Many of the Liberians at the workshop believe that the prevalence of sexual exploitation and violence within the refugee community is the grim legacy of protracted warfare throughout west Africa during recent decades. Many of the fighting factions use rape and sexual slavery to terrorise and oppress populations, which has had the effect of fraying the fabric of society to such an extent that there is now a certain level of tolerance of sexual exploitation.
Its 10am, 35 degrees, and we have already debated the physical and social differences between men and women; sex change operations; the capability of women to rape men; and the age of sexual consent. It's a hot and heavy morning in a refugee camp in eastern Sierra Leone and Ranita, a feisty Sierra Leonean nurse, is running an MSF workshop on "Sexual and Gender Based Violence."
The participants - a mixture of medical staff, camp managers, traditional birthing attendants, the camp chairman, religious leaders and local NGO workers - are really getting into it, fired up by Ranita's encouragement: "Come on ladies, I want to hear from you - don't just go with what the men say!" The aim of the workshop, which is part of a pilot project being run by MSF since autumn 2002, is to raise awareness about sexual violence amongst the people responsible for the social and medical welfare of the camp. "Can you talk to bacteria and ask it to stop causing disease?" asks Ranita.
"NO!" yells the audience. "Can you talk to a community and ask it to stop sexual violence?" "YES" choruses the group.
For most of the participants - all of them Liberians who fled the brutal Liberian civil war - sexual violence and exploitation is something that is rarely discussed so openly. The majority of victims of rape or sexual exploitation are shamed into silence since cultural taboos discourage people from talking about such things. Yet, as becomes clear from the heated debates during the workshop, sexual violence and exploitation are recognised by the participants as being widespread in the camp community.
"Many cases of rape go unreported, which means that the rape survivors often suffer not only psychological trauma but also serious physical health problems," explains Francoise Duroch, who set up the programme and others like it in Chad and Burundi.
"Survivors may be infected by HIV/AIDS or other sexually transmitted diseases. They may sustain injuries to their sexual and reproductive organs. They may become pregnant, which can pose serious health risks for very young teenagers. The successful medical treatment of rape victims is time-dependant.
"The morning-after-pill and the prophylaxis for preventing the transmission of HIV/AIDS both have to be taken within three days of sexual intercourse. We hope that by raising the awareness of the community about these issues, people will be encouraged to report rape more frequently and faster, which will enable them to get the urgent medical treatment they need."
Refugees are vulnerable to sexual exploitation or attack because they have neither money, protection nor power. Young women who have been separated from their husbands or families whilst fleeing the fighting in Liberia are particularly vulnerable, since they have no support network around them. Many cases of rape or sexual abuse occur when refugees go outside the camp to fetch firewood or food; whilst washing clothes or bathing in rivers; or when teenage girls are sent alone to the market. The legal process for trying rapists in Sierra Leone is costly, lengthy and heavily bureaucratic and so the law offers little real protection either.
Many of the Liberians at the workshop believe that the prevalence of sexual exploitation and violence within the refugee community is the grim legacy of protracted warfare throughout west Africa during recent decades. Many of the fighting factions use rape and sexual slavery to terrorise and oppress populations, which has had the effect of fraying the fabric of society to such an extent that there is now a certain level of tolerance of sexual exploitation.
One of the group, a Pastor, says: "I believe that what we are here to understand is basically the effect of war. In our situation here as refugees, you find individuals in society who are psychologically affected and who do things that they ought not to do. People come in with mental decline and do things which are anti-social."
In circumstances in which most people have very few resources and in which gender roles are strictly defined, it is perhaps not surprising that sex becomes a commodity to be exploited in many refugee camps. Sex is often seen as "payment". A girl may be forced to have sex in order to get a small amount of food for herself or her family. In West Africa it is unacceptable for a woman to build her own shelter - a man has to do it.
Therefore a women without a husband needs to find a man to help her and she may well be obliged to "pay" with sex if she has no other means. When the workshop turns to the subject of gender roles, the debate becomes boisterous. "Doris, what is the classic gender role of a woman in Africa?" asks Ranita.
"We are not able to make decisions. We have to be in the kitchen. We are housewives. We take care of the kids. We take care of the husbands.
We don't go to meetings." "Mister Chairman, what is your gender role as am African man?" "To take care of my wife and my children. To provide education and shelter. To feed my family. To attend meetings. To sit down in hammocks...[at this he is drowned out by loud sniggering and snorts from the women in the group]" Much of the challenge of improving medical care for survivors of sexual violence is tackling the social stigma attached to rape.
Rape survivors often feel guilty and worry that the community will blame them for what happened. Its for this reason that MSF decided to approach the issue at a community level. "SGBV is a community concern," explains Ranita to the group during the workshop. "We need you community leaders to help us care for the survivors of SGBV.
We need you to understand the referral system for people who have been raped: how will you care for the survivor? Who will you send her to for help and support? What medical and psychological support does she need?" The Sierra Leonean staff working in health clinics and referral centres that serve the refugee and local population have also undergone training by SGBV specialists in treating and caring for survivors of sexual violence. The first part of the training involves defining exactly what is meant by "rape" and "sexual violence".
Definitions can vary significantly between countries and cultures - in some countries any sexual act that occurs outside marriage is considered to be rape. The group then discusses the medical protocols that need to be followed when treating rape survivors and brainstorms how to get the message across to the community that people should seek medical help as soon as possible after being raped. They also learn about the importance of referring patients on to organisations providing legal advice and long-term trauma counselling.
"Since the MSF awareness-raising project started a year ago, the number of people seeking medical and psychosocial care after sexual violence has increased," says Duroch. "However, there's still a very long way to go, especially in terms of encouraging people to get medical help within 72 hours.
MSF hopes that talking about the subject openly with the community leaders and local medical staff will encourage discussion within the wider community and eventually make it easier for rape survivors to seek medical attention quickly."