Effects of Sexual Violence on Survivors and the Need for Services
Nearly all survivors of sexual violence interviewed by Human Rights Watch described their feelings of profound anxiety, shame, anger, depression, and fear. Three women told Human Rights Watch that they regularly contemplated suicide. Others described frequent psychosomatic problems like headaches, insomnia, and nightmares. Many remained with serious and at times debilitating physical impairments they suffered as a consequence of the sexual attack. Human Rights Watch interviewed women who had been so violently raped that for months following their ordeal, they were unable to walk. For others, even sitting and bending to do routine housework caused extreme pain. Women routinely complained of bleeding, aches in their abdomens, and burning pain when they urinated or tried to have sex with their partners. Doctors and other medical workers described having treated many survivors whose genital and reproductive tissue had been torn and damaged or who had suffered miscarriages or difficulties giving birth on account of the sexual attack they had endured. Others suffered from botched illegal abortions they sought out after having become pregnant following their ordeal.
Not a single rape survivor interviewed by Human Rights Watch reported that the perpetrators had used a condom, putting these women and girls at especially high risk for sexually transmitted infections, including HIV/AIDS. Medical treatment available for HIV/AIDS and other sexually transmitted infections was grossly inadequate, as were nearly all gynecological, reproductive health, and psychological medical services for rape victims. All too often, families and communities ostracized or punished rape survivors, in particular those who spoke out about the abuse they endured. While NGOs have displayed courage under fire, they have not been able to cope with these survivors health and counseling needs.
One civil society leaders testimony about her work with survivors of sexual violence encapsulates many of the psychological and physical effects of sexual violence:
Women who were especially badly injured as a result of rape had difficulty walking, and experienced bleeding and discharge in the genital area. Most women interviewed felt severe pain for weeks, months, or even years after the rape, especially in the abdomen and vagina. Women who were physically abused in other ways also endured suffering related to their beatings or torture. One woman who had been raped for over a year during the war by rebels in Bouaké explained her appalling physical condition after she managed to escape:
One woman described how her two daughters were in agony after being gang raped and having wooden sticks shoved inside their vaginas by rebels during the war in western 18 Montagnes. She described blood literally pooling on the floor under her children.
Doctors working with victims of rape listed some of the worst physical consequences as being internal and external bleeding, discharge, and uterine prolapse, when the uterus descends into the vagina or beyond.169
Health workers in both rebel- and government-held areas of Côte dIvoire noted that the sexual abuses women suffered, in addition to displacement, increased poverty, and the destruction to health centers and hospitals had had serious consequences for maternal health. They spoke of numerous women who had either miscarried or died during childbirth, apparently as a result of what they had endured.170
Others suffered from rape-related complications during their pregnancy or labor. One woman who was nine months pregnant described how she nearly died after being gang raped by rebels in the western town of Danané:
One midwife in Danané recounted to Human Rights Watch how from 2002 to 2003 she assisted in birthing the children of numerous women who had been forced to flee their homes and villages during periods of active hostilities.
Since the beginning of the armed conflict, some health workers noted an increase in abortions, despite the fact that the procedure is illegal. Most traditional midwives and gynecologists interviewed by Human Rights Watch described having attended to large numbers of women and girls who attempted to get abortions and suffered complications as a result. Doctors and traditional midwives all speak of a rising trend since the beginning of the conflict of women and girls struggling with botched illegal abortions coming to them in dire medical condition.
From their conversations with patients, many believe that the rise is directly related to the armed conflict and the rising trends of rape, sexual exploitation, and survival sex, as well as the war-related economic pressures an unwanted child would bring on families already struggling to cope.173 A midwife at a hospital in Guiglo told Human Rights Watch how the demand for abortions and the emergencies resulting from poorly performed abortions had risen considerably at her hospital at least since the war began:
The Penal Code provides for ten years of imprisonment for those who carry out abortions and their assistants in addition to fines ranging from approximately US$300 to US$16,000.175 Women seeking abortions also face prison time and fines. Dr. Lassina Sanogo, a general practitioner in the rebel-held town of Bouaké, noted that, Clandestine abortions have attained dangerous levels in our hospitals during these four years of crisis, both on the rebel and government side. 176
Women seeking illegal abortions from unqualified practitioners risk very serious injury, including infertility, infection, genital tearing, and death. A study conducted in 2005 by a local non-governmental organization showed that 34 percent of the 2,400 women interviewed for the survey had undergone at least one abortion. According to the study, 30 percent of women and girls of those who sought abortions in the north were obliged to have backstreet procedures that often led to complications, some of them fatal.177 It is crucial to reform Côte dIvoires abortion laws.
