Sexual violence against migrants and asylum seekers. The experience of the MSF clinic on Lesvos Island, Greece.

OBJECTIVES: Sexual violence can have a destructive impact on the lives of people. It is more common in unstable conditions such as during displacement or migration of people. On the Greek island of Lesvos, Médecins Sans Frontières provided medical care to survivors of sexual violence among the population of asylum seekers. This study describes the patterns of sexual violence reported by migrants and asylum seekers and the clinical care provided to them.
METHODS: This is a descriptive study, using routine program data. The study population consisted of migrants and asylum seekers treated for conditions related to sexual violence at the Médecins Sans Frontières clinic on Lesvos Island (September 2017-January 2018).
RESULTS: There were 215 survivors of sexual violence who presented for care, of whom 60 (28%) were male. The majority of incidents reported (94%) were cases of rape; 174 (81%) of survivors were from Africa and 185 (86%) of the incidents occurred over a month before presentation. Half the incidents (118) occurred in transit, mainly in Turkey, and 76 (35%) in the country of origin; 10 cases (5%) occurred on Lesvos. The perpetrator was known to the survivor in 23% of the cases. The need for mental health care exceeded the capacity of available mental care services.
CONCLUSION: Even though the majority of cases delayed seeking medical care after the incident, it is crucial that access to mental health services is guaranteed for those in need. Such access and security measures for people in transit need to be put in place along migration routes, including in countries nominally considered safe, and secure routes need to be developed.

Introduction

Sexual violence is widespread. It is reported to be particularly common in unstable environments such as where there are displaced populations and in conflict zones [1]. It is defined as ‘any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic a person’s sexuality, using coercion, threats of harm or physical force, by any person, regardless of relationship to the victim, in any setting, including but not limited to home and work’ [2]. Rape is an act of sexual violence and involves oral, anal or vaginal forced penetration by any part of the body or by any kind of object [2], and is undertaken against both sexes. Sexual violence can cause life-changing health and social problems for survivors [3].

There are many potential consequences of sexual violence, including sexually transmitted infections (STI), vaginal/rectal bleeding, other genital or body injuries, pain during sexual intercourse, unwanted pregnancy, psychosomatic issues, mental health problems, and even suicidal ideation, self-harm, and death [1, 4]. Longer term impacts may include behavioral problems, isolation, guilt, rejection by the family, or an inability to take care of the family, and may prevent a woman from marrying due to cultural taboos [5, 6]. People who have experienced sexual violence are also at higher risk of further attacks in the future [7]. Furthermore, it may also have a societal impact, and can considerably destabilize communities, in particular when used as a weapon of war [8].

Due to its stigmatizing nature, survivors of sexual violence do not always seek care, or may do so after a delay, limiting the medical care that can be provided (as treatments such as post-exposure prophylaxis for Human Immunodeficiency Virus (HIV) and other sexually transmitted diseases are contingent on early presentation). Sexual violence can affect both women and men [2], but men may find it more difficult to talk about it, as they are not expected to show weakness or lack of masculinity [9], or possibly because sexual violence services are linked to female health centers [10]. Consequently men may be more likely to delay or avoid seeking help for sexual violence.

A number of studies have focused on sexual violence in unstable contexts; of those, most were conducted in conflict or post-conflict zones [4, 11–13]. A more limited number of studies have focused on sexual violence among people in transit (this includes refugees, migrants, and asylum seekers); often in specific contexts, such as among migrants in transit in South and Central America [Violence Against Women. 2019 ">14-16] and among refugee populations during/following conflict [17, 18]. Out of all migration contexts, only a few studies have been published on sexual violence among displaced populations attempting to enter Europe. Keygnaert et al. [19] highlighted the risk of sexual violence that sub-Saharan migrants and asylum seekers faced when attempting to cross to Europe from Morocco. Freedman highlighted how current policies increased insecurity and vulnerability to sexual violence among women, and that insufficient medical and psychological support were being provided for female victims of violence in their countries of origin or in transit [20].

Sexual violence can and does occur anywhere along the route of displaced populations to safety. To be effective, medical care needs to be provided as soon as possible after the incident. Therefore a better understanding of the patterns of sexual violence and the needs of its survivors in the context of migration is required, in order to improve and upscale the provision of care to this extraordinarily vulnerable population [21]. Health projects in migration settings offer an opportunity to understand and to document the risks and needs of migrants and asylum seekers who have experienced sexual violence. Ideally such projects will improve the screening process for sexual violence among people in transit and among people who are involuntarily contained for indeterminate periods of time, and result in better packages of care for sexual violence survivors.

The Greek island of Lesvos is very close to the Turkish border. It was the first arrival point and a geographically restricted site for a large number of people in transit seeking safety on European soil. The medical humanitarian organization Médecins Sans Frontières (MSF) operated a clinic for survivors of sexual violence on the island. The aim of this study was to describe the patterns of sexual violence experienced by migrants and asylum seekers, as reported to the MSF Clinic on Lesvos, and the clinical and mental health care provided to them, between September 2017 and January 2018.

Materials and methods

Design

This was a descriptive study using routine program data.

General setting

Since early 2015, Greece has been at the forefront of the European refugee crisis. Greece is a country with many island communities: Lesvos is the third largest island of Greece, with an area of approximately 1,600 km2. It is located in the northeast of the Aegean and is only 10 km from the east coast of Turkey. It is therefore the most accessibly island within the European Union. Its population is almost 86,500 [22]. In March 2016 the Balkan route for migrants travelling to the EU was closed and the EU-Turkey deal was implemented a few days later. According to the new regulations [23], asylum seekers had to complete their asylum procedure at the first landing point, the Greek islands, with no option to move to the mainland (hence a geographical restriction) unless they were deemed vulnerable. As a result, the islands became congested, accommodating many more migrants and asylum seekers than originally planned [24].

According to the United Nations High Commissioner for Refugees (UNHCR) official website, the population of Moria camp (the largest and most congested camp on Lesvos) reached 5,000 at the beginning of September 2017, overwhelming its original planned capacity of 2,300 [25]. Moreover, with only occasional transfers of people to the mainland and a total of 8,474 people arriving on Lesvos between September 2017 and January 2018, a vast increase in the population accommodated in Moria camp was seen over this period. By February 2018, the camp still had approximately 5,000 residents [25]. All camps on Lesvos were administered by the Greek authorities and UNHCR was present for the protection matters.

Specific setting

MSF has provided health services on the island of Lesvos since July 2015. The Greek public health system was already overwhelmed by the economic crisis that started in 2009, with increased demand and decreased resources [26, 27]. Many of the people in transit on the islands had significant psychiatric needs, commonly due to trauma they faced in their country of origin or during the migration. Their needs exceeded the capacity of the trained staff in the local health care system, particularly the capacity to provide psychiatric care and trauma therapy. The lack of appropriately trained cultural mediators was also a problem.

