Content note: This post mentions childhood sexual assault.
This is my second time working for Médecins Sans Frontières / Doctors Without Borders (MSF) in the conflict-affected Northwest and Southwest regions of Cameroon.
Violence between government forces and separatist non-state armed groups has escalated in recent years. The hostilities have direct consequences for local communities, but the violence isn’t the only cause of suffering.
People here are facing displacement, poverty, the disruption of family support networks, an increasing sense of hopelessness and constant exposure to violence.
She peeps to see who I am and quickly goes back into hiding. Her eyes look scared.
For some people, thresholds of good and evil can change. And in a dysfunctional justice system, crimes that were rare before become almost normality.
I would like to share a story of one of our patients who is a survivor of sexual assault. Not committed by armed forces who often use rape as a weapon of war, but by a member of her community. Another unnecessary victim representing the countless girls and women and boys and men that are collateral damage as result of a violence-infected society.
A special emergency
It is Monday. Ghost-town. No movements on the streets. The message is clear. Stay at home or you will be punished! Armed groups are reinforcing these regular lock-downs every Monday. Exceptions are medical staff on the way to work and emergencies coming with our ambulances.
A few minutes ago, our medical team leader got a call. An emergency is waiting at the ER. It is a special emergency.
I call Madame Bridget, our midwife in charge. When she picks the phone, I say: “We have a window case.”
She responds: “I will be right there!”
After I arrive at the hospital I walk towards the ER. I see a woman and a young girl sitting patiently on the bench in the waiting area. I slowly approach and greet them and introduce myself. The woman greets me back.
The girl sits very close to the women, clinging onto her arm. I assume it’s her mother. She just peeps to see who I am and quickly goes back into hiding. Her eyes look scared.
Silence can be hard to handle sometimes
I explain that we have to wait for Madame Bridget and then we can go to the consultation room together. Five minutes waiting that feel way too long. I keep silent. This is not the place and moment to start talking.
When I see Madame Bridget arriving, I feel relieved. Silence can be hard to handle sometimes. We finally enter in our specially equipped room, sit down and close the door.
“My name is Raimund and this is Madame Bridget. I am a psychologist and Madame Bridget is a midwife. We want to sit together and find out what happened and how we can help you in the best possible way. Is it ok for you both that the four of us are together in here?” I ask.
The mother nods. The girl keeps quiet.
I explain that with their consent Madame Bridget will do a physical exam and provide different medical treatments if necessary. I say that I want to support them on how to move forward from this point on.
I wish we had already recruited a female psycho-social counsellor. In most cases it is easier for the female patients. But for now, it’s me. Because of that, I try to be extra sensitive about asking whether they are comfortable to have me there.
The woman is the mother of this girl, who is under ten years old. She explains to us that on Saturday afternoon, Violet* started complaining about pain in her vagina. But she did not want to say what had happened. The mother beat her until she confessed that, while the mother was working on the farm earlier that day, the mother’s boyfriend had pulled down her underwear and put “his skin on hers”.
I feel like I'm choking. I am nervous. I've never talked to a suspected perpetrator before
After he was confronted with what the girl had said, the boyfriend went to the village council to announce that the girl was lying, and that the mother just wanted to damage his reputation. In order to prove that he is not the perpetrator, he brought both to the hospital this morning.
“What, he is here?!” I ask surprised?
“Yes, he is outside. It’s the guy with the pullover,” says the mother.
Madame Bridget instructs me to go and talk to him.
“We should test him for HIV. In the meantime, I will do the physical exam,” she says.
I leave the room.
"Not the police, not a judge"
When I approach the guy with the pullover, I feel like I'm choking. I am nervous. I never talked to a suspected perpetrator before. My head starts spinning, I feel anger rising. I look at him and can’t stop thinking about the girl and what the mother told us.
“Stop!” I tell myself. ”I am not the police, not a judge. I am here to help.”
I take a deep breath and introduce myself. We talk in a quiet place. Confidential. He swears he is innocent. He agrees to be tested for HIV. I leave him.
