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There
are various forms of sexual violence. Rape, the most often cited form
of sexual violence, is defined in many societies as sexual intercourse
with another person without his/ her consent. Rape is committed when
the victim's resistance is overwhelmed by force or fear or other coercive
means. However, the term sexual and gender-based violence encompasses
a wide variety of abuses that includes sexual threats, exploitation,
humiliation, assaults, molestation, domestic violence, incest, involuntary
prostitution (sexual bartering), torture, insertion of objects into
genital openings and attempted rape. Female genital mutilation and other
harmful traditional practices (including early marriage, which substantially
increases maternal morbidity and mortality) are forms of sexual and
gender-based violence against women which cannot be overlooked nor justified
on the grounds of tradition, culture or social conformity.
Since
perpetrators of sexual and gender-based violence are often motivated
by a desire for power and domination, rape is common in situations of
armed conflict and internal strife. An act of forced sexual behaviour
can threaten the victim's life. Like other forms of torture, it is often
meant to hurt, control and humiliate, while violating a person's physical
and mental integrity.
Perpetrators
may include fellow refugees, members of other clans, villages, religious
or ethnic groups, military personnel, relief workers and members of
the host population, or family members (for example, when a parent is
sexually abusing a child). The enormous pressures of refugee life, such
has having to live in closed camps, can often lead to domestic violence.
In many cases of sexual violence, the victim knows the perpetrator.
Because
incidents of sexual and gender-based violence are under-reported, the
true scale of the problem is unknown. The World Bank estimates that
less than 10 per cent of sexual violence cases in non-refugee situations
are reported.
Two
principal types of under-reporting are found in refugee situations:
-
under-reporting
by the victims, which can lead to distorted figures that suggest
there is no problem; and
-
an
absence of figures relating to sexual violence within official statistics.
(The
number of recently reported rape cases in stabilised refugee settings
can be found in Table 1.)
It
is essential to know that the problem of sexual violence is serious.
Reporting and interviewing techniques should be adapted to encourage
both victims and relief workers to report and document incidents. Reporting
and follow-up must be sensitive, discreet and confidential so no further
suffering is caused and lives are not further endangered.
In
reporting, it is recommended that definitions (such as confirmed rape
cases or sexual violence, in general) are provided and a rate calculated
(for example, the number of reported cases per 10,000 people over a
given period of time). This rate would allow for monitoring of trends
and comparisons with other areas.
Sexual
and gender-based violence has acute physical, psychological and social
consequences. Survivors often experience psychological trauma: depression,
terror, guilt, shame, loss of self-esteem. They may be rejected by spouses
and families, ostracised, subjected to further exploitation or to punishment.
They may also suffer from unwanted pregnancy, unsafe abortion, sexually
transmitted diseases (including HIV), sexual dysfunction, trauma to
the reproductive tract, and chronic infections leading to pelvic inflammatory
disease and infertility.
Causes
and Circumstances of Sexual Violence
Sexual
and gender-based violence can occur during all phases of a refugee situation:
prior to flight, during flight, while in the country of asylum, during
repatriation and reintegration. Prevention and response measures must
be adapted to suit the different circumstances of each phase.
In
conflict situations, sexual violence may be politically motivated --
when, for example, mass rape is used to dominate or sexual torture is
used as a method of interrogation.
It
may result from long-standing tensions and feuds and the collapse of
traditional societal support. In situations in which the refugees are
considered to be materially privileged compared to the local population,
neighbouring groups may attack the refugees.
The
psychological strains of refugee life may aggravate aggressive behaviour
towards women. Male disrespect towards women may be reinforced in refugee
situations where unaccompanied women and girls may be regarded by camp
guards and male refugees as common sexual property.
If
men are responsible for distributing goods and necessities, women may
be subject to sexual exploitation. Those women without proper personal
documentation for collecting food rations or shelter material are especially
vulnerable.
Women
may have to travel to remote distribution points for food, water and
fuel; their living quarters may be far from latrines and washing facilities;
their sleeping quarters may be unlocked and unprotected.
Lack
of police protection and lawlessness also contribute to an increase
in sexual violence. Police officers, military personnel, relief workers,
camp administrators or other government officers may themselves be involved
in acts of abuse or exploitation. If there are no independent organisations,
such as UNHCR or NGOs, to ensure personal security within a camp, the
number of attacks often increases.
