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Women's Health in Context
War, Rape, and Genocide: Never Again?
Martin Donohoe, MD, FACP
Medscape Ob/Gyn & Women's Health 9(2), 2004. © 2004 Medscape
Posted 10/18/2004
Introduction
The ongoing genocide in the Sudan -- where 50,000 people have been killed, more than 1 million
made homeless, and where thousands of women have been gang-raped by the governmentsupported Janjaweed militias -- has focused international attention on the issue of rape in war. [1]
History
There were 250 wars in the 20th century, and the incidence of war is rising.[2] Most conflicts are
within and between small states, many in sub-Saharan Africa. At the close of the 19th century,
most casualties were among soldiers; today, 85% to 90% are among civilians.[2]
Women have always been considered among the "spoils of war." Accounts of rape in war date
back to ancient Greece -- the archetypal abduction of Helen of Troy and the rape of the Sabine
women, for example.[3] Many hundreds of thousands of women have been raped in wars in the
past hundred years. Examples include the following:
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In World War II, Japanese soldiers forced between 100,000 and 200,000 women into
sexual slavery. Most were from Korea, but others came from Burma, China, Holland,
Indonesia, the Philippines, and Taiwan.[4] These so-called "comfort women" were usually
sent to the front lines where they were forced into sexual slavery. Some underwent
forced hysterectomies to prevent menstruation and thereby make them constantly
available.[4] More than half of the women and girls died as a direct result of the treatment
they received.[5] Many survivors were detained in the program for 3 to 5 years, and most
were raped 5 to 20 times per day.[5] For 3 years of enslavement, this comes to a low
estimate of 7500 rapes per person. Japan has not compensated any of these victims.[5]
Rape occurred during the Vietnam War. Perpetrators included US soldiers; few have
been brought to justice.[6]
During Bangladesh's 9-month war for independence in 1971, between 250,000 and
400,000 girls and women were raped, leading to an estimated 25,000 pregnancies.[3]
In Rwanda, at least 250,000 women were raped in the 1994 genocide.[7]
During the 1990s, more than 20,000 Muslim women were raped as part of an ethnic
cleansing campaign in Bosnia.[7]
Credible allegations of sexual humiliation and rape against female detainees at US
facilities in Afghanistan and Iraq have been well documented.[8-11]
Other conflicts in which rape was widespread include civil wars in the Democratic
Republic of the Congo, Liberia, Sierra Leone, and Somalia.
War and "Masculinity"
The persistence of war and its accompanying sexual violence throughout history relates in part to
the pervasive glorification of war and its acceptance as a means of resolving conflict. [4] This
glorification is linked to antiquated definitions of appropriate masculine behavior and coming-ofage rites. The vocabulary and imagery of war are laden with denigrations of the feminine and
perverse phallic imagery of weapons as extensions of male generative organs. [4] Sexual imagery
is employed in advertisements for arms, which are described in terms of "hardness, penetration,
and thrust."[4] Military bases are commonly associated with prostitution, which is tacitly accepted
by commanding officers and local authorities.[4,7] Men dominate as the major decision makers
when it comes to pursuing militarization, fighting wars, and resolving international conflicts. [4]
Violence and Rape in War
Women and girls subject to rape in war are already vulnerable, suffering from both individual and
societal forms of violence.[12-15] Individual forms of violence include domestic abuse, involuntary
marriage, marital rape, forced labor, dowry-related murder, bride burning, honor killings, forced
abortion and prostitution, child prostitution and sex slavery.[12-14] Examples of societal forms of
violence against women, structural forms of discrimination or deprivation that affect women as a
class, include poverty, limited opportunities for employment or education, divorce restrictions,
salary inequities, political marginalization, and impaired access to reproductive health services. [1214]
Rape in war includes both individual, albeit widespread, acts of sexual violence and the
systematic rape of women and children as an act of genocide, a strategy to terrorize and
ethnically cleanse a population.[3,16] Rape in war is usually more sadistic than rape outside of war,
if that is possible. Genocidal rapes are often committed in the presence of a woman's husband
and children, who are often then killed. This compounds the subjugation and humiliation of the
enemy. If the woman becomes pregnant, she may be forced to bear a child that has been
"ethnically cleansed" by the seed of the rapist. In Rwanda after the 1994 genocide, as many as
5000 children were born to women as a result of rape.[16] These offspring became known as
enfants mauvais souvenir, or children of bad memories. Many women have difficulty caring for
these children, and there have been reports of abandonment and infanticide. [16]
Although less common than female sexual assault during war, men have been raped; forced to
rape or commit sexual assault on others or to perform fellatio and other sexual acts on guards
and each other; and suffered castrations, circumcisions, and other sexual mutilations -- all under
threat of torture and/or death.[17] Male prisoners of US forces at Iraq's Abu Ghraib prison suffered
numerous forms of sexual humiliation, such as being forced to adopt homosexual group sex
poses.[8] Under several national and state legal systems, it is a legal impossibility for a man to be
raped. Healthcare providers are often inadequately trained to recognize and care for such victims.
