Individual agency and social support in healing from conflict-related sexual violence: A case history from eastern DRC

ABSTRACT

Examining the experience of a male survivor of rape through the salutogenic model and ecological theory, this case study explores how he moved towards the direction of health after an atrocious experience of sexual violence perpetrated by members of an armed group. The study illustrates how he was able to deploy agency by undertaking a number of health-promoting actions to recover from the physical, mental, and social effects of conflict-related sexual violence. Initiatives in the process of improving one’s health include self-care practice, searching for specialised care when self-care seems inefficient, relocation to new a setting post-rape, starting a business, testing one’s reproductive capacities, marrying, taking care of the way he dressed, learning a new language, developing public speaking skills, owning a piece of land, having regular medical check-ups and ascending to power and decision-making bodies. His narrative shows how these initiatives are mirrored by both opportunities and setbacks. While more traditional survey-based studies focus on identifying which practices might be helpful in a healing context, this study sheds light on how an individual healing process might be complex and nuanced and is an important starting point towards our efforts to theorise resilience for male survivors.

KEYWORDS:

• Individual agency
• social support
• health promotion
• male survivors of sexual violence

Introduction

Current scholarship on conflict-related sexual violence against men focuses on the prevalence, forms, causes, and consequences of sexual violence against men, various care needs for survivors post-rape, and barriers to care – including how masculinity norms hinder access to care and threaten their well-being (Corboz et al., 2023; Grey & Shepherd, 2013; Sivakumaran, 2010). Recently, Alexandre et al., (2022) demonstrated that the holistic care model including medical, psychological, socioeconomic, and legal support for survivors of conflict-related sexual violence has been designed mainly to meet female survivors’ needs while male survivors struggle for care in these women’s centred programmes. Furthermore, when men are subject to sexual violence by other men, their masculine attributes are considered to have been taken away, and they are subject to ridicule and shame by community members (Christian et al., 2011).

Sexual violence against men is regarded as deviant to heterosexuality and to hegemonic masculinity defined by Connell and Messerschmidt (2005) as a set of norms and practices that embody ‘the most honored way of being a man in a particular setting’. Sexual violence against men leads to social exclusion and stigma seriously compromising survivors’ position in patriarchal societies (Widanaralalage et al., 2022a). Some dominant misconceptions regarding sexual violence against men are rooted in gender inequality emphasising the authority of men over women and other marginalised men such as ‘real men cannot be raped’; ‘male rape only concerns gay men’; ‘men who are raped asked for it’; ‘male rape is not traumatic’ (Widanaralalage et al., 2022a).

The aforementioned misconceptions about sexual violence against men obscure its prevalence, deny survivors’ suffering, and hinder the recognition of this phenomenon (Widanaralalage et al., 2022a). Several male survivors do not seek care due to the shame and stigma associated with sexual violence (Widanaralalage et al., 2023). The lack or limited care options for male survivors raises the question of whether they remain passive to the disastrous effects of conflict-related sexual violence or they exert agency over this situation and retake control of their lives post-sexual abuse.

This case study argues that viewing male survivors as forgotten helpless victims obfuscates our understanding of their agency deployed in their everyday life to keep themselves healthy physically, mentally, and socially after brutal conflict-related sexual violence experiences. Dominant narratives in the literature of conflict-related sexual violence against men analyse their experience through a pathogenic lens concluding that their bodies and minds are damaged by rape acutely, chronically, or fatally, and their plight receives little/no attention from service providers (Carpenter, 2017; Kiss et al., 2020). However, although most male survivors are indeed left untreated post-rape, this does not necessarily mean that they continue to suffer permanently from physical, emotional, and social effects of sexual violence.

The purpose of this article is to look closely at one case history – ‘Joseph’ – to illustrate how recovery can move along a health/disease continuum and how even despite the scarcity of intervention, survivors can exercise agency to recover holistically and regain their sense of manhood post-rape. Antonovsky (1996) points out that we are all always in the dangerous river of life and we can swim both downstream (towards disease) and upstream (towards health). I examine Joseph’s story through the lenses of Antonovsky’s salutogenic model Bronfenbrenner’s social ecological theory (1986; 1995) and masculinity studies to analyse how he was able to exercise agency and ‘swim toward health’. I understand ‘health' as a state of optimal physical, mental, and social well-being, and not merely the absence of disease and infirmity (Antonovsky, 1996). Joseph’s story illustrates the complexity of the healing process and demonstrates the role of personal agency, which is crucial to understand in our efforts to theorise resilience strategies for male survivors of sexual violence in armed conflicts and know how to support them.

Conflict-related sexual violence against men

In this paper sexual violence is understood 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 (UN, 1998).

Precise estimates of the magnitude of conflict-related sexual violence against men are difficult to obtain due to underreporting by male survivors. However, 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. It is also estimated that sexual violence against men is prevalent across various communities during peacetime including in prisons (Russell, 2007; Wolff et al., 2006; Widanaralalage et al., 2022a).

