Episodes of Violence Suffered by Migrants Transiting Through Libya: A Cross-Sectional Study in a Reception and Healthcare Centre

Introduction: The Central Mediterranean Route, passing through Libya, is one of the most dangerous for migrants. Episodes of violence have been documented but have not been accurately quantified. The objective of the study was to estimate the prevalence of episodes of violence suffered in Libya by migrants consulting a Médecins du Monde reception and healthcare centre. Methodology: Monocentric cross-sectional study. All migrants over the age of 18 years who had passed through Libya and arrived in Europe from 2017 during the recruitment period (February -May 2019). The presence of emotional distress was considered as an exclusion criterion.. The proportion, frequency and factors associated to physical, deprivation and sexual violence were estimated through a bespoken questionnaire, as well as healthcare access and psychosocial support needs. Results: 98 people were recruited and 72 were interviewed (17 refused to participate and 9 were excluded). 76.4% were men, mean for the age was 31.9 years, 76.4% had low educational level, 66.7% came from Ivory Coast and 59.7% had left their country for security reasons. The median length of stay in Libya was 180 days. The overall proportion of participants having suffered from violence was 96.4% among men and 88.2% among women. The prevalence of physical, deprivation and sexual violence for men and women were 94.2%, 81.7% and 18% and 80.0%, 86.7% and 53.3%, respectively. No other statistical differences were found. Access to healthcare in Libya was non-existent. 63.9% of participants were oriented to psychosocial support after the interview. Conclusions: The vast majority of migrants report having been victims of violence during their transit through Libya. Women are at particular risk of sexual violence. Psychosocial support for this population is urgent.


Background
Several reports show that violence related to migration, including physical assault, torture and sexual violence, is a sad reality (1)(2)(3). Among the migratory routes, the Central Mediterranean, which crosses Libya, is one of the most dangerous (2) .
Libya has been frequently indexed by the media for its migration policy and several international organisations have collected evidences and testimonies relating the violence suffered by migrants (4-6). Nevertheless, there are no scientific study which collected quantitative evidence on this subject.
The objective of this study was to quantify the episodes of violence according to their typology, to determine its associated factors, as well as to assess healthcare access and need for psychosocial support among migrants having transited Libya and visiting a Médecins du Monde (MdM) reception and healthcare centre.

Methods
The study was cross-sectional and monocentric. The target population was the beneficiaries of the MdM reception and healthcare centre in Paris. Individuals aged over 18 years old, with foreign nationality, having transited through Libya and having arrived in Europe from 2017 were included. Participants were excluded if they presented emotional distress, assessed by the Refugee Health Screener-15 (RHS-15) (7). Patients were recruited during the medical consultations and once they had consented to participate they passed to an isolated room where the survey was performed by an specialised doctor, who previously evaluated the exclusion criteria.
A sample size according to a prevalence of violence of 95%, a margin of error of 5% and a confidence interval (CI) of 95% was set to 72 individuals. Sampling was exhaustive until accomplishing the sample size.
The data collection tool was a bespoken online survey (KoboTool Box). Data were automatically added to a secure database. A two-weeks pre-test period was conducted in order to test the survey feasibility.
The study assessed two types of violence: direct and witnessed. In both cases, physical, sexual and deprivation violence episodes were tracked. Physical violence was divided in "episodes with firearms" (i.e. injury, aggression, shooting) and "episodes without firearms" (physical injury, beatings, threat). Sexual violence addressed "episodes of rape", deprivation violence included suffering from or witnessing "episodes of detention", "episodes of food deprivation", "episodes of confiscation", "episodes of racketeering", and "episodes of separation of family members". The frequency and the perpetrators of these episodes were also tracked. For the former it was set to "daily", "weekly", "less than once a week" or "very rare" and the latter was divided in "governmental forces", "armed groups", "civils" or "not identified". Healthcare access during the journey in Libya and need for psychosocial support after the interview were also assessed. Participants were oriented to specialised teams with their agreement.
The descriptive analysis for continuous variables used mean ± standard deviation, median, interquartile range and T-student tests. Percentages with a 95% confidence interval and Chi2 tests were used for categorical variables. Stata v.15 software was used for statistical analysis.
This study was conducted in compliance with the ethical principles of the Helsinki Declaration. All participants received a written information sheet, and their participation was voluntary after providing verbal informed consent. All information provided was anonymised and confidentiality was ensured. Psychosocial support was available throughout the interview for all participants.
Main Findings 5 98 people were recruited and 72 were interviewed from February to May 2019 (17 refused to participate and 9 were excluded).  In addition, related to the episodes of physical violence, 38% of participants reported daily violence, 48% weekly violence, 15% less than weekly and 5% rarely. These percentages were 37%, 54%, 9% and 0% and 41%, 25%, 34% and 0% for deprivation and sexual violence, respectively. In 54% of the cases perpetrators were not identified, 29% were civil, 10% armed groups and 7% governmental forces.