Another deep breath.
When I come back to our consultation room, Madame Bridget steps outside and gives me a short summary on the results on her assessment. They are conclusive. I feel nauseous.
Another deep breath.
Madame Bridget goes back in to give the girl prophylaxis for tetanus, hepatitis B, and several different sexually transmitted infections, including HIV.
I ask again for permission to enter the room. The mother nods. The girl is quiet. No eye contact. I stay a safe distance from her.
I emphasise that what she needs most now is a lot of attention, love and protection
I discuss with the mother what she wants to do next, whether the alleged perpetrator still lives with them, whether there are steps she can take to guarantee the safety of the girl and herself, whether she should involve the police or leave everything to the traditional council.
Normal reactions in abnormal circumstances
I explain to the mother how her daughter might react in the next days and weeks and that these reactions are normal in these abnormal circumstances.
She could have nightmares, be very anxious and overly clingy with her, not want to leave the house anymore or be alone, or she might start wetting her bed again.
She might be aggressive with her or others, she might start withdrawing herself, stop playing, be sad and quiet. Maybe she starts asking questions about what happened or any sexual topics.
Maybe she starts re-enacting what happened that afternoon with someone else. Any obvious change compared to how she was before is possible.
I emphasise that what she needs most now is a lot of attention, love and protection. I also explain that beatings and punishment will not help the girl to better cope with the situation. The mother and I discuss other parenting approaches she can use.
A tiny smile
The girl is making more and more eye contact with me. I see how she starts looking at one of our big plastic boxes filled with toys and painting material and balloons.
While I tell the mother how great and important it was for them to come to the hospital today, and how important it is for them to come back for the follow-up appointments, I gently slide the box closer towards the girl and, from a distance, open the lid.
Her eyes are locked with the small box of colouring pencils. I gently turn to Violet and ask her if she likes colouring. Her mother translates for me since she only speaks Pidgin-English. Violet nods hesitantly.
I try to make her understand that she can take a box of pencils and one of the books to draw in. She quickly takes them and pulls them very close to her chest as if obviously claiming them as hers now. I see a tiny smile on her face.
As they leave, they promise us to come back next week to follow-up with the next dose of vaccine and to check on how Violet is doing. The mother doesn’t have a phone and there is rarely network anyways in the remote area where they live.
As the mother, the girl and the guy with the pullover walk away together towards the exit of the hospital I start having doubts. Did we do our best? Is she safe now? Can and should we involve the police in a place where justice has a price and victims could suffer more due to public stigmatisation? Did we really act in the best interest of our patient?
Little did I know that a few days later the village council would meet and decide over the verdict and the sentence. The guy with the pullover will have to pay 10 crags of beer, a common punishment for crimes to be solved without involvement of the police. Who will get the beer? The village council. All men.
A new family
Violet and her mother are back after one week. The mother explains to us that after that day at the hospital, Violet has gradually gone back to how she was before. She doesn’t leave her alone though and the two of them are very close. She plays with the neighbour kids and is a normal child in this very abnormal context.
They live with her grandmother as a new family now. We will ask them to visit us again in the coming weeks.
Sexual violence affects millions of people all over the world. It can brutally shatter the lives of women, men and children and is considered a medical emergency. The psycho-social consequences can torment a human being for years, leading to severe mental health problems, and in some cases resulting even in death by suicide.
But it does not have to be this way.
Early, even simple interventions like counselling the families in how to create a safe and caring environment can already start to boost the healing process and may eventually prevent the development into a devastating future.
Time will show how Violet will cope with her trauma. She will grow up, become a teenager, a woman. Maybe she will have a healthy and loving relationship with a partner, start a family and live a “normal” life. None of this is up to us. But I want to believe that we can help to give her and her family a chance to heal.
*Names and identifying details have been changed or omitted. Top photo shows a psychosocial support activity for children by the MSF team at Maroua General Hospital in Cameroon - it does not depict the child described in this post.