Care and Support of Male Survivors of Conflict-Related Sexual Violence
Sexual Violence is:
"Any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, acts to traffic, or acts otherwise directed against a person's sexuality using coercion, by any person...in any setting..." Sexual violence as defined by the World Report on Violence and Health (Jewkes, Sen and Garcia-Moreno 2002: 149).
The world is increasingly aware that armed conflict and sexual violence against women and girls often go hand in handii. However, armed conflict also brings danger of sexual violence for men and boys. Male survivors of sexual violence are less likely than women and girls to disclose assaults (Callender and Dartnall 2011), with the result that such violence is "vastly under-represented" in official statistics (WHO 2002: 154). Nevertheless, sexual violence against men and boys-including rape, sexual torture and mutilation, castration, sexual humiliation, forced incest and forced rape, and sexual enslavement-is a pervasive feature of armed conflicts around the globe. It can emerge in any form of conflict-from interstate wars to civil wars to localised conflicts-and in any cultural context (Russell 2008).
Given increased international awareness of sexual violence against men and boys, as well as the growing global push to end conflict-related sexual violence,iii there has never been a better time for male survivors' needs to be recognized as a priority public health issue worldwide, and to extend our understandings of gender based violence to include men and boys. There is a need to seek out adult male needs, as social and medical services are often organized around the needs of women and children. In many conflicts, males are targeted for sexual violence in order to destroy their masculine identity at both the personal and social level (Sivakumaran 2007, Russell 2007). Sexual violence against boys may also be gender-based. For instance, a ten-year old boy is not castratedv because he is a child; he is castrated because he is a future man.
This briefing paper provides commentary on sexual violence against men and boys in conflict settings, and highlights promising programming and therapeutic approaches in the care and support of male survivors. It is based on key elements of the research and practitioner literature and discussions held on the Sexual Violence Research Initiative (SVRI) Online Discussion Forum in February and March 2010, on care and support for men and boy survivors of sexual violence in conflict settings.
The nature of sexual violence againstmenand boys
Sexual violence can take many forms, and includes both physical and mental violence that is carried out through sexual means or that targets the victim's sexuality and sexual and reproductive health. Directed against males, it generally falls into three overall patterns (Agger 1989, Sivakumaran 2007, Russell 2007, Lewis 2009):
- Forcing amanor boy to take part in sexual acts, often humiliating ones;
- Inflicting pain and/or damage to the genitals with the overt or covert threat of interfering with future sexual pleasure;
- Inflicting damage to the genitals designed to prevent future reproduction.
Sexual violence against males is sometimes committed with the intent of ultimately causing the victim's death-for instance through heavy bleeding as a result of violence to the victim's genitals or anus (Lewis 2009: 29).
How common is sexual violence againstmenand boys in conflict areas?
In the last decade alone, sexual violence against male civilians and combatants, both adults and children, has been reported in 25 conflicts across the world. If one includes sexual exploitation of boys displaced by violent conflicts, the list encompasses the majority of the 59 armed conflicts identified in the 2003 Blaauw 2002,HumanSecurity Center 2005: 69).
Until recently, there has been little statistical information on levels of sexual violence against males during conflicts-largely because men and boys are often very reluctant to report such violence, but also partly due to a lack of awareness on the part of those collecting information or offering help. However, recent studies on conflict-related sexual violence, as well as existing studies on torture, paint a disturbing picture.
- In Liberia, according to a study of 1666 adults conducted in 2008, 32.6% of the study's 367 male former combatants had experienced sexual violence, mostly at the hands of soldiers or rebels. Of these, 81% reported current symptoms of post-traumatic stress disorder, and 14% had attempted suicide (Johnson . 2008).
- In the Democratic Republic of Congo (DRC), according to a study of 998 adults conducted in 2010, 23.6% of the study's 405 men had experienced sexual violence during their lives, 64.5% of whom had experienced it in the context of the country's civil wars. Of these cases, 92.5% of the perpetrators were men, and 11.1% were women, mostly women combatants. Of the survivors, 56% reported current symptoms of post-traumatic stress disorder and 47.5% of major depression, and 22.8% had attempted suicide (Johnson . 2010).
- Males, like females, are particularly vulnerable to sexual violence in detention. Surveys of male torture survivors, both from conflict zones and from repressive states, have consistently shown high levels of sexual violence in detention, frequentlywell over 50% (Lunde and Ortmann 1990, Meana . 1995, Peel 1998). In Bosnia, for example, 80% of the 5,000 male concentration camp victims in the Sarejevo Canton reportedly were raped in detention (Mudrov i 2001: 64, cited in Sivakumaran 2010).
