Ethiopia 

Armed conflict erupted in the Tigray region of Ethiopia in November 2020 between the government of Ethiopia and the Tigray People’s Liberation Front. For the last year, the Human Rights Council’s own independent investigative body, the International Commission of Human Rights Experts on Ethiopia (ICHREE), has asserted “reasonable grounds to believe that all parties to the conflict committed serious violations and abuses, including war crimes and crimes against humanity.” They persist even following the signing of the Cessation of Hostilities Agreement almost a year ago.  

PHR and the Organization for Justice and Accountability in the Horn of Africa (OJAH) reviewed 305 medical records from health facilities across Tigray. Our recent joint report documented that survivors experienced sexual violence at the hands of multiple perpetrators – sometimes in the form of sexualized enslavement – and faced significant delays in reporting and seeking medical care. Our findings were consistent with those in ICHREE’s final report, which found that combatants violated international human rights and humanitarian law and bear responsibility for “crimes of rape and sexual violence against women and girls in Tigray.” Survivors of sexual violence, primarily women and girls, who sought care between November 2020 and July 2023 in Tigray alone exceeded 10,000, according to ICHREE.  

Calling the conflict “one of the deadliest of the 21st century,” ICHREE delivered a report and comprehensive investigative findings and legal determinations in this Session, concluding with a clear warning of the “acute risk of further atrocity crimes in Ethiopia.” The UN Special Adviser on the Prevention of Genocide has also warned of “the continued presence of risk factors for genocide and related atrocity crimes in the country.” 

With this in mind, PHR, OJAH, the Health Professionals Network for Tigray, and other partners spent months advocating with Human Rights Council Member States to call for sustained independent monitoring. Together with Amnesty International and the International Bar Association’s Human Rights Institute, PHR and partners presented the findings of our research during the interactive dialogue on Ethiopia, side events, and briefings to highlight the urgent need for sustained monitoring and accountability, including the extension of ICHREE’s mandate. 

Yet on October 4, survivors and affected communities in Ethiopia and abroad watched in disbelief as the Council let ICHREE’s mandate lapse. Member States even declined to call for weaker forms of engagement. Not even the European Union, which had called for ICHREE’s creation in the first place, took action to renew it. The resulting lack of sustained independent monitoring will inevitably lead to further impunity and unchecked abuse. The Council’s inaction has effectively eliminated its ability to scrutinize one of the most egregious human rights crises in the world today.  

According to ICHREE, “The vast majority of Ethiopians asked by the Commission about accountability and healing expressed their complete lack of trust in Ethiopian State institutions to carry out a credible process of transitional justice.” Yet, in ICHREE’s place, responsibility devolves to the African Union and the joint investigative team of the Office of the High Commissioner of Human Rights (OHCHR) and the Ethiopian Human Rights Commission. Neither of these mechanisms is sufficiently independent or impartial to ensure accountability. Indeed, the African Union failed to release its own report, effectively silencing itself, and the government of Ethiopia has barred independent monitors from conducting investigations on the ground. 

The Council should be credited for fully extending 14 other thematic and country mandates during this Session and for creating an independent international fact-finding mission on Sudan. But its readiness to ensure investigation of patterns of violations in Sudan but not in neighboring Ethiopia sent mixed messages about the Council’s will to pursue truth-telling and accountability on behalf of all equally. That inconsistent application of its mission risks fueling impunity for similar crimes elsewhere. 

PHR is committed to working with partners to provide ongoing documentation of sexual violence, sexual slavery, and attacks on health care in Ethiopia as the conflict continues.  

Syria 

The 54th Council Session marked the 12th year of reporting on the human rights and humanitarian crisis in Syria through its Independent International Commission of Inquiry on the Syrian Arab Republic. As PHR’s report She Pays the Highest Price: The Toll of Conflict on Sexual and Reproductive Health in Northwest Syria documents and the Commission’s new report affirms, the situation in Syria remains dire. Debates and recommendations to the Human Rights Council on the situation in Syria have stagnated; the Commission is merely able to “reiterate” its past demands due to stark political divides among Member States.  

