AJTS - African Journal of Traumatic Stress
A publication of African Psycare Research Organisation In Collaboration with Makerere University College of Health Science.
Sexual And Gender-Based Violence And Torture Experiences Of South Sudanese Refugees In Northern Uganda: Health And Justice Responses
AUTHORS: 1*Helen Liebling, 1Hazel Barrett, 2Lilly Artz and 3Faddy Glady Canoguru
1Coventry University, United Kingdom
2Gender, Health and Justice Research Unit, University of Cape Town
3Kitgum Women’s Peace Initiative, Kitgum, Uganda
Dr Helen Liebling
Coventry University, United Kingdom
This British Academy/Leverhulme-funded research (Grant: SG170394) investigated the impact of sexual and gender-based violence (SGBV) and/or torture on South Sudanese refugees’ health and rights and the responses of health and justice services in Northern Uganda. It involved thematic analysis of the narratives of 20 men and 41 women refugees’ survivors of SGBV and/or torture; their experiences in South Sudan, their journeys to Uganda and experiences in settlements. 37 key stakeholders including health and justice providers were also interviewed regarding their experiences of providing services. The research demonstrated close linkages between physical, psychological, social/cultural and rights/justice impact. There was limited screening, health and support services; and access to formal justice, with many relying on informal justice mechanisms. Refugees largely fled South Sudan to escape human rights abuses. Their experiences resulted in significant effects that received limited treatment or justice. The authors recommend holistic services for refugees which, incorporates health and justice elements including screening and documentation of human rights abuses, specialist medical treatment and the opportunity to access group counselling.
INTRODUCTION AND CONTEXTSouth Sudan gained independence from Sudan in 2011 and then fighting broke out in 2014. Since then, conflict has spread across the country and has led to immense loss of life and destruction of property. Almost 400,000 people have been killed and over four million people displaced (Braak, 2016). The South Sudan displacement crisis is now the largest in Africa and the third largest globally after Syria and Afghanistan (UNHCR, 2019a). Uganda has experienced a rapid influx of refugees displaced by the violence in South Sudan, particularly in 2016 when over a million people crossed the border in a three-month period seeking sanctuary (UNHCR, 2016). As of August 2019, over 800,000 refugees had fled from South Sudan into Uganda. Eighty-two percent of these were women and children (Adaku et al. 2016; UNHCR, 2019b). About 92% of these exiles live in refugee settlements alongside local communities whilst urban centres, such as Kampala, are home to only eight percent of the refugee population (UNHCR, 2019b). Thus, the needs for health and education services are greatest in refugee settlements, which tend to be in isolated and remote areas of the country with poor infrastructure and communication. Whilst the number of refugees per 1,000 inhabitants in Uganda has tripled to 35 since 2016, putting a huge pressure on local resources and services, external aid has been progressively dwindling, causing major gaps in the refugee response. The level of funding for the refugee response in Uganda reached an all-time low in 2019, with only 42 percent of contributions received in October 2018. Implementing partners face enormous challenges in stabilising existing programmes and meeting the minimum standards of service provision, let alone investing in long-term and more sustainable interventions. Severe underfunding has particularly compromised the quality of child protection, education services with limited investments in prevention and responses to sexual and gender-based violence (SGBV), environmental protection, support for host communities, and infrastructure. In comparison to many other countries across the globe, not least the economically richer parts of the world, Uganda’s willingness to host such large numbers of refugees stands out as positive and exemplary, which is to be applauded (International Refugee Rights Initiative, 2018). However, it is vital that there is a clear understanding of both the gap between rhetoric and reality, and the pitfalls of the settlement policy. Whilst funding is important, it cannot replace rigorous policy making and implementation that is attuned to the needs of refugees (International Refugee Rights Initiative, 2018). According to UNHCR (2019a), with 34 percent of its population living below the poverty line (US $1.9 per person per day), Uganda may be unable to fully realize a comprehensive refugee response and maintain its progressive refugee policy without adequate support from the international community The conflict in South Sudan is characterized by human rights violations, including SGBV and torture (UNHCR, 2017a; 2017b). Reports cite high levels of sexual abuse and torture; particularly rape of refugees by both government soldiers and rebel fighters (Isis-WICCE, 2015). Most refugees have experienced a multitude of human rights abuses. However in-depth information and evaluation regarding the needs of these refugees is lacking (The Guardian, 2018). Adaku et al. (2016) found diverse mental health and psychosocial support problems amongst South Sudanese refugees living in Northern Uganda, yet there are few services. This research argued for services addressing refugees’ social concerns and mental health problems. It called for further research of an in-depth nature investigating the impact of experiences on South Sudanese refugees and to address the current health and justice service provision gaps.
