Gender Violence:The Health Impact – Sexual Violence in Conflict & Access to Medical Care
December 9, 2014 Leave a comment
Conflict-Related Sexual Violence
In war as in peace, the identity of women as individuals with agency often gets subsumed by the symbolic ‘woman’ who is varyingly used to represent nations and communities – as markers of communal boundaries, as repositories of ethnicity and culture, as the standard bearers of values and morality and as bearers of children. The policing of women’s bodies in these circumstances serves the larger purpose of protecting the integrity of the nation and maintaining the fabric of the patriarchal community. Transgressing from these roles often comes with sanctions that have grave physical, psychological, social and economic consequences for women.
In war, the vulnerability of women to violence is manifold precisely because of what this symbolism represents to the enemy: when conquering armies treat women as the “spoils of war”, it serves the dual purpose of destroying the reproductive capacity of an ethnic group and also emasculating the enemy (Seifert 1994). Apart from being used as a strategy of war, in both international and ethnonational conflicts, the devastation caused by prolonged exposure to armed violence leads to a breakdown of socially sanctioned behaviour and norms resulting in a pervasive violation of human rights that includes sexual violence.
Whatever the reasons, in conflict and post-conflict settings, both as a tactic and as a consequence of war, sexual violence affects women disproportionately. However, a neglected and often under-discussed aspect of conflict related sexual violence is that it also claims men and boys as victims. The experiences of sexually assaulted men in conflict often mirror those of women in terms of the physical, reproductive, sexual, psychological and social consequences they face (Sivakumaran 2007). In this context, the gendered characterization of “victor as male and vanquished as female” is also notable. Regardless of their sex, perpetrators are masculinized and victims are feminized. Thus, sexually-assaulted and raped men are gendered as female and face stigma, ostracism and a negation of their masculinity (Goldstein 2001, p.371).
Sexual violence in conflict can take many forms. Women are subject to sexual assault, rape, gang rape, forcible conscription and sexual slavery, enforced prostitution, sex trafficking and forced impregnation. Men are subject to rape, gang rape, forced rape of others, forced fellatio and masturbation, genital violence, forcible conscription and sexual slavery, castration and sexual mutilation. All of these have debilitating short and long-term health consequences and require comprehensive and sustained public health interventions that not only respond and rehabilitate but also prevent and inform.
Sexual Violence in Conflict & Related Health Consequences
Beginning with bruises, wounds, concussions, broken bones and internal injuries and ending in death, the physiological repercussions of sexual violence in conflict are many and varied. Sexual assault can result in genital injuries, profuse vaginal and anal bleeding, gynecological complications including but not restricted to chronic pelvic pain, pelvic inflammatory disease and urinary tract infections as well as vaginal and rectal fistulas and fibroids.
The devastation of all types of infrastructure during protracted conflicts has an impact on health care as well and results in crumbling health systems, a dearth in health care providers and medical resources. Conflict also creates serious impediments to safe access to medical care. In the immediate aftermath of sexual violence, women are susceptible to both unwanted pregnancies and sexually-transmitted infections including HIV/AIDS. And lack of access to medical care and the stigma associated with accessing medical care for injuries related to sexual violence triggers secondary cycles of health issues such as unsafe and self-induced abortions and an intensification of other physical symptoms due to lack of care (Garcia-Moreno 2014, Amnesty International 2004).
The mental health and psycho-social consequences of sexual violence during and after conflict are particularly disabling. Survivors of sexual violence are vulnerable to many psychological and emotional disorders including anxiety, depression, self-blame, behavioural and eating disorders, post-traumatic stress, traumatic flashbacks and suicide ideation and these feelings are exacerbated by the social stigma, isolation, ostracism and rejection from family and community that they encounter (Alcorn 2014). Studies suggest that survivors of assault are more likely to access health systems frequently due to increased insecurity and a poor perception of their own health. They present with many psychosomatic illnesses and report cardio-pulmonary and neurological symptoms such as migraines, shortness of breath, palpitations, chest pain, hyperventilation, choking sensation, insomnia, fatigue etc (Jina & Thomas 2013, Harris & Freccero 2011, Josse 2010).
