1 BACKGROUND Genocide is defined as:

Any of the following acts committed with intent to destroy, in whole or in part, a national, ethnical, racial or religious group, as such: (a) killing members of the group; (b) causing serious bodily or mental harm to members of the group; (c) deliberately inflicting on the group conditions of life calculated to bring about its physical destruction in whole or in part; (d) imposing measures intended to prevent births within the group; (e) forcibly transferring children of the group to another group. (United Nations office on Genocide Prevention & the Responsibility to Protect, n.d., Article II.)

While not explicitly listed among those crimes, rape is one of the most commonly implemented weapons of torture in the context of genocide (Alison, 2007; Schott, 2011). The International Criminal Tribunals of Rwanda and former Yugoslavia, respectively, and the Special Court for Sierra Leone, have each recognized mass rape as a crime against humanity and an act of genocide (Marochkin & Nelaeva, 2014; Schott, 2011).

Genocidal rape was implemented as an explicit military policy during the genocide and ethnic cleansing of Bosnian-Herzegovinian and Croatian people by Serbians between 1991 and 1995 (Allen, 1996). It was estimated that 35,000 women, primarily Muslim, were raped, impregnated, and prevented access to abortions so that they would give birth to Serbian children (Daniel-Wrabetz, 2007; Erjavec & Volčič, 2010a). In Rwanda, Hutu extremists used genocidal rape to humiliate the Tutsi and induce a painful death during the genocide perpetrated against the Tutsi in 1994 (Mukamana & Brysiewicz, 2008; Nowrojee, 1996). Approximately 350,000 women were raped, but only one in six of them survived. It is estimated that between 2000 and 10,000 children were born as result (Bijleveld et al., 2009; Nowrojee, 1996). In both the Yugoslavia and Rwandan cases a large proportion of women was raped as part of an overall strategy to disappear an ethnic group. Clearly, genocidal rape is complex and its ramifications go beyond the primary victims–families, communities, nations, and the global community are all affected (United States Holocaust Museum, n.d.; Van Ee & Kleber, 2013).

While women are the primary victims of genocidal rape, children born of that genocidal rape are also victims (Carpenter, 2009; Clark, 2014). Van Ee and Kleber (2013) classify the children born of rape as secondary victims and noted that, while their birth cannot be considered a crime against the children, they become victims through the crimes committed against their mothers. From conception, these children are vulnerable to threats to their health and well-being, with the possibility that these threats continue across the life course. For example, their identity as the offspring of the perpetrator places them at greater risk for abuse in childhood (Nowrojee, 1996; Van Ee & Kleber, 2013). However, most of what we know about these children and their lives is from their mothers’ perspectives (Mukamana & Brysiewicz, 2008; Nowrojee, 1996).

As the children born of genocidal rape move from childhood into adolescence and early adulthood, there is a need to understand how their early life experiences relate to their current health and well-being. A limited number of published studies document the experiences and needs of the children from their own perspective. The goal of this paper is to synthesize the scholarly work that reported experiences and needs of individuals conceived via genocidal rape. By understanding experiences and needs from the children's perspectives, we can work toward designing effective interventions to prevent or mitigate the potential consequences of adverse life experiences related to being conceived through genocidal rape.

2 METHODS

Research among children born of genocidal rape is still at an early stage, and most published studies use a qualitative approach. We only identified one study that use a quantitative approach (Banyanga et al., 2017). Therefore, we conducted an integrative review so that we could present a comprehensive perspective on the experiences and needs of individuals conceived via genocidal rape (Whittemore & Knafl, 2005). The integrative review process consists of five stages: (1) problem identification, (2) literature search, (3) data evaluation, (4) data analysis, and (5) presentation.

