Rape and Sexual Assault – Larkin Callaghan

In Country of Sustained Conflict, Two Women Work Toward Peace

Few countries in the world have suffered from such a sustained period of war and conflict as the Democratic Republic of the Congo (DRC). This Central African nation, the second largest on the continent, has endured wars resulting in over five million deaths since 1998. The country remains in a state of near-constant conflict, despite the presence of the United Nations’ largest peacekeeping mission in the world, known as MONUSCO. Women have suffered disproportionately, particularly in regards to sexual violence, with the DRC being labeled the “rape capital of the world.”

Spearheading efforts to protect women and offer services to victims are two lifelong Congolese gender justice activists, Chantal Kakozi and Josephine Malimukono, whose successes are noteworthy in an environment rife with gender inequity and militarization. Kakozi is the co-founder of Solidarité des Femmes de Fizi pour le Bien-Etre Familial (SOFIBEF), which addresses sexual and gender-based violence by raising awareness through media, offering psychosocial support to survivors, and pushing for judicial reform to protect women’s rights. Malimukono focuses largely on women’s economic empowerment, working with Ligue pour la Solidarité Congolaise (the League for Congolese Solidarity) to promote civil and socioeconomic women’s rights.

“We have seen women taking the lead in the peace-building effort in the DRC, especially when it comes to sexual violence and gender-based violence, and also in promoting the respect for human rights. We’ve also seen the emergence of many women-led organizations at the community level,” says Kakozi. This is particularly important, she noted, because of the erosion of social cohesion that occurs in communities where violence against women is so prevalent.

Kakozi, who has done significant advocacy work around the U.N. Security Council’s Resolution 1325, says that in the DRC the implementation of particularly important since women and children are the ones paying the biggest price in the conflict. Legally, both women say, the government has said they are taking steps to ensure women are involves in decision-making. But practically speaking, that hasn’t happened, both also report.

“In the parliament, I know that some women are advocating for political parties to have a 50/50 percent representation, but that is not happening at all,” says Malimukono.

“It’s an ongoing struggle for us when it comes to the implementation of SC resolution 1325, and what is written in our Constitution about women [being represented in Parliament]. We are not seeing that happen at the practical level, and we’re still fighting for women to be able to access decision-making spaces and be able to add their voices in all forums of discussion on peace efforts and reconstruction,” adds Kakozi.

Congolese women are pushing for their voices to be heard, even when they are shut out.

“Women have used their own money – they have saved and used their own money to travel and attend negotiations for peace. I want to give you an example – in 2008, there were negotiations in Nairobi, and we women from North Kivu province, we mobilized, organized, we used our own money, and we took the bus, from Goma to Nairobi,” says Malimukono. Once there, the women were denied entry to the negotiations room.

In spite of these setbacks the women push forward, though security poses a constant threat to their success. In 2008, Malimukono’s group built alliances with several militia groups by engaging with spouses of military leaders to get their message to male militia leaders.. As recently as 2011, they were hopeful of the work they were doing. But the uprising of M23 last year [a rebel group that formed in April in 2012; one of M23’s leaders, Bosco Ntaganda, surrendered last Monday] undermined their work.

Given the increasing number of deaths in detention centers and the recently publicized rash of sexual assaults committed by Congolese army battalions – which, as Malimukono points out are often blended with former rebel group members – trustworthy partnerships in peace building seems more important than ever. Kakozi says of the more recent reports of sexual violence, “It looks like it’s happening much more in places where the Congolese army and other armed groups are fighting each other. The unfortunate thing also is that we all know perpetrators of sexual violence are coming from all layers of society.”

The widespread militarization makes it difficult to address the issue of impunity in these cases. They praise the efforts of some MONUSCO units, Kakozi in particular discussing how they intervened in 2011 to help securitize local tribunals that went after high-ranking military commanders who had committed rapes and sexual assaults throughout the Fizi territory. MONUSCO also covered the expenses incurred by Kakzoi’s organization, SOFIBEF, from hosting many of the rape survivors during the trials so they could testify.

That being said, both women stress the need for more help from the mission in curbing incessant uprisings, which prevent the government from doing work that benefits its population. Kakozi says, “We are wondering about the effectiveness of MONUSCO when there seem to be newer armed groups, that seem stronger and are still perpetrating crimes – so we wonder how MONUSCO is doing its work in terms of preventing and responding to violence.”

