The United Nations reports that more than one in three women have experienced physical or sexual violence at some point in their lives. Research shows that these traumatic experiences have both short- and long-term effects on a survivor’s health, making them more likely to seek help from a health care provider. This impact goes beyond physical injuries, often leading to psychological consequences as well. As a result, health care providers serve as a critical and oftentimes the first point of contact for survivors of sexual and gender-based violence. Proper care is essential to ensure their safety and improve outcomes. 

Despite this, many health care professionals lack technical skills and confidence in screening and treating survivors of sexual violence. Additionally, negative attitudes toward survivors of sexual violence are common among medical staff. This not only affects the quality of care survivors receive but can also lead to further stigma and trauma and discourage them from seeking further treatment or reporting future violence. While there has been a focus on improving clinical skills, many health care professionals still lack training in forensic documentation and the important role they play in medicolegal investigations. 

“The collaboration between the health care providers, law enforcement and legal systems will ultimately improve. This shared knowledge will foster trust and efficiency in resolving forensic cases benefiting both the victims of sexual and gender-based violence and Kenya’s justice system as a whole.”

The gap between the needs of survivors and the training of health professionals worldwide is no different here in Kenya, where women experience high rates of sexual and gender-based violence. According to the Kenya Demographic and Health Survey of 2022, 13 percent of women in Kenya have experienced sexual violence in their lives, while 34 percent have experienced physical violence. For years, PHR has worked across Kenya with civil society and survivor organizations to understand the scale of gender-based violence but to also examine the needs of survivors, including physical and psychological support, as well as legal avenues to access justice, redress and reparation.  

As part of our work to build sustainability and co-develop solutions with impacted communities, our medical and human rights teams in Kenya have developed and piloted a rights-based curriculum on forensic documentation for health professionals. Now, thanks to a partnership with the Kenya Medical Training College (KMTC), new solutions are being scaled, set up for sustainability, and having a big impact. 

Phase One: PHR and KMTC Identify the Gaps 

The KMTC, a college under the Ministry of Health, is entrusted with the role of training various disciplines in the health sector, including clinical officers and nurses, who are often the first responders in sexual and gender-based violence cases. The college has 84 campuses strategically located in 45 of the 47 counties in Kenya, offering 95 medical courses within its 18 departments. PHR first partnered with KMTC in 2020, when PHR’s team conducted institutional capacity development projects at key health care facilities in Kenya. We co-developed a month-long clinical rotation training program to equip nearly 200 KMTC students with the skills to comprehensively assess and treat survivors of sexual violence and document forensic medical evidence to support their cases. The KMTC students learned first-hand how to conduct forensic evaluations and were mentored by hospital staff at the Gender-Based Violence Recovery Centers in these hospitals. 

After formalizing the partnership in 2022, PHR supported KMTC’s clinical medicine department to assess the gaps in forensic documentation among health care workers. The results told us the needs were still stark: 61 percent of the respondents cited difficulties in handling sexual violence cases, including medicolegal documentation. Health workers indicated that the correct collection of evidence, as well as understanding laws around sexual and gender-based violence were also challenges.  

Towards a Sustainable Solution 

Guided by these new insights, PHR and KMTC collaborated on solutions. The first step was to formally integrate PHR’s curriculum into KMTC’s core diploma course, a three-year program offered through in-person classes across 42 campuses in the country with more than 2,000 students enrolling annually. In 2024, we additionally spearheaded a new degree track called the Higher National Diploma in Clinical Forensic Medicine. The higher diploma is a two-year program available for all enrolled nurses and clinical officers. Currently, it is being piloted at the Nairobi KMTC campus, with 25 students enrolled. 

PHR and KMTC hope that this strategy for integrating forensic documentation into health professional curricula will standardize best practices in forensic documentation across the country, leading to improved patient outcomes both in terms of care and access to justice.  