2.1 Search strategy

Sources of articles included MEDLINE via PubMed, PsycInfo, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and Social Services Abstracts. The search was conducted in May–June 2019 followed by data analysis and writing of the manuscript. The search was last updated in February 2021 prior to submission of this work for publication to ensure that we included all available articles in searched databases published through that date. Keywords were child/children, born of war, child of war, war adolescents, unwanted pregnancy, unwanted child, child of bad memory, rape, sexual violence, sexual abuse, sexual offense, abduct, genocide, holocaust, war crime, war offenses, war, and ethnic cleansing. Relevant citations obtained from the retrieved studies’ reference lists were also evaluated. Selected studies were abstracted using a matrix method (Garrard, 2017).

2.2 Study selection

Inclusion criteria were: (1) a primary study whose main focus was children born of genocidal rape; 2) published through February 2020 in a peer-reviewed journal or a doctoral dissertation; and 3) written in either English or French. Exclusion criteria were: 1) studies that report on mothers’ perspective rather than that of individuals born of genocidal rape; and 2) studies on individuals born of rape outside the context of genocide.

2.3 Study quality

The quality of reviewed studies was appraised used Critical Appraisal Skills Programme (CASP) qualitative checklist for qualitative studies (Critical Appraisal Skills Programme, 2018). The Critical Review Form – Quantitative Studies was used to assess the quality of the quantitative study (Law et al., 1998) (Table 1).

TABLE 1. Characteristics of studies included in this review Authors (year) Country Study Purpose Population Study quality Methods Main Findings Themea Godard & Ukeye (2012) Rwanda To explore the life course of the mothers and children Mothers and children (children age 17 years) Low Cross-sectional design Qualitative semi-structured focus group interviews: one for mothers and one for children Desire to know their birth origins Shame and guilt Therapeutic group helped to address some effects of genocidal rape 1,2,3,4 Muhayisa et al. (2016) Rwanda To explore the needs and psychosocial resources available children and mothers

19 mother-child dyads

(children age: 17 years)

Medium Observations Qualitative semi-structured interviews Genograms, drawings of families using animals, stated the family motto Lack of family roots/link Shameful origins Cause of family conflict Double the risk of trauma Desire to do better than father 1,2,3,4 Hogwood et al. (2017) Rwanda To explore how the young people born of sexual violence experienced the disclosure and how this impacted and affected their sense of identity Five females and five males aged 18 and attending school at the time of the study High Cross-sectional design Qualitative semi-structured interviews Learning about their new identity is a complex, difficult and painful process Knowing the truth is appreciated by the young people 1,2,3,4 Denov et al. (2017). Rwanda To explores the perspectives, lived experiences, and needs of children born of genocidal rape 60 youth born of genocidal rape aged 20 or 21 years old High Cross-sectional design Qualitative semi-structured, focus groups interviews Art activity (draw a history and life courses, using the metaphor of a “river of life”) Struggles with identity and belonging Ambivalence in the mother–child relationship Desire to learn about one's birth origins and heritage Participants found it helpful being together with other young people with whom they share experience 1,2,3,4 Eramian & Denov. (2018) Rwanda To investigate the dilemmas of talk and silence faced by Rwandan youth born of rape committed during the 1994 genocide against Tutsi 60 youth born of genocidal rape aged 20 or 21 years old High Cross-sectional design Qualitative semi-structured interviews Art-making activity (draw a history and life courses, using the metaphor of a “river of life”) Identity and belonging Complexity and dilemma either disclosing or concealing one birth origins, related to genocidal rape. Social and cultural influence to the meaning of the “truth” and truth telling 1,2,3 Denov and Kahn (2019) Rwanda To examine the complex reality of victimhood, social stigma and identity as a result of conflict-related sexual violence, alongside participants’ desire for societal recognition 60 youth born of genocidal rape aged 20 or 21 years old High Cross-sectional design Qualitative semi-structured interviews, focus groups Art-making activity (draw a history and life courses, using the metaphor of a “river of life”) Identity and link to the perpetrator father Stigma and rejection from family, community and school Recognition of complex victimhood and justice Youth role in reconciliation and peace building 1,2 Kahn and Denov (2019) Rwanda To describe the pathways to healing and well-being. 60 youth born of genocidal rape aged 20 or 21 years old High Cross-sectional design Qualitative semi-structured interviews, focus groups Art-making activity (draw a history and life courses, using the metaphor of a “river of life”) Young people's mental health Coping strategies to address their own and mothers’ mental health difficulties Pathways to healing including intrapersonal, interpersonal, and social 3,4 Denov and Piolanti (2020) Rwanda To explore and analyze youth's perspectives on their biological fathers and fatherhood. 60 youth born of genocidal rape aged 20 or 21 years old High Cross-sectional design Qualitative semi-structured interviews, focus groups Negative effects (including emotional, and socio-economic) related to absence of biological father Ambivalent and conflicting feelings about the perpetrator-father Father has significant role in the offspring identity formation and sense of belonging Perceived mothers’ role, as mediators of the father-offspring relationships, lead to the mothers-offspring tension-filled relationships 1,2,3 Banyanga et al. (2017) Finland and Belgium To investigate the trauma experienced by the women who were raped as well as the trauma of the children born as a result of rape during the 1994 Rwandan genocide and its aftermath 341 Rwandan Diaspora living in Finland and Belgium. 18 women had been exposed to rape, and nine individuals were born as a result of rape Medium Cross sectional design Quantitative surveys

