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Hostilities faced by people on the frontlines of sexual and reproductive health and rights: a scoping review
  1. Victoria Boydell1,
  2. Kate Gilmore2,
  3. Jameen Kaur3,
  4. Jessica Morris3,
  5. Rebecca Wilkins4,
  6. Frieda Lurken4,
  7. Sarah Shaw5,
  8. Kate Austen5,
  9. Molly Karp6,
  10. Sally Pairman7,
  11. Maria Antonieta Alcalde8
  1. 1Institute of Women's Health, University College London, London, UK
  2. 2International Development Department, The London School of Economics and Political Science, London, UK
  3. 3International Federation of Gynecology and Obstetrics, London, UK
  4. 4International Planned Parenthood Federation, London, UK
  5. 5MSI Reproductive Choices, London, UK
  6. 6International Confederation of Midwives, The Hague, Netherlands
  7. 7International Confederation of Midwives, The Hague, The Netherlands
  8. 8IPAS, Chapel Hill, North Carolina, USA
  1. Correspondence to Dr Victoria Boydell; vickyboydell{at}gmail.com

Abstract

Frontline workers for sexual and reproductive health and rights (SRHR) provide life-changing and life-saving services to millions of people every year. From accompanying the pregnant, delivering babies and caring for the newborn to supporting those subjected to sexual violence; from treating debilitating infections to expanding contraceptive choices; from enabling access to safe abortion services to countering homophobia: all over the world frontline SRHR carers and advocates make it possible for so many more to experience dignity in sex, sexuality and reproduction. Yet they are also subjected to hostility for what they do, for whom they provide care, for where they work and for the issues they address. From ostracistion and harassment in the workplace to verbal threats and physical violence, hostilities can extend even into their private lives. In other words, as SRHR workers seek to fulfil the human rights of others, their own human rights are put at risk. Yet, as grave as that is, it is a reality largely undocumented and thus also underestimated. This scoping review sets out to marshal what is known about how hostilities against frontline SRHR workers manifest, against whom, at whose hands and in which contexts. It is based on review of six sources: peer-reviewed and grey literature, news reports, sector surveys, and consultations with sector experts and, for contrast, literature issued by opposition groups. Each source contributes a partial picture only, yet taken together, they show that hostilities against frontline SRHR workers are committed the world over—in a range of countries, contexts and settings. Nevertheless, the narratives given in those sources more often treat hostilities as ‘one-off’, exceptional events and/or as an ‘inevitable’ part of daily work to be tolerated. That works in turn both to divorce such incidents from their wider historical, political and social contexts and to normalise the phenomena as if it is an expected part of a role and not a problem to be urgently addressed. Our findings confirm that the SRHR sector at large needs to step-up its response to such reprisals in ways more commensurate with their scale and gravity.

  • review
  • public health
  • obstetrics
  • health systems

Data availability statement

Data sharing not applicable as no datasets were generated and/or analysed for this study.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjgh-2023-012652

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Broadly, that frontline sexual and reproductive health and rights (SRHR) workers may confront hostility for the work they do, that is, reprisals.

    What this study adds

    • This review presents the first ever global compilation of the available evidence about the hostilities that frontline SRHR workers face and finds that those hostilities are underestimated, underdocumented, and thus poorly responded to.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, OR POLICY

    • This paper provides a needed starting point from which to better inform, guide and develop more effective rights protection, safeguards, remedies and redress for those working on the frontline of SRHR, and it offers directions as well for future research.

    Introduction

    Frontline workers for sexual and reproductive health and rights (SRHR) provide life-changing and life-saving services to millions of people every year. From accompanying the pregnant, delivering babies and caring for the newborn to supporting those subjected to sexual violence; from treating debilitating infections to expanding contraceptive choices; from enabling access to safe abortion services to countering homophobia: all over the world frontline SRHR carers and advocates make it possible for so many more to experience dignity in sex, sexuality and reproduction. We include clinicians such as midwives and gynaecologists/obstetricians, community health workers, peer-educators and volunteers, as well as those who are researching, advocating for, and organising to publicly demand universal access to high-quality sexual and reproductive health services globally. We include those working in maternal health, sexual health, contraception and safe abortion provision; those working for the prevention and treatment of sexually transmitted infections included HIV/AIDS, for the provision of comprehensive sexuality education (CSE), as well as for care of survivors of violence against women and harmful traditional practices and for prevention of the same.