Nonetheless, the Council’s vote to extend the Commission of Inquiry’s mandate for another year signals some commitment to seeing that one of the most entrenched and catastrophic human rights crises in the world remains part of the Council’s docket. Violations committed by the Syrian government with Russian support are still ongoing, with the most recent attack on medical facilities documented a few days ago in northwest Syria. 

Ukraine  

The 54th Session of the Human Rights Council provided scrutiny of ongoing war crimes and crimes against humanity in Ukraine – and, to a degree, the crime of aggression. 

PHR reiterated its calls for prevention and accountability for the pattern of attacks on health care systems and medical professionals since Russia’s full-scale invasion of Ukraine in February 2022 in the form of three interventions this session. The first was via PHR’s ongoing engagement with the Commission of Inquiry on Ukraine, which presented an oral update to the Council, and engagement with Member States during the Interactive Dialogue.  

The second was calling for accountability in the context of the UN Special Rapporteur on the human rights situation in the Russian Federation’s first report to the Council. PHR condemned the more than 1,000 attacks that have been perpetrated against Ukraine’s health care system; called for restitution for the $2.5 billion in damage to health infrastructure; and called out Russia’s policy of “passportization” in the temporarily occupied territories, under which access to health care and essential medicines is restricted to those with Russian passports, jeopardizing the right to health and to life.  

The third intervention was calling on Member States to vote against Russia’s bid for readmission to the Human Rights Council because of its flagrant human rights violations at home and atrocity crimes in Syria, Ukraine, and elsewhere. Together with Ukrainian partners, PHR plans to build on this momentum at the Universal Periodic Review of the Russian Federation in November.   

Widespread human rights abuses persist in Ukraine with near impunity. Although the Commission took tentative steps in this session to condemn violations by the Russian Federation, more sustained efforts to promote accountability are necessary. The Commission of Inquiry’s oral update, following its most recent visit to Ukraine, previewed a strong report next month to the UN General Assembly. The Council secured sustained documentation of Russia’s human rights record by extending the mandate of the Special Rapporteur on Russia for another year. And, perhaps most significantly, the UN General Assembly denied the Russian Federation’s application for renewed membership in the Human Rights Council, extracting a political price for its appalling human rights record.  

It was a reminder of the power the Council can wield when it chooses to. 

Photo: A view of a meeting during the fifty-fourth session of the Human Rights Council. UN Photo/Jean Marc Ferré

Executive Summary

The conflict in Tigray, Ethiopia between the government of Ethiopia and the Tigray People’s Liberation Front (TPLF), with involvement from Eritrean military forces and numerous ethno-regional militia groups, has been marked by widespread conflict-related sexual violence. Reports of conflict-related sexual violence as a significant element of the conflict surfaced both before and after the signing of the Cessation of Hostilities Agreement (CoHA) in November 2022 by the government of Ethiopia and the TPLF. This report – prepared by a joint research team composed of professionals with medical and public health training and expertise in Ethiopia and Physicians from Human Rights (PHR) – finds that, since the start of the conflict in November 2020 until June 2023, military actors have perpetrated brutal and widespread acts of conflict-related sexual violence in Tigray and that these acts have not ceased following the signing of the CoHA.

A medical and human rights research team reviewed 305 randomly selected medical records from multiple health facilities in Tigray, Ethiopia, with the goal of documenting types and patterns of conflict-related sexual and gender-based violence perpetrated against civilians in Tigray between November 2020 through June 2023. Of the 305 records reviewed, 304 records included reports of conflict-related sexual violence, overwhelmingly affecting women and girls, with survivors of conflict-related sexual violence ranging in age from eight to 69.

Key Findings

The medical records reviewed paint a stark picture of the systematic and widespread infliction of conflict-related sexual violence by government armed forces and militias. All parties to the conflict failed to prevent and halt conflict-related sexual violence and to ensure that survivors are able to report and seek care for the devastating injuries caused by these acts.

