Considerations for Working with Survivors of Sexual Violence

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Introduction to Sexual Violence[edit | edit source]

Sexual violence is a global concern which is occuring in every culture, in all levels of society and age groups throughout the world. It is a rising global issue as sexual violence can bring devastating consequences to the mental health and well-being of a person, contributing to , However, data on most aspects of sexual violence today are lacking in many countries.[1] There is a huge need everywhere for more research to be done on all aspects of sexual violence. According to current available data, nearly every one in four women during her lifetime has suffered an attempted or completed rape by an intimate partner,[2][3][4] whereas up to one-third of adolescent women reported their first sexual experience as being forced. [5][6][7]

Despite the vast majority of victims being women, men and children of both genders are also experiencing sexual violence. Between 8% and 31% of girls and 3% and 17% of boys experience Childhood Sexual Violence (CSV) worldwide.[8] In Southeast Asia, a recent review suggested that approximately 10% of boys and 15% of girls have experienced at least one form of sexual violence in their childhood.[9] Sexual violence can take place within a variety of settings including home, workplace, schools and the community. In many cases, it begins in childhood or adolescence.

Sexual violence has a significant negative impact on the health of the population. The potential reproductive and sexual health consequences are numerous – unwanted pregnancy, sexually transmitted infections (STIs), human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/ AIDS) and increased risk for adoption of adoption of risky sexual behaviours (e.g. early and increased sexual involvement, and exposure to older and multiple partners). The mental health consequences of sexual violence can be just as serious and long lasting. Victims of child sexual abuse, for example, are more likely to experience depression, substance abuse, post-traumatic stress disorder (PTSD) and suicide in later life than their non-abused counterparts.Worldwide child sexual abuse is a major cause of PTSD, accounting for an estimated 33% of cases in females and 21% of cases in males.[9]

Sexual Abuse and Exploitation in Humanitarian Settings[edit | edit source]

Sexual abuse is a global problem with statistics from the United States revealing that 1 in every 3 women and 1 in every 4 men experienced sexual abuse involving physical contact in their lifetime.[10]  Sexual abuse is not limited to physical contact. It encompasses a range from verbal sexual abuse (unwanted sexual comments) to forced penetration and coercion. The coercion can be in the form of blackmail and threats. Any sexual advance without consent is considered sexual abuse, including sexual acts performed to a victim who is intoxicated, drugged, mentally impaired or asleep.[11]

The occurrence of sexual abuse and exploitation is higher in armed conflict than in stable non- displaced settings. Sexual abuse occurs during the height of armed conflict, during displacement and post conflict.[12] A study conducted on 288 women in East Timor found that 23% of the respondents were sexually abused during conflict and that10% experienced abuse in the post-conflict period.[13] Sexual exploitation occurs in the form of transactional sex-where sex is exchanged  in order to be granted priority treatment  in their  cases and faster release from detention centers , for food, money and to guarantee safe passage across closed borders by smuggler. [12][14]

The factors that contribute to the increased occurrence of sexual violence and exploitation in armed conflict and displacement are(6):

Breakdown of Services

  • Services such as law enforcement and the legal, health and educational systems, are ruined or weakened during war. Ongoing conflict leads to damaged infrastructure and essential staff are forced to flee.

Family Separation

  • Family separation puts women and unaccompanied children at an increased risk for sexual abuse and exploitation. Due to their gender and age, they may depend on other parties to get them to safety and this increases their vulnerability.

Conflict Scenario

  • The conflict scenario may psychologically affect the men and their ability to perform their usual social, cultural and economic roles and provide protection as they usually do in the family and community settings.

Community and Societal Factors

  • Community and societal factors that continue to condone gender- based violence against women also play a part. Beliefs in the society edging towards male superiority, gender inequality and discrimination continue to contribute to violence against women.

