Introduction

Since the beginning of mankind, conflict among various groups of individuals has resulted in numerous acts of violence. From a historical perspective, sexual violence has mostly been considered a “by-product” of conflict that mostly affects women and girls in war-afflicted areas. With the various atrocities that occurred in the 1990s, political agents, international actors and the entire world were forced to confront the issue of sexual violence in conflict areas and recognize the interaction between war methods and gender specific human rights violations. The magnitude of violence altered perceptions of sexual violence in armed conflicts- now seen as techniques of warfare. Violence against girls and women could no longer be considered isolated events but rather systematic attacks used to curtain certain groups. With the everchanging nature of international humanitarian law and advocacy for the prosecution of sex crimes affiliated with conflicts, rape has become a punishable offense under international law.

This paper will utilize the definition of rape provided by the International Criminal Court; this definition includes “… the penetration, however slight, of any part of the body of the victim or of the perpetrator with a sexual organ […] with any object or any other part of the body (International Criminal Court, 2011).  Aside from the semantics of prosecution of rape, one of the defining aspects of war rape is its contribution to social isolation, stigmatization and increased rates of mental disorders (Vinck et al., 2007). In recognizing the effects of war rape, governments and non-governmental agencies have established support systems to aid victims of rape. This paper will focus on the experiences of females regarding the World Health Organization’s (WHO) recommendations for mental health interventions related to sexual violence. In this analysis, the question arises of whether standardized sexual violence interventions are effective in conflict-afflicted settings and whether there is a danger in the board generalization of lived experiences in conflict areas.

Psychological Effects

Similar to rapes occurring in peacetime, survivors of war rape tend to be at a higher risk of psychological problems; these problems stem from the traumatic experience of rape. While each rape case is different, victims tend to share similar symptoms or “experiences” of trauma. During the first few months after a rape, victims express feelings of acute distress such as fear, shame, disorientation and vulnerability (Cohen & Roth, 1987). While some psychological consequences of rape can subside after a certain period, if left untreated, other consequences can escalate to a devasting level where it can impair daily functioning of a survivor or become deadly. This paper will focus on the long term psychological consequences of rape such as anxiety disorders, depression, and nightmares/flashbacks (Cohen & Roth, 1987). Following a rape, a survivor may display symptoms of post- traumatic stress syndrome (PTSS) such as re-experiencing the rape, avoiding things related to the rape, numbness and increased anxiety (Mason & Lodrick, 2013). Escalation to or the persistence of severe symptoms can be attributed to the experience of re-victimization, where other individuals may deny the occurrence of the rape or blame the survivor (Mason & Lodrick, 2013).

Societal Effects

In addition to the psychological effects that result from war, rape as a method of warfare can affect the relationship of a rape victim with their community. With a change in association between a victim and their extended relationships, war rape has the unique ability of structurally affecting a community without afflicting direct violence against the men (Swiss, 1993). Before delving into the impact of war rape on individuals and communities, it’s imperative to discuss the difference between war rape and rape during peace time as societal effects tend to be emphasized due to increased conflict and violence. In general, the cultural framework of rape is an expression of dominance and inequality towards women as it is based on societal gender power imbalances (MacKinnon, 1994). Establishment of gender inequality creates a sense of male entitlement over female’s bodies, thus perpetuating a cycle of objectification and violence against women. In this light, rape during peacetime stems from a socio-cultural dynamic of inequality and commodification of female sexuality. While war rape develops within the same general context, this dynamic is slightly different due to ethnic, religious and social conflicts that give rise to violence.

