By Dr Heidi Riley and Clara May
Content warning: contains mention of sexual violence and suicide.
President Volodymyr Zelensky of Ukraine recently remarked that, in the post-war world, ‘the accumulated pain of the war … only becomes more unbearable with time’ and that ‘no one can be left alone with the war and its effects on the minds and souls’.[i]
Image: President Volodymyr Zelensky visits Bucha in April 2022, after its liberation from Russia during the Russo-Ukrainian war. Credit: Shutterstock/Dmytro Larin.
Almost two years have passed since Russia invaded Ukraine, and mental health is high on the agenda for the Ukrainian government. The World Health Organization (WHO) estimates approximately 9.6 million people in Ukraine may have a mental health condition as a result of exposure to conflict, while Ukraine’s Ministry of Health expects 15 million people will require psychological support to manage mental health problems caused by the war.[ii]
Spearheaded by Ukraine’s First Lady, Olena Zelenska, a National Program of Mental Health and Psychosocial Support (MHPSS) aims to provide affordable and effective mental health services for anyone who wishes to use them, while a campaign launched in March 2023 encouraged Ukrainians to look out for each other’s mental wellbeing.[iii] The summit at which President Zelensky made his comments was organised under the theme ‘Mental Health: Fragility and Resilience of the Future’.[iv]
Ukraine has a big task on its hands, and it’s not alone. Around the world, populations in countries affected by conflict are vulnerable to experiences of trauma and its various manifestations. In 2019, the WHO estimated that one in five people living in a conflict zone experience some form of trauma symptom, such as PTSD, depression, anxiety, or sleeping disorders. In Gaza, it is estimated that 97.5 percent of 10 to 19-year-olds suffer from PTSD, and this will rise acutely in response to the current conflict.[v]
Humanitarian aid to help deliver psychosocial support (PSS) is both welcome and necessary. Yet, recent research carried out by the Cross-Border Conflict Evidence, Policy and Trends (XCEPT) research programme suggests that, when it comes to addressing conflict-related trauma, men and boys are often overlooked. Not only does this have an impact on the wellbeing of affected individuals, but research suggests that addressing conflict-related trauma amongst men is also vital for prevention of continued insecurity and conflict transformation more broadly.[vi]
Overlooking men in humanitarian responses
In a conflict setting, men and boys are affected by direct violence.[vii] They are most at risk of death by violence or summary execution. They are more likely to be imprisoned or disappeared. They suffer beatings and torture due to gender norms which assume them to be the protectors and leaders of a community, rendering them targets of violence. They also experience conflict-related sexual violence (CRSV) to a much greater extent than was previously assumed.[viii]
Yet, male victims are underrepresented in PSS services delivered by humanitarian organisations.[ix] A study for XCEPT of 12 INGOs and NGOs operating in Syria, Iraq and South Sudan found that only two of the organisations operated PSS programmes targeted at conflict-affected men.[x] These were a trauma awareness training programme run by Catholic Relief Services (CRS) in South Sudan and a programme of psychoeducation workshops run by Relief International (RI) in northern Syria.
Although international organisations, such as the United Nations Inter-Agency Standing Committee (IASC), have made commitments to focusing on gender-related needs in their humanitarian work, for many this equates simply to focusing on women and children.[xi] Common stereotypes surrounding gender reinforce the idea that men are primarily the perpetrators, or that they may not need help coping with traumas.[xii] This means that, while there are already insufficient resources dedicated to helping women and girls, there are even less for men.
Such gendered assumptions around the incompatibility of masculinity and vulnerability permeate academic and policy circles, but it is important to note that this is not clear cut. There is a noticeable imbalance in attention paid to manifestations of PTSD amongst Western servicemen, versus the very limited recognition of trauma experienced by civilian men in FCAS.[xiii] These inconsistencies raise questions around how stereotypes of masculinity also intersect with race or other identity markers.
