The Vicious Circle of Health Security: Vaginal Fistula in Conflict Settings and Its Interdependency with Female Oppression

Abstract

The complex and multilayered interdependence of health and security gets exceedingly obvious in conflict-related sexual violence (CRSV); however, its scientific study is exceptionally invisible. Political unrest increases incidence of gender-based violence (GBV). Rapes, including gang rapes, and forced insertion into the female genitalia of foreign bodies such as bottles, sticks, and weapons can lead to injury of the vagina and the development of traumatic vaginal fistulas (TVF). This paper aims to give structure to the particular characteristics of traumatic vaginal fistula in conflict settings and its immanent linkage to human security. The authors reviewed all papers concerning prevalence and causes of CRSV-caused TVF (CRSV-TVF) that were available on PubMed and GoogleScholar in February 2021. Findings were integrated into feminist theory on CRSV to identify the connecting linkages of security, health, and gender equality. CRSV-caused TVF illustrate well the complex interdependences of health and security: (1) insecurity leads to a higher prevalence of sexual violence; (2) sexual violence can serve as a weapon of war; (3) insecurity prolongs sufficient medical care; (4) vaginal fistula impede female empowerment and societal development. The multiple threads of their connection reveal several implications for the prevention and treatment of TVF. The reciprocal connection of CRSV and security exemplifies a vicious circle of health security.

1. Introduction

During the past years, health security underwent a remarkable upswing especially triggered by the prominent link of infectious diseases’ outbreaks and their impact on political peace and stability. Its strong recognition was additionally fanned by the pandemic of SARS CoV-2. In contrast to that, the early literature on health security mainly focused on the unidirectional link of how conflicts directly and indirectly cause health problems [1]. Today’s recognition of health security has broadened its understanding and emphasizes the mutual impact of health and security. The complex and multilayered interdependence of health and security gets exceedingly obvious in conflict-related sexual violence (CRSV); however, its scientific study is exceptionally invisible.

Political unrest increases the incidence of gender-based violence (GBV) and its physical and mental consequences while simultaneously hindering timely medical treatment. Rapes, including gang rapes, and forced insertion into the female genitalia of foreign bodies such as bottles, sticks, and weapons can lead to injury of the vagina and the development of vaginal fistulas (VF). VF are abnormal openings between the vagina and the urogenital tract and/or rectum and allow uncontrolled and constant outflow of urine and feces through the vagina. In addition to the physical consequences, women and girls with VF also must cope with psychological and social burdens of stigmatization and social isolation. Encouragingly, awareness and measures on VF increased have during the last years, not least because of several international initiatives such as the United Nations Population Fund campaign to “End Fistula” [2] and the adoption of a United Nations (UN) resolution in 2016 [3]. However, most endeavors target the characteristics of obstetric VF (OVF), while specifics in the prevention and therapy of traumatic VF (TVF) in terms of medical, legal, social, and psychological aspects are not met. CRSV-caused TVF (CRSV-TVF) exemplify the particular interdependence of security and health. Today, with the means of modern medicine, fistulas are both essentially avoidable and easy to treat. There also does not appear to be a significant incidence of TVF outside of regions of armed conflict [4].

There is no clear consensus on the terminology of conflict-related settings. In this study, the term is used to describe situations of basic insecurity before, during, or after a political or ethnonational conflict with a low threshold of armed force and interruption of law and justice.

This study integrates findings from a systematic review of the prevalence of CRSV-TVF into feminist theory of International Relations (IR). Thus, the methodological approach is two-part and marks the research as a translational project between medicine and political science.

2. Prevalence of CRSV-TVF

Prevalence of CRSV-TVF was systematically reviewed and findings embedded into feminist theory on CRSV to identify the connecting threads of TVF, conflict, security, health, and gender equality.

2.1 Eligibility criteria

Types of studies: All publications studying prevalence and causes of CRSV-TVF. CRSV-TVF was defined as vaginal fistula that resulted directly from rape, gang-rape, or forced insertion of foreign bodies into the female genitalia. VF resulting from inappropriate abortion or prolonged labor from an unwanted pregnancy after CRSV were not included as well as VF that already existed when CRSV happened. Indicating symptoms, that is, leakage of urine or feces, were interpreted as VF. Only studies written in English, French, or German were included.

