The current climate surrounding immigration enforcement and deportation has created widespread fear that, according to health care providers, is directly reducing health care utilization. This avoidance extends beyond those that are undocumented to visa-holding immigrants, mixed-status families, and even U.S. citizens. Telehealth has emerged as a vital tool for maintaining access to care while minimizing perceived risks of immigration enforcement encounters, reflecting both patient preference and provider adaptation. However, telehealth has limitations: many health conditions require in-person care, not just as a preference but as a necessity, which restricts the extent to which telehealth can be relied upon as a meaningful mitigation tool.

Providers report that fear is already contributing to negative health outcomes among individuals of a broad range of immigration status, including delayed care, missed preventive services, and treatment interruptions. Many note that patients are arriving sicker, with some anticipating more advanced disease presentations, such as late-stage cancers. Children in mixed-status families are especially vulnerable, with parents in some cases refusing essential services like post-surgical rehabilitation due to immigration-related concerns, indicating a broader, long-term public health impact that extends beyond individual patients.

At the institutional level, responses to immigration enforcement pressures vary widely. While some health care systems have implemented clear protocols and staff training, others offer little guidance or have removed patient-facing materials altogether. This moment presents an opportunity for institutions to lead with clarity by establishing standardized best practices that protect both patients and providers, and by reinforcing the health system’s role as a trusted space for all.

Many health care workers described experiencing situations consistent with “dual loyalty,” whereby they navigate conflicting demands between their professional obligations and institutional or perceived legal constraints. In the absence of consistent institutional support and to respond to their dilemma, some health care providers have developed informal strategies to protect their patients, including modifying documentation practices, adjusting referral patterns, and expanding telehealth services – efforts that highlight both the resilience of providers and the pressing need for systemic solutions.

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Are you a health care professional based in the United States? If so, you have unique insights into how federal policy changes, including President Trump’s Executive Orders (EOs), initiated on or after January 20th, 2025, affect both health care access and delivery.

This confidential survey, which takes no more than 15 minutes to complete, seeks to understand how Trump-era policies have directly or indirectly affected your patients who are undocumented or have insecure immigration status, as well as the ethical and institutional challenges faced by healthcare providers. Findings from this research will inform policy recommendations to safeguard healthcare access and ethical medical practice for all.

Deceptively known as “less-lethal,” these weapons can in fact cause severe injuries and even death when used with excessive force. Physicians for Human Rights has worked extensively on the health impacts of these weapons and has issued the following guidance to help people seeking to exercise their right to protest prepare for, protect against, and treat tear gas and other chemical irritant (e.g., pepper spray) exposure.

What to wear to protect yourself against tear gas and other chemical agents when protesting:

• Facemask. Scarves or bandanas large enough to cover your face from nose to chin can serve as substitutes.
• Shatter-resistant eye protection (e.g. shatter-resistant sunglasses, swim goggles, or a gas mask)
• Clothing covering all your skin as much as possible
• Comfortable, closed, protective shoes that you can run in
• AVOID wearing contact lenses, which can trap irritating chemicals, such as tear gas powder, underneath. If you do wear contacts lenses, keep a full facial gas mask or goggles on at all times.
• AVOID wearing makeup such as eyeliner, for the same reason.

What to bring to a protest:

• Water in your own plastic bottle with a squirt top (to drink and to wash off your skin or eyes)
• A backpack or a drawstring bag – rather than an over-the-shoulder or a cross-body bag – in case you need to run
• Identification and/or emergency contact information (consider writing this on your skin)
• Cash for food and transportation or cash bail, in case you are arrested. Check how much bail is in your location.
• Inhaler, epipen, and several days of prescription medication, in case you are arrested
• A medical alert bracelet or information about any chronic medical conditions or allergies
• A change of clothes, in case you are exposed to chemical irritants

How to protect yourself against tear gas and other chemical irritants:

Agent CS, the most commonly used form of tear gas, is a crystalline powder that is converted into a fine spray and propelled from a grenade or canister by a small pyrotechnic explosion. Agent OC, commonly known as pepper spray, is essentially a highly concentrated form of hot pepper. Though tear gas was classified as a chemical weapon in 1993 and banned from use in international warfare, law enforcement officers are still allowed to use it on civilians in the United States. Some localities are starting to ban use of these chemicals for crowd control by police in the wake of Black Lives Matter protests and their violent disruptions.

