Providing psychological support to victims of sexual violence without delay is a priority for MSF staff. The patient must be able to speak confidentially and share their burden in an environment of trust. Early, appropriate psychological support and comfort are essential to a victim’s recovery.
Depending on the size and context of the MSF project this support will be provided by a counselor, or a nurse or doctor. Every patient is different, so these health workers must balance listening, gathering information, examining, advising, and reassuring. Ideally they will be able to provide follow-up and continuity of care. But for many reasons patients may only attend the clinic once, so it is important to offer as much support as possible in one visit.
In MSF’s projects it is typically national staff who provide first-line medical and psychological care. Each brings knowledge of their community and their culture to their work. Not surprisingly, this work can weigh heavily. They may be shocked by the extent of sexual violence in their own community, or, simply, deeply affected by the individuals that they treat. To help them cope, MSF also provides professional support in regular group and one-on-one sessions.
Here, MSF staff members share their experiences and perspectives on the effects of sexual violence and their role providing care.
"The Trauma is Intense"
Pascale Pynson, a psychologist working in MSF's program at Lavender House Clinic in Mathare slum in Nairobi, Kenya, sees a considerable number of young children in the clinic.
“Our program offers comprehensive care to victims of sexual violence, including access to a 24-hour hotline and pick-up by ambulance. We see about 200 people at the clinic every month, most of whom are under 18. Of this number, 25 percent are children under the age of 12.
In my work, children under 12 are a really important focus of the program. They need to receive specific support using different techniques like play therapy; we also check their main symptoms with questionnaires adapted for their lower age. When you are under 12 and you have this kind of trauma, your psychological needs are different to an older child or an adult, and psychological care is mandatory to recover.
Here, in 80 percent of cases, the assault is committed by somebody the child knows. So the trauma is intense because it was a person that this child was used to associating with in a certain way.
Sometimes the trauma is not a rape—there is no physical violence noted, it’s more like sexual abuse. But for a child, this can have a big effect; they withdraw from their usual social life as a child. For instance, when the child is going to school, they won’t focus on their homework or school issues and they won’t be joking with their friends. There will be a lot of pain, it’s a disturbance for them, and sometimes they won’t tell the parents immediately either, which means they keep everything secret.
This is connected to the fact that most of the time the perpetrator will threaten the child. At the same time they give some rewards, they will give sweets, they will give the child something to eat, a little toy, or let them watch a television show, and so the offending can go on and on. In 10 percent of cases the perpetrators are immediate family members such as the father, step-father, or sometimes the cousin or brothers. It’s something that happened to the child in a normally trustful environment, and suddenly trust doesn’t exist anymore.”
In Mathare most of the children have the support of a guardian and, where not, the MSF clinic has developed strong links with children’s and social services for external support.
Care for Caregivers
Clare Brennan has recently returned from Port Harcourt in southern Nigeria. As mental health activity manager, her responsibilities included providing psychological support to the national staff within the clinic on a regular basis.
"Our national staff are at the forefront of providing care for victims of sexual violence and give [of] themselves wholeheartedly. MSF values 'care for caregivers' so it is essential that support for our staff is prioritized at the commencement of a project.
"Given that I couldn’t be present for every consultation in Port Harcourt, it was important for me to get a true understanding of how the staff were managing the stories of victims, and how they were providing psychological care. As the project activity increased, it was essential that each staff member was supported, both emotionally and in their skill development.
"I facilitated individual clinical supervision with both the national nurse counselors and the national doctors on a fortnightly basis. Essentially, this was a forum for my colleague to air any concerns relating to a particular victim and the victim’s story, explore any feelings they had related to the story, and to receive support in managing these as well as exploring various psychological interventions.
"Many staff described the acts of sexual violence as being an abomination; it is most difficult for them to fully comprehend the extent to which sexual violence is occurring in their own community. The staff are undoubtedly affected by the experiences and stories shared by the victims – which is testament to their skills as counselors, their compassion and the sheer magnitude of the victim experience."
Juliana Nhamburo, a nurse counselor working within MSF's sexual violence project in Mbare, Zimbabwe, admits her role is not easy.
"Seeing victims of sexual violence crying in a session is not easy. It needs a person with a strong heart. It does not require one to have a heart of a soldier or a lion, but a humanitarian heart.
"When you see them walking with smiles on their faces, one can conclude that all is well with them, but they will be suffering inside and pretending to be strong. Their lives will be hell until they share their experiences with someone they completely trust.
