THE AFTERMATH OF RAPE AND OTHER FORMS OF SEXUAL VIOLENCE
Stigmatization of Victims
Women and girls who have been raped and otherwise sexually abused have been psychologically damaged as well as physically injured by these crimes, and many will never fully recover. A significant number of women and girls have become pregnant as a result of being raped and an unknown number have been infected with HIV, dramatically altering their future lives, livelihoods, and prospects. Other family and community members may also be psychologically or physically affected as a result of sexual violence against women and girls. A woman abducted and raped by Kinyarwanda-speaking attackers said simply that afterwards "my head was not right."159
The situation of rape victims is made worse by the stigma that is attached to such violence. In many cases these women and girls are ostracized, and find themselves at the margins of society.
One doctor treated a fifteen-year-old girl who had been raped by several men as an outpatient to avoid drawing attention to her case. He also treated her without charge. He commented, "We can do little else to prevent her being rejected. It's not her fault," he said. "Physically she'll probably get better, although we don't know yet if she contracted any other illness. And on the psychological level, it remains a problem. She lost her virginity, which is something very important in the village. She can't even talk about it."160
In some cases husbands rejected their wives upon learning they had been raped, sometimes on the pretext that the woman must have consented to the sexual relations. In one such case, a woman raped by RCD soldiers said:
Afterwards I went home. I tried to hide it from my husband but he found out. He said that I had accepted it voluntarily. He said this although I had bruises and marks where the soldiers had pressed their fingernails into my inner thigh.161
In another case, a woman who had been raped by a former Rwandan soldier hoped to keep the crime from her husband but sought advice from her pastor:
When I got home, I went to the pastor to tell him what had happened. His wife heard our conversation, and she went around and told everyone about it. Now I am an outcast. No one will come to see me or share anything with me. My second husband said he was unlucky with wives because he had already lost two wives before me. We don't get along. Sometimes he says I should go back to [my first] husband...or I should go be with another man in the forest.162
Some husbands simply put their wives out the door, refusing further contact with them. In others they allowed the women to remain in the household but took a second wife, relegating the rape victim to a subordinate position.163
Families of husbands and of the victims themselves sometimes rejected women and girls who had been raped. Francine M., a thirty-five year old widow and mother of six, was raped by three RPA soldiers at Kasika, South Kivu, in August 1998. They also killed her husband in front of her. Afterwards her husband's brothers accused her of being a "traitor," an "accomplice" of the attackers, suggesting she could not have survived otherwise. They said she had become "everyone's woman." She left Kasika and is now living in Bukavu. She continues to suffer from abdominal pain three years later. "My body has become sad," she said. "I have no happiness."164
Husbands and families often weighed many issues in determining their response to the rape of a woman in the household. In deciding the long-term results of the crime, they considered whether the woman might have become pregnant and if so what responsibilities would be involved in raising the child. Families also considered the possibility that the victim might have been infected, particularly by HIV/AIDS, which would impose the burden of care on the family. The amount of public attention given to the crime also influenced the reaction of husbands or others in the family. This is one reason why victims preferred keeping silent about the crimes.