Health Consequences
Physical sequelae of rape in war include traumatic injuries, sexually transmitted diseases
(including HIV infection), and pregnancy.[3,4,16,18] Emergency contraception, antibiotics, and access
to abortion are extremely limited. Short-term psychological consequences include fear and a
profound sense of helplessness and desperation.[4] In the long term, patients experience
depression, anxiety disorders (including posttraumatic stress disorder), multiple somatic
symptoms, flashbacks, difficulty reestablishing intimate relationships, shame, persistent fears,
and a blunting of enjoyment in life.[4,18]
Refugee Camps
Girls and women in refugee settings are also at risk of rape during armed conflict. [16] At border
crossings, they may be forced to endure rape as a "price of passage." Refugee camp guards may
rape women or force them into sex in return for protection from bandits or for basic goods,
including food.[16] The presence of abusive guards within camps, and bandits just outside, makes
simple tasks such as going to the latrine or gathering water or firewood (usually the woman's job)
dangerous, even life-threatening.[16,19]
Human Rights Issues
Violence against women and girls violates several principles enshrined in international and
regional human rights law, including the right to life, equality, security, equal protection under the
law, and freedom from torture and other cruel, inhumane, or degrading treatment.
Rape was specifically identified as a war crime for the first time in the Tokyo War Crimes Trials
after World War II, when commanders were held responsible for rapes committed by soldiers
under their command.[3] In 1993, the United Nations Commission on Human Rights passed a
resolution placing rape, for the first time, clearly within the framework of war crimes. [3] This was
reinforced by the 2001 ruling of the International War Crimes Tribunal in the Hague that rape of
civilians is a crime against humanity.[20] The International Criminal Tribunals for Rwanda and the
former Yugoslavia have successfully prosecuted cases of rape as a war crime and as an act of
genocide.[16] Other international agreements regarding the treatment of women in war include the
following:
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The Convention on the Elimination of all Forms of Discrimination Against Women
(CEDAW), adopted by the UN General Assembly in 1979, which calls for equality of the
sexes in political, social, cultural, civil, and other fields.[7]
UN Security Council Resolution 1325 (adopted in 2000), which mandates the protection
of, and respect for, the human rights of women and girls. It calls on all parties to armed
conflict to take specific measures to protect women and girls from gender-based
violence, particularly rape and sexual violence.[7,21]
The International Criminal Court (ICC), established by international treaty in 2002, which
codifies accountability for gender-based crimes against women during military conflict by
defining sexual and gender violence of all kinds as war crimes.[7]
Regrettably, the United States has not signed UNSCR 1325, nor joined 162 other countries in
ratifying CEDAW.[22] Despite the fact that 139 countries have signed on to the ICC, the United
States has failed to do so, in part out of fear that its own soldiers may be prosecuted for crimes
against humanity, including rape.[23]
Role of Health Professionals
The medical community can play an important role in confronting the atrocity of sexual assault in
war by documenting incidents of rape; using medical data to verify widespread rape; using
techniques of medical science to validate victims' testimony; and treating individual victims. [3]
Managing victims of sexual violence during war entails conducting a full history and physical
examination; treating physical injuries and sexually transmitted diseases; offering emergency
contraception and referral for abortion; providing counseling and psychological support;
facilitating the reporting of rape to the appropriate authorities; gathering forensic evidence; and
providing a certificate documenting findings of the rape examination (in triplicate, with a copy for
the victim, the United Nations High Commission of Refugees and the provider's medical
agency).[16] Health exams should be conducted in a confidential manner by trained workers in a
safe environment. Female providers should be widely available.[16]
Preventing sexual violence in camps for refugees and internally displaced people entails placing
water collection points and latrines in central, well-lighted areas; ensuring that food is distributed
directly to women; and housing female-headed groups and unaccompanied children in safe
areas.[16] Women should be involved in designing and helping to run the camps.[16]
Conclusions and Recommendations
The world's population is growing exponentially. Simultaneously, we are destroying the earth and
our common resources, such as the air we breathe and the water we drink. [24] Millions die each
year of starvation and diseases wrought by the ravages of poverty. Much of the world's
population lacks access to clean drinking water, sanitation, and even minimal healthcare. [24]
These stressors increase chances of hostilities. Furthermore, the growing worldwide supply of
small and large arms, facilitated in part by the US government on behalf of military contractors,
provides readily available tools for terrorizing, maiming, and killing soldiers and civilians alike. [2]
Each war represents a failure of our species to live in harmony, a waste of precious human
capital, a further scourge on the environment, and a crime against all humanity. And rape in war
represents the malevolent nadir of human behavior. Given the increasing spread of technology
and materials for the construction of weapons of both small- and large-scale destruction, the
enormity of the social and environmental problems facing humanity, and the realistic potential for
the demise of the human species, rapid change is desperately needed. Such change would
include moral leadership by the United States, through limiting its excessive consumption of
natural resources, building alliances and working with the United Nations to solve international
disputes, and vigorously investigating its own human rights abuses (eg, Abu Ghraib) and
prosecuting those responsible (no matter how elevated their status in the government). The
United States should join the other nations of the world in signing on to international agreements,
such as:
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The Convention on the Elimination of Discrimination Against Women
UN Security Council Resolution 1325
The International Criminal Court
The Kyoto Protocol on Climate Change
The Convention on the Prohibition of Anti-Personnel Land Mines
The Comprehensive Nuclear Test Ban Treaty
The Convention on the Rights of the Child
The Convention on Economic, Social and Cultural Rights and
The Convention for the Suppression of Traffic in Persons
Finally, the United States should join forces with the international community to apply rapidly both
economic and military pressure, including the protective use of military troops, to halt genocide
and mass rape when it occurs anywhere in the world. Regrettably, as the continuing massacre in
the Sudan makes clear, we are once again failing to do so. Inevitably, this will be bemoaned
when our current generation of "leaders" later laments, "Never again."
