Rape in Armed Conflicts in the Democratic Republic of Congo: A Systematic Review of the Scientific Literature

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Article

Reference

Rape in Armed Conflicts in the Democratic Republic of Congo: A Systematic Review of the Scientific Literature

KABENGELE MPINGA, Emmanuel, et al.

Abstract

We conducted a systematic review of the scientific literature between 1996 and 2013 on rape in war-ridden Eastern Democratic Republic of Congo (DRC) in order to better understand the interest of the scientific community in describing the magnitude and characteristics of the problem. The literature search was conducted in French and English using several databases (Pubmed, PsycInfo, Sapphire, BDSP, Embase, Rero, and Web of Science) with the key words

"rape and DRC" combined with several Medical Subject Headings concepts. Our systematic review yielded 2,087 references, among which only 27 are original studies, that is 20 are based on population surveys and the remaining 7 are original data based on case studies and reviews. Ten studies provided prevalence rates of rape victims, 18 provided specific information on the profile of the victims, 10 reported that most of the perpetrators of rape were military personnel, 14 referred to the negligence of the government in protecting victims, and 10 reported a lack of competent health-care facilities. The awareness of rape in conflict-ridden DRC is still limited as reported in the [...]

KABENGELE MPINGA, Emmanuel, et al . Rape in Armed Conflicts in the Democratic Republic of Congo: A Systematic Review of the Scientific Literature. Trauma, Violence and Abuse , 2017, vol. 18, no. 5, p. 581-592

DOI : 10.1177/1524838016650184 PMID : 27207763

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Article

Rape in Armed Conflicts in the Democratic Republic of Congo: A Systematic Review of the Scientific Literature

Emmanuel Kabengele Mpinga

¹

, Mapendo Koya

²

,

Jennifer Hasselgard-Rowe

¹

, Emilien Jeannot

^1,3

, Sylvie B. Rehani

⁴

, and Philippe Chastonay

⁵

Abstract

We conducted a systematic review of the scientific literature between 1996 and 2013 on rape in war-ridden Eastern Democratic Republic of Congo (DRC) in order to better understand the interest of the scientific community in describing the magnitude and characteristics of the problem. The literature search was conducted in French and English using several databases (Pubmed, PsycInfo, Sapphire, BDSP, Embase, Rero, and Web of Science) with the key words ‘‘rape and DRC’’ combined with several Medical Subject Headings concepts. Our systematic review yielded 2,087 references, among which only 27 are original studies, that is 20 are based on population surveys and the remaining 7 are original data based on case studies and reviews. Ten studies provided prevalence rates of rape victims, 18 provided specific information on the profile of the victims, 10 reported that most of the perpetrators of rape were military personnel, 14 referred to the negligence of the government in protecting victims, and 10 reported a lack of competent health-care facilities. The awareness of rape in conflict-ridden DRC is still limited as reported in the scientific literature: Published scientific papers are scarce. Yet more research would probably help mobilize local authorities and the international community against this basic human rights violation.

Keywords

rape, torture, human rights, DR Congo, armed conflict

Introduction

For two decades, the African Great Lakes region has returned to the cycle of armed conflict with the epicenter being located in the eastern Democratic Republic of Congo (DRC). This region has experienced a succession of wars and armed conflicts since the so-called ‘‘Liberation War’’ that ended the regime of Mobutu led by the Alliance of Democratic Forces for the Liberation of Congo (AFDL) in 1996–1997. That war was followed by the war in 1998–2002 between the regime of Laurent-De´sire´ Kabila and the Rwandan, Burundi, Uganda, Namibia, Zambia, Chad, Angola, Zimbabwe, and Tanzania armed forces (De Villirers, 2005; Nashi, 2013). Then came the conflict between the National Congress for the Defense of the People (CNDP) and the Armed Forces of the Democratic Republic of Congo (FARDC) in 2007 and finally the conflict with the March 23 (M23) Movement in 2012–2013 (Huening, 2013). At present, the military operations being conducted against the Democratic Forces for the Liberation of Rwanda and those of Uganda, the Allied Democratic Forces (ADF or ADF-Nalu) as well as numerous militias on Congolese territory maintain the East of the country in a permanent state of war.

From a historical perspective, rape of women was a known phenomenon in precolonial African societies. In these

societies, the construction of social identities by the forced subjugation of weaker clans or ethnic groups, the struggles to access land or forests, purveyors of vital resources as well as the building of empires and kingdoms, have sometimes been accompanied by raids on livestock and the kidnapping of women (Chre´tien, 1991).

During colonization, rapes were reported as one of the methods of social control and exploitation which the regime of Le´opold II and after him the Kingdom of Belgium used. Inci- dentally, Brittain notes that:

1Institue of Global Health, University of Geneva, Geneva, Switzerland

2MPH Program, University of Geneva, Geneva, Switzerland and University of Applied Health Sciences (HESAV), Lausanne, Switzerland

3University of Applied Sciences of Western Switzerland, Geneva, Switzerland

4College of Pharmacy, University of Texas, Austin, TX, USA

5Swiss School of Public Health, Zurich, Switzerland

Corresponding Author:

Emmanuel Kabengele Mpinga, Institute of Global Health, University of Geneva, Campus Biotech, 9 Chemin des Mines, 1202 Geneva, Switzerland.