When a tear gas canister explodes, CS powder sprays into the air and adheres to any moisture it can find, including the tears in your eyes, the sweat on your skin, the grease in your hair, and the saliva and mucus that cover your mouth and airways.

Symptoms of tear gas exposure can include the following, according to the CDC:

• Eyes: Excessive tearing, redness, burning, blurred vision
• Skin: Burns and rash
• Mouth: Burning, irritation, drooling, trouble swallowing
• Nose: Running, burning, and swelling
• Lungs: Chest tightness, shortness of breath, wheezing, coughing, choking sensation
• Stomach: Nausea and vomiting

What to do if you’re exposed to tear gas or other chemical irritants:

What to do immediately:

• Get out of the cloud of tear gas and away from the general area as soon as you can. Seek high ground, as most forms of tear gas are heavy; the closer you are to the ground, the higher the concentration of gas.
• Walk, don’t run. Running may cause you to breath more heavily, filling your lungs with more tear gas. Try to keep your breathing even.
• If your eyes have been exposed and are burning or blurry, flush them with water immediately. Try not to touch your eyes, nose, or mouth. Use water from your water bottle to flush. If you can find an open drinking fountain or sink in a public restroom, flush your eyes with water for 10 to 15 minutes.
• There is no evidence that baking soda or milk is better than cool water alone. There is one small randomized controlled trial that found that baby shampoo is no better than water. Using baby wipes or makeup wipes if water is not immediately available may cause increased irritation.
• If possible, and you are not affected yourself, help others by moving them to a clean and ventilated area.
• Do not try to remove the tear gas canisters, as doing so may put you at an increased risk for further harm and injury.

How to further get rid of the chemical irritant:

• Change your clothes as soon as possible. Rinse your body as soon as you get to a location with a shower. Take off your shoes outside your home to keep them from bringing any powder indoors.
• Shed all the clothes you were wearing and hang them in an open, ventilated area for at least 48 hours before washing them. If you are not able to keep them in an open place, story them in a sealed bag until they are ready to be washed. Do not mix them with uncontaminated garments, as CS powder can be active for as long as five days after being released.
• Take a cold shower for at least 20 minutes to prevent the chemicals from irritating your skin any further. Do your best not to breathe in more tear gas during the shower, and keep your eyes closed. Wash your hair especially well.
• If you’re still having symptoms 30 minutes or so after getting all the agents off, are having eye or lung issues, or are at all concerned about your exposure, seek medical care.

What to do if your rights have been violated:

• Review “Know Your Rights” documents before heading out to a protest, such as this ACLU guide.
• If your rights are violated by law enforcements officers, when you can, write down everything you remember from the scene, including the officers’ badge and patrol car numbers.
• Get contact information for witnesses.
• Take photographs of any injuries. Get medical treatment right away if you need it and ask for a copy of any medical records.

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Resources:

1. Physicians for Human Rights: “Lethal in Disguise: The Health Consequences of Crowd-Control Weapons”
2. Physicians for Human Rights:  Crowd-control Weapons Fact Sheets

Recent changes in regarding U.S. immigration enforcement have created new challenges for health care providers who are committed to ensuring care for all patients. This guide does not constitute legal advice but offers essential information to navigate the evolving enforcement landscape while upholding your duties as a health care professional. As a health care provider, your primary responsibilities are to:

• Maintain trust with all patients, regardless of immigration status

• Understand your legal rights and obligations

• Know how to respond if immigration enforcement occurs in your facility

• Advocate for institutional policies that protect patient access to care

As a Health Care Worker, What Can You Do?

Despite these challenges, health care facilities still maintain legal protections that they can assert if confronted with warrantless enforcement actions. As a health care provider, you have both legal rights and ethical responsibilities to maintain spaces for your patients that are free from immigration enforcement within medical settings.

