Background
Armed conflicts in the eastern Democratic Republic of Congo (DRC) have caused over five million casualties and displaced hundreds of thousands of civilians in the past two decades [
1], with a devastating ongoing impact that persists today [
2]. During these wars, the civilian population has been a primary target through, amongst other war strategies, looting, brutal massacres, torture, sexual violence, and cannibalism [
3,
4].
The tactic that has heightened worldwide attention to the Congolese wars is sexual violence, a ‘weapon of warfare’ [
5,
6] that has been strategically used in numerous conflicts throughout history [
7‐
9] to humiliate, dominate, instill fear in, disperse, and/or forcibly relocate civilian members of communities and ethnic groups [
10]. Though exact numbers on the prevalence of sexual violence in the region do not exist, there are overall estimates of nearly 1.69 to 1.80 million eastern Congolese women aged 15 to 49 years who report histories of being raped [
11]). Not only are individuals seriously harmed, but also the social tissue that holds society together is torn, communities and families are destroyed and demoralized [
12,
13], and cultural and political solidarity is undermined [
14]. In eastern DRC, sexual violence has been used in armed conflict with extreme brutality and destructiveness [
5,
11,
14,
15]. Recent reports also shed light on other dimensions of sexual violence in this war-ridden environment. A considerable increase in sexual violence perpetrated by civilians (as opposed to military personnel) and in sexual violence against minors [
16,
17] has been observed in these regions, with various reports and studies alluding to a ‘normalization’ or ‘civilization’ of rape in eastern Congo [
5]. While officially the signing of peace agreements has brought the armed conflict in eastern Congo to an end, eastern Congolese communities perceive their region as remaining in a continuous state of war, with ongoing sexual violence as one of the principal indicators [
2]. These evolutions call for a broader perspective on sexual violence in these warring contexts, since the singular discourse of ‘rape as a weapon of war’ systematically neglects other forms of sexual violence, such as domestic sexual violence and sexual violence perpetrated by civilians [
2,
18].
The consequences of sexual violence for victims’ mental health have been extensively described [
19‐
21], although evidence of the impact of sexual violence, in particular on adolescents, remains limited [
22]. In addition, studies have tried to identify factors impacting on these mental health consequences. Recent research has widened the scope from a dose-effect study of traumatic exposure on posttraumatic stress symptoms [
23] to a broader model that includes daily stressors as important factors influencing mental health [
24‐
27]. Daily stressors encompass both current difficult material and situational living circumstances (e.g., unemployment, disease, poverty, poor housing) and social stressors. Social stressors are widespread in community reactions to sexual violence in war-affected regions like eastern Congo [
5,
28‐
30] and include attitudes of blaming the victim, exonerating the rapist, and stigmatizing and rejecting the victim [
29,
31]. Stigmatization, in particular, has been shown to have a large impact on the wellbeing of sexual violence victims [
32‐
34].
Sexual violence, and the social reactions it elicits, can possibly be framed within broader sociocultural perspectives on gender [
18]. In DRC, as in many countries, gender norms and discourses are generally described as being supportive of the idea that women should be powerless and submissive [
2,
35,
36], and should fulfill men’s sexual needs. This kind of sociocultural gender norm, which promotes unequal gender standards, may justify violence against women [
37,
38] and even lower the psychological threshold for sexual violence [
2].
These norms also influence how victims often do not label their experiences of sexual violence as rape, because they perceive such coercion as normal [
38] even if it complies with all legal definitions of rape. Equally, experiences of sexual violence often remain undisclosed because of fear of stigma, blame, or additional violence [
39‐
41]. Additionally, a predominant ‘rape as a weapon of war’ discourse may instill particular stereotypes of sexual violence. As such, rape may be related to acts of sexual violence that are committed by strangers [
42] or the military. Hence, victims might feel constrained from labeling an experience of sexual violence as rape or from seeking support if the sexual violence does not fit these stereotypes [
43‐
46].
In developing countries, where young people rarely affirmatively answer general questions on ‘forced sex’ or ‘rape’, but still do experience a high prevalence of diverse forms of sexual violence (e.g. forced sex within marriage, attempted rape or fondling, exchange or transactional sex, forced prostitution), the concept of ‘non-consensual sexual experience’ , defined as a range of behaviors that includes unwanted penetrative sex, attempted rape, unwanted touch, and non-contact forms of abuse, is more often used [
38,
47]. Factors influencing whether young people label a non-consensual experience as rape are related to existing stereotypes of ‘typical rape’ , the nature of acquaintance or relationship with the perpetrator, the perpetrator’s behavior or level of intoxication, and the labeling of coercion as a normal sexual act [
44,
48,
49].
Still, these forms of non-consensual sexual experience, which girls and young women endure but do not label as rape, may also have considerable mental and physical health consequences [
50,
51]. These may possibly differ from the impact of acknowledged rape experiences. Some studies have found that women who label experiences of sexual violence as rape tend to show less negative psychological consequences [
52]. Moreover, they recover more quickly, since they are able to ‘redefine’ their experience [
53], they reduce their feelings of self-blame [
54], and more often seek support from others [
55,
56]. By contrast, Layman and colleagues (1996) [
57] found that self-reported rape victims develop more posttraumatic stress symptoms.