    Those who work on the frontlines of SRHR, whether advocating for or delivering services, are a distinct group of health workers by virtue not only of their expertise, but for the aggression directed against them, which intersects with the abuse that health workers are subjected to more generally. The violence faced by frontline workers has intersecting drivers. First and foremost, violence against health workers is rooted in gender, racial and class stereotypes.1 2 However, contrary to global health and human rights standards,3 4 at certain times and in certain places, political and religious actors have promoted and leveraged public discourse, policies and laws antagonistic to SRHR; for example, against comprehensive sexuality education, contraception and safe abortion services. Amplified by conservative media and anti-SRHR groups, the result is that millions on the frontlines of SRHR face antagonism daily. Those sociopolitical forces help foster hostility against frontline workers and their workplaces; hostile acts that may violate workers’ rights to health and safety in the workplace, their rights to physical and mental integrity and to non-discrimination, as well as their rights to freedoms of expression, assembly and information. There are significant implications here, given not only the duty of care that employers owe their staff but the responsibilities too of the state and its authorities to respect, protect and fulfil the rights of frontline workers. There are implications also for global health actors and the international community more broadly.

    Concerned about those implications, in 2022, a consortium of leading SRHR bodies: representing thousands of providers of SRHR services (FIGO and ICM) along with organisations providing and advocating for SRHR services and policy reform the world over (MSI Reproductive Choices, IPAS and IPPF)—came together to jointly issue a Call to Action for more effective support of frontline SRHR workers.5 One of the consortium’s next steps is to issue this scoping review which marshals the available evidence about how such hostilities are manifested, against whom, at whose hands and in which contexts.

    Methods

    We undertook the scoping review by adopting Colquhoun et al’s framework that allows for an iterative approach, responding to the fact that researchers increase their familiarity with a subject as they collect data.6 In this case, as we became aware of the limitations of a particular source that is, of the peer reviewed literature, we sought out other sources to build up a more comprehensive account of the available evidence. As a result, data were collected from a total of six sources: the peer-reviewed and grey literature; SRHR sector surveys; from consultations with sector experts, news reports and from newsletters issued by opposition groups. Our sources are outlined below:

    • Peer-reviewed literature: to compile the evidence available in the peer-reviewed literature, we consulted public health and social science databases between the period January 2000 to May 2022 (Web of Science, PsycInfo, and Medline). We searched for relevant articles using three search terms: hostilities, frontline workers and SRHR. A total of 9295 unique records were identified (see online supplemental annex 1). Their titles and abstracts were then reviewed against our inclusion criteria. A total of 40 papers then underwent a full paper review, of which 19 were further excluded, leaving 21 papers for data extraction and analysis (see online supplemental annex 3).

    • Grey literature: to identify relevant grey literature, we searched the online resources of World Health Organisation, United Nations Fund for Population Activities, International Labour Organisation, International Planned Parenthood Federation, Ipas, FIGO, International Condeferation of Midwives, MSI Reproductive Choices, Frontline Defenders and the Centre for Reproductive Rights. Sixteen relevant publications were found; five of which had not been identified from among our other sources. We hand-searched the bibliographies of those five to identify additional materials.

    • Survey data: we also searched for sector surveys of hostilities in the online and other grey literature and sought the advice of our consortium members. As a result, eight surveys of hostilities towards those providing and advocating for SRHR services were identified and assessed.

    • Expert informant interviews: our interviews of SRHR sector experts familiar with the subject were designed to complement and contextualise the findings of the scoping review. Following a semistructured interview guide, interviews were conducted with eight experts: three working for multilateral agencies (such as the OHCHR and WHO) and five for international non-governmental organisations. Detailed notes of those interviews were coded and summarised. We did not seek ethical approval given that interviewees were asked to speak in their professional capacity and the interviews covered non-sensitive questions about programme interventions.