One of the commonly noted problems associated with sexual violence is vulnerability to infection; rape survivors are at particularly high risk for contracting sexually transmitted infections (STIs), including HIV/AIDS, which can lead to major complications in reproductive health or even death. A 2005 report by Doctors Without Borders (Médecins Sans Frontières, MSF) described a case in which a child died of sexually transmitted infections in their hospital:
Many rape survivors told Human Rights Watch about physical ailments that typify STIs: discharge, discomfort, lack of control over urination, inability to become pregnant, and other symptoms that disrupt their lives and cause them tremendous anxiety.
Medical practitioners with MSF have encountered alarmingly high rates of STIs in clinics they operate in western Côte dIvoire: some 20 percent of the adults visiting their clinics in some towns were infected. The teams are convinced that the actual prevalence is higher and that many STIs, including HIV/AIDS, often go undiagnosed and untreated. Like other health providers, MSFs analysis of the situation is that Family separations and the influx of soldiers have left many women and young girls vulnerable to sexual violence, prostitution, unwanted pregnancy and STIs.179
While drastic in its own right, the high level of STIs accompanies a parallel increase in the prevalence of HIV/AIDS throughout Côte dIvoire, making prevention and treatment efforts all the more urgent. The prevalence of HIV/AIDS is estimated between 7 percentand 10 percent,giving Côte dIvoire a generalized HIV epidemic and the highest HIV prevalence in West Africa.180 This is suspected to have increased since the beginning of the war given its destructive impact on the health system.181 According to ONUCI, the HIV pandemic in Côte dIvoire has an increasing gender dimension, with 300,000 women infected in 2005.182
The risk of HIV/AIDS infection increases when a rape injures a woman so badly that her genital tissue is torn or bleeds. Obviously, tearing of genital tissue in repeated or gang rape greatly increases the chances of rapists infecting their victims with STIs. It is very likely that a number of women and girls raped by soldiers and other armed men have contracted HIV/AIDS, particularly since the prevalence of HIV infection among military forces is generally above the average infection rate of the population in many conflicts, and violent assault increases the risk of infection through tears and injuries to genital tissue.183
Rape and other forms of sexual abuse inflict often devastating psychological and social effects upon not only the victims, but their families and communities as well. Nearly all rape survivors interviewed by Human Rights Watch experienced psychosomatic pains (headaches, stomachaches, listlessness, and insomnia), and feelings of profound anxiety, panic attacks, shame, anger, depression, loss of self-esteem, and fear of men or sex. One of the most tragic aspects of these womens psychological anguish is that many of them suffer alone, without the benefit of support or understanding. Terrified of being divorced, ostracized, infected with HIV/AIDS, or abandoned by their family and community, rape survivors cope as best they can with their mental health problems in silence and isolation.
One woman raped in 18 Montagnes by rebels during the war declared that she could hardly live with her overwhelming anger.
More frequently than anger though, rape survivors expressed extreme anxiety and despair. One Ivorian woman living in a Liberian refugee camp described how she felt after having been raped by rebels in Côte dIvoire:
Many survivors of sexual abuse felt trapped by their past, unable to move on. One woman who was raped by rebels during the war said:
Several interviewees, like a young woman who was raped by rebels in 18 Montagnes, said they seriously considered committing suicide.
Numerous survivors told Human Rights Watch that their shame, depression, and fear prevented them from having normal sexual relations, and several expressed extreme anxiety that their husbands would leave them as a result.
