REFUGEE MALE SURVIVORS OF SEXUAL VIOLENCE: CHALLENGES OF ACCESSING MEDICAL CARE IN UGANDA

by Charles Waddimba

Uganda is host to large numbers of refugees and asylum seekers from neighbouring countries in the Great Lakes Region, including South Sudan, Democratic Republic of Congo (DRC), Burundi and others. Under the Refugee Regulation Act 2010, Uganda offers the opportunity to anybody fleeing his or her country, who manages to enter Uganda, free access to health and the right to settle in a place of their choice, whether in camp settlements or urban centers 1. Although they are entitled to health care, however, several reports have revealed that male survivor of sexual violence in Uganda have difficulties accessing medical and health care services in practice. This is because they fear persecution and stigmatisation for being considered ‘homosexual’, despite their having been victims, or even being married. The environment in health care service places does not help these victims of sexual violence to open up about their traumatic and health- threatening experiences during war and displacement. My own study suggests that attitudes of medical staff and government officials with responsibility for addressing refugee-related problems should certainly be more receptive to the special needs of this especially vulnerable group of refugee men.

A lot of information about sexual violence against men has been hidden or silenced. These men do not fit dominant ideas that a man should be ‘strong’. Yet they are strong to even survive such violence and pain. To maintain the norms of ‘real men’ in Ugandan society, what is called masculinity, male victims of sexual violence are not taken seriously as men. A plethora of studies looks at how societal stigmatisation of male survivors of sexual violence damages lives. This short blog takes a step further towards understand challenges of these male survivors, given that they are made invisible as men, because of dominant ideas about masculinity and what a ‘real’ man is.

Boys and men are always told ‘BE A MAN’. If a man or a boy cries due to suffering or pain, then he is told, don’t be weak. Norms of how a man should feel, look, talk, act spread through society and have done more harm in preventing others from realising how male victims, just because they are men, also can be brave, strong, and yet suffer at the same time from sexual violence. These men have survived, and that is their strength. They need understanding, not jokes and rude comments. Not only doctors and officials can have bad attitudes towards male refugees who are victims of sexual violence. Society also, including media and religious institutions insist that men should be ‘strong’, are the leaders, the breadwinners, can take care of others, and do not need taken care of by others; they are not ‘weak’. These attitudes really opened my eyes during my interviews with male victims. The UNHCR resettlement criteria which look after the weak, the vulnerable and those survivors of sexual violence, only recognise women and girl survivors, and do not include male survivors for resettlement opportunities 2. Maybe men are not allowed to be victims, just as women cannot be too ‘strong’?

When it comes to experiences of survivors in accessing health care, barriers mean they often fear to disclose their health conditions until it has become worse or is too late for treatment, due to shame of being a victim of another man. This fear of being ridiculed or rejected hinders them accessing required health care, and alongside bad attitudes from staff. Even when eventually survivors pluck up the courage to go to the medical centre and talk about their condition, and their past medical problems, health care providers do not know how to listen to, treat and generally care for male survivors of sexual violence. Local village centres have inadequate medical supplies, but also the doctor or nurse may think the man is inventing his story; anything around sexual violence can bring out the worst in people, who may ‘blame the victim’, male as well as female.

There are a whole series of myths that I found, which seem to make it very difficult for many people to simply acknowledge male victims of sexual violence as genuine victims, as having good reasons for feeling vulnerable, or in poor health and in need of care. The myths include
these kinds of statements that those refugee male victims of sexual violence reported hearing.
“A man cannot be raped”
“A real man would defend himself against another man trying to rape him”
“He must have consented”
“A man who has been penetrated is a woman”
“He must now be a homosexual”.3
These are just some of the horrible things that are said to such men, who are already suffering and so isolated that some of them even commit suicide. This not only further hurts the survivors of sexual violence. It also creates in them a real fear of seeking help in future. The profound harm suffered by most male survivor during conflict and during flight often requires months of medical attention which they often do not get, resulting in infections, illness and trauma that could have been avoided if medical care had been accessed soon enough. For the victims to recover and feel whole again, the many NGOs that deal with sexual violence, especially of refugees and in conflict areas, need to provide services for the lower number of male survivors of sexual violence as well as for women. These men as well as these women need special help in accessing medical and health care services.

Unfortunately, popular culture in Uganda is steeped in heterosexist ideology, more than before. This makes male victims of sexual violence invisible, and tends to support violence and discrimination against them, on the grounds of what is claimed to be their ‘homosexuality’. Another myth! Both victims and perpetrators should not be placed in the same category of ‘deviants’. Those men who attack other men violently, may not be homosexual either, but certainly the victims as a social category should be protected and given health care they need, not stigmatised and made to suffer once again through no fault of their own. Being raped does not make you a homosexual.

