WHEN the women who fill the beds in Panzi hospital heard that Denis Mukwege had won the Nobel peace prize, they got up and started dancing. Laughter and clapping echoed through the hospital wards. Many women are recovering from internal damage caused by rape. One 30-year-old, suffering intermittent bleeding after being raped in a forest, says she was feeling weak that day. “But when I heard that Papa Mukwege had won that prize, I was so happy, I had to stand up and dance. He won it for helping us.”

Dr Mukwege’s co-winner is Nadia Murad, a member of Iraq’s Yazidi minority and a former sex slave of Islamic State (IS). She wrote a book called “The Last Girl” because she wanted to be the last girl in the world with such a story. That these two brave campaigners won the prize says much about changing attitudes. For centuries rape in war was seen as inevitable. But recent years have seen widespread revulsion and a determination to curb it.

None too soon. Since 1999, when Dr Mukwege founded his hospital, perched on a grassy hillside in his hometown of Bukavu in the east of the Democratic Republic of Congo, it has treated over 40,000 survivors of sexual violence. The perpetrators have nearly always gone unpunished. Though many of his staff have decorated their offices with his portrait, the man himself is modest. A gynaecologist and obstetrician, trained in Burundi and France, he is delighted that the prize will make it harder for his government to claim that the country is at peace. “Rape is used systematically, methodically,” he says. “Women are ashamed and stay silent.”

The endless stream of women, children and even babies with maimed insides has sometimes brought him close to despair. He remembers the helpless rage he felt when an 18-month-old baby was brought in with genitals mangled by rape. After treating her he called 50 men into his office and begged them to go to the village and find the culprits. But the rapists—rebels from one of the region’s several militia groups—had long since melted back into the bush.

Punishing the victim

The doctor blames such atrocities on a culture of impunity. Gloria, a Panzi patient in her twenties, says she was raped by three militiamen on the edge of a mud path. They were celebrating a victory over the national army. The men, each toting a Kalashnikov, grabbed her and three friends as they walked through scrubland. “They beat me, then they laid me on the ground, put a cloth over my head and raped me. They said if I moved they would shoot. Three of them did it, one after the other,” she says, with startling composure.

When she returned to her village, bleeding heavily, her husband saw she had been raped and abandoned her. She was rejected by most of her neighbours. After three years of sporadic bleeding and acute abdominal pain, some women from her church collected money so she could travel to Dr Mukwege’s clinic. When he examined her, at first she felt “ashamed”. But he was kind and she soon saw him as a friend. “Thanks to him I am still here,” she says.

Dr Mukwege has had to make big sacrifices. He lives “almost as a prisoner”, inside the hospital compound. It is not safe to walk the streets. He survived an assassination attempt in 2012 and fled to Belgium with his family. His former patients rallied to bring him home, writing without reply to Congo’s president, Joseph Kabila, and to the UN’s secretary-general at the time, Ban Ki-moon. Then, he says, his voice cracking, “they started coming to the hospital every Friday to leave $50 that they had collectively earned by selling fruit and vegetables.” The money was for his air fare. These women survive on less than $1 a day. “I decided that their sacrifice was greater than mine and so I came back.”

The assassination attempt came soon after the doctor had given a speech at the UN lambasting Congo’s leaders for letting conflict and rape continue. Even now, his government does not feign admiration for him. “We commend a fellow citizen for this honour but have not always agreed with his observations,” the Minister of Information mumbled about his award.

Worldwide, however, awareness of sexual violence in war has risen. Hundreds of thousands were raped in the 1990s, during the Bosnian war and the Rwandan genocide. The international tribunals set up after those conflicts broke new ground in the prosecution of sex crimes. In 2008 UN Security Council resolution 1820 recognised sexual violence as a tactic of war. In 2014 Angelina Jolie, an actress, and William Hague, then the British foreign secretary, played host to a summit in London on ending wartime rape.

The invisibles

Some types of wartime sexual violence are often still overlooked. Men and boys can also be victims. Charu Lata Hogg, the founder of the All Survivors Project, a charity, says that this issue is “a blind spot in law, policy and humanitarian response”.

In Sri Lanka, for example, where many men suffered sexual violence in army detention during a 26-year civil war that ended in 2009, the law does not recognise male rape, and so does not ban it. In countries where gay sex is illegal, men who have been raped feel not only shame but also fear, in case they are accused of being accomplices to a crime. Few speak up, let alone seek help. So the prevalence of male rape in war is even harder to estimate than that of female rape. According to a study by the UN High Commissioner for Refugees, refugee women in Jordan last year estimated that 30-40% of men from their communities in detention in Syria suffered sexual violence. The problem is starting to be recognised. Cases at the International Criminal Tribunal for the former Yugoslavia (ICTY) included sex crimes against men.