As a response to these needs, MSF aimed to fill this gap by adapting its clinical services in the summer of 2017. A clinic was set up in Mytilene, the capital of Lesvos, for the provision of mental health care, medical care and social support for migrants and asylum seekers who had developed severe mental health disorders, including people who experienced torture (as defined in [28]) and sexual violence (as defined in [2]) at any point in their travels or prior to departure. A clinical database of sexual violence survivors was established when this clinic was set up.

In additional, an outpatient clinic was set up just outside Moria camp by the end of 2017. This was to provide paediatric, sexual and reproductive healthcare services. This including care for survivors of sexual violence presenting less than 120 hours after the assault (in contrast with the Mytilene clinic, where there was no such limitation on the timing of the incident). This time limit was established for the outpatient clinic because of the limited capacity of this clinic and taking into consideration the effectiveness of the medication offered in case of sexual violence. Data from all these sexual violence cases, of both locations, were entered in the same database.

Survivors of sexual violence with medical needs could either present themselves directly to one of the clinics requesting medical assistance, or could be referred to the sexual violence service by MSF staff from the other services (psychologist, doctor) or by another health Non-Governmental Organization (NGO). Mental health care was initially offered to migrants and asylum seekers who were either referred by MSF staff or who were self-referred. After September 2017, the mental health services also accepted referrals from other health NGOs, but no longer accepted self-referrals.

The medical and mental health care services were tailored to the needs of this group. Specifically, sexual violence survivors were offered a package of medical care based on the MSF protocol. This consisted of prevention of HIV (facilitating access to the hospital for Post Exposure Prophylaxis [PEP]), treatment of STI, emergency contraception, vaccination against Hepatitis B and Tetanus, and care of wounds or health complications after the sexual violence (Table 1). Mental health support as well as social support was available according to the patient’s needs. Provision of a medical certificate was also offered, covering the medical examination of the patient and the incident as reported by the patient. Follow up appointments were scheduled based on the initial assessment of needs, with an average of three visits.

Table 1

MSF protocol on health services offered at Lesvos MSF clinic to survivors of sexual violence, 2017–18.

Medical Management of Sexual Violence
Interval §	Services recommended*
≤72hours	Post exposure prophylaxis (PEP) for HIV**
	Emergency contraception***
	STI prophylaxis or treatment †
	Tetanus vaccine
	Hepatitis B vaccine
	Mental health care
>72–120 hours	Emergency contraception
	STI prophylaxis or treatment
	Tetanus vaccine
	Hepatitis B vaccine
	Mental health care
>120 hours—6 months	STI prophylaxis or treatment
	Tetanus vaccine
	Hepatitis B vaccine
	Mental health care

*All the services were provided after patient's consent and according to their health status and the type of sexual violence. Care of physical injuries and referral for termination of pregnancy (in case of a positive pregnancy test) was also offered. Additionally, medical certification was offered to all patients.

** In contrast with other contexts, in Greece MSF facilitates the access to PEP rather than administering it directly, due to the Greek legislation. PEP was generally offered only following penetration by the penis vaginally, anally or orally and only if presenting within 72 hours.

***Emergency contraception was offered in case of vaginal penetration, to every female ≥8 years old and/or after development of secondary characteristics of gender. Contraceptive methods offered were either pills or an Intrauterine Device.

§ Standardized time intervals as used in the MSF SV database

† Sexually Transmitted Infections

Study population and period

The study included all male and female migrants and asylum seekers who sought clinical care for sexual violence at the MSF clinics on Lesvos Island, Greece between 1st September 2017 and 31st January 2018. This included individuals seeking care in the outpatient clinic in Moria, or in the Mytiline mental health clinic.

Sources of data and variables

All the data were extracted from the standardized, pseudonymized MSF database for sexual violence (as described in [12]) and the waiting list of the mental health department of the MSF Lesvos Project. The outcome measurement was the number of survivors of sexual violence recorded. Other variables recorded were age, sex, nationality, location of incident (categorized as country of origin, in transit, on Lesvos), setting of incident (categorized as during migration activities [i.e. while on the move], during daily activities [i.e. any regular activity such as work or attending a market, not conducted at home], at home, in an institution [i.e. at school, church, prison], during an abduction situation, and others), time between incident and presenting for care (categorized as <72h, 72-120h, 5d-1m, 1m-1y, >1y), type of perpetrator, type of sexual violence (categorized as rape, forced prostitution, and sexual touching), and associated violence. No information was collected systematically on the time spent in transit; anecdotal reports suggest this ranged from several weeks to several years, with 6 months being the median duration of travel.

Analysis and statistics

The data analysis was performed using Epidata Analysis software version 2.2.2.186 (EpiData Association, Odense, Denmark). A descriptive analysis was done: means (standard deviations) were calculated for continuous data. Categorical data were summarised using frequencies and proportions. Groups were compared using the Chi-square test. P-values <0.05 were considered significant.

Ethics approval

As a posteriori analysis of routinely collected programme data, the national ethics bodies in Greece did not consider this study as falling under their jurisdiction for ethics review. As the study was considered low risk and of public health importance, it was conducted under the exceptional approval of the medical director of Médecins Sans Frontières-Operational Centre Brussels.

Results

Between September 2017 and January 2018, the MSF clinic on Lesvos recorded 215 patients presenting for care following sexual violence. The socio-demographic characteristics of these survivors and the location of the incident are shown in Table 2. Among these cases, 155 (72%) were female and 60 (28%) were male. The vast majority of the patients [208 (96%)] were living in Moria camp. The majority of the incidents of sexual violence [118 (55%)] occurred during migration, almost all of which took place in Turkey, and 76 (35%) occurred in the country of origin. Ten incidents (5%) in Lesvos were also documented. Only 6 (3%) of the cases presented in the appropriate timeframe to receive optimal care (<72 hours).

Table 2

Characteristics of 215 survivors of sexual violence, visiting the MSF clinic, Lesvos, Greece (September 2017-January 2018).