Culture and religious beliefs around what it means to be a ‘real man’ is a problem. Negative social judgements and strong cultural norms are attached to men, and men are not supposed to be victims. This makes men with problems stay in the culture of silence. Refugees are a kind of ethnic minority in Uganda, and they find it even harder to be ‘real men’ since they lack money, income, job opportunities and social contacts. What it means to be a woman or a what it means to be a man are defined by cultural expectations of each sex, male and female. When a man seems not to meet what is expected of a man, he may have a hard time. He may also turn his trauma inward, and hate himself. Social ideas about masculinity, gendered stereotypes, social taboos and other factors against masculinity norms elucidate why many male survivors take years, or even decades to open up and seek help. There are few reported cases. Their small numbers are then used to justify further neglect and ignoring the problem in the hope that it will go away. It will not go away. The same problems that women had more in the past, of being blamed for being raped, or being accused of consenting to the sexual violence, or being blamed
for ‘adultery’, even though they were raped, are now all used against male victims of sexual violence.

Attitudes of health care providers have not been open enough for many male survivors of sexual violence. The widespread negative responses and subtle mockery towards them from nurses and doctors, is something they encounter, for example, in Mulago national hospital. Yet this is the main hospital that the Uganda government has dedicated to the treatment of survivors of forms of GBV (Gender-based violence), including especially rape and sexual torture and violence, in Uganda. If these men cannot feel comfortable seeking help in Mulago, where can they go?

What captured my attention during my own study for my masters, was how the decision not to have a shelter program for male survivors was justified in relation to the Ministry of Gender, Labour and Social Development. Yet gender is about women and men, both, not just about women. The Ministry has a shelter provision program for the women who have experienced sexual violence, and this includes victims who are refugees. This program enables Ministry staff to monitor recovery of these women, and make sure they are regularly getting check-ups and following their medical treatment. Yet male victims of sexual violence are just as likely, and maybe more likely, to have to be treated, for example for HIV/AIDs or other diseases, injuries and infections. The government claims that having male victims in the shelter alongside women could prevent women from getting better. They can surely have a shelter for men. This would help their recovery.

The UNHCR sometimes hinted during the study that some male refugees who say they have been sexually violated may be claiming this because they think this way they can qualify sooner for resettlement in a third country. This is very unfair for a refugees who tries to open up and honestly present their problems. It can be painful for that person not to be believed by doctors, and by officials in the immigration system. Someone who is not believed will not disclose in future, and their levels of trust will be very low. All this damages their healing process. Survivors reported in this study that talking about their experiences of sexual violence is the hardest thing for them to do. They may never have told these things to anyone, not even their family. Yet someone they don’t know thinks it is alright to laugh at this story. He can end up further traumatised when he is met with disbelief or ridicule. So not only the UNHCR but also the Government of Uganda immigration officials should become much more sensitive when it comes to casting doubt on refugee male sexual violence victims’ and their accounts of what happened to them, and how their health is suffering. Otherwise doctors and officials will risk re-victimizing male survivors who come to their agencies to seek help, and instead feel stigmatised.4

As a way of closing these loopholes, some years ago RLP (Refugee Law Project) took on the responsibility of identifying, and lobbying and advocating for male survivors of sexual violence. RLP asked for recognition of the problem, and for funds to train doctors and others, and to provide the medical care, counselling and other assistance needed for survivors. RLP has worked in partnership with the Ntinda private hospital in Kampala district, Uganda.

Recommendations
Translation
Advocacy needs to change to suit refugee audiences. Most documents are only circulated in English, which makes it hard for refugees who don’t speak English to get information. Therefore, translation of documents about how to get help for male victims of sexual violence
would be very helpful.

Art and Music Therapy

I recommend that male victim activists should explore using art, music, gardening, sports, dance and drama and cookery or carpentry etc. and other creative ways to become more positive about their situation. These methods can also be used to influence public attitudes, media and the youth, the youth being the pillars of tomorrow. Below are some more recommendations to support male survivors of sexual violence in their struggles to get proper medical care and other health services.

For NGOs (non-governmental organizations):

Sensitisation of professionals, victims and the public. NGOs and medical institutions, especially in camp settlements, should sensitize refugees to what they are able to help with, and not help with, so that the most vulnerable refugees, including male survivors of sexual violence, can access the services these institutions provide. As mentioned above, there needs to be some investment in translating information about availability of services.