There is however an academic debate regarding who perpetrates sexual violence against men. DiMarco et al. (2022) argue that 80% of sexual violence against men is perpetrated by women. However, recently, Widanaralalage et al. (2022b) questioned the interpretation of these findings arguing that authors have adopted an outdated definition of sexual violence in their analysis considering rape as a ‘copulation resisted to the best of the victims’ ability’. Widanaralalage et al. (2022b) state that defining rape on the basis of the victims’ efforts or inability to defend themselves historically resulted in victim-blaming and disqualification of many rape cases in the U.S. legal system. Furthermore, by conceptualising sexual violence as a heteronormative crime, DiMarco et al.(2022) overlook the real experiences of gay, bisexual men and LGBTQ people who can also be both victims and perpetrators of sexual violence (Widanaralalage et al., 2022b). Research has demonstrated that conflict-related sexual violence is also extensively perpetrated by men against other men (eg. Schulz, 2018) to humiliate or punish both victims and their communities. However, in a study conducted in the United Kingdom, Weare (2018) shows that in some situations men are forced to penetrate female perpetrators of sexual violence.

The most frequent forms of rape against men in armed conflict settings include anal penetration, oral sex, forced masturbation, enforced nudity, forced sterilisation, and genital violence (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 and symptoms related to sexually transmitted infections, and reduced desire for sexual activities with their partners (e.g. Christian et al., 2011; Chynoweth et al., 2017). Most mental health symptoms are related to post-traumatic stress syndrome (PTSD), anxiety and depression, feeling of helplessness, persistent anger, guilt, shame, low self-esteem, unhealthy self-blame, and confusion (Widanaralalage et al., 2022a). It is widely reported that male survivors lose their sense of manhood in addition to experiencing a loss of economic productivity post-rape (Christian et al., 2011).

Most male survivors remain untreated post-abuse due to several barriers, including but not limited to the inadaptability of care programmes to their needs, toxic masculinity ideals keeping them from seeking care, scarcity/absence of services, unawareness of existing support programmes, and unqualified service providers to meet their needs (Alexandre et al., 2022; Corboz et al., 2023). While we know that many male survivors face complex barriers to care and suffer acutely, chronically, or die of rape-related symptoms, little is known about how male survivors move towards the direction of health after sexual violence despite complex barriers and maladapted programming. Understanding how male survivors improve their physical, mental, and social health after rape is a focus of this paper.

Analytical framework

The findings of this paper were analysed through the salutogenic model (Antonovsky, 1996), social-ecological theory (Bronfenbrenner, 1986; 1995), gender theory, and masculinity studies to unpack how the complex personal, environmental, cultural, political, and socioeconomic factors contribute to the promotion of health in Joseph’s case. I use these perspectives because they each draw attention to the subject’s own agency, and the purpose of this paper is to examine how healing might take place in the scarcity of service provision.

Antonovsky’s salutogenic model conceptualises health and illness as a continuum, rather than a dichotomy. I rely on its two main concepts, ‘sense of coherence’ and ‘resistance resources’ to unpack how Joseph was able to draw from existing resources to move towards the direction of health after sexualised violence. The concept of sense of coherence refers to a person’s view of life and capacity to respond to stressful situations. It is a personal way of thinking, being, and acting, with an inner trust enabling human beings to identify, benefit, use, and re-use the resources at their disposal for the promotion of their health (Eriksson, 2017). Sense of coherence allows me to understand how Joseph’s ways of thinking and behaving led him to take advantage of available resources to promote his general well-being.

Resistance resources in the salutogenic model can be generalised or specific. The former refers to potentially available resources for engagement in a wide range of circumstances, and the latter denotes particular resources relevant to particular circumstances (Eriksson, 2017). In the case of Joseph’s situation, I looked at which specific and general resources he used to move towards the direction of health and well-being after rape. Resistance resources can be genetic, constitutional, psychosocial, cultural and spiritual, material, and can have preventive health orientations (Eriksson, 2017). They can also exist at multiple levels including the individual, group (family), subculture, and whole society levels (Eriksson, 2017).

Although the salutogenic model constitutes a robust analytical framework through which to understand the origins of health for male survivors, it does not delineate clearly how multiple societal entities including personal, environmental, cultural, social, political, and historical factors interact in the promotion of health. I thus also draw from Bronfenbrenner’s social ecological model, which posits that human development occurs through constant interactions between individuals and their multiple, interconnected environmental contexts (Bronfenbrenner, 1986; 1995). Bronfenbrenner’s ecological model situates environmental factors that influence human behaviour in five main interactive levels: individual, microsystem, mesosystem, exosystem, and chronosystem levels.