Compared to other Rwandan youth who were not born of rape, young people born of rape:

Reported less fear, more likely to love and forgive the perpetrators of the genocide No significant difference in terms of trauma symptoms More likely to use alcohol as a coping strategy 3 Zamperini et al. (2017) Rwanda To explore and discuss the theme of memory and reconciliation policy in the Rwanda post-genocide context 20 mothers of children born of genocidal rape and 20 children born of geocidal rape (8 males and 12 females) Medium Cross sectional design Narrative interviews Participant-situated observation methods Ambivalence and contradictory emotions and action due to a desire to have a father Stigma attached the crime of the father 1,2,3,4 Erjavec and Volčič (2010a) Bosnia and Herzegovina To present how the adolescents represent themselves and their life situation 11 adolescents (14-16) born of war rape/from organization High Cross-sectional design Qualitative semi-structured interviews Sense of hostility Role reversal (e.g., take care of the mothers) Children feeling responsible of reconciling the war enemies Severe psychological and physical abuses 3,4 Erjavec and Volčič (2010b) Bosnia and Herzegovina To analyze the metaphors used when a specific topic is emotionally difficult to talk about 19 adolescents – all Bosnians High Cross-sectional design Qualitative semi-structured interviews Use of metaphorical language to express their painful situations Metaphors used for self-representation: ‘shooting target’, ‘cancer’ and ‘warrior’ 1,2,3,4 aTheme key: 1 = Birth Origin Stories, 2 = Belonging to Family and Community, 3 = Intergenerational Legacy, 4 = Strategies to Move Forward. 2.4 Search outcomes

A total of 24 articles were reviewed. Twelve articles met inclusion criteria (Figure 1: PRISMA Flow Chart [Moher et al., 2009]). These articles described the genocide in Rwanda (n = 10) and Bosnia and Herzegovina (n = 2), respectively. Of the 10 Rwandan articles, five reported different aspects of the same study. Similarly, the two articles from Bosnia and Herzegovina were drawn from a single study. Aims of the studies included exploring: (1) the life experiences of adolescents and young adults born of genocidal rape, (2) psychosocial needs and resources of the mothers and their children, and (3) interventions to address the needs of the individuals born of genocidal rape.  Most of the studies were of high quality (8/12), three studies fell in the moderate category, and one was of low quality (Table 1).

PRISMA flow chart [Colour figure can be viewed at wileyonlinelibrary.com] 2.5 Analysis

An inductive process was conducted by the first author to construct and describe themes which were discussed and refined by co-authors. After an in-depth reading of each article and extraction of the findings, we proceeded to code and cluster the related findings to derive themes. Extracted findings were used to describe those themes.

