Gendered dimensions of health in refugee situations: An examination of sexual and gender-based violence faced by refugee women in Nakivale refugee settlement,Uganda

Uganda and refugees

Uganda hosts 1.4 million refugees which is the highest in Sub-Saharan Africa (World Bank, 2019). Around 65.5 percent of refugees in the country come from South Sudan, 26.6 percent from the Democratic Republic of the Congo (DRC), and the rest from Burundi, Somalia, Rwanda and Eritrea (World Bank, 2019). Most are fleeing insecurity and ethnic violence (Mwenyango, 2020). The majority of refugees in Uganda live in settlements including Kyaka II, Nakivale, Oruchinga, Kyangwali, Kiryandongo, Paralonya, Rhino Camp, Imvepi, Madi Okolllo, Maaji, Bid Bidi and the integrated camps of Adjumani (Office of the Prime Minister [OPM], 2015). These are located in the poorest districts with significant challenges in the provision of services. Most of the refugees in the settlements are women and female household heads (World Bank, 2019). The rights of refugee women and in Uganda are protected under Article 33 of the Refugee Act (2006), which is also an adaptation of the 1951 Convention. For example, in addition to economic, social, cultural, and civil rights, affirmative action is advocated to protect them from gendered oppression. The most striking feature of refugee protection is access to land for construction and subsistence farming.

Gender, migration and violence

Women form a large proportion of the refugee population worldwide (World Bank, 2019). The interconnections between gender, forced migrations and violence have been commented on in the large body of literature (Alsaba and Kapilashrami, 2016; Crawford et al., 2017; Fassetta et al., 2016; Fassetta and Quinn, 2018; Freedman, 2019; Fry et al., 2019; Manandhar et al., 2018; Palattiyil and Sidhva, 2011). Gender represents existing relations and expectations among people and reflects the distribution of power within those relationships (Manandhar et al., 2018). Migration sometimes changes existing gender relations due to differences in the ideological, historical, religious, economic and cultural influences in new destinations (Moser, 2003). Freedman (2019) argues that displacement, loss of economic and social capital and the altered gender roles create diverse forms of violence for women, men and children. While women face physical, sexual and psychological abuse, violence is an ignored determinant of migrant health (World Health Organization [WHO], 2015). Existing conceptualisations of gender focus on the roles of women as mothers and caregivers (Horn, 2010; Manandhar et al., 2018) and are limited in analysing the extent, causes and impact of SGBV on women’s well-being.

Refugees and SGBV

Refugee women’s health is determined by pre-migration events, experiences during flight and after settlement (WHO, 2018). The experiences and conditions in the places of origin include war, conflict and human rights violations, sexual and gender-based violence, trauma, disrupted health systems and vulnerability. During transit, refugees face risky conditions, loss, exposure to violence and disease based on gender inequality (Mwenyango and Palattiyil, 2019). These processes combined with the loss of social and protective networks and absence of services exacerbate women’s suffering. SGBV against women is associated with physical and reproductive health effects including injuries, unwanted pregnancy, sexually transmitted infections (STIs) including HIV, pelvic pain, urinary tract infections and fistula (Wakabi, 2008). Mental health effects of SGBV include post-traumatic stress disorder (PTSD), depression, anxiety, suicidal behaviour and sleep disturbances (Fernandes and Miguel, 2009). While the pre- and post-migration issues can cause and intensify SGBV, there is a threat that these may be undetected among refugee women. Hence, the victims might not access attendant human rights protection under national and international law (Bukuluki et al., 2020). This suggests the importance of rights and appreciation of gender aspects in social work assessments of need and the design of interventions with refugees.

Social work and refugee service

Social work as a frontline profession is key in responding to the social determinants of refugee health (Bywaters and Davis, 2012; Delavega et al., 2019). Professional social workers in the settlement (with other specialists) mainly implement administrative and assistance measures (Mwenyango and Palattiyil, 2019). However, this role could be expanded with measures that alleviate immediate tensions through counselling in cooperation with earlier arrivals or members of new arrivals. This could be combined with actions that ensure effective legal advice for victims of SGBV. Such practice requires the skills to listen, identify needs, provide psychological support and refer when necessary (Hall, 2006). In partnership with clients, they have great potential to impart information concerning SGBV (such as description, causes, effects and available services) to women (Valtonen, 2008). Besides, social workers have the skills to explore human rights violations posed by SGBV at the micro, meso and macro levels. Research is an important tool for the advancement of refugee women and one which the social work profession is well equipped to undertake.

