Stigma of Victims of Sexual Violence ’ s in Armed Conflicts: Another Factor in the Spread of the HIV Epidemic?

Sub-Saharan Africa continues to record the bulk of new people infected with Human immunodeficiency virus/acquired syndrome (HIV/AIDS) UNAIDS estimated that 1.9 million in 2010 [1]. This area is also the most affected by armed conflict and sexual violence against women. According to estimates, 8-10% of people infected by the HIV/AIDS are affected by armed conflict, a humanitarian crisis and a displacement of populations [2].

Over past decades, several African countries have experienced armed conflicts, including Sierra Leone, Rwanda, Uganda, Burundi, The Ivory Coast, Chad, Mali and the Republic Democratic of Congo (DRC). During the Rwanda genocide in 1994, the number of rape victims was estimated between 250.000 and 500.000 [3]. In Sierra Leone, between 50 000 and 60 000 displaced women has suffered from sexual violence [4]. Among these conflicts is that of the DRC, described as “first African war”. It is the deadliest since the Second World War. It has already caused more than 5.4 million victims, and continues to involve more than 45.000 deaths each month [5,6]. Since the beginning of the year 2012 and the resumption of hostilities in the East of the DRC, It has been reported more than 2.2 million people who have left their homes, fleeing the atrocities. They live now in internal displaced persons camps [7].

Mass rape and other forms of sexual violence are used as weapons of war to destroy the women and communities [8]. An American study estimates between 1.69 and 1.8 million, the number of women who have suffered these atrocities [9]. According to the authors of this study, 400.000 women and young girls have been raped between 2006 and 2007.

Beyond the cruelty of rape and its multiple consequences on health, the victims are stigmatized and rejected by their husbands, their families and their communities. According to a study conducted in the Kivu [10], 29% of raped women were rejected by their families, 6% by their communities.

Our study aims to identify the causes and implication of stigma on the health of the victims, and the prevention of the AIDS epidemic. It is an unavoidable factor to field interventions. An effective fight against the discrimination of the raped women could increase the request and the offer for care, and provide effective answers to the needs of the victims. Among indispensable interventions, support of victims is a priority [11] it aims to provide medical care: i) the prophylactic treatment and healing of Sexually Transmitted Infections (STIs), including AIDS, ii) the prevention of large unwanted pregnancies, iii) a psycho-social assistance.

It is about a study carried out on the basis of qualitative investigation database, conducted between March and April 2010 in Bukavu, Eastern DRC. Through individual interviews and focus groups, we had interviewed the victims of sexual abuse, the alleged aggressors, soldiers and armed fighters, including child soldiers, as well as the privileged witnesses, health, justice, civil society stakeholders, opinion leaders and the leaders of international institutions. The women victims were selected on the basis of types of violence, the age and the marital status. Alleged aggressors were selected on the basis of the same criteria, and by level of education. These variables may have an influence on the consequences of sexual violence among the victims. The privileged witnesses were approached due to their involvement in the understanding and fight against sexual violence. Interviews were recorded, transcribed and analysed by categorization.

The stigma of women victims: an epidemiological issue

It arises from the opinion of interviewed people, in particular the victims, customary and religious leaders, the actors of civil society, that victims most often are silent and do not denounce the undergone atrocities. They renounce consequently to preventive and curative medical care, as well as the psychological assistance, indispensable to the victims of sexual violence. One of the evoked main reasons is the fear of stigma, which have as a consequence, the insulation of victims, social exclusion and dislocation of families. The stigma of victims is now becoming a key factor in the support of victims, and an epidemiological real issue. Other reasons were evoked to justify the silence which became a negative adaptation mechanism: there are the shame and taboo surrounding sexuality issues in the communities concerned, Women who have lower status are not allowed to talk about sexuality in public; ii) the permanent insecurity linked to the political instability in these provinces; the fear of reprisals on behalf of armed groups who are standing at the scene, and the anarchic integration of armed fighters into the army and the national police force; the abuse of justice and repair in favor of victims.

Perception of the causes of stigma

The comments of interviewed people show that the stigma of women victims of sexual violence are related to several reasons, we mention below.

Rigid social norms in respect of women

The socio-cultural organization which places women in a position of subordination, particularly in rural areas, is the foundation on which is grafted all forms of discrimination and violence against women. In traditional communities, patriarchal norms that place particularly emphasis on virginity and want that women arrive virgin to the marriage reject therefore any other forms of sexuality outside of marriage. In this context, chastity and virginity of women reflect the family’s honor. Rape and other forms of sexual violence that go against rules that constitute the social conditions of access to sexuality in these communities, expose the victims to the stigma, discrimination and social exclusion.