Women and girls rejected by husbands and families were often impoverished as well as humiliated. Francine M., who moved to Bukavu with her six children, now sells avocados and rents a house for three dollars a month, an amount she has difficulty paying.165 Another young woman who had been raped by Hutu combatants in Masisi was rejected by her husband. Now in Goma, she is pregnant and has no permanent roof over her head. She lives in the ruins of destroyed houses and earns small sums of money by transporting heavy loads.166 Several girls we interviewed at Sake, near Goma, had been expelled from their homes after they were raped at a young age. Some of them were pregnant. They were often forced into hazardous and low-paying labor. For example some of the women interviewed earned money by carrying heavy loads or working as household help.167
Unmarried women and girls who became pregnant as a result of rape were far less likely to find husbands in the future and so risked remaining always on the margins of society. In the estimation of one doctor, an unmarried woman who had a child in such circumstances would have only a 20 percent chance of being married in the future. 168According to one group of Congolese women, a girl who had been raped and given birth was "a girl no boy can marry."169 Yet most unmarried girls who became pregnant as a result of rape generally gave birth to the children even though they understood that doing so made it impossible to hide the rape and also entailed the burdens of bringing up the child. Congo is a predominantly Roman Catholic country and abortion is illegal under Congolese law and not condoned by Congolese culture, even in the case of rape.170 According to one doctor, women and girls who decided to end pregnancies sought abortions not from medical doctors but from unqualified personnel, with all the attendant risks of complications. "If it is done," he said, "it's done by charlatans."171
One young woman recounted what happened after she was raped by an RCD soldier in October 2001. At first she said nothing to anyone else but she finally confided in her employer, who gave her the money for a pregnancy test and HIV test. When she learned that she was pregnant, the employers suggested she have an abortion. "I spoke with my father," said the young woman, "and he asked me-would a child stop you continuing with your studies? I said no and he said I should keep the child. My father is a Christian. He said he would stand by me." She continued:
I haven't yet told my brothers. I don't know how I am going to tell them. I don't know what I am going to say, how I am going to introduce it. I already don't know how to explain why I vomit. I stay in my room all day. If God gives me this child and the child asks who his father is, what am I supposed to say?172
Some husbands have supported their wives after they have been raped. One woman raped by Mai-Mai and FDD combatants near Kazimia in June 2001 needed three days of hospital care to begin her recovery. When she returned home, her husband, a development worker, welcomed her. He said, "We are together-it [the rape] was not her fault."173
A greater willingness to speak out about the crimes has helped reduce the stigmatization from which the survivors suffered. In Shabunda, where women and girls have been the most outspoken about having been raped, they have formed an association of 500 members to support women and girls who have been raped.
In other areas, priests are using their sermons to publicize the availability of medical treatment and counseling for victims of sexual violence at church funded centers in Bukavu. Although few will be able to avail themselves of these services, simply raising the issue of sexual violence publicly in such a forum helps reduce the stigma attached to sexually abused women and girls and makes it easier for them to seek help.
Medical Consequences and HIV/AIDS
Many women and girls suffer from injuries, internal bleeding, fistulas and incontinence as a result of rape. Some are pregnant and experience medical complications during the pregnancy. Many women and girls also contract sexually transmitted diseases, including HIV/AIDS. Experts estimate that about 60 percent of regular troops and militia-men in Congo are infected with HIV/AIDS and have warned that the war exacerbates an existing HIV/AIDS crisis. The people in Congo have yet to realize the full extent of the destruction brought upon them by the sexual violence used against women and girls.
Few women or girls seek medical treatment after rape because health care and testing for sexually transmitted diseases or HIV/AIDS is so expensive, because in some areas there are few health care service providers and most of them are men, and because seeking care makes it likely that the rape will become known and the victim will be stigmatized. Generally, medical staff are poorly trained, have little or no specialized experience in treating the consequences of sexual violence, are not paid, and are demoralized; medical centers are poorly equipped; and many facilities have been pillaged or destroyed.
One doctor said, "Those we see are just a sample. We probably see only the extreme cases."174 A nurse agreed. "If [women and girls] have been raped and are really sick and they have to seek medical attention, some go to hospitals," she said. "If they don't have to, they don't speak about it to anyone, and don't seek medical help."175 Some women and girls have been seriously and sometimes permanently injured or disabled in the course of being raped or otherwise sexually assaulted. Women and girls who have survived acts such as being shot in the vagina, as described above, or repeated gang rape, amateur emergency surgery, and so on are likely to have very serious clinical problems.
In one particularly serious case, a woman who had recently given birth was gang-raped by four Kiswahili-speaking armed men in the forest near Shabunda. A fistula developed between her vagina and her rectum. Unable to leave the forest all she could do was washed herself with warm water and leaves from the trees. She related:
After a month I went to the nurses in the bush. These were nurses who had been taken hostage by the Mai-Mai. The nurses tried to stitch me up, using the kind of cord that is used to braid hair. There was no anesthetic and no hygiene. But it came apart after some days.176
Fifteen months later this young woman reached Shabunda and was finally been able to seek medical assistance. She is hoping to go to Bukavu for specialized surgery to repair the fistula. Many doctors do not have the facilities or expertise to treat such patients, even if the women and girls can reach them in the first place. Even with the best possible treatment, many of these women and girls are disabled for life and need long-term therapy. The psychological trauma caused by rape is likewise rarely addressed, and the reluctance to discuss the experience even with family members or friends compounds the problem.
