Sixteen-year-old Florence was an orphan doing domestic work when the January 2010 earthquake hit Haiti. She moved with the family she worked for to a displacement camp, where her employer raped her. The rapist threatened to harm her even more if she told anyone, so she didn’t see a doctor. Besides, she didn’t have the money, the means, or the information she needed to get care. She discovered she was pregnant.

Months into her pregnancy, Florence decided to press charges. But the lack of a post-rape medical exam not only affected her health; it also prevented her from pursuing justice for this horrible crime.

In Haiti, the justice system relies on certificates from care practitioners after a post-rape examination as foundational evidence for prosecuting rape. Without this medical certificate, rape charges will not proceed successfully; and because significant numbers of rape victims cannot or do not seek medical attention following rape, many attackers are never charged or punished.

There are few instances in which the health and human rights of women and girls intersect in such an immediate way as after violence. Ending violence against women and girls, like that endured by Florence, is a public health imperative.

Sexual violence causes physical injury, disability, and even death. It can result in sexually transmitted disease, poor reproductive health, unwanted pregnancies, unsafe abortions, and depression. The public health community, including local and international health providers active in Haiti, needs to be prepared to handle the health and social consequences of violence against women, and to work to prevent this violence. Playing a role in successful prosecutions, including by issuing medical certificates after rape, is only one of many ways health professionals can take an active role in ending violence against women.

In Haiti, where I interviewed more than 120 women and girls about sexual violence and access to health care in 2010 and 2011, the government is doing little to inform the public about access to post-rape care, and few health providers are trained to address gender-based violence. Professional schools for doctors and nurses do not include instruction on treating gender-based violence as part of their core curricula or continuing learning programs. Doctors and nurses may not necessarily know how important medical certificates are for rape prosecutions. So even when girls like Florence are able to overcome obstacles in getting to a health facility, they may still not receive appropriate medical services, or the correctly completed medical certificate they need.

November 25 was the 30^th anniversary of the International Day for the Elimination of Violence Against Women. Over these 30 years, enormous gains have been made in some countries in passing laws against sexual and domestic violence and in developing guidelines for health providers to identify, treat, and refer victims of gender-based violence to appropriate services. In Haiti, these gains are just now starting to be made—slowly—with the criminalization of rape in 2005 and new legislation addressing violence against women being discussed.  But these gains mean little to women like Florence when the reality of seeking health services or justice is a far cry from the laws and guidelines.

Health professionals may not know that the women and girls they treat have experienced sexual violence and about the resulting trauma. Naomi, 25, didn’t tell anyone that a man had raped her, but she had an already-scheduled family planning appointment at a clinic shortly after. “I didn’t tell them I had been raped, because I was ashamed,” she told me.Unlike Florence, she had reached medical care—she was there in front of a health professional—and still Naomi slipped through the system.

Health professionals’ ability to recognize, treat, and work to prevent violence against women can have a significant impact on the human rights of women everywhere, and is especially critical in disaster or displacement situations with high risk of sexual violence, like Haiti.

In Haiti, and indeed in many other countries, public health authorities should take immediate steps to inform the public about where victims can go for post-rape care, as well as steps necessary for legal redress, such as obtaining medical certificates. Public health officials should work with medical and nursing schools to ensure that providers have proper training and the ability to recognize signs of violence if a patient is reluctant to speak.

Public health officials should also work with the many nongovernmental organizations operating in Haiti to make sure health professionals know what services are available for psychosocial support, legal assistance, or relocation to safe housing for women victims of violence. Without this, appropriate health care and legal redress will remain out of reach for women like Florence and Naomi.

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Amanda Klasing is the Americas researcher for the Women’s Rights Division at Human Rights Watch and author of the organization’s report, “‘Nobody Remembers Us’: Failure to Protect Women’s and Girls’ Right to Health and Security in Post-Earthquake Haiti.”