Women and girls are more vulnerable to sexual violence and exploitation both in stable and unstable environments as compared to men and boys. They are often abducted and held captive as sexual slaves by armed groups. Sexual abuse among male victims is rarely reported because it is associated with greater stigma as compared to sexual abuse among women and girls. Men and boys are particularly vulnerable when they are forcefully recruited by armed militia or when they are held in detention centers. Children can also be victims especially when abducted by rebel groups and often undergo abuse repeatedly.[12]

Most perpetrators of sexual abuse are men, however, in some instances, such as the Rwandan genocide, women have been found to instigate and participate in armed conflict sexual abuse. Forcibly recruited child soldiers in Liberia perpetrated sexual violence.[12] Perpetrators of armed conflict sexual abuse and exploitation include: army and  state security officials; militia and rebel groups; civilians such as fellow refugees and displaced people within camps and asylum centers; humanitarian workers; border guards and bandits.[12](6).

Accurately determining the prevalence of sexual violence in conflict situations is difficult. Researchers are usually faced with security, methodological, ethical and scientific challenges.[13] Firstly, the survivors are reluctant to report either to the police or healthcare workers in both conflict and stable environments due to feelings of shame, guilt, fear of retaliation, assumption they will not be believed, lack of support structures and social stigma.[11](7) Secondly, armed conflict is a political issue. Many governments fear condemnation and resulting sanctions from the international community on the violation of human rights that thrives in conflict. Governments and other state agencies therefore tend to downplay reports of sexual violence. Thirdly, it is unethical to ask individuals about sexual violence while conducting research without the provision of the required care. In most humanitarian crisis situations, the access and provision of care to survivors of sexual violence is often inadequate limited by factors such as distance, cost and stigma(8) Lastly, conducting research on sexual abuse in unstable environments poses a security threat to both the researcher and the respondent (6).

The nature of sexual violence perpetrated in conflict situations falls into 2 main categories(6):

  • Sexual violence is utilized as a weapon of warfare due to consequences on the survivor as well as its far- reaching effects on the survivor’s family and community. Rebels and militia in Democratic Republic of Congo (DRC) use sexual abuse against men to emasculate the men and break down the family unit because in their culture a man is considered the head of the household. This abuse against men usually leads to social stigma and discrimination of the entire family(9).Sexual violence has also been used to terrorize communities and as a tool of genocide in countries such as  Rwanda.[12]
  • The perpetrators of sexual violence in conflict settings also include abusers who exhibit opportunistic behavior in the climate of impunity found in war zones. These perpetrators take advantage of the breakdown in social and legal systems for sanctioning sexual violence. 

The motives behind armed conflict sexual abuse include:[12]

  • To advance military agenda, instill terror and cause flight from a particular target territory
  • To torture and humiliate victims in order to ensure compliance among captives
  • To punish and humiliate enemy groups
  • To destroy family and community structure by the perpetrators publicly raping victims, forcing the victims to view rape of their family members or forcing the victims to rape their own family members.
  • To affirm their aggression and brutality. Some perpetrators consider it a boost to their morale or a “reward for their bravery”  
  • Sexual abuse can also be used as an act of genocide-targeting a specific ethnic/social group as was the case in the Rwandan genocide of 1994.
  • Specific cultural beliefs e.g. some rebel groups in Democratic Republic of Congo believe raping a virgin leads to invincibility.

Root Causes and Risk Factors for Sexual Abuse[edit | edit source]

According to the ecological model, Sexual abuse is a complex issue that occurs as a result of the interaction of four factors: individual, relationship, societal and community factors(10)(11).

The individual and relationship factors have been identified as risks for sexual abuse against women and have been found to increase the likelihood of men perpetrating sexual violence.

Community and societal factors consist of the acts society has normalized that may condone sexual violence against women.

Armed Conflict Sexual Abuse Against Males[edit | edit source]

There is a higher occurrence of sexual abuse against women and girls compared to sexual abuse of males in scenarios of conflict and forced displacement. Consequently, a lot of literature is available and numerous studies have been conducted on armed conflict sexual abuse against women and girls. Limited studies have been conducted on sexual abuse of male survivors. Sexual abuse is however common among male survivors in forced displacement and conflict as well(12).