At the individual level, I look at which personal initiatives/decisions Joseph (pseudonym) took to regain physical, mental, and social well-being and how this affected his identity as a man. At microsystem level, I seek to understand how Joseph interacted with his immediate environment such as family members and friends in his quest to recover and regain his sense of manhood, which I understand as a set of socially, constructed ideas about men as gendered persons with specific needs and values (Gardiner, 2002). The mesosystem level looks at interconnections and linkages between individuals and exosystems including organisations such as hospitals, churches, humanitarian organisation, mental health services etc. Here, I analyse whose services and which organisations Joseph used in his ecosystem to access care and how. The macrosystem includes societal norms, expectations, and beliefs, values that form the broader social environment (Campbell et al., 2009). At this level, I look at to which extent Joseph’s personal values and beliefs conform with or diverge from dominant societal norms, values, and beliefs of hegemonic masculinity. The chronosystem level looks at changes that occur over time between persons and their multiple environments. At this conceptual stage, I look at how Joseph’s health evolved from the time of the rape through the post-rape period, and how Joseph’s perception of self and his manhood changed over time.

To operationalise the salutogenic and ecological models, I also draw from different aspects of masculinity studies and gender theory. Masculinity studies look at social expectations of being a man – including roles, behaviours, and attributes that are considered as appropriate for a man in a particular society. As Connell and Messerschmidt (2005), I see masculinity as a fluid and dynamic social construct taking diverse and sometimes contradictory forms across time, space, and situations. As part of gender theory, masculinities can be constructed, performed, achieved, lost, and regained in light of norms that define what it means to be a man in a particular setting.

The concept of hegemonic masculinity differentiates between external and internal hegemonies respectively referring to the dominance of men over women and of men over other marginalised men including gay men and male survivors of sexual violence who are often excluded from patriarchal dividends including status, prestige, and other socioeconomic advantages (Connell & Messerschmidt, 2005; Demetriou, 2001). Although only a few men achieve hegemonic masculinity ideals, many men position themselves in relation to them (Connell & Messerschmidt, 2005). Some of the basic expectations of being a man in Africa include but are not limited to being heterosexual, being married, feeding and protecting the family, being tough, invulnerable, powerful, and in control (Alexandre et al., 2022; Alexandre & Moke Mutondo, 2022; Schulz, 2018). Sexual violence against men often leads to a feeling of crisis in one’s sense of manhood as it is incompatible with hegemonic masculinity expectations. However, Messerschmidt and Quest (2023) show that there are ‘peace and violence centered’ forms of masculinities in various societies. This paper portrays both peaceful and violent masculinities in Joseph’s journey towards health and shows how they are informed by the gender order and culture of his community.

Methods

This retrospective case study sets out to explore in-depth the healing process of a single male survivor of sexual violence in eastern DRC and the factors that sustained it. Case studies are used in social sciences for in-depth examination of a single individual, group, or event (Priya, 2014). Studies using primary data to analyse sexual violence against men are scarce due to the reticence of several male survivors in participating in such sensitive research (Widanaralalage et al., 2022a). Most research on sexual violence against men draws from archival research, literature reviews, and attitudinal studies (Widanaralalage et al., 2022a). Given the scarcity of data on the healing process of male survivors, there is a bunch of information we can learn from a single case study and generate questions/hypotheses for future research. The purpose of a case study is not to generalise over some broader populations but rather to gain a thorough understanding of a case in ‘a real context’ and generate hypotheses that can then be tested in comparable situations or generate questions for future research (Priya, 2014). This paper is based on a three-hour interview with a male survivor of sexual violence in Walungu, in eastern DRC conducted in May 2023, and on some observations I made when I visited his village in January 2024. He was identified through the Department of Mental Health at Mulamba Hospital in Walungu territory. Mulamba Hospital is a One Stop Center associated with Panzi Foundation DRC offering medical, psychosocial, socioeconomic, and legal support to survivors of sexual violence, predominantly women. I approached the department with a request to speak to male survivors of sexual violence and was given the contact information for five men who had completed care at least five years ago. Only Joseph (pseudonym) was available for an in-depth interview.

The interview took place over a drink in a private setting at a hotel in Walungu. I obtained oral informed consent from Joseph prior to the interview, and let him know that he could withdraw from the interview or skip questions he felt uncomfortable answering.

I assured him that the study was for academic purposes and that his identity would be protected throughout the research process. This study was part of a large research project approved by the South Kivu Provincial Ethics Committee under CNES001/DPSK/29PM/02023.

