Comment
Conflict-related sexual violence is a public health and human rights concern, as well as a matter of peace and security, and is the focus of the Global Summit to End Sexual Violence in Conflict in London, UK, on June 10–13, 2014. Sexual violence is not an inevitable consequence of conflict.1 More can be done to prevent it and to hold individuals accountable for it. Understanding different patterns of sexual violence across conflicts can help guide prevention and response. Yet knowledge of the nature and size of the problem and of effective responses remains surprisingly limited. In the past two decades, sexual violence against women has been documented in conflicts in Africa, Asia, eastern Europe, and Latin America,1,2 although estimates of prevalence vary widely, ranging from 4·3% in Kosovo to 39·7% in eastern Democratic Republic of Congo (DRC).2,3 Data, however, are not comparable because studies use different definitions and methodologies, so there is a need for standardised definitions and measurements that also take account of ethical and safety considerations of collecting data in traumatised populations.4 The scarcity of data from population-based surveys has fuelled certain misconceptions,5 and limited policy and programmatic investments in conflict-related sexual violence. Although there is increased reporting of sexual violence in conflict, there are insufficient data to assess trends. In some settings, brutal forms of sexual violence, including gang rape, have been reported, but these might not be the norm. Women and girls suffer disproportionately from conflict-related sexual violence, although men and boys can also be victims. Moreover, sexual violence during conflict occurs in the context of the sexual violence that is ongoing in the lives of women before, during, and after the conflict, not only by combatants but also by partners and other members of the family and community.6 Sexual violence, whether conflict-related or not, is associated with short-term and long-term health consequences, including injuries, HIV and other sexually transmitted infections, unwanted pregnancies, traumatic fistulae, depression, post-traumatic stress disorder, and anxiety; it can also lead to stigma and social rejection.7 Provision of acute and long-term health-care and psychosocial support is critical to the wellbeing of survivors. Yet conflict and post-conflict settings pose www.thelancet.com Vol 383 June 14, 2014
major challenges to service delivery: infrastructure is fragile, human resources are scarce and overstretched, services are disrupted, supplies are hard to come by, and insecurity impedes access to services. Additionally, women might not know that services are available and that some interventions, such as post-exposure prophylaxis for HIV or emergency contraception, are time-sensitive.8,9 Even when services are available, women might not use them due to stigma, fear of reprisals, concerns about confidentiality, or lack of confidence in disrupted services. The care that is provided to survivors of sexual violence needs to be integrated into existing health services, such as reproductive and maternal health, mental health and psychosocial support, and emergency care services, and not developed as a standalone service. Since many health workers have not been trained to provide post-rape care, sexual and reproductive health services are a good entry point for providing such training and ensuring women’s access to services. Awareness about sexual violence and its effects, and the clinical care for survivors of rape, including the provision of first-line psychological support and appropriate mental health care, needs to be part of the training curricula of health-care providers, including nurses and midwives.8 Clinical training should also include the care of adolescent and child survivors of sexual violence. The mental health and psychosocial needs of sexual violence survivors have long been neglected, despite their importance for long-term recovery of survivors. Although WHO has guidance on care of depression, post-traumatic stress disorders, and other conditions,10,11 evidence of the effectiveness of interventions applied to survivors of sexual violence is scant.12 The limited evidence that is available relates to interventions that require substantial capacity building and external resources, such as a groupbased cognitive processing intervention in the DRC.13 There is a need to develop low-intensity, evidence-based mental health interventions that do not rely on specialists and are scalable. Knowledge of interventions that prevent sexual violence in conflict is also scarce. A systematic review found little evidence for the effectiveness of interventions to reduce incidence, risk, and harm from sexual violence in conflict and post-conflict settings,14 although this finding might reflect inadequate investment in evaluations of interventions rather than a lack of existing interventions.
