Section 4 At the Time of Crises

#### **Chapter 12**

## Refugee Camps in Greece: Conditions in Reception Facilities on Gender Perspective

*Foteini Marmani*

#### **Abstract**

An attempt to objectively and comprehensively record the modern living reality of asylum seekers based on their own perspective and the views expressed by the academic and administrative staff employed at accommodation structures has been made. Emphasis is placed on women, and the common problems they encounter regardless of gender, but also on individual differences identified between female and male asylum seekers. Therefore, the present paper focuses on the living conditions in temporary accommodation centres and on the existing social relationship structures being shaped at such centres, with special emphasis on the dimension of gender (single women, single mothers). The aim of this paper was, then, to collect documented material and evidence on current practices concerning specific vulnerable groups, on the grounds that such groups still remain in obscurity to some extent and their survival is hugely dependent on individual initiatives and occasional assistance received. Our motive was the lack of comparative data, drawing attention to specific vulnerable groups in temporary accommodation centres and hostels in Athens and Lavrion and to their living conditions. Consequently, the realization of this research, for the implementation of which a combination of quantitative and qualitative methods has been employed, is considered to be a minimum prerequisite for the creation of a humanitarian policy addressing refugees in Greece, as a Member State of the EU. The findings highlight the concerns about the service quality including: (1) the lack or variations in the frequency of funding, (2) the absence of women's participation in decision-making as their responsibilities residing in these centres usually fulfill their "stereotypical" roles: child care, cooking and cleaning, (3) the difficulties in recording/identifying specific incidents are mainly due to a lack of knowledge and a lack of staff, which is typical of the centres surveyed by Doctors Without Borders in Europe, but also due to the fear overwhelming violent victims, preventing the disclosure of facts and contributing to the maintenance of this bleak picture of the victims. (4) the need for psychological support due to problems that can become more severe after long periods of waiting at centres due to the uncertain outcome of asylum procedures hindering their adjustment. (5) the lack of childcare provisions inhibits employment for women. In addition as the vast majority of female refugees are poorly educated and cannot easily find a (legitimate) job—until after a long stay—they basically get employed at the informal home-based work sector and/or at other marginalized sectors of the labour market. The present research may contribute to the: (a) provision of a clear-cut picture of the gender dimension within the refugee context, (b) identification of the female refugee population's needs and the detection of the problems they encounter, (c) the evaluation of the effectiveness of services and structures supporting refugees and (d) exploitation of results and findings for policy design.

**Keywords:** gender, asylum seekers, needs, women, refugees, staff

#### **1. Introduction**

A key finding with reference to refugee and asylum seeker reception centres, undoubtedly, involves the location of such centres and, by extension, the place destined for their temporary settlement in our country. A triple typology has practically been induced: to the present moment, urban, semi-urban and rural centres are present. The criterion for the first and third group is rather obvious, provided that both the "city" and the "rural area" respectively, as socio-cultural contexts of living within traditional conceptual approaches of the terms, presently constitute widely acknowledged matters. On the other hand, suburban areas are those whose population does not exceed the number of permanent residents. The National Centre for Social Solidarity in Thessaloniki and the Sperhiada centre used to be active in the past, as well as the Lavrion centre, constituting one of the structures where our research has been conducted, embody three typical cases rendering the identified groups [1] more concrete.

Centres falling under the first group, are, by necessity, all housed in blocks of flats, old buildings, which are considerably damaged and lack maintenance provisions; they are devoid of special areas for joint activities and arranged in multiple layers that render their internal functionality problematic. Centres included in the second group are usually located in open spaces fronted by building perimeter and include space in the courtyard or adjacent sites for exercising collective action; they also encompass special areas allotted to the administrative and other departments of the centre, a separate classroom for children or adults, clinic and so on. The infrastructure of centres being part of the third group, however, is not elaborated on within the context of the present paper and therefore a comprehensive reference to it was deemed unnecessary.

It is worth mentioning that, under the restrictive measures taken by the European Union, existing centres are transferred from urban to rural areas, close to their external borders or new centres are established in them. Such measures are also roughly applied by the new member-states of the European Union such as Poland, where refugee centres are founded in its sparsely populated southeastern side (Pontlach), Slovenia and Lithuania [1].

A diversity of heterogeneity categories is evident in centres, comprising ethnic heterogeneity (with reference to the nation-state), political (political differences, given that political refugees are primarily involved), cultural (different culture and civilization), social (directly related to legal and economic heterogeneity) and economic, legal heterogeneity (resulting from the legal recognition and exemplifying an existential character), ascribing the corresponding status to refugees. Collective heterogeneity can also be witnessed (with the family serving as a central match point, e.g. a single-parent family or another type of grouping, e.g. coming from the same village) and individual heterogeneity (refugees are usually sorted by gender or age). The last heterogeneity category is sociologically explained by reference to

*Refugee Camps in Greece: Conditions in Reception Facilities on Gender Perspective DOI: http://dx.doi.org/10.5772/intechopen.113088*

the "ascribed status" (e.g. sex—woman, race—black) and the "achieved status" (e.g. education— lawyer) [1].

Security provision should be a prioritized service offered to refugees at each centre. The latter feel very insecure and are taken over by feelings of persecution; they fear the unknown, which is justified considering their living conditions in their home country and their attempt to escape from this country. These concerns are related to their effort to preserve their "mental health" and health "care", and should be provided at these centres. Therefore, the ground should be laid so that further health problems do not emerge and unpleasant situations can be prevented (e.g. preventive medicine-medical examinations).

Furthermore, centres' contribution to finding a job, and thus to providing the potential for a dignified living, is critical. The provision of legal support by the centres is imperative, given the insufficient knowledge of the language, ignorance of the prerequisites demanded by the bureaucratic certification system, the multiple endogenous pathogenic nature of the Greek bureaucratic system, the feeling of insecurity among refugees and the inability to move. The centres' staff contribution may lead to the acquisition of one's legal status. Besides, the assistance provided by psychologists and specialized personnel could help resolve refugees' individual and family problems and adopt a more positive approach to this population.

Another significant provision could involve the interconnection of refugees with the world outside the Greek territory through the use of mobile phones to communicate with people in their families or via satellite television to learn what is happening in their country of origin.

Finally, learning the Greek language is a key concern for refugees and ensuring classrooms and teaching staff is remarkably crucial. Likewise, the provision of opportunities for cultural expression, religious worship and entertainment are also considered fundamental.

In Greece and less often in the rest of Europe, two types of administrative detention centres can be identified. More specifically, we come across:


In relation to the number of detention centres (closed) in Europe, intended for illegal immigrants under administrative detention in Morocco, Belgium, Malta, Greece and other countries, the number of reception centres (open), as often referred to, is not huge.

Open centres to accommodate Third World nationals are usually part of the package of measures for asylum seekers, or more generally for the Third World nationals requesting international protection.

The Doctors without Borders [2] research revealed the existence of different types of open centres for asylum seekers in some countries, displaying the following functions:

• reception: detection of the category the foreigner belongs to, initial examination of acceptance in the process of applying for asylum—reception and accommodation of asylum seekers during the asylum procedure.

• return preparation for those whose application for asylum has been rejected.

In this way, in Denmark, for instance, asylum seekers are initially sent to reception centres, then to accommodation centres and eventually to return centres in case their application is rejected.

The centres are located in different places, but while this research was being conducted, several ones were reported to be found in relatively isolated areas: some industrial areas on the outskirts of cities, but also in the suburbs, in places that are difficult to access. In many countries, geographic isolation (centres located in sparsely populated areas, even in forests) and difficulties in accessing some of the centres (extremely poor public transport) constitute real problems for asylum seekers.

As being the case for closed centres, a number of open centres were operated in existing facilities that were "recycled" to accept asylum seekers. Problems arise in readjusting the use of facilities, designed for other uses that sometimes differ greatly from social housing ones. Except for delaying asylum seekers' integration into the host society, distant centres geographically create the feeling of being marginalized and abandoned, thus not meeting the demands of a dynamic individual and collective approach.

The concentration of a large number of asylum seekers in large centres for long periods of time appears to trigger problems such as conflictual relations, devoid of humanism, both within centres and outside of them, considering that there are countries whose indigenous population is hostile to the concentration of foreigners in their country, due to its not being familiar with people of different origins and cultures.

Numerous cases of psychological depression have, therefore, been observed to a greater extent at distant and/or large centres. On the assumption that people can be kept in reception centres for several months, or even years, physical conditions can have a significant influence on the quality of the residents' lives. When these conditions are not adapted to their needs or deteriorate, they can damage personal or family relationships irreparably and create or exacerbate vulnerable situations due to problems comprising lack of privacy, violence and so on. Excessive restrictions imposed on the freedom of movement encourage residents' withdrawal and isolation, who may feel that they are kept unfairly "locked". This is considered to be an additional obstacle impeding residents' smooth integration into the host society.

Throughout the studies conducted [3], the fact that women require special attention because of their greater vulnerability to different types of violence within centres has been highlighted. The issue of domestic violence has already been mentioned. This type of violence is exceptionally difficult to identify, as it is aided by the lack of privacy while the way of living at the centres due to overcrowding and other factors appears to cause tension and multiple problems. The difficulty emerging in identifying incidents of violence and sexual abuse against women was reported throughout our research. Single women, living in extremely vulnerable situations, are greatly exposed to various forms of abuse, especially sexual ones. Such risks were observed in countries such as Hungary, Poland and Slovakia. The risk of violence in general and the risk of violence against women in particular increases as a result of the large number of single, not engaged in activities, and isolated men at these centres.

Conducting a comparative review of the reception status and conditions for asylum seekers in selected European countries, it could be argued that attempts to harmonize the reception system for asylum seekers in European countries, could definitely be attributed to existent, significant differences that can decisively

#### *Refugee Camps in Greece: Conditions in Reception Facilities on Gender Perspective DOI: http://dx.doi.org/10.5772/intechopen.113088*

impact the distribution of "asylum demand" to various Member States of the European Union. However, such divergences and disparities cannot be utterly eliminated, since internal conditions, geographical and transportation data, the standard of living, the level of social benefits, unemployment problems, problems related to crime/public safety and so on vary greatly in different regions of the continent.

With reference to Greece and based on research carried out by the Doctors without Borders [2] it can be concluded that immigrants' living conditions at the detention centres are unacceptable, hygiene and the distribution of relief items are inadequate, there is a lack of information, interpretation and medical monitoring that complicate detainees' lives. However, the situation is expected to improve as a result of new centres' opened in areas, such as Amygdaleza, Corinth and in other parts of Greece, provided, of course, that the conditions and procedures for foreigners' placement in these areas will be appropriate.

As regards asylum seekers' accommodation structures, which were thoroughly investigated by Tsovili and Voutira [3], it is indicated that there are no provisions for psychological care and medical examinations, as well as legal support. Training is essentially confined to seminars teaching the Greek language while job finding is not actively encouraged. Furthermore, there is no participatory approach to guests and none of the centres has presented awareness-raising programs on intercultural issues. Leisure activities are also limited and the guests' psychology is poor due to insecurity and anxiety while no restrictions are exerted on their exercising their religious duties and the freedom of movement. The main problem is the lack of stable funding, which generated changes to service quality.