I note my positionality as a Congolese young man and a researcher with experience working with male survivors of sexual violence at Panzi Hospital and at Panzi Foundation DRC. My long-time research with survivors of sexual violence at Panzi Foundation DRC and at Panzi Hospital made me familiar with the challenges they face during care delivery and in the community. However, this interview offered a new window through which to zoom differently the experience of a male survivor digging deeper into his personal agency other than how my organisations impacted his life. This study did not present any conflict of interest between the researcher and Panzi Foundation DRC which is an organisation specialising in the holistic treatment of conflict-related sexual violence against women. Generating evidence-based data and systematic studies on coping strategies for male survivors within limited treatment options is of interest to both the researcher and the organisation to better understand how best to assist male survivors of conflict-related sexual violence in the future. I explained to Joseph that his participation was on a voluntary basis and there could not be negative implications with regard to his relations with the Panzi Hospital and Panzi Foundation DRC if he refused to participate in this study. Joseph understood the academic nature of the study and consented to participate voluntarily.

At the beginning of the interview, I did not have any preconceived idea regarding how a man might bounce back from the multifaceted adverse effects of rape. I listened carefully to Joseph and relied exclusively on his experiences and testimonies which enabled me to capture unbiased new experiences, insights, and explanations. From the beginning of the interview, I promised Joseph protection and anonymity throughout the research process which established trust between us. However, being a Congolese man speaking the same language as Joseph also increased the degree of trust. I conducted the interview in Swahili, which is the vernacular language in eastern DRC. I asked Joseph about his experience of war trauma, his health-seeking behaviour, how he understood himself as a man, and which steps he took to start a new healthy life after the traumatic event of rape.

Prior to the interview, a psychologist from Mulamba Clinic was contacted to provide emotional assistance in case Joseph experienced emotional problems during the interview. As Joseph understood the focus of the interview and consented to participate beforehand, he found pleasure in sharing his story with the researcher to raise awareness about sexual violence against men which he believed remained unknown for many people and organisations. No emotion problem was observed during the interview.

The interview was recorded and transcribed, then translated into English. The interview was analysed using thematic analysis which consists of identifying, analysing, and interpreting qualitative data patterns (Braun & Clarke, 2006). Morse (2008) states that 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). The interview was read and coded multiple times, and I organised the key findings into general themes, described below.

Findings

Pathogenic elements enter Joseph’s body and mind

Before showing the direction towards the health end of the continuum, it is worth discussing first how Joseph became a victim of sexual violence.

Joseph is 45 years old. He was abducted along with other men and women in 2006 by armed men affiliated with Democratic Forces for the Liberation of Rwanda (FDLR). The FDLR settled in eastern DRC following the flight of Hutu extremists to eastern Congo after their involvement in the 1994 Rwandan genocide (Tshiband, 2009). This rebel group is comprised of perpetrators of the 1994 Rwandan genocide, Hutu members of the former Rwandan army as well as a mix of displaced Rwandan Hutus (Hedlund, 2014; Marriage, 2016; Tshiband, 2009). The FDLR is known for several human rights violations in eastern DRC including massacres, murders, tortures, pillages, lootings and sytematic rapes (Alexandre et al., 2021; Tshiband, 2009).

Joseph was 27 years old when he first encountered members of the FDLR armed group in Nindja. He explained that around 60 armed men came to his village on 3 October 2006 at 9 PM. Five armed men entered Joseph’s house to loot and kill, while others were strategically dispatched to different houses in the village. Joseph stated, ‘I was reading the bible to prepare a sermon for my fellow youth at church, then I heard people coming towards the door with extreme brutality and asked us in Kinyarwanda to open the door’. The armed men ultimately broke the door and entered Joseph’s house by force. Joseph said that his sister and mother started crying, and that ‘as a man, they thought I could fight back; they tied me up so that I could not make any movement’. Then the armed men asked his mother to bring everything of value to the household including money, clothes, and goats. Joseph’s father was away when the incident occurred. After the pillaging, his mother was shot and died on the spot. Joseph explained: ‘after killing my mother, they took me outside the house and two of the rebels raped me in front of other people in the village’. He said, ‘I felt humiliated being turned into a woman in public!’.

After looting and public rapes, the rebels needed a workforce to help them carry looted objects to their camp. Joseph was chosen among the people to carry the spoils looted in different houses of the village. According to Joseph, around 50 people were abducted: roughly 80% were women and 20% men. They walked for two days to reach the rebel camp in a thick forest. He recalled that ‘if you say that you are tired on the way, the rebels said that they are going to give you an eternal rest, which means killing you’. Joseph reported that some people were killed on the way to camp because they felt exhausted. Joseph and the other abductees arrived in the camp and were enslaved by rebels for four months: ‘We became their servants, responsible for cooking, fetching water, and washing their uniforms’.

Joseph reported that both women and men were systematically raped during captivity. The forms of rape he experienced personally were anal penetration, fellatio, forced intercourse with other men and women in the captivity camp, insertion of objects in private parts, beatings on his genitals and what I refer to as ‘land-rape’, which Joseph explains as when ‘armed men dug some small holes in the ground, and then asked you to penetrate them and ejaculate’. Joseph reported that he had serious physical injuries associated with the various forms of sexual violence he experienced. ‘I had rashes all over my body due to sexually transmitted diseases, and also had sores on my private parts’. He adds, ‘I am not sure why I did not die there. (…) I felt like I was a useless person. I wanted to die instead of living in such a situation’. Joseph said the rebels offered little food to keep captives alive while torturing them. ‘I cursed the day I was born’, he said.