Email: [email protected]

TRAUMA, VIOLENCE, & ABUSE 1-12ªThe Author(s) 2016

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in the 1890s, it was the job of the Force Publique to force the Congolese to supply the wild rubber from the forests which had replaced ivory as the dominant factor in the economy. Each area was given a quota and, if it was not met, punishment had to be ruthlessly meted out, with hostage taking, rape, and the cutting off of ears and hands. The soldiers of the Force Publique were not trusted by their officers, who obliged them to bring back either the rubber or the ears and hands of villagers as proof that they had enforced the quota’’ (Brittain, 1999, p. 141)

The rape of women and girls was one of the characteristics of the armed struggle for independence in Africa. This has been reported in Algeria (Branche, 2002; Turshen, 2002), in Mozambique (Turshen, 2001), and in Kenya (Pommerolle, 2006) to mention but a few examples.

In some countries, after gaining independence, military and dictatorial regimes, arising from coups or falsified elections, have also resorted to violence and rape to subdue internal opposition or armed rebellions. During these conflicts, as noted by Jackson (2002, p. 3), ‘‘mutilation, torture of women and children, violent rituals and the forcible involvement of relatives, children and spouses in killing and rape are used as a means of waging war primarily by militia groups and by some state proxies.’’ Such situations have been all too numerous over the past 50 years and have not spared any region of the African continent: from Angola to Algeria, Sierra Leone, Uganda and Zimbabwe; from Congo Brazzaville to Senegal and Darfur; and from Mali to the Central African Republic and the DRC.

It has been reported that in 1998 Judge N Pillay of the International Criminal Tribunal for Rwanda, later to become the United Nations (UN) High Commissioner for Human Rights, said ‘‘From time immemorial, rape has been regarded as spoils of war. Now it will be considered a war crime’’

(Fomerand, 2014).

Indeed, rape in the course of war goes back to the early ages (Vikman, 2005). Focusing on Africa and approaching the issue from a public health perspective, the field of research on rape in armed conflicts in Africa is underdeveloped as is that of violence (Heise et al., 1994). Although studies focusing primarily on the epidemiological knowledge related to the forms and prevalence of rape, on understanding the roles and functions of rape in military strategies, on assessments of the impact of rape on individuals, families, and communities exist, the World Health Organization has stressed the need for a more systematic approach to the issue (Rowley, Garcia-Moreno, & Dartnall, 2012).

Several studies report that rape often goes unreported because the rapists are known to the victims and because of the stigma the victims and their families might be exposed to (Carol Henry & Ofori-Atta, 1998; Coker-Appiah & Cusak, 1999). These studies report that women victims of rape are usually blamed for having provoked men and might sometimes be married off quickly to protect the family from further dis- crimination. In her review on the issue, Turshen considers ‘‘that rape and forcible abduction of women are strategies of war that are systematically used to assert power over ethnic groups, by

overpowering their women’’ (Turshen, 2001, p. 1). Social acceptance mechanisms of masculine aggression through state-supported violence also seem to play a role as reported by some authors (Coker-Appiah & Cusak, 1999; Imam, Amina,

& Fatou, 1997). Furthermore, existing legal systems that rein- force gender stereotypes to the extent of criminalizing some activities of women are also considered noxious (Tibatemwa- Ekirikubinza, 1999). Ampfolo et al. advocate for legislative changes, based on international covenants, in order to tackle the problem of violence against women (Ampfolo, Beoku-Bett, Njambi, & Osirim, 2004).

More recently, the systematic rape of women and girls as a war strategy has been repeatedly reported by various authors (Ayele, 2011; Pratt & Wernick, 2004). Systematic rape in the course of war has now been labeled a crime against humanity by the International Criminal Tribunals for Rwanda and the Former Yugoslavia (Askin, 2004). Nevertheless, the use of systematic rape as a war strategy continues, notably in the war-ridden east of the DRC, where it has reached an unprece- dented scale (Mukwege, Mohamed-Ahmed, & Fitchett, 2010).

Although the phenomenon of systematic rape in African countries appears to be linked to armed conflicts (e.g., Liberia, Sierra Leone, Uganda, Somalia), there have been worrying developments in the DRC due to the following:

! The nature and duration of the conflict: It is neither an ideological nor a liberation conflict that is going on in Eastern RDC but rather an ongoing strategy of the authors and planners of the Rwandan genocide of 1994. This ongoing armed conflict, cyclical, chronic, and unresolved to date, is facilitated by a weak central government, by the involvement of neighboring countries and by the failure of international diplomacy, as suggested by many authors and political analysts (She- khawat, 2009; Stearns, 2013).

! The human tragedy: More than 5 million deaths as well as the emergence and/or amplification of new social, economic, and political practices, including the systematic rape of women and girls as a weapon of war (Coghlan et al., 2006, 2007).

! Rapes: They do not appear to be isolated acts of armed fighters but rather stem from a strategy of war. The planners and perpetrators of this practice eventually aim to change the demography of the region. Based on the Resolution 1820 of the Security Council, Maedl recalls that ‘‘mass rape is a tactic of war which intends to humiliate, dominate, instill fear in, disperse and/or forcible relocate civilian members of a community or an ethnic group’’ (Maedl, 2011, p. 130). Going even further, Carter argues ‘‘systematic rape should be concep- tualized not only as a war crime, but also as a destructive and increasingly deployed war weapon.’’ As such, rape should be submitted to arm controls and statecraft, assuming its rightful place as a topic of security studies, and thus of International Relations, analysis (Carter, 2010, p. 367).

