1 For the purposes of this article, we understand sexual violence to mean “any sexual act or attempt to obtain a sexual act by violence or coercion, unwanted sexual comments or advances, acts to traffic a person or acts directed against a person's sexuality, regardless of the relationship to the victim”, according to the World Health Organization (WHO). See WHO, World Report on Violence and Health, 2002, p. 149. In turn, we understand rape as an act of obliging an individual to have sexual intercourse against his or her will, using force, violence and any other form of coercion. It is considered a felony in the criminal laws of most countries. See Bouchet-Saulnier, Françoise, The Practical Guide to Humanitarian Law, 2nd English-language ed., Rowman & Littlefield, Lanham, MD, 2007, p. 355Google Scholar.

2 A review of reports and websites of different humanitarian actors, while reflecting involvement in sexual violence, does not provide details on medical care; comparison is thus difficult. The International Rescue Committee states that it “[c]ounseled and provided essential services to over 27,000 survivors of gender-based violence” in its 2013 report, available at: www.rescue.org/blog/2013-annual-report-read-about-irc%E2%80%99s-lifesaving-work-and-impact (all Internet references were accessed in December 2014).

3 MSF, International Typology data, internal MSF document. Yearly figures as of 2005–2006 are available in the MSF International Activity Reports, available at: www.msf.org/international-activity-reports.

4 Le Pape, Marc and Salignon, Pierre (eds), Une guerre contre les civils: réflexions sur les pratiques humanitaires au Congo Brazzaville (1998–2000), Khartala, Paris, 2003, p. 109Google Scholar.

5 Personal verbal communication with former members of the board of MSF France, 2008.

6 Françoise Duroch and Sophie Marchand, Forgotten Crimes: Sexual Violence in the Context of Armed Conflict, MSF, Etat d'Urgence Production, 2006, available at: www.dailymotion.com/video/xrn91h_forgotten-crimes-sexual-violence-in-the-context-of-armed-conflict_news.

7 Claire Fourçans, “De la répression par les juridictions internationales des violences sexuelles pendant les conflits armés: rappel de quelques exemples récents”, Science and Video, No. 2, 2010, pp. 155–156.

8 The Akayesu case, which found Jean-Paul Akayesu guilty of rape as a crime against humanity, amongst other crimes, was the first international judgement to define rape, thereby setting an important precedent. International Criminal Tribunal for Rwanda (ICTR), The Prosecutor v. Jean-Paul Akayesu, Case No. ICTR-96-4-T, Judgement (Chamber I), 2 September 1998. See also F. Bouchet-Saulnier, above note 1, p. 551.

9 Jean-Hervé Bradol, former president of MSF France, remembers his own reaction when, during a discussion with a European Community Humanitarian Office consultant about the Burundian refugee camps in Rwanda in 1993, he was asked: “You have nothing planned for the women?” He explains: “The question annoyed me at the time, because of the degree of difficulty we had to deal with in the camps. But overall, the consultant was right. In these camps, single women were at a high risk of being raped. At the very least we can spread the word that contraceptives exist. A raped woman does not have to fall pregnant.” See M. Le Pape and P. Salignon (eds), above note 4, p. 161.

10 United Nations High Commissioner for Refugees (UNHCR), Sexual Violence against Refugees: Guidelines on Prevention and Response, 1995, p. 7.

11 François Bourdillon, Compte rendu de mission Congo Brazzaville: prise en charge médicale des femmes ayant subi des violences sexuelles, internal MSF document, 2000.

12 Duroch, Françoise, “Le viol, l'humanitaire en désarroi”, Revue Les Temps Modernes, No. 627, 2004, p. 3Google Scholar.

13 The Mano River scandal erupted in 2002, when UNHCR and Save the Children Fund published a report accusing tens of non-governmental organizations of exchanging help for sexual favours in the refugee camps of Guinea, Sierra Leone and Liberia. See Daphne Lagrou, Sexual Violence Response in OCB-Projects: Recommendations and Analysis, internal MSF report, 2011, p. 13. See also Note for Implementing and Operational Partners by UNHCR and Save the Children UK, “Sexual Violence and Exploitation: The Experience of Refugee Children in Guinea, Liberia and Sierra Leone”, February 2002, available at: www.unhcr.org/3c7cf89a4.html.

