Prevalence of War-Related Sexual Violence and Other Human Rights Abuses Among Internally Displaced Persons in Sierra Leone

Sierra Leone gained independence from England in 1961. By 1991, the country's dire economic and political conditions set the stage for the emergence of the Revolutionary United Front (RUF), which claimed to be a political movement with the aim of salvaging the country from the endemic corruption of the All Peoples Congress regime.¹ A military coup in 1992 overthrew the All Peoples Congress regime.¹ Subsequent international and local public pressure led to a democratic election in 1996, which was won by Tejan Kabbah.¹ Under Kabbah, the Civil Defense Forces, a progovernment militia, was strengthened to protect government-held areas against the rebels.¹ In May 1997, the Sierra Leonean Army overthrew Kabbah, formed the Armed Forces Revolutionary Council regime, and joined forces with the RUF.¹ In March 1998, the West African Intervention Force ousted the Armed Forces Revolutionary Council/RUF junta and reinstated Kabbah.²

In January 1999, the Armed Forces Revolutionary Council/RUF invaded Freetown and committed egregious human rights abuses against the civilian population.³ In 1999, the international community brokered a cease-fire, which led to the signing of the Lome Peace Agreement, a controversial power-sharing agreement between the government of Sierra Leone and the RUF that granted amnesty to all combatants, except those who committed crimes of genocide, crimes against humanity, or war crimes.⁴ The United Nations Mission in Sierra Leone was established and is currently the world's largest United Nations (UN) peacekeeping mission.⁵

In May 2000, the RUF took 500 UN peacekeepers hostage.² In September 2000, the RUF staged cross-border attacks in neighboring Guinea.⁶ Guinean armed forces subsequently invaded Sierra Leone to dislodge the RUF. Under pressure, a cease-fire agreement was signed between the RUF and the government of Sierra Leone.⁷ In May 2001, the Disarmament, Demobilization, and Reintegration Program resumed in numerous districts, including the diamond-producing areas.⁸

Sierra Leone is one of the poorest countries in the world despite having rich mineral resources. It has the unfortunate distinction of having the highest infant (316/1000) and child (182/1000) mortality rates and the lowest life expectancy (38 years) of all countries.⁹ Only 34% of the population have access to safe drinking water and 11% to adequate sanitation.⁹ Sierra Leone's decade-long conflict has cost tens of thousands of lives. Though all parties to the conflict have reportedly committed abuses, systematic abuses have been attributed primarily to the RUF, including murder, rape, and mutilation of civilians.¹⁰ Approximately 400 000 people have fled Sierra Leone into neighboring Guinea and Liberia as refugees.¹⁰ At the time of this study, there were 334 061 registered¹¹ and approximately 500 000 to 1 million unregistered internally displaced persons (IDPs) in Sierra Leone (Figure 1).^{12 - 13}

Increasingly, health professionals have recognized the importance of documenting the nature and extent of human rights abuses during complex humanitarian emergencies. Such information is often essential in informing regional policy decisions, guiding humanitarian relief efforts, planning treatment and prevention programs for the survivors of human rights abuses, and holding perpetrators accountable for their actions.^{14 - 15} For these reasons, we conducted a population-based assessment of the prevalence and impact of sexual violence and other human rights abuses among IDPs in Sierra Leone.

At the time of the study, registered IDPs were living in a total of 21 camps or locales in 7 districts and the western area of Sierra Leone. To obtain a representative sample, we selected camps and/or locales on the basis of IDP arrival time and the place of residence before displacement. Since the proportion of recent arrivals (after May 2000) was known for each camp and/or locale, we were able to select camps and/or locales to reflect the known proportion of two thirds of the recent arrivals in all IDP camps and/or locales. A total of 4 sample locations from 3 different districts and the western area of Sierra Leone were included in the study. The camps and/or locales included those that best represented the IDPs' home district and/or region of the country. The 4 districts from which camps and/or locales were sampled represented 91% of the IDP population in Sierra Leone. Camps and/or locales located in 4 other districts were excluded on the basis of inaccessibility due to safety concerns or an inadequate number of IDPs for sampling (<5000).

