Human Rights Abuses and Concerns About Women's Health and Human Rights in Southern Iraq

Context Although human rights abuses have been reported in Iraq, the full scope of these abuses has not been well documented.

Objective To assess the prevalence of human rights abuses since 1991 in southern Iraq, along with attitudes about women's health and human rights and women's rights and roles in society, to inform reconstruction and humanitarian assistance efforts in Iraq.

Design Cross-sectional, randomized survey of Iraqi men and women conducted in July 2003 using structured questionnaires.

Setting Three major cities in 3 of the 9 governorates in southern Iraq.

Participants A total of 1991 respondents representing 16 520 household members.

Main Outcome Measures Respondent demographics, information on human rights abuses that occurred among household members since 1991, women's health and human rights, opinions regarding women's rights and roles in society, and conditions for community health and development.

Results Respondents were a mean age of 38 years and were mostly of Arab ethnicity (99.7% [1976/1982]) and Muslim Shi'a (96.7% [1906/1971]). Overall, 47% of those interviewed reported 1 or more of the following abuses among themselves and household members since 1991: torture, killings, disappearance, forced conscription, beating, gunshot wounds, kidnappings, being held hostage, and ear amputation, among others. Seventy percent of abuses (408/586) were reputed to have occurred in homes. Baath party regime-affiliated groups were identified most often (95% [449/475]) as the perpetrators of the abuses; 53% of the abuses occurred between 1991 and 1993, following the Shi'a uprising, and another 30% between 2000 and the first 6 months of 2003. While the majority of men and women expressed support for women's equal opportunities for education, freedom of expression, access to health care, equality in deciding marriage and the number and spacing of children, and participation in community development decisions, there was less support among both men and women for women's freedom of movement, association with people of their choosing, and rights to refuse sex. Half of women and men (54% and 50%, respectively) reported agreeing that a man has the right to beat his wife if she disobeys. Fifty-three percent of respondents reported that there were reasons to restrict educational opportunities for women at the present time and 50% reported that there were reasons to restrict work opportunities for women at the present time.

Conclusions Nearly half of participating households in 3 southern cities in Iraq reported human rights abuses among household members between 1991 and 2003. The households surveyed supported a government that will protect and promote human rights, including the rights of women. However, currently, neither men nor women appear to support a full range of women's human rights.

The people of Iraq have endured 35 years of repression and widespread human rights violations under the Baath regime of Saddam Hussein.^1-3 After the 1991 Gulf War, the regime suppressed popular uprisings among 14 of 18 governorates, including major insurrections in the predominantly Kurdish North and mostly Shi'a South.¹ Thousands of Iraqis have reportedly disappeared, but the full scope of these atrocities, especially those perpetrated against the Shi'a after their 1991 uprising against the Baath regime, is unknown. More than 150 mass graves have been discovered recently throughout Iraq, some of which may contain victims of the 1991 Baath regime repression of this Shi'a uprising.⁴

The purpose of this study was to assess the nature and scope of human rights abuses in southern Iraq since the Shi'a uprising in 1991. More specifically, the study was designed to identify specific human rights abuses and perpetrators, to determine health and human rights concerns with a focus on women's rights, and to examine Iraqi views on women's rights and roles in society and provisions for community health and development.

The major city from each of 3 of 9 governorates in southern Iraq was included in the study (Figure 1). According to local community and religious leaders, the 3 cities chosen best reflected the range and extent of abuses that are reported to have occurred throughout the South. At the time of the study, 931 600 people were living in An Najaf Governorate, with 585 600 in An Najaf city; 1 454 200 in Dhi Qar Governorate, with 560 200 in An Nasyriyah city; and 769 600 in Maysan Governorate, with 362 600 in Al Amarah city.⁵

To determine an appropriate sample size for this study, we assumed a prevalence of abuses of 0.05, with a margin of error of ±0.01% at a 90% confidence level. The sample size required given these conditions was 1293 households.⁶ However, our sample design included 2 levels of clustering, and we therefore assumed a design effect of 2; thus, the calculated sample size was 2586.⁶ We sampled 2276 households in proportions relative to the population size of each city (Table 1).