A
multi-sectoral team approach is required to prevent and respond appropriately
to sexual and gender-based violence. A committee or task force should
be formed to design, implement and evaluate sexual violence programming
at the field level. Refugee representatives, UNHCR, UN partners, NGOs
and government authorities should be members of this task force. Each
member of the task force, representing relevant sectors/ partners (such
as protection, health, education, community services, security/ police,
site planning, etc.), should identify his/ her role and responsibilities
in preventing and responding to sexual and gender-based violence.
The
most effective measures require that the refugee community participates
in promoting a safe environment for all. Women leaders need to be involved;
and women's refugee committees and groups should be established to represent
women's interests and to help identify and protect those most vulnerable
to sexual violence. Traditional birth attendants (TBAs) can be a valuable
source of information and a channel for disseminating protection messages.
It is important to have at least one trained female protection officer
at the site. Host countries and international relief organisations have
a responsibility to provide the refugee community with funding, technical
assistance and the safety measures necessary to allow the refugees to
design and implement responses to the problem.
Experience
has shown that community-based groups, commonly called anti-rape or
crisis intervention teams, should be established. These groups can help
raise awareness of the problem, identify preventive measures and be
at the forefront of providing assistance to survivors.
Public
information campaigns on the subject of sexual violence should be launched
(while respecting cultural sensitivities). Topics could include preventive
measures, seeking assistance, laws prohibiting sexual violence, and
sanctions and penalties for perpetrators. Pamphlets, posters, newsletters,
radio and other mass media programmes, videos and community entertainment
can all be used to transmit information about preventing sexual violence.
The refugee community and health workers must understand the importance
of the problem and have the confidence to report all cases of sexual
violence as soon as possible.
Refugee
camps can be designed to enhance physical security. Alternatives to
closed camps should always be sought. When designing and organising
camp facilities, help protect refugees by:
-
locating
latrines, water points and fuel collection areas in accessible places;
-
making
special arrangements for housing unaccompanied women, girls and
lone heads of households;
-
locking
washing facilities;
-
providing
adequate lighting on paths used at night;
-
providing
security patrols; and by
-
avoiding
shared communal living space with unrelated families.
Essential
items, such as food, non-food and shelter materials, should be distributed
directly to women. That way, women will not have to exchange sexual
favours for these items. Women should be involved in, if not administer,
the food distribution system.
Women
and men should not be detained together unless they are family members.
Appropriate organisations must be allowed access to detainees to monitor
their safety and living conditions.
Life
in refugee camps can lead to a breakdown of traditional social structures,
frustration, boredom, alcohol and drug abuse, and feelings of powerlessness
that may contribute to aggression and sexual violence. Therefore, educational,
recreational and income-generating activities must be promoted.
The
response to each incident of sexual violence must include protection,
medical care and psychosocial treatment.
Immediately
following an incident of sexual violence, the physical safety of the
survivor must be ensured. All actions must be guided by the best interests
of the survivor and her wishes must be respected at all times. Wherever
possible, the identity of the survivor should be kept secret and all
information kept locked and secure from outsiders.
Health
workers should give the survivor as much privacy as she needs and reassure
her about her safety. She may want a family member or friend to accompany
her throughout the procedures. She should not be pressured to talk or
be left alone for long periods. If the incident occurred recently, medical
care may be required. The survivor should then be escorted to the appropriate
medical facilities. It also may be necessary to contact the police,
if the survivor so decides.
The
likely course of events and all the procedures that may follow should
be carefully explained to her to ensure informed consent and preparedness.
The
key elements of a medical response to sexual violence are described
below. Health care professionals must be specially trained to undertake
post-sexual violence medical care. Psychosocial support should begin
from the very first encounter with the survivor. A protocol should be
adopted to guide the medical and psychosocial care provided to survivors.
A
doctor (or qualified health worker) of the same sex should conduct the
initial examination and follow-up. The survivor should be prepared for
the physical examination and perhaps accompanied (if she so wishes)
by a staff member who is familiar with the proceedings, or by a family
member or friend. Strict confidentiality is essential. Staff dealing
with the survivor must be sensitive, discreet and compassionate.
Take
a Complete History and Do a Physical Examination
The
survivor should not shower or bathe, urinate or defecate, or change
clothes before the medical examination, as evidence may be destroyed.
A
detailed history of the attack should be documented, including the nature
of the penetration, if any, whether ejaculation occurred, recent menstrual
and contraceptive history, and the mental state of the survivor. Procedures
for medical examination after rape should be established and follow
national laws, where they exist.