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! The scale of rapes: This raises the question of the appro- priateness of the care provided to rape victims, be it health care, legal rehabilitation processes, or social reintegration. UN reports estimate that the annual number of rape cases amount to 15,000. Some authors, based on a recent household survey, report an estimate 26 times higher (Palermo & Peterman, 2011; Peterman, Palermo,

& Bredenkamp, 2011).

! The weakness of the answers provided by the State in response to this practice: be it in terms of justice, of rehabilitation, or of access to health care given to survivors, although the importance of this kind of action is well recognized as summed up by Kalonda and others ‘‘Sexual violence against women has impacted public health by spreading sexually transmissible diseases including HIV/

AIDS, causing unwanted pregnancies, leading to the gynecological complications of rape-related injuries, and inflicting psychological trauma on the victims. Officials in the DRC must set up appropriate structures to cope with the medical, psychosocial and legal effects of sexual violence’’ (Kalonda, 2008, pp. 577-578; Mansfield, 2009).

! A lack of synthesized knowledge about this practice in the context of the region: Yet knowledge is necessary for the development, implementation, and evaluation of prevention and monitoring programs.

Our paper, through a systematic review of the scientific literature, aims to answer the following question: Is there empirical research that over the past fifteen years has monitored and described the extent of systematic rape in war- ravaged eastern DR Congo? From a public health perspective, this question is relevant and even crucial if action against systematic rape based on scientific evidence is to be considered and implemented with some success.

The choice to conduct a systematic review of the literature means the evolution of the scientific production on the issue should be able to be monitored over time. It should also allow relevant data on the profiles of perpetrators and victims to be collected as well as on the circumstances of occurrence of rapes and on the response to the problem by the State and other stakeholders. For example, more accurate knowledge regarding the impunity enjoyed by the perpetrators of rape could give some insight into the weaknesses of the judicial system and/

or the possible protections the perpetrators enjoy from those who plan and conduct military operations in the region where the rapes occur. Furthermore, the results of this systematic review may identify research topics in areas where accurate data are lacking.

This approach enables exploring answers to questions that a single study could not provide such as:

! Is there any research on this practice in the region?

! What are the major characteristics of the scientific output, in terms of volume, topics studied, methods used,

and researchers involved (locals, nationals, and internationals)?

! Can such work contribute to the development of research and the prevention of rape, care and rehabilitation of rape victims?

Methods

First, a systematic literature review explored the following databases between January 1996 and February 2013: Pubmed, Psychinfo, Sapphire, BDSP, Embase, Rero and Web of Sci- ence. The search strategy used the following key words in English and French: ‘‘Rape and Democratic Republic of the Congo’’ and ‘‘Viol et Republique De´mocratique du Congo’’.

Taking into account the definition of rape (ASSER, 2014), these key words were associated with the following Medical Subject Headings (MeSH): ‘‘Sex Offenses, Rape, Democratic Republic of the Congo’’; ‘‘Rape/psychology, Rape/rehabilitation’’; ‘‘Rape/statistics and numerical data’’; ‘‘War Crime, Rape/Stress Disorders/therapy’’; ‘‘ Sex Offenses/psychology’’;

‘‘Rape/ legislation and jurisprudence’’; ‘‘Democratic Republic of Congo/Sex Offenses’’; ‘‘Democratic Republic of Congo/

Rape/ therapy/disease management.’’

Second, since obtaining original and empirical research cen- tered on the rape of women in Eastern DRC was the premise of our approach, the first set of data obtained through exploring the different databases mentioned earlier was reviewed independently by two of the authors (E.K.M. and M.K.) in order to exclude letters or press releases, reviews, books and chapters of books, summaries of books, conference reports, course notes, glossaries and articles, and reviews on the rape of men and boys as well as articles and reviews on intertribal warfare.

Third, the independently retained articles were discussed among the authors in order to obtain a consensus on a final data set.

Fourth, each article of the final data set was analyzed according to a reading grid, which included the following:

! Formal aspects: A serial number assigned to each article based on the alphabetical order of the name of the first author; the title as provided by the authors; and the references of the article (publication journal, the year of the study, the volume and page numbers, and WEB references).

! Aspects related to the content: The location of the study;

the design of the study (descriptive, analytical, experi- mental, etc.); the objectives of the study; the populations studied as well as the period of study; and conclusions and outcomes of each study.

! With regard to the study designs, prior categorization was made based on the types of classical studies encountered in health sciences and social sciences (epidemiological studies, social analysis and reviews). Other categories were added taking into account the mixed nature of the studies. A study is considered mixed if it

Kabengele Mpinga et al. 3

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uses two or more different methods to answer the research questions (Ahrens & Pigeot, 2005; Creswell

& Plano Clark, 2011; Johnson et al., 2007; Miller &

Salkin, 2002). For example, studies on rape based on the analysis of social structures from a legal perspective were categorized as social and legal analysis, while those discussing the role of political institutions in the outbreak or use of rape for political purposes were classified under the category of social and political analysis.

Finally, studies exclusively considering the history of rape in the region were classified as historical studies.

Results

Process of the Literature Review

The methodology used for this review is shown in Figure 1.

