In mental health, as elsewhere, institutions operate according to archetypes that skew funding and support efforts. The case of the Democratic Republic of the Congo illustrates the consequences of this mode of operation for men’s access to care.
In the Democratic Republic of the Congo (DRC), a recent policy on mental healthMinistère de la Santé publique, Hygiène et Prévention, « Politique sous-sectorielle de santé mentale », Secrétariat général à la Santé, République démocratique du Congo, 2022. has set out to improve the integration of mental health at all levels of the public healthcare system. It comes two decades after an initial programme, which managed to incorporate psychosocial support services into just 10% of public healthcare activities.Idem. In many of the country’s provinces, those seeking care are required to travel hundreds of kilometres along unpaved roads to find a psychologist.World Health Organization, Mental health Atlas country profile 2014: Democratic Republic of the Congo, … Continue reading These discouraging conditions, combined with organisational difficulties (poor infrastructure) and operational challenges (lack of qualified personnel and material/financial resources), are significant barriers to the universal access advocated under the new policy.
Inclusive policy, piecemeal implementation
According to the document outlining the programme, the entire Congolese population should have access to mental health services and help with addressing problems linked to psychological trauma. The text recognises the growing needsMinistère de la Santé publique, Hygiène et Prévention, « Rapport final de l’atelier de réflexion sur l’intégration de la Santé mentale dans les soins de santé primaire en République … Continue reading resulting from the armed conflicts, epidemics and poverty which have chronically afflicted the Congolese population since the 1990s. In practice, however, it is clear that multiple areas of exclusion exist, starting with men – including the perpetrators of violence themselves – who are largely marginalised by mental health services. Invisibilised in public health policy, ignored by care providers and stigmatised by society, men’s psychological suffering is rarely considered. This article, stemming from the authors’ observations in eastern DRC, spotlights the discursive and sociocultural mechanisms underlying the marginalisation of men in mental health issues. In our article, we start by examining the way in which humanitarian policies, heavily influenced by the discursive framework of “rape as a weapon of war”, focus their mental healthcare services predominantly on female victims of sexual violence and which, in so doing, almost systematically excludes men. At the same time, local norms of masculinity constitute a further barrier to men’s access to mental healthcare. We then explore the attitudes of communities and healthcare providers towards manifestations of male suffering and the exclusion resulting from these. These political and sociocultural aspects constitute a serious – albeit little acknowledged – obstacle to the provision of inclusive mental healthcare in the DRC. We conclude the article with a series of concrete proposals for improved integration and awareness of the needs of men and of perpetrators of violence in mental health programmes.
First, we would like to emphasise the fact that any attention focused on men’s suffering in no way diminishes the gravity of the violence experienced by women and the extent of their needs in terms of psychological services. Women and girls are indeed disproportionately affected by violence. However, in a context such as that of the DRC where most people have experienced numerous forms of victimisationMarian T. A. Tankink and Henny Slegh, Living Peace in Democratic Republic of the Congo: An Impact Evaluation of an Intervention with Male Partners of Women Survivors of Conflict-Related Rape and … Continue reading, it is necessary to pay more conscious attention to men’s experiences. It must be admitted that debates in the care sector and feminist circles tend to quickly become bogged down in zero-sum arguments on the appropriation by men of “funding for women”.Jerker Edström, “The male order development encounter”, IDS Bulletin, vol. 45, no. 1, 2014, pp. 111–123, … Continue reading
We argue that in the DRC the silence shrouding men’s suffering has left a significant proportion of them – whether victims or perpetrators of violence – with no solutions to their problems, despite the fact that this suffering interweaves with and exacerbates that of their spouses, children and the community in general.Chris Dolan, “Has patriarchy been stealing the feminists’ clothes? Conflict-related sexual violence and UN Security Council resolutions”, IDS Bulletin, vol. 45, no. 1, 2014, pp. 80–84, … Continue reading Indeed, our research shows that, in a wider context of deep-seated structural violence, men are constantly exposed to the violence of armed individuals, to corruption and criminality, and this compounds the poverty they experience, leading to feelings of mistrust, confusion and social isolation. As a result, their combined identities as perpetrators, survivors and witnesses of this violence must be carefully considered. Acknowledging that men, like women, experience extreme levels of suffering – albeit in different ways – is a prerequisite for the establishment of a more comprehensive and inclusive mental health system that benefits the whole community.
