Global Issues in Sexual Assault
In the 1990s, during the conflicts in Bosnia, Rwanda, the Democratic Republic of the Congo, and Liberia, rape became weaponized as a form of torture,1 genocide,2 and a means of humiliating and demoralizing the opponent.3 Although women are subjected to sexual torture far more often than men,4 sexual assault is calculated to destroy not only the man or woman who is raped, but entire families and communities. Rape of men is meant to be the ultimate humiliation of conquest, and the rape of women highlights the inability of men to perform their role as protectors of women and children. In the Congo, for example, over half of the victims of military rapes are children, 10% of them less than 10 years of age. In the ultimate depravity, fathers are forced to rape their daughters and sons their mothers in the presence of the entire community as a means of achieving total submission through fear.5
Systematic, repeated rape is now an adjunct to genocidal extermination camps and has been used in Sudan, Guatemala, the Congo, Rwanda, and Bosnia.2 During the Bosnian War (1992 to 1995), the Serbian paramilitary created rape camps to imprison women and adolescent girls, and torture and gang rape them over months with the "assistance" and compliance of the local authorities.6 There are reports, out of Liberia specifically, describing the dual role of combatants who are commanded to torture, rape, and murder and then to gratify the sexual desires of their superior officers in order to keep their jobs.7 Societies demoralized by war, fearful of torture and death, hungry and poor, and knowing that there are no consequences for their assailants, often come to regard violence and the expectation of violence as customary and acceptable.2,4,5,6,7,8
Plagued by both poverty and concerns for their daughters, many parents coerce young girls into early marriages as a way of fetching a good bride price for a virgin daughter, who has not yet been raped by the military or paramilitary combatants. Instances of girls as young as 11 or 12 years being given in marriage to men in their 60s have been reported.8,9 Girls who run away are beaten by their families and returned to their husbands either to protect the family's reputation or because some of the money from the bride price has already been spent. In many such traditional cultures, victims of rape are blamed for their assault and bring shame upon their families. Women may not access medical care without the permission of their husbands, increasing the likelihood that rape will never be reported.9 And although sexual assaults by strangers are widely acknowledged as crimes, rape in marriage, sexual coercion in schools, demands for sex in return for a job, and forced marriage are tolerated or socially condoned in many countries. Women are expected to be submissive and sexually available to their husbands at all times, and it is considered both a right and an obligation for men to use violence in order to "correct" or chastise women for perceived transgressions.10
When rape is used as a weapon of war, the consequences to women are severe. Many women suffer fistulas, incontinence, infertility, depression, suicidal ideation, suicide, abandonment by family, and exile by the community.2,4,5,11,12 Women who have been raped are more likely to be sexually abused again2 and are more likely to engage in high-risk sexual behavior, such as exchanging sex for food and money, having sex with military personnel for perceived benefits of association with the powerful, and having unprotected sex with individuals known to be human immunodeficiency virus positive.13 Both rape and high-risk sexual behavior in exchange for food, money, and/or cosmetics are reported to be frequent among internally displaced persons living in refugee camps.12,13,14
However disturbing these reports may be, investigation of the literature reveals that physicians and scientists still do not have a comprehensive understanding of the dynamics of sexual violence, that methods of data collection remain understandably flawed, and that methodology, including single-site studies of self-reports by small populations, may indeed not represent the scope of the actual problem. Although some countries' medical associations have issued guidelines to clinicians, global clinical standards of care need further development.15 Journalists with an incomplete understanding of biostatistics often report inaccurate information that remains as fact in the minds of the general public, as evidenced by a media report that 75% of Liberian women were raped during the country's civil war. Peer-reviewed studies have set the estimated number at 9.2% to 15%, with 77% of women who were assaulted reporting sexual violence.16 Overreporting of such sensitive data may make good news, but ultimately, it damages the credibility of future reports. Underreporting may trivialize a major human rights violation and the suffering of its victims.
Human rights organizations, national governments, physicians, and physician organizations must continue to take firm steps to ensure sanctions against governments, societies, and individuals who tolerate such practices. REFERENCES 1.
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