Sexual violence occurs in all societies and in all contexts at any time. Destabilization of societies often results in increased levels of violence, including sexual violence. These are the contexts in which MSF works most, bringing assistance to people affected by crisis and conflict. Sexual violence is particularly complex and stigmatizing and generates long-lasting consequences; care for its victims is a priority, and every MSF project should be prepared to offer related assistance. However, the challenges are multiple and need to be considered as part of care efforts: legal considerations, confidentiality, protection, stigma and perception, as well as access to, and acceptance of, assistance and its instrumentalization.
This article aims to share an analysis of Médecins Sans Frontières' (MSF) involvement in the care for victims of sexual violence. MSF has been providing assistance to victims of sexual violence in numerous locations since 1999. The strategy and organization of assistance vary depending on the location and context. MSF focuses on medical care for victims of sexual violence; most of the victims seen by MSF teams are victims of rape.Footnote 1 Assistance includes treatment of injuries, prevention of sexually transmitted infections (STIs), prevention and management of unwanted pregnancy, post-exposure prophylaxis (PEP) for the prevention of HIV infection, vaccinations for tetanus and hepatitis B, psychological support and the provision of medico-legal certificates.
Over the past ten years, MSF has provided medical care to almost 118,000 victims of sexual violence in over sixty countries.Footnote 2 The ten countries with the highest caseload during this period were the Democratic Republic of the Congo (DRC), Liberia, Burundi, Zimbabwe, Kenya, Guatemala, Nigeria, Haiti, South Africa and Papua New Guinea. They account for 90% of all the victims of sexual violence that MSF has assisted.Footnote 3
The first part of this article looks at the main events and circumstances that led the organization to develop specific medical care for victims of sexual violence. The second part gives an overview of the assistance that has been provided over the past ten years. The third part discusses the challenges MSF encounters in the implementation of assistance and includes reflection on the limits of MSF action, which highlight the complexity of the issue of sexual violence as part of an aid response in contexts of armed conflict and other crisis.
MSF's history of response to victims of sexual violence
For several years following its creation in 1971, MSF offered a limited response to victims of rape until the need for specific medical care became clear. The first treatment programme for victims of sexual violence was established in the Republic of the Congo (RC) in 1999.Footnote 4 Former members of the MSF leadershipFootnote 5 in the 1970s and 1980s state that the issue of rape had long been on the agenda of the board of directors but was not followed up with the launch of specific action because it was considered to relate more to human rights than to emergency medical action.
Historically, several events led MSF to realize both the magnitude of the sexual violence problem and its human and medical consequences.Footnote 6 First, in the Bosnian and Rwandan conflicts in the 1990s,Footnote 7 where MSF ran important assistance programmes, large-scale sexual violence terrorized the population. Both contexts had high international media coverage, and the violence to which the civilian population was subjected led to the creation of two ad hoc international tribunals resulting in the indictment of Jean-Paul Akayesu regarding his role in the Rwandan genocide, to name but one.Footnote 8 While the organization was appalled by the human suffering of such violence, it took time and other events for MSF to assume an institutional role regarding sexual violence and to develop a systematic medical response for victims. The awareness of the political nature of systematic rape in both contexts contributed to the initial caution when approaching sexual-violence-related needs.Footnote 9
Second, the threat of the HIV pandemicFootnote 10 and the discovery of post-exposure prophylaxis (PEP) in 1997, as a means to preventing the deadly consequences of HIV infection for rape victims, became the starting point for relevant medical activityFootnote 11 in MSF. PEP presented a treatment with a proven added value for the patient. It would allow MSF to function within the known framework of medical care and a “patient–medical staff” relationship.Footnote 12
Finally, the Mano River scandal in 2002Footnote 13 created a new perspective regarding sexual violence that required urgent action: the role of assistance in creating opportunities for sexual violence and other forms of abuse, as well as the direct responsibility of humanitarian actors in preventing their own contribution to such forms of abuse. An Inter-Agency Steering Committee reportFootnote 14 stated that “[t]he foundations of sexual exploitation and abuse are embedded in unequal power relations”, and while the conclusions of the report were not validated,Footnote 15 the suggestion that systematic exploitation could involve all humanitarian actors did resonate in the international aid arena. Most sexual violence programmes started as of 2003.Footnote 16
The latter two elements were the main factors that influenced MSF's current perception of activities relating to care for victims of sexual violence.