3 RESULTS

Table 1 summarizes the results of the 12 studies included in this review. The participants (individuals born of genocidal rape) in these studies ranged from 14 to 21 years of age during the studies.

3.1 Data synthesis

Four shared themes were identified by this analysis and were present across study locations (Bosnia and Herzegovina or Rwanda). The first focused on the long and complex process of learning that individuals were born as a result of genocidal rape. The second centered on a sense of fractured belonging – belonging in the family and community of both the victim mother and perpetrator father. The third theme, intergenerational legacy, considered the consequences of rape experiences beyond the mothers to their offspring born as a result. The last theme identified strategies for moving forward in life, including peer support and group counselling.

3.2 Shared themes 3.2.1 Birth origin stories

Youth born of genocidal rape grew up almost solely with their mothers. In some cases, the fathers killed the mothers’ family members and other people in the neighborhood (Erjavec & Volčič, 2010a; Godard & Ukeye, 2012). The discovery of their birth origins was a long process that required, for some, an intervention from a third party such as a counselor. Some young people did not have to ask or actively search for their origins. They became aware of their birth origins through unintended or unplanned disclosure. For example, the mother might get angry with her child and tell them that they look like their father-perpetrator, or a neighbor might disclose who their father was (Denov et al., 2017; Erjavec & Volčič, 2010a; Kahn & Denov, 2019).

While the young people experienced a strong desire to know their origins, the discovery of the truth brought challenges (Denov et al., 2017; Erjavec & Volčič, 2010a; Godard & Ukeye, 2012). For some, it was the knowledge of their violent conception by unknown perpetrators. For others, the mothers were unable or unwilling to share with their child the identity of their fathers. Knowing the truth of their birth origins was a painful experience, both because of knowledge their mothers had been raped and that their fathers had committed a heinous crime. Awareness of this truth was often accompanied by personal shame because the children often felt guilty about their fathers’ crimes (Erjavec & Volčič, 2010a; Godard & Ukeye, 2012; Hogwood et al., 2017).

3.2.2 Belonging to family and community

The youth were faced with the question of how to belong to both the victims’ and perpetrators' families (Erjavec & Volčič, 2010a; Hogwood et al., 2017; Muhayisa et al., 2016). The disclosure of one's origins revealed the truth about the fathers’ crime, and as a result some young people lost interest in building a relationship with and a sense of belonging to their fathers and/or their fathers’ families (Denov & Piolanti, 2020). Hogwood et al. (2017) noted different reactions between Rwandan boys and girls, with boys expressing anger, disgust, shame, and a desire to distance themselves from their fathers, while girls expressed mixed feelings about the relationship with their fathers. While girls wished to have their fathers in their lives, they also acknowledged the crimes they had committed.

The sense of belonging to their mothers and their mothers’ families was also compromised. Young people across several studies experienced an ambivalent and changing relationship with their mothers; at one moment they felt loved and cared for, and at other times they felt mistreated and abused. Some mothers asserted that their children were burdens that they had to carry without any support from their families, the community, or the government (Denov et al., 2017; Godard & Ukeye, 2012; Muhayisa et al., 2016).

The lack of belonging extended to the community level, where young people were marginalized while their mothers experienced social exclusion. Adolescent girls born of genocidal rape in Bosnia and Herzegovina described themselves as “shooting targets” in reference to being a passive target of aggressive action by others (Erjavec & Volčič, 2010a). They also used the metaphor of “cancer” to express internalized guilt pertaining to the feeling that their existence is a constant reminder of the painful experience and a source of conflict between family members. In Rwanda, many young people described their dilemma of either sharing or concealing their identity (Eramian & Denov, 2018).