METHODOLOGYThe research design was qualitative, cross-sectional, descriptive and used a psychological/health and human rights approach to investigate the experiences of South Sudanese refugees living in Northern Uganda and assess the availability and use of services available to them. The research was distinctive as: (1) It collected and analysed in-depth qualitative data regarding the lived experiences of South Sudanese refugees (2) It examined state and non-state health and justice service provision (3) It investigated the quality of service responses and diversity, and (4) It provided evidence for informed policy formulation for future responses to such emergencies. Following authorisation to carry out the research by Coventry University, the Uganda National Council for Science and Technology, Gulu University and the Office of the Prime Minister in Uganda, data collection took place in May and June 2018. Two refugee settlements were selected for the study: Adjumani and Bidi Bidi. In each settlement SGBV and torture survivors, as well as service providers, were invited to volunteer to participate in the research. In total 61 refugee survivors of SGBV and torture participated in the research including 41 women (15 in Adjumani and 26 in Bidi Bidi) and 20 men (11 in Adjumani and 9 in Bidi Bidi) (see Table 1). All were adults over the age of 18 years who had fled from South Sudan and who self-reported having experienced SGBV and/or torture, either in South Sudan, on the journey to Uganda or whilst in Uganda. Table 1. Survivors participating in research by refugee settlement and by gender
|Adjumani (Pagrinya & Mungula)||11||15||26|
|Geographical Location||United Nations Organisations||Ugandan Government||International Non-Governmental Organisations||National Non-Governmental Organisations||Refugee Welfare Councils|
|Adjumani Refugee Settlement||4||7||4||0||3|
|Bidi-Bidi Refugee Settlement||0||2||1||0||3|
(Chair of the Refugee Welfare Council in Adjumani)We were informed by service providers that SGBV counselling services were available for both men and women who identified or reported cases. However, there were limited counselling services available for those refugees who had experienced torture. Whilst the majority of the interviewed women refugees confirmed they had participated in more than one counselling session. Sixty-five percent of men refugees had not received any counselling.
(Chair of Refugee Welfare Council, Adjumani)
Human Rights Abuse Experiences of Refugee Survivors The majority of the interviewed refugees fled from South Sudan in mid-2016 when there was re-escalation of conflict between government and opposition forces after Riek Machar was reinstated as Vice President. Refugees made the journey to the south on the Ugandan border by land, often taking weeks to make their way undetected through the ‘bush’. They crossed the border and were processed at one of three ‘gateways’. Due to the huge numbers arriving in a short space of time, the Government of Uganda gave them all sanctuary. However due to the large population numbers, UN processing was minimal, with few if any being asked about the human rights abuses they experienced and getting this being recorded. For most participants this research was the first time they had told their stories about their experiences of migration and their settlement in Northern Uganda. For some, the opportunity to tell their stories was at the same time both upsetting but also deeply cathartic. One woman talking during a focus group discussion in Pagirinya said:
|Human Rights Abuse Experiences of Refugee Survivors||Torture SGBV Child marriage Domestic Violence Abduction|
|Service provision||Screening Health services Justice and rights-related services Access to education, basic rights and livelihoods Training, sensitisation and use of media Involvement of Faith-Based Organisations Care of staff|
|Impact of experiences||Psychological/emotional impact Physical health impact Socio-cultural impact Violence Justice and rights impact Security|
|Gender issues||Lack of gendered understanding Stigma and shame Need for gender-informed specialist services Family conflict and domestic violence|
- Socio-cultural impact
- Justice and rights impact
