Considerations for Working with Survivors of Sexual Violence

Original Editor - Jeniffer Chepkemoi from The Center for Victims of Torture as part of the PREP Content Development Project

Top Contributors - Naomi O'Reilly, Jess Bell, Kim Jackson and Kirenga Bamurange Liliane  

Introduction to Sexual Violence[edit | edit source]

Sexual violence is a global concern. It occurs in every culture, in all levels of society and affects all age groups throughout the world. It is a rising global issue as sexual violence can have a devastating impact on the mental health and well-being of affected individuals. Data on most aspects of sexual violence today are lacking in many countries.[1] There is a significant need for more research to be done on all aspects of sexual violence. According to current available data, nearly one in four women have suffered an attempted or completed rape by an intimate partner in their lifetime,[2][3][4] and up to one-third of adolescent women have reported that their first sexual experience was forced.[5][6][7] Statistics from the United States reveal that one in three women and one in four men experience sexual abuse involving physical contact in their lifetime.[8] Sexual abuse is not limited to physical contact; it encompasses a range from verbal sexual abuse (for example, 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 on an individual who is intoxicated, drugged, mentally impaired or asleep.[9]

Despite the vast majority of victims being women, men and children of both genders also experience sexual violence. Worldwide, between 8% and 31% of girls and 3% and 17% of boys experience childhood sexual violence.[10] 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.[11] Sexual violence can take place within a variety of settings including the 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 including unwanted pregnancy, sexually transmitted infections (STIs), human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and increased risk for adoption of risky sexual behaviours (for example, 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. Survivors 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.[11]

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

The occurrence of sexual violence and exploitation is higher in armed conflict than in stable non-displaced settings. Sexual violence 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 that 10% 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 case and faster release from detention centres. It might also be exchanged for food, money and to guarantee safe passage across closed borders by smugglers.[12][14] The factors that contribute to the increased occurrence of sexual violence and exploitation in armed conflict and displacement include the following:[15]

Breakdown of Services[edit | edit source]

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

Family Separation[edit | edit source]

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 Scenarios[edit | edit source]

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

Community and Societal Factors[edit | edit source]

Community and societal factors that continue to condone gender-based violence against women also play a part. Beliefs in 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 centres. Children can also be victims especially when abducted by rebel groups and often undergo abuse repeatedly.[12]

Most perpetrators of sexual violence 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 violence and exploitation include: army and state security officials; militia and rebel groups; civilians such as fellow displaced persons within camps and asylum centres; humanitarian workers; border guards and bandits.[12][15]

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 health care 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.[9][16] 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 thrive in conflict situations. 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 required care. In most humanitarian crisis situations, access and provision of care to survivors of sexual violence is often inadequate and limited by factors such as expertise, distance, cost and stigma.[16] Lastly, conducting research on sexual abuse in unstable environments poses a security threat to both the researcher and the respondent.[15]

Nature of Sexual Abuse in Armed Conflict[edit | edit source]

The nature of sexual violence perpetrated in conflict situations falls into 2 main categories:[15]

  • Sexual violence is utilised 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 the Democratic Republic of Congo (DRC) used sexual violence against men to emasculate the men and break down the family unit; in their culture, a man is considered the head of the household. This violence against men usually leads to social stigma and discrimination of the entire family.[17] Sexual violence has also been used to terrorise 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 behaviour 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.

Motives Behind Armed Conflict Sexual Abuse[edit | edit source]

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

  • To advance military agenda, instil 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 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 violence 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.[18][19] 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 normalised that may condone sexual violence against women.

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

There is a higher occurrence of sexual violence against women and girls compared to males in the context of conflict and forced displacement. Consequently, a lot of literature is available and numerous studies have been conducted on armed conflict sexual violence against women and girls, while limited studies have been conducted on sexual violence against males. Sexual violence is, however, common among male survivors of forced displacement and conflict.[20]

The extent of armed conflict sexual violence against males varies across different conflict affected zones. In Eastern DRC, the prevalence of sexual violence against males in was 23.6%.[21] In Sudan, 46.9% men reported either witnessing sexual violence against a man or being subjected to sexual violence.[22] The numbers are underestimated due to underreporting by the survivors, as well as the inability of health care providers and humanitarian workers to identify survivors who are reluctant to self-identify. Most survivors choose not to report because of stigma, fear, guilt and confusion.[20]

