Acknowledgments

All Survivors Project (ASP) is profoundly grateful to all those who participated in this study for generously giving their time and sharing their experiences during interviews, validation meetings and workshops.

We particularly thank the male victims/survivors of conflict-related sexual violence (CRSV) whose lived experiences, insights, and recommendations about accessing healthcare form the foundation of this report. Their voices and expertise were central to shaping our understanding of survivor-centred care.  

We extend our gratitude to Médecins Sans Frontières (MSF) Spain and the Tongolo Project for their invaluable collaboration in the research design, facilitation of victim/survivor engagement, and provision of follow-up support. We particularly acknowledge the significant contributions of Françoise Niamazime, Field Study Coordinator; Liliana Palacios, Health Advisor; Augusto Llosa, Epidemiology Advisor; Gisa Kohler, Operational Manager; and Angie Carrascal, Sexual Violence Referent, for their close collaboration, technical expertise and comprehensive review of this report.

We would also like to acknowledge the valuable expertise and contributions of Dr Joelle Mak, Assistant Professor, London School for Hygiene and Tropical Medicine, and Dr Julienne Corboz, Independent Researcher, in developing the initial research protocol, and Dr Elisabet le Roux, Research Director at the Unit for Religion and Development Research, Stellenbosch University, for her contributions to the protocol development and training of data collectors for this study.

ASP is grateful to Dr Emilie Venables, then Senior Humanitarian Advisor with ASP, for leading on data collection, and to Delphine Brun, Independent Humanitarian Consultant, for conducting further research. ASP is grateful to members of the Research Advisory Group (RAG) for their support and guidance during the multi-country, survivor-centred research project of which this report on Central African Republic is a part. Aimé Moninga, Nadine Tunasi, Pieter Ventevogel, Eva Deplecker, Fatma Hacioglu, Corine Ornella Charlotte Mboumoua, Murielle Volpellier, Esther Dingemans and Jennifer Rumbach have provided valuable insights throughout the project.

Executive summary

Conflict-related sexual violence (CRSV) against men and boys remains an underreported issue and one which is often overlooked in healthcare and other responses. In the Central African Republic (CAR), where the healthcare system is fragile, there are significant obstacles to accessing timely, quality, gender-competent, survivor-centred medical care and mental health and psychosocial support (MHPSS) for all victims/survivors of sexual violence, both conflict and non-conflict-related. However, the relative invisibility of sexual violence against men and boys, along with the associated taboos, stigma, and shame, also create a range of gender-specific barriers.

All Survivors Project (ASP), with the support of Médecins Sans Frontières (MSF) Spain, conducted interviews with male victims/survivors of sexual violence and with key governmental and non-governmental stakeholders responsible for designing, implementing, or otherwise supporting healthcare and associated responses to sexual violence in CAR. Based on these interviews, ASP and MSF Spain explored the experiences of individual male victims/survivors in accessing healthcare. In particular, they explored, in a survivor-centred manner, the aspects of care that victims/survivors valued, good or promising practices by healthcare providers, and how healthcare and associated responses could be strengthened to fully address the rights, needs and wishes of male victims/survivors including those with diverse sexual orientation, gender identity, gender expression and sex characteristics (SOGIESC).¹

The scale of sexual violence, including CRSV, in CAR, is such that it has been described as a public health crisis.² Although most documented incidents involve sexual violence against women and girls, there is also a discernible pattern of CRSV against men and boys that is particularly common during armed attacks or when they are held captive by non-state armed groups (NSAGs).³ Despite efforts to improve responses, CAR’s public health system is unable to provide even basic services to most victims/survivors of all genders, particularly those living outside of the capital Bangui. In practice, most medical and MHPSS services for sexual violence victims/survivors, both conflict and non-conflict-related, are provided or supported by non-governmental organisations (NGOs).

All 25 victims/survivors interviewed for this report accessed care through MSF’s Tongolo Project in Bangui – a project which provides holistic care including medical treatment, MHPSS, and guidance on pursuing legal action and obtaining protection.⁴ Male victims/survivors’ responses to questions about what aspects of the care from MSF they valued provided important insights into what constitutes a survivor-centred approach. They highlighted in particular:

• The safe location and accessibility of facilities: MSF clinic was described as easy to find and victims/survivors said they felt safe and secure in the enclosed compound.
• Timely access to treatment: Several victims/survivors said that they valued the speed with which they were seen after arriving at MSF health facilities.
• Assurances of confidentiality: Due to the fear that others could find out that they were victims/survivors of sexual violence, great store was placed on confidentiality by victims/survivors. Almost all interviewed victims/survivors said that the principle of and procedures for ensuring confidentiality had been explained to them and they understood it and felt reassured.
• Avoidance of repeated disclosure of experience of sexual violence: Victims/survivors appreciated not having to repeatedly disclose their experience of sexual violence, with most saying they only had to explain what had happened to them once throughout their care journey with MSF.
• Free care: The fact that MSF’s services were free of charge was important to many of the victims/survivors and an important enabler in their ability to seek care.
• The welcoming and respectful attitudes of healthcare workers: Victims/survivors spoke about having felt “welcome” or “well received”, describing their reception variously as “calm”, “kind” and “empathetic.” All felt that they had been treated respectfully, in a non-judgmental manner, and that they were listened to and believed.
• The professionalism of staff: Victims/survivors referred to feeling that the staff were well-trained and had the appropriate skills to work with people who have suffered the trauma of sexual violence. This perception instilled confidence among victims/survivors, fostering trust in the care provided.

However, most interviewed victims/survivors only sought or were able to access healthcare weeks, months, or in several cases, years after the incident of sexual violence. Access to healthcare in all except five cases occurred outside the recommended window of 72 hours.⁵ The reasons given for the delays highlighted broader, systemic barriers both to the availability and accessibility of survivor-centred healthcare. Key informants provided further insights into these barriers and, although not all appeared to be familiar with the concept of a survivor-centred approach, they were acutely aware of both general and gender-specific obstacles facing victims/survivors in accessing timely, safe, quality healthcare. This indirectly indicates the need to strengthen the operationalisation of the principles of survivor-centredness across healthcare responses in CAR.

Following a social-ecological model of public health,⁶ the barriers identified can be understood according to four interrelated levels: structural, organisational, community/interpersonal and individual, all of which must be addressed if victims/survivors of sexual violence are to receive the care they require and to which they have a right.

At a structural level, barriers included: the limited availability of basic medical and MHPSS care for immediate, emergency needs of victims/survivors of conflict-related and other forms of sexual violence (particularly outside of the capital Bangui) and for longer-term care; the scarcity of specialist MHPSS; the inadequate financial support for victims/survivors to address their immediate material needs including shelter, food and transportation; the absence of longer-term support for income-generation and livelihood opportunities; and insufficient or short-term funding for the public health system’s response to sexual violence and for United Nations (UN) and international non-governmental organisation (INGO)-led programmes which in both instances undermines the availability, sustainability and continuity of responses.

At an organisational level, barriers include: the lack of sufficient numbers of healthcare workers with the training, skills and experience to recognise and respond appropriately to sexual violence against men and boys; a failure to fully consider either barriers to healthcare for men and boys or the needs and wishes of male victims/survivors in the design and implementation of healthcare services; the stigmatisation and other negative attitudes and behaviours by healthcare workers towards male victims/survivors, which may also be pronounced for male victims/survivors with diverse SOGIESC; a lack of basic equipment and medication at some healthcare facilities; a lack of respect for patient confidentiality and privacy; and the imposition of fees and other costs which make healthcare services unaffordable for many.

At a community and interpersonal level, ASP identified barriers related to taboos around sexual violence against men and boys, along with the perpetuation of misunderstandings and myths about sexual violence against men and boys. This feeds victims’/survivors’ fears of stigmatisation by family and community members and subsequent shame, rejection, loss of standing in the community and family breakdown. This fear often causes victims/survivors to hide their experiences of sexual violence and isolate themselves.

And finally, at an individual level, the internalisation of social stigma leads to the reproduction of shame and “blame the victim” discourses by the victims/survivors themselves. This internalisation prevents them from seeking care and assistance. Moreover, male victims/survivors often lack knowledge of available services and/or perceive them to be for women and girls only.

Beyond these barriers to accessing healthcare, victims/survivors spoke of other unfulfilled needs and how these continued to hinder their full recovery. The main gaps highlighted by victims/survivors and reinforced by key informants were:

• The absence of longer-term medical and mental healthcare for the consequences of sexual violence. Interviewed victims/survivors described how they continued to suffer physical and psychological consequences of sexual violence, but that in the absence of a quality and universally accessible public health system that is free of charge, symptoms often went untreated.
• The lack of livelihood support. Only two of the interviewed victims/survivors received any form of livelihood support (in both cases cash or items to address immediate needs). All described significant economic harms associated with their experience of sexual violence, with many having been displaced and lost their means of generating income. The lack of immediate and long-term economic support/opportunities for training and the lack of possibilities to find a job was a source of concern among both victims/survivors and key informants. This lack of support also acts as a barrier to accessing healthcare and undermines the prospects of a full recovery.
• The justice gap. Although rule of law institutions dedicated to addressing sexual violence and transitional justice mechanisms have been established in CAR,⁷ prospects for justice for most victims/survivors of sexual violence are limited. Interviewed victims/survivors had little confidence in the justice system and chose not to pursue criminal complaints for reasons including the cost, the lengthy process, and fear that it would be re-traumatising or would expose them to public shame. Yet even if justice appeared unobtainable, it was regarded by victims/survivors as something that could contribute to their recovery and rehabilitation.