Sexual violence was often perpetrated by groups, and at times involved captivity and use of weapons. Analysis of this data revealed that rape committed by multiple perpetrators accounted for the majority of documented acts (76%; n=233), followed by rape committed by a single perpetrator (22%; n=68). The incidents examined in this review most commonly were carried out in groups, with a median of three perpetrators. It is noteworthy that there were 10 records in which patients reported experiencing captivity during the occurrence of multiple-perpetrator rape, consistent with enslavement and sexual slavery. The incidents frequently involved perpetrators who used weapons or other forms of violence concurrently with sexual-violence acts. Several accounts also described the murder of family members, including children, before, during, or after rape.

Survivors identified perpetrators as largely belonging to Eritrean or Ethiopian armed forces. Most commonly, survivors identified perpetrators as speaking the Tigrigna language (66%), which is spoken in both Eritrea and Tigray. Survivors also largely identified perpetrators as appearing to belong to military and paramilitary groups (96%) and were previously unknown to the survivors (99%). While not all records indicated the affiliation of perpetrators, in 143 instances survivors identified at least one perpetrator as being from the Eritrean military, which reportedly operated in alignment with Ethiopian government forces during the 2020-2022 conflict period.⁸ 30 percent of perpetrators were identified as speaking Amharic. In 16 instances survivors identified perpetrators as being part of the Ethiopian military. More specific data about other identifying features (e.g., color of military uniform, insignia, identifying speech patterns such as accents) was not available in these records.

Survivors have serious health needs from conflict-related sexual violence, but face delays in reporting and seeking medical care. The medical records reflect serious physical and psychological consequences of conflict-related sexual violence, both short- and long-term, including mental health issues such as post-traumatic stress disorder (PTSD) (13%) and depression (17%), unintended pregnancy self-reported by the survivor (8%), and reproductive organ injuries and disorders (11%), including urinary incontinence, fecal incontinence, abnormal uterine bleeding, uterine prolapse, chronic pelvic pain, and fistulas. Records show that in multiple instances, conflict-related sexual violence may have resulted in pregnancy (27% of patients tested for pregnancy at the time of examination were positive) or contraction of HIV (11% of patients tested for HIV were positive).

The data also showed significant delays in seeking medical care. There was a median period of five months between the reported incident and survivors presenting at health facilities. Although it is unclear what caused the delays (e.g., stigma, fear for one’s safety, ongoing conflict affecting transportation and access to health facilities), such delays suggest an underreporting of cases of conflict-related sexual violence.

Conflict-related sexual violence is ongoing, even following the CoHA. The medical records reviewed showed many instances of conflict-related sexual violence occurring after the November 2022 CoHA: 169 incidents of conflict-related sexual violence occurred before the signing of the CoHA in November 2022 and 128 incidents occurred after November 2022. The scale and nature of these violations has not materially changed since the peace agreement was signed, except for the notable fact that 95 percent of conflict-related sexual violence experienced by children and adolescents under 18 years old occurred following the signing of the CoHA.

Conclusions

The scale of cases, pattern of incidents, and description of perpetrators suggest that these incidents of conflict-related sexual violence were both widespread and systematic. The findings of this investigation are consistent with other publicly available reports and are indicative of the use of rape and other forms of sexual violence as a tool of war against civilian populations to terrorize communities and inflict grave harms.

This data points to the high likelihood that military forces, likely associated with the Ethiopian and Eritrean governments, have caused serious violations of human rights and committed atrocity crimes such as war crimes (e.g., torture and humiliating or degrading treatment, rape and sexual violence, sexual slavery) and crimes against humanity (e.g., persecution, torture, enslavement and sexual slavery, rape) as defined in the Rome Statute of the International Criminal Court and in international jurisprudence. These violations have caused survivors significant harm, leading to an urgent need for medical and psychosocial support.

It is imperative that the international community actively ensure that perpetrators of these crimes and human rights abuses are held to account and that survivors can receive both access to justice as well as necessary medical aid and reparations to support recovery and rehabilitation. Particularly in light of the deteriorating security situation in Amhara and concerns about atrocity prevention, it is critical to send a clear message that there will be accountability for human rights abuses. The research findings unequivocally indicate that there is a need for ongoing independent monitoring and documentation to ensure survivors can report the abuses they suffered, have their experiences documented, and have evidence for accountability gathered in a timely manner and properly preserved.