Others experienced depression resulting from infertility, sometimes temporary, which they believed was related to the sexual assault they had endured. Rape survivors menstrual periods were often disrupted either by the physical trauma of rape, or by STIs contracted during unprotected sex with their rapists. Some women and girls who were raped found themselves unable to become pregnant again, leading to tremendous psychological anguish in a culture where fertility is considered to determine social worth.
A 2005 study by an international NGO in Côte dIvoire found that 58 percent of victims of sexual assault were blamed and rejected by their family or community following the assault. Only 36 percent of victims polled characterized the response of the family and community as supportive.188
Following a sexual assault, rape victims have often been rejected by their families, left by their husbands, or, if unmarried, unable to find a husband, especially if they denounce the perpetrator or pursue justice for the assault. One twenty-five-year-old who was gang raped in Abidjan in 2005 described how she was abandoned by her family after speaking out against her rapists, in this case students from FESCI:
The situation of women and girls who become pregnant after rape can be even more dire. Those who cannot or do not want to seek abortions struggle to find ways of living with children born out of rape, especially if they and their children are rejected by the family, which is often the case.
Once a family rejects a victim of sexual violence, it can be difficult to facilitate her re-entry into the family unit. A community social worker explains:
Most women and men who were interviewed alluded to or revealed profound psychological discomfort when questioned about rape, and spoke to the deep cultural revulsion around the issue of sexual violence. Most could not clearly designate the word rape in a local language. Interviewees used words to describe rape that reflected not only the violent, repulsive, and embarrassing nature of the crime and its destructive effects upon the survivor, but also the negative impact on the survivors family and community.
Many Francophone Ivorians refer to ruining the child (gâter, as in, to destroy). In Guiglo, Guéré men used the term O Pkaké, which signifies forced, to designate rape, alluding to the notion of physical force. Women preferred the term O Kôhô, which means ruined or dirtied, and underscores the notions of rupture and of destruction of a person after she has been raped. In Yacouba in the 18 Montagnes region, the term used is Yanshiyi when a child is raped, and Yene Whompi when a woman is raped. Both terms allude to destruction and violence.191
Poverty, nonexistent or expensive medical services, and the stigma attached to rape victims appear to have deterred many who suffered sexual abuse from seeking treatment and as such, place them at higher risk for illness and psychological trauma.
Health and social workers interviewed believe that the majority of survivors of sexual violence receive inadequate or no medical treatment following their assault.192 This was certainly the case for victims of sexual violence interviewed by Human Rights Watch. Most of them complained of untreated or poorly treated physical and psychological problems related to the rapes.193 The lack of medical care for victims of sexual assault appears to be attributable to a number of factors. First, poverty and the high cost of medical services make it harder for some survivors of sexual abuse to seek treatment and as such, place them at higher risk for illness and psychological trauma.
Second, the health care system in Côte dIvoire has been ravaged by the armed conflict, especially in the rebel-held north. Already in 1998, only approximately 30 percent of the population country-wide had access to primary health care.194 With the outbreak of fighting from 2002 to 2003, many medical facilities in the north were plundered and partially destroyed. At least 90 percent of public health personnel working in New Forces territories were reportedly reassigned to the government-controlled south. Many rape survivors, especially those who live in rural areas, cannot access even basic medical services, and few can afford to pay for transport to a clinic.
Third, social stigma attached to rape deters women from seeking treatment for fear that a medical visit will make the rape publicly known. For instance, nearly all local leaders, local medical staff, and humanitarian workers interviewed in the southwestern town of Guiglo believed that women and girls who went to seek medical treatment concealed their rape experiences because of shame.195
Fourth, many women opt for traditional healers rather than unfamiliar Western health workers. Many health practitioners maintain that survivors of sexual violence seek treatment at clinics or hospitals only in the case of a medical emergency, preferring instead to either remain silent or seek out a traditional healer.196 Most traditional healers are women with fairly good knowledge of female anatomy and local plants. However, they have little or no knowledge of or access to modern medicine. For example, no traditional healers interviewed by Human Rights Watch had ever heard of the short and affordable course of antiretroviral drugs known as post-exposure prophylaxis (PEP). Prompt PEP administration reduces the risk of HIV transmission. PEP can be administered alongside emergency contraception, which makes it much less likely that a woman who has been raped without a condom will get pregnant.