Participants were selected using cluster sampling to obtain a representative sample in each of the 3 cities.⁷ For each city, a satellite map was broken into sectors using main or secondary roads as the borders. Sectors and subsequent clusters of housing blocks within each city were then chosen randomly. A sampling interval (n) was calculated by dividing the number of households in the cluster by the number of interviews to be conducted in the cluster. A starting household was determined by random number generation and each nth household was interviewed until each surveyor had 5 completed surveys in each cluster, taking into account the average number of refusals. Each cluster had 16 to 24 households.

We randomly sampled 20 clusters in each of 8 different sectors in An Najaf and An Nasyriyah and 20 clusters in each of 6 different sectors in Al Amarah. Overall, the sample was composed of 47% (1 496 900/3 155 400) of the total population in the 3 governorates and 16% (1 496 900/9 329 100) of the total population in southern Iraq.⁸ Sectors were excluded if they had fewer than 200 households; were industrial, market, or agricultural areas; or were deemed unsafe by local authorities. Rural areas were excluded because of lack of clearance of mines and unexploded ordnance at the time of the survey.

An Iraqi member of a Physicians for Human Rights (PHR) team interviewed 1 person (aged ≥18 years) per household in our sample. Household members were asked whether they were willing to be interviewed and, if so, to nominate the household member who could most accurately provide information about the experiences of the entire household since 1991. An assertive attempt was made to ensure that women were not excluded as respondents. In most instances, if only 1 adult, male or female, was present at the time a household was visited, that person was interviewed.

The survey contained 80 questions on respondent demographics, information on human rights abuses that occurred among household members since 1991, women's health and human rights, opinions regarding women's rights and roles in society, and conditions for community health and development.⁹ Although a 10-year recall of events is generally considered reliable,¹⁰ we asked about events since 1991 because the Shi'a uprising at that time was a major traumatic event in the South and can be reliably recalled.¹¹ Regarding abuses, respondents were asked whether they or members of their household were forcibly separated from others or had disappeared, were beaten, shot, killed, tortured, sexually assaulted or raped, or kidnapped, were held hostage, or had their ears amputated. For each abuse, respondents were asked the age of the abused person at the time of the abuse, the type and date of the abuse, where the abuse occurred, the identity of the perpetrator, and whether they had witnessed the actual abuse or the after-effects of the abuse. Respondents were also asked whether they or household members were forcibly conscripted, forced to walk in minefields, injured by land mines, forced to act as a human shield, or exposed to chemical or biological weapons. Opinions were assessed by a response of "agree" or "disagree" to statements concerning women's rights and roles in society. The community health and development component of the survey contained 10 questions about the relative importance of different rights for community health and development, selected on the basis of health and human rights concerns identified in other studies.^12-15 Finally, the survey assessed whether participants believed there was any reason to restrict education or work opportunities for women and girls. The questions regarding restriction of work or educational opportunities used "yes" or "no" responses. All other questions used a Likert-like scale (range, 1-5, with 1 representing "not important" and 5 representing "extremely important").

The questionnaire was written in English and translated into Arabic and the accuracy of the translation was checked by back-translation into English. Eight regional, human rights, and medical experts reviewed the questionnaire for content validity. Interviewers administered the survey in Arabic, in which they all were fluent. The survey was pilot tested among 6 Iraqi refugees in Kuwait City, and the resulting suggestions regarding clarity and cultural appropriateness were incorporated.

The survey interviews were conducted by 12 Iraqi men and 8 Iraqi women who were trained and supervised by the PHR field supervisor and 3 trained Iraqi research team leaders.¹⁶ Researcher training consisted of 3 days of classroom teaching and role play followed by several days of field observation and continuous supervision.¹⁶

All interviews were conducted during a 15-day period in July 2003. Interviews lasted approximately 20 to 30 minutes and were conducted in the most private setting possible. All questionnaires were reviewed for completeness and for correctness of data recording after the interview by the interviewers, then by the Iraqi research team leaders, and, finally, the PHR field supervisor at the end of each day.

This study was reviewed and approved by an independent ethics review board, developed for this research project by PHR and composed of 5 individuals with expertise in clinical medicine, public health, bioethics, and international health and human rights research. The ethics review board was guided by the relevant process provisions of Title 45 of the US Code of Federal Regulations¹⁷ and complied with the Declaration of Helsinki, as revised in 2000.¹⁸ All data were kept anonymous. Verbal informed consent was obtained from all participants, who did not receive any material compensation.

