A version of this article was published in the International Review of the Red Cross, April 2015.
Dr. Françoise Duroch has a master’s degree in history, law and human rights and a doctorate in education sciences from the University of Lyon 2. She is a former research coordinator for the Research Unit on Humanitarian Stakes and Practices (UREPH) of MSF Switzerland and is currently the manager of the Medical Care under Fire project at the MSF International. She has worked on sexual violence issues since 2001.
Catrin Schulte-Hillen is a midwife and has a master’s degree in public health, a license in applied epidemiology and statistics, and a diploma in business administration. She has worked for MSF since 1989 in a variety of roles at both field and headquarter level. As of 2011, she coordinates MSF’s working group on reproductive health and sexual violence care.
Keywords: sexual violence, rape, victim, medical care, MSF
Over the past 10 years, MSF has provided medical care to approximately almost 118,000 victims of sexual violence. Integrating related care into MSF general assistance to populations affected by crisis and conflicts has presented a considerable institutional struggle and continues to be a challenge. Tensions regarding the role of MSF in the care to victims of sexual violence and when facing the multiple challenges inherent in dealing with this crime persist. An overview of MSF experience and related reflection aims to share with the reader on one hand the complexity of the issue, and on the other hand the need to continue fighting for the provision of adequate medical care for victims of sexual violence, which after all and despite the limits, is feasible.
Sexual violence occurs in all societies and in all contexts at any time. Destabilization of contexts often results in increased levels of violence, including sexual violence. These are the contexts where MSF works most, bringing assistance to people affected by crisis and conflict. Sexual violence is particularly complex and stigmatising and generates long-lasting consequences; care for its victims is a priority and every MSF project should be prepared to offer related assistance. However, the challenges are multiple and need to be considered as part of care efforts: legal considerations, confidentiality, protection, stigma and perception as well as access to, and acceptance of, assistance and its instrumentalisation.
This article1 aims to share an analysis of Médecins Sans Frontières’ (MSF) involvement in the care for victims of sexual violence. MSF has been providing assistance to victims of sexual violence in numerous locations since 1999. The strategy and organization of assistance vary depending on the location and context. MSF focuses on medical care for victims of sexual violence; most of the victims seen by MSF teams are victims of rape2. Assistance includes treatment of injuries, prevention of sexually transmitted infections (STIs), prevention and management of unwanted pregnancy, post-exposure prophylaxis (PEP) for the prevention of HIV infection, vaccinations for tetanus and hepatitis B, psychological support and the provision of medico-legal certificates.
Over the past ten years, MSF has provided medical care to almost 118,000 victims of sexual violence in over 60 countries.3 The ten countries with the highest caseload during this period were: Democratic Republic of Congo (DRC), Liberia, Burundi, Zimbabwe, Kenya, Guatemala, Nigeria, Haiti, South Africa and Papua New Guinea (PNG). They account for 90% of all the victims of sexual violence that MSF has assisted.4
The first part of this article looks at the main events and circumstances that led the organization to develop specific medical care for victims of sexual violence. The second part gives an overview of the assistance that has been provided over the past ten years. The third part discusses the challenges MSF encounters in the implementation of assistance and includes reflection on the limits of MSF action, which highlight the complexity of the issue of sexual violence as part of an aid response in contexts of armed conflicts and other crisis.
MSF’S History of Response to Victims of Sexual Violence
For several years following its creation in 1971, MSF offered a limited response to victims of rape until the need for specific medical care became clear. The first treatment programme for sexual violence victims was established in Congo Brazzaville in 1999.5 Former members of MSF leadership6 in the 1970s and 1980s state that the issue of rape had long been on the agenda of the Board of Directors, but was not followed up with the launch of specific action because it was considered to relate more to human rights than to emergency medical action.
