Submission to the United Nations Economic, Social and Cultural Rights Committee in Advance of the Review of Colombia

73rd Pre-Session: 16-20 October 2023

Ensuring Survivor-centred Healthcare for Men and Boy Victims/Survivors of Conflict-Related Sexual Violence in Colombia under the International Covenant on Economic, Social and Cultural Rights (ICESCR) 

Introduction

1. All Survivors Project (ASP) is an international non-governmental organisation that supports global efforts to eradicate conflict-related sexual violence (CRSV) and strengthen national and international responses to it through research and action on CRSV against men and boys. ASP has been working on supporting access to justice for male victims/survivors in Colombia since 2020.
2. This submission focuses on men and boys in Colombia, including those with diverse sexual orientation, gender identity, gender expression and sex characteristics (SOGIESC), who are victims/survivors of CRSV. It focuses on male victims/survivors because they represent a category of people that are often less easily identified or supported within existing responses to CRSV. However, it also highlights barriers which impact any victim/survivor of CRSV, not just men and boys. This submission is therefore intended to draw attention on and complement efforts to address CRSV against women and girls, recognising the disproportionate impact of CRSV on them and the ways in which gendered inequalities, institutions, and identities drive CRSV. 
3. This submission addresses one main area of concern relating to the insufficient availability of and access to safe, timely, quality, survivor-centred medical care and mental health and psychosocial support services for victims/survivors of CRSV in Colombia including men and boys (articles 2, 3, and 12).
4. It is based on research conducted in Colombia in 2022 by ASP with the support of female and male victim networks. The research explored the availability of and access to timely, quality health responses for male victims/survivors of CRSV, including those with diverse SOGIESC, their experiences of healthcare services, and the extent to which services are survivor-centred. The research was qualitative and involved: a desk review of literature on sexual violence against men and boys in Colombia and of relevant laws and policies relating to health sector responses for sexual violence (including CRSV); a mapping of key stakeholders involved in health sector services for victims/survivors of CRSV; key informant interviews with 35 stakeholders from healthcare and other related sectors; and in-depth interviews with 23 male victims/survivors of CRSV from 11 conflict-affected departments.^[1] This submission is also informed by previous work by ASP on investigating patterns of CRSV against men and boys in Colombia for a co-authored confidential submission to the Special Jurisdiction for Peace which contained cases of 81 male victims/survivors of CRSV.^[2]

