While this indicates a significant improvement in access to care for survivors—due in part to increased community outreach, improved referral pathways for specialized care, and expanded programs—it also signals that sexual violence remains a severe public health emergency across the county and is not solely a consequence of conflict.
The report, Invisible Wounds: MSF findings on sexual violence in CAR between 2018 and 2022, highlights the main barriers people face in accessing care and the gaps that exist for survivors of sexual violence, including basic and comprehensive medical care, access to protection, social services, and legal support. It also renews calls to the Central African government and national and international organizations to take immediate action, and provides recommendations to improve the availability and quality of services for sexual violence survivors.
“Sexual violence in CAR is a taboo public health emergency and cannot be solely addressed as an armed conflict-related problem,” says Khaled Fekih, MSF country director in CAR. “Despite some positive developments over the past five years, many survivors of sexual violence don’t report [the assault or] seek treatment. We know the number of patients [treated] is still just the tip of the iceberg.”
- While there has been progress, many gaps remain in access to care for survivors of sexual violence in CAR, from comprehensive to basic medical care, including psychiatric care for complicated cases and initial psychosocial support.
- Most patients delay seeking care after experiencing sexual violence due to the cost of care, insecurity in the area, and fear of stigma.
- Precarious living conditions in displacement camps can make people more vulnerable to sexual violence.
- Care is less accessible in provinces experiencing conflict, compared to the capital city of Bangui
- Specific groups such as men, children, and adolescents face additional barriers to care.
- Most perpetrators go unpunished.
A public health emergency
In CAR, sexual violence is a public health crisis and cannot only be addressed as a consequence of armed conflict. Approximately 70 percent of patients says they were attacked by someone known to them, for example, someone from their community. Approximately 20 percent of patients reported being assaulted by unknown armed perpetrators, but this did increase to 40 percent in some cities, including Bangui, during times of intensified conflict and in camps for displaced people. Further, a study conducted by MSF this year found that in conflict-affected settings, more broadly, people who resort to unsafe methods to terminate an unwanted pregnancy are more likely to face serious complications.
Timely access to care is vital
Rape is a medical emergency. If a survivor is able to seek care within the first 72 hours after an assault, they can receive vital medication to prevent sexually transmitted infections (STIs), such as post-exposure prophylaxis, to prevent HIV infection. Emergency contraception must also be administered within five days to prevent unwanted pregnancy. Psychological care and social support are also important as soon as possible, however, mental health care and some other health services can be provided after the 72-hour window.
Medical examinations carried out close to the time of an assault may provide useful documentation to help victims seek justice—though very few perpetrators are convicted because of flagrant impunity.
Of the survivors treated by MSF during this period, on average, only 32 percent arrived at our health facilities to seek care within 72 hours of the attack. Although this represents a continuous increase from 16 percent in 2018 to 35 percent in 2022, this remains worryingly low, and it took some victims years to receive the care they need.
The distance to travel to a health facility, the cost of transport, and lack of awareness of care available were often cited as reasons for a delay in seeking care. In some locations, patients reported traveling up to 80 miles to find care. “You need to know that there are health care providers that can give you the necessary assistance, but unfortunately this is not always guaranteed,” says Christian Serpande, an MSF data analyst.
Fear of stigma
Stigma and fear also pose significant barriers to people seeking care. Some MSF staff reported that the potential for forced marriage or family and community rejection to afraid to talk about their experience or seek care. In some situations, this has lead to suicidal thoughts.
Young people are particularly scared to talk about what they have been through.
About 5 percent of patients were male. Our staff assume this is likely due to the stigma men face—we know it is extremely difficult for male survivors to come forward. “Men who have suffered an attack often become dependent, they feel worthless. And this is not acceptable for them,” says Gwladys Ngbanga-Yema, a psychologist at MSF’s project in Bangui, where 7 percent of survivors were male. Most male patients need psychiatric treatment.
About 40 percent of patients treated by MSF in this five year period were younger than 18 years old. “In the maternity ward, we often see pregnant girls who are 13 and 14 years old,” says Jean Nepo Hakizamungu, MSF’s medical team leader in Bangassou, where 80 percent of sexual violence victims were children. “People [work] very late in the fields, which are at times very far away from the family houses. Some even go to farm in the fields in the neighboring Democratic Republic of Congo. Hence many young girls stay alone in the house and are more exposed to the risk of assault.”
Recommendations to help survivors access care and support
The increase in sexual violence survivors seeking care highlights the impact of MSF’s efforts to raise awareness of available services, including by building networks of community health workers in rural areas, door-to-door health promotion, radio spots, and theatre groups to spread health messages; identifying representatives in the community to facilitate the referral of patients to care; and engaging with local authorities, police, and other partners. However, more must be done to address the remaining gaps in access to care and support.
“A much stronger collective and holistic approach is needed to do more, faster and better. It must be a survivor-centered approach based on confidentiality, empathy, and respect,” concludes Fekih.
MSF provides additional recommendations to address sexual violence in CAR, including:
- Decentralize services, including a full medical package and psychosocial support, in order to guarantee access to care 24/7 across a broader geographical area
- Increase support for a multi-sectoral response, including through physical and mental health support, protection, social support, and safe spaces for survivors.
- Offer survivors the option of safe abortion care in order to prevent maternal deaths due to unsafe abortions.
- Encourage the development of strategies to tackle the root causes of sexual violence and change harmful social norms, with the aim of reducing the risk of sexual violence, including at the legislative, policy, and community levels.
- Provide access to free legal services to help survivors overcome their trauma from experiencing sexual violence.
- Provide much more legal and socioeconomic support so survivors can reintegrate into society without being penalized or stigmatized.