Historically, several events led MSF to realize both the magnitude of the sexual violence problem and its human and medical consequences.7 First, in the Bosnian and Rwandan conflicts (in the 1990s)8 and where MSF ran important assistance programs, large-scale sexual violence terrorized the population. Both contexts had high international media coverage, and the violence to which the civilian population was subjected led to the creation of two international tribunals as well as ad hoc jurisdiction such as the indictment of Jean-Paul Akayesu regarding his role in the Rwandan genocide, to name only one.9 While appalled by the human suffering of such violence, it took time and other events for MSF to assume an institutional role regarding sexual violence and to develop a systematic medical response for victims. The awareness of the political nature of systematic rape in both contexts contributed to the initial caution when approaching sexual violence related needs.10
Second, the threat of the HIV pandemic11 and the discovery of Post-Exposure Prophylaxis (PEP) in 1997, as a means to preventing the deadly consequences of HIV infection for rape victims, became the starting point for relevant medical activity12 in MSF. PEP presented atreatment with a proven added value for the patient. It would allow MSF to function within the known framework of medical care and a “patient–medical staff” relationship.13
Finally, the ‘Mano River scandal’ in 200214 created a new perspective regarding sexual violence that required urgent action: the role of assistance in creating opportunities for sexual violence and other forms of abuse, as well as the direct responsibility of humanitarian actors in preventing their own contribution to such forms of abuse. An Inter-Agency Steering Committee report15 stated that “[t]he foundations of sexual exploitation and abuse are embedded in unequal power relations”, and while the conclusions of the report were not validated16, the suggestion that systematic exploitation could involve all humanitarian actors did resonate in the international aid arena. Most sexual violence programmes started as of 2003.17
The call to act: an epidemic of rape and an aid scandal
In Congo Brazzaville in 1999, the medical assistance MSF could offer victims of rape began to take shape. MSF assisted the displaced population fleeing fighting in the Pool region to return to Brazzaville. Apart from the obvious needs, which included high levels of malnutrition and trauma, people’s accounts of events in the Pool and on their way to Brazzaville described the systematic rape of women and children.18 The main effort of assistance was initially focused on malnutrition, and it took months for MSF to get involved in assisting victims of rape. Some of the rape victims received care in the form of a specialized consultation in the Makelekele and Talangai hospitals, supported by a non-governmental organization (NGO), namely the International Rescue Committee (IRC). Care was basic: antibiotics were provided when available. Prevention of HIV infection, management of unwanted pregnancy and psychological support were not part of any systematic care. The potential of HIV infection changed the perception of the consequences of rape; it attributed a gravity that was measurable in terms of morbidity-mortality. A request to let victims of rape benefit from PEP was met with months of refusal from the Ministry of Health (MoH) in Brazzaville. The MSF team also had to fight strong resistance within the organization and among other aid actors, who disregarded the need for specific assistance, because, as some said at the time, “one does not die of rape.”19 The shocking lack of empathy implied in the statement still resonates. At the time the tension such attitude created and finally the overwhelming number of victims led to an agreement for a systematic medical approach.20 A medical doctor of the Brazzaville team21 had worked with HIV-positive patients in Europe and knew the potential of PEP; the team pushed for its use for victims of rape, together with the morning-after pill and treatment for the most common STIs.22
In Brazzaville MSF invested for years and explored different avenues to assist victims of sexual violence far beyond its core medical role, including social and legal support, and understanding the importance of public awareness as a tool to reduce stigma. The “Tika Bika Viol” campaign23 in 2003 aimed to foster political will and generated a more favourable environment for victims to come forward and receive assistance. An assessment in 2005, however, showed no increase in the number of victims attending MSF sexual violence consultations in Brazzaville24; a context where the incidence of rape is likely to have stayed high for quite some time.