Medical ethics underscore that health care workers’ responsibility is to maintain strong therapeutic relationships with your patients. This means clinicians have ethical obligations to prioritize preserving patient trust and confidentiality in all clinical interactions. Health care facilities provide services essential for the health, wellness, and safety of not only patients, but also for the whole community.

Proactively Reassure Patients

Clearly communicate that immigration status does not affect a patient’s right to receive medical care.  For example: “We provide care regardless of immigration status” and “You have the right to remain silent if approached by immigration authorities.” Reinforce HIPAA and other privacy requirements.

Do Not Ask About Immigration Status Unless Required

As an ethical best practice, avoid asking for patients’ immigration status. If you must collect such information for a patient, ensure that information is secure and separate from medical records. If state laws require asking about status, inform patients they are not required to answer, using language like:

“I am required to ask you the following question about your presence in the United States. You do not have to answer this question.”

Monitor and Address Rumors in the Community

If false reports of immigration enforcement presence spread, issue accurate information to patients and local networks in a timely manner to reduce cancellations and fear. NYC Health + Hospitals had to do this on January 30, 2025 in response to misinformation circulating that they were handing information to ICE. Their statement, shared on social media, read: “We care about your health, not your immigration status. Despite misinformation on Instagram, NYC Health + Hospitals/Elmhurst is NOT reporting any person or patient seeking care to the police. All New Yorkers should seek care without fear.”

Share Know-Your-Rights Information

Display or distribute Know-Your-Rights Information to help ensure that patients understand their rights. Share how you are ensuring that ICE cannot enter private medical spaces without a judicial warrant. Make materials available in multiple languages relevant to your patient population.

Ensure Institutional Preparedness and Protections Against Immigration Enforcement

All health care facilities, including hospitals, clinics, mobile clinics, and community-facing health events, should have clear protocols for responding to immigration enforcement. Health care workers should advocate to their institutions to have clear policies in place. Hospitals should train staff to ensure that enforcement agents do not enter private spaces without verification from a designated staff member and a judicial warrant. Institutions should establish designated private areas where enforcement actions are restricted and develop clear response protocols for law enforcement requests. Institutions should also ensure all public-facing staff are trained on how to interact with immigration authorities and have access to the contact information for the designated administrator or legal team in case of enforcement encounters.

Letter from the Executive Director

The state of the world is harrowing. 5.7 billion people live in autocracies, a 23 percent increase compared to ten years ago, meanwhile more than 120 armed conflicts are happening around the world and there are more refugees than ever before. Compounding these problems, climate change radically threatens the lives and livelihood of people around the world. An increasing number of authoritarian regimes are actively undermining the international human rights legal framework; alarmingly, the United States is also now weakening respect for human rights and accountability and even hindering the lifesaving work of the World Health Organization. These regressive forces threaten the well-being of people everywhere.

To meet this moment, PHR will double down on our effective strategies for stemming human rights abuses.

To meet this moment, PHR will double down on our effective strategies for stemming human rights abuses. We will wield the power of the health care community to promote justice and healing to protect those who are particularly vulnerable. We will mobilize to protect asylum seekers, women whose reproductive rights are under attack, and minorities who are all too often targeted by police in the United States as well as sexual violence and torture survivors and health care professionals working in conflict zones globally, among others.

PHR’s strategic plan for 2025 to 2028 allows us to meet the urgent need for the expertise and insight of health professionals, who are uniquely positioned to have a powerful impact at the intersection of health and human rights. Health professionals are not only able to assess and document human rights abuses, but they are also often among the first to recognize emerging crises as frontline responders providing critical medical care to those affected. When health professionals embrace the role of human rights advocates, they are some of the strongest assets in the fight against injustice.

PHR’s strategic plan for 2025 to 2028 allows us to meet the urgent need for the expertise and insight of health professionals, who are uniquely positioned to have a powerful impact at the intersection of health and human rights.

Therefore, a key component of PHR’s strategic plan for 2025 to 2028 is to strengthen our networks of health professionals by expanding partnerships and creating new opportunities for health professionals and allied partners to speak out and share their expertise to inform policymakers, opinion-shapers, and the public. In this consequential time for global human rights, this strategic plan will allow PHR to wield our proven approaches against serious violations including sexual violence, torture, and attacks on health in conflict, while ensuring we are able to respond effectively and nimbly to new challenges such as climate change.

