Stigmatized gay, bisexual and transgender Syrian refugees who survived sexual violence in war are struggling to get medical or mental health care, human rights groups said on Wednesday.
More than 40 LGBT+ survivors in Lebanon told Human Rights Watch that they were raped, sexually harassed and had their genitals burned by government forces and armed groups, including Islamic State, resulting in physical and psychological trauma.
But existing services tend to focus on women and girls and survivors said they were reluctant to seek help for problems like depression and rectal bleeding because of shame.
"There's already so much stigma ... so imagine in a conflict setting where violations are rife. The minute they even see you presenting as soft, they will take it as a sort of excuse to attack," said Sara Kayyali, HRW Syria researcher.
"When you're gay in Syria and this happens to you, your own family - and we've documented cases of this - will tell you, 'Get out, leave the country. I wish they killed you'," she told the Thomson Reuters Foundation.
Government officials in Syria and Lebanon - which hosts almost 1 million Syrian refugees according to the United Nations - did not immediately respond to requests for comment.
A crackdown by Syrian President Bashar Assad on protesters in 2011 led to civil war, which has killed hundreds of thousands of people and made millions refugees. Assad now holds most of the country, except for pockets in the north.
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The United Nations said in 2018 that sexual violence meted out against thousands of men and women by Syrian government forces and allied militias constituted war crimes and crimes against humanity.
Men who are gay or perceived to be gay and trans women who may be viewed as men are often subjected to sexual abuse or harassment at checkpoints, in detention centres and during house raids, leaving them emotionally scarred, Kayyali said.
"Because of their trauma, they're not really able to move on with their lives or have normal relationships," she said.
"Years later, they still wake up with nightmares."
A gay man interviewed by HRW said he was raped with sticks during detention and a trans woman in the army said she pretended to be a man by shaving her head to stay safe.
For LGBT+ rape victims within Syria, the situation is even worse. The law criminalizes gay sex with up to three years in jail and LGBT+ people risk execution by extremist armed groups, said Ian Alkadi, founder of LGBT+ Arabic, a Syrian lobby group.
"They can't seek help anywhere. This has depressed us because we can't do anything about it and the only thing they can do is escape abroad," he said by phone from Germany where he is based.
Violence against LGBT+ Syrians has been prevalent since the start of the war and refugees who have experienced extreme forms of abuse need specialised support, said Bertho Makso, executive director of Proud Lebanon in the country's capital, Beirut.
Makso said trans people were particularly vulnerable, with some trading sex for basic needs like food and facing further violence.
"They are neglected and forgotten," he said.