The burden placed on health care systems during conflict is enormous and what little remains in terms of resources and persons are found wanting when it comes to both therapeutic and medico-legal interventions for sexual violence. Standardised practices for response and clear, survivor-centric protocols and guidelines while present, are lacking in implementation. This in turn adds another layer to the victimization by obstructing survivors’ access to justice and reinforcing impunity for conflict-related sexual crimes (Cottingham, Garcia-Moreno & Reis 2008).
The Role of the Health Sector
The collapse of political, administrative and essential services during conflict means that the short-term and long-term health needs of women go unmet and this has far reaching public health consequences for women, children, families and communities.
Women (and other survivors of sexual violence) have to overcome monumental challenges to access health care during conflict and many reasons contribute to this:
- There is a pervasive under-reporting of sexual violence in conflict due to fear of social consequences (Physicians for Human Rights 2008).
- Physical access to health centres maybe barred and the routes too dangerous, leading to the probability of further violence.
- In an environment characterized by impunity, survivors often deny themselves health care for fear of violent reprisals and re-victimization (Apple & Martin 2014, Advocacy Forum & ICTJ 2010).
- In protracted conflicts, the violation of medical neutrality by warring factions causes a high attrition rate amongst health workers and women are left with little or no choice regarding their own reproductive and sexual health (Khandey 2004, Asia Watch & PHR 1993).
Sexual violence in conflict and the conspiracy of silence that surrounds its treatment, documentation and prosecution has led to an increased focus on creating sustainable, confidential and non-discriminatory response mechanisms. A growing body of evidence is now available on the development and implementation of accessible, rights-based, survivor-centric health systems and existing guidelines and protocols propose concrete plans for a multi-sectoral, inter-agency, collaborative approach to health that adopt a gendered perspective and comprise of physical, reproductive, psycho-social and medico-legal interventions.
The ‘Guidelines for Gender-Based Violence Interventions in Humanitarian Settings Focusing on Prevention of and Response to Sexual Violence in Emergencies’ (IASC 2005) and ‘The Inter-Agency Field Manual on Reproductive Health in Humanitarian Settings’ (IAWG 2010) are the most comprehensive of their kind and establish minimum standards of care in emergency situations. The IASC Guidelines takes a wide-ranging look at the planning, development and implementation of minimum interventions in the pre-conflict preparedness phase, emphasizes the detailed application of a Minimum Prevention and Response (MPR) program at the peak of the conflict and also provides an overview of the activities to be undertaken in the post-conflict stabilization phase. The IAWG Field Manual incorporates an updated Minimum Initial Service Package (MISP) for reproductive health that includes preventing and managing the consequences of sexual violence in conflict by integrating a comprehensive reproductive health services system into the public health system rather than offering services in isolation. The objectives of the MISP are to identify local organizations to carry out interventions and ensure accessibility of services to women and children and involving community members, especially women, as stakeholders in the process.
The free availability of emergency contraceptives in conflict situations is critical in providing women with options regarding their sexual and reproductive health. Brown (1994) references the ethno-national conflicts in the former Yugoslavia and Bangladesh to highlight the importance of birth control technologies as well as emergency contraceptives in helping women regulate their own reproductive capacities and therefore reduce the potency of rape as a weapon of cultural destruction in conflict. An important resource for health care professionals in this context is ‘The Emergency Contraception for Conflict-Affected Settings’ (RHRC Consortium n.d.).
In addition to developing robust, gender-sensitive health systems to respond to the needs of survivors of sexual violence during conflict and engage in awareness and public education, prevention efforts will be augmented if standardised protocols are implemented for the collection of medico-legal evidence. This will enable women to approach judicial processes with greater confidence and aid in instituting a culture of accountability, reparation and punishment to counter impunity. In this regard, the Clinical Management of Rape Survivors (WHO & UNHCR 2004) and the Guidelines for Medico-Legal Care for Victims of Sexual Violence (WHO 2003) are both useful tools in setting universal standards for the collection, documentation, storage, transfer and use of medical evidence to seek legal recourse. These guidelines also stress on therapeutic interventions including psycho-social care that need to be made available to survivors.