The marginalisation of men in humanitarian discourse
Throughout the DRC, more than 90% of the mental healthcare infrastructure is managed by non-governmental organisations (NGOs),Ministère de la Santé publique, Hygiène et Prévention, « Politique sous-sectorielle… », op. cit. compensating for the inability of the Congolese State to provide this care. As a result, the provision of mental healthcare is subjected to the pressures of fundraising and humanitarian priorities, notably in crisis zones.
In her analysis of institutional responses to sexual violence in armed conflicts in the DRC, Chloé LewisChloé Lewis, Gender protection/Protecting the gender order: rethinking responses to sexual violence in armed conflict and its aftermath, Unpublished Thesis, 2018, Oxford University. describes the emergence of the archetypal “female rape victim” and her influence on the discourse of humanitarian actors. This archetype, representing Congolese women as distraught, brutalised and victimised, led to UN resolutions 1325 and 1820 and conferred an indisputable legitimacy on the structure of international response. Lewis presents the (female) victim subject as a “powerful cultural resource” when it comes to setting the agenda,R. Charli Carpenter, “Women, children, and other vulnerable groups: gender, strategic frames and the protection of civilians as a transnational issue”, International Studies Quarterly, vol. 49, … Continue reading which in her view explains why it has endured. Although the archetype of the “female victim” has attracted international attention regarding the extent of “rape as a weapon of war” and helped to develop comprehensive humanitarian responses for women and girl victims, this one-sided narrative nevertheless remains an issue. In effect, the hegemony of this simplified and essentialist model of the “female-victim” coincides with the emergence and wide dissemination of that of the “male-perpetrator”. As Lewis explains, “whether it is explicit or not, the shared vision of the Congolese woman is based on conflicting assumptions regarding the Congolese man and reifies them. It is primarily a question of his identity [and] the sexual harm he (inevitably) commits”.Chloé Lewis, Gender Protection…, op. cit., p. 219.
This simplified imagery of “female victim” and “male perpetrator” has significant material implications in the sense that it leads to exclusion by influencing priorities in terms of the recipients of the services provided. Nevertheless, in the guidelines of the Interagency Standing CommitteeIASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings, 2007, … Continue reading concerning mental health and psychosocial support in emergency situations, men are explicitly included as a vulnerable population with an increased risk of psychological problems. However, in the Congolese context, resources remain implicitly directed towards women. For example, most of the research on mental health issues carried out in the DRC is focused on sexual violence perpetrated on women and children formerly associated with armed groups.An Verelst, Maarteen De Schryver, Eric Broekaert et al., “Mental health of victims of sexual violence in eastern Congo: associations with daily stressors, stigma and labelling”, BMC Women’s … Continue reading This is because these two groups are seen de facto as vulnerableCamille Maubert, “Critical perspectives on child protection in the Democratic Republic of Congo”, Humanitarian Alternatives, no. 19, March 2022, pp. 46–59, … Continue reading and as being disproportionately affected by violence. In contrast, the Congolese man is only perceived through the lens of suffering inflicted and not of suffering endured.
We argue here that the wide dissemination of these archetypes results in a form of epistemic exclusion by preventing men’s suffering from being “known” and therefore taken into account. While the psychological suffering of men has been well documented by certain organisations,Promundo-US, Living peace groups: Implementation manual and final project report, GBV prevention and social restoration in the DRC and Burundi, 2014, … Continue reading it is difficult for humanitarian actors to think outside the discursive box.Camille Maubert, “From the ‘évolué’ to the ‘genré’ man: A decolonial analysis of gender transformative interventions in the Democratic Republic of Congo”, 4th Global Conference on … Continue reading As a result, access to the status of “victim” or “traumatised person”, both entitled to psychological support, is in part conditioned by the hegemonic discourse in effect in the DRC. Researchers Maria Eriksson Baaz and Maria SternMaria Eriksson Baaz and Maria Stern, Sexual Violence as a Weapon of War? Perceptions, Prescriptions, Problems in the Congo and Beyond, Zed Books, 2013. denounce this partial attention paid by the humanitarian industry, which acts as confirmation bias meaning that only information in line with the dominant narrative is retained while the rest is considered unintelligible.