Male survivors are subjected to sexual violence and exploitation in their 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 high risk of sexual violence. Gay and transgender survivors are also at an increased risk and have reported being sexually abused by multiple perpetrators.[23] Men have been found to be particularly vulnerable to sexual violence while in detention centres and when they are forcefully recruited by rebel groups.[12]

The forms of sexual violence in men include but are not limited to:[20][23]

  • Genital violence, including electrocution, tying heavy objects on the genitalia, beatings of the genitalia
  • Enforced nudity accompanied by verbal sexual threats
  • Enforced masturbation
  • Forced sterilisation (castration) usually performed through crude means - e.g. fellow captives biting off each other’s testicles [20]
  • 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.[20] 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 violence 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. Perpetrators sexually abuse men to strip them of their masculinity. In the Democratic Republic of Congo (DRC), raping a man changes him into a woman in the eyes of his family and community, making the survivors question their sexuality and prevention of procreation through forced sterilisation.

Lastly, sexual violence against men which targets specific ethnic, racial or religious groups can be used to symbolically assert dominance, which thus disempowers the entire group.

Table 1. Consequences of Sexual Violence in Male Victims.[17][23]
  • Sexually transmitted infections
  • Sexual dysfunction
  • Anal pain
  • Rectal trauma (abscesses and fissures which may lead to painful sitting and coughing)
  • Infertility
  • Fecal incontinence
  • Genital impairment
  • Post-traumatic stress disorder
  • Sleeplessness
  • Intrusive thoughts of torture and rape during intimacy
  • Depression
  • Anxiety
  • Suicide ideation
  • Shame
  • Stigma for self and family
  • Self-exile from the community, wife is also consequently shamed and stigmatised when the husband leaves
  • Unable to work or contribute to household income

Barriers to Accessing Health Care[edit | edit source]

There are a number of factors that get in the way of men accessing health care post sexual violence. These include:[20][23]

  • Male survivors of sexual violence are less likely to seek health care compared to female survivors of sexual violence due to shame, fear of retaliation, fear of discovery and consequent social stigma. There is also the fear of arrest in countries where there are laws prohibiting same sex relations. Masculinity stereotypes also lead to an under reporting of sexual violence. Men may be expected to not be expressive and to “cope like a man”.
  • Reluctance to self-identify in health care settings. Similarly, health care providers tend to focus on anal rape only as opposed to looking out for other indicators such as sexual dysfunction, incontinence and genital scarring. This means male survivors are not easily identified and are, therefore, at risk of inadequate assessment and management.
  • Some health care 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 himself. Homophobia among health care workers interferes with the provision of quality health care.
  • Most gender-based violence centres are linked to woman's 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 health care providers as well as first line responders in humanitarian crisis situations.

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

Over the past years, humanitarian organisations have recognised 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 violence during armed conflict still remains a major problem.[15] Women disproportionately bear the brunt of armed conflict sexual violence since they are more vulnerable than men. The weighted prevalence of sexual violence among female displaced persons in 14 countries affected by conflict was estimated at 21.4%. One in every five displaced women in complex humanitarian settings experienced sexual violence,[24] 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 displaced persons may also be faced with language barriers, not knowing where to report to, fear of officials and deportation. Closure of borders in countries of asylum leads to panic among displaced persons seeking asylum in European Union states and therefore instances of sexual violence are not reported as victims fear of being delayed in their onward journey.[14] The access and availability to reproductive health services can be hampered by cost, distance and stigma.[16]

Women and girls experience sexual violence and exploitation during conflict, during displacement and post-conflict. Abuse happens in various settings such as fields, detention and asylum centres, camps for displaced persons, 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 camps for displaced persons, 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.[15] Many female displaced persons 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 displaced persons 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 centre.

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 the sex trade and sexual exploitation.

While living in camps for displaced persons, women are often scared of other displaced persons within the camp. Inadequate accommodation and sanitary facilities in asylum centres place women at increased risk for sexual violence: there are few toilets and these are shared among the male and female displaced persons; there is no running water, so there is a need to use outside taps; there are communal bathrooms with little or no privacy, which forces women and girls to shower after dark; there are overcrowded living arrangements.[14][15] 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, with 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. The controlling partner may force their partner to do things against their will (e.g. wear a certain type of clothing, not go out with friends, have sex, etc.). As a result, some women are unable to leave their abusive partners for fear of continuing the journey to safety alone.[14]

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

The health consequences of sexual violence against women can be grouped into immediate- or medium- to long-term consequences. Immediate consequences result directly from the sexual violence incident, whereas medium- to long-term effects occur during the period after violation.[9][25] The consequences may also be fatal or non-fatal depending on the extent of injuries.

