A social ecological approach to understanding service utilization barriers among male survivors of sexual violence in three refugee settings: a qualitative exploratory study

No evidence, no problem? A critical interpretive synthesis of the vulnerabilities to and experiences of sexual violence among young migrants in Europe

BACKGROUND

Growing evidence indicates that young migrants are particularly vulnerable to sexual violence, however most research has focused on instances of sexual violence occurring in conflict zones and during transit. Much less attention has been given to the vulnerabilities to and experiences of sexual violence among young migrants in Europe.

OBJECTIVES

To understand the scientific evidence regarding the experiences of and vulnerabilities to sexual violence among young migrants (aged 11-30 years) in Europe.

METHODS

A search of three databases resulted in 1279 peer reviewed articles published between 2002 and 2022. Of these, 11 were included in this review. A critical interpretive synthesis methodology was applied.

RESULTS

Few studies investigate sexual violence among young migrants in Europe. The existing studies focus on very specific sub-groups of migrants, and as such, experiences of persons outside these groups are largely absent from the academic discourse. How sexual violence is understood varies across studies, often conflated with other forms of violence, hampering comparisons. However, the results of this review indicate that young migrants in Europe, both male and female, experience sexual violence and there are multiple sources of vulnerabilities at all levels of the socioecological model.

CONCLUSION

The scarcity of research regarding sexual violence among young migrants in Europe could give rise to the perception that no evidence means no problem, resulting in a continued lack of attention to this issue. There is a critical need to address this gap to inform prevention interventions, to identify victims, and to facilitate access to care.

A qualitative study on the health system-related needs in women survivors of rape

BACKGROUND

Rape, as an adverse incidence, leads to irreparable complications and consequences in women. Provision of health services to women survivors of rape requires catering for their real needs and identifying current deficits as well as barriers. The present study aimed to explore health system-related needs in women survivors of rape.

METHODS

In the present qualitative study, the participants consisted of 39 individuals, including 19 women survivors of rape and 20 individuals with work experience in providing services to women survivors of rape. The participants were selected using the purposive sampling method with a maximum variation in Isfahan, Iran. Data were collected through in-depth interviews as well as field notes and were concurrently analyzed via conventional qualitative content analysis method.

RESULTS

After analyzing the interviews, the health system-related needs of women survivors of rape were classified into two main categories: 1- The need for efficient medical care services with three sub-categories, namely "receiving services with respect for privacy and confidentiality", "non-judgmental behavior and approach", and "the need to receive empathy and the feeling of not being alone", and 2- The need for desirable conditions and structure to provide services with two sub-categories, namely "the need to receive comprehensive and integrated services", and "establishing specialized centers for providing services to survivors".

CONCLUSIONS

Overall, explaining and highlighting the health system-related needs of women survivors of rape could provide a suitable basis for policy-making and planning according to their real needs. Receiving continuous services in separate centers with confidentiality and empathy could reduce the worries and concerns of women survivors of rape and help improve their health.

Neurological Care of Refugees and Other Forcibly Displaced Persons

There are more than 100 million forcibly displaced persons (FDPs) in the world today, including a high number of people who experience neurologic symptoms and presentations. This review summarizes the conceptual frameworks for understanding neurological health risks and conditions across the migration journey (premigration, migration journey, and postmigration) and life span, including special attention to pediatric FDPs. The interaction with psychiatric illness is discussed, as well as the available published data on neurologic presentations in FDPs in the medical literature. A social determinant of health lens is used to provide ways in which forcible displacement can influence brain health and neurological outcomes. Priorities and future needs for the neurological care of refugees and other FDPs are suggested.

