don’t want to report because they are afraid of what might happen to their families”, Manco said. “If the aggressors have money or power, they may threaten the woman before she even thinks of pressing charges. In these cases, they have nothing to win if they report. they can only lose”.
In 2008, 218 victims of sexual violence were seen by MSF teams in Chocó. Of these, 44% were women between 19 and 45 years old, 35% from 13 to 18 years old and 15% under 12. to find more cases, the team in 2008 started looking for victims more actively. “We started asking people systematically if they had been victims of sexual violence”, said Dr. Bernal. “We have found more cases, but many happened a long time ago and don’t require any medical intervention anymore”.
Accessing patients within 72 hours of the rape is a challenge in MSF projects in Colombia. Only one-quarter of those seeking care in the hospital or in mobile clinics in Quibdo arrive within three days. “They are scared to come, they are afraid that the case will be disclosed and people will find out they have been raped”, said Petra Alders, MSF project coordinator in Quibdo. “That is why we always stress the issue of confidentiality. They need to be reassured that the services we provide are absolutely confidential and we will not share the information with anybody else”.
Many patients reveal old cases of abuse when they come to a consultation for a different health complaint. Manco, the MSF psychologist explained, “Sometimes they come for a different reason and in the middle of the consultation we find out the origin of the problem is a case of abuse that happened five or even 10 years ago. Other times the current problem is completely unrelated to the abuse, but as they feel at ease during the consultation they start telling us old stories that they had never told anybody”.
To encourage victims to come forward for care, the health promotion team organises workshops with patients while they wait for their consultation at the mobile clinics. “We talk about family planning, antenatal care and also sexual violence”, explains Deysi Garro, MSF psychologist working in the mobile clinics. “We explain what they need to do if it happens to them, where to seek help. We use personal testimonies, songs and other activities to raise their awareness. These talks also show them what to do in case someone who has suffered rape tells them about it. They learn how to listen and what to do to help the person”.
Local Awareness and National Advocacy: Helping Women Overcome Barriers
In order to improve awareness of sexual violence in Quibdo and to break through the barriers that prevent women from accessing services, MSF engages in local and national discussions on sexual violence. “We speak openly about sexual violence in Quibdo”, said alders. “We put the issue on the table with other organizations and also work with the media. It is an important step to break through the taboo, but of course it takes time”.
Following the MSF survey carried out in 2008, the MSF team in Colombia also launched a national advocacy effort to improve access to health care for victims of sexual violence. MSF asked the Colombian government to clarify the legislation and, most importantly, ensure that adequate services are available to rape victims. Spelling out the steps that a victim must take in order to receive medical, psychological and legal services is also essential to improve the quality of care offered to victims and ensure access to those who need it.
Read the full report: Shattered Lives
© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)