A significant number of women and girls are infected with sexually transmitted diseases through rape and for any or all of the above reasons do not seek treatment unless it is absolutely necessary. The large majority of rape victims interviewed had never received any medical treatment after the rape, and often did not even tell doctors about the rape when they gave birth. Social workers and medical staff confirmed that only a small minority of victims ever get any treatment. Thus, many relatively easily treatable sexually transmitted diseases remain untreated, some causing considerable pain and inconvenience to the woman, and some causing irreversible consequences. The most deadly disease that can be contracted through rape is HIV/AIDS. Not only are the lives of HIV-positive women and girls shortened and their livelihood possibilities seriously impaired, but being HIV-positive or even being suspected of being positive adds to the stigma of rape to make for a double stigmatization of these women and girls. One woman who had been raped said that her husband rejected her, saying he was afraid that she had contracted HIV and would "contaminate" him.177 The scarcity and high cost of HIV testing makes it more difficult for women who are not infected to demonstrate this to their husbands and families.
In Resolution 1308 (2000), the Security Council explicitly recognized that the HIV/AIDS pandemic is exacerbated by armed conflict, as have others.178 The secretary-general reported to the General Assembly in 2000 on children in armed conflict and noted the "...haunting images, from place after place, of adolescent victims of rape, which has become as much a weapon of warfare as bullets and machetes...Armed conflicts also increasingly serve as vectors for the HIV/AIDS pandemic, which follows closely on the heels of armed troops and in the corridors of conflict."179 It has been reported that rates of sexually transmitted diseases among soldiers are two to five times higher than those of civilian populations and that during armed conflict the rate of infection can be up to fifty times higher.180 The U.S. Institute for Peace in 2001 estimated that the HIV prevalence rate among combatants in the D.R. Congo war is 60 percent.181 It is likely that a high percentage of Rwandan soldiers are HIV-positive.182 Dr. Tshioko Kweteminga of WHO-Congo has commented that the displacement and multiple troop movements between Congo and neighboring countries have set Congo up for a major "explosion of HIV/AIDS," a view held by many.183 Rwandan troops returning with the virus from Congo will put the civilian population of Rwanda at increased risk of contracting HIV.
The national HIV prevalence rate in Congo was officially given as 5.1 percent as of end 1999-derived from sentinel site data184-but this figure is widely thought to underestimate the current prevalence.185 In July 2001, WHO reported that national figures collected through the health information system cite just under 10,000 new cases of HIV for 2000. It commented, "But public health authorities estimate the real figures, based on the sentinel site information, are more like 173,000 new cases a year, with a total of almost 1.3 million adults and children already living with HIV."186 Various surveys of women and girls in antenatal clinics in some of the bigger cities were conducted from the mid-1980s to the mid-1990s, but since then political instability and war have impeded regular surveillance. Eastern Congo is particularly devoid of good data.
Surveys in the last few years indicate that HIV prevalence among blood donors in the city of Bukavu is 10 to 12 percent, but it is not clear how representative this group is of the general population or of communities most affected by the war.187 One NGO-based health expert estimated the prevalence in Bukavu to be of the order of 15 to 20 percent, given the results of various small-scale studies.188 Prudence Shamavu, director of the Bukavu office of Fondation Femmes Plus, a national organization working against HIV/AIDS, said one study indicated that the HIV prevalence among prostitutes in the city of Bukavu is as high as 45 percent.189 WHO reported that a study of patients in the General Hospital of Bukavu found a HIV infection rate of 32 percent among adult males, 54 percent among adult females, and 26.5 percent among children.190 Health experts interviewed agreed that the prevalence of HIV/AIDS is growing rapidly in North and South Kivu and constitutes an urgent problem. They urged international assistance for conducting a valid prevalence survey.
Compared to other parts of eastern, central, and southern Africa, even those that are poorly served by health services, eastern Congo is desperately lacking in services related to HIV/AIDS. Services meant to prevent HIV/AIDS are almost nonexistent. The public health promotional messages and information campaigns that have come to be fairly widespread through much of Africa are virtually absent in eastern Congo. Shamavu noted it has been difficult to interest donors in usual preventive activities such as mass media campaigns, and donor funding is necessary as the authorities in the region have not allocated significant resources to HIV/AIDS programs.191 She also noted that it has taken some time for all the relevant players in the health sector, including the Roman Catholic church, a major health service provider, to come to a consensus on the content of messages to disseminate.
