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Editorial in War Is Common, Devastating, and Too Often Ignored The PLoS Medicine Editors

ape in war is by no means a new million displaced people [8], and Health care professionals and phenomenon, but its escalation 500,000 victims of sexual violence humanitarian organizations working Ras a deliberate, strategic, and [9] since 1991. Recent escalation of in conflict zones have long recognized political tactic is now undeniable. Most fighting has fuelled international the use of rape as a weapon of war, of its victims are women and girls, but press reports of a country more lawless providing documentation from the men and boys suffer too. Whether than perhaps anywhere else on earth ground that also reveals the absence isolated or systematic, rape’s effects and where women are frequently and of an adequate international response. are devastating to individuals and systematically victimized [10–13]. This Human Watch reported this damaging to whole communities. The “pandemic of sexual violence,” says year that “women and girls continue physical consequences can include Stephen Lewis, the former United to be brutally beaten and raped” by unwanted pregnancies, sexually Nations special envoy for HIV/AIDS in police, militia, and rebel groups in transmitted infections including HIV, Africa, is “obscene,” “insanely savage,” Darfur [21]. No progress has been and genital injury including fistula, and can only be described as “” made five years after the Sudanese all of which can leave women scarred, [10,14]. Dr. , the government promised to combat disabled, unable to conceive, and founder of the Panzi Hospital in sexual violence in the region and the deemed unsuitable for marriage [1,2]. eastern Congo that treats ten women UN–African Union The brutality of war rape is evident in survivors of rape every day, calls this forces were to mobilize security and genital mutilation, forced captivity, war on women “the monstrosity of the protection for women. Médecins Sans gang in public or in front of century” [15]. Nonetheless, in areas Frontières has provided family members, and rape with objects of armed conflict rape is committed care for tens of thousands of victims of such as glass, sticks, gun barrels, mostly with and has been sexual violence in conflict zones, and and machetes [1,3]. Psychologically largely ignored by the international continues to report that most of these the effects are no less devastating. community. attacks are perpetrated with impunity Traumatized by the event, women As a terror tactic, rape aims to by militia or military personnel [19]. are often unable to care for their destroy or expel populations or ethnic has documented children or households, fear leaving groups, impregnate women, intimidate violations occurring in their homes, can become socially civilians, pillage land and resources, conflict zones where perpetrators are ostracized and isolated, and may be and may serve to increase military rarely if ever held accountable, and rejected by their husbands, families, or morale [16–18]. Husbands or family continually laments the international communities [1–3]. members, sometimes forced to watch, community’s lack of response to sexual First recognized as a problem are also traumatized. In camps violence [22]. internationally in the mid-1990s when in Darfur and , where hundreds While international courts now “rape camps” that enslaved women and of thousands of Sudanese people recognize rape as a war crime, a crime girls were discovered in the former are displaced, women are essentially against humanity, a form of , , systematic rape is now imprisoned because they cannot even understood not as an unfortunate travel to get firewood or water without Citation: The PLoS Medicine Editors (2009) Rape in but inevitable by-product of war, but risking being raped [19]. In the DRC, war is common, devastating, and too often ignored. PLoS Med 6(1): e1000021. doi:10.1371/journal. instead as a defining tactic of modern different militia groups have distinct pmed.1000021 conflicts. Following the genocide in and recognizable ways by which they PLoS Medicine , where an estimated 500,000 rape women, thus marking women Copyright: © 2009 The Editors. This is an open-access article distributed under women were raped in 1994, a landmark with a signature that often mutilates the terms of the Creative Commons Attribution decision by the International Criminal and scars them for life, but also License, which permits unrestricted use, distribution, and reproduction in any medium, provided the Tribunal recognized rape as a crime of establishing the armed group’s power original author and source are credited. genocide under [4]. and control. During the June 2008 UN Mass rape has been documented for meetings at which rape was classified Abbreviations: DRC, Democratic Republic of the Congo; DWI, Index recent conflicts in , Burma, as a weapon of war, the former UN Columbia, Liberia, Sierra Leone, and peacekeeping commander Major E-mail: [email protected] Somalia [5,6]. General Patrick Cammaert summarized The PLoS Medicine Editors are Virginia Barbour, The toll of the ongoing conflict the effect of rape as a war tactic when Jocalyn Clark, Larry Peiperl, Emma Veitch, Mai Wong, in the Democratic Republic of the he reported: “It has probably become and Gavin Yamey. Congo (DRC) is staggering: an more dangerous to be a than a Provenance: Written by editorial staff; not externally estimated 5.5 million deaths [7], 1.5 soldier in an armed conflict” [20]. peer reviewed

