Gender-Based Violence in Humanitarian Settings: UNFPA's Programme Role

EXECUTIVE SUMMARY

Gender-based violence in humanitarian settings is one of the most complex, under-resourced, and persistently contested programme areas in international humanitarian action. The evidence that GBV increases in every humanitarian emergency — across conflict, natural disaster, and displacement settings — is consistent and well established. The specific forms of GBV that increase, the populations most affected, and the most effective responses are more contested. UNFPA holds a structurally unique position in this space: as the global lead agency for the GBV Area of Responsibility (GBV AoR), UNFPA is the designated coordinator for GBV prevention and response across the entire humanitarian system in most emergency settings. This leadership role — mandated by the UN Secretary-General and formalized through the Cluster System — gives UNFPA normative authority, coordination responsibility, and accountability that no other humanitarian actor holds in the GBV space.

The GBV AoR leads UNFPA to play a fundamentally different role in humanitarian GBV than in its development programming: it is primarily a coordinator and standard-setter, not a direct service provider. In most emergency settings, international NGOs — particularly the International Rescue Committee (IRC), CARE, the International Medical Corps (IMC), and others — are the primary frontline GBV service providers. UNFPA facilitates the coordination group, sets global standards, provides technical support, manages the GBVIMS data system, and advocates for resources. The quality of UNFPA's humanitarian GBV work is therefore most directly measurable through coordination quality indicators (coverage of services mapped, gap analysis quality, standard compliance among members) rather than direct service delivery metrics.

Clinical management of rape (CMR) is the most time-critical GBV service: the 72-hour window for effective HIV post-exposure prophylaxis is a hard clinical constraint that the humanitarian system regularly fails to meet. The most common CMR failure mode is not a supply problem — UNFPA pre-positions the necessary supplies — but a staffing and activation problem: trained providers are not available at accessible facilities within the first days of an emergency. GBV prevention programming has a substantially weaker evidence base than GBV response; the interventions most likely to actually reduce GBV prevalence (community norm change, legal deterrence, economic empowerment) are difficult to implement in acute emergency contexts and have long time horizons. Systematic reviews find that current prevention approaches produce measurable changes in attitudes and knowledge but limited evidence of reductions in GBV incidence.

The most significant structural problem facing humanitarian GBV programming is chronic underfunding. GBV consistently receives less than 1% of total humanitarian funding, despite the overwhelming evidence that it affects the majority of women and girls in any humanitarian crisis and despite its status as a MISP-level priority. This gap between acknowledged priority and actual resource allocation is the defining challenge of the programme area — and the most important single point for donors to engage with.

KEY FACTS

1. UNFPA as GBV AoR lead: UNFPA is the designated global lead agency for the GBV Area of Responsibility (GBV AoR) — the coordination mechanism for GBV in all humanitarian settings. This role is mandated within the UN Cluster System and gives UNFPA unique coordination authority that no other actor holds.
2. GBV in every emergency: A consistent finding across hundreds of humanitarian assessments over 30 years: GBV — including intimate partner violence (IPV), sexual violence, and transactional sex — increases in every humanitarian emergency. Increased risk factors include: displacement, destruction of community protective structures, loss of livelihoods, disruption of rule of law, overcrowding in camps, and increased alcohol consumption.
3. Prevalence estimates: Reliable GBV prevalence data in humanitarian settings is difficult to obtain. Best available estimates from major humanitarian operations suggest 1 in 5 women in conflict-affected settings has experienced sexual violence during the conflict (Stark & Ager, 2011; Peterman et al., 2011). Intimate partner violence rates in displacement settings are typically higher than pre-displacement rates.
4. CMR 72-hour standard: PEP for HIV prevention must be initiated within 72 hours of sexual assault exposure to be effective; optimal initiation is within 24 hours. This is the hardest operational constraint in CMR, consistently missed in the first days of most emergencies.
5. Reporting rates: Studies consistently find that fewer than 10–20% of GBV survivors report to formal services in humanitarian settings (GBVIMS global data; Palermo et al., 2014). GBVIMS data therefore reflects patterns in service access and reporting behaviour, not GBV prevalence.
6. GBV funding gap: GBV typically receives 0.1–1% of total humanitarian funding (UN OCHA Financial Tracking Service analysis; GBV AoR Global Reports), despite being a stated priority in all major humanitarian frameworks and affecting the majority of women in most crises.
7. GBVIMS: The GBV Information Management System — co-developed and managed by a consortium including UNHCR, UNICEF, IRC, IMC, and UNFPA — is used in 30+ humanitarian settings to collect, standardise, and safely share GBV incident data. It is the only standardised inter-agency GBV data system globally.
8. GBV AoR scope: The GBV AoR coordinates prevention and response across protection, health, legal/justice, psychosocial, and livelihoods sectors. In most humanitarian settings, the GBV AoR coordination group includes 10–30 organisations.
9. MHPSS gap: Comprehensive psychosocial support — beyond psychological first aid — is unavailable in the majority of humanitarian GBV programmes. Clinical psychology and psychiatric services are especially rare. This is a documented, persistent gap across virtually all emergency settings.
10. Legal and justice services: Access to justice for GBV survivors — including reporting to police, prosecution, legal aid, and documentation — is available in fewer than 40% of assessed humanitarian settings (GBV AoR Global Report 2022). This is a major unmet need.
11. Male and boy survivors: Men and boys experience sexual violence in humanitarian settings, particularly in conflict. CMR services and GBV coordination frameworks are designed primarily for female survivors; male survivors face additional stigma barriers and are systematically underserved. The proportion of male survivors in specific conflicts (DRC, Uganda, South Sudan) has been documented by researchers but GBV programmes rarely have dedicated male survivor pathways.
12. Digital GBV: Online harassment, image-based abuse, and digital surveillance of women in humanitarian settings are growing concerns that existing GBV frameworks do not adequately address. This is an emerging programme gap identified in recent GBV AoR reviews.
13. UNFPA's CMR provision model: UNFPA advocates for and supports task-sharing of CMR to trained nurses and midwives — not restricted to physicians. This policy position, supported by WHO clinical guidelines and evidence from multiple settings, significantly expands CMR coverage in settings where doctors are scarce.
14. Survivor-centred approach: The survivor-centred approach (also termed trauma-informed care) is the foundational principle of UNFPA-endorsed GBV response: the survivor's safety, confidentiality, respect, and non-discrimination are non-negotiable; decisions about disclosure, reporting, and service use are the survivor's alone. This principle is formally adopted but unevenly operationalised.
15. GBV in conflict vs. natural disaster: The character of GBV differs by crisis type. In conflict settings, sexual violence by armed actors (including weaponised rape) is prominent. In natural disaster settings, intimate partner violence and opportunistic sexual violence in displacement are more common. GBV AoR coordination mechanisms operate across both crisis types but programming emphasis varies.