With victims of rape, especially war rape, the process of re-victimization renders victims at a risk of social isolation as well as rejection by their communities. For some women and girls who experience war rape, there is the feeling of having “lost their value” (Ward & Marsh, 2006). In Burundi, women remarked about how they “had been mocked, humiliated and rejected by women relatives, classmates, friends and neighbors” (Ward & Marsh, 2006). For married women, they may be abandoned by their husbands for fear of contracting HIV or due to perceived dishonor that is placed on the household. Because of local ethnic conflicts in war zones, rape can be a means of ethnic cleansing, which by definition, indicates a societal issue. In this context, rape is not simply an event of opportunity but rather a systematic choosing of women due to their ethnicity or religion to “contaminate the enemy’s blood and genes” (Farwell, 2004). For cultures where there is an emphasis on family honor and the sacredness of female sexuality, methodical raping is utilized to dishonor women, their families and the men these women represent. The forced reproduction of a perpetrator’s genes as a means of extermination is due to certain cultural practices where children are viewed as belonging to the father (MacKinnon,1994). In this sense, any child born of rape is of the “enemy’s” ethnicity, thus seen as outcasts in a community. During ethnic cleansing, mass rape of women is utilized to destroy entire ethnic groups by destroying the protectors of culture- women (Farwell, 2004). Not only are women’s lives affected by psychological injuries but their roles in society becomes damaged as they become worthy of rejection.

Liberia

Recent conflict in Liberiabegan with border incursions from Sierra Leone in 1989 as well as territorial conflicts between armed groups (Cohen & Green, 2012). In 1990, violence reached its peak when armed groups crossed into Liberia from the Ivory Coast to overthrow the government ruled by Samuel Doe (Swiss,1998).  Due to increased ethnic tensions during the Doe regime, seven different armed groups were in constant conflict with one another. In 1997, Charles Taylor was elected President, thus ending more than 7 years of conflict and violence (Swiss, 1998). While sexual violence was already present in Liberia pre-civil conflict, rape and sexual violence became increasingly common during years of intense conflict (post-1990) (Lekskes et al., 2007). Analogous to its rise to the international stage, cases of rape became apparent with increased documentation of sexual abuse of minor children for prosecution in court. Before such a system, sexual violence was limited to and dealt with by communities. Often for the sake of limiting social damage, marriage after rape was accepted; this was a measure to preserve the value of a victim as well as ensure a “future” for the victim (Lekskes et al, 2007). In Liberia, types and intensity of sexual violence differed based on regions. In some regions, gang rape in public was favored while in other regions, rape occurred in more private and isolated areas. With sentiments considering rape as “provocation by [a] woman” and not a crime by a man, this creates differences in societal reactions (Lekskes et al., 2007). Due to the nature of a public rape, this allows for the possibility of discussion among community members as the secretive nature of sex has been abandoned. In other communities, victims of sexual violence keep their rape a secret to prevent stigmatization and social isolation. While some Liberian adult women refuse to acknowledge or call themselves victims of sexual violence, sexual abuse of minor girls (as early as 18 months) is socially unacceptable (Lekskes et al, 2007). In acknowledging and working against a specific population’s experience with sexual violence (i.e. sexual abuse of minor girls), this opens more discussion about sexual violence against adult women and treatments needed for healing.

Until the beginning of 2006, mental health in Liberia was not prioritized enough due to a lack of money allotted for psychological care. Due to a lack of clinical care, many non-governmental organizations have undertaken the responsibility of providing psychosocial care in Liberia. One NGO, the Concerned Christian Community (CCC) provide counseling to women; the counseling teams utilize a community-based approach to provide care. In teams of three or four people, they visit each village weekly to provide free medical and counseling services. After counseling, the organization offers skill-based training, where the women can learn how to construct water pumps and latrines (Lekskes et al., 2007). Qualification for the program includes selection based on story of sexual abuse and psychological condition even though the criteria to determine psychological condition are not clear (Lekskes et al., 2007). During the initial individual session, history is taken; this includes social history pre-war, family history and a mental status exam as well as victims are encouraged to discuss the “entire story of what happened to them during the war” (Lekskes et al, 2007).