PLoS Medicine | www.plosmedicine.org 0001 January 2009 | Volume 6 | Issue 1 | e1000021 and a constituent act of genocide that emergency contraception, post- 7. Coghlan B, Brennan RJ, Ngoy P, Dofara D, Otto B, et al. (2006) Mortality in the demands international regulation exposure prophylaxis, HIV testing, Democratic Republic of Congo: A nationwide [9], concerns are mounting that due antiretroviral therapy, and counseling. survey. Lancet 367: 44-51. to lack of preparation and political We can lobby to ensure that these 8. High Commissioner for (2008) Global appeal 2009 will, the international criminal court efforts to respond medically to sexual update. Democratic Republic of the Congo. is too frequently dropping charges violence be linked to broader justice Available: http://www.unhcr.org/publ/ of sexual violence in their war crimes efforts. As part of the care that is PUBL/4922d4100.pdf. Accessed 22 December 2008. prosecutions [23]. In addition, there is imparted to women, for example, we 9. Turkovich T (2008 June 2004) As DR Congo the deplorable matter of peacekeepers should insist that medical responsibility crisis persists, UN classifies rape as weapon of war. UNICEF. Available: http://www.unicef. themselves raping women and girls include supporting survivors to bring org/infobycountry/drcongo_44598.html. [24,25]. charges if they wish, and advocating Accessed 22 December 2008. Medical professionals are powerful for international courts to investigate 10. Ensler E, Lewis S. The never ending war. Huffington Post. Available: http://www. lobbyists whose recognition of the and prosecute perpetrators of huffingtonpost.com/eve-ensler-and-stephen- devastation could galvanize support for sexual violence. But because these lewis/the-never-ending-war_b_150668.html. the work of humanitarian organizations prosecutorial efforts are reactive Accessed 29 December 2008. 11. Goodspeed P (2008 December 1) Rape now and advocacy groups in documenting and involve only a small fraction of war strategy in Congo, doctor says. National sexual atrocities and holding states the perpetrators, they are limited in Post. Available: http://www.nationalpost.com/ news/world/story.html?id=1015611. Accessed accountable when human rights holding those responsible accountable 22 December 2008. and international law are violated. and in protecting potential victims. 12. Holmes J (2007 October 11) Congo’s rape Together with medical journalists and Thus our support must also emphasize war—Savage sexual violence is sweeping the troubled nation, demanding a global response. editors they have done much to try that justice work be twinned with Los Angeles Times. Available: http://articles. to expose the devastation of sexual preventative efforts such that latimes.com/2007/oct/11/opinion/oe- violence during conflict [26–28], but protecting women and girls from holmes11. Accessed 22 December 2008. 13. (2008) World News: Democratic we can all do more to document and sexual violence becomes a central part Republic of the Congo. Available: http://www. disseminate the research and accounts of peacekeeping and security efforts guardian.co.uk/world/congo. Accessed 22 December 2008. of health workers, nongovernmental [21]. 14. The Stephen Lewis Foundation (2007 organizations, and survivors. Rape as a weapon of war is September 13) Stephen Lewis calls for a new A recent set of articles in PLoS unconscionable. Medical journalists UN initiative to end sexual violence in the Medicine eastern region of the DRC. Available: http:// [29–31] introduced a new and editors, along with health care www.stephenlewisfoundation.org/news_item. tool called the Dirty War Index (DWI) professionals, have the authority, the cfm?news=1988&year=2007. Accessed 22 that can distinguish highly undesirable skills, and the audience to draw the December 2008. 