Characteristics of Sexual Assault Among Men Receiving a Forensic Medical Examination

Sexual assault is a form of violence disproportionately perpetrated against women by men; however, men also experience high rates of sexual victimization. While recent research exploring victimization of sexual assault among men does exist, little is known about situational characteristics and consequences surrounding men's assault experiences. Therefore, the current study examines narratives of men's sexual assault to further understand the unique experiences of men receiving a sexual assault medical forensic examination. To accomplish this, we conducted a retrospective medical chart review of sexual assault narratives from N = 45 men receiving a sexual assault medical forensic examination at a large academic medical institution in the southeastern United States. Three general constructs were identified within the records: a) Perpetrator use of coercive tactics, b) Memory loss, and c) Contextual factors. Nested within these constructs, five specific themes emerged, including: a1) Use of weapons and physical force; a2) Tactical administration of alcohol and drugs; b1) Difficulties remembering assault; c1) Consensual sexual activity turned non-consensual; c2) Incarceration. Findings from the present study common identified characteristics of sexual assaults among men receiving a sexual assault medical forensic examination, including coercive tactics used by perpetrators, consequences of sexual assault, and high-risk settings for male victimization.

Service-seeking behaviors among male victims of violence in five African countries: The effects of positive and adverse childhood experiences

BACKGROUND

Violence against boys and men is widely under-reported. Boys and men face unique and gendered barriers to accessing services following experiences of violence.

PARTICIPANTS AND SETTING

The study is a secondary data analysis of five nationally representative population-based Violence Against Children and Youth Surveys (VACS) conducted in Kenya (2019), Côte d'Ivoire (2018), Lesotho (2018), Mozambique (2019), and Namibia (2019). Analysis was limited to males between 18 and 24 years who experienced lifetime physical or sexual violence.

OBJECTIVE AND METHODS

We analyzed the association between positive and adverse childhood experiences (PCEs and ACEs), and seeking post-violence services among males using bivariate chi-squared tests and multivariable logistic regression.

RESULTS

8.02 % (5.55-10.50 %) of male victims between the ages of 18 and 24 sought services for any lifetime physical or sexual violence. Witnessing interparental violence and experiencing death of one or both parents were each associated with increased odds of having sought post-violence services (aOR 2.43; 95 % CI: 1.25-4.79; aOR 2.27; 95 % CI: 1.14-4.50), controlling for education, violence frequency, and violence type. High parental monitoring was associated with increased odds of service seeking (aOR 1.79; 95 % CI: 1.02-3.16), while strong father-child relationship was associated with lower odds (aOR 0.45; 95 % CI: 0.23-0.89).

CONCLUSION

These findings contribute to limited research on service-seeking behaviors among men and boys. While some parent-youth relationship factors were associated with higher odds of service-seeking, the outcome remained rare. Age and gender-related barriers should be addressed where post-violence care services are offered.

Addressing the needs of cisgender, heterosexual men and LGBTIQ+ survivors of sexual violence: a scoping review of service delivery and funding priorities among humanitarian organisations

Sexual violence in humanitarian contexts is a global public health issue. Yet, evidence suggests that humanitarian organisations may not always be inclusive of cisgender, heterosexual men and LGBTIQ+ survivors in their responses. This scoping review examines the extent to which global organisations focusing on sexual and gender-based violence (SGBV) address the needs of cisgender, heterosexual men and LGBTIQ+ survivors in service delivery and funding priorities. We examined grey literature published from 2013-2023 on SGBV service delivery and funding priorities in humanitarian contexts. Forty-seven documents were included in the final analyses, which comprised content and thematic analyses. Many of the documents acknowledged cisgender, heterosexual men or LGBTIQ+ individuals as at-risk groups; however, there was a lack of comprehensive discussion of these groups. Documents on LGBTIQ+ individuals referred to the group as a monolith, making little distinction among the LGBTIQ+ experience and the need to tailor responses to meet intersectional needs. Documents on men emphasised their role as perpetrators and allies, while overlooking that they also experience sexual violence. Findings support the critical need to address gaps in humanitarian programme and donor priorities to better ensure inclusion of cisgender, heterosexual men and LGBTIQ+ individuals without ignoring the needs of women and girls.