Characteristics	N	(%)
Total	215	(100)
Age group (years)
≤10	<5	(<5)
11–20	42	(20)
21–30	88	(41)
31–40	71	(33)
>40	11	(5)
Mean (SD)	28.2	(8.2)
Sex
Female	155	(72)
Male	60	(28)
Current migrant camp
Moria’s camp	208	(96)
Karatepe’s camp	6	(3)
Other	<5	(5)
Nationality groups
Central and East Africa1	95	(44)
West Africa2	78	(36)
North Africa3	<5	(<2)
Middle East4	25	(12)
Other	12	(6)
Not Recorded	4	(2)
Location of incident
Country of origin	76	(35)
In transit
Turkey	106	(49)
Other transit country	12	(6)
Lesvos	10	(5)
Other/unknown	11	(5)
Interval between incident and presenting for care
<72 h	6	(3)
72–120 h	0	(0)
5 days-1 month	22	(10)
1 month-1 year	174	(81)
>1 year	11	(5)
Not recorded	2	(1)

1Central and East: Congo, Democratic Republic of the Congo (DRC), Central African Republic (CAR), Ethiopia, Eritrea

2West: Cameroon, Nigeria, Mali, Burkina Faso, Gambia, Guinea (Conakry), Guinea Bissau

3North Africa: Morocco

4Middle East: Afghanistan, Iran, Iraq, Syria, Palestinian living in Syria

Characteristics of the cases seen by MSF, stratified by location of the event, are shown in Table 3. Delays in presentation were directly related to the attack occurring prior to arrival in Greece. A higher proportion of reported attacks on male survivors took place during migration period [40 (34%)], rather than in the country of origin [12(16%)]. The incident characteristics, stratified by location of the event, are presented in Table 4. Incidents tended to be more violent in the country of origin than in transit, with higher proportions of armed perpetrators (country of origin 45% vs transit 14%, p<0.01) and with more associated violence (country of origin 71% vs. transit 43%, p<0.01). Perpetrators of incidents during migration were more likely to be civilians who were unknown to the survivors.

Table 3

Characteristics of 215 survivors of sexual violence presenting at the MSF clinic, stratified by location of the sexual violence incident, Lesvos, Greece (September 2017-January 2018).

Characteristics	Location of incident
	In Country of origin		During Transit5		On Lesvos
	n	(%)	n	(%)	n	(%)
Total	76		118		10
Age group (years)
≤10	1	(1)	1	(1)	0	(0)
11–20	14	(18)	21	(18)	4	(40)
21–30	33	(43)	51	(43)	2	(20)
31–40	22	(29)	41	(35)	3	(30)
>40	6	(8)	4	(3)	1	(10)
Sex
Female	64	(84)	78	(56)	7	(70)
Male	12	(16)	40	(34)	3	(30)
Nationality groups
Central and East Africa1	38	(50)	47	(40)	6	(60)
West Africa2	22	(29)	49	(42)	1	(10)
North Africa3	0	(0)	1	(1)	0	(0)
Middle East4	11	(14)	12	(10)	2	(20)
Other	5	(7)	5	(4)	1	(10)
Not Recorded	0	(0)	4	(3)	0	(0)
Interval between incident and requesting care
<72 h	0	(0)	1	(1)	5	(50)
3 days-1 month	1	(1)	20	(17)	1	(10)
1 month-1 year	69	(91)	94	(80)	2	(20)
>1 year	6	(8)	3	(3)	1	(10)
Not recorded	0	(0)	0	(0)	1	(10)

1) Central and East Africa: Congo (Kinshasa) Congo (Brazzaville) Central African Republic, Ethiopia, Eritrea.

2) West Africa: Nigeria, Mali, Burkina Faso, Gambia, Guinea (Conakry) Guinea (Bissau) Cameroon.

3) North Africa: Morocco.

4) Middle East: Iran, Iraq, Syria, and Afghanistan.

5) Transit: any country where the victim resided at any point in time between leaving the country of origin and arriving in Lesvos.

Table 4

Characteristics of 215 sexual violence incidents, stratified by location of the sexual violence incident, among survivors of sexual violence visiting the MSF clinic, Lesvos, Greece (September 2017-January 2018).

	Location of incident
Characteristics	In country of origin		During Transit1		On Lesvos
	N	(%)	N	(%)	N	(%)
Total	76	(100)	118	(100)	10	(100)
Type of perpetrator
Unknown civilian	11	(14)	49	(42)	7	(70)
Known civilian	7	(9)	26	(22)	2	(20)
Military	17	(22)	1	(1)	0	(0)
Smuggling groups	3	(4)	13	(11)	0	(0)
Family member	11	(14)	3	(3)	0	(0)
Institutional agent	9	(12)	4	(3)	0	(0)
Policeman	6	(8)	1	(1)	0	(0)
Organized gangs	1	(1)	0	(0)	0	(0)
Other	2	(3)	4	(3)	0	(0)
Not Recorded	9	(12)	17	(14)	1	(10)
Armed Perpetrator
No	17	(22)	67	(57)	7	(70)
Yes	34	(45)	16	(14)	0	(0)
Not recorded	25	(33)	35	(30)	3	(30)
Type of event
Rape	74	(97)	107	(91)	10	(100)
Sexual Slavery and forced prostitution	1	(1)	8	(7)	0	(0)
Sexual touching	1	(1)	0	(0)	0	(0)
Not Recorded	0	(0)	3	(3)	0	(0)
Setting of incident
During migration	4	(5)	68	(58)	7	(70)
Daily activity	10	(13)	20	(17)	1	(10)
Home	27	(36)	3	(3)	0	(0)
Institution	14	(18)	7	(6)	1	(10)
Abduction situation	5	(7)	0	(0)	0	(0)
Other	1	(1)	1	(1)	0	(0)
Not Recorded	15	(20)	19	(16)	0	(0)
Associated violence:
None	22	(30)	67	(57)	7	70
Beaten	25	(33)	28	(24)	3	(30)
Tortured	9	(12)	4	(3)	0	(0)
Witness of violence	13	(17)	1	(1)	0	(0)
Detained/ incarcerated	4	(5)	4	(3)	0	(0)
Robbed of property	1	(1)	1	(1)	0	(0)
Forced labor	1	(1)	5	(4)	0	(0)

1) Transit: any country where the victim resided at any point in time between leaving the country of origin and arriving in Lesvos.

Health services provided by the MSF clinic to patients are shown in Table 5. Termination of pregnancy was requested by 3 out of the 10 pregnant women who attended the clinic. It could not be ascertained whether pregnancies were the result of the rape.

Table 5

Health services provided to 215 survivors of sexual violence at the MSF clinic in Lesvos, Greece (September 2017—January 2018).

Health services	Females		Males
	Provided		Provided
	n	(%)	n	(%)
Total	155		60
Eligible for PEPa	5	(3)	1	(2)
Access to PEP (among eligible)	5	(100)	1	(100)
Eligible for Emergency Contraception	5	(3)	NAb
Provision of Emergency Contraception (among eligible)	3	(60)	NA
Sexually transmitted infections: prophylaxis/treatment	92	(59)	29	(48)
Tetanus vaccination	66	(43)	26	(43)
Hepatitis B vaccination	64	(41)	26	(43)
Physical examination c	134	(86)	39	(65)
Genital examination	101	(65)	22	(37)
Anal examination	33	(21)	22	(37)

a PEP: post-exposure prophylaxis for HIV

b NA: not applicable

c Investigation for wounds

The total number of new referrals to mental health services at the MSF clinic (n = 825 in the whole period) and the number of clients on the waiting list by month are shown in Fig 1, where new referrals increased from less than 100 to more than 300 during November 2017, and then decreased to less than 100 again for the following month. The number of persons on the waiting list for mental health care increased from less than 100 to 553. The numbers increased substantially in November 2017, coinciding with referrals being accepted from other health NGOs, rather than only through MSF services and self-referrals. Due to the overloading, only very severe cases could be taken over by mental health department.

