Meeting the needs of victims of sexual violence through reparations

Photo: The women of Sepur Zarco.

As part of the Women, Peace and Security #UN1325 ten year anniversary I was asked to speak at the UNSG Special Representative on Sexual Violence and the International Organisation for Migration’s organised event on reparations for sexual violence in New York (31st October). This is my talk reflecting on our project on the implementation of reparations at Queen’s University Belfast we have been working in seven countries emerging from conflict and spoken to around 400 individuals, including victims, perpetrators, reparation programme designers, as well as healthcare practitioners. As a registrar doctor in obstetrics and gynaecology in Northern Ireland, I have been approaching reparations from a medico-legal perspective, in particular with victims of sexual violence. I have been asked to speak on the immediate and important needs of victims and a helpful way to approach these issues is through a series of questions: who; what; when; and how?

Who to repair?

In relation to the who; this speaks to who are the eligible victims and beneficiaries of reparations. There are three key tensions here.

First we need to appreciate the differentiated impact of harm and resultant needs on an individual and community; this will affect how they understand, express and engage on reparations. Vulnerable, rural and marginalised groups such as LGBTQI+, those based on gender identity, children, elderly, and those with disabilities may not have the time or resources to engage on reparations, fill in forms or be aware that they could be eligible. Moreover such individuals can suffer prolonged and multiple forms of sexual violence, due to their vulnerability and marginalisation. It may be best to prioritise such individuals when it comes to receiving certain forms of reparation in order to mitigate their harm from worsening.

A related issue is how do we support such vulnerable or marginalised individuals from engaging and benefiting from reparations, as they often do not have sufficient evidence or paperwork to support their claims. In Peru’s domestic reparation programme, a lower evidentiary threshold is used for sexual violence based on ‘good faith’, in which their statement is taken and then corroborated by relevant news or other sources. Whereas in Nepal victims of sexual violence were excluded from the reparation programmes, and when we spoke to the government they said that this was because they did not come forward. So we also need to create a conducive space for victims to speak about reparations.

Second the notion of ‘conflict-related sexual violence’ or rape as a weapon of war, while useful in bringing attention to the issue, is problematic in framing the totality of sexual violence that occurs during wartime. Reparations solely based on rape as a war tactic risks neglecting sexual violence in detention centres, homes and private spaces, where the perpetrators are often known to the victim and who are taking advantage of the disorder caused by conflict to carry out sexual violence.  By way of example, in Northern Ireland, victims of sexual violence were ineligible for compensation when the perpetrator was under ‘the same roof.’  These victims have needs that should fall into a reparation programme. While these two forms of sexual violence might appear to be different, they have the same source, i.e. patriarchy. Therefore, it makes sense to generate reparation programmes that include both categories, if reparations are serious about contributing to tackling the root causes. In addition, in prolonged conflicts, perpetrators can also be victims of sexual violence and need to be included in reparation programmes. In practice they are often excluded, due to their role in victimising others, such as in Colombia and Peru, leaving a situation where some sexual violence is implicitly justified and not redressed.

Third some victims of sexual violence may not define themselves on their direct violations they have suffered themselves, but rather on the other harm that has been caused to them and the resulting needs. For instance, we spoke to some victims of sexual violence in Nepal, who were demanding justice for family members who were tortured or disappeared. This is not to suggest that needs for sexual violence are secondary or binary with other violations, but that victims and survivors may see these other issues as more pressing. So we have to be careful that in highlighting sexual violence and making it visible that we are not invisibling or simplifying victims’ experience and needs. This leads us on to what to repair?

What to repair?