Another program, Women’s Health and Development Program (WHDP), provided support to women through skill training for income generating activities such as soap making and tie-dying fabrics. With this program, there is no direct counseling however, the program does reinforce that establishment of coping skills (Lekskes et al, 2007).  In a study done to evaluate PTSD symptoms in women, there was reduction in PTSD symptoms for those involved in the CCC program, while there was an increase in PTSD symptoms for those involved in WHDP. Women involved in both interventions displayed a reduction in PTSD symptoms. This indicates that while learning skills and coping strategies may be important at some points of recovery, the chance for women to express what happened to them may be more important for the healing process. While each NGO has its own recommendations concerning care for victims of rape, the World Health Organization (WHO) recommends that women survivors be provided first line support within the first 5 days of assault. This support includes “providing practical care and support, listening without pressuring her to disclose information” as well as taking a complete history that includes time and type of assault, risk of pregnancy and mental health status (WHO, 2013). In the case of CCC, their regulations coincided with the recommendations from WHO, however while such recommendations may work theoretically or in the long term, these recommendations don’t include the discrepancies that can occur due to vagueness of language. While CCC carried out extensive intakes, many counselors did not have a clear idea of what type of interventions to perform, did not pay attention to the traumas the participants went through as well some would advise survivors to “forget what happened to them and not to blame themselves” (Lekskes et al, 2007).  This highlights that while trauma informed counseling interventions can positively affect survivors, due to the vagueness and lack of adequate training for counseling, this leaves room for much improvement. While the interventions from WHDP were insufficient by themselves, when combined with CCC interventions, they resulted in a reduction of PTSD symptoms.  It’s imperative to recognize the importance of providing women with income generating skills and coping strategies especially in countries where socio-economic problems are still persistent. By allowing women to express their experience as well as create employment possibilities, this can foster hope, distract women and allow women to reconstruct their lives.

Bosnia

During the Bosnian War (1992-1995), violence took a gendered form as Bosnian Serbian forces utilized rape as an instrument of ethnic cleansing (Loncar et al., 2006). With the inflammation of Serbian nationalist sentiment against Bosnian Muslims (Bosniaks) in 1989, aggression towards Bosniaks were further stirred up due to stories about the role a small group of Bosniaks played in the Ustase genocide during the 1940s. Due to years of social and political resentment against the former Ottoman empire, President Milosevic was able to increase Serbian nationalism through stories of murder and oppression (Bensel & Sample, 2015). Serbian forces, under President Milosevic’s command, set up roadblocks near ethnic villages; these soldiers were instructed to burn down Muslim homes, Ottoman Empire architecture and Islamic mosques (Bensel & Sample, 2015).As Serbian forces began to target Bosniak civilian population, such forces set up “rape camps” where they would rape the women repeatedly and only released them once the women became pregnant (Benson & Sample, 2015). As mentioned previously, these children of rape would be considered to have the perpetrator’s “ethnicity”, thus furthering Bosnian Serbian nationalist sentiment. In a study done by Loncar and others (2006), many Bosnian women who participated expressed that they were raped more than once and by different perpetrators as well as were raped every day during captivity. Many of the rapes were accompanied by threats of death, physical injury or injury to family. Immediately after the rapes, victims expressed that they suffered through episodes of depression, avoidance of thoughts associated with the trauma and feelings of self-blame (Loncar et al., 2006). A year after the trauma, most victims suffered from depression, social phobia and PTSD.

In the case of Bosnia, this paper will discuss psychosocial interventions in the United States for Bosnian female refugees.  For cases of demonstrated symptoms of PTSD, refugees can undergo Cognitive- Behavioral Therapy (CBT) to treat trauma-related distress. CBT as a treatment involves managing distress by changing the way people think and behave. In this study, individuals were referred through health clinics, a refugee agency as well as individuals could also self-refer themselves into the program (Schulz et al., 2006). Assignment to a therapist was based on availability as well as sessions took place in participants’ homes as many participants did not have them means to attend a private practice. During intake, participants received information about services provided, PTSD and the treatment process. Unlike other interventions that emphasize complete history at initial intake, several sessions were allotted to assess symptoms and to determine case-specific treatment goals (Schulz et al., 2006). The therapist and patient would negotiate the length of treatment and duration of therapy sessions. For this study, participants showed a significant decrease in PTSD symptoms at termination of treatment (Schulz et al., 2006). With the spread of assessment occurring over several sessions, this allowed for adequate time to identify symptom severity.