Recommendations

While Ethiopia is mandated to undertake a transitional justice process under the terms of the CoHA, benchmarks for monitoring have yet to be released publicly and it is unclear whether accountability will be incorporated as of the time of publication of this report. The findings of our report point to past and ongoing involvement of forces aligned with the Ethiopian government in carrying out conflict-related sexual violence. Consequently, there is significant reason to doubt the credibility of investigations, documentation, and accountability and justice processes left solely to the oversight of the national government. In light of these findings, which are being published as the risk of future human rights violations is increasing due to intensifying conflict in other parts of Ethiopia, there is an urgent need for international and regional action in addition to national efforts to ensure credible monitoring, documentation, investigations, prosecutions, and justice for the grave violations committed.

This report is being released at a time when several independent investigative mechanisms seem likely to be closed, despite evidence of ongoing violence in violation of the CoHA and international human rights and humanitarian law. Following the CoHA, there have been serious concerns about the status of the UN International Commission of Human Rights Experts on Ethiopia (ICHREE)– the Human Rights Council-mandated mechanism for investigation and documentation of human rights violations and atrocity crimes in Ethiopia. The Commission is expected to provide a summary report to the UN Human Rights Council in September 2023, but there are strong indications that ICHREE’s mandate may not be renewed beyond that time, in part due to pressure from the Ethiopian government to defer to national mechanisms including the CoHA-mandated transitional justice process. Similarly, the Commission of Inquiry (COI) established by the African Commission on Human and Peoples’ Rights to investigate violations of international human rights law and international humanitarian law and identify perpetrators for purposes of pursuing justice and accountability also faced opposition by the government of Ethiopia. The COI’s mandate was recently terminated, prior even to the publication of a single report of its findings and recommendations.

Based on the data presented in this report, Physicians for Human Rights and Ethiopian partners make the following recommendations to international, regional, national, and local actors: 

1. Guarantee and support impartial documentation and accountability for serious human rights violations and atrocity crimes that have occurred; 
2. Ensure unfettered, continued independent and impartial monitoring of and reporting on ongoing conflict-related sexual violence, including the situation of children and adolescents; 
3. Ensure a credible and benchmarked transitional justice process that meaningfully responds to the perspectives and needs of survivors of human rights violations including conflict-related sexual violence; and 
4. Facilitate access to physical and mental health services and other forms of rehabilitation for all survivors of conflict-related sexual violence, without discrimination.

To realize these recommendations, we call for the following measures by specific actors:

To the Ethiopian government and federal regional authorities:

• Rigorously and immediately implement all recommendations of the UN International Commission of Human Rights Experts on Ethiopia in their reports to the UN Human Rights Council (A/HRC/51/46);

• Cooperate fully with investigations by all UN, regional, local, and international non-governmental human rights monitors, including to ensure unrestricted access to all regions of Ethiopia and protection from reprisal for their work;

• Direct the Ministry of Justice and the Ethiopian Inter-Ministerial Task Force on Accountability and Redress of Violations to suspend, investigate, and bring to justice members of Ethiopia’s armed forces who have overseen or participated in violations of international human rights law and international humanitarian law, including those violations and abuses that may amount to war crimes or crimes against humanity, in accordance with international and regional standards and national law;

• Ensure that survivors of sexual violence, and communities disproportionately impacted by sexual violence, are meaningfully engaged in designing transitional justice efforts, that they can participate without risk of retaliation, and that their perspectives, safety, and needs are prioritized;

• Allow unfettered access to humanitarian aid, including medical services, without discrimination, including to members of vulnerable populations and specifically survivors of conflict-related sexual violence; and

• Ensure appropriate redress and reparations for and provide free, timely, and adequate medical, psychosocial, and legal services to all survivors of conflict-related sexual violence without discrimination, fully respecting their privacy and ensuring their protection against reprisals.

To all parties to the conflict, including the governments of Ethiopia and Eritrea:

• Halt all forms of violence, including rape, enslavement and sexual slavery, and other forms of conflict-related sexual violence; protect civilians; and condemn sexual and gender-based violence, as mandated under international human rights law and humanitarian law as well as agreed to by the parties to the CoHA;

• Publicly condemn and issue orders to prevent and cease immediately all abuses, including all forms of sexual and gender-based violence, and facilitate investigation and prosecution of these abuses and justice for survivors;

• Exclude from any peace agreement the provision of amnesty or immunity for serious violations of international law; and

• Comply with the obligation of each party to a conflict to allow and facilitate the delivery of impartial humanitarian relief consignments for civilians in need of supplies essential to their survival.