Sexual violence encompasses a range of violations which a reparation programme should be attuned to. As such, reparation is for the harm as a result of the violation, which may give rise to certain needs. If we approach this in terms of the potential spectrum of needs, as we heard this morning victims and survivors can have physical, psychological, social, economic and moral needs. However not all of these can or should be met by a reparation programme, and be better provided by other actors or programmes. That said if we think about Maslow’s hierarchy of needs, victims may require their basic needs of survival and security be met before, such as feeding and supporting themselves and their family, or waiting until the end of hostilities, before they can take the time to engage on reparation, truth and justice issues. However for other victims, needs are not necessarily progressively ordered in this way and very much depends on the context.

From our fieldwork three common needs stood out that could be met by a reparation programme:

  1. First, mental health support which can be delivered through a range of actors and services, from psycho-social interventions, psychotherapy and medication.
  2. Second sensitization to the issue of transitional justice and pathways for redress, in order to help victims to articulate their needs on a rights and reparation basis.
  3. Third for those suffering serious injuries or health complications as a result of sexual violence, specialised medical care is often needed. This needs to be appropriate as far as possible. From my own practice and speaking to other medical practitioners in Uganda, fistula surgeons may be required to repair traumatic genital fistula as a result of rape; however, the majority of genital fistulas are the result of obstetric factors, such as prolonged or obstructed labour without access to appropriate medical care. Accordingly, such needs may not always fit within the parameters of a reparation programme.

The ‘what’ issue is also connected to the appropriate timing and sequencing of providing measures, as it may be beneficial to implement some forms before others, such as medical rehabilitation.

When to repair?

Time can be a mitigating factor for speaking about loss and trauma, but it can also exacerbate the physical and psychological harm caused when not redressed, allowing it to fester. In dealing with the health consequences from sexual violence some needs are time-critical, such as providing prophylaxis for HIV (72 hours), Hepatitis A and B vaccines, emergency contraception within 120 hours… Where programmes do exist they may also take years to be fully attuned to the needs of victims, currently Colombia is updating its Protocol on Medical Assistance to Victims of Sexual Assault, to include specific guidelines for armed conflict victims to ensure a comprehensive response to those who may have long-term medical needs.

It also takes time for victims to become mobilised. In Peru, victims of forced sterilisation by the state were excluded from engagement on the truth commission and reparation programme, which were set up for victims of the conflict and Fujimori regime. It took time for them to comprehend how their rights were violated, become organised and to recover, due to surgery complications some of those experienced.

At the same time it may be too soon after the violations for victims to be engaged on reparations when the impact of the harm has not fully manifested itself. For instance in Northern Ireland, many victims who were left seriously injured and disabled including those violently raped, were often judged to have a life expectancy of 15 years in the 1970s for the amount of their compensation, yet 45 years on they are still alive and left in poverty, as some have said to us they now feel like ‘beggars’.

On the other hand reparations can equally be too late, such as in the Bemba case at the ICC, that while the defendant was later acquitted, the reparation process started some fifteen years after the mass rapes. This meant that many victims had died from sexual transmitted diseases or left in terrible hardship and rejected from their communities by the time reparations were about to be determined. This underlines the significance of how we can coordinate timely approaches to repairing victims’ harm, and how far?

How far?

In meeting victims’ needs we also need to think about how far we need to go in redressing the harm of the past, present and future. We saw that victims of sexual violence need physical and psychological rehabilitation, but how will this work in practice when there is no infrastructure or specialised medical staff in their region. Do they travel, risking being exposed, will their costs be covered, and what does this say about the sustainability and local development of healthcare provision if these violations occur again? Reparation and redressing sexual violence not only require measures such as rehabilitation and compensation, but also institutional and legislative reform. Some of these reforms may not occur during the lifetime of the direct victim, so how do we address these issues today?

If we are concerned about meeting victims’ needs we also have to engage with difficult issues of changing laws around sexual and reproductive rights such as abortion, that women’s lives are not put at further risk if they choose to have a termination of pregnancy after being raped. In Northern Ireland we have only this month decriminalised our abortion law, where previously women who were raped had to travel to another country to obtain such a service.