Fig 1

New referrals to MSF mental health care and total number of patients on the mental health waiting list, Lesvos, 2017.

Discussion

This study on survivors of sexual violence among migrants and asylum seekers receiving care in the MSF clinic on Lesvos Island showed that almost all survivors had experienced the violence before reaching Lesvos. About a third of the incidents occurred in the country of origin and almost half during transit in Turkey. However, a number of incidents also occurred on Lesvos itself, reflecting a gap of the protection services on the island. Out of all types of sexual violence, rape accounted for more than 90% of the incidents reported.

A surprisingly high proportion of survivors (28%) were male, comparable with another survey by MSF which showed that 17% of all male refugees underwent sexual attacks in their efforts to leave from Central America [29]. Other facility-based studies in non-migration contexts present lower proportions of male survivors, including in an urban slum in Kenya (8%) and in post-conflict settings such as Liberia (2%) and eastern DRC (3%) [11-13]. However, our findings echo other studies in conflict areas of DRC, showing that 24% of adult males had experienced sexual violence at some point of their life [30], and in Lebanon with 20% of survivors being men and boys [31]. We do not know the reasons for the high rate of male survivors in our study. The fact that the clinic mainly offered mental health care services may have lowered the barrier for men to seek care, as sexual violence does not need to be disclosed at entry with such a setup. Also, the trust developed from patients towards the psychologist during mental health treatment might have led to disclosing and referral for medical care. Sexual violence to men may also be more prevalent in populations of migrants and asylum seekers, as it is a common component of torture. This is often directed at men and may be more frequent in such populations [32]. It may be used to humiliate and intimidate by officials and gang leaders who act as facilitators for the migration process (termed “migration professionals” in [19]). Our observation that sexual violence against males was more common during the migration phase supports this speculation.

While the majority of the asylum seeker population in Lesvos came from the Middle East, the most common countries of origin among sexual violence survivors were DRC and Cameroon, both for incidents perpetrated in the country of origin and for incidents occurring during transit. From our data, it is not possible to discern whether this reflects differences in prevalence of sexual violence according to the survivor’s nationality, or differences in health-seeking behavior (possibly also linked to differing lengths of stay on Lesvos, depending on country of origin). Strikingly, our study showed that countries such as Turkey usually considered safe for migrants and asylum seekers, present a high risk of sexual violence; half of the reported sexual violence occurred there.

The perpetrator was known to the survivor (including family members) in 23%. This is a lower proportion than in more stable settings: in large urban and/or post-conflict settings, individuals known to the survivor represent 40–80% of the perpetrators [11–13, 33]. In conflict areas, perpetrators known to survivors tend to represent a much smaller proportion [12], and the same seems to hold true for migration contexts. This could be related either to underreporting of incidents when the perpetrators were known, or to the high exposure to unsafe situations during the migration period.

Many migrants and asylum seekers, including survivors of sexual violence, requested mental health support. The need for psychological care could not be met, reflected in the long waiting list after November 2017. Anecdotally, a volunteer doctor working in the camp reported finding the mental health services so overwhelmed there was no point in referring people who would normally benefit from mental health services.

We found that 94% of the survivors of sexual violence had been raped. This is much higher than what has been reported in other settings. In South America 60% of sexual violence incidents concerned rape [34], whereas in the United States of America 21% of sexual violence survivors had been raped [35]. A suspicion of sexual slavery or trafficking was sometimes present during consultations in the clinic but there was no hard evidence, as the information revealed by the patients was not always complete or they had not understood what exactly had happened. As expected, sexual slavery/exploitation occurred more commonly during the highly vulnerable migration period. Other forms of sexual violence, such as intimate partner violence, may have remained underreported due to issues related to stigma, shame, and lack of protection services.

The medical care that could be offered to sexual violence survivors was usually relatively limited, as most sought care months after the event, limiting the treatment options available. The psychological impact of sexual violence and working in a cross-cultural manner was often complex. The lack of access to mental health care contributed to delays in the psychological assessment and adequate support of the patient. As psychological support is the mainstay of care for survivors presenting late, this placed a constraint on the quality of care provided. It was challenging for MSF to meet this huge need for mental health support.

Sexual violence services, including mental health support, should be an intrinsic component of care in all migration contexts, ideally offered along the route as well as in reception hotspots. Additionally, adequate security services need to be present to ensure that no new incidents of sexual violence can occur during the reception period, and to provide a sense of safety that will prevent deterioration of mental health conditions resulting from the history of sexual violence.

There is good evidence that countries considered safe such as Turkey (and Morocco, as in [19]) did not adequately protect people who were migrating through the country. This apparent lack of care is reinforced by the fact that Turkey, for example, offers only temporary protection to Syrian refugees, including permission to stay, basic rights and services [36].

It is recommended that health services should be available for survivors of sexual violence and to ensure people without documentation can still access protection services in these transit countries, as well as in EU Member States. The pursuit of externalization of migration policies is likely contributing to lack of safety of, and accountability to, displaced populations experiencing sexual violence.

We have shown that sexual violence care can be provided to this population, even providing access for male survivors, which is rarely achieved to this extent. The MSF model can thus be considered appropriate for identification and provision of care for both male and female survivors of violence in an asylum seeker/migrant population, though issues of scalability need to be examined, as shown by the long waiting times. Since MSF is an NGO, other actors, including governmental authorities, should take up similar programs in similar settings, particularly hotspots for new arrivals, to ensure prompt and comprehensive care for sexual violence survivors. The capacity of mental health care services must be properly planned to adequately meet the needs of this group.

This study had a number of limitations. There was a relatively small number of sexual violence survivors who attended the clinic, which limits the amount of data available for analysis of risk factors. Correct categorization of the cases was often difficult due to limitations imposed by the database and, in some cases, because of lack of full information disclosed by the patient. This was compounded by having to work cross-culturally and in different languages, which may have caused misunderstandings. All these may have resulted in missing or incorrect information. Additionally, it should be emphasized that this was a facility-based study, taking into consideration only those survivors who presented for care: there may thus be a selection bias against individuals who did not seek care in the first place, and/or an underrepresentation of sexual violence in general due to a reluctance to seek care.

Conclusions

Sexual violence had been experienced by an appreciable number of migrants and asylum seekers arriving in Lesvos. The medical services that MSF provided were able to cope with the numbers, but the inadequate capacity of the mental health services made it difficult to refer and support all survivors of sexual violence who would have benefitted from such services.

When planning services to provide clinical care for survivors of sexual violence amongst migrants and asylum seekers, it is crucial that more attention is given to the mental health needs of this vulnerable group. Furthermore, provision of adequate clinical care and security measures for people in transit need to be put in place on routes that migrants use, including in countries, normally considered as safe for migrants.

