Ask the GBV experts
In the course of preparing this issue on gender-based violence, some questions arose, so we asked the two experts in the SSMJ Editorial Board: Dr Koma Akim, a general and obstetric fistula surgeon working in Bor State Hospital in South Sudan, and Dr Nyakomi Adwok, a psychiatrist with working experience in the UK and Kenya.
Dr Koma Akim
SSMJ: How does one deal with the problem that it often takes time for an abused woman to seek help? She may have to get permission from a male relative or community leader? Is this a problem in South Sudan?
Dr Akim: Yes, it is, and it is a complicated issue. In addition to the reasons given, there are others such as the status of women in the South Sudanese society, lack of trust in some healthcare practitioners, sociocultural and economic factors that may encourage violence against women, and the safety and security of the affected woman.
SSMJ: Please explain why there is a lack of trust in healthcare practitioners?
Dr Akim: Most of the people entrusted with helping abused women are men and this does not give a woman the confidence to seek help from a healthcare centre. One woman explained to me that the reason why few abused women seek help from a One Stop Centre was because the person charged with helping them is often a man, and yet the person who abused them is also a man! She said, “Can a lion be a judge in a dispute between an antelope and another lion?” Although healthcare workers are trained how to counsel abused women and girls without bias, survivors are still reluctant to seek help in time because of the perceived impartiality of the healthcare worker.
SSMJ: Which sociocultural issues delay abused women seeking help?
Dr Akim: Most women are brought up believing that it is the right of the man to abuse his wife as a sign of love, and not doing so indicates that he does not love her! This is a common belief amongst some of the ethnic tribes in South Sudan. It is not until women are enlightened that spousal abuse is not a sign of love, that they start to develop the courage to seek help. This takes time as a woman needs to internalize the pros and cons of seeking help and what the repercussions of this decision would be on her future relationship with her husband.
SSMJ: What is Female Genital Mutilation (FGM)?
Dr Akim: Female genital mutilation is the complete or partial removal of the external genitalia. It is often done for non-medical purposes and is a form of Gender-Based Violence (GBV).
SSMJ: Does FGM have any health benefits for women and girls?
Dr Akim: No. FGM harms the health and well-being of women and girls and affects them psychologically. It, at times, can lead to death, and in the long term, it affects their sexuality and reproduction.
SSMJ: Is FGM a problem in South Sudan? If so, does it occur in all States? What form of FGM?
Dr Akim: According to anecdotal evidence, the sixty-four ethnic tribes in South Sudan do not practice FGM in any form. However, an assessment carried out by UNICEF in 2015 found that the prevalence of FGM in South Sudan was about 1%. These cases of FGM were mainly in Bahr el Ghazal and Upper Nile regions, areas that border Sudan and are inhabited by Sudanese refugees. There is a paucity of information and current statistics on the prevalence of FGM in South Sudan.
SSMJ: Is FGM illegal in South Sudan?
Dr Akim: Yes, it is illegal in South Sudan. Practicing FGM in any form is a criminal offence. Both the Child Act and the Penal Code prohibit FGM and set out the punishments for perpetrators of FGM.
- The FGM/C Research Initiative. Distribution of FGM/C across South Sudan https://www.fgmcri.org/country/south-sudan
- South Sudan: The Law and FGM May 2018 https://www.orchidproject.org/wp-content/uploads/2019/02/south_sudan_law_report_v1_may_2018.pdf
Dr Nyakomi Adwok
SSMJ: What are the physiological/emotional effects of rape on a woman or girl?
Dr Adwok: Injuries, pregnancies and STIs are some of the physical and physiological outcomes associated with rape.
On an emotional level, the impact of sexual violence varies from person to person. There is no right or wrong way to feel afterwards and there is no timeline for “getting over it”
Many survivors experience negative emotions, which can include anger, shame, guilt and anxiety. For many girls and women, rape is a traumatic event. The effects of trauma can include low mood associated with suicidal thoughts, flashbacks, social withdrawal and substance misuse. These can be experienced shortly after the assault or for several years after.
The mental and physical impacts of rape can affect a person’s ability to study, work, maintain relationships or even carry out basic activities of daily life like taking a shower.
SSMJ: Do these differ if the abuser is an intimate partner, a person known to the woman, or a stranger such as a soldier?
Dr Adwok: Survivors of sexual assault by an intimate partner have been shown to experience psychological symptoms at higher rates than survivors of sexual assaults by strangers. They are also almost twice as likely to suffer from depression or anxiety.
SSMJ: Do they differ by the age and maturity /parity of the woman/girl?
Dr Adwok: Women can experience rape and sexual abuse at any time in their life. Sexual assault occurring at a young age before an individual has developed the mental, physical, emotional, and social resources to cope can be especially devastating. Studies have shown that girls and young women who experience sexual abuse demonstrate early onset puberty and maladaptive sexual development. They are also more prone to develop obesity and mental or physical illnesses. Girls and young women are also at risk of dropping out of school and teen motherhood.
SSMJ: How can healthcare practitioners, and a woman’s community and family provide the physiological and emotional support and care needed for an abused woman to heal?
Dr Adwok: Apart from assessing for and treating any immediate health concerns, health practitioners also have a responsibility to safeguard their patients and if necessary, refer them to organisations that can offer practical support.
One way that all these groups can support abused women is to respond to their disclosures in a compassionate, non-judgmental way. This includes the disclosure of the assault and their response to it. People respond to assault in many different ways, some of which can be surprising. It is important for those close to victims to know there is no script or timeline they have to follow.
One overlooked way families can support a victim of sexual assault is to acknowledge and address their own response to their loved one’s suffering. This can be done with a therapist or a trusted friend or family member.
- Du Mont J, Woldeyohannes M, Macdonald S, Kosa D, Turner L. A comparison of intimate partner and other sexual assault survivors’ use of different types of specialized hospital-based violence services. BMC Womens Health. 2017 Aug 7;17(1):59. https://doi.org/10.1186/s12905-017-0408-9
- Trickett PK, Noll JG, Putnam FW. The impact of sexual abuse on female development: lessons from a multigenerational, longitudinal research study. Dev Psychopathol. 2011 May;23(2):453-76. https://doi.org/10.1017/S0954579411000174.