Sexual violence against men and boys in conflict and forced displacement: implications for the health sector

Abstract Sexual violence against men and boys is commonplace in many conflict-affected settings and may be frequent in relation to forced displacement as well. Adolescent boys, forming the majority of unaccompanied minors globally, are a particularly vulnerable group. Yet sensitised health services for adult and adolescent male sexual violence survivors are scarce, and barriers to accessing care remain high. We describe current challenges and gaps in the provision of health care for male survivors in settings affected by conflict and forced displacement, and provide suggestions on how to improve service provision and uptake.


Introduction
In the fall of 2016, two of the authors travelled to refugee settings in the Middle East and Greece, respectively, to undertake projects related to sexual and gender-based violence.* We heard disturbing accounts of sexual violence, including sexual exploitation and abuse, against refugee men and boys and found few accessible services available, particularly for adolescent boys and adult men. † In the Middle East, refugees shared horrific stories of sexual violence, including sexual torture and rape, against men and adolescent boys in Syria by both state and non-state actors. In their countries of asylum, some refugees reported sexual exploitation of men and boys. Gay and transgender refugees described being sexually preyed upon by multiple perpetrators. Yet, many aid workers, including health providers, were either unaware of these problems or were unsure how to address them. Some did not believe men or boys were being sexually victimised. One gender-based violence programme manager in Iraq described how, when she raised the issue during a training on post-rape care, doctors and nurses burst out laughing, "How can a man be raped?" In Greece, shelter providers told stories of older men sexually exploiting unaccompanied boys aged 14-17 in Pedion tou Areos, a large park in Athens, in exchange for money, food, clean clothing, and other basic needs. Despite widespread acknowledgement of this problem, practitioners lacked the guidance and evidence-based approaches necessary to prevent these boys from being repeatedly exposed to sexual abuse. When boys disclosed this form of harm, providers often did not know where to refer them for appropriate medical and psychosocial care.
In this paper, we spotlight the needs and gaps in physical health service provision for male survivors in conflict-affected settings as well as situations of forced displacement. Sexual violence against men and boys includes oral and anal rape including *SKC travelled to Lebanon, Jordan, and the Kurdistan region of Iraq in October 2016 to undertake research for UNHCR on sexual violence against men and boys in the Syria crisis. JF was deployed as a Gender-based Violence Specialist to UNFPA in Greece from August 2016 to January 2017 to develop and coordinate responses to gender-based violence against refugees, migrants, and asylum seekers in camps and urban settings. † Note that sexual and gender-based violence services for women and girls require significant strengthening across these settings as well.
with objects, genital violence, forced sterilisation such as castration, sexual slavery, forced sexual activity with other people, animals, or corpses, and other forms of sexualised violence of comparable gravity. 1 The burden on men and boys Although limited research on sexual violence against males in conflict has been undertaken, in settings where it has been explored, conflictrelated sexual violence against men and boys has been identified as "regular and unexceptional, pervasive, and widespread". 1 For example, in selected conflict-affected territories of the eastern Democratic Republic of the Congo (DRC), a populationbased survey found that almost one quarter of men (23.6%) had experienced sexual violence. 2 A survey of men living in a conflict-affected state in Sudan revealed that almost half (46.9%) had experienced or directly witnessed the sexual abuse of a man. 3 In Liberia, a population-based survey unveiled that one-third (32.6%) of former male combatants reported experiencing sexual violence. 4 Sexual violence against men and boys was widespread during the conflict in the former Yugoslavia, as documented by Amnesty International and in UN reports, as well as by the International Criminal Tribunal for the former Yugoslavia and domestic courts. 