Background

In August 2017, Myanmar’s armed forces, known as the Tatmadaw, and security forces committed widespread and systematic violence against Rohingya communities in Myanmar’s northern Rakhine state [1]. These “clearance operations” were, in the words of a 2018 United Nations (UN) independent international fact-finding mission report, “brutal and grossly disproportionate,” targeting hundreds of villages and the entire Rohingya population [2].

The violence caused more than 720,000 Rohingya to flee Myanmar for neighboring Bangladesh between August 25, 2017 and July 31, 2019 [3]. Most refugees arrived in the first 3 months of the crisis, creating the world’s largest refugee camp in the district of Cox’s Bazar [3]. As the Rohingya arrived serious human rights violations, including sexual violence, committed during the “clearance operations” were documented [1, 2, 4,5,6,7,8,9,10,11,12]. A variety of actors found that attacks against Rohingya communities were excessively violent, widespread, methodical, and committed on a massive scale [1, 8]. The UN fact-finding mission stated “[the attacks] constituted crimes against humanity, war crimes, and underlying acts of genocide accompanied by inferences of genocidal intent.” [2].

Documented acts of conflict-related sexual violence (CRSV) included rape, multiple perpetrator rape, mass rape, sexual assault, sexual violence or the threat of sexual violence followed by the killing of victims, forced witnessing, forced nudity, and violence targeting sexual organs [5, 7, 9,10,11, 13, 14]. While there has been extensive documentation of violence experienced by the Rohingya while in Myanmar, this research has largely focused on collecting the experiences of individual Rohingya survivors. The observations of health care workers who interacted with or treated Rohingya refugees for their injuries, both physical and psychological, have not been systematically captured. Health care workers play an important role in documenting human rights violations of this nature as they can speak to the reported violations and overall patterns of injuries in this population and identify survivors’ ongoing needs. The documentation of this perspective addresses a gap in the current literature on this topic.

The goal of this research was to document patterns of injuries and understand the health conditions of Rohingya refugees, with a particular focus on sexual violence, after their arrival in Bangladesh after August 2017.

Methods

This qualitative research was composed of 26 semi-structured interviews with health care workers who provided direct care to Rohingya refugees in Bangladesh between August 2017 and August 2020. We defined health care workers broadly, including physicians, nurses, midwives, mental health and psychosocial support workers, case managers, community health care workers, and health volunteers. Health care workers were affiliated with a variety of organizations and worked in a variety of health care settings, all within the refugee camps which are in the Cox’s Bazar district of Bangladesh. Health care workers who had cared for Rohingya patients in Bangladesh any time after August 2017 were included. Healthcare workers who worked in the refugee camps immediately after August 2017 and in 2018 could capture the acute effects of the violence, while those working in the refugee camps after 2018 could speak to both the violence experienced by survivors in Myanmar and the long-term physical and mental impacts of this violence. Data was collected from November 2019 to August 2020. The study was approved by the Institutional Review Board at Georgetown University (GU-HRB-503) and received exemption through the PHR Ethics Review Board.

Health care worker respondents were identified through snowball sampling. Important profiles for study respondents were identified using inclusion criteria (health care workers who had worked with Rohingya patients in Bangladesh any time after August 2017) and emergent findings to ensure sample diversity and that data collected was ultimately responsive to the research objectives [15]. The final sample size was determined by reaching “data saturation” to maximize variability and ensure adequate data to identify themes and patterns [16].

Data collection and analysis

Data was collected using a semi-structured interview guide and a demographic form to capture respondents’ background and work experience with the Rohingya. The key topics included in the interview guide were the respondents’ professional background and the context of their work with the Rohingya; their experiences treating Rohingya patients and injuries observed due to physical violence; their experiences treating Rohingya patients in relation to sexual and gender-based violence (SGBV); the mental health status they observed in their patients; factors associated with disclosure of SGBV; and challenges in providing health care and addressing trauma. The interview guide topics were consistent throughout the project, however as the team collected and analyzed data, changes were incorporated into the guide to ensure that interviews addressed emergent themes.