Norms of masculinity and the invisibility of men’s suffering
At community level, norms of masculinity constitute a further barrier to men’s access to mental healthcare. In the DRC, as in many patriarchal societies, shared attitudes and behaviour are influenced by a set of rules and values which dictate how men and women should behave. According to authors Carol Gilligan and Naomi Snider, “more insidiously, patriarchy also exists internally, shaping how we think and feel, how we perceive and judge others, our desires, our relationships and the world we live in”.Carol Gilligan and Naomi Snider, Why Does Patriarchy Persist?, Polity, 2018, p. 6. In other words, social norms of masculinity and femininity determine behaviour but also the emotions judged to be appropriate for each sex.
Patriarchy is based on male detachment, the attenuation of empathy and the concealment of vulnerability. In a system where men are expected to be dominant, they are at risk if they show too much vulnerability. Commenting on the psychological dimensions of patriarchy, bell hooks explains that “the patriarchal culture really does not care if men are unhappy. […] Patriarchal mores teach a form of emotional stoicism to men that says they are more manly if they do not feel”.Bell Hooks, The Will to Change: Men, Masculinity and Love, Washington Square Press, 2004, p. 5. There is only one emotion that patriarchy values when it is expressed by men: anger.
In the DRC, society’s expectations of men are for them to be physically and mentally strong, to be responsible and provide for all the family’s needs and to control their emotions. To be a man means to be in charge all the time, to feel in control and never show any weakness. Boys are encouraged not to cry and men not to speak of their problems, even with their wives. Our observations of men participating in the activities of the Congolese NGO Ghovodi (Groupe des hommes voués au développement intercommunautaire, Groups of Persons Vowed to Intercommunity Development)Camille Maubert, “Critical perspectives…”, art. cit. working to reduce violence within families show how these men are not able to be open about their psychological and emotional needs, despite an overload of expectations and multiple daily stressors. Some of them talk of a state of anger and internal distress that they are unable to express without violence. In the face of social norms stigmatising male weakness, men deal with their malaise alone – and sometimes turn to destructive coping mechanisms (alcohol, drugs, high-risk behaviour).
Norms of masculinity are thus a significant barrier to men’s use of mental health services. Even when these are available, men are often reluctant to seek support from them because maisons d’écoute (counselling centres) and other mental healthcare facilities are regarded first and foremost as services for women and girls. Furthermore, those who do approach them are sometimes given a poor reception by care providers who themselves adhere to the social norms and do not take them seriously. Chris Dolan,Chris Dolan, “Letting go of the gender binary: Charting new pathways for humanitarian interventions on gender-based violence”, International Review of the Red Cross, vol. 96, no. 894, 2014, … Continue reading who studies the marginalisation of male victims of sexual violence, shows they have difficulty in being recognised as victims and in obtaining medical and psychological support. According to him, this is due both to the staff on the ground lacking awareness of how to treat male survivors and to cultural prejudices. Aside from sexual violence, the collective silence on the suffering of men and the social stigmatisation of expressions of weakness are key factors in the marginalisation of men.
Avenues for reflection
This article highlights the influence of essentialist discourse both in humanitarian policies (with the archetypes of female victim and male perpetrator) and within communities (with their norms of masculinity) on the acknowledgment, acceptability and treatment of male suffering. Expectations for males to be strong and practically invincible on the one hand and the invisibility of their psychological needs on the other lead to the de facto exclusion of men from mental health care. We will conclude with some proposals aimed at improving psychological support for men.
- Changing the approach to mental health through the concept of intersectionality:Kimberlé William Crenshaw, On Intersectionality: Essential Writings, The New Press, 2014. this concept refers to the interconnected nature of social categorisations such as race, class and gender, creating overlapping and interdependent systems of discrimination. The overriding emphasis placed on gender as the framework for “awareness” of suffering creates hierarchies in which women’s suffering is visible and alternative experiences and understanding are muted. An intersectional approach makes it possible to factor in the many possible identities of men who can at once be both the perpetrators and the victims of violence.
- Working on the community environment: recognising men’s suffering and its direct link to violence experienced by women leads us to question approaches centred on the individual and to propose a collective approach at family or community level. This work on factors underlying personal trauma would make it possible to establish a resilient, protective environment, leading to more lasting improvements in mental health.
- Encouraging the creation of communal structures for expression – for example within churches or neighbourhoods – to foster individual and collective awareness of men’s suffering.
Translated from the French by Fay Guerry