He was freed four months later by a rebel commander, who, according to Joseph, was not among the group that abducted them, but rather joined the rebel camp three months later. Joseph had known him before captivity and was surprised to see him in a military uniform in the rebel camp. When he went to the river to fetch water one day, this commander offered to help him escape as long as he did not attribute the escape to his actions should he get caught. The commander wished him good luck, and then Joseph started a journey back home. ‘I walked for a week to reach home; I was slow because I was in a critical health situation’. Joseph survived on forest fruits and food he begged for at villages he passed through on his journey back home.

Moving towards health post-sexual abuse

Joseph mentioned that many people in Nindja knew he was a survivor of sexual violence because the rebels raped him publicly during the attack on the village. ‘I felt so ashamed and did not want to appear in public, so I stayed in our house’, he said. ‘Some people said behind my back: look at the female-man’. Describing Joseph as a ‘female-man’ indicates that the society expected only women to be victims and men to be perpetrators of sexual violence reflecting gendered stereotypical expectations echoed in other conflict-ridden countries (e.g. Schulz, 2018).

In addition to the social stigma associated with rape, Joseph also continued to suffer physically and psychologically. He therefore took some conscious initiatives to address the consequences of sexual violence and recover as a ‘man’. Joseph was well aware of what was expected of men in his community.

First, he began to address the physical effects of rape. At the outset, he tried self-care at home to relieve sexual violence symptoms. ‘I took some medicinal herbs known for curing infections, but the symptoms did not improve’. Finally, he decided to go to a local clinic for appropriate care. However, Joseph did not have money to pay medical fees at the clinic. Some family members and friends contributed some money to cover his medical fees. ‘My relatives and some friends understood that I was not in good health; they contributed some money and took me to a local clinic’. This statement suggests that community members should not be seen exclusively as stigmatising because they can also express sympathy. However, Joseph’s sense of coherence must also be acknowledged in the process of seeking care, as he realised that his immediate environment could be an important resource to help him get to the clinic. ‘I asked for help and men of good will helped me’. The contributions from microsystem level (family members and friends) were partly influenced by his personal decision to seek care.

Joseph was hospitalised for two weeks and received treatment in a local clinic, providing an example of how exosystems in his environment contributed to his movement towards health. Joseph said that he did not choose to go to the clinic at first because he avoided sharing his story with third parties. ‘I was afraid I would be identified as gay by the medical staff’, he said. However, Joseph said that he was treated fairly. ‘I did not tell them the whole truth about my experience’, he admitted. His treatment included antibiotics to fight gonorrhoea, lotions to address itchy skin, and vitamins. While Joseph found relief from pain, he complained that ‘my back and groin continued to hurt despite the care, but thanks to God I was negative for HIV’.

When Joseph realised that the treatment he received was not sufficient, he started thinking about alternatives. He learned from those close to him that Panzi Hospital in Bukavu offered more specialised care. He had to wait until he could find a ride to Bukavu. Eventually, he was offered a ride by the Red Cross, which drove him for free to Panzi Hospital. The free drive that he found in his environment was an important contribution towards his movement towards health.

After arriving, he was hospitalised for four weeks. Although Panzi Hospital specialises in holistic care for survivors of sexual violence, Joseph said that medical care was his priority as he had injuries on his private parts that were not cured at his local hospital. However, Joseph believed in the interdependence between physical and mental health: ‘When you feel pain in your genitals, you feel extremely traumatised mentally’, he noted, perceiving his mental distress as originating from physical conditions. He said that a survivor himself has an important role to play in his own emotional healing: ‘The greatest psychologist is yourself. If you do not heal yourself psychologically, no psychologist will help you regardless of his academic qualifications and experience’.

Joseph said that his strategy to heal himself emotionally was to accept his experience and transcend it. ‘If you do not accept your problem, you will be miserable during your lifetime’. Implicitly Joseph is saying that a survivor must have a capacity to manage stress and not the latter to manage him indirectly referring to the sense of coherence coined by Antonovsky (1996). Furthermore, Joseph drew from his Christian beliefs to heal emotionally: ‘The Bible says we should forgive those who do wrong against us; I forgot the past and put my hope in Jesus my savior’. Although he benefited from psychological support, he sees personal efforts and faith in Jesus as a more important factor in the psychological healing process. Previous research has also established that spirituality is an important aspect of the healing process for many patients as it can lead to a reduction in stress, relief of pain, improved recovery from surgery, reduced depression and anxiety, prevention, and recovery from substance abuse (Gockel, 2009; Torosian & Biddle, 2005).

