Summary of the Paper

Authors: G.M. Mugisho, R. Maroyi, S.Nabami, C. Kasherwa, A. Bitenga, D. Mukwege

The quality-of-care assessment is an important indicator of the efficiency of a healthcare system. In the Democratic Republic of the Congo (DRC), despite the implementation of the holistic care model for the treatment of sexual and gender-based violence (SGBV) victims, little is known about the client’s perception of this model and its outcome. This study aimed to examine the expected and perceived satisfaction of service recipients through the OneStop-Center model of health care in eastern DRC.

This descriptive and analytical cross-sectional study was conducted at Panzi Hospital (PH), in eastern DRC. Data were collected by a mixed-methods approach, 64 Victims of Sexual Violence participated in individual (in-depth) interviews and 150 completed the Survey. The Kruskal–Wallis test was used to compare the mean item scores of sexual violence victims’ satisfaction.

Summary of the Paper

One-Stop Centre (OSC) was developed after years of treating girls and women who had been raped and suffered severe bodily harm. Victims of sexual violence received only medical care from 1999 to 2003. Psychological care was added to medical care in 2004. Legal and socioeconomic assistance were added to the OSC model in 2008. Patients come from all over the city of Bukavu in the South Kivu province, and elsewhere in DRC. During their stay, they receive holistic care in the OSC by benefiting from a complete package through four pillars: medical, psychological, legal, and socio-economic reintegration.

The Panzi OSC model provides more than just holistic individual care; it also serves as a platform for achieving healthy living at the micro, meso, and macro levels, thereby facilitating the realisation of the right to health for all. On arrival, they are eager to recover from their physical, psychological, and from economic conditions, and regain their human dignity. From their admission, they are treated and accompanied by a multidisciplinary team of medical, psychosocial, legal, and socio-economic specialists.

Summary of the Paper

The findings from this qualitative analysis demonstrated that the victims admitted at PH had various expectations and needs on arrival depending on their social identity and residence locations. For instance, the VSVs coming from remote areas with ongoing armed conflicts mentioned concerns related to their security in the post-treatment period and the risks of re-victimization that this could incur. Conversely, those who came from the urban neighborhood, with relative security raised various concerns related to their legal reparation and ongoing access to other support services.

The Kruskal–Wallis analysis confirmed statistically significant differences (p < 0.1) in satisfaction with legal support based on the victims’ residential locations, social support based on their age groups, occupational therapy based on their religious denominations, and accommodation based on their professional activity.

Results

• More than 80% of victims treated at Panzi Hospital are satisfied with the variety of care provided in each pillar.
• There was a statistically significant difference in legal support based on the victims’ ranked means of origin. Victims from Bukavu reported an average level of satisfaction of 51%, followed by those from outside South Kivu at 50.68% and those from rural South Kivu at 39.5%.
• Victims aged 45 and over were 93% satisfied, while victims aged 25–34 were 64% satisfied.
• Victims aged 25–44 reported that the rape had severely harmed their social lives, to the point where they had lost trust and confidence in their surroundings. They desired for total rehabilitation through the treatment they received at Panzi and hoped that PH could continue to support them mentally and financially for an effective reintegration into their communities.

Research Recommendations

Patients from neighboring provinces have reported that it is difficult for them to get to Panzi in order to receive quality holistic care. PH must also include rehabilitation and support for family members and/or the community.

The results of this study showed that the services provided by PH met the expectations of the victims. Although victims admitted to PH had varying expectations and needs based on their social identity and residence locations, they all expected physical and psychological restoration as well as socioeconomic reintegration and legal assistance.

Christian women (Protestants and Catholics) are more satisfied with ergotherapy than women of other religious communities. Students and farmers were delighted with the accommodation’s possibilities offered by PH. They wished to continue being supported to escape their misery after discharge. Therefore, additional efforts should be made to improve the quality of care according to this holistic model. It is essential to assess the level of beneficiary satisfaction using psychological satisfaction scales (e.g., the Life Satisfaction Scale developed by American psychologist Ed Diener) and participatory methods and techniques to ensure that Panzi’s actions achieve the desired results.