Cover: Injured patients in the wards of Bukavu General Hospital days after M23 rebels launched their attack on Bukavu, Democratic Republic of Congo, 2025. Photo by Hugh Kinsella Cunningham/Getty Images

I will never forget when violence broke out during Ukraine’s Revolution of Dignity in 2013-2014. On a very cold winter day in Kyiv, confrontation between police and protesters escalated. I watched a bus burn in front of me on a central street. Even then, it seemed to me like an omen. Those of us who hoped the protests would bring about a brighter future in Ukraine knew the country would never be the same. Many lives were lost, but Ukraine chose a path of transformation. What followed, however, was beyond what any of us could have imagined.

Russia’s annexation of Crimea in 2014 felt almost physical – like losing a part of your own body. As Russian-backed militias took over Ukrainian administrations in Donetsk and Luhansk, we waited for the world to react. The response was timid. With time, we turned inward, focusing on reforms and making sure the sacrifices of those years were not in vain.

I was in the United States when Russia launched its full-scale invasion of Ukraine in February 2022. My friends and family back home were under bombardment, trying to evacuate or joining the fight. I spent sleepless night thousands of miles away, waiting to hear if they were alive. I did what I could do from afar – protests, donations, volunteering. But I knew I had to return. I knew I had to let the world see, hear, and understand what was happening to Ukraine.

I found my purpose in documenting war crimes in Ukraine with Physicians for Human Rights (PHR), ensuring that what was happening to Ukraine was being witnessed around the globe.

Attacks on Health as a Strategy of War

We knew that documenting these attacks was critical not only for collecting evidence but also for capturing patterns of violence in conflict and analyzing the broader impacts on the population. Documentation is so much more than gathering facts: it is also about memorialization, ensuring that truth is preserved to help future generations remember their history.

Documentation is so much more than gathering facts: it is also about memorialization, ensuring that truth is preserved to help future generations remember their history.

As we reach three years since Russia’s full-scale invasion in February 2022, the scale of destruction in my country is staggering. From the outset, health care was in the crosshairs. Russia immediately began attacking hospitals and health care workers, a tactic it honed for years in Syria, meant to break resistance and terrorize civilians. This assault on the health care system is not incidental – it is a war strategy. The destruction of hospitals, targeting of medical personnel, and coercive measures against health care workers and patients in occupied areas all serve to weaponize Ukrainians’ access to medical care, and maximize suffering, ultimately jeopardizing our way of life and making it impossible to lead a normal existence on these territories.

Russia’s attacks on energy infrastructure routinely disrupt power supply for our daily life; At my home in Kyiv we deal with power blackouts and utility shutdowns regularly. But many have not fully appreciated how these attacks also triggered a cascade effect on health care. Ninety-two percent of health care workers surveyed by PHR reported power outages in their facilities due to Russian attacks on energy. Two-thirds of the health care workers we surveyed told us these outages affected medical procedures, with surgeries postponed and interrupted, water supply interrupted, diagnostic equipment rendered unusable, and medication storage affected leading to spoilage.

The destruction of hospitals, targeting of medical personnel, and coercive measures against health care workers and patients in occupied areas all serve to weaponize Ukrainians’ access to medical care, and maximize suffering, ultimately jeopardizing our way of life.

The war is in every darkened operating room where doctors perform surgeries by flashlight and in every occupied hospital where Russian forces dictate which patients receive care.

Since 2022, Ukraine’s health care workforce has shrunk by 20 percent, and those who remain, continue to care for their patients under impossible conditions. An overwhelming majority – 83 percent – of health workers surveyed by PHR reported increased stress, burnout, and other challenges due to attacks on energy infrastructure and disruption of services.

Pathways to Justice

Attacks on health in conflict zones around the world are on the rise. Health facilities and workers are protected under international humanitarian law: in conflict settings, attacks on health facilities and workers can amount to war crimes or crimes against humanity. Yet these attacks have gone unpunished for decades. From Chechnya to Syria, from Sudan to Myanmar, Russia and other perpetrators have destroyed hospitals and clinics with impunity. The barrage of attacks on health in Ukraine is a chance for the international justice system to finally take a stand.