“Even if they don’t have a clause about militarization in their mandate, they still have to find a way to help our government to do that work,” adds Malimukono.

Despite these struggles with restricted access to the negotiations room and widespread militarization, the women remain dedicated. Last November, when Goma fell under M23, Malimukono says women from the North Kivu province came together and wrote a letter to Susan Rice, asking her to be the spokesperson on behalf on the women of North Kivu. While they have not received a response, the effort is part of their goal to engage the international community more fully in their struggle.

Malimukono and her team are also currently reviewing the most recent peace accord, signed in Addis Ababa in late February, for its incorporation of the role of women. The fact that it was signed by eleven African nations and guaranteed a special envoy – recently announced to be former Irish President Mary Robinson – is significant, both women said, despite that Kakozi noted it tackles issues that were promised to be resolved in a similar 2008 agreement. If it addresses the decentralization of power to the grassroots level, she also wonders how that might be accomplished without the explicit incorporation of women, whose leadership is most evident at the community level. Of significance, Malimukono says that on the same night the peace deal was signed, the there were killings in Rushuru and Kitshanga. Both women await the effectiveness of the accord, which they say will be evident soon enough on the ground.

When asked for her strongest statement to the global community as they ask for support, Malimukono said, “My message remains the same. The militarization – [ending it] is the only way out. We are not free.”

Originally published in MediaGlobal.

Retraumatization: The Increased Risk of HIV Transmission among Abuse and Assault Victims

While the transmission of HIV and the causes of HIV-related death are actually more complicated—and even more nuanced—than public discussion would let on, a few presumptions about it remain fairly accurate.

For women who are marginalized in their communities, who are victims of abuse or assault, and who are economically or socially dependent on a spouse, the risk of them contracting HIV or dying from multiple complications from AIDS is simply greater than that of women fortunate enough to not be subjected to these circumstances. Take these scenarios:

The power dynamic in an abusive relationship may prohibit women from being able to protect herself from a partner who refuses to wear a condom
Women in poverty and those who need to rely on a partner for financial support may have greater risk of comorbid infections than women of economic independence. They are less likely to have the health insurance and relationship with a healthcare provider that would support HIV testing and provide the essential—and expensive—HIV medications to ensure a healthy life and lower the risk of co-morbid infections
People without social support, living in fear of what an HIV-positive diagnosis means, or those who have reason to fear stigma around personal behavior when seeking treatment are less likely to know where to access treatment or seek it out because of that fear, stigma and lack of support

Common sense would seem to support these statements. But until recently, the pathways of infection were not always clear, and while the conclusions above seemed certainly reasonable, specific data to support them had been difficult to collect. Two recent studies led by a UCSF-researcher have changed that. One synthesized what is known about PTSD and exposure to trauma among HIV-positive women, and the other explored the root of this relationship.

The results were remarkable. HIV-positive women had between two and six times the rates of childhood and adult physical and sexual abuse, and PTSD. The snapshot of risk behaviors among HIV-positive women was sobering:

	Sample size	Number (%) of participants with each characteristic
Sexual activity
Any sexual activity in the past 6 months	113	61 (54.0%)
With a main partnerMedian number of main partners (if any)	61	43 (70.5%)1 (range 1–2)
With casual partnersMedian number of casual partners (if any)^a	61	23 (37.7%)1 (range 1–25)
Sex with any HIV negative or unknown serostatus partners (if sexually active) in the last 6 months	61	51 (83.6%)
Disclosure of HIV status less than all of the time with these partners	51	29 (56.9%)
Using condoms less than all of the time with these partners	51	31 (60.8%)
Detectable viral load	51	30 (58.8%)
Disclosure of HIV status less than all of the time, and using condoms less than all of the time, and a detectable viral load	51	16 (31.4%)
Substance use (any, recent)
Cigarettes	110	71 (64.5%)
Alcohol	111	50 (45.0%)
Marijuana	111	39 (35.1%)
Crack/cocaine, heroin, and/or methamphetamines	111	45 (40.5%)
IDU^b	112	11 (9.8%)
IDU who share needles	11	5 (45.5%)
IDU who have a detectable viral load	11	6 (54.5%)

There were striking findings in terms of both HIV treatment failure and the impact of the above risk behavior in these women, bringing us the first real data hoping to explain this relationship. Those who suffered from recent trauma had more than four times the odds of anti-retroviral (ART) failure while on treatment than HIV-positive non-victims—and this was seemingly not due to self-reported poor adherence to the medication. One potential explanation offered by the study authors is that abuse and trauma interfere with an individual’s ability to stay on a consistent medication schedule, which is essential for control of the virus. Other studies have confirmed that abuse manifest as control, in which a male partner prevents his HIV-positive female partner from accessing services at a clinic out of fear that the stigma of HIV would be attached to him.