BACKGROUND AND CONTEXT

GBV in Humanitarian Settings: Why It Increases

The relationship between humanitarian crises and GBV is not coincidental. Multiple structural factors create conditions for GBV:

Breakdown of protective structures: Families, communities, social networks, and institutions that normally provide some protection from violence are disrupted by displacement and conflict. Women who would be deterred from violence by community accountability may have no such protection in displacement settings.

Rule of law collapse: In conflict settings, legal deterrents to violence may disappear entirely — no functioning police, no courts, no prosecution. Even in natural disaster displacement, legal protections may be temporarily suspended or unenforceable.

Physical environment: Poorly designed refugee and displacement camps with inadequate lighting, communal sanitation facilities (requiring women to walk alone at night), and insufficient security create predictable vectors for sexual violence. The evidence on how camp design affects GBV risk is well documented (UNHCR camp planning guidance; IRC programme reports).

Economic vulnerability: Loss of livelihoods increases transactional sex (survival sex, coerced sex for access to food, water, or shelter), intimate partner violence driven by economic stress, and trafficking risk. Economic empowerment programmes — providing women with some independent income — are the most robustly evidenced GBV prevention intervention in development settings, and the evidence for their protective effect in humanitarian settings, while weaker, is growing.

Weaponisation of rape in conflict: Sexual violence as a weapon of war — used deliberately by armed actors to terrorise, displace, and humiliate communities — is a distinct phenomenon from opportunistic GBV. It is documented in the DRC, South Sudan, Myanmar/Rakhine State, Syria, and many other conflict settings. UNFPA's GBV response addresses this within the humanitarian system; accountability (prosecution, reparations) is primarily the mandate of the International Criminal Court and UN human rights bodies.

UNFPA's GBV Leadership: Historical Development

UNFPA's designation as GBV AoR lead was formalised through the 2005–2009 Humanitarian Reform process that created the UN Cluster System. The decision to designate UNFPA reflected its reproductive health mandate (sexual violence is a reproductive health as well as a protection issue), its presence in most humanitarian settings, and the absence of another obvious sector lead. UNHCR is the lead for protection overall but does not have a specific GBV service delivery mandate; WHO leads health; UNFPA bridges the health-protection interface.

In practice, UNFPA's GBV coordination role requires it to work across cluster boundaries — coordinating with health (CMR, MHPSS), protection (legal services, case management), livelihoods (economic empowerment), and camp management (physical safety infrastructure). This cross-sectoral mandate is both the role's strength (GBV requires a comprehensive response) and its operational challenge (UNFPA must coordinate with clusters it does not lead).

WHAT UNFPA DOES: PROGRAMME DETAIL

GBV Area of Responsibility Coordination

Global level: The GBV AoR at global level maintains a secretariat hosted by UNFPA in Geneva and New York. It produces global standards (including the GBV AoR Handbook for Coordination, the IASC GBV Guidelines), training resources, and global advocacy materials. It coordinates the GBV AoR network of country-level coordinators and provides technical support to them.

Country level: UNFPA staff lead or co-lead the GBV coordination group in most humanitarian settings. The typical structure:

• GBV sub-cluster or working group meeting: monthly in stable situations, weekly or more frequently at emergency onset
• Participants: UNFPA, UNHCR, UNICEF, UN Women, OCHA, major international NGOs (IRC, CARE, IMC, NRC, MSF, Oxfam), national NGOs, and sometimes government representatives
• Functions: 4Ws mapping (who is doing what, where, when), gap analysis, standard-setting, information sharing, joint advocacy to the Humanitarian Country Team for resources

Coordination quality indicators (what good coordination looks like):

• All major GBV service providers participating in coordination
• Updated 4Ws map available and shared at least monthly
• Gap analysis producing specific action recommendations
• Joint advocacy for funding resulting in increased GBV allocation
• Common GBV referral pathway known to all service providers and accessible by communities

Coordination failure modes (documented in IEO and external assessments):

• GBV coordination meetings held but not producing actionable gap analysis
• Information shared within the coordination group not reaching community level
• Coordination used for reporting rather than problem-solving
• UNFPA country offices that co-lead GBV AoR while being primarily development-oriented are sometimes not equipped to run effective humanitarian coordination — the skills required are different from development programme management

Clinical Management of Rape (CMR)

CMR is the health sector's immediate response to sexual violence. UNFPA promotes and supports CMR provision in all humanitarian settings through: standard-setting (WHO CMR protocol), capacity building (training health providers), supply provision (Kit 0B from the IARH Kits), and coordination to ensure services exist where needed.

The current WHO CMR protocol (2019 guidelines) covers:

1. Immediate first response:

   • Psychosocial first aid (PFA): the immediate supportive response before any medical assessment. Acknowledges disclosure, ensures safety, provides human connection. PFA does not require specialist training and should be provided by any health provider or community worker who first receives a survivor.
   • Privacy and confidentiality assurance.

2. Medical assessment and history:

   • Survivor-led history of the assault — no more detail than clinically necessary; avoid re-traumatisation
   • Medical history (relevant current conditions, medications, contraceptive use, HIV status if known)
   • The principle: the medical history serves the survivor's health, not investigation or documentation

3. Physical examination:

   • Only with explicit, informed consent
   • Treatment of injuries: wound care, assessment for fractures, laceration repair
   • Forensic examination (collection of evidence for legal purposes): only if the survivor requests and only if forensic capacity exists. Forensic evidence collection should not delay or substitute for medical care.