The first step of the review yielded 2087 documents. The second step, taking into account the exclusion criteria, enabled 31 articles with empirical data to be selected, of which 4 were further excluded as the authors were not able to reach a consensus concerning these articles. The 27 references which were finally retained are listed in Table 1. More than half of the studies were published in 2011 (n ¼9) and in 2012 (n¼6).

Most of the studies were published in English (n ¼26). The principal authors were mainly non-Congolese, that is, Ameri- can (n¼11), European (n¼10), Canadian (n¼1), and Israeli (n ¼ 1). Only four studies were directed by Congolese researchers. Regarding the study design, 10 studies were retro- spective, 3 cross-sectional, and 1 prospective. Furthermore, there were six qualitative studies, one case study, and two literature reviews focusing on the prevalence of rape. Other study designs were of sociolegal (2), sociopolitical (1), and historical nature (1). These studies were published in biomedical (11), epidemiology and public health (5), humanitarian (4), social science (3), and psychology journals (1).

Characteristics of the Selected Studies

Ten studies provided the prevalence levels of rape victims, which varied, depending on the studied population, between 0–10%(studies 4 and 12) and 100%(studies 13 and 23). Inci- dence rates were reported in 6 studies. One study, which analyzed the situation between 2004 and 2008, reported a 50%

decrease in the total number of complaints of rape, a decrease of 84%in the total number of reported gang rapes, and a 78%

decrease in the total number of reported assaults involving gang rape and sexual slavery (Study 1). Yet, a study comparing the situation between the two periods (1996–2003 and 2004–

2011) revealed that 17.8% of women reported an increase in exposure to sexual violence during the war, and 4.8% of women reported exposure to sexual violence after the war;

while 7.3%of women reported sexual assault during or after the conflict (study 4).

Ten studies analyzed the profiles of the perpetrators of rape.

In a majority of cases (between 52% and 73% of cases

depending on the study), the perpetrators were military personal (Studies 2 and 5). Over time, there was some marked evolution: In 2004, 1% of rapes was committed by civilians (Study 1); between 2004 and 2008, the rapes by civilians increased to 39%, while those committed by armed combatants decreased by 70% (study 16). Eighteen studies provided detailed information on the profile of the victims: The victims were women of any age, of any social classes, of many different ethnic groups, and of any marital status (Studies 13, 16, and 25). Sex slaves were mostly young girls of whom 62.5%had not yet finished primary school (Study 16).

Ten studies focused on the access to care for rape victims.

First, they emphasized the almost complete lack of specialized structures, except for the Panzi General Hospital in Bukavu (Studies 14 and 15). They further reported a scarce supply of care, especially in rural settings (Study 20) as well as long delays in accessing health facilities (up to 350 days) (Studies 5 and 13). Finally, they described the difficult coexistence between traditional and modern medicines on the one hand and a lack of government-run mental health-care facilities on the other hand (Study 9).

Fourteen studies insisted on the responsibility of the State to protect the population through reforming army and security services (Study 15), through promoting research and peace- building processes (Study 17), or through promoting social and economic reintegration of rape victims and their families (Study 6). Other studies emphasized the importance of justice for the victims, especially the importance of the fight against impunity, recalling that only 18.3% of rapists are brought to justice (Studies 16 and 15).

Finally, 8 research groups submitted their projects to receive the approval of an ethics committee, mostly from foreign research institutions. Some ethics committees were associated with the Panzi Hospital (Studies 8, 18, and 27). One study requested permission from the national and provincial health department directors (Study 7). Table 2 sums up the most relevant data reported in the different studies.

Strengths and Weaknesses of the Studies

One should keep in mind that the studies were carried out in an area of maximal insecurity, with limited resources and often with little local support.

Some weaknesses should be mentioned:

! Selection bias:Most of the data presented in the studies were collected in health centers or at local or international nongovernmental organizations (NGOs) offices;

this as a matter of fact excludes data concerning victims who had not had the opportunity to consult such institutions, either due to fear of stigma, humiliation, and exclusion or because of limited availability of (or limited access to) those infrastructures.

! Information bias:Most of the data were not collected through direct contact with victims or their relatives:

Indeed most of the data presented in the reviewed

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studies come from health care or NGOs registries, which means valuable primary information may have been lost. Some recall bias may also exist when information was given by the victims themselves because of faulty memories. Furthermore, there may be

certain communication difficulties between researchers and victims not only due to language problems but also due to cultural aspects: Indeed, the majority of investigators were foreigners (Europeans or Amer- icans), making it potentially difficult for victims to Prevalence Incidence Authors

pro!ile Victims’

pro!ile Access

to care Role of

State Ethics Committee Volume of

produc!on Populations studied

Country of origin of !irst author

Language Study

design Year of

publication Journal Reading

grid Articles

retained (27) Results of sources Rero : 0 PubMed : 31 BDSP : 0 Embase : 2056 Web Science: 0 Saphir : 0 PsycInfo : 9 Total : 2087 Sources

Rero, Pubmed, BDSP, Embase, Web Science, Saphir, PsycInfo,

Search strategies

Viol et Republique Démocratique du Congo Rape and Democratic Republic of the Congo

MESH “Sex Offenses, No Exp , Rape, Democratic Republic of the Congo " in Pubmed

Other MeSH were “Rape/psychology, Rape/rehabilitation, Rape/statistics and numerical data, War Crime, Rape/Stress Disorders/therapy, Sex Offenses/psychology, Rape/ legislation and jurisprudence, Democratic Republic of Congo/Sex Offenses, Democratic Republic of Congo/Rape, therapy/disease management

Inclusion criteria

. Articles in French or English . With or without abstract

. From January 1st 1996 to February 28th 2013 Exclusion criteria

. Letters, reviews, comments, books, chapters of books, book summaries, conference archives, lecture notes . Articles and reviews on rape of men and boys

Figure 1.Methodological process.

