No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
The Legacy of Gender-Based Violence and HIV/AIDS in the Post-Genocide Era: Stories From Women in Rwanda
Abstract
Drawing on qualitative interviews with 22 Rwandan women, we describe the lived experiences of women survivors of Gender-Based Violence (GBV) more than a decade and a half after the 1994 Genocide. We argue that the intersection between GBV and HIV/AIDS has long-term implications: the majority of women interviewed continue to endure trauma, stigma, social isolation, and economic hardship in the post-genocide era and are in need of expanded economic and mental health support. Our findings have implications for the importance of providing integrated psychosocial support to survivors of GBV post-conflict contexts.
... Calhoun and Tedeschi (2014) have found five factors for posttraumatic growth: personal strength, new possibilities, relating to others, appreciation of life, and spiritual change. Some of the characteristics of PTG have been described as the continued presence of family members, the support and strength in denouncing, evidencing no guilt or shame, and the desire for reconciliation (Álvarez 2015;Suarez 2013;Kuwert et al. 2014;Park et al. 2016;Eichhorn et al. 2015) and strong desires to live and hope for the future (Garnett et al. 2015). Hence, despite the deeply negative effects of sexual victimization, resilience appears as one of the psychological characteristics that may help victims protect themselves from worse effects or even drive them to posttraumatic growth. ...
... The literature review on trauma, social and political violence, and sexual abuse covers different topics. The first one is related to the purpose of this type of violence-in political conflict contexts, it has been described as a systematic weapon to inflict trauma on the civilian population or as a way for one of the groups involved in the conflict to advance their social and economic position over the enemy and destroy families and communities to take power (Garnett et al. 2015). ...
... Women who have been victims of sexual violence in war contexts have been shown to have higher symptoms and signs of trauma; however, a large majority of the survivors do not report or disclose their experience out of fear of rejection, stigmatization, being ostracized from society, or even the possibility of revenge from the abusers when they are part of the same community. This further leads to other negative outcomes, such as loss of employment, limited political, civil, and property rights, and a lack of medical or psychological help (Garnett et al. 2015). Thus, women often feel that their feminine dignity and intimacy are destroyed, accompanied by a feeling of strangeness about their own selves and a rupture of identity and self-image (Gamondi 2004;Morales 2012;Park et al. 2016;Valz Gen 2016). ...
Sexual violence is highly prevalent in sociopolitical conflict contexts. Even though its
negative effects are well documented, further research is needed on how community experiences of social growth and rebuilding could positively impact victims of sexual violence in these contexts.
As a starting point, we conducted a two-phase systematic review. The first phase focused on the relationships between sociopolitical conflict, sexual violence, and psychological effects or trauma (2010–2017), and, in addition to the deep negative psychological effects, it also found reports of posttraumatic growth in victims. This led to a second phase that related sexual violence in sociopolitical conflict contexts to posttraumatic growth and resilience (2017–2022). We found nine publications
documenting experiences of resilience and posttraumatic growth in victims of sexual violence in sociopolitical conflicts. Interestingly, resilience and posttraumatic growth were shown not only in victims but also in communities and new generations, which is relevant to understanding the long-lasting effects of violence in contexts of sociopolitical conflict.
... Calhoun and Tedeschi (2014) have found five factors for posttraumatic growth: personal strength, new possibilities, relating to others, appreciation of life, and spiritual change. Some of the characteristics of PTG have been described as the continued presence of family members, the support and strength in denouncing, evidencing no guilt or shame, and the desire for reconciliation (Álvarez 2015;Suarez 2013;Kuwert et al. 2014;Park et al. 2016;Eichhorn et al. 2015) and strong desires to live and hope for the future (Garnett et al. 2015). Hence, despite the deeply negative effects of sexual victimization, resilience appears as one of the psychological characteristics that may help victims protect themselves from worse effects or even drive them to posttraumatic growth. ...
... The literature review on trauma, social and political violence, and sexual abuse covers different topics. The first one is related to the purpose of this type of violence-in political conflict contexts, it has been described as a systematic weapon to inflict trauma on the civilian population or as a way for one of the groups involved in the conflict to advance their social and economic position over the enemy and destroy families and communities to take power (Garnett et al. 2015). ...
... Women who have been victims of sexual violence in war contexts have been shown to have higher symptoms and signs of trauma; however, a large majority of the survivors do not report or disclose their experience out of fear of rejection, stigmatization, being ostracized from society, or even the possibility of revenge from the abusers when they are part of the same community. This further leads to other negative outcomes, such as loss of employment, limited political, civil, and property rights, and a lack of medical or psychological help (Garnett et al. 2015). Thus, women often feel that their feminine dignity and intimacy are destroyed, accompanied by a feeling of strangeness about their own selves and a rupture of identity and self-image (Gamondi 2004;Morales 2012;Park et al. 2016;Valz Gen 2016). ...
Sexual violence is highly prevalent in sociopolitical conflict contexts. Even though its negative effects are well documented, further research is needed on how community experiences of social growth and rebuilding could positively impact victims of sexual violence in these contexts. As a starting point, we conducted a two-phase systematic review. The first phase focused on the relationships between sociopolitical conflict, sexual violence, and psychological effects or trauma (2010–2017), and, in addition to the deep negative psychological effects, it also found reports of posttraumatic growth in victims. This led to a second phase that related sexual violence in sociopolitical conflict contexts to posttraumatic growth and resilience (2017–2022). We found nine publications documenting experiences of resilience and posttraumatic growth in victims of sexual violence in sociopolitical conflicts. Interestingly, resilience and posttraumatic growth were shown not only in victims but also in communities and new generations, which is relevant to understanding the long-lasting effects of violence in contexts of sociopolitical conflict.
... Despite these efforts, there continues to be a lack of access to comprehensive medical and psychological care for Rwandan survivors of GBV including IPV (Russell et al. 2016;Zraly et al. 2011). According to the WHO (2005), Rwanda only spends 1% of its health budget on mental health services (Zraly et al. 2011). ...
... A recent study conducted by the University of Rwanda with Oxfam (2017) found that 78.8% of women reported "fear of stigma" as the primary barrier to reporting violence, followed by because an "arrangement between families was made instead" (73.5%), or "feeling that it will change nothing" (65.2%). Given that Rwandan women's poverty and financial dependence on their spouses have been identified as significant barriers to women seeking care, the need to provide integrated health and psychosocial services that support women economically has been strongly emphasized (Russell et al. 2016;Umubyeyi et al. 2016;Mannell and Dadswell 2017). Supportive community responses to GBV survivors are especially important in Rwanda, given the evidence that men and women are overwhelmingly more likely to ask for help from their neighbors or family members when experiencing physical or sexual violence (NISR 2016). ...
... Individual support and home visits were also important for those who faced barriers to attend the safe spaces or publicly share their experiences. This openness supported attendees' well-being, which confirms other research in Rwanda indicating that GBV survivors wished to openly discuss their experiences to move forward with their lives (Russell et al. 2016). The solidarity developed at the safe spaces and the concept of 'power within' also supported attendees' confidence and well-being, and was said to reduce anxiety and loneliness. ...
Within intimate partner violence (IPV) prevention programmes that raise awareness of women's rights and the forms and consequences of IPV, there is a need to ensure response mechanisms for IPV survivors. Indashyikirwa is a Rwandan IPV prevention programme, which established 14 women's safe spaces, whereby men and women could access support for IPV, be referred or accompanied to other services. This paper draws on qualitative interviews with safe space facilitators, attendees, staff and observations of activities at various points across the programme. Thematic analysis was conducted to assess the process and impact of the spaces. Attendees generally preferred the women's safe spaces over formal services for IPV disclosure and support, and the spaces also enhanced the quality of and linkage to formal IPV response services. The safe spaces further supported well-being and economic empowerment of attendees. Lessons learned from implementing this model are offered, including how to ensure safe, inclusive and integrated sources of support within broader IPV prevention efforts.
... As a product of GBV, isolation resulting from GBV can be triggered by social stigma (or the fear of such stigma) associated with the exposure of 'act of abuse' to the public (Khanlou et al. 2020;Russell, Lim, Kim and Morse 2016). In some instances, victims are ostracised by family and friends, leading to long-term social, economic, and psychological impacts such as post-traumatic stress disorder (PTSD) and depression among others (Shimba and Magombola 2021;Russell et al. 2016;Kaithuru 2015). ...
... As a product of GBV, isolation resulting from GBV can be triggered by social stigma (or the fear of such stigma) associated with the exposure of 'act of abuse' to the public (Khanlou et al. 2020;Russell, Lim, Kim and Morse 2016). In some instances, victims are ostracised by family and friends, leading to long-term social, economic, and psychological impacts such as post-traumatic stress disorder (PTSD) and depression among others (Shimba and Magombola 2021;Russell et al. 2016;Kaithuru 2015). The fear of such shapes the decision of victims and perpetrators. ...