19 Sep 2019

PONE-D-19-20179

Sexual violence against migrants and asylum seekers. The experience of the MSF clinic on Lesvos Island, Greece.

PLOS ONE

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Reviewer #1: Partly

Reviewer #2: Partly

**********

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Reviewer #1: No

Reviewer #2: I Don't Know

**********

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Reviewer #2: No

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Reviewer #1: Very interesting topic, there is little known about forced migration to Greece, a country affected by a very interesting economic crisis. The authors have conveyed the magnitude of sexual violence and the devastating effect it has on displaced people. A valuable contribution of this manuscript is the information on male and female survivors of sexual abuse.

I have included my comments in an attached document

Reviewer #2: Thank you so much for this piece, which I was extremely excited to read. I found it very interesting, as it contains valuable data re: profiles of SV survivors and their perpetrators. I would be eager to have these insights from MSF’s records in the public domain and I think the article could be an important contribution to our understanding of sexual violence in migration, despite the small sample size.

I have a few specific notes and questions, then some global comments.

Specific notes and questions:

- It would be additionally valuable to identify any trends possible re: kinds of violence / perpetrators associated with different patient profiles – eg, what can we learn about who is at risk of what, where, from whom? As it is, the tables and discussion are largely static, with little analysis across data points. Data analysis would be strengthened by cross-sectional observations – eg, while noting that 23% of cases involved perpetrators known to victim, this could perhaps be disaggregated by national origin or kind of violence to better identify important situational trends and better understand disinclination to report to authorities, for example.

- Terminology: How were terms defined and phrased during survey? What is “compelled rape” as compared to "rape"? What is “daily activity”? Was torture clearly defined and understood? (Eg, “beaten” v “tortured” and also rape as a form of torture?). My suspicion is that the intake or screening instrument was a relatively blunt, which is not uncommon. However, this limitation or any reflections would be valuable to discuss, as conflation or confusion around terms of sexual violence seems to be a common challenge for all of us. Also, it is unclear whether forms of SV considered included intimate partner violence or sexual exploitation (latter of which was mentioned in conclusion and listed as an “associated violence” though unclear how defined or understood by MSF patients.) IPV can involve sexual violence and of course can have serious physical and psychological sequelae as well. Moreover, data indicate that rates of IPV remain high in conflict periods as well as in the context of forced displacement – is this major form of harm accounted for here? And if not, why not?

- I worry that lines 264-266 contain information that is not technically accurate. While it is true that medical evidence of vulnerability is helpful to an asylum-seeker ultimately, my understanding is that the vulnerability screening for migrants arriving in Greece is actually a pre-admissibility / procedural step that simply determines whether someone is exempt from the EU-Turkey deal, such that they would be permitted to apply for asylum in Greece. It is not technically part of the asylum application itself. This also matters because medical certification of vulnerability including sexual violence may be useful for protection purposes (eg, finding that one is exempted from Turkey bounce-back and can instead apply for asylum in Greece) without being legal relevant for a Convention-based claim for refugee protection (if the harm suffered or feared does not involve one’s country of origin, as seems to be the case with many migrants exploited and abused in transit.) I advise rewording after consultation with expert on Greek asylum process.

- I am also not sure about lines 267-272. There are some conclusory theories / statements re: why # of SV reports from Congolese v. Cameroonian migrants may differ – some statements re: exposure to conflict increasing risk of SV but also theories about how relatively long stays in camp may contribute to willingness to disclose SV. Is there data to support this theory? It may well be true but it seems there are insufficient data to infer these relationships. One could also theorize that different =people have different tendencies towards disclosure, either at group or individual level, not related to time spent in a camp.

- It may also be worth mentioning that medical certifications / records might be useful in proving torture cases or trafficking cases, not just asylum. (Though these forms of harm can also be the basis of an asylum claim.)

- Do the authors have any thoughts re: relative numbers (215 cases reported between Sept 2017 – Jan 2018)? Are these among new arrivals or general camp population? And if general population, why think so low compared to 5000 residents? It might help to explain how many of the total Moria resident population (for example) the MSF team actually reached, which might account for the winnowing down to 215 SV survivors. At any rate, this all raises the crucial issue of disclosure of sexual violence and how barriers may differ among groups and individuals – the discussion section touches on underreporting and disclosure but does not fully develop theories on it that are grounded in the data. This may be difficult with the limited data available but if there is any qualitative material in MSF records that could shed light on decisionmaking re disclosure, that would be fascinating indeed.

Global comments:

I think the data presented are incredibly valuable and these findings should be shared. However, as noted above, it would help to have clarification of MSF’s work on Lesvos and how the intake questionnaire was administered and translated, so we can better gauge how well the terms were understood by the migrants themselves.

Policy and practice recommendations seem extremely important, particularly re: a) provision of mental health support services, b) inclusion of male survivors in screening & support efforts, and c) false reliance on “safe countries” like Turkey and Morocco. To strengthen these points, more background info / explanation would be helpful.

- Eg, re: the mental health impacts of sexual and gender-based violence, as well as whether any mental health assessment was done with this population as part of MSF activities. The recommendation is sound but comes from out of nowhere.

- Eg, whether one sees higher rates reported among specific sub populations of patients (as in Afghan teens on the move, who received a degree of attention several years ago), which might indicate which men and boys are most vulnerable in what situations.

- Eg, more context re: EU-Turkey deal and its bottlenecking impact on Greece, including the assumption that Turkey is a safe country for return and adjudication. It could help, for example, to explain the major migration routes – as well as the short distance between Lesvos and Turkey, which would explain how the vast majority of migrants on Lesvos came through Turkey. Cites to reported human rights abuses against migrants in Turkey would help make the point re: false reliance on safe third country policy.

I would definitely welcome the eventual publication of these data and insights, as I think the data is so important and MSF’s crucial work on Lesvos warrants significant attention. However, to strengthen the piece, I do suggest a strengthening of the discussion section and close proofread and technical / stylistic edit by a native English speaker.

**********

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Reviewer #2: Yes: Kim Thuy Seelinger

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Submitted filename: PONE-D-19-20179_Review_22aug19.docx

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20 Feb 2020

To the editor, PLOS ONE

Dear editor,

Thank you for your message including the reviews of our paper. We have amended the paper following the comments, and we think the paper is better now. In our responses below we refer to line numbers in the new revised version with track changes. Reviewers’ comments are shown, and our response is given point by point in BOLD.

Response to Reviewers

2. You indicated that ethical approval was not necessary for your study. We understand that the framework for ethical oversight requirements for studies of this type may differ depending on the setting and we would appreciate some further clarification regarding your research. Could you please provide further details on why your study is exempt from the need for approval and confirmation from your institutional review board or research ethics committee (e.g., in the form of a letter or email correspondence) that ethics review was not necessary for this study? Please include a copy of the correspondence as an "Other" file.