Other services, notably access to HIV testing and counseling, are accessible only to a tiny percentage of the population through a few of the better equipped health facilities. HIV tests cost up to US $5 in some parts of the region, a price beyond the reach of much of the population. The majority of the women and girls met by Human Rights Watch researchers were aware of the possibility of HIV infection, and many indicated that if testing were accessible to them they would be tested. "Some women do ask for HIV tests and they want to know if they have sexually transmitted diseases. They dance when they find out that they're HIV-negative," said a health worker.192 Antiretroviral treatment for HIV-positive women and girls or treatment to prevent mother-to-child transmission is virtually nonexistent. Even opportunistic infections, such as tuberculosis, diarrhea, meningitis and pneumonia, are mostly not treated because people cannot afford to pay for medicine.
The international organization Population Services International recently began a condom promotion campaign in Bukavu, but condoms have otherwise been and remain difficult to obtain. Médecins sans Frontières-Holland has begun a pilot activity in Bukavu providing information and counseling about sexual practices to young people, street children, and prostitutes.193
In agreement with considerable social science research, the U.N. Development Fund for Women (UNIFEM) claims that the HIV/AIDS epidemic "would not have reached such vast proportions" if women and girls in Africa and elsewhere had been able to refuse unwanted and unprotected sex.194 A report to the U.N. Commission on the Status of Women concluded: "Women's and girls' relative lack of power over their bodies and their sex lives, which is supported and reinforced by their social and economic inequality, makes them more vulnerable in contracting and living with HIV/AIDS."195 The control of women and girls in eastern Congo over their sex lives is even further weakened in the context of the current war and their vulnerability to contracting HIV/AIDS thus even greater.
The risk of HIV transmission in intercourse that results from sexual violence is, moreover, much higher than during consensual sex. Genital injuries, including tearing and abrasion of the vaginal wall or other organs, increase the likelihood of transmission if the assailant is HIV-positive. In addition, protective vaginal secretions that are normally present in uncoerced sex are absent in cases of rape. Girls who have not yet reached puberty are at particular risk of HIV transmission as they are more likely than older girls and women to suffer genital injuries during rape.196
During the 1996-1997 war in the Congo, military authorities distributed condoms to some soldiers, but they then stopped that practice. According to one RCD military doctor, military authorities now treat the subject as taboo and were doing nothing to prevent or limit the spread of the virus in RCD ranks. He noted that the prevalence of HIV/AIDS among RCD troops is "very high," and that it is even higher among the wives and children of these soldiers.197 He warned that unless the taboo is broken, many more people will die.198
The RPA is, however, taking some steps to deal with HIV/AIDS prevention and treatment within its ranks, including opening a testing center at Kanombe military hospital in 2001 and having Population Services International carry out an eighteen-month project focused on preventing HIV/AIDS and distributing condoms to RPA troops.199The project, which is funded by the U.S. Agency for International Development, operates only in Rwanda and does not include education on sexual violence.200 This project obviously faces a large challenge. A recent study reported in a Rwandan newspaper that soldiers' "life expectancy impressions" helped account for the high HIV prevalence among them.201 It is frequently reported that soldiers and others who feel they stand a high risk of dying anyway do not take precautions against contracting HIV.
159 Human Rights Watch interview, Bukavu, October 18, 2001.
160 Human Rights Watch interview, Bukavu, October, 2001.
161 Human Rights Watch interview, Uvira, October 31, 2001
162 Human Rights Watch interview, Goma, October 25, 2001.
163 Human Rights Watch interview, Bukavu, October 16, 2001.
164 Human Rights Watch interview, Bukavu, October 18, 2001.
165 Human Rights Watch interview, Bukavu, October 18, 2001.
166 Human Rights Watch inteview, Goma, August 1, 2001.
167 Human Rights Watch interviews in Sake, October 26, 2001.
168 Human Rights Watch interview, Bukavu, 17, 2001.
169 Human Rights Watch group interview with Banyamulenge women, Bukavu, October 18, 2001.
170 Under arts. 165 and 166 of the Congolese penal code, abortion is prohibited and anyone assisting a woman to have an abortion can be punished.
171 Human Rights Watch interview, Bukavu, 17, 2001.
172 Human Rights Watch interview, Goma, October 26, 2001.
173 Human Rights Watch group interview, Uvira, November 2, 2001.
174 Human Rights Watch interview, October, 2001. Because doctors have been arrested or threatened after speaking with journalists, we omit the names and places of work of doctors interviewed for this report.