Negative consequences of conflict-related sexual violence on survivors: a systematic review of qualitative evidence

BACKGROUND

Conflicts exacerbate dynamics of power and inequalities through violence normalization, which acts as a facilitator for conflict-related sexual violence. Literature addressing its negative outcomes on survivors is scant. The aim of this systematic review was to analyze the qualitative evidence reported in scientific literature and focusing on the negative consequences of conflict-related sexual violence on victims' physical, psychological, and social dimensions of health in a gender-inclusive and disaggregated form.

METHODS

A literature search was conducted on January 13, 2023 on Pubmed, Scopus, and PsychArticles. The search strings combined two blocks of terms related to sexual violence and conflict. A time filter was applied, limiting the search to studies published in the last ten years. Information regarding the main characteristics and design of the study, survivors and their experience, and about conflict-related sexual violence was collected. The negative consequences of conflict-related sexual violence on the physical, psychological, and social dimension of victims were extracted according to the Biopsychosocial model of health. The review followed the Joanna Briggs Institute methodology for systematic reviews and relied on the Preferred Reporting Items for Systematic reviews and Meta-Analyses.

RESULTS

After full text review, 23 articles met the inclusion criteria, with 18 of them reporting negative repercussions on physical health, all of them highlighting adverse psychological outcomes, and 21 disclosing unfavorable social consequences. The negative outcomes described in multiple studies were sexual and reproductive health issues, the most mentioned being pregnancy, manifestations of symptoms attributable to post-traumatic stress disorder, and stigma. A number of barriers to access to care were presented as emerging findings.

CONCLUSIONS

This review provided an analysis of the negative consequences of conflict-related sexual violence on survivors, thus highlighting the importance of qualitative evidence in understanding these outcomes and addressing barriers to access to care. Conflict-related sexual violence is a sexual and reproductive health issue. Sexuality education is needed at individual, community, and provider level, challenging gender norms and roles and encompassing gender-based violence. Gender-inclusive protocols and services need to be implemented to address the specific needs of all victims. Governments should advocate for SRHRs and translate health policies into services targeting survivors of CRSV.

Sexual exploitation of children: Barriers for boys in accessing social supports for victimization

BACKGROUND

The global evidence regarding sexual exploitation of children (SEC) is expanding, however, the majority of research continues to focus on girls. ECPAT International's Global Boys Initiative is a major contribution to broadening knowledge by exploring how sexual exploitation impacts boys specifically.

OBJECTIVE

This discussion paper explores data from the initiative to better understand how boys and children of all genders may be impacted by sexual exploitation.

PARTICIPANTS AND SETTING

During 2019-21, research was undertaken by ECPAT member organizations into the sexual exploitation of boys in 10 primarily low-and-middle income countries globally. The initiative also supported a global systematic scoping review of published and gray literature published in this issue (Moss et al., in press).

METHODS

Gender norms analysis of Initiative data identifies critical thematic issues impairing access to support services for victimized boys.

RESULTS

Most disconcerting is gender-based stigmatization from services that can compound children's trauma. Justice-based, rather than trauma-informed models of support predominate in responses for boys. Legal frameworks create barriers when binary gendered terminology defines sexual violence, thereby excluding anyone other than women and girls from protection.

CONCLUSIONS

Three solutions emerged to improve access to support for more children affected by sexual exploitation: (1) challenge problematic gender norms and consequent practices, such as gendered terminology in legislation, that create barriers for boys and gender-diverse children; (2) create psychologically, emotionally, and physically safe circumstances (i.e. trauma-informed care) for all children to know help-seeking is possible; and (3) undertake proactive support that specifically connects boys and gender-diverse children to therapeutic services like drop-in centers, night-time counseling, and emergency shelter.

