4.1 Interview with adolescent survivors
Adolescents’ knowledge of contraceptive methods was unsatisfactory. The majority of the survivors do not attend school resulting in a lack of understanding of the sex education curriculum integrated into the education system.
School enrolment is a prerequisite for access to complete sexuality education, but the most marginalized adolescents, who are often most at risk of adverse sexual and reproductive health outcomes, are often the least likely to attend school [15].
The adolescent survivors are marginalized due to the past rape, exposing them to adverse Sexual and Reproductive Health (SRH) outcomes. The researcher was unable to review the sex education curriculum at Kavumu School to determine if the content was accurate and relevant to the population served.
Adolescents require a knowledge base and practical skills to make informed choices, avoid and overcome problems, and know where to turn for help when needed [16].
Complete sexuality education can help adolescents acquire knowledge and thinking skills, positive values, including respect for gender equality, diversity and human rights; and attitudes and skills that contribute to safe, healthy and positive relationships [16].
Under human rights law, States have an obligation to provide contraceptive information and services to adolescents. States are required to adopt legal measures and policy instruments to ensure access to affordable, safe and effective contraceptive methods for all people, including adolescents [17].
Human rights standards also state that complete sexuality education programs must be developed with adolescents and included in compulsory school curricula [18].
Donmozoun et al stated that it is important for adolescent girls to be encouraged to engage in sexual activity as late as possible that could be at risk given their young age, lack of experience and poor negotiating capacity for responsible sexual and reproductive health [19].
The stigma associated with rape, regardless of its origin tends to marginalize women Within the focus groups, it was widely agreed that an offer of marriage should be accepted as their general prospects were not ideal. Marriage is perceived as a divine blessing in the community, regardless of age.
The proportion of women married as children has declined by 15% worldwide over the past decade [20].
Women married before the age of 18 may be at greater risk of intimate partner violence. Child marriage also has negative consequences for educational attainment and enrolment in secondary school [21, 22, 23].
The one that states that sexual intercourse is painful, we think that we can talk about a kind of post-traumatic stress disorder that reverberates in sexuality and risks destroying sexual health in the future.
Talking about sexuality, especially with teenage girls, is a difficult exercise. Whereas these young people nowadays have a need for this communication [24].
Culture but also religion are sometimes obstacles to sex education and do not make it possible to popularize these services in this conflict zone, which explains the ignorance of survivors. They find it important to use contraceptive methods to plan pregnancies, but they have never used them. Is this a ban? the absence of services in the environment? or an ineffective awareness...
In some African countries such as Burkina Faso, Ghana, Malawi and Uganda, socio-psychological reasons and financial cost remain barriers to access to these sexual and reproductive health services [25].
Adolescent girls' knowledge of STIs and HIV is not satisfactory. They are superficial limited to name; without understanding the health consequences of HIV/AIDS. Ignorance of the transmission of the disease by these young people is a risk to their future already troubled by rape. Here again, comprehensive sexuality education is important to acquire this knowledge.
HIV is transmitted through the exchange of body fluids containing the virus, such as blood, breast milk, semen and vaginal secretions [26]. The most advanced stage of HIV infection is acquired immunodeficiency syndrome (AIDS). There is currently no cure for HIV infection or AIDS [27].
With regard to the issue of sexual violence against women, all these girls always refer to their rape episode when answering the question. Sexuality is seen differently in these girls and may become a problem in the future.
Sexual violence, used as a "weapon of war" to humiliate, terrorize and destroy communities has very long-term consequences. Not only are women and girls scarred forever, but the children born of these rapes do not find their place in the community and have a more than uncertain future [1].
Traditional conceptions of sexual purity and a woman's heavy reliance on marital status for social recognition make rape and other aspects of sexual assault difficult for community members to interpret culturally [1].
4.2 Interview with young women survivors
After understanding the explanation of contraception in their local language, several women showed interest in using it for family planning purposes. We understand that procreation has a meaningful place in the lives of these women.
On the other hand, contraception is still seen by some of these women as something bad not to use because it could lead to gynecological health disorders on the one hand and on the other hand, they think that procreation is a divine blessing that should not be prevented. They are unaware of the benefits of contraception. Women who are aware of this want to access some of these methods but face many obstacles including community prejudices, socio-cultural representations of contraception, and the refusal of health workers to recognize the sexual and reproductive health needs of survivors.
Yet a minority had good reasons for using contraceptive services at one time. We believe that these women could have used these methods as a preventive measure after an unfortunate situation affecting reproductive health. This leads us to believe that contraception would be seen by this minority of surviving women as a spare wheel after an uncontrollable period of reproductive health.