In 2024, the International Criminal Court (ICC) issued charges against Russian commanders for war crimes related to attacks on Ukraine’s energy infrastructure, citing “alleged strikes … directed against civilian objects” and “the expected incidental civilian harm and damage … clearly excessive to the anticipated military advantage.” This is an important step, but it is not enough.

Attacks on health must be prosecuted as the international crimes that they are. The ICC, national courts, and mechanisms of the United Nations must ensure these violations are investigated. Additionally, the international community should pressure those states which provide Russia with the weapons used to destroy hospitals – accountability must extend to those who enable these attacks.

Justice, however, is not just about courtrooms. For survivors of attacks, conflict-related sexual violence, torture and other violations, justice means recognition, safety, and support. Survivors in Ukraine need access to medical and psychological support, as well as trauma-informed forensic documentation. The Ukrainian government has taken important steps in this direction, creating new investigative units and support centers. But much more is needed: better training for health professionals, an enabling legal and policy environment, stronger coordination between legal and medical sectors, and survivor-centered approaches to justice.

Justice, however, is not just about courtrooms. For survivors of attacks, conflict-related sexual violence, torture and other violations, justice means recognition, safety, and support.

Health care workers, hospitals, and civilian infrastructure need urgent financial assistance, and survivors require continued support. Recent cuts by the United States to its international aid has put millions at risk in Ukraine.

Resilience and Hope

By the end of the third year of the full-scale invasion and after 11 years of war, we are understandably tired. International support is wavering and the Trump administration is embracing Russian talking points. But this is not the time to turn away. The consequences of disengagement are not just about Ukraine; they are about the future of international law, state sovereignty, and global stability. Strongmen of the world are emboldened by impunity and are testing the limits of international resolve. By ensuring accountability for the crimes being committed in Ukraine, we are all safer from the threat of aggression and tyranny.

By ensuring accountability for the crimes being committed in Ukraine, we are all safer from the threat of aggression and tyranny.

There are a lot of ways in which our lives in Ukraine have changed over the last few years. Falling asleep and waking up to the sounds of explosions, swooshing missiles, and buzzing drones, trying to squeeze life in between blackouts, and getting painfully used to losses – all of this does not come easily. But this is also the most rewarding place for me to be as Ukrainians and people from other countries come together in their resolve to support a more just future.

The countless stories of Ukrainian clinicians’ resilience give me hope:

The doctor from a town near Kyiv who provided care for her whole community during Russian occupation, despite knowing her husband and son were being held captive by Russian forces.

A doctor in an occupied city who refused to transfer identifying information about his patients to the new Russian authorities at grave personal risk.

The medic held in a Russian prison camp, trying to treat his comrades despite inhumane conditions and no available medications.

A doctor performing surgeries under bombardment and threats of the Russian army.

A pediatrician rushing to save colleagues and patients after a cluster munition attack on the hospital.

An obstetrician in a bomb shelter, caring for pregnant women and new mothers, and the youngest generation of Ukrainians.

These stories of defiance and dedication in the direst of circumstances, though, demand more than admiration. It’s up to all of us – in Ukraine and globally – to ensure their courage is met with documentation, memorialization, justice, accountability, and redress.

In armed conflicts around the world, sexual violence is perpetrated at an alarming rate – including against children. Multiple challenges limit evidence collection, preventing accountability for sexual violence. In the Democratic Republic of the Congo, Physicians for Human Rights and our partners are supporting child survivors of sexual violence through the creation of child-friendly spaces. After only six months of operation, these spaces have supported more than 500 children in the DRC. Watch to learn more about how we are helping children on their pathways to justice with our partners at Panzi Hospital and HEAL Africa.

Filmed in the DRC in partnership with Panzi Hospital and HEAL Africa. Produced by Hannah Dunphy, Deputy Director of Communications, PHR. Edited by Gabriel Baron.

