EXECUTIVE SUMMARY
Women and girls in Afghanistan are extremely vulnerable to gender-based violence (GBV) and face substantial barriers accessing healthcare facilities to seek help after such violence. This is widely known. Much less is known about sexual violence committed against men and boys, the barriers male victims/survivors face accessing healthcare facilities, or the quality of healthcare provision available to them.
This report presents the findings of research conducted by international non-governmental organisation All Survivors Project (ASP) with its partner on the ground in Afghanistan, Youth Health and Development Organization (YHDO). With this research, ASP and YHDO seek to:
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Cast light on the healthcare needs and experiences of male victims/survivors of sexual violence in Afghanistan and the barriers they face accessing quality healthcare services.
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Understand the practices of healthcare providers, and the barriers they face, in supporting male victims/survivors of sexual violence.
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Learn about how a survivor-centred approach to healthcare provision is applied in Afghanistan in the case of male victims/survivors.
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Produce a set of recommendations for enhanced survivor-centred healthcare services for male victims/ survivors of sexual violence that can be used to develop a tool for the health sector.
The research was conducted in three provinces of Afghanistan: Kabul, Balkh and Kandahar, with data collection conducted during the second half of 2020, under special measures adopted in light of the COVID-19 pandemic.
The research adopted a qualitative approach involving four key methods: -
A desk review, including literature on sexual violence against men and boys and the health sector response, with a focus on evidence from Afghanistan.
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A stakeholder mapping to identify existing systems of healthcare response that include coverage of male victims/survivors, conducted predominantly through a desk review of online documents.
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Ten key stakeholder interviews were conducted with a range of individuals, from government, national and international NGOs, and UN agencies.
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Ninety-seven in-depth interviews were conducted – 27 with male victims/survivors of sexual violence, 44 with healthcare providers working in different types of static health care facilities, and 26 with community health workers.
The results of the ASP/YHDO study suggest that the health sector is currently a vastly underused entry point for male victims/survivors of sexual violence in Afghanistan, due to multiple and cumulative barriers preventing them from accessing healthcare services.
Before elaborating on these barriers, the report outlines the structure of Afghanistan’s healthcare system under which services operate at three main levels: community, district, and provincial/regional. There is an upward referral system under which more complex cases are referred to higher levels where there are larger numbers of healthcare staff, services and resources. In addition to the different types of static and mobile health services overseen by the Ministry of Public Health, some health facilities are run privately.
A range of services has been developed specifically to address the health care needs of victims/survivors of GBV, although these are largely directed towards women and girls. Thirty-seven Family Protection Centres (FPCs) have been established in 26 provinces and form part of a wider multi-sector response to GBV programme that provides health, police and justice services for victims/survivors, with FPCs providing the primary entry point. FPCs are located in government provincial and regional hospitals to ensure their sustainability within the national health system, and provide support to victims/survivors, including basic health services, medical support, psychosocial counselling, legal support, help in collecting evidence and providing referrals to other services. FPCs may not be accessible for all victims/survivors, particularly those who live in more remote locations. Consequently, some NGOs working in humanitarian response now send mobile outreach teams to visit communities and provide GBV services and referrals.
Several resources have been developed by a range of organisations to facilitate higher quality of health care provision for victims/survivors of GBV, although, much like GBV services, these resources are largely directed towards women and girls. These include a training manual for health professionals on a traumasensitive approach to care for victims/survivors of GBV in Afghanistan; Standard Operating Procedures for Healthcare Sector Response to GBV; and the GBV Treatment Protocol for Healthcare Providers in Afghanistan (GBV Treatment Protocol).
The GBV Treatment Protocol contains comprehensive information and guidance on a range of topics, including legal frameworks and requirements, patient flow, confidentiality, documentation and reporting, survivor-centred care, identifying and responding to patient disclosures of GBV, and different types of care for victims/survivors. The Protocol is intended to provide guidance on healthcare response to all GBV victims/ survivors; however, although it notes that men and boys, particularly adolescent boys, can experience sexual exploitation and violence, the Protocol emphasizes that women and girls are disproportionately affected by GBV and the Protocol is largely targeted towards them.
The barriers preventing male survivors/victims of sexual violence accessing quality healthcare services are detailed in the ASP/YHDO report and are outlined in Table 1 below. Adopting a social ecological model of public health, the barriers are differentiated by level, of which there are five: individual, interpersonal, community, organisational, and structural. These barriers do not operate in isolation and male victims/survivors face multiple, mutually reinforcing barriers, making access to healthcare services extremely challenging.
Poverty and inability to pay for services, including fees in private healthcare facilities (which are often perceived to be of higher quality and safer) and for medications or other services in government facilities, were highlighted as important barriers. Further, victims/survivors with poor socio-economic status living in rural or remote areas were reported to struggle to pay for transport to access a healthcare facility at the district level or in the provincial centre.
The legal and policy environment in Afghanistan in relation to male victims/survivors of sexual violence appears to be an important structural barrier to help-seeking. Despite no legal requirements for mandatory reporting of GBV cases in Afghanistan, male victims/survivors reported strong fears that healthcare providers would disclose their case to judicial actors without their consent. These fears are likely linked to same-sex sexual acts being criminalised and concerns that, despite rape being criminalised under the Penal Code, healthcare providers will make judgements about whether sexual acts are consensual or non-consensual.
The research found some examples, specifically in Balkh province, where this appears to be the case.