To conclude

Ultimately we have to be modest on what reparations can and cannot do. Not only to make them feasible, given the resources that they can muster, but also in being honest to victims in informing their expectations and that certain needs require action sooner rather than later. As such, it can be helpful to map out the harm victims have suffered and their needs, to demonstrate why better co-ordination should exist between assistance and reparation.

We need to recognise that in claiming for reparations, it takes time, to decipher the: who, what, when and how. Therefore, when reparation programmes are implemented for victims of sexual violence, there needs to be sensitivity to potential obstacles. If claims for reparations are time-barred, some victims may miss the opportunity or they may feel that are not ready to engage in these processes within a designated time period. Further still, some victims of sexual violence may not want to claim reparations or come forward, and so respecting their choices is important. That said, the process of demanding reparations can be a significant pathway for victims to vindicate their good name and seek measures to alleviate the consequences of sexual violence.

Finally, having the correct legal, political and social tools to apply pressure to the state to implement reparations are key. Human rights is a useful framework here in that it gives us tools to hold the state to account to ensure victims’ right to remedy and reparation, but also respects victims’ agency and dignity. This can be seen by the courageous struggle of the women of Sepur Zarco in Guatemala where after years of campaigning with civil society allies they manage to secure the conviction of those responsible for the sexual enslavement as well as an order on reparations. So in demanding reparations for victims of sexual violence, we are not seeing them as dependants with needs, but as dignified human beings with agency and rights. The role for us is to find a way to support victims in their campaign, by echoing their voices and putting pressure on states to ensure their rights to reparations.





Prioritising Reparations for Conflict-Related Sexual Violence over Prosecution and Prevention

Today the 19th of June marks the International Day for the Elimination of Sexual Violence in Conflict, intended to raise awareness of the need to put an end to conflict-related sexual violence. 2019 also marks the 10 year anniversary of the creation of the mandate of the Office of the Special Representative on Sexual Violence in Conflict. While the past decade has seen initiatives such as the UK’s Preventing Sexual Violence Initiative (PSVI), sexual violence remains prevalent. Moreover, international action has become a shrinking space for adequately responding to victims and survivors’ needs, such as the recently regressive 2019 Women, Peace and Security Resolution 2467 that removed all reference to sexual and reproductive services.

As a registrar doctor in obstetrics and gynaecology conducting a PhD on reparations for conflict-related sexual violence I have interviews dozens of victims of CRSV and come across many in my own practice, which continue to evidence inadequate reparations to remedy their harm. My research has also highlighted the value of an interdisciplinary approach to such complex topics, rather than remaining in our own professional or disciplinary silos, there needs to be a more coordinated response to victims’ needs. As such with victims, healthcare practitioners and transitional justice actors in Peru, Colombia and Uganda I have been exploring a medico-legal approach to reparations for CRSV to better appreciate the harm and stigma of victims and their families, how to more appropriately respond to the harm, but also the role and responsibility healthcare professionals play, such as in forced sterilisation in Peru.

This blog hopes to highlight some of my preliminary findings, in that while there has been increasing attention to reparations for CRSV, it has seen a blurring between charity/ assistance and a rights based approach to reparations that degrades remedying victims’ harm. These questions are not just academic, but also reflect victims’ experience, such as the comfort women’s rejection of funding without acknowledgement of responsibility or apology from the Japanese government. Moreover, reparations are more about providing victims with just compensation, but recognising their harm and ensuring their rights to also medical, legal and social rehabilitation along with other remedial measures (satisfaction, restitution and guarantees of non-repetition). As such this post outlines the key principles for guiding reparations for CRSV that go beyond prosecution and prevention that continue to dominate the international community’s response to such violence. There principles highlight that reparations can more appropriately respond to victims’ harm and experience, while complementing the broader goals of accountability and prevention of recurrence.