The call to act: An epidemic of rape and an aid scandal
In the RC in 1999, the medical assistance that MSF could offer victims of rape began to take shape. MSF assisted the displaced population who were fleeing fighting in the Pool region and returning to Brazzaville, offering medical aid at way-stations and upon arrival in the capital. Apart from the obvious needs, which included high levels of malnutrition and trauma, people's accounts of events in Pool and on their way to Brazzaville described the systematic rape of women and children.Footnote 17 The main effort of assistance was initially focused on malnutrition, and it took months for MSF to get involved in assisting victims of rape. Some of the rape victims received care in the form of a specialized consultation at the Makelekele or Talangai hospital, supported by a non-governmental organization called the International Rescue Committee. Care was basic: antibiotics were provided when available. Prevention of HIV infection, management of unwanted pregnancy and psychological support were not part of any systematic care. The potential of HIV infection changed the perception of the consequences of rape; it attributed a gravity that was measurable in terms of morbidity-mortality. A request to let victims of rape benefit from PEP was met with months of refusal from the Ministry of Health in Brazzaville. The MSF team also had to fight strong resistance within the organization and among other aid actors, who disregarded the need for specific assistance because, as some said at the time, “one does not die of rape”.Footnote 18 The shocking lack of empathy implied in that statement still resonates. At the time, the tensions such attitudes created, and eventually the overwhelming number of victims, led to an agreement for a systematic medical approach.Footnote 19 A medical doctor of the Brazzaville teamFootnote 20 had worked with HIV-positive patients in Europe and knew the potential of PEP; the team pushed for its use for victims of rape, together with the morning-after pill and treatment for the most common STIs.Footnote 21
In Brazzaville MSF invested for years and explored different avenues to assist victims of sexual violence far beyond the organization's core medical role, including social and legal support, and understanding the importance of public awareness as a tool to reduce stigma. The “Tika Bika Viol” campaignFootnote 22 in 2003 aimed to foster political will and generated a more favourable environment for victims to come forward and receive assistance. An assessment in 2005, however, showed no increase in the number of victims attending MSF sexual violence consultations in Brazzaville,Footnote 23 a context where the incidence of rape is likely to have stayed high for quite some time.
The experience of responding to sexual violence has also pushed MSF to its limits in terms of legal and social support:
If the legal environment was explored in the interest of better understanding, it seems clear that, beyond the medico-legal certificate, MSF does not have a particular added value in an environment where the juridical system is dysfunctional. The same applies to social support; the activities directly related to patient care have proven to be a real added value, but beyond this, MSF does not have the means to assume a larger role in this area.Footnote 24
The situation in the RC was brought to international public attention,Footnote 25 but the recognition of the problem and the clarification of the relevant medical role that MSF could haveFootnote 26 did not immediately result in an expansion of assistance to victims of rape in other contexts, such as in the DRC, where MSF had worked for many years. That change happened in 2002 with the Mano River scandal.Footnote 27 The public exposureFootnote 28 of the problem galvanized MSF into assessing the reality of abuse in MSF operations, establishing related preventive measures,Footnote 29 reflecting on the challenges inherent to the work in contexts where insecurity and violence are prevalentFootnote 30 and animating a movement-wide discussion on MSF's role in reducing/preventing rape and assisting victims of violence.Footnote 31 Most importantly, however, it triggered the start-up of several projects in Burundi, South Africa, Sierra Leone and Guinea in 2003 in order to respond to the needs of victims of sexual violence.Footnote 32 Public pressure played some role in this, but equally important was the need to understand the reality of the victims and how best to assist them.
For MSF, it was necessary to gain experience and to strengthen the medical approach when responding to the needs of this particular group of people. Also, it was necessary to act in order to gain the legitimacy needed to speak out about the relatively underexposed problem of sexual violence in the context of conflict and crisis. Indeed, there was tension within MSF regarding the organization's initial imbalance between voice and action regarding sexual violence:
While we are just starting to work on some of these issues, i.e. to provide care to women who were victims of rape, it is indecent for MSF to embark on large pontificating speeches that demand the immediate end of the impunity and universal access to healthcare in a devastated country where the state postpones the resumption of its operations.Footnote 33
Over 100,000 victims assisted in ten years: Development of operational support and policies, 2004–2013
Since 2004, MSF has undertaken a yearly inventory of key medical activities in the field. This data collection includes the number of victims of sexual violence treated medicallyFootnote 34 in MSF projects; it does not yet include a breakdown according to sex and age, but this is planned for the near future. The data reflected in the MSF International Activity Reports Footnote 35 are strictly defined and only include action that is implemented under the direct responsibility of MSF.Footnote 36 Over a ten-year period, MSF teams assisted a total of 117,618 victimsFootnote 37 of sexual violence, predominately rape, in sixty-one countries.
Figure 1 shows the number of projects providing care (blue line) and the number of victims who received medical care. It reflects a relatively stable investment over the past ten years.
Figure 1. Medical care for victims of sexual violence in MSF projects, 2004–2013. Source: MSF, International Typology data, 2004–2013.