The research identifies several rape myths that circulate about why sexual violence against men and boys occurs. Male victims/survivors are more likely to reproduce victim-blaming discourses, perhaps due to internalised stigma and blame received from others. In contrast, healthcare providers are more likely to justify the behaviour of perpetrators by suggesting that social and cultural norms and practices, including expensive weddings and gender segregation, lead to men’s uncontrollable sexual desire. In either case, perpetrators are not portrayed as being actively responsible for the sexual violence they perpetrate, with the locus of responsibility being placed on victims/survivors and their families.
The ASP/YHDO report examines how communities might support male victims/survivors of sexual violence.
It suggests that community health workers (CHWs) could play a role in supporting male victims/survivors and facilitating their access to health facilities, although there are gaps in CHWs’ knowledge of how to provide confidential and survivor-centred care. The report also suggests that community leaders, religious leaders and members of community health councils may also have a role to play in reducing barriers to male victim/survivors’ access to healthcare facilities by raising awareness of and preventing stigma against male victims/survivors and supporting them to access services. However, significant work needs to be done with community and religious leaders to challenge their negative attitudes and potentially violent behaviours towards male victims/survivors.
The report describes the perspectives of male victims/survivors and of healthcare providers on the care pathway for male victims/survivors in health facilities, and the typical experiences that men and boys might expect to have in receiving care, including survivor-centred care. The majority of the healthcare providers interviewed had knowledge about the characteristics of a survivor-centred approach and in most cases were able to articulate how such an approach would be implemented with male victims/survivors, even though few of them had ever provided services to a male victim/survivor of sexual violence.
The descriptions given by healthcare providers on how to implement such an approach were largely in line with the guidance provided in the GBV Treatment Protocol, despite few of them having been trained in the use of the Protocol and the Protocol being largely framed around the needs of women and girls. To identify and illustrate the extent to which current practices and systems to address the needs of male victims/ survivors are aligned with the GBV Treatment Protocol, the ASP/YHDO research findings are set alongside the guidance in the Protocol – including its guidance to ensure respect, empathy, and non-judgement, to ensure privacy and confidentiality, and in relation to the question of referrals to judicial actors, and of survivor choice and control.
Despite the healthcare providers’ overall knowledge of survivor-centred care, the report points to significant dissonance between their descriptions of the care they would provide to a male victim/survivor, and the treatment that male victims/survivors expect to receive. This could be due to victims/survivors being unaware of more recent advancements in health sector responses to GBV more generally. However, it may also be due to persisting gaps in healthcare providers’ attitudes, knowledge and practices with regards to male victims/ survivors of sexual violence.
For ethical and safety reasons, the victims/survivors interviewed for this research were all adults, leaving an acknowledged gap in the research. However, several male victims/survivors disclosed that they had first experienced sexual violence as a child. Healthcare providers also described how services may differ for boys in comparison with adult men, and several healthcare providers reported having previously provided services to boy victims/survivors of sexual violence. Consequently, some retrospective analysis of healthcare provision for boys is provided.
Healthcare providers did articulate barriers that boy victims/survivors of violence face in accessing healthcare services, including lack of knowledge of how to access a facility. However, healthcare providers appeared to lack awareness of the different needs of adults and children, and an understanding of how the evolving capacities of the child should be integrated into healthcare response. This may be due to most of the healthcare providers interviewed never having provided services to male victims/survivors of sexual violence, whether boys or adults. However, lack of understanding of or capacity to implement an approach that recognises the evolving capacities of the child was also found among healthcare providers who reported having provided services to girl victims/survivors of sexual violence, suggesting that there is a wider gap in this area.
More broadly, the research identifies other gaps in the provision of healthcare services to male victims/ survivors of sexual violence. Healthcare providers emphasized, for example, the unavailability of psychosocial services for victims/survivors of violence, and the lack of capacity of psychosocial counsellors to deliver services specifically to male victims/survivors of sexual violence.
One of the most important healthcare needs of male victims/survivors of sexual violence is to be treated with no judgement, blame or stigma. Victims/survivors also strongly emphasised the importance of confidentiality and the need to trust that a healthcare provider would not disclose their case to family or community members and, importantly, judicial actors, without their consent. Healthcare providers also emphasised the importance of these principles of care; however, it is unclear the extent to which they are implemented in practice. The research findings suggest that some healthcare providers may reproduce blame or stigma when male victims/survivors of sexual violence engage in sex work or if they identify as having diverse SOGIESC.
Further, the research points towards a possible gap in healthcare providers’ recognition of male victims/ survivors with diverse SOGIESC as a vulnerable group in need of services, or as legitimate victims/survivors of sexual violence. This lack of recognition may be due to assumptions that male victims/survivors with diverse SOGIESC who access health facilities for sexual violence have in fact consented to sexual acts and, thus, that these cases should be classed as sodomy, which is illegal under the Afghan Penal Code. It is unclear from the research what kinds of legal provisions healthcare providers are required to abide by with regards to male victims/survivors of sexual violence, including respect for confidentiality and rights to instigate the criminal justice process or not. Although the GBV Treatment Protocol articulates legal provisions for female survivors, the protocol does not articulate the rights of male victims/survivors of sexual violence.
Concerns about stigma and shame feed into victim/survivors’ fears of disclosure of sexual violence to healthcare providers, and subsequent fears that they may be punished or experience further violence from perpetrators or even families if healthcare providers breach confidentiality and share their cases with others, including judicial actors. Victims/survivors also reported fears of being raped or sexually abused by healthcare providers and suggested that male victims/survivors with diverse SOGIESC may be at particular risk. These fears of confidentiality breaches, or of experiencing further sexual violence at the hands of a healthcare provider, feed into deep lack of trust in healthcare provision, which restricts victims/survivors from accessing a healthcare facility or disclosing their experience of sexual violence to a healthcare provider.