The widespread awareness of and efforts to address these barriers among policymakers, practitioners, and other informants with whom ASP spoke was encouraging. However, considering the mutually reinforcing barriers and the enormous needs in CAR, a considerable investment by state and non-state actors is required. This investment would strengthen healthcare responses and ensure these responses are complemented and reinforced by effective justice processes that provide victims/survivors with redress and reparations for human rights abuses committed against them. Victims/survivors must be at the centre of this process – both informed about, and involved in the design, implementation, monitoring and evaluation of healthcare services. Services must be designed and implemented in a survivor-centred manner, taking into account differentiated harms, needs, and wishes according to gender, age, and other intersecting individual and group factors.

Summary of key recommendations

The following recommendations are addressed to all relevant national and international stakeholders, including but not limited to, government entities, INGOs/NGOs and civil society organisations who operate, support, fund or influence decision-making within the healthcare sector. The recommendations aim to strengthen healthcare and related responses for victims/survivors of conflict-related and other forms of sexual violence.

While these recommendations specifically address sexual violence against men and boys, many also apply to broader measures needed to enhance responses for all victims/survivors, ensuring that victims/survivors of all genders and ages have access to safe, ethical, quality, and gender- and age-competent medical care and MHPSS, consistent with the principles of survivor-centred care. The provision of health support for male victims/survivors should not affect, limit or otherwise negatively impact services for women and girls.

Ensure victim/survivor safety, confidentiality, respect and non-discrimination in all medical facilities and referral systems.

• Medical facilities should offer comprehensive, quality, timely, and free-of-charge care to all victims/survivors of sexual violence, addressing the diverse needs of individuals based on gender, age, sexual orientation, gender identity and expression, and other characteristics.
• Healthcare facilities must be designed to allow discreet access, avoiding public exposure and ensuring privacy. Private, soundproofed rooms should be available for consultations to maintain confidentiality and respect.
• Medical facilities should implement strict protocols to safeguard the confidentiality of victims/survivors. This includes the secure storage of medical records and controlled access to sensitive information. All healthcare staff, including doctors, nurses, administrative personnel and security staff, should receive training on maintaining confidentiality, privacy, respect and non-discrimination in their interactions with victims/survivors.

Ensure that competent and adequate healthcare services are tailored to meet the specific needs and preferences of male victims/survivors, including by centring the views, experiences and expertise of these victims/survivors.

• Long-term partnerships with victims/survivors and victim/survivor groups should be established to ensure their experiences guide the development of healthcare services. Meaningful engagement with these groups as peer partners should be implemented throughout the entire programme cycle, from development to evaluation.
• Targeted needs assessments should identify the specific risks and vulnerabilities faced by men and boys affected by sexual violence. The collection of sex- and age-disaggregated data is key to monitoring access of male victims/survivors to services and ensuring equal access for all.
• Creating safe and discreet entry points into healthcare facilities for male victims/survivors is crucial, with clear pathways throughout the care process. Male survivors should be allowed to request providers of their preferred gender, and healthcare teams should include professionals trained in the specific needs of male victims/survivors, including those with diverse SOGIESC.
• Psychosocial support programmes specific for male victims/survivors should be designed to provide a safe, non-judgmental environment for discussing their experiences. These programmes could include individual counselling and group support to help address self-stigmatisation, guilt and the impact of sexual violence on relationships and self-perception.

Provide specialised capacity-building for healthcare providers on sexual violence against men and boys, including care for male survivors.

• Healthcare providers must receive specialised training on the unique challenges faced by male victims/survivors of sexual violence. This training should address common myths, negative attitudes and discriminatory behaviours, equipping providers to offer respectful and empathetic care.
• National medical curricula should incorporate the specific harms and challenges associated with sexual violence against men and boys. This includes detailed training on clinical case management that centres identification, assessment, physical examination and treatment protocols.
• Training should also emphasise the importance of survivor-centred medico-legal documentation, ensuring that physical and psychological findings are recorded accurately and ethically.

Enhance awareness and access to healthcare for male victims/survivors of sexual violence through community-based education and outreach.