All participants completed an informed consent process including a written form and oral confirmation before commencing qualitative interviews. With acknowledgment of the ethical concerns related to sharing patients’ experiences that were shared with health care workers in confidence, respondents were not asked to provide specific patient’s stories but rather speak to their own recollections and experiences. When respondents shared individual patient’s stories, by way of example, they were not asked to provide any identifiable information regarding the patient’s experiences shared as part of the interview.

All interviews except one were conducted remotely via video and voice calls. Each interview took approximately 50 min. Interviews (n = 20 in English and n = 6 in Bangla) were conducted by four researchers (two physicians and two social scientists based in the United States and Bangladesh). All interviewers received orientation to the research objectives, interview guide and key themes and interview procedures to include a standardized approach. Interviewers participated in frequent debriefs throughout the data collection process to ensure continued alignment on the data collection approach. Interviews conducted in English were transcribed verbatim by a professional transcription service (Rev). Interviews in Bangla were transcribed and translated into English by a team of qualified transcribers and translators and reviewed for accuracy by the interviewer, fluent in both English and Bangla.

All interview transcripts were deidentified prior to analysis and any identifiable information recorded about respondents was saved separately from all data in password protected files.

The research team reviewed the data and developed a coding dictionary. After a first round of coding in Dedoose [17], the team conducted a qualitative intercoder reliability assessment on a sample of transcripts which indicated consistency in overall use of the codes as they were defined for the study.

The research team reviewed coded data, identified themes and patterns, and created a narrative reflecting the data, responding to the research objectives and interpreted within the context of other published sources on sexual and gender-based violence among the Rohingya.

Results

Twenty-six health care professionals from different countries and different specialties and disciplines were interviewed. Table 1 provides a description of the cohort.

Table 1 Demographic information for respondents
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Table 2 provides an overview of the key themes from 26 semi-structured interviews with health care professionals. These themes are discussed in greater detail in the below sections. Health care workers universally reported hearing accounts and seeing evidence of SGBV committed against Rohingya people of all genders by the Myanmar military and security forces. All health care workers interviewed observed some of the physical and psychological consequences of such acts against the Rohingya.

“I would say everybody. I would absolutely say everybody we saw [was] suffering from the effects of the violence and from the trip altogether.... I don’t think we saw anybody in good condition.” A nurse working in Cox’s Bazar in 2017

“Trauma shows up in a lot of ways for a lot of different people. Everyone there is traumatized, I would say, without a doubt.” A physician working in Cox’s Bazar in 2017 and 2018

Table 2 Overview of Findings
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Conflict-related sexual violence experienced by the Rohingya in Myanmar

Health professionals noted a pattern of CRSV that included sexual violence and multiple perpetrator rape accompanied by other violent acts, such as beatings, shootings, and killing of family members.

“Most of the cases are very similar. Families killed in front of them and raped, [survivors] escaped in the bush across the border.” A nurse midwife working in Kutupalong camp in 2017

“They give some example[s] like, when the army [was] at their villages and initially they [were] trying to beat them, and if there is any female … they raped them, and after rape, they killed them.” A clinical psychologist working in Cox’s Bazar in 2018

“She was raped by one of the Myanmar military personnel.” An emergency room physician working in Kutupalong camp in December 2017

Conflict-related sexual violence followed by other violent acts

Health care workers heard that their patients were forced to witness acts of violence, including sexual violence, against their family members. Women and men were separated during the attacks and respondents shared that after separation the men were killed and the women were forced to watch the men be killed, and then raped. Survivors shared that they left Myanmar for Bangladesh following these violent attacks.