5,6 Sexual violence against boys and men in relation to forced displacement has also been documented. Of the incidents of rape reported to the Gender-based Violence Information Management System (GBV IMS) ‡ in Lebanon from January to May 2016, for example, 20% were reported by refugee men and boys; the total number of survivors was not specified. 7 Keygnaert et al 8 found that men were the victims in 53 (37.2%) of 142 reported incidents of rape among sub-Saharan refugees and asylum seekers in Morocco. A Médecins Sans Frontières survey of 429 refugees fleeing violence in Central America found that 17.2% of the men reported experiencing sexual abuse while in transit through Mexico. 9 For unaccompanied boys, the issue has reached new urgency as the number of registered unaccompanied childrenthe majority of whom are malehas risen five-fold globally since 2010. 10 The refugee and migrant crisis in Europe in particular has drawn global attention to the sexual exploitation and abuse of unaccompanied adolescent boys, who comprised 89% of the 63,300 unaccompanied minors applying for asylum in the European Union in 2016. 11 Although empirical research is limited, aid worker accounts, media stories, and UN, NGO, and academic reports highlight that unaccompanied boys experience sexual exploitation and abuse both during migration and upon arrival in destination countries. For example, a 2016 study involving 61 interviews with unaccompanied migrant children in camps in Northern France and along the coast of the English Channel found that boys and girls were regularly sexually abused by traffickers. 12 It noted that along the migration route from Afghanistan to Calais, in particular, "sexual abuse of boys appears to be commonplace". 12 In Libya, a needs assessment of 122 migrant women and children who were travelling along the Central Mediterranean migration route from North Africa to Italy found sexual violence to be widespread at borders and checkpoints, and noted that boys experience "various forms" of sexual violence during migration. 13 The sexual abuse and exploitation of unaccompanied adolescent boys upon arrival in Europe has been increasingly documented in Greece and Italy. 14,15 A 2017 study on this issue in Greece described the sexual exploitation of boys from Afghanistan, Syria, Iraq, Iran, and Bangladesh. Desperate for money to survive in Greece or to pay a smuggler to leave, they were sexually abused in parks, hotels, or private residences for small payments. 16 While most of the documentation of sexual exploitation and abuse of boys is focused on the route to Europe, other dangerous routes expose children to sexual and physical violence, such as the route from Central America to the United States, and the route from Myanmar through Southeast Asia. 10

Health impact and gaps
Sexual violence has destabilising, multi-dimensional consequences, and the physical health impact alone on male survivors can be significant. ‡ GBV IMS is a data management system that enables service providers working with survivors of sexual and gender-based violence to safely collect, store, analyse, and share data. Note that GBV IMS data are from reported cases only and are not representative of the total incidence or prevalence of sexual and gender-based violence in each setting. In the Middle East, for example, a number of agencies providing services to male survivors have not adopted the use of the GBV IMS and their data are, therefore, not included in the GBV IMS data.
Health consequences may include, among other things, sexually transmitted infections including HIV, incontinence, genital and rectal impairment, infertility, sexual dysfunction, and full or partial castration. Indeed, two studies on sexual violence in eastern DRC and Croatia/Bosnia found that 13% and 12% of male survivors, respectively, endured traumatic genital injury. 17 Some male rape survivors suffer from rectal trauma, such as abscesses and fissures, which can make sitting, moving, and even coughing painful. This requires specialised reparative surgery. Without it, sufferers may struggle for years with pain as well as malodorous faecal leakage and the associated social and economic costs, such as ostracism and poverty. Though the scope of physical trauma requiring specialised care is unknown, we cannot assume it is small: for example, in specific areas in eastern DRC, an estimated 760,000 men and boys have survived sexual violence. 2 Even if a small percentage require specialised services, this entails thousands of men.