There are a number of principles on reparations for gross violations of human rights or grave breaches of international humanitarian law. Pablo de Greiff, former UN Special Rapporteur on truth, justice, reparations and guarantees of non-recurrence, suggests a number of principles to assess the effectiveness of reparation programmes of completeness; comprehensiveness and complexity; integrity or coherence; finality; and munificence.

Completeness involves the coverage of the ‘whole universe of potential beneficiaries’. Comprehensiveness covers the distinct types of violations or harm, with complexity concerning the variety of measures, such as going beyond just compensation. Integrity involves internal and external coherence, which refers to the relationship between different types of reparations and other transitional justice mechanisms respectively. Finality pertains to whether a reparation programme closes other avenues for victims to bring redress. Lastly, munificence relates to the scope of a reparation programme’s benefits. The Colombian reparation programmes aims to meet these principles, but faces problems of scale and deliverability.

However there is little guidance on conflict-related sexual violence. The 2005 UN Basic Principles on the Right to Remedy and Reparations is gender neutral, even blind, just providing a principle of non-discrimination. The civil society driven 2007 Nairobi Declaration on Women’s and Girls’ Right to a Remedy and Reparations also outlines the importance of transforming the structures of violence which give rise to sexual violence such as CRSV, but it is not binding on states.

Ruth Rubio Marin adds two further categories from a gender perspective on implementing reparations, in particular for sexual violence: openness; and transformative potential. Openness refers to the ‘level of participation of victims, victims’ groups, and other relevant actors in civil society in the design of a reparations program’. This openness not only improves the transparency and effectiveness of such reparation programs and outcomes, but Rubio-Marin suggests it can also have a ‘reparative effective by affirming the victims’ status as active citizens’ recognised and respected by the state. Rubio-Marin indicates that the transformative potential is the extent to which a reparations program has the ‘capacity to subvert, instead of reinforce, pre-existing structural inequalities’, not limited to gender hierarchies. Victims of sexual violence often face stigma from their family, community and society that disincentives them from speaking out or punishes those who do so.

A Medico-Legal Approach

A medico-legal approach would add three further principles to provide a more victim-sensitive approach: do no harm; vulnerability; and temporality. Do no harm – ensures that reparations do not compound victims’ harm, and safeguards against uninformed risks of procedures and interventions. Importantly a do no harm approach would stipulate that victims are treated with respect and dignity (both in process and outcomes) so as to guarantee they are not coerced to chose a measure they are not satisfied with nor does it reinforce stigma. For instance, when offering psychological support, victims may also need physical support or vice versus. It is imperative to recognise how one may impact the other at different points in a person’s lifetime, which needs to be reflected in referral pathways for each individual. Alternatively only offering them short term reparation when they need long term support, may cause them further harm and distrust of service providers, especially when their health trajectory is likely to degrade due to age and/or disability.

Any actor involved in reparation can cause deliberate or unintentional harm. In one interview with a local counsellor in Uganda, they told me about a male victim of sexual violence for whom they cared. When this victim went to a doctor in his local hospital he was disbelieved that he was a victim of sexual violence and was rejected from having treatment. Accordingly a component of ‘do no harm’ is recognising and challenging unsafe or unethical practice. Similarly in Colombia the use of purple bracelets helps to identify victims of sexual violence, intended to reduce victimisation by avoiding asking victims about the violation, but as an obvious marker can also cause stigma in itself an unintended harm.

Vulnerability – the situation of vulnerability appreciates how certain groups are impacted more than others, or uniquely harmed, and what type of measures would facilitate redressing intersecting violations. Further still the principle of vulnerability can facilitate a transformative approach and reveal health inequities. The principle requires priority to certain individuals who are vulnerable to access reparation to alleviate their suffering from compounding further. This may include victims of displacement and in displaced persons camps where high rates of sexual violence occurs. For sexual violence being identified as a victim in a reparation programme may cause further social repercussions such as stigma. In Colombia victims in rural areas spoke of insecurity, infiltration of health services by armed groups or social and economic marginalisation that mean they suffered multiple violations and have no service provider to turn to in order to avoid further victimisation.