3.2.3 Intergenerational legacy

Individuals born of genocidal rape carry an intergenerational legacy, in the sense that the crime has far reaching consequences beyond the physical and emotional trauma of the mothers. In addition to the maternal genocide- and rape-related stress to which the offspring were exposed during the prenatal period, some young people survived unsuccessful clandestine abortion attempts and pre- and postnatal starvation intended to make the fetus or the infant suffer (Godard & Ukeye, 2012). Many mothers did not receive prenatal care and/or the children themselves did not receive essential postnatal health care such as vaccinations (Godard & Ukeye, 2012; Muhayisa et al., 2016). Physical and emotional abuse from their families and communities, especially at younger ages, was not uncommon among young people included in the reviewed studies (Erjavec & Volčič, 2010a; Muhayisa et al., 2016).

Behaviors such as frequent crying, aggression, withdrawal, and other traumatic symptoms were also commonly observed among the young people born of genocidal rape (Godard & Ukeye, 2012; Muhayisa et al., 2016). Banyanga et al. (2017) reported a higher use of alcohol as a coping mechanism among Rwandans born of genocidal rape currently living outside Rwanda, compared to their peers.

3.2.4 Strategies to move forward

Despite the pain of knowing the truth about their birth origins and the aftermath of the truth being revealed, some positive outcomes were reported. The truth of their parentage played a role in improving the relationship between mothers and their children as the latter came to understand their mothers’ experience and reactions. In addition, knowing the truth about their birth origins served as starting point for the formulation of new and positive identities (Denov et al., 2017; Erjavec & Volčič, 2010b; Hogwood et al., 2017). For example, the metaphor of “warrior” was used by adolescents from Bosnia and Herzegovina to describe new and preferred identities as agents of reconciliation and peace (Erjavec & Volčič, 2010b). Some young people considered the possibility of reconciliation with their fathers as well as the reconciliation between victims’ and perpetrators’ communities (Banyanga et al., 2017; Erjavec & Volčič, 2010b; Zamperini et al., 2017). Some participants did not describe being mistreated or abused by their mothers (Denov et al., 2017; Erjavec & Volčič, 2010b). For example, the mother of one female participant came to terms with her rape experience, became an activist against sexual violence, and provided care to her daughter (Erjavec & Volčič, 2010b).

4 DISCUSSION

Ours is the first review that specifically focuses on the experiences and outcomes of youth and young adults born of genocidal rape from their own perspective. We did identify a single review by Van Ee and Kleber (2013) that focused on children born of wartime rape; however, the focus was not on children's experiences from their own perspective and only one paper considered in that review reported primary data from the offspring of genocidal rape specifically. Our study is the first to synthesize the genocidal rape experience of searching for and processing one's birth origins, conflicted senses of belonging, the issue of identities other than ethnic identity within their communities, and tools for effectively moving forward.

The young people born of genocidal rape in both Rwanda and Bosnia and Herzegovina experienced issues related to their birth origins and sense of belonging (Denov & Piolanti, 2020; Erjavec & Volčič, 2010a; Muhayisa et al., 2016). It took a complex and painful process for the young people to discover their birth origins (Erjavec & Volčič, 2010a; Godard & Ukeye, 2012). This finding is similar to other literature that indicates children who experience neglect, stigma, and other psychosocial difficulties due to their birth origins search for their roots and experience rejection by their families and community (Carpenter, 2007; Taylor, 1999; Van Ee & Kleber, 2013). Similarly, some young people in the studies reviewed here experienced rejection by their mothers and mother's families, yet they rejected being a part of their “perpetrator” father's community. Hardships related to birth origins and lack of a sense of belonging were reported among children of war, whether or not conception occurred by rape, as long as the fathers were from the enemy group (Mochmann, 2008; Shanahan & Veale, 2016).

Genocidal rape has an intergenerational legacy; the offspring endure the effects of the crime committed against the mothers. This could explain psychological consequences such as guilt, shame, anger, as well as social consequences including discrimination and rejection, expressed by the participants in the reviewed studies (Erjavec & Volčič, 2010a; Hogwood et al., 2017). In addition, children can endure intergenerational trauma and hidden grief. This is especially true if their fathers killed the mothers’ family members (Godard & Ukeye, 2012; Muhayisa et al., 2016). There is compelling evidence that exposure to adverse life experience, in particular prenatal and early childhood, could have long lasting effects including increased risk of chronic diseases in later life (Gluckman & Hanson, 2006). Studies that have examined posttraumatic stress disorder (PTSD) among children of genocide survivors in Rwanda (Perroud et al., 2014) and Holocaust survivors (Yehuda et al., 2014) support the intergenerational transmission of PSTD through epigenetic mechanisms operating on stress pathways.

