Medical experts have urged bold action to end sexual violence at a Paris meeting, as a scandal over well-known writer Gabriel Matzneff puts France's attitudes to abuse under the spotlight.
More than 400 doctors and health professionals gathered at Paris' Unesco headquarters this week for the seventh international conference on sexual violence.
While the conversation around violence against women has gained traction in the wake of the #MeToo movement and recent government consultations on the topic, campaigners point out that women, men and children continue to be the targets of physical and sexual assault.
Doctor Wissam El Hage is a psychiatrist from Tours in western France and Isabelle Daigneault is a psychology professor from the University of Montreal. They share their views on what's working and what's not in tackling sexual violence and why France and Canada differ in their approach.
Q. Two years after #MeToo, what has changed?
A. A lot has changed in two years because of the hashtag #MeToo and different hashtags. There's been a lot of discussion in French society and this is good because the victims do not feel so alone. They may open up more easily to talk about their problems and what they experienced.
Q. Victims of sexual assault often don't report it. New measures by the French government to tackle domestic abuse would ease doctor-patient confidentiality restrictions if a patient is at risk. Is this a good idea?
A.It is a controversial measure because it goes against medical secrecy, which is a form of protection for both doctors and victims. Victims feel safe coming to their doctor to speak about their problems and to find help. I don't think that would be the case if they knew their doctor was no longer bound by secrecy. Also, we don't know how this will work. Is it a medical problem or is it up to the justice or the police to take control? This is something that has to be ironed out.
Q. Victims of sexual assault often don't report it. New measures by the Domestic violence and sexual violence… what's the difference?
A.Sexual violence is one part of violence. The common part is violence and you can find domestic abuse more frequently in couples, where you have verbal, harassment and physical violence and in the end you can also have sexual violence. The thing is to tackle violence in general, to help people talk about it.
Q. How difficult is it for victims of sexual assault to open up?
A.It's like when you experience a film of horror. When you go through experiences of violence it is very painful, very distressing for the patients, but the job that we do is to help them to cope with it, to transform this horror into something more normal and integrate it into their lives.
Q.What case has struck you the most?
A.Each case is unique, sometimes you feel helpless, you feel like your job is not really improving the situation and then you discover a few months or a few years later the evolution of the patient, of his social and family situation and this is very helpful to us to continue to do this job.
Q.What are the different stages of the healing process?
A.When victims have experienced violence during their childhood, they go through feelings of shame, guilt, emotional distress and this can lead them to depression, post-traumatic stress, addictions and personality disorder. In other cases, they will have some kind of resilience and will seek help. The only way they can come out of their horror movie is by talking. When they accept to talk about it, to face up to it and accept their emotions. When they stop avoiding their past, an improvement can start to occur.
Q. So, talking is the key to treating sexual violence?
A.It's not just talking about it, it's how you do it. It has to be in a secure place and with a person of trust; and we help the person to cope and to confront their emotions in a safe way where they don't feel overwhelmed.
Q.Do you have the means to do your job?
A.Last year, the French government created 10-12 centres dedicated to the treatment of victims, essentially trauma centres. It's a first step. Ten centres are quite little for France but it's a good start. What's needed however is at least 30-50 trauma centres, outpatient care units across the country where victims can reach out to professionals in the trauma field.
Q. One obstacle hampering efforts to tackle sexual violence has been the issue of time limits, some cases are too old to be prosecuted. What's your view on time limits?
A.I think this is a justice point of view, because for a doctor there are no limits. In some cases, people who suffer sexual violence, 30 percent of them only discover their symptoms 20 years later, triggered peraps by another traumatic event. So I think from a doctor's point of view there's no limits of time, the justice has a different way of reasoning, a different way of thinking [to doctors].
Things are rather different in Canada, where doctors and the police work in tandem.
Q. How does Canada tackle sexual violence?
A.We have a multi-tiered agreement between all the people involved in domestic violence or sexual abuse, for example doctors, police men, judges, lawyers, are obliged to work together. Everyone needs to have a way of working with domestic violence survivors, sexual abuse survivors so they have to report if there's a case of abuse that comes to their attention, especially doctors.
Q. France is considering easing medical-secrecy restrictions if a patient is at risk. Is this a good idea?
A. It's a good start that doctors are allowed to speak but it's not enough. One of the reasons I think that Quebec is seen as more ahead or advanced is because we have a multi-sectorial agreement, which has been in place since 2001. This has helped because everybody knows what they're expected to do.
Q. Canada is often cited as an example in the fight against sexual violence, how well is it doing?
A. Every year there are new budget announcements dedicated to sexual violence prevention in Quebec. What is a bit disappointing at times is that the money is always announced when the government has an incentive to do so, so when there's an issue or case that becomes public and people go to the media and talk about it and when there's an election coming up, then there's a lot of money that's available. (…) So there's funding but it's never stable.
Q. It's been two years since the #MeToo movement, triggered by sexual allegations against Harvey Weinstein, has a lot changed?
A.One good thing that has come out of this is that a lot of women have come forward and spoken about their experiences of sexual assault, and the #Metoo movement has been liberating for a lot of women and has helped them break their isolation. However, there has also been a backlash, people have started blaming women more than before and are taking the defence of the perpetrators.
Q.There have been a lot of awareness campaigns to eliminate sexual violence but how do we achieve real action?
A. We need to start with sexual education for children, and this will include gender equality so that men respect women regardless, and that women have a voice. We need to start younger so that these little boys when they grow up will not perpetrate sexual assault, and that women will not need to defend themselves because it's going to be eradicated.
Q. In France, nearly 150 women died at the hands of their partners or ex partners last year, experts reckon early child abuse is to blame for domestic violence. What's needed to treat child abuse?
A. First of all, we have to know that it happened. And it's difficult because if we're thinking about the #Metoo movement it's relatively feasible for an adult to disclose and get help but for a child it's much more difficult. Somebody has to be the child's voice, and so who will be responsible for that? Perhaps midwives, doctors and social workers, people who work closely with children could be one way. There needs to be intervention but maybe beforehand there should be an assessment of the child's needs because not every child has the same consequences from family violence or sexual assault, so it needs to be done on a case-by-case basis.
Q. Out of the victims that you've treated, which one case has struck you the most?
A. What a difficult question. The children or adolescents that I remember most or have marked me most are those that are resilient.
It's one of the subjects of my research: the consequences of child sexual abuse and what helps some children to overcome the abuse and be resilient. Some that have impressed me the most are those that would even as young as 12 and 13 go around high schools and give testimony to what happened to them and help others to disclose and get help, that is I think the thing that touches me the most.