14 Inter-Agency Standing Committee, Report of the Task Force on Protection from Sexual Exploitation and Abuse in Humanitarian Crisis, June 2002, p. 1.

15 Pierre Hazan, “L'Onu relativise les dérives de l'humanitaire”, Libération, 25 October 2002.

16 D. Lagrou, above note 13, p. 7.

17 MSF, “MSF Top 10 Under-Reported Humanitarian Stories of 1999”, available at: www.msf.org/article/msf-top-ten-under-reported-humanitarian-stories-1999. In the RC, the problem of rape had been known to the community since the end of the first war in 1997 and an awareness campaign had been organized by the United Nations Fund for Population (UNFPA) and the International Rescue Committee before the war broke out again. F. Bourdillon, above note 11, p. 2.

18 Personal interview with Dr Joanne Lui, MSF International President, Geneva, October 2014.

19 Dr Jean-Herve Bradol, “Images du malheur et qualité des secours”, in M. Le Pape and P. Salignon (eds), above note 4, p.10.

20 Personal interview with Dr Jean-Clément Cabrol, Director of Operations, MSF Switzerland, Geneva, September 2014.

21 Marc Le Pape, “Guerres et viols au Congo: des urgentistes à Brazzaville, 1999–2000”, Séconde journée d’étude Guerre et Médecine, February 2004, Paris, available at: www.msf-crash.org/drive/2b0a-mlp-2004-guerre-et-viols-au-congo-des-urgentistes-a-brazzaville-_fr-art-p.8_.pdf. MSF had just started a campaign to push for access to essential drugs (see Access Campaign, available at: www.msfaccess.org/the-access-campaign), including antiretrovirals, which were practically inaccessible to HIV patients in the contexts where MSF worked. The MSF clinical guidelines at the time (1999) did not yet include PEP as a protective measure for health staff, and neither was it considered a preventive option for victims of sexual violence (MSF, Clinical Guidelines, 1999, p. 191).

22 MSF, Tika/Bika, viol. Viol, je dis non!, briefing paper, February 2003, available at: www.msf.fr/actualite/publications/tikabika-viol-viol-je-dis-non.

23 Emmanuelle Chazal, Gaelle Fadida and Claire Reynaud, Victimes de violence sexuelles: l'expérience de Brazzaville 2000–2005, internal MSF document, p. 3.

24 Ibid., p. 29.

25 MSF, above note 17.

26 “The programme has allowed MSF to understand that a patient who has been raped requires specific care. Much has been said about the ‘victims of sexual violence’ model; from a medical perspective, it took time for the approach to adequately address basic questions – hepatitis B vaccination, provision of antiretroviral treatment to those patients tested HIV positive, termination of pregnancy … Today, the protocol is distributed throughout missions and medical kits have been adapted according to this [new] need.” E. Chazal, G. Fadida and C. Reynaud, above note 23, p. 29 (our translation).

27 See above note 14.

28 “Sierra Leone: les agences réagissent aux problèmes des abus sexuels”, IRIN News, 6 June 2002, available at: www.irinnews.org/fr/report/66876/advancedsearch.aspx.

29 MSF, Code of Ethical Behaviour, internal MSF document, 2005.

30 Guillaume Le Gallais, Quelques réflexions sur les enjeux de sécurité, internal MSF document, 2004, p. 2.

31 Francoise Duroch, “Violence sexuelles: elements historiques et antropologiques”, Messages (internal MSF journal), No. 130, May 2004, p.8, available at: www.msf.fr/sites/www.msf.fr/files/2004-05-01-Messages130VF.pdf.

32 MSF International Activity Report 2003–2004, available at: www.msf.org/international-activity-report-20032004.

33 Jean-Hervé Bradol, “Dossier: l'offre de soins aux femmes”, Messages, No. 30, May 2004, p. 5.

34 MSF, Typology Definitions, internal MSF document, 2010, p. 4.

35 MSF International Activity Reports are available at: www.msf.org/international-activity-reports.

36 “All recorded activities should be conducted by MSF teams. In other words, MSF assumes the entire responsibility of the medical act. Medical activities conducted by others (Ministries of Health) through donations or funding should not be considered as an activity.” MSF, Typology Definitions, internal MSF document, 2005, p. 1.