According to Mr. Felix Mutua, Head of Clinical Medicine Department, incorporating the PHR material and tools in both degree tracks makes clinical forensic medicine more practical for students and aligns it with the realities of modern forensic and clinical practice.  

“The curriculum is valuable as it is helping students gain specialized knowledge and practical skills to handle medicolegal cases such as assault, sexual violence and workplace injuries,” said Mutua. “There is a lot of hands-on training in forensic case analysis, evidence collection and court testimony practical skills. The new and improved modules will help them gain a competitive edge by acquiring unique skills that are highly sought after in health care and legal professions. They will also be able to offer quality of care to our patients.” 

Overall, PHR and KMTC hope that this strategy for integrating forensic documentation into health professional curricula will standardize best practices in forensic documentation across the country, leading to improved patient outcomes both in terms of care and access to justice.  

What Next?  

The next phase of the partnership will include training for lecturers at the college to equip them with the necessary tools and training to instruct students using this improved curriculum. This is especially vital due to the nuances of responding to sexual and gender-based violence. Partnerships with law enforcement, legal experts, and forensic specialists will be essential for training instructors. 

PHR and KMTC also intend to continue collaborating with national health care institutions, professional bodies, and policy makers to ensure further adoption of the forensic documentation curriculum in private universities and colleges.  

Technology will also play a role in scaling this innovation. Online learning, webinars, and the KMTC digital platform will supplement in-person training. This will make it accessible to a broader audience of health care professionals in remote or underserved areas. 

Finally, the curriculum will be dynamic and adapt to new legal precedents, changes in health care technology, and evolving patient care standards. An ongoing process of evaluation and revision, based on feedback from students, oversight institutions and legal experts, will help keep the program current and effective. 

PHR is excited that the partnership with KMTC has already produced enthusiasm and positive feedback from students and faculty alike. But the real results of this scaling are yet to come. In the words of Mr. Mutua, the long-term impact of the revamped curriculum promises to be a game-changer. “The collaboration between the health care providers, law enforcement and legal systems will ultimately improve,” said Mutua. “This shared knowledge will foster trust and efficiency in resolving forensic cases benefiting both the victims of sexual and gender-based violence and Kenya’s justice system as a whole.”  

We could not agree more. 

Executive Summary

Before the full-scale invasion by Russia in February 2022, Ukraine boasted one of the most developed power sectors in Europe, with universal access to electricity.[1] However, by June 2024, available capacity had plummeted by 85 percent due to Russia’s systematic attacks on energy infrastructure.[2] Russia has blocked gas transit to Ukraine, seized assets, launched cyberattacks, and, since October 2022, systematically bombed Ukraine’s energy infrastructure. By September 2024, Russia had allegedly destroyed all thermal power plants and nearly all large hydroelectric power plants.^[3]

This report – a joint undertaking by Physicians for Human Rights (PHR) and Truth Hounds (TH) – documents the cumulative and reverberating impacts of these attacks on energy on health care in Ukraine. As recognized by the United Nations Human Rights Monitoring Mission in Ukraine (UN HRMMU) and the United Nations Independent International Commission of Inquiry on Ukraine, attacks on energy have had devastating impacts on the health sector in Ukraine.[4] Despite clear protections for health and energy infrastructure in conflict under international law,[5] both sectors have been targeted by Russia. Through research surveying over 2,200 health care workers in Ukraine and case studies, Health Care in the Dark: The Impacts of Russian Attacks on Energy in Ukraine establishes patterns of how energy disruptions translate into short- and long-term health harms and how these harms may be considered violations of international law.

The Russian Federation must immediately cease its aggression and stop attacking health care workers and facilities, targeting energy infrastructure essential to civilian life, and refrain from indiscriminate attacks that endanger both health and civilian energy systems. 