For traditional contraceptive methods, we think that the modernism of our society could be at the root of the disappearance of these traditional contraceptive techniques or simply the ineffectiveness of these methods. Let us not forget also that the repeated wars in these environments, the displacement of families, the elimination of populations would be crucial issues in the disappearance of certain cultural or traditional practices useful to health.
All social groups in the world have particular beliefs and cultural practices, some of which are beneficial, some of which are neither beneficial nor harmful, and still others that may be dangerous to a certain group, including women [28].
This unanimous rejection of the practice of safe abortion in the region is linked to a socio-cultural factor. The society of these regions does not support the termination of pregnancy regardless of its age (or the mode of occurrence) because of certain reasons mentioned by these women above. This is because some of these women survivors have children who were born of rape. They prefer to keep their pregnancy at the cost of their socio-cultural belief.
Since the beginning of the armed conflict in 1996, widespread sexual violence in eastern DRC has resulted in numerous pregnancies related to sexual violence [6].
Data on pregnancies related to sexual violence are limited, but studies in the DRC have estimated the prevalence of pregnancies related to sexual violence at 6–7% among survivors of sexual violence [29, 30].
Services that perform abortions should refrain from value judgments and not coercion, but respect the informed and voluntary decision of women and girls to terminate an unwanted, inappropriate or accidental pregnancy, as well as their right to autonomy, confidentiality and privacy [31, 32, 33].
The DRC is a signatory to the Maputo Protocol, a regional treaty on women's rights that requires states to legalize abortion when necessary to protect a woman's physical and mental health, as well as in cases of rape, incest and fetal abnormality [34]. In March 2018, the government published the protocol in the country's official gazette, signifying the official entry into force of the treaty [35]. The application of this protocol is not effective in the DRC, nor is it possible in an area of armed conflict.
The cultural approach intervenes in the understanding of this phenomenon of abortion. It is then important to know what is the socio-cultural representation that this community gives to problems such as abortion, childbirth, ... By this, we will understand that the approach to raising awareness on this subject would have to be reviewed or apprehended with sensitivity.
If these women do not recognize acts of mutilation, it does not necessarily mean that it does not exist. We showed them about sexual mutilation through what is done in the communities.
On the other hand, acts of genital mutilation have been observed in Kavumu where several women have been sexually abused [12].
Female genital mutilation has no known health benefits. However, they can have immediate health consequences, such as hemorrhage, shock, infections and death. They can also have long-term health and social consequences, such as post-traumatic stress disorder, menstrual problems, and painful and painful sex [36].
On the subject of early marriage, there is still hope that these young women think that it is not better for a girl to marry too young, whether it is forced or not. We even noticed that their justifications revolved around their past experience. In relation to this question, the opinion of men would be crucial because in this kind of society the voice of a woman is not taken into account unlike that of a man.
To prevent child marriage, interventions must be multi-sectoral and address the many determinants of the problem through the adoption and implementation of laws and policies; mobilization of families and communities; the provision of health, social and legal services; and girls' empowerment [31].
We were shocked to find that other survivors believe that having unprotected sex with an unknown partner regardless of rape would lead to trauma. We understand that some of them no longer believe in a full, healthy and satisfying sexual relationship after what they have been through.
In addition to the physiological and psychological trauma that victims may endure, they are forced to undergo scrutiny from family and community members and live at the mercy of the social and cultural implications of what happened to them [1].
The openness of Kavumu survivors to knowledge of condoms is due to its proximity to the city of Bukavu. Although Kavumu has been an area of atrocities, it remains the area of opening to the city of Bukavu as it is home to the only airport in the South Kivu region. Accessibility to this city is fluid, which allows a popularization of SRH services. But some of the reasons given for refusing to use it could stem from the prejudices these women have about condoms. Let us not forget also that Kavumu is a potentially Catholic region and encouraging condom use would encourage women to "debauchery".
If we notice the ignorance of condoms and HIV/AIDS among Bunyakiri survivors, we may think that awareness programs are ineffective. The isolation of the region with armed groups still active today, but also the impassability of roads on this axis can limit access to education and prevention services in this region. The HIV Post-Exposure Prophylaxis (PEP) Rape Kit could be given to these women, but none of them know what it is.
Male and female condoms also provide dual protection against unwanted pregnancies and STIs, including HIV [37].
Understanding the sexual and reproductive behaviors of young women who are particularly at risk, as well as the factors that protect them or put them at risk of HIV infection, sexually transmitted infections (STIs) and unwanted pregnancies are crucial [38].