Assuming a prevalence rate of sexual assault (based on a previous estimate by Médecins Sans Frontières of 14% of Freetown residents witnessing rape in 1999)¹⁶ to be between 10% and 20%, we determined the following sample sizes would be needed. For a 20% prevalence (18%-22% margins), sample size would range from 653 at 80% confidence to 1071 at 90% confidence. For a prevalence of 10% (9%-11% margins), sample size would range from 1457 at 80% confidence to 2377 at 90% confidence. We therefore planned to include approximately 1000 households in the study due to safety and logistical constraints during the period of the survey. Households were selected in each camp and/or locale in proportion to the distribution of IDPs in that location. A total of 1048 households were selected from the 3 camps and 1 town (Mile 91 Township).

All study participants were selected using systematic random sampling or a combination of systematic random sampling and cluster sampling.¹⁷ In sampling IDPs, we first mapped all domiciles within the camp, cluster, or town, then conducted a systematic random sample of the entire camp, cluster, or town. Sampling details are published elsewhere.¹⁸

The survey contained 49 questions pertaining to demographics, physical and mental health perception, personal experiences of war-related sexual assault, experiences of war-related human rights abuses among household members, opinions regarding punishment and justice for perpetrators, and attitudes on women's human rights and roles in society. The survey also assessed the lifetime prevalence of non–war-related sexual assault among respondents.

Physical and mental health perception, fears of sexual assault in communities either by combatants or noncombatants, and family relationships after the sexual assault were assessed using Likert-type scales. Opinions and views on women's roles in society were asked of all female heads of the household. Opinions were assessed by a response of "agree" or "disagree" with statements concerning human rights and women's roles in society.

Regarding human rights abuse experiences, respondents were asked whether they or their household members had been beaten, shot, killed, tortured, seriously injured, sexually assaulted, raped, abducted, had violent amputations, or been subjected to forced labor by combatants during the past 10 years (eg, since when the war started). Respondents also were asked if their homes were burned and/or property was looted. For each abuse, participants were asked the sex of the abused, type of abuse, who they thought committed the violation, and consequence of the abuse. Finally, all participants were asked about non–war-related sexual assault experiences in their lifetime committed by noncombatants, such as family members, friends, or civilian strangers, including age at assault, type of sexual assault, and identity of the perpetrators.

Regarding war-related sexual assault experiences during the past 10 years of war, respondents were asked when the incident occurred, where it took place, the sexual abuse type, the identity of the perpetrator, the number of attackers, the duration of the assault, and the consequences of the sexual assault. In addition, these women were asked their opinions regarding the punishment of perpetrators, and whether they were interested in giving their name to the proposed Special Court or the Truth and Reconciliation Commission.

The questionnaire was written in English, the official language of Sierra Leone, translated into Krio, the lingua franca of Sierra Leone, and back-translated into English. The questions on sexual assault and sexuality were written by Sierra Leonean women who conduct research in this area and who provide treatment services to survivors of sexual assault in Sierra Leone. Researchers learned to administer the survey in Krio in which they all were fluent and collaborated on a translation from the Krio into the 2 other main languages in Sierra Leone (Mende and Temne). These translations were checked for accuracy by members of the Physicians for Human Rights/United Nations Mission in Sierra Leone team. Seven regional human rights and sexual violence experts reviewed the questionnaire for content validity. The survey was pilot tested among 12 IDP women in Freetown and suggestions were incorporated for clarity and cultural appropriateness.

The survey interviews were conducted by 21 Sierra Leonean women trained and supervised by the Physicians for Human Rights/United Nations Mission in Sierra Leone field team. The 5-member team had extensive experience in research, psychological counseling with survivors of sexual assault and torture, sexual assault aid programs for Sierra Leonean refugees and IDPs, and human rights issues. Researcher training consisted of 8 to 9 days of classroom teaching and role-play followed by several days of field observation and continuous supervision.