4. Emergency contraception:

   • Levonorgestrel 1.5mg (single dose) within 120 hours of assault; most effective within 72 hours (odds ratio for pregnancy approximately 0.2 vs. no intervention when taken within 72 hours)
   • Copper IUD insertion within 5 days: most effective form of emergency contraception (>99% effective); also provides ongoing contraception
   • Offer both options; ensure the survivor can choose freely

5. HIV post-exposure prophylaxis (PEP):

   • Initiate within 72 hours; maximum effectiveness if started within 24 hours; ineffective if started after 72 hours
   • 28-day regimen: current WHO recommendation is TDF+FTC+DTG (tenofovir-emtricitabine-dolutegravir) or equivalent; starter pack contains 3–7 days; full 28-day supply must be arranged
   • Adherence counselling is essential — incomplete courses provide partial protection and risk resistance development
   • Follow-up at 72 hours (confirm PEP tolerable, assess adherence) and 28 days (complete course), with HIV testing at 6 weeks, 3 months, and 6 months if initially HIV-negative

6. STI prophylaxis:

   • Standard WHO protocol: azithromycin (1g single dose) for chlamydia/non-gonococcal urethritis; cefixime (400mg single dose) for gonorrhoea; metronidazole (2g single dose) for trichomoniasis/BV; benzathine penicillin 2.4 MU IM for syphilis prophylaxis
   • In penicillin-allergic patients: doxycycline 100mg twice daily for 14 days for syphilis prophylaxis

7. Hepatitis B and tetanus vaccination:

   • Hepatitis B: if not previously vaccinated, 3-dose series initiated at first visit; if previous vaccination status unknown, vaccinate
   • Tetanus: if wound present and vaccination status not current, give tetanus toxoid; administer tetanus immunoglobulin (TIG) for contaminated wounds

8. Safe abortion (where legal):

   • Management of pregnancy resulting from rape includes provision of or referral for safe abortion where national law permits
   • UNFPA's position: where safe abortion is legal, it is part of CMR. Where it is illegal, UNFPA supports post-abortion care for complications.

9. Referral and follow-up:

   • Referral to: specialist psychosocial support (where available), legal/justice services (where available and safe), economic support services (if relevant), case management
   • Document the referral; ensure the survivor has a named contact at the referral service
   • Follow-up visit plan: minimum at 72 hours (PEP adherence) and 28 days (PEP completion)

Task-sharing for CMR: WHO guidelines explicitly endorse that trained nurses and midwives can provide the full CMR protocol — physician involvement is not required. UNFPA has advocated strongly for this, because requiring physician-level providers for CMR drastically limits coverage in settings where doctors are rare. The evidence that nurse/midwife-provided CMR produces equivalent outcomes to physician-provided CMR is moderate-strong (comparative studies from Uganda, Kenya, DRC; WHO systematic review used to develop the 2019 guidelines).

GBV Case Management: The Full Response Pathway

CMR addresses the immediate medical needs. Full GBV case management is the multi-sectoral follow-up that addresses the broader consequences of GBV over time.

The five elements of GBV case management:

1. Safety assessment and planning: Immediately assess whether the survivor faces ongoing risk from the same perpetrator(s), from community members who might react to disclosure, or from security forces. Develop a specific safety plan — concrete actions the survivor can take to reduce risk. This is the most urgent non-medical element of GBV response.

2. Psychosocial support: Individual and group counselling using trauma-informed approaches. Levels of support available should be matched to survivor needs:

   • Level 1 (all helpers): Psychological first aid — basic supportive presence
   • Level 2 (trained case workers): Structured psychosocial support — addressing grief, resilience building, coping skills
   • Level 3 (specialised MHPSS): Clinical psychology, cognitive processing therapy (CPT) for PTSD, psychiatric care Most humanitarian settings can provide Level 1–2; Level 3 is rare.

3. Legal and justice referral: Connecting survivors to legal aid, police reporting, court accompaniment, and documentation services where these exist and where the survivor chooses to use them. In most humanitarian settings, legal services are either absent or inaccessible. Where they exist, UNFPA coordinates (not directly provides) through the GBV AoR referral pathway.

4. Material support: Addressing immediate material needs that may have been disrupted by the GBV incident — shelter, food, non-food items. Referral to relevant clusters.

5. Reintegration and economic support: In protracted settings, supporting survivors' economic independence — vocational training, income-generating activities, microcredit linkages — both as a practical need and as a protective factor against future GBV.

What most humanitarian settings actually provide: CMR (sometimes, where trained providers and supplies exist); some psychosocial support (Level 1–2 in most settings); very limited legal services (fewer than 40% of settings have functioning legal referral pathways per GBV AoR 2022 data); limited or no economic support. The gap between the comprehensive case management model and what is actually available is substantial and persistent.

GBV Information Management System (GBVIMS)

GBVIMS is the inter-agency system for collecting, managing, and safely sharing GBV incident data in humanitarian settings. It was jointly developed by UNHCR, UNICEF, IRC, IMC, and UNFPA and is managed by a Steering Committee co-led by these organisations.

System components:

• Incident Recorder (IR): A standardised spreadsheet/database tool where service providers document each reported GBV incident using the Incident Report Form (IRF). The IRF captures: type of GBV, relationship to perpetrator, time and location of incident (without identifying information), services received, and referral. Data entry is done by case workers; it documents what survivors have disclosed to services, not GBV that was not reported.
• Statistical Report: Generated from aggregated IR data; identifies trends in GBV type, timing, location, and service gaps at programme and country level
• Data Sharing Protocol (DSP): Governs how data is shared between organisations. Survivor data is never shared individually; aggregated data is shared according to a defined protocol. The DSP negotiation between participating organisations is often one of the most time-consuming elements of establishing GBVIMS in a new setting.
• Gbvims+: A more advanced digital platform being rolled out as an upgrade to the original spreadsheet-based tool; enables real-time data entry, automated analysis, and mobile-device compatibility.