"My experience working as a nurse counselor, providing comprehensive medical care and psychological services to sexual violence victims at the Mbare Clinic, has not been easy. You see people that are bitter and have lost hope of a brighter future. You see people whose egos have been bruised, who have been betrayed by people that are close to them, and who have lost their sense of being and trust.
"Most of them bemoan lost opportunities in life because of what they will have gone through. Most of them suffer from the effects of sexual violence, which include getting infected with HIV; sexually transmitted infections; unwanted pregnancies; lost opportunities, for example, when a girl is forced to drop out of school because of pregnancy; physical injuries; [and] psychological, social, and emotional trauma.
"For one to be able to interact with victims, one really has to be able to listen to them [and] have a compassionate and humanitarian heart. If a victim sees that they can trust you, he or she can give you underlying information which helps you to understand their problems deeply."
A door-to-door campaign was instrumental in bringing a young victim forward in Harare, Zimbabwe, as Juliana Nhamburo, nurse counselor at MSF's Mbare Project, explains.
"I remember the story of a girl who was sexually abused by her father for a long time from when she was younger, but could not disclose the abuse to anyone because of the threats that she was receiving from him.
"She only managed to share her story when MSF conducted a 'door-to-door campaign' to educate community members about sexual violence and the importance of seeking medical treatment within 72 hours when one is sexually abused.
"Although the victim missed the emergency treatment within the stipulated timeframe, she was able to receive psychosocial support and was assisted to get temporary shelter in a safer place while pursuing her case with the courts.
"Our teams try and assist the victims by providing medical examination where necessary, providing medical treatment according to protocols, providing a medical certificate and, when requested, giving expert evidence in courts and attending to their needs. We also provide psychosocial support through counseling services. This process helps them to heal and recover from their traumatic experience.
"Some victims are rejected by their family, husband, and friends when they share their experience. Because of this, some women just suffer in silence. Victims of sexual violence need to be supported in every way possible."
Weapon of War
Sylvie is a Central African midwife; Agnes is a French psychologist. Together they care for victims of sexual violence in a specialized clinic established by MSF in Bangui General Hospital, in the capital of Central African Republic (CAR). Here, they describe the suffering experienced by the women, the omnipresence of violence in CAR since conflict broke out there in December 2013, and the efforts to provide care and comfort within the clinic.
"One day Fatou, a young mother of three children, came to us. She had been working in the fields, her small children alongside her, when a group of armed men appeared. Everyone fled but the men caught Fatou and raped her. That was 2013. Then, in September 2015, she was at home when her house was attacked. She was taken with some other women and children to another house, where the attackers killed the men and raped the women. Later she managed to escape and was able to reach Bangui, where she was referred to us," explains Sylvie.
Sylvie and her colleague Agnes are too often witness to stories like these, of women raped several times during their lifetime, and of terrorized and traumatized children.
The Assaults Occur in Situations of Extreme Violence
"Here, in the context of armed conflict, rape is less an issue of sexual impulse than it is a weapon of war," says Sylvie. "The assaults happen in full view of the community, the family, and the children, in between the murders and the houses set alight." MSF opened its sexual violence care program in Bangui General Hospital in July 2014 to kick-start a response to the needs of victims where previously there had been none. The medical team also undertakes outreach activities in health centers in PK5 district and M’Poko and Castor camps. A free ambulance service has also been established.
Since the clinic opened, the medical team has cared for 1,087 victims, almost exclusively women, 18.5 percent of them minors. Only 158 of the 1,087 arrived within 72 hours after the assault. Delays in seeking a consultation are most often explained by poverty, which means it is not always possible to find transport; lack of knowledge about the free services offered by MSF; and insecurity, which makes it hard to get around.
Widespread insecurity has also occasionally curtailed MSF's prevention and protection activities, including awareness-raising, and has also had an impact on the capacity for judicial support to the victims. "Our Central African staff are exposed to potential reprisals by the perpetrators of the violence," explains Agnes. "So it is the international staff who respond to the summons to Court." Protection of the victims is a huge challenge for MSF’s team. MSF staff members do everything they can to avoid returning victims to the same situation and the same environment that led to their assault.
Agnes and Sylvie hope that the democratic and institutional transition underway in CAR will calm the political situation; break the cycle of violence; and help expand preventive, treatment, and protection services for the victims of sexual violence.