2.2 Information sources

Eligible publications were identified by searching electronic databases, publication lists of included authors, and reference lists of articles. This search was applied to PubMed (2000-present) and GoogleScholar (1962-present). The search was completed on 15 February 2021. Search items used were “traumatic vaginal fistula,” “vaginal fistula,” “prevalence traumatic vaginal fistula,” and “vaginal fistula conflict”.

2.3 Study selection

Papers were excluded when their title indicated a sole focus on obstetric fistula or medical treatment of VF. All other manuscripts were screened by abstract. Suitable papers were reviewed full paper and, if appropriate, included in qualitative analysis. After a thorough selection, seven studies were included for qualitative analysis. Search of PubMed and GoogleScholar produced 257 search results. Seven additional manuscripts were identified through publication and reference lists. Two hundred and sixty-four studies remained after duplicates were removed. Of these, 218 were excluded since their title indicated that they did not meet the eligibility criteria. Abstracts of 46 manuscripts were reviewed for suitability. Twenty-five studies were examined full text. The study selection process is documented in Figure 1.

Figure 1.

PRISMA 2009 flow diagram on study selection process.

2.4 Study characteristics, results of individual studies, and synthesis of results

Table 1 summarizes study results.

Study No.	Country, authors, year of publication	Fieldwork setting and date	Study design	Number of female subjects	Number of people suffering from VF/TVF	Prevalence of CRSV-caused TVF	Mean and range of age
Democratic Republic of Congo (DRC)
1	RFDA et al. [5]	South Kivu 15 Sep - 15 Dec 2003	Cross-sectional survey and focus groups	492	n.a./200	40.7%	32 [12–70]
2	Dossa et al. [6]	Goma Jul - Aug 2012	Cross-sectional	320	n.a./99	24%	27.7 [15–45]
3	Mukwege and Nangini [7]	Panzi Hospital, South Kivu 1999 - Aug 2006	Case series	7519	n.a./1225	16.3%	n.a
4	Baelani and Dunser [8]	Goma (DOCS Hospital) Jan 2009 - Oct 2010	Case series	1343	n.a./121	9%	n. a
5	Onsrud et al. [9]	Panzi Hospital, Bukavu Nov 2005 - Nov 2007	Retrospective Analysis of Hospital Records	604	604/5	0.8%	17.2 [3–37]
6	Longombe et al. [10]	Goma (DOCS Hospital) Apr 2003 - Jul 2006	Case series	4715	702/445	63.4%	n.a.
Uganda
7	Kinyanda et al. [11]	Northern Uganda 2005	Cross-sectional	573	114/34*	5.9%	89% were 24 years or more

Table 1.

Characteristics of included studies and prevalence of CRSV-caused TVF.

*

Leakage of urine and stool as symptom of vaginal fistula.

Most studies were done in the Democratic Republic of the Congo [11]. Study designs ranged from case series [7, 8, 10] to cross-sectional surveys [5, 6, 11]. One study was designed as retrospective analysis of hospital records [9]. Fieldwork was done between 1999 and 2012, and results were published 2 to 5 years later. All studies included more than 300 subjects. The number of subjects varied between 320 and 7519. Age of subjects was not reported in all studies but ranged between 3 and 45 years when reported. The total prevalence of VF (including for example obstetric) was only given in three studies [9, 10, 11]. Prevalence of CRSV-TVF varied substantially. The highest prevalence was 63.4% [10]. The lowest prevalence was 0.8% [9]. All studies, however, agree that CRSV-TVF is an independent medical condition that results directly from CRSV. It occurs under particular circumstances and does not correspond to other forms of VF or intimate sexual violence. All studies deduce relevant socio-economic consequences from CRSV-TVF.

2.5 Risk of bias in individual studies

We acknowledge that findings are probably biased by missing or little robust data. All studies are also susceptible for underreporting: subjects may not report their assault due to shame and stigmatization fears. Data were collected retrospectively from medical reports [7, 8, 9, 10] or structured interviews [5, 6, 11]. Association to CRSV was recorded by patients’ statements, which may impair its reliability. Studies reporting data from medical reports only include women that were treated in hospitals and are not representative of the population. Additionally, these studies report on cases that were medically diagnosed and treated and may miss cases that were left undiagnosed or untreated. The selection of interviewees was done by the snowball technique [5], personal contacts [6] or as a structured screening questionnaire as part of a medical intervention in two internally displaced persons camps [11]. These selections are prone to selection biases especially for reasons of shame and stigmatization. Dossa et al. discuss their weak representativeness as a major limitation but describe their sample to be similar to the target population [6]. Another risk of bias arises from the origin of data. Most studies assumed VF when indirect symptoms such as vaginal leakage of urine or feces were reported [5, 6, 11]. Two studies do not explicitly state how VF was diagnosed [7, 10]. Gynecological examination is the only suitable measure for a reliable assessment of prevalence but is hardly feasible under logistical, social, political, and cultural circumstances in the areas and populations of interest.

