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Sexual violence often continues to impact the physical and mental well-being of survivors long after the abuses were committed. In addition to the reluctance of some survivors to seek medical treatment, the lack of health facilities, especially in the provinces, as well as the survivors' lack of money for transport, medical treatment and drugs has meant that the health status of survivors is poor.170 Survivors also were often only able to seek medical treatment months after the abuse had happened, for example when they managed to escape rebel captors and make their way to a health center.

The probability of transmission of HIV and certain other sexually transmitted diseases (STDs) is greatly increased in violent sex and any sex where a woman or girl is injured. Doctors and other health personnel interviewed by Human Rights Watch reported a high prevalence of STDs amongst victims, as the armed conflict in Sierra Leone, like other armed conflicts, served as a vector for sexually transmitted diseases.171

A World Health Organization (WHO) report found an alarmingly high prevalence rate of HIV/AIDS amongst Sierra Leone Army soldiers. According to the report, the SLA tested 176 soldiers and eighty-two civilians working for the army who had prolonged diarrhea, tuberculosis, weight loss or pneumonia, and found a HIV-positive rate of 41.9 percent (or 108 persons). Among the group tested were eighty female soldiers of whom thirty tested positive (37.5 percent). As many SLA soldiers defected to the rebel factions, it is likely that victims of sexual violence by them have been infected with the virus.172 A U.N. report on the impact of conflict on children states 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.173 Commercial sexual exploitation of women by soldiers, including peacekeepers, also contributes to the spread of STDs, including HIV/AIDS.174 In 1997, tests showed that 70.6 percent of commercial sex workers in Freetown were HIV positive compared to 26.7 percent in 1995.175

The 2002 report by the Joint United Nations Programme on HIV/AIDS (UNAIDS) on the global AIDS epidemic estimated that by the end of 2001 there were 170,000 persons aged between fifteen and forty-nine living with HIV/AIDS in Sierra Leone. UNAIDS estimates that more than 50 percent of this figure (90,000) are women and girls.176 More accurate figures on HIV/AIDS prevalence in Sierra Leone, as opposed to estimates, should be known when the U.S. Centers for Disease Control and Prevention (CDC) publish their report based on a nationwide HIV/AIDS prevalence survey conducted in May 2002.177 The government of Sierra Leone should ensure that future information campaigns on HIV/AIDS are designed both to impart basic information and to help reduce stigma, especially in light of the large number of survivors of sexual violence who may have been infected with HIV.

Other health problems are vasico-vaginal and vasico-rectal fistulas (VVFs and VRFs), as a result of the rape(s) especially of young girls but also of mature women; complications when giving birth; prolapsed uterus; trauma; and unwanted pregnancies. Health professionals have noted high rates of pregnancies amongst young girls with likely resultant illness, injury, and even death, due to pregnancy-related complications. These girls are likely to experience future complications including uterine problems and scarring, reducing their ability to have a normal sex life or to conceive or carry a child to full term in the future. The health of children born to abducted girls is also likely to suffer as the girls often have no one to teach them motherhood skills, contributing to high rates of infant mortality. The health risks are further exacerbated by various factors that impede safe sex, including lack of information about HIV/AIDS, as well as cultural practices and beliefs that undermine the use of reproductive health services and contraception.178 The lack of attention paid until recently to conflict-related sexual violence has meant that the health needs of women and girls have not received as much attention or funding as required to adequately address the scale of the problem. In general the Sierra Leonean health services lack trained and motivated personnel, medical equipment and supplies, drugs, and blood for transfusion. The reproductive health infrastructure, which was poor before 1991, virtually collapsed during the war.179 There are only six specialist obstetricians and gynecologists in Sierra Leone.180 Treatment for sexually transmitted diseases is limited to the main towns and outreach by mobile clinics in some chiefdoms.

Mental health services for survivors of sexual violence are inadequate and as of 2002 there was only one qualified psychiatrist in the country. FAWE Sierra Leone, which has substantial expertise in treating survivors of sexual violence, believes that counseling on a massive scale is needed to ensure that the women and girls can face the future.181

Stigmatization and Shame of Survivors
The rebels frequently committed crimes of sexual violence in public places. A.M., a twenty-year-old male, reported that when he was held in captivity in State House in Freetown from January 8, 1999 for three days, he saw from his cell window RUF/AFRC combatants raping about twenty to twenty-five girls each night on the grounds.182 Given that rape has been committed on such a systematic and widespread scale and was witnessed by many people, it seems that rape survivors, particularly in urban centers, are generally not stigmatized by society. Survivors interviewed have expressed fear of rejection by their families and communities, but in practice it seems that their fears are unfounded. Most survivors are accepted back into their communities, with their families simply overjoyed to find that they are still alive.

Nevertheless, some women, like R.K. who was raped by the CDF (see above, p. 48), have been rejected by their husbands:

I told my husband what happened. He cried and rejected me. He said he will find another wife. My family has begged him to accept me as it was not my fault. He does not love me anymore. I am annoyed because I was the senior wife and now he does not treat me well.183

Girls and women who voluntarily joined the rebel forces are less likely to be welcomed back.