In the Indian context, the Ministry of Health and Family Welfare has released guidelines and protocols for medico-legal care of survivors of sexual violence that are also intended for adaptation and use in situations of communal and caste conflicts and seeks to lay out the components of a comprehensive health care response to sexual violence. Detailed instructions are provided for examining marginalised and special groups including transgender and inter-sex persons, persons of alternate sexual orientation, sex workers, persons with disability and people facing caste, class or religion based discrimination (MoHFW 2014).
The core of health care efforts in the response and prevention of sexual violence in conflict should be grounded in two main pursuits: the provision of physical, sexual and reproductive and psycho-social care for survivors of sexual violence by sensitized and trained health workers and enabling the legitimacy of policy and justice mechanisms in prevention efforts by documenting and establishing broad patterns of sexual violence before, during and after war.
Other Useful Resources
The following websites have a wealth of resources on sexual and gender-based violence and its impact on reproductive and sexual health in conflict settings and address both prevention and response.
- The Sexual Violence Research Initiative (http://www.svri.org/)
- The Reproductive Health Response in Crises Consortium (http://www.rhrc.org/)
- Reproductive Health Access, Information and Services in Emergencies – The RAISE Initiative (http://www.raiseinitiative.org/home/)
- The Inter-Agency Working Group on Reproductive Health in Crises (http://iawg.net/)
- The International Campaign to Stop Rape and Gender Violence in Conflict (http://www.stoprapeinconflict.org/)
- Alcorn, T 2014, ‘Responding to Sexual Violence in Armed Conflict’, The Lancet Series, 383, No.9934, pp.2034-37, viewed on 5th December 2014, <http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673614609703.pdf>.
- Amnesty International 2004, Live Blown Apart: Crimes against Women in Times of Conflict, Amnesty International Publications, London, viewed on 5th December 2014, <http://www.amnesty.org/en/library/asset/ACT77/075/2004/en/944d7605-d57f-11dd-bb24-1fb85fe8fa05/act770752004en.pdf>.
- Asia Watch & Physicians for Human Rights 1993, Rape in Kashmir: A Crime of War, Human Rights Watch, New York, viewed on 5th December 2014, <http://www.hrw.org/sites/default/files/reports/INDIA935.PDF>.
- Advocacy Forum & International Centre for Transitional Justice 2010, Across the Lines: The Impact of Nepal’s Conflict on Women, Advocacy Forum & International Centre for Transitional Justice, Nepal, viewed on 5th December 2014, <http://www.peacewomen.org/assets/file/Resources/NGO/justvaw_acrossthelines_ictjandnpl_december2010.pd>.
- Brown, CA 1994, ‘Reproductive Control and Ethnic Conflict’, A Journal of Social Justice, 4, No.1, pp.85-92.
- Cottingham, J, Garcia-Moreno, C & Reis, C 2008, ‘Sexual and Reproductive Health in Conflict Areas: The Imperative to Address Violence against Women’, BJOG: An International Journal of Obstetrics and Gynaecology, 115, no.3, pp.301-303, viewed on 5th December 2014, <http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2007.01605.x/pdf>.
- Garcia-Moreno, C 2014, ‘Responding to Sexual Violence in Conflict’, The Lancet Series, 383, No.9934, pp.2023-24, viewed on 5th December 2014, <http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673614609636.pdf?id=gaah_M2bYkA35–NASmIu>.
- Goldstein, SJ 2001, War and Gender, University Press, Cambridge.
- Harris, L & Freccero, J 2011, Sexual Violence: Medical and Psychosocial Support, Human Rights Center, University of California-Berkeley, viewed on 5th December 2014, <http://www.law.berkeley.edu/HRCweb/pdfs/SVA_MedPsych.pdf>.
