Hidden survivors of sexual violence: challenges and barriers in responding to rape against men in Eastern DRC

H IDDEN SURVIVORS OF SEXUAL VIOLENCE : CHALLENGES AND BARRIERS IN RESPONDING TO RAPE AGAINST MEN IN E ASTERN

DRC

In Partial Fulfilment of the Requirements for a Master of Science in Peace and Development Work, June 2021.

Author: Ali Bitenga

Supervisor: Susanne Alldén Examiner: Jonas Ewald Term: Spring Semester 2021

Subject: Peace and Development Work Level: Master

Master’s Thesis

C ONTENTS

... 1

1. Background and Justification ... 6

1.1. Purpose and relevance of the study ... 7

1.2. Delimitations and limitations ... 8

1.3. Thesis structure ... 8

2. Literature review ... 10

2.1. Explaining sexual violence against men and care for survivors ... 10

2.2. Locating knowledge gaps in the literature ... 12

2.3. Historicity of sexual violence against men in armed conflicts ... 13

2.4. Prevalence of sexual violence against men in armed conflicts ... 13

2.5. Forms of sexual violence against men in armed conflicts ... 14

2.6. Causes of sexual violence in armed conflicts ... 15

2.7. Consequences of sexual violence against men in armed conflicts ... 16

2.8. Positioning the thesis in relation the literature ... 17

3. Theoretical /Analytical Frameworks ... 18

3.1. Ecological framework ... 19

3.2. Holistic care model for survivors of sexual violence ... 20

3.3. Gender theory and the concept of hegemonic masculinity ... 20

4. Methods of investigation ... 23

4.1. Research settings ... 23

4.2. Research design and data collection ... 25

4.3. Reflexivity and positionality ... 29

4.4. Ethical consideration ... 29

4.5. Data analysis ... 30

5. What it means to be a man in Eastern DRC ... 31

5.1. How perception of masculinity affects health-seeking behaviour for male survivors of sexual violence ... 38

6. Challenges and barriers related to assistance of male survivors of sexual violence ... 44

6.1. Response to sexual violence ... 44

6.2. Challenges and barriers related to Medical care ... 45

6.3. Challenges and barriers related to psychological care ... 48

6.4. Socioeconomic challenges and barriers ... 51

6.5. Legal challenges and barriers ... 52

7. Systemic inattention to the plight of male survivors of sexual violence ... 55

7.1. Consequences of inattention to male survivors’ needs on gender sensitive

programming ... 62

Conclusion ... 63

References ... 66

Index ... 76

Abstract

Most studies on sexual violence against men focus on forms, causes and consequences of

this phenomenon giving little/or no attention to complex challenges and barriers affecting

access to care for survivors. Drawing from semi-structured interviews with service

providers, male survivors and from focus group discussions with community members in

Eastern DRC, this thesis set out to explore challenges and barriers related to meeting the

needs of male survivors of sexualized violence. Findings were interpreted through the

lenses of ecological and gender theories and through hegemonic masculinity and holistic

care model concepts. Generally, findings show that gender beliefs regarding masculinity

and rape, lack of information about care programmes for male survivors, a dysfunctional

justice system, distance from home to care programs and insecurity were perceived as

major impediments to care access for male survivors. While masculinity constituted a

barrier to health care for most male survivors, this thesis shows that it can also facilitate

access to health care for some survivors. Discussion and analysis of the findings point out

to a systemic inattention around the issue of sexual violence against men reinforcing

barriers to health care. The thesis shows that existing responses have mainly been designed

to address sexual violence against women and need to be re-adapted to male survivors

without losing focus on female survivors as they suffer most from sexual violence.

Acknowledgement

First, I would like to express my deepest gratitude to my supervisor Susanne Alldén for encouragement, constructive feedbacks, mentoring and humor during this Master’s thesis preparation. In the beginning, I felt incapable of completing this thesis in due time but you told me: ‘you can do it Ali, I do not see the reason that can delay your thesis.’ This encouragement and trust led me to the completion of this Master’s thesis. Above all, I take this advantage to thank you for your mentorship throughout my academic journey in both DRC and in Sweden. I owe a lot to you.

I would like to extend my gratitude to my interviewees in DRC including to male survivors, service providers and community members who accepted to share their experiences and stories with me in order to reveal the ‘unspoken’ to the world. I also wish to thank my colleagues and friends who invested financially and emotionally in my studies at Linnaeus University. My special thanks to Lisa Peters, Maria Baard, Naama Haviv, Peters Frantz, Lynn Nygaard and many more friends I wish to keep anonymous. I could not have started this Master’s programme without your invaluable support.

Finally, I would like to thank all my tutors at Linnaeus University namely Jonas Ewald,

Christopher High, Manuela Nilsson and Heiko Frantz. I learnt a lot from you and will never

forget you. Jonas, the concept of ‘multilevel analysis’ I learnt from you in the course of

International Context and Politics of Peace and Development has become my academic

credo to analyze social and political phenomena as you will realize in this thesis.

1. B ACKGROUND AND J USTIFICATION

The Eastern part of the Democratic Republic of the Congo has experienced armed conflicts for more than two decades. Due to higher prevalence of sexual violence in armed conflicts, the DRC has been branded the rape capital of the world (BBC, 2010). Although Sexual violence affects both women and men in the DRC, it has received greater attention as a crime against female survivors while male survivors remain almost invisible in academic discourses, policy debates and programming (Christian et al., 2011). The hyper-invisibility of rape against men in academic discourses, policy and programming is what Grey and Shepherded (2013) described as ‘absent present’ cases of sexual violence in armed conflicts.

Johnson et al (2010) reveals that there are approximately 760,000 men in need of sexual violence related care in North Kivu, South Kivu, Ituri, and Maniema in Eastern DRC.

However, assistance for male survivors is daunting and problematic in part due to their unwillingness to report sexual violence (Carpenter 2006, kiss et al., 2020). While we know that male survivors need post rape care, there is no systematic scholarly discussion regarding challenges faced by service providers and survivors of sexual violence themselves respectively when providing and seeking care, and about causes of underreporting (Dolan, 2014; Grey & Shepherd, 2013; Carpenter, 2006).

I argue that silence around the issue of sexual violence against men is a social phenomenon

in itself, which needs to be scrutinized and theorized. The DRC presents a good case from

which to learn challenges and barriers related to assistance of male survivors given higher

prevalence of sexual violence in the country and existence of care programmes (see

Peterman et al., 2011; Johnson et al., 2010).