Understanding the effect of gender-based violence on uptake and utilisation of HIV prevention, treatment, and care services among transgender women: a qualitative study in the greater Kampala metropolitan area, Uganda

BACKGROUND

Transwomen (also known as transgender women) are disproportionately affected by all forms of gender-based violence (GBV). The high prevalence of physical, sexual and emotional violence not only predisposes transwomen to HIV infection but also limits the uptake/access to HIV prevention, care, and treatment services. Despite the high prevalence of HIV infection and GBV among transwomen, there is limited evidence on how GBV affects the uptake and utilisation of HIV prevention, care, and treatment services. Therefore, this qualitative study explored how GBV affects uptake and utilisation of HIV prevention, treatment, and care services among transwomen in the Greater Kampala Metropolitan Area (GKMA), Uganda.

METHODS

This participatory qualitative study was conducted among transwomen in the GKMA. A total of 20 in-depth interviews, 6 focus group discussions, and 10 key informant interviews were conducted to explore how GBV affects the uptake and utilisation of HIV prevention, treatment, and care services among transwomen. Data were analysed using a thematic content analysis framework. Data were transcribed verbatim, and NVivo version 12 was used for coding.

RESULTS

At the individual level, emotional violence suffered by transwomen led to fear of disclosing their HIV status and other health conditions to intimate partners and healthcare providers respectively; inability to negotiate condom use; and non-adherence to antiretroviral therapy (ART). Sexual violence compromised the ability of transwomen to negotiate condom use with intimate partners, clients, and employers. Physical and emotional violence at the community level led to fear among transwomen traveling to healthcare facilities. Emotional violence suffered by transwomen in healthcare settings led to the limited use of pre-exposure prophylaxis and HIV testing services, denial of healthcare services, and delays in receiving appropriate care. The fear of emotional violence also made it difficult for transwomen to approach healthcare providers. Fear of physical violence such as being beaten while in healthcare settings made transwomen shun healthcare facilities.

CONCLUSION

The effects of GBV on the uptake and utilisation of HIV prevention, care, and treatment services were observed in individual, community, and healthcare settings. Across all levels, physical, emotional, and sexual violence suffered by transwomen led to the shunning of healthcare facilities, denial of healthcare services, delays in receiving appropriate care, and the low utilisation of post-exposure prophylaxis, and HIV testing services. Given its effects on HIV transmission, there is a need to develop and implement strategies/ interventions targeting a reduction in GBV. Interventions should include strategies to sensitize communities to accept transwomen. Healthcare settings should provide an enabling environment for transwomen to approach any healthcare provider of their choice without fear of experiencing GBV.

Participation in Everyday Occupations Among Rohingya Refugees in Bangladeshi Refugee Camps

IMPORTANCE

Bangladesh hosts a large number of Rohingya refugees from Myanmar. Living in refugee camps, the Rohingya refugees face challenges in everyday occupations because of violence, limited opportunities, and corporal punishment by the community.

OBJECTIVE

To explore how Rohingya refugees experience participation in everyday occupations while living in temporary refugee camps in Bangladesh.

DESIGN

Phenomenological study to describe, understand, and interpret the meanings of life experiences in particularly adverse conditions.

SETTING

Rohingya refugee camps in Bangladesh.

PARTICIPANTS

Fifteen purposively selected participants from the camps.

OUTCOMES AND MEASURES

In-depth semistructured interview, as well as participant and environmental observations. Researchers used line-by-line data analysis to capture quotations and patterns using interpretive phenomenological analysis, which included establishment of initial codes, interpretation, determining selected codes, and categorization.

RESULTS

The research identified four major themes-(1) mental stress, sleep disturbances, and daily occupations; (2) adjustment to inconsistent daily activities; (3) complex relationships and limited social roles that decreased occupational engagement; and (4) involvement in precarious occupations that exacerbated severe health risks-and four subthemes-(1) fragmented family relationships, (2) formation of new relationships to perform social roles, (3) inconvenient and inaccessible living conditions, and (4) continuation of unlawful work to survive.