Social Justice and rights issuesSocial justice services included assistance in taking cases to court, protection and child safeguarding, access to justice, education regarding rights, and limited support with access to health care. Ugandan police received training on providing justice for refugees and followed procedures for crime reporting, completed the necessary paperwork and also assessed the perpetrator’s mental state. However, there were many logistical challenges to getting justice for refugees, including insufficient numbers of police officers, lack of transport, paper and pens to make reports and a lack of fuel for police vehicles and motor bikes. For example, in Pagrinya, Adjumani settlement, the police station only had access to one motorcycle to provide policing for approximately 250,000 people. Social justice support was said to be particularly lacking for women survivors of SGBV. The courts were long distances away and it was reported that 10% of cases waited over one year to be heard. Service providers informed us that the recent use of mobile courts was attempting to assist with this. The conflicting laws between South Sudan and Uganda on child marriage were causing difficulties and the police in Uganda were trying their best to educate South Sudanese that in Uganda it was unlawful for a girl under the age of eighteen to marry. Cultural traditions were considered important by refugees to resolve justice issues. However, in the case of South Sudan refugees, these often contradicted Ugandan law.. For example, we were informed by service providers that refugee registration details, including the name of household heads, could be changed on request by household members. Sometimes, household separation was done on request by specific cases by the Office of the Prime Minister based on unacceptable circumstances e.g. child marriage. Mobile courts had been introduced in all zones in Bidi Bidi Settlement to reduce on the challenges of logistics. Some women police officers have also been deployed in the settlement to settle family disputes along gender lines. It was reported by the service providers we spoke to that supervision structures were being put in place by stakeholders with the aim of tackling bribery.
Gender issuesIt was generally felt that gender sensitivity, inequalities and more sensitive approaches towards gender differences were needed. Male survivors were often excluded from programmes and men found it difficult to discuss mistreatment by women. It was felt that men found it harder to disclose abuses and providing medical treatment assisted them to overcome stigma and shame e.g. of sodomy rape. Service providers, including prisons, lacked knowledge to deal with men who had been raped . Also, child trafficking needed to be tackled. There also needed to be more focus on tackling gynaecological health problems of women who found these issues stigmatising and therefore did not come forward for treatment. Chris Dolan, Director of the Refugee Law Project stated thus:
CONCLUSION AND RECOMMENDATIONSThematic analysis of interviews with South Sudanese men and women refugee survivors of SGBV and/or torture and stakeholders resulted in four themes: experiences of refugee survivors, service provision for survivors, impact of experiences, and gender issues. All the refugees whom we spoke to shared their experiences of SGBV and/or torture. Few had previously been asked about their human rights abuses. Despite the significant physical health, emotional, social-cultural and rights impact of their experiences, the health and justice service responses were minimal. Few refugees, particularly men, had access to counselling. To conclude, our research argues that SGBV and/or torture are violations of refugees’ rights; their bodies and health, and therefore their right to health care and social justice should go ‘hand in hand’ (Liebling & Baker, 2010). It is important that service providers remain sensitive to gender differences, cultural context, and approaches are informed by a considered understanding and normalisation of the impact of refugees’ traumatic experiences (Liebling, 2018). Whilst many refugees recognise, they would struggle to get ‘formal’ justice for the human rights abuses committed against them in South Sudan, they did appreciate having the opportunity to narrate their experiences. Provision of the holistic model we recommend would ensure refugees and their families feel validated which in turn will assist them to utilise their resilience and agency to continue the process of recovery (Liebling et al. 2014; Liebling & Baker, 2010). The following recommendations are made for Ugandan and international partners to further develop and implement where practical:
- Comprehensive screening and treatment of human rights abuses: All refugees should be screened and treated regarding their human rights abuse experiences. Clinics need to be better resourced and require logistics to carry out their work effectively including regular supplies of medication and treatment, surgery facilities and vehicles. Post-exposure prophylaxis and emergency contraception is urgently needed in the local health clinics to prevent HIV infection and conception of a child following rape.
- Adequate staffing for physical and psychological health care: We recommend where possible that the Ministry of Health together with NGOs including Doctors of the World (Medecins Sans Frontiers) employ physical and psychological health care staff to bring the settlements up to at least the Ministry of Health minimum health care requirements.
