Aetiology

The aetiology of CRSV is complex and unique to each conflict and circumstance. While the adoption of sexual violence as a military strategy can often be difficult to prove, it appears to have been purposively used on many occasions for tactical gains or as a means to increase influence.4 For example, during military rule in Haiti in the early 1990s, sexual violence was employed to exert political control. Women were raped as punishment for the alleged political activity of their husbands to discourage such activity.5 CRSV has also been used with the aim of ethnic cleansing. In the inter-ethnic war in Bosnia and Herzegovina in the 1990s, Bosnian Muslim women were held in ‘rape camps’ until they were pregnant to ensure they bore children of Serb ethnicity.6

Sexual violence has also been used by military groups to gain influence over their own personnel. In Uganda, some child soldiers forcibly recruited to the Lord’s Resistance Army (LRA) were forced to watch, or commit, acts of sexual violence against others, sometimes their own relatives. It was perceived that their resulting guilt or fear would reduce the risk that they would defect from the LRA. Sex has also been used as a ‘reward’ for soldiers. For example, the Armed Islamic Group fighting in Algeria in the 1990s adopted a strategy of kidnapping local women to force them into short-term ‘pleasure marriages’ with its fighters,7 and the Japanese Imperialist Army imposed longer-term marriages for the ‘comfort women’ captured from their enemies during World War II.8

Sociocultural beliefs may exert an influence on the basis behind CRSV. Some troops involved in the conflict in the Democratic Republic of the Congo (DRC, for example, held the belief that raping a virgin woman would render them invincible.7

Certain cases of CRSV are opportunistic in that perpetrators may take advantage of vulnerable individuals or groups. This occurs on a variety of scales and is illustrated by the widespread reporting of sexual violence in refugee camps1 and in individual cases of victims targeted by local civilians outside of the relative safety of their homesteads.7

Constructs of masculinity may play a role in CRSV. Attributes such as displays of physical strength, demonstrating sexual performance and threatening the roles of other men in protecting women close to them have been postulated as underlying contributors to CRSV.4 9 These theories may be significant when considering that CRSV might be tackled by addressing the gender imbalance in positions of authority, as described below.

History of CRSV

Sexual violence has been a feature of conflict since ancient history.10 There are references to CRSV in the Old Testament and certain ancient Greek narratives openly describe women as the spoils of war.10–12 Subsequent accounts of CRSV are largely unreliable and often based on reports generated by one side accusing their opposition. For example, details of Viking offences arose from English Christian chronicles. One historian highlighted the lack of Western records of CRSV committed by Christian crusaders, whereas it was documented emotively in Muslim writings from the same period. There is more consistent evidence that sexual violence was written into English military policy in the 1400s as a justifiable act of revenge when a city under siege refused to surrender.13

In the modern era, the controversial Bryce Report included 13 accounts of rape committed by German soldiers in World War I.14 During World War II, CRSV was more apparent as a widespread issue in Europe15 and a disturbing tactical policy in the Far East.16 More recently, there is evidence of large-scale CRSV in conflicts in Algeria, Bosnia, Burundi, Colombia, DRC, Haiti and Liberia among others.7

CRSV in the present day

It is suspected that the incidence of CRSV has increased in recent decades, but reporting and data collection measures are impeded by features inherent to many conflicts. These obstacles include dangerous environments, mobile populations and disrupted infrastructure,17 in addition to sociocultural issues such as fear of reprehension, ostracisation or punishment in those reporting CRSV.9

A UN Security Council resolution, released in 2013, mandates that the UN Secretary-General releases an annual report on the scale of CRSV.18 The most recent report (March 2019) details the perpetration of CRSV in Afghanistan, Burundi, the Central African Republic, DRC, Libya, Mali, Myanmar, Nigeria, Somalia, South Sudan, Sudan, the Syrian Arab Republic and Yemen.1 Notably, while the scale of CRSV presented in the report seems vast, these data are only drawn from reports which have been formally verified by the UN.1 While this approach may increase accuracy, it risks omitting conflicts without active UN involvement, such as the Mexican drug war.19 20