CONCLUSIONS AND RELEVANCE

Rohingya refugees should receive comprehensive health and rehabilitative care because of their perilous mental health conditions, precarious occupations, and lack of trustworthy relationships with family and neighbors. What This Article Adds: Rohingya refugees experience imbalanced, deprived, and maladapted occupations in refugee camps. Suggestions to improve their lived experience with further peer support programs may help them participate in occupation-based rehabilitation services to facilitate their social integration.

[Assessment of the Individual Experience of Sexual Violence in War and Forced Displacement and its Consequences Among Male Victims: A Narrative Literature Review]

From a psychological perspective, male survivors of sexual violence in the context of war and forced displacement represent a highly burdened population. An adequate assessment of traumatic events and trauma related disorders is often hampered by both disclosure barriers from the patient side as well as by lack of awareness on the part of healthcare professionals regarding male victimization. Based on a narrative literature review, relevant characteristics of violence and their relation to the diagnostic process are elaborated on eight dimensions of individual experience of violence (form of violence, frequency and severity, perpetrator-victim context, societal discrimination, subjective evaluation, concept of masculinity, culture-specific norms, and trauma sequelae). The dimensions are delineated in a case study. In order to thoroughly assess sexualized experiences of violence, there is a need for sensitivity on the part of practitioners to the signs of male victimization and regular assessment of sexualized violence in male patients. In this context, certainty about the confidentiality of the information disclosed and recognition of the injustice are of central importance for those affected. In the long term, the development of specialized support services for male victims is needed.

Enhancing a survivor-centred approach to healthcare provision in Afghanistan: Understanding and addressing the barriers faced by male victims/survivors of sexual violence

BACKGROUND

Men and boys may experience sexual violence, particularly in conflict settings. However, in Afghanistan little is known about the barriers they face accessing healthcare services.

OBJECTIVE

The objectives are to identify barriers to healthcare provision for male victims/survivors of sexual violence in Afghanistan and identify ways to enhance survivor-centred healthcare.

PARTICIPANTS AND SETTING

Data were collected in three provinces with adult male victims/survivors of sexual violence (n = 27), healthcare providers (n = 44), and community health workers (n = 26). Boys were not interviewed due to ethical reasons; however, we include retrospective analysis where possible.

METHODS

The methods include semi-structured, qualitative interviews with participants. Data were analyzed thematically according to a social ecological model of public health. The study was ethically approved by the Afghan Ministry of Public Health.

RESULTS

Male victims/survivors of sexual violence in Afghanistan face multiple and cumulative barriers to accessing healthcare services. Stigmatization and fears of being sexually abused by healthcare providers are particularly accentuated for those victims/survivors with diverse sexual orientation, gender identity, gender expression, and sex characteristics (SOGIESC). Boy victims/survivors also face particular barriers, including healthcare providers' lack of knowledge of the evolving capacities of the child.

CONCLUSIONS

Survivor-centred healthcare response to male victims/survivors of sexual violence should address barriers at multiple levels of the social ecological model, and respond to the needs of male victims/survivors from different vulnerable groups, including boys and those with diverse SOGIESC.

Severity, symptomatology, and treatment duration for mental health disorders: a retrospective analysis from a conflict-affected region of northern Nigeria

Background

Mental Health and psychosocial support (MHPSS) programs are essential during humanitarian crises and in conflict settings, like Nigeria’s Borno State. However, research on how types of traumatic stress and symptom severity affect clinical improvement is lacking in these contexts, as is consensus over how long these patients must engage in mental health care to see results.

Methods

Records from 11,709 patients from the MHPSS program in Pulka and Gwoza local government areas in Borno State, Nigeria from 2018 and 2019 were retrospectively analyzed. Patient information, symptoms, stress type, severity (CGI-S scale), and clinical improvement (CGI-I and MHGS scales) were assessed by the patient and counselor. Associations between variables were investigated using logistic regression models.