Data analysis

Quantitative data were organised, edited and coded (using numerical codes) and entered for analysis using the Statistical Package for the Social Sciences (SSPS Version 17.0). Descriptive statistics were generated such as frequency distribution tables, cross-tabulations, univariate and bivariate analyses (chi-square statistics). Qualitative data analysis was completed using a phenomenological approach as proposed by Hycner (1985: 280–293). This was aimed at gaining access to respondents’ social world and to interpret it from their point of view (Bryman, 2001). Hence, the interviews were transcribed, followed by bracketing and phenomenological reduction, crystallised and condensed. This led to central themes that provided a deeper understanding of the data.

Socio-demographic characteristics of refugee women

More than half of the refugee women were Congolese (55.2%), and 41.4 percent were Rwandese and Burundians. Women of other nationalities (Somalis, Tanzanians and Eritreans) formed a small percentage (3.5%). Since the age of consent in Uganda is 18 years, those of this age and over could contribute. A majority (61.2%) of the women were married (n = 229), 20.1 percent were single and only 18.7 percent were separated or widowed. A substantial percentage (30.0%) of the women had six or more children. The women predominantly worked as peasants (58%) on the nationals’ (local Ugandans’) farms. A great number (41.4%) had spent seven or fewer years in education, while an equivalent percentage (40.1%) had never attended school. More than half (69%) had lived in the settlement for over 5 years.

Sexual and gender-based violence in the settlement

Refugee women in the settlement reported different types of violence and abuse. This section presents the forms of SGBV including domestic violence, community or peer violence, sexual violence and survival sex.

Domestic violence

Nearly half (46.7%) of the refugee participants had experienced domestic violence in the form of physical assault and psychological abuse. Domestic violence in the settlement is mainly caused by trauma, alcoholism and high levels of poverty. For example, many households survived on a single meal (65.8%) a day because food rations (3 kg of flour and every other item) distributed per month for individuals were insufficient. Domestic violence was mainly perpetrated by intimate male partners as reflected in these statements:

Continued intimate partner violence . . . on average we have sixteen cases reported monthly. (Protection Officer, American Refugee Council, ARC)

The men[spouses] beat us, they leave us and go to find other women, and leave us at home alone, . . . we are the ones who go to find firewood which is a challenge here so the woman does not have time to rest. (Congolese woman, Rubondo)

In addition to heavy workloads, women reported not being appreciated. Instead, a substantial percentage (30.5%) reported being abandoned by partners. For instance, a refugee single mother said,

After I gave birth, without even finishing one day he left me and went somewhere to another woman . . . I’m the father and I’m the mother. (Congolese woman, Rubondo)

The refugee men who abandoned their families were suspected to be involved in multiple sexual relationships. This caused emotional pain for women as echoed by a key informant:

A man doesn’t even have to beat a woman here [settlement], it happens, but it’s not as much as the emotional abuse that is going on. (Assistant counsellor, OPM)

This suggests that strained relationships caused physical and psychological problems among women. Sometimes, structural conditions (such as scarce resources) forced refugee families to sell the material assistance items to more established refugees. Although this was considered important to cover basics and non-food items not distributed by the United Nations High Commissioner for Refugees (UNHCR), in many situations, women did not approve of these transactions, and this resulted in domestic violence.

The findings also indicate that experience of domestic violence differed among different ethnic groups of refugee women. For example, Somali and Burundian women were described as highly exposed to violence due to social norms, as stated by key informants:

The Somali women are so vulnerable; they are married off at [a] tender age . . . and the parent has no reason to say no because that is tradition, they have to do it; and also the way they behave, they are always isolated, to reach out to them becomes a problem. (Community Development Officer, Finnish Refugee Council)

They [refugees] say, like those rape cases and defilement, ‘do not go and report, why do you report?’ Somalis believe in their religion and to them, defilement is not there. (Police officer)

This suggests that cultural and religious aspects not only caused violence but also sustained it. Women did not report violence because they were afraid of breaching these norms while some only reported when they suffered health issues, as seen in this statement:

They [survivors of rape] only come here to report it when they have had medical complications, for example, fistula, [or] unwanted pregnancies. (Protection Officer, ARC)

Another key informant provided another reason for not reporting violence and said,

Most of the problems come [because] some people are ignorant especially about the laws of Uganda. (Protection Officer, HIJRA)

The statement suggests that various factors interact with gender to cause suffering for women. This might explain attempts by some organisations to integrate gender aspects into their policies, as revealed by another key informant:

The UNHCR standards sphere talks about the need to focus on men, women, gender . . . [but] how it plays out in terms of these communities doesn’t come out clearly. (Social work academic)

The quotes earlier give the impression that the factors which make women vulnerable to violence are structural and multifaceted. And although organisations tried some interventions, their practices did not completely address gender issues.

Community violence

Community or peer violence was described as a type of violence perpetrated against refugees by other refugees. This form of violence was widely reported among the Somali community with strict group loyalty. The victims were accused of breaching conventional group values such as rules on marriage or lifestyle. One participant described this violence:

I came here [rented place] to rent, [but], they don’t want me to stay [in NRS] because they tell me [that if] the father of my first children died, why did I get married to a second man? (Somali woman, Base Camp)

Peer violence occurred due to long-standing conflicts and acquaintance from countries of origin or previous camps as explained by another participant:

Before I was staying in [the] Somali zone ² but I changed the place I used to stay, now I’m here in [the] Ethiopian zone. I changed because of the problem with my daughter . . . When I reached Uganda, some people knew me in Kakuma [refugee camp in Kenya], we were in the refugee camp together. They are the ones who brought my information here. They tell everyone that my daughter was raped in Kakuma by two men. (Somali woman, Base Camp)

Peer violence was not only harmful to victims but also their families (usually single mothers and siblings) due to stigma, discrimination and isolation. For instance, this participant explained that her son could not play with other children in the community and she could not do any small-scale trade because of stigma. A key informant provided a different justification of community violence and said,

To have nine nationalities within one area is not easy and they have their differences even those people coming from the same country. (Protection Officer, ARC)

This suggests that differences in lifestyles and norms impacted social relations and similarly influenced violence.

Sexual violence

Sexual violence describes any kind of unwanted sexual act or an attempt to obtain a sexual act by coercion or force. Several women in this study were victims of sexual exploitation (25.2%), forced marriages (12.2%), forced prostitution (7.8%) and female genital mutilation (4.3%). However, the narratives of rape dominated interviews, as shown in these statements:

I was coming from Mbarara, the driver took us to a place called Lugaga, it was raining too much . . . I was remaining alone waiting for the driver, then the driver himself raped me. (Congolese single mother, Base Camp)

Once they [women] hear there is some free food at the health facility, some of them tend to wake up as early as they can. Take an example at 5[a.m.], they start walking from home so that they can reach here fast and they get food fast, so men trap them on the way. (Counsellor, MTI)

This suggests that the perpetrators manipulated weak targets at any given opportunity. Sexual violence partly occurred due to the rural nature of the settlement, which provided perpetrators with ‘dwellings’ for committing crimes. Sexual violence was associated with reproductive and mental health effects among the victims, as stated by this key informant:

We see many people with mental health problems. Women – they are like five of them with suicidal tendencies and two of them are ‘Nalongos’ [mother of twins] . . . but she tells you ‘for me the only thing I want is to kill these children’. (Protection Officer/Counsellor, ARC)

This reflects severe mental health issues. Although states are obligated to protect refugees in their territories, women reported several challenges to pursuing justice. For instance, one participant who reported being raped by a neighbour said,

I went to this office, ³ I told them the issue, they then said they will come to me to do a follow-up, I waited and waited nobody came. (Burundian woman, Rubondo)

This suggests challenges in the professional and social protection systems. The key informants revealed that each zone in NRS was designed to have one police post, even though the zones were extensive. However, the police post in Base Camp lacked reasonable office space for handling cases and yet in Rubondo, a new structure was just being constructed. The key informant poignantly spoke about the difficulties of meeting the needs of SGBV victims:

Somebody [refugee] comes and sits there. If you don’t call that person, they will finish the whole day there seated but [she] has a problem. (Police officer)

It appears that anxiety, unfavourable conditions such as one police post per zone, lack of confidence in public offices led to little recourse to justice.