The data were analyzed using STATA statistical software.¹⁹ To control for clustering and design effect, the sample was weighted by the number of sectors from each city, the number of samples per location, and the response rate in each cluster. Complex survey variance estimates were calculated using Taylor series linearization. All errors are nominal errors due to the inability to sample every sector randomly. For 2 × 2 cross-tabulations containing cells with expected frequencies of fewer than 5, statistical significance was determined using the Fisher exact test; Yates' corrected χ² was used for all others. For cross-tabulations with greater than 2 rows, statistical significance was determined using the Pearson χ² statistic. Analysis of variance was used for statistical comparison of means. For all statistical determinations, significance levels were established at P<.05.

A household was defined as "people sleeping and eating under the same roof." Torture was defined according to the United Nations Convention Against Torture,²⁰ and beatings were considered single episodes of beating (<10 minutes) of limited intensity. Groups affiliated with the Baath party regime were the Army, Republican Guard, Navy, Air Force, Air Defense Force, Border Guard Force, paramilitary, the Fedayeen Saddam, and Baath party members.²¹ Sexual assault included rape and other forms of sexual assault, such as molestation, sexual slavery, being forced to undress or being stripped of clothing, forced marriage, and insertion of foreign objects into the genital opening or anus.²² Regime-related prevalence of sexual assault included experiences of sexual assault committed by members or affiliated groups of the Baath Party regime since 1991. Lifetime prevalence of non–regime-related sexual assault included experiences of sexual assault committed by family members, friends, or civilians at any time in a woman's lifetime. Spousal abuse was defined as a beating or forced intercourse by a spouse. A suicide attempt was defined as a deliberate action with potentially life-threatening consequences during the last year.²³ Suicidal ideation was defined as thoughts of suicide or of taking action to end one's own life during the last year and included all thoughts of suicide (but not action), whether the thoughts did or did not include a plan to commit suicide.²⁴

Of the 2276 households sampled, 1991 households completed the study (89.7% response rate). The sample comprised 1172 male (58%) and 814 female (42%) respondents (Table 1). The demographic characteristics of the respondents closely reflected those of the population sampled.⁸ Respondents had lived in the areas surveyed on average for 22 (SD, 1.1) years (range, 1-91 years). Seventy-two percent of respondents were married and the most common religion reported was Muslim Shi'a (1906/1971 [96.7%]).

The household representatives reported on the experiences of 16 520 household members, including themselves (mean household size, 8 [SD, 0.09]) since 1991 (Table 2). Of the 16 520 household members, 8190 (49.6%) were female and 8330 (50.4%) were male. Forty-seven percent of all household respondents in the sample (930/1991) reported 1 or more abuses among household members since the year 1991 and a total of 1018 individual incidents of specific forms of human rights abuses among the 16 520 household members. Seventy percent of the abuses (408/586) were reported to have occurred in the homes of respondents.

For all abuses reported, 61% of respondents (608/1012) witnessed the abuse, and among respondents who reported that they could identify the perpetrator, groups affiliated with the Baath party regime (449/475 [95%]) were identified most often. The coalition forces were also identified as perpetrators by 3% of respondents (20/475), as reported elsewhere.⁹ Respondents indicated that more than half (53%) of the abuses among household members occurred between 1991 and 1993 during the Shi'a uprising and 30% between 2000 and the first 6 months of 2003 (Figure 2).

Respondents reported that 0.04% of household members (7/16 520) had experienced regime-related sexual assault since 1991. Five percent of respondents (87/1870) reported knowing in their lifetime of someone who had experienced sexual violence committed by groups affiliated with the regime. Twenty-seven percent of respondents reporting household abuses (259/947) reported suicidal ideation during the last year. Twenty percent of respondents who did not report household abuses, however, also reported suicidal ideation (179/898). Seven percent of household respondents who reported household abuses (65/946) and 5% of those who did not (44/897) reported attempting suicide in the last year.

Reproductive health characteristics are reported in Table 3. Ninety-six percent of women (660/689) reported wanting to marry at the time of marriage, and 71% (446/624) stated that the number and spacing of children was decided equally between husband and wife. Eighty-two percent of female respondents (606/767) reported always having to obtain permission from a husband or male relative to access health care and 54% (332/619) reported receiving prenatal care for all of their pregnancies. Use of birth control was reported by 50% of women (386/766). Of an additional 370 women, 87% (321) reported not wanting birth control and 13% stated they wanted some form of birth control but did not have access to it.