References
1. Robinson S. The tragedy of the Sudan. Time. October 4, 2004: 45-61.
2. Levy BS, Sidel VW (eds). War and public health - Updated edition. Washington, DC:
American Public Health Association; 2000.
3. Swiss S, Giller JE. Rape as a crime of war - a medical perspective. JAMA. 1993;270:612615.
4. Ashford MW, Huet-Vaughn Y. The impact of war on women. In Levy BS, Sidel VW (eds).
War and Public Health - Updated edition. Washington, DC: American Public Health
Association; 2000.
5. United Nations Commission on Human Rights, 51st session, Agenda item 11. War rape.
Available at: http://www.webcom.com/hrin/parker/c95-11.html. Accessed 9/20/04.
6. Staff. Tiger Force: Elite unit savaged civilians in Vietnam. Toledo Blade 2003 (October
22). Available at
http://www.toledoblade.com/apps/pbcs.dll/article?AID=/20031022/SRTIGERFORCE/110
190169. Accessed 9/18/04.
7. Marshall L. Militarism and violence against women. Z Magazine. 2004 (April):16-18.
8. Miles SH. Abu Ghraib: its legacy for military medicine. Lancet. 2004;364:725-729.
9. Article 15-6 Investigation of the 800th Military Police Brigade (The Taguba Report).
Available at http://news.findlaw.com/hdocs/docs/iraq/tagubarpt.html#FRother2.19.
Accessed 10/10/04.
10. Captain Donald J. Reese's sworn statement and interview. (Appendix to Taguba
investigation). Available at:
http://www.usnews.com/usnews/news/articles/040709/CPT_Reese.pdf. Accessed
10/10/04.
11. Colonel Thomas M. Pappas' sworn statement and interview. (Appendix to Taguba
investigation). Available at:
http://www.usnews.com/usnews/news/articles/040709/Pappas.pdf. Accessed 10/10/04.
12. Heise LL, Raikes A, Watts CH, et al. Violence against women: a neglected public health
issue in less developed countries. Soc Sci Med. 1994;39:1165-1179.
13. Donohoe MT. Violence and human rights abuses against women in the developing world.
Medscape Ob/Gyn and Women's Health. 2003;8(2). Posted 11/26/03. Available at:
http://www.medscape.com/viewarticle/464255.
14. Donohoe MT. Individual and societal forms of violence against women in the United
States and the developing world: an overview. Curr Women's Hlth Reports. 2002;2:313319.
15. Donohoe MT. Violence against women: epidemiology, recognition, and management of
partner abuse and sexual assault. Hospital Physician. October 2004; in press.
16. Shanks L, Schull MJ. Rape in war: the humanitarian response. CMAJ. 2000;163:11521156.
17. Carlson ES. Sexual assault on men in war. Lancet. 1997;349:129.
18. Amnesty International. Rape as a tool of war. Fact Sheet. Available at:
http://www.amnestyusa.org/stopviolence/factsheets/rapeinwartime.html. Accessed
10/12/04
19. Darfur Humanitarian Emergency. USAID. Available at:
http://www.usaid.gov/locations/sub-saharan_africa/sudan/darfur.html. Accessed
10/12/04.
20. Kafala T. What is a war crime? BBC News. 2003 (July 31). Available at
http://www.bbc.co.uk/gov/pr/fr/-/2/hi/europe/1420133.stm. Accessed 9/18/04.
21. Ward J, Vann B. Gender-based violence in refugee settings. Lancet. 2004;360(Suppl 1).
Available at
http://www.thelancet.com/journal/vol360/isss1/full/llan.360.s1.medicine_and_conflict.2336
9.1. Accessed 9/23/04.
22. Staff. National Organization of Women. Armies at war use rape as a weapon. Available at
http://www.now.org/nnt/fall-99/viewpoint.html. Accessed 9/17/04.
23. Official Web site. Rome Statute of the International Criminal Court. Available at
http://untreaty.un.org/ENGLISH/bible/englishinternetbible/partI/chapterXVIII/treaty10.asp.
Accessed 10/2/04.
24. Donohoe MT. Causes and health consequences of environmental degradation and social
injustice. Soc Sci Med. 2003;56:573-587.
Martin Donohoe, MD, FACP, is a practicing internist and teaches public health.
Disclosure: Martin Donohoe, MD, has no significant financial interests or relationships to disclose.
Public Health and Social Justice Website
http://www.phsj.org
martindonohoe@phsj.org