The South Africa Police Service reported that during the first week of lockdown (26 March-2 April 2020) necessitated by the coronavirus pandemic, the Police department received over 87,000 GBV complaints (Mlambo 2020). Therefore, it is not appalling to know that South Africa has one of the highest rates of gender-based violence globally and is becoming increasingly unsafe, especially for women. In this study, the salient points about factors that promote acts of gender-based violence (hereafter GBV) and the culture of silence around GBV pre-and post-Covid-19 are examined. The role of creativity as a means of communication is also unpacked. Therefore, how the muted can still 'speak' through art-based interventions and other creative methods are explored. The focus is on GBV reports and studies in South Africa, especially during the 2020 total lockdown necessitated by the global pandemic-the coronavirus (Covid-19). Studies conducted pre-Covid-19 are also examined. Consequently, the study adopts a scoping review of literature to identify factors that aid acts of aggression towards the vulnerable within South Africa during the Covid-19 lockdown. In identifying these factors, the study illuminates other alternatives to speaking audibly to extinguish the silence culture.
... The United Nations High Commission on Refugees defines gender-based violence (GBV) as an act perpetrated against a person's will based on unequal power relationships and gender norms (United Nations High Commissioner for Refugees December 31, 2020). In asylum seekers, GBV has often been the result of attempts to inflict trauma and destabilize certain ethnic groups or communities in conflict settings (Russell et al., 2016). While GBV can be perpetrated against men, women, boys, and girls, in this paper we focus on violence against women. ...
... Patients who have experienced GBV have higher rates of depression, PTSD, and disordered alcohol use (Roberts et al., 2018). Additionally GBV has been linked to higher rates of HIV, syphilis, gonorrhea, and chlamydia transmission, as well as a greater number of sexual partners (Russell et al., 2016;WHO July 22, 2020;Roberts et al., 2018). ...
Introduction
Over 25,000 individuals are granted asylum status in the United States annually. Gender-based violence (GBV) has historically been supported as a claim for persecution to apply for asylum. In women, GBV is a known risk factor for sexually transmitted infections, poor mental health, and worse perinatal outcomes. Less is known about the links between GBV, asylum seekers, and gynecologic outcomes or care utilization. Reported rates of gynecologic care-seeking are low in asylum-seeking women and women with histories of GBV often experience barriers to care. We hypothesized that asylum-seeking women with a history of GBV at the Libertas Center, a comprehensive center for survivors of torture in New York City, would receive low rates of recommended gynecologic screening and infrequent gynecologic care.
Materials and Methods
: This retrospective cross-sectional study included adult self-identified female patients who had completed intake at the Libertas Center from 2005-2020. In order to examine the relationship between GBV and gynecologic care use, patients were included if they had an electronic medical record (EMR) at Elmhurst Hospital, were female, 18 years of age and older, and had ever experienced GBV in their lifetime. EMRs were reviewed for medical and psychiatric diagnoses as well as routine components of gynecologic care and were linked to intake data from the Libertas Center characterizing patients’ torture history. The primary outcome of this study was whether or not patients attended a gynecology visit. Demographic characteristics, medical histories, adequacy of gynecologic care, and gynecologic care-seeking behavior were compared between the gynecologic care group and the no gynecologic care group.
Results
A total of 249 female patients were seen at the Libertas Center from December 2005 until January 2020 at the time of data collection. The prevalence of GBV in this population was 48%. Among women who suffered GBV, 81 received medical care at Elmhurst Hospital and 44 (54%) of these received gynecologic care. Nearly 50% of those patients who sought care at Elmhurst carried a diagnosis of post-traumatic stress disorder or depression. Women who received gynecologic care were significantly more likely than those who did not receive gynecologic care to have had an Emergency Room visit (68% vs. 41%), an obstetric visit (32% vs 3%), and/or have been seen by a social worker (46% vs 24%; all p<0.05). Women who saw a gynecologist were significantly more likely to have completed four basic gynecologic care measures (Pap smear, gonorrhea/chlamydia screen, pelvic exam, and mammogram if applicable) compared to women who did not (77% vs 8%, p<0.05).
Conclusion
This study characterizes the gynecologic care utilization of female patients within a comprehensive care center for survivors of torture. We found a high lifetime rate of gender-based violence of 48% in this population. Adequate gynecologic care was uncommon among those who experienced GBV. However, gynecologic care was significantly more likely in patients receiving gynecologic specialty care, which frequently occurred after initial interaction with another provider (i.e. Emergency Department providers). These findings highlight the importance of trauma-informed care and establishing pathways to help asylum seeking and refugee women receive adequate gynecologic care. Further research is needed to explore specific barriers to gynecologic care in this population, how programs for asylum-seekers can integrate gynecologic care into existing structures for medical and mental healthcare, and how to increase awareness amongst providers on the prevalence of GBV and the gynecologic needs of these patients.
... A loss of trust and social cohesion with both physical and cultural fragmentation continuing years after a genocide were additional social consequences (Akhavan et al., 2020;Vale, 2020). Six studies noted genocidal rape survivors' experiences with poverty and financial hardship (Crosby et al., 2016;Denov & Piolanti, 2019;Kahn & Denov, 2022;Kantengwa, 2014;Russell et al., 2016;Walstrom et al., 2013). Noted poverty-related issues included poor access to medical care and associated resources and the loss of housing. ...
The unique forms of trauma experienced by survivors of genocidal rape are not well understood. Hence, we conducted a systematic scoping review regarding the consequences for survivors of rape during genocide. Searches conducted in PubMed, Global Health, Scopus, PyscInfo, and Embase produced a total of 783 articles. After completing the screening process, 34 articles were eligible for inclusion in the review. The included articles focus on survivors from six different genocides, with most focusing on either the genocide of the Tutsis in Rwanda or the Yazidis in Iraq. The study findings consistently show that survivors deal with stigmatization as well as a lack of both financial and psychological social support. This lack of support is partly due to social ostracization and shame but is also attributed to the fact that many survivors' families and other providers of social support were murdered during the violence. Many survivors, particularly young girls, reported dealing with intense forms of trauma both as a direct result of sexual violence and due to witnessing the death of their community members during the period of genocide. A notable proportion of survivors became pregnant from genocidal rape and contracted HIV. Group therapy was shown to improve mental health outcomes across numerous studies. These findings have important implications and can inform recovery process efforts. Psychosocial supports, stigma reduction campaigns, community reestablishment, and financial assistance are integral in facilitating recovery. These findings can also play an important role in shaping refugee support programs.
... Refugees in many contexts occupy some of the lowest positions in society, and adolescent refugee girls thus often face a greater threat of GBV and exploitation than other girls (Glass et al. 2018). Experiencing increased GBV in conflict settings also can have a lasting effect on the physical and mental wellbeing of women and girls (Russell et al. 2016). Further illustrating this, Stark et al. (2017) found that exposure to sexual violence prior to settling in Ethiopia had a negative effect on refugee girls' sense of wellbeing and safety. ...
Refugee girls are one of the most marginalized groups in the world when it comes to school participation, and they are half as likely to enroll in secondary school as their male peers. Gender disparities can be made worse by conflict and displacement, and they often increase as children get older. As many low- and middle-income host countries move toward more inclusive models of refugee education, it's critical to identify barriers that may differentially limit the inclusion of refugee girls. I use two unique household surveys, conducted in Ethiopia, to examine the household and community factors that shape participation in secondary school. My findings suggest that the magnitude and sources of disadvantage vary across groups. Domestic responsibilities and concerns about safety in the community are more likely to limit secondary school participation for refugee girls than for refugee boys and host community girls. Other factors, including parental education and exposure to gender-based violence, are less likely to differ between refugee and host community girls. These findings have implications for education and social protection policies that target girls' education and wellbeing in both refugee and host communities.
... [12] Rwandan families and communities continue to be affected by heightened stressors such as HIV, poverty, and a growing substance abuse issue. [13,14] Mental Health concerns related to trauma or stressors in adolescence and adulthood increase the risk for depression, anxiety, post-traumatic stress disorder, high-risk sexual behaviors, low self-esteem, social isolation, drug and substance abuse. [15] Cardiovascular diseases have emerged as one of the most common causes of death in individuals with HIV. ...
No AbstractKeywords: Human Immunodeficiency Virus, communicable diseases, non-communicable diseases, Rwanda, sub-Saharan Africa
... In 2005, 11 years after the widespread and systematic enactment of wartime rape during the genocide, Cohen et al. (2009) demonstrated that PTSD and depressive symptoms were high for all women tested, whether HIV positive or negative, and the vast majority of the women who were HIV positive showed depressive symptoms. Women who confront the long-term consequences of gender-based violence during the genocide along with HIV/AIDS continue to endure personal, psychosocial, and economic hardship (Russell, Lim, Kim, & Morse, 2016). In general, the psychological consequences for those who survived the 1994 genocide are multifactorial and carry complex mental health implications, including transgenerational trauma, increased risk of suicide, and episodes related to retraumatization (Rieder & Elbert, 2013;Roth, Neuner, & Elbert, 2014;Rubanzana, Hedt-Gauthier, Ntaganira, & Freeman, 2015;Rugema, Mogren, Ntaganira, & Krantz, 2015). ...