1.1. P URPOSE AND RELEVANCE OF THE STUDY

Weiss (2010) argues that the lack of knowledge and programming to address sexual violence against men is in part due to the ways in which sexual violence and masculinity have been constructed in most modern societies. This study has three main interrelated research goals. First, i will explore how community perception of masculinity influences health-seeking behaviour of male survivors. Second, i shall investigate how services providers, male survivors and communinity members perceive challenges and barriers related to assistance of male survivors . Finally, i will examine causes of underreporing of sexual violence against men and draw a chain of responsibilities. Specifically, this thesis contributes to the academic debate on sexual violence against men by answering three interelated research questions:

 How does the community perception of masculinity affect health-seeking behaviour of male survivors?

 How do service providers, male survivors and community members perceive challenges and barriers related to meeting the needs of male survivors of sexualized violence ?

 What are factors contributing to underreporting of sexual violence against men ?

Panzi Hospital in Eastern DRC has provided care to more than 80. 000 survivors of sexual

violence of whom 1% are male survivors (see Berg& Mukwege, 2016). This figure

suggests that most male survivors do not benefit from assistance in Eastern DRC but factors

explaining the scarcity or absence of gender sensitive services have not been systematically

studied and theorized. Studying barriers and challenges related to assistance of male

survivors of sexualized violence and causes of underreporting is therefore,

epistemologically important as it can broaden our understanding of multiple factors hampering access to care for male survivors. Some scholars point out that most service providers lack practical skills to respond to sexual violence against men in several countries around the world (eg., Dolan, 2014; Kiss et al., 2020). I argue that the idea that service providers lack skills to respond to sexual violence against men ontologically obfuscates our understanding of complex factors hindering access to care for male survivors.

1.2. D ELIMITATIONS AND LIMITATIONS

This thesis draws from semi-structured interviews with service providers, male survivors and from focus group discussions with community members in Eastern DRC. It looks specifically at three main service providers in South Kivu namely Panzi Hospital, Panzi Foundation DRC and Mulamba Clinic. The thesis focuses on challenges and barriers related to assistance of male survivors of sexualized violence in South Kivu. It is beyond the scope of this thesis to discuss causes of sexual violence against men in eastern DRC and how to respond to this phenomenon. The findings of this thesis should not be generalizable to all conflict contexts as it only draws from a few respondents in Eastern DRC. However, its findings provide important insights into how perceptions of masculinities shape both how care is sought and given, which can at some extent, illuminate other conflict-ridden countries with a similar situation.

1.3. T HESIS STRUCTURE

This thesis is structured as it follows. After the introduction, the second chapter reviews

what is known about sexual violence against men in armed conflicts and positions the thesis

in relation to the literature. Then, theoretical and methodological discussions follow

respectively in the third and the fourth chapters. Findings and analysis are combined, and

are presented in the fifth and sixth chapters. The fifth chapter discusses what it means to

be a man in Eastern DRC and how masculinity influences health-seeking behaviour for

male survivors. The sixth chapter presents challenges and barriers related to assistance of

male survivors from the perspectives of service providers, male survivors and community

members. The last chapter is a systematic discussion of the previous two chapters and how

they feed into theories, and attempts to grasp causes of underreporting of this phenomenon.

2. L ITERATURE REVIEW

The aim of this chapter is to gain an understanding of existing research and debates relevant to the topic and then position the thesis in the literature about sexual violence against men.

I start by showing how sexual violence has been conceptualized, and then provide a definition of what is understood as sexual violence in the thesis before presenting ‘the known and the unknown’ in different subsequent subsections.

2.1. E XPLAINING SEXUAL VIOLENCE AGAINST MEN AND CARE FOR SURVIVORS

Rape has traditionally been conceptualized as the forced penetration of a woman by a male

perpetrator (see Weiss, 2010). However, this conceptualization of rape is problematic as it

feminizes victimization, overlooks its various forms and most importantly, sidelines male

survivors in policy and programming (Kiss et al., 2020). The dominant discourse on sexual

violence in armed conflicts portrays males as perpetrators and females as victims (see

Weiss, 2010; Onyango & Hampanda, 2011). This thesis circumvents the simplistic binary

construct of ‘male perpetrator and female victim’, and adopts a more gender-neutral and

broader definition of sexual violence including its different forms. Sexual violence is

understood in this thesis as any physical or psychological violence carried out through

sexual means or by targeting sexuality – including rape, attempted rape, molestation, sexual

slavery, being forced to undress or being stripped of clothing, forced marriage and insertion

of foreign objects into the genital opening or anus, forcing individuals to perform sexual

acts on one another or harm one another in a sexual manner, or mutilation of a person’s

genitals (United Nations,1998).

Sexual violence negatively affects physical, psychological and social well-beings of survivors (Mukwege & Nangini, 2009). However, several survivors of sexual violence do not have access to adequate health care in conflict-ridden countries due to several barriers including but not limited to shame and lack of health care services ( Gracia-Moreno et al., 2015). The holistic care model has been implemented in several conflict-ridden countries primarily for female survivors to address various consequences of sexual violence in armed conflicts (Mukwege& Berg, 2016). The holistic care model is built around four pillars including medical, psychological, socioeconomic and legal pillars. The medical pillar addresses health consequences associated with rape including sexually transmitted diseases, unwanted pregnancies for women etc. The psychological pillar provides psychosocial support to survivors helping them heal from trauma, depression, anxiety etc.

The socioeconomic pillar provides loans, microcredits and vocational training programmes to survivors. The legal pillar provides legal assistance to survivors.

There is evidence that the holistic care model helps female survivors regain their dignity and agency at micro (personal) and macro (community) levels (Mukwege & Berg, 2016).

Although sexual violence against men in armed conflicts has occurred in more than 25 countries, most male survivors do not benefit from health care assistance (see Onyango &

Hampanda, 2011). For this reason, Onyango and Hampanda (2011) call for gender-

sensitive sexual health services for male survivors as biologically different persons from

women. Lwambo (2013) points out that the effects of sexual violence on male survivors

may affect women and communities in different ways given the interactive nature of

gender. Therefore, women and community in general can be affected in different ways if

men are left untreated.

2.2. L OCATING KNOWLEDGE GAPS IN THE LITERATURE

Significant progress has been made to advance our understanding of sexual violence against men in armed conflicts. However, the existing literature mainly focuses on six main themes elaborated on further below including historical accounts, prevalence, forms, causes, consequences of this phenomenon and various care needs for male survivors post- rape. No research has so far been conducted at operational level within the holistic care model to generate empirical evidence regarding the extent to which the model responds to male survivors’ specific needs as gendered persons, and challenges associated with their care. Using an ecological analytical framework, this thesis covers this knowledge gap and sheds light on complex challenges and barriers that male survivors and service providers face respectively when seeking and providing care.

