A Catch-22: Health care staff burdened by mandatory reporting of sexual violence

Health workers on duty in Beni, North Kivu region, the Democratic Republic of the Congo. Photo by: Vincent Tremeau / World Bank / CC BY-NC-ND

BARCELONA — The onus on health professionals to report sexual violence creates a potential conflict with their duty of care to the patient, and can make workers a target for retaliation by perpetrators, experts warn.

In some countries, health care personnel are obliged to report known or suspected cases of sexual or gender-based violence to the authorities. This can be done without the victim’s consent and, in some cases, is a precondition to providing them with medical care.

These requirements are part of national efforts to investigate and prosecute violent crimes and, according to clinical management guidelines published by the World Health Organization, are often intended to protect survivors. However, the guidelines also warn that the process can deny victims of any decision making power and can lead to them facing further safety concerns or legal consequences, for example, in countries where extramarital sex is illegal.

Health professionals are also burdened by their role in the reporting process, particularly those working in armed conflict or emergency contexts, where cases of sexual and gender-based violence tend to be higher. Staff can be reluctant to become involved in a legal process that does not protect their own identity and could lead to retaliation from perpetrators and, as health practitioners, they are also troubled by their inability to help those who need it, experts said.

“Medical providers find themselves in a Catch-22 situation — caught between the law and their medical duties and obligations.”

Jess Skinner, a humanitarian policy adviser, British Red Cross

One clinical psychologist, based in the Middle East region with the International Committee of the Red Cross, who asked to remain anonymous due to the sensitivity of the issue, told Devex that the realities of mandatory reporting were complex. While they were aware that sexual violence occurred often, they did not always know when, as victims would choose not to disclose it. When they did, things became difficult, said the source, who, due to local mandatory reporting requirements is unable to treat patients without evidence that a police report has been completed.

“It makes me really sad when you [have to] follow the procedure, but the procedure itself can make matters worse,” they said. “You want to be able to offer support to someone that has gone through that [sexual violence] … but in many instances, mandatory reporting stops you from being able to do that.”

They added that the reporting process can also stigmatize and blame victims, and that “It doesn’t feel like the procedure is there to support people.”

Mandatory reporting does create legal and ethical dilemmas for health care providers, agreed Jess Skinner, a humanitarian policy adviser with the British Red Cross, during an online event earlier this month. “Medical providers find themselves in a Catch-22 situation — caught between the law and their medical duties and obligations,” she said.

Skinner, co-author of a recent report looking at the humanitarian impact of mandatory reporting of sexual violence, explained how these requirements can vary between countries and contexts — they can be delineated by law, a matter of policy, or even just be widely practiced. But in all the contexts that Skinner looked into “there was confusion around the law, around the procedures, the obligations and there was differential application.”

Speaking at the same event, Camille Michel, a legal adviser at Médecins Sans Frontières, said that mandatory reporting can create a number of operational and practical challenges for organizations. Guidelines can be vague or contradictory and the exact roles and responsibilities of field staff can be unclear, she said.

“This confusion leads to stress and diverse practices … paralysis of the system and reluctance from health care staff to provide care for fear of not being compliant or for not knowing the specific procedure,” Michel said.

Questions arise as to who is expected to report an incident and to which authorities, and if this can be done anonymously. The lack of confidentiality is an issue for health professionals, the psychologist said, and even when reporting requirements are clear, the implementation of these is still problematic.

“I know because of my training that the issues created by the reporting process are not my fault, but many of my colleagues blame themselves,” they said. “They might not have done something wrong, but they feel they have, despite only wanting to step in to help someone.”

Sophie Sutrich, head of addressing sexual violence at ICRC, told Devex in an email that the organization works to ensure colleagues have access to training on mandatory reporting and information on the latest clinical and sectoral guidance. Topics such as health ethics and informed consent are covered within these, she noted.

Being up-to-date with local requirements and complying with them is a huge responsibility for health organizations and failure to do so can in theory lead to legal action or sanctions.

One global health organization told Devex, however, that they recommended that their staff respect patient wishes and abide by medical ethics first and foremost. They added that they had never seen the materialization of sanctions against any actors for not meeting the mandatory reporting requirements.

But staff still fear personal repercussions, especially in communities where the topic of sexual violence is taboo. “Mandatory reporting can pose significant risks to the safety of health care personnel — it can make them the target for retaliation by perpetrators or communities,” Skinner said.

Training on local sensitivities and specific aspects of the job that staff need to be aware of is important and something that all ICRC staff receive, Sutrich added. The aim is to provide them with “a good understanding of the context they are working in.” But this isn’t always enough.

While never feeling personally in danger, the ICRC psychologist knows of colleagues who have encountered problems for their role in reporting. In some health facilities “there have been a lot of threats from the perpetrators, trying to get people not to report,” they said.

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