37 MSF, International Typology data and MSF International Activity Reports, 2004–2013, see above note 35.

38 Johnson, Kirsten, Scott, Jennifer, Rughita, Bigy 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”, The Journal of the American Medical Association, Vol. 304, No. 5, 2010, pp. 553–562CrossRefGoogle ScholarPubMed.

39 Bullock, Clayton M. and Beckson, Mace, “Male Victims of Sexual Assault: Phenomenology, Psychology, Physiology”, Journal of the American Academy of Psychiatry and Law, No. 39, No. 2, pp. 197–205Google Scholar, April 2011, available at: www.jaapl.org/content/39/2/197.long.

40 MSF, Final Report: Comprehensive Care Project for Sexual Violence Survivors, Guatemala City, 2007–2012, 2012, p. 15; Buard, Vincent et al. , “Characteristics, Medical Management and Outcome of Survivors of Sexual Gender-Based Violence, Nairobi, Kenya”, Public Health Action, Vol. 3, No. 2, 2013, p. 110CrossRefGoogle Scholar; MSF, Rapport de capitalization du partenariat MSF Suisse et Sofepadi 2010–2013, Bunia, RDC, internal MSF document, 2013, p. 28; Roka, Jerlie Loko, Van den Bergh, Rafael, Au, Sokhieng, De Plecker, Eva et al. , “One Size Fits All? Standardized Provision of Care for Survivors of Sexual Violence in Conflict and Post-Conflict Areas in the Democratic Republic of Congo”, Public Library of Science, Vol. 9, No. 10, 2014, p. 3Google Scholar.

41 Sexual violence training is generally presented as a part of reproductive health-care sessions. MSF, Overview SV Related Documents and Tools, internal MSF document, 2014. Limited e-learning tools are available.

42 In Nairobi for Somali staff, and in Kampala for staff in the region, in 2012; two trainings are forthcoming in 2015 in Kampala and for staff in the Central African Republic.

43 These trainings have included forty to forty-five MSF staff, both international and national, every year since 2008. Debbie Cunningham, Follow-Up Evaluation of MSF Intersectional Sexual and Reproductive Health Course 2006–2010, MSF, 2012, available at: http://issuu.com/msfuk/docs/cunningham_srh/1?e=1061369/9715426.

44 In 2005, MSF's head of mission in Sudan was arrested and charged with crimes against the State following MSF's report on sexual violence. See MSF, “MSF Shocked by Arrest of Head of Mission in Sudan – Charged with Crimes against the State”, press release, 31 May 2005, available at: www.msf.org/article/msf-shocked-arrest-head-mission-sudan-charged-crimes-against-state.

45 MSF, Care for Victims of Sexual Violence: Situations with Displacement of Population, pocket guide, Version 3.0, 2013; MSF, Sexual Violence: Guidelines for Medical and Psychological Care of Rape Survivors, 2010 ed.; MSF, Sexual and Gender-Based Violence: A Handbook for a Response in Health Services Towards Sexual Violence (internal documents). To facilitate the preparation of teams in the field, a “rape kit” was developed; it includes enough drugs and vaccines to treat fifty adults and twenty-five children.

46 Joye, Sylvie, “La femme comme butin de guerre à la fin de l'Antiquité et au début du Moyen Âge”, in Trevisi, Marion and Nivet, Philippe (eds), Les femmes et la guerre de l'Antiquité à 1918, Economica/Institut de Stratégie Comparée, Paris, 2010, pp. 91–108Google Scholar.

47 Duroch, Françoise, “Violences sexuelles en République Démocratique du Congo: résistances et appropriations institutionnelles par les ONG”, L'Autre, Cliniques, Culture et Sociétés, Vol. 11, No. 2, 2010, p. 209Google Scholar.