To the international community:

• Actively support the renewal of the mandate of the International Commission of Human Rights Experts on Ethiopia (ICHREE);

• Ensure well-resourced, ongoing impartial, independent documentation of and public reporting on human rights and international humanitarian law violations since the onset of hostilities on November 3, 2020, including by supporting a succession plan for ICHREE should the mandate not be renewed. This includes a plan for preservation of evidence marshaled by ICHREE as well as the designation of a similarly empowered investigative mechanism;

• Promptly support the investigation of and accountability for those credibly implicated in serious rights abuses in Ethiopia under international law, including through universal jurisdiction;

• Condition non-humanitarian funding for the government of Ethiopia on its demonstrable, measurable progress in providing accountability and justice for atrocity crimes, including public acceptance of this commitment and the establishment of clear benchmarks and timelines for implementation;

• Monitor and ensure full compliance with the commitments and obligations agreed to in the CoHA;

• Ensure that domestic accountability and justice processes are only endorsed if they are impartial, transparent, non-discriminatory, inclusive of survivors of the conflict, including survivors of sexual violence, and ensure their safety and rights in engaging such processes;

• Fund and provide technical support to strengthen knowledge of the transitional justice process among survivors and build capacity among health, law enforcement, and justice sector actors to support investigations and prosecutions of conflict-related sexual violence and facilitate access to remedies and reparations for survivors of sexual violence; and

• Prioritize survivor-centered, trauma-informed care and rehabilitation for survivors of conflict-related sexual violence in humanitarian support to Ethiopia, with specialized care for children and adolescents.

To the Office of the United Nations High Commissioner for Human Rights and the Ethiopian Human Rights Commission Joint Investigation Team (JIT): 

• Ensure that all parties to the conflict implement in particular recommendations #5 and #6 of the JIT’s 2021 report, specifically to “[e]nd all forms of sexual violence against women and girls, men and boys, including targeting of civilians on the basis of their gender or ethnicity;” and “[i]ssue clear, public, and unequivocal instructions to all armed forces and groups, that all forms of sexual and gender-based violence (SGBV) are prohibited and punishable on the basis of direct and command responsibility, including superiors who ordered or failed to prevent or stop violations.”

To the African Commission on Human and People’s Rights:

• Promptly reconsider the decision to terminate the mandate of the Commission of Inquiry and ensure that its mandate concludes, at least, with a report of its findings and recommendations.

What We Do

For more than 35 years, Physicians for Human Rights (PHR) has worked at the intersection of medicine, science, and law to end human suffering, save lives, and secure justice and universal human rights for all.

PHR mobilizes the medical community to defend rights and advance justice. Our global network of thousands of health professionals, lawyers, and human rights researchers and activists has worked across five continents to ensure accountability for attacks on health care infrastructure and personnel and for sexual violence in conflict zones, end torture and ill-treatment, speak out for the right to protest safely, halt the use of excessive force by police and security forces, and safeguard the rights and health of asylum seekers.

• We train health, legal, and law enforcement professionals to document evidence of human rights abuses and to work together to bring that evidence to court, hold violators accountable, and secure justice for victims and survivors.
• We investigate mass atrocities and advocate to protect health care facilities and personnel from attack.
• We pioneer innovative, survivor- centered, and trauma-informed tools and are leaders in creating global standards that strengthen justice and accountability.

Our evidence is used by international and local justice mechanisms, United Nations bodies, policymakers, and journalists to bring human rights abusers to justice, prosecute war crimes, reform policies and practices that undermine human rights, secure reparations for survivors, and spur action in the face of growing rights violations.

Explore the Annual Report below or download it here.

Working to End Attacks on Health Workers and Hospitals

PHR has documented attacks on health care since our founding. We expose the persecution, torture, and killing of health professionals, the bombing of hospitals and ambulances, the obstruction of access to health care, and the blockading of medical aid to populations in conflict zones.