Corbis
Responding to sexual violence in conflict
Published Online June 10, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60963-6 See Editorial page 2019 See Comment page 2021 See Special Report page 2034 See Perspectives pages 2038, 2039, and e19
For the Global Summit to End Sexual Violence in Conflict see hƩps://www.gov.uk/ government/topical-events/ sexual-violence-in-conflict For Preventing Sexual Violence Initiative see http://www. stabilisationunit.gov.uk/how-toget-involved/preventing-sexualviolence-initiative.html
2023
Comment
One study in the review suggested that firewood distribution programmes helped to reduce risk of sexual violence, whereas legal interventions seemed to increase the risk because of lack of protection and support for those who choose to disclose or testify.14 The review noted that programmes with multiple components, including community engagement, seemed more likely to reduce risk of sexual violence.14 Since stigma, shame, and lack of information and resources can prevent women from seeking help, community-based interventions that build on local initiatives and protect anonymity are important. Forensic or medicolegal services are another important aspect of the health response to sexual violence during conflict, and part of the path to legal redress, if the survivor wants it. In conflict settings, the lack of trained personnel, infrastructure, and functional national systems, including police, health, and judicial systems, make the delivery of these services difficult. Having access to justice can contribute to healing, but the collection of evidence should be one element of a comprehensive health-care response. Secondary data from health-service providers or official complaints to law enforcement could provide contextual or pattern evidence for sexual violence prosecutions in an international court,15 but these data must be collected and shared in an ethical and safe way.4 Efforts to end impunity, as promoted by the UK Government’s Preventing Sexual Violence Initiative, are important. These efforts, however, must be complemented by investments in national systems and programmes to address the social and economic drivers of conflict-related sexual violence. Rather than setting up parallel and unsustainable systems specific to sexual violence in conflict, critical national systems need to be rebuilt and a workforce needs to be trained and supported to provide effective, sustainable responses. Donor countries have a part to play in supporting the development of national systems, and to ensure sustainable access to health, justice, and social support.
The Summit should galvanise actors from all sectors to take urgent action to prevent and respond to sexual violence before, during, and after conflict. Claudia García-Moreno Department of Reproductive Health and Research, World Health Organization, Geneva 1227, Switzerland [email protected] I am grateful to Chen Reis and Christina Pallitto for their review and useful suggestions on this Comment. The views expressed in this Comment are my own and do not necessarily represent policy of WHO. I declare no competing interests. ©2014. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved. 1 2 3
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5
6 7
8
9
10
11 12
13 14
15
Wood EJ. Variation in sexual violence during war. Polit Soc 2006; 34: 307–41. Stark L, Ager A. A systematic review of prevalence studies of gender-based violence in complex emergencies. Trauma Violence Abuse 2011; 12: 127–34. Johnson K, Scott J, Rughita B, et al. Association of sexual violence and human rights violations with physical and mental health in territories of the Eastern Democratic Republic of the Congo. JAMA 2010; 304: 553–62. WHO. WHO ethical and safety recommendations for researching, documenting and monitoring sexual violence in emergencies. Geneva: World Health Organization, 2007. Human Security Report Project. Human Security Report 2012: sexual violence, education, and war: beyond the mainstream narrative. Vancouver: Human Security Press, 2012. IRC. Let me not die before my time. Domestic violence in West Africa. New York: International Rescue Committee, 2012. Jewkes R, Sen P, Garcia Moreno C. Sexual violence. In: Krug E, Dahlberg LL, Mercy AJ, Zwi AB, Lozano R, eds. World report on violence and health, 2002. Geneva: World Health Organization, 2002: 147–81. WHO. Responding to intimate partner violence and sexual violence against women. WHO clinical and policy guidelines. Geneva: World Health Organization, 2013. WHO/UNHCR. Clinical management of rape survivors: developing protocols for use with refugees and internally displaced persons. Geneva: World Health Organization, 2004. Dua T, Barbui C, Clark N, et al. Evidence-based guidelines for mental, neurological and substance use disorders in low- and middle-income countries: summary of WHO recommendations. PLoS Med 2011; 8: e1001122. Tol W, Barbui C, van Ommeren M. Management of acute stress, PTSD and bereavement: WHO recommendations. JAMA 2013; 310: 477–78. Tol WA, Stavrou V, Greene MC, Mergenthaler C, van Ommeren M, García-Moreno C. Sexual and gender-based violence in areas of armed conflict: a systematic review of mental health and psychosocial support interventions. Confl Health 2013; 7: 16. Bass JK, Annan J, McIvor SM, et al. Controlled trial of psychotherapy for Congolese survivors of sexual violence. N Engl J Med 2013; 368: 2182–91. Spangaro J, Adogu C, Ranmuthugala G, Powell Davies G, Steinacker L, Zwi A. What evidence exists for initiatives to reduce risk and incidence of sexual violence in armed conflict and other humanitarian crises? A systematic review. PLoS One 2013; 8: e62600. Aguirre Aranburu X. Sexual violence beyond reasonable doubt: using pattern evidence and analysis for international cases. Leiden J Int Law 2010; 23: 609–27.