Numerous barriers impede men and boys from accessing the care they deserve. Male survivors are less likely to seek health care than female survivors, 17,18 due to a variety of context and culture-specific factors including shame, fear of community discovery and the resulting social stigma, fear of reprisals, and fear of arrest in settings where same sex relations are criminalised. Some men and boys may have difficulty verbalising sexual violence, instead preferring to speak about "abuse" as sexual violence is frequently understood as being directed towards women and girls alone. 19 The health impact of sexual violence can present itself differently in men and boys than it does in women and girls, making it difficult for health providers to identify possible survivors. Health providers may focus on anal rape and miss indicators of other forms of sexual violence, such as sexual dysfunction, incontinence, and genital scarring. 20 There is a tendency to attribute more agency to male survivors of sexual exploitation and sex trafficking than to girls. For example, boys may be perceived as "prostituting themselves" or "experimenting with their sexuality" and, therefore, less in need or deserving of protection or support. 21 Clinical care for survivors is sometimes embedded in maternal and child health programmes or gender-based violence services that require disclosure of sexual violence, which can hinder male survivors from accessing care. 22 Clear protocols and sensitised referral points for adult male survivors are rare in humanitarian settings, leaving aid workers unsure of where to refer survivors; there are notable exceptions, such as in Beirut, Lebanon, where a small yet effective referral system for male and transgender survivors has been established. For survivors with rectal trauma, reparative surgery may not be available; where it is available, systems to effectively link survivors with these services may not yet be established, such as in Jordan at the time of this writing.
Although this paper focuses on physical health consequences, it is important to highlight that the mental health impact of sexual violence on men and boys can be severe, and can include depression, anxiety, post-traumatic stress disorder, and suicidal ideation. 23 As such, it is imperative that humanitarian health actors develop targeted guidance on how to provide care for male survivors, such as the manual on management of sexual violence against males by MOSAIC, a local nonprofit organisation in Beirut. 24 Both male and female health personnel need training and sensitisation on how to appropriately identify and care for male survivors. Without proper sensitisation, providers may overlook survivors or induce further emotional injury. For example, some health providers may believe that all male survivors are gay or that men and older boys cannot be sexually victimised. Homophobic and other negative attitudes from health providers can cause additional humiliation and harm and deter other survivors from seeking care.

Future directions
In 1994, the International Conference on Population and Development affirmed the right to health for refugees and internally displaced persons, and this includes men and boys who have suffered sexual violence. 25 A multi-sectoral approach is required to fully meet the needs of male survivors, and health actors play an important role in this process. As a starting point, men and boys need to be better included in relevant guidance, protocols, assessments, and communications materials. 26 Humanitarian agencies must raise awareness among and sensitise health staff, as well as other front-line responders including those working in protection, mental health, and gender-based violence. Health providers, reproductive health focal points, case managers, social workers, and indeed all humanitarian responders need to understand that straight as well as gay, transgender, and other gender nonconforming men and boys are vulnerable to sexual victimisation in conflict and displacement, that male survivors have a variety of health, psychosocial, and other needs, and that they have a right to compassionate, good quality care. Health actors must ensure that clinical management of rape trainings adequately integrate men and boys, dispel myths about male sexual victimisation, and address negative provider attitudes towards male survivors. Referral mechanisms that include sensitised referral points for male and LGBTI survivors should be routinely established. Male survivors with rectal trauma must be identified and supported to access care, including the option of resettlement if medical care is unavailable in-country. Men and boys are not a monolithic group, and attention should be given to the range of male survivors, such as young boys, adolescents, gay and bisexual men and boys, transgender men and women, straight adult men, as well as men and boys with disabilities. Finally, greater degrees of precision and accuracy in data collection, analysis, and reporting, including by GBV IMS actors, are essential to better understand and address the scope and nature of sexual violence against males.
While barriers to men and boys' access to health servicessuch as linking all sexual violence care with women's health services or female-only sexual violence focal pointsshould be identified and addressed, it is critical to ensure that interventions to meet the health needs of male survivors dovetail with existing efforts targeting women and girls, who bear the brunt of sexual violence and whose health and gender-based violence-related needs remain high across humanitarian settings. § Indeed, clinical management of rape survivors is a longstanding gap in humanitarian crises, 27 and humanitarian agencies and donors must work to ensure all sexual violence survivorswomen, girls, men, and boysrealise their right to life-saving health care. The consequences of rape and other forms of sexual violence transcend far beyond the individual and can have devastating ripple effects across communities long after conflict and displacement have ended.