Chapter 3
Prevent and Manage the Consequences of Sexual Violence

OBJECTIVE TO PREVENT AND MANAGE THE CONSEQUENCES OF SEXUAL VIOLENCE.   What are the key actions that should be taken: 1)   to reduce the risk of sexual violence? Design and locate settlements for the displaced population, in consultation with the population and women in particular, to enhance physical security. Locate latrines, hygiene and water points in accessible, secure places. Provide latches to lock latrines and washing facilities. Provide adequate lighting on paths used at night. Provide security patrols. Provide direct transport to firewood collection sites or patrol collection routes in close collaboration with displaced women and girls. Ensure the inclusion of female workers in food distribution, registration and other services. Ensure the presence of female protection officers. Discuss sexual violence issues during health coordination meetings. Identify individuals or groups that may be at higher risk of sexual violence (e.g., single female-headed households, unaccompanied minors, etc.) and, in consultation with these persons themselves, address their protection and assistance needs. For example, make special arrangements for housing unaccompanied women, girls and boys and women-headed households. Ensure confidential reporting system (so beneficiaries have the possibility of reporting suspicious and threatening behaviors before incidents occur). 2)   to respond appropriately to survivors? Ensure a standard medical response to sexual violence survivors, including the option of emergency contraception, preventive treatment for STIs, post-exposure prophylaxis for prevention of transmission of HIV, and tetanus and hepatitis B vaccinations and wound care as appropriate. Ensure privacy and confidentiality of the survivor. Ensure the presence of same-sex, same-language health worker or chaperone and, if the survivor wishes, a friend or family member, present for any medical examination. Ensure the physical safety of the survivor immediately following an incident of sexual violence.[19] Ensure the displaced population is informed of the availability and location of services for sexual violence survivors. Ensure the availability of appropriate, culturally appropriate psychosocial support. Ensure that locations where incidents of sexual violence have occurred are identified and documented and relevant preventive measures are established. A useful resource that provides guidance to health care providers for medical management after rape of women, men and children is Clinical Management of Rape Survivors: A guide to the development of protocols for use in refugee and internally displaced person situations.[20]

What is sexual violence?

Sexual violence is any non-consented action of a sexual nature, including rape and sexual exploitation among other acts. Sexual violence is a subset of the broader category of gender-based violence (GBV). GBV is an umbrella term for any harm that is perpetrated against a person's will that results from power inequities that are based on gender roles. Violence may be physical, sexual, psychological, economic or socio-cultural.[21]

The focus of addressing sexual violence in the MISP is the prevention of rape, provision of medical care for rape survivors and ensuring the availability of essential psychosocial services. Once a situation stabilizes and all components of the MISP have been implemented, attention can be given to preventing the wider array of violence issues, including domestic violence, early and/or forced marriage, female genital mutilation/cutting, forced sterilization or pregnancy, forced or coerced prostitution, trafficking of women, girls and boys and additional forms of GBV.

Why is preventing sexual violence a priority?

Although sexual violence is common even during peacetime, war and conflict increase incidents of rape and other forms of sexual violence. This dire reality is reflected in an increasing number of documented reports and research. Women and adolescents are especially vulnerable to sexual abuse committed by combatants. The use of rape as a weapon of war has been documented in several conflicts as an effective means of controlling, degrading and humiliating a community.[22]

Who is responsible for preventing and managing incidents of sexual violence?

A multi-sectoral team approach is required to prevent and respond appropriately to sexual violence. A committee or task force should be formed to design, implement and evaluate sexual violence programming at the field level. The purview of the task force should encompass all technical sectors and all geographic areas. Representatives of the displaced community, UNHCR, UN partners, NGOs and government authorities should be members of this task force. Each member of the task force, including displaced women and girls, representing relevant sectors/partners (such as protection, health, education, community services, security/police, site planning, etc.) should identify her/his role and responsibilities in preventing and responding to sexual violence.