All interviews were conducted over a 4-week period in the calendar year 2001. Interviews with participants lasted approximately 25 to 60 minutes and were conducted in the most private setting possible. All questionnaires were reviewed for completeness and for correctness of recording after the interview by the researchers themselves, and then reviewed by the field supervisors at the end of each day.

This research was reviewed and approved by an independent group of individuals with expertise in clinical medicine, public health, bioethics, and international human rights research. In addition, permission for the study was granted by UN officials, camp administrators, and local community leaders in each area surveyed and there were no limitations on movement or surveying. The research was conducted in accord with the Declaration of Helsinki, as revised in 2000.¹⁹ Every effort was made to ensure protection and confidentiality and to reduce any potential adverse consequence to the participants. All data were kept anonymous. Verbal informed consent was obtained from all participants and parental consent was obtained for all participants younger than 18 years. Participants did not receive any material compensation. To reduce the risk of possible retraumatization among respondents, researcher training included extensive sensitization to this issue by a psychologist and social worker who specialize in sexual violence. Respondents who reported sexual assault were referred to existing services.

A perpetrator was defined as any person who directly inflicts violence or abuse.²⁰ Torture was defined according to Common Article 3 of the Geneva Convention.²¹ Sexual violence included rape²² and other forms of sexual assault, such as molestation, sexual slavery, being forced to undress or being stripped of clothing, forced marriage, and insertion of foreign objects into the genital opening or anus. Gang rape was defined as rape by 2 or more individuals. Mental health counseling was defined as "having someone to talk to about your problems who will listen and give emotional support." A household was defined as those people sleeping and eating under the same roof before first displacement. Female head of household was considered the woman who knows the most about the persons in the household. War-related prevalence of sexual violence included experiences of sexual assault committed by combatants during the past 10 years of war. Lifetime prevalence of non–war-related sexual violence included experiences of sexual assault committed by family members, friends, or civilians at any time in a woman's lifetime. These 2 prevalence rates did not overlap since the perpetrator categories were mutually exclusive.

The data were analyzed using STATA statistical software.²³ For 2 × 2 cross tabulations containing cells with expected frequencies of less than 5, statistical significance was determined using Fisher exact test. Yates corrected χ² was used for other analyses with frequencies greater than 5. For cross-tabulations with greater than 2 rows, statistical significance was determined using Pearson χ² test. Analysis of variance was used for statistical comparison of means and the Kruskal-Wallis test was used for comparison of medians. For all statistical determinations, significance levels were established at P<.05.

Of the 1048 households sampled, 991 female heads of household participated in the study (95% response rate). Seven women were not eligible, 41 were not available at the time of sampling, and 9 either were opposed to the survey, refused to participate, or requested that the interview be stopped.

Demographics of the respondents are presented in Table 1. The mean (SE) age was 34 (0.48) years (range, 14-80 years). The majority of the women sampled were poorly educated, Muslim, married, from either the Temne or Mende tribes who most commonly reported their occupation as farmers, petty traders, and business women. Nearly one quarter of women were either separated or widowed due to war, had been displaced more than 4 times since 1990 and had, on average, lived in the IDP camps or Mile 91 Township for 18 months. Fifty-seven percent of women reported that they had been displaced between 1 and 6 years ago, and 41% of women had been displaced between 6 and 10 years ago.

The majority of women perceived their general health (89%) and mental health (94%) as fair or poor (Table 1). Two hundred eighty women (28%) reported suicidal ideation (thoughts or feelings), and 34 had attempted suicide (3%). Women reported what would help their state of mind the most: 97% indicated humanitarian assistance would help the most; 96%, medical assistance; 94%, income-generation projects; 89%, religious counseling and support; 84%, skills training; and 72%, mental health counseling.

