Africa continues to experience some of the worst cases of war related sexual violence with the situation in some parts of the continent such as Eastern Democratic Republic of Congo characterized by indiscriminate sexual violence [1, 2]. Sexual violence in these situations is mainly perpetrated by armed groups who use it to humiliate, intimidate, and dominate women, girls, their male partners and entire communities . This situation of mass sexual abuse of communities including the rape of children as young as 10 months has been described as "murderous madness" . It is hoped that the adoption of the landmark UN resolution 1820 (2008) which, "demands the immediate and complete halt to acts of sexual violence against civilians in conflict zones" will focus world attention on this epidemic problem .
War related sexual violence for purposes of this study is considered to be equivalent to sexual torture which Lunde and Ortmann (1998) have described as presenting in four forms, namely: i) violence against the sexual organs; ii) physical sexual assault, i.e. sexual acts involving direct physical contact between victim and torturer, between victim and victim, between victim and an animal, or all three of the above; iii) mental sexual assault i.e. forced nakedness, sexual humiliations, sexual threats and witnessing others being sexually tortured; iv) a combination of the three above . According to Lunde and Ortmann (1998) the important point about sexual violence is that the victim is subjected to involuntary sexual acts which because they are involuntary, are psychologically painful, whether or not they are also perpetrated with physical harm .
Long term health consequences of war related sexual violence include reproductive health problems, surgical problems and psychological health problems in the survivors. Reproductive health problems have been reported to include: pain in both external and internal genitalia; menstrual disturbances; urination and defecation problems; sexual problems such as sexual dysfunction; rectal and vaginal fistulae and traumatic genital injury; urinary tract infections; STDs including pelvic inflammatory disease, HIV/AIDS; disturbance of reproduction including infertility; and precancerous and/or cancerous cervical tumours [1, 2, 4–7]. Destruction of breast tissue may result in necrosis of the papillae so that a mother cannot breastfeed her infant, which is often the only available source of nutrition for babies in situations of war .
As surgical consequences, survivors of war related sexual violence may report uncharacteristic lower lumbar pain sometimes radiating to the pelvis or gluteal region, with many having difficulties in standing or sitting for long periods . Psychological consequences of war related sexual violence include post traumatic stress disorder (PTSD), anxiety disorders including phobias, psychosomatic symptoms, psychogenic pain, conversion-dissociative disorder, major depressive disorder, self-injurious behaviour including suicidality, alcohol and substance abuse and altered self-image and view of the world [4, 6, 7].
However few systematic studies of the reproductive, surgical and psychological effects of war related sexual violence have been undertaken in the African socio-cultural setting.
Setting of the study
Northern Uganda has suffered chronic warfare for the last 20 years, with a conflict waged between the central government army (the Uganda Peoples Defence Forces; UPDF) and a vicious rebel group, the Lord's Resistance Army. This conflict has led to the mass traumatisation of the population including the abuse of human rights, and the forced displacement of over 2 million people (80% of the population in the region) into internally displaced persons camps. Since 2006, the Sudan sponsored peace talks between the Uganda government and the Lord's Resistance Army have brought relative peace to the region with people gradually returning to their homes; as a result both government and the international community have begun focusing on the rehabilitation and resettlement of the war survivors. However often such rehabilitation and resettlement programs fail to address the mental health and reproductive health needs of war survivors; when these needs are addressed it is done in a very superficial manner.
This paper will examine the specific long term health consequences of war related sexual violence among women from two internally displaced persons camps in Kitgum district, in war affected Northern Uganda, with the aim of highlighting the burden of these problems.