    • News reports: we searched the news database ProQuest for records between 2010 and 2022, using the search terms, and identified a total of 4652 that we then assessed against our inclusion and exclusion criteria. A total of 67 news reports were deemed relevant and underwent data extraction (see online supplemental annex 2).

    • Materials produced by opponents of SRHR: to provide contrast with the expert and independent sources reviewed, we also examined an archive of literature issued over a 30-month period between April 2020 and August 2022 by groups well known for their opposition to SRHR. The purpose was to understand how the organised opposition understands hostilities, and to draw such comparisons as may be relevant.

    Supplemental material

    We must acknowledge that this review has some significant limitations. First and foremost, we included only materials published in English, meaning the wealth of information reported in other languages was not captured. This also introduces a bias towards English-speaking contexts. In addition, our search terms and inclusion/exclusion criteria may have inadvertently limited the material that we captured across the different sources.

    Results

    Our scoping review draws on six sources that combined provide a broad basis for assessing the current body of knowledge (see table 1). The sources examined help build up an overall picture of the evidence available on the hostilities to which frontline SRHR workers are subjected.

    View this table:
    Table 1

    Summary of data sources

    Our search of the peer-reviewed literature found limited attention given to the subject matter. In large part, peer-reviewed literature approached the topic only indirectly, if at all. The grey literature sources gave more coverage of individual anecdotes, related news reports as well as survey data. However, none of the grey material we examined approached hostilities against frontline workers as a topic in its own right. The other sources reviewed further enriched our understanding. The limited survey data available on the topic, much of which related to abortion services, indicated that, when asked, frontline workers report high levels of hostilities. This finding was mirrored in the advice of experts, who also described work underway to respond to such hostility.

    However, our review of news coverage from a range of countries provided confirmation that those working for SRHR are indeed subjected to variety of aggressions. That finding suggests other sources we reviewed had failed to give hostilities due attention. Also, news coverage, along with the survey data found, suggests significant content on the topic is not making its way into the peer-reviewed and grey literature. Our review of the materials issued by groups opposed to SRHR found no acknowledgement of hostility against workers for SRHR, including at the hands of their own supporters but found, by contrast, that close attention is given to hostility deemed to be directed against anti-SRHR staff, supporters and/or partners.

    Hostilities as reported by the peer-reviewed literature

    Across the 21 peer-reviewed papers included, hostilities were noted as occurring in several countries (eg, Australia (n=2); South Africa (n=2); the USA (n=2), Canada (n=3). One paper included global comparisons, while two made regional comparisons, with single papers focusing, respectively, on China, Egypt, the UK, Ghana, Iran, Zambia, Zimbabwe and Eswatini. Ten papers focused on hostilities experienced by those providing HIV/AIDS services. Five papers focused on abortion service providers. All papers focused exclusively on clinical staff in clinical settings with little attention paid to the experience of other frontline workers. Only one paper examined the frequency of hostilities against SRHR frontline workers.

    Most peer-reviewed papers made only passing reference to the existence of hostilities, doing so either at the start of the paper or in their background sections. Hostilities were rarely a central topic. Papers focused instead on stigma (n=16) or on litigation (n=5) against workers. Across this literature, stigma was used as an umbrella term for combinations of hostile acts and emotions, covering bullying or blame causing discomfort, burnout, or fear, including fear of violence. Most papers built on Goffman’s (1963) understanding of stigma as ‘an attribute that is deeply discrediting’ that labels people as ‘different’ or ‘deviant’, which causes lack of acceptance, loss of status and opportunities, and fuels inequalities. Fear of losing status makes people less likely to talk openly about their experiences and perpetuates a sense of isolation.7 Even when explicitly describing hostile acts committed by others, the literature assessed their significance solely in terms of the resulting stigma that individual workers were said to personally experience. Stigma was seen to have a range of effects on frontline workers themselves, on the types of care provided, and on the ways in which care was made available, with papers noting that at times stigma prevented provision of SRH services.