Results

Clinical improvement increased with consultation frequency (OR: 2.5, p < 0.001 for CGI-I; OR: 2, p < 0.001 for MHGS), with patients who received three to six counseling sessions were most likely to improve, according to severity. Survivors of sexual violence, torture, and other conflict/violence-related stressors were nearly 20 times as likely to have posttraumatic stress disorder (PTSD) (OR: 19.7, p < 0.001), and depression (OR: 19.3, p < 0.001) symptomatology. Children exposed to conflict-related violence were also almost 40 times as likely to have PTSD (OR: 38.2, p = 0.002). Most patients presented an improvement in outcome at discharge, per both counselors (92%, CGI-I) and self-rating scores (73%, MHGS).

Conclusion

We demonstrate a threshold at which patients were most likely to improve (3 sessions for mild or moderate patients; 6 sessions for severe). In addition, we identify the specific types of stress and symptom severity that affected the number of sessions needed to achieve successful outcomes, and highlight that some stress types (especially torture or having a relative killed) were specifically linked to PTSD and depression. Therefore, we emphasize the importance of classifying patient stress type and severity to identify the appropriate duration of care needed.

Status of the stateless population in Thailand: How does stigma matter in their life?

Background

The stateless population in Thailand live by accessing all public services, including the health care system. Stigma is a crucial factor impacting these individuals’ lives and their access to medical care. This study aimed to understand the experience of the stateless population in Thailand and how they overcome the problem of stigma.

Methods

A qualitative method was used to elicit information from key informants who were members of the stateless population, which was classified as those who did not hold Thai identification cards (IDs). A questionnaire was used to guide the interview, which was conducted in a private and confidential room. The interviews were conducted after voluntary agreement was obtained from the participants; each interview was held in August 2021 and lasted for approximately 45 minutes.

Results

Fifty-one people participated in the study; 68.6% were females, 86.3% were married, and 90.2% were Akha or Lahu. The stateless population in Thailand reported four types of perceived stigma: having a lower ability to request that their needs be met, not being equal to others, not being able to qualify for health care services and being ranked below other hill tribe people who have IDs. The phrase “life is nothing” was presented by the participants, who reported that they felt like an invisible population in Thailand. Some participants reported that other hill tribe people who have IDs act as stigma perpetuators among members of the stateless population who do not have IDs. Maintaining their privacy within their village, trying to obtain a Thai ID, and practicing the Thai language were the main ways of avoiding the stigma reported by the stateless population. Obtaining a Thai ID was detected as the top goal in their aim to overcome the stigma problem.

Conclusions

The stateless population in Thailand live as an invisible population and are negatively treated via various patterns from others. Accessing Thai IDs and education are argued to be the most effective procedures for addressing the problem under the implementation schemes of the relevant organizations.

Sexual Violence Against Men in Conflict and Post-Conflict Settings: A Qualitative Research Methodology

Sexual violence against men in conflict and post-conflict settings is under-researched. Men’s reluctance to talk about their experiences in conflict and post-conflict settings has contributed to the subject being a difficult area of inquiry. This article describes the research design and the strategies employed by the first author, who conducted qualitative research with South Sudanese male refugees who were survivors of sexual violence and have resettled in two communities in Uganda since the onset of the 2013 South Sudan conflict. The qualitative research is a part of a mixed-method program of research for the first author’s doctoral research that focused on sexual violence perpetrated against men in conflict and post-conflict settings. Based on the learnings during the fieldwork in this complex research setting and by drawing on best practices in qualitative research, this article proposes guidelines that can assist researchers who conduct qualitative research with vulnerable populations (across multiple disciplines) on sensitive topics such as sexual violence. The guidelines include five key steps: spending time in the community before participant recruitment and data collection, fostering a trust relationship with stakeholders, using appropriate gatekeepers, making participants feel at ease throughout the research, and using the snowballing sampling technique. The key steps are interdependent and can be adapted to suit the research context. These guidelines can be useful across multiple disciplines and subject areas.