In the DRC, large numbers of sexual violence victims come forward and the task of helping them comes under the general assistance that MSF provides in situations of conflict and displacement. Elsewhere, the majority of projects with high caseloads (more than 500 cases in one year) were set up specifically with the intention of addressing sexual violence care either as specialized care or as part of HIV or women's health care. These interventions are in post-conflict or stable settings rather than in conflict areas. In the latter, where sexual violence can be expected as part of the general upsurge of violence, few MSF projects apart from those in the DRC have seen a large caseload of victims of sexual violence. Rather than representing the incidence of sexual violence, this shows the difficulty that teams have in offering care in conflict settings and the difficulty that victims have in coming forward, be it for lack of access or fear of stigma and retaliation.
Data on the age and sex of victims of sexual violence are generated at project level; variations in age groups are partly due to an effort to adapt to countries' national data reporting on the issue. What we do know from different reports and studies is that the overwhelming majority of the victims of sexual violence seen in MSF projects are female. Men and boys represent approximately 5%, which, according to other reports is lowFootnote 38 and reflects the additional barriers men may haveFootnote 39 in coming forth to seek assistance. Around half of the victims seen in MSF projects are under the age of 18, with a significant number being young and even very young children.Footnote 40
Ensuring more and better training and guidance for staff
MSF is essentially a “generalist” organization with multiple medical ambitions; care for victims of sexual violence is one of many health needs that MSF responds to as part of its assistance to populations in need. Any prepared medical team needs to be able to provide medical care to victims of rape; this cannot rely only on specialists. Other aid actors seem to increasingly opt for specific sexual violence advisers and officers to increase their response capacity. In MSF, the main strength for response is seen in the critical mass of staff that has organized sexual violence care over the past ten years in many different contexts and which allows the increasing integration of care, despite competing priorities and limitations, into all relevant operations, be they emergency response or regular programmes.
Preparing staff to respond to needs arising from sexual violence is increasingly addressed in briefings and training, but a number of other issues are on the list of priorities. MSF policy on sexual violence and related care is not systematically included in relevant trainings and meetings.Footnote 41 There are one-week-long sexual violence trainings offered in the field,Footnote 42 and a day session on sexual violence is part of the two-week training for midwives and medical doctors involved in women's health-care projects.Footnote 43
Since 1999, different MSF projects have documented the approach to sexual violence care, the strategies that were used, and related outcomes. These projects also reflect important efforts made in terms of awareness, both of the problem of sexual violence itself and of the barriers to adequate assistance. Local, regional and international advocacy efforts have contributed to overcoming some of these obstacles in different contexts and to creating an environment for dialogue with national and international actors. This is part of the experience of sexual violence care, and can help to inform teams of its added value – but also of the backlash that can be experienced when taking a public stance on issues as sensitive as sexual violence.Footnote 44
Different operational centres of MSF have developed tools and guidance for sexual violence care.Footnote 45 These practical guides are developed to allow staff with no specific experience to be able to recognize needs related to sexual violence, to organize medical care including patient flow, to manage outreach and public information, to deal with medical certificates and patient confidentiality, and to record data and monitor activities.
There is agreement on the medical preventive and therapeutic measures that should be offered to any victim of sexual violence approaching MSF for assistance. However, the lack of common implementation guidelines within MSF on why, when, where and how to start specific sexual violence care seems somewhat symbolic of the lack of consensus on the organization's role. The absence of a transversal effort to address sexual violence throughout relevant MSF trainings may be indicative of the subject being overlooked among the organization's priorities.
Challenges in caring for sexual violence victims
Sexual violence as part of conflict is as old as humankind itself.Footnote 46 As an aid organization, however, it is the ten-year delay between the direct exposure to large-scale sexual violence in Rwanda and Bosnia and the implementation of a specific aid response which concerns MSF. Related dynamics have been analyzed closely in MSF and beyond, and several challenges emerge as factors explaining the delay in starting specific care in the first place.
Conflicting priorities are a central challenge that continues to be relevant today, and implementing programmes related to sexual violence remains a particularly difficult task.Footnote 47 The issue obliges humanitarian organizations to rethink their strategies, including their position regarding the provision of contraception and safe abortion care – a situation that might isolate them from the political support they need, notably (but not solely) to obtain funds. Moreover, due to the risk of victims' stigmatization, humanitarian actors need to ensure a sensitive approach, adapted to local possibilities and the cultural environment and able to evolve with the setting.Footnote 48 The issue of sexual violence forces them to assess and study with particular care the environment in which they are working before delimiting their scope of intervention. Several people in MSF have highlighted the technical and ethical challenges inherent in caring for victims of sexual violence, particularly those related to the status of women and the difficulty that staff face in dealing with the sensitivities around sexuality in societies where MSF is called to assist and where the organization's understanding of cultural norms is limited.Footnote 49 Furthermore, the concrete medical needs arising from rape and the way to address the most delicate of these, in a context where customs and perceptions are relatively unknown, are recognized as important challenges:
All areas dealing with the status of women make us feel uneasy. Speaking to a raped woman about psychological support, what does that mean in Africa? She tells us she needs an abortion. What do we do? We know very well that we will be dealing with difficult questions, which will permanently lead us back to the role of women in society.Footnote 50
Another issue that emerges for MSF – as for other humanitarian actors, particularly emergency organizations – is the difficulty in determining the limits of its role and responsibilities when faced with victims who require medical care, but also assistance and consideration beyond the medical, often in the longer term.Footnote 51 The social and cultural perception of rape – as well as its inherently sensitive nature – requires that any medical intervention be undertaken in such a way as not to contribute to harming the victim any further. Victims are often invisible,Footnote 52 as women and particularly men are frequently very reluctant to seek assistance; consequently, reaching them requires a proactive approach. Meanwhile, the structure of operations may make it extremely difficult to maintain victim confidentiality – a major concern, given that the stigma and taboos surrounding sexual violence in many cultures can potentially lead to harm rather than help. The difficulty lies in reaching a justifiable balance between the added value that medical care can have for the victim, both in the short and long term, and the exposure to the social risk that rape-related stigma involves, including the risk of the victim being ostracized.