What GBVIMS tells you:

• Patterns of GBV incidents as reported to services: trends over time, geographic distribution, types of violence, perpetrator relationship
• Service utilisation patterns: who is reaching services and who is not
• Service gap identification: cases presenting at one service point without follow-up, missing referral steps
• Evidence for resource advocacy: documented caseload data to support requests for GBV programme funding

What GBVIMS does not tell you:

• GBV prevalence or incidence at population level — the data represents the very small minority of survivors who report to services
• Total GBV burden — no setting has data on unreported GBV, which is the vast majority
• Whether prevention programmes are working — GBVIMS captures service utilisation, not violence occurrence

GBV Prevention Programming

Prevention is the component of humanitarian GBV programming with the weakest evidence base and the most complex implementation challenges.

Primary prevention approaches used in humanitarian settings:

1. Community awareness and dialogue programmes: Community sessions, often facilitated by trained community members, that address gender norms, rights, and GBV. Target both mixed groups and separate men's/women's/youth groups. The most commonly used curriculum is the UN Women RESPECT framework and various IRC/CARE community approaches.

2. Engaging men and boys: Structured programmes that engage men and boys on gender norms, masculinity, and GBV. Evidence from development settings (e.g., Promundo's Program P; CARE's Engaging Men Through Accountable Practice - EMAP; South African MenEngage programmes) shows measurable changes in attitudes and self-reported behaviour in some contexts. Evidence from humanitarian settings is substantially weaker.

3. Safe spaces for women and girls: Provides physical protection from violence for women and girls who attend; provides information, peer support, and referral in a safe environment. Does not prevent GBV outside the safe space. Evidence that safe spaces reduce overall GBV prevalence is limited; evidence that they are valued by users and provide other psychosocial benefits is stronger.

4. Lighting and infrastructure improvements: Improving lighting at latrines, water points, and walkways in displacement settings reduces the risk of sexual violence at known high-risk locations. Practical and achievable; the evidence base is case-based rather than experimental.

5. Economic empowerment: Providing women with income or economic resources reduces financial dependency and the risk of survival sex. Evidence from development settings is moderate-strong (multiple reviews show associations between women's economic autonomy and reduced IPV). Evidence from acute humanitarian settings is limited.

6. Cash and voucher assistance (CVA): Unconditional cash transfers have been associated in some studies with reductions in IPV and survival sex in humanitarian settings, primarily through the economic empowerment pathway. A 2019 IRC study in South Sudan found that unconditional cash transfers were associated with significant reductions in sexual and physical violence. This is among the strongest recent evidence for a prevention intervention in humanitarian settings, though replication is needed.

Evidence quality for GBV prevention in humanitarian settings: Overall very weak to weak. The most recent comprehensive systematic review (Vu et al., 2014; updated analyses by Stark & Ager, 2011 and subsequent researchers) found that:

• Most GBV prevention programmes in humanitarian settings have not been rigorously evaluated
• Programmes that have been evaluated typically measure attitudes and knowledge change, not GBV incidence
• The few evaluations that measure GBV incidence show inconsistent and generally non-significant results
• This does not mean prevention programmes are ineffective — the evidence gap reflects under-investment in evaluation, not evidence of harm. But it does mean programme claims of prevention impact cannot be supported by the current evidence base.

Psychosocial Support Frameworks

UNFPA operates within two complementary frameworks for psychosocial response to GBV survivors:

Psychological First Aid (PFA): WHO/UNICEF/IASC framework for immediate psychosocial support in emergencies. PFA is not counselling — it is a basic supportive response that any health worker, humanitarian staff member, or trained volunteer can provide. Core elements: Look (assess safety and needs), Listen (give attention, listen actively), Link (connect to information, services, basic needs). UNFPA trains health workers and community volunteers in PFA as part of CMR and GBV programme preparation.

Mental Health and Psychosocial Support (MHPSS): The IASC MHPSS framework organises psychosocial support in a pyramid: basic services and security (base) → community and family supports → focused non-specialist supports → specialist services (apex). UNFPA's GBV response primarily works at the middle levels (community supports, focused non-specialist supports); the apex (clinical psychology, psychiatry) requires partners with specialist mental health mandates (WHO, IMC, mhGAP network).

The MHPSS gap: Specialist mental health services are absent in the majority of humanitarian settings. PTSD, depression, and anxiety are endemic among conflict-affected women and GBV survivors. The gap between demand for specialist mental health services and available supply is one of the most consistently documented failures in humanitarian response. UNFPA advocates for MHPSS resources through the GBV AoR but does not have the technical mandate to directly provide specialist services.

THE EVIDENCE BASE

GBV Prevalence in Humanitarian Settings — Evidence Quality: Moderate (for broad pattern); Weak (for specific prevalence estimates)

The evidence that GBV increases in humanitarian settings is consistent across setting types and geographic regions. The specific prevalence estimates are weak because:

• Population-based surveys of GBV in active conflict zones are logistically and ethically constrained
• Most available data comes from service statistics (GBVIMS) which represent only reported cases
• Cross-sectional surveys of displaced communities use varied methodologies (different definitions, question framing, sampling frames) making comparison problematic
• Key studies use retrospective reporting with recall bias

Key references:

• Stark & Ager (2011): Systematic review of sexual violence in conflict settings. Found that while methodological quality was low, the pattern of increased sexual violence was consistent. 1-in-5 women experiencing sexual violence in some conflict settings based on best-available evidence. Evidence quality: weak (reflects underlying data limitations, not review quality).
• Peterman et al. (2011): Cross-sectional survey in DRC (n=3,436). Found lifetime conflict-related sexual violence prevalence of 39.7% among women and 23.6% among men. This study generated controversy (Wood, 2012 critiqued the methods as overestimating systematic rape) but remains widely cited.
• Gupta et al. (2009): Cross-sectional study of Darfur (Sudan) displaced women; documented very high rates of sexual violence during displacement.
• GBVIMS Global Report (annually): Aggregated data from GBVIMS-participating settings. Most recent reports document hundreds of thousands of incidents recorded per year across all settings. To be interpreted as a floor, not a ceiling.