The extent of armed conflict sexual violence against males varies across different conflict affected zones. For instance in Eastern DRC, the prevalence of sexual violence against males in was 23.6%(13) whereas in Sudan, 46.9% men reported either witnessing  sexual violence against a man or being subjected to sexual violence(14)The numbers are underestimated due to underreporting by the victims as well as the inability of healthcare providers and humanitarian workers to identify the victims who are reluctant to self-identify. Most victims choose not to report because of stigma, fear, guilt and confusion(12).

Male victims are subjected to sexual abuse and exploitation in the countries of origin, during migration and in the countries of asylum. Sexual violence against males happens to a range of survivors including young boys, adolescents, straight adult men, transgender men and women, gay and bisexual men and boys. Unaccompanied adolescent boys aged 14-17 years are at a particularly higher risk of sexual abuse. Gay and transgender survivors are also at an increased risk and have reported being sexually abused by multiple perpetrators(15). Men have been found to be particularly vulnerable to sexual abuse while in detention centers and when they are forcefully recruited by rebel groups.[12]

The forms of sexual abuse in men include but are not limited to(12) (15):

  • Genital violence e.g.  electrocution, Tying heavy objects on the genitalia, beatings on the genitalia
  • Enforced nudity accompanied by verbal sexual threats
  • Enforced masturbation
  • Forced sterilization(castration) usually performed under crude means such as fellow captives  biting off each other’s testicles(12)
  • Oral and anal rape (including with objects)
  • Sexual slavery
  • Forced sexual activity with other people, animals or corpses

There are various motives for sexual violence of men in scenarios of armed conflict(12).Firstly, sexual violence  is used to assert power and dominance over the victims. It is meant to empower the perpetrators and disempower the victims, their families and the community at large. Public sexual abuse is used to spread terror across communities and prove the men are powerless and unable to protect both themselves and their community. Secondly, sexual violence is used to emasculate the male victims. In many societies, it is assumed that a man should be able to resist any attack. When they are sexually abused the perpetrators do it in order to strip them of their masculinity In Democratic Republic of Congo (DRC) raping a man changes him into a woman in the eyes of his family and community, making the victims question their sexuality and prevention of procreation through forced sterilization. Lastly, sexual abuse against the men targeting specific ethnic, racial or religious can be used to symbolically assert dominance and disempowerment of the entire group.

Consequences of sexual violence in males

Barriers to Accessing Healthcare[edit | edit source]

There are a number of factors that often come in the way of men accessing healthcare post sexual violence (12)(15) they include:

Male survivors of sexual violence are less likely to seek healthcare as compared to female survivors of sexual violence due to shame, fear of retaliation, fear of discovery and consequent social stigma and the fear of arrest in countries in which they are laws prohibiting same sex relations. Masculinity stereotypes also lead to under reporting of sexual violence. Men are expected to not be expressive and to “cope like a man”.

Reluctance to self-identify in healthcare settings as well as health care providers focus on anal rape only as opposed to looking out for other indicators such as sexual dysfunction, incontinence and genital scarring leads to male survivors not being easily identified and at risk of inadequate assessment and management.

Some healthcare providers have a negative attitude towards male survivors of sexual violence. Some believe all male survivors of sexual abuse are gay or that men and boys cannot be sexually abused. Consent may be assumed because a man should have been able to defend themselves.  Homophobia among healthcare workers interferes with the provision of quality healthcare.

Most gender -based violence centers are linked to women health services and as a result of this, male survivors are not open to seeking assistance in such settings.

Humanitarian agencies should strive to raise awareness of sexual violence against men among healthcare providers as well as first line responders in humanitarian crisis situations.