3. CRSV-TVF in the realm of feminist theory

Scientific discourse on whether, how, and why concepts of gender influence IR became prominent in late 1980s, especially in the realm of feminist scholars. One theoretical core is the distinction between sex (in its biological meaning) and gender (being socially constructed) [12]. Feminist theory debates on gender as an organizing principle in private as well as public and argues on gendered power in IR. CRSV is a central subject of research [12]. Feminist scholars identified CRSV as an instrument for maintaining hegemonic masculinity or rather patriarchal hierarchies [13, 14, 15, 16]. Feminist theoretical explanations of wartime rape can be divided into three main epistemological strains: essentialism (women get raped to manifest the concept of militaristic masculinity), structuralism (women get raped as an attack against their ethnic, cultural, religious, and/or political group), and social constructivism (women or men get raped and are thereby feminized, while the perpetrators become masculinized) [14, 15, 17, 18, 19]. The shattered social and hierarchical structures in phases of political unrest accelerate strategies such as CRSV to reaffirm gender roles and their societal order, more specifically subordination of women [15, 16].

The systematic review identified the particular circumstances facilitating CRSV-TVF. Embedding these into feminist theory reveals the complex interdependence of security and health displaying multiple threads of their connection: (1) insecurity leads to a higher prevalence of sexual violence; (2) sexual violence can serve as a weapon of war; (3) insecurity prolongs sufficient medical care; (4) vaginal fistula impede female empowerment and societal development.

4. Insecurity leads to a higher prevalence of sexual violence

Prevalence of sexual violence and the associated health and social consequences for the survivors increase significantly during violent political conflicts [5, 6, 7, 8, 9, 10, 11, 20]. Symptoms that lead back to GBV are substantially more common in conflict-affected countries, such as DRC [21]. Collapsed health systems lead to reduced surveillance of illnesses, and clinical data are often not accessible. Additionally, insecurity reduces the collection and availability of epidemiological data. Thus, conflict-affected contexts create an obstacle to assess the significance of the disease for society. Ground-breaking work was done by Maheu-Giroux et al., who estimated the prevalence of VF in 19 sub-Saharan African countries by using data from demographic and health surveys [21]. The questionnaires were answered during a face-to-face interview of fertile women and included questions on symptoms of urine and stool leakage and the reasons for this condition. The study group found a lifetime prevalence of 0.3% for VF-symptoms for fertile women in sub-Saharan Africa [21].

While CRSV-TVF may account for only a small proportion of VF, its association to political unrest is significant. Dossa et al. were able to show that CRSV led six times more often to TVF than non-conflict-related sexual violence [6]. This indicates that not only GBV is more common in conflict-related settings, but the medical consequences of CRSV are also more severe.

5. Sexual assault as a weapon of war to perpetuate hegemonic masculinity

In situations of armed conflict, sexual violence can be used for strategic purposes as a means of exerting power with the aim of punishing both enemies and collaborators and committing acts of terror and discrimination, particularly against ethnic minorities, or simply for personal satisfaction and reward, which depends largely on the organizational structure of the armed groups and security forces and their central command’s level of control and delegation [5, 22, 23]. In some cases, girls and women are abducted and abused as sexual slaves [5, 23, 24]. Some rebel organizations, such as the Lord’s Resistance Army or Boko Haram, heavily rely on the abduction of child soldiers as well as on forced marriages [25, 26, 27]. Armed conflict during the Second Congo War (1998–2003) and its aftermath gained sad notoriety by its extreme forms of sexual violence [5, 8, 10, 28]. Yet, its attribution to conflict is disputed, since prevalence of sexual violence is high even during relatively peaceful periods [29]. The atrocities of the self-titled Islamic State structurally include sexual slavery and CRSV as a tactical weapon of war, aiming for religious cleansing and populating their territory [24]. Yazidi (non-Muslim) women get impregnated with “Muslim” fetuses to eradicate the enemies’ population while simultaneously expanding their own [24]. Pregnant women held as sex slaves suffer forced abortion since sex with enslaved pregnant women is religiously not allowed [24]. The International Criminal Tribunal for Rwanda defined the cruelty of GBV during the many years of conflict in Rwanda as an integral part of genocide [30]. This was the first time of political-institutional recognition of this strong feature of GBV. However, scientific consideration of CRSV as genocide got prominent long before during the scientific reappraisal of the civil war in former Yugoslavia [15, 17, 18]. Multiple cases of structural forced impregnation of imprisoned women in “rape camps” are documented and hint to the special role of women as biological reproducer of the targeted population [15, 17, 18]. Women are seen to play a key role in reproducing ethnonational identity by constructing and maintaining collectivity and culture [13]. Hence, CRSV on women is not indiscriminate but serves as a weapon of war to attack the reproduction of ethnonational groups [13]. These strategic purposes of GBV in conflict-related settings emphasize its significance as a weapon of war.