In 1994, the Rwandan genocide claimed the lives of approximately 1 million Tutsi and moderate Hutu citizens. Systematic rape was a strategic component of the Hutu extremist plan to eradicate the Tutsi minority population. This involved collective and repeated sexual assaults with brutal violence, public humiliation, and torture. This article maps the ongoing psychological impact on Rwandan genocide rape survivors and identifies implications for international nursing practice. The research formalizes their narratives, identifying a number of interconnected elements that combine to produce myriad forms of chronic psychological suffering in the Rwandan context. This work in turn reveals the specific needs of these survivors that may be addressed by nursing. It allows nurses, as experts in managing the human responses to health and illness, to develop a more complete understanding of psychological suffering as it pertains to vulnerable populations during and in the wake of extreme social conflict. This clarifies the roles of nurse educators, clinicians, and policy advocates as key agents in providing genocide rape survivors with the resources and expertise needed to effectively manage their ongoing trauma.
... Family-based interventions hold promise for promoting child mental health and well-being for families affected by HIV in low-and middle-income countries (Rochat, Bland, Coovadia, Stein, & Newell, 2011;Rochat, Mkwanazi, & Bland 2013;Rotheram-Borus et al., 2003;Visser et al., 2012). In post-genocide Rwanda, families are often affected by compound stressors, such as HIV, poverty and a legacy of community violence (Betancourt et al., 2014;Russell, Lim, Kim, & Morse, 2015). HIV-affected caregivers experience higher rates of mental-health problems, harmful alcohol use, conflict and intimate partner violence (IPV) (Li et al., 2014;Longmire-Avital, Holder, Golub, & Parsons, 2012;WHO, 2010). ...
HIV-affected families report higher rates of harmful alcohol use, intimate partner violence (IPV) and
family conflict, which can have detrimental effects on children. Few evidence-based interventions
exist to address these complex issues in Sub-Saharan Africa. This mixed methods study explores the
potential of a family-based intervention to reduce IPV, family conflict and problems related to
alcohol use to promote child mental health and family functioning within HIV-affected families in
post-genocide Rwanda. A family home-visiting, evidence-based intervention designed to identify
and enhance resilience and communication in families to promote mental health in children was
adapted and developed for use in this context for families affected by caregiver HIV in Rwanda.
The intervention was adapted and developed through a series of pilot study phases prior to
being tested in open and randomized controlled trials (RCTs) in Rwanda for families affected by
caregiver HIV. Quantitative and qualitative data from the RCT are explored here using a mixed
methods approach to integrate findings. Reductions in alcohol use and IPV among caregivers are
supported by qualitative reports of improved family functioning, lower levels of violence and
problem drinking as well as improved child mental health, among the intervention group. This
mixed methods analysis supports the potential of family-based interventions to reduce adverse
caregiver behaviors as a major mechanism for improving child well-being. Further studies to
examine these mechanisms in well-powered trials are needed to extend the evidence based on the promise of family-based intervention for use in low- and middle-income countries.
Introduction: Gender-based violence (GBV) is violence directed against a person because of their gender. Both women and men experience gender-based violence, but the majority of victims are women and girls. Sexually transmitted infections (STIs) are infections that are transmitted from one person to another through sexual contact. There is evidence that GBV increases the risk of STIs and pregnancy. The objective of this study was to determine the prevalence of STIs and pregnancy among GBV patients attending the Isange One Stop Center at Ruhengeri Referral Hospital.
Methodology: This retrospective study involved the consultation of archived data and recorded data in files for all GBV cases received from January to December 2021. The victim’s information, such as laboratory findings, residential sector information, demographic characteristics, and months in which GBV cases were recorded. The Statistical Package for the Social Sciences (SPSS) version 20 was used for data analysis.
Results: A total of 308 GBV cases were reported, 93.8% of which involved females. Most victims (46.4%) were adolescents aged 11–20 years. Urban areas, particularly the Muhoza (26%) and Cyuve (22.1%) sectors, reported the highest number of cases. The prevalence of STIs among GBV victims was 68.5%, with trichomoniasis (18.2%) and gonorrhoea (14.6%) being the most common infections. Hepatitis B and syphilis were identified in 6.2% and 5.2% of the patients, respectively.
Conclusion: Although efforts are being made in Rwanda to fight against GBV, the number of GBV cases is continually increasing, with the incidence of STIs and undesirable pregnancies increasing, especially among young adolescents. Therefore, additional focus and efforts are needed to lower this rate of GBV among young adolescents. Preventive measures should be improved to eliminate GBV cases and subsequent effects.
Gender-based stigma (GBS) occurs across the globe and harms health and well-being, particularly among women. Yet, there remains a need for synthesized literature to better understand the impact of GBS on health care-related outcomes. Addressing this gap, this scoping review summarizes what is known about GBS and health care-related outcomes among cisgender persons in Africa. We followed Preferred Reporting Items for Systematic Reviews and Meta Analysis extension for Scoping Reviews guidelines to examine the state of evidence related to GBS and health care-related outcomes in African countries. We searched two online electronic databases (PubMed, PsychINFO) for articles published on/before April 20th, 2023. Articles were included if they (a) were published in the English language, (b) reported primary research in Africa, (c) examined GBS at the individual level among cisgender persons, and (d) examined health care-related outcomes. We identified 24 articles for inclusion spanning 14 countries, including 18 qualitative, three quantitative, and three mixed-methods studies. Thematic analyses of qualitative articles identified four overarching themes: GBS is intersectional; differential treatment from societal gender norms and gender role expectations; gendered loss of autonomy and human rights violations in health care; and gender-based violence (GBV). Quantitative findings included that GBV experiences are widespread and may shape health care access, and there are linkages between GBV and HIV. Findings underscore that intersectional, multilevel experiences of GBS impede health care access and rights in the African region across diverse contexts, populations, and health issues. Future research can include additional GBS dimensions and marginalized communities.
This paper makes a normative argument about transformations of public health as a necessary condition required in any transitional justice process. We seek to bridge the gap between the fields of genocide and public health to understand the recursive relationship between genocide and the social determinants of health. We show that structures and institutions established during genocide create enduring impacts on the public health outcomes of victim and survivor groups even after the ousting of the original perpetrators. Our comparative analysis of the Rwandan Genocide and the colonial genocide of Indigenous communities in Canada surveys the available public health literature and argues that perpetrators of genocide deliberately design public health systems for the explicit purposes of destroying target communities over the longue durée . When these systems are insufficiently transformed, post-genocide societies face significant barriers to transitional justice and reconciliation as a direct result of their impacts on survivor communities. In Rwanda, delayed addressal of the HIV/AIDS epidemic engineered by the Hutu Power regime continued to victimize Tutsi women decades after the mass killings have ended; in Canada, legacies of family separation and the Indian Residential School system have straddled Indigenous communities with high rates of comorbidities and early death consistent with colonial genocide policies.
Most qualitative social justice research is guided by a critical theory–based understanding of justice, which conceives of justice as something that can be achieved, made present. For Derrida, however, justice can never arrive, be present; it is in fact impossible. Justice always exceeds our specific expectations of the future. Derrida’s second definition of deconstruction, which deals with the unstable relationship between justice and law, is examined, followed by a discussion of the deconstructibility of the law and the undeconstructibility of justice. Derrida’s concept of justice is ontological, whereas critical theory’s concept of justice is epistemological. For Derrida, and continental philosophy in general, however, epistemology has its ultimate basis in ontology. An important implication of Derrida’s concept of justice for critically informed qualitative social justice research is that justice cannot function as a guiding principle or ideal. Thus, the call to justice is an infinite one that researchers can never satisfy.
While stigma experienced by people living with HIV (PLWH) is well documented, intersectional stigma and additional stigmatized identities have not received similar attention. The purpose of this metasynthesis is to identify salient stigmatized intersections and their impact on health outcomes in PLWH in sub-Saharan Africa. Using Sandelowski and Barroso’s metasynthesis method, we searched four databases for peer-reviewed qualitative literature. Included studies (1) explored personal experiences with intersecting stigmas, (2) included ≥1 element of infectious disease stigma, and (3) were conducted in sub-Saharan Africa. Our multinational team extracted, aggregated, interpreted, and synthesized the findings. From 454 screened abstracts, the 34 studies included in this metasynthesis reported perspectives of at least 1258 participants (282 men, 557 women, and 109 unspecified gender) and key informants. From these studies, gender and HIV was the most salient stigmatized intersection, with HIV testing avoidance and HIV-status denial seemingly more common among men to preserve traditional masculine identity. HIV did not threaten female identity in the same way with women more willing to test for HIV, but at the risk of abandonment and withdrawal of financial support. To guard against status loss, men and women used performative behaviors to highlight positive qualities or minimize perceived negative attributes. These identity management practices ultimately shaped health behaviors and outcomes. From this metasynthesis, the Stigma Identity Framework was devised for framing identity and stigma management, focusing on role expectation and fulfillment. This framework illustrates how PLWH create, minimize, or emphasize other identity traits to safeguard against status loss and discrimination. Providers must acknowledge how stigmatization disrupts PLWH’s ability to fit into social schemas and tailor care to individuals’ unique intersecting identities. Economic security and safety should be considered in women’s HIV care, while highlighting antiretrovirals’ role in preserving strength and virility may improve care engagement among men.
Resisting a single-axis framework and adopting intersectionality in gendered security research and practice ensures that more inclusive and holistic security, and thus sustainable peace, is achieved in post-conflict societies. Yet, the way in which intersectionality is used in research and policy-making determines different outcomes that either take us further away or closer to that goal. The aim of this study is to explore how gender intersects with other systems of oppression to create experiences of gendered (in)security in Rwandan communities. My research suggests that the failure to cultivate a thorough understanding of intersectionality in gender security practice results in gender-based violence (GBV), gender discrimination and gender hierarchies, all of which threaten the sustainability of peace in the post-conflict era.