Armed Conflict Sexual Abuse Against Women[edit | edit source]

Over the past years, humanitarian organizations have recognized and taken steps to prevent armed conflict sexual violence and exploitation. Various guidelines have been developed by the United Nations High Commissioner for Refugees (UNHCR) and the Interagency working group for the prevention and response to armed conflict sexual abuse since 1995 however sexual abuse during armed conflict still remains a major problem (6). Women disproportionately bear the brunt of armed conflict sexual abuse since they are more vulnerable in comparison to men. The weighted prevalence of sexual violence among female refugees in 14 countries affected by conflict was estimated at 21.4%. One in every five refugees and displaced women in complex humanitarian settings experienced sexual violence(16), yet this is considered to be an under estimate.

There are multiple barriers associated with disclosure. Survivors of sexual violence globally are reluctant to report to the authorities due to feelings of shame, guilt and fear of retaliation. The situation is no different for survivors in environments of conflict and forced displacement. In addition to their reluctance to report, female refugees may also be faced with language barriers, not knowing where to report to, fear of officials and deportation. Closure of borders in the countries of asylum leads to panic among refugees seeking asylum in European Union states and therefore instances of sexual violence are not reported due to fear of being delayed in their onward journey. (5).The access and availability to reproductive health services can be hampered by cost, distance and stigma(8).

Women and girls experience sexual violence and exploitation during the conflict, during displacement and post conflict. The abuse happens in various settings such as fields, detention and asylum centers, camps for refugees and displaced people, military sites and their homes. Family violence during conflict is also prevalent. Women are likely to experience intimate partner violence due to trauma, elevated stress and loss of livelihood associated with armed conflict. Women and girls have also been abducted by armed militia and kept as sexual slaves. Within refugee camps women and girls have been attacked when performing their daily chores such as fetching water or collecting firewood.

In addition to sexual violence, women are also particularly vulnerable to sexual exploitation. Women are likely to be exploited when they are obtaining essential goods from men.(6) Many female refugees are forced to engage in transactional sex with smugglers in order to ensure their safe passage into countries of asylum whose borders have been closed. Transactional sex was also reported in detention centers in Macedonia where female refugees desperate to enter European union states were required to have sex with male guards after they were promised priority treatment of their cases and faster release from the detention center.

During conflict and forced displacement, women are vulnerable to soldiers and armed combatants, bandits, border guards, human traffickers, smugglers, and humanitarian workers. Women are subjected to various violations such as rape, forced participation in sex trade and sexual exploitation.

While living in refugee camps, female refugees are scared of other refugees. Inadequate accommodation and sanitary facilities in asylum centers place women at increased risk for sexual violence. There are few toilets to be shared among the male and female refugees, no running water thus the need to use outside taps, communal bathrooms with little or no privacy which forces the women and girls to shower after dark and overcrowded living arrangements(5)(6). Some women do not leave their rooms at night even if they need to use the toilet for fear of their security. Women also experience family and conjugal violence. Conjugal violence often involves repeated violent episodes, and one partner taking control of the other person and engaging in harmful behaviours toward them. Conjugal violence differs from arguments within a couple primarily because it involves an imbalance of power between partners, for instance, the controlling partner may include: - forcing their partner to do things against their will (wearing a certain type of clothing, not going out with friends, having sex, etc.). As a result, some women are unable to leave their abusive husbands for fear of continuing the journey to safety alone(5).

Health Consequences of Sexual Violence in women[edit | edit source]

The health consequences of sexual violence against women can be grouped into either immediate or medium to long term consequences. Immediate consequences result directly from the sexual abuse incident whereas medium to long term effects occur during the period after violation(17).[11] The consequences may also be fatal or non-fatal depending on the extent of injuries.

Common Sequelae of Sexual Abuse

Sexual and gender- based violence results in many consequences ranging from physical, psychological, and social effects (18).