Background: Conflict-related sexual violence

1. Women and girls have been disproportionally affected, and in 2015 Colombia’s Constitutional Court recognised that sexual violence against women and girls in the context of the armed conflict was a widespread and systematic practice.^[3] However, men and boys are also among the victims. Of the 38,412 people registered by the Victims Unit as victims/survivors of CRSV, 2,943 are male (or 7.7% of the total number).^[4] Separately, the National Centre for Historical Memory (Centro Nacional de Memoria Histórica – CNMH) has reported 17,332 victims of sexual violence in the context of the armed conflict between 1958 and 2022, including 1,642 (or 9.5% of the total number) men, of whom 395 were children at the time of the incident.^[5]
2. Cases of sexual violence against men and boys have also been documented by medical institutions and humanitarian organisations. The National Institute of Legal Medicine and Forensic Sciences (through medico-legal examinations) registered 373 men and boy victims of sexual violence during the period 2004-2016.^[6]Médecins Sans Frontières (MSF) has reported that in 2016 it supported 722 victims of sexual violence in its clinics in the district of Buenaventura in the department of Valle del Cauca and the municipality of Tumaco in the department of Nariño, of whom 10% were men. In these cases, alleged perpetrators were reported to include family members, partners, ex-partners and neighbours, but also included members of “[criminal] band(s) or armed group(s)”.^[7]
3. Despite the signing of the Final Peace Agreement between the government and FARC-EP in 2016, women, men, girls and boys, continue to be subjected to sexual violence at the hands of NSAGs. Between 2017 and 2023, the Victims Unit has registered 5,027 cases of CRSV of which 4,522 have affected women and girls (or 90% of the total number), 385 (or 7.6% of the total number) affected men and boys, and 120 were committed against LGBTI people.^[8]
4. However, CRSV in Colombia, as is the case elsewhere, is significantly under-reported and the real figures of those affected by CRSV there are generally thought to be much higher. With regard to women, Colombia’s Constitutional Court has referred to a “triple process” of invisibility, silence, and impunity in facilitating sexual violence against them, ^[9] while the CNMH and others have noted that the silence is even greater in the cases of men and boy victims/survivors of sexual violence.^[10] The extent of CRSV against men and boys with diverse sexual orientation or gender identity and other LGBTI+ people is also regarded as being very significantly under-represented in official figures. ^[11]
5. Since 2020 efforts by civil society and national victim groups have led to an increasing recognition of the sexual victimisation of men and boys during the armed conflict. In 2022, following a two year investigation, ASP co-authored a submission to the Special Jurisdiction for Peace which included 81 cases of sexual violence against men and boys that occurred between 1989 and 2015 particularly in the departments of Magdalena and Chocó and the region of Montes de María. The targeted victims constituted a heterogenous group: ten men identified as gay or bisexual, 71 as heterosexual, 20 were boys at the time of the incident, and several identified as Afro Colombian. A detailed analysis of cases found that that these victims were typically attacked in their homes; while cultivating their land; or while travelling along roads and highways where armed groups were present and in confrontation. Their experiences were characterised by extraordinary levels of brutality – the vast majority involved anal rape often by more than one person and sometimes in public or in the presence of family members. The testimonies tell of being bound and beaten. In addition, the victims were threatened with violence and death if they reported the incidents. In many cases, sexual violence was accompanied by or took place in the context of other serious violations of international law, including unlawful killings, torture and other ill-treatment, and extortion. In almost all the analysed cases, victims were forcibly displaced because of the sexual violence, which deprived them of their livelihoods. Most reported severe physical and psychological injuries because of the sexual violence they suffered, for which most had not received any medical or psychosocial support. Indeed, the impact of the experiences of sexual violence on the victims who provided their testimonies has been devastating. Even now, many years after the events, most are still living with the physical, psychological, economic and other consequences of the crimes committed against them. 

Legal guarantees to the right to health for victims/survivors of sexual violence and CRSV under national law and key routes to access care