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Table 1.Articles Retained for the Systematic Review.

1. Bartels, S. A., Scott, J. A., Leaning, J., Kelly, J. T., Mukwege, D., Joyce, N. R., & VanRooyen, M. J. (2011). Sexual violence trends between 2004 and 2008 in South Kivu, Democratic Republic of Congo.Prehospital and Disaster Medicine,26, 408–413. doi:10.1017/s1049023x12000179 2. Bartels, S., Kelly, J., Scott, J., Leaning, J., Mukwege, D., Joyce, N., & VanRooyen, M. (2013). Militarized sexual violence in South Kivu,

Democratic Republic of Congo.Journal of Interpersonal Violence, 28, 340–358. doi:10.1177/0886260512454742 3. Brown, C. (2012). Rape as a weapon of war in the Democratic Republic of the Congo.Torture, 22, 24–37.

4. Casey, S. E., Gallagher, M. C., Makanda, B. R., Meyers, J. L., Vinas, M. C., & Austin, J. (2011). Care-seeking behaviour by survivors of sexual assault in the Democratic Republic of the Congo.American Journal of Public Health, 101, 1054–1055. doi:10.2105/ajph.2010.300045 5. Duroch, F., McRae, M., & Grais, R. F. (2011). Description and consequences of sexual violence in Ituri province, Democratic Republic of

Congo.BMC International Health and Human Rights, 11, 5. doi:10.1186/1472-698x-11-5

6. Glass, N., Ramazani, P., Tosha, M., Mpanano, M., & Cinyabuguma, M. (2012). A Congolese-US participatory action research partnership to rebuild the lives of rape survivors and their families in eastern Democratic Republic of Congo.Global Public Health, 7, 184–195. doi:10.1080/

17441692.2011.594449

7. Johnson, K., Scott, J., Rughita, B., Kisielewski, M., Asher, J., Ong, R., & Lawry, L. (2010). Association of sexual violence and human rights violations with physical and mental health in territories of the Eastern Democratic Republic of the Congo.Journal of the American Medical Association, 304,553–562. doi:10.1001/jama.2010.1086

8. Kelly, J., Kabanga, J., Cragin, W., Alcayna-Stevens, L., Haider, S., & Vanrooyen M. J. (2012). ‘If your husband doesn’t humiliate you, other people won’t’: Gendered attitudes towards sexual violence in eastern Democratic Republic of Congo.Global Public Health,7, 285–298.

doi:10.1080/17441692.2011.585344

9. Kwon, S. R. (2009). Invisible wounds from the Congo war.CMAJ Canadian Medical Association Journal, 181, 367–368. doi:10.1503/

cmaj.090930

10. Longombe, A. O., Claude, K. M., & Ruminjo, J. (2008). Fistula and traumatic genital injury from sexual violence in a conflict setting in Eastern Congo: Case studies.Reproductive Health Matter, 16, 132–141. doi:10.1016/s0968-8080(08)31350-0

11. Maedl, A. (2011). Rape as weapon of war in the Eastern DRC? The victims’ perspective.Human Rights Quarterly, 33,128–147. doi:10.1353/

hrq.2011.0005

12. Mankuta, D., Aziz-Suleyman, A., Yochai, L., & Allon, M. (2012). Field evaluation and treatment of short-term psycho-medical trauma after sexual assault in the democratic Republic of Congo.Israel Medical Association Journal, 14, 653–657. ://WOS:000311867200001

13. Malemo Kalisya, L., Lussy Justin, P., Kimona, C., Nyavandu, K., Mukekulu Eugenie, K., Jonathan, K. M., . . . Hawkes, M. (2011). Sexual violence toward children and youth in war-torn eastern Democratic Republic of Congo.PloS one, 6, e15911. doi:10.1371/

journal.pone.0015911

14. Morris, K. (2009). Denis Mukwege: caring for victims of sexual violence in the DRC.Lancet, 373, 713. doi:10.1016/s0140-6736(09)60425-6 15. Mukwege, D. M., & Nangini, C. (2009). Rape with extreme violence: The new pathology in South Kivu, Democratic Republic of Congo.PLoS

Medicine, 6, e1000204. doi:10.1371/journal.pmed.1000204

16. Nelson, B. D., Collins, L., VanRooyen, M. J., Joyce, N., Mukwege, D., & Bartels, S. (2011). Impact of sexual violence on children in the Eastern Democratic Republic of Congo.Medicine, Conflict, and Survival, 27, 211–225.

17. Omba Kalonda, J. C. (2007). Impact socio-economique du conflit en Republique Democratique du Congo sur la sante des femmes et des enfants. [Socioeconomic impact of armed conflict on the health of women and children in the Democratic Republic of the Congo].

Medecine Tropicale: Revue du Corps de Sante Colonial, 71, 192–196.