As for the specific problems women are faced with, the maintenance of their stereotypical roles, involving lack of participation in decision-making and limited access to higher education and vocational training programs, is observed. Further, women's specific health needs are only met when requested and their employment is not actively promoted.

The data collected for the current host practices relating to single women and female-headed single-parent families hosted at the:


The research hypotheses for the questionnaires were formulated based on the research objectives, the relevant literature and the knowledge and experience we have acquired as regards the organization and operation of asylum seekers' temporary hosting structures. Two central research hypotheses have been proposed with reference to the questionnaire addressed to the professionals (structures' academic and administrative staff):


#### **2. Research methodology**

The research methodology followed comprises a set of research tools, both quantitative and qualitative. The qualitative and quantitative methods share common ground in that the collection of accurate information on social phenomena is attempted but tends to differ in terms of the type of information and the way the latter is being gathered. The combined and complementary use of quantitative and qualitative methods is considered to be the most effective methodological approach towards achieving a thorough presentation and delineation of the social reality dimensions.

There was a combination of quantitative and qualitative methods, involving desk research in libraries and archives, fieldwork comprised of qualitative data collection by in-depth interviews and quantitative data collection with face-to-face interviews and structured questionnaires to be completed by the interviewees (centre management, specialized staff and asylum seekers, regardless of gender) within a time frame of 15–20 min. By means of combining open and closed-ended questions with quantitative and qualitative data analysis respectively, an effective and comprehensive approach towards social reality was attempted. Furthermore, through reconciling and combining two research methods, the in-depth interviews and the questionnaire technique—tools whose exploitation was compelling as already mentioned—have been used as part of the qualitative and quantitative approaches respectively. The in-depth interviews conducted before the quantitative interviews significantly contributed to the preparation of the structured questionnaires, which had to be stated in alignment with the particularities of the population in question. In addition, my personal involvement as a researcher and as an interpreter prevented this research work from becoming a mere compilation of typically completed questionnaires. After getting the permission of each centre, the interviews were conducted in the morning and the afternoon at the centres of Accommodation using random sampling selection of the refuges being present on the days of the visit, with a view of involving the largest possible number of residents during the period of 22/11/2011 till 20/03/2012. Each of the aforementioned techniques entails a host of advantages and disadvantages but their combined use was considered to be most effective.

The population number i.e. the total number of asylum seekers accommodated at the five centres of the research, during the period of Nov 2011–March 2012 amounts to 308 adults (66.5% males, 33.5% females) and 162 children. The total number of professionals employed by these centres is 55.

The size of sample comprised 207 asylum seekers, 89 females (42.99% and 118 (57.01%) males, coming from countries, such as Turkey, Afghanistan, Iraq, Iran and Syria, as well as 37 professionals (scientific and administrative staff) of the structures participating in the research. Participants' ages ranged from 18 to 46 years.

#### *Refugee Camps in Greece: Conditions in Reception Facilities on Gender Perspective DOI: http://dx.doi.org/10.5772/intechopen.113088*

The sampling technique applied was stratified random sampling, where the population under study was divided into two relevant subgroups/strata (guests hosted, professionals) and from each subgroup the sample was drawn randomly.

The research tools employed involved two differently structured questionnaires. In order to best cover different parameters and attitudes on the quantitative questionnaires, the qualitative method of three in-depth interviews preceded. With regards to the structured questionnaires, the first one was to be completed by the guests hosted at the centres and shelters and it included initially 22 questions all closed except the last, with a significant number of multiple choice questions, questions of scale. Specifically to investigate the needs of women were added four more open-ended questions, were addressed only to women.

The questionnaire addressed to the target group was structured on the following themes:


Similarly, the questionnaire addressed to the administration and clerical staff of the centre, which was answered by 37 professionals, included 29 questions, all closed except one, with a significant number of responses YES/NO and scale questions. The open-ended question asked respondents to report the three most common problems encountered in the structures when it comes to single women and women heads of families.

The questionnaire addressed to professionals is structured on the following themes:


The completion of the questionnaires did not necessitate the inclusion of personal data in order to ensure participants' anonymity. To create case-appropriate research tools, the study of the UNHCR questionnaire, following the design of the UNHCR Guidelines on the Protection of Children and Women Refugees, was deemed necessary. Accordingly, the UNHCR interview form, whose design resembles the one of the UNHCR questionnaire, was taken into consideration while creating the interviews content.

The grounds for selecting the specific tools vary. Our decision has primarily been founded on: firstly, it's being a weighted, valid and reliable tool; secondly, it's being used in similar studies; and thirdly, the provision of a wealth of information in areas related to the content of the current research.

#### **3. Findings**

Data for our analysis comes from 207 questionnaires completed by adult asylum seekers, 89 females and 118 males as well as from 37 questionnaires completed by professionals at five temporary accommodation centres for asylum seekers: at the Lavrion centre, at the Doctors of the World, Nostos, Praxis and Arsis NGOs. At the same time, professionals employed at these centres—administrative and scientific staff—were interviewed on the issue of refugees' way of living at the abovementioned structures.

Specifically, the issue of space was given prominence at the Lavrion centre, as precast settlements with container houses have already been set up at a location, named Neraki, providing the bare essentials for dignified living (i.e. air conditioning, kitchen and toilets). Refugees residing in the existing facilities at the Lavrion centre do not wish their being transferred at the time being, for they consider the town to be well out of reach while their representatives have already visited the new facilities and put forth their demands (e.g. exterior lighting, fencing and so on). Based on the existing planning schemes, 80 men are to be transferred to the new settlement premises. The existence of a public transit service (public bus) every half an hour to facilitate their access to the city centre was also accentuated. At the existing building, Kurdish and Afghan asylum seekers reside in separate rooms, while single men and women live separately from their families. At the same time, the issue of stable, reliable and flexible funding was raised, in collaboration with social services, as the central problem facing the centre. In most cases, variations in financing bring about variations in service quality. The delay in granting political asylum along with the termination of welfare benefits and employment opportunities for refugees was also acknowledged. Finally, the insufficient staff catering for asylum seekers' needs, embodies an additional adversity.

The most significant problem all centres are confronted with involves the lack of funding. With reference to the Arsis centre, the incorporation of educational activities such as learning the Greek language, supporting teaching for preschool and school-age children, opportunities for creative play in children etc. were reported. The majority of such activities are performed on a voluntary basis in consultation with stakeholders and the municipality. A range of services including legal support, updates received from employment counselors, and psychological support both inside and outside the centre in direct contact with professionals are offered while the role social services hold on families' responsibilities-organization, medical issues and, in general, the satisfaction of refugees' needs is of tantamount importance. Recurrent problems encompass the absence of permanent doctors resulting in medical care being offered at hospitals with interpreters' unavoidable mediation and the coverage of guests' fundamental needs or provision of sanitation supplies through the centres' own resources and donations.

The problem emerging from the lack of funding is discussed with the Doctors of the World staff, along with the issues of the provision of relief items and the termination of welfare benefits. Guests are temporarily hosted in the Doctors of the World

#### *Refugee Camps in Greece: Conditions in Reception Facilities on Gender Perspective DOI: http://dx.doi.org/10.5772/intechopen.113088*

centre for a short period of time (2–4 months). Families residing in the facilities of the same centre, are placed on a different floor from the one single men or men suffering from problems are staying at (victims of torture, damaged health); there is a specially designed space destined for creative activity (Greek language courses, craft workshops and so on). Refugee children attend schools situated in the area (cross-cultural).

At the Nostos centre the lack of staff (auxiliary, scientific) is reported as a major problem and refugees' participation in the weekly scheduled work of the centre is also noticed. The Nostos centre provides legal support to refugees.

At the Praxis centre socially vulnerable women take precedence over the rest of the guests while cases of psychiatric diseases and unaccompanied minors cannot be attended to. The integration program adopted is biannual and rests on learning the language and seeking job opportunities. Single-parent families from Africa and men suffering from serious health problems are also hosted in the centre. Creative activities include individual and group sessions; the centre's spatial arrangement is dependent on the guests' different features (sex, country of origin, *etc.*). Praxis offers accommodation but meals are not provided since the independent survival and activation of refugees is set as a strategic goal by the centre. Donations for bare necessities are crucial for all centres, including Praxis. The polyclinic inside Praxis and hospitals offer their services whenever medical issues emerge. When medical incidents turn up at hospitals, the problem of not having an interpreter becomes apparent.

Our initial hypothesis is that hosting structures share common problems, such as stable funding, leading to staff strikes—similar to the one the employees at the Lavrion centre went on due to long-term deprivation of their legal earnings—or hunger strikes that asylum seekers at the same centre embark on, is verified. Besides, staff shortages and lengthy asylum procedures hold the centres' work back.

The centre's staff was encouraged to respond to the same questionnaire, containing a set of 32 open and closed-ended questions. The total number of respondents was 37, including 7 from the Doctors of the World, 6 from Nostos, 9 from Praxis, 7 from Arsis and 8 from the Lavrion centre.

With reference to the recruitment/training frequency, women hosted in the structures are employed as staff members during program design and implementation so that their participation in issues of their immediate interest can be prompted within the participatory approach. 46% of the respondents replied that they rarely recruit/ educate women hosted in the centre (**Figure 1**).

It can be argued that women's participation in decision-making is basically nonexistent at the centres where the present research has been carried out. Women's responsibilities residing in these centres usually fulfill their "stereotypical" roles: child care, cooking and cleaning. Traditionally, women are not encouraged towards decision making and holding central positions in other walks of life that are equally important, encompassing their education or their children's education, professional opportunities, *etc*.

As for the respondents' view on the extent women hosted in the structures enjoy the same freedom as men, especially single or single mothers, 86% of the respondents provided a positive answer while negative responses to this question were recorded at the centres of Lavrion and Arsis (**Figure 2**).

Therefore, no restrictions on both sexes' freedom of movement are observed, a fact that could kindle the feeling of isolation and thus hinder asylum seekers' integration into the host society.

#### **Figure 1.**

*"How often are female of asylum seekers recruited/educated as staff members of the accommodation centres in order to participate in the design and application of accommodation programs?" (Footnote question #2) Sample = service provider (professionals).*

#### **Figure 2.**

*(Footnote question #3) Do female asylum seekers, especially single or single mothers hosted in the structures enjoy the same level of freedom as males? Sample = service provider (professionals).*

As regards spatial arrangements at hosting structures to ensure that single women and mothers are well protected and safe, 86% of the responses of the staff gathered were positive while negative answers were only recorded at the Lavrion centre (**Figure 3**). The results demonstrate that the UNHCR guidelines are applied in support of women's safety.

Moreover, as evident in **Figure 4** based on the law percentage of reported incidents, there are several difficulties in identifying the incidents of violence, such as sexual harassment against female asylum seekers, mainly due to lack of knowledge and a lack of staff, which is typical among the centres surveyed by the Doctors Without Borders in Europe, but also due to the fear overwhelming violence victims, *Refugee Camps in Greece: Conditions in Reception Facilities on Gender Perspective DOI: http://dx.doi.org/10.5772/intechopen.113088*

#### **Figure 3.**

*(Footnote question #6) Do spatial arrangements applied at the accommodation structures make female asylum seekers hosted at the centres feel safe and well protected? Sample = asylum seekers.*

#### **Figure 4.**

*Question #7: At your knowledge, which one, if any, of the following incidents of violence against female asylum seekers has been identified/reported to your centre? Sample = Service provider (Professionals).*

preventing the disclosure of facts and contributing to the maintenance of this bleak picture of the victims.