HIV-positive victims of recent trauma also all reported experiencing what the study calls “coerced sex,” and have over three times the odds of un-traumatized women of having sex with HIV-negative or status-unknown individuals. They had greater than four times the odds of inconsistent condom use, potentially exposing those casual partners to the virus. While high-risk sex behavior is always a factor in HIV-transmission, HIV-positive individuals who adhere consistently to HIV treatments are significantly less likely to infect HIV-negative partners during sex. So the lack of treatment adherence among traumatized HIV-positive women combined with the risky sex behavior is a great concern.

Interestingly, these figures were only significant among women who experienced recent trauma, indicating that the ongoing—not merely one occurrence—circumstances of abuse are the key to the relationship between HIV-infection and HIV-related illness and death. This can actually be seen as a snapshot of hope—if we are able to offer abuse, assault, and PTSD victims the appropriate support to heal from the experiences, we may be able to weaken the HIV/trauma relationship.

These studies draw a clear line between victims of assault and trauma and both the spread of HIV within their communities and the increased risk of HIV-related illness and death. But interestingly, the risk goes much deeper than these socioeconomic circumstances. The conversation around HIV transmission is generally split into one of two categories: social and behavioral—risky activity, injection drug use, the prejudicial judgment of sex workers; and medical and clinical—how the virus infiltrates the immune system, takes over cells, and how it is and isn’t suppressed with antiretroviral medications. What isn’t usually discussed is the possible combination of these two categories and how together they create a perfect storm for potential infection.

Recent studies have shown that those individuals suffering from PTSD had significantly higher rates of cytomegalovirus (CMV) in their body. A virus that is found in between 50%-80% of adults in the United States, CMV remains largely undetected—latent, suppressed, unproblematic—in healthy individuals. It’s also seen as a marker of immune health and function, and of the body’s ability to control potential infections. Given that 30% of American women with HIV/AIDS have PTSD (five times the national average), the potential relationship between their HIV-status and even further compromised immune function could lead to a myriad of comorbid infections and premature death. Other research has also shown that additional biological mechanisms may prevent ART-treatment from being as effective as possible, including high cortisol (stress hormone) levels. Not only do these victims have to fight against abuse and assault, they have been left without the essential social support to decrease risky behaviors that may expose others to the virus, and their own bodies are in revolt.

Collecting this kind of information is difficult. It requires consistent and positive communication between women and providers, unobstructed access to medical care and uninterrupted ART treatment, and of course, in this example, most importantly—removal from an abusive environment.

The combination of immunosuppression due to PTSD, the detectable rates of HIV in traumatized women whose viral loads are not suppressed by consistent anti-retroviral treatments, and the concurrent risk behaviors of abused HIV-positive women, all contribute to higher rates of HIV-infection in communities, as well as the potential for co-morbid infections and HIV-related death. Until these women are able to find the essential social and community support, free from abuse and trauma, and until their access to care and preventative measures are fully realized, the relationship between trauma and HIV will only deepen.

Sebelius Caves, Girls Pay the Price

By now, I’m sure you’ve all heard that Kathleen Sebelius, the Secretary of Health and Human Services, has blocked the recommendation of the Food and Drug Administration that the over the counter (OTC) drug Plan B, commonly known as the ‘morning after pill,’ be made available without a prescription for girls of all ages. It is currently available without a prescription to girls ages 17 and up, and requires a prescription for girls ages 16 and below.

It is worth noting that this is the first time a Secretary of HHS has overruled the FDA. This is not insignificant. The purpose of HHS is to promote the health, safety, and well-being of Americans. The FDA is an obvious component of this. While the FDA is an agency of HHS, the purpose of the FDA is to promote and protect public health, through the regulation of OTC and prescription medications, vaccines, food safety, medical devices, and more. They do this through clinical trials and testing, which is how we come to know of drugs’ side effects as well as how significantly they aid in the relief of what they purport to treat. The FDA recruits researchers who understand both the purpose of and execution of this research. Attempts have been made to loosen the regulations of the FDA; for example, some terminally ill patients have petitioned the FDA to allow them to access experimental drugs after Phase I of a trial – the FDA has denied these requests due to the lack of research regarding a drug’s long-term effects post- Phase I. The FDA is not without criticisms; they have been accused of being both too hard and too lax on the pharmaceutical industry. Members of the FDA have also expressed feeling pushed to present certain results. Scientists at the FDA complained to Obama in 2009 that they felt pressured under the Bush administration to manipulate data for certain devices, and the Institute of Medicine also appealed for greater independence of the FDA from the powers of political management.

