The issue of sexual violence involves every country and social class; it may occur within the family or broader community. But sexual violence increases with factors of poverty, during times of conflict, displacement and natural catastrophe, and it preys on the young.
We highlight a number of these risk factors below.
In general, young women are at greater risk of rape than older women. As for any woman exposed to sexual violence, without appropriate care this can lead to sexually transmitted infections, HIV, unwanted pregnancy and psychological trauma. But a lack of available care can be exacerbated by a lack of appropriate services for all their sexual and reproductive health needs.
The barriers to care are often far worse for younger women because may fear that they will not be believed when they disclose the assault; or they may lack the confidence or even the language to explain what happened. The sense of guilt too can be overwhelming. Sexual assault can also change the life course of a girl who wished to complete school, seek financial independence, or be able to plan her first pregnancy.
In many settings where MSF works sexual violence care for children is non-existent, yet the youngest victims need the most robust support. In Mathare, Kenya, for example, one in four of our patients are under 12 years of age. Without early psychological care it can be difficult for children to recover from the experience, presenting a significant setback to their growth and development. But like adolescents, accessing care relies on their own bravery in speaking up, and a sensitive guardian responding to their plight.
MSF is rare in offering care for children in addition to adults in a number of contexts. The consultation environment, tools and processes have been carefully adapted: child-friendly rooms; adapted questionnaires; child-centred techniques such as play therapy. But there are many challenges to overcome for the children and the care providers. Many children are related to their abuser. Some are homeless, or orphaned, which has increased their vulnerability. Can they return home, or do they need a refuge? The issue of protection looms large for these young victims.
With a majority of patients under 18 years of age, Médecins Sans Frontières continues to refine its services to address the complexity of their needs.
Conflict & Displacement
During conflict, sexual violence including rape can be used as a weapon, to punish, control or humiliate communities. The breakdown of law and order that often accompanies conflict increases the risk and incidence of sexual violence.
When crossing borders, women can face assault from bandits or border guards abusing their power, or abduction by traffickers. Families are often separated during conflict, leaving solo women or children at increased risk. In the insecure environment of a refugee or an internally displaced person’s camp, women may be forced into prostitution to support their families, sexually exploited by those in power, or sexually assaulted when collecting water or wood.
If people are displaced they may find it harder to access care due to complete lack of services, distance, transport barriers, lack of finances, language barriers, and uncertainty about the available services and their quality. Additionally, in their new environment, a refugee or migrant is often left feeling isolated and trapped after an attack due to a lack of personal and formal support systems.
These testimonies highlight how women on the move are particularly vulnerable. It is important to mitigate their risk with adapted services and protection measures.
Weapon of war
Sylvie is a Central African midwife; Agnes, a French psychologist. Together they care for victims of sexual violence in a specialised clinic established by Médecins Sans Frontières in Bangui General Hospital, in the capital of Central African Republic. Here they describe the suffering experienced by the women, the omnipresence of violence in CAR since 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 terrorised and traumatised children.
The assaults occur in situations of extreme violence
Says Sylvie, ”Here, in the context of armed conflict, rape is less an issue of sexual impulse than it is a weapon of war. 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 there was none. The medical team also undertakes outreach activities in health centres 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 per cent 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.
Prevention and protection activities including awareness-raising have also sometimes had to be reduced; and the insecurity 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. So it is the international staff who respond to the summons to Court,” explains Agnes. Protection of the victims is a huge challenge for MSF’s team, to try to avoid letting them return to the same situation and the same environment that led to their rape.
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.