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Traumatic Fistula

What is traumatic fistula?

Traumatic fistula is ‘an abnormal opening between the reproductive tract of a woman or girl and one or more body cavities or surfaces, caused by sexual violence, usually but not always in conflict and post-conflict settings.’¹ It is a result of direct gynaecologic trauma, usually from violent rape, mass rape, including forced insertion of objects such as gun barrels, beer bottles and sticks into a woman’s vagina. The brutal rape can result in genital injury and can lead to the formation of a rupture, or fistula, between a woman’s vagina, her bladder, rectum, or both.

Women with fistula are unable to control the constant flow of urine and/or faeces that leak from the tear. Affected women are often divorced by their husbands, shunned by their communities, and unable to work or care for their families.²

Traumatic fistula, therefore, compounds the psychological trauma, fear and stigma that accompanies rape—with the same risk of unwanted pregnancy, vulnerability to sexually transmitted infections (STIs), including HIV, and diminished opportunities to marry, to work or be participate in the larger community.

Expert surgeons trained in fistula repair can mend the damage. Post-operative care should include trauma counseling, rehabilitation and even physical therapy. As with obstetric fistula, however, some women are unable to heal even after several surgeries, and are left permanently damaged.
 

A 5-year-old girl was brought to [Dr. Mukwege]. Her tormentors had raped her and then fired a pistol into her vagina. She was operated on twice at Panzi Hospital without success before being sent to a hospital in the United States where surgeons tried twice more to repair the damage. They failed, too. She'll spend the rest of her life with a colostomy bag. Rod Nordland, “Congo's Wounds of War: More Vicious than Rape” Newsweek, Monday, November 13, 2006

Prevalence of Traumatic Fistula

• The changing nature of warfare and the increasing numbers of civil and regional conflicts are exposing more civilians, and particularly women and girls, to greater vulnerability. The type of violent rape that can lead to traumatic fistula is common in war zones and in post-conflict settings and used both as a weapon of terror and as a form of gender-based torture.³
• Sexual violence has become an increasingly popular weapon in war, used to win and maintain control over civilians and territory, destabilize populations, terrorize women and humiliate the men who cannot protect them from sexual attack. In some contexts, sexual violence has been used strategically in order to facilitate ethnic cleansing and genocide.
• Medical personnel have observed high numbers of traumatic fistula cases in the conflict and post-conflict countries of Burundi, Chad, Democratic Republic of Congo, Sudan, Burundi, Rwanda and Sierra Leone. It has also been reported in other countries such as Ethiopia, Guinea, Kenya, Liberia, Somalia, Tanzania, and Northern Uganda.
• However, violent sexual assault of women and girls outside of armed conflict can also lead to this condition. Traumatic fistula from domestic violence has been documented in Ethiopia, India, and even the United States.⁴ In Ethiopia, healthcare workers have reported traumatic fistula in under-age married girls whose young bodies are too immature for sex—particularly where it includes violence.
• The prevalence of traumatic fistula however, remains unknown. Data collection is difficult in conflict and post-conflict settings, in part because victims fear further attacks, stigma, and lack awareness regarding the availability of fistula repair services. These are compounded by poor health-care infrastructure and ongoing insecurity. The absence of data affects the capacity of stakeholders to grasp the real magnitude of the problem.
• Consequently, researchers can only determine the extent of traumatic fistula by the numbers of women reporting to repair centres and health facilities for treatment. Researchers estimate that for every woman who makes it to a clinic, many more hide away because they either have no access to medical care or remain too ashamed of their condition to ask for help.
• The Addis Ababa Fistula Hospital of Ethiopia reported 91 cases of faecal incontinence between 1991-1997: 78 resulting from sexual intercourse within marriage⁵, and 13 due to rape. 73 of the married girls were under 15, as were 12 of the rape cases.⁶
• In the Democratic Republic of Congo, one UNFPA-supported Ministry of Health assessment undertaken in six provinces found that out of a documented 432 fistula cases, 14.1 per cent were the result of trauma.

What are the health and socio-economic implications?

• Women who are affected by fistula are affected by two deep sources of stigma: the first resulting from their status as rape victims, and the second from their chronic incontinence.
• Long-term medical complications for the survivors of violent rape may include uterine prolapse, infertility and miscarriages.⁷
• The medical repair of traumatic fistula is similar to that of obstetric fistula: women need access to specialized, delicate, and very complex surgical services. In places where obstetric fistula programmes exist, women who suffer from traumatic fistula can often access the services they do desperately need.
• Repair for traumatic fistulas can be less complex in cases where there is less direct tissue injury and less scarring. In other cases, however, especially those involving the forced insertion of foreign objects into the vagina and/or rectum, tears can be more complicated and difficult to repair.⁸
• Healing takes time. While the repair of traumatic fistula may not require the preoperative wound healing period that is often necessary for repair of obstetric fistula, the psychological needs of rape victims are greater.
• The social and economic fabric is quickly eroded when women, who play an important role in the maintenance of local economies, abandon their work because of fear and insecurity or when injury prevents them from feeding and caring for their families. ⁹

Recommendations for Prevention, Protection and Empowerment ¹⁰

Prevent:

• Coordinate activities between, and raise awareness at, the community, health and social services, police and security forces, and the legal justice systems
• Commission well-researched information about the causes, impact, and magnitude of traumatic fistula to support effective advocacy and plan effective interventions on the ground.
• Take a stand of ‘zero tolerance for acts of sexual and gender-based violence, and hold governments and other institutions accountable for the safety and well-being of women, men and children affected by conflict’.
• Include information regarding traumatic fistula military within the curricula of peacekeepers, police force as well as in medical and social work schools. Work with male leaders to put a halt to this terrible practise and encourage them to punish perpetrators.