18. Onsrud, M., Sjoveian, S., Luhiriri, R., & Mukwege, D. (2008). Sexual violence-related fistulas in the Democratic Republic of Congo.

International Journal of Gynecology and Obstetrics, 103,265–269. doi:10.1016/j.ijgo.2008.07.018

19. Peterman, A., Palermo, T., & Bredenkamp, C. (2011). Estimates and determinants of sexual violence against women in the Democratic Republic of Congo.American Journal of Public Health, 101, 1060–1067. doi:10.2105/ajph.2010.300070

20. Rybarczyk, M., Tosha, M., Mbika, B., Bulonza, P., Ramazani, P., Zahiga, I.,. . .Glass N. (2011). Evaluation of medical supplies essential for the care of survivors of sex- and gender-based violence in post-conflict Eastern Democratic Republic of Congo.Medicine, Conflict, and Survival, 27, 91–110.

21. Salim, F. (2012). Holdstock-Piachaud Prize essay. War and the systematic devastation of women: the call for increased attention to traumatic gynaecological fistulae.Medicine, Conflict, and Survival, 28, 125–132.

22. Schafer, L. H. (2002). True survivors: East African refugee women.Africa Today, 49, 29–48. doi:10.1353/at.2003.0015

23. Schalinski, I., Elbert, T., & Schauer, M. (2011). Female dissociative responding to extreme sexual violence in a chronic crisis setting: The case of Eastern Congo.Journal of Traumatic Stress, 24, 235–238. doi:10.1002/jts.20631

24. Spiegel, P. B., Bennedsen, A. R., Claass, J., Bruns, L., Patterson, N., Yiweza, D., & Schilperoord, M. (2007). Prevalence of HIV infection in conflict-affected and displaced people in seven sub-Saharan African countries: A systematic review.The Lancet, 369, 2187–2195.

doi:10.1016/S0140-6736%2807%2961015-0

25. Steiner, B., Benner, M. T., Sondorp, E., Schmitz, K. P., Mesmer, U., & Rosenberger, S. (2009) Sexual violence in the protracted conflict of DRC programming for rape survivors in South Kivu.Conflict and Health, 3, 1–9.

26. Virginie, S., Halima, Y., & Blower, S. (2010). Assessing the impact of mass rape on the incidence of HIV in conflict-affected countries.Aids, 24, 2841–2847. doi:10.1097/QAD.0b013e32833fed78

27. Trenholm, J. E., Olsson, P., & Ahlberg, B. M. (2011). Battles on women’s bodies: War, rape and traumatisation in eastern Democratic Republic of Congo.Global Public Health, 6, 139–152. doi:10.1080/17441690903212065

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Table2.CharacteristicsoftheScientificArticlesonRapeofWomeninDemocraticRepublicofCongo. VolumeofProduction

20022007200820092010201120122013 11342961 PopulationsstudiedWomenofallages,anysocioeconomicstatus(children,teenagers,youngadults,mothers,grandmothers) CountryoforiginoffirstauthorUnitedStatesEuropeCongoOthers 111042 LanguageofthearticleEnglishFrench 261 StudydesignRetrospectiveProspectiveQualitativeCross-sectionalSociopolitical analysisSociolegal analysisHistoricCasestudyFreereviewReviewofthe literature 10163121111 TypeofjournalBiomedicalEpidemiologic/ publichealthHumanitarianSociologicalSociomedicalPsychological 1154241 IncidencelevelStudies:1,4,10,15,20,and26 PrevalencelevelBetween0%and10%Between10% and30%Between30%and50%Between50%and 70%Between70%and100%Others Studies4and12Study9Studies1and7Study1Studies13and23Studies3,24,and26 ProfileoftherapeperpetratorsStudies:1,2,4,5,7,11,13,15,16,and25 ProfileofthevictimsStudies:2,3,4,5,6,7,11,12,13,14,16,17,18,19,21,22,23,and25 Healthstructures,accesstohealthservicesStudies:4,5,9,12,13,15,20,21,25,and26 RoleofStatesStudies:7,8,10,11,12,15,16,17,19,20,21,22,26,and27 ConsultationofanethicscommitteeYesNo Studies:1,4,6,7,8,18,20,24,and27Studies:2,3,5,9,10,11,12,13,14,15,16,17,19,21,22,23, 25,and26

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engage in a discussion regarding serious issues affecting their intimacy.

Some strengths should also be mentioned:

! The work carried out in the different studies was submitted to and accepted by peer-reviewed journals, except in 2 cases.

! Nineteen articles present data with numbers (articles 1, 2, 4, 5, 7, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 23, 24, 25, and 26).

! Twelve studies present data from large samples (in numbers) when considering the fact that the data come from a conflict zone.

Discussion

Research on rape faces several challenges: First, there are the epistemological and conceptual dimensions related to the definition and typologies of rape seen through different lenses (sociological, legal, epidemiological, historical, etc.); second, there are the methodological issues, such as the choice of relevant indicators, the interpretation of collected data, the consideration of possible bias, and so on; third, there are ethical and communication issues to take into account, such as considering the relevance of a study to be implemented or such as informing the victims of rape and their families in an appropriate way of the implication of participating in a study; fourth, there are cultural dimensions that all research studies on rape should take into consideration, such as the stigma and discrim- ination the victims and their families might face; finally, one should not underestimate the risk researchers take when inves- tigating systematic rape in a war-ridden country (Campell &

Wasco, 2005; Stark et al., 2009; Wood, 2006).