Furthermore, the literature points out to the ‘hyper-invisibility’ of sexual violence against men in programming, policies and in academic discourses (Kiss et al., 2020; Grey &

Shepherded, 2013). I argue that the silence around the issue of sexual violence against men

is in itself a social phenomenon that needs to be scrutinized and theorized in order to better

understand its origins. while male survivors ’s underreporting /lack of reporting is well

known , the reasons why men are more likely to abstain from seeking care are poorly

understood and rarely addressed. The next subsections discuss what is known about sexual

violence in armed conflicts including but not limited to history, forms, causes, and

consequences of sexual violence against men.

2.3. H ISTORICITY OF SEXUAL VIOLENCE AGAINST MEN IN ARMED CONFLICTS

Evidence shows that sexual violence against men in armed conflicts is as old as the war itself (eg.Vikaman, 2005). This author shows that since antiquity Herodotus wrote about the Persian practice of castrating male enemies during war. This practice was also frequent in ancient Egypt, Rome and in Israel during fightings. Raping men and women of the conquered cities symbolized ‘total victories in total wars’ in several ancient civilisations (Vikman, 2005). This author shows that in several ancient battlefield most men were killed and more women were raped than the former: ‘women are raped in Zion, young women in the towns of Judah’ (Lamentations: 5.11) cited by Vikman, 2005). The Ottoman Turks were also infamous for gang-raping male enemy officers during war to prove their authority over conquered territories (Onyango & Hampanda, 2011). Sexual violence against men in current armed conflicts however, has been labelled as the ‘forgotten method of torture’

(UN OCHA, 2008, p.1) which is more prevalent than governments, health care providers and scholars have recognized (Onyango & Hampanda, 2011).

2.4. P REVALENCE OF SEXUAL VIOLENCE AGAINST MEN IN ARMED CONFLICTS

According to a report by the United Nations (2019), precise estimates on the magnitude of

this phenomenon are difficult to obtain due to underreporting by male survivors. Despite

of the scarcity of data, some studies have attempted to look at prevalence of sexual violence

against men in armed conflicts. Russell (2007) shows that more than 50% of male detainees

experienced sexualized torture in Yugoslavia. 80% of the 5,000 men in Sarajevo Canton

Camp, reported being raped (Mudrovˇci´c, 2001). A survey of men living in a conflict-

affected state in Sudan reveals that almost half (46.9%) had experienced or directly

witnessed sexual abuse of a man (Nagai et al 2008). A population-based survey by Johnson

et al (2008) in Liberia reveals that one-third (32.6%) of former male combatants reported surviving sexual violence. Johnson et al (2010) show that almost one quarter of men (23.6%) had experienced sexual violence during conflicts in Eastern DRC. However, Jones and Pratt ( 2008) Cited by Onyango and Hampanda ( 2011) show that sexual violence against men is also prevalent in institutions such as prisons, gangs, male sports and fraternities in peace times . This evidence suggests sexual violence against men should not only be read as a war related phenomenon but also as ‘a peacetime real problem.’ Cockburn (2010) suggests that peacetime and war related sexual violence are connected and influence each other in a continuum.

2.5. F ORMS OF SEXUAL VIOLENCE AGAINST MEN IN ARMED CONFLICTS

The most frequent forms of rape against men include anal penetration, oral sex, forced masturbation, enforced nudity, forced sterilization, genital violence and ‘forced rape’

(Oosterhoff et al., 2004; Russell, 2007; Sivakumaran, 2007). The Tabuga report cited by

Sevakumaran (2007) shows that groups of males’ detainees in Iraqi prisons were forced to

masturbate themselves while being photographed and videotaped. Survivors may also be

forced to masturbate their perpetrators (Christian et al., 2011). In Bosnia male survivors

reported of being hit on the genitals ‘using metal hampers, metal bars’ and being kicked

with boots. Baaz and Stern (2010) show that in Eastern DRC civilian men are sometimes

forced to have public sexual intercourse with their daughters, mothers or wives and threated

to death in case of denial. This form of sexual violence against men is understood in this

thesis as ‘forced rape’ as some men are obligated to rape other men or women against their

own will. However. Weiss (2010) shows that women can also be perpetrators of sexual

violence against men. This evidence challenges the narrow definition of rape as the forced penetration of a woman by a male perpetrator.

2.6. C AUSES OF SEXUAL VIOLENCE IN ARMED CONFLICTS

Causes of sexual violence in armed conflicts are complex and have been theorized in different ways by different scholars. According to some theorists, sexual violence in armed conflict is more an expression of power rather than an instrument of sexual gratification (Bartels et al., 2010; Mukwege & Nangini, 2009). However, Baaz & Stern (2018) cautions against the ‘desexualisation’ of rape in armed conflicts as this phenomenon has complex root causes. The sociobiological theory of rape posits that sexual violence can sometimes be driven by biological urges in human societies (Dusek, 1984). Recent research also shows that some male perpetrators justify rape against women and men through biological concepts ( Baaz & Stern, 2009). However, this biological deterministic framing has been challenged by some theorists as sexual violence occurs in several conflicts settings where combatants have ample access to sex (Bitenga et al., 2021; Wood, 2014).

The idea that rape against men and women is used to punish and humiliate communities is

grounded in its framing as a ‘weapon of war’ in armed conflict (see Mukwege & Nangini,

2009). The weapon of war discourse posits that combatants pursue pure militaristic and

political goals by raping women and men during armed conflicts. Leiby’s (2009)

comparative study of Guatemala and Peru shows that sexual violence can be used as a

strategy or as a tactic of war to terrorize civilians, to repress the opposition, or as an

instrument for ethnic cleansing. Castrations, beating men’s genitalia and deliberate

transmission of diseases are often interpreted as strategies to destroy men’s reproductive

capacities in order to ensure effective ethnic cleansing (Onyango & Hampanda, 2011). In

Eastern DRC rape against men and women is reported to be used as an effective method to maintain control over minerals as armed perpetrators expect that local population will flee away and leave the land open to economic exploitation (Banwell, 2014).

I argue that these different framings of sexual violence in armed conflicts should be seen as complementary rather than contradictory. For instance, the weapon of discourse reveals that some commanders explicitly or implicitly encourage sexual violence in armed conflicts (Bitenga et al., 2021; Schneider et al., 2015). Baaz and Stern (2009) extend the conceptualisation of conflict related sexual violence by revealing that its motivations transcend strategic purposes and include sociocultural, political, legal and socioeconomic factors.

