Don���t let the suffering make you fade away: An ethnographic study of resilience among survivors of genocide-rape in southern Rwandaq Maggie Zraly a,b,*, Laetitia Nyirazinyoye a a School of Public Health, National University of Rwanda, Kigali, Rwanda b Department of Anthropology, The Pennsylvania State University, University Park, PA, USA a r t i c l e i n f o Article history: Available online 12 February 2010 Keywords: Rwanda Resilience Global mental health Post-conflict Rape Women Genocide Mental health promotion a b s t r a c t Rape has been used in contemporary armed conflicts to inflict physical, psychological, cultural and social damage. In endeavoring to address the psychological damage of collective violence, some researchers and global health practitioners are turning toward post-conflict mental health promotion approaches that centrally feature resilience. Though previous findings from resilience and coping research are robust, few studies have actually investigated resilience among genocide-rape survivors in cultural context in non-Western settings. This paper presents ethnographic data gathered over 14 months (September 2005 to November 2006) in southern Rwanda on resilience among genocide-rape survivors who were members of two women���s genocide survivor associations. Study methods included a content analysis of a stratified purposive sample of 44 semi-structured interviews, as well as participant-, and non- participant-observation. Resilience among genocide-rape survivors in this context was found to be shaped by the cultural-linguistic specific concepts of kwihangana (withstanding), kwongera kubaho (living again), and gukomeza ubuzima (continuing life/health), and comprised of multiple sociocultural processes that enabled ongoing social connection with like others in order to make meaning, establish normalcy, and endure suffering in daily life. The results of this research show that the process of resil- ience among genocide-rape survivors was the same regardless of whether genocide survivor association membership was organized around the identity of genocide-rape survivorship or the identity of widowhood. However, the genocide-rape survivors��� association members were more involved with directing resilience specifically toward addressing problems associated with genocide-rape compared to the members of the genocide widows��� association. The findings from this research suggest that ethno- graphic methods can be employed to support resilience-based post-conflict mental health promotion efforts through facilitating collective sexual violence survivors to safely socially connect around their shared experiences of rape, neutralizing social threats of stigma and marginalization. �� 2010 Elsevier Ltd. All rights reserved. Introduction Rape is a violation of the social body as well as a violation of the self (Cahill, 2001). When perpetrated on a massive scale, rape provokes maximum terror by damaging and destroying multiple aspects of human life including social bonds, cultural practices, bodies, and psyches (Robben & Suarez-Orozco, 2000). According to the World Health Organization���s (2002) typology of violence, rape q The research on which this paper was based was supported by a Fulbright Grant from the International Institute of Education, and a Baker-Nord Center for the Humanities Graduate Research Assistance Grant through Case Western Reserve University. In addition, this material is based upon work supported by the National Science Foundation under Grant No. 0514519. A generous 2009 Ethel-Jane Westfeldt Bunting Summer Scholarship at the School for Advanced Research on the Human Experience provided the time and space for revising this manuscript. The National University of Rwanda (NUR) School of Public Health provided institutional support for this research, the Center for Conflict Management at NUR provided safe spaces to carry out this research, and the NUR Research House, provided a supportive environment for this work. UWAMUGUHA Clementine, �� NDAMUZEYE Chrysostome, NTWARI Justice, UWINEZA Josiane, NKUSI Inga Jessica, UWAMAHORO Chantal, GASANA Marcellin, GATETE Thierry Kevin, and NIRAGIRE Herve �� all provided invaluable research project assistance. We are deeply grateful to the leaders and members of AVEGA-Agahozo and Abasa who shared their experiences and granted their permission to conduct this research. And we are very thankful to the District and Sector leaders in the Southern Province of Rwanda who supported this research. Lastly, the authors wish to thank the anonymous reviewers who read and commented on earlier drafts of this paper, which was significantly advanced by their insightful suggestions. * Corresponding author. Department of Anthropology, The Pennsylvania State University, University Park, PA, USA. Tel.: ��250 78 0336 3449. E-mail address: maggie.zraly@gmail.com (M. Zraly). Contents lists available at ScienceDirect Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed 0277-9536/$ ��� see front matter �� 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2010.01.017 Social Science & Medicine 70 (2010) 1656���1664

employed in armed conflict, war or genocide can be understood as both collective and sexual violence (CSV). CSV has been used in contemporary genocide and warfare to create widespread fear and demoralization, to deliberately subvert community relationships, and to degrade and humiliate targeted groups of people (Gingerich & Leaning, 2004 Reid-Cunningham, 2008). Current academic debates on the issue of war- and genocide-rape have questioned whether the international criminalization of rape signals true progress in the struggle to eradicate all forms of CSV or deeper entrenchment of problematic assumptions regarding wom- en���s agencies and identities (Barnes, 2005 Farwell, 2004). Scholars have argued that ������sexual violence as a deliberate strategy in war and political repression by the state is connected in a range of ways to sexual violence in all other contexts,������ (Kelly, 2000: 45), and that the roots of violence against women pattern social order during both peace time and war time (Olujic, 1998). Re-visitation of the 2000 ������Landmark������ Resolution 1325 on Women, Peace and Security, the United Nations Security Council (2005) noted that sexual gender- based violence is a persistent obstacle for achieving women���s peace, well-being and security, especially in post-conflict settings. Though women and girls comprise the overwhelming majority of CSV victims/survivors, women and girls also inhabit multiple and overlapping identities and roles during and after violent conflict. These social positions include