Data collected by TH and PHR since the start of the full-scale invasion shows that the cumulative impacts of Russia’s direct attacks on health facilities, as well as strikes on energy infrastructure with reported impact on health care facilities, have impeded health care delivery and endangered patients and health care workers alike. For example, since the start of the full-scale invasion, health care workers and patients at the Okhmatdyt National Specialized Children’s Hospital have faced multiple attacks that have caused death and suffering. Airstrikes shattered its windows in March 2022, forcing vulnerable patients, including terminally ill and immunocompromised children, to be treated underground despite the grave health risks of doing so.[6] On October 10, 2022 – the day that Russia began its large-scale aerial assault on Ukrainian energy infrastructure – a missile strike killed one of Okhmatdyt’s doctors as she drove to work.[7] In the months that followed, frequent power outages lasting up to several days resulted in lights shutting off in all departments but intensive care. The energy cuts jeopardized patient health by interrupting or delaying surgeries; forcing surgeons to operate in darkness illuminated only by headlamps; discontinuing flow of water to the hospital, creating unhygienic conditions; and rendering diagnostic and treatment equipment unusable.^[8]

“You can work in this mode for a couple of years, but not forever. […] For me, Okhmatdyt was a fortress. I thought a children’s hospital wouldn’t get hit.”

On July 8, 2024, a missile hit the hospital’s toxicology building, killing two civilians, injuring 50 others, and knocking out power and water in the hospital.[9] Dr. Anastasiia Zakharova, a pediatrician and department head at Okhmatdyt, recalls: “It was dark and dusty,” she remembers, hearing “beeping devices, signaling errors [and] the screams of children.”[10] Her colleague, Dr. Svitlana Lukyanchuk, did not survive the impact.[11] The hospital was left non-functional, with temporary power generation systems taking days to restore services.[12] As Dr. Lesia Lysytsia, a pediatric ophthalmological surgeon, reflected: “You can work in this mode for a couple of years, but not forever. […] For me, Okhmatdyt was a fortress. I thought a children’s hospital wouldn’t get hit.”[13]

Similarly, the Mariupol Regional Intensive Care Hospital has also faced challenges after the full-scale invasion. In February and March 2022, the hospital endured several direct attacks during the assault on Mariupol, while the siege cut off its power.[14] The hospital was later occupied by Russian forces and turned into a military base.[15] By December 2022, the hospital had relocated to Kyiv with the help of medical personnel who evacuated from Mariupol.[16]

Even in its new location, the hospital’s functionality is often limited due to ongoing attacks on energy infrastructure. Dr. Olena Lazarieva, an intensive care anesthesiologist, describes how the hospital faces frequent blackouts: “Sometimes during my 16-hour shift, the power was on for 40 minutes, sometimes for an hour and a half.”[17] Without electricity, surgeries are postponed, and lifesaving equipment is at risk of failing: “If there are severe patients, if they need oxygen, artificial lung ventilation, without electricity, it can be bad,” says Dr. Lazarieva.[18] “When you hear an [air raid] alarm, you immediately think what to do – whether there will be a power outage, whether the oxygen station will work, what to do next during the surgery,” says another doctor at the hospital.[19] Physicians report that patients experience panic attacks and cardiac arrhythmia due to lack of power and face delays in surgery and other essential health care.

Despite the international legal prohibition on attacks on health care and attacks on civilian energy infrastructure, the Russian Federation’s ongoing aggression has severely impacted Ukraine’s health care system, with attacks on energy infrastructure causing widespread disruptions in many hospitals like Okhmatdyt and Mariupol.