The scope and barbarity of CRSV is broad. Within a single setting, victims may be exposed to rape, gang rape, sexual slavery or forced marriage.1 7 Various harrowing insults have been documented, including forced sexual activity with family members or animals, in addition to purposeful genital trauma such as electric currents applied to male genitalia or hot oil poured into women’s vaginas.7 CRSV can occur in the victim’s own home, in farm fields, at checkpoints or places of detention (including in interrogation scenarios), in addition to military or refugee camps.1 7 9

CRSV has been perpetrated against men, women and children, both military and civilian.1 7 9 It is thought that women represent the majority of victims, but there are discrepancies in reporting between men and women, with likely under-reporting in men.1 The majority of CRSV research has, to date, focused on female victims and it is thought that men disproportionately avoid reporting episodes of CRSV against them for fear of displaying weakness or being labelled as a homosexual in countries in which homosexuality carries a legal or social penalty.1 21 The scale of the discrepancy of reporting of CRSV between genders is unknown.

Recent reports suggest that the majority of acts of CRSV are perpetrated by non-state actors,1 but it would be incorrect to assume the culprits solely operate within rebel or terrorist factions. For example, the Human Rights Council compiled a report in 2018 which documented acts of rape and sexual violence committed by state-controlled Myanmar armed forces.22

Rates of sexual violence perpetrated by civilians, such as acts of domestic violence, increase during times of conflict. Underlying theories on the causation of this include increased violent activity related to personal psychological stress or arising from the relative lawlessness within communities resulting from conflict.23 Concerningly, there have also been reports of sexual exploitation and abuse committed by aid workers and UN peacekeepers deployed to protect their eventual victims.7 24

Effects of CRSV

Sexual violence, as a highly intimate violation of a victim’s human rights, can have profound physical, psychological and social sequelae. Genital trauma can cause bleeding, abrasions, fissures, fistulae or organ perforation which may lead to chronic pelvic pain, pelvic organ dysfunction (including infertility or incontinence) or death. Rape may lead to pregnancy (with all associated complications) and the transmission of sexually transmitted infections.25 The psychological trauma caused by sexual violence may lead to post-traumatic stress disorder.26 Victims of sexual violence may be ostracised from their community as adulterers or may be punished or killed by their own relatives for an insult on their family’s ‘honour’.7 25 Children conceived via rape may become victims of infanticide or neglect, or face exclusion from their communities.⁷

Prevention of CRSV

In 2000, the UN Security Council issued a resolution based on the protection of women and girls at times of conflict. Relating to sexual violence, they called on all parties involved in armed conflict to protect women and girls from gender-based violence while emphasising the responsibility of established states towards achieving this. Unfortunately, the practical response to this resolution was limited. Large-scale CRSV atrocities continued to occur, including widespread rape in the DRC conflict in 2005.27 Further resolutions followed, including UN Resolution 1820 which declared that CRSV constituted a war crime.28

In 2012, Lord William Hague, as former UK foreign secretary, and Angelina Jolie, as UN Special Envoy of the High Commissioner for refugees, founded the Preventing Sexual Violence in Conflict Initiative. Since formation, this initiative has overseen the training of 17 000 military and police personnel on sexual violence issues and has deployed a UK-based team of specialists, including lawyers and social workers, to regions affected by CRSV on multiple occasions.29

In 2013, members of the G8 summit declared that they recognised the need to bolster the UN’s efforts against CRSV and committed their support to this cause.2 Further political collaboration followed in 2014, when London hosted The Global Summit to End Sexual Violence in Conflict. The members of the summit called for better recording of CRSV and launched a tool (the International Protocol on the Documentation and Investigation of Sexual Violence in Conflict) designed to assist both governmental and non-governmental organisations.30 The UN Security Council since has continued to actively investigate and condemn CRSV. Notably, the UN Secretary General has announced special measures and strict sanctions against any UN personnel committing acts of sexual violence.1

The UN and the other political bodies describe the need to establish a gender balance when assigning individuals to key roles countries dealing with CRSV.2 29–31 These roles reside in the political, security and judicial sector, in electoral preparation and in wider post-conflict reconstruction. Such a gender balance may improve representation of victims of CRSV and provide them with approachable sources of assistance. In addition, it could counteract prevailing masculinity in positions of authority, which may curb CRSV related to the constructs of masculinity described above.9 21 Interestingly, similar approaches have been previously been instated on a local basis, without external political intervention, in the emergence of women’s political movements in response to CRSV in Colombia and Myanmar.32 33