The survey conducted by Physicians for Human Rights gives an indication of survival strategies employed by women who had been raped: of the ninety-four interviewees reporting having themselves experienced sexual violence, sixty-one (or 65 percent) told someone about their case(s) of sexual violence. The majority of these survivors (fifty women and girls or 53 percent) reported their experience to a health care provider in a hospital, health care center or to a traditional healer, albeit on average five months after the incident(s) occurred. Among those not reporting these incidents and who stated a reason (twenty-eight out of thirty-three), the reasons given were feelings of shame or social stigma (eighteen women and girls or 64 percent), fear of being stigmatized or rejected (eight women and girls or 28 percent) and not having trust in anyone (six women and girls or 21 percent). Eighteen women and girls (19 percent) reported that discussions with family members helped them to try to forget about the incident(s). Other survivors reported that what helped most was to try and forget about the incident (46 percent), support of family (35 percent), a health care provider (33 percent) and traditional medicine (32 percent).184

Human Rights Watch also found that many survivors feel intense personal shame that the rebels have defiled them, and therefore often do not report the crime or seek medical attention. S.G., the fifty-year-old widow who had both arms amputated after being raped (see above p. 36), described the shame and anger she felt after her ordeal:

I didn't even tell my people about the rape. It's such a shameful act. Not just because of the rebel's age, but also because never in my life have I had sex with someone besides my husband. I was a good woman. Can you imagine how I felt when this young boy raped me, kicked me and then told me to get out of his sight after doing this to me? And without my arms, how can I as a woman even clean myself, let alone take care of my affairs. We're farmers and how am I to farm now? Both the rape and amputation are awful ... but later when thinking about what happened, I was even angrier about the rape than the amputation because for him to have done that to me was like killing me inside because of the shame. Sex is something you should enjoy together with your man. But to do it like that, to handle me like that, to torture me like that and then kick me and leave me like that ... it's too much. But I guess I was somehow lucky. There could have been ten people doing that to me.185

P.S. twenty-five, who was abducted and gang raped by the West Side Boys in January 2000, explained why she had not reported her rapes:

I didn't want to tell anyone what happened. I was ashamed because it is bad enough being done like this, but having a rebel do it is even worse. I felt so bad because I wanted to save myself for someone special. I went to secret society and they instructed us not to be involved in sex until we were ready to marry. And now I'm afraid because of AIDS. When I think of them I feel so angry.186

170 PHR report, p. 45.

171 Human Rights Watch interviews with Dr. Olayinka Koso-Thomas, Freetown, February 25, 2002; Dr. Noah Conteh, Freetown, March 1, 2002 and Dr. Bernard Fraser, Freetown, March 3, 2002.

172 World Health Organization, HIV/AIDS in Sierra Leone: The Future at Stake-The Strategic and Organizational Context and Recommendations for Action (Freetown, 2000), p. 3.

173 See United Nations Security Council resolution 1308 on the responsibility of the Security Council in the maintenance of international peace and security: HIV/AIDS and international peacekeeping operations, July 17, 2000; and Graça Machel, "The Impact of Armed Conflict on Children: A critical review of progress made 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, at

174 Human Rights Watch interview, UNAMSIL medical personnel, Freetown, April 30, 2002.

175 Ministry of Health and Sanitation, National AIDS/STD Control Programme Annual Report for 1998 (Freetown, Ministry of Health and Sanitation, 1998), p. 3.

176 UNAIDS, Report on the Global HIV/AIDS Epidemic 2002 at, p. 190. This figure is based on a total population of 4,587,000.

177 Human Rights Watch interview with Dr. Joaquim Saweka (WHO Sierra Leone Representative), Freetown, May 3, 2002. The preliminary results of the CDC showed a prevalence rate of 4.9 percent.

178 Only 297 of 4,923 women (or 6 percent) surveyed by the government in 2000 reported that they used contraceptives. This low prevalence of contraception use is due to lack of access to family planning services within the communities, inadequate health facilities, especially in the provinces, lack of disposable income to pay for these services, and the low education of women. Only 3 percent of women with no education used contraception compared to 8 percent of women with primary education and 14 percent of women with secondary or higher education. Another worrying factor is the unwillingness of partners to use condoms, which does not bode well given the high prevalence of HIV/AIDS and other STDs. See Government of Sierra Leone, The Status of Women and Children in Sierra Leone, pp. 55-58.

179 UNDP, Human Development Report 2001, p. 198.

180 WHO and the Ministry of Health and Sanitation, Assessment of District Hospitals in Sierra Leone for the Delivery of Safe Motherhood and Reproductive Health Services (Freetown: 2002), p. 10. The Assessment also found that physicians attended only 3 percent of births whereas traditional birth attendants assisted in 38 percent of births nationally. Ibid. pp. 56-57. Only 10 percent of 4,923 women surveyed by the government in 2000 reported that they received antenatal care from a physician. See Government of Sierra Leone, The Status of Women and Children in Sierra Leone, p. 10.

181 Human Rights Watch interview with Christiana Thorpe (founding chairperson of FAWE Sierra Leone Chapter), Freetown, March 22, 2002.

182 Human Rights Watch interview, Freetown, April 12, 1999.

183 Human Rights Watch interview, Freetown, August 21, 2000.

184 PHR report, p. 51 and Table 6 on p. 54. Women could select more than one of the choices given.

185 Human Rights Watch interview, Bo, March 2, 2000.

186 Human Rights Watch interview, Freetown, February 8, 2000.

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