• Community-based education and outreach efforts should improve awareness of and access to healthcare for male victims/survivors of sexual violence. This includes targeted awareness campaigns designed to inform male victims/survivors of their rights and available services, as well as the protocols in place to protect their safety and confidentiality.
• Community health workers, gender-based violence (GBV) and child protection workers, and other relevant actors should be trained to provide sensitive and survivor-centred care to male victims/survivors. This training should equip them to offer appropriate support and referrals, ensuring the needs of male victims/survivors are met with dignity and respect.

Work towards the development of long-term, nationwide medical responses embedded in a holistic care framework.

• National and international stakeholders should work to expand the geographical reach of public healthcare, ensuring that comprehensive, high-quality, and free-of-charge medical and psychosocial support is accessible to all victims/survivors across the country.
• Stakeholders should develop nationwide, long-term medical responses integrated into a holistic care framework. This should not only include immediate healthcare but also ongoing mental health services and support. Survivors should be able to access legal assistance and socio-economic reintegration support, fostering full recovery and well-being for all victims/survivors.
• National strategies and protocols addressing sexual violence should incorporate the needs of male victims/survivors.

Further enhance understandings of sexual violence against men and boys through research and data.

• In-depth research is needed to continue improving the understanding of the specific needs and experiences of male victims/survivors. This could include in-depth consultations with survivor groups and a thorough assessment of how existing healthcare services are responding — or failing to respond — to their needs and wishes. Consultations such as this would help identify gaps and improve the effectiveness of support and care provided.
• Ongoing monitoring, data gathering and documentation efforts must be strengthened to include incidents of sexual violence against men and boys. Personnel involved in these processes must be trained to safely and ethically identify and document such cases. Information must be shared securely and anonymously among relevant stakeholders.

Strengthen financial support for responses to CRSV for all victims/survivors.

• Adequate and sustained funding is crucial to developing comprehensive services that address the diverse needs of victims/survivors. These services include healthcare, mental health support, legal assistance, socio-economic reintegration and support groups. Securing robust financial resources ensures that interventions are effective, sustainable, and accessible to all victims/survivors regardless of gender, age or other characteristics.
• Stakeholders should fund and facilitate the development of male survivor networks and peer support groups, empowering victims/survivors to offer mutual support and actively shape the services victims/survivors receive.

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1. The research formed part of multi-country project by ASP in Afghanistan, CAR and Colombia aimed at strengthening understandings of and responses to the experiences, needs and wishes of men and boys, including those with diverse SOGIESC. See ASP and Youth Health and Development Organization (YHDO), Enhancing Survivor-Centred Healthcare Response for Male Victims/Survivors of Sexual Violence in Afghanistan, March 2021; ASP, Enhancing Survivor-Centred Healthcare for Male Victims of Conflict-Related Sexual Violence in Colombia, September 2023. ↩︎
2. Médecins Sans Frontières (MSF), “Sexual violence remains a public health crisis in Central African Republic”, 15 April 2021. ↩︎
3. See for example, All Survivors Project (ASP), “I don’t know who can help”: Men and boys Facing Sexual Violence in Central African Republic, 14 February 2018. ↩︎
4. For further information about Tongolo and other MSF projects in CAR see, MSF, Invisible Wounds: MSF’s findings on sexual violence in CAR between 2018 and 2022, 24 October 2023. ↩︎
5. 72 hours is the timeframe for emergency contraception, HIV prophylaxis and treatment for sexually transmitted infections to be effective and during which specimens for evidentiary purposes are ideally collected. See World Health Organisation (WHO), Guidelines for Medico-legal Care for Victims of Sexual violence, 2003. ↩︎
6. Sarah Chynoweth et al., A social ecological approach to understanding service utilization barriers among male survivors of sexual violence in three refuge settings: a qualitative exploratory study, Conflict and Health, 14: 43, 8 July 2020. ↩︎
7. These include: the UMIRR, the Joint Unit for Rapid Intervention and Eradication of Sexual Violence against Women and Children (Unité Mixte d’Intervention Rapide et de Répression des Violences Sexuelles Faites aux Femmes et aux Enfants) composed of elements the police and gendarmerie and civilian which provides an integrated response (investigation, basic medical care, psychosocial support and legal service) to victims/survivors of sexual violence; the Special Criminal Court established to investigate and prosecute serious human rights violations and violations of International Humanitarian Law committed since 2003; and The Truth, Justice, Reparation and Reconciliation Commission with a mandate to establish the truth about “serious national events” from 1959 to 2019 and recommend reparations for victims of serious human rights violations, which was closed down in 2024, https://www.ohchr.org/en/press-releases/2024/07/central-african-republic-independent-expert-calls-transparency-and. ↩︎