We use our investigations and data to spotlight violations, generate evidence to support justice processes, and advocate at the highest levels for protection of medical facilities and health professionals on the front lines. We galvanize the global medical community to act in solidarity with their colleagues under fire around the world.

With the start of Russia’s full-scale invasion of Ukraine in February 2022, PHR and our partners on the ground launched a rapid response investigation into widespread attacks by Russian forces on Ukraine’s health system. Together, we documented at least 707 attacks on health care in Ukraine in 2022 alone – the most comprehensive dataset to date of these egregious violations of international law – and are sharing this crucial evidence with justice mechanisms building prosecutions of war crimes and crimes against humanity.

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PHR has been documenting attacks on health care in Syria since the start of the conflict there in 2011: more than 600 assaults on medical facilities and the killing of almost 1,000 health care professionals. Fully 90 percent of these illegal attacks were perpetrated by the Syrian government and/or its Russian allies. We have published more than a dozen reports on the horrific impacts of these attacks on health, most recently on how Syrian women and girls have suffered from the loss of access to sexual and reproductive health care. Read the report.

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As You Review our Annual Report, Empower Change Through a Generous Gift

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For more than three decades, PHR has worked to protect the rights of people fleeing violence and persecution. Every year, hundreds of PHR-trained clinicians conduct pro bono forensic physical and psychological evaluations of asylum seekers that support their immigration cases so they can be granted protection in the United States. We also investigate and document persecution and ill-treatment of asylum seekers and migrants on both sides of the U.S.- Mexico border, including the terrible harms of forced family separation by U.S. officials – and we use our data to advocate for a more just and humane immigration system.

PHR’s researchers and investigators use the power of science and medicine to expose police violence, state torture, and the excessive use of force by government security forces against peaceful protesters worldwide. We debunk pseudoscience that excuses police violence and advocate to stop the use of chemical and dangerous crowd-control weapons.

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“We cannot move forward unless we reckon with the past. In this regard, the survivors of past election-related violence should be helped to obtain justice and accountability.”

Naitore Nyamu-Mathenge, PHR Head of the Kenya Office

Every year, tens of thousands of adults and children experience sexual violence during armed conflict. A key reason for impunity is the lack of high-quality forensic evidence and survivor- centered justice processes.

Since 2011, PHR has tackled this crisis in the Democratic Republic of the Congo (DRC), Iraq, and Kenya through innovative technology, hands- on training, and forging powerful networks of health, law enforcement, and legal professionals that are helping secure justice for survivors.

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In the wake of the U.S. Supreme Court’s 2022 overturning of Roe v. Wade, PHR is stepping up our advocacy for reproductive rights and justice. We have begun new research and advocacy with partners on the health and human rights harms of abortion restrictions and the “dual loyalty” crisis clinicians face when they are forced to deviate from established standards of care, putting their patients at risk and violating clinicians’ medical and ethical obligations.

We’re mobilizing health professionals and building networks with reproductive justice advocates to document the health and rights harms caused by abortion bans on both patients and providers, and to speak out for accountability and reform.

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PHR was the galvanizing force behind the team of international experts who, in 1999, created the Istanbul Protocol, UN guidelines that are the gold standard for conducting effective investigations into allegations of torture. In 2022, the UN Office of the High Commissioner for Human Rights published the new edition of the Istanbul Protocol, the culmination of a multiyear effort spearheaded by PHR that brought together 180 experts from 51 countries. The new edition provides critical guidance to States on how to fulfill their treaty obligations to investigate, prosecute, and punish torture under international law.

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Inspiring the Next Generation of Health and Human Rights Activists

PHR is deeply committed to growing the ranks of new health professional human rights activists. Our Student Program has 90 chapters at medical schools across the United States and around the world, where we connect medical and health students with the resources and skills to advocate for health and human rights locally, nationally, and globally.

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“None of this would be possible without your unstinting support. I want to thank you for your partnership and belief in our work. We in turn pledge to continue to provide PHR’s unique combination of science and advocacy in defense of human rights.”

Saman Zia-Zarifi, PHR Executive Director