An alternative to cognitive-behavioral therapy is testimony psychotherapy, where “a survivor’s trauma story is told and documented” (Weine et al., 1998). Testimony has been a way for individual recovery as well as a means for bearing witness to realities related to sexual violence. Due to the nature of documentation, there is an explicit understanding that the survivor’s stories are becoming part of a collective experience thus can reduce individual suffering (Weine et al., 1998). Participants were recruited through outreach work in the Chicago Bosnian community. For assessment, all participants were screened for traumatic stress, depression and psychosocial functioning. Each participant received a clinical assessment that included complete prior psychiatric history, mental health status and a checklist for commonly diagnosed disorders (via definitions of DSM- IV). On average, psychotherapy consisted of six sessions and the entire procedure lasted about six weeks (Weine et al., 1998). The final document was given back to the survivor and signed by the survivor. One copy was given to the survivor and the second was sent to the archives of the Project on Genocide, Psychiatry and Witnessing. The testimony psychotherapy decreased both PTSD symptoms and severity in participants (Weine et al., 1998). There was also a reduction in depressive symptoms and there were no apparent negative effects that accrued from the study. From this study, this emphasizes the importance of allowing survivors to express their stories as it can reduce symptoms and improve functioning. Similarly, to the interventions utilized in these studies, Cognitive Behavioral Therapy is recommended by WHO as well as there is some aspect of shared decision making (in terms of whether to take HIV prophylaxis) (WHO, 2013). On the other hand, Testimony Psychotherapy did not utilize complete history at initial intake especially concerning the sexual assault; this could be attributed to the process of an individual documenting their experience for themselves as opposed to a healthcare worker documenting the experience. In either case, documentation of the experience seems to be the key as it provides a way for a survivor to convey their experience.

Rwanda

While atrocities against humanity have been a consistent aspect of mankind, few have reached the international stage and historical memory as much as the Rwandan Genocide of 1994. Within 100 days, 75% of the Tutsi population in Rwanda were killed

(Weitsman, 2008).

The Hutu government encouraged propaganda to incite violence against Tutsi men, women and children; much of this propaganda led to the killing of Tutsi women. The propaganda depicted Tutsi women as promiscuous as well as portrayed feelings of superiority toward Hutu men (Weitsman, 2008). Reintroducing the aspect of sexual violence where there is an imbalance in power between the genders and male dominance over women, much of the violence during the genocide was directed at Tutsi women. One witness expressed the killing of a baby as it emerged from its mother’s body, “a multitude of rapes with foreign objects […] and the burning of a women’s pubic hair “(Weitsman, 2008). Unlike the sexual violence enacted in Bosnia that was directed towards reproduction, rape in Rwanda was mostly conducted with foreign objects- tools of all sorts such as spears, gun barrels and bottles. The systematic rape that took place was utilized to degrade, punish and humiliate Tutsi women. As a consequence of the genocide, rates of mental disorders have elevated in Rwanda; there has been increased rates of depression, PTSD and general anxiety symptoms (Heim & Schaal, 2014). Despite the high prevalence of mental disorders in Rwanda, access to mental health treatment is still limited. In 2011, there were only five psychiatrists and one neuropsychiatric hospital based in Rwanda (Heim & Schaal, 2014). This lack of health professionals can be attributed to the fact that 80% of Rwanda’s professionals were either killed or fled the country (Zraly et al., 2011).

