Unless there are urgent medical needs such as critical injuries, providing psychological support to victims of sexual violence without delay is a priority for MSF staff. The patient needs to be able to speak confidentially, and share their burden in an environment of trust. Appropriate psychological support and comfort at this early stage can aid a victim’s recovery. For many patients it can be a slow process to be able to reveal what has happened—each patient is different. Depending on the size and context of the project this support will be provided by a counsellor, or a nurse or doctor. These staff need to 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 the 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 people to their work. Yet not surprisingly their 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 provides professional support in regular group and one-on-one sessions. Below, our staff 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 Médecins Sans Frontières’ program at Lavender House Clinic in Mathare Slum in Nairobi, 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 per cent are children under the age of 12.
In my work, children the under 12s 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 per cent 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 withdrawal 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 ten per cent 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 themselves wholeheartedly. MSF values ‘care for caregivers’ so it is essential that support for our staff is prioritised 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 counsellors 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 counsellors, their compassion and the sheer magnitude of the victim experience. “
TBC Clare Brennan worked as Mental Health Activity Manager in MSF’s sexual violence clinic in Port Harcourt, Nigeria. One of the biggest challenges has been to dispel the misconception that rape should not be talked about—because it is shameful, taboo, or the fault of the victim. In response, MSF’s services have emphasised providing a safe space for people to talk and acknowledge their experiences.
As part of the team that developed the clinic’s services after it opened in June 2015, Clare reflects on the different ways the counselling adapted to the context.
“I learnt pretty quickly that ‘people in Nigeria don’t talk about their feelings’ – namely due to negative perceptions surrounding mental health and the sense that there are many hardships experienced, so why should sexual violence be any different? Particularly for children, they are discouraged from sharing their feelings. With this in mind, the idea of introducing counselling for the victims was in itself an intervention that required careful consideration. The interventions had to be adapted to suit the needs of the victims and their families – many are educated but many are not. At a basic level, it was supporting the staff to engage therapeutically through various techniques such as play. The counselling interventions are short-term given our medical protocol, so we ensured that we prioritised the immediate issue for the victim and their family.
“Some interventions included risk management, relaxation and anxiety management (fun breathing exercises with balloons!), activity scheduling and simple interventions for parents to support their child. It was important that the interventions were simple and also fun. The national staff were essential in supporting me with developing interventions that ‘worked’. Perhaps we overcomplicate things in the Western world. The staff were eager to implement interventions that would facilitate change, support recovery and contribute to greater health and personal outcomes for the victims.”
The Port Harcourt clinic in southern Nigeria offers:
- Round-the-clock services
- Confidential medical care, counselling and psychological care
- Follow-up consultations with regular phone support available
- Referral to higher-level health facilities for medical and psychological treatment
- Community liaison and health promotion.
Care for caregivers
Unless there are urgent medical needs such as critical injuries, providing psychological support to victims of sexual violence without delay is a priority for MSF staff. The patient needs to be able to speak confidentially, and share their burden in an environment of trust. Appropriate psychological support and comfort at this early stage can aid a victim’s recovery. For many patients it can be a slow process to be able to reveal what has happened—each patient is different. Depending on the size and context of the project this support will be provided by a counsellor, or a nurse or doctor. These staff need to 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 the 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 people to their work. Yet not surprisingly their 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 provides professional support in regular group and one-on-one sessions. Below, our staff share their experiences and perspectives on the effects of sexual violence, and their role providing care.
“Suffering inside”
Juliana Nhamburo, a Nurse Counsellor working within Médecins Sans Frontières’ 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 counsellor, 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, psychological, social and emotional trauma.
“For one to be able to interact with victims, one really has to be able to listen to them, 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.”
ONE-STOP CARE
To provide the best quality of care to victims of sexual violence from the first moment of contact, Médecins Sans Frontières has defined an essential package comprising medical and psychological care, and medical certification. Confidentiality is ensured for all patients.
This care comprises:
- Treatment of physical injuries
- Prevention, treatment and vaccination against infections
- – Post exposure prophylaxis (PEP) against HIV infection – Treatment against potential reproductive tract infections (chlamydia, gonorrhoea, syphilis, trichomoniasis) – Vaccination against Hepatitis B and tetanus infection
- Prevention and management of unwanted pregnancy (emergency contraception, pregnancy test, safe abortion) or refer to antenatal care for a continuing pregnancy.
- Psychological support, including counselling and provision of, or referral to, more specialised psychological or psychiatric support.
- Provision of a medical certificate to patients, with copies kept as proof of medical care provided and the clinical findings. A medical certificate signed by an authorised medical person is required as proof to press charges against the perpetrator.
- Médecins Sans Frontières centres offer these essential services to all family and sexual violence victims in their first visit, in the one place. This means that integrated medical and psychosocial assistance is provided at the earliest opportunity in ‘one-stop’, so that victims of violence do not have to move back and forth between different service providers. Having to traipse between multiple sites to seek care creates impossible barriers for many victims, forcing them to repeatedly explain and relive the violence they experienced, which can lead to disengagement and re-traumatisation. Follow-up sessions for psychosocial support and medical care are available for each victim.