The objective of the present review of the scientific literature on rape in war-ravaged eastern DR Congo was to investigate whether there was any empirical research monitoring and describing the extent of systematic rape in war-ravaged eastern DR Congo.

Our systematic review yielded 2087 documents, among which only 27 were original studies either based on population surveys (20) or presenting original data based on case studies and reviews (7). Ten studies provided prevalence rates of rape victims; 18 provided specific information on the profile of the victims; 10 reported that most of the perpetrators of rape were military personnel; 14 referred to the negligence of the government in protecting victims; and 10 reported a lack of competent health care facilities.

Based on our analysis, the answer to the research question is yes, but the scientific output is limited in light of the importance of the problem on the ground. Similarly, scarce scientific interest/output has been reported regarding the violence against women during armed conflicts (Tol, Stavrou et al., 2013).

There might be different reasons for such limited interest of the scientific community: one could be political insecurity and instability, which have been shown to significantly influence

research activities (Breyer, Terzian, & Lowther, 2007); one could also mention a possible lack of readily available funding for human rights projects, as some authors have suggested (Wiher-Fernandez, 2011).

We limited our review to studies focusing on women and girls, victims of rape, in accordance with Diken and Lausten who state that ‘‘most studies of war rape either focus on woman as victim or on the soldiers as aggressors’’ (Diken & Laustsen, 2005) and in accordance with Clifford who mentions that

‘‘females are the primary target, especially in patriarchal societies due to their luxury and value in the community’’ (Clifford, 2008, p. 5). However, one should keep in mind that the whole issue is more complex than it seems at first glance, since victims may also be men and perpetrators may be women, as some authors, notably Sivakumaran, have reported:

Sexual violence is committed against men more frequently than is often thought. It is perpetrated at home, in the community and in prison; by men and by women; during conflict and in time of peace. It has been written that, in some respects, the situation facing male rape victims today is not so different from that which faced female victims, say, two centuries ago. (Sivakumaran, 2007, p. 253)

A recent review of the literature on this issue found only two known studies: a survey conducted in Sierra Leone and another in DR Congo in which the authors specifically studied the gender of victims and abusers (Cohen, Green, & Wood, 2013).

Only four studies in our review were led by Congolese researchers, three of them affiliated to Congolese research institutions, though there were 253 institutions of higher education in the DR Congo in 2005 with as many as 1,383 teachers and 7,027 scientific staff (Virima, 2013). Such a paradox might have several explanatory factors:

! An unfavorable structural context for scientific research, which could be summarized as insignificant resources allocated to education and research, that is, around 0.30% of the GNP between 2005 and 2010 (Virima, 2013).

! A low attractiveness of the research topic and little interest of researchers in the field.

! Material conditions not conducive to the development of research (e.g., low wages).

! The context of insecurity and periodic wars in the country.

! Weak conceptual and methodological analytical tools.

The overrepresentation of foreign authors in our review could have two opposing consequences: On the one hand, it might contribute to creating a certain critical distance and rela- tive objectivity in studying the issue, while, on the other hand, it might exacerbate the misunderstanding of underlying cultural and strategic factors. Indeed, one has to keep in mind that the quality of the research might be affected because foreign research teams are often not well aware of the subtleties of the

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language when interviewing victims nor of certain cultural aspects related to the situation (taboos, etc.; Scott, Miller, &

LLyod, 2006).

The predominance of English articles in our review is not a surprise, but it could trigger some significant bias both in terms of understanding the issue and in shaping possible intervention strategies. The predominance of English as the primary scientific language is well known: Monie`re has reported that 89%of scientific publications are in English versus 3% in French (Monie`re, 2004). A recent systematic review of literature in the field of health and human rights between 1999 and 2008 reported that 90% of publications were in English (Mpinga, Verloo, London, & Chastonay, 2013).

The biomedical orientation of the published articles may be explained by the victims’ need for medical care and by the medicohumanitarian dimension of rape in war situations. But this may only partially describe the social and political dimensions of the systematic use of rape in contexts of conflict and mean a whole range of potential and necessary actions to era- dicate, or at least reduce, the problem are missed.

Epidemiological data reported in the examined studies raise several critical points, such as the definition of rape used, the methods of data collection, the contexts in which the studies were conducted, and possible actions to be taken afterward.

The wide range of prevalence rates (0–100%) may reflect the existence of conceptual and methodological difficulties. We share Kivlahan’s and Ewigman’s statement (Kivlahan & Ewig- man, 2010), that is, ‘‘we do not know the prevalence of rape falling on international war because no detection or reporting system exists, and rape is often not reported for fear of further violence.’’ There might indeed be underreporting, as suggested by Hagen who states that:

the lack of statistics on victims who were murdered or perished due to injuries during or after the assault and the risk of stigmatization of survivors; as a result, establishing exact figures of rapes victims is difficult and any statistics that are available represent only a small proportion of the actual number of incidents. (Hagen, 2010) Being aware of the profile of perpetrators of rape is an impor- tant point to consider when developing prevention, care, or rehabilitation programs. It is also crucial when developing strategies against rape in war contexts. While it is widely accepted that the majority of rapists are military personal, a reversal of this profile, with a predominance of civilians as rapists (as reported in study 16), is a most challenging subject. Such a reversal can probably only be understood as a change in war strategies by the parties involved, with the intention being to conceal their responsibilities.