Atrocities against women are more widely acknowledged, bringing support for those, like Dr Mukwege, who deal with their consequences. Whether they are growing less common is hard to say. In absolute terms, they probably are, simply because wars are rarer than they were a generation ago. But whether the number of sex crimes in a typical war is rising or falling is unknown. Data that appear to show an increase may merely reflect improved reporting. There are also inconsistencies in how “sexual violence” is defined; some definitions are limited to penetrative rape, others include shaving women’s heads. And there is huge variation in how likely victims are to report an attack, depending on local customs.

But, it is certain that the problem persists. In South Sudan a UN survey found that 70% of women in civilian camps in Juba had been raped. And, as women in refugee camps in Bangladesh give birth to babies conceived in rape, aid workers are only beginning to grasp the scale of sexual violence, mostly gang rape, during the brutal expulsion of 1m Rohingya people from Myanmar last year.

The idea has caught on that rape is a weapon of war: that commanders order their men to do it to terrorise populations or to achieve other military objectives. That is sometimes true. Ms Murad’s rapists were following an explicit, written doctrine that IS jihadists were free to enslave and “marry” captured infidels. IS commanders encouraged this, partly to destroy the Yazidi faith (by killing the men and enslaving the women), and partly as a recruiting tool—join the jihad and gain a sex slave.

Such written orders are vanishingly rare, however. Usually, even when mass rape is clearly being used for strategic ends, such as the “ethnic cleansing” in Bosnia, Darfur, Myanmar and Rwanda, it is fiendishly hard to prove who is to blame. Rape in war is complex. Perpetrators are not always combatants—at Panzi, for example, over the past ten years, 34% of victims were raped by civilians. Nor is rape always part of a military plan. A commander can prohibit, tolerate or order it. Understanding why it happens should make it easier to prevent it, and to prosecute the culprits. Not all armies and militias rape. Over a third of the 91 big civil wars in 1980-2012 had no large-scale sexual violence. In El Salvador’s civil war National Liberation Front militiamen very rarely raped and those who did were punished severely. The militias needed civilians for shelter and intelligence, and trained fighters not to outrage them. The otherwise brutal rebel Tamil Tigers in Sri Lanka prohibited sexual abuse. The National Resistance Army in Uganda had a code of conduct noting that “many women are wives or daughters of somebody, somewhere.” Crucially, argues Elisabeth Wood of Yale University, in all these cases, commanders had both the will and the control to enforce such rules. Some combat groups commit mass rape without clear orders. Some men doubtless do it because, in the fog of war, they can get away with it. But rape in war can be markedly different from in peacetime. It is usually more violent, sometimes involving sticks or rifles. It is also more likely to be done in public, to maximise humiliation, and to involve many perpetrators. In “Rape during Civil War”, Dara Kay Cohen of Harvard notes that though less than a quarter of reported peacetime rapes are gang rapes, in war the figure is estimated to be three-quarters or more.

Fighters take part in gangrapes to forge bonds with each other, argues Ms Cohen. What they are doing is taboo and dangerous—some contract crippling sexually transmitted diseases from it. Having done something so vile together, they become partners in crime and this helps foster group loyalty. This may be why, as Ms Cohen found, conscripts, who may have been abducted or press-ganged, are more likely to rape than volunteers. They start off with little or no loyalty to the unit. Commanders know this, and so allow or encourage them to commit sexual crimes as a group, knowing that this will bind them together. Armies that switch from voluntary recruitment to the forcible sort, such as the Civil Defence Forces in Sierra Leone, tend to become more sexually violent.

Policymakers need to recognise such early-warning signals. It might also help if commanders were held responsible for tolerating widespread sexual violence, rather than just for ordering it. One insight noted in the debrief notes from the International Criminal Tribunal for the Former Yugoslavia was that it was unhelpful to require investigators to prove that sexual violence was used strategically, because this was all but impossible.

The world has tried to deter wartime rape largely by bringing war leaders to justice. High-profile prosecutions matter, but they cost millions of dollars and often fail. Nearly 20 years after the establishment of the International Criminal Court, it has yet to convict anyone for sexual violence as a war crime. A Congolese warlord was acquitted in June.

Prosecuting perpetrators is seldom the survivors’ priority, either. (Though Ms Murad urges that IS commanders face justice.) More worry about food and shelter, says the International Committee of the Red Cross. Rape victims often suffer stigma, social isolation and even, like Gloria, abandonment by their families. They also require protection, because even after war is over, high levels of rape tend to persist.

Dr Mukwege says he has kept going, even through the darkest of times, thanks to his patients’ unrelenting will to carry on. When she limped into his clinic, Gloria half collapsed against a tree in the courtyard. Now she is strong enough to face the future. “When I go back to my community I will walk through the village to show everyone I am alive,” she says. “I’ll show them there is life after rape.”