Joseph returned home after one month of hospitalisation. Panzi Hospital covered transportation costs for him and provided 50 USD for food on the way back to his village. Joseph said, ‘When I left Panzi Hospital, I felt cured compared to how I was before’. Joseph saw physical and mental health as preconditions for resilience: ‘You cannot pretend to be a man while you are struggling with poor health; people will notice that you are weak even if you hide’. Panzi Hospital as an exosystem in Joseph’s environment was crucial for his recovery.

Negotiating manhood after emasculation: Initiatives and challenges

After discharge from Panzi Hospital, Joseph worked first on his ‘social health’ in order to effectively reposition himself as a man in the community. Initiatives he took included saving some funds, relocating to a new place, starting a business, testing his reproductive capacities, marrying, taking care of the way he dressed, learning a new language, purchasing land, making new friends, and having regular medical checkups. However, these initiatives were characterised by both opportunities and setbacks and should not be understood in a linear manner.

Joseph believes that money is not the sole determinant of manhood but an essential component of it. When he was discharged from the hospital, he waited in Bukavu until he found a free ride from his friend who drove him back to the village in a public bus. ‘I received some money from Panzi Hospital for the ride back, but I kept the cash because I knew that I could use it for other important things’. When he arrived home, he told his family about his plan to move to a different village. To support his move, the family sold bananas from the family farm and gave him 25 more dollars. Joseph only stayed for two weeks before relocating to another village about 30 km away. Joseph explained the move by saying, ‘I could not have peace of heart and mind in my home village because many people knew what happened to me’. The financial resources from Panzi Hospital and from his family facilitated his move towards health, but the decision to move was his own initiative. Migration to a new setting as Joseph’s case exemplifies, is one of the frequent responses to many stressful events including wars and climate change (Jacobson et al., 2019)

After arriving in the new village, he stayed at his uncle’s house for a year. Six months after his arrival, he started a small business with the money he saved from Panzi Hospital and from his family. He started selling diverse commodities including sugar, salt, soaps, pens, sweets, etc. When he realised that his business had grown, Joseph decided to settle in that village and rented his own house. ‘I wanted to become autonomous from my uncle and his family’, he said. The idea that men should be autonomous is common in the wide repertoire of masculinity ideals in eastern DRC (Freedman, 2016; Lwambo, 2013).

In addition, Joseph engaged in premarital sexual activities to test whether his reproductive health was in working order. Joseph stated: ‘To be a man means to be capable of having children’. This idea is consistent with the phallocratic/hegemonic masculinity idea that values heteronormativity and reproductive capabilities for men and women (Edwards, 1994). Joseph said, ‘In three years, I fell in love with two women and had a child with each’. Joseph justified his decision to have children by saying that ‘some people believed that I was a sterile gay man, and they were surprised when I had children’. This statement shows that Joseph adopted values and beliefs from his macrosystem that define healthy masculinity in relation to reproductive capabilities (Ouzgane & Morrell, 2005). When Joseph reported that his manhood was questioned, he was referring to people back in his home village who knew that he experienced rape and to some people in his current village who have learned his situation through other people from his home village.

The extent to which the two women consented to have children with Joseph is not certain, and his decision seems to have been informed by the gender order in his patriarchal community that expects men to be heterosexual and to decide whether to have sex or children (Alexandre et al., 2022). Furthermore, the two women bore the burden of having children without being officially married, and might have run the risks of sexually transmitted diseases suggesting that Joseph adopted ‘violence centered masculinities’. Previous research has also established that some male survivors try to recapture their status as men by engaging in stereotypically masculine behaviours including risk-taking sexual behaviours, excessive drinking, and acting aggressively and violently (eg., Widanaralalage et al., 2022a).

Joseph married a different woman in 2011 whom he recognises as his official wife. Compared to the first two women who were not informed about Joseph’s experience of sexual violence, he informed his wife about his rape experience before marriage. ‘She said as long as I have no HIV and other infections, she can accept me’. His decision to talk about his rape experience to his wife is inconsistent with the essentialist hegemonic idea that victims hide their rape victimisation from third parties (Koss, 2018). Joseph pointed out that although his new wife accepted his experience, she was wary about the potential effects of the rape: ‘If I had HIV, she could see me as a virus that will ruin her life. So, we went to get the test and it was negative’. Joseph now has two daughters and one son with his current wife. At the chronosystem level, it can be argued that the existence of children and a wife improved Joseph’s own perception of his manhood as well as changed the way the community perceived him (a sterile gay man). Schulz (2018, p. 88) also found in a study conducted in Uganda that the perception of a full achievement of manhood is attained through marriage. Joseph identifies himself as a mushamuka which means ‘mature man’ in Mashi because he is the head of his family and able to provide food and pay school fees for his children. Messerschmidt and Quest (2023) argue that providing food for the family, paying school fees for the children, and caring for the family is part of complex forms of ‘peace centered masculinities’.