The key objective of my study is to critically evaluate the value of analysing the inner workings of intersectionality for the Rwandan context, gendered security research and practice, and Women, Peace and Security (WPS) work. The inner workings of intersectionality refer to the modes, dynamics, contestations and strategies that surround the concept. I use three logics to explore the inner workings of intersectionality. These are the logics of domination, addition, and interdependence. The logics are used in combination to cultivate a holistic understanding of intersectionality. I use a deconstructive discourse analysis to reveal how the different logics, and indeed the inner workings themselves, are (re)produced and the effects that the logics have, and have had, on gendered security in Rwanda. My conceptual exploration of the inner workings of intersectionality draws from examples in colonial, post- colonial and post-genocide Rwanda. I use a multi-level analysis, focussing on the everyday experiences of marginalised women, whose social location lies at the intersection of multiple systems of oppression, while also paying attention to larger structural power differentials that are filtered through the global economy and global security. My study shows that there is a link between the utilisation of intersectionality according to the logics and gendered (in)security.
Rwanda is a useful case study for the analysis of intersectionality because the history of Hutu/Tutsi political violence lends itself to an intersectional analysis. In addition, despite Rwanda’s robust gender equality and gender security policy and legal frameworks, gendered
iii
insecurities, such as persistently high rates of GBV, continue to threaten the sustainability of peace in the post-genocide era. My analysis reveals how intersections have generated complex experiences of violence in Rwanda’s past; how the misappropriation of intersectional thinking can lead to the creation of gendered (in)security silences, which allows gender discrimination to thrive and threaten peace in the contemporary moment; and how positive intersections can be cultivated through community forums for generating positive peace and gender justice at a local level.
This book explores the role of gender in influencing war-fighting actors’ strategies towards the attack or protection of civilians.
Traditional narratives suggest that killing civilians intentionally in wars happens infrequently, and that the perpetration of civilian targeting is limited to aberrant actors. Recently, scholars have shown that both state and non-state actors target civilians, even while explicitly deferring to the civilian immunity principle. This book fills a gap in the accounts of how civilian targeting happens, and shows that these actors are in large part targeting women rather than some gender-neutral understanding of civilians. It presents a history of civilian victimization in wars and conflicts, and then lays out a feminist theoretical approach to understanding civilian victimization. It explores the British Blockade of Germany in World War I, the Soviet ‘Rape of Berlin’ in World War II, the Rwandan genocide, and the contemporary conflict in northeast Nigeria. Across these case studies, the authors lay out how gender is key to how war-fighting actors understand both themselves and their opponents, and therefore plays a role in shaping strategic and tactical choices. It makes the argument that seeing women in nationalist and war narratives is crucial to understanding when and how civilians come to be targeted in wars, and how that targeting can be reduced.
ISBN 92 75 12292 X " Listen to the voices of these women and girls telling their stories. They are asking us to hear them and do something about gender-based violence, the most pervasive form of abuse in the world. This is an important book, and I hope it will make a difference. " —Isabel Allende
Disclosure of human immune deficiency virus (HIV) positive status has a key role in the prevention and control of HIV/AIDS. The failure of people infected with HIV to disclose their positive status can expose their sexual partners to the virus. Identifying the factors associated with status disclosure is a priority issue as high proportion of people living with HIV do not discloses their status and to design appropriate strategy to deal with the issues this involves. The aim of this study was to assess the disclosure and its associated factors of HIV positive status to sexual partners among patients attending antiretroviral therapy (ART) clinic follow up at Mekelle Hospital, Tigray, Ethiopia.
An institution based cross sectional study was conducted at Mekelle hospital. Samples of 324 individuals were selected by using systematic random sampling techniques from July 1st until the 30th July 2012. The data was collected by trained data collectors through pretested semi structured questionnaire. The collected data was cleaned, coded, entered and then analysed using SPSS version 16.0 windows program. Descriptive statistics, binary and multivariable regression analysis with 95% confidence interval was carried out and p value less than 0.05 used to determine the significant association.
A total of 324 people on ART care follow up were interviewed with 100% response rate. The overall HIV status disclosure to sexual partner was 57.4%. Among those who disclosed their HIV status 58.0% of them told their partner after one month of initial diagnosis. The study showed that there is significant association between knowing HIV status of sexual partner [AOR = 16.69, 95% CI (5.4, 51.65)], duration of HIV related care follow up [AOR = 5.48, 95% CI (2.17, 13.80)] and discussion before HIV testing [AOR = 4.33, 95% CI (1.43, 13.08)] with HIV positive status disclosure to sexual partner.
A HIV positive status disclosure to a sexual partner in this study was lower than what was reported in other studies in Ethiopia. The duration of HIV related care follow up, knowing partners HIV status and prior discussion were the main factors which affect the practice of HIV positive status disclosure to their sexual partners.
A review of the book, "The Rwanda Crisis: History of a Genocide."
Rape is regularly committed during a period of collective violence such as war. The article discusses the Rwandan genocide during which rape was used with the deliberate intent to destroy in whole or in part the Tutsi community. Rape is not often studied in such particular contexts, so little is known about its prevalence in genocide; as a consequence, the comprehensive impact of genocidal incidents remains underaddressed. We estimate the prevalence of rape victimization (i.e., the number of women raped) during the Rwandan genocide in 1994. In doing so, we apply a methodology in which we use conservative victimization estimates, disaggregating between victims who were killed and victims who survived. We arrive at an estimated lower bound of a little more than 350,000 female rape victims, most of whom were Tutsi. We discuss the importance of arriving at reliable estimates, the methodology, and implications for future research.
English
This article describes the experiences of returnees from exile into Kigali, Rwanda and the efforts of the Government of Rwanda (GoR) and the UNHCR to meet the needs of returnees, and to deal with the aftermath of the genocide. Particular attention is paid to the Gacaca courts and the role of social work therein. We identify gaps in services and make recommendations in respect of the refugee phenomenon on the African continent.
French
Cet article décrit l'expérience des exilés qui retournent à Kigali, au Rwanda, ainsi que les efforts du Gouvernement du Rwanda et du Haut Commissariat des Nations Unies pour les réfugiés (UNHCR) pour répondre à leurs besoins et aux séquelles du génocide. L'étude porte une attention particulière aux Juridictions Gacaca et au rôle du travail social dans ce contexte. Elle identifie des lacunes dans les services et formule des recommandations concernant le phénomène des réfugiés sur le continent africain.
Spanish
En este artículo describimos las experiencias de los retornados del exilio en Kigali, Rwanda y los esfuerzos del gobierno de Rwanda (GoR) y la UNHCR para conocer las necesidades de los retornados y tratar con las secuelas del genocidio. Se pone especial atención en los tribunales Gacaca y en el papel del Trabajo Social en ello. Identificamos vacíos en los servicios y hacemos recomendaciones respecto al fenómeno del refugiado en el continente africano.
The term ‘identity’ tends to have positive connotations. This article presents an example of a lethal form of identity politics, where self-expression was not possible for victims or victimizers. At the time, killings in Rwanda in 1994 were presented by (and to) the international media as the outcome of deep-seated ‘ethnic’ or ‘tribal’ hatred, between Tutsi and Hutu Rwandans. However, research on the period, oral testimonies from all sides, video evidence and court cases at the UN Tribunal in Arusha established since the genocide, have all confirmed that this was not the case. It has become clear that the killings were systematic, planned and enforced bureaucratically. The rural and urban Hutu population were persuaded to kill neighbours, friends, family members and strangers, and such killings were planned on a national scale and meticulously monitored. Genocide of the Tutsi was organized by a beleaguered inner core of state functionaries, principally comprising top military officers who came mainly from north-western Rwanda and who refused to implement the terms of the Arusha peace Accords (1991–4). Rwanda's genocide of Tutsi in 1994 is the most dramatic example of ‘race science’ in action since the Holocaust, with which some parallels are drawn in this article. In both cases, the genocide option was arrived at during a time of economic and political crisis, and a mix of terror and bribery was used to gain popular compliance. To make the genocide thinkable, myths of origin were reinvented and differential forms of citizenship enforced. Identity politics became a means of legitimizing collective violence and scapegoating, and a knife in the back of the civilian population as a whole, victims and victimizers alike.
This article presents unique material from in-depth interviews with 16 women in Rwanda who have testified in the gacaca, the village tribunals initiated to enhance reconciliation after the 1994 genocide. The aim of the interviews was to learn more about how testifying in such a public event as the gacaca affects psychological health. Do the women find the experience healing or retraumatizing? Are there other effects involved? There has been an assumption that testifying in truth and reconciliation commissions is a healing experience for survivors, and healing has been a central concept in the general reconciliation literature and in political rhetoric around truth commissions. However, the findings of the present study are alarming. Traumatization, ill-health, isolation, and insecurity dominate the lives of these testifying women. They are threatened and harassed before, during, and after giving testimony in the gacaca. The article provides a picture of the reconciliation process that we seldom see.