The experience of responding to sexual violence has also pushed MSF to its limits in terms of legal and social support: “If the legal environment was explored in the interest of better understanding, it seems clear that, beyond the medico-legal certificate, MSF does not have a particular added value in an environment where the juridical system is dysfunctional. The same applies to social support; the activities directly related to patient care have proven to be a real added value, but beyond this, MSF does not have the means to assume a larger role in this area.” 25 The situation in Congo Brazzaville was brought to international public attention,26 but the recognition of the problem and the clarification of the relevant medical role MSF could have27 did not immediately result in an expansion of assistance to victims of rape in other contexts, such as in the DRC where MSF had worked for many years. That change happened in 2002 with the ‘Mano River Scandal’.28 The public exposure29 of the problem galvanized MSF into assessing the reality of abuse in MSF operations or lack thereof and establishing related preventive measures,30 reflecting on the challenges inherent to the work in contexts where insecurity and violence are prevalent31 and animating a movement-wide discussion on MSF’s role in reducing/preventing rape and in assisting victims of violence32. Most importantly, however, it triggered the start up of several projects in Burundi, South Africa, Sierra Leone and Guinea in 2003 in order to respond to the needs of victims of sexual violence.33 Public pressure played some role in this, but equally important was the need to understand the reality of the victims and how best to bring them assistance.
For MSF, it was necessary to gain experience and to strengthen the medical approach when responding to the needs of this particular group of people. Also, it was necessary to act in order to gain the legitimacy needed to speak out about the relatively underexposed problem of sexual violence as a part of conflict and crisis. Indeed, there was tension within MSF regarding the organization’s initial imbalance between voice and action regarding sexual violence.
“While we are just starting to work on some of these issues, i.e. to provide care to women who were victims of rape, it is indecent for MSF to embark on large pontificating speeches that demand the immediate end of the impunity and universal access to healthcare in a devastated country where the state postpones the resumption of its operations.”34
Over 100,000 victims assisted in TEN years: Development of operational support and policies 2004-2013
Since 2004, MSF has undertaken a yearly inventory of key medical activities in the field. This data collection includes the number of victims of sexual violence treated medically35 in MSF projects; it does not yet have a breakdown according to sex and age, but this is planned in the near future. The data reflected in the MSF “International Activity Report”36 are strictly defined and only include action that is implemented under the direct responsibility of MSF.37 Over a ten-year period, MSF teams assisted a total of 117,618 victims38 of sexual violence, predominately rape, in 61 countries.
Medical care for victims of sexual violence in MSF projects 2004–2013. Source: MSF Typology data 2004 to 2013.
The graph shows the number of projects providing care (blue line) and the number of victims who received medical care. It reflects a relatively stable investment over the past 10 years.
In DRC, large numbers of sexual violence victims come forward and helping them comes under the general assistance MSF provides in situations of conflict and displacement. Elsewhere, the majority of projects with high caseloads (> 500 cases in one year) were set up specifically with the intention of addressing sexual violence care either as specialised care or as part of HIV or women’s healthcare. These interventions are in post-conflict or stable settings rather than in conflict areas. In the latter, where sexual violence can be expected as part of the general upsurge of violence, few MSF projects apart from those in DRC have seen a large caseload of victims of sexual violence. Rather than representing the incidence of sexual violence, it shows the difficulty teams have in offering care in conflict settings and the difficulty victims have coming forward, be it for lack of access or fear of stigma and retaliations.
Data on the age and sex of victims of sexual violence is generated at project level; variations in age groups are partly due to an effort to adapt to countries’ national data reporting on the issue. What we do know from different reports and studies is that the overwhelming majority of the victims of sexual violence seen in MSF projects are female. Men and boys represent approximately 5%, which, according to other reports is low39 and reflects the additional barriers men may have40 in coming forth to seek assistance. Around half of the victims seen in MSF projects are under the age of 18, with an important number being young and even very young children.41
Ensuing more and better training and guidance for staff
MSF is essentially a “generalist” organization with multiple medical ambitions; care for victim of sexual violence is one of many health needs MSF responds to as part of assistance to populations in need. Any prepared medical team needs to be able to provide medical care to victims of rape; this cannot rely only on specialists. Other aid actors seem to increasingly opt for specific sexual violence advisors and officers to increase their response capacity. In MSF, the main strength for response is seen in the critical mass of staff that has organized sexual violence care over the past 10 years in many different contexts and which allows the increasing integration of care, despite competing priorities and limitations, into all relevant operations, be the emergency response or regular programs.