“Most of the women tell me [a] very, very similar story. When they were in Myanmar ... a group of men who had uniform[s] [which] look like a police or army, something like that, came to their house and ... [t]hey were raped in front of their family. After that, they took all the men.... They beat them and killed them, and they put all men into the fire and all women are taken to somewhere else in [an] empty house and they had to take off their clothes and they were naked. Men who ha[d] a kind of uniform look came to the house and they raped those women every day until they became unconscious. When those women [woke] up, [there was] fire around the house, so they tried to run away to the river which is a border to Bangladesh, and they crossed the river ... to come to Bangladesh.” A nurse midwife working in Kutupalong camp in 2017

Forced witnessing of sexual violence

Multiple patients shared stories with health care workers about being forced to witness the rape of others, including their mothers and sisters.

“I remember an elderly lady who came in just with a bladder infection, a UTI. And then somehow the conversation devolved into the fact that she had watched her daughter-in-law get gang raped by six soldiers in their home.” A volunteer physician working with Rohingya refugees in January 2018

“Some of the patients who narrated, the male patients who narrated their loved ones having this [sexual violence] happen and witnessing it. There's no denial that this happened.” A volunteer physician working in Cox's Bazar in 2018

This forced witnessing of sexual violence was often perpetrated against male survivors.

“They had to leave their country all of a sudden, their houses were set on fire, their farming lands, their farming lands were set on fire, and even something like killing his brother by shooting in front of him or raping his sister in front him has also happened.” A coordinator of services for male and transgender Rohingya survivors since 2018

Rape by multiple perpetrators

Multiple health care workers heard from their patients about women being confined in houses where they were repeatedly raped, often by multiple perpetrators. Several respondents noted that survivors described the rape as being perpetrated in a systematic, organized fashion.

“She and, I think, around 14 other women had been taken and locked into a house, and ... they were all gang raped.” A nurse practitioner working in an outpatient clinic in 2017

Sexual violence was also perpetrated against young people one respondent shared the story of a young girl of about 12 or 13 years old.

“There were five women in total who took shelter there, including her [the young girl’s] mother, elder sister, and aunt. Then four to five military officers attacked there. They blindfolded their eyes and tied up their hands and feet. Once they were tied up, they became victims of gang rape. After the gang rape, they decided to burn these women.... But how this teenage girl managed to untie her hands only Allah knows that. She freed her hands.... She fled away from there to a piece of land.... When the girl crawled into that land, she was shot.… Her mother and others were burnt. All of them. She saw that happening.” A paramedic and psychosocial support officer working in Cox’s Bazar since 2017

Sexual violence experienced by gender diverse people

Perpetration of sexual violence in Myanmar was not limited to women and girls – acts of sexual violence were also experienced by men, boys, hijra (third gender) and transgender people. Respondents shared stories of providing care to these patients, though these patients were often reluctant to share their experiences.

“We have found ... adults and young boys, they also became victims of physical violence.... There are one or two who had become victims of sexual violence, there are one or two like this.” A clinical psychologist working with Rohingya refugees since 2017

Disclosure of experiences of sexual violence

Respondents shared that Rohingya women often shared incidents of sexual violence that they had experienced while receiving care for a variety of other health reasons, such as addressing sexual and reproductive health (SRH) complaints, seeking care for physical symptoms or mental health support, as opposed to encounters for post-rape care services. Health care providers also described how experiences of sexual violence were only shared after patients were asked directly during initial medical intake interviews.

“She had complaints of vaginal discharge, so I asked her if I could examine her vaginally. And then, when I did the exam, it looked like she had some trauma, just from the scars on her perineum. So, I asked her a few questions about that, and then she started crying and talked to me about her experience of rape at the hands of the military, the Myanmar military.” A nurse practitioner working at an outpatient clinic in Kutupalong camp in 2017

Perceived increases in the number of pregnancies and births following sexual violence

Health care workers sometimes learned about the sexual violence their patients had experienced while women were seeking pregnancy-related care. Respondents noted observing higher numbers of pregnant women in the months that would correspond to conception during the period of violence in Myanmar, around August 2017.