6. Insecurity prolongs sufficient medical treatment

Traumatization of these crimes are profound and significantly affect physical and mental health likewise [20, 31]. From a medical point of view, VF is a curable condition. If patients can be operated in time, their chances of physical cure are high. Prompt surgical closure of the defect is the only possible form of treatment and way to avoid further complications. With the means of modern medicine, it is currently possible to achieve permanent physical cure of VF in approximately 90% of fistula patients [32]. Political unrest makes it more difficult for survivors to access effective medical care. Access to adequate medical care can be assumed to be delayed in the majority of cases [4]. Women in the DRC received treatment with an average delay of 2 years after the development of their VF, and in some cases, they had to wait as long as 5 years [9]. This is partly due to the fact that access to medical services is usually more difficult during times of social unrest. The necessary healthcare structures may be completely non-existent; the women may not know about the services, or they may be inaccessible to them, or they are unable to pay for them [2, 4, 8]. The surgical repair and postoperative care of each patient costs about $300 [4] to $400 [2].

Women who become survivors of sexual violence are not only exposed to the risk of developing VF but also at an increased risk of contracting sexually transmittable diseases (STD) such as HIV/AIDS. Early diagnosis and treatment of these diseases is highly important, not only for the individual patients but also in order to prevent the infections from spreading further. Therapeutic interventions for CRSV-TVF must therefore also include diagnostic and treatment of infectious diseases. Enabling easy access to post-exposure medication should be an essential element of international efforts.

Unwanted pregnancies can result in an additional psychological burden for the women, who are frequently unable to identify with the fetus. If they perform an abortion themselves, there is a high risk of injury to the genital tract and development of VF. Where pregnancies are carried to term, women are frequently left on their own without medical care, since their families have abandoned them [10]. This increases the risk of OVF. At the same time, existing VF can lead to infections of the womb or the urinary or intestinal tracts, thus endangering the health of both mother and child. Without adequate medical care, terminating a pregnancy for medical reasons, for example, because the mother is too young, may result in the development of VF [9] as well as presents a great risk to the health of the mother. Humanitarian interventions should therefore also promote broad access to (post-coital) contraception to avoid unwanted pregnancies and the associated complications. This can also be supported by awareness-raising campaigns to protect women and girls from unwanted pregnancies. However, it is also important to make provision for legal and safe abortions. Women who have become pregnant against their will must have the right to terminate these pregnancies without being at risk of prosecution. Provision must also be made for women to carry their pregnancies to term safely and with the support of medical care, irrespective of whether they have been cast out by their families. Thus, in order to improve treatment opportunities for women with CRSV-TVF, it is first necessary to maintain or render possible access to healthcare services in conflict situations. In addition, there is also a need for information on existing healthcare services, awareness campaigns, to reduce stigmatization and efforts to promote women‘s reintegration into society.

7. Vaginal fistula maintain female oppression by impeding female empowerment and societal as well as economic development

As described above, CRSV serves as an appropriate weapon to perpetuate hegemonic masculinity during conflict. Meger suggests to analyze perpetrator’s motivations from three different levels: individual, sociocultural, and structural, with the latter focusing on maintaining power and control over productive resources [33]. According to Meger, globally disadvantaged men are motivated to enter into forces and participate in sexual assault to regain hegemonic masculinity through economic gain by exploitation of raw materials [33]. We argue that hegemonic masculinity or rather female oppression is additionally maintained by CRSV through the social and economic exclusion of victimized women by stigmatization, discomfort, and the medical condition itself.