Preparing staff to respond to needs arising from sexual violence is increasingly addressed in briefings and training, but a number of other issues are on the list of priorities. MSF policy on sexual violence and related care is not systematically included in relevant trainings and meetings.42 There are one-week-long sexual violence trainings offered in the field43, and a day session on sexual violence is part of the two-week training for midwives and medical doctors involved in women’s healthcare projects.44
Since 1999, different MSF projects have documented the approach to sexual violence care, strategies that were used and related outcomes. They also reflect important efforts made in terms on awareness, both highlighting the problem of sexual violence itself and the barriers to adequate assistance. Local, regional and international advocacy efforts have contributed to overcoming some of the obstacles in different contexts and to creating an environment for dialogue with national and international actors. This is also part of the experience of sexual violence care, and can inform teams of its added value, but also the backlash that can be experienced when taking a public stand on issues as sensitive as sexual violence.45
Different Operational Centres of MSF have developed tools and guidance for sexual violence care.46 These practical guides are developed to allow staff with no specific experience to be able to recognize needs related to sexual violence, to organize care including patient circuit, outreach and public information, to deal with medical certificates and patient confidentiality, and to record data and monitor activities.
There is agreement on the medical preventive and therapeutic measures that should be offered to any victim of sexual violence approaching MSF for assistance. However, the lack of common implementation guidelines in MSF on why, when, where and how to start specific sexual violence care seems somewhat symbolic of the lack of consensus on the organization’s role. The absence of a transversal effort to address sexual violence throughout relevant MSF trainings may be indicative of the subject being back-staged among the organization’s priorities.
Challenges in caring for sexual violence victims
Sexual violence as part of conflict is known as long as mankind47. As an aid organization however, it is the ten-year delay between the direct exposure to large-scale sexual violence in the context where MSF worked (Rwanda and Bosnia), and the implementation of a specific aid response, which draws attention. Related dynamics have been analyzed closely in MSF and beyond and several challenges emerge as factors explaining the delay in starting specific care in the first place.
Conflicting priorities are a central challenge that continues to be relevant today, and implementing programmes related to sexual violence remains a particularly difficult task.48 The issue obliges humanitarian organizations to rethink their strategies, including their position regarding the provision of contraception and safe abortion care, a situation that might isolate them from the political support they need, notably – but not solely – to obtain funds. Moreover, due to the risk of victims’ stigmatization, humanitarian actors need to ensure a sensitive approach, adapted to local possibilities and the cultural environment and able to evolve with the setting.49 It forces them to assess and study with particular care the environment in which they are working before delimiting their scope of intervention. Several people in MSF highlighted the technical and ethical challenges inherent in the care for victims of sexual violence, particularly those related to the status of women and the difficulty for staff to deal with the sensitivities around sexuality in societies where MSF is called to assist and where the organizations understanding of cultural norms is limited.50 Furthermore, the concrete medical needs arising from rape and the way to address the most delicate ones, in a context where customs and perceptions are relatively unknown, is recognized as an important challenge.
“All areas dealing with the status of women make us feel uneasy. Speaking to a raped woman about psychological support, what does that mean in Africa? She tells us she needs an abortion. What do we do? We know very well that we will be dealing with difficult questions, which will permanently lead us back to the role of women in society.”51
Another issue that emerges for MSF – as for other humanitarian actors, particularly emergency organizations – is the difficulty in determining the limits of its role and responsibility when faced with victims who require medical care, but also assistance and consideration beyond the medical, often on the longer-term.52 The social and cultural perception – as well as the sensitive nature of rape – requires that any medical intervention be undertaken in such a way as not to contribute to harming the victim any further. Victims are often invisible,53 as women and particularly men are frequently very reluctant to seek assistance; consequently, reaching them requires a pro-active approach. Meanwhile, the structure of operations may make it extremely difficult to maintain victim confidentiality – a major concern, given that the stigma and taboos surrounding sexual violence in many cultures can potentially lead to harm rather than help. The difficulty lies in reaching a justifiable balance between the added value medical care can have for the victim, both in the short and long term, and the exposure to the social risk that rape-related stigma involves, including the risk of the victim being ostracized.