Summary of the Paper

Authors: Denis Mukwege and Cathy Nangini

A 2009 paper published in PLOS Medicine studied all patients admitted to Panzi Hospital between 1999 and 2006. Of the 9,778 patients, 7,519 (76.9%) were rape survivors.

This research finds that in eastern DRC, the destructive and sadistic behaviour systematically perpetrated by different armed groups between 1999 and 2009 signals a new pathology classified as rape with extreme violence (REV). The Panzi Hospital in Bukavu, South Kivu, is one of the few established medical centers that has the capacity to treat REV cases.

Research Recommendations

1. Ensure that leaders in the eastern DRC and neighboring regions take responsibility and act to end the atrocities in DRC.

2. Help create and train a national army and police force that is ready and able to protect civilians.

3. Develop a mechanism for the traceability of minerals as a way forward for ultimately reducing the reliance of armed groups on DRC’s resources.

4. Address impunity for sexual violence in the International Criminal Court (ICC) and the current national courts, including the period before the creation of the ICC.

5. Assist all organizations that provide psychological, medical, legal, and social care to REV survivors

Summary of the Paper

Authors: S. A. Bartels, J. A. Scott, D. Mukwege et al.

Using a non-systematic convenience sample, interviews were conducted with sexual violence survivors as they presented to the hospital in 2006.

A total of 1,021 records were reviewed from sexual violence survivors who received care in 2006 under Panzi Hospital’s Victims of Sexual Violence Program.

Summary of the Paper

Among sexual violence survivors presenting to Panzi Hospital in 2006, the majority of attacks occurred in women’s own homes, often at night. This represents a pattern of violence that differs from other conflict settings and has important implications regarding protection strategies. Sexual violence in South Kivu was also marked with a predominance of gang rape, thus increasing the risk of serious injury as well as the likelihood of an individual woman contracting a sexually transmitted infection (STI). Sexual slavery was noted to be more common among young, single women and was found to have a high rate of resultant pregnancy.

Research Recommendations

The UN and other humanitarian organizations implementing protection programs in eastern DRC should consider strategizing with local women and community leaders to devise new protection protocols specific to the attack patterns within the region.

That the next generation of young Congolese women is being specifically affected by sexual slavery and its resultant pregnancies, may have important economic and societal implications since the experience likely challenges the ability of these women to become professional and community leaders, and thus limits their opportunity to advance the status of women in Eastern DRC.

Summary of the Paper

Authors: D. Mukwege and M. Berg

Between 1999 to 2015, Panzi Hospital treated 48,482 following extreme sexual violence.

37,382 women received treatment for gynaecological problems after complicated childbirth or poor medical treatment, of which many were the results of rape.

1.5% of patients were men.

Summary of the Paper

The One Stop Centre at Panzi Hospital in eastern Democratic Republic of Congo has been developed after years of treating girls and women who have been raped in combination with extreme bodily harm.

OSC comprises four pillars, covering medical, psychosocial, legal, and socioeconomic care needs, which are fulfilled in partnership. Based on genuine listening to a harmed girl’s or woman’s personal narrative, personalised care is planned, implemented, and documented with the aim of achieving health and reintegration in society.

OSC gives more than holistic individual care; it provides a platform for achieving a healthy life at the micro- (the person) and meso- (local society) levels and, if conscientiously and systematically implemented in all health care structures, facilitates achievement of the right to health for all on the macro (national) level.

Research Recommendations

The OSC care approach should be conscientiously and systematically implemented in all health care structures, it is a strong tool to achieve the right to health for all, even in a country that lacks a health care organisation of adequate quality.

Challenges to the OSC model:

1. acceptance and integration of mental health into the primary health care system
2. lack of political will, which delays the replication of the OSC model
3. the need for ongoing evaluations by staff on structures and protocols used, followed by revisions

Summary of the Paper

Authors: S. Bartels, J. Scott, J. Leaning, D. Mukwege, R. Lipton, and M. VanRooyen

The current work is a retrospective chart review of women presenting to Panzi Hospital in 2006 requesting post-sexual violence care. The goals were to describe the demographics of sexual violence survivors and to define the physical and psychosocial consequences of sexual violence in Eastern DRC.