Clinical Management of Rape — Evidence Quality: Strong (for individual components); Moderate (for full protocol effectiveness in humanitarian settings)

• PEP effectiveness: Systematic review (Ford et al., 2014, Cochrane) — no placebo RCT of PEP is ethical, but evidence from occupational exposure studies, case-control data, and biological mechanism provides strong evidence for effectiveness. Time-sensitivity (72-hour window) is well established.
• Emergency contraception: Cochrane review (Cheng et al., 2017) confirms levonorgestrel EC reduces pregnancy risk by approximately 85% when taken within 24 hours (diminishing to approximately 58% at 48–72 hours). Evidence quality: strong.
• Task-sharing CMR to nurses/midwives: Multiple comparative studies (Uganda, Kenya) and WHO systematic review confirm comparable clinical outcomes between nurse/midwife and physician CMR provision. Evidence quality: moderate.
• Survivor-centred approach: The evidence base for trauma-informed care approaches in GBV response is derived primarily from high-income country clinical psychology literature; limited direct evidence from humanitarian settings. The principle is supported by strong consensus and some qualitative evidence but no RCTs. Evidence quality: weak for effectiveness; strong for ethical justification.

Psychosocial Interventions — Evidence Quality: Moderate

• Cognitive Processing Therapy (CPT) for PTSD in humanitarian settings: Ertl et al. (JAMA, 2011) RCT in northern Uganda (n=108 war-affected individuals including GBV survivors): CPT significantly reduced PTSD and depression symptoms compared to wait-list control. Evidence quality: moderate (small sample; setting-specific).
• Group trauma-focused CBT in Rwanda: Neuner et al. (BMC Psychiatry, 2008): group Narrative Exposure Therapy reduced PTSD symptoms. Further evidence from multiple settings of adapted trauma-focused interventions.
• Psychological first aid: No RCT evidence for PFA effectiveness (ethical and practical constraints); consensus-based support from clinical organisations and qualitative evidence.

GBV Prevention — Evidence Quality: Very Weak to Weak

• IRC Cash Transfer study (South Sudan, 2019): Quasi-experimental evaluation (n=1,800) found significant reductions in sexual and physical violence in households receiving unconditional cash transfers vs. waitlist controls. This is among the strongest available evidence for a prevention intervention. Evidence quality: moderate (quasi-experimental; single setting).
• Community-based prevention programs: Multiple small evaluations (CARE EMAP in Côte d'Ivoire; IRC programs in South Sudan, DRC). Most show attitude change; few show behaviour change; fewer show violence reduction. Systematic reviews (Ellsberg et al., Lancet, 2015; Paluck et al., systematic reviews of gender norm change) conclude that evidence is insufficient to determine what works.
• Safe spaces: Primarily qualitative evidence; valued by participants; limited evidence on violence prevention outcomes.

IMPLEMENTATION REALITIES

The Coordination vs. Implementation Confusion

The most fundamental implementation challenge is the frequent confusion between UNFPA's coordination role and a direct implementation role. In many humanitarian settings:

• Communities and government partners assume UNFPA provides GBV services, because UNFPA leads coordination
• UNFPA country offices accept responsibility for gaps in GBV service delivery that are actually the responsibility of implementing NGOs
• Implementing NGOs defer to UNFPA on service design questions that should be locally contextualised
• The result is that UNFPA is accountable for outcomes it does not directly control, and implementing agencies lack the programme ownership and accountability that effective service delivery requires

This confusion is documented in IEO country evaluations of UNFPA's humanitarian programmes (Ethiopia, DRC, Jordan). The appropriate model is: UNFPA coordinates and advocates; NGOs implement; UNFPA holds the system accountable for gaps through coordination mechanisms.

Survivor-Centred Principles vs. Operational Pressure

The survivor-centred approach requires that the survivor controls all decisions about disclosure, services, and legal action. In practice, operational pressures frequently undermine this:

• Mandatory reporting requirements: Some settings have mandatory reporting laws that require health providers to report GBV to police, removing survivor choice. UNFPA advocates against mandatory reporting in humanitarian settings because it prevents disclosure and access to medical care.
• Donor reporting requirements: Donors require numbers of survivors served; this creates incentives to document cases even when survivors have not consented to documentation. UNFPA's data protection protocols (GBVIMS data sharing protocols) attempt to address this but are imperfectly operationalised.
• Provider attitudes: Even trained CMR providers may hold attitudes that lead them to question survivor credibility, impose moral judgements, or pressure survivors toward legal reporting. Ongoing supervision and mentoring — not just initial training — is required to maintain provider standards.

Country-Specific Realities

DRC (Democratic Republic of Congo): The DRC has been described as "the rape capital of the world" (a description critiqued by some researchers as both inaccurate in magnitude and unhelpful in characterisation but reflecting genuinely very high rates of conflict-related sexual violence). UNFPA DRC runs one of the largest humanitarian GBV programmes in the world — multiple CMR facilities, a large GBV coordination group, and extensive community mobilisation. The IEO evaluation of UNFPA DRC (2019) found that CMR services were available at health facilities in conflict-affected areas with higher coverage than in most comparable settings, but that access barriers (distance, safety of travel, provider shortage at night/weekends) remained significant. The DRC programme is simultaneously one of UNFPA's best humanitarian GBV programmes and one facing the most extreme challenges.

Syria/Jordan/Lebanon (Syrian displacement crisis): The Syrian crisis created a large humanitarian GBV caseload in both Syria and refugee settings in Jordan, Lebanon, and Turkey. UNFPA's GBV response in Jordan and Lebanon has been evaluated as relatively strong in urban settings; in rural and informal settlement settings, coverage is lower. One distinctive feature of the Syrian crisis: the significant proportion of survivors who require legal assistance related to marriage, divorce, and child custody under Syrian and host country legal frameworks — a component of GBV case management that is often absent.

Bangladesh (Rohingya): The Rohingya crisis generated a large-scale GBV response in Cox's Bazar. UNFPA leads the GBV sub-cluster and operates multiple women-friendly spaces. The challenge in this setting is the combination of: high population density in a small geographic area; very limited survivor willingness to report to formal services (due to fear of deportation, community stigma, and distrust of services); and the specific vulnerability of adolescent girls facing early and forced marriage within camps. Adolescent-specific GBV programming is one of the most underdeveloped elements in Cox's Bazar.