The costs of failing to act
Gendered expectations may result in a lack of attention being paid to conflict-related trauma in men and boys, but such norms also impact on the way trauma is experienced. For example, where men are often assumed to be the defenders and protectors of family or society, becoming unable to safeguard family may perpetuate a sense of trauma-associated stress. Similarly, when men are unable to fulfil masculine expectations of being the provider, this again can impact on a sense of wellbeing, that may manifest in negative ways.[xiv]
Recent XCEPT research on the experiences of ex-military Syrian refugees in Turkey found that, for many, practical concerns about being able to provide for their families were a cause of anxiety, leading them to exist in unstable ‘disturbing’ situations.[xv] A representative from an organisation based in Syria also noted that such situations exacerbated suicidal tendencies:
‘Where the men are sitting at home, or looking for a job, and women are the only providers for the family … in mental health terms, this has become one of the stressors for men – that they cannot provide the needed help for the family or children. Actually, it’s one of the suicide situations [amongst men] in this area.’[xvi]
Masculine expectations can also cause men to employ maladaptive coping behaviours, such as risk-taking, withdrawal, or self-harm. Such behaviour can be attributed to a desire to avoid ‘displays of emotional distress, which would be discordant with, and threatening to, masculine identity and performance’.[xvii] Men can therefore be less inclined to seek, or accept, help and support, a choice which increases the risk of developing negative coping mechanisms.[xviii] Concerns about stigma are not unfounded. One study on the survivors of male sexual violence in Northern Uganda found that many were refused help as it wasn’t believed men could have been victims of CRSV.[xix]
Without receiving proper support, male responses to trauma may develop into a normalisation of violence as a coping strategy. In extreme cases, this can lead to appetitive aggression, whereby an individual gains a sense of pleasure out of violence, which could be a way of buffering the development of PTSD symptoms.[xx] Research has found that, in the aftermath of violent conflict, domestic violence tends to rise when former fighters return home. Community violence can also increase as a result of PTSD symptoms and appetitive aggression.[xxi]
Addressing conflict-related trauma in men and boys thus benefits not just their own wellbeing, but the wellbeing of their families and the wider community. After taking part in the programme run by CRS in South Sudan, participants reported benefits such as being able to control stress and channel anger in ways which avoided self-destructive behaviour or lashing out at family members.[xxii]
Addressing conflict-related trauma amongst men
Research carried out by XCEPT highlighted four key points to guide the delivery of PSS programmes for men and boys. In situations where there is limited access to basic needs, these programmes are inevitably deprioritised. This is where using innovative and integrative programming can be beneficial. Such programmes may involve mainstreaming PSS interventions into broader livelihood programmes and context-specific services, which encourages participation and complements efforts to cater to primary needs.
Programmes should also be designed through a culturally sensitive masculinity lens to ensure uptake. This includes using neutral terminology to avoid stigma surrounding mental health; respecting societal norms by scheduling sessions to work around employment commitments or livelihood activities; and considering under what circumstances it is appropriate to host group or individualised programming. For example, for LGBTQI+ men, or in instances where men have suffered sexual violence, individual, confidential sessions reduce risk to the individual, whereas group workshops may be more beneficial for psychoeducation programmes that benefit from peer-to-peer support mechanisms.
Moral injury, the impact of carrying out an action that transgresses an individual’s ethical or moral standards, is often side-lined in PSS programming due to its association with perpetrators of violence. In some situations, engaging with moral injury-induced trauma can be beneficial, as it allows individuals to deal with feelings of anger, which may otherwise find an outlet in the perpetration of violence in the community.
Importantly, local communities should also be engaged in programme design to ensure services are context appropriate. In the programme run by RI, for example, a scoping exercise was initially carried out to establish themes men wanted to focus on. The themes selected tended to revolve around stress and anger management, for which family members then reported ‘good results’ among participants who had been working on these issues. Involving local communities can also help increase the sense of ownership and legitimacy amongst participants, which encourages attendance and engagement.
Although men are often on the frontline of conflict, they are also often overlooked in humanitarian responses to trauma. This affects their individual wellbeing, and the wellbeing and security of wider society, which may bear the burden of maladaptive coping behaviours caused by unaddressed trauma. To make sure PSS efforts succeed, it is important they take the cultural context and local needs into account. While an increase in focus and resources on conflict-related trauma amongst men is important as a matter of both wellbeing and conflict prevention, it remains crucial that this should not lead to the diversion of services away from women and girls, which also continue to be insufficient and under-resourced.
[i] https://kyivindependent.com/worlds-first-ladies-gentlemen-discuss-mental-health-at-zelenskas-summit-in-kyiv/
[ii] https://www.economist.com/europe/2022/08/06/ukraine-is-on-the-edge-of-nervous-breakdown
[iii] https://www.president.gov.ua/en/news/olena-zelenska-rozpovila-yak-vtilyuyetsya-iniciativa-zi-stvo-80109
[iv] https://www.president.gov.ua/en/news/olena-zelenska-na-yes-2023-mentalne-zdorovya-osnova-stijkost-85541
[v] Farah Heiba, Mental health in Middle East conflict zones: How are people dealing with psychological fallout? https://www.arabnews.com/node/1894521/middle-east
[vi] Heidi Riley, Men and Psychosocial Support Services Programming, XCEPT, 2023. https://icsr.info/wp-content/uploads/2023/07/XCEPT-Briefing-Note-Men-and-PSS-programming.pdf
[vii] Kreft, Anne-Kathrin; Agerberg, Mattias. Imperfect Victims? Civilian Men, Vulnerability, and Policy Preferences, 2023, 1-17.