Four (0.4%) of 1057 respondents reported a regime-related rape or sexual assault among a family member (not just household members) since 1991. When asked about lifetime experiences of non–regime related sexual assault, 2% (40/1873) reported a personal account of sexual assault and 6% (122/1870) knew of someone who had experienced sexual assault. Twenty-three percent of respondents (434/1916) reported that they knew of someone who experienced violence, including beatings, by a spouse and 8% (61/782) reported a personal experience of violence/beatings by a spouse.

Education and work opportunities for women were both highly supported by men and women. However, men were significantly less supportive than women of these rights and of women's civil and political rights. Half of respondents agreed that there were reasons to restrict women's educational opportunities (53%) and work opportunities (50%) outside the home at the present time. (Table 4). Both men and women were less likely to support women's rights to associate with persons of their choosing and to be able to move about in public without restrictions. Both men and women supported women's rights to choose a husband, equal rights in the decision to decide timing and spacing of children, and inclusion of women in developing policies that may affect their health. The right to refuse sex was not as well supported by either men or women, and both agreed that women had an obligation to have sex with their husbands even if they disagreed. There was little support for the notion that a good wife obeys her husband even when she disagrees. However, more than half of both men and women agreed that a man had a right to beat his wife if she did not obey him. Finally, the majority of men and women agreed that strict dress codes were appropriate for women.

The majority of respondents rated the relative importance of women's basic human rights such as sanitation and clean water, food and shelter, equal access to health care, and education as "important," "very important," or "extremely important" (Figure 3). However, less than half of all respondents indicated that work opportunities for women are important. The majority of respondents supported legal protection of women's rights, participation of women in community health and development decisions, and women's freedom of expression; however, the majority of respondents did not rate participation of women in government or women's freedom to move about in public as important (Figure 3). There were no significant differences between female and male participants in their level of support for any of the basic, non–sex-specific human rights except for support for education and work opportunities for women. Support for each of the civil and political rights for women assessed was similar among men and women except for the importance of women's participation in government and in community development decisions, for which there was significantly greater support among women than among men.

These findings indicate that groups affiliated with the Baath Party regime have committed widespread human rights abuses against civilians in southern Iraq since 1991, including torture, killings, disappearances, forced conscription, beatings, gunshot wounds, hostage taking, and forced ear amputations, among others. Forty-seven percent of respondents in the 3 cities surveyed reported at least 1 of these abuses among household members. The extent of abuses reported over nearly 12 years in 3 cities suggests that human rights abuses represented an integral component of Baath party rule. The abuses reported in this study occurred primarily during the years 1991-1993, following the Shi'a uprising, and between 2000 and 2003, a time when the regime was or may have believed it was threatened. The need for justice and accountability for such human rights abuses has been acknowledged in recent years^25-27 and the limited ability of such measures noted as well.²⁶

Rape and other forms of sexual violence in conflict are crimes against humanity.^28-31 Survey respondent estimates of the prevalence of regime-related sexual assault (0.04%) among household members since 1991 and lifetime prevalence of regime-related sexual assault (5%) are less than the rates reported over 10 years in both Liberia (15%)³¹ and Sierra Leone (9%)¹⁶ but exceed that of some other population-based assessments of refugees and displaced persons (0%-0.1%).^14,32,33

Respondent estimates of lifetime prevalence rate of non–regime-related sexual assault ranged between 2% and 6% (Table 3). Although this is less than the lifetime rate in the United States,³⁴ it represents a significant problem for women and may be underreported due to societal stigma and fear of dishonoring one's family. Rates of sexual violence vary greatly based on research methods and populations surveyed.³⁵ Other than a qualitative report on rape and sexual violence in Baghdad,³⁶ however, there are no studies assessing the prevalence of either war-related or non–war-related sexual violence in Iraq.