This article describes the concept of posttraumatic growth. its conceptual founda- tions, a/id supporting empirical evidence. Posttraumatic growth is the experience of positive change that occurs as a result of the struggle with highly challenging life cri- ses. It is manifested in a variety ofways, including an increased appreciationfor life in general, more meaningful interpersonal relationships, an increased sense ofpersonal strength. cha/lged priorities, and a richer existential and spiritual life. Although the term is ne..", the idea that great good can come from great suffering is ancient. We pro- pose a nlOdelfor understanding the process ofposttraumatic growth in which individ- ual characteristics, support and disclosure, a/Id more centrally, significant cognitive processing involving cognitive structures threatened or nullified by the traumatic events, play an important role. It is also suggested that posttraumatic growth mutually interacts with life wisdoma,1d the development of the life narrative, and that it is an on- going process, not a static outcome. In his memoir, No Such Thing as a Bad Day, Hamil- ton Jordan (2000) described some of the changes he experienced following his battle with cancer:
Organized rape has been an integral aspect of warfare for a long time even though classics on warfare have predominantly focused on theorizing ‘regular’ warfare, that is, the situations in which one army encounters another in a battle to conquer or defend a territory. Recently, however, much attention has been paid to asymmetric warfare and, accordingly, to phenomena such as guerrilla tactics, terrorism, hostage taking and a range of identity-related aspects of war such as religious fundamentalism, holy war, ethnic cleansing and war rape. In fact, war rape can be taken as a perfect example of an asymmetric strategy. In war rape the soldier attacks a civilian (not a fellow combatant) and a woman (not another male soldier), and does this only indirectly with the aim of holding or taking a territory. The primary target here is to inflict trauma and through this to destroy family ties and group solidarity within the enemy camp. This article understands war rape as a fundamental way of abandoning subjects: rape is the mark of sovereignty stamped directly on the body, that is, it is essentially a bio-political strategy using (or better, abusing) the distinction between the self and the body. Through an analysis of the way rape was carried out by the predominantly paramilitary Serbian forces on Bosnian soil, this article theorizes a two-fold practice of abjection: through war rape an abject is introduced within the woman’s body (sperm or forced pregnancy), transforming her into an abject-self rejected by the family, excluded by the community and quite often also the object of a self-hate, sometimes to the point of suicide. This understanding of war rape is developed in the article through a synthesis of the literature on abandonment (Agamben, Schmitt) and abjection (Bataille, Douglas, Kristeva) and concomitantly it is argued that the penetration of the woman’s body works as a metaphor for the penetration of enemy lines. In addition it is argued that this bio-political strategy, like other forms of sovereignty, operates through the creation of an ‘inclusive exclusion’. The woman and the community in question are inscribed within the enemy realm of power as those excluded.
Little is known about the impact of trauma in postconflict, low-income countries where people have survived multiple traumatic experiences.
To establish the prevalence rates of and risk factors for posttraumatic stress disorder (PTSD) in 4 postconflict, low-income countries.
Epidemiological survey conducted between 1997 and 1999 among survivors of war or mass violence (aged >/=16 years) who were randomly selected from community populations in Algeria (n = 653), Cambodia (n = 610), Ethiopia (n = 1200), and Gaza (n = 585).
Prevalence rates of PTSD, assessed using the PTSD module of the Composite International Diagnostic Interview version 2.1 and evaluated in relation to traumatic events, assessed using an adapted version of the Life Events and Social History Questionnaire.
The prevalence rate of assessed PTSD was 37.4% in Algeria, 28.4% in Cambodia, 15.8% in Ethiopia, and 17.8% in Gaza. Conflict-related trauma after age 12 years was the only risk factor for PTSD that was present in all 4 samples. Torture was a risk factor in all samples except Cambodia. Psychiatric history and current illness were risk factors in Cambodia (adjusted odds ratio [OR], 3.6; 95% confidence interval [CI], 2.3-5.4 and adjusted OR,1.6; 95% CI, 1.0-2.7, respectively) and Ethiopia (adjusted OR, 3.9; 95% CI, 2.0-7.4 and adjusted OR, 1.8; 95% CI, 1.1-2.7, respectively). Poor quality of camp was associated with PTSD in Algeria (adjusted OR, 1.8; 95% CI, 1.3-2.5) and in Gaza (adjusted OR, 1.7; 95% CI, 1.1-2.8). Daily hassles were associated with PTSD in Algeria (adjusted OR, 1.6; 95% CI, 1.1-2.4). Youth domestic stress, death or separation in the family, and alcohol abuse in parents were associated with PTSD in Cambodia (adjusted OR, 1.7; 95% CI, 1.1-2.6; adjusted OR, 1.7; 95% CI, 1.0-2.8; and adjusted OR, 2.2; 95% CI, 1.1-4.4, respectively).
Using the same assessment methods, a wide range of rates of symptoms of PTSD were found among 4 low-income populations who have experienced war, conflict, or mass violence. We identified specific patterns of risk factors per country. Our findings indicate the importance of contextual differences in the study of traumatic stress and human rights violations.
Exposure to intimate partner violence (IPV) is a common feature of women living in low- and middle-income countries. Several studies have shown a significant association between IPV against women and mental health in both developed and in low- and middle-income countries. In postconflict settings, the relationship between IPV and mental health is likely more complex, given the high levels of violence experienced by the population as a whole. In this cross-sectional study the authors explore the association between IPV and common mental health disorders (CMD), and more specifically, suicidal ideation, among inhabitants of postgenocide Rwanda. The authors use the concept of “mutual partner violence,” thereby exploring the association between IPV and CMD in victims, perpetrators, and those who state they are both. Data of 241 married men and women were used. Symptoms suggestive of CMD were established by use of the Self-Reporting Questionnaire (SRQ-20), and physical intimate partner violence was measured using the Conflict Tactics Scale, Short Version (CTS2S). The authors applied multivariate logistic regressions with total SRQ-20 scores (above/below cutoff) and suicidal ideation as the outcome measures and corrected for age and gender. The study findings suggest that reported IPV is associated with CMD (odds ratio [OR] = 1.7, 95% confidence interval [95% CI] = 0.92-3.15) and suicidal ideation (OR = 1.6, 95% CI = 0.70-3.53). Those who state to be both victim and perpetrator (OR = 1.75, 95% CI = 0.82-3.72), or only perpetrator (OR = 3.13, 95% CI = 0.49-20.0), are more likely to report mental health problems than victims and people who do not report IPV. In a postconflict situation, perpetrators of IPV may suffer from mental health problems as much as, or even more than, victims. Longitudinal data are needed to clarify the complex relationship between CMD and IPV, especially if outcomes may also be related to other forms of violence experienced in the past.
Although prevention efforts aimed at eliminating the occurrence of sexual assault are clearly needed, it is also important to consider how we can prevent further trauma among those already victimized. Prior research suggests that rape survivors may experience victim-blaming treatment from system personnel (termed secondary victimization or the second rape). This research examined how postassault contact with community systems exacerbated rape victims' psychological and physical health distress. Findings revealed that the majority of rape survivors who reported their assault to the legal or medical system did not receive needed services. These difficulties with service delivery were associated with both perceived and objective measures of negative health outcomes. Contact with the mental health system, rape crisis centers, or religious communities was generally perceived by victims as beneficial. This study suggests that the trauma of rape extends far beyond the assault itself, as negative community responses can significantly elevate distress.
One of the most significant shifts in current thinking on war and gender is the recognition that rape in wartime is not a
simple by-product of war, but often a planned and targeted policy. For many feminists ‘rape as a weapon of war’ provides a
way to articulate the systematic, pervasive, and orchestrated nature of wartime sexual violence that marks it as integral
rather than incidental to war. This recognition of rape as a weapon of war has taken on legal significance at the Rwandan
and Yugoslav Tribunals where rape has been prosecuted as a crime against humanity and genocide. In this paper, I examine how
the Rwanda Tribunal’s record of judgments conceives of rape enacted as an instrument of the genocide. I consider in particular
how the Tribunal’s conception of ‘rape as a weapon of war’ shapes what can be known about sexual violence and gender in the
Rwandan genocide and what cannot, the categories of victims legally recognised and those that are not, and the questions pursued,
and those foreclosed, about the patterns of violence before and during the genocide.
The objective of this study was to review original research on the intersection of violence against women by intimate partners and risk for HIV infection and highlight opportunities for new research and programme development. Seventy-one articles presenting original, peer-reviewed research conducted with females aged 12 years and older in heterosexual relationships during the past decade (1998-2007) were reviewed. Studies were eligible for inclusion if they addressed intimate partner violence (IPV) against women and HIV/AIDS as mutual risk factors. The prevalence of IPV and HIV infection among women varies globally, but females remain at elevated risk for both IPV and sexually transmitted/HIV infection, independently and concurrently. Comparisons between sero-negative and -positive women varied by geographic region; African HIV-positive women reported higher rates of victimisation while findings were inconsistent for HIV-positive women in the USA. Studies among various populations support the existence of a temporally and biologically complex relationship between HIV risk, lifetime exposure to violence and substance use, which are further complicated by gender and sexual decision-making norms. A possible link between violence-related post traumatic stress disorder and comorbid depression on immunity to HIV acquisition and HIV disease progression warrants further investigation. Sexual risk related to IPV works through both male and female behaviour, physiological consequences of violence and affects women across the lifespan. Further physiological and qualitative research is needed on the mechanisms of enhanced transmission; prospective studies are critical to address issues of causality and temporality. Prevention efforts should focus on the reduction of male-perpetrated IPV and male HIV risk behaviours in intimate partnerships.