Summary of the Paper

The mean age of presentation to Panzi Hospital was 36 years with an age range of 3.5 years to 80 years. 90% of survivors are either illiterate or had up to primary education.

The mean time span between the incident and presentation to Panzi Hospital was 16 months, and the median was 11 months.

Ailments reported were: pelvic pain (22% of women), lumbar pain (11%), abdominal pain (7%), and pregnancy (6%).
36% of women were also concerned about STIs and health, and 6% reported abandonment by husbands and this was more common after gang rape.

Research Recommendations

Treatment programs for survivors of sexual violence must specifically address the economic hardships faced by victims. Programs must meet their time-sensitive medical needs and must provide them with psychological care.

Summary of the Paper

Authors: J. T. Kelly, T. S. Betancourt, D. Mukwege

Surveyed a non-random sample of 255 women attending a referral hospital and two local non-governmental organizations to characterize their experiences of sexual and gender-based violence (SGBV). The authors conducted focus groups of 48 women survivors of SGBV to elaborate on survey findings. Quantitative and qualitative data underwent thematic and statistical analysis respectively.

Summary of the Paper

Of the women surveyed, 193 (75.7%) experienced rape. Twenty-nine percent of raped women were rejected by their families and 6% by their communities. Thirteen percent of women had a child from rape.

Widowhood, husband abandonment, gang rape, and having a child from rape were significant risk factors for social rejection. Mixed methods findings show rape survivors were seen as “contaminated” with HIV, contributing to their isolation and over 95% could not access prophylactic care in time. Receiving support from their husbands after rape was protective against survivors’ feelings of shame and social isolation.

Research Recommendations

Rape results not only in physical and psychological trauma, but can destroy family and community structures. Women face significant obstacles in seeking services after rape. Interventions offering long-term solutions for hyper-vulnerable women are vital, but lacking; reintegration programs on SGBV for women, men, and communities are also needed.

More work is needed to understand the risk factors that make a husband likely to abandon his wife after rape; to identify possible intervention points; and to elaborate the effects of rape on a woman’s livelihood and future.
More work needs to be done to understand how economic interventions, for both women and men, can facilitate social reintegration for vulnerable populations and facilitate community-level post-conflict recovery.

Summary of the Paper

Authors: S. Bartels , J. Scott , J. Leaning , J. Kelly , D. Mukwege , N. Joyce & M. VanRooyen

This study was a retrospective, descriptive, registry-based evaluation of sexual violence survivors presenting to Panzi Hospital between 2004 and 2008.

This study aimed to: (1) investigate overall frequency in number of Eastern DRC sexual assaults from 2004 to 2008 inclusive; (2) determine if peaks in sexual violence coincide with known military campaigns in Eastern DRC; and (3) study the types of violence and types of perpetrators as a function of time.

Summary of the Paper

Throughout the five-year study period, the highest number of reported sexual assaults occurred in 2004, with a steady decrease in the total number of incidents reported at Panzi Hospital from 2004 through 2008. The highest peak of reported sexual assaults coincided with a known militant attack on the city of Bukavu. A smaller sexual violence peak in April 2004 coincided with a known military clash near Bukavu

Over the five-year period, the number of sexual assaults reportedly perpetrated by armed combatants decreased by 77% (p = 0.086) and the number of assaults reportedly perpetrated by non-specified perpetrators decreased by 92% (p < 0.0001). At the same time, according to the hospital registry, the number of sexual assaults reportedly perpetrated by civilians increased 17-fold (p < 0.0001).

This study was limited by its retrospective nature, by the inherent selection bias of studying only survivors presenting to Panzi Hospital, and by the use of a convenience sample within Panzi Hospital.

Research Recommendations

After years of military rape in South Kivu Province, civilian adoption of sexual violence may be a growing phenomenon. The social mechanisms that prevent sexual violence will have to be rebuilt and sexual violence laws will have to be fully enforced to bring all perpetrators to justice. Proper rehabilitation and reintegration of ex-combatants may also be an important step towards reducing civilian rape in Eastern DRC.