Nonexistent, inadequate, or expensive medical services place survivors of sexual abuse at even higher risk for medical problems, especially in the case of rape survivors who have contracted HIV. Despite the high estimated prevalence rates for HIV in Côte dIvoire, little is being done to combat its spread outside the major city centers. As the health system is in a dilapidated state, drugs, equipment, and staff to deliver services are in short supply or lacking altogether.
Given the reports of sexual violence and the devastating consequences of HIV/AIDS, medical clinics should routinely screen for sexual violence; address reports of sexual violence; and systematically provide information to patients regarding transmission, voluntary testing, counseling, and treatment for HIV/AIDS. It is vital to increase education, prevention, and treatment of STIs, as well as prevention of mother-to-child transmission of HIV, treatment of opportunistic infections, and treatment of AIDS with effective medication.
Some dozen Ivorian humanitarian organizations working country-wide provide services to survivors of sexual violence including psychological counseling, legal aid, healthcare, and HIV/AIDS testing; however, these groups lack financial, logistical, or other capacity to cope with the magnitude and degree of severity of local cases. At least one health center that provided HIV testing and counseling closed in 2006 due to a lack of funds. Moreover, there are few shelters for emergencies, and virtually no long-term shelters, rape centers, or rape hotlines. International organizations such as MSF, the International Rescue Committee (IRC), and Save the Children have tried to intervene and fill the gaps. However, they too have faced resource constraints, threats of budget cuts, and threats by armed groups, making it impossible to provide services to the large numbers of women and girls in need.
167 Human Rights Watch interview with a civil society leader, Man, September 2006.
168 Human Rights Watch interview, Monrovia, Liberia, October 2006.
169 Human Rights Watch interviews with the Interim Country Director of Médecins Sans Frontières-Belgium (MSF-B), the Country Director of MSF-B, and other MSF-B staff, Abidjan and Man, Côte dIvoire, September 2006.
170 Human Rights Watch interview with health workers in both rebel- and government-held areas of Côte dIvoire, Côte dIvoire, September 2006.
171 Human Rights Watch interview, Monrovia, Liberia, September 2006.
172 Human Rights Watch interview with a womens rights leader, Danané, Côte dIvoire, September 2006.
173 Human Rights Watch interviews with traditional midwives and gynecologists, Côte dIvoire, September 2006.
174 Human Rights Watch interviews with staff at a hospital in Guiglo, Guiglo, Côte dIvoire, September 29, 2006.
175 Abortion remains illegal in Côte dIvoire. Specifically, Article 366 stipulates that whosoever, by food, drink, medicine, surgical procedures, violence, or any other means, procures or attempts to procure an abortion of a pregnant woman, whether or not with her consent, will be punished by imprisonment of one to five years and a fine of 150,000 (US$238.78) to 1,500,000 CFA francs (US$2,387.81). A woman who procures or attempts to procure her own abortion, or consents to the use of the means administered for that purpose, is subject to punishment of six months to two years of prison and a fine of 30,000 (US$47.76) to 300,000 CFA francs (US$477.56). Persons belonging to the medical profession or a profession involving public health who promote or procure the means to induce abortion, are subject to one to 10 years of imprisonment and a fine of 150,000 (US$238.78) to 10,000,000 CFA francs (US$15,918.75). They may also be prohibited from practicing their professions. (Penal Code, Art. 366). The only situation in which an abortion is legal is when it is necessary to save a womans life. (Penal Code, Art. 367.)
176 Seguela Aly Ouattara, Côte d'Ivoire: Abortion - Illegal, Sought After, Sometimes Fatal, Inter Press Service (Johannesburg), August 23, 2006.
177 Objectif santé [local NGO, aka Goal: Health), unpublished study, 2005.
178 International Activity Report 2005, Ivory Coast: Renewed violence deepens crisis, Doctors Without Borders, 2005, available online at http://www.doctorswithoutborders.org/publications/ar/i2005/ivorycoast.cfn.