Finally, a persistent difficulty within MSF to agree on a common terminology regarding sexual violence seems somewhat symbolic of the varying ambitions that are pursued implicitly and explicitly around the subject. “Rape” describes a specific act of violence; the majority of victims of sexual violence MSF sees are actually victims of rape. “Sexual violence” defines a larger scope of sexual acts and attempts thereof that use force, including coercion54 and that violate the physical and/or emotional integrity of a person. “Gender-based violence” and “violence against women” emerge from a rights-based concern for gender inequity and for the status of women that allows violence to be committed against them. The term “gender” in this case tends to implicitly exclude concern for male victims of sexual violence, although this is the result of an erroneous interpretation of the term. The term “gender” was promoted through the 1995 Beijing conference in strong association with the subject of women’s empowerment.55 “Victim” is the term used in legal documents and procedures56, but “the stigmatization and perceived powerlessness associated with being a victim” is seen as a drawback of the terminology as early as 1995.57 “Patient” describes the medical status of a person who has been subject to an assault, related need for medical assistance and the commitment to confidentiality due to all patients. Further, the denomination “patient” recalls the medico-legal responsibility of medical practitioners when treating a victim of an assault, which is regulated under most national legislation. Finally, “survivor” is a commonly used term, which addresses the above-mentioned concerns for stigmatization. Literally, a survivor is a person having overcome a deadly threat, be it violence, disease or accident, but related to sexual violence it is often used to describe a living victim, even of usually non-fatal harm, to honour the strength of an individual to heal and to empower them58. The implications different terms involve can be in contradiction and can, when used systematically or for the sake of political correctness, lead to misunderstanding regarding the objective pursued. In MSF, this discussion has happened on and off for years, with strong opinions against the systematic use of mainstream language59. For MSF, as a medical and humanitarian actor, the terms “patient” and “victim” seem most appropriate.
The above challenges, which all contributed to the organization’s initial hesitation to engage, continue to be relevant and are part of the decisions relating to maintaining and expanding sexual violence care in MSF projects. Experience in care for victims of sexual violence over the past decade has revealed additional challenges, including the need for continuous efforts to overcome both internal resistance and external factors that stand in the way of adequate assistance to victims of sexual violence.
Challenges related to the organisation and acceptance of medical treatment
More than the medical treatment itself, the challenges are related to the organization and acceptance of care within the specificities of each context.
For the most part, the medical treatment of victims of sexual violence, particularly rape, is straightforward. There are cases however where the trauma inflicted is so extreme that intensive care and emergency surgery are required and repair surgery may be necessary to avert long term suffering from traumatic fistula61. For most victims of sexual violence, however, medical care consists of a set of basic curative and preventive measures, which can be provided in any prepared health facility - but there are a number of technical and ethical challenges involved. Without this care though, rape can lead to important short- and long-term health consequences.
Timely medical assistance
MSF will assist any victim of sexual violence, even if the assault took place a long time ago. Coming forward and speaking about the event is important, even months or years afterwards. Vaccinations against tetanus and hepatitis B62 will be relevant for months after the assault and the treatment of some STIs can prevent important long term health consequences. The potential of some preventive measures is, however, limited to the first few days after the assault. PEP for the prevention of HIV infection has to begin within seventy two hours of the assault, and although emergency contraception can be offered up to 120 hours after the event, it is most effective in the first seventy hours. After this, the success rate63 halves. Even in established programmes where MSF works specifically on sexual violence, not all and sometimes not even half of the victims come within seventy two hours of the assault. This was observed as early as the initial Brazzaville intervention64 and remains valid today.65
Adherence with treatment and follow-up
The additional exposure to risk, which follow-up visits can involve, needs to be taken into account: the risk related to stigma, of being identified as a patient going to a health facility that offers sexual violence care and the risk that is inherent in breaching geographical distance in many of the contexts where MSF works and which involves potential attack, robbery and rape. Coming to follow-up consultations requires patients to weigh the balance of risk and benefit, and often patients seem to opt for not taking risks.