Where boys are concerned, figures on sexual violence and abuse against children in displacement are extremely hard to obtain. However, to give a general idea of the scale of childhood sexual abuse, the World Health Organization has estimated that in a single year (2002), 73 million boys as well as 150 million girls experienced forced sexual intercourse or other forms of sexual abuse(WHO2006: 12).
Psycho-social and physical consequences
For men and boys, as forwomenand girls, sexual violence is a particularly vicious attack on personal and social identity whose psychological consequences often far outlive those of other forms of violence (Agger 1989, Hardy 2002). A few prominent, often overlapping themes emerge in accounts of the perpetration and experience of male-directed sexual violence.
- Demoralisation and destruction. As a generalized strategy ofwar, sexual violence is designed to terrify, demoralise and destroy family and community cohesion (Russell 2008).
- Emasculation. Sexual violence is often carried out against males to attack and destroy their sense of masculinity ormanhood-aconstant concern ofmany survivors (Sivakumaran 2007: 269).
- Feminisation. Attackers and survivors often make direct reference to sexual violence making males feel that that they have been "turned into awoman"-a statement revealing patriarchal notions ofwomen's lesser statusworldwide. (Sivakumaran 2007).
- Homosexualisation. Rape by another male can be aimed at stripping amanor boy of his heterosexual status-a particularly powerful attack in cultures where homosexuality is socially or religiously taboo or subject to extremepunishment (Sivakumaran 2007).
- Stigmatisation. Silence may be preferable to reporting forsomemale victims, for fear of ridicule and seen asweak or inadequate or being labeled homosexual or bisexual (Doherty & Anderson, 2004).
Male survivors of both adult and childhood sexual violence display a wide range of severe physical and psychological consequences of their experiences ( 2009: 57-66).
Physical, psychological and social consequences of male-directed sexual violence (Van Tienhoven 1993; Hardy 2002; Dube 2005; Crome 2006; Lewis 2009; Men and Healing 2009, Walker et al. 2005).
Physical: Male survivors may experience ruptures of the rectum; damage to the penis and testicles; penile/testicular/anal/rectal pain; HIV/AIDS; other sexually transmitted infections; other genital infections; abscesses; damage to reproductive capacity; or sexual dysfunction from physical sources.
Physical/psychological: At the intersection of the physical and the psychological levels, sexual violence survivors are highly likely to suffer from the physical manifestation, or "somatising," of emotional trauma. Common somatic complaints among male survivors include chronic pain in the head, back, stomach, joints, pelvis or heart; problems urinating or defecating; high blood pressure; general malaise; loss of appetite and weight; exhaustion; palpitations; weakness; sleeplessness; and sexual dysfunction, including impotence and premature ejaculation, that cannot be attributed to physical damage.
Psychological: Male survivors may experience feelings of overwhelming shame, humiliation, anger, fear and/or powerlessness; destruction of gender identity; or confusion over sexual orientation. These feelings can lead to withdrawal; depression; sleep disorders; loss of concentration; outbursts of anger and aggression; compulsive sexual behaviour; anxiety disorders and phobias; alcohol or drug abuse; fantasy and withdrawal; self-harm; and suicide attempts.
Social: As a result of the physical and psychological consequences outlined above, male survivors may experience marital and family problems, social withdrawal, delinquency, or losing their job (Lewis 2009; Oosterhoff et al. 2004; Walker et al 2005). For example, wives sometimes request to be divorced from men experiencing impotence as a consequence of sexual violence (interviews, International Council for the Rehabilitation of Torture Victims, July 2006). Where the violence is known to others, male survivors face being shunned by their community-a consequence well understood by perpetrators, who will sometimes spread word of assaults unofficially in order to ensure social ostracism (Peel 2004).
Disclosure and collection issues
It is generally accepted that rape and sexual violence are under-reported by both women/girls and men/boys globally. Men and boys face many of the same barriers to reporting sexual violence as women and girls do (Collings et al. 2005: 279, Sorsoli et al. 2008: 334), including:
- Shame. Men may find it difficult to talk about being victimized, which they consider incompatible with "being a man"-either in terms of the attack ("a man should have been able to protect himself") or in terms of its aftermath ("a man should be able to cope"). Men may feel particularly ashamed by an involuntary physical response to an assault (erection, ejaculation) (Peel et al. 2000, Peel 2004).
- Confusion and ignorance. Men and boys may lack the words to describe their experiences, or be uncertain about whom to approach or what is required for them to disclose violence. Lack of awareness amongst the general public and by professionals also contributes to lack of services and appropriate responses, often leading to discrimination and the subsequent silencing of victims. (Peel 2004, Hilton 2008).