[viii] Philipp Schulz, “The ‘Ethical Loneliness’ of Male Sexual Violence Survivors in Northern Uganda: Gendered Reflections on Silencing,” International Feminist Journal of Politics 20, no. 4 (2018): 583–601.
[ix] https://pscentre.org/men-dont-cry-a-participatory-workshop-on-mhpss-for-men-and-boys-in-humanitarian-settings/; Brun, Delphine. Men and Boys in Displacement: Assistance and Protection Challenges for Unaccompanied Boys and Men in Refugee Contexts. CARE and Promundo, 2017.
[x] Heidi Riley, Men and Psychosocial Support Services Programming, XCEPT, 2023. https://icsr.info/wp-content/uploads/2023/07/XCEPT-Briefing-Note-Men-and-PSS-programming.pdf
[xi] Gupta, Geeta Rao, Caren Grown, Sara Fewer, Reena Gupta, and Sia Nowrojee. “Beyond Gender Mainstreaming: Transforming Humanitarian Action, Organizations and Culture.” Journal of international humanitarian action 8, no. 1 (2023): 5–5.
[xii] Brun, Delphine. “Why Addressing the Needs of Adolescent Boys and Men Is Essential to an Effective Humanitarian Response.” Apolitical. co. 27 January 2023. https://apolitical.co/solution-articles/en/why-addressing-the-needs-of-adolescent-boys-and-men-is-essential-to-an-effective-humanitarian-response
[xiii] Heidi Riley, Men and Psychosocial Support Services Programming, XCEPT, 2023. https://icsr.info/wp-content/uploads/2023/07/XCEPT-Briefing-Note-Men-and-PSS-programming.pdf
[xiv] Brun, Delphine. Men and Boys in Displacement: Assistance and Protection Challenges for Unaccompanied Boys and Men in Refugee Contexts. CARE and Promundo, 2017.
[xv] Alison Brettle, ICSR, 2023. https://icsr.info/2023/03/29/forgotten-refugees-the-experiences-of-syrian-military-defectors-in-turkey/
[xvi] Heidi Riley, Men and Psychosocial Support Services Programming, XCEPT, 2023. https://icsr.info/wp-content/uploads/2023/07/XCEPT-Briefing-Note-Men-and-PSS-programming.pdf
[xvii] O’Loughlin, Julia I., Daniel W. Cox, Carl A. Castro, and John S. Ogrodniczuk. “Disentangling the Individual and Group Effects of Masculinity Ideology on PTSD Treatment.” Counselling psychology quarterly 35, no. 3 (2022): 587–604.
[xviii] Slegh, H., W. Spielberg, and C. Ragonese. Masculinity and Male Trauma: Making the Connections. Washington: Promundo US, 2022.
[xix] Schulz, 592.
[xx] Slegh, H., W. Spielberg, and C. Ragonese. Masculinity and Male Trauma: Making the Connections. Washington: Promundo US, 2022; Hecker, Tobias, Katharin Hermenau, Anna Maedl, Harald Hinkel, Maggie Schauer, and Thomas Elbert. “Does Perpetrating Violence Damage Mental Health? Differences Between Forcibly Recruited and Voluntary Combatants in DR Congo.” Journal of traumatic stress 26, no. 1 (2013): 142–148.
[xxi] Nandi, Corina, Thomas Elbert, Manassé Bambonye, Roland Weierstall, Manfred Reichert, Anja Zeller, and Anselm Crombach. “Predicting Domestic and Community Violence by Soldiers Living in a Conflict Region.” Psychological trauma 9, no. 6 (2017): 663–671.
[xxii] Catholic Relief Services. Strengthening Trauma Awareness and Social Cohesion in Greater Jonglei, South Sudan: A Case Study on the Impact of Social Cohesion Programming. CRS, 2022. https://www.crs.org/our-work-overseas/research-publications/strengtheningtrauma-awareness-and-social-cohesion-greater
This publication was produced as part of the XCEPT programme, a programme funded by UK International Development from the UK government. The views expressed do not necessarily reflect the UK government’s official policies.