To the question concerning the types of women assumed to be more susceptible to prostitution or trafficking, the results generated, after having been qualitatively and quantitatively processed, are presented.

From the responses compiled, the highest percentage of respondents felt that single, underage (50%) women are more susceptible to prostitution. Single women with or without children, Afghan and African women were recorded to be at risk (it needs to be mentioned that this response was only recorded at Praxis, hosting Afghan and African women).

The initial hypothesis that single women living under exceptionally precarious conditions, are principally exposed to various forms of abuse, especially sexual one is verified. These risks are also mentioned in the Doctors without Borders [2] research for countries such as Hungary, Poland and Slovakia.

With reference to instances of single women or mothers seeking help to face psychological and adjustment problems, serious psychological problems stemming from torture or sexual abuse, and problems due to xenophobic and racist reactions, it is revealed that:

As far as the request for treatment for psychological/adjustment problems is concerned, the majority of respondents replied that such instances are a recurrent phenomenon (54%, **Figure 5**).

In regard to the request for treatment for serious psychological problems stemming from torture or sexual abuse, the majority of respondents replied that the appearance of such instances is quite regular (38%, **Figure 5**).

In regard to the request for troubleshooting these xenophobic and racist reactions the majority of respondents replied that such instances are rare (43%, **Figure 5**).

As a consequence, our initial hypothesis, assuming that asylum seekers, especially women, are in need of psychological support due to problems that can become more severe after long periods of waiting at centres and due to the uncertain outcome of asylum procedures hindering their adjustment, is confirmed.

#### **Figure 5.**

*Question #15: At your knowledge, which one, if any, of the following type of psychological type of assistance has been recorded after a request from female asylum seekers hosted at the centre? Sample = 37 Service providers (Professionals).*

#### *Refugee Camps in Greece: Conditions in Reception Facilities on Gender Perspective DOI: http://dx.doi.org/10.5772/intechopen.113088*

Professionals were, then, urged to indicate the reasons for women's refusal to visit a male doctor and identify the ways they handled such a phenomenon. Their responses were qualitatively processed and essentially involved the cultural background, fear of the male sex and shame. As for effective management ways, the latter encompass visiting a doctor outside the centre, persuasion procedures and appointments with female doctors and avoiding granting the request.

Cultural background emerges as the principal reason for refusing to visit a male doctor at 74% (**Figure 6**), while the typical approach towards handling refusal entailed female doctor appointment arrangements (54%). Not meeting the request only comes as a response from a single respondent at the Lavrion centre whereas fear of the male sex was only provided by a single respondent at the Nostos centre. Besides, as regards the Lavrion centre the most notable answers on handling the phenomenon were divided between the response provided by the external doctor and persuasion procedures (33% for each response, **Figure 7**).

Responses are principally related to different cultures and the ways disease is approached by immigrants and refugees, as well as to the different perceptions of the professionals' role in providing health services. Cultural differences among ethnic groups suggest that people perceive their physical and mental health in a different manner, potentially justifying differences in the exploitation of health services by immigrants. Quite often patients' religious and cultural identity is not respected. For instance, medical incidents occurring in Muslim women should be treated by female doctors or nurses. However, all necessary measures to meet women's demands appear to be taken at the structures in question.

#### **Figure 6.**

*(Footnote question #17) What is the reason female asylum seekers hosted ATE centres avoid/refuse to visit a male doctor? Sample = service provider (professionals).*

**Figure 7.**

*(Footnote question #18) What measures have been employed by centres to assist female asylum seekers who refuse to visit a male doctor? Sample = service provider (professionals).*

In addition, as far as provisions for looking after working mothers' children are concerned, 76% responded that there are no childcare provisions while positive answers were provided by Praxis and Arsis. Through correlating childcare welfare with employment frequency within the structure, the existence of welfare in the cases of women who have never or rarely worked at the centre, as suggested by the respondents, was apparent (**Figure 8**). Therefore, the hypothesis that the lack of childcare provisions inhibits employment is confirmed.

As to the educational level of the majority of women hosted in the centre (university, secondary, compulsory education, illiterate, other), 2,7% of the Professional respondents maintain that only "few" women have obtained university education, 56.8% support that a limited/rare number of women have received secondary education, 37.8% suggest that several women have received compulsory education; 89.2% claim women to be illiterate and only 8.1% of respondents contend that a limited number of women have reached another education level (**Figure 9**).

It is, thus, accepted that the vast majority of female refugees ([3]: at a higher percentage than the one possessed by men refugees) are poorly educated, and cannot easily find a (legitimate) job—until after a long stay—basically get employed at the informal home-based work sector and/or at other marginalized sectors of the labour market. This is becoming more complicated due to bureaucratic, lengthy and costly recognition procedures of their Greek language knowledge, and due to the absence of stable skill certification schemes.

*Refugee Camps in Greece: Conditions in Reception Facilities on Gender Perspective DOI: http://dx.doi.org/10.5772/intechopen.113088*

#### **Figure 8.**

*(Footnote question #23) Do centres provide childhood provisions for working mothers and in what frequency? Sample = service provider (professionals).*

#### **Figure 9.**

*Question #24: How many female asylum seekers hosted at centres, have received a University, a Secondary, a Compulsory none/Illiterate or other education level? Sample = 37 Service providers (Professionals).*

#### **Figure 10.**

*Question #25: Who is facing the most problems? Sample = asylum seekers.*

However, at this point it is worth noting that a Multicultural Centre was run under the auspices of the Red Cross at the Lavrion centre, hence contradicting the research of Tsovili and Voutira [3], which highlights the absence of intercultural sensitivity.

The last question asked to both men and women is about who they think has the most problems. From the respondents' answers, which were qualitatively processed, three options emerged, men, women and both in terms of the problems they face.

In particular, the answer that women have more problems was the most frequent answer.

As for those who said that men have more problems, the highest percentage of responses was from men. As regards those who answered that women have more problems, the highest percentage is again recorded among men, while as regards those who answered that both have problems; the highest percentage is again recorded among male respondents (**Figure 10**).

#### **4. Discussion**

Research conducted by the Doctors without Borders [2] revealed the existence of different types of open centres for specific functions in some countries. In the meantime, no distinction has been drawn between reception and accommodation centres in Greece, as in other European countries.

It was then confirmed that stable, reliable and sustainable funding, as argued in the research of Tsovili and Voutira [3], as well as the lack of consistent funding bringing about changes heavily impacting the quality of services provided, are central issues all centres keep encountering. Moreover, the termination of welfare benefits for a long period of time and delays in asylum recognition procedures, perplexing staff lives in the structures, constitutes another critical issue.

As regards the participatory approach adopted within the framework of the centres' daily operation, it was found that the former is functional at an initial stage

#### *Refugee Camps in Greece: Conditions in Reception Facilities on Gender Perspective DOI: http://dx.doi.org/10.5772/intechopen.113088*

at several structures, while in others, including the Lavrion centre, it is not applied, especially in terms of participation in food preparation, hence confirming the conclusion of non-participatory approach within the centres' daily function, drawn in the research of Tsovili and Voutira [3], thus complicating asylum seekers' lives and leading to exclusion at the same time.

The hypothesis that no centre has presented awareness-raising programs on intercultural issues or study courses, aimed at getting all guests involved and contributing to the fight against social exclusion, is refuted since a Multicultural Centre under the auspices of the Greek Red Cross was in operation until mid-2011 at the Lavrion centre.

Furthermore, women's participation in decision-making is almost non-existent at the centres examined, a fact that should not only be attributed to the lack of encouragement offered by the structures but also to each nationality's culture, verifying the initial hypothesis and the UNHCR research conclusion, along the lines of which women residing in the centres fulfill their "stereotypical" role: child care, cooking and cleaning; nonetheless, they are not encouraged towards decision making and holding central positions in other walks of life that are equally important, encompassing their education or their children's education, professional opportunities, etc.

The hypothesis that the lack of childcare services throughout the day largely prevents single women from attending language courses or other training and educational programs is confirmed, except for the Arsis NGO, where such a service is somewhat available.

Divergence of opinion between professionals and refugees as to whether women's specific health needs (gynecological, psychological) are only satisfied upon request, that is, when a woman residing in the centre is in need of a doctor or nurse, as the professionals mention that preventive control is carried out whereas the refugees support that this control takes place only in the event of being requested by women. Opinions are also divided as to the availability of informative material or training courses on health and hygiene issues.

At some centres, the existence of non-specially trained and soundly qualified in asylum issues (legal, social and psychological) staff but also the lack of knowledge of the refugees' actual needs and even difficulty in identifying violence and sexual abuse incidents have been revealed.

Controversy has arisen between refugees and professionals interviewed as to the spatial arrangements made and safeguarding women at the structures. The professionals responded that arrangements have been made so as to ensure women's protection but female asylum seekers maintain that they do not feel safe and that they face more problems than their male counterparts.

At the Lavrion centre both male and female asylum seekers are faced with the same problem, involving their reaction to being transferred to a centre just outside the city. Besides, it is confirmed that in a suburban area, such as Lavrio, women's employment/ training as staff members is rare in comparison to employment opportunities offered at structures within urban centres, such as Athens [1]. The fact that employment opportunities are scarcer for female asylum seekers in semi-urban centres, such as the Lavrion centre, while the situation is the same for men regardless of their location, is also verified.

According to the staff at the structures examined, rarely has a female asylum seeker run the risk of being led to prostitution or trafficking; consequently, our hypothesis is refuted. However, as hypothesized, single women or minors are more susceptible to the risk of prostitution or trafficking. This is true for African and Afghan women at a particular structure, verifying the hypothesis of Foster, Micklin, Newell, Kemp [4] who argue that women refugees constitute a high-risk group for violence, sexual abuse and rape. A considerable amount of women are being abused in the host country or are victims of forced prostitution (trafficking), while others have already experienced a similar personal tragedy. As stated in Mac Williams [5], women coming from countries with political or social problems, experience high levels of stress and undergo "triple victimization" by the perpetrator, the authorities (e.g. the police) and the state or other bodies, whose attitude lessens or downgrade the importance of violence episodes. Ellseberg et al. [6] report that the war in Nicaragua has led to a long history of physical violence against women, which constitutes a predictor of the victims' subsequent emotional distress and psychological problems.

Female asylum seekers, sometimes, report experiencing physical assault, rape and threats to the staff, hence verifying our initial hypothesis; nevertheless, they have never or rarely mentioned kidnapping, provision of sexual services in exchange for receiving documents or other assistance, prostitution, child trafficking, violence associated with military authorities and finally, the mention of sexual harassment is almost unheard of, partly confirming our hypothesis.

It has been observed that women do often face psychological and adjustment problems, serious psychological problems usually as a result of torture or sexual abuse and rarely as a result of xenophobic and racist reactions. Some illustrative cases involve those of women suffering from psychological problems as an aftermath of sexual abuse and torture by military authorities during their escape, domestic violence and murder of their family members.