A survey of 2,261 health care workers conducted as part of this research project indicates that the experiences of clinicians in Mariupol and Okhmatdyt hospitals are far from unique. Key findings from the survey include: 

• The overwhelming majority (92.3 percent) of health care workers report experiencing power outages at their health facility as a result of attacks on energy infrastructure.
• Two-thirds of health care workers (66.3 percent) reported that power outages due to attacks on energy infrastructure affected medical procedures in their facilities.
• Specifically, 8.4 percent noted delays in elective surgeries, 1.7 percent experienced interruptions during surgery, and 1.8 percent reported failures in life support systems due to outages.
• Outages disrupted communication systems (35.7 percent), water supply (21.5 percent), heating and ventilation (19 percent), and elevators (16.5 percent).
• 7.8 percent of respondents noted malfunctions in diagnostic equipment, such as X-ray machines and MRIs due to outages.
  Medication storage issues, leading to spoilage, were reported by 13.8 percent, and 3.6 percent informed about problems with storing biological samples like blood or embryos.
• Permanent health harms (36 reports) and deaths (20 reports) were also reported.  
  82.9 percent of health workers experienced increased stress, burnout, and other challenges due to these attacks on energy infrastructure and disruption of services, with 27 percent facing these hardships daily.

Preliminary analysis suggests that these attacks may constitute violations of international law, including the laws of war and the human rights to life and health, and in some cases may give rise to criminal culpability as a matter of international criminal law. Accountability is crucial to deter future violations, uphold legal obligations, and provide justice and reparations for survivors. Immediate action is needed to investigate these attacks, support Ukraine’s health care system, and ensure the long-term recovery of critical infrastructure.

Conclusion and Recommendations

The Russian Federation must immediately cease its aggression and stop attacking health care workers and facilities, targeting energy infrastructure essential to civilian life, and refrain from indiscriminate attacks that endanger both health and civilian energy systems. Further, PHR and TH also make the following recommendations:

To Prosecutors and Investigative Bodies:

• Focus investigations on attacks on energy and health infrastructure as war crimes and crimes against humanity, ensuring integration of cases and collaboration between national and international teams.
• Dedicate resources to building cases of harm to the health care system and preserving evidence for future legal use.

To the Government of Ukraine:

• Implement legal and policy measures to ensure that attacks on energy and health care are fully documented and investigated.
• Fully document health impacts and support affected patients and health care facilities, including providing mental health assistance.

To the International Community:

• Increase the support to Ukrainian health care facilities to respond to their critical needs.
• Publicly denounce attacks on health and energy infrastructure and advocate for their immediate cessation.
• Enhance enforcement of international norms protecting health care and civilian infrastructure, support accountability mechanisms, and condemn arms sales violating UN resolutions.
• Improve data collection and sharing on attacks impacting health and energy services.
• Strengthen cooperation with non-governmental organizations (NGOs) and national health agencies to improve documentation as well as resilience of health care facilities affected by prolonged power outages.