The
results of the physical examination, the condition of clothing, any
foreign material adhering to the body, any evidence of trauma, however
minor, scratches, bite marks, tender spots, etc., and results of a pelvic
examination should be documented. Health workers should collect materials
that might serve as evidence, such as hair, fingernail scrapings, sperm,
saliva and blood samples.
The
following tests may be indicated to establish pre-existing conditions:
syphilis blood test, pregnancy test and HIV test.
Treatment
for common sexually transmitted diseases (STDs), such as syphilis, gonorrhoea
and chlamydia, may be indicated. A tetanus vaccination should be considered.
1.
Emergency contraceptive pills (ECPs) can prevent unwanted pregnancies
if used within 72 hours of the rape. As described by WHO "emergency
contraceptive pills (ECPs) work by interrupting a woman's reproductive
cycle -- by delaying or inhibiting ovulation, blocking fertilisation
or preventing implantation of the ovum. ECPs do not interrupt pregnancy
and thus are not considered a method of abortion." WHO acknowledges
that this description does not command consensus and that some believe
that ECPs are abortifacients. Women and health workers holding such
belief may be precluded from using this treatment and women who request
this service need to be offered counselling so as to reach an informed
decision.
ECPs
should not be seen as a substitute for regular use of contraceptive
methods. Women should be counselled concerning their future contraceptive
needs and choices.
See
Annex 1 for details on using ECPs.
2.
Copper-bearing IUDs can be used as a method of emergency contraception.
They may be appropriate for some women who wish to retain the IUD
for long-term contraception and who meet the strict screening requirements
for regular IUD use. When inserted within five days, an IUD is an
effective method of emergency contraception.
However,
IUD insertion requires a much higher degree of training and clinical
supervision than ECPs. Clients must be screened to eliminate those who
are pregnant, have reproductive tract infections, or are at risk of
STDs, including HIV/ AIDS.
As
for ECPs, some women and health workers may be precluded from using
this treatment and women who request this service need to be offered
counselling so as to reach an informed decision.
Provide Follow-up Medical Care
A
woman should be counselled to return for follow-up examinations one
to two weeks after receiving initial medical care. Health care providers
should monitor her follow-up care. Further tests and treatment, such
as testing for or treatment of STDs or referral to other RH services,
may be indicated during follow-up. Further visits may also be required
for pregnancy and HIV testing.
Psychosocial Care
Survivors
of sexual violence commonly feel fear, guilt, shame and anger. They
may adopt strong defense mechanisms that include forgetting, denial
and deep repression of the events. Reactions vary from minor depression,
grief, anxiety, phobia, and somatic problems to serious and chronic
mental conditions. Extreme reactions to sexual violence may result in
suicide or, in the case of pregnancy, physical abandonment or elimination
of the child.
Children
and youth are especially vulnerable to trauma. Health care providers,
relief workers and protection officers should devote special attention
to their psychosocial needs.
Survivors
should be treated with empathy, care and support. In the long term,
and in most cultural settings, the support of family and friends is
likely to be the most important factor in overcoming the trauma of sexual
violence. Community-based activities are most effective in helping to
relieve trauma. Such activities may include:
-
identifying
and training traditional, community-based support workers,
-
developing
women's support groups or support groups specifically designed for
survivors of sexual violence and their families, and
-
creating
special drop-in centres for survivors where they can receive confidential
and compassionate care.
See Further Readings.
These
activities must be culturally appropriate and must be developed in close
cooperation with community members. They will need on-going financial
and logistical support and, where appropriate, training and supervision.
Quality counselling by trained workers, such as counsellors, nurses,
social workers, psychologists or psychiatrists -- preferably from the
same background as the survivor -- should also be provided as soon after
the attack as possible. Reassurance, kindness and total confidentiality
are vital elements of counselling. Counsellors should also offer support
if the survivor experiences any post-traumatic disturbances, if she
has difficulty dealing with family and community reactions, and as she
goes through any legal procedures.
The
objectives of counselling are to help survivors:
-
understand
what they have experienced,
-
overcome
guilt,
-
express
their anger,
-
realise
they are not responsible for the attack,
-
know
that they are not alone, and
-
access
support networks and services.
Caution
should be exercised before intervening in domestic situations because
the survivor and/ or other relatives could be subjected to further harm.