Thank you for this clarification question – the ethics situation around this study is indeed complex. We have submitted the study protocol to a number of national ethics bodies (including the Committee of Bioethics of the Medical School of the National and Kapodistrian University of Athens; the ethics committee of the University of Aegean; the ethics committee of the National School of Public Health; and the National Bioethics Committee). All the ethics committees we approached stated that the protocol fell outside of their jurisdiction: we include one such correspondence as “Other” file in the submission; we can provide an English translation if required. This reflects the general administrative gap that exists in Greece for ethics reviews for researchers who are not formally connected to an academic institution and who are not conducting clinical trials, as retrospective reviews of programme data are not covered in the national guidelines for ethics review.

MSF has its own process for ethics review for studies that are based on routine programme data, which is granted if a set of pre-defined criteria are satisfied (in terms of data protection, general public health benefit, etc.). However, one of these criteria requires the “approval by the relevant national ethics bodies”. This could not be obtained in Greece for the reasons mentioned above. We have therefore obtained the specific, exceptional approval to conduct this study from the medical director of MSF-Operational Centre Brussels, considering the study’s low risk as it used routinely collected, anonymised programme data, retrospectively, and its public health importance. We have rephrased the ethics section accordingly.

Comments to the Author

Reviewer #1:

General comments:

-Very interesting topic, there is little known about forced migration to Greece, a country affected by a very interesting economic crisis. The authors have conveyed the magnitude of sexual violence and the devastating effect it has on displaced people. A valuable contribution of this manuscript is the information on male and female survivors of sexual abuse.

We thank the reviewer for these supportive comments.

An important concept that needs to be clarified are the categories of the location of the sexual assault. The three categories are country of origin, in transit or in Lesvos. It is unclear how long someone may be ‘in transit’ for.

Thank you for raising this point. The time “in transit” can vary from weeks/months up to several years – this information is not collected routinely (to avoid patients feeling interrogated about their migration history). Anecdotal evidence suggests the median duration in transit was 6 months, and we have added this as estimate in the manuscript (Sources of data paragraph, as we do not wish to imply this was a study finding).

Timing is an important part of this analysis that needs clarification. There is a variable called ‘interval incidence-care’ that ranges from less than 72h to over a year. It seems that the clinic only sees acute cases (less than 72h), however 91% of cases presented within 1 month to 1 year since the incident.

We have provided more detail of the time between the incident and presenting for care in table 2 and 3. Additionally, we have clarified in the setting section that there was indeed a time restriction of <120 hours in the outpatient clinic located directly outside the Moria camp, but that there were no time restrictions for patients accessing the more mental health-focused Mytiline clinic.

This technical level of information needs to be considered in the methods section and in the analytic plan. Of importance, each variable should be carefully defined in the methods section. For example, there is discussion of PEP eligibility but not what the eligibility criteria is.

Thank you, we have attempted to provide all relevant definitions in table 1.

The final section on mental health services is interesting, however the manuscript is already filled with 5 tables on health services and detailed information on sexual violence. I would recommend removing the section on mental health or more clearly including it in the objective statement and analysis plan. It seems to me that the questions about volume of new referrals to the MSF clinic is different from the main line of inquiry related to sexual violence.

As bridging the mental health care gap in contexts such as Lesvos is a major public health issue, we have opted to keep the MH service analysis in the manuscript, and have thus modified the objectives to include mental health care, see line 162 and 187-196 of the tracked version of the manuscript.

Currently, the manuscripts reads more like an organizational report and less like an academic article. Below is a list of recommendations intended to improve the scientific contribution of the manuscript and its readability to a wider audience.

General comments:

-Kindly use the term ‘survivor’ in place of ‘victim’

-The manuscript should be reviewed for typo’s

-Rephrase sentences to start with words and not numbers

Tables

-suppress cell sizes under 5 to protect confidentiality

-review for consistency in font size, decimals

-Review table titles for consistency

-Include the total n for each column in Tables 3 and 4

Thank you. We have made these alterations, with the exception of some of the smaller cell sizes, which were considered not to hold any risk for participant confidentiality.

Abstract

-Please present the frequency (n) and percentages for each variable

-The conclusion focuses on accessing services and mental health care, however there are not estimates on mental health presented in the results

-In place of words in quotations (e.g. “safe”), state the issue more objectively

We have modified the abstract according to these suggestions, and have expanded on the mental health aspect in the Results section.

Introduction

-I would generally review the manuscript to ensure that the title, abstract and manuscript are all conveying the same message.

Thank you – we have gone through the full manuscript and have revised accordingly.

-The first three paragraphs of the introduction focus broadly on sexual violence and it’s consequences. While interesting, the most important contribution of this article is the problem of sexual violence in humanitarian settings, in which there is an extensive amount of literature that should be added to the introduction. The specific situation of Greece and migration through the Mediterranean Sea, Balkans or the surrounding geographic area is a critical area to include. The issues surrounding migration by water or to islands would add value to the introduction section and the literature in general.

We have revised the introduction in accordance with the reviewer’s suggestions.

-In the fourth paragraph, the distinction between people in ‘transit or containment’ compared to those in conflict or post-conflict is unclear. The term containment is often used in infectious disease and outbreaks scenarios. Please clarify the term as it is used in this article or consider replacing it.

Thank you. We have replaced the term containment.

-Please review the objective statement so that it clearly prepares the reader for the methods and results section. A lot of the methods and part of the results feature issues of mental health, however this is not covered in the introduction or the objectives. This should be reconciled.

Thank you. In the objectives we added “mental health”, and we give numbers of those seeking mental health care in results, see line 254-261 of the tracked version of the manuscript.

Methods

-There are six paragraphs dedicated to describing the setting. Please pick out the key points that summarize the setting and how it specifically relates to the research objectives and study design. I recommend moving some of the ‘General setting’ section to the introduction and include academic references

Thank you. We understand the point raised by the reviewer but we feel the introduction is already long and sets the general scene of sexual violence among populations in transit; we are concerned that moving parts of the setting to the introduction could confuse the reader, and could feed into the notion that this study is rather an organizational report, as highlighted by the reviewer above. We would prefer to leave the setting description as is, but if you feel strongly it should be moved we will do so.

-In the Study population and period section, please describe the inclusion criteria and exclusion criteria. Is the sample restricted to people in the Moria camp who accessed the clinic and self-disclosed as survivors of sexual violence? Is the Moria camp an UNHCR camp? These details will clarify the external generalizability of the results.

The study population consists of all individuals seeking care for sexual violence with MSF – this includes people who sought care at the outpatient clinic (for incidents within the past 120 hours) and people who sought care in the Mytiline clinic. We have tried to clarify this further in the manuscript. Moria is a camp managed by the Greek authorities, but with a UNHCR presence.

-All variables presented in the tables should be previously defined in the methods

Thank you. We have defined all the variables in lines 185-194 in the tracked version of the manuscript.