Many of the young people sampled in the reviewed studies described feeling discriminated against by their families and communities. We recently reported that children of genocidal rape survivors in Rwanda experience both more adverse childhood experiences (ACEs) and worse mental and physical health outcomes than children born to genocide survivors only (Uwizeye et al., 2021). Reports of higher perceived discrimination during pregnancy has been shown to be associated with altered physiological stress reactivity in offspring (Thayer & Kuzawa, 2015). Therefore, it is possible that the individuals born of genocidal rape could be themselves affected by the horrors of war, potentially through epigenetic changes (Conching & Thayer, 2019). These findings serve as a call for studies of the associations between early life stressful experiences and adult physical and mental health of young people born of genocidal rape as well as their children.

Expressing painful emotions can be difficult, and appropriate techniques are required to facilitate the process. One example is the use of art therapy in Rwanda and Uganda (Denov & Lakor, 2017; Muhayisa et al., 2016). Group therapy has been reported effective in one of our reviewed studies (Godard & Ukeye, 2012), as well as in other populations such as genocide survivors (Connolly & Sakai, 2011), incest survivors (Waller, 1992), and incarcerated juveniles (Persons, 2009). Group therapy is effective where mental health professionals are scarce and not accessible to all who need mental health services (Slayton et al., 2010).

These findings shed light on the experiences and needs of the children born of sexual violence during genocide; however, there are limitations to this review. Only studies that could be retrieved through the selected databases and written in French and English were included. It is possible that other investigators may have used different keywords or languages resulting in omission of some relevant articles from our review. The reviewed studies were conducted only in Rwanda or Bosnia and Herzegovina, where the ethnopolitical goals of genocidal rape differed. For the Serbians, the goal was to generate more Serbians through rape, thus replacing the Muslim Bosnians (Snyder et al., 2006). For the extremist Hutus, rape was a tool of ethnic elimination; children conceived by Hutu fathers and Tutsi mothers were not considered “pure Hutus”, and some of these offspring were not spared during the genocide (Nowrojee, 1996; Taylor, 1999). In the reviewed studies, difficulties related to ethnic identity were described only by young people from Bosnia and Herzegovina, where ethnic categories remain culturally enforced (Erjavec & Volčič, 2010a; Erjavec & Volčič, 2010b). In contrast, Rwanda decided that to promote unity after the genocide: the labels of politically and colonially constructed ethnic groups – Hutu, Twa, and Tutsi – would not be used (National Unity & Reconciliation Commission, 2016). Therefore, the Rwandan young people did not express difficulties related to ethnicity. Despite these differences, however, the themes we identified were largely consistent between Rwanda and Bosnia and Herzegovina, suggesting that many of the experiences of genocidal rape and their consequences may be common across disparate cultures and theaters of conflict.

There are remaining gaps in knowledge for future studies to address. For example, the extent to which reported adverse experiences may affect the mental and physical health outcomes of the young people in adulthood have not yet been systematically explored. Our recent study did demonstrate that being born of genocidal rape was related to worse health outcomes in adulthood, but the sample was small, and restricted only to those conceived during the 89 days of the genocide limiting comparisons to later exposures; it remains to be seen how these adverse mental and physical health persist into older age (Uwizeye et al., 2021). Furthermore, the mechanisms through which those experiences are linked to health in later life need to be examined in order to develop new therapies. Interventions to address the health outcomes need further research to validate what approaches are most successful and introduce new evidence-based approaches. Also, the findings of this review highlight the need for establishment and refinement of policies around child protection that facilitate early identification of victims and provide care. It would be important to ensure that there are protective systems implemented at the family and community level