2.7. C ONSEQUENCES OF SEXUAL VIOLENCE AGAINST MEN IN ARMED CONFLICTS

Some scholars show that psychological consequences of rape are more pronounced for male survivors than for their female counterparts (Johnson et al., 2010; Onyango &

Hampanda, 2011; Christian et al., 2011; Sivakumaran, 2010). For male as well as female survivors there are multiple medical, psychological, and socioeconomic consequences associated with rape. Physical health consequences of sexual violence against men include weakness, headaches, body aches, loss of appetite, bloody noses, incontinence of urine and stool, fever, symptoms related to sexually transmitted infections, and reduced desire for sexual activities with their partners (e.g., Chynoweth et al., 2017; Christian et al., 2011).

Some male survivors suffer from rectal trauma, such as abscesses and fissures, which can

make sitting, moving, and even coughing painful (Chynoweth et al., 2017). Most mental

health symptoms are related to post-traumatic stress syndrome (PTSD), anxiety and

depression (Oosterhoff et al., 2004). Furthermore, more men report substance abuse post rape and are more likely than female survivors to commit suicide (Johnson et al., 2010).

Physical and psychological consequences of rape have socioeconomic implications on male survivors. The socioeconomic cost of rape on male survivors is enormous as most of them lose their capacity to work due to rape-associated trauma (Christian et al, 2011).

Lwambo (2013) points out that in many societies, men represent virility, strength and power of the family and are expected to be economically productive. When they are raped, their masculine attributes are considered by the community to have been taken away and lose their economic productivities (Christian et al., 2011). Male as well as female survivors need appropriate holistic care after rape addressing its physical, psychological, socioeconomic and legal consequences (ibid).

2.8. P OSITIONING THE THESIS IN RELATION THE LITERATURE

While we know forms, causes, consequences, and care needs for male survivors of sexual

violence, there is little/ no knowledge about challenges and barriers to health care for male

survivors of sexual violence. The literature indicates that sexual violence against men is

often underreported due to shame and stigma by community members (see Christian et al.,

2011; Dolan, 2014). I argue that these barriers are not exhaustive and limits further our

understanding and capacity of theorisation. Using an ecological analytical framework, this

thesis captures a complexity of socially constructed gendered norms, experiences,

ideologies and responsibilities at multiple levels making it difficult to have access to care

for male survivors. My contributions in the scholarly debate on sexual violence against

men are threefold. First, I show through empirical evidence how perception of masculinity

affects health-seeking behaviour for male survivors of sexual violence. Second, I shed light on complex challenges and barriers related to assistance of male survivors’ needs, and third, I theorize causes of inattention to male survivors’ plight based on findings discussed in the fourth and fifth chapters of this thesis and on other relevant literature.

3. T HEORETICAL /A NALYTICAL F RAMEWORKS

Due to the interdisciplinary nature of this research, my analysis will engage with different but complementary analytical frameworks. I argue that barriers and challenges related to assistance of male survivors of sexualized violence are multifaceted and need to be situated in broader social, cultural, economic, and political contexts. I reject the idea of a single independent ‘reality out there ’ hampering access to care for male survivors and argue for a complexity of socially constructed gendered norms, experiences, ideologies and responsibilities , which need to be understood and deconstructed at multiple levels of analysis. The findings of this thesis were read mainly through an ecological model to understand how the multifaceted environmental, cultural, and personal factors reinforce one another resulting in low /poor health seeking behaviour for male survivors of sexual of violence.

There are however, many ecological analytical frameworks and it is beyond the scope of

this thesis to discuss each of them. Ecological theory posits that human development occurs

through constant interactions between individuals and their multiple, interconnected

environmental contexts (Bronfenbrenner, 1986; 1995). Bronfenbrenner’s ecological model

recognizes a complexity of factors influencing human behaviour and decision-making

processes. Bronfenbrenner’s ecological model subdivides environmental factors that

influence human behaviour in six main levels, which are in a constant interaction including

individual, microsystem, meso system, exosystem, microsystem and chronosystem levels.

I used Bronfendbrnner model to grasp the complexity of challenges and barriers related to assistance of male survivors in Eastern DRC.

3.1. E COLOGICAL FRAMEWORK

The individual level of the model comprises bio-psycho-social characteristics of the person. Researching the bio-psycho-social characteristics of men helped me understand how men identify themselves biologically, psychologically, and socially as gendered persons and how sexual violence affects their identity as men in a particular ecological setting. The microsystem level looks at interpersonal interactions between individuals and members of their immediate environments such as families, peers and friends. At microsystem level, I examined how male survivors of sexualized violence are seen by their families and peers and how this perception promotes or hinders health-seeking behaviour.

The mesosystem level focuses on interconnections and linkages between individuals and

social systems including with the exosystem. According to Campebel et al (2009), the

exosystem comprises organizations including but not limited to legal, medical, mental

health services. At this level, I explored how survivors and community members perceive

exosystems referred to here as service providers. The macrosystem in turn includes societal

norms, expectations, and beliefs, values that form the broader social environment

(Campebel et al, 2009). At this conceptual level, I looked at how macrosystem norms

influence exosystem practices, values, attitudes of survivors themselves and service

providers. The chronosystem level encompasses the changes that occur over time between

persons and their multiple environments. The chronosystem level enabled me to understand

pre-sexual and post sexual violence situations of male survivors, and how services

providers are readapting, changing or unchanging their services for male survivors in the course of time, and at which extent the macrosystem influences or promotes status quo in the treatment of male survivors .

3.2. H OLISTIC CARE MODEL FOR SURVIVORS OF SEXUAL VIOLENCE

Although, the ecological model described above provides a robust analytical framework to understand the phenomenon at multiple levels, it did not allow me to understand substantially how exosystems operate in a pragmatic sense, and how survivors react to gendered forms of assistance. Therefore, I used other concepts and theories to operationalize the ecological ‘meta-theory’ in the analysis. The concept of holistic care model was applied within exosystems to analyse needs and challenges related to assistance of male survivors at medical, psychosocial, socioeconomic, and legal levels (see Mukwege& Berg, 2016). However, both the ecological model and the holistic care concept are blind to subjective versus objective gendered norms and practices that guide how care is sought and given, and therefore needed to be offered ‘a gender sensitive sight’ though other theories and concepts.