Stent performance: never too late to sort it out Published Online March 14, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60461-X See Articles page 2047
2024
Drug-eluting stents have greatly improved the clinical outcomes of patients undergoing percutaneous coronary intervention by mitigating the risk of restenosis inherent to bare-metal stents, and are now the standard of care.1 However, the antirestenotic effectiveness achieved with
early-generation drug-eluting stents during the first year after implantation came at the cost of delayed arterial healing of the treated coronary artery segment,2 which was associated with a small increase in the risk of stent thrombosis that emerged only during very late follow-up www.thelancet.com Vol 383 June 14, 2014
Conflict-related sexual violence is a public health and human rights concern, as well as a matter of peace and security, and is the focus of the Global Summit to End Sexual Violence in Conflict in London, UK, on June 10–13, 2014. Sexual violence is not an inevitable consequence of conflict.1 More can be done to prevent it and to hold individuals accountable for it. Understanding different patterns of sexual violence across conflicts can help guide prevention and response. Yet knowledge of the nature and size of the problem and of effective responses remains surprisingly limited. In the past two decades, sexual violence against women has been documented in conflicts in Africa, Asia, eastern Europe, and Latin America,1,2 although estimates of prevalence vary widely, ranging from 4·3% in Kosovo to 39·7% in eastern Democratic Republic of Congo (DRC).2,3 Data, however, are not comparable because studies use different definitions and methodologies, so there is a need for standardised definitions and measurements that also take account of ethical and safety considerations of collecting data in traumatised populations.4 The scarcity of data from population-based surveys has fuelled certain misconceptions,5 and limited policy and programmatic investments in conflict-related sexual violence. Although there is increased reporting of sexual violence in conflict, there are insufficient data to assess trends. In some settings, brutal forms of sexual violence, including gang rape, have been reported, but these might not be the norm. Women and girls suffer disproportionately from conflict-related sexual violence, although men and boys can also be victims. Moreover, sexual violence during conflict occurs in the context of the sexual violence that is ongoing in the lives of women before, during, and after the conflict, not only by combatants but also by partners and other members of the family and community.6 Sexual violence, whether conflict-related or not, is associated with short-term and long-term health consequences, including injuries, HIV and other sexually transmitted infections, unwanted pregnancies, traumatic fistulae, depression, post-traumatic stress disorder, and anxiety; it can also lead to stigma and social rejection.7 Provision of acute and long-term health-care and psychosocial support is critical to the wellbeing of survivors. Yet conflict and post-conflict settings pose www.thelancet.com Vol 383 June 14, 2014
major challenges to service delivery: infrastructure is fragile, human resources are scarce and overstretched, services are disrupted, supplies are hard to come by, and insecurity impedes access to services. Additionally, women might not know that services are available and that some interventions, such as post-exposure prophylaxis for HIV or emergency contraception, are time-sensitive.8,9 Even when services are available, women might not use them due to stigma, fear of reprisals, concerns about confidentiality, or lack of confidence in disrupted services. The care that is provided to survivors of sexual violence needs to be integrated into existing health services, such as reproductive and maternal health, mental health and psychosocial support, and emergency care services, and not developed as a standalone service. Since many health workers have not been trained to provide post-rape care, sexual and reproductive health services are a good entry point for providing such training and ensuring women’s access to services. Awareness about sexual violence and its effects, and the clinical care for survivors of rape, including the provision of first-line psychological support and appropriate mental health care, needs to be part of the training curricula of health-care providers, including nurses and midwives.8 Clinical training should also include the care of adolescent and child survivors of sexual violence. The mental health and psychosocial needs of sexual violence survivors have long been neglected, despite their importance for long-term recovery of survivors. Although WHO has guidance on care of depression, post-traumatic stress disorders, and other conditions,10,11 evidence of the effectiveness of interventions applied to survivors of sexual violence is scant.12 The limited evidence that is available relates to interventions that require substantial capacity building and external resources, such as a groupbased cognitive processing intervention in the DRC.13 There is a need to develop low-intensity, evidence-based mental health interventions that do not rely on specialists and are scalable. Knowledge of interventions that prevent sexual violence in conflict is also scarce. A systematic review found little evidence for the effectiveness of interventions to reduce incidence, risk, and harm from sexual violence in conflict and post-conflict settings,14 although this finding might reflect inadequate investment in evaluations of interventions rather than a lack of existing interventions.