Summary of the Paper

Authors: S. Bartels , J. Scott , J. Leaning , J. Kelly , D. Mukwege , N. Joyce & M. VanRooyen

This study was a retrospective, descriptive, registry-based evaluation of sexual violence survivors presenting to Panzi Hospital between 2004 and 2008.

Trained female health care providers privately interviewed women who presented to hospital requesting postsexual assault services between 2004 and 2008.

Summary of the Paper

This analysis revealed that the majority of sexual assaults are perpetrated by armed combatants and that armed combatants and civilians perpetrate distinctly different types of assaults. One striking feature of rape in South Kivu is the high prevalence of gang rape, which was reported by almost 60% of all sexual violence survivors presenting to Panzi Hospital. Armed combatants were responsible for most of the gang rape with only 1% of such rapes reportedly committed by civilians. The majority of attacks described in this dataset occurred in the woman’s own home, often at night and usually perpetrated by armed combatants.

This information is critical for the development and implementation of successful protection programs. The shame and humiliation inflicted by these crimes is intended to prohibit recovery and reintegration into society, and to thereby destroy the victims’ families and communities.

Research Recommendations

Protection of women in South Kivu will require new strategies that take into account the unique nature of sexual violence in DRC. Engaging with local communities, the UN and other aid organizations is necessary to create new context-appropriate protection programs.

Summary of the Paper

Authors: B. Nelson, L. Collins, D. Mukwege , N. Joyce, S. Bartels & M. VanRooyen

Semi-structured questionnaires were administered among a convenience sample of women <18 years of age presenting for post-sexual-violence care at Panzi Hospital in South Kivu, DRC. Analysis included quantitative and qualitative methods to describe the characteristics of the violence, perpetrators, and survivors and to illuminate common themes within the narratives. A total of 389 survivors of Sexual Gender Based Violence under the age of 18 were interviewed between 2004 and 2008.

Summary of the Paper

There were several differences, with respect to attack characteristics, between the paediatric and adult populations that presented to Panzi Hospital during the study period. The most notable of these differences related to the types of violence and the types of perpetrators. The odds of rape Not Otherwise Specified among children were 5.6 times greater than the odds of rape NOS among adult survivors. In contrast, the odds of gang rape among paediatric survivors were 0.14 times the odds among adult survivors. Furthermore, the odds among paediatric survivors for being attacked by a civilian were 92.6 times greater than the odds of civilian attacks among adult survivors.

There was a 39-fold increase in reports of civilian-perpetrated sexual assault and a 70% decrease in reports of armed combatant perpetrated sexual assault. Additionally, there was a six-fold increase in reported incidents of rape NOS and a 28.5% decrease in reported incidents of gang rape.

Research Recommendations

The predominant pattern of sexual violence perpetrated against children in Eastern DRC has important implications for child protection. Even if all militias in Eastern DRC were de-armed and demobilized, girls would continue to face significant risk of sexual violence perpetrated by their fellow civilians and by persons in positions of authority within the community. To address this, the environment of impunity must end and sexual violence laws must be enforced with a zero tolerance policy.

Although DRC actually boasts one of the most robust sexual violence laws in sub-Saharan Africa, those laws remain poorly enforced. In Eastern DRC, those responsible for upholding the law, such as police, magistrates, judges and lawyers, are few in number, poorly paid and overwhelmingly male. Measures to address these deficits should include incorporation of trained female personnel into the judicial system, mass dissemination of the law and systematic training for all judicial officials.

Summary of the Paper

Authors: M. Onsrud, S. Sjoveian. R. Luhiriri, D. Mukwege

A retrospective analysis of hospital records from 604 consecutive patients who received treatment for gynecologic fistulas at Panzi Hospital between November 2005 and November 2007.

The purpose of this research was to determine the magnitude of traumatic gynecologic fistulas caused by sexual violence in the Democratic Republic of Congo.

Summary of the Paper

24 (4%) reported that their fistulas had been caused by sexual violence; of these, 5 (0.8%) had developed fistulas as a direct result of forced penetration with foreign objects and/or gang rapes.
6 had a fistula before they were raped, 9 developed iatrogenic fistulas following inappropriate instrumentation to manage rape-induced spontaneous abortion or stillbirth, or after abdominal hysterectomy, and 4 developed fistulas after prolonged and obstructed labor.