179 Top 10 Most Underreported Humanitarian Stories of 2005: Crisis Deepening in Ivory Coast, Doctors Without Borders, 2005, available online at http://www.doctorswithoutborders.org/publications/reports/2006/top10_2005.html#ivorycoast; and Doctors Without Borders, International Activity Report 2005, Ivory Coast: Renewed violence deepens crisis.
180 For a 7 percent estimate, see World Health Organization Country Page and HIV/AIDS report at http://www.who.int/countries/civ/en/. See also website for the Joint United Nations Program on HIV/AIDS (UNAIDS) Country Profile for Côte dIvoire: http://www.unaids.org/en/Regions_Countries/Countries/côte_d_ivoire.asp. For a 10 percent estimate, see Doctors Without Borders, Renewed violence; The United States Department of Health and Human Services Center for Disease Control (CDC), The Emergency Plan in Côte d'Ivoire, http://www.cdc.gov/nchstp/od/gap/countries/Côte_d_Ivoire.htm.
181 The World Health Organization, Côte dIvoire, Summary Country Profile for HIV/AIDS Treatment Scale-Up, December 2005, p. 2. The political and military crisis in Côte dIvoire has limited the national capacity to respond to the HIV/AIDS epidemic for the past few years. Trained health personnel are lacking, and the situation has been aggravated by the displacement of existing human resources towards the non-occupied regions. Existing HIV/AIDS interventions are largely concentrated in Abidjan and some other large cities. Drug prices are prohibitive for most people attending accredited centers. Facilities for laboratory monitoring are inadequate. Seealso, Betsi NA, Koudou BG, Cisse G, Tschannen AB, Pignol AM, Ouattara Y, Madougou Z, Tanner M, Utzinger J., Effect of an armed conflict on human resources and health systems in Côte d'Ivoire: prevention of and care for people with HIV/AIDS, AIDS Care, May 2006;18(4), pp. 356-65.
182 ONUCI, Fourth Report.
183 Human Rights Watch, DRC The War Within the War: Sexual Violence against Women and Girls in Eastern Congo, June 2002, http://www.hrw.org/reports/2002/drc/Congo0602.pdf, p. 77; Pieter Fourie and Martin Schönteich, Africa's New Security Threat: HIV/AIDS and Human Security in Southern Africa, African Security Review Vol. 10 No 4, 2001, http://www.iss.co.za/Pubs/ASR/10No4/Fourie.html; Timothy Docking, AIDS and Violent Conflict in Africa, United States Institute of Peace Special Report No. 75, October 15, 2001, http://www.usip.org/pubs/specialreports/sr75.html.
184 Human Rights Watch interview, Abidjan, Côte dIvoire, September 2006.
185 Human Rights Watch interview, Nimba County, Liberia, October 2006.
186 Human Rights Watch interview, Nimba County, Liberia, October 2006.
187 Human Rights Watch interview, Abidjan, Côte dIvoire, September 2006.
188 Anonymous NGO, Sexual violence in 18 Montagnes.
189 Human Rights Watch interviews, Abidjan, Côte dIvoire, September 2006.
190 Human Rights Watch interview with a civil society leader, Man, Côte dIvoire, September 2006.
191 Anonymous NGO, Sexual violence in 18 Montagnes.
192 Human Rights Watch interviews with health and NGO workers, Côte dIvoire, September 2006. A workshop conducted by an international NGO with 20 local NGOs working on childrens rights found that there is no formal system to assist victims of sexual violence with respect to medical, psychosocial, or legal services, and no coordination system or national plan.
193 Human Rights Watch interviews, Côte dIvoire, Liberia, Mali, Burkina Faso, September-November 2006.
194 United Nations Population Fund (UNPF), The State of World Population (UNPF: 1998), p. 70.
195 Human Rights Watch interviews with local leaders, local medical staff, and humanitarian workers, Guiglo, Côte dIvoire, September 2006.
196 Human Rights Watch interviews with representatives of Médecins Sans Frontières-France, Médecins Sans Frontières-Belgium, and Médecins Sans Frontières-Holland, Abidjan, Côte dIvoire, September 2006.