"In Canada, where we have identified the treatment of sexual violence as a medical issue and a priority for care, the continuing stigma around sexual violence is an ongoing challenge that prevents many victims from receiving the treatment they need. In places like South Sudan, where conflict is already destroying lives and the healthcare system has collapsed, those challenges can seem even more overwhelming."
Trigger Warning: This story contains information about sexual assault and/or violence which may be triggering to survivors, and which some readers may find disturbing.
Today is International Women's Day. Doctors Without Borders/Médecins Sans Frontières (MSF) is using this opportunity to highlight sexual violence as an urgent health and medical issue.
Mariko Miller is an emergency nurse and sexual assault nurse examiner in Vancouver, B.C. She has undertaken five medical postings overseas with Doctors Without Borders/Médecins Sans Frontières (MSF) — most recently in Bentiu, South Sudan, where she was the nursing activity manager at a project that provides clinical care to people affected by war and conflict.
By Mariko Miller
Sexual violence is one of the world’s most pressing women’s health issues. At least one out of every three women worldwide has experienced some form of sexual violence, and its effects on physical, mental and reproductive health can be devastating. Those who survive their encounters can experience long-term effects, from the physical complications of unwanted pregnancies or infection to severe psychological trauma.
It is also vastly under-reported: Access to medical care for victims of sexual violence is hindered by a variety of barriers, which can have a paralyzing effect and can prevent victims from reporting assaults or seeking medical care. These barriers come in various forms: Stigma, feelings of shame and fear — of public exposure, of the legal process, of being blamed, or simply of not being believed. Furthermore, the reality that most assailants are known to their victims, which results in increased fear of retaliation and social consequences, can have a silencing effect.
Even in the world’s most sophisticated health systems, these barriers create incredible challenges when it comes to providing emergency medical care to vulnerable people. In Canada, according to the federal Department of Justice, it is estimated that 78 per cent of sexual assaults are not reported to police — a shocking figure in a country that is extremely well-resourced and resoundingly clear on its condemnation of sexual violence as a crime.
Rape as a weapon of war
In countries affected by conflict, risk of sexual violence is exponentially higher. This is not just a result of insecurity but also because, in many contexts, rape and sexual violence are used as weapons of war. Fighters seek to dehumanize their adversaries and demonstrate their ruthlessness and strength through violent physical and sexual assaults. In South Sudan, where a vicious and ongoing civil war has been creating mass displacement since December 2013, this is an alarming reality for girls and women, who, due to armed conflict and insecurity, are particularly exposed and vulnerable. In Bentiu, South Sudan — where I recently worked as a nursing activity manager with Doctors Without Borders/Médecins Sans Frontières (MSF) delivering emergency medical care to people affected by conflict — anecdotal reports of rape, violation and assault among the displaced population are shockingly commonplace.
In Canada it is estimated that 78 per cent of sexual assaults are not reported; in countries affected by conflict, the barriers to reporting can be much greater.
Even without widespread reporting or reliable data, it is clear that the level of sexual violence occurring in war-affected places like Bentiu is exceedingly high. It is also incredibly brutal, in ways that can be shocking even to people accustomed to stories of sexual violence in other contexts: A colleague of mine described a victim whose genitals had been violently disfigured by a gunshot wound; our patients included girls as young as 11 who had been raped.
These horrifying acts represent a medical emergency as much as a humanitarian one. Victims deserve access to medical care, for both the physical and psychological effects of rape. In Bentiu, as in other parts of South Sudan, sexual violence is part of a list of urgent medical needs that also include emergency and primary care, malnutrition, and maternity services. But for victims who are already struggling simply to survive in a conflict zone — to find enough food and water, to persevere against disease, to keep their families alive — seeking treatment for the effects of sexual violence can sometimes seem impossible.
Reaching patients in need
The challenge for organizations such as MSF, or anyone initiating medical activities for sexual and gender-based violence (SGBV), is to find a way to actually reach the patients who need treatment. Given the extent of underreporting — which can be exacerbated by cultural factors, or by the impact of crisis and conflict on health-seeking behavior, this can be a difficult task.
Making care both accessible and acceptable to victims is an essential first step. Creating a safe, female-only space where discretion and confidentiality exists, and creating community awareness are crucial priorities.
In Bentiu, MSF is initiating Knowledge Attitudes and Practice (KAP) surveys to better understand the perception of sexual violence and to help identify cultural barriers to accessing care. We are working with traditional birth attendants and outreach workers to help spread awareness to communities regarding the availability of services and encouraging survivors to access emergency medical care.
The importance of providing access and medical care for victims of sexual violence cannot be overstated. Not only is providing psychological first aid and preventing unwanted pregnancy, HIV and other sexually transmitted infections an essential medical service, but it contributes greatly in restoring dignity and alleviating the suffering of the survivor.
In Canada, where we have identified the treatment of sexual violence as a medical issue and a priority for care, the continuing stigma around sexual violence is an ongoing challenge that prevents many victims from receiving the treatment they need. In places like South Sudan, where conflict is already destroying lives and the healthcare system has collapsed, those challenges can seem even more overwhelming.
But even if facts and figures are difficult to collect, the needs remain clear: Sexual violence is a medical emergency and a women’s health crisis. We must make effective treatment available to all who need it now.