Intended for healthcare professionals

Editorials

Sexual violence in Ukraine

BMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o1016 (Published 22 April 2022) Cite this as: BMJ 2022;377:o1016
  1. Jenevieve Mannell, associate professor
  1. Institute for Global Health, University College London, 30 Guilford Street, London WC1N 1EH, UK
  1. j.mannell{at}ucl.ac.uk

A devastating war crime with far reaching consequences

On 24 February 2022, Russia launched a military invasion of Ukraine. Reports of sexual violence against women and girls began to emerge less than two months later. Multiple perpetrator rape, sexual assault at gunpoint, and rape in front of children have been reported to non-governmental and human rights organisations in Russian controlled areas.1 Research on the use of rape as a weapon of war in other armed conflicts around the world tells us that we should not be surprised.

The use of sexual violence against civilians during armed conflict is widespread and is now recognised as a war crime by the International Criminal Court. Yet, the reasons why men commit conflict related sexual violence vary. Most rapes committed by armed groups in the Democratic Republic of Congo (DRC), for example, were intended to terrorise civilians to gain control over land and other resources.2 By contrast, the rape and sexual slavery of Tutsi women during the Rwandan genocide in 1994 was a means of stripping an entire ethnic group of its humanity.3 In former Yugoslavia, sexual violence by the Serbian authorities was part of a government sanctioned strategy to destroy the lives and reproductive abilities of Bosnian Muslim women and their communities.4 The underlying motivations for the sexual violence against Ukrainian women and children will eventually become clear.

What we do know is that sexual violence has long term consequences. Women and girls’ experiences of sexual violence are associated with significant increases in the rate of severe mental health problems, including post-traumatic stress disorder, depression, and thoughts of suicide.5 Past experiences of sexual violence also increase the likelihood that women and girls will experience other forms of violence later in life, including intimate partner violence,6 in ways that further exacerbate their poor mental health.7

Less well recognised is the potential for conflict related sexual violence to destroy communities, cultural identities, and social networks in Ukraine and elsewhere. Nearly 30 years after the Rwandan genocide, unwanted pregnancies from conflict related sexual violence has led to widespread loss of identity, fraught relationships with families, and the stigmatisation of an entire generation.8 A large qualitative study of community perceptions of sexual violence after a decade of conflict in the DRC highlighted the extensive isolation and shame experienced by violence survivors.9 In these ways, conflict related sexual violence has the power to undermine the stability of entire societies.

Although ensuring systems of accountability and punishment for perpetrators is the key to prevention and social change in the long term, a swift and effective international response to the survivors of sexual violence in Ukraine is critical now. But what should be done?

Identifying survivors of conflict related sexual violence among Ukrainian refugees is challenging. Women and girls in most settings are reluctant to report their experiences for several reasons including stigma,10 fear of social isolation,9 and simply not wanting to relive the trauma through its telling.11 Men, boys, and lesbian, gay, bisexual, trans, and intersex (LGBTI) populations also experience conflict related sexual violence, which often goes unrecognised.12 Approaching refugees with a survivor centred approach that is inherently non-discriminatory and considers the diverse needs of people who have experienced multiple traumatic events is therefore essential.13

Once survivors have been identified, the task of providing individualised mental health support becomes somewhat easier. A recent review of psychological interventions for survivors of gender based violence in humanitarian settings showed the potential for cognitive behavioural therapies (common elements treatment approach and interpersonal psychotherapy), mindfulness therapeutic approaches, and exposure oriented interventions (eye movement desensitisation and reprocessing and narrative exposure therapy).14

Although these individual therapeutic options have some supporting evidence, treating individuals does little to tackle the broader issues of stigma and loss of community identity that can arise from conflict related sexual violence. A recent systematic review of interventions to reduce sexual violence in humanitarian settings points to the potential of comprehensive community based strategies to increase the economic empowerment of women survivors and challenge the gendered social norms that contribute to stigmatisation and exclusion.15 But we are still a long way from being able to implement such strategies in Ukraine.

In the meantime, there is much that can be done to prepare a better future for all survivors of conflict related sexual violence. Providing fast track visas to Ukrainian refugees is an obvious starting point.16 Better evidence on how to prevent conflict related sexual violence is also urgently needed.17 For both of these to happen, however, researchers, funders, and policy leaders need to move beyond thinking of sexual violence as a problem for the mental health of a small number of unfortunate individuals. This is a problem that affects whole societies, and there is simply far more at stake for Ukraine.

Footnotes

  • Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: none.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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