3.3. G ENDER THEORY AND THE CONCEPT OF HEGEMONIC MASCULINITY

Gender theory and masculinity studies (see Gardiner, 2002, p. 10) were used to explore

social constructions that frame the concept of ‘men’ as gendered persons with specific

needs and values, and how service providers perceive and respond to the latter in the

holistic care model. While sex refers to biological differences between men and women,

gender is a set of socially constructed attributes, behaviours, roles, and norms associated

with each sex. Gender constructs are usually designed at the macrosystem level and are

constantly produced and reproduced in social practices including in exosystems. Through gender theory lenses, I examined masculinity and womanhood to understand at which extent services provided to male survivors within exosystems produce or reproduce existing gender expectations in Eastern DRC.

However, the social gender theory has been critiqued for its reductionist binary analysis focusing on dominance of men over women eclipsing intra-gender differences within gender categories. Donaldson (1993) states that hegemonic masculinity forms a structure in which most men exercise control over women and over other men. The concept of hegemonic masculinity distinguishes between external and internal hegemonies, the latter referring to the dominance of men over women while the former denoting supremacy of men over other men. Internal hegemonic masculinity ensures dominance of heterosexual men over gay men and other men such as male survivors of sexual violence (see Demetriou, 2001). To be able to produce/reproduce itself patriarchy promotes heteronormativity in the sense of ‘man the penetrator and woman the penetrated.’ Male survivors of sexual violence and gays are subordinated to heterosexual men and are usually excluded from what Connell cited by Demetriou (2001) called ‘patriarchal dividends’ including social status, prestige and a series of material advantages including political, cultural, economic, and legal benefits. The concept of hegemonic masculinity is relevant in this thesis at micro and macro levels of analysis to shed light on how male survivors are considered in their immediate environments and to which extent are included in or excluded from patriarchal dividends;

and how the fear of exclusion leads to under reporting and poor health seeking behavior.

Masculinity studies look at private attributes of men’s embodiment, sexuality, and emotion

that form the notion of ‘men’ as gendered persons (Gardiner, 2002, p. 10). Masculinity

studies helped me to analyze the concept of men in Eastern DRC from biological, social, economic, and psychological angles.

It is worth noting that some analysts prefer the concept masculinities to masculinity for several reasons (eg., Demetriou, 2001 ; Gardiner, 2002). First, what is defined as masculinity varies historically and over time. Second, masculinity varies cross-culturally, and different cultures have their own ways of describing masculinity. Third, to be a man changes over the course of one’s life. Even within a given society and time, masculinity can mean different things to different people. These multiple theoretical perspectives informed the analysis of data on challenges and barriers related to assistance of male survivors of sexualized violence in Eastern DRC.

I provide below a graphic representation of the ecological theory. The concept of holistic care model, hegemonic masculinity and gender theory were used throughout the ecological model. The graphic representation of the ecological model below was borrowed from Campbell et al (2009).

HOLISTIC CARE MODEL

Individual Assault Microsystem Meso-exosystems Macrosystem Chronosystem

Figure 1. Ecological model

4. M ETHODS OF INVESTIGATION

This chapter provides a brief introduction of the research settings, epistemological and philosophical assumptions underpinning this research, how data was collected and analysed. I also discuss my positionality as a Congolese young male researcher researching masculinity in DRC and its implication on this study.

4.1. R ESEARCH SETTINGS

This thesis relies on an extensive fieldwork conducted from March to April 2021 with male survivors, service providers and community members in Bukavu city and in Mulamba grouping in South Kivu province. Bukavu is the capital city of South Kivu province lying at the extreme southwestern edge of Lake Kivu with an estimated urban population of 1,078,000 in 2020 (Population Stats, 2021). Both Panzi Hospital and Panzi Foundation DRC are located in Bukavu city. Mulamba grouping is situated in Walungu territory 70 kilometres away from Bukavu, and was home to different armed groups from 1998 to 2013 including Democratic Forces for the Liberation of Rwanda (FDLR) and different Rai Mutomboki armed factions (CDJP, 2015). As compared to Mulamba, Bukavu has seen a relative calm in recent years and was lastly occupied by Rwanda backed Congolese rebel group in May 2004 (see Trenholm, 2013, p. 29). The rates of sexual violence are however, reported to be high in both settings (see Cikuru et al., 2021; Peterman et al., 2011).

Service providers interviewed included Panzi Foundation DRC, Panzi Hospital and

Mulamba Clinic in Walungu territory. Panzi Hospital specializes in the treatment of

conflict related sexual violence and provides medical and psychological assistance to

survivors (Bartels et al., 2010). Panzi Foundation DRC is located at a walking distance (10 minutes) from Panzi Hospital, and provides psychological, legal and socioeconomic supports to survivors of sexual violence who benefit from medical assistance at Panzi Hospital (see Amisi et al., 2018). Panzi Foundation DRC runs a support programme referred to as ‘One Stop Centre aiming at providing holistic care services to survivors of sexual violence in one place in different settings in DRC; the goal being to make services as close as possible to those in need (Mukwege & Berg, 2016). Panzi Foundation DRC also carries out outreach missions to provide care to survivors of sexual violence and to women with various gynaecological conditions in remote places in DRC. One of the goals of Panzi Foundation DRC is to support the work of Panzi Hospital beyond its catchment area (see Bress et al., 2019). Panzi Foundation DRC runs two One Stop Centres in rural areas in South kivu including Mulamba, and Bulenga Clinics respectively located in Walungu and Kalehe territories (Mukwege & Berg, 2016). All the aforementioned institutions were created by Doctor Denis Mukwege and work jointly to assist survivors of sexual violence.

These institutions are major service providers and pioneers of the holistic care model in

DRC and host both female and some male survivors. They constitute important sites of

academic investigations for sexual violence, gender and health in the region given their

experience in these fields. For recognition for his fight against sexual violence in armed

conflicts, Dr Denis Mukwege who is the founder of these institutions received a Nobel

Peace Prize in 2018 along with Nadia Murad ( Rubin, 2019). Bryman (2016) suggests that

purposive sampling is a master concept in qualitative research and provides evidence -

based data from respondents or institutions with experience/or knowledge of the

phenomenon under study. The experience of these service providers in assisting survivors

of sexual violence offers a unique opportunity from which to learn challenges and barriers related to care for male survivors.

4.2. R ESEARCH DESIGN AND DATA COLLECTION

According to Bryman (2016), a case study design focuses on an intensive investigation of a particular case. I argue that the Eastern part of the DRC presents a good case from which to learn about conflict related sexual violence and its associated care given higher proportions of sexual violence and existence of care programmes for survivors in this region. An exploratory research is the process of investigating a problem that has not been thoroughly investigated in the past (see Alase, 2017). Challenges and barriers related to male survivors’ assistance are still largely undocumented. Therefore, I use a qualitative exploratory method to gain an in-depth understanding of this least researched problem.