Finally, a persistent inability within MSF to agree on a common terminology regarding sexual violence seems somewhat symbolic of the varying ambitions that are pursued implicitly and explicitly around the subject. “Rape” describes a specific act of violence; the majority of victims of sexual violence MSF sees are actually victims of rape. “Sexual violence” defines a larger scope of sexual acts and attempts thereof that use force, including coercion,Footnote 53 and that violate the physical and/or emotional integrity of a person. “Gender-based violence” and “violence against women” emerge from a rights-based concern for gender inequity and for the reduced status of women that allows violence to be committed against them. The term “gender” in this case tends to implicitly exclude concern for male victims of sexual violence, although this is the result of an erroneous interpretation of the term. The term “gender” was promoted through the 1995 Beijing conference in strong association with the subject of women's empowerment.Footnote 54 “Victim” is the term used in legal documents and procedures,Footnote 55 but “the stigmatization and perceived powerlessness associated with being a victim” was seen as a drawback of the terminology as early as 1995.Footnote 56 “Patient” describes the medical status of a person who has been subjected to an assault, with its related need for medical assistance and the commitment to confidentiality that is due to all patients. Further, the denomination “patient” recalls the medico-legal responsibility of medical practitioners when treating a victim of an assault, which is regulated under most national legislation. Finally, “survivor” is a commonly used term that addresses the above-mentioned concerns regarding stigmatization. Literally, a survivor is a person who has overcome a deadly threat, be it violence, disease or accident, but related to sexual violence the term is often used specifically to honour the strength of an individual and their efforts to heal, and to empower them.Footnote 57 The implications that different terms involve can be in contradiction and can, when used systematically or for the sake of political correctness, lead to misunderstanding regarding the objective pursued. In MSF, this discussion has happened on and off for years, with strong opinions against the systematic use of mainstream language.Footnote 58 For MSF, as a medical and humanitarian actor, the terms “patient” and “victim” seem most appropriate.
Regarding mainstream language, the inherent risk of the near-systematic denomination of sexual violence as a “weapon of war” should be highlighted. This term is often used by international agencies and organizations when referring to large-scale rape in the eastern DRC. Such labelling risks introducing a hierarchy of victims, with priority attention given to those thought to be a result of military practice. In reality, the distinction between sexual violence as a planned military strategy or a tolerated practice amongst armed groups and the sexual violence that occurs in a conflict setting but has no direct relation to military instructions is rarely clear. The label is also highly counterproductive to efforts that seek to reintegrate victims of sexual violence into a social framework of ever-evolving ethno-political alliances in some contexts.Footnote 59
The above challenges, which all contributed to the organization's initial hesitation to engage, continue to be relevant and to influence decisions relating to maintaining and expanding sexual violence care in MSF projects. Experiences in care for victims of sexual violence over the past decade have revealed additional challenges, including the need for continuous efforts to overcome both internal resistance and external factors that stand in the way of adequate assistance to victims of sexual violence.
Challenges related to the organization and acceptance of medical treatment
More than the medical treatment itself, the challenges involved in caring for victims of sexual violence are related to the organization and acceptance of care within the specificities of each context.
For the most part, the medical treatment of victims of sexual violence, particularly rape, is straightforward. There are cases, however, where the trauma inflicted is so extreme that intensive care and emergency surgery are required and reparative surgery may be necessary to avert long-term suffering from traumatic fistula.Footnote 60 For most victims of sexual violence, however, medical care consists of a set of basic curative and preventive measures, which can be provided in any prepared health facility – but there are a number of technical and ethical challenges involved. Without this care, rape can lead to important short- and long-term health consequences.