The commissioner of the FDA, who is a physician, reports to the Secretary of HHS. Sebelius’ job is not one of medicine or research, and requires a background in neither. It does require a background in politicking, which is exactly what we’re seeing here. The purpose of pointing that out, and of articulating that this is the first time a Secretary of HHS has overruled an FDA recommendation, is that Sebelius’ refute would not be based on differing scientific results, or research that opposes the FDA’s recommendations – because there is none. The override has different drivers, and the assumption floating out there – for good reason, since there is little alternate explanation – is to appease social conservatives and the anti-abortion contingents.

Plan B is not the abortion pill. It is the equivalent of an increased dose of a daily birth-control pill, and has no effect on already established pregnancies – it prevents pregnancy from occurring. Scientists within the FDA unanimously approved the access of the drug without a prescription for girls of all ages, after an expert panel put the recommendation forward. It is, to quote a USC pharmacist, one of few drugs that is so “simple, convenient, and safe.”

The conservative Family Research Council claims that requiring a prescription will protect girls from sexual exploitation and abuse – I fail to see how requiring a girl to get a prescription will protect against sexual violence, especially since girls may be attempting to get Plan B because sexual violence has already occurred. This comment is also a flagrant indication of misunderstanding of sexual violence and abuse – a young girl is not likely to disclose to an unknown physician that she is being sexually abused or assaulted and that’s why she needs a prescription for Plan B. Make no mistake, this ban is a victory for anti-abortion rights activists. If a girl cannot prevent a pregnancy from occurring, she is subsequently faced with trying to terminate an existing pregnancy (again – that could have been prevented!). Given how reproductive and abortion rights have been systematically chipped away at for the past few years, this girl who did not want the pregnancy and tried to prevent it from happening but was denied because she is shy of 17 years, will be in an even worse position. This is what anti-abortion activists are counting on – that once she is pregnant she will have to carry to term.

Plan B can prevent abortions from happening. HHS, with its mission of protecting the health and welfare of all citizens, should do everything they can to protect the health of girls’ reproductive development, which includes the prevention of unwanted pregnancy at its earliest stage. The girls under the age of 17 who need Plan B the most are the ones who also need it to be as easily accessible as possible. Much like requiring parental permission for abortions for girls under the age of 18, this ban actually can put girls at risk. Many girls will not have the family support, financial means, or healthcare to manage a pregnancy; some girls may face parental and familial abuse if they have to admit to needing to prevent a pregnancy with Plan B. What if a girl is a victim of sexual assault within her family? Should she be forced to deal not only with this trauma, but also have to determine how to prevent herself from being forced to carry a fetus to term as a result of this tragedy? Most girls under the age of 17 do not have easy access to clinicians and hospitals on their own, nor are they able to navigate our increasingly complex healthcare system on their own, which they would not only need to do to access Plan B, but would need to do within 72 hours for the pill to be effective. Girls whose bodies are not ready for pregnancy, girls who were victims of assault and rape and incest, girls whose futures will be dramatically changed and opportunities truncated – they all become casualties of this ban. Before we start sex-shaming and proclaiming that they shouldn’t have had sex if they didn’t want to deal with the consequences, let’s remember that these girls were not miraculously impregnated. Whether consensual or not, a boy was involved. This is a gendered issue – the girls are the ones who will have to deal with the lack of access to Plan B, physically, mentally, and emotionally.

Originally, advocates in 2003 successfully petitioned Plan B to be available OTC for girls 18 and up (after having been available with a prescription since 1999), but a judge overruled that decision and lowered the age to 17 after he deemed the decision had been made politically, not for scientific reasons. It appears that history is repeating itself.

Good Riddance, Paterno.

After watching the appalling, immature response to the rightful firing of Joe Paterno last night, I had difficulty sleeping. I could not reconcile in my mind how people were so willing to further discard these children who were victimized, further negate their trauma and reduce their suffering to something negligible and less important than the football trophies lining Penn State’s halls. I’m not introducing the main characters of this post, because by now I’m sure you all know them.