South Sudan: A setting with extremely high rates of GBV, including conflict-related sexual violence, early marriage, and very high IPV rates. UNFPA South Sudan operates in highly insecure environments with frequent forced interruptions to programming. The cash transfer evidence cited above (IRC South Sudan 2019) was generated in this setting and represents a significant programme learning. The challenge: cash transfer programmes require functioning financial systems; in hyperinflationary and conflict-disrupted South Sudan, sustaining such programmes is operationally very difficult.

The Male Survivor Gap

Men and boys are survivors of sexual violence in humanitarian settings — particularly in conflict settings where they may be targeted by armed actors as a form of torture and humiliation. The DRC, Uganda, Syria, and Somalia have all documented significant male survivor caseloads in conflict settings. However:

• GBV coordination frameworks and services are designed primarily for female survivors
• CMR facilities rarely have dedicated privacy provisions for male survivors
• Male survivors face extreme stigma and are even less likely to report to services than female survivors
• Provider training on male CMR is rare
• UNFPA's GBV programming addresses male survivors in its guidance documents but implementation of specific male survivor pathways is very limited

This is one of the most consistently under-addressed gaps in humanitarian GBV programming and one where advocacy for change is both feasible and important.

Chronic Underfunding: The Structural Problem

The most important systemic implementation reality is the chronic mismatch between the acknowledged priority of GBV and the resources allocated to it. Analysis of UN OCHA Financial Tracking Service data across multiple humanitarian appeals consistently finds:

• GBV-specific funding represents 0.1–1% of total humanitarian funding
• Within health cluster funding, reproductive health (of which GBV response is a component) is systematically underfunded relative to other health priorities
• The GBV AoR's own assessments find that available GBV services reach fewer than 30% of women in need in most humanitarian settings
• The funding gap for full GBV response in major humanitarian operations is estimated at USD 300–500 million per year globally (GBV AoR Global Report, 2022)

This underfunding is not primarily a result of donors being unaware of GBV — it is a result of systematic allocation decisions across humanitarian appeals that consistently prioritise other sectors. Changing this requires donor pressure within humanitarian appeal prioritisation processes.

FUNDING, SCALE AND RESOURCES

UNFPA GBV Budget

UNFPA does not publish a disaggregated GBV budget. Available data:

• UNFPA's humanitarian response appeals: approximately USD 400–600 million annually; GBV response is one of three core humanitarian programme areas
• GBV coordination and response is estimated to account for approximately 25–35% of UNFPA's humanitarian programme expenditure
• The GBV AoR Secretariat (hosted by UNFPA) is funded through UN assessed contributions and voluntary contributions from donors; annual budget approximately USD 3–5 million for the global secretariat function

The Investment Case for GBV Response

Unlike maternal health or family planning, the GBV investment case is not primarily expressed in cost-per-DALY terms, because GBV's harms extend well beyond measurable DALYs:

• The economic costs of GBV — lost productivity, healthcare costs, long-term mental health impacts, care burdens — are estimated at 1–4% of GDP in affected countries (World Bank analyses)
• CMR specifically is highly cost-effective: at USD 100–200 per survivor served (including PEP, EC, and STI treatment), it is among the cheapest acute medical interventions with high direct health value
• The broader case for GBV prevention and response is primarily a rights and human security case: women's rights to life, physical integrity, and equality — rather than a cost-effectiveness case alone

KEY DEBATES AND CONTESTED QUESTIONS

1. Does UNFPA's Coordination Role Produce Better GBV Outcomes?

The most fundamental question about UNFPA's GBV AoR leadership is whether coordination — as distinct from direct service provision — produces measurable improvements in GBV outcomes. The evidence is limited:

• Comparative assessments (settings with and without effective GBV AoR coordination) show that coordination is associated with fewer service gaps, better referral pathway quality, and higher proportions of CMR protocols met (GBV AoR 2022)
• However, coordination quality varies enormously between settings, and poor coordination is documented even in settings where UNFPA maintains a large country office presence
• The most honest assessment: effective coordination is necessary but not sufficient; it cannot substitute for underfunded services, unqualified providers, or hostile political environments

2. Primary Prevention vs. Response in Resource-Constrained Settings

Given the very weak evidence for GBV prevention programmes in humanitarian settings, should scarce resources be allocated to prevention or to response (CMR, case management)? The prevention advocates argue that response is reactive and perpetuates the cycle; the response advocates argue that the evidence gap for prevention does not justify diverting resources from services that definitely help survivors. Both positions are defensible; the optimal allocation is not clear from the evidence.

3. Reporting Requirements and Survivor Autonomy

Some humanitarian settings have laws or programme designs that require GBV to be reported to police or authorities when disclosed to service providers. This is in direct conflict with the survivor-centred approach and the evidence that mandatory reporting reduces disclosure and access to medical care. UNFPA's position (mandatory reporting is harmful in humanitarian settings) is well-founded; operationalising it requires engagement with national legal frameworks and sometimes diplomatic tension with host governments.

4. Evidence-Based vs. Needs-Based Service Provision

Should GBV programme design be driven primarily by evidence of what works (constrained evidence base, largely from development settings) or by needs assessment data (which consistently shows massive unmet need for response services)? The practical humanitarian position is that waiting for better evidence before scaling services is ethically unacceptable when women are experiencing violence now. The research community argues that scaling unproven interventions without evaluation perpetuates an evidence gap that weakens future programming.

5. Digital GBV and Emerging Forms of Violence

Online harassment, image-based abuse, and digital surveillance affect women in humanitarian settings increasingly as mobile phone penetration increases. Existing GBV frameworks — designed for physical violence — do not adequately address digital GBV. UNFPA has no specific digital GBV programme in most settings; this is an acknowledged gap with no clear operational response at present.