Timely medical assistance
MSF will assist any victim of sexual violence, even if the assault took place a long time ago. Coming forward and speaking about the event is important, even months or years afterwards. Vaccinations against tetanus and hepatitis BFootnote 61 will be relevant for months after the assault, and treatment of some STIs can prevent significant long-term health consequences. The potential of some preventive measures is, however, limited to the first few days after the assault. PEP for the prevention of HIV infection has to begin within seventy-two 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 seventy hours; after this, the success rate halves. Even in established programmes where MSF works specifically on sexual violence, not all and sometimes not even half of the victims come within seventy-two hours of the assault. This was observed as early as the initial Brazzaville interventionFootnote 62 and remains valid today.Footnote 63
Adherence to treatment and follow-up
Another challenge is adherence to prophylactic treatment and vaccination schedules. PEP to prevent HIV infection as a result of rape requires a twenty-eight-day regimen of a triple therapy of antiretroviral drugs.Footnote 64 Studies from different MSF projects providing sexual violence care confirm compliance with the full treatment in around half of patients. Some patients may finish their treatment but do not come back for follow-up; their compliance cannot be confirmed by MSF.Footnote 65 Vaccination against tetanus and hepatitis B infection poses a similar problem: several doses are necessary to achieve adequate protection, but few patients come for follow-up.Footnote 66
The additional exposure to risk that follow-up visits can involve needs to be taken into account: the risk related to the stigma of being identified as a patient going to a health facility that offers sexual violence care, and the risk that is inherent in breaching geographical distance in many of the contexts where MSF works and which involves potential attack, robbery and rape. Coming to follow-up consultations requires patients to weigh the balance of risk and benefit, and often patients seem to err on the side of caution.
Prevention and management of unwanted pregnancy
A girl or woman who has been a victim of sexual violence may want to know whether she fell pregnant as a result of the rape or whether she was pregnant at the time of the rape, especially if she is considering terminating the pregnancy or putting the child up for adoption. A pregnancy test and emergency contraceptives are routinely offered to female victims of rape.Footnote 67 In projects where MSF cares for victims of sexual violence, a large number of the girls and women at risk of pregnancy following rape accept the offered emergency contraception.Footnote 68 Most countries make specific allowances for the use of emergency contraceptives, generally and in the case of rape;Footnote 69 only exceptionally is the use of emergency contraceptives challenged in case of rape, and this situation then requires particularly careful handling by the teams.Footnote 70
Much more challenging is the question of abortion, where opposing forces include legal, religious and cultural dynamics. The first draft for field-testing of the Clinical Management of Rape Survivors guide elaborated by the World Health Organization in 2001 alludes to the problem of unwanted pregnancy as a result of rape and the need for safe abortion care. The guidelines seem to propose a compromise between political acceptance and medical needs, recommending that women be referred to safeFootnote 71 and legalFootnote 72 abortion services –in light of the lack of such services in many contexts, this continues to be a correct but impractical statement. The guidelines add:
Where safe abortion services are not available, women with unwanted pregnancies may undergo unsafe abortions. These women should have access to post abortion care, including emergency treatment of abortion complications, post abortion family planning counselling, and linkages to other reproductive health services.Footnote 73
Not much has changed in international guidance; in general, the legal directive rather than women's needs are stated as the reference frame determining the availability of safe abortion care. The specific provisions and restrictions coming from some donorsFootnote 74 present a significant additional barrier for many organizations and agencies in their efforts to adequately address the need for safe abortion care.
Emergency contraceptives are only an effective measure against pregnancy in the first 72 hours after an assault. MSF sees women who arrive weeks or months after a rape with an advanced pregnancy, and who request termination. Provision of safe abortion care is part of MSF's medical protocol for sexual violence careFootnote 75 based on the medical and human needs of patients, whenever feasible. Despite ongoing efforts to expand safe abortion care and independently of the legal framework which often makes allowances for specific circumstances (incest, rape, etc.),Footnote 76 ensuring care for all women and girls in need continues to be a challenge and is still not offered in all relevant MSF projects.Footnote 77 Religious, cultural and social dynamics in many contexts continue to render abortion unacceptable and stigmatizing, for women, communities and even for some health staff.
Caring for children
A number of MSF projects have reported that around half or sometimes more than half of the victims of sexual violence are children, including very young children.Footnote 78 Caring for children presents additional challenges, such as treatment protocols, the need for drugs in syrup form rather than pills and, more importantly, dealing at times with severe physical and psychological trauma. It is important that staff are at ease with children and can make them feel safe, and to ensure this, specific preparation of staff may be required. Often, however, immediate challenges are less related to the treatment itself; they are related to the child's safety, to the risk of future aggression and to the natural desire to protect the child.
This is particularly relevant as MSF's first project in Brazzaville already noted an increasing percentage of children among the victims of sexual violence in the post-conflict phase, and a shift to an increasingly complex domestic environment in which the future exposure of children to violence was a growing concern.Footnote 79 Similar situations have been observed in other MSF post-conflict situations, such as Burundi and Liberia, and MSF programmes with a specific focus on violence, like those in Papua New Guinea, Guatemala and Honduras. In a number of these MSF projects, the majority of the perpetrators are known to the victim and the assault happens in the home or close vicinity.Footnote 80 The question of the protection of the child becomes an inevitable one, but there are no ready-made answers. It seems that none of the alternatives are good: sending the child back to family or community and the known aggressor or exposing the child to an unknown environment, separated from family and community, and which may also then harbour risk of violence and abuse. For a medical team to see the same child over and over again, to treat the results of abuse a second and a third time without wanting to do something to protect the child, is impossible. In many contexts the capacity for MSF to contribute to an acceptable solution is, however, very limited.