The 991 household representatives reported on the experiences of 9166 household members, which included themselves and those who lived with them prior to their displacement (mean [SE] household size, 9.4 [0.11]; Table 2). Of the 9166 household members, 5001 (55%) were women and 3983 (44%) were men. Sex was not indicated for 182 persons. Overall, 13% (1157) of household members reported incidents of specific forms of war-related human rights abuses, including abductions, beatings, killings, sexual assaults and other abuses (Table 2). Regarding sexual assault, 94 (9%) of the 991 respondents reported 1 or more war-related sexual assault experiences. Study participants also reported war-related sexual assault among 396 (8%) female and 6 (0.1%) male household members. The prevalence of war-related sexual assault among female household members may be as high as 11% (554/5001) if 158 women are included who did not report sexual assault per se, but did report abduction with the likely consequence of sexual assault, and who became pregnant, or experienced vaginal bleeding, pain, swelling, uterine pain, vaginal discharge, or sexually transmitted disease. Burning of homes and/or looting of property also was reported among 1836 household members (20%). For all abuses reported, the RUF was identified in 1490 cases (40%) as the perpetrator. Consequences of all abuses reported among household members included 420 being killed (11%), 321 having bodily injury (8%), and 455 reported "no consequence" (12%). Respondents reported that 36 (9%) female household members became pregnant as a consequence of their assault. Respondents reported that the majority of the abuses among household members occurred in the last 3 years with most of these occurring between 1997 and 1999.

Nine percent (94/991) of the respondents reported a personal account of sexual assault (Table 3). The mean (SE) number of attackers was 3.2 (0.39). Sixty-eight percent of the assaults reportedly occurred in the last 3 years, with more than half (54%) in their home villages and 22% while fleeing. More than half (60%) of the abuses lasted less than 1 week. Sixty-three of the sexual assaults (67%) occurred between 1997 and 1999. In addition, 22 (23%) women reported being pregnant at the time of the attack with an average gestation of 3 months. Fifty-three percent of respondents and 47% of female household members who were sexually assaulted reported "face-to-face" contact specifically with RUF forces, compared with less than 6% for any other combatant group.

Overall, 79 respondents (84%) reported the identity of 1 or more of their perpetrators. Of these, 52 were reported to be RUF forces. Other perpetrators reported included Armed Forces Revolutionary Council, West Side Boys, unspecified rebels, and current and former members of the Sierra Leonean Army. The UN peacekeepers and Civil Defense Forces militia forces were not identified as perpetrators among respondents reporting sexual assault. Rape was reported by 84 of the 94 sexually assaulted women and 31 reported being gang raped. Also, approximately one third of the 94 women reported abduction and being forced to undress or stripped of clothing. Nine women reported forced marriage to combatants, and 6 women reported pregnancy as a consequence of the assault. The most commonly reported consequences of the assault included bodily injury and/or physical disability, sexually transmitted disease, and reproductive complications, which included miscarriages.

A total of 901 respondents (91%) reported being worried about the possibility of sexual assault committed by combatants on themselves or family members, with 161 (16%) describing their concern as "quite a bit" and 740 (75%) as "extremely." Concern about sexual assault by family members, friends, or civilian strangers was lower (39% responded with quite a bit or extremely worried). In addition, 91 respondents (9%) reported sexual abuse (occurring at a mean [SE] age of 15 [1.2] years) by family members, friends, or civilian strangers during their lifetime.

Of the 94 respondents reporting war-related sexual assualt, 61 reported the incident(s) to another person (Table 4). Of those who did not report the assault, the most common reasons were "feelings of shame or social stigma" (n = 18; 64%), fear of being stigmatized and/or rejected (n = 8; 28%), and not having trust in anyone (n = 6; 21%). Fifty women reported seeking help after the attack and 40 of these women reported that they informed a health care clinician (physicians, nurses, or health care workers) of the specifics of the attack. On average, these women sought help 5 months after the assault(s) occurred. Hospitals (n = 25; 50%), traditional healers (n = 20; 40%), and health centers (n = 19; 38%) were the most common places in which women sought help after the assaults. Women reported what helped most after the assault was trying to forget about the incident (n = 43; 46%), support of family (n = 33; 35%), counseling from a health care clinician (n = 31; 33%), and care from a traditional healer (n = 30; 32%).