Table of Contents

1. Introduction
2. Section One – Foundations
   • Toolkit Overview
   • Foundational Principles on Consent, Assent and Dissent
   • Evidence-Based Standards, Norms, and Good Practices
3. Section Two – Curricula
   • Multisectoral Curriculum Summary
   • Advanced Pediatric Curriculum Summary
4. Section Three – Practical Approaches
   • Guidance Sheet on Child-Centered Spaces
   • Fact Sheet on Play Therapy
   • ViVoMo Fact Sheet
5. Section Four – Case Studies
   • Play Therapy Case Study
   • Kavumu Case Study
   • ViVoMo Case Study
6. Section Five – Additional Resources
   • Additional Resources

Introduction

Conflict-related sexual violence is an enduring problem globally. The burden of this violence often affects the most vulnerable within society, including women and girls, racial or other minorities, refugees and internally displaced persons, and in particular, children. According to the UN Secretary-General’s 2024 report on children and armed conflict, almost 30,705 grave violations were committed against children in armed conflict, with sexual violence affecting 1,470 children, globally from January to December 2023.[1] That report indicated that sexual violence against children in conflict affected areas increased by at least 25 percent compared to the previous year, despite cases of sexual violence being vastly underreported due to “stigmatization, the fear of reprisals, harmful social norms, the absence of, or lack of access to, services, impunity and safety concerns,” indicating that the true number of children affected by conflict-related sexual violence is likely much larger.[2]

Survivors often face stigmas and prejudices when reporting sexual violence, and these problems can be exacerbated when working with child survivors who depend on parents, guardians, or other responsible adults to advocate on their behalf. Resources and capacity development for professionals on survivor-centered documentation and judicial processes is limited in conflict, post-conflict, and low resource settings, which can result in evidence not being properly collected or being collected in a way that leads to the retraumatization of survivors. There is also a lack of knowledge standardized approaches and practices for documenting sexual violence in children and, where evidence-based good practices do exist, they are often not shared in a way that can inform wider national, regional or international practices and policies. This toolkit seeks to address these gaps.

Physicians for Human Rights (PHR) developed the Child-Centered Documentation Toolkit to provide practical tools for professionals seeking to reduce the barriers child survivors face when seeking accountability and justice. The toolkit also seeks to improve the documentation and justice pathway for survivors by emphasizing trauma-informed and rights-based approaches, as well as supporting child autonomy and well-being. The principal goal of this toolkit is to create stronger pathways for trauma-informed and survivor-centered documentation and justice processes for child and adolescent survivors. This toolkit seeks to provide practical resources for professionals to use along the documentation and justice pathway to improve trauma-informed and survivor-centered approaches.

PHR developed this toolkit in consultation with experts, partners, and a global community of practice through roundtable discussion and systematic review of resources available for the documentation of sexual violence against children in national, regional, and international contexts in addition to experienced gained during implementation of programmatic and capacity development activities.

This toolkit has been divided into five separate sections with specific objectives to help actors involved in sexual violence response ensure trauma-informed documentation and survivor-centered approaches are applied at various stages of the justice process for child and adolescent survivors. These five sections are:

Section One: Foundations

• Section one reviews the key concepts that inform the toolkit as well as the overall background and context that informs the creation of the tools and resources within the toolkit. In addition, this section focuses on the foundational concepts of consent, assent, and dissent as they relate to children and adolescents, with emphasis on their evolving capacity across all steps of the justice pathway, with specific consideration for conflict-settings. Consent, assent, and dissent are essential components of survivor autonomy, including that of children, and should be prioritized at all times.

Section Two: Capacity Development

• Section two introduces two PHR curricula that can be used to strengthen the capacities of professionals working with child survivors: the multisectoral curriculum and the pediatric curriculum, each of which provide practical guidance for professionals to apply the foundational concepts outlined in module one. These include capacity development on implementing trauma-informed and survivor-centered approaches along the documentation and justice pathway for child and adolescent survivors. The module reviews each curriculum briefly and provides further information for those who wish to access and implement the specific curriculums.