The 5% to 7% attempted suicide rate reported in this study appears exceptionally high.³⁷ This suggests a considerable mental health burden in the areas we studied and the need to conduct mental health assessments and provide appropriate care. Currently in Iraq, mental health services are extremely limited. There are reported to be fewer than 100 practicing psychiatrists and a lack of therapeutic medications and social support systems.³⁸

The domestic violence rate documented in this study (50/1000 personal experiences of spousal abuse by respondents) is nearly 7 times the US rate (7.7/1000).³⁹ There has been very little documentation of domestic violence rates in the Middle East; however, lifetime rates in Egypt and Turkey are reported to be 340 and 580 per 1000, respectively.⁴⁰ This is not surprising, given that nearly half of both men and women surveyed agreed that a man had a right to beat his wife if she disobeys him. Such attitudes and experiences are likely to have serious health consequences for women until they are addressed effectively.

Neither men nor women indicated full support for women's civil and political rights, including freedom to move about in public and to participate in government. Despite more than 90% of men and women expressing support for equal opportunities for education and more than 70% expressing support for work opportunities for women, more than half of both indicated that there were reasons to restrict education and work opportunities at the current time. Lack of support for such rights for women may be related to implementation considerations, such as in adequate numbers of teachers, employment opportunities, and safety issues, among others.

Education has been reported to be associated with health status.^41,42 Restrictions on education may affect women's ability to make informed choices regarding health practices, access health care services, interact with health care personnel, and participate in treatment regimens.⁴³

Respondents considered the protection of basic human rights essential for meeting basic needs and for rebuilding Iraqi society. Legal protections for women and participation of women in community development decisions were considered by men and women to be important. Women's participation in government and freedom of expression or movement, however, were deemed less important, especially among men. Previous studies in Afghanistan have shown the detrimental health effects of rights discrimination among women.¹² The findings of this study suggest that sex- and rights-based approaches are important considerations in promoting community health and development in Iraq and that men may not fully support the health and human rights interests of Iraqi women. Currently, the new Iraqi Governing Council and ministries include a limited number of women. Finally, Resolution 137, which changes Iraqi family law to Sharia law and is a violation of international law, seeks to impose arbitrary interpretations of Islamic law on Iraq and strip Iraqi women of basic human rights, including health-related issues. Although supported by the Iraqi Governing Council, it cannot be signed into law unless the US Interim Authority also signs it.⁴⁴

This study was designed to enable generalizations within the 3 cities we sampled and the 3 governorates they represent, with a combined population of nearly 3 million people. The findings cannot be generalized to all of southern Iraq or any other region. In addition, the exclusion of certain unsafe sectors and sectors with fewer than 200 homes in the cities sampled may have resulted in underestimates or overestimates of the number of abuses in these cities.

Although interviewers were careful to explain that there would be no material or other gain by participating in the survey, respondents may have exaggerated abuses or other responses if they believed it was in their interest to do so. It is likely that the prevalence of regime-related sexual violence in the study was underestimated because of willful nondisclosure of sexual violence, cultural issues surrounding the shame of rape and sexual violence, or the lack of privacy in some of the interviews, despite efforts to ensure privacy for all. Identification of the perpetrators of abuses may also have been distorted by personal, family, religious, or revenge motives.⁴⁵ The study was not designed to test hypotheses about factors associated with specific health outcomes or attitudes. Also, since respondents were asked to independently rate the importance of specific human rights, it is not possible to assess perceived priorities for the human rights studied.

The frequency of killings and gunshot wounds may have been overestimated since reports of these abuses did not distinguish between civilian and noncivilian. The extent to which the alleged incidents represent lawful actions in the course of war vs violations of international humanitarian law by Coalition forces is not clear. Also, abuses by Coalition forces may have been underestimated, since those most likely to allege such abuse (prisoners of war) may not have been represented in the sampling frame,⁴⁶ or overestimated if respondents falsely reported crimes for political or other reasons.

The findings in this study indicate that nearly half of all households in 3 southern cities in Iraq reported experiencing human rights abuses among household members between 1991 and 2003. Such abuses represent considerable challenges for justice and accountability and the need to address individual and community mental health needs on a large scale. The mental health burden may represent a significant challenge to the Iraqi health system. The households surveyed supported a government that will protect and promote human rights, including the rights of women. However, the lack of support for certain women's rights by both men and women may make the full range of women's human rights difficult to achieve. Consequently, restrictions on women's rights and/or ineffective representation may have significant, adverse health consequences for women and girls. This study suggests a need for a sex- and rights-based approach, such as that developed in Afghanistan,⁴⁷ for reconstruction and community health and development in Iraq.