Contrary to quantitative studies, which use deductive approaches to test theories, this thesis draws on an inductive logic of inquiry interpreting empirical data through existing theories (Bryman, 2016). Specifically, I conducted a micro-scale analysis of challenges related assistance of male survivors in Eastern DRC to inform the debate on abstract notions of gender, masculinities, and barriers to health care.

To capture the complex nature of a social problem, various respondents need to be taken

into account. Triangulation is an approach to collect data from a variety of sources in order

to offer a more balanced explanation of the problem under study (Yeasmin & Rahman,

2012). I triangulated perspectives from service providers at Panzi Hospital, Panzi

Foundation DRC, Mulamba clinic, male rape survivors and community members to enable

in-depth exploration and cross verification of findings from different sources. Community

members were included in this study because their beliefs, values and perceptions are likely

to affect the extent to which men seek help and how the survivors are understood by service providers (see Christian et al., 2011). Although the findings of this case study of Eastern DRC cannot be generalized to all conflicts contexts, they nonetheless present some insights about sexual violence against men and how perceptions of masculinities shape both how care is sought and given, which can at some extent, inspire other conflict-ridden countries with a similar situation.

The study is grounded both ontologically and epistemologically in a constructivist- phenomenological approach in social sciences, which helps researchers understand meanings that are constructed from experiences lived by subjects under study (Qutoshi, 2018). Phenomenological analysis is interpretive and seeks to grasp a complex picture of a phenomenon sometimes dealing with conflicting, counterintuitive perspectives from the participants. It is worth noting that the contradictory nature of social reality does not indicate that one perspective is true and the other is false, but it rather shows the complex nature of a social problem. Agar (2004) underscores the strength of interpretative approaches in research when dealing with ‘non-algorithmic nature’ of complex human behaviours. If conflicting perspectives emerge in empirical materials, the task of the researcher is then to organize them into recognizable patterns when he/she immerses himself/herself in the data and literature (see Bevir & Rhode, 2006; Creswell, 2013).

I used a purposive sampling technique and selected informants based on their particular

knowledge of, and/or experience with the focus of empirical inquiry (see Higginbottom,

2004). In phenomenological/interpretative studies, interviews are typically conducted with

groups of individuals who have first-hand knowledge of an event, situation or experience

(Creswell, 2013). Three medical doctors, four psychologists, three lawyers and two

specialists of socioeconomic reinsertion were interviewed individually using a semi- structured interview guide. Individual interviews have been adopted as an effective way to approach service providers, as most of them are usually busy. Each person was interviewed according to the timing that fits him/her best. One doctor and one psychologist were from Mulamba clinic in Walungu territory. Interviews with service provided were conducted by myself in French within professional settings at Panzi Foundation, Panzi Hospital and at Mulamba Clinic. Generally, service providers were asked how they define manhood, how they support male survivors, and about challenges and barriers related to their assistance.

Interviews with service providers were all recorded and took 35-60 minutes. All service providers were males except for one legal service provider who was female.

To triangulate information, I interviewed individually nine male survivors who benefited from care in One stop Centre system. Two survivors were treated at Mulamba Clinic and were living in Mulamba, and six were treated at Panzi Hospital and were living in Bukavu at the time of interviews. Service providers facilitated my contacts with male survivors who benefited from care. To be part of this research, male survivors had at least 18 years old. Roughly, male survivors were between 24-46 years old. I conducted interviews with survivors in Swahili, which is a vernacular language in use in Eastern DRC.

Generally, male survivors were asked about the meaning of ‘being a man’ in Eastern DRC,

causes of delayed health seeking behaviour and the challenges faced when seeking care

within the holistic care model. One male survivor was interviewed in a private place at

Mulamba Clinic as he was still under treatment. The rest of interviews were conducted

outside the clinical settings in private places in the community as most of survivors were

already discharged from services. Only three male survivors accepted their voices to be

recorded and notes were consequently taken for the remaining interviews with survivors.

Interviews with survivors took 40-55 minutes depending on how much they had to say.

However, I spent several hours with some male survivors in the community learning more about their situations in informal conversations. As a researcher and a staff at Panzi Foundation and Hospital, I developed close ties with some survivors I met there and who have become my friends with whom we can talk social issues, sport etc. This position allowed me to learn more in informal conversations after completion of formal interviews.

Finally, three focus group discussions (FG) were conducted with community members in

Bukavu in each of the three communes of the city including one in Ibanda, Kadudu and

Bagira. No FG was conducted in Mulamba due to time and budget constraints. Community

members were selected based on three main criteria: (1) they had to be men , (2) must have

heard or witnessed sexual violence against men in the community and (3) give consent to

the study. Community respondents were reached out through personal contacts and through

a snowballing approach. Initially, I contacted some people I knew who directed me to

potential respondents with knowledge about sexual violence against men in different

communes in Bukavu. Because community members were not necessarily survivors of

rape, I assumed that they would be comfortable to express their general opinions about

sexual violence against men in FG. Each FG comprised between five and seven men aged

between 23- 55 years old and took 60 -90 minutes. I conducted FG with community

members in Swahili language. Respondents in FG were asked what it means to be a man

in Eastern DRC, why male survivors refrain from seeking care on time and how this

behaviour is influenced by local perceptions of masculinity. All interviews with service

providers and community members were recorded and notes were taken during interviews.

4.3. R EFLEXIVITY AND POSITIONALITY

I note my position as a young man, researcher at Panzi Hospital and Panzi Foundation DRC speaking the same languages with respondents. Studying masculinity from an ‘insider positionality’, my work has turned into deconstruction and analysis of social norms that have long guided my understanding of gender. However, I avoided as much as possible bringing preconceived thoughts during interviews and relied exclusively on experiences and testimonies of the respondents themselves, which enabled me to capture unbiased new experiences, insights, and explanations. I have tried to challenge my personal bias by maintaining a distance from the subject matter, and by asking non-directive questions to the respondents. However, being a Congolese man myself with a mastery of local languages facilitated communication with my respondents resulting in rich conversations.

4.4. E THICAL CONSIDERATION

Data collection was conducted in line with ethical standards for research involving human subjects with a particular attention paid to the protection of respondents’ identities and respecting participants’ integrity and confidentiality. All participants were informed that the study was for an academic purpose and their identity would be protected throughout the research process. The study was approved by Panzi Foundation DRC and I personally sought to obtain oral informed consents of all participants prior to the interviews. I did not plan to ask male survivors questions related to their personal experience of sexual violence.

However, Bryman (2016) points out that qualitative research is flexible and can move in

different directions depending on what the interviewees themselves choose to emphasize.