1. The right to health is enshrined in Colombia’s Constitution, which states that “all individuals are guaranteed access to services that promote, protect, and restore health,” and the State has a duty “to organize, direct, and regulate the provision of health services…,”^[12] It is also recognised in legislation including Statutory Law 1751 of 2015 (sometimes referred to as the Statutory Health Law)  which establishes health as an autonomous fundamental right which should include the interrelated elements of availability, acceptability (including respect for medical ethics and of diverse cultures of individuals, ethnic minorities, peoples and communities), accessibility (including non-discrimination, physical accessibility, affordability and access to information) and quality.^[13]
2. .^[14] It also establishes the duty of the State to ensure the availability of health services in marginalised areas and the need to adopt effective, progressive and continuous measures so that people living in remote areas have timely access to the health services they need.^[15]
3. The right to health specifically for victims of sexual violence is also included in Law 1719 of 2014 on Access to Justice for Victims of Sexual Violence, Especially Sexual Violence During the Armed Conflict, which requires the health sector treat victim/survivors as a priority and free of charge. It further stipulates that sexual violence should be regarded as a medical emergency, regardless of the time between when it occurred and when medical care is sought, and that psychosocial care must be provided for as long as required and cannot be restricted by either financial or time constraints.^[16]
4. The right to mental health care for the general population (conflict-affected and non-conflicted affected alike) is set out under Law 1616 of 2013, known as the Mental Health Law, which provides, inter alia, the right to integrated specialised and interdisciplinary care and the right to a psychotherapeutic process for as long as required.^[17]
5. The right to reparation for victims/survivors of grave human rights violations is also enshrined in the Constitution^[18] and reinforced by various laws and judicial decisions. Chief among these is Law 1448 of 2011 (the Victims and Land Restitution Law or “Victims Law”). Among the reparative measures provided for under the Victims Law is humanitarian aid for “victims of crimes against sexual freedom, integrity and development”, which includes emergency medical and psychological care,^[19] All public and private hospitals are required to provide such emergency care to any conflict victims (including of CRSV) who require it, regardless of their ability to pay or any other conditions.^[20]
6. The Victims Law also provided for the establishment of the Programme of Psychosocial and Integral Health Care for Victims (Programa de Atención Psicosocial y Salud Integral a Víctimas, PAPSIVI), to provide (non-emergency) health care as well as physical, mental, and/or psychosocial rehabilitation, to victims of the armed conflict.^[21]  Set up in 2013, under the responsibility of the Ministry of Health, PAPSIVI comprises two components: comprehensive healthcare and psychosocial care.^[22] The former covers medical and mental health care which, in practice, is provided under the regular health system and coordinated by the EPSs.^[23]The psychosocial care component is provided by non-profit organisations and, is currently provided primarily through mobile outreach teams which offer conflict victims who are registered with the Victims Unit a limited number of individual, family or community psychosocial counselling and other support sessions.^[24]
7. However, also in response to acknowledged weaknesses, including the limited availability and lack of coordination and continuity of care provided under the current PAPSIVI model, the programme is in the process of being reformed. In accordance with a Ministry of Health August 2022 decree and September 2022 resolution, PAPSIVI will be gradually integrated into the regular health system, such that by 2031 it will be an integral part of the system. This will involve inter alia setting up comprehensive care teams in public hospitals comprising a doctor, a psychologist, a social worker, a nurse, and a community health worker (a victim/survivor of the armed conflict) with overall responsibility for the physical, mental and psychosocial health care of conflict victim/survivors. The new model is reportedly being piloted at the time of writing. ^[25]
8. Separately, the Victims Unit also offers psychosocial support through its “Emotional Recovery Strategy at Group Level” (EREG), programme which is provided primarily via its Regional Centres for Attention and Reparation to Victims (Centro Regional de Atención y Reparación a Víctimas, CRAV).