Caring for men
How to adequately respond to the needs of male victims also poses a great challenge,Footnote 81 as the taboo around the subject remains huge, both for victims and for their families, and even for doctors and humanitarian workers.Footnote 82 Sexual violence stays largely invisible due to the attached stigma, especially when committed against men.Footnote 83 Some polemicsFootnote 84 have questioned whether MSF structures and the provision of care are well adapted to this type of patient: “One problem with the exclusive focus on sexual violence is that it tends to downplay the ways in which sexual violence is not only (or simply) – as sometimes suggested – a war against women or a ‘systematic pattern of destruction toward the female species'.”Footnote 85
Trauma, fear and guilt: The role of psychological support
The deepest wounds for a sexual violence survivor are often the ones that are invisible, with the trauma having long-lasting effects on a person's ability to function and carry on with their lives. Psychological care is therefore part of MSF's overall sexual violence care, and aims to reduce the impact of trauma related to the violence.Footnote 86
A baseline study that MSF undertook in 2011 in Mbare, Zimbabwe, in order to prepare a sexual violence response showed that 71% of people interviewed in the community acknowledged that psychological problems were one of the consequences of sexual violence.Footnote 87
In conflict and emergency situations, or within highly insecure contexts, providing psychological care can be a challenge. Teams are overwhelmed with work, or staffing may be reduced for security reasons, limiting the focus to life-saving activities. Space, together with language barriers, can be a constraint to adequate privacy and confidentiality for medical examinations and counselling. It is not only the knowledge of vocabulary but also the comprehension of different metaphoric terms used to describe anything related to sexuality, and also applying the description of rape, that may cause problems. A translator may or may not be able and willing to understand and transmit the subtlety of exposed information and implications related to different social norms. Also, when working with translators, there is a degree of uncertainty as to the attitude that is displayed towards victims. Another (sometimes self-imposed) barrier can be the lack of expertise (or self-perceived expertise) needed to address psychological needs: “At times the medical care giver feels helpless when there is no psychologist in the project. This may lead to him/her avoiding the emotional aspect of caring for victims of sexual violence as it is considered too specialized.”Footnote 88
Psychological support is an integral part of the medical consultation of any victim of sexual violence; the dialogue with the patient aims to understand the circumstances of the assault and the specificities of the patient's situation in order to propose the most adapted treatment approach and counselling. Compassionate listening and a respectful professional attitude towards the patient, as well as privacy and the assurance of confidentiality, are the bases for patients' trust and willingness to share.
Often, the initial medical visit will be the only opportunity to assist the victim; though the figures differ depending on context, in general few patients come for follow-up visits. Reinforcing the skills of medical staff to ensure “psychological first aid” as part of the immediate care for victims of sexual violence is therefore a priority and is included in the majority of MSF projects.Footnote 89 That said, while data show low return rates of victims for follow-up sessions, MSF has not ventured into assessing the psychological support needs that victims may experience in the longer term. These may well manifest months or years after an assault, affecting emotional, sexual and physical well-being and requiring specialized follow-up and care at that time. The degree to which MSF could assist in the longer term requires further reflection and will depend largely on the context.
Medical examination and treatment: A patient's choice
It is a legal and ethical principle that medical staff should seek patients' valid consent before starting any kind of physical examination or medical intervention. This includes the medical examination of victims of sexual violence.Footnote 90 Medical staff who conduct examinations without the patient's prior consent can be charged for assault in some contexts, and in some jurisdictions the results of an examination conducted without prior consent cannot be used in legal proceedings.Footnote 91
Obtaining informed consent from a patient requires explaining all aspects of the consultation to the patientFootnote 92 and asking for agreement to proceed. It requires ample time to put the patient at ease, to explain what is going to take place in understandable terms, to listen to the patient and to understand her/his needs and reactions. Consent of minors is particularly challenging; establishing the legal responsibility of an adult over a minor needs to be assessed case-by-case with the best interests of the child in mind.
Ensuring confidentiality: A long-term commitment
As a medical humanitarian organization, MSF's actions are driven by solidarity with individuals affected by conflict and crisis: the most vulnerable, the excluded, the victims of violence. Medical assistance is primarily an individual action, a “patient–medical staff” relationship based on a commitment that the assistance given will directly benefit the patient. It is this implicit promise and the related obligations to act at all times in the best interests of the patient and to preserve their confidentiality that are the foundation of trust which may motivate patients to come forward and seek assistance.