While psychosocial interventions have typically focused on the impact of war rape on the raped women themselves, few studies examine the relationship between women and their child. With the context of this child being born out of rape, traumatization of the mother can interfere with the psychological development of the child (Hogwood et al., 2014). Often, both mother and child are stigmatized and experience social isolation. With the introduction of the NGO, Foundation Rwanda and Survivors Fund (FRSF), there is an initiative to support mothers with various types of resources (Hogwood et al., 2014). In this community counseling program, women were selected through a local NGO (Kanyarwanda). The groups met twice a month and the groups were facilitated by female Rwandese counselors. The groups aimed to provide resources to mothers, a safe place to share experiences, provide psycho-education and to help the women learn strategies to deal with their experience (Hogwood et al., 2014). They also aimed to help the women gain knowledge about disclosure and strengthen their relationship with their child.

An evaluation tool was administered to all group members during the first session; the counselor would read the questions and the women would answer the questions individually and privately. The mothers were asked to rate their life on scale of 0-10. where 0 is the worst life possible. They were later asked if they had other people to talk to about their problems, how much they accepted their child and how happy they were as parents (Hogwood et al., 2014).  This tool was asked again during the half way point and at the end of the duration of the group counseling. After three months, a follow-up group was organized, and the evaluation was repeated for a fourth time. By the end of the treatment, individuals rated the counseling groups as helpful, reported improvement in life satisfaction and increase in acceptance of being a parent to a child born out of rape (Hogwood et al., 2014). Unlike WHO recommendations that seem to emphasize individual counseling, FRSF alternatively encouraged group counseling with the aim of future disclosure on the part of the women. A key aspect of the group counseling is that it encouraged women to connect with other women in a similar situation as well as reduce their sense of social isolation. In contrast with this aspect of group counseling, individual counseling may not reduce feelings of social isolation as it is a private, individual act. Another key difference is a lack of extensive information required at intake; the women were only asked to rate their lives on a subjective scale. The reason for this would be they are most likely disclosing such information during their group counseling sessions. Similar to the testimony therapy, there is a feeling of collectiveness, however in this case, there is a lack of documentation.

While diagnosis of mental disorders is on the rise in conflict areas (and everywhere in general), the quality of care for such disorders are not necessarily consistent throughout conflict areas. The World Health Organization has established some recommendations in providing care to survivors of sexual violence such as care through listening and offering information in a one to one environment. There is also an emphasize on individual counseling (WHO, 2013). While such recommendations seem to be the basis for adequate care for survivors, the vagueness of such recommendations leaves much room for mistakes to occur during the process of care. As seen in Liberia, many counselors especially community-based counselors were not necessarily aware of what constitutes proper listening and identification of trauma.  Also, we’ve seen alternative ways of typical interventions such as cognitive behavioral therapy, in terms of therapy at home as well as new ways to witness such violence through testimony therapy. Mothers in Rwanda utilized group counseling to heal as well as reduce the feeling of social isolation. Through this paper, it is important to highlight that standardization of mental health may be adequate for determining mental health status but in terms of providing care, care comes in many different forms. Depending on the needs of the intended population, different forms of counseling and therapy may be more efficient.

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To be able to be provide sufficient nursing care to all, nurses must understand and demonstrate culture respect and awareness. Nurses and all health care professionals must demonstrate cultural competency, cultural sensitivity. The health care system is a cultural diverse area that all health care professionals must utilise and thoroughly understand to be able to provide reliable care to all individuals no matter their race, age, sex and background. Nurses must understand that different cultures have different customs and beliefs and nurses must know how to provide correct nursing care to these different individuals.

Culture refers to the cumulative deposit of knowledge, experience, beliefs, values, attitudes, meanings, hierarchies, religion, roles, relations, and possessions acquired by a group of people in the course of generations through individuals and groups. Culture can be a system of knowledge shared by a small or large group of people. A culture can be a is a way of life of a group of people-their behaviours, beliefs, values, and symbols that they accept, generally without thinking about them, and that are passed along by communication and imitation from one generation to the next, this is the way of their life.