-Some of the statistics described in the methods section are not presented in the results section or tables. For example, the statistical analysis section describes using chi-square tests, however p-values, significance levels or chi-square estimates are not presented in the tables or text. There is mention of ‘groups’ but the group comparisons are not defined. Perhaps in transit vs Lesvos camp? Please clarify. If this is one of the main objectives of the analysis, it should be clearly stated in the objective statement and the analysis plan should be able to address the objectives

Thank you for highlighting this inconsistency – we performed statistical tests to compare incident typologies between transit and country of origin, which is now clearly stated in the results section.

-There are many cells with small cell sizes where chi-square tests are not the most appropriate statistical test. Small cell sizes below 5 should be suppressed to protect confidentiality.

Thank you. We have made these alterations, with the exception of some of the smaller cell sizes, which were considered not to hold any risk for participant confidentiality.

Results

-Please include n(%) in the results section

The results have been updated accordingly.

-Use numeric estimates in place of descriptors such as ‘a higher proportion’ or ‘increased substantially’. This is particularly important if significance testing was not performed. Keep the results section to describe the statistics and put the interpretations into the discussion section

We have attempted to reduce the use of qualifiers in the results section, and have added the proportions to the text.

In the ‘Specific setting’ section it says that the Moria camp provides services for those who presented for care less than 120 hours following the assault. However, in the results it says that 81% experienced sexual violence between 1-12 months before getting care. Please review.

Thank you for highlighting this point of confusion – we have added clarification in the setting and study population paragraphs, to clarify that patients could present through two routes: the Moria outpatient clinic (seeing only urgent cases <120 hours) and the Mytiline mental health clinic where older cases of sexual violence were also seen.

Table 4 as described in the text says ‘Incidents tended to be more violent in the country of origin, with higher proportions of armed perpetrators and with more associated violence’ - This has not be statistically evaluated

For this number we have added the p-value, line 228-231 in the tracked manuscript.

Figure 1 is unclear

⁃ ‘List Closed’ is an unclear category

Thank you. We have amended Figure 1, and “list closed” has been replaced with “Intakes to waiting list suspended”.

Discussion

-Please clarify the issue with unofficial ‘migration professionals’ in paragraph three of the discussion

This term is used to refer to individuals who act as facilitators for migration in an official or unofficial capacity – now clarified in the text.

-Justify conclusions based on the shown results, avoid anecdotal information

We have tried to provide more clear justifications of the conclusions in the discussion section.

-In the discussion of known perpetrators, please related the finding to comparable populations. The study of police reported sexual assault cases in the UK is not an appropriate reference.

We agree that the setting is not similar, and we have provided a number of references from MSF settings instead.

Limitations section

-Include description of the measurement bias, selection bias

We have added these in lines 356-359 in the tracked manuscript.

References

-Review for typos and inconsistent formatting

Thank you, corrections have been made.

Reviewer #2:

Specific notes and questions:

- It would be additionally valuable to identify any trends possible re: kinds of violence / perpetrators associated with different patient profiles – eg, what can we learn about who is at risk of what, where, from whom? As it is, the tables and discussion are largely static, with little analysis across data points. Data analysis would be strengthened by cross-sectional observations – eg, while noting that 23% of cases involved perpetrators known to victim, this could perhaps be disaggregated by national origin or kind of violence to better identify important situational trends and better understand disinclination to report to authorities, for example.

We agree that analysis of disaggregated data would be interesting with bigger datasets for identifying risk factors, but our dataset is insufficient for this. We would like to focus on the story as descriptive. Further disaggregation would, also, hold a risk for identification of individuals, and patient safety is our first concern.

- Terminology: How were terms defined and phrased during survey? What is “compelled rape” as compared to "rape"? What is “daily activity”? Was torture clearly defined and understood? (Eg, “beaten” v “tortured” and also rape as a form of torture?). My suspicion is that the intake or screening instrument was a relatively blunt, which is not uncommon. However, this limitation or any reflections would be valuable to discuss, as conflation or confusion around terms of sexual violence seems to be a common challenge for all of us. Also, it is unclear whether forms of SV considered included intimate partner violence or sexual exploitation (latter of which was mentioned in conclusion and listed as an “associated violence” though unclear how defined or understood by MSF patients.) IPV can involve sexual violence and of course can have serious physical and psychological sequelae as well. Moreover, data indicate that rates of IPV remain high in conflict periods as well as in the context of forced displacement – is this major form of harm accounted for here? And if not, why not?

The reviewer is correct to point out that the intake instrument was relatively blunt, and principally recorded what was reported by the survivor. However, a level of standardisation was maintained: the clinic accepts all cases of sexual violence according to the WHO definition (provided in the introduction), which can indeed include IPV and/or sexual exploitation. However, we believe this to be a minority among our patients, likely due to reporting bias (as stated more explicitly now in the limitations section): we anticipate that in an environment of high population density and exceedingly limited protection services, IPV will be considerably underreported (which is also seen in other MSF contexts). It is likely that a number of cases of rape by a “family member” are in fact cases of IPV. As these considerations are largely anecdotical, we opt not to develop them in detail in the manuscript. Concerning torture, MSF uses the ICRC definition, and due to the specialisation of the Mytiline clinic in providing care for victims of torture and ill-treatment, we believe this term to have been used appropriately by all staff. We have now also included the reference to the ICRC definition of torture in the manuscript, and in general have attempted to provide more clear definitions for all terms used.

- I worry that lines 264-266 contain information that is not technically accurate. While it is true that medical evidence of vulnerability is helpful to an asylum-seeker ultimately, my understanding is that the vulnerability screening for migrants arriving in Greece is actually a pre-admissibility / procedural step that simply determines whether someone is exempt from the EU-Turkey deal, such that they would be permitted to apply for asylum in Greece. It is not technically part of the asylum application itself. This also matters because medical certification of vulnerability including sexual violence may be useful for protection purposes (eg, finding that one is exempted from Turkey bounce-back and can instead apply for asylum in Greece) without being legal relevant for a Convention-based claim for refugee protection (if the harm suffered or feared does not involve one’s country of origin, as seems to be the case with many migrants exploited and abused in transit.) I advise rewording after consultation with expert on Greek asylum process.

Thank you. We agree, and have opted to remove the paragraph.

- I am also not sure about lines 267-272. There are some conclusory theories / statements re: why # of SV reports from Congolese v. Cameroonian migrants may differ – some statements re: exposure to conflict increasing risk of SV but also theories about how relatively long stays in camp may contribute to willingness to disclose SV. Is there data to support this theory? It may well be true but it seems there are insufficient data to infer these relationships. One could also theorize that different =people have different tendencies towards disclosure, either at group or individual level, not related to time spent in a camp.

We agree that there may be difference in willingness to disclose and report according to the culture of the survivor, and we acknowledge that we do not have data on this. We have adapted the statements in discussion and limitations of the research.