Temporality – focuses on how the impact of harm can change over time (increase, reduce or resolve). It also requires consideration of the appropriate moment for which reparations to be applied. For example, HIV (human immunodeficiency virus) can develop into AIDS (acquired immunodeficiency syndrome) and conditions to related immunocompromise and late presentation of HIV, such as certain HIV-associated malignancies and opportunistic infections. This underlines the importance of providing humanitarian assistance or interim relief to victims to mitigate their health being worsened or morbidity increasing.  Equally, harm may not manifest until years after registration programme has closed, such as delayed expression of psychological effects or sub-threshold symptoms that do not meet clinical criteria of diagnosis until later in life. For instance in Colombia, medical professionals spoke about victims of CRSV often taking years to come forward, often ten or twenty years later as the consequences of their sexual violence become so acute that they can no longer hide it or cope.

An array of sensory triggers may contribute towards the manifestation of psychological distress that may be linked to sexual violence, like a further traumatic or life event, such as childbirth or a new intimate or sexual relationship. Stigma from sexual violence and the added possibility of a mental health illness functions as a barrier to timely diagnosis (stigma multipliers). Temporality also raises the question of whether reparations are the most suitable intervention given the stage of transition a society may be in (and who they are willing to accept as eligible victims for reparations at a specific time point).

Together these principles indicate that sexual violence in conflict and other situations of mass victimisation raises difficult and complex issues that are perhaps glossed over in the rhetoric of ‘ending rape in war’ or even the notion of ‘conflict-related sexual violence’ as a distinct phenomena for prosecution and reparation. At the same time there is a place for healthcare service provision and reparations to complement each other. As doctors we are not trained or practice in terms of who is a victim and who is not. Nonetheless, social and cultural contexts can shape personal attitudes of healthcare practitioners. In general terms we think of the patient as a person and treating their symptoms and working out the cause or diagnosis and formulating an individualised treatment plan for them that aims to improve outcomes. There is a lot to be learnt in these terms of seeing the person and their suffering. Importantly reparations are victim-centred measures intended to remedy and acknowledge their harm, prevention and prosecution are important, but if we are serious about justice for these types of violations it has to start with it benefiting those most directly affected.

Photo of Nurse Norbert Chambu treats approximately five victims of SGBV a week, by USAID

After the Nobel Peace Prize: Aligning justice, health and reparation for victims of conflict-related sexual violence


A doctor examines a patient at the Mother and Child Health Center during a visit by the Special Representative of the Secretary-General on Sexual Violence in Conflict to Mogadishu, Somalia, on April 2, 2013. (AMISOM)

This year’s Nobel Peace Prize pair (Dr Denis Mukwege and Nadia Murad) provides the platform to intensify our efforts to address the consequences of conflict-related sexual violence (CRSV). There are inherently sensitive and complex issues surrounding sexual violence. Often victims face stigma from their community and family, causing what can be debilitating injuries and at times diminishing their quality of life through the physical and psychological consequences as a result of the sexual violence. This harm is only compounded by inadequate healthcare facilitates and insufficiently trained healthcare personnel, making victims more vulnerable. There are a diverse amount of efforts to address CRSV, from humanitarian and healthcare workers, to more broadly international organisations and to an extent the International Criminal Court in cases such as Ongwen. With Friday marking International Day of the Girl it is also worth highlighting the impact of CRSV on children, on whom such violence can have a devastating impact on their physical (trauma to genital, urinary retention and fistulas) and mental health with long term consequences.