The action or inaction of States with regard to their capacity to implement prevention, care, and rehabilitation programs for victims of rape is a significant public health challenge and one for action as well as research. In the present context of the DR Congo, the extent of rape in conflict zones is indicative of the failure of the central authorities to control parts of the national territory, labeled by some authors as ‘‘territory without state’’

(Vircoulon, 2006). Indeed, the DR Congo is ranked the second most failed state in the world, only surpassed by Somalia, according to the Failed State Index of the American Organiza- tion Fund of Peace (Fund For Peace, 2013). The ‘‘informalisa- tion’’ of the State is not only apparent in the economic sector. It also exists in the heart of the army and security services, since rebel movements are not the only perpetrators of systematic rape. Furthermore, the effective contribution of the UN peace- keeping forces (since 1999 in the conflict areas) to the stabili- zation process and the fight against violence and rape has not yet been well studied (Wanki, 2011).

Finally, only a fourth of the studies obtained approval from an ethics committee, mainly from non-DR Congo committees:

This might reflect some operational difficulties of local ethics committees, as the difficulties encountered by the recently established ethics committee within the School of Public Health of Kinshasa (Effa et al., 2007; Oukum-Boyer, Munung,

& Ntoumi, 2013; Tshikala et al., 2012). This also stresses the importance of establishing efficient ethics validation processes for field research, especially in domains where basic human rights are violated.

Our review no doubt missed the ‘‘gray literature,’’ local reports of NGOs, and research papers published in other lan- guages than French and English. Yet through our approach we tried to stay as close as possible to the recommendations for quality systematic reviews (Liberati et al., 2009).

Recommendation for Practice

! To create and support local research groups as well as field health professionals in the long run.

! To facilitate the dissemination of study results at the local, national and international levels.

! To provide a voice to the victims of rape.

! To disseminate good practice in research and care.

Policy Recommendations

There is a need to institute a mixed International Criminal Tribunal

! Comprising the Ordinary Courts of the country involved (in our case the DRC) and a Court composed of international judges appointed by the international judicial system:

! In order to investigate and establish responsibility for rape-related crimes and to rehabilitate the victims of rape.

Research Recommendations

Our review reveals a strong focus of the research community on the medical aspects related to rape in conflict areas, which might reflect the need for emergency and long-term care for rape victims. It might also stress the need for new research axes, such as:

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! the epistemological reflection on rape of women in a specific cultural and sociopolitical setting, like the one in eastern DR Congo;

! the epidemiological dimension of the profile changes of perpetrators of rape and possible camouflage strategies of involved groups; and

! the identification and evaluation of individual, local, national and international responses to the problem and their capacity to actually help victims and to contribute to the eradication of rape.

Conclusion

The practice of rape is widespread throughout history, territories, and civilizations, in particular during armed conflicts.

In the DRC, its extent and permanence has had a massive and deep impact on individuals and communities.

Our review of the literature shows that the knowledge pro- duced on this subject remains limited and fragmented. Episte- mological and methodological challenges could most certainly be overcome by increased local research efforts and technical support through international research networks. Increased investment in this area is a professional and moral imperative, especially for the Congolese researchers in order to inform policy makers on the need for prevention of rape and the care and rehabilitation of direct and indirect victims of rape.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies

Emmanuel Kabengele Mpinga, MHA, MPH, PhD, is a Professor at the Institute of Global Health, Faculty of Medicine, University of Gen- eva. His research interests and teaching are connected to epistemology of the links between public health and human rights, threats to these rights in health systems, the right to health indicators, and training needs for health professionals as a prevention strategy. Prof. Kabengele has also devoted the last two decades on studying and intervening on political instability, violence and human insecurity in many African countries as expert for Peace keeping United Nations Missions.

Mapendo Koya is a Lecturer at University of Applied Health Sciences (HESAV), Lausanne, Switzerland University of Applied Sciences of Western Switzerland (HES-SO). Her research focuses on public health/community health and vulnerable populations. She is also interested on State violence and health systems responses.

Jennifer Hasselgard-Rowe, MPH, PhD, works at the Institute of Global Health of the Faculty of Medicine of the University of Geneva.

Her academic background is in law and she has worked on human rights and health issues in detention for several years. Her principal fields of expertise are human rights law, international humanitarian

law and substance use issues (particularly harm reduction and other evidence-based public health policies and practices) as well as the intersections between global health and human rights.

Emilien Jeannot, MPH, PhD(C), is currently a Lecturer at the Master of Advanced Studies in Public Health of University of Geneva at the Faculty of Medicine at the University of Geneva and a researcher at the University of Applied Sciences of Western Switzerland, Geneva, Switzerland. He is also a consultant in statistics and epidemiology at the Youth Health Service (Geneva). He developed expertise on epidemiology of infectious diseases, monitoring of vaccination programs and project management in health promotion.

Sylvie B. Rehani, PhD(C), is a Pharmacist Student at the College of Pharmacy, University of Texas, Austin, United States. Rehani is working on traditional and complementary medicines in armed conflict affected areas of Kivus in Democratic Republic of Congo.

Philippe Chastonay, MD, MPH, is a former professor of public health at the University of Geneva and deputy director of the Swiss School of Public Health. His main fields of interest are public health training, medical education and health inequalities.