Women who suffer from CRSV are especially socially disadvantaged and stigmatized [4]. The patients are isolated due to both their physical condition, since social intercourse is difficult due to their urinary and faucal incontinence, and the associated problems of hygiene and the smell. Moreover, in some societies, fistulas are considered to be a punishment for immoral sexual behavior or to have been caused by witchcraft [9]. The women are also stigmatized by their role as victims of a sexual offense. As a result of the rape, they are often abandoned by their partners and families and marginalized by society [10].

In addition to the treatment of physical and psychological sequelae, patients should be provided with support for their legal claim. In most situations, the survivors have no claim to damages, and the perpetrators are never legally prosecuted for their crimes: in some cases, the rapes are not even punishable by law [4, 34]. This impunity promotes the continuation of gender-based violence. In a similar way, Boesten describes a “continuum of violence” that connects GBV in peacetime settings with CRSV and acknowledges its mutual roots such as structural misogyny and gender inequality [35]. This goes along with an assumption of Meger: “Until the structure of gender hierarchy is addressed, the culture of GBV is at risk of persisting long after the conflict ends.” [33]. Meger argues that CRSV manifests the economic and political inequalities of women by reproducing intergender relations [33]. CRSV-TVF symbolize how a medical condition derived from CRSV perpetuates economic inequality: women suffering from VF are naturally unable to become economically independent. CRSV hinders gender equality not only from a structural or epistemological perspective but also directly by causing medical conditions like TVF.

8. Discussion

Considering the results of the systematic review in the light of feminist theory on CRSV reveals multiple linkages of security, health, and gender, stressing the health security dimension of CRSV. Individual security, law, and justice are lowered in conflict-affected settings, leading to reduced threshold of armed force. Additionally, experienced trauma of conflict parties may increase the brutality of sexual assaults. Simultaneously and to the authors’ view foremost, CRSV can be used as a strategic means of war. In contrast to non-CRSV, political or ethnonational motivation of GBV may be used systematically and with the aim to destroy the enemy’s population. It thereby highlights how physical injury can serve as a matter of people’s security. The insecure conditions of conflict settings impede early medical treatment of health effects, which as well stresses how insecurity impairs people’s health. In the aftermath, health consequences of CRSV, such as TVF, hinder victims from reintegration in society, underlining the long-time effect of CRSV on human security. On a structural level, CRSV serves as a strategic measure to perpetuate female oppression and patriarchal hierarchies by disabling victimized women from societal, political, and economic development and thus impairs human security.

While it is scientifically well known that the attempting idea that women are inherently more peaceful than men is simply not true [36, 37], Caprioli and Boyer were able to prove via multivariate regression that higher levels of gender equality go along with lower levels of violence during crises [37]. Subsequently, gender equality may help prevent TVF not only through less violent conflicts but, as described above, also through a changed epistemological understanding of femininity and masculinity.

Emphasizing the multifaceted links between health security and CRSV has limitations. Securitizing CRSV may lead to more political attention and raise awareness as well as global funds but carries the risk of simplification and short-sighted programming [38]. Carpenter has drawn important conclusions about CRSV against men and boys and its implication for human security [39]. This is a significant aspect of GBV and must not be disregarded.

9. Conclusion

CRSV and its medical consequences shed light on the many facets of health security. The complex interdependence of CRSV and health security reveals several implications for the prevention and treatment of TVF, asking for holistic programs that address the particular linkage of medical, legal, and social requirements. Patients need access to medical programs that offer timely and safe treatment of TVF as well as prevention and treatment of STDs, unwanted pregnancies, improved birth control, and safe abortions as well as psychological support. Legal endeavors need to reduce the incidence of sexual violence by enhancing and promoting the legal claim of patients and stopping the impunity of the perpetrators. Holistic programs need to include social services and educational programming related to the reasons, consequences, and treatment of TVF to prevent stigmatization and support patients that are abandoned by their families and work and peer groups and are unable to make a living due to their illness. In sum, the prevention and treatment of TVF is strongly connected to gender equality and the role of women in societies referring back to human security and exemplifies a vicious circle of health security. Further research needs to be done to quantify the burden of TVF in ongoing conflicts and by that enhance its political recognition and provide evidence for urgent international action.

Acknowledgments

Supported by the Open Access Publishing Fund of Leipzig University.

Conflict of interest

The authors declare no conflict of interest.