- Psychological support and counselling: We recommend provision of group and individual trauma counselling and psycho-social support for refugees and their children involving health care teams and community organisations. There needs to be clear referral pathways into these services. Training to increase the capacity of health professionals in settlement health centres to be able to assess the health needs of refugees with trauma-related difficulties and provide person-centred counselling would be helpful. It is important that issues of shame and stigma are addressed sensitively by service providers as this assists disclosure. Specialist medical treatment for men and women survivors is essential. Services need to tackle drug and alcohol abuse particularly amongst the youth as well as domestic violence. The services should be informed by involvement of the Refugee Welfare Councils and include traditional approaches to promote recovery and integration. Training of community and peer refugee counsellors would also help improve access to services. We also recommend developing effective support systems for service providers to maintain positive emotional health and tackle burnout. Reflective groups for staff to support each other and recruitment of adequate staff numbers would assist reduce the burden on staff.
- Improved education and livelihoods: We recommend the need for increasing the resourcing of Government primary schools including the number of classrooms, teachers and books. Credit and loans could be available to support the establishment of social enterprises, which would assist refugees with an income and to be able to provide emotional support within their groups, their family and to other survivors in the settlements. The provision of more secondary schools in the settlements and vocational training for the youth would be helpful.
- Police improvements: The recruitment of police including more women police officers to Bidi Bidi and Adjumani refugee settlements would be a short term solution. The police also require logistical support including more private rooms for interviewing survivors, vehicles, and practical resources to carry out their role. This would enable them to provide more effective security and outreach services in the settlements.
- Social justice: The “culture” of sexual and gender-based violence including domestic violence needs to be broken by continued awareness campaigns in the refugee settlements (Isis-WICCE, 2015). We envisage local dialogue and debate that covers the dignity of women, men and children and respect due to them, and their value, equality and the tragic consequences on them and their communities when they are subjected to sexual violence. This debate should include men and boys so that they too are part of the solution. Provision of specialist treatment for SGBV and torture survivors should be extended to enable survivors, including men who find it particularly difficult, to come forward. The use of locally trained mentors through the Refugee Welfare Councils would assist with this.
- Legal justice and policy: Extending the use of mobile courts as well as regular visits by organisations assisting refugees resolve social justice issues would help improve access to justice. Refugee policy should include provision and resources for treatment for survivors of human rights abuses and anti-discrimination provisions with penalties for those who abuse refugees including adverse consequences in the law for those who violate this.
LimitationsThis qualitative research included participants’ in-depth narratives. It is acknowledged that a relatively small sample size was used and therefore there are limitations regarding generalisability of the findings. The project recruited refugee survivors of SGBV and torture through the Refugee Welfare Councils in the settlements, therefore the participants had a certain degree of expertise regarding the subject of inquiry. Service providers were recruited from a range of UN, Government, International and National Non-Government Organisations, who therefore had a range of expertise regarding the research.
AcknowledgmentsWe are most grateful to all those we interviewed including refugees, the Government of Uganda and all stakeholders, for their participation and the knowledge and experiences they shared. We hope that this summary in some small way repays that investment of time. For further discussion please contact: Dr Helen Liebling E-mail: Helen.Liebling@coventry.ac.uk, Professor Hazel Barrett E-mail: H.Barrett@coventry.ac.uk, Professor Lilly Artz E-mail: email@example.com. and Ms Faddy Gladys Canogura E-mail: firstname.lastname@example.org.
- Adaku, A., Okello, J., Lowry, B., Kane, J.C., Alderman, S., Musisi, S. and Tol, W.A. (2016) Mental health and psychosocial support for South Sudanese refugees in northern Uganda. Conflict & Health, 10, 18, 1-10.
- Braak, B. (2016) Exploring Primary Justice in South Sudan: Challenges, concerns, and elements that work. Project was funded by NWO-WOTRO in collaboration with the Knowledge Platform on Security and Rule of Law. Van Vollenhoven Institute for Law, Governance, and Society, and Cordaid in cooperation with the Justice and Peace Commission of the Catholic Diocese of Tombura-Yambio.
- Braun, V. and Clarke, V. (2006) Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 2, 77-101.
