War on the Female Body: Rape and Sexual Violence during Conflict

Volume 10 Issue 1
Review
Peer reviewed article

 

Abstract

Sexual violence has an enormous burden on individuals and communities worldwide. Women and girls are particularly vulnerable, with one in three women globally estimated to experience physical or sexual violence in their lifetime. Rape and sexual violence has severe physical and psychological consequences in any circumstance. This article focuses on rape as a weapon of war, the sociological impacts of which can be widespread and long-lasting. This is especially due
to the ensuing terror and disruption to livelihoods, relationships and morale. A recent example explored in this article was the rapes of over 200 women and girls in October 2014 by Sudanese military forces. Doctors and health workers can provide sensitive medical care to victims of sexual violence. However, medical care is only a fraction of the individual’s healing; the coordination of psychological and community support is integral to addressing their needs holistically, and can help potentially bridge barriers in accessing services.

Introduction

In October 2014, over 200 women and girls in the town Tabit, Sudan were raped by Sudanese government troops, according to Human Rights Watch report.[1] Witnesses described uniformed soldiers systematically looting, beating residents, and raping women and girls in their homes and on the streets.[1] The civilian attacks and mass rapes were denied by the Sudanese government, and the town intimidated and repressed against speaking out about the crimes, with some even restricted access to medical care following rape. [1]

Sexual violence is a major human rights and pub- lic health issue worldwide.[2] It causes serious physical and psychological suffering, and can have long-lasting and widespread impacts on individuals and communities.[2] Sexual violence is broadly defined as any sexual act, attempted sexual act, unwanted sexual comments or advances against a person’s sexuality by means of coercion such as physical force, intimidation, or blackmail.[2] Sexual violence encompasses a spectrum of manifestations including rape by intimate partner or non-partner, forced abortion and female infanticide, sexual abuse of children and people with intellectual disabilities, female genital mutilation, forced prostitution and sexual trafficking.[2,3] Another form of is that which occurs during armed conflict [2], such as the use of rape as a weapon of war. Rape in conflict settings is used as a militarised strategy to weaken and dehumanise enemies, attacking identity and social bonds. It is also employed as a means of terror and ethnic cleansing.[3]

Whilst sexual violence is perpetrated against both men and women, it particularly affects women and girls. One in three women globally will experience physical and/or sexual violence by an intimate partner or non-partner, according to the World Health Organisation (WHO).[4,5] Women and girls are especially vulnerable to violence and discrimination in societies and cultures which lim- it their social status and control. Violence against women is an expression as well as reflection of gender inequitable norms, and disparities in opportunities and empowerment. Thus, if violence against women is ever to be eliminated, it is imperative to address the root issue of gender inequality.

This article is a response to the mass rapes in Tabit, exemplifying the intertwinement of health and human rights issues associated with rape in conflict settings. For such a horrific act of bru- tality, it has been met with relative silence and response nationally and internationally. This reit- erates that sexual violence remains an under-rec- ognised issue, despite its devastating effects and widespread prevalence. In addition, this article examines medical and social implications for victims of sexual violence, barriers in accessing services and the role of doctors, health workers and communities in providing appropriate care and preventing the perpetuation of violence.

Sexual Violence During Conflict: Rape as a Weapon of War

Rape and sexual violence occurs during times of peace, however it escalates during armed conflict and humanitarian crises.[6] This causes extensive physical and psychosocial trauma not only to the individual victims, but to their families and communities. This amplification of dam- age throughout communities contributes to the rationale and effectiveness of militarised rape in inflicting widespread, long-lasting harm. The female body is thus more than mere spoils of war; when considered communal property, they serve as strategic targets through which to weaken morale and debilitate community bonds.

History shows us examples of women and girls targeted for sexual violence during conflict. During World War II, Japanese soldiers abducted and forced into sexual slavery an estimated 100 000 to 200 000 women from Korea, China and the Philippines.[3,7] For centuries, sexual violence was considered an inevitable side effect of war, rather than a preventable or punishable human rights violation. This changed following the recognition of rape as a war crime, following post-WWII Tokyo war trials.[3] However, rape and sexual violence occurred during armed conflict throughout the late 20th century, including in Bangladesh, Uganda, Sierra Leone and the Democratic Republic of Congo.[3,8] Rape was also used as a means of ethnic cleansing, with mass rapes of Tutsis by Hutus in Rwanda [9], and systematic rapes of women in the former Yugoslavia to terrorise civilians into fleeing.[3] Since the Rome Statute of the International Criminal Court in 1998, rape and other forms of sexual violence are considered crimes against humanity.[10] During conflict and humanitarian crises, sexual violence manifests in two major forms. The first is militarised sexual violence, distinguished as strategic, systematic and perpetrated partly or fully by government and/or state military forces. Examples include systematic rapes of civilians, such as those in the former Yugoslavia and Tabit, Sudan in 2014. The second form is opportunistic sexual violence, the abuse of women and girls at increased vulnerability due to conditions attributed to conflict and insecurity.[6] This includes sexual assault of women and girls collecting firewood, food or water. This is a particular issue in camps for internally displaced persons (IDP) and refugees in Sudan and neighbouring Chad during the ongoing conflict in Sudan.[8] Due to limited resources in heavily populated camps, families are forced to venture beyond the confines to forage for food and supplies, despite the risk of assault. Under such conditions, some families perceive that women and girls collecting firewood risk ‘only’ rape by Janjaweed militias, whereas men will almost certainly be killed.[8] It is also reported that women and girls at IDP or refugee camps may be forced to exchange sexual favours for food and necessities, including to peacekeepers and authorities supposedly responsible for their protection.[6]