Research Recommendations

Traumatic fistulas are rare compared to obstetric fistulas. Fistulas indirectly related to sexual violence are likely to be more common than those directly related. All fistulas resulting from sexual violence, whether direct or indirect, should be considered traumatic and special care should be given to these women.

Summary of the Paper

Authors: J. Bress, G. Kashemwa, C. Amisi, J. Armas, C. McWhorter, T. Ruel, A.J Ammann. D. Mukwege & L.M Butle

To overcome the barriers to providing a constant inventory of post-rape care medications to survivors of sexual violence within 72 hours, Global Strategies and Panzi Hospital implemented the Prevention Pack Program. The Prevention Pack Program combines community sensitisation, provision of a pre-packaged post-rape medical kit, and a cloud-based and GPS-enabled inventory management system.

Delivery

Between 2013 and 2017, we provided 2081 post-rape medical kits to survivors of sexual violence at 13 sites in the South Kivu Province of the DRC.

Between 2013 and 2017, a total of 8206 individuals presented for care following rape at the study sites. Of the 1414 individuals who presented in the rural areas, 1211 (85.6%) did so within the first 72 hours of reported rape

Program Recommendations

The Prevention Pack Program can improve delivery of immediate post-rape medical care in remote conflict settings by addressing inventory challenges and creating a map of demand for post-rape care across wide geographies.

Summary of the Paper

Authors: D. Mukwege, O.M. Ahmed, J.R. Fitchett

The Democratic Republic of the Congo (DRC) is tremendously wealthy. Abundant in gold, diamonds, tantalum, tin, copper, zinc and cobalt, the natural resources in Africa’s third largest country are not equally benefiting the people. The DRC should sustainably be making use of their natural resources to develop the country, whose health, education and transport systems all suffer to this day from the effects of conflict. Instead, the DRC is divided with rebels, corrupt governments and foreign investors all fighting in one way or another for control over the country’s wealth. The following article focuses on the emergence of rape as a strategy of war in the DRC.

Summary of the Paper

The impact of rape in war in the DRC in this context is identical to conventional war. Displacement of the population occurs, leaving rebels in control of the attacked villages. Militia rape and torture repeatedly, often in public and with relatives, humiliating the victim and their family. Community members feel insecure, vulnerable and socially excluded, exacerbated by the militia vandalising, burning and terrorising the villages. The population in these areas subsequently reduces. Destruction of reproductive organs leads to the inability to reproduce.

A further impact of rape as a strategy of war is the destruction of the economic infrastructure. Militia burn private property and villages, rob or burn harvest, plunder natural resources and drive communities into extreme poverty. Destruction of the social fabric, by public rape and torture, children born to rape victims, loss of community identity and social coherence ultimately leads to an organisational failure and further occupation of territory.

Research Recommendations

Immediate assistance can be offered in the form of curative treatment and access to healthcare to the victims of sexual violence. Fighting for justice and for the deterrence of the attackers must play a pivotal role in redressing the issue.

Prevention requires the input from a wide variety of sectors, but most importantly depends on lasting peace in the Great Lakes region of eastern Africa. We need to strengthen the underlying determinants of health and ensure tangible political stability to lay the foundations for social reconstruction, economic development, and the health, education and transport systems. A stable and developing DRC is key to Africa’s long-term future.

Summary of the Paper

Authors: S. Bartels, J. Scott, J. Kelly, N. Joyce, D. Mukwege & M. VanRooyen

In the DRC sexual violence is used systematically to destroy communities and to
extinguish the personal dignity of its survivors. This study aimed to describe the
psychosocial consequences of sexual violence within this context.

This was a retrospective registry-based study using a nonsystematic convenience sample. Female sexual violence survivors were interviewed as they presented to Panzi Hospital requesting post-sexual assault care. The interviews were conducted in private by trained female personnel. The semi-structured interview, based on a two-page questionnaire, allowed the patient to describe her sexual violence experience in an open, self-reporting narrative. A total of 4,311 records were reviewed.