Section Three: Practical Approaches

• Section three includes examples of practical approaches and tools to strengthen trauma-informed documentation for child survivors, especially when collecting physical evidence and/or documenting children’s testimony/experiences. Child-centered approaches are emphasized in this module. This includes key considerations for implementing child-centered spaces and their role in ensuring a trauma-informed and survivor-centered approaches along the documentation and justice pathway. It includes introductions to important concepts, such as “play therapy” which can be helpful in facilitating documentation and supporting child testimony. Additional practical approaches are also referenced here.

Section Four: Case Studies

• Section four applies the concepts, approaches, and tools described in sections one through three to real world examples through the presentation of case studies. This is intended to reinforce how this toolkit and these good practices can be applied in practice. Through these case studies, you will be able to make direct connections to their specific context, further assisting you in learning about these approaches and understanding how to apply these approaches to your own work to promote trauma-informed documentation for child-survivors.

Section Five: Additional Resources

• Section five includes links to additional materials and resources such as international protocols, guidance documents, and other appendices referenced throughout the toolkit.

Intended Audience

This toolkit is intended as a guide and resource for all actors along the documentation and justice pathway. This includes those from clinical, judicial and advocacy settings, including social services and civil society. This includes first responders such as health care providers, police, and law enforcement; as well as actors within legal systems, such as lawyers, magistrates, prosecutors; and other survivor advocates, such as social workers. Specific roles may vary by region or context, but all those who work along the justice pathway involved with documentation of sexual violence with children may find reviewing this toolkit, or elements of it, useful in their work.

How the Toolkit Works

The Documentation and Justice Pathway

The underlying conceptual framework for this toolkit is the documentation and justice pathways, which may include accountability, remedies, redress, acknowledgement or transitional justice, among others. The modules were developed based on these pathways, however, they do not necessarily correspond to specific points. They have different applications along a documentation and justice pathway and may be used multiple times throughout the process. For example, the foundational concepts of consent, assent, and dissent discussed in Module One must be assessed and reassessed throughout every step of a documentation and justice pathway.

Documentation and justice pathways are the “track” or “path” that sexual violence documentation, be it physical or testimonial evidence, “travels” from crime to different accountability processes, be it a criminal prosecution, reparations, or other justice and accountability process. The pathways cross law enforcement, clinical, and judicial spaces – though it is not necessarily strictly linear. Accountability and justice processes may require back and forth along the different steps of a pathway, especially after the first response stages. Different contexts and jurisdictions may also have variations of these pathways. As such, the pathways represented here are a generalized framework that can be adapted to specific and different local contexts. It also is important to understand that these pathways do not exclusively seek strictly legal accountability in the form of criminal prosecutions, but rather, broader justice and remedy for sexual violence. This accountability may take the form of survivors having better access to care and services or simply being recognized as survivors. Because of this, it is important to think of the pathway in a wider context of justice, not necessarily bound by national or local judicial processes.

Survivor-centered and trauma-informed approaches are essential to ensure that survivor well-being, safety, and autonomy are respected and preserved at all times, particularly by seeking ways to protect survivors from retraumatization and mitigate social stigmas that survivors of sexual violence may face. These considerations are important for child survivors, who are even more vulnerable to retraumatization because of their age and developmental stage.[3]  Survivor-centered and trauma-informed approaches must be incorporated along the pathway at all stages, including assessment of survivor consent, assent, and dissent.

Implementation of the Toolkit

PHR recommends that practitioners review the entirety of the toolkit, however, the toolkit does not necessarily need to be completed chronologically. You are welcome to mix and match separate sections and pull from the toolkit what you need to address your specific situations or contexts. This introduction provides context for the entirety of the toolkit and any additional resources or appendices referenced in sections one to four will be found in section five.

Each section will include a list of brief objectives that link the content of the module with the overall goal of the toolkit.

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[1] Special Representative of the Secretary-General on Children and Armed Conflict, “Children and Armed Conflict: Report of the Secretary-General.”

[2] Ibid.

[3] Mazurana and Carlson, “The Girl Child and Armed Conflict: Recognizing and Addressing Grave Violations of Girls’ Human Rights”; Office of the Special Representative of the Secretary-General for Children and Armed Conflict, “Keynote Statement at the Global Summit on Sexual Violence, London.”