Humanitarian Crisis in Sudan and Mass Rapes in Tabit

Conflict between government and rebel forces in Sudan has spanned over a decade since 2003. This has been driven by political and ethnic tensions, as well as long-standing struggles for scarce land and resources.[8,11] Villages have been destroyed, with inhabitants slaughtered and terrorised. Many attacks are racially targeted due to Fur, Masalit or Zaghawa ethnicity, pre- dominant groups composing rebel forces known as the Sudan Liberation Army (SLA) and the Justice and Equality Movement (JEM).[8] These form a resistance against a government they feel marginalises interests of non-Arab populations. Ongoing issues with insecurity, loss of livelihoods and mass displacement have resulted in over 300 000 deaths due to direct violence, disease and starvation, with around 2 million internally displaced persons and refugees fleeing to neighbouring Chad.[11,12]

Attacks against civilians in the village Tabit in the Darfur region of Sudan over three days commencing October 30th, 2014 are a brutal example of rape used as a weapon of war. According to over 130 witness interviews con- ducted and cross-referenced by Human Rights Watch, the attacks – including rapes, beatings and detainment – were perpetrated systematically by armed, uniformed Sudanese government soldiers. [1] Witnesses reported that soldiers entered houses, accused residents of links with rebels, detained or removed men and raped women and girls in their homes. During night at- tacks, men were reportedly forced out of house- holds and taken to distant locations, leaving women extremely vulnerable. Most victims were raped multiple times, often by multiple men, and in front of their families or friends. Even children were not spared from the violence, with victims and witnesses describing rapes of girls under 18.[1]

In addition to severe physical and psychological trauma inflicted on the village, intimidation from government authorities has contributed towards ongoing fear and repression. Residents have allegedly been deterred against speaking out about the crimes under threats including beatings and imprisonment. One interviewee likened the situation to “living in an open prison”, with military presence day and night and the prevention of female residents from exiting or visitors from entering.[1] The Government of Sudan and local authorities have publicly denied the crimes, as have some local traditional leaders, possibly under coercion. Members of the community have been instructed not to speak about the incident, especially not to Human Rights Watch or African Union United Nations peacekeepers.[1] This silencing and deprival of justice, with the crimes left unpunished, has been a further insult over- shadowing the attacks.

Another serious issue has been the deterrence and prevention of sexually assaulted women and girls from receiving medical care at clinics and hospitals. According to the report, some women have not sought help due to fear of arrest and further abuse as punishment for disclosing the rapes. There is also the belief that many doctors work for the government or that clinics are ob- served by intelligence staff. Others describe local authorities refusing to assist victims to access medical doctors, intimidating health professionals and punishing families attempting to bring rape victims for medical attention.[1]

Medical Implications of Rape

Survivors of rape and sexual violence often suffer various physical and gynaecological problems as well as psychological distress. Substantial evidence exists regarding adverse health consequences. These include gynaecological complications [13,14], sexually transmitted infections [15,16], unwanted pregnancies [14], unsafe abortions [16], post-traumatic stress disorder and depression (Table 1).[16] Victims may also experience fear and shame [3], and face ostracism from their partners, families or community. [2,9] Their suffering may also be exacerbated by limited access to health services, or social taboo surrounding sexuality and sexual violence. Fistula, chronic pelvic pain and infertility are gynaecological complications caused by rape. [13,16] Conflict-related sexual violence is significantly more likely than non-conflict sexual violence to cause fistula (traumatic or obstetric) or chronic pelvic pain, according to a study in the Democratic Republic of Congo.[14] Traumatic gynaecological fistula is an extremely debilitating injury involving abnormal communication be- tween the reproductive tract and internal organ, usually bladder or rectum.[17] Due to resulting urinary and/or faecal incontinence, women are often shunned and alienated by their communities. Particularly violent sexual assault such as gang rape or the use of foreign objects during rape leads to such fistulas.[17]

Unwanted pregnancy and unsafe abortions are also possible consequences of rape. In their inability to access medical care during conflict, desperation may drive women to endanger their lives with unsafe abortion [6], especially in countries where abortion is illegal. Abortion may also be an urgent matter in order to prevent the manifestation of rape as a visible, socially taboo pregnancy, particularly in cultures where female chastity is linked with family honour. In addition, pregnancy may serve as a distressing physical reminder of assault to the mother, and children born out of rape are at higher risk of neglect and malnutrition [6].