Joseph said that his wife plays a central role in his general health and well-being. Joseph’s wife grows food such as cassava, sweet potatoes, beans, and vegetables. One part of the harvest is sold and another is used as food in Joseph’s household contributing to the nutrition and health of her family in general. Joseph praised the role of his wife in the promotion of health by stating, ‘I could not live longer without her. She cooks for us, she makes sure my clothes are clean, and she is available for me for support whenever I need her’. Cooking and doing some domestic chores are tasks predominantly performed by women in eastern DRC (Mulumeoderhwa, 2022). However, Joseph said that sometimes the relationship with his wife gets tense especially when he uses family money to buy beer for his friends. ‘If I spend money on beer, she is mad at me and spends several days without talking to me’. While his wife sees buying beer for friends as a threat to the household’s economy, Joseph perceives it as a strategy to reaffirm his manhood in the community: ‘A true man cannot expect other men to buy beer for him every day. I buy for them sometimes when I have money’. Joseph enjoys making friends and spending his free time with other men in the village. Spending money on beer to please his friends while his family needs it for survival can be categorised as an economic violence against his family.

Joseph is conscious that initially his manhood was destabilised by rape. To appear as ‘a real man’, he pays close attention to the way he dresses: ‘I want to be always clean and well dressed, not only myself but also my wife and my children’. According to Joseph, ‘If a man is poorly dressed and looks miserable, people start questioning his manhood’. Joseph goes further by saying: ‘It is even better for your wife to be well-dressed than yourself’. He explained: ‘The way your wife dresses will tell people whether her husband is a strong man or not’. Determining how the family members need to dress in order to boost his status as a man in the community denotes Joseph’s attachment to the patriarchal norms of his society that promote men’s power and prestige (Allen & Devitt, 2012).

Although Joseph often generates some income through his business and agricultural activities, his financial capacity is insufficient to meet all his material needs. Joseph embodies a sacred principle: ‘I never ask a person from my home villages to help me financially or give me clothes’. While he buys some clothes for himself when he can, he also relies on a network of friends outside his home village to have some more clothes and occasional financial support. This finding is consistent with Schulz (2018) who reported that some male survivors in Uganda choose to hide their stories in some contexts and reveal it in others, especially where they estimate that they will not be so exposed to shame. ‘Of course, I can share beer with friends from my home village, but I can never ask them for money or any other support’.

Another step Joseph took to bolster his own self-image was to develop his language skills. His mother tongue is Mashi. Although he has never been in Tanzania, he speaks Swahili fluently with a Tanzanian accent. He said that he worked on his Swahili after he settled in his new village. He learned pure Swahili from the radio and from newspapers. Several people in eastern DRC assume that Tanzanian Swahili is of higher quality compared to eastern Congo Swahili, which borrows from many languages. Joseph said that he learned pure Swahili because he wanted to develop rhetorical skills and win the respect of community members. The ability to speak fluently in public is expected for men in eastern DRC (Alexandre et al., 2022).

In addition, Joseph volunteers as a radio broadcaster in the village: ‘Only smart people can speak on the radio’. Topics he has covered include citizens and development, marriage and dowry, etc. He reported that he goes to a local radio station twice a week and he is much appreciated as a broadcaster.

Fluency in both Mashi and Swhili has allowed him to play a central role in the village council, which is the local body in charge of conflict resolution and development. According to Joseph, only men are part of this council. He said, ‘If I did not speak Mashi and Swahili fluently, I could never sit on the village council’. Sitting on the village council is volunteer, but a honourable work that provides prestige, joy, and respect for Joseph. His promotion to the village council challenges the hegemonic masculinity idea that those whose heterosexuality is in question are excluded from what Connell cited by Demetriou (2001) called ‘patriarchal dividends’ including social status, prestige, political, cultural, economic, and legal benefits. Hollander (2014) stated that the concept of hegemonic masculinity is sometimes irrelevant when it is confronted with empirical reality in eastern DRC, especially when for instance a male survivor ascends to decision-making bodies of his village, goes to the hospital regularly to ensure he is healthy or when he reports to his prospective wife that he experienced sexual violence.

Joseph said that he goes to a hospital 26 km away from where he lives for a medical check-up every six months. As a survivor of conflict-related sexual violence, Joseph has free access to care at this hospital. When he cannot go there, he goes to a neighbourhood chemist for medicine to treat his symptoms. Joseph also benefitted from a project implemented by Panzi Foundation DRC that aimed at improving the socioeconomic conditions of survivors. ‘I received 800 USD from Panzi and I added 300 USD from my savings to buy a piece of land, which I plan to build a house on soon’. Other studies have shown that owning a house is an important aspect of masculinities and manhood in Africa (Gibbs et al., 2014). However, Myrttinen and Schulz (2023) argue that assistance to male survivors is legitimate but sometimes carries a message of ‘re-masculinizing’ that often matches with survivors’ wishes, but risks re-establishing patriarchy.