For more information:

Human Rights Watch: ‘Nobody Remembers Us’: Failure to Protect Women’s and Girls’ Right to Health and Security in Post-Earthquake Haiti

Women face particular danger of sexual assault and violence when searching for firewood in the bush outside of the camps. With many refugees in competition for wood, tensions are high. Boisson quotes  Sinead Murray of the International Rescue Committee as saying, “There’s a fear of going to the bush because they think they are going to encounter violence. Many women say that there are men in the bush and these men have guns and they’re going to attack.”

Even the numbers of reported attacks in Dadaab are misleading; the stigma associated with sexual assault, coupled with lack of confidence that perpetrators will be penalized, leads to an underreporting of gender-based violence. While aid groups work to offer counseling to victims and provide female refugees with whistles and flashlights, the pervasive threat of violence against women in the camps reveals the complete lack of protection and security of the displaced Somalis.

Voice of America also reports on sexual violence against Somali women.

Photo by Oxfam East Africa [CC-BY-2.0 (www.creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

Sexual violence against civilian populations during armed conflict is recognized as a deliberate tactic of war, the gravity of which determines whether it is considered a war crime, a crime against humanity, or an element of genocide [see Statute of the International Criminal Court art 7.1(g) and art 8.2(b)(xxii); Security Council Resolution 1325 on women, peace and security (SCR 1325) para 11; Security Council Resolution 1820 on widespread or systematic violence in armed conflict paras 1, 4]. The widespread and systematic rape, sexual slavery, forced prostitution, and recruitment and kidnapping of civilians is at pandemic proportions in the Democratic Republic of the Congo (DRC). The majority of victims are children. By November 2008, World Vision spokesperson, Kevin Cook, and Save the Children spokesperson, George Graham, considered the DRC to be potentially the world’s worst place to be a child. The Congolese army is the single biggest perpetrator of sexual abuses according to a Human Rights Watch report published in July. This is despite commitments from both the government and the military that those found guilty of such human rights abuses would be punished. However, sexual violence offenses extend beyond the Congolese army to rebel groups, armed actors, and even UN personnel.

The deadliest war since World War II, the forgotten conflict in the DRC as been particularly devastating for women and children, who remain targets of sexual violence. These attacks are frequently exceptionally brutal, including gang rape, rape with a weapon, and rape accompanied by serious bodily harm. The medical consequences include death from injuries, contraction of HIV, pregnancy, or the development of a fistula. The psychosocial impact can be just as serious. Victims face stigma and familial and social rejection or ostracism. This can restrict their access to education or marriage and leave them displaced and at risk of further abuse.

In March 2009, a Comprehensive Strategy on Combating Sexual Violence in the DRC was finalized by the UN Office of the Senior Advisor and Coordinator on Sexual Violence after consultation with key stakeholders. The four strategic components are the following:

1. Combating impunity for cases of sexual violence;
2. Prevention of sexual violence and protection of victims;
3. Security sector reform; and
4. A multi-sectoral response for survivors of sexual violence

Further, the Sexual Violence Research Initiative, an initiative of the Global Forum for Health Research, facilitated its first conference, SVRI Forum 2009: Coordinated evidence-based responses to end sexual violence, earlier this month. Held in Johannesburg, South Africa, the global event assembled 200 experts for the purpose of endorsing research, highlighting good practice in program design, and fostering increased partnership and network building in the field of sexual violence.

Internationally, there is a need to redress the inadequacy with which sexual violence is addressed. The degree to which sexual violence is a gross human rights violation and public health concern is frequently downplayed. This has limited the development of empirically based policy and public health prevention programs and response services.

It is important, therefore, to substantiate the legitimacy of sexual violence as a major public health concern for policymakers, researchers, and programmers by raising the profile of this frequently taboo subject and bringing it into the public arena. Public health scholars and human rights advocates, thus, have a key role to play in directing the research agenda and contributing to institutional capacity building.

Strategies require a systematic, coordinated effort to address sexual violence through increased information exchange, enhanced partnership formation, and further engagement in multi-disciplinary actions. The Interagency Standing Committee Taskforce on Gender and Humanitarian Assistance consisting of over 20 key stakeholders within the UN and NGOs developed cross-cutting minimum intervention guidelines to prevent and respond to sexual violence in humanitarian settings.