Protect:

Strengthen the health response in crisis states. Currently, when the annual UN Inter-Agency Consolidated Appeals Process (CAP) for countries in crisis is launched, health programs receive less than 25 per cent of resources requested.¹¹

• Standardize UN and international agency emergency responses to include clinical services—including proper medical examinations, emergency contraception, fistula surgery, qualified personnel who can offer skilled obstetrical and gynecological services, appropriate equipment, counseling and psychological care.
• Interventions should also include access to anti-retroviral treatments, and family planning care to avoid unwanted pregnancies.
• Design outreach programmes that will bring affected women living in remote communities to health-care facilities. Develop protocols at existing rape centers well establish counseling and care standards for fistula patients
• Develop systems at the community level to document atrocities and refer them to appropriate national and international legal mechanisms, with the existence of traumatic fistula as evidence. Support enforcement of laws criminalizing violence against women
• In post-conflict justice and accountability mechanisms, “Recognize the right and ensure access to material and symbolic reparation, including restitution, compensation, rehabilitation, satisfaction and guarantees of non-repetition for all survivors”¹²
• Work with the community and the media to raise awareness and inculcate a supportive atmosphere for the survivors of traumatic fistula and other forms of gender-based violence. Work to change community perceptions and attitudes that exacerbate the stigma, discrimination and exclusion suffered by affected women
• Devise a strategy to tackle gender-based violence and incorporate it into the health, legal and security sectors.¹³

Empower

• Support victim’s organizations and develop programmes to integrate affected women back into their communities.

   

• Support affected women through education, economic empowerment and social recognition

Resources:

• Amnesty International. Lives Blown Apart: Crimes Against Women in Times of Conflict, 2004.
• EngenderHealth, 2005, Traumatic gynecologic fistula as a consequence of sexual violence in conflict settings: A literature review,” New York: The ACQUIRE Project.
• Human Rights Watch, The War within the War: Sexual violence against women and girls in eastern Congo. http://www.hrw.org/reports/2002/drc/ 
• Human Rights Watch, Seeking justice: The prosecution of sexual violence during the Congo war. http://hrw.org/ reports/ 2005/drc0305/index.htm 
• Reproductive Health Response in Conflict Consortium, Gender-based Violence Tools Manual for Assessment and Program Design, Monitoring, and Evaluation in Conflict-affected Settings (New York, Reproductive Health Response in Conflict Consortium, 2004). www.rhrc.org
• Brussels Call to Action to address sexual violence in conflict zones and beyond. www.unfpa.org/emergencies/symposium06

1 Acquire Project, June 2006, “Traumatic Gynecologic Fistula: A Consequence of Sexual Violence in Conflict Settings, A report of a meeting held in Addis Ababa, Ethiopia, September 6-8 2005.”
2 EngenderHealth, 2005, “Traumatic gynecologic fistula as a consequence of sexual violence in conflict settings: A literature review,” New York: The ACQUIRE Project.
3 Amnesty International. Lives Blown Apart: Crimes Against Women in Times of Conflict, 2004. Online at www.amnesty.org
4 Muleta, M., and Williams, G. 1999. Postcoital injuries treated at the Addis Ababa Fistula Hospital, 1991–97. Lancet 354(9195):2051–2052; Sharma, G. P. 1991. Post- coital vesico-vaginal fistula (a case report). Medical Journal Armed Forces India 47(3 ) :223–224; Parra, J. M. , and Kellogg, N. D. 1995. Repair of a recto-vaginal fistula as a result of sexual assault. Seminars in Perioperative Nursing 4(2):140–145 quoted in EngenderHealth, “Traumatic gynecologic fistula”
5 Traumatic fistula can also result in cases where very young girls enter marriage and have sexual intercourse with their husbands.
6 Muleta, M and Williams, G. (1999). Postcoital injuries treated at the Addis Ababa Fistula Hospital, 1991-1997. The Lancet, 354, 2051-2052.
7 Amnesty International, Lives Blown Apart: Crimes Against Women in Times of Conflict, 2004
8 Acquire Project
9 RHRC Consortium. Fact Sheet on Gender based violence. Online at http://www.rhrc.org/rhr%5Fbasics/gbv.html
10 For more recommendations, see the Brussels Call to Action to address sexual violence in conflict zones and beyond, online at www.unfpa.org/emergencies/symposium06
11 Elizabeth Rehn and Ellen Johnson Sirleaf, “Women, War Peace: The Independent Experts’ Assessment,” p14
12 Brussels Call to Action
13 Jeanne Ward and Mendy Marsh, Sexual Violence Against Women and Girls in War and Its Aftermath: Realities, Responses and Required Responses. A Briefing Paper for the Symposium on Sexual Violence in Conflict and Beyond (21-23 June, 2006)