warriors, soldiers, mothers and wives socializing men for war and/or against war, political leaders, feminists, heroes, war reporters, spies, and the dead (Elshtain & Tobias, 1988 Enloe, 2000 Lorentzen & Turpin, 1998 Saywell, 1986). For example, women were both ������agents and objects������ in the 1994 Rwandan genocide (Sharlach, 1999: 387), during which rape, gang rape, sexual torture, sexual slavery, and forced ������marriage������ were used systematically against an estimated 200,000 to 350,000 women and girls (African Rights, 2004 Amnesty International, 2004 Bijleveld, Morssinkhof, & Smeulers, 2009). Though grassroots networks of women coalesced to provide care for the twenty- to fifty-thousand women and girls who survived genocide-rape (Cohen, d���Adesky, & Anastos, 2005 Turshen, 2002), observers have noted the threat of severe stigmatization and marginalization if their status was or became known by their families or the public community (Amnesty International, 2004 Mukamana & Brysiewicz, 2008). Moreover, women and girls who were already known in their communities to have survived rape have been suspected of harboring sexually transmitted infections (especially human immunodeficiency virus (HIV)), accused of having collaborated with genocide perpetrators in order to survive, deemed unable to marry, abandoned by their husbands, or affected by ostracizing medical problems such as obstetric fistula (Amnesty International, 2004). Under the guidance of the WHO directive to address the psychological damage of war and conflict, the global health community is in the midst of learning how best to respond to various forms of collective violence (WHO, 2002). The extent of short- and long-term negative health consequences from CSV is extremely difficult to estimate. Furthermore, the challenges of meeting the myriad health needs of survivors of CSV are compli- cated by the absence of adequate health care in many conflict- affected settings (Ward & Marsh, 2006 Zraly, Betancourt, & Rubin-Smith, in press). Health-related consequences of CSV are unwanted pregnancy, gynecological complications and injuries, sexually transmitted infections (including HIV/acquired immuno- deficiency syndrome (AIDS)), post-traumatic stress disorder (PTSD), common mental disorders, and suicidal thoughts and behaviors (WHO, 2002). Reports have documented disproportion- ally high rates of HIV/AIDS among genocide-rape survivors in Rwanda (African Rights, 2004 Nduwimana, 2004), as well as persistent psychiatric suffering (Amnesty International, 2004). Survivors of rape in war and genocide often experience trauma and other forms of mental health distress (Gingerich & Leaning, 2004 Mercy, Butchart, Dahlberg, Zwi, & Krug, 2003 Ward & Marsh, 2006). However, war-related trauma is a complex and controversial concept and there is ������no agreement on the appro- priate type of mental health care������ (Kienzler, 2008: 218) that should be provided following collective violence. While some researchers have suggested that the trauma of political violence be approached as a normal psychosocial response (Bracken, Giller, & Summerfield, 1997 Pedersen, 2002 Summerfield,1999), others have endeavored to ������determine and verify the effects of violent conflicts on the mental health of those affected by focusing on war trauma, PTSD, and other trauma-related disorder,������ (Kienzler, 2008: 218). To move beyond this impasse, Miller and Rasmussen (2010) have suggested bridging the conceptual frameworks of psychosocially oriented and clinically focused approaches to post-conflict mental health. The resilience way Increasingly, researchers and practitioners are exploring the applicability of salutogenic (health-centered) post-conflict mental health promotion approaches (Almedom, 2004 Betancourt & Khan, 2008 Ghosh, Mohit, & Murthy, 2004). Mental health promotion is a public health strategy that seeks to protect and strengthen existing mental health, to prevent future threats to mental health at the group (e.g. community or population) level, and to specifically and historically addresses issues of power and inequalities (Friedli, 2009). Rooted in the field of developmental psychopathology, the concept of resilience generally ������refers to positive patterns of functioning or development during or following exposure to adversity, or, more simply, to good adaptation in a context of risk,������ (Masten, 2006:4). This process is comprised of ������overcoming the negative effects of risk exposure, coping successfully with traumatic experiences, and avoiding the negative trajectories associated with risks,������(Fergus & Zimmerman, 2005: 399). The interdisciplinarymentalhealthpromotionmovementand the discipline of public mental health are converging around the knowl- edge that mental health and mental illness are not mutuallyexclusive states (Payton, 2009) and that resilience is a pivotal concept for improving mental health (Friedli, 2009 Panter-Brick, 2010). Since the mid-1990s, the notion of resilience has been applied to communities and groups under the broad definition of a process that promotes social relationships, social structures, and community functioning amidst adversity or violent situations (Ahmed, Seedat, van Niekerk, & Bulbulia, 2004 Clauss-Ehlers & Levi, 2002 Hernandez, �� 2002). Emotional integrity despite the experience of extreme human horror has also been suggested as a definition of post-trauma resilience (Jenkins, 1996). Foregrounding the link between emotion and resil- ience allows for inquiries that treat resilience as ������cultural d and culturally specific d without ontologizing either the individual or social,������ (Beoellstorff & Lindquist, 2004: 438). Though research investigating actual post-conflict resilience processes and resilience in non-Western ethnographic context is sparse (for exceptions see Fernando, 2006 Lothe & Heggen, 2003 Ungar et al., 2007), research concerning the impact of political violence and trauma on mental health, especially among children, has expanded in the past decade (Betancourt & Khan, 2008 Murthy &Lakshminarayana,2006).Forexample,researchershaveexamined trajectories of trauma-related mental illness following exposure to political violence among refugee children and youth in North America (Beiser, Turner, & Ganesan, 1989 Rousseau, Drapeau, & Rahimi, 2003) and compared youth resilience across cultures (Ungaretal.,2007).Theresults of thesestudiesilluminate thenotion that across different populations, context and culture playa defining role in determining what constitutes risk, protection, and resilience M. Zraly, L. Nyirazinyoye / Social Science & Medicine 70 (2010) 1656���1664 1657