There are some barriers to legal action against those responsible for CRSV. First, international variation exists on the legal definitions of different forms of sexual violence and on the burden of proof required for a conviction. For example, legislation in some countries recognises rape, but not other forms of sexual violence, as an offence. In other cases, charges of rape may be dropped if the perpetrator subsequently marries their victim.7 34 Second, judicial systems may be heavily impeded by the breakdown in infrastructure in addition to the shortage of expertise and resources in the post-conflict period. Finally, victims may be excluded from, or attacked by, their own communities for testifying.7 Despite these obstacles, progress has been made in legal action against CRSV and barriers have been broken with each landmark case. Between 1998 and 2001, international criminal tribunals in former Yugoslavia and in Rwanda achieved the first convictions for rape and other forms of sexual violence as war crimes.7 The International Criminal Court (ICC), established in 2002, has a mandate to try criminals under crimes of international concern, including CRSV. It considers that both perpetrators and, importantly, their military commanders can be held accountable for acts of sexual violence in conflict. In 2016, the ICC passed its first conviction against an individual, Jean-Pierre Bemba Gombo of the DRC, for acts of CRSV committed by soldiers under his charge. Bemba has since been acquitted of this conviction following an appeal.35 More recently, there have been calls for international tribunals against members of Islamic State for perpetrating acts of CRSV against Yazidi women and girls.36

The judicial response to CRSV is evolving, with further work into unchartered territories with each case brought to trial. Legal action for CRSV perpetrated against Yazidi women may represent an opportunity for further progress in applying international law to CRSV.

Care of victims

The level of care provided for victims of CRSV has varied widely, from minimal support to examples of comprehensive, holistic treatment at a single point of access. The WHO has published guidelines for the medicolegal care for victims of sexual violence and emphasises the importance of ready access to forensic testing, medical care, psychological treatment, legal services and social support, ideally with treatment or referral achieved through a single point.37 One example of holistic care provision is that provided by the Panzi hospital in DRC, which has treated more than 48 000 survivors of sexual violence to date. As a single centre, it has provided medical care (including post-exposure HIV prophylaxis), gynaecological surgery, psychiatric treatment, social care, financial aid and legal assistance in addition to referral to places of safety. Its founder, Denis Mukwege, was recently awarded the Nobel Peace Prize for his work.38

The action taken by the Truth and Reconciliation Council (TRC) of Sierra Leone, created to address human rights abuses following the civil war in the 1990s, is also an example of addressing barriers to the provision of care and justice for victims. The TRC recognised the preceding harm and ongoing threat to victims of CRSV and provided them with medical assistance, independent female interviewers and transport to and from closed hearing venues to allow them to safely deliver statements for use in court.7

Formal evaluations of CRSV survivor programmes are sparse. Difficulties in consistent research design and ethical complications have been cited as potential barriers to such investigation.39 Overall, despite certain examples of provision of comprehensive care for victims of CRSV, research on best practice in CRSV management is lacking.

The future

A multifaceted approach is required to address the complex widespread issue of CRSV. First, a greater understanding of the true current scale of the issue is required. Investigation should be thorough, using consistent definitions for the various forms of sexual violence.40 Second, political declarations should be followed with corresponding tangible action to prevent and manage CRSV.1 24 41 Finally, continuous evaluation of such actions is required to determine which approaches are effective and suitable for future use.39

Implications for DMS personnel

DMS personnel should maintain an awareness of the prevalence of CRSV in addition to an understanding of current political efforts to tackle the issue. As they may encounter CRSV in their operational roles, whether in conflict or humanitarian activities, they should be able to recognise the sequelae and know the best course of action for management in each circumstance. To date, no UK Defence guidance exists to support this. Clinical recognition and individual management of CRSV is outside the scope of this paper, as each case and operational circumstance are unique. However, it is noted that operational medical planning and pre-deployment training should incorporate the potential for encountering CRSV and those in clinical roles must be supported to manage CRSV. If adequately prepared and equipped, DMS personnel have the potential to provide steadfast assistance in harrowing times for victims of CRSV in delivering medical, psychological or logistical support.