Summary of the Paper

Material losses were common in this study, including cash, food, clothing, and livestock. The loss of personal valuables or the family home would be devastating in any circumstance, but is particularly acute in Eastern DRC where many families live in precarious situations. The potential for lost income after rape-related injury or the potential loss of the male head of household amplifies the magnitude of the resource extraction.

Survivors also reported the deaths of children and/or husbands at the time they were sexually assaulted, causing immense emotional distress. Spousal abandonment left women vulnerable to poverty, as Congolese policy and socio-cultural customs continue to discriminate against women. Sexual violence programs must focus on the family as a whole, including support services for the spouses of women who have been raped.

Conclusions

To confound the personal psychological and physical trauma that women face after experiencing sexual violence, many women lose their personal belongings and the families’ valuables in the attack and are left to grieve the deaths of their spouses, children and other family members who were killed during the assault.

Furthermore, women are sometimes abandoned by their spouses and/or become pregnant as a result of the sexual assault, and both of these sequelae were particularly distressing to survivors. In addition to providing timely medical care, it is critical that aid programs address the psychosocial needs of sexual assault survivors. The approach to survivor care must also involve men at all stages, allowing families and communities to recover together as a unit.

Summary of the Paper

Authors: G.B Kimoni, R. Martin, D. Mukwege, S.N Ntamwenge, C. Kerchove & A. Goelz

The study is qualitative analysis of those affected over 10 days. The study population consisted of 61 survivors of sexual violence including adolescents aged 10 to 19 and females aged 20 to 40. 6 adolescent girls and 55 young women survivors receiving psychosocial follow-up were part of the study. Information was collected using 4 focus groups conducted at two sites in the South Kivu region (Kavumu and Bunyakiri). Discussions were transcribed into a composition book and analyzed according to context.

Summary of the Paper

This study analyzes sexual and reproductive health issues among survivors of sexual violence in conflict settings in the DRC. Methods to avoid pregnancy are generally unknown in the adolescent cohort. The girls were unaware of the consequences of unprotected sex, or HIV and AIDS. The more mature women, for their part, unanimously refute the practice of voluntary termination of pregnancy. They are aware of the efficacy of contraception though it is not in common use. Early marriage is not condoned by them.

Research Recommendations

In light of this work, there is a need for more effective and comprehensive sexual education programs that integrate reproductive health issues for survivors of sexual violence. The approach must be inclusive and take into account socio-cultural values.

The psychosocial impact of conflict-related sexual violence can provide insight into how the experience of such an act may affect survivor perceptions of sexual and reproductive health.

Summary of the Paper

Authors: A.B Alexandre, K.M Mutondo, J.B Balegamire & D. Mukwege

Thirty interviews were conducted: twenty with ex-combatants and ten with soldiers currently serving in the Congolese regular army FARDC. Respondents had to: (1) have directly or indirectly witnessed sexual violence in armed conflicts in any part of the DRC and (2) have served as a combatant either in the Congolese regular army or in an armed group.

This paper sets out to explore sexual violence in armed conflict from the perspective of the combatants themselves. Combatants report that they want to protect women and men in armed conflicts, but the contexts in which they operate lead them, contrary to their wishes, to behave violently against the civilians they are supposed to protect.

Summary of the Paper

Despite ideals of good soldiering and prohibition of rape in armed groups, sexual violence occurs frequently in armed conflicts in eastern DRC. Respondents provided biological and socioeconomic justifications as the main hindrances preventing them from achieving their ideals of good soldiering. Men’s sexual desire was viewed as having natural driving forces which requires satisfaction from women. Such a perception of masculinity is linked to the idea that combatants need regular leave, money or regular access to prostitutes or comfort women (Enloe 2000). However, this biological rationalization of rape in armed conflicts has been challenged by some scholars as widespread sexual violence still occurs in some conflict settings where combatants have ample access to sex and prostitutes (Wood 2014).

A weapon is nothing but a tool designed to inflict harm or damage, and sexual violence has done so devastatingly in eastern DRC whether ordered or not. It leads to mass displacement, physical and psychological damage, family separation and socio-economic deterioration, affecting victims and communities in a multidimensional manner which could arguably qualify it as a ‘weapon of mass destruction’ in some contexts in eastern DRC.

