The WHO estimates that 30% of women worldwide have been or will be victims of Sexual Violence (SV) at least once in their lives [1]. This percentage is increasing in developing countries and in conflict zones, where SV is used as a weapon of war. Many countries are affected by this phenomenon, particularly the Kivu region in the eastern part of Democratic Republic of Congo (DRC) where almost 40% of the female population have been victims of this type of SV. These SV will have serious consequences for the health of survivors, particularly at pelvic and psychological level. However, no study has used validated questionnaires to assess these consequences, particularly on sexual function. This lack of data is problematic when it comes to setting up appropriate rehabilitation treatment in the care centers for survivors in Kivu. The aim of this original study is to assess the impact of SV on the sexual function of Congolese women survivors living in the Kivu region.

The research protocol for a retrospective cohort study was drawn up. Following sample calculation, 328 women living in the cities of Goma and Bukavu were recruited in hospitals and medical centers, via health professionals and community relays. Women who volunteered and signed the consent form to participate in the study were divided into two groups: SV survivors and the control. The inclusion criteria used were: being over 18 years of age, living in DRC, speaking French or a language able to be translated, and being a SV survivor. Exclusion criteria were: pregnancy and early postpartum. In addition to a questionnaire collecting socio-demographic data and information on SV (type of sexual assault, age at onset of sexual assault, number of assaults suffered, type of assailants, number of assailants, duration of assault, associated genital mutilation), sexual function was assessed using the FSFI questionnaire, validated in French [2], under the supervision of a trained physiotherapist. Descriptive and inferential statistical analysis comparing the two groups was then performed. As most of the data were discrete variables, most of the tests used were non-parametric, with a significance level of 5%. The Mann-Whitney U test was used for inter-group comparisons, and the Pearson's Chi-squared and Fisher's exact tests were used to compare categorical variables between groups.

The project is currently at the end of its recruitment phase, and preliminary results are currently being analyzed. From October 2022 to May 2023, 259 participants have been recruited (123 in the control group and 136 in the SV group). Preliminary analyses show that the two groups are broadly comparable in terms of demographics. The median age (Q1-Q3) of the groups was 30 (23-44) in the control group and 27 (21-39) in the SV group. No participants were excluded from the analysis. 
Most sexual assaults were committed by armed groups (47.8%), all involving penetrative rape. For 33.8% of the SV survivors, the sexual assault was the victim's first sexual experience (Table 1). 
There was a significant difference between the two groups in 4 of their FSFI sub-scores: sexual arousal, lubrication, orgasm, and pain. The total FSFI score was also significantly different between the two groups, with a lower score for the SV group. Finally, a higher proportion of subjects in the SV group scored below the cut-off value of 26.55 than in the control group (Table 2).

To our knowledge, this study is the first to compare the sexual function of Congolese SV survivors living in Kivu with a control group, using a validated questionnaire.
Observing the preliminary results of this study, the SV group presents a higher rate of subjects with sexual dysfunctions than the control group, particularly if the SV is related to war conflicts. This is consistent with the literature found on the subject, but partly contradicts the study by Dossa et al, 2015 [3], which showed a greater decrease in sexual desire among the SV group than the control group. This was not found in this study, where there was no significant difference between the control and SV groups for the FSFI desire sub-score. This could be explained by the fact that the French version of the FSFI used was culturally validated for the French and not the Congolese population. It is possible that the cultural understanding and interpretation of the terms desire and arousal are different for Congolese and French women.  
Finally, although the proportion of women with a score below the cut-off value of 26.55 was higher in the SV group than in the control group, there was still a significant proportion of women with sexual dysfunctions in the control group (85.2%). This raises questions about the quality of the sexual lives of Congolese women living in Kivu, and the impact that a conflict environment can have on the sexual health of civilians living there.

The preliminary results of this study show a higher prevalence of sexual dysfunction in female survivors of SV in the Kivu region. Further analysis is required to assess the impact of different SV characteristics on the FSFI score, considering confounding factors. The project is supported by regional partners, where the clinical data will enable referral hospitals to establish rehabilitation protocols in line with the field. At the international level, these data will enable better management of migrant survivors.

World Health Organization, VAW-IAWGED. Violence against women prevalence estimates, 2018: global, regional and national prevalence estimates for intimate partner violence against women and global and regional prevalence estimates for non-partner sexual violence against women. Executive summary. 2021.
Wylomanski, S., Bouquin, R., Philippe, H. J., Rouzier, R., Dréno, B., & Quereux, G. (2013, December). Validation de la version française du Female Sexual Function Index auprès d’un échantillon de la population féminine française. In Annales de Dermatologie et de Vénéréologie (Vol. 140, No. 12, p. S473). Elsevier Masson.
Dossa, N. I., Zunzunegui, M. V., Hatem, M., & Fraser, W. (2014). Fistula and other adverse reproductive health outcomes among women victims of conflict-related sexual violence: a population-based cross-sectional study. Birth (Berkeley, Calif.), 41(1), 5–13. https://doi-org.biblioproxy.hes-vd.ch/10.1111/birt.12085

Continence 12S (2024) 101579
DOI: 10.1016/j.cont.2024.101579