The 1994 genocide in Rwanda led to the loss of at least 10% of the country's 7.7 million inhabitants, the destruction of much of the country's infrastructure, and the displacement of nearly 4 million people. In seeking to rebuild societies such as Rwanda, it is important to understand how traumatic experience may shape the ability of individuals and groups to respond to judicial and other reconciliation initiatives.
To assess the level of trauma exposure and the prevalence of posttraumatic stress disorder (PTSD) symptoms and their predictors among Rwandans and to determine how trauma exposure and PTSD symptoms are associated with Rwandans' attitudes toward justice and reconciliation.
Multistage, stratified cluster random survey of 2091 eligible adults in selected households in 4 communes in Rwanda in February 2002.
Rates of exposure to trauma and symptom criteria for PTSD using the PTSD Checklist-Civilian Version; attitudes toward judicial responses (Rwandan national and gacaca local trials and International Criminal Tribunal for Rwanda [ICTR]) and reconciliation (belief in community, nonviolence, social justice, and interdependence with other ethnic groups).
Of 2074 respondents with data on exposure to trauma, 1563 (75.4%) were forced to flee their homes, 1526 (73.0%) had a close member of their family killed, and 1472 (70.9%) had property destroyed or lost. Among the 2091 total participants, 518 (24.8%) met symptom criteria for PTSD. The adjusted odds ratio (OR) of meeting PTSD symptom criteria for each additional traumatic event was 1.43 (95% CI, 1.33-1.55). More respondents supported the local judicial responses (90.8% supported gacaca trials and 67.8% the Rwanda national trials) than the ICTR (42.1% in support). Respondents who met PTSD symptom criteria were less likely to have positive attitudes toward the Rwandan national trials (OR, 0.77; 95% CI, 0.61-0.98), belief in community (OR, 0.76; 95% CI, 0.60-0.97), and interdependence with other ethnic groups (OR, 0.71; 95% CI, 0.56-0.90). Respondents with exposure to multiple trauma events were more likely to have positive attitudes toward the ICTR (OR, 1.10; 95% CI, 1.04-1.17) and less likely to support the Rwandan national trials (OR, 0.90; 95% CI, 0.84-0.96), the local gacaca trials (OR, 0.80; 95% CI, 0.72-0.89), and 3 factors of openness to reconciliation: belief in nonviolence (OR, 0.92; 95% CI, 0.87-0.97), belief in community (OR, 0.92; 95% CI, 0.87-0.98), and interdependence with other ethnic groups (OR, 0.86; 95% CI, 0.81-0.92). Other variables that were associated with attitudes toward judicial processes and openness to reconciliation were educational level, ethnicity, perception of change in poverty level and access to security compared with 1994, and ethnic distance.
This study demonstrates that traumatic exposure, PTSD symptoms, and other factors are associated with attitudes toward justice and reconciliation. Societal interventions following mass violence should consider the effects of trauma if reconciliation is to be realized.
In 2003, Rwandan women’s associations issued an international
call to aid women who had been raped and infected with human immunodeficiency
virus (HIV) during the genocide, and who were becoming sick and dying. As
difficult as it was for the world to comprehend the tragedy of the 1994 events,
it was even more incomprehensible that while women with HIV were not receiving
antiretroviral medications, alleged perpetrators were receiving treatment
in prison.1
This article summarises findings from ten countries from the WHO multi-country study on women's health and domestic violence against women.
Standardised population-based surveys were done between 2000 and 2003. Women aged 15-49 years were interviewed about their experiences of physically and sexually violent acts by a current or former intimate male partner, and about selected symptoms associated with physical and mental health. The women reporting physical violence by a partner were asked about injuries that resulted from this type of violence.
24,097 women completed interviews. Pooled analysis of all sites found significant associations between lifetime experiences of partner violence and self-reported poor health (odds ratio 1.6 [95% CI 1.5-1.8]), and with specific health problems in the previous 4 weeks: difficulty walking (1.6 [1.5-1.8]), difficulty with daily activities (1.6 [1.5-1.8]), pain (1.6 [1.5-1.7]), memory loss (1.8 [1.6-2.0]), dizziness (1.7 [1.6-1.8]), and vaginal discharge (1.8 [1.7-2.0]). For all settings combined, women who reported partner violence at least once in their life reported significantly more emotional distress, suicidal thoughts (2.9 [2.7-3.2]), and suicidal attempts (3.8 [3.3-4.5]), than non-abused women. These significant associations were maintained in almost all of the sites. Between 19% and 55% of women who had ever been physically abused by their partner were ever injured.
In addition to being a breach of human rights, intimate partner violence is associated with serious public-health consequences that should be addressed in national and global health policies and programmes.
Health systems in countries emerging from conflict are often characterised by damaged infrastructure, limited human resources, weak stewardship and a proliferation of non-governmental organisations. This can result in the disrupted and fragmented delivery of health services. One increasingly popular response to improve health service delivery in post-conflict countries is for the country government and international donors to jointly contract non-governmental organisations to provide a Basic Package of Health Services for all the country’s population. This approach is being applied in Afghanistan and Southern Sudan and is planned for the Democratic Republic of Congo. The approach is novel because it is intended as the only primary care service delivery mechanism throughout the country, with the available financial health resources primarily allocated to it. Although the aim is to scale up health services rapidly, including sexual and reproductive health services, there are a number of implications for such sub-sectors. This paper describes the Basic Package of Health Services contracting approach and discusses some of the potential challenges this approach may have for sexual and reproductive health services, particularly the challenges of availability and quality of services, and advocacy for these services.
Résumé
Dans les pays émergeant d’un conflit, les systèmes de santé sont souvent caractérisés par des infrastructures endommagées, des ressources humaines limitées, la faiblesse de la direction et une prolifération d’organisations non gouvernementales, ce qui peut aboutir à une désorganisation et une fragmentation des services de santé. Pour améliorer la prestation des services de santé dans ces pays, il est de plus en plus fréquent que le gouvernement national et les donateurs internationaux passent conjointement un contrat avec des organisations non gouvernementales chargées d’assurer un ensemble de services sanitaires de base pour toute la population du pays. Cette approche est appliquée en Afghanistan et au Sud Soudan, et elle est prévue pour la République démocratique du Congo. Elle est novatrice en cela qu’elle est le seul mécanisme de prestation des soins de santé primaires dans l’ensemble du pays et que les ressources financières de santé sont principalement allouées par son truchement. Même si le but est d’élargir rapidement les services de santé, y compris de santé génésique, il existe un certain nombre de conséquences pour ces sous-secteurs. Cet article décrit l’approche contractuelle de l’ensemble de services sanitaires de base et aborde certains de ses enjeux potentiels pour les services de santé génésique, en particulier du point de vue de la disponibilité et la qualité des services, et du plaidoyer pour ces services.
Resumen
Los sistemas de salud en países emergentes de conflicto suelen caracterizarse por una infraestructura deficiente, recursos humanos limitados, liderazgo débil y una proliferación de organizaciones no gubernamentales. Esto puede propiciar la interrupción y fragmentación de la prestación de servicios de salud. Una respuesta cada vez más popular para mejorar dicha prestación en países post-conflicto es que el gobierno del país y los donantes internacionales contraten conjuntamente organizaciones no gubernamentales para proporcionar un Paquete Básico de Servicios de Salud para toda la población. Esta estrategia se está aplicando en Afganistán y Sudán Meridional, y está planeada para la República Democrática del Congo. Es una estrategia novedosa porque fue ideada como el único mecanismo de prestación de servicios en el primer nivel de atención, en todo el país, con los recursos financieros de salud disponibles principalmente asignados a ella. Aunque el objetivo es la rápida ampliación de los servicios de salud, incluidos los de salud sexual y reproductiva, existen numerosas implicaciones para estos subsectores. En este artículo se describe la estrategia de contratación del Paquete Básico de Servicios de Salud, y se analizan algunos de los retos posibles en cuanto a los servicios de salud sexual y reproductiva, particularmente los retos de disponibilidad y calidad de los servicios, así como su promoción y defensa.
Health systems in countries emerging from conflict are often characterised by damaged infrastructure, limited human resources, weak stewardship and a proliferation of non-governmental organisations. This can result in the disrupted and fragmented delivery of health services. One increasingly popular response to improve health service delivery in post-conflict countries is for the country government and international donors to jointly contract non-governmental organisations to provide a Basic Package of Health Services for all the country’s population. This approach is being applied in Afghanistan and Southern Sudan and is planned for the Democratic Republic of Congo. The approach is novel because it is intended as the only primary care service delivery mechanism throughout the country, with the available financial health resources primarily allocated to it. Although the aim is to scale up health services rapidly, including sexual and reproductive health services, there are a number of implications for such sub-sectors. This paper describes the Basic Package of Health Services contracting approach and discusses some of the potential challenges this approach may have for sexual and reproductive health services, particularly the challenges of availability and quality of services, and advocacy for these services.