However, most studies of sexual violence in war and armed conflict, in particular those conflict situations where sexual violence was/is used on a wide scale, do not differentiate between rape and non-consensual sexual violence, and only focus on self-reported rape. Additionally, little is yet known about the associations between daily stressors and stigmatization, victims’ own labeling of the sexual violence, and adolescents’ psychological wellbeing. This research therefore investigates the psychological sequelae of sexual violence in adolescent girls in war-affected eastern DRC in relation to their experiences of daily stressors and stigmatization and to their own labeling of the sexual violence they underwent (i.e. as ‘rape’ or as ‘non-consensual sexual experience’).
Discussion
More than one third of the eastern Congolese girls in this study reported experiences of sexual violence, which is congruent with the high prevalence of sexual violence in eastern Congo that has been reported for many years [
11]. Girls who lived in poorer socioeconomic situations, as well as girls who have lower parental availability (one or two parents deceased), reported more sexual violence experiences than their peers. While little research has been undertaken in this context, other studies alluded to the risk that both a poorer socioeconomic status and parental separation could lead to a higher prevalence of sexual violence [
2]. On the other hand, sexual violence could in its turn also lead to more difficult economic situations or to separation from parents (exclusion from family).
It is noteworthy, however, that about 63% of the girls who reported sexual violence did not label this experience as rape, although legally, their experiences of sexual violence qualified as such [
66]. This was probably engendered by the strong current discourses describing rape in Congo as a ‘weapon of war’ , thereby seemingly silencing rape by civilians or other forms of sexual violence (e.g. forced sexual experiences in marriage), which are described as ‘everyday, and even boring’ [
6]. Particular sociocultural gender norms about rape may also have restrained victims from labeling their sexual violence experiences as rape because of either uncertainty as to whether or not an experience was rape [
67] or fear of stigmatization [
39].
This latter element shows up as highly relevant in our study, since girls who label their experiences as rape are clearly confronted with more negative social responses, as shown in the high levels of reported stigmatization experiences. We hereby need to acknowledge that these experiences of stigmatization referred to perceived stigmatization, which might be higher in particular conceptualizations of sexual violence (i.e. when the sexual violence is labelled as ‘rape’), linked to certain expectancy effects with regards to stigmatisation.
Next to these higher levels of stigmatization, for both war-related traumatic experiences and material daily stressors we found similar patterns as for stigmatization: rape victims clearly reported more of these compared to victims who reported non-consensual sexual violations, although the latter group also experienced more of all investigated stressors (war-related trauma, daily stressors, and stigmatization) compared to girls who did not report any sexual violence experience. This clearly shows that sexual violence is mostly not a single trauma event, but goes hand in hand with exposure to other impacting events, whether concurrently with, preceding, or in the aftermath of the sexual violence, the latter being particularly the case with stigmatization of the victim by the wider community [
5,
28‐
30].
This accumulation of stressors and traumatic events is one of the greatest explanatory factors in the mental health impact of sexual violence on adolescent victims, as shown in the high prevalence of mental health problems in this study, both in participants who labeled the sexual violence as rape as those who did not [
52,
57,
68]. However, contrary to the expectation that – given the lower exposure to all investigated stressors in victims of non-consensual sexual violence compared to rape victims and the high explanatory role of these factors in mental health outcomes – the latter group would report significantly higher levels of mental health symptoms, we did not find significant differences between the two groups in symptoms of posttraumatic stress (avoidance), depression and anxiety. And for hyperarousal and intrusion symptoms (PTSD), we even found higher levels in girls who did not label their sexual violence experience as rape, in this respect also differing from other studies that reported higher levels of PTSD symptoms in acknowledged compared to unacknowledged rape victims [
52]. Possible explanations for this interesting finding could be that, as suggested in the literature, the acknowledgement of non-consensual sexual experiences as rape allows the victim to ‘redefine’ the experience and/or to reduce feelings of self-blame [
53,
54], two mechanisms that can lower the mental health impact of the traumatic events [
40]. The evidence suggests, although not consistently, that victims of sexual violence who do not label their sexual violence experience as rape report more impaired coping [
52], which is in its turn associated with negative mental health outcomes after a traumatic experience [
41,
69]. Another hypothesis is that the elevated negative social reactions of the community to adolescents’ experiences of rape could induce these girls to cope more actively so as to ensure their wellbeing, including possibly also to search more for (other) sources of social support [
56]. Although further study is required to investigate these findings, it is clear that the labeling of the sexual violence as ‘rape’ or as ‘non-consensual sexual experience’ has important associations with the exposure of the adolescent girl victim to other stressors (war-related trauma, daily stressors and stigma) and with the mental health consequences of these impacting experiences.
