By Lydia Day
By January 2013, less than two years into the Syrian conflict, there were only three public mental health facilities in Syria remaining. Between late December 2012 and early January 2013, one of these facilities, the Ibn Khaldun Psychiatric Hospital, suffered severe shelling and bombardment. The intensity of this attack forced doctors to flee the hospital, abandoning patients without food or water. Patients began to leave the bombed-out hospital for the streets of Eastern Aleppo. It was reported by both News24 and the Syrian Observatory for Human Rights that two of these patients were subsequently killed by snipers.
This is one example of the extreme impact that explosive weapons use in Syria has had on mental health facilities. Dr. Zaher Sahloul, a Syrian-American trauma specialist and former president of the Syrian American Medical Society, estimated in 2017 that there were 50 psychiatrists remaining in Syria, roughly half of those who were there before the conflict began in 2011. Before the conflict, Syria had relatively well-developed medical facilities and had a high number of doctors for the region. However, this was not the case for its mental health facilities, which were understaffed and underdeveloped. Both the state and humanitarian agencies did not provide enough institutional or local support for mental health issues.
Medical facilities in Syria have been devastated by the conflict. Both Russia and Syria have been accused of deliberately targeting hospitals and civilians as part of their bombing campaigns. Both states, however, have strenuously denied that such attacks are intentional, arguing instead that they are unfortunate collateral damage. Organisations such as Bellingcat and Syrians for Truth and Justice have carried out extensive investigations into these claims, focusing on Idlib where hospitals were at the forefront of the conflict. Physicians For Human Rights have also produced a map documenting all attacks on healthcare facilities in Syria since the beginning of the conflict.
“The hospital where I was treated was far from a fully equipped hospital; it was more like a dispensary. They could manage to do some emergency procedures, but they were not equipped with what I needed. Also, it was a scary place. It had been shelled many times. We were all in the basement so that the bombs would not reach us. It still did not feel safe. We knew that it was a target. All hospitals were.”
Moreover, the impact of these attacks on healthcare facilities in Syria are deeply gendered. This is especially pertinent when it comes to mental health and psychiatric support. This article asks how, in the context of the Syrian conflict, mental health is gendered and why it is useful to acknowledge the role of gender. It builds upon Action on Armed Violence’s (AOAV) previous work in investigating the relation between explosive violence and gender.
The United Nations High Commissioner for Refugees (UNHCR) has identified three categories of mental health impacts from conflict. These are: the impact on people with pre-existing mental health issues, the impact on those with mental health issues caused by conflict internally, and the mental health of refugees and displaced people. This article traces how each of these categories are gendered.
Mental health and psychological effects of the Syrian conflict
Prior to the conflict, there were no extensive reports on the prevalence of psychological disorders amongst the Syrian population. The International Committee of the Red Cross (ICRC) report that Syria largely adheres to the World Health Organisation’s (WHO) projections of mental disorders in adult populations affected by emergencies. However, these projections are not disaggregated by gender. There have also been no extensive quantitative studies done into the gendered prevalence of mental disorders and psychological effects in the Syrian conflict. Thus, it is necessary to rely on anecdotal reports to ascertain how gender and mental health may be linked.
Surveys assessing the mental health of Syrian refugee populations begin to expose the psychological toll the conflict has taken. The German Federal Chamber of Psychotherapists reported that around 50% of Syrian refugees living in Germany had mental health problems. The International Medical Corps (IMC), also found high rates when they examined health facilities for internally displaced people and Syrian refugees. Their findings were that over 50% using these facilities had emotional disorders and over 25% of children had intellectual and developmental issues.
Several NGO and humanitarian agency reports begin to elucidate how the psychological effects of conflict may be gendered. Humanity & Inclusion note that female Syrian refugees in Jordan and Lebanon were significantly more likely to cite the fear, stress, and distress caused by explosive weapons as a reason for fleeing than men.
The widespread Sexual and Gender Based Violence (SGBV) in the Syrian conflict may also be a significant factor in understanding gendered psychological effects. ISIS have used rape and sexual violence as a weapon of war against civilian populations, especially against Yazidi women. Many women and girls, and to some extent men and boys, have been exposed to SGBV resulting from conflict-related violence and societal breakdown. This has been augmented by the use of explosive weapons against civilians in populated areas as women and girls face displacement and unsafe homes. The prevalence of SGBV in the Syrian conflict is likely to have significant psychological effects on survivors. The ICRC report states that it is SGBV which is the most under-addressed by mental health services in refugee camps, perhaps due to a strong clash between religious and sexual taboos.