---

[1] “Ukraine Energy Damage Assessment,” UNDP, March 2023, https://ukraine.un.org/sites/default/files/2023-04/UNDPUkraineEnergy_ExecutiveSummary_eng.pdf.
[2] “Only 27% of large TPPs are operating in Ukraine – Shmyhal,” Suspilne, June 7, 2024, https://suspilne.media/763681-v-ukraini-pracuut-lise-27-velikih-tes-smigal/..
^[3] Kateryna Hodunova, “Russia has destroyed all thermal power plants, nearly all hydroelectric capacity in Ukraine ahead of winter, Zelensky says,” September 25, 2024, https://kyivindependent.com/russia-destroys-all-thermal-power-plants-nearly-all-hydroelectric-capacity-in-ukraine-ahead-of-winter-zelensky-says/.
[4] “Update by the Chair of the Independent International Commission of Inquiry on Ukraine at the 57th session of the Human Rights Council,” Independent International Commission of Inquiry on Ukraine at the 57th session of the Human Rights Council, September 23, 2024, https://www.ohchr.org/en/statements-and-speeches/2024/09/update-chair-independent-international-commission-inquiry-ukraine; “Attacks on Ukraine’s Energy Infrastructure: Harm to the Civilian Population,” UN Human Rights Monitoring Mission in Ukraine, September 2024, https://ukraine.ohchr.org/sites/default/files/2024-09/ENG%20Attacks%20on%20Ukraine%E2%80%99s%20Energy%20Infrastructure-%20%20Harm%20to%20the%20Civilian%20Population.pdf 
[5] First Geneva Convention Article 19; Article 19 of the First Geneva Convention holds that “protection to which civilian hospitals are entitled shall not cease unless they are used to commit, outside their humanitarian duties, acts harmful to the enemy.” There is no set definition as to what constitutes “acts harmful to the enemy.” But examples of acts that are not “harmful to the enemy” – including using small arms in self-defense, actions to defend the sick and wounded and the presence of sick or wounded combatants under treatment, or of small arms and ammunition taken from these combatants but not yet handed over to proper service – make clear that the term is narrow. See Additional Protocal 1 13(2). Moreover, even when a health care facility loses its protected status by being the site of “acts harmful to the enemy,” the attacking party must still give the health facility warning of attack within, where appropriate, “a reasonable time limit” of the attack. Under IHL, energy infrastructure is only a valid target when it qualifies as a military object; otherwise, IHL prohibits attacks on energy infrastructure as civilian objects DoD Law of War Manual § 5.6.8.5; Commentary of 1987 on Additional Protocol I, note 3(b) to Article 52.
[6] “Pain and Miracle: Chronicles of the War at Kyiv Children’s Hospital ‘Okhmatdyt,” LB.UA, November 19, 2022, https://lb.ua/society/2022/11/19/536252_bil_i_divo_hroniki_viyni_kiivskoi.html; “Children’s Hospital in Kyiv Amid Russia’s Attack,” Time, March 14, 2022, https://time.com/6152374/children-hospital-kyiv-ukraine-russia/.
[7] “Kyiv Doctor Killed in Airstrike,” The Washington Post, March 26, 2023, https://www.washingtonpost.com/world/2023/03/26/doctor-kyiv-airstrike-killed-car/.
^[8] Survey; Interview with Dr. Lesia Lysytsia, conducted by Truth Hounds on September 10, 2024 (on-file); “The largest children’s hospital in Ukraine continues to operate and provide care to children despite the power outage,” Okhmatdyt, November, 24, 2022, https://ohmatdyt.com.ua/najbilsha-dityacha-likarnya-ukrayini-prodovzhuye-pratsyuvati-ta-nadavati-dopomogu-dityam-nezvazhayuchi-na-vimknennya-svitla/.
[9] “Health cluster: Okhmatdyt children’s hospital attack response – Key figures and humanitarian efforts,” Health Cluster Ukraine, July 10, 2024, https://reliefweb.int/report/ukraine/health-cluster-okhmatdyt-childrens-hospital-attack-response-key-figures-and-humanitarian-efforts.
[10] Interview with Dr. Anastasiia Zakharova, conducted by Truth Hounds on September 6, 2024 (on-file).
[11] “Health cluster: Okhmatdyt children’s hospital attack response – Key figures and humanitarian efforts,” Health Cluster Ukraine, July. 10, 2024, https://reliefweb.int/report/ukraine/health-cluster-okhmatdyt-childrens-hospital-attack-response-key-figures-and-humanitarian-efforts.
[12] “Russians destroy 2 energy substations on premises of Okhmatdyt children’s hospital,” Ukrainska Pravda, July 9, 2024, https://www.pravda.com.ua/eng/news/2024/07/9/7464822/.
[13] Interview with Dr. Lesia Lysytsia, conducted by Truth Hounds on September 10, 2024 (on-file).
[14] Interview with Dr. Oksana Kyrsanova, conducted by the Media Initiative for Human Rights on March 19, 2022 (on-file); Interview with Dr. Oksana Kyrsanova, conducted by the Media Initiative for Human Rights on December 2, 2022 (on-file); “‘They Drove a Tank and Two Armored Personnel Carriers and Started Shooting Houses Around…’ How the Russians Captured the Hospital in Mariupol, and What Happened There After That,” 0629.com.ua Mariupol City Website, March 31, 2022, https://www.0629.com.ua/news/3362062/voni-prignali-tank-i-dva-btra-i-pocali-rozstriluvati-budinki-navkolo-ak-rosiani-zahopili-likarnu-v-mariupoli-i-so-tam-vidbuvalos-pisla-cogo; “Armoury, Prison, Graveyard: Mariupol Intensive Care Hospital under Russian Occupation,” International Partnership for Human Rights, Truth Hounds, Global Diligence, November 2022, https://www.iphronline.org/wp-content/uploads/2022/11/Mariupol-report_for_distribution_final_1.pdf; ““Our City Was Gone”. Russia’s Devastation of Mariupol, Ukraine,” Human Rights Watch, SITU, Truth Hounds, 2024, p. 49, p. 87, https://www.hrw.org/sites/default/files/media_2024/02/ukraine0224web.pdf.
[15] ““Our City Was Gone”. Russia’s Devastation of Mariupol, Ukraine,” Human Rights Watch, SITU, Truth Hounds, 2024, p. 21, https://www.hrw.org/sites/default/files/media_2024/02/ukraine0224web.pdf; Interview with the witness W-5748, conducted by Truth Hounds on September 18, 2024 (on-file); Interview with witness D-2594, conducted by Truth Hounds on June 23, 2023, (on-file).
[16] “Lost equipment and displaced doctors. How Mariupol regional hospital works in Kyiv,” Suspilne Donbas,  April 01, 2023, https://suspilne.media/431571-vtracene-obladnanna-ta-mediki-pereselenci-ak-oblasna-mariupolska-likarna-pracue-u-kievi/; Mariupolska City Council, Telegram, Post on December 22, 2022, at 11:44, https://t.me/mariupolrada/12175?single.
[17] Interview with Dr. Olena Lazarieva, conducted by Truth Hounds on August 25, 2024 (on-file).
[18] Interview with Dr. Olena Lazarieva.
[19] Interview with the witness W-5748.