Survival sex

Survival sex was described as a practice of engaging in sex to meet daily needs such as food. The data show that only 0.6 percent of the respondents reported waged work as translators (at the health centre or an NGO). Most women (58%) were peasants who walked long distances out of the camp to secure farm work from locals; 19.8 percent were self-employed in small food and merchandise kiosks; and 11.3 percent casual labourers such as housemaids (for established refugees and professional staff of agencies) and commercial sex workers. Others (10.4%) did not report any means of income. Some of this work directly exposed women to SGBV. Other women engaged in transactional sex based on promises of help, such as in the construction of shelter and provision of basic requirements. Refugees generally received building materials such as poles and plastic sheets; however, some women household heads lacked construction skills and refugee men took advantage of this to lure them into sexual affairs. One participant described the inadequacies of her survival strategy:

Because of the bad life that I’m living, I’m forced to have men and they always promise to help me and then when I produce, they reject me. (Congolese woman, Juru Camp)

Most of these relationships, though temporary, resulted in children. Furthermore, women were forced into commercial sex to meet family needs, as revealed by a key informant:

In the reception centre, most girls indulge in prostitution because that is the only way they can get money, actually, we even heard sadder stories that some husbands also send out their wives to do that. (Assistant counsellor, OPM)

Although this might be perceived as self-imposed violence, likewise, it depicts structural violence against women. Trading women’s bodies for survival exposed them to reproductive health issues.

Gender dimensions of health in exile

The findings reveal the plight of being both a woman and refugee. The narratives of SGBV against women in NRS reflect the interplay between women’s social identity, migration and well-being. A similar study of Syrian refugee women and girls in Lebanon revealed forms of SGBV including child marriage, domestic violence (DV) and intimate partner violence (IPV), sexual exploitation and assault, intimidation and fear of violence within their communities. Mass rapes have also been reported in Bosnia, Somalia, DRC and Myanmar (Roupetz et al., 2020; Wakabi, 2008). While refugee participants in this study reported varied forms of violence (domestic, sexual, survival and community), the perpetrators were mostly male (fellow refugees and intimate partners). Besides, individual women faced diverse challenges and experiences subject to gender norms and collective values. This happens because some gender norms place women in inferior positions compared to their male counterparts (Fry et al., 2019). Alsaba and Kapilashrami (2016) state that violence during and after displacement is influenced by the impact of conflict on the gendered distribution of social and economic resources. Refugee women often lack social connections and do not benefit from community resources because of traditional influences and attempts by males to ‘protect’ them from unknown dangers (Stamatel and Zhang, 2018). Evidence shows that refugee women who seek refuge for themselves and not in the company of men are exploited by border guards and local officials who demand sexual favours to get the necessary papers, while others serve as temporary wives (Ewles and Simnett, 2003; Fry et al., 2019). This reveals double jeopardy in the search for protection (Palattiyil and Sidhva, 2011). In this study, existing socio-economic challenges such as poverty triggered domestic, survival and sexual violence. For instance, reports of exploitation based on promises (such as the construction of houses) reflect women’s vulnerability. Due to the traditional sex-determined division of roles in many parts of Sub-Saharan Africa (Fry et al., 2019), it is not uncommon for women to lack simple construction skills. By merely giving them building materials and not supported with construction, authorities implicitly expose them to exploitation. Furthermore, sexual violence is indicated as a recurrent issue in refugee settlements where women must travel long distances for food, water and firewood (Horn, 2010; Mulumba, 2011; WHO, 2015). For instance, Papadopoulos (2008) revealed the presence of widespread rapes of Somali refugees in the Dadaab camp (Eastern Kenya) as they ventured out of the camps to collect firewood. SGBV violates women’s rights, leads to reproductive health problems (such as forced pregnancy, unsafe abortions, fistula and STIs), mental health repercussions and even death. Wakabi’s research of sexual violence among refugee women from Eastern DRC found unprecedented rates of trauma, physical injury including fistula, unwanted pregnancy, infertility and HIV/AIDS (Wakabi, 2008). Similar reports of traumatic experiences and aggravated mental health have been recorded among refugee women in the United Kingdom (Carey-Wood et al., 1995; Palattiyil and Sidhva, 2011; Stewart, 2005). In Europe, violence against women occurs due to alterations in the traditional power balance within households as a result of migration (UNHCR, 2019). Svenberg et al.’s (2009) study of Somali refugees in Sweden revealed that women gained more influence in the family hierarchy than in their homeland due to unemployment among men. The loss of male traditional authority of provision and protection was connected with increased violence and associated psychological effects among refugee women. The proliferation of SGBV among refugees calls for developing, promoting and strengthening violence monitoring and response systems to protect women and the weak targets.