    The peer-reviewed literature focused more on personal experiences of stigma rather than on the patterns of abuse that drive individual psychological responses or on those perpetuating stigmatising practices. Social stigma experienced and internalised by those providing services to people living with HIV/AIDS was reported,8–10 being seen also to lead to burn-out.11 Several studies discussed blame as part of stigma. Farrag and Hayter (2013), for example, documented how school nurses fear they may be ‘morally judged by being involved in sex education’.12 Others reported that workers’ professional activities were curtailed for fear of the threats to their personal safety but did not document details of that hostility.13–15

    The peer-reviewed papers that discussed litigation in this context focused on occasions when the law was used as a threat to frontline SRHR workers. Examples included the prosecution of clinical workers, compelling healthcare practitioners to appear in court as witnesses and the use of their clinical documentation in court proceedings. Several articles reported that health professionals’ interactions with patients had been used in criminal proceeding for non-disclosure of HIV/AIDS.16 17 Hood et al (2007) found that when ‘midwives felt in the spotlight and targeted’ by legal inquiries, they ‘experienced ‘turmoil’ and ‘confusion’ by what they considered to be the ‘cloak and dagger’ affair of the inquiry’.18 The papers, however, made little to no reference to the role of the law in protecting, rather than threatening, those working on the frontlines of SRHR.

    Overall and resoundingly, the peer-reviewed literature was silent on the hostilities confronting frontline workers. The few articles that did give this attention adopted narratives that individualised and depoliticised the hostilities to which frontline workers are subjected, focusing instead on the emotional consequences while neglecting core questions regarding structural drivers, rights, accountability and justice.

    Hostilities as reported in the grey literature

    We found more evidence about the hostilities facing frontline workers in the grey literature than the peer-reviewed literature. Relevant materials (n=21) gathered from SRHR sector organisations in the main were either surveys or case studies of abortion care providers. This material showed that hostilities occur beyond the clinical setting and that their impacts cause more than stigma alone. The case studies published to raise awareness and support for those on the frontline illustrated that hostilities are not confined to clinical workers and that impacts extend into workers’ social and personal lives. For example, an abortion activist in Poland who had joined a peaceful protest ‘…to defend courts to act free from political influence, the rights of teachers, and the rights of LGBTQI+people’ was arbitrarily charged with the crime of ‘incitement to animal abuse’ while her husband lost his job at a state-owned company.19 A sexual and gender-based violence activist in Sudan faced reprisals for ‘working on LGBT+health and rights, you can imagine how that goes. It is not safe, and I do not think it is possible’.20 Significantly, the grey literature suggested that hostilities against frontline workers are not isolated events, but rather the result of coordinated strategies by organised groups.

    Hostilities as reported in the SRHR sector survey data

    The surveys that we identified in this review were found in the grey literature and by recommendation of consortium partners. Predominantly, they focused on the experience of abortion providers. Five focused on abortion providers in the US, two on abortion providers globally, while only one survey explored the experiences of providers working on a range of SRHR services (see table 2 for the main findings).

    View this table:
    Table 2

    Main findings from survey sources

    The surveys found that when asked, abortion providers and those providing other SRHR services report being subjected to a wide range of hostilities, from online harassment to threats to their personal safety and physical violence. Across the eight surveys reviewed, 31 different types of hostilities were identified, including hostility directed at the worker themselves, at the clinical setting and targeting SRHR organisations (see table 3).

    View this table:
    Table 3

    Types of hostilities

    The survey data, although principally gathered from abortion care providers, suggest that a wide range of hostilities have been directed against frontline SRHR workers and in several different country settings.

    Consultations with research, policy and service provision experts

    Given the paucity of evidence available in the peer-reviewed and grey literature, we then consulted with global SRHR experts involved in service provision and advocacy or working on evidence, guidelines and/or policy (see table 4). Our aim was to seek their advice both on sources we may have overlooked, and on what they understood to be relevant trends in the hostilities facing SRHR workers.

