Claudine repeatedly slams her hand against the table as she talks. Bang, bang, bang. She tells me after yelling and beating at the door, the men eventually broke it, pushing into her home in Burundi’s capital, Bujumbura. They gang raped Claudine, one of dozens of women and girls attacked in the city between 2015 and 2016 because, they were married or related to members of opposition parties.
The global women’s rights movement has been fighting an uphill battle for recognition and care of rape victims in conflicts. National governments, the United Nations, local groups, and humanitarian organizations like the Red Cross or Medecins Sans Frontiers struggle in the middle of crises to provide emergency post-rape care that meets World Health Organization (WHO) standards. This includes prophylaxis against HIV transmission within 72 hours of the rape, emergency contraception within 120 hours, and a physical examination.
Emergency deadlines for treatment, chaotic circumstances, and limited capacity have meant that the health response to rape has focused on immediate needs. There has been less attention and capacity to support victims struggling with longer-term health impacts of rape, especially depression, anxiety, or post-traumatic stress disorder. “I wake up screaming and have nightmares,” Claudine, who had been raped nine months earlier, told us. “I still feel worried all the time. My heart is always scared.”
Rape survivors are being left behind along with millions of other people who lack access to quality mental health care, chronically underfunded all over the world, especially so in middle- and low-income countries where 76 to 85 percent of people with severe mental disorders receive no treatment. In crises, women like Claudine—who take care of their households and children, but struggle and feel irrevocably changed by their trauma—may spend hours waiting at clinics for malaria drugs or vaccines for their kids but are unlikely to get support or treatment for depression, even though mental health illnesses create many kinds of burdens to families and communities, and not just the victim. “I am always angry with my children now,” another rape survivor told me.
My colleagues and I at Human Rights Watch are not medical experts. But again and again when we interview women and girls to document patterns of rapes in conflicts and victims’ access to health care afterward, the long-term devastation of rape shocks us. We leave interviews stunned not only by the brutality of rape but also by the shame and disconnect to reality that many victims still feel long afterward.
We use interviewing techniques to minimize distress for survivors and do our best to ensure they feel in control during the interview. And we make sure that we can provide referrals to support organizations, especially as we may be the first people to whom they have told their stories. It’s frustrating to discover that even when emergency capacity exists, long-term mental health services are typically absent or of poor quality. Interviewees have told us that health care providers treat them dismissively and without compassion. “They said I was just making it up, to get asylum,” Claudine said about the international nongovernmental organization workers who ran the only program for rape survivors in her refugee camp. This is a serious problem: WHO guidelines for post-rape care are clear that ensuring a victim feels believed and supported are important parts of an adequate first level intervention.
Research has established that sexual violence victims are more likely to experience depression, anxiety, substance abuse, and post-traumatic stress disorder. Victims of potentially traumatic events eventually have higher rates than the rest of the population of other illnesses like cancer, cardio-vascular disease, and diabetes. Some research suggests that rape is more likely to lead to PTSD than other forms of trauma.
Doesn’t time heal? Women and girls use their strength and spirit, and if they’re lucky, family and community, to manage: They are not hopeless or helpless. Many humanitarians in this field say they believe that most survivors heal by themselves. But in our experience, this is not necessarily true. One of my colleagues in 2015 interviewed more than 100 women who had been raped—often in brutal gang rapes—during Kenya’s 2007-2008 post-election violence. “It is in me, and it has refused to go away,” said one. Almost 10 years had passed but often survivors reported chronic depression, anxiety, and unexplained pain that interfered with their abilities to work, care for their children, and be full members of their communities.
The Medica Zenica group, which has provided long-term services to survivors in Bosnia and Herzegovina, found that more than 57 percent of the women they interviewed showed clinically relevant PTSD symptoms more than 20 years after they were attacked.
When we have investigated mass sexual violence—in South Sudan, Central African Republic, Iraq, and Somalia—we have found that governments are typically unwilling or unable to provide health care. Often, it’s government forces that are raping women or attacking ethnic groups; they are the ones doing the damage. No matter who the perpetrators are, in times of war little money is funneled into health care. Often countries with conflict are also countries where women’s rights and health needs are given little consideration, even in the best of times. In refugee camps, aid agencies shoulder the work.
Aid work includes an area of services called “Mental Health and Psycho-Social Support” (MHPSS), which includes the support of victims of sexual violence. Mental health in humanitarian crises used to be a “ghetto” of humanitarian action, almost totally ignored. It wasn’t seen as that important. Things have improved, helped by the increased understanding we have now of the huge detrimental impact of poor mental health on economic recovery, but we frequently find little or no emergency care of this type is available, even for victims of horrific human rights abuses like rape or torture.