If the survivor has to return to the abuser, retaliation may follow,
especially if the abuser learns that the matter has been reported. Each
situation needs to be individually assessed in close cooperation with
colleagues to determine the most appropriate response. Health care providers
may choose to refer the matter to a disciplinary committee, inform the
authorities, or provide discreet advice to the survivor about her options.
These
children may be mistreated or even abandoned by their mothers and families.
They must be closely monitored and support should be offered to the
mother. It is important to ensure that the family and the community
do not stigmatise either the child or the mother. Foster placement and,
later, adoption should be considered if the child is rejected, neglected
or otherwise mistreated.
The
government on whose territory the sexual attack occurred is responsible
for taking remedial measures, including conducting a thorough investigation
into the crime, identifying and prosecuting those responsible and protecting
survivors from reprisal. In all cases, the wishes of the survivor should
be respected when pursuing the legal aspects of the case. Confidentiality
must be ensured.
All
agencies should advocate the enactment and/ or enforcement of national
laws against sexual violence in accordance with international legal
obligations. These should include prosecution of offenders and the implementation
of legal measures to protect the survivor.
The
local UNHCR Protection Officer must be familiar with the national criminal
and civil law on the subject of rape and sexual violence before an incident
occurs so he/ she will know what procedural steps should be taken and
what advice should be given to survivors. (See Appendix Two.)
Monitoring
Monitoring
cases of sexual violence should be a routine task of health care providers,
protection officers and others, as appropriate. In addition, there should
be regular assessments of the providers' ability to offer comprehensive
medical and psychosocial care for rape survivors. Ideally, care should
be given as soon after a rape as possible.
Sexual
Violence Indicators
Indicators
to be collected from the health-facility level
- Incidence
of sexual violence (reported cases/ 10,000 population)
- Coverage
of services for survivors
- Timely
care for survivors
Indicators
that might be measured annually
- Prosecution
of sexual violence offenders
- Coverage
of health-worker training that serves survivors of sexual violence
(Refer
to Chapter Nine -- Monitoring and Surveillance.)
Checklist
for Sexual Violence Programme
Key
Interventions -- Preventing Sexual Violence
-
Ensure
proper documentation for women
-
Increase
availability of female protection officers and interpreters and
ensure that all officers have knowledge of UNHCR Protection Guidelines
and UN Security Guidelines for Women
-
Facilitate
the use of existing women's groups or promote the formation of women's
groups to discuss and respond to issues of sexual violence
-
Improve
camp design for increased security for women
-
Include
women in camp decision-making processes, especially in the areas
of health, sanitation, reproductive health, food distribution, camp
design/ location
-
Distribute
essential items such as food, water and fuel directly to women
-
Train
people at all levels (NGO, government, refugee, etc.), to prevent,
identify and respond to acts of sexual violence.
Key Interventions -- Responding to Sexual Violence
-
Develop/
adapt protocols and guidelines that would limit further traumas
to survivors of sexual violence
-
Engage
socially and culturally appropriate support personnel as a first
contact with people who have been subjected to sexual violence
-
Provide
prompt and culturally appropriate psychosocial support for survivors
and their families
-
Provide
medical follow-up immediately after an attack that also addresses
STDs, HIV infection and unwanted pregnancy
-
Establish
closer links among protection officers, women's groups, TBAs and
community leaders to discuss issues related to the attacks
-
Document
cases while respecting survivors' wishes and confidentiality.
Sexual Violence Incident Report Form
Annex
to this chapter
Annex 1
Emergency Contraceptive Pill Regimens
Further
Readings
"Emergency
Contraception: A Guide for Service Delivery", WHO, Geneva, 1998.
"Emergency
Contraception Pills: A Resource Packet for Health Care Providers and
Programme Managers", Consortium for Emergency Contraception, New York,
1997. Heise,
Lori L. "Violence Against Women: The Hidden Health Burden", World Bank
Discussion Papers, No. 255, The World Bank, Washington, DC, 1994.
"How
To Guide: Community-based Response to Sexual Violence: Crisis Intervention
Teams -Ngara, Tanzania", UNHCR, Geneva, 1997. "How
To Guide: Developing a Team Approach to Prevention and Response to Sexual
Violence -Kigoma, Tanzania", UNHCR, Geneva, 1998. "Mental
Health for Refugees", WHO/ UNHCR, Geneva, 1994. "Security
Guidelines for Women", United Nations Security Coordination Office,
United Nations, New York, 1995.
"Sexual
Violence against Refugees: Guidelines on Prevention and Response", UNHCR,
Geneva, 1995.
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