"My Heart is Always Scared": The simmering mental health crisis for rape victims in war

"Noor," 16, said an Islamic State fighter raped her multiple times. She is one of the few Yazidi girls getting regular psychosocial treatment.

ROTHNA BEGUM/HUMAN RIGHTS WATCH

Claudine repeatedly slams her hand against the table as she talks. Bang, bang, bang. She tells me after yelling and beating at the door, the men eventually broke it, pushing into her home in Burundi's capital, Bujumbura. They gang raped Claudine, one of dozens of women and girls attacked in the city between 2015 and 2016 because they were married or related to members of opposition parties.

The global women's rights movement has been fighting an uphill battle for recognition and care of rape victims in conflicts. National governments, the United Nations, local groups, and humanitarian organizations like the Red Cross or Médecins Sans Frontières struggle in the middle of crises to provide emergency post-rape care that meets World Health Organization standards. This includes prophylaxis against HIV transmission within 72 hours of the rape, emergency contraception within 120 hours, and a physical examination.

Tight windows for treatment, chaotic circumstances, and limited capacity have meant that the health response to rape has focused on immediate needs. There has been less attention and fewer resources to support victims struggling with longer-term health impacts of rape, especially depression, anxiety, or post-traumatic stress disorder. "I wake up screaming and have nightmares," Claudine, who had been raped nine months earlier, told us. "I still feel worried all the time. My heart is always scared."

Rape survivors are being left behind along with millions of others who lack access to quality mental health care, which is chronically underfunded all over the world, especially in middle-and low-income countries where 76 to 85 percent of people with severe mental disorders receive no treatment. In crises, women like Claudine—who take care of their households and children, but struggle and feel irrevocably changed by their trauma—may spend hours waiting at clinics for malaria drugs or vaccines for their kids but are unlikely to get support or treatment for depression. Unaddressed mental health illnesses place burdens on families and communities, not just the victim. "I am always angry with my children now," another rape survivor told me.

My colleagues and I at Human Rights Watch are not medical experts. But again and again when we interview women and girls to document patterns of rape in conflicts and victims' access to health care afterward, the long-term devastation shocks us. We leave interviews stunned not only by the brutality of rape but also by the shame and disconnect to reality that many victims still feel years later.

We use interviewing techniques to minimize distress for survivors and do our best to ensure they feel in control during the conversation. And we show up ready to provide referrals to support organizations, especially as we may be the first people to whom they have told their stories. It's frustrating to discover that even when emergency capacity exists, long-term mental health services are typically absent or of poor quality. Interviewees have told us that health-care providers treat them dismissively and without compassion. "They said I was just making it up, to get asylum," Claudine said about the international nongovernmental organization workers who ran the only program for rape survivors in her refugee camp. This is a serious problem: WHO guidelines for post-rape care are clear that making sure a victim feels believed and supported is an important part of an adequate first-level intervention.

Research has established that sexual violence victims are more likely to experience depression, anxiety, substance abuse, and post-traumatic stress disorder. Survivors of potentially traumatic events eventually have higher than average rates of cancer, cardiovascular disease, and diabetes. Some research suggests that rape is more likely to lead to PTSD than other forms of trauma.

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