Table 2. Health Consequences of Sexual Violence in Women.
Immediate Consequences Medium to Long Term Consequences
  • Haemorrhage
  • Shock
  • Urinary tract infections
  • Urinary incontinence
  • Urinary retention
  • Back pain
  • Irritable bowel syndrome
  • Gastrointestinal symptoms e.g.nausea, bloatedness, diarrhea, abdominal pain
  • Chronic pain syndromes
  • Fibromyalgia
  • Poor perception of health
  • Cardiopulmonary and neurological type symptoms e.g. hyperventilation, shortness of breath, palpitations, numbness and weakness
  • Migraines and headaches
  • Unintended pregnancy
  • Sexually transmitted infections
  • Unsafe abortions
  • Genito-anal trauma
  • Fistulas
  • Pelvic inflammatory disease
  • Infertility
  • Painful periods
  • Pain with sexual intercourse
  • Sleep difficulties
  • Panic disorder
  • High likelihood of engaging in risky behavior such as unprotected sex, multiple partners, alcohol and drug abuse
  • Eating disorders
  • Early consensual sexual initiation in cases of child sexual abuse
  • At higher risk of re-experiencing sexual abuse
  • Femicide after sexual abuse
  • Suicide
  • Infanticide following conception from rape
  • Death from unsafe abortions
  • Death from pregnancy related complications
  • AIDS related deaths

Common Sequelae of Sexual and Gender Based Violence[edit | edit source]

Sexual and gender-based violence can have many consequences ranging from physical, psychological, and social effects.[26] Common sequelae of sexual and gender-based violence can be categorised as follows:

  1. Fatal outcomes
  2. Non-fatal outcomes
    • Physical trauma
      • Physical injury
      • Somatoform issues such as functional impairment and chronic pain,
      • Sexual and reproductive health issues include unwanted pregnancy, miscarriages, abortion, HIV/STIs, low birth weight, pelvic inflammation, and various gynecological issues
    • Psychological trauma
      • Mental health issues
      • Negative health behaviours

Physical Injuries[edit | edit source]

The most common areas for physical injuries (e.g. bruising, fractures, broken bones, fissures, lesions, and haemorrhaging) are the face, neck, head, genital areas, and anus. It should be noted that quantifying the amount of injuries from sexual and gender-based violence remains a problem. The majority of those experiencing it fear more abuse, torture, violence, and possibly even death from perpetrators if they disclose the gender-based violence to authorities.

Anal Fissures[edit | edit source]

Anal tear refers to ruptures/ tears that are caused on the thin and smooth inner mucosal lining of the anus and rectum. Anal tears are caused by forceful anal sex. Anal tears can lead to difficulties in passing stool due to pain and inflammation of the anus. Furthermore, it can result in bacterial infection of the anus and hence increase pain. The prevalence of anal tears in male rape is higher than in female rape.[27]

Vaginal Fissures and Prolapse[edit | edit source]

Typically, in conducive environments, the vagina is supposed to self-lubricate before sex. However, during sexual abuse, the vagina does not naturally lubricate. Hence, the forceful penetration of the penis or inserted object during rape causes vaginal tearing. In addition to vaginal tears or cuts, vaginal prolapses can occur. A prolapse is when parts of the reproductive system (e.g. the vagina, uterus) descend from their normal position. This occurs when the muscle networks around the reproductive system are compromised / weak. Other organs linked to the reproductive tract such as the bladder may also be affected.