Coupled with effective community awareness, access to essential curative and preventive care for victims motivates them to seek out help. The presence of relevant treatment in their community increases community-wide understanding that such violence has serious medical consequences and is unacceptable.
Access to and availability of quality services also encourages more people to present within the crucial 72 hours after an assault, and this is one marker of success for our programs. But at the same time there remain many reasons why victims may not present in this time-frame, and for women or girls who come later, it is still possible to deliver pertinent care.
As our specialists remind, “Timely medical assistance is vital after rape. PEP for the prevention of HIV infection has to begin within 72 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 72 hours. After this, the success rate halves. However, Médecins Sans Frontières will assist any victim of sexual violence even if the assault took place a long time before. Vaccinations against tetanus and Hepatitis B are relevant for months after the assault and the treatment of some sexually transmitted infections can prevent important long-term health consequences “
For psychological support too, although our counsellors will always wish to see an assault victim as soon as possible, their door is open at any time.Round-the-clock
With women and girls at risk of sexual violence any hour of day, the only fitting response is round-the-clock services. In Mathare, in the Eastlands district of Nairobi, the extra hours, coupled with a toll-free number and free ambulance pick-up service, have been instrumental in getting a high percentage of women to present to MSF’s clinic within 72 hours—79 per cent in 2015.
Project Coordinator Corinne Torre has seen the dramatic changes in timely access for victims. At the beginning we only opened the Monday to Thursday, on a daily basis 8am until 5pm. But as people in Mathare cannot necessarily get access to transport, and many of our cases happen after 4 or 5pm, some because of drugs, or because of alcohol, people were not able to report cases to us. So we added ambulances, which is quite new for MSF by the way, and we go and we pick the patients from everywhere in the slums. So this means that we have an emergency phone number, they call us, we go and pick up the patient, and we bring the patient back to the clinic.
As a result we’ve seen a huge increase in patients, because before we were dealing with on average 150 new cases per year. Now it’s more than 2,600 cases in a year, or almost 200-240 cases per month.
In fact, we have two ambulances. We added one more ambulance because we also need to refer patients. They can need additional assistance that we can’t provide, such as shelter, protection, legal referral, or an X-ray. Our clinic provides medical care: we take care of the patient; we do the first consultation; we do HIV tests; we provide everything in terms of drugs to ensure that they will be safe enough; but if they have fractures or considerable injuries we have to refer them. So we have one ambulance just for referring the patient to the hospital, or for instance to UNHCR [United Nations High Commissioner for Refugees] as well, because we have a lot of refugees who have been assaulted in their countries who arrive here and then they are raped again”.
The Mathare project continues to evolve. What began in 2008, just after the post-election violence, as a slow increase in patients who had been sexually abused within that particular eruption of violence, has become a constant flow, in a context where violence is endemic. To the question of why, Corinne replies, “We were dealing with only Mathare at the beginning, but now we are dealing with all Eastlands, which means we are covering a population of about 2 million people. But why we have so many cases isn’t because we have more perpetrators in Nairobi county. It’s because we have increased our services in a way that better meets the needs of population, and there is more awareness of the services.Caring inside and outside
In the Papua New Guinean highlands, in Hela Province, Tari Hospital and the MSF-run Family Support Centre combine to provide one-stop care for victims of sexual and intimate partner violence. Adequate and timely medical and psychological care is crucial to help minimise the consequences of violence. But sexual violence and rape stay largely unreported due to stigma. To promote the availability of care, MSF’s teams also highlight that it is confidential, and free.
Nurse Aoife Ni Mhurchu has been working in Accident & Emergency caring for the strong women of Tari.
“The women come here in the safe knowledge that they have this free, essential service here, that it is confidential, absolutely confidential; they know that they’re safe here, they know that we look after them, inside and outside. We will look after their medical and surgical needs in Accident & Emergency if they have been badly beaten as well, if they have any limbs fractured, if they have any broken bones, any lacerations that need suturing—we will look after all of that.
Often they come in in shock—sometimes they can’t even talk to us. Sometimes they may have been left for dead somewhere, and they will either have been found by somebody else and brought in, or even sometimes they’re left at the hospital gate here. So initially we assess them and we look after their medical and surgical needs and as soon as possible; then we refer them to the Family Support Centre, where we will also look after their counselling. We encourage them to keep coming back for counselling, in order to actually heal on the inside as well. These women are very resilient, and they do come, and the awareness is growing. And they come of their own free will, and they all benefit from it.
I have met very strong women here in Tari. Whether it’s through their life experience, through everything that they’ve had to go through, through poverty, through the hard work that they do. They’re very strong farmers and they also suffer a lot in their lifetimes. You can really see a sisterhood here, between the women on the wards, even if they don’t know each other, or even if they’re from different wantoks [kin networks], you can really see that they look after each other very well. They come in here after they’ve been beaten, after being raped, with horrific injuries, and still, a short time later, you see them grinning, chatting away, very grateful to us for looking after them. They’re very resilient women.”