Furthermore, at all structures counseling services and psychological support are provided and are often used by asylum seekers while there is provision for women's special health needs, related to gynaecologic control and pregnancy. In addition, updates on health problems can be provided according to the structures' staff, contradicting our hypothesis.

It is confirmed that women often refuse, with minor deviations among structures, to visit a male doctor, primarily because of their cultural background and different cultural values, but also due to the fear of the male sex and feeling ashamed. On the social workers' part, the typical way of handling women's refusal to visit a male doctor involves setting an appointment with a female one, although persuasion procedures hold an important role in this research, especially at the Lavrion centre.

At all structures Greek language courses are provided often in collaboration with other NGOs; nonetheless, according to the staff at the structures, women enjoy equal access to educational or other programs, refuting the hypothesis that women and children do not generally have access to higher education or vocational training. Additionally, while conducting the present research, the poor educational level of women residing in the structures, as opposed to that of men, is revealed.

Finally, based on the views expressed by the staff, women, at all structures, are informed about their rights along the lines of international, European and national law structures according to the research of the Doctors Without Borders [2] no sufficient information is offered to newcomers about their legal status, the detention system and their rights, as well as the opportunity to apply for asylum at detention centres.

#### **5. Conclusion**

The present research was conducted at asylum seekers' accommodation centres during the period between November 2011 and March 2012 and has led to a series of *Refugee Camps in Greece: Conditions in Reception Facilities on Gender Perspective DOI: http://dx.doi.org/10.5772/intechopen.113088*

interesting conclusions about the gender dimension in the investigation of asylum seekers' needs.

From the perspective of the administrative and scientific staff of these structures, the lack of funding that perplexes the structures' financing, the lack of staff to some extent, the termination of welfare benefits and delays in asylum procedures constitute major problems all centres, both urban and suburban, are faced with.

The staff was not fully aware of the exact number of guests, the existence of specific provisions for women's special health needs and the free exercise of their religious duties. It was also reported that asylum seekers are rarely hired/trained in programs that benefit them directly and therefore the latter do not participate in decision-making processes.

At the Lavrion centre, women hold positions in active leading structures (such as the PKK). On all structures' premises, spatial arrangements have been made to ensure women's protection, who enjoy the same freedom as men and equal access to the bare necessities of life. The professionals do not consider women residing in the structures susceptible to prostitution and trafficking. However, minors, single women and women of African and Afghan origin run a higher risk. Additionally, women admitted to facing physical attacks when escaping their homeland.

Provisions for women's special health needs are limited to gynecological control and pregnancy but updates and informative material on hygiene issues are provided. For women not wishing to visit a male gynecologist, a visit to an external, female doctor is rescheduled. In addition, counseling services are available at all accommodation structures and are often used by women, who face a host of problems and adjustment difficulties, including psychological problems due to sexual abuse and torture by military authorities.

Moreover, child custody services are not available at the majority of hosting structures, yet Greek language courses are provided. Unemployed, poorly educated women enjoy equal access to educational programs as men. There is freedom in religious expression and women's meetings take place within the context of social groups. Their primary concern revolves around taking care of their children.

Finally, NGOs' role in providing humanitarian assistance and support is fairly positive with the majority of respondents suggesting that help in everyday life stems from donations.

In conclusion, it could be argued that the structures' role is extremely important in terms of providing assistance, counseling/psychological support, bare necessities and accommodation but the lack of knowledge evident in a small but significant proportion of professionals, the lack of childcare and work promotion services, as well as limited financing and the insufficient amount of staff employees need to be taken into consideration and addressed through new policies and proposals to the structures and the Greek state.

A number of critical suggestions associated with institutional reforms and services are mentioned below. The Greek state (and in particular the Ministry of Public Order and the Ministry of Health and Welfare) should:


seekers' reception comply with internationally recognized standards and the Greek law.


Special recommendations addressed to the Greek Government and NGOs running reception centres (minimum standards and related issues):


*Refugee Camps in Greece: Conditions in Reception Facilities on Gender Perspective DOI: http://dx.doi.org/10.5772/intechopen.113088*

#### **Author details**

Foteini Marmani Harokopio University, Athens, Greece

\*Address all correspondence to: fondana1@yahoo.gr

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] Kontis A, Petrakou I, Tatsis N, Chlepas N. European and Greek Asylum Policy, Central Refugee and Asylum Seekers with Rejections in Greece. Athens: Publications Papazisis; 2005

[2] Doctors without Borders. Research Undocumented Immigrants. Greece: Doctors without Borders; 2010

[3] Tsovili T, Voutira E. Practical Reception of Asylum Seekers in Greece with Special Emphasis on Mothers Alone, Single Women and Children Who Have Been Separated from Their Family. Athens: UNHCR; 2004

[4] Foster J, Micklin D, Newell B, Kemp C. Refugee women. 2002 Διαθέσιμο στην ιστοσελίδα. Available from: www.baylor. edu.Charles\_Kemp.refugee\_women.htm

[5] Dobash E, editor. Rethinking Violence against Women. London: Sage Publications; 1998

[6] Ellseberg M, Caldera T, Herrera A, Winkvist A, Kullgren G. Domestic violence and emotional distress among Nicareguan women: Results from a population – Based study. American Psychologist. 1999

#### **Chapter 13**

## The Vicious Circle of Health Security: Vaginal Fistula in Conflict Settings and Its Interdependency with Female Oppression

*Isabella B. Metelmann and Alexandra Busemann*

#### **Abstract**

The complex and multilayered interdependence of health and security gets exceedingly obvious in conflict-related sexual violence (CRSV); however, its scientific study is exceptionally invisible. Political unrest increases incidence of gender-based violence (GBV). Rapes, including gang rapes, and forced insertion into the female genitalia of foreign bodies such as bottles, sticks, and weapons can lead to injury of the vagina and the development of traumatic vaginal fistulas (TVF). This paper aims to give structure to the particular characteristics of traumatic vaginal fistula in conflict settings and its immanent linkage to human security. The authors reviewed all papers concerning prevalence and causes of CRSV-caused TVF (CRSV-TVF) that were available on PubMed and GoogleScholar in February 2021. Findings were integrated into feminist theory on CRSV to identify the connecting linkages of security, health, and gender equality. CRSV-caused TVF illustrate well the complex interdependences of health and security: (1) insecurity leads to a higher prevalence of sexual violence; (2) sexual violence can serve as a weapon of war; (3) insecurity prolongs sufficient medical care; (4) vaginal fistula impede female empowerment and societal development. The multiple threads of their connection reveal several implications for the prevention and treatment of TVF. The reciprocal connection of CRSV and security exemplifies a vicious circle of health security.

**Keywords:** vaginal fistula, traumatic fistula, gender-based violence, conflict-related sexual violence, health security, gender equality

#### **1. Introduction**

During the past years, health security underwent a remarkable upswing especially triggered by the prominent link of infectious diseases' outbreaks and their impact on political peace and stability. Its strong recognition was additionally fanned by the pandemic of SARS CoV-2. In contrast to that, the early literature on health security mainly focused on the unidirectional link of how conflicts directly and indirectly

cause health problems [1]. Today's recognition of health security has broadened its understanding and emphasizes the mutual impact of health and security. The complex and multilayered interdependence of health and security gets exceedingly obvious in conflict-related sexual violence (CRSV); however, its scientific study is exceptionally invisible.

Political unrest increases the incidence of gender-based violence (GBV) and its physical and mental consequences while simultaneously hindering timely medical treatment. Rapes, including gang rapes, and forced insertion into the female genitalia of foreign bodies such as bottles, sticks, and weapons can lead to injury of the vagina and the development of vaginal fistulas (VF). VF are abnormal openings between the vagina and the urogenital tract and/or rectum and allow uncontrolled and constant outflow of urine and feces through the vagina. In addition to the physical consequences, women and girls with VF also must cope with psychological and social burdens of stigmatization and social isolation. Encouragingly, awareness and measures on VF increased have during the last years, not least because of several international initiatives such as the *United Nations Population Fund* campaign to "End Fistula" [2] and the adoption of a United Nations (UN) resolution in 2016 [3]. However, most endeavors target the characteristics of obstetric VF (OVF), while specifics in the prevention and therapy of traumatic VF (TVF) in terms of medical, legal, social, and psychological aspects are not met. CRSV-caused TVF (CRSV-TVF) exemplify the particular interdependence of security and health. Today, with the means of modern medicine, fistulas are both essentially avoidable and easy to treat. There also does not appear to be a significant incidence of TVF outside of regions of armed conflict [4].

There is no clear consensus on the terminology of conflict-related settings. In this study, the term is used to describe situations of basic insecurity before, during, or after a political or ethnonational conflict with a low threshold of armed force and interruption of law and justice.

This study integrates findings from a systematic review of the prevalence of CRSV-TVF into feminist theory of International Relations (IR). Thus, the methodological approach is two-part and marks the research as a translational project between medicine and political science.

### **2. Prevalence of CRSV-TVF**

Prevalence of CRSV-TVF was systematically reviewed and findings embedded into feminist theory on CRSV to identify the connecting threads of TVF, conflict, security, health, and gender equality.

#### **2.1 Eligibility criteria**

Types of studies: All publications studying prevalence and causes of CRSV-TVF. CRSV-TVF was defined as vaginal fistula that resulted directly from rape, gang-rape, or forced insertion of foreign bodies into the female genitalia. VF resulting from inappropriate abortion or prolonged labor from an unwanted pregnancy after CRSV were not included as well as VF that already existed when CRSV happened. Indicating symptoms, that is, leakage of urine or feces, were interpreted as VF. Only studies written in English, French, or German were included.

#### **2.2 Information sources**

Eligible publications were identified by searching electronic databases, publication lists of included authors, and reference lists of articles. This search was applied to PubMed (2000-present) and GoogleScholar (1962-present). The search was completed on 15 February 2021. Search items used were "traumatic vaginal fistula," "vaginal fistula," "prevalence traumatic vaginal fistula," and "vaginal fistula conflict".

#### **2.3 Study selection**

Papers were excluded when their title indicated a sole focus on obstetric fistula or medical treatment of VF. All other manuscripts were screened by abstract. Suitable papers were reviewed full paper and, if appropriate, included in qualitative analysis. After a thorough selection, seven studies were included for qualitative analysis. Search of PubMed and GoogleScholar produced 257 search results. Seven additional manuscripts were identified through publication and reference lists. Two hundred and sixty-four studies remained after duplicates were removed. Of these, 218 were excluded since their title indicated that they did not meet the eligibility criteria. Abstracts of 46 manuscripts were reviewed for suitability. Twenty-five studies were examined full text. The study selection process is documented in **Figure 1**.

#### **2.4 Study characteristics, results of individual studies, and synthesis of results**

**Table 1** summarizes study results.

Most studies were done in the Democratic Republic of the Congo [11]. Study designs ranged from case series [7, 8, 10] to cross-sectional surveys [5, 6, 11]. One study was designed as retrospective analysis of hospital records [9]. Fieldwork was done between 1999 and 2012, and results were published 2 to 5 years later. All studies included more than 300 subjects. The number of subjects varied between 320 and 7519. Age of subjects was not reported in all studies but ranged between 3 and 45 years when reported. The total prevalence of VF (including for example obstetric) was only given in three studies [9–11]. Prevalence of CRSV-TVF varied substantially. The highest prevalence was 63.4% [10]. The lowest prevalence was 0.8% [9]. All studies, however, agree that CRSV-TVF is an independent medical condition that results directly from CRSV. It occurs under particular circumstances and does not correspond to other forms of VF or intimate sexual violence. All studies deduce relevant socioeconomic consequences from CRSV-TVF.