“It was … nine months after August of 2017. So, there was a huge increase in the births because of all the women who were raped.” A physician working in Kutupalong camp in 2018

“I expected we would have a lot of unwanted delivery and undesired babies in April [un]til June.” A nurse midwife working in Kutupalong camp in 2017

A few respondents believed that many of the children who they saw in their health centers were born of rape.

“The second time I went back [to the camps] in July [2018], that would have been ... 11 months [after the violence], so many of the babies that were products of rape had been born. It was untalked about. Nobody said anything and the babies would be brought in…. They'd be accepted into the community, into the family. Obviously, the mom was there, but there was no discussion of how that baby came into being.” A pediatrician working in Cox’s Bazar in 2017 and 2018

Seeking pregnancy termination

Some health care workers were specialists in SRH and described women asking to terminate their pregnancies which were reportedly related to rape prior to arrival in Bangladesh. It was dually challenging for survivors to cope with an unwanted pregnancy and seek termination of this pregnancy due to both cultural and religious norms and legal restrictions on abortion in Bangladesh.

“They were interested in this [abortion]. They were interested because everyone in the family knew that she was unmarried. Moreover, she couldn’t tolerate the fact that she was going to be the mother of a child [born of rape].” A paramedic and psychosocial support officer working in Cox's Bazar since 2017

Mental health status of survivors

Health workers shared that many survivors who they treated showed signs of mental health conditions associated with trauma. Many patients were reluctant to share their experiences or express their feelings, demonstrating passivity during treatment, and often remaining silent and motionless.

“We ... found that most of them [the refugees] were suffering from PTSD. They had full-blown symptoms. We noticed that ... [they] even didn’t feel comfortable in talking to us. We were taking care of them, but they couldn’t manage to trust us completely.... At that time, there were some symptoms in them like their response, anxiety, hastiness, I mean very unstable, and some were in depression, like they were depressed and were not talking at all.... And it was like they came through such a crisis, many of them seemed to be totally blank. No emotion was working on their mind. They couldn’t answer any question they were being asked. They cried continuously. Upon being asked about anything, the first answers they gave were about what they had seen there. How they have come here. They described the difficulties of the situation, how much they had to walk, so many deaths, then rapes and other fears. That they were scared, these things were very common in them.” A clinical psychologist working with Rohingya refugees since 2017

Survivors also commonly presented to health care workers with psychosomatic complaints. Upon further probing, many of these complaints were presumed to stem from trauma.

“A huge number of our patients had somatic complaints, like very vague. Like, ‘I've had a headache or a stomachache or backache.’ And then, when you dig deeper into how long have these things been going on, it's been going on as long as they left their home or as long as they've been living in the camps. So, we certainly saw a lot of patients who we couldn't find anything wrong with them clinically and it seemed like the providers would attribute it to just a stress reaction that's manifested in a physical way. And that was very, very common.” An emergency nurse working in satellite health clinics in December 2017

Barriers to disclosure of sexual violence

It was also noted that sometimes those who had witnessed sexual violence were more likely to disclose it than the survivors themselves. Health care workers shared that survivors were often reluctant to disclose due to stigma, which could further contribute to their trauma and also create an additional barrier to seeking care.

“The men were the ones who were more likely to share their trauma stories, and also talk about the women having this happen to them. The women, I think, that I did have speak about their stories, they focused a lot on the environmental things, like the houses being burned, or I mentioned the babies being burned or thrown in the river. Those came from women that I spoke to. They didn't really go into the gender-based violence or the rape when they shared their trauma stories.” A volunteer physician working in Cox’s Bazar in 2018

Discussion

Health workers’ narratives provided new perspectives regarding the systematic and complex sexual violence inflicted upon the Rohingya population. Interviewing health professionals allows for the collection of individual stories, observation of population level trends as each professional has likely treated hundreds of Rohingya patients and analysis of the specific physical and psychological sequalae of sexual violence. This study further reinforces the importance of collecting data from sources other than the survivors themselves. By interviewing health professionals, this study enabled the collection of survivor and witness accounts more broadly, while avoiding retraumatizing survivors and protecting patient privacy.