The Reality of Implementing the MISP in Pakistan [23] The Women's Commission conducted a year-long MISP assessment in Pakistan from 2002 to 2003 to advocate for improved RH services for Afghan refugees who had fled their country from the bombings following the September 11 attacks on the United States. Most staff had not received refresher training and lacked proper equipment and supervision to adhere to universal precautions to prevent the spread of HIV. Condoms were available in most settings but were not always free. Prevention and management of sexual violence went largely unaddressed. Emergency obstetric care was available, but many women did not have the means to access services due to high transportation costs. The assessment revealed that while isolated efforts had been made to improve the quantity and quality of RH care for Afghan refugees, many programs were limited to traditional maternal and child health services, and the quality of RH care was a significant concern.

Who is impacted most by sexual violence?

Most reported cases of sexual violence among displaced people-and in most settings around the world-involve male perpetrators committing violent acts against females.[24] However, men and boys may also be at risk of sexual violence, particularly when they are subjected to detention or torture. While all women in situations of conflict are susceptible to sexual violence, female adolescents are exceptionally vulnerable as they are often targeted for sexual exploitation and rape. In addition, systematic sexual violence, even if exclusively perpetrated against women and girls, often affects and undermines the entire community, including the fathers, brothers, husbands and sons of the survivor.

Who are the perpetrators of sexual violence?

Perpetrators may be others who have been displaced by the conflict or disaster; members of other clans, villages, religious groups or ethnic groups; military personnel; rebel forces; humanitarian workers from UN or NGO agencies; members of the host population; or family members. Rape may be used as a strategy of war to intimidate and traumatize a population, in which case the perpetrators are enemy combatants; perpetrators of opportunistic rape can be anyone acting with impunity in the climate of lawlessness that accompanies armed conflict.

When does sexual violence occur?

Sexual violence can happen during all phases of displacement: prior to fleeing one's home area, during flight, while in the country of asylum and during repatriation and reintegration. In addition, sexual and domestic violence frequently escalates in displaced settings as normal social structures are disrupted. Immediate prevention and response measures must be adapted to suit these different circumstances.

Good practices in preventing and managing the consequences of sexual violence observed in Darfur [25] Clinic staff in North Darfur distributed emergency contraception (EC) to village midwives in addition to a flyer (in Arabic) developed by the MISP Coordinator on why and where women and girls can access care for rape. African Union (AU) commanders in North Darfur were informed by the MISP Coordinator to refer all rape survivors to a local clinic for treatment. The AU civilian police (CIVPOL) patrol also distributed information flyers (in Arabic) on the benefits and availability of care for survivors of sexual violence after an attack. In North Darfur, the MISP Coordinator conducted meetings with CIVPOL members about the importance of the clinical management of rape survivors. In West Darfur, midwives were identified as sexual violence protection focal points and internally displaced women could approach these focal points confidentially; the focal points referred women to receive medical care. In North Darfur, traditional birth attendants (TBAs) delivered messages on sexual violence to the community. In South Darfur, women's health teams conducted community outreach to survivors of sexual violence. Some agencies immediately established women's centers in camps which provide a safe place for women and girls and provide a space for survivors of sexual violence to receive confidential, holistic care in an environment that minimizes the social stigma.

What are some situations that put women and girls at risk of sexual violence?

It has been shown that women without their own personal documentation for collecting food rations or shelter materials are vulnerable because they are dependent on males for their daily survival and may be forced to provide sexual favors to obtain these essential items. It also has been demonstrated that when men (fellow displaced persons or humanitarian actors) are responsible for distributing food and other essential goods, women may be subject to sexual exploitation, that is, they may be forced to perform sexual favors for men in order to obtain their survival needs.

Women and girls may have to travel to remote distribution points for food, firewood for cooking fuel and water. Their living quarters may be far from latrines and washing facilities. Their sleeping quarters may also be unlocked and unprotected. Lighting may be poor. Male and female latrines and washing facilities may not be separate. All of these circumstances leave women vulnerable to attack or abuse.

