All Survivors Project Foundation, ‘The Health of Male and LGBT Survivors of Conflict-Related Sexual Violence’, 2020

EXECUTIVE SUMMARY

KEY FINDINGS

• Weak and sparse evidence base for intervention development and evaluation;

• No studies on interventions targeting men, boy and LGBT survivors specifically and explicitly;

• No evaluations of interventions addressing physical health, sexual and reproductive health and medico-legal responses;

• De-contextualised findings of many impact evaluations on mental health;

• Studies conducted only in a few countries;

• Most interventions are single sector approaches, but flexible and comprehensive models are valued.

Conflict-related-sexual-violence (CRSV) against women and girls has received increasing attention globally. At the same time, less is known about men, boys and LGBT persons who suffer CRSV. Research estimates that, in some context, the magnitude of CRSV against men and boys is extremely high, with prevalence rates ranging from 32.6% in Liberia to 21% in Sri Lanka. The health and social consequences of CRSV for the lives of men, boys and LGBT persons are severe and long-lasting. CRSV against men, boys and LGBT persons is largely motivated by gendered expression of domination and control. Despite the severe health and social burden associated with CRSV, evidence on interventions addressing the health and wellbeing of male and LGBT survivors of CRSV remains scarce, and limited resources and support are available to target their needs.

This report addresses these gaps by summarising and expanding on key findings from a forthcoming realist review by the authors on health interventions for men, boys and LGBT survivors of CRSV. The review was preceded by a first workshop with key international stakeholders (London, 11-12 October 2018) to identify parameters and scope of a conceptual framework on responses for male and LGBT survivors in conflict and displacement settings.
Findings from the realist review were complemented with results from a second experts meeting (Geneva, 5 March 2019) with international stakeholders and a rapid review of medical and mental health guidelines and protocols for assisting survivors of sexual violence. This report aims to contribute to the growing field of research, intervention development and implementation on CRSV against men, boys and LGBT persons.

A systematic approach was used to identify evaluations of interventions addressing the medical and mental health of male and LGBT survivors of CRSV. To inform a theory of change for interventions responding to the health needs of survivors, the review then used a purposive approach to explore gender differences in implementation, mechanisms of change and outcomes of interventions.

We did not find any evaluation of interventions that specifically and explicitly targeted the needs of male or LGBT survivors of CRSV. Most studies we identified were on Mental Health and Psychosocial support (MHPSS) interventions. Although some interventions identified in our systematic search included male participants, the results were not disaggregated by gender. No studies evaluated interventions that explicitly included LGBT participants.

This report uses the umbrella term LGBT to include a number of groups defined by diverse sexual orientations and gender identities. Our analysis focussed on sexual minority men and transgender people, though studies which present data disaggregated by the categories within the LGBT concept, remain extremely limited. Therefore, our review does not provide a basis for conclusions about each of these groups individually.

The results of our rapid review of international guidelines and protocols also suggests that the specific needs and vulnerabilities of male and LGBT survivors still receive limited attention in international documents guiding policy and practice. Although CRSV against male and LGBT survivors have been increasingly recognised in these documents, most still do not provide specific recommendations on how to design and implement interventions that respond to the specific needs and concerns of these populations.

Evidence on the implementation, evaluation and effectiveness of these guidelines is also sparse. In our literature review, we found only one pilot evaluation of implemented guidelines on CRSV that offered promising results.

Our literature review found that access and continuity of care are deeply affected by insecurity, population mobility, limited infrastructure, gender and social norms, and restricted financial and human resources. In settings where the nature and duration of the conflict are particularly severe, health systems are largely affected or inexistent. In many settings, the presence of armed groups hinders dislocation from home to the nearest point of care both for clients and providers and affects home visits. Looting and pillage of health facilities may also reduce adherence by forcing clients to travel further to seek care. This politically fragile and resource limited context affects how priorities are defined in the policy agenda, and the availability, accessibility, acceptability and quality of services. Interventions that rely on community-based models of care may provide valuable alternatives to access and treatment for all survivors.

Community-based interventions can also tackle common barriers in access to care for male and LGBT survivors, including lack of knowledge about existing services, the belief that available services only provide care for women and girls, or uneasiness to access services.

The review identified different interventions aiming to facilitate survivors’ access to services, although none reported specific strategies to engage male or LGBT survivors. Strategies to improve access to care included training community leaders, core groups and “counsellor mothers”; relying in internet-based treatment and local service networks; implementing home visits, mobile clinics and one-stop strategies.