48 F. Duroch, above note 12, p. 3.

49 Rapes directly compete with other priorities that also require action, and predominantly Western teams have a hard time understanding the cultural components involved: phenomena linked to sexuality are a sensitive point (taboos, discrimination, sensitivity). Joanne Liu and Pierre Salignon, “Victimes de viols, dispositifs de soins”, in M. Le Pape and P. Salignon (eds), above note 4, pp. 112–113.

50 Quote by former MSF France President Jean Hervé Bradol in M. Le Pape and P. Salignon (eds), above note 4, p. 160.

51 Augustin Nallet, “Violence Against Women in Conflict Affected Settings: An Overview of the Policies Designed and Implemented by NGOs”, cited in Françoise Duroch, “Resistance et appropriations institutionnelles des Organisations Non Gouvernementales autour de la notion de violences sexuelles”, Thèse de Sciences de l’éducation, UMR Education et Politique, presented 17 December 2008.

52 Françoise Duroch, “Figures de l'altérité féminine victimaire”, Science and Video, No. 2, 2010, available at: http://scienceandvideo.mmsh.univ-aix.fr/numeros/2/Pages/Duroch.aspx.

53 WHO, above note 1, Chapter 6, p. 3.

54 The 1995 Fourth World Conference on Women in Beijing marked a significant turning point for the global agenda for gender equality. The Beijing Declaration and the Platform for Action, adopted unanimously by 189 countries, is an agenda for women's empowerment and considered the key global policy document on gender equality. It sets out strategic objectives and actions for the advancement of women. Available at: www.unwomen.org/en/how-we-work/intergovernmental-support/world-conferences-on-women#sthash.hjeATv8c.dpuf.

55 See, for example, Rome Statute of the International Criminal Court, 17 July 1998 (entered into force 1 July 2002), UN Doc. A/CONF.183/9 (Rome Statue).

56 “The term ‘victim’: Although the term ‘victim’ is used in these Guidelines, the stigmatization and perceived powerlessness associated with being a ‘victim’ should be avoided by all concerned parties. While victims require compassion and sensitivity, their strength and resilience should also be recognized and borne in mind.” UNHCR, above note 10, p. 3.

57 Clark University, “A Definition of Rape, Sexual Assault and Related Terms”, available at: www.clarku.edu/offices/dos/survivorguide/definition.cfm.

58 “It is not worth supporting a mass of political correctness. When I hear MSF in the DRC denouncing ‘rape as a weapon of war’ and at the same time calling the victims ‘rape survivors’, I am baffled by the contradiction. A survivor is someone who exceptionally escaped near-certain death. Often, combatants aim for the large-scale use of rape, as a strategy of terror that wants women to survive, even wants them to become pregnant … Survival in this case is not the exceptionally happy outcome the term suggests.” Jean-Hervé Bradol, above note 33, p. 5.

59 Véronique Moufflet, “Le paradigme du viol comme arme de guerre à l'Est de la République démocratique du Congo”,Afrique Contemporaine, Vol. 3, No. 227, 2008, pp. 119–133, available at: www.cairn.info/revue-afrique-contemporaine-2008-3-page-119.htm.

60 A medical condition in which trauma leads to the development of a hole between the vagina and bladder and/or rectum, resulting in chronic incontinence among other issues.

61 MSF, Medical Protocol for Sexual Violence Care, 2nd ed., MSF Reproductive Health and Violence Care Working Group, internal document, 2014, p. 2.

62 E. Chazal, G. Fadida and C. Reynaud, above note 23, p. 5.

63 MSF, Hidden and Neglected: The Medical and Emotional Needs of Survivors of Family and Sexual Violence in Papua New Guinea, 16 June 2013, p. 1818, available at: www.doctorswithoutborders.org/sites/usa/files/06-15-Papua-New-Guinea-Sexual-Domestic-Violence%20report.pdf; Tayler-Smith, Katie, Zachariah, Rony et al. , “Sexual Violence in Post-Conflict Liberia: Survivors and Their Care”, Tropical Medicine and International Health, Vol. 17, No. 11, 2012CrossRefGoogle ScholarPubMed; MSF, Final Report, above note 40, p. 24; J. Loko Roka et al., above note 40, p. 4.