IMPLICATIONS BY AUDIENCE

For Frontline Staff and Practitioners

Immediate response priorities:

• The 72-hour PEP window is the most time-critical clinical requirement. If a survivor presents after sexual assault, your first question is: how long ago did this happen? If within 72 hours, initiate PEP immediately before anything else if it might cause delay.
• Apply the survivor-centred approach from the moment of first contact: believe the survivor, ensure privacy, do not pressure disclosure or documentation, let the survivor lead all decisions.
• Provide psychological first aid, not therapy. Unless you are a trained counsellor, PFA is what you provide: listen actively, acknowledge what the survivor has experienced, ensure safety, connect to practical needs.
• Know your referral pathway before you need it. The referral pathway should be a document — a phone number list and a set of agreements with named organisations — not something you figure out when a survivor presents.
• Document carefully. The Incident Report Form (GBVIMS) captures what the survivor disclosed and consented to share. Never include identifying information that the survivor has not consented to. Explain to survivors what information will be shared and with whom before documenting anything.

Provider self-care: Regular GBV casework exposure without adequate supervision and debriefing causes secondary traumatic stress. Programme managers must ensure that all staff providing GBV services have access to regular supervision (at minimum monthly group debriefing) and know how to access mental health support if needed. This is not optional — it is essential for sustained quality service provision and staff retention.

Male survivors: If a male survivor presents, apply the same survivor-centred approach, CMR protocol, and documentation standards. Ensure privacy — male survivors often face additional stigma concerns. If your facility lacks a private space for male survivors, escalate this gap to your programme manager immediately.

Referral quality: A referral is only meaningful if the survivor successfully accesses the service being referred to. Follow up on referrals — at the 72-hour PEP follow-up visit, ask whether the survivor attended the psychosocial or legal service you referred them to. If they did not, understand why and address the barrier if possible.

For Programme Managers and Decision-Makers

• Invest in CMR availability before emergencies occur: Ensure that all health facilities in your programme area that could serve as CMR points are: (1) staffed with at least one CMR-trained provider available 24/7; (2) stocked with unexpired Kit 0B; (3) known to communities as a safe CMR point. Do not wait for an emergency to establish this.
• Coordination quality over meeting frequency: Measure the GBV AoR coordination group you facilitate by outputs, not meetings held. Key outputs: updated 4Ws map shared monthly, gap analysis acted upon, referral pathway known to all implementing organisations, data protection protocols signed by all GBVIMS partners.
• Integrate GBV into sector programming: GBV does not happen only in GBV-specific programmes. It is relevant in: health (CMR), shelter (camp design), livelihoods (economic autonomy protection), WASH (sanitation safety), food security (food-for-sex coercion prevention). Facilitate cross-sector integration through the GBV AoR coordination mechanism.
• Survivor data protection is non-negotiable: If GBVIMS is in place, audit the data sharing protocol compliance annually. Survivor confidentiality is both an ethical obligation and a practical prerequisite for disclosure — if communities believe that using GBV services creates risk of exposure, they will not use them.

For Donors and Board Directors

• The GBV funding gap is the primary strategic problem: Less than 1% of humanitarian funding going to GBV is the single most important number in this document. It means that acknowledged priority does not translate into resource allocation. Donors can change this by: earmarking GBV-specific contributions, using humanitarian appeal influence to advocate for increased GBV allocation, and conditioning health cluster funding on evidence of GBV integration.
• CMR is the highest-value specific investment: At USD 100–200 per survivor served and clinically proven to prevent HIV, unwanted pregnancy, and STI, CMR is the most cost-effective acute GBV response investment. Funding that ensures CMR services are available with trained providers in all UNFPA humanitarian settings is the most direct, attributable GBV investment available.
• UNFPA's value is in coordination, not just service delivery: When evaluating UNFPA's humanitarian GBV programme, assess coordination quality — not just services delivered by UNFPA directly. Ask: how many GBV service providers are coordinated through the GBV AoR? Is the referral pathway functional? Is GBVIMS in place and generating actionable data? These are the indicators of UNFPA's distinctive value.
• Invest in evidence for prevention: The most persistent programmatic gap in humanitarian GBV is the evidence base for prevention. Funding rigorous evaluations of cash transfer programmes, community norm change programmes, and safe space approaches in multiple humanitarian settings would generate evidence that could transform the sector's investment decisions.

For Researchers

• Population-based GBV measurement in humanitarian settings: Methodological innovation is needed for reliable, ethical, population-representative measurement of GBV in crisis settings. WHO Violence Against Women Survey methodology (used in development settings) is impractical in most acute humanitarian contexts. Adapted tools (such as the VACS — Violence Against Children Survey — adapted for adults in emergency settings) are being developed but not yet validated. This is a priority measurement research area.
• Mechanistic understanding of GBV drivers in crisis: The general statement that "GBV increases in every emergency" needs unpacking. Which specific forms of GBV increase? Under what conditions? What are the primary pathways (economic, social norm, security, displacement-related)? Understanding this at a more granular level would enable more targeted prevention programming.
• Long-term outcomes of GBV survivors: What are the 1, 5, and 10-year outcomes for women who received CMR vs. those who did not? Who received comprehensive case management vs. who did not? Prospective cohort studies would provide essential evidence on the value of services and on which components have the greatest long-term impact.
• Male survivor research: The epidemiology of male sexual violence in humanitarian settings is significantly under-researched. Basic prevalence data, understanding of barriers to service access, and evaluation of adapted CMR protocols for male survivors are all research priorities.
• Cash transfers and GBV prevention: The IRC South Sudan 2019 study is promising but needs replication across settings. Multi-site cluster-RCT of unconditional cash transfers with GBV outcomes would provide the strongest evidence for the economic empowerment prevention pathway.
• Prevention programme evaluation: Any rigorous evaluation of a GBV prevention programme in a humanitarian setting — using pre-registered protocols, control groups, and GBV incidence (not just attitude) outcomes — would make a significant contribution to the field.

CURRENT STATUS AND FUTURE DIRECTIONS

UNFPA's GBV humanitarian programme continues under the 2022–2025 Strategic Plan, with humanitarian GBV response explicitly identified as a strategic priority. The scale of humanitarian need continues to grow: the number of people in humanitarian need increased from approximately 270 million in 2020 to 339 million in 2023 (OCHA estimates), driven primarily by protracted conflicts in Ukraine, DRC, Yemen, Sudan, Ethiopia, and Myanmar.