#### **2.5 Risk of bias in individual studies**

We acknowledge that findings are probably biased by missing or little robust data. All studies are also susceptible for underreporting: subjects may not report their assault due to shame and stigmatization fears. Data were collected retrospectively from medical reports [7–10] or structured interviews [5, 6, 11]. Association to CRSV was recorded by patients' statements, which may impair its reliability. Studies reporting data from medical reports only include women that were treated in hospitals and are not representative of the population. Additionally, these studies report on cases that were medically diagnosed and treated and may miss cases that were left

**Figure 1.** *PRISMA 2009 flow diagram on study selection process.*

undiagnosed or untreated. The selection of interviewees was done by the snowball technique [5], personal contacts [6] or as a structured screening questionnaire as part of a medical intervention in two internally displaced persons camps [11]. These selections are prone to selection biases especially for reasons of shame and stigmatization. Dossa et al. discuss their weak representativeness as a major limitation but describe their sample to be similar to the target population [6]. Another risk of bias arises from the origin of data. Most studies assumed VF when indirect symptoms such as vaginal leakage of urine or feces were reported [5, 6, 11]. Two studies do not explicitly state how VF was diagnosed [7, 10]. Gynecological examination is the only suitable measure for a reliable assessment of prevalence but is hardly feasible under logistical, social, political, and cultural circumstances in the areas and populations of interest.


*The Vicious Circle of Health Security: Vaginal Fistula in Conflict Settings and Its… DOI: http://dx.doi.org/10.5772/intechopen.113139*

**Table 1.**

 *Characteristics of included studies and prevalence of CRSV-caused TVF.*

#### **3. CRSV-TVF in the realm of feminist theory**

Scientific discourse on whether, how, and why concepts of gender influence IR became prominent in late 1980s, especially in the realm of feminist scholars. One theoretical core is the distinction between sex (in its biological meaning) and gender (being socially constructed) [12]. Feminist theory debates on gender as an organizing principle in private as well as public and argues on gendered power in IR. CRSV is a central subject of research [12]. Feminist scholars identified CRSV as an instrument for maintaining hegemonic masculinity or rather patriarchal hierarchies [13–16]. Feminist theoretical explanations of wartime rape can be divided into three main epistemological strains: essentialism (women get raped to manifest the concept of militaristic masculinity), structuralism (women get raped as an attack against their ethnic, cultural, religious, and/or political group), and social constructivism (women or men get raped and are thereby feminized, while the perpetrators become masculinized) [14, 15, 17–19]. The shattered social and hierarchical structures in phases of political unrest accelerate strategies such as CRSV to reaffirm gender roles and their societal order, more specifically subordination of women [15, 16].

The systematic review identified the particular circumstances facilitating CRSV-TVF. Embedding these into feminist theory reveals the complex interdependence of security and health displaying multiple threads of their connection: (1) insecurity leads to a higher prevalence of sexual violence; (2) sexual violence can serve as a weapon of war; (3) insecurity prolongs sufficient medical care; (4) vaginal fistula impede female empowerment and societal development.

#### **4. Insecurity leads to a higher prevalence of sexual violence**

Prevalence of sexual violence and the associated health and social consequences for the survivors increase significantly during violent political conflicts [5–11, 20]. Symptoms that lead back to GBV are substantially more common in conflict-affected countries, such as DRC [21]. Collapsed health systems lead to reduced surveillance of illnesses, and clinical data are often not accessible. Additionally, insecurity reduces the collection and availability of epidemiological data. Thus, conflict-affected contexts create an obstacle to assess the significance of the disease for society. Groundbreaking work was done by Maheu-Giroux et al., who estimated the prevalence of VF in 19 sub-Saharan African countries by using data from demographic and health surveys [21]. The questionnaires were answered during a face-to-face interview of fertile women and included questions on symptoms of urine and stool leakage and the reasons for this condition. The study group found a lifetime prevalence of 0.3% for VF-symptoms for fertile women in sub-Saharan Africa [21].

While CRSV-TVF may account for only a small proportion of VF, its association to political unrest is significant. Dossa et al. were able to show that CRSV led six times more often to TVF than non-conflict-related sexual violence [6]. This indicates that not only GBV is more common in conflict-related settings, but the medical consequences of CRSV are also more severe.

#### **5. Sexual assault as a weapon of war to perpetuate hegemonic masculinity**

In situations of armed conflict, sexual violence can be used for strategic purposes as a means of exerting power with the aim of punishing both enemies and collaborators

#### *The Vicious Circle of Health Security: Vaginal Fistula in Conflict Settings and Its… DOI: http://dx.doi.org/10.5772/intechopen.113139*

and committing acts of terror and discrimination, particularly against ethnic minorities, or simply for personal satisfaction and reward, which depends largely on the organizational structure of the armed groups and security forces and their central command's level of control and delegation [5, 22, 23]. In some cases, girls and women are abducted and abused as sexual slaves [5, 23, 24]. Some rebel organizations, such as the Lord's Resistance Army or Boko Haram, heavily rely on the abduction of child soldiers as well as on forced marriages [25–27]. Armed conflict during the Second Congo War (1998–2003) and its aftermath gained sad notoriety by its extreme forms of sexual violence [5, 8, 10, 28]. Yet, its attribution to conflict is disputed, since prevalence of sexual violence is high even during relatively peaceful periods [29]. The atrocities of the self-titled Islamic State structurally include sexual slavery and CRSV as a tactical weapon of war, aiming for religious cleansing and populating their territory [24]. Yazidi (non-Muslim) women get impregnated with "Muslim" fetuses to eradicate the enemies' population while simultaneously expanding their own [24]. Pregnant women held as sex slaves suffer forced abortion since sex with enslaved pregnant women is religiously not allowed [24]. The International Criminal Tribunal for Rwanda defined the cruelty of GBV during the many years of conflict in Rwanda as an integral part of genocide [30]. This was the first time of political-institutional recognition of this strong feature of GBV. However, scientific consideration of CRSV as genocide got prominent long before during the scientific reappraisal of the civil war in former Yugoslavia [15, 17, 18]. Multiple cases of structural forced impregnation of imprisoned women in "rape camps" are documented and hint to the special role of women as biological reproducer of the targeted population [15, 17, 18]. Women are seen to play a key role in reproducing ethnonational identity by constructing and maintaining collectivity and culture [13]. Hence, CRSV on women is not indiscriminate but serves as a weapon of war to attack the reproduction of ethnonational groups [13]. These strategic purposes of GBV in conflict-related settings emphasize its significance as a weapon of war.

#### **6. Insecurity prolongs sufficient medical treatment**

Traumatization of these crimes are profound and significantly affect physical and mental health likewise [20, 31]. From a medical point of view, VF is a curable condition. If patients can be operated in time, their chances of physical cure are high. Prompt surgical closure of the defect is the only possible form of treatment and way to avoid further complications. With the means of modern medicine, it is currently possible to achieve permanent physical cure of VF in approximately 90% of fistula patients [32]. Political unrest makes it more difficult for survivors to access effective medical care. Access to adequate medical care can be assumed to be delayed in the majority of cases [4]. Women in the DRC received treatment with an average delay of 2 years after the development of their VF, and in some cases, they had to wait as long as 5 years [9]. This is partly due to the fact that access to medical services is usually more difficult during times of social unrest. The necessary healthcare structures may be completely non-existent; the women may not know about the services, or they may be inaccessible to them, or they are unable to pay for them [2, 4, 8]. The surgical repair and postoperative care of each patient costs about \$300 [4] to \$400 [2].

Women who become survivors of sexual violence are not only exposed to the risk of developing VF but also at an increased risk of contracting sexually transmittable diseases (STD) such as HIV/AIDS. Early diagnosis and treatment of these diseases is

highly important, not only for the individual patients but also in order to prevent the infections from spreading further. Therapeutic interventions for CRSV-TVF must therefore also include diagnostic and treatment of infectious diseases. Enabling easy access to post-exposure medication should be an essential element of international efforts.

Unwanted pregnancies can result in an additional psychological burden for the women, who are frequently unable to identify with the fetus. If they perform an abortion themselves, there is a high risk of injury to the genital tract and development of VF. Where pregnancies are carried to term, women are frequently left on their own without medical care, since their families have abandoned them [10]. This increases the risk of OVF. At the same time, existing VF can lead to infections of the womb or the urinary or intestinal tracts, thus endangering the health of both mother and child. Without adequate medical care, terminating a pregnancy for medical reasons, for example, because the mother is too young, may result in the development of VF [9] as well as presents a great risk to the health of the mother. Humanitarian interventions should therefore also promote broad access to (post-coital) contraception to avoid unwanted pregnancies and the associated complications. This can also be supported by awareness-raising campaigns to protect women and girls from unwanted pregnancies. However, it is also important to make provision for legal and safe abortions. Women who have become pregnant against their will must have the right to terminate these pregnancies without being at risk of prosecution. Provision must also be made for women to carry their pregnancies to term safely and with the support of medical care, irrespective of whether they have been cast out by their families. Thus, in order to improve treatment opportunities for women with CRSV-TVF, it is first necessary to maintain or render possible access to healthcare services in conflict situations. In addition, there is also a need for information on existing healthcare services, awareness campaigns, to reduce stigmatization and efforts to promote women's reintegration into society.

#### **7. Vaginal fistula maintain female oppression by impeding female empowerment and societal as well as economic development**

As described above, CRSV serves as an appropriate weapon to perpetuate hegemonic masculinity during conflict. Meger suggests to analyze perpetrator's motivations from three different levels: individual, sociocultural, and structural, with the latter focusing on maintaining power and control over productive resources [33]. According to Meger, globally disadvantaged men are motivated to enter into forces and participate in sexual assault to regain hegemonic masculinity through economic gain by exploitation of raw materials [33]. We argue that hegemonic masculinity or rather female oppression is additionally maintained by CRSV through the social and economic exclusion of victimized women by stigmatization, discomfort, and the medical condition itself.

Women who suffer from CRSV are especially socially disadvantaged and stigmatized [4]. The patients are isolated due to both their physical condition, since social intercourse is difficult due to their urinary and faucal incontinence, and the associated problems of hygiene and the smell. Moreover, in some societies, fistulas are considered to be a punishment for immoral sexual behavior or to have been caused by witchcraft [9]. The women are also stigmatized by their role as victims of a

#### *The Vicious Circle of Health Security: Vaginal Fistula in Conflict Settings and Its… DOI: http://dx.doi.org/10.5772/intechopen.113139*

sexual offense. As a result of the rape, they are often abandoned by their partners and families and marginalized by society [10].