64 MSF, above note 61, pp. 5–6.

65 Patients came back for follow-up consultation and completion of treatment was confirmed. Other patients may have completed, but did not return for a follow-up consultation. K. Tayler-Smith et al., above note 63, p. 3158; MSF, Final Report, above note 40, p. 27.

66 V. Buard et al., above note 40.

67 MSF, MSF Policy for Reproductive Health and Sexual Violence Care, final version, International Working Group on Reproductive Health and Sexual Violence Care, internal MSF document, March 2014.

68 MSF, Hidden and Neglected, above note 63, p. 21; MSF, Final Report, above note 40, p. 29.

69 Center for Reproductive Rights, Governments Worldwide Put Emergency Contraceptives in Women's Hands: A Global Review of Laws and Policies, briefing paper, September 2004, available at: http://reproductiverights.org/en/document/governments-worldwide-put-emergency-contraception-into-womens-hands.

70 Anastasia Moloney, “No Option to Unsafe Abortion for Many Rape Victims in Honduras – MSF”, Thomson Reuters Foundation, September 2014, available at: www.trust.org/item/20140909174405-khgtc/.

71 WHO, Clinical Management of Rape Survivors, 2001, p. 23.

72 This includes “[c]ountries where abortion is otherwise illegal [but where] pregnancy termination is allowed after rape”. WHO, Guidelines for Medico-Legal Care for Victims of Sexual Violence, 2003, p. 66.

73 WHO, Outcome of the Inter-Agency Lessons Learned Conference: Prevention and Response to Sexual and Gender-Based Violence in Refugee Situations – Draft for Field Testing, Geneva, 27–29 March 2001, p. 19.

74 On US funding, see Louisa Blanchfield, Abortion and Family Planning-Related Provisions in U.S. Foreign Assistance: Law and Policy, Congressional Research Services, 31 January 2014, p. 3.

75 MSF, above note 61, p. 14; MSF International Activity Report 2013, p. 19, available at: www.msf.org/international-activity-report-2013-addressing-women%E2%80%99s-health-needs.

76 UNFPA, World Abortion Policies, 2013.

77 MSF, Reproductive Health and Sexual Violence Care in MSF, activity report, 2013.

78 MSF, Hidden and Neglected, above note 63, p. 17; MSF, Final Report, above note 40, p. 16; K. Tayler-Smith et al., above note 63, p. 1358; V. Buard et al., above note 40, p. 110.

79 MSF, Civilians Under Fire: Humanitarian Practices in the Congo, 1998–2000, available at: www.doctorswithoutborders.org/civilians-under-fire-humanitarian-practices-congo-1998-2000.

80 K. Tayler-Smith et al., above note 63, p. 1358; V. Buard et al., above note 40, p. 110; MSF, Hidden and Neglected, above note 63, p. 16,

81 K. Johnson et al., above note 38, pp. 553–562.

82 Wynne Russell, Alastair Hilton and Michael Peel, Care and Support of Male Survivors of Conflict-Related Sexual Violence, Sexual Violence Research Initiative Briefing Paper, 2011, available at: www.svri.org/CareSupportofMaleSurviv.pdf; Will Storr, “The Rape of Men: The Darkest Secret of War”, The Observer, 17 July 2011.

83 W. Russell, A. Hilton and M. Peel, above note 82, p. 4.

84 Marc Le Pape, “Viols en temps de guerre, les hommes aussi”, Issues de secours (blog of Libération), 1 November 2011, available at: http://humanitaire.blogs.liberation.fr/msf/2011/12/-viols-en-temps-de-guerre-les-hommes-aussi-.html.

85 Baaz, Maria Eriksson and Stern, Maria, The Complexity of Violence: A Critical Analysis of Sexual Violence in the Democratic Republic of Congo (DRC), Nordiska African Institutet, Sida, 2010, p. 43Google Scholar.

86 Hustache, Sarah, Moro, Marie-Rose et al. , “Evaluation of Psychological Support for Victims of Sexual Violence in a Conflict Setting: Results from Brazzaville, Congo”, International Journal of Mental Health Systems, Vol. 3, No. 7, 2009CrossRefGoogle Scholar, available at: http://link.springer.com/article/10.1186%2F1752-4458-3-7#page-1.