Today is the International Day for the Elimination of Violence Against Women and the start of 16 Days of Activism to End Violence Against Women. Around the world, women continue to face staggering levels of violence, including sexual and gender-based violence. Globally, the UN estimates that 736 million women – nearly one in three – have experienced physical and/or sexual violence by an intimate partner, non-partner sexual violence, or both at least once in their lives. 

PHR will continue fighting for justice for survivors of conflict-related sexual violence and empowering the clinicians and professionals who support them.

In 2025, the global community will mark the thirtieth anniversary of the Fourth World Conference on Women and adoption of the Beijing Declaration and Platform for Action (1995). An ambitious blueprint for advancing women’s rights, the Beijing Declaration remains a north star for the protection of the rights of women and girls everywhere. Physicians for Human Rights (PHR) supports the goals of the UNiTE campaign to advance policies to end violence against women at the national and international level, and advance accountability for perpetrators of violence against women. 

For more than 35 years, PHR has been a leader and innovator in the promotion of justice and healing for survivors of conflict-related sexual violence: women and girls, but also men, boys, and people of diverse genders. We use rigorous science-based and trauma-informed approaches to address violence in contexts as diverse as the Democratic Republic of the Congo (DRC), Ethiopia, Iraq, Kenya, Syria, Ukraine, and the United States.  With our partners, PHR has helped achieve landmark victories for justice around the globe. Here’s a closer look at how we work:  

We Document Violations of Human Rights  

PHR conducts rigorous investigations to document and corroborate reports of conflict-related sexual violence. By partnering with health care workers who are providing clinical care to survivors, we have documented evidence of sexual violence in places like Ethiopia, and most recently, the staggering levels of sexual violence in the DRC’s ongoing conflict. We have helped to shine a light on the severe harms caused by restrictions on reproductive rights: in the United States, we have documented the impact of abortion bans on patients and clinicians alike, and in places like Syria, our research has shown how attacks on health have prevented women and girls from accessing essential sexual and reproductive care. 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.  