Résumé
Dans les pays émergeant d’un conflit, les systèmes de santé sont souvent caractérisés par des infrastructures endommagées, des ressources humaines limitées, la faiblesse de la direction et une prolifération d’organisations non gouvernementales, ce qui peut aboutir à une désorganisation et une fragmentation des services de santé. Pour améliorer la prestation des services de santé dans ces pays, il est de plus en plus fréquent que le gouvernement national et les donateurs internationaux passent conjointement un contrat avec des organisations non gouvernementales chargées d’assurer un ensemble de services sanitaires de base pour toute la population du pays. Cette approche est appliquée en Afghanistan et au Sud Soudan, et elle est prévue pour la République démocratique du Congo. Elle est novatrice en cela qu’elle est le seul mécanisme de prestation des soins de santé primaires dans l’ensemble du pays et que les ressources financières de santé sont principalement allouées par son truchement. Même si le but est d’élargir rapidement les services de santé, y compris de santé génésique, il existe un certain nombre de conséquences pour ces sous-secteurs. Cet article décrit l’approche contractuelle de l’ensemble de services sanitaires de base et aborde certains de ses enjeux potentiels pour les services de santé génésique, en particulier du point de vue de la disponibilité et la qualité des services, et du plaidoyer pour ces services.
Resumen
Los sistemas de salud en países emergentes de conflicto suelen caracterizarse por una infraestructura deficiente, recursos humanos limitados, liderazgo débil y una proliferación de organizaciones no gubernamentales. Esto puede propiciar la interrupción y fragmentación de la prestación de servicios de salud. Una respuesta cada vez más popular para mejorar dicha prestación en países post-conflicto es que el gobierno del país y los donantes internacionales contraten conjuntamente organizaciones no gubernamentales para proporcionar un Paquete Básico de Servicios de Salud para toda la población. Esta estrategia se está aplicando en Afganistán y Sudán Meridional, y está planeada para la República Democrática del Congo. Es una estrategia novedosa porque fue ideada como el único mecanismo de prestación de servicios en el primer nivel de atención, en todo el país, con los recursos financieros de salud disponibles principalmente asignados a ella. Aunque el objetivo es la rápida ampliación de los servicios de salud, incluidos los de salud sexual y reproductiva, existen numerosas implicaciones para estos subsectores. En este artículo se describe la estrategia de contratación del Paquete Básico de Servicios de Salud, y se analizan algunos de los retos posibles en cuanto a los servicios de salud sexual y reproductiva, particularmente los retos de disponibilidad y calidad de los servicios, así como su promoción y defensa.
This article describes the concept of posttraumatic growth, its conceptual foundations, and supporting empirical evidence. Posttraumatic growth is the experience of positive change that occurs as a result of the struggle with highly challenging life crises. It is manifested in a variety of ways, including an increased appreciation for life in general, more meaningful interpersonal relationships, an increased sense of personal strength, changed priorities, and a richer existential and spiritual life. Although the term is new, the idea that great good can come from great suffering is ancient. We propose a model for understanding the process of posttraumatic growth in which individual characteristics, support and disclosure, and more centrally, significant cognitive processing involving cognitive structures threatened or nullified by the traumatic events, play an important role. It is also suggested that posttraumatic growth mutually interacts with life wisdom and the development of the life narrative, and that it is an on-going process, not a static outcome.
Sub-Saharan Africa most affected by armed conflict and
sexual violence
used as weapon of war. This area continues to record more new infections of HIV/AIDS. Among these conflicts, the Democratic Republic of Congo is deadliest since World War II, it caused more than 5, 4 million victims, more than 1, 80 million women and girls have been
sexually abused
. Beyond the cruelty of rape and its consequences, the victims are stigmatized and rejected by their families and communities. Wanting to escape the stigma and discrimination, the majority of victims do not report violence against forgoing preventive and curative care. Our study shows that Stigma and discrimination of victims of sexual violence are associated with the perception of rape and rigid social norms to the detriment of women, the fear of contagion to sexually transmitted infections, as well as shame and guilt families and communities. These factors increase the vulnerability of victims; exacerbate the consequences of sexual violence by isolating and denying care and social support. They could promote the silent spread of the AIDS epidemic. This analysis suggests the need for an effective fight against stigma. It involves: i) advocacy, communication and social mobilization at the community, ii) training of
medical staff
including traditional healers to support victims, iii) strengthening the capacity and resources of the health system, and iv) promoting of change in society through the adoption of sound social values and the emancipation of women.
Since the end of the Cold War, the traditional security paradigm has been insufficient. Transnational threats and internal conflicts are gaining significance within the security framework, including HIV/AIDS. Rwanda is both an AIDS-torn and a war-torn society, and the atrocities of the Rwandan genocide have exacerbated the problems of HIV/AIDS in Africa and contributed to its risks to human, national and international security. This paper examines HIV/AIDS in Rwanda in the context of the 1994 genocide and as a threat to human, national and international security through a post-conflict lens. It considers the actions to address the problem and provide recommendations for future action. A young child carries another, too weak to walk, at an orphanage near Goma in July 1994 (c) 1994 Corinne Dufka Securitization of HIV/AIDS HIV/AIDS is the greatest threat to mankind today, the greatest weapon of mass destruction on the earth. – US Secretary of State Collin Powell 1 HIV/AIDS has increasingly been considered a security threat by the governments of developed countries (particularly the United States and the United Kingdom) and international organizations such as the United Nations. For example, the US National Intelligence Council's identification of HIV/AIDS as a threat to US national security, and the human security of US citizens underscores that HIV/AIDS can be considered a security threat beyond the regions where it has the most direct impact: New and reemerging infectious diseases will pose a rising global health threat and will complicate US and global security over the next 20 years. These diseases will endanger US 1 "Could AIDS explode in India?" The Economist, April 17 – 23, 2004, pg. 9.
This article situates the sexual violence associated with the Rwandan civil war and 1994 genocide within a local cultural history and political economy in which institutionalized gender violence shaped the choices of Rwandan women and girls. Based on ethnographic research, it argues that Western notions of sexual consent are not applicable to a culture in which colonialism, government policy, war, and scarcity of resources have limited women's access to land ownership, economic security, and other means of survival. It examines emic cultural models of sexual consent and female sexual agency and proposes that sexual slavery, forced marriage, prostitution, transactional sex, nonmarital sex, informal marriage or cohabitation, and customary (bridewealth) marriages exist on a continuum on which female sexual agency becomes more and more constrained by material circumstance. Even when women's choices are limited, women still exercise their agency to survive. Conflating all forms of sex in conflict zones under the rubric of harm undermines women's and children's rights because it reinforces gendered hierarchies and diverts attention from the structural conditions of poverty in postconflict societies.
For centuries, the rape of women has been used as a tactic of war to advance one group's political, economic, social, or religious position over another. Systematic mass rape devastates individual women and destroys the fabric of families and communities. This article argues that the systematic nature of rape as a tactic of war exists against a backdrop of rigid cultural norms of gender and women's sexuality, social dominance and power within group conflict, and a soldier's social identity as a man and a member of a particular military.
There are too many easy reasons to want to forget horrors, especially the horrors that constitute genocide. Living through a situation develops a different level of awareness and response than being distant and not personally implicated in it. This realization highlights the need to recognize that it is not because of the lack of compassion that we tend to “forget” so quickly, but rather it is the lack of right understanding about how to make a difference that is complicit in our cognitive failures. The intent of this reflection is to provide a context for remembering Rwanda and for providing a healing perspective on similar disasters. In this regard, a brief overview and historical context of the conflicts that led to the killing in Rwanda is presented, followed by a discussion of the survival issues experienced by the women of Rwanda during the 100 days of terror and death and the implications of a healing perspective.
Sexual and gender-based violence in armed conflicts lacks visibility and is not fully understood as it is often labelled as a woman's-only issue. Its gendered nature extends beyond the actual period ofconflict, into the period of rehabilitation and reconstruc tion, carrying with it many physical and psychological problems. The sufference endured by women both during the following the conflict is strictly related to the rooted structural gender inequalities within societies in general. In situations of conflict women's oppression and abuse further increase their usual subordination. For example, traditional barriers to health care, including the lack of diagnostic equipment and adequate treatment; the insufficiency of premises for the treatment of survivors; the lack of dedicated venues to seek assistance; poor supplies of essential and specific drugs, together with an inadequacy of health personnel, become even more problematic, and all contribute to poor primary health care.
Therefore, understanding the roots of unequal gender treatment, and thus the cultural setting of a community; becomes essential when dealing with the phenomenon of sexual violence. In particular, multidimensional and gender-sensitive health responses to sexual violence should be designed, and services taking into account its multifaceted nature should be provided.