Barriers to health care for victims/survivors of CRSV

1. Victims/survivors of CRSV typically require both immediate and long-term specialised medical and mental health and psychosocial support (MHPSS) care. Yet accessing timely, quality healthcare services had been challenging for most of the male victims/survivors interviewed by ASP. Of the 23 men interviewed:
   • Only two sought medical care within 72 hours of being subjected to CRSV (with one doing so only after a second incident of sexual violence).
   • Most others sought healthcare many years after the incident of CRSV – seven had sought medical care over a decade after the event, and one only 40 years later.
   • Six said that although they had sought healthcare for injuries resulting from sexual violence, they had not actually disclosed that they were victims/survivors of sexual violence.
2. There was consensus among all those interviewed (victims/survivors and key informants) that unless urgent medical treatment for serious physical injuries was required, male victims/survivors typically do not seek healthcare and that, even where medical treatment is sought, men and boys generally do not disclose the real reason for their injuries or symptoms. 
3. One of the victim/survivors who had contracted syphilis as a result of CRSV said that he had not received an accurate diagnosis for many years because he was too fearful to disclose to the doctor what had happened to him. He explained that, “I kept going to the doctor and the doctor prescribed me painkillers, drugs that calmed me down for a while. In 2018 I had a very bad relapse, I went to the doctor and that is where the doctors, through the EPS, did a thorough follow-up. They sent me for a series of tests and that is where they discovered that I had the disease. I had had it for many years.”^[26]
4. Such delays have serious consequences, with the impact of injuries and physical health often worsening if left untreated, and the risk of HIV and other STIs dramatically increases if post-exposure prophylaxis (PEP), and other treatment, such as post-exposure Hepatitis B vaccination and treatment for syphilis and gonorrhoea, are not quickly administered.^[27] Recovery from the mental health and psychosocial impacts of CRSV may also be delayed if gender-competent, survivor-centred support is not quickly and easily available to victims/survivors.^[28]
5. The importance of psychosocial support was emphasised by both victims/survivors and key informants with one victim speaking about how the psychosocial support provided under PAPSIVI had “brought him back.”  But there was also significant criticism of the design, scope and approach of the support offered both under PAPSIVI and under the Victim Unit’s EREG programme, with several research participants questioning whether they were suitable for providing the long-term, quality, survivor-centred support that victims/survivors of CRSV are entitled to and which they desperately need.
6. The research pointed to multiple reasons why victims/survivors are unwilling or unable to access appropriate healthcare, many of which relate to the general weaknesses in the provision of healthcare which impact any victim/survivor of CRSV, not just men and boys. These included at the structural level: (1) uneven availability of basic medical and mental healthcare and of specialised care for victims/survivors of CRSV, (2) lack of clarity over requirements on healthcare workers to report sexual violence, (3) challenges in the design and delivery of MHPSS through PAPSIVI and by the Victims Unit; at the organisational level (4) under-resourced and ill-equipped healthcare facilities and high staff turnover resulting in loss of expertise and experience and disruption in care continuity, (5) lack of respect for confidentiality and privacy of victims/survivors, and at the  community level: (6)insecurity resulting from the presence of non-state armed groups which restricts travel and access to services, (7)and negative community attitudes towards victims/survivors and resulting stigmatisation.
7. However, some of the barriers identified were more gender-specific and often underpinned by factors including (1) a lack of awareness that men and boys (as well as women and girls) can suffer CRSV; (2) non-gender inclusive (or in some cases gender-exclusive) policies, protocols and guidelines on healthcare support to victims/survivors of sexual violence (laws or policies that do not acknowledge male vulnerability to sexual violence can directly affect the availability of medical care and other support for male victims/survivors and should be revised so that they are gender-inclusive);^[29] (3) lack of understanding of the gender differentiated harms that can result from sexual violence; and (4) deep-rooted cultural constructs of masculinity and sexuality which not only affect attitudes of healthcare workers towards male victims/survivors, but also profoundly influence the way in which harms are internalised by affected individuals and the responses of their families and communities.   
8. The research findings highlight the appalling physical, psychological, psychosocial and socio-economic harms resulting from CRSV and how these are exacerbated by the lack of availability and/or inaccessibility of timely, quality healthcare services.
9. The multi-layered barriers identified point to the need for far-reaching, coordinated efforts by all those responsible for or involved in the provision of healthcare to strengthen responses for all victims/survivors of CRSV to ensure that their rights, needs and wishes are addressed. In so doing, it is essential to recognise that men and boys (both heterosexual/cisgender men/boys and those with diverse SOGIESC), can be victims/survivors of sexual violence and for medical and MHPSS services to be gender-competent and be both accessible to and have the resources, skills and capacity to provide the long-term, specialised care that these individuals require.  
10. In its recommendations, it should be noted that the Truth Commission also called upon the Ministry of Health, the Victims Unit and municipal and departmental health secretariats to strengthen the comprehensive health (physical and mental) and psychosocial care for all conflict-victims, including by “guaranteeing continuity of service, personnel training, sustainability of processes and expansion of coverage in general through, among others, the implementation of mobile strategies in rural areas.” It also called for capacities (protocols and training) to be strengthened to address particular and disproportionate impacts of certain victimizing events including “sexual and reproductive violence.” Its recommendations further emphasised the need for measures to be designed in coordination with the victims and their organisations, to address and repair specific damages according to the victimising event, and to apply the principal of “differential approaches to gender, ethnicity, disability and life course.” The Truth Commission also highlighted the importance of advancing “the investigation and visibility of this violence [CRSV against men] and in the psychosocial care of the victims.”^[30]