- It may also be worth mentioning that medical certifications / records might be useful in proving torture cases or trafficking cases, not just asylum. (Though these forms of harm can also be the basis of an asylum claim.)

Thank you for your comment. While we agree that this is an additional possible impact of certification, following the removal of the paragraph on medical evidence and vulnerability, we feel it may be confusing to introduce this information.

- Do the authors have any thoughts re: relative numbers (215 cases reported between Sept 2017 – Jan 2018)? Are these among new arrivals or general camp population? And if general population, why think so low compared to 5000 residents? It might help to explain how many of the total Moria resident population (for example) the MSF team actually reached, which might account for the winnowing down to 215 SV survivors. At any rate, this all raises the crucial issue of disclosure of sexual violence and how barriers may differ among groups and individuals – the discussion section touches on underreporting and disclosure but does not fully develop theories on it that are grounded in the data. This may be difficult with the limited data available but if there is any qualitative material in MSF records that could shed light on decision making re disclosure, that would be fascinating indeed.

We fully agree – unfortunately, there is no qualitative data available on this point. We have mentioned it more explicitly now as a limitation in discussion.

Global comments:

I think the data presented are incredibly valuable and these findings should be shared. However, as noted above, it would help to have clarification of MSF’s work on Lesvos and how the intake questionnaire was administered and translated, so we can better gauge how well the terms were understood by the migrants themselves.

Policy and practice recommendations seem extremely important, particularly re: a) provision of mental health support services, b) inclusion of male survivors in screening & support efforts, and c) false reliance on “safe countries” like Turkey and Morocco. To strengthen these points, more background info / explanation would be helpful.

- Eg, re: the mental health impacts of sexual and gender-based violence, as well as whether any mental health assessment was done with this population as part of MSF activities. The recommendation is sound but comes from out of nowhere.

- Eg, whether one sees higher rates reported among specific sub populations of patients (as in Afghan teens on the move, who received a degree of attention several years ago), which might indicate which men and boys are most vulnerable in what situations.

- Eg, more context re: EU-Turkey deal and its bottlenecking impact on Greece, including the assumption that Turkey is a safe country for return and adjudication. It could help, for example, to explain the major migration routes – as well as the short distance between Lesvos and Turkey, which would explain how the vast majority of migrants on Lesvos came through Turkey. Cites to reported human rights abuses against migrants in Turkey would help make the point re: false reliance on safe third country policy.

Thank you - see changes in lines: 109-113 of the tracked manuscript re: distance, island’s info

331-333of the tracked manuscript re: limited human rights in refugees.

I would definitely welcome the eventual publication of these data and insights, as I think the data is so important and MSF’s crucial work on Lesvos warrants significant attention. However, to strengthen the piece, I do suggest a strengthening of the discussion section and close proofread and technical / stylistic edit by a native English speaker.

Thank you, we have attempted to improve the language throughout the

manuscript.

Submitted filename: Response to Reviewers.doc

Click here for additional data file.

26 May 2020

PONE-D-19-20179R1

Sexual violence against migrants and asylum seekers. The experience of the MSF clinic on Lesvos Island, Greece.

PLOS ONE

Dear Dr. BELANTERI,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Vedat Sar, M.D.

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Dear Ms.Belanteri

Thank you for re-submitting your manuscript. Both reviewers see considerable merit in your study, however, one of the reviewers has still concerns you may address in a revision.

We would be glad to see a re-revised version of this manuscript.

Best regards,

Vedat Sar,MD

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #2: Yes

Reviewer #3: Partly

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: I Don't Know

Reviewer #3: N/A

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Reviewer #2: No

Reviewer #3: No

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PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: No

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6. Review Comments to the Author

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Reviewer #2: Thank you for the attentive revision. I am sincerely looking forward to seeing this piece in print. Article needs one more close proofread, however, as several typos remain (for example in lines 111, 217, 246).

Reviewer #3: This topic is certainly timely and the work that the organization has done is admirable. But what this paper presents is less than a scholarly article and reads more like a research report -- and even then a somewhat limited one. There is a descriptive overview of this particular case and context but there is little that is drawn in terms of conclusions or steps for either corrective action, intervention or even suggestions for future study. There were many important findings that were mentioned in passing in the paper but not ever really followed up on. For example, the data suggests significant variance in the gender composition of survivors from what we commonly know, but this is not explored in greater detail. The percentage of survivors who were actually raped is also not commented upon other than briefly. The implication that so-called 'safe' countries are not safe at all was another avenue not followed. These are but a few. I am thus unable to recommend publication even though the topic is significant and it appears that the authors have already gone to some length to address earlier reviews.

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Reviewer #2: Yes: Kim Thuy Seelinger

Reviewer #3: No

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28 Aug 2020

To the editor, PLOS ONE

Dear editor,

Thank you for your message including the reviews of our paper. We have amended the paper following the comments, and we think the paper is better now. In our responses below we refer to line numbers in the new revised version with track changes. Reviewers’ comments are shown, and our response is given point by point in BOLD.

Response to Reviewers

Reviewer #2: Thank you for the attentive revision. I am sincerely looking forward to seeing this piece in print. Article needs one more close proofread, however, as several typos remain (for example in lines 111, 217, 246).

Thank you for your comments. All necessary changes are made accordingly.

Reviewer #3: This topic is certainly timely and the work that the organization has done is admirable. But what this paper presents is less than a scholarly article and reads more like a research report -- and even then a somewhat limited one. There is a descriptive overview of this particular case and context but there is little that is drawn in terms of conclusions or steps for either corrective action, intervention or even suggestions for future study. There were many important findings that were mentioned in passing in the paper but not ever really followed up on. For example, the data suggests significant variance in the gender composition of survivors from what we commonly know, but this is not explored in greater detail. The percentage of survivors who were actually raped is also not commented upon other than briefly. The implication that so-called 'safe' countries are not safe at all was another avenue not followed. These are but a few. I am thus unable to recommend publication even though the topic is significant and it appears that the authors have already gone to some length to address earlier reviews.

Thank you.

We recognise the limitations of the research. Thus, this is mentioned in “Discussion”, lines 346-355.

All necessary changes from native English co-author are done to improve the language issues found in the manuscript.

Submitted filename: Response to Reviewers.doc

Click here for additional data file.

2 Sep 2020

Sexual violence against migrants and asylum seekers. The experience of the MSF clinic on Lesvos Island, Greece.

PONE-D-19-20179R2

Dear Dr. BELANTERI,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Vedat Sar, M.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

The authors addressed reviwers' requests.

Reviewers' comments:

7 Sep 2020

PONE-D-19-20179R2

Sexual violence against migrants and asylum seekers. The experience of the MSF clinic on Lesvos Island, Greece.

Dear Dr. Belanteri:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Vedat Sar

Academic Editor

PLOS ONE