Today when people move across continents with the help of technology their culture and heritage moves along with them. Almost each and every continent is populated with people from different nations who have diverse traditions and cultures. So knowledge of health traditions and culture plays a vital role in nursing. People from different cultures have a unique view on health and illness. Culture specific care is a essential skill to the all nurses, as Australia continues to consist of many immigrants who have become assimilated into one culture. ‘Cultural diversity is a challenge for community nurses and can present many difficulties in the provision of quality nursing care and in achieving the best possible health care outcomes.’ (Contemporary Nurse Journal 1992-2010)

Gathering accurate information on the cultural diversity of the client group is the key

to planning for quality nursing care for culturally diverse clients.

‘By investigating service use and health trends, it may be possible to identify issues

relevant to particular language or cultural groups. This may also indicate a need to

develop new strategies tailored to certain cultural groups or target interventions to

tackle specific health and welfare issues.'(Government Department of Human Services 2006)

The responsiveness of an health care professionals to the communities and/or cultural groups it helps can be greatly effected by developing and maintaining a culturally diverse and aware workforce. Employing nurses who speak other languages or have experience and understanding of other cultures can be an important for improving an health organisation’s awareness and sensitivity to different cultures. ‘Cultural awareness training for staff can raise consciousness of cultural issues more broadly and contribute significantly to improved service delivery.’ (Government Department of Human Services 2006)

To be culturally competent a nurse needs to understand their own cultural and world views and those of the patient, and nurses need to avoided stereotyping to the scientific cultural area. Cultural competence is obtaining cultural information and then applying that knowledge. Cultural awareness allows nurses to see the entire picture and improves the quality of care and health outcomes.

Adapting to different cultural beliefs and practices requires flexibility and a respect for others view points. Cultural competence means to really listen to the patient, to find out and learn about the patient’s beliefs of health and illness. ‘To provide culturally appropriate care we need to know and  to understand culturally influenced health behaviours.’ (culturediversity.org. 1997-2008)

In Australia nurses don’t have to travel to far to encounter a lot of cultural differences, such as ethnic customs, traditions and beliefs. To be culturally competent the nurse needs to learn how to mix a little cultural understanding with the nursing care they offer. Perceptions of illness and disease and there causes varies by different cultures, these individual preferences affect the approaches to health care. Culture also influences how people seek health care and how they behave toward health care providers. How nurses care for patients and how patients respond to this care is greatly influenced by culture. Health care professionals must have the ability and knowledge to communicate and  to understand all health behaviours influenced by culture.

Cultural competence requires nurses to have an awareness of the fact that there are many different belief systems. The beliefs that different cultures may have about health care and sometimes their aversion to it, may be difficult for some nurses to understand but all health care professionals must understand that nurses don’t need to understand these beliefs completely, but need to respect and show some understanding and a willingness to learn.

Drawbacks to cultural sensitivity can include stereotyping, discrimination, racism, and prejudice.  There may be situations in which some nurses may show a lack of sensitivity without realising it or intending to offend someone. Nurses should never make assumptions about individuals and their beliefs.  Nurses should ask questions about cultural practices in a professional and thoughtful manner if they don’t fully understand the culture. Show respect for the patients support group, whether it is family, friends, religious leaders etc. Understanding where men and women fit in the patients culture is necessary, in some cultures, the oldest male is the decision-maker for the rest of the family, even with regards to treatment decisions. All nurses must make an effort to gain the patients trust and develop a rapport.

‘Cultural competence is the ability to provide effective care for clients who come from different cultures. It requires sensitivity and effective communication, both verbally and non-verbally.’ (nursetogether.edu.au 2009)

In conclusion nurses as a whole need to be culturally diverse in the way the provide quality health care. They need to understand that all patients are different and they will all need different nursing care to fit their culture. Nurses need to respect, understand and learn from different people about their different cultures. Nurses must not be racist, discriminatory or show any prejudice to any patient about their culture, just because it isn’t the same as the nurses doesn’t mean that it is wrong. The Australian Health care system is culturally diverse so all health care professionals need to uphold a high standard of care to all know matter their culture and if cultural awareness and understanding is administered nurses can provide a holistic approach to health care.