Of necessity is the focus on cross-cultural sensitivity in the design and implementation of interventions. Different socio-cultural conceptualizations of mental health and well-being need to be recognized so that measures are directed in a culturally meaningful manner. Ideally, rather than transpose an existing model from a locality with a different value system, programs should foster participatory programming that incorporates indigenous healing principles and existing systems and structures. Furthermore, it is important to focus on inclusion of stakeholders (both male and female) and empowerment. An illustrative example includes the indigenous healing practices utilized for war-affected children in Angola and Mozambique. Purification or cleansing rituals of former child soldiers attended by family and community mark the transition from the “contamination” of war and death to acceptance and validation. These symbolic healing methods address the local conceptualization of psychosocial well-being in terms of appeasing the spirits in a culturally meaningful manner.

An article in the current WHO Bulletin highlights the intrinsic difficulties in developing a national framework and implementing a multi-sectoral program (psychological well-being, physical health, and justice measures) to respond to sexual assault victims. The lesson from the field contextualizes the problem in the resource-poor, horizontal primary health care system present in Kenya. It presents challenges and lessons learned that can be used to inform policy. It is through the dissemination and sharing of such research that the issue of sexual violence receives greater visibility. Increasingly, researchers will be able to build on the body of literature to evaluate, shape, and deliver better services for survivors of sexual violence. It is from such initiatives that activists and researchers can advance sexual violence research, policy, and programs that will translate to meaningful changes in the lives of those affected.

Selected links for additional reading:

Association for Women’s Rights in Development (AWID)

BBC News Africa, Country Profile DRC

GBV Prevention Network

Harvard Humanitarian Initiative

IASC Sub-Working Group on Gender and Humanitarian Action

Interagency Gender Working Group (IGWG)

Joint Consortium on Gender Based Violence

Reproductive Health Response in Conflict Consortium

Sexual Violence Research Initiative

Stop Rape Now

United Nations Development Fund for Women (UNIFEM)

United Nations International Research and Training Institute for the Advancement of Women (UN-INSTRAW)

United Nations Population Fund (UNFPA)

VDay, 2009 Spotlight: DRC

WHO Gender-Based Violence Site

The African women’s organization Akina Mama wa Afrika, which means “solidarity among women” in Swahili, met recently in Kampala to discuss new efforts to prevent violence against women in conflict and post-conflict areas of Africa. This group is seeking to improve legal and judicial systems to better protect the rights of women. They believe improved documentation of women’s experiences is the first step, as there is a critical lack of statistics surrounding these crimes. “Shame constrains many women’s actions,” says Annie Chikwanha, Senior Fellow at the African Human Security Initiative Institute of Security Studies. “Most times you have to seek permission of men to access the woman’s voice. Men insist on listening to the conversation. So the women feel constrained…” Instead, Chikwanha says, “it is women who suffer these atrocities so they should talk about them instead of a third party who can distort the information…let us empower women with skills to have these experiences documented.”

The recent conviction of five men in a Democratic Republic of Congo (DRC) military court for the rape and torture of civilian populations is being hailed as a step forward in preventing sexual violence. These men, who committed crimes while in a local militia group, were found guilty of assault and battery, and rape; four were sentenced to life imprisonment and one to 30 years in prison. They are also required to pay significant financial compensation to their victims. Other groups have recently held public demonstrations and protest marches, often the first of their kind, despite possible threats to the women involved. Women’s groups in Chad are also attempting to improve reporting rates, legal prosecution of perpetrators, and laws protecting women’s sexual and reproductive rights.

These efforts come amidst new reports of sharply increasing rape cases in the DRC. The eastern province South Kivu has experienced Rwandan Hutu militia assaults against civilians, which resemble past attacks in South Kivu in 1998 and 1999. The use of rape as a method of war in Africa has grown increasingly common, even in areas where conflict has officially ended.