Common sequelae of sexual and gender-based violence can be categorized as follows:

  1. Fatal Outcomes
  2. Non-Fatal Outcomes
    1. Physical Trauma
      • Injury
      • Sexual & Reproductive Health Issues
      • Somatoform Issues
    2. Psychological Trauma
      • Mental Health Issues
      • Negative Health Behaviours

Common Sequelae of Sexual & Gender-based Violence

Physical Trauma includes: -

  1. Physical Injury
  2. Somatoform issues such as functional impairment and chronic pain,
  3. While sexual and reproductive health issues include unwanted pregnancy, miscarriages, abortion, HIV/STIs, low birth weight, pelvic inflammation, and various gynecological issues
    • Physical Injuries
    • Pelvic inflammation and chronic pelvic pain
    • Anal Fissures
    • Vaginal Fissures and Prolapse
    • Functional Impairment
    • Gynecological Issues
    • FGM

References[edit | edit source]

  1. ↑ World Health Organization (WHO). Sexual Violence. Available from: https://www.who.int/violence_injury_prevention/violence/global_campaign/en/chap6.pdf ( Accessed 19 September 2020)
  2. ↑ Hakimi M et al. Silence for the sake of harmony: domestic violence and women’s health in central Java. Yogyakarta, Gadjah Mada University, 2001.
  3. ↑ Ellsberg MC. Candies in hell: domestic violence against women in Nicaragua. Umea ̊, Umea ̊ University, 1997.
  4. ↑ Mooney J. The hidden figure: domestic violence in north London. London, Middlesex University, 1993.
  5. ↑ Jewkes R et al. Relationship dynamics and adoles- cent pregnancy in South Africa. Social Science and Medicine, 2001, 5:733–744.
  6. ↑ Matasha E et al. Sexual and reproductive health among primary and secondary school pupils in Mwanza, Tanzania: need for intervention. AIDS Care, 1998, 10:571–582.
  7. ↑ Buga GA, Amoko DH, Ncayiyana DJ. Sexual behaviour, contraceptive practice and reproductive health among school adolescents in rural Transkei. South African Medical Journal, 1996, 86:523–527.
  8. ↑ Barth, J., Bermetz, L., Heim, E., Trelle, S., & Tonia, T. (2013). The current prevalence of child sexual abuse worldwide: A systematic review and meta-analysis. International Journal of Public Health, 58, 469–483.
  9. ↑ 9.0 9.1 Fry, D., & Blight, S. (2016). How prevention of violence in childhood builds healthier economies and smarter children in the Asia and Pacific region. BMJ Global Health, 1, i3–i11
  10. ↑ Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees resettled in. Lancet. 2005;365 (Panel 1):1309–14. Available from: https://search-proquest-com.kuleuven.ezproxy.kuleuven.be/docview/199005701/fulltextPDF/6ADB41F9BE454EE6PQ/1?accountid=17215
  11. ↑ 11.0 11.1 11.2 WHO. Understanding and addressing violence against women. WHO Publications. 2012;52(81):458–693. Available from: http://apps.who.int/iris/bitstream/handle/10665/77434/WHO_RHR_12.37_eng.pdf;jsessionid=07DCE61B242A5EEC9C283DC063FF3B84?sequence=1
  12. ↑ 12.0 12.1 12.2 12.3 12.4 12.5 12.6 12.7 Kunz R, Grimm K, Bastick M. Sexual Violence in Armed Conflict :Global Overview and Implications for the Security Sector. Geneva; 2007. Available from: https://dcaf.ch/sites/default/files/publications/documents/sexualviolence_conflict_full.pdf
  13. ↑ 13.0 13.1 Ward J, Brewer J. Gender-based violence in conflict-affected settings: overview of a multi-country research project. Forced Migr Rev. 2004;19:26–8.
  14. ↑ Freedman J. Sexual and gender-based violence against refugee women: a hidden aspect of the refugee “crisis.” Reprod Health Matters. 2016;24(47):18–26. Available from: http://dx.doi.org/10.1016/j.rhm.2016.05.003
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