- IASC Task Force on Gender and Humanitarian Assistance 2005, Guidelines for Gender-Based Violence Interventions in Humanitarian Emergencies: Focusing on Prevention and Response to Sexual Violence, Inter-Agency Standing Committee, Geneva, viewed on 5th December 2014, <http://gbvresponders.org/wp-content/uploads/2014/04/GBV_Guidelines_English.pdf>.
- Inter-Agency Working Group on Reproductive Health in Crisis 2010, Inter-Agency Field Manual on Reproductive Health in Humanitarian Settings, UNHCR, Geneva, viewed on 5th December 2014, <http://www.who.int/reproductivehealth/publications/emergencies/field_manual_rh_humanitarian_settings.pdf?ua=1>.
- Jina, R & Thomas, LS 2013, ‘Health Consequences of Sexual Violence against Women’, Best Practice and Research: Clinical Obstetrics & Gynaecology, 27, No.1, pp.15-26.
- Josse, E 2010, ‘They came with two guns’: The Consequences of Sexual Violence for the Mental Health of Women in Armed Conflicts’, International Review of the Red Cross, 92, no.877, viewed on 5th December 2014, <http://www.icrc.org/eng/assets/files/other/irrc-877-josse.pdf>.
- Khandey, Z 2004, ‘Negotiating Reproductive Health Needs in a Conflict Situation: A Case of Kashmir Valley’, Medico Friend Circle Bulletin, 1-3, viewed on 5th December 2014, <http://www.mfcindia.org/mfcpdfs/MFC307.pdf>.
- Ministry of Health and Family Welfare 2014, Guidelines and Protocols: Medico-Legal Care for Survivors/Victims of Sexual Violence, Government of India, New Delhi, viewed on 5th December 2014, < http://uphealth.up.nic.in/med-order-14-15/med2/sexual-vil.pdf>.
- Physicians for Human Rights 2008, Rape as a Weapon of War: Accountability for Sexual Violence in Conflict, Physicians for Human Rights, Cambridge, viewed on 5th December 2014, <https://s3.amazonaws.com/PHR_other/rape-as-a-weapon-of-war.pdf>.
- Reproductive Health Response in Conflict Consortium, Emergency Contraception For Conflict-Affected Settings: A Reproductive Health Response in Conflict Consortium Distance Learning Module, RHRC Consortium, viewed on 5th December 2014, <http://www.rhrc.org/resources/general_fieldtools/er_contraception/ec_brochure_english.pdf>.
- Seifert, R 1994, ‘War and Rape: A Preliminary Analysis’, in Stiglmayer A (ed.), Mass Rape: The War against Women in Bosnia-Herzegovina, University of Nebraska Press, Lincoln and London, pp.54-72.
- Sivakumaran, S 2007, ‘Sexual Violence Against Men in Armed Conflict’, The European Journal of International Law, 18, No.2, pp.253-276, viewed on 5th December 2014, <http://ejil.org/pdfs/18/2/224.pdf>.
- WHO & UNHCR 2004, Clinical Management of Rape Survivors: Developing Protocols for use with Refugees and Internally Displaced Persons, WHO, Italy, viewed on 5th December 2014, <http://gbvaor.net/wp-content/uploads/sites/3/2012/10/Clinical-Management-of-Rape-Survivors-Developing-Protocols-for-Use-with-Refugees-and-Internally-Displaced-Persons-WHO-UNHCR-2004.pdf>.
- World Health Organization 2003, Guidelines for Medico-Legal Care for Victims of Sexual Violence, WHO, France, viewed on 5th December 2014, <http://gbvaor.net/wp-content/uploads/sites/3/2012/10/Guidelines-for-medico-legal-care-for-victims-of-sexual-violence-WHO-2003.pdf>.
Swetha Shankar is a trained counselor and works on issues related to gender, conflict and violence. She is the coordinator of the 2014 edition of the Prajnya 16 Days Campaign Against Gender Violence.