Pelvic Inflammation and Chronic Pelvic Pain[edit | edit source]

These conditions are usually the result of unprotected sex and rape. Pelvic inflammation occurs when a sexually transmitted disease (usually gonorrhea or chlamydia) reaches the fallopian tubes, uterus, and the ovaries; on rare occasions, it can also occur after childbirth, miscarriage, or abortion. Inflammation of the pelvis is due to bacteria and affects the normal functions of the reproductive system, which can sometimes lead to infertility.[28] It has been found that pelvic inflammation is more common in female survivors of sexual and gender-based violence than male survivors.[28]

Functional Impairment[edit | edit source]

The term functional impairment refers to the limitation of one’s normal psychological or physical bodily functioning, and an inability to carry out functions in their daily lives. In many cases, victims of sexual abuse are faced with stressful experiences and depression and are unable to carry on with their work due to diminished self-esteem, low morale, senses of isolation, loneliness, as well as suicidal thoughts and feeling worthless.[29] One Australian study found that while there were many outcomes associated with the experience of sexual and gender-based violence, the majority of victims experienced an overall disability that impaired daily function.[30]

Gynecological Issues[edit | edit source]

Gynecological issues that are related to sexual violence include pelvic pain, vaginal irritations, vaginal swelling, and infertility.

Female Genital Mutilation[edit | edit source]

Female Genital Mutilation / Cutting (FGM/C) encompasses “procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons."[31] Currently about 200 million women have undergone female genital mutilation in over thirty countries.[26] Although many women and human right activists have universally indicated the intention to end the practice and to categorise it as a form of sexual and gender-based violence, several countries still categorise FGM as a cultural tradition or hygiene precaution (e.g. comparing it to male circumcision) even though there has never been conclusive evidence or data to confirm positive health reasoning.[32]

Classification of FGM[edit | edit source]

Female genital mutilation can be classified into four major types:

Type I[edit | edit source]

Clitoridectomy: Removal of the prepuce, with or without cutting out of part of or the entire clitoris. Healing after the procedure can often be so complete that someone untrained in FGM/C may not detect this type of cutting.

Type II[edit | edit source]

Excision: Removal of the entire clitoris, with partial or total cutting of the labia minora. This is the most common form of FGM/C. Although no stitching takes place, deep cutting of the labia minora may result in raw surfaces that fuse together during healing, creating a false infibulation. In some places where Type II FGM is practised, such fusion is accidental, while elsewhere it is deliberate.

Type III[edit | edit source]

Removal of the clitoris, the labia minora and the labia majora, followed by infibulation - i.e. the stitching together of the raw surfaces to create a small opening to ensure passage of urine and menstrual blood. In a few cases, infibulation has been done over an intact clitoris, and so care needs to be taken when performing surgical procedures for an infibulated woman.

Type IV[edit | edit source]

Includes pricking, piercing or incising of the clitoris and/or labia; stretching of the clitoris and/or labia; cauterisation by burning of the clitoris and surrounding tissue; scraping of tissue.

Prevalence of FGM[edit | edit source]

Different states have different prevalence rates of FGM on girls and women aged between 5 to 49 years and it has been reported to be as high as 90%. As of February 2018, the World Health Organization declared a decrease in FGM practice, but with high prevalence still existing in countries located near the horn of Africa (e.g. Somalia, and West-African countries like Guinea).

Complications of FGM[edit | edit source]

Immediate Physical Complications due to the Procedure[edit | edit source]

  • Injury to the adjacent tissue of the urethra, vagina, perineum and rectum.
  • Fracture or dislocation resulting from forceful holding down of girls and the girls’ struggle due to the resultant pain.
  • Failure to heal as a result of wound sepsis.

Long-term Physical Complications[edit | edit source]

The most frequent complications include:

  • Keloids, and vaginal narrowing due to scarring
  • Some experience difficulty during sex and at delivery - increased based on the severity of cutting
  • Damage to the perineum or anus
  • Vulvar tumours
  • Infertility
  • Prolapse

Gynaecological Complications[edit | edit source]

  • Infertility
  • Reproductive tract infections
  • Vesico-vaginal fistula (VVF)
  • Recto-vaginal fistula (RVF)
  • Other gynaecological complications:
    • Difficulty in passing urine as a result of partial blockage of urinary opening
    • Menstrual flow difficulties
    • Recurrent urinary tract infections
    • Keloid scarring
    • Vulval cysts and abscesses

Obstetric Complications[edit | edit source]

  • Inability to become pregnant
  • Reduced vaginal opening affects the delivery of babies and appears to be the main factor responsible for other obstetric problems in women with FGM/C.
  • Prolonged labour and/or obstruction which can lead to obstetric fistula
  • Postnatal genital wound infection

References[edit | edit source]

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