This paper addresses human rights vio- lations in the context of gender power relationships and calls attention to the need to examine the s tandards for human rightsassessments in the context of refu- gee situations. This research is based on fieldwork carried out with Rwandan Hutu refugees during an 18-mon th as- signment as Project Directorfor CARE International in Ngara, Tanzania. Par- ticipant obseruations, interviews, sur- veys, and focus group discussions yielded a wealth of data concerning the coping strategies of men and women. Women's coping strategies made them vulnerable: women without partners we the least protected and took thegreatest risks in their eflorts to survive and feed their children. Their adaptive behaviour increased their
In institutionalizing gacaca, the Rwandan government has launched one of the most ambitious transitional justice projects the world has ever seen. But gacaca is controversial, and its contribution to postconflict reconciliation is unclear. Through public opinion surveys, trial observations, and interviews, this study provides a window into how gacaca has shaped interethnic relations in one Rwandan community. Although gacaca has brought more people to trial than the ICTR, transnational trials, and the ordinary Rwandan courts combined, gacaca exposes—and perhaps deepens—conflict, resentment, and ethnic disunity. Lies, half-truths, and silence have limited gacaca's contribution to truth, justice, and reconciliation.
Purpose:
We examined whether established associations between HIV disease and HIV disease progression on worse health-related quality of life (HQOL) were applicable to women with severe trauma histories, in this case Rwandan women genocide survivors, the majority of whom were HIV-infected. Additionally, this study attempted to clarify whether post-traumatic stress symptoms were uniquely associated with HQOL or confounded with depression.
Methods:
The Rwandan Women's Interassociation Study and Assessment was a longitudinal prospective study of HIV-infected and uninfected women. At study entry, 922 women (705 HIV+ and 217 HIV-) completed measures of symptoms of post-traumatic stress and HQOL as well as other demographic, clinical, and behavioral characteristics.
Results:
Even after controlling for potential confounders and mediators, HIV+ women, in particular those with the lowest CD4 counts, scored significantly worse on HQOL and overall quality of life (QOL) than did HIV- women. Even after controlling for depression and HIV disease progression, women with more post-traumatic stress symptoms scored worse on HQOL and overall QOL than women with fewer post-traumatic stress symptoms.
Conclusions:
This study demonstrated that post-traumatic stress symptoms were independently associated with HQOL and overall QOL, independent of depression and other confounders or potential mediators. Future research should examine whether the long-term impact of treatment on physical and psychological symptoms of HIV and post-traumatic stress symptoms would generate improvement in HQOL.
This paper draws attention to the obligation and opportunity to respond to the mental health impacts of collective sexual violence (CSV) among genocide-rape survivors in post-genocide Rwanda. Qualitative data gathered from CSV survivors who were members of Rwandan women's genocide survivor associations are presented to illustrate how they strive to overcome adversity while seeking access to quality mental health care and using informal community mental health services. The results reveal that a system of high quality, holistic health and mental health care is yet needed to meet Rwandan CSV survivors' complex and serious health and mental health needs. Given that a rural health system, modelled on community-based, comprehensive HIV/AIDS care and treatment, is currently being implemented in Rwanda, we recommend enhancements to this model that would contribute to meeting the mental health care needs of CSV survivors while benefiting the health and mental health system as a whole within Rwanda.
The purpose of this study was to explore the lived experience of women who were raped during the 1994 genocide in Rwanda.
A phenomenological approach was used and this study was carried out in Rwanda in three different locations. The 7 participants took part in three semi-structured, individual interviews which were audiotaped.
Participants reported many themes unique to Rwandan women survivors of genocide. These themes included violation by perceived inferiors, loss of dignity and respect, loss of identity, social isolation, loss of hope for the future (i.e., HIV/AIDS), the ongoing torture of rape babies, and developing a sense of community.
Rwandan women survivors of the 1994 genocide have lived through unimaginable suffering. Limited information is available regarding the experiences of these rape survivors and this information could create awareness and some understanding of what these women endured.
This study can help nurses to understand the sequelae of war and rape and thus have needed information which can be used to offer assistance to women in these circumstances.
Large numbers of pregnant women in Africa have been invited to participate in studies on HIV infection. Study protocols adhere to guidelines on voluntary participation after pre-test and post-test counselling and informed consent; nevertheless, women may consent because they have been asked to do so without fully understanding the implications of being tested for HIV. Our studies in Nairobi, Kenya, show that most women tested after giving informed consent did not actively request their results, less than one third informed their partner, and violence against women because of a positive HIV-antibody test was common. It is important to have carefully designed protocols weighing the benefits against the potential harms for women participating in a study. Even after having consented to HIV testing, women should have the right not to be told their result.
Current public health policy encourages partner notification to protect those at risk of HIV infection. Provider experiences with partner notification, domestic violence, and women with HIV compel a reassessment of this strategy. In a survey of 136 health care providers in Baltimore, substantial numbers reported knowledge of their HIV-infected patients' experiences with domestic violence before and after partner notification. Providers believed that fear of physical abuse, emotional abuse, and abandonment are important reasons why many female patients resist partner notification. Provider opposition to partner notification was strong in cases where female patients faced a risk of domestic violence. The realization that HIV-infected women fear and experience domestic violence has broad implications for health care practice. The authors recommend changes in provider practices to insure that the risk of domestic violence is identified and addressed, and that partner notification strategies do not threaten the safety of HIV-infected women. They also highlight areas for further research on the connections among partner notification, domestic violence, and women with HIV.
Women represent an increasing proportion of AIDS cases and anecdotal reports suggest some face substantial risks when others learn they are HIV-positive. The purpose of this paper is to describe women's fears and experiences regarding disclosure of their HIV status. Fifty HIV-positive women, ages 16-45 from urban teaching hospital outpatient clinics, were interviewed using an in-depth, qualitative interview. Eighty-six percent of the women were African American and 56% were current or former IVDU. At the time of the interview, 88% of the women had known their HIV status for a year or more. All but one woman had disclosed her HIV status to at least one person and 82% had disclosed to multiple people. Although two-thirds of the women had been afraid to disclose to others because of concerns about rejection, discrimination or violence, three-quarters of the sample reported only supportive and understanding responses to their disclosure. One-quarter of the sample reported negative consequences of disclosure, including rejection, abandonment, verbal abuse and physical assault. Disclosure-related violence was discussed by nine women (18%): two who feared violence were relieved to find a supportive response; four chose not to disclose their status because they feared violence; and three women were verbally or physically assaulted. Fear of mistreatment figured prominently in decisions about disclosure among this sample. That many women found supportive and understanding responses is encouraging. However, there were sufficient examples of negative consequences, including violence, to suggest individualized approaches to post-test counseling, enhanced support services for HIV-positive women, and public education to destigmatize HIV-disease.
The purpose of this paper is to review the available literature on the intersections between HIV and violence and present an agenda for future research to guide policy and programs. This paper aims to answer four questions: (1) How does forced sex affect women's risk for HIV infection? (2) How do violence and threats of violence affect women's ability to negotiate condom use? (3) Is the risk of violence greater for women living with HIV infection than for noninfected women? (4) What are the implications of the existing evidence for the direction of future research and interventions? Together this collection of 29 studies from the US and from sub-Saharan Africa provides evidence for several different links between the epidemics of HIV and violence. However, there are a number of methodological limitations that can be overcome with future studies. First, additional prospective studies are needed to describe the ways which violence victimization may increase women's risk for HIV and how being HIV positive affects violence risk. Future studies need to describe men's perspective on both HIV risk and violence in order to develop effective interventions targeting men and women. The definitions and tools for measurement of concepts such as physical violence, forced sex, HIV risk, and serostatus disclosure need to be harmonized in the future. Finally, combining qualitative and quantitative research methods will help to describe the context and scope of the problem. The service implications of these studies are significant. HIV counseling and testing programs offer a unique opportunity to identify and assist women at risk for violence and to identify women who may be at high risk for HIV as a result of their history of assault. In addition, violence prevention programs, in settings where such programs exist, also offer opportunities to counsel women about their risks for sexually transmitted diseases and HIV.
Gender-based violence and gender inequality are increasingly cited as important determinants of women's HIV risk; yet empirical research on possible connections remains limited. No study on women has yet assessed gender-based violence as a risk factor for HIV after adjustment for women's own high-risk behaviours, although these are known to be associated with experience of violence.
We did a cross-sectional study of 1366 women presenting for antenatal care at four health centres in Soweto, South Africa, who accepted routine antenatal HIV testing. Private face-to-face interviews were done in local languages and included assessement of sociodemographic characteristics, experience of gender-based violence, the South African adaptation of the Sexual Relationship Power Scale (SRPS), and risk behaviours including multiple, concurrent, and casual male partners, and transactional sex.
After adjustment for age and current relationship status and women's risk behaviour, intimate partner violence (odds ratio 1.48, 95% CI 1.15-1.89) and high levels of male control in a woman's current relationship as measured by the SRPS (1.52, 1.13-2.04) were associated with HIV seropositivity. Child sexual assault, forced first intercourse, and adult sexual assault by non-partners were not associated with HIV serostatus.
Women with violent or controlling male partners are at increased risk of HIV infection. We postulate that abusive men are more likely to have HIV and impose risky sexual practices on partners. Research on connections between social constructions of masculinity, intimate partner violence, male dominance in relationships, and HIV risk behaviours in men, as well as effective interventions, are urgently needed.
Rwanda: Death, despair and defiance
- African Rights
Rwanda: “Marked for death,” rape survivors living with HIV/AIDS in Rwanda Retrieved from http
- Amnesty International
Education Initiative
- Foundation Rwanda
Foundation Rwanda. (2012a). Education Initiative. Retrieved from http://www.foundationr
wanda.org/ourimpact/educationinitiative.aspx