Prevention and management of unwanted pregnancy
Emergency contraceptives are only an effective measure against pregnancy in the first seventy two hours after an assault. MSF sees women who arrive weeks or months after a rape, with an advanced pregnancy and who request termination. Provision of safe abortion care is part of MSF’s medical protocol for sexual violence care77 based on the medical and human needs of patients, whenever feasible. Despite ongoing efforts to expand safe abortion care and independently of the legal framework which often makes allowances for specific circumstances (incest, rape, etc),78 ensuring care for all women and girls in need continues to be a challenge and is still not offered in all relevant MSF projects. 79 Religious, cultural and social dynamics in many contexts continue to render abortion unacceptable and stigmatising, for women, communities and even for some health staff.
Caring for children
This is particularly relevant as MSF’s first project in Brazzaville already noted an increasing percentage of children among the victims of sexual violence in the post-conflict phase and a shift to the domestic environment and an increasingly complex situation whereby the future exposure of children to violence grew concerning.81 Similar situations have been observed in other MSF post-conflict situations, such as Burundi and Liberia, and MSF programmes with a specific focus on violence like those in Papua New Guinea, Guatemala and Honduras. In a number of these MSF projects, the majority of the perpetrators are known to the victim and the assault happens in the home or close vicinity.82 The question of the protection of the child becomes an inevitable one, but there are no ready-made answers. It seems that none of the alternatives are good: sending the child back to family or community and the known aggressor or exposing the child to an unknown environment, separated from family and community, and which may also then harbour risk of violence and abuse. For a medical team to see the same child over and over again, to treat the results of abuse a second and a third time without wanting to do something to protect the child is impossible. In many contexts the capacity for MSF to contribute to an acceptable solution is, however, very limited.
Caring for men
How to adequately respond to the needs of male victims also poses a great challenge,83 as the taboo around the subject remains huge, both for victims and their families, and even for doctors and humanitarian workers.84 Sexual violence stays largely invisible due attached stigma, especially when committed against men.85 Some polemics86 have questioned whether MSF structures and the provision of care are well adapted to this type of patient: “One problem with the exclusive focus on sexual violence is that it tends to downplay the ways in which sexual violence is not only (or simply) – as sometimes suggested – a war against women or a ‘systematic pattern of destruction toward the female species’.”87
Trauma, fear and guilt: the role of psychological support
Often, the initial medical visit will be the only opportunity to assist the victim; depending on contexts, few patients come for follow-up visits. Reinforcing the skills of medical staff to ensure “psychological first aid” as part of the immediate care for victims of sexual violence is therefore a priority and adapted to the majority of MSF projects.91 That said, while data shows low return rates of victims for follow-up sessions, MSF has not ventured into assessing the psychological support needs victims may experience in the longer term. These may well manifest months or years after an assault, affecting emotional, sexual and physical wellbeing and requiring specialized follow-up and care at that time. The degree to which MSF could assist in the longer term requires further reflection and will depend largely on the context.
Medical examination and treatment: a patient’s choice
Obtaining informed consent from a patient requires explaining all aspects of the consultation to the patient94 and asking for the agreement to proceed. It requires ample time to put the patient at ease, to explain what is going to take place in understandable terms, to listen to the patient and to understand her/his needs and reactions. Consent of minors is particularly challenging; establishing the legal responsibility of an adult over a minor needs to be assessed case-by-case with the best interests of the child in mind.