Key developments in the current period:

Ukraine response: The Russian invasion of Ukraine (2022) created the largest displacement crisis in Europe since World War II and a significant humanitarian GBV caseload, including documented conflict-related sexual violence by Russian forces. UNFPA has established GBV coordination and CMR services across Ukraine and in neighbouring countries hosting refugees (Poland, Moldova, Romania). The Ukraine response has mobilised significantly more funding per capita than most African or Asian crises — an equity issue that the GBV AoR has flagged.

Sudan crisis (2023–): The outbreak of conflict between the Sudanese Armed Forces and the Rapid Support Forces in April 2023 has generated one of the fastest-growing humanitarian crises in recent years, with massive displacement and severe access constraints. GBV, including weaponised rape, has been documented. UNFPA's response capacity in Sudan has been severely constrained by security and access limitations.

Surge in digital GBV: As mobile phone access expands even in the most marginalised populations, online harassment, image-based abuse, and digital tracking by abusive partners are affecting women in humanitarian settings. UNFPA has begun addressing this in programme guidance but does not yet have operational digital GBV programmes in most settings.

GBVIMS+ rollout: The upgraded GBVIMS+ digital platform is being rolled out across major humanitarian operations. Full adoption across all GBV partners in all settings is a multi-year process and requires investment in device access, connectivity, and training.

Integration with COVID lessons: Remote service delivery models — telephone counselling, remote case management, digital safe spaces — developed during COVID-19 restrictions have been partially incorporated into UNFPA's GBV programme toolkit. The evidence on their effectiveness relative to in-person services is limited but growing.

SOURCES

1. WHO: Clinical Management of Rape and Intimate Partner Violence Survivors: Developing Protocols for Use in Humanitarian Settings, 2019 — The authoritative clinical guidance for CMR in humanitarian contexts. Covers the full CMR protocol, clinical management details, and guidance for adapting protocols to specific settings. Mandatory reading for all CMR providers. [who.int]

2. IAWG on RH in Crises: MISP Field Manual, 2018 — Contains the full MISP Objective 2 (prevent and respond to sexual violence) operational guidance, which is the framework for CMR in the MISP context. [iawg.net]

3. GBV AoR: Handbook for Coordination of GBV Interventions in Humanitarian Settings — The operational reference for GBV AoR coordination. Covers coordination structures, tools, referral pathway design, GBV AoR governance. Essential for coordination staff. [gbvaor.net]

4. IASC: Guidelines for Integrating Gender-Based Violence Interventions in Humanitarian Action, 2015 — The cross-sectoral integration framework; establishes the responsibility of all humanitarian actors (not just GBV specialists) to integrate GBV risk reduction into their programming. [interagencystandingcommittee.org]

5. GBVIMS Steering Committee: Guidance and Tools — Complete GBVIMS documentation including Incident Report Form, data analysis guidance, and data sharing protocol templates. [gbvims.com]

6. Stark L, Ager A, "A systematic review of the evidence for community-based approaches for strengthening sexual violence prevention in conflict-affected settings," Trauma Violence Abuse, 2011 — The foundational systematic review of GBV prevention evidence in humanitarian settings. Consistently cited conclusion: evidence base is weak. [journals.sagepub.com]

7. Peterman A et al., "Estimates and determinants of sexual violence against women in the Democratic Republic of Congo," American Journal of Public Health, 2011 — Widely cited cross-sectional study from DRC; documents high prevalence; also the subject of methodological critique (see Wood, 2012). Illustrates both the importance and the limitations of GBV prevalence research. [ajph.aphapublications.org]

8. Ellsberg M et al., "Prevention of violence against women and girls: what does the evidence say?" Lancet, 2015 — Comprehensive review of evidence on GBV prevention across development and some humanitarian settings. Summary: community-based norm change and economic empowerment have the strongest evidence; evidence base still limited. [thelancet.com]

9. Ertl V et al., "Community-implemented trauma therapy for former child soldiers in Northern Uganda," JAMA, 2011 — RCT evidence for trauma-focused intervention effectiveness in a humanitarian-affected population. Demonstrates that evidence-based psychological interventions can be implemented in conflict settings. [jamanetwork.com]

10. Ford N et al., "Post-exposure prophylaxis following sexual violence in resource-limited settings," Sexually Transmitted Infections, 2014 — Review of PEP effectiveness evidence in low-resource settings, including humanitarian contexts. Confirms effectiveness and time-sensitivity. [sti.bmj.com]

11. IRC: A Rigorous Multi-Site Evaluation of Cash and Voucher Assistance (South Sudan, 2019) — The most robust recent evidence for a GBV prevention intervention in a humanitarian setting. Unconditional cash transfers associated with significant GBV reduction. [rescue.org]

12. Palermo T et al., "Forgotten or forbidden: reporting on sexual and domestic violence in conflict-affected settings," Journal of Trauma & Dissociation, 2014 — Examines barriers to GBV reporting in humanitarian settings; documents the low reporting rates that underlie GBVIMS limitations. [tandfonline.com]

13. GBV AoR: Annual Global Report — Annual reporting on GBV AoR global operations, coverage data, and funding analysis. Source for the funding gap statistics cited in this document. [gbvaor.net]

14. UNFPA: Gender-Based Violence in Humanitarian Action — programme documentation and country reports — UNFPA's own operational documentation of GBV humanitarian programming. [unfpa.org]

15. UNHCR/UNFPA: Action Against Sexual and Gender-Based Violence: An Updated Strategy — The joint UNHCR-UNFPA strategic framework for GBV in refugee settings. Defines the coordination relationship between the two agencies and their respective operational roles. [unhcr.org]

RELATED DOCUMENTS

• UNFPA-W-04: MISP (the broader humanitarian reproductive health framework)
• UNFPA-O-08: Terminology (GBV AoR, GBVIMS definitions)
• UNFPA-W-06: FGM (a harmful practice addressed in development and some humanitarian settings)
• UNFPA-W-07: Child marriage (overlap with protection in humanitarian settings)
• UNFPA-C-04: Where UNFPA's results are disputed