Discussion
Human rights' violations in Libya have been documented for years by international organizations, think tanks or journalists (4,8-10). Nevertheless, these evidences come mainly from individual testimonies, reports or press releases. The added value of our study resides in its methodology, that enables to quantify the prevalence of this episodes in the general population of migrants hosted in a European country.
Our results show that the vast majority of people suffered from long imprisonment and confinement, where violence was systematic and of a huge magnitude. In most cases, the episodes of physical violence were suffered every day or almost every day and deprivation episodes lasted for the whole journey. In addition, perpetrators were very difficult to identify (more than a half of the participants simply called them "the Arabs").
It have been denounced by many NGOs that physical violence occurs mainly in places of confinement and is closely linked to the exploitation of migrants, forced labour and extortion (4,11,12). Firearms are very common and often used for threat, but episodes of mass murders and shootings have also been documented. A number of reports mention that extortion is a common practice. However, NGOs note that migrants are often abducted by smugglers when they arrive in the country. They can be released if they pay, themselves or their families but they can also be sold to another smuggling group (4,11).
In our study, women are particularly vulnerable to sexual violence. This has also been documented by other reports pointing that sexual violence is a common practice during the detentions or before being released (13-16). One third of the victims of sexual violence of the study stated that episodes were very common (daily or almost daily and by multiple perpetrators). The results of the study show that men are also exposed to sexual violence. Nevertheless, this type of violence might have been underestimated, especially for men, as the nature of the violence, which affects their privacy, sexuality and gender identity, makes it difficult to speak up.
As it has been shown in our study, access to healthcare in Libya is almost non-existent.
Our study shows that any of the participants had ever been treated by a doctor or had received medication during their journey. It has been documented that the health system in Libya is collapsed and it is facing serious problems due to infrastructure damage, lack of medicines, medical equipment and staff (10) (17).
Most people asked for psychological support after the questionnaire, reflecting a real urgency. Literature has well document how mental health disorders occur as a consequence of migration, mainly linked to forced, unplanned, poorly planned or illegal migration, low educational level, isolation, lack of support and perceived discrimination (18)(19)(20).

Limitations
The profile of participants is restricted to the recruitment location, which affects the external validity. nevertheless, as there were no access barriers and this centre in one of the biggest and most popular for underprivileged people in France, results could apply for a larger population of undocumented migrants arriving in Europe. In addition, the refusal and exclusion linked to emotional distress could have avoided the most vulnerable individuals from participating, probably due to the difficulty of evoking traumatic events.
Moreover, it is possible that sexual violence was underestimated, especially among men, as it was normally evoked as witnessed. Finally, the low proportion of women could also limit the statistical power for this group.

Conclusions
Violence in Libya is structural and systematic. Women are also very exposed to sexual violence. There is an almost total lack of healthcare access in Libya. It is urgent to develop a strategy to provide psychosocial and medical support to migrants suffering from violence.

Ethics approval and consent to participate
This research project was approved by the INSERM Institutional Review Board (IRB). The study was conducted in compliance with the ethical principles of the Helsinki Declaration.
All participants were informed of the study's objectives and design, and their participation was voluntary after providing verbal informed consent.

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests

Authors' contributions
NL, CR, NG and AG have participated on the study conception and design. LR, CR, EAF have implemented and coordinated the data collection and analysis. LR, EAF wrote the first article draft. All authors commented on the draft and provided substantial inputs. All authors read and approved the final manuscript.

Acknowledgements
We are grateful to all the participants of this study for their valuable testimonies. We are also grateful to all volunteers and employees who collaborated in the different stages of the study, and all the collaborators in MdM headquarters (France operations, Health and Advocacy Direction).