The medical consequences of sexual violence: MSF report eastern DRC

"One day I was in the forest looking for wood and cassava tubes. As I had finished, two armed men appeared. They hit me on the face with the butt of their gun. I threw the wood at them and started to run. But I fell on the ground and they took off all my clothes. One was holding me, sticking his knife on my throat, and the other one raped me. They were angry and were spitting at me. I was thinking about my husband, about how he would react and about death. Since then, I feel pain when I urinate and in the abdomen. I have the impression that my vagina is wide open. I have no courage anymore and my husband insults me. I have nightmares at night and feel that God has abandoned me."
25-year-old woman, raped in March 2003

During the war, most women did not seek any medical care after they had been raped. There were simply no appropriate health services available or they felt ashamed, were too sick or lived too far away to seek emergency assistance in the first days following the incident. As treatment has become possible, the medical consequences of such widespread sexual violence are becoming apparent.

Increased HIV/AIDS and STI transmission
Rape increases the risk of HIV/AIDS transmission significantly, because forced sexual intercourse is accompanied by injuries and bleeding which enhances transmission of the virus as compared to during consensual sex. Physical injury from sexual violence can be very serious, especially in young girls. It was recently estimated that the HIV prevalence in South Kivu could reach 20 per cent.7 Sexual violence is likely to have been a significant contributory factor to this increase.

"Since I was raped two years ago, my fiancé broke the engagement and I haven't met anybody else, because men think I might be infected with AIDS. I am very worried - who can tell me these men were not contaminated when they did this to me? Because of all these preoccupations, I often think about this event, especially at night. Raping is like killing someone." 21-year-old woman, November 2003

Most of the patients presenting at the MSF clinic complain about abdominal pain and fear of having contracted sexually transmitted infections (STIs). The MSF team clinically diagnoses and treats infections using the syndromic approach. In addition to being a source of chronic pain, STIs may lead to infertility.

Reproductive health
Unwanted pregnancies as a result of rape can force women to seek an unsave abortion. MSF has seen cases of pelvic inflammatory disease almost certainly arising from such procedures. Other reproductive health problems reported to MSF have included interruptions or abnormalities to the menstrual cycle or delayed conception. Decreased sexual desire or pain during sex is particularly common and very damaging to family and relationships.

"We had fled from our village and built a bivouac - a small hut - in the bush to protect us from the war. I was there with my husband and my family. One night, a group of armed men came to loot our house. They took me and the other woman who was in my house to accompany them on their route. On the way, I was raped by four of them. I thought I was going to die. The next day, three armed men came back to our house and asked us for money.We said we had been looted the day before and we didn't have anything to offer anymore so they told us "you are going to feel this." The other woman and I were raped again - by all three of them. I was 2 months pregnant then. Four months later, I miscarried. Since then, I feel a lot of pain in the body, especially in the abdomen and in the back. I feel weak and I wish I could be pregnant again but since the incident, it seems like I cannot keep a pregnancy. I sleep quite well at night, but whenever I see armed men in front of me, I am terrified." 23-year-old woman raped in August 2001

Some rape victims have reported to MSF that they believed they were pregnant when subjected to sexual violence. Of 51 patients allegedly pregnant at the time of the rape, almost 35 per cent reported having had a problematic pregnancy as a consequence. The consequences included immediate or delayed miscarriage, neonatal death, or an infant with congenital abnormalities.

The term "faible" or weak is used to describe a weak child considered lesser than the other children of the family. Although there is no proven direct link between sexual violence and poor reproductive health, this is the perception of many women. For instance, it is a common belief that breast milk is contaminated as a result of rape causing mothers to avoid breastfeeding thereby endangering the newborn's life. An unknown number of pregnancies are deliberately aborted in total secrecy.

"That day, two months ago, I had gone to the fields to pick cassava leaves and firewood. Suddenly, a man appeared before my eyes and called to me, as I came closer to him, he asked me "are you alone?" Then, another man appeared and said, "If she doesn't want to have sex with us we will just kill her!" When I heard I was going to die my heart failed - and I just let myself be raped by the two of them. At that time I was seven months pregnant, and when I finally got back home I miscarried - the same night." 26-year-old woman, November 2003

MSF provides medical treatment to those women who have experienced sexual violence. Emergency contraceptive pills are given to prevent pregnancy and Post Emergency Prophylaxis (PEP) is given to help prevent the possible transmission of HIV/AIDS to women who present themselves within 72 hours after the rape happened.

Beyond 72 hours after the incident took place, there is less that can be done medically. The sooner patients come to the clinic the better, and therefore education of local communities and health workers is an important part of tackling the problem.

Physical injury
Most rape victims report some kind of physical injury such as pain all over the body and in particular areas where they have been beaten with fists, weapons or sticks. Many complain of joint pains to the hip and back when their legs have been extensively and violently spread out. The pain experienced at the time of the incident has left its stubborn mark even years after the rape - on both the victims' bodies and minds.

Survivors feel weak, sick, soiled, and even despite a lack of physical pathology the scar persists.

Download the entire report here in PDF format.

7 Dr Francois Lepira, director of the national programme against AIDS, quoted by the United Nations Integrated Regional Information Network (IRIN) on the 5th of November, 2003.