If survivors chose to speak about their own experiences, I let them do so. Furthermore, the rights of the participants to withdraw from the study or skip questions they felt uncomfortable answering were guaranteed. All the interview records were protected in a folder with a password and can only be accessible to me. I kept all interviews and quotes anonymous to protect identity of different respondents.

4.5. D ATA ANALYSIS

Qualitative analysis is a continuous, non-linear and labour-intensive activity. I conducted preliminary analysis after I completed each interview /FG and continued to read /listen back and forth to the materials until I made sense of the data. Two main sources were subjected to analysis in this study including field notes and interviews summaries from audio-recordings. Field notes provided a forum for documenting observations, informal conversations and what Agar (2008) called ‘rich points’ of interviews. Field notes were integral part of the data and informed the analysis. I listened to audio-recordings multiple times with the aim to understand the content of the interviews and summarized them. I transcribed original quotes from audio recordings and translated them verbatim from Swahili/French into English for analysis. All the materials were analysed using thematic analysis (Braun & Clarke, 2006 ) .

The difference between qualitative content analysis (QCA) and thematic analysis in

qualitative research is confusing at first glance. While QCA uses categories to classify data,

themes are used to define what data is about in thematic analysis. Morse (2008) eloquently

quells the confusion between categories and themes. The author states that categories result

from asking: what is in the data? While themes are a response to the inquiry: what is this

data about? Themes are produced through a mapping and defining process, and findings

are confirmed through constant comparison with the original materials (Braun & Clarke, 2006). Four overarching and interrelated themes emerged out of the interviews namely (1) what it means to be a man in Eastern DRC, (2) how masculinity affects health-seeking behaviour, (3) challenges and barriers to assist male survivors of sexual violence and (4) systemic inattention to the plight of male survivors.

5. W HAT IT MEANS TO BE A MAN IN E ASTERN DRC

The aim of this chapter is to discuss masculinities in Eastern DRC in order to understand how the local framing of ‘manhood’ affects health-seeking behaviour for male survivors of sexual violence. I start by describing local perceptions of bio-psycho-social characteristics of men before discussing how masculinity affects health-seeking behaviour for male survivors of sexual violence.

From a biological point of view, all respondents understood a ‘man’ as any person with natural males’ reproductive organs mainly a phallus, which was at the centre of discussions about masculinity. ‘To be a man, you need first to have a penis’, said a community member.

However, a man’s penis was seen beyond its biophysical appearance and included physiological and social functions: ‘Your penis must be able to do its work.’ ‘When there is a boy in the community that dates several girls, his peers will say that he is a ‘ real man’, said a community member.

To value males’ sexual virility, a young man from community said: ‘when he finishes

sexual intercourse, the woman must limp, if she stands up and walks in a normal way, that

means you are not doing the job of a man.’ However, different statements from interview

reveal that the more men advance in age and take more social responsibilities, the more

they distantiate themselves from ideals of a ‘macho man’ with a strong sexual virility. In

this perspective, a 54- year- old man said : ‘ when I was young, I used to think that having more women made me a man but I regret to day, I spent a lot and gained nothing in the end.’ Old married men with multiple young unmarried female partners were referred to as

‘ Papa Impolies’ which means ‘impolite fathers.’ However, having multiple sexual partners was seen as a proof masculinity for most young boys. A few respondents thought that intellectual capacities are more important that biological attributes for men. ‘I do not think man means physical strength or sexual virility, a man means money and education’, said a community member.

While several survivors biologically understand a man as a person with penis and with a strong sexual virility, some complained that they lost virility because of rape: ‘When it happened to me, I also lost my male’s power for almost one year, and it was so ridiculous.’

‘Your wife will be saying if you are a man or a woman’, said another survivor. Not having a physiologically ‘functional phallus’ was understood as a sign of emasculation by most respondents. ‘A man wearing a pair of trousers without a strong penis within, is that a man?’, questioned a community member.

Different interviews showed that socio-biologically, men identify themselves in relation to

their phallus and its capacity to penetrate women (heteronormativity). ‘According to some

community members, men do whatever is possible to maintain their sexual virility because

it makes them men: ‘when you feel you have no man’s power, you buy some wine or

product that can help bring it back.’ However, some male survivor said that it is expensive

to afford aphrodisiac products due to poverty. ‘When you miss what to eat, how will you

afford Buka mbeto?’ The latter is a local aphrodisiac wine that several men are interested

in, which means ‘break the bed.’ Arguably, breaking the bed during sexual intercourse is a

real proof of masculinity.

The glorification of heteronormativity and problematization of same sex sexual intercourse was obvious in most interviews. Men who perform sexual intercourse with other men were referred to in Mashi language as Ntazi. The concept Ntazi is charged with anti-masculinity connotations and is used to refer to gays or to men who are ‘sexually impotent’, and is regarded as the most depreciative/lethal masculine status. ‘If you want to irritate a man in my village, you call him in Ntazi’, said a community member. According to this respondent, when a man is referred to as a Ntazi, he can react by physical violence or say:

‘bring me your sister or wife and will show you.’ Male survivors of sexual violence were identified as ‘gays’ by most community members due to the fact that they were once penetrated. However, male survivors did not refer to themselves as such. ‘The rebels turned me into their wife, but I am not a gay.’ However, some survivors point out to the concept Ntazi not refer to themselves as gays per se but to erectile dysfunctions resulting from rape.

‘I do not get erection anymore’, said a survivor.

Furthermore, to be a man from a biological perspective, also meant to be ‘physically strong.’ According some respondents, men are expected to be physically stronger than women who were framed as ‘weak creatures’ by most community members and survivors.

Most respondents reported that a man is he who mobilises his physical and intellectual

strengths to defend himself, others, and the community suggesting a combination of

biological and psychological capacities. ‘When there is armed insecurity in Bukavu, boys

are asked to make patrol because they are strong enough to fight with armed robbers’, said

a community member. The same respondent continued: ‘men have to make sure that

community and families are protected against attacks.’

However, some respondents recognized that not all men possess physical strength as expected. ‘You cannot ask old men to carry heavy objects or fight because they are now exhausted’, said, respondent. This finding suggests that the perception of masculinity can change overtime as explained earlier at the chronosystem level of the ecological theory.

Other biological characteristics of men cited by respondents included having beard and a

‘strong voice’, but were seen as less important than sexuality and physical strength.