Considering the above, ASP recommends that the Committee include the following in its LOI:

• Please report on the steps taken by the State Party to ensure availability of timely, quality primary healthcare including in remote, rural and conflict-affected areas, and easily accessible specialised medical and MHPSS for all CRSV victims/survivors without discrimination.
• Please report on the status of the review of the 2012 Sexual Violence Protocol which should have been updated every two years from its adoption according to Resolution 0459.  Please clarify what consultation are being undertaken with civil society and with female, male and LGBTI+ victims/survivors of sexual violence to inform the revision.
• Please report on the status of the ongoing process to reform PAPSIVI and on the psychosocial support offered by the Victims Unit and whether and how specific attention is being paid to ensuring that the capacity, skills and resources are in place to provide long-term, gender-competent and age-appropriate psychosocial support to all victims/survivors of CRSV.
• Please report on measures being taken in the form of developing guidelines, conducting trainings, or implementing procedures to change attitudes among health care workers and other personnel who are likely to treat victims/survivors of CRSV and whether these are inclusive of sexual violence against men and boys in addition to women and girls.
• Please provide information on how laws and policies to ensure access to health care for victims of sexual violence are gender inclusive. 
• Please provide information on measures taken within health care services to facilitate access to and enable safe, confidential disclosure by all victims/survivors of sexual violence, including men and boys.
• Please indicate which legal, policy and practical measures have been taken by the State Party to protect health facilities, health and humanitarian workers and others involved in providing care and assistance to victims/survivors of CRSV.

^[1] Forthcoming report by ASP. Colombia will be the second in a series of reports published as part of ASP’s multi-country project on survivor-centred healthcare for male victims/survivors of CRSV. 

^[2] See ASP, Deponer las Armas, Retomar las Almas (Laying Down Arms, Reclaiming Souls): Sexual Violence against Men and Boys in the Context of the Armed Conflict in Colombia, 19 June 2022, https://allsurvivorsproject.org/deponer-las-armas-retomar-las-almas-laying-down-arms-reclaiming-souls/ (hereinafter ASP, Laying Down Arms, Reclaiming Souls, June 2022).

^[3] Constitutional Court of Colombia, Special Chamber for the monitoring of Judgment T-025 of 2004, Order 009 of 2015, (Spanish only), https://www.corteconstitucional.gov.co/T-025-04/AUTOS%202015/Auto%20009%20del%2027%20de%20enero%20de%202015seguimiento%20ordenes%202%20y%203%20del%20auto%20092-08.pdf  

^[4] Figures from the Single Registry for Victims of the Victims Unit, https://cifras.unidadvictimas.gov.co/Cifras/#!/hechos, cut-off date 30 June 2022 (accessed 25 July 2023).

^[5]  Figures from the Memory and Conflict Observatory of the CNMH, “El Conflicto Armado en Cifras” https://micrositios.centrodememoriahistorica.gov.co/observatorio/portal-de-datos/el-conflicto-en-cifras/ , cut-off date of 31 March 2023 (accessed on 19 July 2023); In addition, according to the JEP’s Analysis of Information Group (Grupo de Análisis de Información, GRAI), 8.7% of the cases of CRSV since 1990 within the “provisional universe of cases” submitted to the JEP are male, JEP Executive Secretariat, Response to Petition by ASP, No. 202301027557, 8 June 2023, on file with ASP. 

^[6] Daniela P. López Gómez, ‘Apuntes para entender la violencia sexual contra los hombres en el marco del conflicto armado colombiano’, Revista Controversia, No. 210, June 2018. According to the article, 223 of the cases were attributed to the Colombian Armed Forces and 91 to paramilitary groups and BACRIM. Spanish only.

^[7] MSF Colombia, Colombia: In the Shadow of the Peace Process. The Impact of other Situations of Violence on the Population’s Health, August 2017, p.21, https://arhp.msf.es/people-and-violence/colombia-shadow-peace-process

^[8] Figures from the Single Registry for Victims of the Victims Unit, https://cifras.unidadvictimas.gov.co/Cifras/#!/hechos, cut-off date 30 June 2022 (accessed 25 July 2023).