    View this table:
    Table 4

    Experts consulted

    Experts told us they knew of little additional literature on the topic. However, those involved in frontline advocacy or service provision spoke of their own experiences of and responses to hostilities and those working on research and on policies spoke in the abstract about related trends, root causes and contexts. Both groups of experts outlined how they and their organisations are increasingly taking steps to improve the protection of frontline workers. Those who create evidence and policies are focusing on more systemic responses, for example, gaining support from WHO Member States through World Health Assembly resolutions, conducting risk assessments, and setting confidentiality agreements with their partners. Those more directly involved in frontline service provision and advocacy are taking a more reactive approach such as developing crisis communication protocols or rapid response grants mechanisms focused on safety and security of frontline workers. The different approaches of the two groups, while in no way contradictory, were not aligned, suggesting a worrying potential both for duplication and for gaps to emerge between policy and practice standards.

    Hostilities reported by news outlets

    While the peer-reviewed and grey literature, including the sector’s surveys, as confirmed by experts, included limited evidence at best, news reports (n=67) provided far more numerous, although sensationalist, accounts of hostilities against frontline workers. Incidents of overt violence received greatest coverage with far more detail given about the hostile acts and their contexts as compared with other sources we reviewed.

    News coverage focused mostly on hostilities committed in the USA (n=32), Canada (n=11), Uganda (n=8), the UK (n=5), India (n=4) and China (n=3). The news reports revealed hostilities are experienced by a wider array of frontline workers than, for example, those providing abortion services alone and that hostilities extend well beyond clinical settings, reaching also into workers’ private lives. News sources reported not only hostilities against those working to support abortion care (n=45), but also against other service providers (eg, those providing antenatal, maternal health and obstetrics services, HIV/AIDS services, contraceptive services, and care of sex workers) (n=3), midwifery (n=2), care for transgender persons (n=15) and LGBTI+activism (n=2).

    However, news coverage of hostility against those providing abortion care was more frequent, detailing critical incidents including ones involving hostility from the state against abortion providers. Some reports covered antiabortion activists’ violent conduct but reported also on advocacy against antiabortion violence and on mechanisms of redress. Many of the US-focused articles found dealt with the murder of Dr George Tiller, an abortion provider in Wichita, Kansas.21–25 Tiller who ‘had previously been shot in the arms. His clinic had been bombed.’ was murdered by an antiabortion activist.21 Much of this coverage was duplicative. However, that repetition is useful in helping understand the associated public discourse. Another North American example receiving news coverage was the murder in Toronto of ‘an outspoken advocate for transgender rights and a strong voice against the violence that impacts her community’.26 It is important to note that similar cases in other regions such as the murder of LGBT+ rights activist David Kato in Uganda in 2011 did not receive the same level of coverage.

    News reports were unique among the sources we reviewed in discussing the source of the hostilities, whether it was known individuals, organised groups and/or state actors. In India, for example, in 2016, a woman was ‘brutally attacked’ in front of a state minister, who did not direct police to intervene during the attack.27 An OB-GYN was reported as ‘murdered over alleged neglect in treatment of an infant’28 and, in 2011, a ‘member of the Karnataka Sex Workers Union was brutally assaulted’.29 In China, in 2012, the Telegraph Herald reported that a rights activist was ‘jailed for campaigning for AIDS patients and orphans’.30 Sources documented examples from the USA, Uganda, India, Thailand and Kenya where healthcare workers had been convicted, and/or doctors’ licenses had been seized, for providing abortion services.31–35 In Turkey, in 2016, ‘police fired rubber bullets and tear gas to break up a rally by the LGBT community’.36 Other reports covered the activities of antiabortion activists, including their plans for large marches and demonstrations.37 38

    Unlike the other sources reviewed, news reports covered questions of justice, remedy and redress. Coverage was given to convictions for criminal acts against frontline workers, including murder and violence.30 39–42 Several articles reported on court rulings against those who had harassed abortion providers by, for example, releasing videos acquired by infiltration,30 43 verbal assault44 45 and the distribution of fliers.46–49 News stories also documented how different actors were advocating for legislative change to better protect abortion providers. For example, in the US State of Ohio, Kovac writing for Aurora Advocacy (2016) reported that a state representative calling for the protection of healthcare workers, was proposing legislation to recognise antiabortion harassment in law.50

    However, the news reports reviewed largely approached hostilities as if isolated incidents only. There was little to no analysis of patterns or trends, nor of root causes or wider forces at play, leaving unreported correlations between hostilities and the anti-SRHR discourse of public influencers.

