Dr. Joseph K. Ruminjo is the Senior Medical Associate with the Safe Motherhood program at EngenderHealth.
I am writing from the FIGO World Congress of Gynecology and Obstetrics in Kuala Lumpur, where the important issue of traumatic fistula is being addressed on this international stage. In recent years, the international health community has increased its focus on obstetric fistula. This tragic condition, usually the result of complicated childbirth, causes women to leak urine and/or feces, and often makes them social outcasts.
Unfortunately, traumatic fistula – an injury most often caused by sexual violence – has until now received little international attention, perhaps due to its taboo nature or the great shame that women feel as a result. Traumatic fistula appears to be especially common in countries experiencing conflict, although it can occur anywhere.
After undergoing what are often life-threatening attacks, survivors must endure the double stigma of having been raped and then smelling of urine or feces. Sufferers are also more susceptible to HIV and other infections and must wrestle with issues such as unintended pregnancy. While fistula can in most cases be surgically repaired, women are often unable to afford treatment or just don't know where to go for help. And they are often abandoned by the very people – relatives, friends – whose support they need.
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While no one knows how many women suffer from traumatic fistula, stories from around the world show the enormous impact of this condition. I'll never forget many years ago while working at a hospital in Kenya, I treated a very young girl who had a fistula as a result of being raped by an adult. To make matters worse, her attacker was infected with gonorrhea. It was a difficult surgery – I operated on her for nearly three hours. Fortunately I was able to repair her fistulas and she received the appropriate antibiotics. Her emotional rehabilitation, however, will go on for the rest of her life.
On November 9, I participated in a panel on traumatic fistula at the FIGO Congress intended to bring these issues to light. The panel was organized by the ACQUIRE Project, a cooperative agreement with USAID that is managed by EngenderHealth.
Experts such as Dr. Longombe Ahuka, a fistula repair surgeon with the organization Doctors on Call for Service (DOCS) described the situation of traumatic fistula in the Democratic Republic of Congo. The DRC has been ravaged by armed conflict for almost 10 years and the impact this war has had on the country's women and girls has been terrible. Sexual assault and rape are commonplace, with limited medical or psychosocial support available. Over one year, 3,826 women who had been sexually assaulted were seen at the DOCS hospital and 436 of them had a traumatic fistula. Most were between 19 and 45, but a sizable number were girls younger than 18, and 10 girls were under 13.
The situation in Northern Uganda was highlighted by Dr. Margaret Mungherera, from the organization Hope after Rape. Since the 1979 war to expel President Idi Amin, violence has overwhelmed Uganda and the abduction and rape of children and women has been widespread. Girls and boys abducted by the Lord's Resistance Army (LRA) are often turned into sex slaves and child soldiers, raped and defiled until they can't walk or forced to commit crimes, some of which are sexually violent and may result in fistula. Hope after Rape works to address the enormous psychosocial effects of sexual violence in Uganda, a task that requires a great deal of time, patience, and awareness of the complexity of the issues. Hope after Rape's main goal is to help rape survivors recover and become re-integrated into their families and communities – mainly by empowering survivors with the information and skills they need to cope with the psychosocial effects of rape and sexual assault.
Can traumatic fistula be eliminated? The challenges to doing so are enormous. Organizations must not only care for survivors' physical and emotional needs, but also have to rise to meet the larger challenge of prevention – ensuring security for all girls and women, both in conflict settings and in their normal everyday lives.