Corbis
Responding to sexual violence in conflict
Published Online June 10, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60963-6 See Editorial page 2019 See Comment page 2021 See Special Report page 2034 See Perspectives pages 2038, 2039, and e19
For the Global Summit to End Sexual Violence in Conflict see hƩps://www.gov.uk/ government/topical-events/ sexual-violence-in-conflict For Preventing Sexual Violence Initiative see http://www. stabilisationunit.gov.uk/how-toget-involved/preventing-sexualviolence-initiative.html
2023
Comment
One study in the review suggested that firewood distribution programmes helped to reduce risk of sexual violence, whereas legal interventions seemed to increase the risk because of lack of protection and support for those who choose to disclose or testify.14 The review noted that programmes with multiple components, including community engagement, seemed more likely to reduce risk of sexual violence.14 Since stigma, shame, and lack of information and resources can prevent women from seeking help, community-based interventions that build on local initiatives and protect anonymity are important. Forensic or medicolegal services are another important aspect of the health response to sexual violence during conflict, and part of the path to legal redress, if the survivor wants it. In conflict settings, the lack of trained personnel, infrastructure, and functional national systems, including police, health, and judicial systems, make the delivery of these services difficult. Having access to justice can contribute to healing, but the collection of evidence should be one element of a comprehensive health-care response. Secondary data from health-service providers or official complaints to law enforcement could provide contextual or pattern evidence for sexual violence prosecutions in an international court,15 but these data must be collected and shared in an ethical and safe way.4 Efforts to end impunity, as promoted by the UK Government’s Preventing Sexual Violence Initiative, are important. These efforts, however, must be complemented by investments in national systems and programmes to address the social and economic drivers of conflict-related sexual violence. Rather than setting up parallel and unsustainable systems specific to sexual violence in conflict, critical national systems need to be rebuilt and a workforce needs to be trained and supported to provide effective, sustainable responses. Donor countries have a part to play in supporting the development of national systems, and to ensure sustainable access to health, justice, and social support.
The Summit should galvanise actors from all sectors to take urgent action to prevent and respond to sexual violence before, during, and after conflict. Claudia García-Moreno Department of Reproductive Health and Research, World Health Organization, Geneva 1227, Switzerland [email protected] I am grateful to Chen Reis and Christina Pallitto for their review and useful suggestions on this Comment. The views expressed in this Comment are my own and do not necessarily represent policy of WHO. I declare no competing interests. ©2014. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved. 1 2 3
4
5
6 7
8
9
10
11 12
13 14
15
Wood EJ. Variation in sexual violence during war. Polit Soc 2006; 34: 307–41. Stark L, Ager A. A systematic review of prevalence studies of gender-based violence in complex emergencies. Trauma Violence Abuse 2011; 12: 127–34. Johnson K, Scott J, Rughita B, et al. Association of sexual violence and human rights violations with physical and mental health in territories of the Eastern Democratic Republic of the Congo. JAMA 2010; 304: 553–62. WHO. WHO ethical and safety recommendations for researching, documenting and monitoring sexual violence in emergencies. Geneva: World Health Organization, 2007. Human Security Report Project. Human Security Report 2012: sexual violence, education, and war: beyond the mainstream narrative. Vancouver: Human Security Press, 2012. IRC. Let me not die before my time. Domestic violence in West Africa. New York: International Rescue Committee, 2012. Jewkes R, Sen P, Garcia Moreno C. Sexual violence. In: Krug E, Dahlberg LL, Mercy AJ, Zwi AB, Lozano R, eds. World report on violence and health, 2002. Geneva: World Health Organization, 2002: 147–81. WHO. Responding to intimate partner violence and sexual violence against women. WHO clinical and policy guidelines. Geneva: World Health Organization, 2013. WHO/UNHCR. Clinical management of rape survivors: developing protocols for use with refugees and internally displaced persons. Geneva: World Health Organization, 2004. Dua T, Barbui C, Clark N, et al. Evidence-based guidelines for mental, neurological and substance use disorders in low- and middle-income countries: summary of WHO recommendations. PLoS Med 2011; 8: e1001122. Tol W, Barbui C, van Ommeren M. Management of acute stress, PTSD and bereavement: WHO recommendations. JAMA 2013; 310: 477–78. Tol WA, Stavrou V, Greene MC, Mergenthaler C, van Ommeren M, García-Moreno C. Sexual and gender-based violence in areas of armed conflict: a systematic review of mental health and psychosocial support interventions. Confl Health 2013; 7: 16. Bass JK, Annan J, McIvor SM, et al. Controlled trial of psychotherapy for Congolese survivors of sexual violence. N Engl J Med 2013; 368: 2182–91. Spangaro J, Adogu C, Ranmuthugala G, Powell Davies G, Steinacker L, Zwi A. What evidence exists for initiatives to reduce risk and incidence of sexual violence in armed conflict and other humanitarian crises? A systematic review. PLoS One 2013; 8: e62600. Aguirre Aranburu X. Sexual violence beyond reasonable doubt: using pattern evidence and analysis for international cases. Leiden J Int Law 2010; 23: 609–27.
Stent performance: never too late to sort it out Published Online March 14, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60461-X See Articles page 2047
2024
Drug-eluting stents have greatly improved the clinical outcomes of patients undergoing percutaneous coronary intervention by mitigating the risk of restenosis inherent to bare-metal stents, and are now the standard of care.1 However, the antirestenotic effectiveness achieved with
early-generation drug-eluting stents during the first year after implantation came at the cost of delayed arterial healing of the treated coronary artery segment,2 which was associated with a small increase in the risk of stent thrombosis that emerged only during very late follow-up www.thelancet.com Vol 383 June 14, 2014