Another medical consequence of rape in conflict is sexually transmitted infections including human immunodeficiency virus (HIV). Risk of HIV transmission is increased in violent, forced rape due to the likelihood of tearing and breaching the vaginal or anal mucosa.[2] It has been speculated that mass rapes contribute to increased HIV epidemics in conflict-affected countries with high HIV prevalence. Limited evidence is available, how- ever one study investigating the impact on HIV incidence in African countries estimated increases of 5 infections per 100 000 females per year in four out of seven countries studied, including Sudan.[15]

Table 1: Medical complications of rape and sexual violence [3,13,17]

Sexual violence in any context causes severe physical, emotional and psychological suffering for victims. Depression, suicidal thoughts, post-traumatic stress disorder, anxiety, feelings of humiliation and fear, social withdrawal, inability to fulfil maternal roles and substance abuse are all adverse outcomes related to rape and sexual abuse.[9] Overall poorer physical and mental health, combined with stigma of sexual violence, contribute to the difficulty victims face in access- ing healthcare and support. Furthermore, these issues may be exacerbated in conflict settings, especially in situations where victims endure or witness more extreme forms of violence. Med- ical care and mental health services, difficult for victims of sexual violence to access even during times of peace, become more inaccessible during conflict due to strain on resources or destruction of infrastructure.

Doctors and other health workers are in a unique position to provide medical care to victims of sexual violence, as well as facilitate access to appropriate psychological and social support services (Table 2). In addition, documenting evidence such as sperm and DNA samples can assist legal proceedings, including identification of attackers where appropriate and with consent. [2,7] Victims should be approached with utmost care, dignity and sensitivity, with awareness that their injuries may be deeper and more extensive than tangible physical complications. Care should be taken to ensure consultation and physical examination causes as little distress as possible. Furthermore, underreporting of rape and sexual violence is common due to innate sensitivity and other personal or social factors, and victims of sexual violence may present with injuries, infections or pregnancy without initially disclosing they have been raped. Thus, medical professionals should be vigilant for signs of aggression or sexual assault, including genital bruising, lacerations or mutilation; missing patches of hair; and bruising on the arms, chest or forehead.[3]

Table 2: Medical response to sexual violence [2]

Whilst medical attention has valuable role in caring for victims of rape and sexual violence, it forms only a fraction of the individual’s process towards healing. The implications on mental health may be long-lasting, and social consequences such as blaming, fear and stigmatisation are a profound cause of suffering, as well as contributing to difficulty in breaking silence about sexual violence and seeking help. Integrated health, legal and community services are a potential means of increasing ease of access to support services. For example, rape crisis centres may provide various services including immediate and follow up medical care, counselling, forensic evidence, legal assistance, community support and education programs.[2]

Social Impacts of Rape During Conflict

The prominent social aftershocks of rape drives the use of militarised sexual violence, a weapon intended to shame and debilitate populations. The intimate link between female chastity, marriage and family honour is viciously exploited when rape is perpetrated on a mass scale.[6] It is used during conflict as a strategic act of terror, humiliation and dehumanisation, a means of destroying community bonds and morale. Local leaders, male community members and parents of children assaulted may feel extremely disempowered or unable to protect their families. Many victims are killed during the assault, others that survive may be blamed, stigmatised or rejected by their communities.[9]

Systematic rape is also employed as a brutal means of ethnic cleansing.[12] Women’s bodies, perceived as communal property, are targeted for impregnation in order to extinguish or pollute blood lines and cultures. This has been exemplified by racially targeted sexual violence during conflict in Darfur, Sudan. Friction between Arab and non-Arab ethnic groups contributes to targeting of civilian populations of Fur, Masalit and Zaghawa ethnicities. Surveys from a retrospective study revealed increased use of racial epithets during combined attacks by Sudanese government soldiers and Arabic Janjaweed militia against ethnic African women (p<0.001). Racial terror and sexual violence is compounded in statements such as, “We will kill all men and rape the women. We want to change the colour…Ar- abs are the husbands of those women”.[12] Moreover, ethnically targeted attacks in Sudan are not merely isolated incidents. Systematic raids of non-Arabic villages by Janjaweed militants, at times in combination with Sudanese government troops, appear to have occurred on a mass scale.[8] A consistent pattern indicative of the systematic nature of these attacks has been described by survivors: raiding forces surround villages, their arrival often signified by sexual assaults of women and girls gathering firewood or water. Men and boys are killed, women and girls raped by attackers entering house to house or gathering groups at a central location. Finally, fleeing survivors, mostly female, are pursued and assaulted as they seek safety in the surround- ing mountains, towns or entering IDP or refugee camps.[8]