In addition to the treatment of physical and psychological sequelae, patients should be provided with support for their legal claim. In most situations, the survivors have no claim to damages, and the perpetrators are never legally prosecuted for their crimes: in some cases, the rapes are not even punishable by law [4, 34]. This impunity promotes the continuation of gender-based violence. In a similar way, Boesten describes a "continuum of violence" that connects GBV in peacetime settings with CRSV and acknowledges its mutual roots such as structural misogyny and gender inequality [35]. This goes along with an assumption of Meger: "Until the structure of gender hierarchy is addressed, the culture of GBV is at risk of persisting long after the conflict ends." [33]. Meger argues that CRSV manifests the economic and political inequalities of women by reproducing intergender relations [33]. CRSV-TVF symbolize how a medical condition derived from CRSV perpetuates economic inequality: women suffering from VF are naturally unable to become economically independent. CRSV hinders gender equality not only from a structural or epistemological perspective but also directly by causing medical conditions like TVF.

#### **8. Discussion**

Considering the results of the systematic review in the light of feminist theory on CRSV reveals multiple linkages of security, health, and gender, stressing the health security dimension of CRSV. Individual security, law, and justice are lowered in conflict-affected settings, leading to reduced threshold of armed force. Additionally, experienced trauma of conflict parties may increase the brutality of sexual assaults. Simultaneously and to the authors' view foremost, CRSV can be used as a strategic means of war. In contrast to non-CRSV, political or ethnonational motivation of GBV may be used systematically and with the aim to destroy the enemy's population. It thereby highlights how physical injury can serve as a matter of people's security. The insecure conditions of conflict settings impede early medical treatment of health effects, which as well stresses how insecurity impairs people's health. In the aftermath, health consequences of CRSV, such as TVF, hinder victims from reintegration in society, underlining the long-time effect of CRSV on human security. On a structural level, CRSV serves as a strategic measure to perpetuate female oppression and patriarchal hierarchies by disabling victimized women from societal, political, and economic development and thus impairs human security.

While it is scientifically well known that the attempting idea that women are inherently more peaceful than men is simply not true [36, 37], Caprioli and Boyer were able to prove via multivariate regression that higher levels of gender equality go along with lower levels of violence during crises [37]. Subsequently, gender equality may help prevent TVF not only through less violent conflicts but, as described above, also through a changed epistemological understanding of femininity and masculinity.

Emphasizing the multifaceted links between health security and CRSV has limitations. Securitizing CRSV may lead to more political attention and raise awareness as well as global funds but carries the risk of simplification and short-sighted programming [38]. Carpenter has drawn important conclusions about CRSV against men and boys and its implication for human security [39]. This is a significant aspect of GBV and must not be disregarded.

### **9. Conclusion**

CRSV and its medical consequences shed light on the many facets of health security. The complex interdependence of CRSV and health security reveals several implications for the prevention and treatment of TVF, asking for holistic programs that address the particular linkage of medical, legal, and social requirements. Patients need access to medical programs that offer timely and safe treatment of TVF as well as prevention and treatment of STDs, unwanted pregnancies, improved birth control, and safe abortions as well as psychological support. Legal endeavors need to reduce the incidence of sexual violence by enhancing and promoting the legal claim of patients and stopping the impunity of the perpetrators. Holistic programs need to include social services and educational programming related to the reasons, consequences, and treatment of TVF to prevent stigmatization and support patients that are abandoned by their families and work and peer groups and are unable to make a living due to their illness. In sum, the prevention and treatment of TVF is strongly connected to gender equality and the role of women in societies referring back to human security and exemplifies a vicious circle of health security. Further research needs to be done to quantify the burden of TVF in ongoing conflicts and by that enhance its political recognition and provide evidence for urgent international action.

#### **Acknowlegements**

Supported by the Open Access Publishing Fund of Leipzig University.

### **Conflict of interest**

The authors declare no conflict of interest.

### **Author details**

Isabella B. Metelmann1 \* and Alexandra Busemann2

1 Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany

2 Department of General, Visceral, Thoracic and Vascular Surgery, Universitaetsmedizin, University of Greifswald, Greifswald, Germany

\*Address all correspondence to: isabella.metelmann@medizin.uni-leipzig.de

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*The Vicious Circle of Health Security: Vaginal Fistula in Conflict Settings and Its… DOI: http://dx.doi.org/10.5772/intechopen.113139*

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[21] Maheu-Giroux M, Filippi V, Maulet N, Samadoulougou S, Castro MC, Meda N, et al. Risk factors for vaginal fistula symptoms in sub-Saharan Africa: A pooled analysis of national household survey data. BMC Pregnancy and Childbirth. 2016;**16**:82. DOI: 10.1186/ s12884-016-0871-6

[22] Butler CK, Gluch T, Mitchell NJ. Security forces and sexual violence: A cross-National Analysis of a principal—Agent argument. Journal of Peace Research. 2007;**44**:669-687. DOI: 10.1177/0022343307082058

[23] Wood EJ. Variation in sexual violence during war. Politics and Society. 2006;**34**:307-342. DOI: 10.1177/0032329206290426

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#### **Chapter 14**

## Causes and Consequences of Toxic Masculinity: Can HeForShe Be a Solution for Gender-Based Violence?

*Monument Thulani Bongani Makhanya*

#### **Abstract**

Aggression and violent behavior are caused by the feeling that a man has to live up to society's expectations of masculinity which is what makes a good man, and that a man ought to be physically fit, have a large penis, protect himself, and uphold the honor of his family and peers, remain true to his convictions, partake in male-oriented activities like behavior sports and drinking, be sexually virulent, and succeed in everything he sets out to do. In order to overcome these preconceived ideas, this article provided an alternative to inculcate positive masculinity which is the HeforShe approach that supports boys and men in achieving equality by opposing negative gender norms and practices. Individuals around the world are encouraged to come together as equal partners to develop a shared vision of a society that values gender equality and to put that vision into action by putting locally suitable solutions into place. Secondary data analysis was used as the data-gathering instrument. To select suitable studies, an inclusion and exclusion criterion was followed. Only peer-reviewed journals were used and web sources and articles from non-peer-reviewed journals were excluded.

**Keywords:** heforShe, masculine attitudes, positive masculinity, stereotypes, gender-based violence

#### **1. Introduction**

When attempting to understand the causes of violence in society, it has been discovered that young males are disproportionately both offenders and victims of violence [1]. This aggression and violent behavior is caused by the feeling that a man has to live up to society's expectations of masculinity which is what makes a good man; that is a man ought to be physically fit, have a large penis, protect himself, and uphold the honor of his family and peers, remain true to his convictions, partake in male-oriented activities like behavior sports and drinking, be sexually virulent, and succeed in everything he sets out to do. Despite the wide variety of masculinities, there is a type of hegemonic masculinity that predominates in a particular society [2]. Other meanings are marginalized by this dominant masculinity in society. Hegemonic masculinity tends to exclude nonwhites, nonheterosexuals, and working-class males, dividing the benefits of patriarchy that these masculinities can access from those that hegemonic masculinity can [3]. Misogyny, homophobia, racism, and forced heterosexuality are all consequences of hegemonic masculinities. Despite this, societal institutions such as corporate culture, governmental authority, and the media all work to perpetuate hegemonic masculinity [4]. When males try to excessively assert their masculinity to make up for their unsure gender identity, they are said to be acting in a hyper-masculine manner. This definition of masculinity emphasizes dominant males who see aggression and violence as acceptable forms of self-expression, power assertion, and conflict resolution. Hypermasculine guys should always be prepared to fight, never exhibit signs of fear or discomfort, and always project an air of authority [5]. Protest masculinity is another significant style of masculinity that should be mentioned in any context. Poor, working-class men who exhibit hyper-masculine behavior as a narcissistic manner of coping with the sense of helplessness and insecurity that results from their low-socioeconomic station in society have been characterized as exhibiting protest masculinity. When a man's perceptions and ideals of what it means to be a man have negative effects on him and/or those around him, this is referred to as toxic masculinity. The dominance of women unites most masculinities [6], and toxic masculinity is one of the main causes of sexual and gender-based violence. Toxic masculinity is when all of the aforementioned stereotypes of men as aggressive, emotionless, and sexually violent have a negative effect on both society and the person. Overcoming these societal pressures and preconceptions that claim values and emotions are "masculine" or "feminine" could be termed positive masculinity [7]. Positive masculinity asserts that while men can be tough and competitive, they can also cry, be sympathetic, be emotionally genuine, take care of their skin, and be mindful of their mental health [8]. It is against this background that this contribution sets out to look at the causes and consequences of toxic masculinity (both for women and men themselves), and suggest an approach, that is, HeForShe movement as a tool for eliminating genderbased violence by transforming toxic masculinity into positive masculinity.

#### **2. Methodology**

Secondary data were used as a research strategy. This is usually data that have already been gathered and analyzed by another party. It is a strategy that shows there is already a public record of this information easily obtainable by using appropriate methods of research. Whenever a researcher wishes to use secondary data, they must seek a range of sources to find them. The difficulties that are commonly associated with the collecting of original data are clearly absent in this situation for the researcher. Secondary data may be both published and unpublished. Reviews, criticisms, editorials, analyses, histories, and comments are a few examples of secondary sources that are printed or electronic [9]. Doing a secondary analysis of qualitative data might be helpful for the researcher who wants to reexamine the opinions and experiences of a target audience or answer open-ended research issues [10]. Through secondary research, information on the topic at hand was obtained.

#### **2.1 Inclusion criteria**

To select suitable studies, an inclusion criterion was followed. Only peer-reviewed journal articles published in the last ten years and a select few dated back to 2009

*Causes and Consequences of Toxic Masculinity: Can HeForShe Be a Solution for Gender-Based… DOI: http://dx.doi.org/10.5772/intechopen.110872*

were used to give more recent data that could illustrate the impact of toxic masculinity. Additionally, articles covering positive masculinity and the HeforShe movement published in English were used in the study.

#### **2.2 Exclusion criteria**

Web sources and articles from nonpeer-reviewed journals were excluded from the research. Also, articles published in other languages except for English and very old sources were not used for this article.

#### **3. The causes of toxic masculinity**

It has been discovered that toxic masculinity develops for a variety of reasons, including the temperament and character of the individual in question. For instance, a boy who had an abusive father as a child can opt to change from the abusive pattern to be better than his father or replicate the patterns of violence (Safer spaces). Hypermasculinity occurs in two forms, first, is when males are more inclined to want to show their manhood by sticking to stricter, more extreme exhibits of traditional masculinity when they are denied full access to patriarchal privileges because they do not conform to hegemonic ideals of masculinity. Second, males who live or associate most frequently with other men exhibit excessive conformance to traditional male role norms. In order to compete with their peers, those who spend most of their time with men tend to try to be rougher and manlier more frequently. There are several reasons why toxic masculinity exists, but only three of them will be emphasized: socialization, family structure, and shifting gender roles [11].

#### **4. Socialization**

Males are frequently socialized to believe that they should lead in every aspect of life (income, relationships, workplace relations, etc.). Even schools are promoting specific gender roles where boys do not need to be emotionally stable, implicitly subscribing to and embracing hegemonic forms of masculinity (Safer spaces). In this approach, some schools support the attitude that men are entitled to more and are more importance than women. In favor of harsh discipline and control, many schools forgo teaching emotional responsibility and discourage empathy, compassion, and nurturing behaviors. Boy conversation is discouraged by society [12]. Fathers are frequently less forgiving, less tolerant, and more unreasonable than moms at home. Discussing sex, HIV/AIDS, condom use, and other risky behaviors with their sons can be challenging for fathers as well (Safer spaces). Males frequently have narrow perspectives on instruction concerning harmful behavior, as well as on introspection and societal reflection. Boys have been socialized to believe that they should not be punished for misbehavior and that they do not often have to take responsibility for their conduct. Girls are trained from a young age to "act like a lady" when they do something wrong, while when males are at fault, they are told "boys will be boys." Boys are socialized to believe in their own superiority not only in schools and at home but also through peer pressure, media, military influences, and political influences, all of which lead to the belief that violence is acceptable behavior in men (Safer spaces).