Violentisation and violence

It is not uncommon for refugees to return to past or even worse experiences in their new destinations. However, what is difficult to comprehend is the realisation that people who fled their countries due to persecution continue being subjected to violence by people with whom they escaped. Given that violence unravels and fragments communities (Tippens, 2017), it is expected that after securing safety, people should build peace and rebuild their lives. The types of post-migration factors that contribute to continual violence cannot be overlooked. Brown and Hunter (2016) suggest that the forms of violence (such as physical, sexual and psychological) and the context of violent acts must be considered in search of answers. They state that it is critical to examine,

The relationship between the person abusing and the person who has been victimised, the setting in which violence has occurred and been allowed to continue, the motivation of the perpetrator and the dynamics that have created opportunities for them to abuse. (Brown and Hunter, 2016: 111)

The women in this study reported continued violence perpetrated by either family or community members. Normally, these should be the first source of protection. The question is why does this kind of violence occur among refugees? This research resonates with the concept of ‘violentisation’ (Hsiao, 2010: 3). This refers to the development process of violence (Athens, 2003 cited in Hsiao, 2010). Although most social experiences are negligible, violent social experiences are usually consequential and unforgettable. According to Athens, the process of violentisation evolves through the following four stages: (1) brutalisation, (2) defiance, (3) violent dominance engagement and (4) virulence. During brutalisation, subjects witness the violence imposed on people close to them such as family members and friends. In the second stage (defiance), subjects desperately long to relieve their pain, however, because their past experiences were about violence, they resort to violence (Hsiao, 2010). In the third stage – violent dominance – they imagine themselves as violent subjugators, assign other people as subordinates and offend against them, which ends in violent actions. Virulence is a result of successful violent dominance. Subjects learn that they are not only capable of violence, but proficient in it; hence, they start to pose as violent subjugators (Athens, 2003 in Hsiao, 2010: 4). Refugees face horror and torture which could explain the process of brutalisation. Past trauma causes pain and might explain individual (perpetrators) recourse to violence. The concept of violentisation helps describe the origins of violence and why victims fail to report it. Violence occurs and is allowed to continue because it is problematic or even impossible for the victims to report abuse. Survivors might also not voice their problems due to shame, self-blame, fear of reprisals or re-victimisation, and mistrust of the system (UNHCR, 2019). Therefore, they do not access services and the motivation of perpetrators is not investigated by authorities. This could explain violent dominance engagement and virulence since violence occurs and the subjugators are not reprimanded. The theory offers insights that could be important in the design of interventions for refugees.

Social-cultural influences and social justice

The larger picture involving the social-cultural influence of violent norms needs to be emphasised. This is important as refugee situations become protracted in controlled environments (Buckley-Zistel and Krause, 2017). Social-cultural factors such as lifestyle, perceptions, values and norms further influence violence and people’s decisions regarding whether to report it. For instance, models that examine the existence of rape contend that it is not only about sex, but also intended to show power and control over the victim by the rapist (Alsaba and Kapilashrami, 2016; Erez and Bhat, 2010). The survivors of SGBV might not report due to fear of not being believed by their support system, or because they do not define themselves as victims due to prevailing social and cultural biases (Erez and Bhat, 2010). Some refugee women do not seek assistance because they have been socialised into subordinate gender roles that embrace the culture of shame and silence in response to violence against women. For instance, Alsaba and Kapilashrami (2016) state that while the Syrian women experienced domestic violence and sexual harassment, these were portrayed as private issues. It is stated that the private and familial relationships between men and women are sites of male domination and oppression of women (Orme and Karvinen-Niinikoski, 2012). Moser (2003) asserts that this is shaped by patriarchal beliefs around men’s rightful control over women’s sexuality. Attempts by women to challenge these (such as reporting violence) are perceived as a betrayal of family and violation of social cohesion (Alsaba and Kapilashrami, 2016). The gender norms that exalt male sexual dominance limit women’s ability to control their reproductive and sexual health and exacerbate related health issues. The social consequences for victims include undermined confidence, stigma and shame. This reveals the urgency of protecting women’s rights through secure access to comprehensive reproductive health information and services.