When I visited his village and his house in January 2024, Joseph unexpectedly showed me his iron sceptre called Kahorho in Mashi which is a symbol of authority that only married men with a family, children, lands, and power are allowed to possess. He acquired this sceptre when he started sitting on the village council some years after his official marriage. I took a walk with him in his village and saw people on the way greeting him with respect while walking with his iron sceptre. Joseph was aware of the fact that he had become a respectable man in his new village. He asked me:‘do you see how much people respect me here?’ After the walk, we returned to his house and he showed me again a sword which he perceived as a defensive instrument in case of external threats against his house. ‘A full man cannot miss a sword’, Joseph commented while explaining to me his role as a man to protect his family.

Discussion and conclusion

Joseph took advantage of general and specific resources at his disposal to move forward in the direction of health. His experience is consistent with the idea that health and manhood are dynamic as they can be accessed, lost, regained, and maintained (see Antonovsky, 1996; Connell & Messerschmidt, 2005; Lwambo, 2013). Joseph’s current health results from a variety of genetic, personal, and ecological sources. I will focus on the social and ecological origins of his health in this discussion.

The pathogenic model of analysis tends to focus on the health-threatening factors in Joseph’s case, remaining blind to some implicit lifesaving and health-promoting initiatives that Joseph experienced on his way to, from, and in the rebel camp. Joseph’s courage and perseverance spared him from being executed on the way to the rebel camp, as those who seemed exhausted on the road to the rebel camp were executed on the spot. To save his life, Joseph scrutinised the rebels’ murderous attitudes and refrained from engaging in life-endangering behaviour by avoiding exhibiting signs of fatigue on the way. Furthermore, rebels provided a small amount of food to Joseph, which kept him alive for a period of time although his health had deteriorated significantly due to brutal rapes. Arguably, rebels used both stick and carrot strategies by raping and feeding their victims. Thanks to past contact with a member of the rebel group, Joseph was freed from captivity and returned home. Not being killed on the way, getting some food in the captivity camp, and being freed from sexual slavery should be part and parcel of his subsequent health analysis as his future post-rape was contingent on these salutogenic factors.

Furthermore, Joseph found significant support from the microsystem level. His friends and family members donated money to help him have access to exosystems for care (clinics and hospitals) which provided necessary care for physical and mental recovery. After physical and psychological care, Joseph also worked on his social health and well-being in accordance with ideas about manhood from his social environment. He worked to improve his health, financial and social situations. He found both support and resistance at various levels of society but was resilient. Support included contributions to cover medical fees, treatment from hospitals and clinics, food from his family, support for transportation costs, free care at Panzi, etc. Resistance and threats to his health included stigma from community members and physical and mental health conditions, but he was able to address them through personal concrete initiatives and found support in his environment. His story shows how male survivors of sexual violence are not simply passive recipients of external support (Edström & Dolan, 2019). As part of his healing journey, Joseph developed leadership skills, improved his financial situation through business and agricultural activities, and ascended to local power structures and prestige. Schulz (2018) also shows that in Uganda male survivors engage in agricultural activities and other income-generating activities for survival.

Joseph’s story also provides some nuance to the narrative about how survivors of sexual violence are rejected by community members. If Joseph had been totally rejected by community members, he would not have received financial support from family members and friends and from exosystems (clinics and hospitals) in his environment. Most importantly, he would not have been able to rise to a position of leadership nor establish himself as a merchant in the community.

While Joseph’s story is only one person’s story and cannot be generalised, it provides great insight into how much agency individuals can exercise in their own healing. Moreover, it illustrates how personal initiative can make the most of what might in many other parts of the world be considered minimal support. The theoretical framework draws attention to both how health is a continuum rather than a fixed state, and how support and resistance are found at multiple levels. His story raises a number of important questions for future research, including how it might be possible for service providers to tailor support based on the kinds of agency and initiative that survivors are able to demonstrate, as well as how to leverage a person’s own resilience in the healing process. Having a better understanding of how individuals can access their own sense of agency could give service providers a better idea of what kinds of support can be best utilised at different levels of society, including at individual, microsystem, mesosystem, exosystem, and chronosystem levels while being mindful of the risks of re-masculinisation.

Acknowledgements

The author thanks the interviewee and Lynn Nygaard from Peace Research Institute, Oslo who provided excellent editing assistance. The author is also thankful to the Insecure livelihoods fellowship which granted a scholarship that enabled him to work on this paper.

Disclosure statement

No potential conflict of interest was reported by the authors.

Data availability statement

Due to the ethical necessity of maintaining participant confidentiality, the interview is not publicly available.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This study was achieved thanks to the scholarship that the author obtained from the Insecure Livelihoods fellowship funded by GIZ in collaboration with Ghent University and le Groupe d’Etudes sur le Conflit et la Securité Humaine in the framework of the Propaix project.