Seeing through the obstacles to the victims: MSF's medical responsibility to victims of sexual violence
"One day I was collecting firewood for my family when three armed men on camels came and surrounded me. They held me down, tied my hands and raped me, one after the other. When I arrived home, I told my family what had happened. They threw me out of the house and I had to build my own hut away from them. I was engaged to a man and I was so much looking forward to getting married. After I was raped, he did not want to marry me and broke off the engagement because he said that I was now disgraced and spoilt...
When I was eight months pregnant from the rape, the police came to my hut and forced me with their guns to go to the police station. They asked me questions, so I told them that I had been raped. They told me that as I was not married, I would deliver this baby illegally. They beat me with a whip on the chest and back and put me in jail. There were other women in jail, who had the same story.... I stayed 10 days in jail and now I still have to pay the fine, 20,000 Sudanese dinars (US$ 65) they demanded of me."
- 16-year-old girl, West Darfur, Sudan
MSF teams regularly witness the results of large-scale and diverse types of violence: state-perpetrated violence, massacres, torture, systematic rape, and so on. Despite this, we have had trouble finding suitable responses to these sensitive and complex issues, only fragments of which are even visible to us. These issues are only made more difficult because our response can compromise the safety of our national and international staff.
There are many reasons why it is sometimes difficult for MSF to respond to victims of sexual violence. There are differences of opinion on what constitutes sexual violence, and cultural obstacles linked to the general stigma surrounding rape make the identification of victims difficult.
It is hard to provide staff sensitivity training on these issues in an extreme emergency situation where many needs must be met quickly. And victims of sexual violence sometimes refuse to come for help. Those who are strongly influenced by religious ideology or are dependent upon others, may fear ostracism, especially by male partners who could abandon them if it became known that they had been raped.
Initial data from various contexts in which we work show the huge range and unpredictability of violence in general and of sexual violence in particular. For example, in recent years, MSF teams in the Ituri region of the Democratic Republic of the Congo (DRC) have been told of the kidnappings of young girls which have been linked to acts of extreme cruelty.
We have seen how rape and the threat of rape are used to terrorize and control civilians in Darfur's displacement camps. Teams have seen the consequences of a rise in civilian and domestic violence in Liberia following the waves of armed conflict that have crossed that country.
"Beginning antiretroviral (ARV) treatment for a four-month-old baby, repairing the perineum of a five-year-old girl, or relieving the pain a 70-year-old woman feels in her anus is more than a scriptwriter of horror films could imagine...."
- Celia Kohn, MSF gynecologist-obstetrician in Bunia, DRC
Medical responsibility is not police work
However, when it comes to responding to the consequences of sexual violence, our medical practices sometimes meet resistance, or we find that our teams are limited by the reality of certain situations. Yet our medical responsibility compels us to avoid making judgments about those who need our help and to overcome any "reflexes" - both conscious or unconscious - that might prevent us from doing as much as we can for victims of sexual violence.
Medical responsibility implies, among other things, an obligation to provide needed resources. That is, a doctor needs to make every possible, up-to-date medical resource available to the patient.
Yet putting this imperative into action in the field sometimes can prove to be very complicated. Violence is composed of intent and harm, the aggressor and the aggrieved - and although the notion is often colored by culture and may have political, economic or religious designs, contextualizing our individual and collective responsibility to people and societies beset by this kind of violence makes the exercise of medical responsibility particularly delicate.
MSF workers themselves are not immune from the misconceptions about rape that exist in larger society. Indeed, there may be a temptation to resort to cultural relativism (perhaps making assumptions about the sexual propensities of a beneficiary population) to hide our own distress when faced with phenomena for which our assistance is (and must be) limited.
One might even hear a comment such as "Does rape really happen in Africa?" or "You know, some people just have a violent sexuality." Such comments imply that all values are relative depending on the cultural context in which they are found. Ironically, the only opinions continually missing from the debate are those of the people themselves. In this kind of discussion, we take away their right of self-determination and the values that concern them.