Refugee Law Project has circulated various videos and documentaries to different stakeholders, but this work should intensify with the local health authorities, health workers, community and religious leaders. This should help to challenge negative perception of male survivors of sexual violence as not ‘real’ victims.

Medical institutions

Medical institutions and counselling agencies should encourage couple counselling among male survivors with sexual violence, with their partners or spouses. This can help avoid family breakups or domestic violence, since very often male survivors may have sexual problems,
including some related to ill health, and just as women find it hard to discuss, so too, and maybe even more, men will not always be able to open up to their wives about their traumatic experiences, especially if they were attacked sexually.

General recommendations

Couple counselling for the survivor and family is an urgent need for improved stability and quick healing for male survivors. Counsellors should endeavour to involve the wives of the male survivors in the counselling process so that they can give some hope and encouragement to the wives as well, who can then better appreciate the need for their husband to seek medical attention and to take appropriate medication regularly. However, men would still be encouraged to become responsible for their own preventative healthcare.

Redefining the term sexual violence, Policymakers should adjust the definition of sexual violence to include issues related to male as well as female survivors. The term ‘she’ and ‘her’ should be replaced either by ‘they’ and ‘their’ or by s/he and hers/his, so that men and women with similar sexual injuries can be helped by improved delivery of both treatment and justice.

Including male survivors of sexual violence in priority resettlement categories. Men and women are not always affected in the same by their experiences of sexual violence. For this reason, UNHCR should adjust its resettlement criteria to include vulnerable male survivors of sexual violence as well, especially those who require treatment for physical and mental health. They do need to get medical services and support than are at a similar level to those offered to women survivors of sexual violence.

The need for screening to identify male survivors. All stakeholders and medical practitioners who receive refugees should come up with screening tools which identify and keep track of cases related to sexual violence for both men and women. This should improve service delivery considerably for both women and men affected by sexual violence.

Support shelters for the victims. The Ministry of Gender, Labour and Social Development needs to provide venues and funding for at least some support shelters for male survivors of sexual violence, preferably in men-only units. This can make the treatment of male victims more sensitive to men’s priorities and concerns.

Sensitisation of inter-religious council. This body consists of leaders of different religious and faith-based denominations in the country. The researcher and activists should organise a meeting and have face-to-face conversations about male refugee survivors of wartime sexual violence. In this way, it is hoped they will understand the difference between a someone choosing to be a gay person and a male survivor who has been attacked and violated.

Language barrier. Bi-lingual NGO activists and survivors who speak both languages should translate at least short versions of articles and laws etc. so these can be disseminated to communities where most male survivors reside. This would help to show that they exist, and give people also an idea of how to support them. Local language translations are important as well, if attitudes are going to improve.

Other forms of advocacy, In this age activists should try and look for other ways to do advocacy on-line, and through phone apps, for example. People – apart from lawyers and academics – do not want to read long, detailed and complex information. Most people would like something that can capture their attention (such as sport, music, drama etc). At the same time, they are being education on the existence of sensitive matters that affect people in their own communities. Male survivors of sexual violence in conflict should be considered full members of their communities.

By and large, this article shows the need to challenge some stigmatising myths that circulate in society and in the world of health and medical care. These are made worse by the often negative self-images of victims and survivors. To enable male survivors of sexual violence to access the full range of medical care they need, social and cultural attitudes need to change so that these victims and survivors are visible to most service providers. Policymakers, government institutions (medical institutions) and NGOs need to cooperate to enhance medical services for this neglected group. This article does not undermine all the efforts to prevent and repair harm caused by sexual violence against women. However, based on the findings from this study about male refugees in Uganda seeking health care, we should be aware that even though male refugee survivors are vulnerable, have suffered and feel pain, even so they are also as brave, as talented and as deserving as any other person who needs proper medical services in order to get well and recover.

  1. PBS NewsHour, Why Uganda is the world’s most hospital refugee destinations,
    ( https://www.youtube.com/watch?v=hDyp45ELPzQ&list=PLVEnIKMg_2WsZovKLMYdCEWzbGreS0gc4 ) , 2016.
  2. United Nation High commission for refugee, 2011 version, 243.
  3. Dr. Chris Dolan, Investigating Conflict-related sexual violence against men in Africa,
    (https://www.youtube.com/watch?v=7ADpH7VkbbY) ,2014.
  4. Patricia. Washington vol 14 no.7, Second assault of male survivors of sexual violence ( San Diego State University, 1999), 3.