Of 88 respondents, 37 thought their perpetrators should be punished and 51 did not. Of the 51 respondents who indicated that their perpetrator should not be punished, the most common reason given was in the "spirit of reconciliation," which was followed by fear of reprisal, no confidence in the system for such punishments, or wanting to forget about the incident. Thirty-four of the respondents reporting sexual assault believed their attacker's commander was aware of the assault. Only 33 women believed that punishment of perpetrators would prevent sexual assaults from happening to others, and 22 of the women were willing to give their names to the proposed Special Court and/or the Truth and Reconciliation Commission.

Ninety-four percent of the 991 Sierra Leonean female respondents agreed that women and girls should have the same access to education as men and boys. Eighty-two percent agreed that women should be able to express themselves freely, 87% responded that there should be legal protection for the rights of women, and 86% reported that women and girls need more education about their reproductive health. However, 81% of women also indicated that a good wife obeys her husband even if she disagrees. The respondents also reported that family problems should only be discussed within the family (78%), that women have the right to control the number and spacing of their children (70%), more should be done to protect women and girls from having sex when they do not want to (74%), and women and girls need more education about their right to refuse sex (71%). More than 60% of these women expressed the view that a man has the right to beat his wife if she disobeys (61%), and that it is a wife's duty/obligation to have sex with her husband even if she does not want to (65%).

The findings of this study indicate that combatants (primarily, members of rebel forces) have committed widespread human rights abuses against civilians in Sierra Leone, including abductions, beatings, killings, sexual assaults of women and men, "capturing" persons for less than 24 hours, torture, forced labor, gunshot wounds, serious injuries, and amputations. These abuses were experienced on an individual level by a substantial number of participants and their household members. The respondents in this study reported at least 1 of these abuses had occurred among 94% of household members during the past 10 years of conflict. The burning of homes and/or looting of property was also commonly reported among household members. The majority of all these abuses occurred between 1997 and 1999, which corresponds with an upsurge in fighting between rebel and government forces.²⁴ Forty percent of these abuses were attributed to RUF forces.

Sexual violence in war has increasingly been recognized as a means of demoralizing individuals, families, and communities,^{25 - 27} and is used as a weapon to disable an enemy by dissolving bonds between family and society.²⁸ Today, in the context of war, rape and other forms of sexual violence have been recognized as instruments of genocide, crimes against humanity, means of torture, and crimes of war,^{29 - 32} and can be prosecuted as such.^{29 ,31 - 32} They also constitute crimes against humanity "when committed as part of a widespread or systematic attack directed against any civilian population, with knowledge of the attack."^{30 - 33}

To generate population estimates of sexual assault among the IDP and non-IDP women in Sierra Leone, we assumed a total IDP population of between 1 and 1.3 million (55% female)¹¹ and a non-IDP population of between 2.7 and 3 million (50% female).^{12 - 13} By extrapolating the number of war-related sexual assaults reported by participants in our sample to the total female IDP population, we estimate that approximately 50 000 to 64 000 Sierra Leonean IDP women may have suffered such human rights abuses. The prevalence of sexual assault among IDP women and girls, including war-related or non–war-related, in this study was 17% (excluding 1% of participants who reported both war-related and non–war-related sexual assault), or an estimated 94 000 to 122 000 individuals. If non–war-related sexual assaults among non-IDP females is added to the IDP totals (assuming a 9% prevalence rate), as many as 215 000 to 257 000 women and girls in Sierra Leone currently may have been affected by sexual assault.

