Why treating rape survivors is so complicated

By — February 1, 2013

On January 25, I gave a talk at Columbia University in New York for “Global sexualized violence: From epidemiology to action,” an all-day symposium co-hosted by WMC’s Women Under Siege and Columbia University's Mailman School of Public Health. This is a version of that talk.

As a clinician engaged in the evaluation of sexually and physically abused and tortured populations, I have often quietly pondered this question: Compared with victims of purely physical violence and torture, why do victims of sexualized violence frequently have such long-lasting effects?

On the surface, this may seem like a simple question. Yet, in my experience, even when the physical consequences of rape are not clinically evident, the victim experiences such deep shame, a sense of complicity, a sense of invasion that extends far beyond the consequences of the most grizzly cases of physical torture and assault. This observation has been true for male victims, victims of pedophiles, child victims, and women. After several decades of caring for sexualized violence survivors, the complexity of the consequences of sexualized violence continues to touch me deeply.

During a recent evaluation, I met a 40-year-old woman who was gang-raped twice by military soldiers in the past decade. The first event was in a maximum security prison in central Africa by four guards. The second event occurred while she was taking shelter in a church with her 2-year-old daughter: Five military police encountered her and raped her in front of her daughter. Both events were politically motivated—she belonged to the opposition party. Both were conflict-related.

Kivlahan with two doctors who work with survivors of sexualized violence in Bukavu, Democratic Republic of Congo. (Courtesy Coleen Kivlahan)

While these terrible events tell part of the story, the more horrific story extends farther back. Her abusive father died when she was 12; her mother was placed in forced isolation from her children for two years in order to be purified because her in-laws believed that she was to blame for the early death of her alcoholic husband. This caused the victim to leave school in fifth grade since there was no financial support for her. She was later sold into forced marriage to a cousin 23 years her senior, who was a military officer. He raped her often. She endured six pregnancies and two miscarriages (due to the daily beatings she sustained). Her husband inserted foreign objects in her vagina, poured boiling water on her, tied her ankles so she could not leave the house (to name only a few of the many assaults on her safety and freedom), and had her arrested and sent to the very prison in which she was raped.

When she escaped and fled to a church, living in poverty, she was raped by soldiers in that town. Finally, she returned to live with her husband because she had no alternative. The victim told me that she is ugly, stupid, deeply ashamed of her life and has lost her honor as a woman.

This woman’s unforgettable case illustrates the complex nature of sexualized violence. Rape is rarely isolated to a single event, and frequently complicated by poverty, lack of education, and poor access to medical care. The complexity is further challenged by the fact that medical and legal evidence is collected and documented inconsistently—sometimes unprofessionally, even offensively. I cannot tell you how many medical affidavits I have read that say only, “Vagina is dirty.” We need to change this.

To that end, I have helped Physicians for Human Rights launch its Program on Sexual Violence in Conflict Zones, a new initiative that will train health and legal experts on best practices for collecting court-admissible evidence and that will forge effective coalitions among regional medical, law enforcement, and legal experts.

There are many systematic challenges we face: rare prosecutions for sexualized violence (both domestic and conflict-related crimes), poorly drafted medical affidavits that lead to poor communication of findings to the justice systems, few well-trained clinicians, and minimal evidence collection by law enforcement or health professionals. PHR’s new interventions include joint training for law enforcement and medical personnel, so that officers can understand medical language and medical practitioners can understand legalese. It also includes the creation of standardized forensic documentation forms that successfully communicate complex findings, the training of key network leaders, mock trials, and consultation on critical and difficult cases.

Ideally, this work will result in the creation and use of nationally recognized documentation forms that can then raise the standards of care and evidence collection, as well as inform national databases that record all sexualized violence events. Through education, training, prosecution, and comprehensive data, we are beginning to address the barriers to reporting, justice, and recovery. Interventions like PHR’s take years. But we will keep trying until no woman comes to me with a file that says she is dirty.