For further reading:

South African rape survey shock

Tracking the war on women in Darfur: Boston doctors detail accounts of rape, assault

Sexual Abuse: New Study Documents Rape’s Grim Toll

UN: End Rape in War – Sexual Violence Soaring a Year After the Security Council Promised Prevention

Congo’s Bemba to stand ICC trial

Video: Rape in Congo

War Against Women: The Use of Rape as a Weapon in Congo’s Civil War

Child rape survivor saves ‘virgin myth’ victims

Intended Consequences: Rwandan Children Born of Rape (exhibition of personal accounts from female survivors of the Rwandan genocide of 1994)

Nowhere to Turn (PHR report on violence against Darfuri women)

Women for Women International (organization helping women survivors of war)

My Sister’s Keeper (women-led humanitarian action group)

Airborne: A Journey into the Challenges and Solutions to Stopping MDR-TB and XDR-TB is a powerful new book written by John Donnelly that features interviews and images to put a human face on the TB epidemic across the world. In her foreword, WHO Director-General Margaret Chan wrote, “I urge you to read the personal stories collected in AIRBORNE. These are human tragedies that should never have happened. But these are also stories about the uplifting success possible when the right elements are in place.”

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Australian Abortion-Aid Ban Lifted

A thirteen-year ban in Australia on providing foreign aid for abortions has been lifted and Australia will provide  funding of up to $15 million for reproductive health activities to help reduce maternal deaths across the world.

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$50 Million US Contribution to UNFPA

President Obama has recently signed legislation to provide $50 million to the United Nations Population Fund (UNFPA) to improve the health of women and children and reduce poverty throughout the world.

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US Capital Blighted by HIV/AIDS

The U.S. Capital has an HIV/AIDS rate on par with or worse than some African nations the city’s health department reports.

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US Urged to Fix Iraqi Refugee ‘Mess’ It Created

As the Iraq war enters its 7th year, the United States is urged to provide aid to Iraqi refugees displaced by the fighting.

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In Reversal, US to Engage with Human Rights Council

President Obama’s decision to become actively involved in the U.N. Human Rights Council raises hope that the administration will take a multilateral, human rights approach to international diplomacy.

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Living in a Sea of Mud and Drowning in Dread

Hurricane season has left Haitians to navigate mud-covered towns; without clear evacuation and reconstruction plans, Haitians fear an even worse situation this year.

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Chad: Fighting Violence Against Women — But How?

Violence against women is endemic in Chad, where in December dozens of women took part in a protest march against the legal gaps and cultural norms that allow for rampant domestic violence, sexual abuse, and underage marriages.

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In Iraq, A Story of Rape, Shame and ‘Honor Killing’

Killing of a pregnant rape victim by her brother reveals the terrible frequency of ‘honor killings’ in Iraq.

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Mentally Ill and in Immigration Limbo

Xiu Ping Jiang, an illegal immigrant from China, faces the harrowing choice of deportation  or detention in a facility where she has, allegedly, received inadequate care for her mental condition.

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Women’s Health Insurance Fairness Act

U.S. Senator John Kerry has introduced a bill that would prohibit health insurance companies from charging women higher premiums and from discriminating against women based on whether they are pregnant.

After initially defending the law as being misunderstood, Karzai later explained that he was unaware of some provisions when he signed it. During a press conference in Kabul on April 27, he made assurances that the new law will be in line with human rights treaties and the Afghan Constitution, which guarantees gender equality. We have yet to see whether these amendments will actually do so. In Afghanistan, opponents of the law include women, hundreds of whom protested in Kabul and faced stoning from male counter-protesters, as well as officials and legislators who claim it represents a return to oppressive Taliban-style rule.

With a backlash against Western interference by both backers and opponents of the law in Afghanistan, it remains unclear how proponents of international women’s rights can best support Afghanis in their own fight against rights violations.

See also:

Video: Stones thrown at Afghan Women Protesters – YouTube

A Woman Among Warlords: Women’s Rights in the Taliban and Post-Taliban Eras – PBS, Sep 2007