This study contributes additional data to a growing body of literature documenting CRSV committed by Myanmar state forces against the Rohingya population in 2017 and its resulting impact on Rohingya survivors, their families and communities [8, 11, 12, 18]. This is one of the first studies relying on accounts of health professionals working in Bangladeshi refugee camps to describe human rights violations against the Rohingya. Importantly, it provides documentation related to two issues that were previously only reported sporadically: occurrences of forced witnessing and of excess births attributed to rape [19, 20].

Data collected from this study corroborates previous reports and contributes to the evidence that sexual violence against the Rohingya in Myanmar was widespread and followed common patterns of perpetration, it was perpetrated by members of the Myanmar military and others wearing uniforms, and, is consistent with and corroborates many other reports [2, 5, 6, 8, 10,11,12, 19].

The finding that survivors routinely disclosed experiences of sexual violence while seeking care for other health concerns, including acute injuries, pregnancy-related care, and psycho-social support, highlights the need to provide health professionals with appropriate training in how to ethically screen for sexual violence in high-risk populations. These findings align with research by Tay et al. (2019) and Parmer et al. (2019) which both indicated that Rohingya refugees were reluctant to report sexual violence or seek care and showed limited help seeking behaviors, likely due to past restrictions on rights and health care in Myanmar [21, 22]. These findings indicate the importance of providing cultural relevant care, potentially outside of traditional medical care delivery pathways, such as through community volunteers or integrated care provision models with other services [21, 23, 24]. Training on screening for CRSV should include skill building on trauma-informed manners of engaging with conflict-affected populations as part of routine medical care [25,26,27]. Data collected for this study suggests that such training would be beneficial for health professionals on both long-term and short-term assignments providing care for populations affected by conflict featuring CRSV.

Multiple narratives about forced witnessing of killings and rapes underscores the need to consider this violence and its impact in both the public health and human rights documentation and accountability spaces [13, 28, 29]. Such instances of witnessing CRSV, though they may not cause physical trauma, are associated with long-term mental health trauma. One study of elderly Austrians found that 18.2% of those who witnessed acts of sexual violence during World War II reported post-traumatic stress disorder (PTSD) many years after the conflict had ended [30]. Naher et al. (2020) found that the negative impact on interpersonal relationships, stemming from the witnessing of sexual violence, was a key issues mental health and psychosocial issue that Rohingya survivors faced [31]. Additionally, a survey of Rohingya adolescents by O’Connor et al. (2021) found that on average they had experienced 3.5 traumatic events, including sexual violence, compared to only witnessing 1.6 such events among Bangladeshi adolescents; this would seem to indicate a larger burden of witnessing among Rohingya survivors with important implications for long term mental health impacts and intergenerational trauma [18].

Despite clear evidence showing the deep impact of forced witnessing on the bystander, forced witnessing of sexual violence is not always articulated as an element of sexual violence or recognized as a separate violation occurring at the same time [30, 32]. Recognition of forced witnessing as an element of sexual violence or a connected trauma can provide deeper appreciation of the varied experiences of CRSV survivors and the crimes committed against their communities, and can promote efforts for redress, remedy, and rehabilitation.