Implications
This study has important clinical implications. First, sexual violence has a large negative impact on adolescents’ mental health [
19‐
21]. While the need for psychosocial support to acknowledged rape victims has been recognized (although often it is not readily available), this study clearly describes the need for mental health support to victims of sexual violence who do not label their experience as rape. Sensitization campaigns to raise awareness of a broadened definition of sexual violence, including other forms of non-consensual sexual experience, and the large negative impact of these experiences, could be a first step towards also reaching out to these adolescents and offering them – where needed and wished – appropriate support services. It is also necessary to address victims’ possible feelings of shame and self-blame, working towards ways to redefine – where needed – the events that took place.
Second, the large prevalence of stigmatization, and its severe impact on victims’ mental health point towards context-oriented interventions. These need to be threefold. First, in psychosocial support offers to adolescent victims, significant context figures (family members, friends, community members) need to be involved [
27,
70] so as to reduce stigmatization mechanisms in the adolescent’s immediate context and to increase social support sources [
24]. Hereby, attention should be paid towards possible differences between perceived and actual or intended experiences of stigmatization. Second, on a community and society level awareness and sensitization campaigns are needed to address the problem of sexual violence and its consequences. Community perceptions and attitudes towards rape, including stigmatization and blaming attitudes, influence how victims of sexual violence label their experiences, impact their mental health [
32‐
34], and restrain adolescents, in particular those who label their experiences as non-consensual sexual experiences, from disclosing them and seeking help [
39,
71]. Hereby, it could be helpful to supersede particular narrow definitions of sexual violence (e.g., with labels such as ‘rape’), and to promote a broader construct, such as ‘sexual or gender-based violence’. Lastly, these sensitization and awareness campaigns also hopefully help to reduce the prevalence of sexual violence, since its prevalence in particular post-conflict contexts is still astonishing. These sensitization activities could address stereotypes of sexual violence and its consequences with the aim of promoting acknowledgment of rape by individuals and of fostering positive social reactions in order to create a supportive social environment [
24,
71,
72]. While often interventions on sexual violence and non-consensual sexual experiences target girls in particular, public health programming seems to be needed for both men and women, on traditional gender roles and norms, and on perceptions of non-consensual sexual experiences [
38].
Overall, an integrative and ecological approach towards psychosocial support for adolescent victims of sexual violence is needed, including not only interventions with the individual victim, but also interventions directed towards the wider social ecology of the adolescents.
Limitations
The interpretation of the study’s findings needs to consider the following limitations. First, although we included several questions in an effort to include different types of sexual violence (rape, several forms of non-consensual sexual experiences), the figures about the prevalence of sexual violence in this study might still be an underestimation of reality, due to fear of accusation or stigma, due to the ongoing insecurity in the region, due to particular emotional connotations possibly linked to the word ‘rape’ , or due to the ways the questions on sexual violence (and the examples given) were framed [
2,
71]. This implies that some adolescents in the ‘non-sexual-violence’ group could still have been victims of sexual violence. On the other hand, although this was clearly and repeatedly stressed during the research, particular expectations by participants of receiving material compensation for their participation or for particular answers might have influenced participants’ responses to increase their reporting of sexual violence experiences.
Second, this study also focuses solely on girls, while also considerable levels of sexual violence towards men and boys in the region have been reported [
28]. This choice was made in close consultation with the local expert team guiding this study, given that boys’ responses might be highly influenced by taboos regarding the sexual violation of boys, rendering this method (self-report measures in a class-room setting) less applicable for boys. Also, for logistical reasons only girls who were in schools were included in the study, reducing its generalizability to out-of-school adolescents.
Third, while the psychological impact of acknowledgement of rape has been studied, there was no previous knowledge of the psychological well-being of the participants. These longitudinal findings could have added to an understanding of whether already existing psychological problems influenced the labeling of the sexual violence experiences as non-consensual sexual experience or as rape. Above, the impact of parental availability was only conceptualized as whether parents were still alive or not, which is possibly not related to parents’ emotional availability.
Last, the questionnaires could not cover all mental health problems, nor all participants’ experiences of trauma or stigmatization, although all questionnaires were rigorously adapted, both culturally and contextually, for use in this particular context.
Acknowledgements
First and foremost we want to thank the participants to this study. We also kindly thank all the Congolese researchers for logistical assistance in data collection and data entry. We would also like to thank Nancy Say Kana, coordinator CCVS RDC, and the whole CCVS RDC team, Dr. Kirere Mathe, ISTM and CME Nyankunde, without whose logistical support and expertise the study would not have been possible.
This study received financial support from Service Peace Building, Ministry of Foreign Affairs, Foreign Trade and Development Cooperation, Belgium. The funding organizations played no role in the design and conduct of the study, the collection, management, analysis, and interpretation of the data, or the presentation, review, or approval of the manuscript. The views expressed in this manuscript are those of the authors and should not be construed as reflecting the official views of the Service Peace Building of the Ministry of Foreign Affairs, Foreign Trade and Development Cooperation, Belgium.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
AV and ID participated in the acquisition of data and revision of the manuscript. AV, ID, MDS conceived of the study, determined the design and provided in Administrative, technical or material support. AV, ID, MDS and EB performed the statistical analysis, interpreted the data, drafted the manuscript and provided a critical revision for important intellectual content. ID and EB obtained funding and provided supervision of the study. All authors read and gave final approval for the version submitted for publication.