In situations like these, you don’t even have to say “I’m on Paterno’s side,” which is just what all the screaming rioters on Penn State’s campus and outside his home are doing. By bemoaning a lost season, a coach’s supposedly truncated career, a football team’s interrupted success, you are contributing your voice to the chorus of people who think this isn’t such a big deal. That the interruption of Penn State’s stellar season is actually what’s pretty sad! That a coach with such success deserves to be forgiven for some things! And they were awful things, but they happened years ago! And he reported it to the Athletic Director, so he did his job!

If you’re a rape or sexual assault victim, that chorus can sound mighty deafening. And ceaseless.

So, I’m here to tell you that this is a big deal. A really $&%/!*$ big deal. And I can’t help but cringe anytime I hear a comment on this issue that hints at anything otherwise. That Paterno didn’t have this in his control. That reporting a criminal act and the victimization of a child to an administrator with no follow-up was sufficient. That marching his ass down to the closest precinct wasn’t something he unquestionably should have done, and ensured that Sandusky didn’t get within a hundred yards of a kid ever again. We are told that we should do the best we can with what we know; Paterno and McQuery did nothing of any consequence with what they knew. They moved at a glacial pace and took actions that were of minimal requirement. They worked at a university and with students, whose well-being is ostensibly the greatest concern of any educational institution. In case anyone doubted that the cash cow athletics of some colleges is what is of greatest concern, I give you this sick and disturbing example. There is quite literally no excuse, no “explanation” of the multiple failures of multiple leaders, that doesn’t rest on the fact that compromising a winning and money-making football team was in no way an option, that this team would not be brought down by ANYthing, not even the physical, emotional, and mental sacrifice of children.

Do I sound pissed? You bet I am. You should be, too. Let’s try, for a daring second, to re-prioritize the issues of our country. Let’s move “college football” from its precious perch and consider the prevention of rape and sexual assault to be of greatest importance. The swift punishment of the criminals who perform these acts to be the first order of business, not falling behind the next desperate grasp for a game win, a series win, a university parade.

I don’t care much what happens to Paterno and the other members of a coaching or admin staff who have had blessed careers and public lives rife with success. What I care about is the little boys who suffered rapes, forced oral sex, molestation, tried to negotiate the fear, humiliation, anger, and physical ramifications of these. Who did not leave the locker rooms, living rooms, camping trips or tents with any swollen bank accounts, any buildings or stadiums named after them, any hordes of fans claiming that they supported them no matter what. Yep. I’m on their side.

And to those screaming Penn State students, knocking over news vans and co-opting an act (rioting) reserved for disenfranchised populations (of which you are not) to demonstrate their subjugation, I’m going to bring this down to as personal a level as I can. I ask of you this: You have a father. Or a brother. Or a son. Or a boyfriend. Or just a close friend. Someone you love and care deeply for. Imagine they had been anally raped in the Penn State locker room, and someone had walked in and seen it and done nothing. Walked right back out instead of saving him. And that the very man you are crowing about knew of it. And turned his head. And your father/brother/son/boyfriend/friend was ignored, his pain deemed not important or relevant, his subsequent suffering that you would have witnessed first hand dismissed and cast aside. Now picture him standing in front of this narcissistic crowd, and asking you to tell him to his face that his raping isn’t as important as your beloved football coach keeping his job. If you can easily do that, then we are in even more depraved trouble than I thought.

After the absurd riots started following his firing, Paterno said that he appreciated the outpouring of support but to please “remain calm and respect the university, its property, and all that we value.”

Respect the university! Nothing about those boys, still, who I knew were raped and assaulted, nothing about respecting them and their pain and ordeal. Respecting the university doesn’t appear to have been on Paterno or McQuery’s mind when they covered up rape, abuse and molestation cases that would ultimately be forever associated with the university and debase its reputation. They showed no respect for the little boys who lives were forever marked by the despicable actions of their buddy Sandusky. They created a chain of administrators and coaches who failed time after time to immediately stop and fix this. So, no, Paterno, despite that your plea was directed at your supporters, I’m pretty riled up and have lost respect for much of Penn State myself. Remain calm and respect the university? – that’s a mighty tall order. Don’t think I can fill it.

He followed his statements with this claim: “With the benefit of hindsight, I should have done more.”

How hollow that rings.