This study also provided unique data on the not-often-openly-discussed topic of excess births – an observed increase in the number of births that would be expected based on historical data and clinical experience – resulting from rapes committed in Myanmar, and also on survivor interest in abortions. The estimations of increased pregnancy and birth rates shared by our respondents are consistent with published studies and observations by other organizations suggesting birth rates above the historical baseline among Rohingya refugees in Bangladesh [20, 22, 33]. Pregnancy termination was challenging for survivors, given the cultural and religious setting, stigma, underreporting of sexual violence and resulting pregnancy, very limited services for abortion despite some successfully implemented care models with limited reach, extreme complications from unsafe abortions, and legal restrictions [24, 34, 35]. The combination of an increased number of births and the difficulty in accessing safe pregnancy termination would seem to indicate that Rohingya women were sometimes forced to continue pregnancies that were unintended or unwanted. Forced pregnancy, in international criminal law and international humanitarian law, includes detainment or confinement as a way the crime of forced pregnancy is understood. The experience of Rohingya survivors being forced to continue pregnancies because of a lack of access to abortions provides an example of an additional way forced pregnancy could also be defined [36, 37].

Limitations

Our study has several limitations. Respondents were recalling their experiences and specific patient histories from events as far back as 2017, though some respondents had relied on written notes from their time spent in Cox’s Bazar recall bias is inherent in the data presented. Some respondents did not begin seeing Rohingya patients until 2018 or later and could speak to the longer-term impacts of the violence experienced but were not able to comment directly on acute injuries sustained in Myanmar.

Study respondents came from a diversity of cultural and geographic backgrounds, but no Rohingya respondents were able to be included in the sample, therefore comments and observations about behaviors impacted by cultural norms should be viewed as highly contextual. The survivors’ experiences recounted in these interviews often relay conversations conducted through the help of an interpreter and therefore must be interpreted with note to the fact that they were communicated through multiple filters, both cultural and linguistic. In spite of these limitations, the narratives collected of Rohingya survivors experiences showed significant similarities.

As with all qualitative research, the analysis and interpretation of data is impacted by interpretation biases that are introduced by the research team. To address this potential bias the research team was multidisciplinary, culturally diverse, and worked collaboratively to mitigate potential biases in the interpretation of results.

Implications for practice and future research

There are key implications of this research for both practice in response to CRSV in humanitarian and conflict-affected settings and for future research areas.

The findings of this research emphasize the importance of offering universal and comprehensive trauma-informed services to all refugees with the presumption of high rates of trauma in this population. Many survivors will never identify themselves and while some survivors may not have been the direct victims of sexual violence, forced witnessing constitutes an additional source of trauma that may not be identified or shared explicitly [18, 21, 35]. Survivor-centered and trauma-informed care training should be a required training component for all health care workers working in similar settings. This is important not only to enhance the care of survivors, but also as a means of addressing potential vicarious trauma affecting health workers. A survivor-centered approach also requires that clear referral pathways and critical mental health services be provided in a consistent and long-term manner and that there is integrated and complementary responses across the health sector [38]. In the presence of these resources, health screenings that include opportunities to sensitively engage survivors of sexual violence should be incorporated, given that many survivors revealed their experiences of sexual violence while seeking other health care. In the absence of mental health and SGBV services, screening for sexual violence is ethically complex and may be ill-advised [39,40,41,42].

Future research could involve multiple areas of inquiry. Continued exploration of the long-term impact of CRSV on Rohingya survivors and on their collective trauma is needed. We must also study the patterns and acute and long-term effects of forced witnessing. The impact of survivor trauma on health workers who care for them should be studied and analyzed. Finally, in uplifting the voices of health care workers, this study highlights the importance of increasing the use of alternative research methods for collecting sensitive data in a manner that avoids the re-traumatization of survivors.

Conclusion

While this study focused on documenting clinical presentations of physical and psychological harm caused by past perpetration of conflict-related sexual violence by the Tatmadaw and Myanmar security forces, these groups continue to use sexual violence as a tactic of intimidation and terror elsewhere in Myanmar. Our findings can inform human rights investigations and service delivery in Rohingya refugee populations in Bangladesh and for ethnic minorities elsewhere in Myanmar. These findings can also support wider calls for justice and accountability for the violations perpetrated by the state forces of Myanmar, in the past, present, and future.