87 MSF, Baseline Study Report on the Perception of Sexual and Gender-Based Violence in Mbare, Harare, Zimbabwe, 2011, p. 14.

88 D. Lagrou, above note 13, p. 41.

89 Experiences from different MSF projects seem to indicate that only a small number of patients require more specialized counselling than the “psychological first aid” that is part of the victim's initial medical consultation. “Characteristics, Medical Management and Outcome of Survivors of Sexual Gender-Based Violence, Nairobi, Kenya”, Public Health Action, Vol. 3, No. 2, 21 June 2013, p. 111Google Scholar.

90 MSF, Medico-Legal Issues: Case Management of Victims of Sexual Violence: Care and Protection, internal MSF document, 2014, p. 3.

91 WHO, above note 72, p. 34.

92 Ibid., p. 34.

93 Laure Wolmark, “Portraits sans visage, des usages photographiques de la honte”, Science and Video, No. 2, 2010, available at: https://scienceandvideo.mmsh.univ-aix.fr/numeros/2/Pages/Wolmark.aspx.

94 MSF, Be Prepared: 10 Steps and “5 Step 2014 Analysis, Operational Center Amsterdam”, internal MSF documents.

95 MSF, above note 90; V. Buard et al., above note 40, p. 1357.

96 MSF, Lessons Learned: MSF's Projects Working on Violence in Urban Settings, internal MSF document, 2011 p.6.

97 United Nations Joint Human Rights Office, Progress and Obstacles in the Fight against Impunity for Sexual Violence in the Democratic Republic of the Congo, 2014, available at: www.monusco.unmissions.org/LinkClick.aspx?fileticket=Gyh_dUBNGcs%3D&tabid=10770&mid=13783&language=en-US.

98 As confirmed by internal MSF reports in the DRC, victims may be reluctant to report the attack to the authorities, often because of fear of reprisals or lack of trust in the judicial and penitentiary system – reinforced by the not uncommon prospect that the perpetrator will escape prison. Geographical distance and the perception of long and difficult judicial procedures (and even fruitless ones – see the recent Minova case) can also be strong disincentives.

99 UN Human Rights Council, “Human Rights Council Holds High-Level Dialogue on Combatting Sexual Violence in the Democratic Republic of the Congo”, 25 March 2014, available at: www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=14435&LangID=E#sthash.jVEwL4wl.dpuf. The MSF statement was read during the Human Rights Council session in Geneva on 25 March 2014 (internal document).

100 MSF, above note 90.

101 The medico-legal certificate states the patient's account of the assault, including all elements that may prove relevant (e.g. time, place, characteristics of the aggressor/s), as well as the findings of the medical examination and related treatments of physical and mental injuries. It is important to note that the information on the assault is a transcript of the patient's account; medical practitioners have no role whatsoever in judging its veracity.

102 MSF pocket guide, above note 45, Sheet 20, “Need to Establish a Medico-Legal Certificate”.

103 For crimes under the jurisdiction of the International Criminal Court, statutes of limitations do not apply. See Rome Statute, Art. 29; see also UN Res. A/RES/2391 (XXIII), Convention on the Non-Applicability of Statutory Limitations to War Crimes and Crimes against Humanity, 26 November 1968, Preamble.

104 E. Chazal, G. Fadida and C. Reynaud, above note 23, p. 26 (our translation).

105 A central component of the UN's strategy for preventing conflict-related sexual violence is addressing impunity and identifying perpetrators. Different resolutions outline related calls for timely and detailed information on assaults and perpetrators. The efforts to compile a database shared among agencies are another example of the drive for data related to sexual (and gender-based) violence. See Gender Based Violence Information Management System (GBVIMS) Steering Committee, “Overview of the GBVIMS”, Version 14, 2010, p. 1.

Claire Magone, “Collecting Data on Sexual Violence: What Do We Need to Know? The Case of MSF in the Democratic Republic of Congo”, Humanitarian Exchange Magazine, No. 60, February 2014, p. 20.

106 Ibid.