PHR is also bridging innovation and forensic evidence collection with our award- winning MediCapt app, which enables clinicians to securely document, store, and transmit evidence of sexual violence. More than twice as effective at producing high-quality data than paper-based forms, this court-admissible evidence strengthens investigations, increases prosecutions, and helps ensure that perpetrators of sexual violence can be tried and convicted for their crimes.

We Empower Communities through Capacity Development 

We build local capacity to support the forensic documentation of sexual violence; evidence that empowers survivors and helps catalyze prosecutions of these crimes. PHR centers survivors – along with medical, justice, and law enforcement actors – to drive progress at a systemic level.  

At the heart of PHR’s work are the multisectoral networks and partnerships built among health care professionals, police officers, forensic analysts, lawyers, and judges. In places like Iraq, Kenya, DRC, and Ukraine, PHR prioritizes a trauma-informed, survivor-centered, multisectoral approach to enhance medical-legal processes for survivors that have proven effective. PHR started developing these trainings in 2011. We have been consistently refining our approach to ensure alignment with best practices, in collaboration with our partners and colleagues living and working in affected communities. 

We Advocate for Justice 

PHR has been committed to holding perpetrators of sexual violence accountable. By supporting strong systems for forensic documentation and pursuing accountability, PHR and our partners aim to strengthen investment in ending cycles of violence and supporting healing. In the wake of the 2007-2008 post-election violence in Kenya, PHR utilized evidence to achieve justice for survivors, including orders for reparation and recognition of the state’s failure to uphold their rights. We have also helped secure major courtroom wins in the DRC: after sexual violence was perpetrated against children in the South Kivu village of Kavumu in 2013, PHR worked with medical, law enforcement, and legal professionals to gather forensic evidence from the survivors, eventually resulting in a landmark conviction of the perpetrators.   

This International Day for the Elimination of Violence Against Women, PHR will continue comprehensively fighting for justice for survivors of conflict-related sexual violence and empowering the clinicians and professionals who support them. Through evidence and advocacy, justice for survivors is possible. 

Social demonstrations called by unions across Colombia on November 21, 2019 were swiftly met with tear gas and stun grenades by law enforcement. Two days later, 18-year-old Dilan Cruz was dead, killed by a bean bag fired from a 12-guage shotgun by a member of the Bogota police. At the time, the so called “less lethal weapon” wielded was authorized for police use under Colombian law.  

Law enforcement personnel around the world routinely use weapons such as these against protesters, human rights defenders, and detainees, inflicting excessive and severe physical and psychological harm. This equipment is too often used or abused by police in ways that do not comply with international and regional standards of police use of force and can even violate the universal prohibition against torture, as outlined by the Convention Against Torture. Recognizing the health harms caused by equipment capable of inflicting torture or cruel, inhuman or degrading treatment, PHR has joined organizations around the globe to call for a comprehensive treaty to end the trade of these weapons. 

The Dangers of “Less than Lethal” Weapons 

“Less lethal” or crowd-control weapons, like tear gas, rubber bullets, and water cannons, are capable of inflicting severe injuries ranging from pain and skin irritation to brain damage, internal bleeding, and even death. Law enforcement personnel frequently use this equipment improperly and indiscriminately without sufficient consideration for vulnerable groups, such as children and elderly individuals, or the potential for harm. 

From its work monitoring human rights violations in protest settings, PHR and our partners have documented overwhelming evidence of the immediate and long-term harm caused by these weapons. The PHR and the International Network of Civil Liberties Organizations (INCLO) report “Lethal in Disguise” documents the harmful health consequences of less lethal weapons and the impact of their use on the meaningful exercise of the freedom of assembly. Following the 2017 Kenyan Presidential election, for instance, police conducted a violent house-to-house campaign targeting protestors with live ammunition, batons, tear gas, and other crowd control weapons, leading to 57 fatalities including minors. From May 26 to July 27, 2020, PHR documented 115 people across the United States who were shot in the head or neck with kinetic impact projectiles during the protests following the death of George Floyd.