Summary of the Paper

Although respondents in this study strongly believe that sexual violence is a serious crime and an immoral act which should be avoided in their ranks, they sometimes perpetrate it systematically, suggesting a disconnect between their good soldiering ideals and own actions. Combatants report that they want to protect women and men in armed conflicts, but the contexts in which they operate lead them, contrary to their wishes, to behave violently against the civilians they are supposed to protect. To mitigate sexual violence in armed conflicts they propose improving their socioeconomic conditions, getting rid of militias and uniting the Congolese army, punishing perpetrators and adequately training new soldiers joining the united army.

Research Recommendations

International discourse on sexual violence in DRC continually focuses on the singular events of brutal, militarized rapes, resulting in an incomplete picture of the situation and thus creating a maladapted humanitarian response. Hyper-visibility is granted to particular narratives of brutal rape while other acts of violence such as killings, domestic violence, structural violence, poverty, gender inequality, corruption, deterioration of the health sector and state failure remain unaddressed (Mertens 2019). Although not exhaustive, the suggestions offered by combatants to end sexual violence in armed conflicts show that complex solutions are needed to prevent and respond to complex factors underlying sexual violence in armed conflicts and change will not occur by dealing with victims alone. As sexual violence in armed conflicts is gendered, anti-sexual violence initiatives should develop more integrative approaches that involve both men and women in the fight and prevention of this form of violence.

Summary of the Paper

Authors: Harvard Humanitarian Initiative; S. Bartels, M. VanRooyen, J. Leaning, J. Scott, & J. Kelly

With the support of Oxfam America and in collaboration with medical staff at Panzi Hospital, researchers from the Harvard Humanitarian Initiative (HHI) performed a retrospective cohort study of sexual violence survivors presenting to Panzi Hospital with a specific aim of answering the following outstanding questions: 1) When, where and how are women being attacked and what makes them vulnerable to sexual violence; and 2) How has the rape epidemic in South Kivu evolved over the last five years?

This was a retrospective cohort study conducted at Panzi Hospital in Bukavu. Using a non-systematic convenience sample, interviews were conducted on sexual violence survivors as they presented to Panzi Hospital requesting services from the Victims of Sexual Violence Program. The hospital’s questionnaire asked basic demographic information and then allowed the patient to describe her sexual violence experience in an open, self-reporting narrative. A total of 4,311 records, representing all post-rape interviews conducted at Panzi Hospital between 2004 and 2008, were reviewed and the relevant information extracted for quantitative and qualitative analysis.

Summary of the Paper

In South Kivu, women are subjected to sexual violence regardless of age, marital status or
ethnicity. The majority of rape survivors are illiterate and rely on subsistence farming to support
their families. Most rape survivors wait extended periods of time before accessing medical care
and many arrive at Panzi hospital alone, without the support of family or friends.
Women in South Kivu are not safe anywhere; they are attacked not only while they farm their
fields or collect firewood in the forest but also in the supposed safety of their own homes, often
while sleeping at night with their families. Just over half of all perpetrators (52%) were identified
as being armed combatants. Although another 42% were identified only as “assailants”, analysis
of the patterns of violence, strongly suggests that this group is also comprised largely of armed
combatants. Thus, the sexual violence in South Kivu is largely militarized.

Summary of the Paper

Military rape in South Kivu is marked with a predominance of gang rape, which was described by almost 60% of sexual violence survivors presenting to Panzi Hospital. Sexual slavery was also common with some women being held captive for several years. Sexual slavery more frequently involved young, single women. The sexual assaults are also remarkable for extraordinary brutality including genital mutilation, instrumentation with foreign objects, forced rape between victims and rape in the presence of family members. There are also horrific reports of young children being slaughtered in front of their parents and of family members being tortured and killed. The military pattern of rape was also notable for a preponderance of pillaging with many survivors reporting the loss of cash, food, livestock, clothing and other valuables. Likewise, there were many descriptions of armed combatants demanding ransom in exchange for the victim’s release from sexual slavery.