Medical confidentiality is a transversal notion to the whole process of medical care, but it is especially complex in relation to sexual violence. Considering MSF's contexts of intervention and activities, challenges are multiple with regard to the organization and identification of medical services, the flow of patients, communication and advocacy efforts, outreach and patient tracing activities, patient referral, and networking with other aid actors or authorities.
First, considering that the issue of sexual violence is heavy with stigma, privacy is a precondition for ensuring medical confidentiality, which is difficult to implement in some contexts – particularly emergency interventions, as already pointed out above. The sensitive nature of photographs, especially in a world of global communication,Footnote 93 adds to the challenge. Victims are increasingly anonymized as a means to ensure confidentiality, but also due to society's discomfort with the subject. The flip side of this preoccupation is underexposure, which does not permit victims to see their own resilience through voluntary and public exposure.
The second aspect of confidentiality is related to documentation and requires specific procedures, as well as a person in charge of the proper management of sensitive files.Footnote 94 MSF keeps a copy of each certificate available to each patient, and so that it can validate or invalidate the authenticity of a medico-legal certificate presented by a person as part of a criminal pursuit and/or compensatory claim.Footnote 95
Thirdly, certain countries impose an obligation to report sexual violence to local authorities or the police.Footnote 96 This leads to the dilemma of medical confidentiality versus the fight against impunity.Footnote 97 Despite many obstacles that make victims unwilling or unable to seek justice,Footnote 98 important efforts of governments and international agencies focus on the fight against impunity. To this end, it is important that victims are identified and encouraged to file their cases. In the DRC, the identification of victims was sought by approaching medical facilities and requesting the patient files of victims of sexual violence. The resulting threat to patient confidentiality prompted MSF to call on the United Nations, saying that “[t]he UN strategy has to ensure a strict separation of roles, both in their attribution and in the way the medical and juridical roles are perceived amongst victims, perpetrators and the population at large”,Footnote 99 as the increasing political drive for the elimination of impunity may impact on the capacity to offer direct, independent and confidential medical care to victims. In several MSF projects in the DRC, staff now refuse to sign certificates because of threats and the potential legal obligations. From MSF's perspective, it is not trivial to put one of its staff through a national or international judicial process, not only due to security risks but also due to the dangers of political repercussions; furthermore, the act of testimony is a delicate practice that few people are comfortable with.
Finally, confidentiality is a concern when working with local organizations. MSF's assistance to victims of sexual violence requires forging relations with local actors, women's groups and social and legal entities in order to create referral options that may address the needs of victims to which MSF has no or limited response. Within the communities associated with opposing parties to a conflict, the use of sexual violence is often endorsed as a statement of condemnation of the adversary and the resulting polarization requires MSF to seek dialogue and working relations with diverse organizations in order to safeguard independence and the capacity to assist all victims, independently of their chosen or perceived alliance.
The legal framework around sexual violence
The legal framework around sexual violence and its related consequences has implications for MSF's capacity to provide timely and adequate medical care. As mentioned above, laws regarding consent, medico-legal obligations, abortion, police involvement or the obligation to denounce, to name only a few, may represent a barrier to offering care to an individual who has been subject to aggression, rather than ensuring his/her protection.
Since the beginning of MSF's involvement in sexual violence care, much effort has been put into developing medico-legal documents and guidance regarding legal proceedings. General guidance cannot, however, respond to the specific situations and needs of each patient, and therefore a legal department in MSF ensures that case-by-case analysis and support is available.
With regard to the medico-legal obligations, the medical care of a victim of sexual violence requires the preparation of a medical certificate under the law of most countries,Footnote 100 where a template of such a certificate is usually available. MSF provides medico-legal certificates for all victims of sexual violence,Footnote 101 including in emergencies.Footnote 102
Amid conflict-like situations, legal systems may collapse, leaving crimes unpunished; a medico-legal certificate can allow a person seeking legal action to provide evidence even years after the assault.Footnote 103 Experience from the RC shows the potential value that medical certificates have in legal proceedings; nine out of ten of the medical certificates produced by MSF and used by victims in court were admitted by the judge.Footnote 104
The justification for collecting patient data
For MSF, collecting patient data is part of the daily routine of medical staff. For victims of sexual violence, information is needed in order to provide adequate medical treatment and also to address potential needs for protection of the patient and for the purpose of the medico-legal certificate.
Basic information includes personal data (name, age, address) and when the assault took place, in order to establish the relevance of PEP and emergency contraception. Further information is required to guide the approach towards dealing with potential HIV infection and pregnancy. Both subjects involve a number of delicate questions: “Was there penetration? Were you bitten or did you bite the aggressor? Do you know your HIV status? Have you already had your period? Are you sexually active? Are you pregnant? Do you want to prevent potential pregnancy?”, and so on.