    Hostilities as reported by organisations opposed to SRHR

    For the benefit of contrast with the other sources reviewed, and to take account of how groups opposed to SRHR report on hostilities, materials produced and/or promoted by selected well known opposition groups were also examined. There was found to be frequent reporting on hostilities in the opposition literature as compared with the other sources examined. Those materials (n=385) were concerned exclusively with the experiences of anti-SRHR supporters with little to no coverage given to hostilities directed against SRHR workers, except where a court case had cleared an anti-SRHR supporter of charges of hostility against an SRHR worker, or where new anti-SRHR legislation was reported as a victory against the SRHR sector. This reporting was packaged in a campaigning manner and often framed in human rights terms, that is, hostilities against anti-SRHR activists were presented as human rights abuses (eg, abuses of their freedoms of expression and religion, their right to protest, etc) with calls issued for accountability of those deemed to be culpable and/or responsible for those abuses. This was in stark contrast to, for example, the ‘stigma’ focus and the ‘exceptionalist’, ‘sensationalist’ framings of hostilities against frontline SRHR workers found in other sources reviewed.

    Discussion

    Our scoping review reveals that, while underreported, hostilities against frontline SRHR workers occur the world over. Yet, despite their extent and seeming frequency, the phenomena remain largely invisible in the evidence base, having received insufficient attention. In this discussion, we attempt to understand why this is the case, what are the consequences and how this might be changed.

    Across the sources reviewed, hostilities were more typically presented as if they were isolated incidents. The aggregate effect of this misrepresentation not only understates both the gravity and wide-ranging impacts of those acts of reprisal, it renders invisible the need for sustained efforts for prevention, support, redress and accountability and it depoliticises the phenomena. By depoliticisation we mean, hostilities against frontline SRHR workers become divorced from the wider historical, political and social contexts that foster, sponsor and perpetuate that antagonism. Our scoping review found that hostile incidents were rarely seen to be part of larger sociopolitical patterns, with their incidence rarely examined against the backdrop of sociopolitical discourses hostile to SRHR. In turn, that depoliticisation works to mask the culpable and their enablers: shielding not only those directly culpable for the acts of hostility but also those who, through public encouragement, incite, enable or condone hostility and thus must bear degrees of responsibility for doing so. It also renders less visible the roles and responsibilities of key duty bearers, including those who are duty bound to protect the rights of frontline workers (ie, employers, professional associations and state authorities). The results are not only that frontline workers’ human rights are not upheld and that mechanisms to support them in the aftermath of hostilities are less than adequate but that too little is being done to prevent the reoccurrence of hostilities and to hold those responsible for them accountable.

    The peer-reviewed literature drives a similar depoliticisation process through its almost exclusive focus on stigma. While stigma is a cause, form and consequence of hostility directed at frontline workers, the relationship between stigma and hostility is complex. Framing hostile events as stigmatisation alone draws our attention to the targeted individuals’ internalised reactions without adequately addressing the existential acts of hostility, the range of harms committed, and the injustice of those harms. It means again that too little attention is paid to the structural drivers of hostilities and the broader ideological and sociopolitical forces that enable, normalise and perpetuate hostilities. It further obscures questions about how stigma itself relates to and invites further hostilities.

    In addition, the peer-reviewed literature focused primarily on stigma experienced by those working in clinical settings. That leaves the stigma experienced by those working in non-clinical roles and in non-clinical settings (eg, health clinics’ administrative staff, community workers providing SRHR information and education) underexamined. Further neglected are the ways in which stigma affects workers’ private lives beyond their workplaces: their interactions with their communities, with their colleagues, with their families and loved ones.

    News reports’ fixation on the most sensational of hostile incidents and Global North bias further limits our understanding. News coverage means that many of us are aware of the bombings of abortion clinics in the US, for example. However, that more sensationalist coverage leaves unreported the fuller range of ‘non-spectacular’ hostilities that grind through the everyday lives of frontline workers around the world. Though less ‘newsworthy’, those hostilities too can have life-changing consequences for those on their receiving end. Yet, with our attention held by accounts of more spectacular and rare incidents, we come to assume that this is what ‘real’ hostilities look like. The result is that other forms of hostility, being underreported, pass us by unnoticed with the gravity of their consequences unseen.