- Guilt. Men who have been forced into sexual violence against others or boys who have been manipulated or coerced into 'taboo' sexual relations, may feel guilty about their actions (Hilton 2008).
- Fear. Men fear that they will not be believed; that their wives will leave them; that their family and community will look down on them; that they will be considered a potential child abuser; that face criminal penalties for being forced to rape; or that disclosure may lead to other unanticipated consequences (Peel 2004). They may also fear being labelled as homosexual, since many societies consider sexual contact between two males indicative of homosexuality, regardless of any elements of coercion or force involved (Sivakumaran 2005).
- Isolation. Due to the silence surrounding the issue, men and boys may believe that their experiences are unique, or that no one will believe or understand them (Peel 2004, Hilton 2008).
Meanwhile, doctors, counsellors and humanitarian workers themselves often do not pick up sexual violence against males. Some are not trained to look for signs of sexual abuse in males; some may take the silence of males on the subject at face value; some may not see men as being vulnerable to sexual violence in the first place (Burnett and Peel 2001: 608).
Care and support for male survivors: programming options
Organizations operating in conflict settings are increasingly aware of the need to include programming specifically directed at sexual violence survivors, and at sexual violence prevention, in humanitarian and disarmament/demobilization/reintegration (DDR) programming. The challenge is to acknowledge males as victims of sexual and reproductive violence while not overlooking their potential role as perpetrators, and while ensuring that attention to women is not diminished as a result (Carpenter 2006).
Public information campaigns. Public information campaigns have the opportunity not only to encourage reporting, but to help the untold number of male survivors who will never come forward to speak about their experiences (Peel 1994: 65). Male survivors rarely have information that might help them contextualise their experience. Indeed, asked what advice they would offer to the police and other professionals dealing with male rape victims, male rape victims in a British study-most of whom had never reported their rape to police, and over 40% of whom had never sought or received counseling-overwhelmingly called for more publicity on sexual violence against males (Walker et al. 2005: 75).
DDR programs. DDR programs are particularly likely to include male survivors, and hence are particularly able-and particularly need-to address male survivors. All DDR programs should:
- Recognise that men and boys may be subjected to sexual violence during military conscription or abduction into paramilitary forces, sometimes as part of integration and initiation rituals.
- Reinforce synergies between DDR and sexual violence programmes.
- Include interventions that focus on both victims and perpetrators of sexual violence, as well as initiatives to prevent such acts from occurring in post-conflict settings.
Themes for public information campaigns
- Public information campaigns should focus on delivering the messages of:
- You are not alone. Survivors often feel crushing isolation due to the silence surrounding sexual violence against males. Publicity campaigns should discuss sexual violence against males not only at the national but also at the international level, to help survivors understand that male-directed sexual violence occurs across the globe, during conflicts and in peacetime.
- It was not your fault. Male survivors need to be reassured that they have not brought sexual violence on themselves through their looks, their stature, or any other personal factor; rather, they have been the victims of brutality, whether individual, organizational or political.
- You do not need to question your sexuality. As noted above, survivors are often particularly confused and ashamed by involuntary physical arousal during an assault (Peel 2004). Publicity campaigns should make clear that involuntary arousal is a common occurrence and that it does not require a survivor to question his sexuality.
- The experience of sexual violence does not make you "less of a man." Publicity campaigns should provide messages that delink masculinity from aggression, invulnerability, and emotional silencing, and provide hopeful images of survivors who based their sense of masculinity on being a loving husband/father/son/brother/friend and a constructive member of the community.
- Men who have experienced sexual violence need the support of their families and communities. Publicity campaigns should seek to quash some of the common misperceptions about sexual violence against males, and to urge empathetic understanding.
Note: It is very important that messages be carefully designed to avoid unintentional reinforcement of traditional concepts of male dominance and discrimination against women and homosexual persons.
Specific reintegration programmes are necessary to help adult and adolescent males who have been forced to rape, both to help them reintegrate into communities that may wish to reject them and to help them address questions of how to establish non-violent relationships with women (DCAF 2007).
Boys who have experienced sexual abuse in conflict/post-conflict or refugee/internally displaced settings have particular needs as well. Programs that may help boys in these settings include generic drop-in centres where staff are trained to respond to sexual assault issues; round-the-clock 'safe spaces;' and telephone help lines for boys to access crisis support, information, advice and referrals, as well as prevention programs (Hilton 2008: 179-187; ECPAT 2006: 78-84). Special attention is necessary to the situation of unaccompanied and separated children, who are particularly vulnerable to abduction, trafficking, and being coerced or manipulated into prostitution or 'survival sex' (ECPAT 2006: 64-69).