Information is required for the treatment approach, for the medico-legal certificate; as part of collective data, such information serves programme management purposes like medical supply management, staffing, location and opening hours of the clinic and the potential need for additional care sites. Finally, information on specific vulnerability of victims and the alleged aggressor's characteristics may be sought as a means to identify potential individual protection needs and as a potential contribution to preventive efforts – for example, changing the location of water and wood for collection and providing recurrent facts regarding assaults to local or international protection forces.Footnote 105
The amount of questions addressed to one patient in the first consultation after a sexual assault can be overwhelming and can potentially alienate the patient and jeopardize the establishment of trust. Actors involved in providing assistance to victims of sexual violence do so with very different objectives in mind; from this emerges a demand for all organizations to contribute sexual-violence-related data on a large range of questions. For MSF, the central objective is the medical care of victims in order to avert the short- and long-term consequences of rape and to help victims recover. Information sought by MSF from individual patients and the corresponding analysis should focus on doing this more effectively.Footnote 106
Conclusion
Ensuring care for victims of sexual violence as part of MSF's general assistance to populations affected by conflict and crisis has represented a considerable institutional struggle and continues to be a challenge. Some resistance within the organization may be seen in relation to the charged nature of the issue, which is at the crossroads of personal opinions and subconscious attitudes regarding the status of women, the notion of violence and the sexual character of this particular type of violence.
Over the past ten years, MSF has garnered important experience from the medical care provided to almost 118,000 victims of sexual violence, primarily victims of rape. This experience reflects limits in the organization's capacity as well as in the victims' acceptance of sexual violence care in the contexts where MSF works. Large caseloads of patients seeking care for sexual violence are seen more frequently in the projects MSF runs in post-conflict settings and in projects responding to urban violence. In the midst of emergencies and conflict, MSF's capacity to assist victims of sexual violence remains, with the exception of the DRC, limited. In these contexts, where MSF strives to address numerous competing needs, sexual violence is often not amongst the immediate priorities, which focus, in general, on actions with a direct impact on mortality.
In addition to the contextual constraints, the invisibility of patients and the need for a proactive approach, as well as the practical and ethical challenges involved in care for victims of sexual violence, all contribute to teams' difficulty in providing adequate and timely care. Where care is offered, the impact of medical treatments is limited; only half of the victims come in time to allow protective measures against HIV infection and unwanted pregnancy, and only some patients return for medical and psychological support follow-up.
Also, victims of sexual violence require more than medical assistance; protection, prevention and legal pursuit are the responsibility of national governments and need international support. But efforts to end sexual violence and related impunity need to be developed in complementarity to medical assistance, and must at all times safeguard and promote the capacity to provide direct, independent and confidential medical care. Further, victims excluded from family and community as a consequence of rape and those in danger of continuous assault and violent repercussions require psychosocial support and protection. These areas of assistance tend to be underserved in general and more so in the middle of a crisis; the benefit of medical care in those cases may be overshadowed by the forsaken perspectives of the victim. When other aid actors are present, be they local or international, it is necessary for MSF to seek collaboration and dialogue with both non-aligned actors and those aligned with the opposing powers in order to facilitate support to all victims in need.
The specific challenges related to care for victims of sexual violence accentuate the general difficulties that MSF faces in providing medical care to populations in crisis, because national laws and powers (State, Church or common perception) may create additional barriers for victims to access care and for care providers to be able to respond fully to the medical needs of victims of sexual violence, including those related to unwanted pregnancy.
MSF continues to struggle with the limits of its role: while the provision of medical care remains a central commitment, the specific difficulties arising from the criminal nature of rape, in legal, political and security terms, cannot be ignored. The potential instrumentalization of the subject of rape and related assistance – for a variety of purposes, including human rights in general, the status of women and the dynamics of conflict – presents a constant challenge. Finally, the multiple unmet needs of victims, beyond medical care, have to be acknowledged. The response to such needs often surpasses MSF's capacity and legitimacy, but few other actors seem to step up with concrete measures. Internally, the degree to which MSF engages in different contexts and at different times in advocacy, prevention and protection efforts is subject to debate, differences and tensions.
Sexual violence care is one of many health needs that MSF aims to address; often, MSF teams are generalists with multiple medical-humanitarian ambitions. Guidelines, trainings and tools cannot replace the need for continuous investment and reflection at all levels of the organization; the main challenges MSF encounters are those inherent to each context, and they change over time. Sexual violence is often part of a larger dynamic of violence, be it during conflict, in post-conflict settings or in stable areas impacted by poverty, precarious living conditions and exclusion. Any assistance is ultimately faced with the complex social dynamics out of which sexual violence is born and with respect to which MSF, as an external actor, is in a delicate position.
MSF will need to continue challenging the limits of the organization's role and actions in order to expand medical care for victims of sexual violence to all relevant contexts and particularly in conflict settings, but will also need to remain vigilant to the risks of instrumentalization and strive to maintain independence from the political pursuits of national and international powers, however promising they may appear.