Fear of contagion to sexually transmissible infections

The victims of rape are perceived like dangerously soiled, to some extent, responsible for what happens to them. They are prejudged guilty. These acts are considered as adultery; expose them to the ostracism from their families and communities. According to the interviewees, stigma and discrimination of victims are accented by: i) the contamination to sexually transmissible infections (STIs), of which the AIDS; ii) the pregnancy resulting from the rape and the birth of a child resulting of a rape. Children who are born from such pregnancies are considered as staining the descendants and are also the subject of stigma. They are often abandoned or sometime killed.

Feelings of shame and culpability of the families and the community

The feeling of shame and humiliation is not limited only to the victims of sexual violence, it also affected the families and the entire community. The men feel guilty of their powerlessness to affront the situation, and think they have lost the protective role of the family and community. The loss of the virginity of young girls involves the loss of the dowry for some parents. These various factors would explain in some cases, the extreme reactions which result in the sigma and the rejection of victims of sexual violence.

The spread of STIs is one of the main consequences of sexual violence [8,12]. It is well-known that the statistics relating to the rape are not always reliable, because the number of rapes is far below the reality [13]. The stigma of sexual violence victims reduce the request of medical care, it is one of the major hurdles to effective answers in favour of the victims. Post-exposure prophylaxis (PEP) [11], may reduce the risk to contract infection to the HIV among exposed women. It must start within 72 hours following sexual assault. The studies conducted in the DRC [10] indicate that the HIV infection contamination increases social exclusion of the victims and that 95% of them did not have access to the prophylactic care within the deadlines. The PEP is epidemiological challenge to massive and systematic sexual violence towards women in the DRC, because they expose the whole communities to the spread of AIDS. Some researchers felt [14] that the armed conflict has a negligible impact on the increase in the prevalence of HIV. Other, however admit that sexual violence in armed conflict, in particular rape used as weapon of war, increase the vulnerability of women to HIV infection. A study [15] evaluating the number of new HIV infection in the countries affected by armed conflicts has shown that under extreme conditions, the mass rapes could annually lead to the infection to HIV of additional 10.000 women and young girls in DRC, this figure could reach 20.000 in Uganda. Another study [16] carried out on database on sexual violence in Africa has shown that sexual violence represent a significant risk of infection to HIV/AIDS. The riskratios have been estimated between 2.4 and 27.1 for the studied situations. The authors of the study shown that the incidence of HIV could increase by 10% if sexual violence is very widespread, and they give three explanations: i) the genital micro-lesions caused by violence constitute the main doors of the viruses; ii) the use of collective rape, very widespread in the DRC [8], iii) the high prevalence of infection with the HIV among the authors of violence. In the DRC, the prevalence of AIDS among soldiers and armed fighters is estimated at 60% [12]. Despite the fact that the DRC is classified among the countries with stable prevalence, the analysis of epidemiological data shows, compared to the prevalence of 4.5% within the Congolese general population [12], a prevalence of 20% among raped women [17] and it passes to 7.6% among internal displaced women [18]. These last were generally victims of violence. In Rwanda, the prevalence of the HIV infection is estimated at 67% among victims of rape during the genocide [19].

Moreover, the stigma and the disapproval lead to isolation and social exclusion of victims; they increase their psychological and emotional suffering. They accentuate the mental disorder generally reported after rape, including depression and post-traumatic stress syndrome [20]. The stigma are also exacerbated by the contamination with STIs, of which the AIDS, gang rapes, a pregnancy and a child resulting from the rape [10]. The same study shows that in DRC, 13% of raped women have a child born from the rape. The sexual violence and their consequences, including the sigma of victims, reduce the capacities of raped women to participate in the development activities, and this therefore increases food insecurity and poverty [21] and increases the vulnerability to sexual exploitation including the HIV infection. This table suggests the need for an effective fight against the stigma. For social change and overcome stigma in various public health problems, the world health organization (WHO) suggests [22] a strategy incorporating the advocacy, communication and social mobilization. It is necessary to change the organization of society and the very rigid social norms which subject women to discrimination and sexual violence [23].

The stigma and the discrimination against victims of sexual violence increase the vulnerability of victims and worsen the consequences of sexual violence. By isolating the victims and by depriving them of medical care and social support, they could promote the silent spread of the AIDS epidemic. Our analysis shows the need for an effective strategy of fight against these factors by: i) an integrated approach encouraging the entire community into Sensitizing, Communication and Social Mobilization (SCMS), with the participation of local and international organizations; ii) ensure the training of medical staff and traditional healers, to detect and take loads the victims; iii) strengthening the capacity and resources of the health system, iv) promote a change in depth in the society through the adoption of healthy social values and the advancement of women.