The implementing partners in the settlement are encouraged by UNHCR to guarantee gender equity in delivering humanitarian assistance. However, organisations succumb to pressure to implement gender-sensitive interventions but without proper planning and preparation. In a broader sense, a gendered analysis needs to focus on social-cultural norms that create unequal gender relations and women’s oppression. Gender-sensitive interventions must also concentrate on realising women’s rights and improvement in women’s well-being (Crawford et al., 2017: 81). Furthermore, it is important that the victims receive justice and therewith, new hope. Responses to ameliorate violence must progress through the following three levels: (1) primary (build safe communities and services to stop abuse), (2) secondary (ensure that any abuse is promptly recognised, referred on and stopped) and (3) tertiary (provide remedies and prevent long-term harm, recovery strategies and ensure that people get justice and move on [Brown and Hunter, 2016]). According to UNHCR guidelines, SGBV prevention interventions should be mainstreamed in all responses both during the emergency phase and programming across all sectors of humanitarian assistance (UNHCR, 2018).

Implications for social work

The central goal of social work is to effect change, and empower and liberate vulnerable groups and individuals (IFSW et al., 2014; Thompson and Thompson, 2016). The findings demonstrate a need for robust social work services such as psychosocial support, legal support, basic needs support, public awareness and community capacity building to improve welfare and contribute to change. To broaden the remit of social work and improve its visibility among the refugee recipients, there is a need to innovate or adapt interventions based on their specific needs (Mwenyango and Palattiyil, 2019). Social workers with a great focus on the service user with their wider social environment (such as family, community support systems, cultural attitudes, and policies) can provide rehabilitative care to refugees reporting SGBV. This care helps to heal the emotional pain and trauma and helps to restore hope.

Furthermore, raising awareness about women’s rights and the laws of the country is one of the long-term solutions to improve health. For instance, some refugee women do not report violence because they are ignorant of available care and laws. As mentioned earlier, the rights of the refugees in Uganda are protected under the Refugee Act (2006). Moreover, reports of exposure to violence necessitate the adoption of a rights-based approach in interventions. This integrates the norms and principles of the international human rights system into the policies and programmes of humanitarian actors (UNHCR, 2008). The approach is founded on the principles of participation and empowerment. It considers respect, protection and fulfillment of human rights as an obligation. The question is how would the adoption of the rights-based approach help to improve women’s health?

Given that Uganda is a low-income country, its national health care system is also facing severe challenges and refugees do not have the opportunity to enjoy full access to their rights including comprehensive quality health services. Adopting a rights approach would aid the government and humanitarian actors to apply both international and national law to identify the needs of women arising from the migration experience and the settlement environment. For instance, in addition to basic needs support, putting in place specific programmes to address the gender needs and empower women would reduce vulnerability.

However, the process of empowerment must be founded on refugee resilience. Despite being victims of human rights violations, refugees must not be underestimated because they are also strong survivors and these qualities are essential for empowerment (UNHCR, 2008). Empowerment, according to Thompson and Thompson (2016: xxvi), involves building on existing strengths and where possible, trying to turn the weaknesses into strengths. Mindful of individual differences and cultural and ethnic diversities among refugees, there is a need to reconcile and work in on-going partnerships. The refugees are the experts of their experiences and it is important to understand their specific needs and make referrals when necessary. They must be involved in the design and implementation of services that effectively respond to their priority needs.

The needs of refugee women cited in this article necessitate competent social work practitioners. This denotes that formal social work education should include refugee studies, cross-cultural counselling and specialised training in the counselling of refugees and victims of torture and trauma (IFSW, 2012). For instance, gender-based violence from the transformation of roles in exile must be remedied by preparing men and women to adjust to such changes. The planning and provision of comprehensive humanitarian responses also require a multi-sectoral integrated approach, for instance, response teams may comprise personnel from protection, health, education and community services. Social workers thus need the training to develop a strong professional identity, confidence in their skills, and areas of expertise that are relevant to inter-professional teams supporting refugees (Delavega et al., 2019).