^[9] Constitutional Court, Order 092 of 2008, 14 April 2008, III.1.1.6.

^[10] See ASP, Laying Down Arms, Reclaiming Souls, June 2022, p.10.

^[11] Of the of 38,412 victims/survivors registered with the Victims Unit, just 628 identified as being lesbian, gay, bisexual, transgender or intersex.

^[12] The Political Constitution of Colombia of 1991, Article 49.

^[13] Congress of Colombia, Statutory Law 1751 of 2015, 16 February 2015, (Spanish only), Article 6, https://www.minsalud.gov.co/Normatividad_Nuevo/Ley%201751%20de%202015.pdf

^[14] Statutory Health Law, Article 11.

^[15] Statutory Health Law, Article 24.

^[16] Law 1719 of 2014, 18 June 2014, Article 23 and 24.

^[17] Law 1616 of 2013, 21 January 2013, Article 6. https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/DE/DIJ/ley-1616-del-21-de-enero-2013.pdf

^[18] The Political Constitution of Colombia of 1991, Transition Article 66.

^[19] Victims Law, Article 47.

^[20] Victims Law, Article 47, paragraph 2 and Article 53.

^[21] Victims Law, Articles 137 and 138.

^[22] PAPSIVI is regulated by Decree 4800 of 2011.

^[23] Ministry of Health, Comprehensive Health Care for Victims, https://www.minsalud.gov.co/proteccionsocial/Paginas/Victimas_Atenc_Integral_Salud.aspx

^[24] The number of sessions varies but according to interviews carried by ASP and secondary sources, it is commonly eight sessions.

^[25] Ministry of Health, Decree 1650 of 2022, 6 August 2022, https://www.funcionpublica.gov.co/eva/gestornormativo/norma.php?i=191746 and Resolution 1739 of 2022, 22 September 2022, https://www.scribd.com/document/637601471/1-1-Resolucion-1739-Asignacion-de-recursos-PAPSIVI-2022

^[26] Interview with a victim/survivor from the Andean region, 27 March 2022, Bogotá.

^[27] According to WHO guidelines, PEP should be offered as early as possible to all individuals with exposure that has the potential for HIV transmission, and ideally within 72 hours. WHO, Guidelines on Post-Exposure Prophylaxis for HIV. Recommendations For a Public Health Approach: December 2014 Supplement to the 2013 Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infections, December, 2014, https://www.who.int/publications/i/item/9789241506830. See also MSF: https://www.msf.org/sexual-violence. 

^[28] IASC, Guidelines on Mental Health and Psychosocial Support In Emergency Settings, 1 June 2007, https://interagencystandingcommittee.org/mental-health-and-psychosocial-support-emergency-settings-0/documents-public/iasc-guidelines-mental

^[29] This includes:  the Ministry of Health’s 2012 “Protocol and Model of Comprehensive Health Care for Victims of Sexual Violence Protocol” (Resolution 0459 of 2012), the Ombudsperson’s Guide to Comprehensive Care for Women Survivors of Sexual Violence, and the National Institute for Legal Medicine and Forensic Sciences 2018 Guide to a Comprehensive Forensic Approach to the Investigation of Sexual Violence. 

^[30] Truth Commission, Final Report, Resistir no es aguantar. Violencias y daños contra los pueblos étnicos de Colombia, August 2022, (Spanish only), https://www.comisiondelaverdad.co/resistir-no-es-aguantar; The Truth Commission’s Final Rpoert refers to ASP’s Deponer las Armas, Retomar las Almas (Laying Down Arms, Reclaiming Souls): Sexual Violence against Men and Boys in the Context of the Armed Conflict in Colombia, 19 June 2022, https://allsurvivorsproject.org/deponer-las-armas-retomar-las-almas-laying-down-arms-reclaiming-souls/