In the field and in the headquarters offices, one can hear snippets of conversations that raise doubts about the victim status of some female patients: Perhaps they want to conceal consensual relations with a partner, or maybe their real motive for seeking treatment after a rape is to get free soap or clothing. Such suspicions also get tangled in a dialogue about whether or not consensual sex between older men and pre-pubescent girls constitutes rape or a form of sexual exploitation.
However, we must remember: medical responsibility is not police work. It is not our job to test the veracity of cases, nor is it our work to explore aspects of anthropology or the social sciences to better understand the context - even though cultural aspects must, of course, be considered. This is true not only in cases of rape, but also in broader terms when dealing with a local population's concepts of health, body image, violence and sexuality.
Our medical responsibility could therefore begin with easing access to care for these female patients for whom such access is often very limited relative to the general population. This can come down to working with the invisible, leaving the responsibility for establishing these activities entirely up to the will and "militancy" of one or more of our staff members.
In emergency situations, making this kind of care available can sometimes spark competition with other health imperatives that must be addressed. In such cases, we are forced to carry out a kind of triage that threatens to create a form of competition among our patients. Our priorities, often dictated by individual or public health issues (e.g., cholera which can kill within hours), remain solidly anchored in an ideological framework that we sometimes forget to question.
"Shouldn't care for victims of sexual violence and rape be one of our first priorities in conflict settings?"
The duty to provide care
While trying to avoid accepting all differences from our norms as "cultural," we also face the potential for taking on an "imperialist" attitude that consists of dictating the populations' best interests - particularly when we are denouncing and bearing witness to practices we oppose and when we are establishing medical care where it is limited or completely lacking.
Medical responsibility is primarily a matter between patient and practitioner.
The obligation to give resources - even when operating in dangerous situations - is above all the obligation to provide care and to ensure its quality. In cases of sexual violence, it could be a matter of giving antibiotic treatment to combat a sexually transmitted infection, giving prophylaxis treatment to prevent HIV infection, providing medicine to avoid pregnancy, performing an abortion or reconstructive surgery, or, of course, addressing psychosocial issues.
Although there is insufficient scientific causal evidence to describe a direct link between sexual violence and HIV transmission, our action in emergency situations must be guided by the time imperative for efficient prophylactic treatment of HIV, despite the fact that these measures sometimes interfere with the management of other public health problems.
Apart from pure prophylactic action, post-exposure prophylaxis (PEP) is one of the only tools we have available in the field to hold back HIV transmission in endemic contexts. Looking back, we know that in Rwanda, thousands of women were infected with HIV/AIDS through widespread systematic rape during the genocide of 1994.
At the time, MSF was not focusing on victims of sexual violence, while being confronted with so many types of violence and enormous insecurity, including harm to its own teams. However, shouldn't we let the consequences of that event serve as a guide for our future action on the issue? Shouldn't care for victims of sexual violence and rape be one of our first priorities in conflict settings, especially knowing the suffering it causes its victims and the long-term health consequences it can have on a whole group?
Is doing something enough?
Experience has shown that it is sometimes difficult for MSF teams to address the consequences of violence without being able to act on the causes. Nonetheless, we should not discount the care that we must and can provide to people, even if it may seem inadequate given the chronic, structural or political nature of the situation. The responsibility that medical practitioners and organizations carry in these emergency situations goes far beyond a legal concept: It also touches on areas of political, ethical and civil responsibility.
Our ability to provide comprehensive care to victims of sexual violence and rape is limited. Yet when one of our doctors signs a medical certificate and hands it to the patient, this act, to some extent, symbolizes the unique responsibility that the doctor has to provide assistance after an episode of sexual violence. By signing the document, the doctor is committing him or herself personally, and taking part in the practice of individual medicine within group and public health care systems.
This can be a healthy exercise for both the doctor and the patient when the suffering of so many victims of sexual violence is often reduced to statistics lacking any names or faces. And it should continue to be the ethical foundation on which our medical practices are based.