The aftermath of fear and terror from rape during conflict can have dire and long-lasting consequences. Women and girls in fear of sexual abuse may be reluctant to leave home and participate in normal routine, crippling the ability of households and communities to function and thrive. Education may be affected when children are afraid to walk to or attend school. House- hold malnutrition and poverty may be intensified when women are afraid to collect firewood, food or water in fear of assault. Economic status and employment is similarly compromised when men are afraid to work or unwilling to leave wives and daughters alone at home.[16] Such sociological impacts are amplified on a mass scale when sexual violence is enacted against large populations. This principle of widespread incapacitation contributes to the continued use of rape as a militarised weapon of war.

Ethnic tension and discrimination is also a major barrier in the provision of and access to medical care in Sudan. Under the former Criminal Procedure Act, in order for patients to legally receive treatment, they were required to obtain a medical evidence form from police, known to withhold forms from individuals of certain non-Arabic tribes.[18] Health workers have also been pressured and intimidated as a deterrent against car- ing for these ethnic populations. An example is the harassment, detainment and interrogation of health workers at the Amel Centre for Treatment and Rehabilitation of Victims of Torture in Darfur. The centre is a non-government organisation providing free legal and clinical services to those affected by human rights violations, including numerous victims of violence (beatings, gunshot wounds) and rape, mainly from tribes of non-Arabic ethnicity. As many as 1 in 2 women who attended from 2004-6 disclosed sexual assault (49.3%), most commonly gang rape (86.1%), and this was potentially an underestimation of the true scope of sexual violence as the majority of patient records at the time were male (252/325 = 77.5%).[18]

Broadly speaking, community involvement is vital in fostering an environment where victims can safely access services and support they need and taking action to prevent perpetuation of sexual violence. Having the support of their community can have a profound influence on healing and protection against further stigmatisation and discrimination. Communities have the capacity to implement measures to prevent the perpetuation of sexual violence, for example through education in schools, support for women’s groups, inclusion of women in decision-making and public awareness campaigns to reduce stigma and acceptability of sexual violence (billboards, radio and television, theatre, public meetings).[2] Integration of sexual violence education with other health and social issues such as reproductive health, HIV, and general violence issues may also help to ease into discussion of sexual violence in settings, especially in situations where it is a sensitive issue.[2] Community activism contributes towards reducing stigma and changing public acceptability of sexual violence.

Conclusion

Sexual violence causes an enormous burden on individuals and communities worldwide, however it remains highly stigmatised and under-recognised. Victims of rape and sexual violence may endure a magnitude of physical and psychosocial consequences. This burden may be deepened by barriers accessing health services and community support, as well as victim blaming, stigmatisation and ostracism. Rape and sexual violence in conflict zones can be particularly debilitating due to weakened social infrastructure, widespread violence and presence of arms, mass displacement and loss of livelihoods, and increased baseline levels of violence against women throughout the population.

The mass rapes of women and girls in Tabit, Sudan are a gross violation of human rights and an unspeakable act of cruelty. It is unspeakable on multiple levels, from the silencing of victims and traumatised communities, to the silence of the international community about the atrocities and others committed throughout the decade of conflict in Sudan. Women and girls continue to be targets of sexual violence, especially due to disparities in opportunities and social status. If we ever hope to reduce the occurrence of sexual violence, it is absolutely crucial that we empower communities and take local and international action to address root causes of gender inequality. As current and future doctors, it is important to maintain awareness that sexual violence is intrinsically linked with personal factors and sociocultural issues. Medical attention is only a part of the individual’s healing process, with psychological and social factors equally as important. Coordination of appropriate health and community support can help address the individual’s needs holistically as well as bridge potential barriers in accessing services. Victims commonly encounter difficulties in accessing care for various reasons, and even those able to access care may not initially disclose sexual violence, and may need careful prompting once a safe environment and trust has been established. Thus a level of vigilance for signs of sexual violence should be maintained to help identify women at risk. Sexual violence may be silenced at first, however by seeking to understand, listening for warning signs and taking appropriate measures, doctors can help to heal and give victims a voice.

Carrie Lee

References

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16. Clifford C, Slavery SM, editors. Rape as a Weapon of War and it’s Long-term Effects on Victims and Society. 7th Global Conference Violence and the Contexts of Hostility Budapest(5-7 May 2008); 2008.

17. Salim F. Holdstock-Piachaud Prize essay. War and the systematic devastation of women: the call for increased attention to traumatic gynaeco- logical fistulae. Medicine, Conflict & Survival. 2012;28(2):125-32.

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