This study indicates that war-related rape and other forms of sexual violence were committed on a widespread basis among IDPs in Sierra Leone. In fact, the prevalence of war-related sexual assaults committed by combatants during the past 10 years of war (8%-9%) was equivalent to the lifetime prevalence of non–war-related sexual assault of 9% committed by family members, friends, or civilians among the study participants and equivalent to the lifetime prevalence of rape in the United States.³⁴ The prevalence of war-related sexual assault in this study was less than that reported in Liberia (15%),³⁵ but exceeded that found in other population-based assessments of refugees and displaced persons (0%-0.1%),^{14 - 15 ,36} including Sierra Leone (2%).¹⁶ In addition, 53% of respondents and 47% of all female household members reporting face-to-face contact with RUF forces reported being sexually assaulted. Sexual assault was reported by less than 6% of respondents reporting face-to-face contact with any other combatant group.¹⁸ Rates of sexual violence vary based on research methods and populations surveyed. Studies of sexual violence in Sierra Leone that include nonprobability samples^{37 - 38} or select populations such as clinic patients^{39 - 40} generally report higher prevalence rates of sexual violence but cannot be generalized to broader populations.

Physical injuries were among one of the most common consequences reported following sexual violence. The adverse physical and psychological consequences of sexual violence are described in other studies.^{41 - 42} The prevalence of sexual assault, including war-related or non–war-related, among IDP women in this study was 17%, which suggests a serious health burden for individual and community members that cannot be addressed adequately by services that currently exist in Sierra Leone.¹⁸ The assistance needs most commonly identified by women reporting sexual assault included humanitarian assistance, including food and shelter, medical care, income-generating projects, and women's support groups. These needs were not significantly different from Sierra Leonean women who did not experience sexual assault but did experience other human rights abuses. The majority of participants reporting sexual violence indicated that their perpetrators should not be punished and, among these women, the most common reasons cited were "in the spirit of reconciliation" and "fear of reprisal/revenge." Also, only a small proportion of these women indicated an interest in giving their names for the Truth and Reconciliation Commission and the Special Court, which are expected to be established by 2002. This rationale may be explained by feelings of shame and/or fear of being stigmatized or rejected, which were also reported in the study, and a desire to put the incident(s) behind them. Such concerns are not unfounded in societies in which women are financially dependent on their husband or extended family and are subjected to structural social inequality on many levels.^{43 - 44} Being cast out of a community or family can have dire consequences not only for the woman but for her children.^{43 - 44}

Despite 80% of women expressing that there should be legal protection for the rights of women, more than half reported that their husbands had the right to beat them and that it was a wife's duty to have sex with her husband even if she did not want to. The apparent disparity between such beliefs and international principles of human rights suggests a need for public discourse and education on local, regional, and international levels.

It is likely that the prevalence of war-related sexual violence in this study was underestimated because of possible willful nondisclosure of sexual violence and the lack of privacy in some of the interviews, despite efforts to ensure privacy. Reasons for willful nondisclosure often include fear of retribution by an assailant, being stigmatized and rejected, blamed for the assault, and/or the psychological consequences of disclosure.⁴⁵ In addition, the average age of participants (female heads of household) reporting war-related sexual assault (mean [SE], 34 [0.48] years) was more than twice the average age of females experiencing non–war-related sexual assaults reported in the study (mean [SE], 15 [1.2] years). Although interviewers were careful to explain that there would be no material or other gain by participating in the survey, the number of abuses reported in the study may have been overestimated or underestimated if IDPs judged that it was in their material, political, or psychological interest to exaggerate or conceal claims of abuse.

The findings in this study indicate that rape and other forms of sexual violence committed by combatants in Sierra Leone were widespread and perpetrated in the context of a high level of human rights abuses against the civilian population. Such findings are often essential in making policy decisions in the region, guiding humanitarian relief efforts, planning treatment and prevention programs for the survivors of sexual assault, and holding perpetrators accountable for their actions.