Research Recommendations

To address this new wave of civilian perpetrated sexual violence, the environment of impunity in DRC must end. Congolese sexual violence laws must be fully enforced and perpetrators must be held responsible. In parallel with upholding accountability, the mindset of an entire society will have to be reset to recognize rape as a morally unacceptable and criminal act.

Meanwhile, sexual violence survivors require urgent support including medical services, psychological counseling and social assistance. The approach to survivor care must involve men at all stages, allowing families to recover together as a unit. In addition to assisting child survivors of sexual violence and children born out of rape, assistance must also be provided to all children who have been indirectly affected by sexual violence. With appropriate interventions, there exists an enormous opportunity to ameliorate the trauma and distress caused to the next generation in South Kivu.

Summary of the Paper

Authors: J. Cikuru, A. Bitenga, J. Balegamire, P. Salama, M. Hood, B. Mukherjee, A. Mukwege & S. Harlow.

This study assessed whether Healing in Harmony (HiH), a form of music therapy, improved women’s mental health following conflict-related trauma and sexual violence in the Democratic Republic of Congo.

This study used a step-wedged design and included 167 women, who completed up to two pre-tests, a post-test, and up to two follow-up interviews at 3 and 6 months after completing the program. The Hopkins Symptoms Checklist was used to measure anxiety and depression. The Harvard Trauma Questionnaire was used to measure post-traumatic stress disorder (PTSD). Generalized estimating equations with unstructured covariance were used to estimate mean change in mental health scores and relative risks (RRs) for screening positive.

Summary of the Paper

In 2015, Make Music Matter partnered with Panzi to incorporate an innovative music therapy program, Healing in Harmony (HiH), into their holistic healing model (Make Music Matter, 2020). Music therapy, that pairs therapy with lyrical music training has been shown to be effective at reducing anxiety, depression, and PTSD. Music stimulates areas of the brain involved in traumatic memory and sensory-emotional processing. As music and trauma are both sensory mediated, music can also provide an alternate means of accessing severe past trauma and facilitate processing of these experiences and expression of related emotions.

HiH provides music therapy to survivors of sexual violence and violence-related trauma. Working with a trained therapist and professional music producer, participants begin the healing process by writing, recording, and professionally producing songs about their emotions and experiences, simultaneously engaging in therapy and developing their own musical artistry. The therapeutic approach, based on CBT aims through group-therapy and lyrical music to help participants verbalize their trauma and initiate the assessment and cognitive stages of the healing process.

Results

Prior to starting the HiH program, 73.9, 84.2, and 68.5% screened positive with median scores being 2.20, 2.70, and 2.06 for depression, anxiety, and PTSD, respectively. The RR for screening positive declined significantly (RR = 0.49 for depression, 0.61 for anxiety, and 0.54 for PTSD) and mean scores declined significantly by −0.54, −0.67, and −0.53 points, respectively, from the pre- to the post-test, declines that were sustained at the 3-month and 6-month follow-up interviews.

Prior to participation in the program, survivors were half as likely to report feeling happy or proud of themselves compared to women who had not experienced sexual violence. However, participation in the program more than doubled the probability of happiness in survivors compared to a 32% increase in other women. 

The probability of reporting being proud of oneself also increased over 250% for survivors post-treatment compared to a 71% increase in other women.

The HiH program was associated with significant improvement in women’s mental health that was sustained up to 6 months post completion of the program despite instability in the region and evidence of continued experience of conflict-related trauma during the study. These data support the value of providing psychological care in the context of ongoing humanitarian crises.

Research Conclusions

Participation in the HiH music therapy program had a positive impact on women’s mental health, with improvements observed in the prevalence of PTSD, anxiety, and depression. Women’s psychological-wellbeing and sense of self-worth also improved. The data suggest benefits of the program were substantially maintained up to 6 months following completion of the program. This impact persisted despite evidence that some women continued to experience conflict-related trauma during the study period. These data support the value of providing an integrated music and psychological care program in the context of ongoing humanitarian crises. Further research should test the HiH program in other humanitarian settings, in male and child conflict survivors, and in clinical comparative trials. Formal evaluation of the impact of the HiH program on reducing stigma and increasing social inclusion at the community level is needed.