Ensuring confidentiality: a long term commitment
Finally, confidentiality is a concern when working with local organizations. MSF’s assistance to victims of sexual violence requires forging relations with local actors, women’s groups and social and legal entities in order to create referral options that may address the needs of victims to which MSF has no or limited response. Within communities around opposing parties, the use of sexual violence is often endorsed as a statement of condemnation of the adversary and resulting polarisation requires MSF to seek dialogue and working relations with diverse organizations to safeguard independence and the capacity to assist all victims, independently of their chosen or perceived alliance.
The legal framework around sexual violence
Amid conflict-like situations, legal systems may collapse leaving crimes unpunished; a medico-legal certificate can allow a person seeking legal action to provide evidence even years after the assault.105 Experience from Congo Brazzaville shows the potential value that medical certificates have in legal proceedings; nine out of ten of the medical certificates produced by MSF and used by victims in court were admitted by the judge.106
The justification for collecting patient data
The amount of questions addressed to one patient in the first consultation after a sexual assault can be overwhelming and can potentially alienate the patient and jeopardise the establishment of trust. Actors involved in the assistance to victims of sexual violence do so with very different objectives in mind; from this emerges a demand for all organizations to contribute sexual violence related data on a large range of questions. For MSF, the central objective is the medical care of victims in order to avert the short- and long-term consequences of rape and to help the victim recover. Information sought by MSF from individual patients and the corresponding analysis should focus on doing this better.108
2 For the purpose of this piece, we understand sexual violence as “any sexual act or attempt to obtain a sexual act by violence or coercion, unwanted sexual comments or advances, acts to traffic a person or acts directed against a person's sexuality, regardless of the relationship to the victim”, according to the World Health Organization (WHO). See WHO, World report on violence and health, 2002, p. 149. In turn, we understand rape as an act of obliging an individual to have sexual intercourse against his or her will, using force, violence and any other form of coercion. It is considered a felony in the criminal laws of most countries. See Françoise Bouchet-Saulnier, The practical guide to humanitarian law, 2nd English language edition, Rowman & Littlefield Publishers, Maryland, 2007, p. 355.
3 Review of reports and websites of different humanitarian actors, while reflecting involvement in sexual violence, but do not provide details on medical care; comparison is thus difficult. The International Rescue Committee states “Counseled and provided essential services to over 27,000 survivors of gender-based violence…” in there 2013 report available at: http://www.rescue.org/blog/2013-annual-report-read-about-irc%E2%80%99s-l... (all internet references were accessed in December 2014).
45 In 2005, MSF head of mission in Sudan was arrested, charged with crimes against the state, following MSF report on sexual violence. See MSF, “MSF shocked by arrest of Head of Mission in Sudan - charged with crimes against the state”, press release, 31 May 2005, available at: http://www.msf.org/article/msf-shocked-arrest-head-mission-sudan-charged...
46 MSF Pocket guide Care for victims of sexual violence – Situations with displacement of population, Version 3.0. 2013; MSF Sexual Violence Guidelines for medical and psychological care of rape survivors, edition 2010; MSF Sexual and gender based violence – A handbook for a response in health services towards sexual violence (internal documents). To facilitate the preparation of teams in the field, a “rape kit” was developed; it includes enough drugs and vaccines to treat 50 adults and 25 children.
47 Sylvie Joye, “La femme comme butin de guerre à la fin de l’Antiquité et au début du Moyen Âge ”, in M. Trevisi, Ph. Nivet (eds.), in Les femmes et la guerre de l’Antiquité à 1918, Economica/Institut de Stratégie Comparée, Paris, 2010, pp. 91-108.
60 Véronique Moufflet, “Le paradigme du viol comme arme de guerre à l'Est de la République démocratique du Congo”, in Afrique contemporaine 3/ 2008 (No. 227), p. 119-133, available at: www.cairn.info/revue-afrique-contemporaine-2008-3-page-119.htm
80 MSF, "Hidden and neglected”, above note 65, p 17; MSF, "Final report, Guatemala city", above note 41, p.16; Tayler-Smith "Sexual violence in post-conflict Liberia”, above note 65, p. 1358; Buard et al., "Survivors of sexual gender-based violence, Nairobi, Kenya", above note 41, p. 110.