Lack of police protection and lawlessness also contribute to an increase in sexual violence. Police officers, military personnel, humanitarian workers, camp administrators or other government officers may themselves be involved in acts of abuse or exploitation. If there are no independent organizations, such as UNHCR or NGOs, to ensure personal security within a camp, the number of incidents often increases. It is important that female protection officers are available since often women and girls are more comfortable reporting protection concerns and incidents of violence to another woman.

Why are incidents of sexual violence often not reported?

Even in non-crisis settings, sexual violence often goes unreported due to a range of factors, including fear of retribution, shame, stigma, powerlessness, lack of support, the unreliability of public services, lack of trust in the health services and the lack of confidentiality and unfamiliarity with the services. All of these circumstances are exacerbated in displaced settings, increasing the likelihood that incidents of sexual violence among the population will go unreported. Therefore, addressing sexual violence goes beyond the clinical management and must also include an environment where women are supported and able to access this care.

Code of Conduct The Code of Conduct [26] (CoC) against sexual exploitation and abuse is a set of agency guidelines that promote respect for fundamental human rights, social justice, human dignity and respect for the equal rights of women, men and children. Implementing MISP activities appropriately means that each agency has a CoC in place and all humanitarian actors are committed to adhering to the guidelines and have been oriented to their responsibilities to prevent sexual abuse and exploitation. The CoC is not only for staff of international agencies. International agencies must also ensure that any staff hired from local organizations or people contracted from the local community or displaced population are oriented to the CoC. All humanitarian actors who have been oriented should sign their agency’s COC. Good Practice One agency conducts an orientation on its CoC for its entire staff and then six weeks later provides a brief refresher session so that staff may share examples from their work of issues discussed during the orientation. This is a promising way to ensure that staff do understand the CoC and can assist the agency in making any necessary modifications to the local context.

MISP Sexual Violence Monitoring

Coordinated multi-sectoral systems to prevent sexual violence are in place Confidential health and psychosocial services to manage cases of sexual violence are available and accessible Number of staff trained in sexual violence prevention and response Indicators to monitor overall coordination Monitor the number of incidents of sexual violence anonymously reported to health and protection services and security officers Monitor the number of survivors of sexual violence who seek and receive health care (anonymous reporting is of utmost importance) Which supplies are needed or which Interagency RH Kit(s) could be ordered to address this issue?[27] Number Name Color Kit 3: Post-Rape sub-kit Pink Kit 9: Suture of Tears and Vaginal Examination sub-kit Purple

Challenges and Solutions

1) The provision of psychosocial services can be challenging to implement in the early stages of an emergency. What if the staff have low capacity and lack the basic skills to provide these services?   Local staff will likely be able to help identify the most appropriate local persons with nonjudgmental, supportive attitudes and good communication skills for this role. It is crucial that all staff that come into contact with a survivor respect the survivor's wishes and ensure that all related medical and health status information is kept confidential and private, including from the survivor's family members. Staff need to communicate in a way that both ensures accurate information and reflects a caring, uncritical attitude. Training programs on psychosocial support can be established once the situation is stable. A good resource that focuses on engagement strategies for work with GBV survivors is the GBV Communication Skills Manual.[28] 2) In certain insecure settings, individual agencies that strongly advocate around the issue of GBV may put their own staff and the operation of the program at risk. How can this be addressed?   It is essential to work in a culturally appropriate way while giving women and girls the opportunity and space to name the violence they have experienced. Because GBV can be a culturally taboo subject, it is necessary that links with key community members who help legitimize talking about GBV are established. If this is not possible, agencies may choose to identify programs as providing more general "women's health services" to avoid sensitivities to GBV and to avoid community advocacy on GBV in the earliest days and weeks of emergencies. The key focus at this time is finding ways to inform the community about the benefits and availability of care for survivors of sexual violence. Later, when better relations have been established with the community and more is understood about GBV in the local context, information, education and communication (IEC) campaign planning and community advocacy should be established.

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NOTES

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