- Dolan, C. (2017) Hidden Realities: Screening for Experiences of Violence amongst War-Affected South Sudanese Refugees in northern Uganda. Refugee Law Project, Kampala. Working Paper 25.
- International Refugee Rights Initiative (2018) Rights in exile policy paper: Uganda’s refugee policies; the history, the politics, the way forward – October 2018. https://reliefweb.int/report/uganda/rights-exile-policy-paper-ugandas-refugee-policies-history-politics-way-forward
- Isis-WICCE (2015) Multi-Sectoral Gender Assessment of the South Sudanese Refugee Response in Uganda. Report to UN Women
- Liebling, H., Barrett, H. and Artz, L. (2019, under review) Sexual and Gender-Based Violence and Torture Experiences of Sudanese Refugees in Northern Uganda: Health and Justice Responses. International Journal of Migration, Health and Social Care
- Liebling, H. (2018) Service Responses for Survivors of Conflict and Post-Conflict SGBV and Torture in the Great Lakes Region. Colleen O’Manique & Pieter Fourie (Eds.) Global Health and Security: Critical Feminist Perspectives.
- Liebling, H., Burke, S., Goodman, S. and Zasada, D. (2014) ‘Understanding the Experiences of Asylum Seekers’. International Journal of Migration, Health and Social Care, 10, 4, 207-219.
- Liebling. H. and Baker, B. (2010) Justice and Health Provision for Survivors of Sexual Violence: a case study of Kitgum, northern Uganda. LAP Lambert. Germany.
- The Guardian. (2018) P. Beaumont. Born out of brutality, South Sudan, the world’s youngest state drowns in murder, rape and arson. 24th June 2018. https://www.theguardian.com/global-development/2018/jun/24/south-sudan-civil-war-refugees-families-flee-murder-rape-arson-nyal-global-development (Accessed 9th April 2019)
- UNHCR. (2019a) Uganda Country Refugee Response Plan: The Integrated Response Plan for Refugees from South Sudan, Burundi and the Democratic Republic of Congo, January 2019-December 2020.
- UNHCR. (2019b) South Sudan Refugee Crisis. USA for UNHCR. The UN Refugee Agency. https://www.unrefugees.org/emergencies/south-sudan/ (Accessed 30th September 2019)
- UNICEF. (2018) Uganda Humanitarian Situation Report.
- UNHCR (2017a). South Sudan Regional Refugee Response Plan. Downloaded on 24th April 2017 from: http://reliefweb.int/report/south-sudan/south-sudan-regional-refugee-response-plan-january-december-2017
- UNHCR (2017b) New refugee settlement opens in Uganda as thousands of South Sudanese continue to flee every day. http://reliefweb.int/report/uganda/new-refugee-settlement-opens-uganda-thousands-south-sudanese-continue-flee-every-day
- UNHCR. (2016) Thousands flee to Uganda after South Sudan flare-up: Influx expected to continue as tension remains high across the border. L. Dobbs (Ed.). 19th July 2019. https://www.unhcr.org/news/latest/2016/7/578e2edb4/thousands-flee-uganda-south-sudan-flare-up.html (Accessed 29th September 2019)
- About The African Journal Of Traumatic Stress
- About CLAMP Refugees, Uganda Project (CLAMP- RU)
- EDITORIAL: Well-Being And The Traumatic COVID-19 Pandemic
- Major Depressive Disorder And Associated Factors Among Adult Refugees Attending A Refugee Center, In Kampala, Uganda
- Trauma And Post-Traumatic Stress Disorder: Approaches To Treatment For Victims In Post-Conflict Communities In Northern Uganda
- Sexual And Gender-Based Violence And Torture Experiences Of South Sudanese Refugees In Northern Uganda: Health And Justice Responses
- Post-Traumatic Stress Disorder Among HIV- Infected Adults Attending An HIV Treatment Clinic In Post-Conflict Gulu District, Uganda
- Preventing Suicide Behavior Using Village Helpers In Post-Conflict Northern Uganda
LETTER TO THE EDITOR: Provision Of Mental Health And Psychosocial Support Services (MHPSS) To Refugees As Persons Of Concern (POCS) In Urban Kampala City: A Case Story At Inter-Aid, Uganda