175 Human Rights Watch interview, Bukavu, October 16, 2001.
176 Human Rights Watch interview, Shabunda, October 22, 2001.
177 Human Rights Watch interview, Sake, October 26, 2001.
178 United Nations Security Council Resolution 1308 (untitled), July 17, 2000. See also Graça Machel, "The Impact of Armed Conflict on Children: A critical review of progress made by and obstacles encountered in increasing protection for war-affected children," report prepared for and presented at the International Conference on War-Affected Children, September 2000, Winnipeg, Canada, p.12, located at http://www.waraffectedchildren.gc.ca/machel-e.asp, accessed May 23, 2002).
179 Report of the Secretary-General to the Security Council on Children in Armed Conflict, pursuant to Security Council resolution 1261 (1999), Para 3. A/55/163-S/2000/712
180 Machel, "The Impact of Armed Conflict on Children," p.12.
181 United States Institute for Peace, "Special Report: AIDS and Violent Conflict in Africa," October 2001, p.5. Also available at www.usip.org. (accessed May 23, 2002).
182 In November 2001 the Rwandan newspaper New Times reported that "research made between 1997 and 2000 indicates that 4 percent of the Rwandan army are HIV positive, compared to the nation's average of 11.1 percent." This figure is unrealistically low. The report states that 56 percent of the RPA (presumably meaning those interviewed) had had sex without a condom. This would suggest that 44 percent have either never had sex or always use a condom, which would be a highly unlikely situation. "4 percent of RPA are HIV positive - Doctor," The New Times, November 5th - 7th, 2001, p.4.
183 Quoted in World Health Organization, Democratic Republic of Congo Health Update, July 2001, p. 2. A delegation of British Parliamentarians recently expressed the same concern after a visit to eastern Congo. See The Monitor, "Defence Force Spreads HIV/AIDS - UK MPs", December 5, 2001.
184 Sentinel site data are data from periodic surveys from a selection of representative locations.
185 Joint United Nations Programme on HIV/AIDS and World Health Organization. Democratic Republic of the Congo - Epidemiological fact sheet on HIV/AIDS and sexually transmitted infections: Update. Geneva, 2000. See also World Health Organization, Democratic Republic of Congo Health Update, July 2001, p. 2.
186 World Health Organization, Democratic Republic of Congo Health Update, July 2001, p. 2.
187 Human Rights Watch interview with Maria Masson, administrator of the Bureau des Oeuvres Medicales of the Roman Catholic Diocese of Bukavu, October 15, 2001.
188 Human Rights Watch interview in Bukavu, October 17, 2001.
189 Human Rights Watch interview in Bukavu, October 18, 2001.
190 World Health Organization, Democratic Republic of Congo Health Update, July 2001, p. 2.
191 Human Rights Watch interview in Bukavu, October 18, 2001.
192 Human Rights Watch interview, Bukavu, October 16, 2001.
193 Human Rights Watch interview with Cory Kik, Médecins Sans Frontières - Holland, in Bukavu, October 16, 2001.
194 UNIFEM, "UNAIDS Partners with UNIFEM to Halt Spread of HIV/AIDS among Women and Girls" (press statement), May 24, 2001.
195 U.N. Commission on the Status of Women, "Agreed Conclusions on Women, the Girl Child and HIV/AIDS," (statement adopted at the 45th session of the Commission, March 2001).
196 U.S. National Institutes of Health, National Institute of Allergy and Infectious Disease, Fact Sheet: HIV Infection in Women, May 2001. Available at http://www.niaid.nih.gov/factsheets/womenhiv.htm. (accessed May 24, 2002)
197 The doctor estimated the percentage to be considerably higher than most estimates of the rate for the population at large but he was reluctant to have Human Rights Watch to publish this information. Human Rights Watch telephone interview, Goma, October 26, 2001.
198 Human Rights Watch telephone interview, Goma, October 26, 2001.
199 For instance a Rwandan newspaper reported that Kanombe Military Hospital in Kigali is to open an HIV/AIDS counseling and testing center before the end of 2001 funded by the United States Agency for International Development (USAID). "Army to open testing and counseling centre," New Times, November 1-4, 2001, p.5.
200 Human Rights Watch interview with Amy Power, program manager, Population Services International (Washington, D.C.), January 15, 2002.
201 "4 percent of RPA are HIV positive - Doctor," New Times, November 5-7, 2001, p.4.