15. Greenberg J (2008 January 23) “Silence” outcomes of conflict on civilian world’s attention to the brutality and gives voice to Congo’s rape victims. Reuters. populations, including rape. The tool’s intolerability of sexual violence in Available: http://www.reuters.com/article/ reviewsNews/idUSN2310829020080124?fb_ novelty is that it expresses prohibited or armed conflicts. We need to step up page_id=8392031367&. Accessed 29 December undesirable (“dirty”) war outcomes as our support of efforts by humanitarian 2008. a ratio (rather than an absolute figure). and advocacy organizations to press 16. Amnesty International (2004) : Darfur: Rape as a weapon of war: Sexual A DWI for war-associated rape could international authorities to take more violence and its consequences. Available: be calculated as: (number raped by concerted actions. Denis Mukwege http://www.amnesty.org/en/library/info/ combatant group/total number having from Panzi Hospital said in November AFR54/076/2004. Accessed 22 December 2008. face-to-face contact with combatant in a speech in Toronto that it is in every 17. Smith-Spark L (2004 August 1) How did rape group) × 100. The tool’s developers, one of us to act to end rape in war. become a weapon of war? Available: http:// news.bbc.co.uk/2/hi/in_depth/4078677.stm. Madelyn Hsiao-Rei Hicks and Michael Speaking up is the very least we can Accessed 22 December 2008. Spagat, argue that as ratios, DWIs do. 18. Kristof N (2008 June 15) The weapon of rape. “lend themselves to comparisons over . Available: http://www. References nytimes.com/2008/06/15/opinion/15kristof. time, between wars, between weapons, 1. Donohoe M (2004) War, rape, and genocide: html. Accessed 22 December 2008. and between warring combatant Never again? Medscape Ob/Gyn & Women’s 19. Médecins Sans Frontières (2005) The crushing groups to identify better versus worse Health. Available: http://www.medscape.com/ burden of rape: Sexual violence in Darfur. viewarticle/491147. Accessed 22 December Available: http://www.doctorswithoutborders. performers.” They acknowledge 2008. org/publications/reports/2005/sudan03.pdf. that “war-associated rape may be 2. World Health Organization (2008) Sexual Accessed 22 December 2008. violence. Available: http://www.who.int/ 20. Worsnip P (2008 June 20) U.N. categorizes difficult to measure due to stigma and gender/violence/sexual_violence/en/index. rape as a war tactic. Reuters. Available: under-reporting, though substantial html. Accessed 22 December 2008. http://africa.reuters.com/world/news/ reports exist” [29]. A related expert 3. (2002) The war within usnN19485901.html. Accessed 29 December the war: Sexual and 2008. commentary says the DWI “provides a girls in Eastern Congo. Available: http:// 21. Human Rights Watch (2008) Five years on, no good example of an answer to a recent www.hrw.org/legacy/reports/2002/drc/ justice for sexual violence in Darfur. Available: call for better use of quantitative public Congo0602.pdf. Accessed 22 December 2008. http://hrw.org/en/reports/2008/04/06/five- 4. United Nations Security Council (1999) Fourth years-0. Accessed 22 December 2008. health data by conflict analysts and Annual Report of the International Criminal 22. Amnesty International (2008) North Kivu: No human rights monitors” [31]. Tribunal for Rwanda to the General Assembly. end to war on women and children. Available: Available: http://69.94.11.53/ENGLISH/ http://www.amnesty.org/en/library/asset/ Those involved in providing, annualreports/a54/9925571e.htm. Accessed 22 AFR62/005/2008/en/f23caedf-8e4a-11dd- researching, and reporting medical December 2008. 8e5e-43ea85d15a69/afr620052008en.html. care can continue to press for support 5. Shanks L, Schull M (2000) Rape in war: The Accessed 22 December 2008. humanitarian response. CMAJ 163: 1152-1156. 23. Glassborow K (2008 October 17) and services for survivors of sexual 6. Wiss S, Giller J (1993) Rape as a crime of war. ICC investigative strategy under violence in conflict areas, including JAMA 270: 612-615. fire. Available: http://www.iwpr.

PLoS Medicine | www.plosmedicine.org 0002 January 2009 | Volume 6 | Issue 1 | e1000021 net/?p=acr&s=f&o=347200&apc_state=henh. Available: http://www.guardian.co.uk/ 29. Hicks MH-R, Spagat M (2008) The Dirty War Accessed 22 December 2008. world/2005/mar/25/unitednations. Accessed Index: A public health and human rights tool 24. United Nations General Assembly (2005) A 22 December 2008. for examining and monitoring armed conflict comprehensive strategy to eliminate future 26. Amowitz LL, Kim G, Reis C, Asher JL, Iacopino outcomes. PLoS Med 5: e243. doi:10.1371/ sexual exploitation and abuse in United V (2004) Human rights abuses and concerns journal.pmed.0050243 Nations peacekeeping operations. Available: about women’s health and human rights in 30. Taback N (2008) The Dirty War Index: http://www.reliefweb.int/rw/lib.nsf/db900sid/ southern . JAMA 291: 1471-1479. Statistical issues, feasibility, and interpretation. LKAU-6B6G4D/$file/Zeid%20report%20 27. [No authors listed] (2004) Sudan and its new PLoS Med 5: e248. doi:10.1371/journal. _A-59-710_%20English.pdf?openelement. weapons of war. Lancet 364: 390. pmed.0050248 Accessed 22 December 2008. 28. Wakabi W (2008) Sexual violence increasing in 31. Sondorp E (2008) A new tool for measuring 25. Bowcott O (2005 March 25) Report reveals Democratic Republic of Congo. Lancet 371: 15- the brutality of war. PLoS Med 5: e249. shame of UN peacekeepers. The Guardian. 16. doi:10.1371/journal.pmed.0050249

PLoS Medicine | www.plosmedicine.org 0003 January 2009 | Volume 6 | Issue 1 | e1000021