#### **5. Dysfunctional family situation**

The idea of family has always been a significant subject in philosophical discussions, and the most prevalent idea that comes to mind when considering the family structure is that of the "nuclear family." This family unit consists of two parents of opposing sexes and their offspring. It has been portrayed in this manner ever since the seventeenth and eighteenth centuries since it was crucial for the spread of the white Western worldview throughout the expansion of colonialism [13]. The way that families are portrayed has started to alter in the twenty-first century and an increasing number of people who reject these conventional ideals are being represented. Because of "shifts in the roles of fathers, mothers, and the increasing emphasis on children's television programming" and "changing demographics," families are more diverse than ever before, and customers are represented by real families that can be found in today's society [14]. Even though the definition may have shifted from what it used to be, some families are dysfunctional, and this can be seen by the revealing patterns of conduct rather than by any physical traits. One is that tough laws are usually upheld. Laws do not challenge the status quo, do not feel your emotions, and do not ask questions are a few examples. These strict family rules, which are undoubtedly unhealthy, might make vulnerable family members feel abandoned or unsupported emotionally [15]. The child's family life may later have a negative impact on all facets of their development. Growing up in a dysfunctional environment could make it tough to transition into adulthood, lose jobs frequently, and have inadequate boundaries in relationships. Families mired in a cycle of dysfunction frequently deal with severe abusive problems such as drug and alcohol misuse, domestic abuse, physical and sexual assault, and emotional abuse. Children can become poisonous in this kind of setting, and regrettably, family issues never go away [16]. The dysfunctional cycle often continues throughout the lives and households of the children of dysfunctional families. In pathological families, at least one parent engages in drug or alcohol misuse or has a mental disease, rendering them dysfunctional and damaged. A child of an alcoholic or an abusive parent is more likely to experience unmet basic physical and emotional needs. In these families, the roles are typically reversed [17]. Because their dysfunctional parents are unable to manage their daily lives, children become more responsible for them. A dictator parent who disregards the desires or sentiments of the other family members rules a dominant-submissive household. While being demanding, the dominant parent offers little in the way of affection, assistance, or constructive criticism. The children frequently experience harsh repercussions for their errors and failings, such as scolding and spanking. There are no middle-ground rules in this kind of home; it is either the parents' way or the highway [18]. Arguments and conflicts are commonplace in a household that experiences frequent conflict. Families frequently quarrel in hurtful ways that leave wounds open and foster a climate of severe antagonism. Conflicts, arguments, fighting, resentment, and stress result from poor communication and an inability to handle difficulties, which wreak havoc in the household. Some homes are chaotic; the only thing that never changes is chaos. Parents constantly come and go, and there are no set family rules or expectations (moving in and moving out of the home or being incarcerated). When they are present, either their parenting abilities are poor, or they are damaging the kids. Children frequently suffer from abuse, neglect, or both [19]. In some households, children are not exposed to warm displays of affection from their parents. Families like these avoid discussing feelings. Normally, parents are emotionally unavailable, cold, and aloof. Children are taught to suppress their own feelings. Children develop low self-esteem and emotions of

*Causes and Consequences of Toxic Masculinity: Can HeForShe Be a Solution for Gender-Based… DOI: http://dx.doi.org/10.5772/intechopen.110872*

unworthiness due to the lack of emotional and physical affection. Social or cultural background is frequently linked to these kinds of dysfunctional households. This dysfunctional type can be the least obvious and least researched [20].

#### **6. Mental health**

The traditional parental or guardian roles are frequent where toxic masculinity is developed, and if it is not addressed, it can be passed down from one generation to the next [21]. It is important to address how masculinity continues to exacerbate mental health issues despite efforts by society to eradicate harmful stereotypes and preconceptions about gender-defined thinking. A toxic masculinity mentality holds that asking for help or direction might make one appear weak. It also involves a mentality that ignores psychological distress because admitting to stress can come off as a weakness [22]. When emotions are disregarded frequently, a person learns to completely shun them. They also learn to hold their emotions inside rather than express them, which leads to internalized discomfort. Long-term melancholy is likely to result in depression and inappropriate emotional expression [23]. Exaggerated self-sufficiency brought on by toxic masculinity can also cause a host of mental health issues, particularly when it comes to social interaction. Men's capacity for interdependence in intimate relationships now is impacted by the historical sexist dynamic that emerged from traditional relationship norms. This could seem as unhealthily dominating behavior in interpersonal relationships, showing signs of narcissism or other personality disorders. When dysfunctional masculinity is not treated, this may manifest as violence and hostility [24].

#### **7. Shifting gender roles**

The notion of leadership that males have inherited is, however, under threat from several social, economic, and political changes that have taken place during the past fifty years. These modifications consist of the liberation and empowerment of both men and women who are thought to exhibit nonhegemonic masculinities. Young men today are caught between what they have learned from their parents, guardians, and societal role models about what it means to be a man and the shifts in gender relations that are taking place in today's society (Safer spaces). This is particularly common when it comes to income and status as the primary provider. Employment and earning money are essential components of manhood because they meet both tangible necessities and sentiments of self-worth [25]. When women and men with nonhegemonic masculinities replace men with hegemonic masculinities as the primary breadwinners in societies where unemployment is high, wages are low, and there are few possibilities to fulfill the obligations of masculinity, this can cause resentment. Salary work and wealth can be utilized to maintain the subjugation of women to men according to several masculine ideologies. Due to this, nations with high rates of unemployment and income inequality are probably more likely to experience excessive male aggression and toxic masculinity [26].

#### **8. The hazardous effects of masculinity**

Traditional masculinities are implicated in a variety of damaging impacts on men's lives and the lives of others [27]. Here are some examples:

#### **8.1 Overcompensation by engaging in dangerous behavior**

Males that exhibit toxic masculinity frequently avoid acting in any way that could be viewed as feminine because they are afraid of femininity. Because being gay is often associated with being feminine, this concern is frequently expressed as homophobia. If men are terrified of being viewed as gay, they may overcompensate in order to demonstrate that they are, in fact, straight [28]. They become bold and aggressive. They do not back down if their dignity or manhood is violated. They do not tolerate insults to their partners or their mothers [29]. Kroeper et al. [30] assert that these men exhibiting masculinity believe in obligatory heterosexuality, in which the compulsion to have sex frequently serves as a means of affirming one's manhood, resulting in risky behavior. When compared to their less traditional friends, men who hold more conventional views of masculinity report greater rates of unsafe sexual behavior, binge drinking, and car accidents.

#### **8.2 Competitiveness because of scarce resources**

In the situation of low resources, male fragility is heightened. In a study by Falk [31], on why men end up emasculated, she discovered that many males are angry at women for anything they perceive to be emasculating, such as women becoming breadwinners or getting promoted ahead of them at work. These social changes brought about by women's empowerment and persistent "invasion" into traditionally male sectors have resulted in what scholars refer to as "threatened masculinity" [32]. Men began to worry more and more about their physical appearance at this point because the male physique and muscularity were among the last remaining symbols of masculinity. As a result, among adolescent boys, support for traditional masculine values is frequently linked to a desire for a bigger, more muscular body [33]. Men who experience body image issues frequently experience depression, low self-esteem, poor weight management, steroid use, and a host of other detrimental effects. Yet there is also competitiveness among males, and it is frequently encouraged [34]. Males are frequently exhorted to pursue domination, power, riches, and success. This competition is typically held in an effort to "win" resources and women. Normal expectations of manhood include the pressure to compete and win; failing to do so will make you appear cowardly [35]. As a result, Matlon [36] argues that dominant masculine notions of urbanity are idealized, with several sexual partners and overt economic power as defining traits. Hegemonic masculinity is shaped by the idea of "the player," a man with money and a woman who positions men in society. Women must be dehumanized in order for men to attain this status and maintain and restore their superiority [37].

#### **8.3 Ineffective dispute resolution techniques**

Traditional masculine adolescent boys are less adept at handling conflict, and their approaches are typically marked by high levels of anger, withdrawal, denial avoidance, and minimal concern for other people's needs [38]. In comparison to girls, they are also more likely to get into disputes over status and power. They prefer to steer clear of approaches to dispute resolution that are seen as feminine. Toughness, dominance, and a readiness to use violence to settle disputes with others are viewed as essential components of the masculine identity (Safer spaces). Boys participate

#### *Causes and Consequences of Toxic Masculinity: Can HeForShe Be a Solution for Gender-Based… DOI: http://dx.doi.org/10.5772/intechopen.110872*

in more delinquent behavior than girls due to the internalization of masculinity that frequently occurs during puberty. This internalization frequently persists throughout adulthood, when males are expected to be strong, independent, in control, emotionless, and show no signs of vulnerability [39]. For "genuine" men, seeking assistance or guidance for pain symptoms or mental discomfort is seen as a show of weakness. So it should come as no surprise that males are very hesitant to seek medical care or consult a therapist [40]. Men who have internalized the concept of masculinity consider themselves as the providers for their wives and children, believing that they are not to be dependent on others or cared for by others. In other words, boys and men typically have very inadequate coping mechanisms for addressing tension and conflict inside themselves as well as between themselves and others without resorting to violence [41].

#### **8.4 Domestic abuse and power dynamics**

According to Schuler et al. [42], women are frequently seen as excessively powerful and unreliable by males because they have been socialized to believe that the leadership mantle belongs exclusively to them. Many males feel alienated and powerless in sexual interactions as a result of the liberty and empowerment of women. Together with societal changes, unemployment, poverty, and low selfesteem, this perceived disempowerment of men has given rise to dominant masculinities marked by extensive sexual networks, and in some extreme cases, the need to exert more control over women [43]. According to research, Shai et al. [44] assert that males always make the decisions about when, where, and how to have sex as well as whether or not a woman should try for a baby and whether or not condoms will be used. Because of men's demand for control, many women are unable to protect themselves from STDs, pregnancy, and unwanted sexual advances. Men are in charge of condom use, which implies that they decide on safer sexual behavior and have a big impact on both partners' risk of contracting HIV. de Shong [45] adds that males frequently utilize the perception of women's alleged incapacity to self-regulate as a justification for using different forms of control, coercion, and violence. In this regard, de Shong [45] states that male's continuous controlling of women's movements is sometimes seen as defending the physical safety and reputation of women, lest they become known as "Jezebels" and "street women." Violence and control are strategies to thwart and punish opportunities for infidelity since it is seen as emasculating. Maleness is associated with the public sphere, while femininity is associated with the private sphere. Indoctrination into a patriarchal culture has contributed to the socialization of gendered ideas of male authority and control, where violence is employed to affirm masculinity. Under this system, men are taught to be domineering and aggressive, and women are taught to be victimized and subservient [46].