Strategies that rely on community-based organisations and resources, and on faith-based organisations, have been promoted as a feasible and cost-effective way to reach vulnerable populations in fragile settings. However, there are limited evaluations of how communitybased and faith-based components may foster awareness, help-seeking behaviours and social inclusion among male and LGBT survivors of CRSV. Researchers have also expressed concerns in relation to tension between specific religious agendas and core values of the rights-based policy framework.

Access to care for survivors of CRSV is also affected by lack of services preparedness to respond to the needs of male and LGBT survivors. Research has suggested that the fear of negative reactions, such as homophobia, disbelief, and blame from the police or health providers may prevent male survivors from disclosing sexual abuse and accessing timely services. Negative attitudes by providers are likely to reinforce survivors’ self-blame, prevent adherence to treatment and prevent recovery. Research also suggests that in some contexts less sympathy is displayed by providers in relation to male survivors when compared to female survivors. LGBT survivors are also more likely to be blamed than those who do not identify as such.

Our review identified three studies of interventions that provided training and sensitisation to health care providers. These interventions targeted both community health workers and clinical personnel. Results from these evaluations were mixed, indicating that more studies are needed.

Key stakeholders in the field recognise the need for inter-sectoral and integrated models of care for survivors of CRSV. Key links identified in our review as important for health responses to CRSV were education and health; protection and MHPSS; physical and mental health; basic needs and mental health; and medico-legal assistance, justice and accountability. However, evidence on the feasibility and effectiveness of these strategic links in different contexts is still missing. One study in our review highlighted the challenges of coordinating different sectors in poorly resourced settings. We did not find data specifically addressing male and LGBT needs.

Findings from evaluations of Mental Health and Psychosocial Support (MHPSS) interventions that included men and boys reported effectiveness in reducing symptoms of depression, anxiety, PTSD, dysfunction or post-traumatic grief. No data on effect-size by gender were published in these studies. Therefore, we cannot determine whether the interventions were equally effective for women and men, or whether they were effective at all for male survivors.
This gap in knowledge is particularly important in light of the gender differences in access, uptake and response to psychological or mental health treatments. Research has indicated that men employ riskier coping strategies, are often less successful in resolving trauma and may find it difficult to share their experiences and emotions. These barriers to interventions’ effectiveness are probably linked to gender differences in motivation, commitment and responses to psychological treatment.

Additionally, in contexts of humanitarian emergencies, the access and effectiveness of mental health interventions depends on the basic needs of survivors being addressed. For example, mental health is unlikely to be prioritised by survivors who are struggling to feed themselves or find shelter. At the same time, mental health can deteriorate if these needs are not met.
Factors such as poverty and armed conflict may act as daily stressors in the lives of CRSV survivors, and can further hinder access to basic health services, compromising positive mental health outcomes.

Initiatives on sexual and reproductive health often focus exclusively on women and girls and refrain from targeting men. However, male and LGBT survivors of CRSV may experience, as a result of the violence, sexually transmitted infections (STIs) including HIV, sexual dysfunctions, genital infections, impotence and infertility among other impacts. These potential health consequences affect not only individual survivors, but their partners, families and communities.

To date, no review, including ours, has identified interventions addressing the long-lasting impact of CRSV on the sexual and reproductive health of men, boys and LGBT survivors.
Nonetheless, male involvement is fundamental for the prevention of STIs and HIV.

There is some evidence supporting HIV and STI education, and condom distribution campaigns in conflict settings. However, to date there is no data on how male and LGBT involvement can help prevention, and even less on targeted initiatives for survivors. Evidence on fertility and reproductive assistance for male survivors of CRSV is also missing.

To our knowledge, our review was the first systematic realist review investigating medical and MHPSS interventions for male, boys and LGBT survivors of CRSV. We identified many evidence gaps on interventions for male survivors of CRSV, including the absence of: studies including LGBT survivors; results disaggregated by gender; studies on physical health, sexual and reproductive health and medico-legal and forensic responses including male and LGBT survivors. Studies including male survivors also had a limited geographical scope. Moreover, there is an age gap in knowledge about CRSV. In the literature, girls and boys are often mentioned in conjunction with women and men respectively, but data disaggregated by age is rarely presented.

The almost exclusive focus of research and policy on heterosexual cis-women’s risk obscures the experience of men, boys and LGBT survivors of CRSV. The neglect of male and LGBT needs may further enhance health and protection risks among these groups. It is therefore critical for researchers, policymakers, providers and other key stakeholders to recognise that the needs of male and LGBT survivors are real and require attention.