Accessing mental health services
The use of explosive weapons has severely harmed the ability of people in Syria to access mental health services. Humanitarian agencies and grassroots organisations in refugee camps or neighbouring countries have provided some services to those fleeing the conflict. For example, the Syrian Arab Red Crescent (SARC) was the first to open clinics with a psychiatrist, a psychotherapist and a speech therapist. They also introduced mobile psychosocial support teams to go between the worst affected places and assess mental health services for children. The IMC have also set up centres for mothers and children to access mental health services.
There are distinctly gendered issues with accessing mental health services in Syria. In their guidelines for mental health practitioners, the UNHCR note that “many segments of Syrian society have sharply defined gender norms that may influence all aspects of mental health and psychosocial support, including the sources of stress, expressions of distress, coping mechanisms and help-seeking behaviour.”
For example, women tend to spend less time in public spaces than men and are expected to have fewer interactions in such spaces. These gendered norms are potentially amplified by the use of explosive weapons as it becomes even more unsafe for women to spend time in streets, hospitals, and marketplaces. So, for women living in Syria, accessing psychiatric facilities may be highly unsafe. These dynamics change, to an extent, for women who are living in refugee camps or who are now living in countries such as Lebanon, Jordan, or Turkey. The services provided by organisations such as Syrian Arab Red Crescent or the IMC are more likely to be attended by women along with their children. The UNHCR notes that if psychosocial support and mental health care are integrated into a more general women’s programme, there may be a much higher participation rate, but a significant issue remains in letting women know that psychosocial services exist. A report by UN Women found that amongst female Syrian refugees living in Turkey, 59% of respondents had not heard of the mental health services available to them.
There are significant gendered hindrances for men and boys accessing mental health care in Syria, as well. UN Women report that in Syrian refugee camps, some of the boys experience a pervasive sense of social isolation and subsequently rarely leave their homes. Stringent gender norms hinder men from accessing mental health services. According to the IMC, many men in these refugee camps do not feel comfortable accessing mental health services due to stigma. Instead, coping mechanisms for trauma and distress include sleeping, social isolation, and displays of anger. There have been reports that domestic violence incidents against women and children in Syria have increased during the conflict. This may be in part due to the stress, lack of access to support services, and trauma of conflict. Testimonies of many Syrian refugees confirm these reports. One woman told UNHCR:
“Men are becoming angry — they can’t provide for their family. My husband wasn’t a smoker— now he is. He is extremely irritated all the time and takes it out on the kids. He is violent towards the kids; he is violent towards me.”
Approaches to improve gender-based access to mental health services for Syrians must also take into account other demographic factors. Both Humanity & Inclusion and HelpAge International note that there has been an increased emphasis on accessing mental health care in social settings, with a focus on accessibility for both elderly and disabled civilians. The emphasis on mothers and children accessing these services together risks side-lining elderly women who also face increased social isolation. This is particularly concerning given that older Syrian refugees in Lebanon and Jordan have displayed three-times higher rates of mental distress than the average refugee population. The integration of mental health services into social activities, such as sports or in community centres, potentially ostracises civilians with injuries caused by explosive weapons.
LGBT+ Syrians also face significant barriers in accessing mental health services, both in Syria and in refugee camps. The risks to this group have significantly increased since the beginning of the conflict, as they have become more vulnerable to abuse and targeting from extremist groups. One LGBT+ survivor of sexual abuse told UNHCR:
“I was detained in Syria for four months. We didn’t have food. They would torture us, violate us. They used sticks. After I was released I could not sit without pain. I still have problems, but I am scared to tell the doctor because he might report me for being gay.”
The high levels of stigma and abuse they face make it difficult for them to access supportive mental health services they can trust.
As the Syrian conflict continues, its effects on the mental health of civilian populations continues to be underreported and under examined. This is especially true when it comes to gender. The lack of mental health services and psychiatric infrastructure in Syria prior to the conflict, the targeting of hospitals, and often inadequate conditions in refugee camps have meant that it is incredibly difficult to provide civilians with mental health support. Yet both the nature of psychological effects and access to these services are distinctly gendered.
While both men and women have access issues, the root causes of this are often different although both governed by strict gender norms. The dissuasion of women from entering public spaces, combined with the increased danger of conflict, means it is often difficult for them to access institutional mental health support. For men, it may be the stigma around discussions of mental health and pressure to be brave which may prohibit their access. And while the work of organisations such as the Syrian Arab Red Crescent and IMC offer some hope that these issues may be addressed, much more needs to be done. Some hard statistical evidence would be a good place to start.
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