Even when these services exist, providers are often just there short-term, vary enormously in quality and quantity, and are rarely systematic or structured around the needs of individuals. The Burundian victims we spoke to were often only getting one or two sessions with counselors before being told to “come back if they had any more problems,” hardly a supportive invitation to survivors plagued with guilt and uncertainty. As they do elsewhere, providers there faced funding shortages, and even when they had money, it was distributed in six-month or one-year tranches—there was no opportunity for long-term programming. Service providers often track survivors for just a few months and then “discharge” them. This might work for some women, but may not work for all.
Coverage in the same country can vary widely. In Iraq, I interviewed Yazidi women and girls who had been held in sexual slavery by the Islamic State, separated from their families and treated as sub-human before they finally escaped to camps for displaced people. Some 20 organizations were providing some level of mental-health assistance. “Every camp is covered,” a U.N. agency rep told me. But while a survivor in one displaced people’s camp had individually focused and deeply committed help from trained counselors and psychologists from a local organization, a girl in another camp might only get an afternoon of gardening with other displaced women hosted by an international organization on patchy six-month funding cycles. In one camp, there was a visiting psychologist, in others, no transport to any services. In all the places I visited, stigma, shame, and a lack of knowledge about what was available were stopping girls and women from accessing care.
Jamila was 14 years old when she was held captive and repeatedly raped by three Islamic State fighters over a period of months. One, she said, “told me he had fed my parents to dogs.” Noreen, 19 when we spoke, still had pain in her legs that seemed to have no physical cause. She wanted to see a psychologist, but didn’t know how she might find one or what her family would say. Neither had received a formal diagnosis. They struck me as strong people, and Jamila had struck up an important friendship with another Islamic State escapee; they help each other cope, she said. But Jamila, who had escaped six months before, still could not manage going to school, and Noreen said that as the months went by she thought more and more about her abduction.
The MHPSS “box” can be ticked by programming that varies widely in scope, quality, and goals. These range from safe spaces for women to sports activities for children to group or individual counseling by psychologists, in some places carefully tailored to needs and the local culture, in other places, not. Even if some of these activities are not doing any harm, some, like one-off workshops, may be using up precious resources. One study concluded that “there is a large gap between the activities that are very popular and the kind of evidence there is for effectiveness of interventions.”
Humanitarians use a pyramid to describe what they believe to be mental health needs: Most people (the base of the pyramid) will heal from potentially traumatic situations like mass displacement with non-specialist support, and only a few, the pyramid’s peak, will need specialized services. This may be the case generally for people affected by war, but my instinct following over 100 interviews with survivors from five different cultures is that rape victims are not equally spread out over the pyramid—they are much more likely to be at the top. One academic told me the problem is that, “the top of the triangle might be much bigger—in fact to think of it as a triangle may be misleading.”
There isn’t enough happening to treat these victims, and there may never be enough money to do this. Even in wealthy countries, there is a dearth of professional mental health care. Much more research is needed to find out what is effective, what could work, and what survivors and others in their traumatized communities are doing to help themselves already. International donors and national governments should strengthen access to quality mental health care in general, not just for rape.
International donors fund a very small number of mental health activities and mental health is just about 1 percent of the World Health Organization’s budget.
A sea change is needed, one that stretches even beyond the most pressing emergencies. One of the most effective ways to improve crisis services is to strengthen overall mental health care. The Overseas Development Institute notes that even though one in four people will be affected by a mental disorder over their lifetime—causing a huge impact on their families, society, and the economy—little attention is paid to mental health care. Fewer than one in 50 people with severe mental disorders receive treatment that has been proven effective, and less than 1 percent of low-income countries’ health budgets go toward mental health.
Rigorous research is needed into what types of intervention work best for rape survivors in conflict and post-conflict zones and how to improve care in both the short and long term. It is critically important, experts say, to adapt programs to national and cultural contexts.
Positive steps are being taken. The U.N. High Commission for Refugees has acknowledged they should do more to provide mental health services, including ensuring that clinical mental health services are available. Researchers found that group psychotherapy—which reaches more women than individual counseling—conducted by locally trained assistants in the Democratic Republic of Congo reduced symptoms, even after only six months. The WHO is piloting programs that provide group therapy to sexual violence survivors from South Sudan in Ugandan refugee camps, and other places and are exploring online interventions. One such program, called “Self-Help Plus,” is especially designed for places “with enormous needs but limited humanitarian access, such as Syria and South Sudan” and shows promise as a stress management package.
There is momentum. But it will take compassion and commitment to move forward. We may have to look into the darkness of other people’s broken hearts to better understand how they are managing despite great odds. If we do, hopefully we can get one step closer to supporting victims of egregious war crimes as they struggle to regain their health and sense of self.