At the psychological level, a man was framed as a person that never or rarely cries, smart, discrete, and resilient to hardships. The statement that a ‘man never cries’

emerged in all interviews with service providers, community members and male survivors. A service provider spoke about the socialization of boys as ‘tearless persons’

in these words: ‘since their childhood, boys are taught to be tough and never to cry, when they face problems, they have to behave as men.’ Experiences shared by community members resonated with the logic of ‘a tearless person’ as exemplified in this quote: ‘when there is a mourning or a serious problem in the community, you will see women crying but men rarely cry.’ According to various respondents, crying is a either a sign of weakness or an expression of empathy that women show more openly than men. ‘If a woman does not cry so hard when a relative dies in my community in Shabunda, people suspect that she might be a witch and might have contributed to the death of the dead person.’

According to cultural norms enacted from the macrosystem level, women are expected

to express feelings and emotions of weakness or of empathy while men were seen as

incarnations of a ‘pure reason’ and strength as stated by a community member: ‘a family

is like a human body, men are heads, women are hearts and children are different

organs.’ Following this human body analogy, ‘men’ are expected to be smart and rationale with a capacity to mobilise knowledge and thoughts necessary for running a family.

In addition to being smart, men were seen as more aggressive than women. ‘When children misbehave, women rarely punish them, but men punish them in order to bring order and discipline in the household.’ Another a community member said: ‘when someone does something wrong in the family, you will see children saying: I will accuse you to the dad because he can whip them for discipline.’ It is worth mentioning that corporal punishment against human beings is a human right abuse (see Bitensky, 2006).

Some interviews show that being a man in Eastern DRC means to possess some dose of

what I call in this thesis ‘constructive and destructive violence’ that co-exist for

equilibrium and constitute important outlets for expression of masculinity. According

to some respondents, the ultimate goal of beating children, which is usually the task of

the father, is to foster discipline, order and harmony in the household. However, this

violence may become destructive when for instance fathers get drunk and start beating

children or their partners. ‘Most men no longer beat their wives in town, but some

continue to do so especially when they are drunk.’ following the reasoning of some

respondents, violence unleashed under alcohol or anger is destructive. ‘Beating your

wife for non-reason is not good but can happen sometimes.’ Patrolling overnight to keep

families and communities safe also suggests the notion of both constructive and

destructive violence. Protecting communities and families is positive but suspected

enemies of communities are beaten /and or sometimes killed. Using violence for good

or bad suggests two poles of exploitation of masculinity, which can either be used constructively or destructively depending on choice of its carrier ‘men’s bodies.’

It is worth mentioning that there are several men in Eastern DRC who are not aggressive and who enact ‘psychological positive masculinities. For instance, some respondent said being a man means being generous, supportive and kind toward others. ‘ when there is a a relative or friend who is hungry or needs transporation fees, you give them something as a man’. The concept of hegemonic masculinity has been critiqued by some sociologists with regard to its fixed character type which is analytically limited as its excludes the complexity of different and competing forms of masculinity (Moller, 2007; Demetriou,2001 ).

However, the concept is still useful for understanding gender relations and dominance of men over women and other men.

Various respondents believed that men are and should be discrete, decisive perseverant and resilient vis-à-vis problems. A community member said: ‘A real man does not talk much about his problems, but he tries first to manage them himself.’ Men were understood in several interviews as skilful persons who operate in discretion and who are capable of enduring difficult problems. ‘A man does not talk much like a woman, if you talk too much you reveal your weaknesses.’ However, different respondents said that a real man should be able to manage public speaking with ease. ‘Speak like a man.’

The capacity of men to adapt to difficult circumstances were summarized in the

following adage from south kivu: ‘a man is like a cassava tree; he can grow from

wherever he is thrown.’ This maxim means that a man can be thrown with brutality in

the most difficult situations and will be successful. In addition , it was stated that a real

man takes decisions once and for all and never changes them as reflected in this Mashi

proverb cited by several respondents: ‘a man changes positions in his bed but never changes positons in his words.’ ‘If a real man says he is going to give you something, he respects his words and give you.’ ‘If the decision works against you will feel, he is a man.’

Socially, a man in South Kivu is meant to become a Mushamamuka, which means ‘a responsible man’ in Mashi language. Being a Mushamuka was seen as an ability to assume a set of responsibilities at family and community levels. To become a Mushamuka, a man must first own a land and a family. According to several respondents, men struggle for women and lands throughout their lives. ‘A man without a woman is not an accomplished man’; ‘man means land and house’ were maxims frequently cited during interviews. In addition, a man is expected to have children who usually embrace his ethnic line. Respondents said a serious curse that can be pronounced against a man in south Kivu is Ukanfanshizo in Mashi language, which means that ‘you will die without leaving an offspring.’ A service provider said: ‘If he has trouble getting children with his wife, he can try to have children with other women’. If he does not have children, he will be regarded as a sexually impotent person, which is extremely depreciative.

As ‘heads of households’ men are expected to lead and take important decisions in their

families such as buying a house, paying school fees for the children, paying medical

bills , solve family problems, providing food ration in the household, paying school fees

for the children, paying medical bills for family members etc. Being a man

socioeconomically meant the capacity to produce income daily or monthly and cover

family expenses whenever needed. ‘If you give food rations, then your wife and children

will respect you’, noted a male survivor. According to different respondents, heads of

households are assisted by women who usually do housekeeping such as cooking, cleaning, doing laundry etc. However, Lwambo (2013) shows that armed conflicts have significantly changed gender dynamics in Eastern DRC. There are many families in which women are providers because men do not have jobs, travelled or because they had died during wars.

While some community members viewed women’s economic productivity as an opportunity for the financial stability for the household, others saw it as a threat to manhood. ‘When you work and she works, you all bring something and sustain the family’, said a community member. Yet, some community respondents were reluctant about the roles of women as main providers: ‘my family being fed by a woman? No this is a humiliation.’ Some male survivors complained that their inability to work or lack of employment contributes to the feeling of loss of manhood. Finally, a man was referred to socially as a cubaka, which means a constructor. Some respondents said a man must be able to build material and immaterial things such has houses or relations, solve conflicts etc. to qualify as a cubaka.

5.1. H OW PERCEPTION OF MASCULINITY AFFECTS HEALTH - SEEKING BEHAVIOUR FOR MALE SURVIVORS OF SEXUAL VIOLENCE

It should be stressed that masculinity is not ‘a given’ but an achievement (Demetriou, 2011;

Wade, 2008). Not meeting the biological, psychological, and sociocultural standards of

masculinity described earlier can cause feeling of shame, humiliation, frustration,

inadequacy, loss of dignity and exclusion in many patriarchal societies across the world

(porter, 2013). To keep their position of authority and prestige in the family and

community, several male survivors choose not to seek care. ‘A man raped by another man