While 2014 saw the efforts by states and celebrities to act to end sexual violence and promote the investigation and prosecution of such crimes, greater efforts need to be made to deliver assistance and reparations to such victims. Awarding the peace prize to Dr Mukwege is an important recognition of the work he has done for decades in providing assistance to victims of CRSV. Humanitarian organisations such as the ICRC and MSF have previously been awarded the peace prize. Yet this year’s acknowledgement highlights the work of an individual medic and a victim/advocate, putting human faces and personal narratives to conflict-related sexual violence. The specificity of this joint award to Nadia Murad, a victim of CRSV and Dr Denis Mukwege, an obstetrician and gynaecologist who is a human rights activist focusing on conflict-related sexual violence, confers a unique message: sexual and reproductive violence in all its forms demands an inclusion of vital actors in navigating solutions to CRSV. Through the healthcare lens, sexual violence may be visualised more comprehensively with enhanced understandings of physical and psycho-social consequences to the general public and legal community.

The timely recognition fittingly appreciates healthcare and humanitarian workers who are quietly enduring continuing security risks. The murder of 25-year-old ICRC midwives Saifura Hussaini Ahmed Khorsa and Hauwa Mohammed Liman in Nigeria serve as a reminder of how healthcare workers have increasingly become targets and special protections in International Humanitarian Law are being breached without regard. Furthermore, deliberately targeting obstetric and midwifery care, which provides women-centred care in conflict/post-conflict settings, could be interpreted as a form of gender and sexual-based harm that impacts communities and potentially intergenerational wellbeing and health. Yet, victims who are healthcare professionals receive less attention. The reasons are multi-faceted, but may be partially attributed to the perceived risks they tolerate to deliver life-altering medical care (bound by ethical duties), which has been echoed by the legal community’s record on pursing justice with no successful convictions for these crimes under international humanitarian law. These risks could be minimised by a stronger abhorrence by the international community and reflection on the value of medical care in terms of minimising the effect of conflict on health as well as their frontline expertise in identifying victims and appropriate remedies. The ICRC has been promoting the immunity from attack of healthcare and humanitarian workers through its #NotaTarget social media engagement.

Moving beyond assistance to reparations

There is also an important role for healthcare and humanitarian workers to contribute to shaping long-term solutions for victims of CRSV, such as reparations. Reparations are measures intended to acknowledge and alleviate the harm suffered by victims, but ultimately they are the responsibility of the state through a dedicated budget-line. There is an emerging practice at the international level for reparations for CRSV, including the Nairobi Declaration as well as state practice in Kosovo. After the collapse of the Bemba case where there was potential for innovating reparations to victims of CRSV, Court-ordered reparations are instead going to be provided as short term assistance.

For reparations for conflict-related sexual violence we have to look beyond just compensation, which can be useful, to trying to comprehensively remedy victims’ harm. This includes adequate and appropriate healthcare services for victims, both in the short term to mitigate injuries or complications becoming any worse, as well as in the medium and long term where victims’ needs and health can deteriorate over time. It also requires community socialisation to educate society on CRSV and not to stigmatise victims, as well as efforts to reintegrate the victims themselves so that they have opportunities to rebuild their lives and lead a dignified life. This is part of the work that Dr Mukwege has been doing through the City of Joy in Bukavu, DRC, but this requires more state engagement that such centres are not limited to single localities, instead part of a state funded nationwide programme. This can be difficult in countries during and emerging from conflict, needing the support and attention of the international community.

On receipt of this accolade, Dr Mukwege has highlighted the need for reparations for victims of sexual violence. He hopes, ’to draw a red line against the use of rape in armed conflict.’ Aligning these two aims is the reparation pillar of guaranteeing non-repetition of such violations. This Noble Peace Prize honours the dedication of medics and humanitarian workers such as Dr Mukwege, as well as the nature of their work which focuses on repairs beyond the legal and on a practical level. Therefore, to an extent the award represents an international acknowledgement of victims of conflict-related sexual violence and resultant harms. In a way this award can be seen as a form of symbolic reparation in acknowledging the wrongfulness of sexual violence, and to an extent the need for the international community to take more responsibility in its prevention and remedy.