#### **8.5 Sexual assault**

According to Jaffe et al. [47], relationships frequently involve rape and assault. This is a result of the previously mentioned uneven power relationships between men and women. Many people have highlighted the connections between toxic masculinity and rape as being brought on, among other things, by men's thirst for dominance, power, and misogyny by punishing women for emasculating them [48]. Norman Kujat [49] brings another important dimension when he states that as a

result of toxic masculinity, male rape is frequently rejected and ignored in society. Because fragility is built into gendered conceptions of femininity, male rape is largely unreported. Because being the victim of rape is seen as a show of femininity and undermines a male's claim to being a man, many male rape victims are too ashamed to report their rapes [50]. This violence promotes the perpetrator's masculinity while denying the victims. The overwhelming stigma and guilt that prevents most victims from seeking help are mostly caused by the sensation of destroyed masculinity and imposed "womanhood" [51]. In jails, the distinction between homosexuality and male rape is blurred, and instead, it becomes a matter of power and rivalry. Because of this, male-on-male intercourse is most prevalent in jails, yet most inmates nevertheless maintain a fundamentally homophobic mindset. Prison "masculinity" is associated with the ability to use specific forms of violence and the ability to withstand them, as well as the idea that once manhood is gone, it can be reclaimed through violence [52]. When inmates who are treated as "women" in jail want to be promoted back to being men, they frequently must stab another prisoner. Male victims may engage in violent compensatory behavior as a result, both inside and outside of prisons. When freed, they frequently explode in fury, trying to regain their manhood by raping again [53].

#### **8.6 Positive masculinity**

Positive masculinity is a perspective that has utilized the engagement of men and boys to help the larger movement for gender equality and women's empowerment (GEWE). Gender transformational approaches have increasingly sought to question and understand males and masculinities, as well as analyze the experiences, attitudes, duties, and responsibilities of men and boys, and how they influence behavior, societal norms, policymaking, and gender equality in general. Positive masculinity has been demonstrated to be critical in eradicating all sorts of violence and prejudice against women and girls [54]. Positive masculinities, on the other hand, provide a critical perspective through which to transform masculinities in ways that promote healthy, peaceful, individual, and social well-being for all [54]. It allows men to appreciate their physical bodies rather than comparing them to the media's portrayal of muscularity and sex appeal. Respect women with dignity. Utilize their masculinity to advocate for women and others. Make and keep friendships. Demonstrate to people that you are emotionally expressive and available to both males and girls. Recognize that rage is not an excuse for violence or abuse. Feel and enjoy touch and tenderness from other males. Instead of destroying and damaging, create and build. Positive masculinity entails males being open and honest about their feelings and desires. It also entails men treating others with kindness and respect rather than utilizing their might to dominate or mistreat them [55].

#### **8.7 HeforShe approach**

HeForShe is a social movement project that gives men and boys a systematic approach and targeted platform through which they may influence change in the direction of the realization of gender equality. A comprehensive strategy that acknowledges men and boys as allies in the fight for women's rights as well as how they stand to profit from greater equality is necessary, according to UN Women, in

#### *Causes and Consequences of Toxic Masculinity: Can HeForShe Be a Solution for Gender-Based… DOI: http://dx.doi.org/10.5772/intechopen.110872*

order to achieve gender equality (HeforShe). The campaign was launched in 2014 by UN Secretary-General Ban Ki-moon and UN Women Global Goodwill Ambassador Emma Watson, who rallied hundreds of thousands of individuals to support it, including celebrities Matt Damon and Barack Obama. At the start of the campaign, UN Women made a call to organize the first 100,000 men, a goal that was accomplished in just three days! HeForShe, which is now four years old, has received almost 1.3 billion promises, a statistic that is continually growing. In the United States alone, 141,000 promises have been made, with men making the vast majority of them (HeforShe). "Accelerate women's economic development, enhance women's participation in peacekeeping and security processes, increase women's political engagement and leadership, and eradicate gender-based violence," are the movement's four main objectives (HeforShe). In the fall of 2015, HeForShe launched IMPACT 10X10X10 after seeing success in its first year. The HeForShe IMPACT 10x10x10 program, which aims to drive change from the top down, involves influential decision-makers from governments, corporations, and academic institutions throughout the globe. The IMPACT Champions, who have developed three bold, paradigm-shifting promises to advance and achieve gender equality for all, are putting the HeForShe concept into action. The UN's 2030 Sustainable Development Goals, particularly SDG 5, which stands for gender equality, are furthered by taking the HeForShe pledge. The SDGs, which went into effect throughout the UN system in 2015, were derived from the Millennium Development Goals, a series of eight worldwide development goals that were in force between 2000 and 2015 which put a focus on three areas: human capital, infrastructure, and human rights. Comparatively, each of the 17 SDGs maintains a list of 169 targets, making them comprehensive and interrelated. Both social and economic development issues are addressed by these aims. SDG 5 places gender equality at the forefront of this new UN development strategy by interspersing the other 16 goals with multiple improved gender equality targets (HeforShe). UN Women has given Goal 5 high commendation for addressing fundamental barriers to gender equality and women's empowerment. We cannot build the world that women and girls need by continuing on as we have been or by making incremental improvements. Only drastic and fearless changes will do (HeforShe).

#### **9. Contexts where HeforShe has had a positive impact**

Heforshe has had a positive effect in some contexts, below is an example of two of those contexts.

#### **9.1 HeforShe in Lesotho**

HeforShe takes the shape of males banding together to launch replies against GBV at their places of employment as well as Institutions of Higher learning, as was previously stated. There are numerous instances of conferences organized by the larger group to confront the plague and to recruit males to aid in its eradication. Lesotho's Symposium of Traditional Leaders and Religious Leaders was held on June 30, 2022, at Maseru's Lehakoe Recreational Complex, with the purpose of fostering a rich and dynamic working partnership between the Principal Chiefs and Faith Leaders. The symposium was organized with the assistance of "Man Up Lesotho," a nonprofit organization that mobilizes men to address HIV susceptibility and sexual gender-based

violence (SGBV). The "Man Up" initiative encourages men to reconsider their positions in society as partners, protectors, and not perpetrators. Traditional leaders are active as protectors of culture and the fabric of Basotho heritage because it touches on the core values of manhood in society. The initiative has created a space for men, particularly men of influence (religious and traditional leaders), to discuss their experiences. These programs include giving immediate and long-term care help to victims of violence (HeforShe, Lesotho). These also include measures to address societal and cultural norms, gender imbalance systems, and general acceptance of VAWG. Throughout the one-day symposium, guests had the opportunity to reflect through participatory lectures on their own concerns and experiences from their time in the office. These conversations called into question the way things were done as well as the damaging attitudes and behaviors. This made it easier to focus on analyzing, sharing, and increasing understanding about core teachings, practices, and hence lessons learned from grassroots people. According to the symposium's conclusions, GBV is encouraged by unfavorable social norms that stress men's honor over women's safety, prioritize men's ability to discipline both women and children, and elevate women's sexual purity above all else. The team sought to work with traditional leaders to develop laws that would challenge harmful social mores and individual viewpoints that support and condone sexual assault and other forms of GBV against women and girls in Lesotho (HeforShe, Lesotho).

#### **9.2 HeforShe in Brazil**

For Brazil to attain gender equality, it was important to remove the obstacles that continue to place women at a disadvantage in all areas of society. In Brazil, systems of violence and discrimination against women coexist alongside laws improving women's rights. Since the 1980s, Brazilian colleges have been doing studies on violence against women, and the results have helped create municipal and national legislation to address the problem. Due to allegations of sexual assault on the university campuses, universities have recently begun to recognize gender-based violence in the classroom. The invitation from USP to participate in the HeForShe Champions program contributed to creating the most favorable conditions for addressing all forms of violations of women's rights [56–58]. The initial priority of HeForShe was to overcome the stigma attached to violence and the anxiety of being exposed. Both inside the university and in the greater community, they implemented several parallel tactics. In addition to holding lectures on the challenges USP confronts in addressing violence against women and the Maria da Penha Law on Domestic and Family Violence, 5000 copies of the Gender Violence in the University booklet were distributed. They participated in 15 activities, some of which were featured in the USP Newspaper, both inside and outside the university. In addition, 33 regional human rights commissions were mapped along with the procedures for establishing and running them. A total of 30 media interviews were also done. They organized working groups, trained members of the committee against gender violence, and established a center at USP for the care of victims of gender-based violence. The university's Code of Ethics was revised, and appropriate sanctions were discussed in addition to methods for dealing with victims of abuse in residence halls. The university's zero-violence policy is overseen by the president's office and is discussed during first-year student orientation, at University Council meetings, and through videos [56]. They supported a variety of programs at the university, including those in the Sociology Department, the Women's Office, the Information Technology Office, student organizations, and research initiatives like

*Causes and Consequences of Toxic Masculinity: Can HeForShe Be a Solution for Gender-Based… DOI: http://dx.doi.org/10.5772/intechopen.110872*

our successful "Interactions at USP" study. HeforShe conducted an online poll that was accessible to all undergraduate and graduate students enrolled at USP in 2017; 13,377 out of 78,984 participants, or 17% of the student body, responded. The survey contained 45 questions concerning demographics and 75 questions about students' experiences at USP, including violence, physical and mental health problems, and other encounters. The poll also included important information on gender- and race-based human rights violations. The results show how serious the issue is at the university and how urgently more targeted, effective action has to be taken [56]. New protocols and practices were created in response to the findings. HeforShe made decisions for the subsequent stages of their journey using information from the "Social Interactions at USP" study and assistance from human rights commissions at universities and other institutions. In addition to creating service centers focused on the welfare of students, they increased the number of Human Rights Commissions for the 42 USP faculties and institutes. They also established service standards and protocols for the training of professionals who work with students. Men's involvement in the effort to end violence against women is still a delicate topic. The HeForShe movement at the university has expanded as a result of the President, Pro-Rectors, and male lecturers' involvement as HeForShe Champions. The HeforShe movement, which is supported by the university's male officials who are also Champions of HeforShe, is challenging the institution's male domination, which is supported by patriarchal principles [56].

#### **10. Conclusion**

Young men typically cite violence as an important tactic they use to establish their control and show their masculinity in their society. Males are believed to have a certain behavioral standard, perpetuated by masculine ideas enforced by stereotypes. As a result of preconceived notions about what makes a good man; they think a man should be physically fit, have a large penis, protect, and uphold the honor of his family and peers, remain true to his convictions, partake in male-oriented activities like behavior sports and drinking, be sexually virulent, and succeed in everything he sets out to do. A conclusion could therefore be drawn that the HeforShe approach could be used which supports boys and men in achieving equality by opposing negative gender norms and practices. Individuals around the world would be encouraged to come together as equal partners to develop a shared vision of a society that values gender equality and to put that vision into action by putting locally suitable solutions into place. The approach will automatically inculcate positive masculinity, which deems that while men can be tough and competitive, they can also cry, be sympathetic, be emotionally genuine, take care of their skin, and be mindful of their mental health.

#### **Author details**

Monument Thulani Bongani Makhanya University of Zululand, South Africa

\*Address all correspondence to: makhanyamt@unizulu.ac.za

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Causes and Consequences of Toxic Masculinity: Can HeForShe Be a Solution for Gender-Based… DOI: http://dx.doi.org/10.5772/intechopen.110872*

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Section 5