Meanwhile, staff sensitization and training in relation to male-directed sexual violence are key for all organizations and local partners working in conflict/post-conflict settings. As well as incorporating male survivor issues in their basic trainings, organizations can develop or contract a range of specialist trainings for working with sexually abused men and boys, for instance on the impacts of sexual violence; defining and identifying abuse; responding sensitively to disclosure; and masculinity and cultural issues (Hilton 2008: 186-187).
Care and support for male survivors
The same factors that make it difficult for men and boys to report sexual violence can make it difficult for them to seek support for the consequences of violence (Crome 2006:1-2). Most studies of male childhood and adult sexual abuse, as well as interviews with torture care providers, suggest that male clients will rarely initiate disclosure without direct questioning (Sorsoli et al. 2008:343; interviews, International Rehabilitation Council for Torture Victims, 2006). Furthermore, addressing the needs of male survivors of conflict-related sexual violence is a highly complex task-particularly since sexual violence is often only one of the many forms of violence and trauma that survivors in conflict zones have experienced (Oosterhoff et al. 2004:71). The reluctance even of men and boys who seek trauma counseling to reveal sexual abuse further compromises the ability of service providers to focus specifically on the aftermath of their traumatic experiences (interviews, International Rehabilitation Council for Torture Victims, 2006; Sorsoli et al. 2008: 343).
Male survivors' cultural contexts may make them more or less reluctant to disclose sexual violence to one or the other gender. Males from some cultural contexts may be highly reluctant to speak of any sexual issue in front of female service providers or interpreter; other males may be completely unwilling to discuss sexual violence in front of another man of their own religion (Peel 1994: 61, 65). As a very broad rule, however, most studies suggest that most males are most likely to find it easier to talk to a woman initially (Sorsoli et al. 2008: 343), though where possible, a choice should be offered.
At a point that they consider appropriate, service providers should ask male clients directly about sexual violence in non-shaming ways (for example, "did anyone ever do anything sexually to you that you did not want them to?"). The issue may need to be raised more than once (Moreno and Grodin 2002: 213).
Beyond disclosure, the general principles of offering support and treatment to boys and men who have been sexually assaulted are similar to those for women and girls. Most importantly, male as well as female survivors need to be believed; to feel physically safe; to feel that their service providers empathizes with them; to feel free from judgment or blame; to be certain that they can speak confidentially; to be given time and encouragement; and to be accepted as a whole person, rather than being reduced to the status of 'victim' or 'perpetrator.'
Themes for care and support
- At the individual or group level, some possible themes for assisting malesurvivors include:
- Helping the client move away from particularly masculine forms of self-blame resulting from narratives of male invulnerability or, in the case of boys, having been entrapped into 'taboo' sexual relations (Peel 1994: 67).
- Reassuring the client about their sexual and moral identity. In particular, it can be very helpful to explain that erection and ejaculation are physiological responses to stress and physical stimulation; that they are not related to an individual's sexuality; and that they do not mean that a survivor is likely to become an abuser in the future (Peel 1994: 67). Service providers may also offer to help a survivor get a physical examination to reassure (if possible) that no lasting physical damage exists-particularly important if a client is suffering from sexual dysfunction (Peel 1994: 67).
- Helping survivors think critically about 'what it is to be a man.' Service providers can support men to see their experiences in the context of traditional expectations of masculinity; critically assess gender roles and religious/spiritual beliefs; and reformulate traditional codes based on their own experiences and needs (Lisak 1995, Kia-Keating et al. 2005, p. 183).
Finally, service providers need to be willing to speak out to raise awareness of sexual violence against males and to support of their clients; otherwise the "stigma, taboo, and feeling of being 'the only one' will continue, and will prevent males from coming forward to access help" (Holmes 1998: 85)
Research findings in Liberia and DRC highlight the urgent need for the humanitarian community to begin to address seriously the needs of men and boys who have experienced sexual violence in the context of violent conflicts. At the moment, the total human cost of the silencing and marginalization of men and boy survivors remains unknown.
Furthermore, the payoff for helping male survivors has the potential to extend beyond the individuals involved to help families and communities, and to combat violence against women and girls as well. When men's experiences of sexual violence are named and validated, this can provide a jumping-off point for including them as partners in efforts to reduce other forms of violence in conflict situations. For example, organizations engaging men in preventing violence against women have found that encouraging men to discuss their own experiences of violence helps them understand the impact of women's experiences of violence, and to renounce such violence. It remains for the humanitarian community to take up this challenge.
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Sexual Violence Research Initiative (SVRI) is hosted by the Medical Research Council, South Africa Reviewed by the SVRI Coordinating Group