    Sallie Han (2022), drawing on Debord (1967), argues that when we focus on spectacles more mundane experiences appear unremarkable and even acceptable.51 Inadvertently, sensational news stories may encourage authorities to normalise all but the most extreme hostility against SRHR workers, and to also ignore their compound effects and the significance of these for them as human rights duty bearers.

    Directly addressing questions of culpability and responsibility are a further omission in all but the opposition literature. By ‘deleting’ the agents of hostility and not giving attention to the roles of agents who bear responsibilities to protect workers, the key law, policy and practice questions are suppressed and crucial human rights dimensions of effective responses to hostilities against frontline workers are also left unaddressed that is, impunity as well as rights to remedy, and redress. When one recalls that these workers are subjected to hostility because they work to fulfil and defend rights to which we all are entitled, this neglect of their right to do so seems even more egregious.

    In sum, our scoping review finds that the gravity of reprisals against SRHR frontline workers is poorly recognised; the impacts of reprisals are broadly underestimated, not only on the individuals concerned but on services provided and on the sector as a whole; the rights of those affected are not upheld as they should be, while the culprits enjoy impunity rather than receive the accountability they deserve. So, the question remains, why has not the SRHR community been paying attention to this issue?

    What lies behind this inattention and inaction warrants further consideration. Yet more pressing still is the need for the SRHR sector at large to step-up collective responses to these reprisals and in ways that are more commensurate with the scale and gravity of the problem. Those working on the frontlines of SRHR must be understood to be rights holders. Violations of their rights should be addressed through support, remediation and legal remedy where appropriate. Steps must also be taken to prevent repetition and to hold those responsible accountable. Other human rights obligations should be met too. Practical steps should be taken to ensure, for example, that employer responses align with human rights standards. Employer organisations should implement dedicated guidelines and protocols, establish helplines, offer mental health support, instigate associated advocacy, prevention, and protection strategies, and establish clear monitoring and reporting systems.2 Donors should also support such efforts.

    Conclusion

    Each source we reviewed helped us assess the available evidence and thereby build up a more rounded understanding of the hostilities to which frontline SRHR workers are subjected. Our scoping review found that hostilities targeting frontline workers are committed the world over and yet remain largely underreported, underestimated and broadly invisible. This failure to acknowledge the scale and pattern of hostilities faced by frontline workers also mean far too little action is taken in response: too little is done by employers to protect their workers from hostilities and to take appropriate and comprehensive action when they are subjected to hostilities; too little is done by judicial and other due-process bodies to hold perpetrators of hostilities to account; and too little is done by the responsible State to meet their duties to tackle the wider social and political root causes of that antagonism. It leaves frontline SRHR workers often ill-prepared for and insufficiently supported in the unsafe environments in which many of them must carry out their work. That they are subjected to these hostilities because of the rights-related work they undertake, surely only underscores why more attention must be given to better protecting their rights too.

    Data availability statement

    Data sharing not applicable as no datasets were generated and/or analysed for this study.

    Ethics statements

    Patient consent for publication

    Acknowledgments

    We are thankful to Robert Dean Smith, Geneva Graduate Institute, who led the full paper review of the peer-reviewed and grey literature and contributed to the review and analysis of the news reporting. We are also grateful to Saheli Chatterjee, Geneva Graduate Institute, who reviewed the abstracts for peer-reviewed literature. We are thankful to all the consortium members for their feedback on the initial protocol as well as feedback the first and final drafts of this manuscript.

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    Supplementary materials

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    Footnotes

    • Handling editor Seye Abimbola

    • Twitter @ICM_CE

    • Contributors All authors contributed to the conception and design of the work. VB and KG designed data collection tools, undertook the data collection for the review, wrote the analysis plan, analysed the data, and drafted and revised the paper. JK, JM, RW, FL, SS, KA, MK, SP and MAC drafted and revised the paper. VB and KG act as guarantors for this paper.

    • Funding This work was supported by MSI Reproductive Choices and International Planned Parenthood Federation.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.