Why We Need a Torture-free Trade Treaty 

The campaign for the creation of a mechanism to regulate the trade of law enforcement equipment that is inherently abusive or could be misused for ill-treatment or torture has grown into a global movement, championed by prominent human rights experts and leaders at the United Nations.  

As outlined in the 2023 thematic study by the Special Rapporteur on Torture, Dr. Alice Edwards, certain items used by law enforcement are inherently torturous (Category A Items, Annex I of the study) and should be prohibited. These include, for instance, thumb cuffs, multiple kinetic impact projectiles, gang chains, and direct contact electric shock weapons. Other items listed in the report, though holding a legitimate use such as leg cuffs, batons, water cannons, and chemical irritant projectiles, can be misused for torture (Category B Items, Annex II of the study) and therefore require an additional level of oversight to prevent serious abuses.  

Other UN experts, including the former Special Rapporteur on the freedom of peaceful assembly and of association, Clément Nyaletsossi Voule, and the Special Rapporteur on Extrajudicial, Summary, or Arbitrary Executions Morris Tidball-Binz, stressed the importance of the treaty given the “worrying and considerable spike in allegations of excessive and unnecessary use of force by law enforcement in the context of assemblies… in prison and custodial settings, [and] medical facilities.” Along with Dr. Edwards, these experts called on states to advance an internationally binding instrument and amend national laws to end the import, export, production, and use of torturous equipment.  

A comprehensive “Torture-Free Trade Treaty” would strengthen the existing anti-torture framework by giving the international community the tools to monitor and enforce state obligations to prevent torture and other ill-treatment. The absence of a binding framework creates an environment that allows states to claim to be committed to ending torture while simultaneously sustaining it in practice. Today, more than 60 member states have pledged to “act together to further prevent, restrict and end trade” in goods used for torture and other ill-treatment. 

To combat the ongoing trade and use of tortuous weapons, the Special Rapporteur on Torture and Torture Free Trade Treaty Network calls on the international community to:  

• Prohibit the manufacturing and trading of equipment whose only practical use is torture or other ill-treatment; 

• Regulate the trade of equipment that is frequently abused for the purpose of torture or other ill-treatment; 

• Obligate states to enact national laws that enforce prohibitions and ensure transparency for the use of such weapons; and  

• Create an independent and international torture-free trade oversight mechanism. 

According to Dr. Edwards, 

“It is time to improve State and corporate accountability for torture… Companies can currently develop and sell items that have no legitimate purpose other than to inflict excessive pain… They are quite literally profiting from human suffering.” 

Crucial to this mission, an international oversight mechanism would be capable of updating lists of prohibited weapons, monitoring their transfer, and reporting on state compliance. The mechanism would also be empowered to monitor states parties’ compliance with the treaty through regular reports submitted by member states. Combined with guidelines for the documentation of cruel, inhumane or degrading treatment and torture such as the Istanbul Protocol, this mechanism would empower civil society organizations to review compliance by member states and help ensure accountability for allegations of torture by sharing evidence with the treaty body.    

PHR is a member of the core committee of the Torture-Free Trade Network formed to campaign for tighter restrictions on the production and trade of law enforcement equipment, and a signatory of the Shoreditch Declaration that established the network. We call on states to promote a resolution for a Torture-Free Trade Treaty at the 2025 United Nations General Assembly and encourage other civil society organizations to join the Shoreditch Declaration to show their support.  

Executive Summary

Since 2021, eastern Democratic Republic of the Congo has experienced an acute escalation in conflict-related sexual violence that has exacerbated suffering from decades of conflict driven by regional tensions among various armed groups and struggles over valuable mineral resources. The reemergence of the March 23 Movement (M23) rebel group in 2021[1] has fueled the crisis, leading to widespread displacement, a weakened health system, food insecurity, and an alarming increase in sexual and gender-based violence. The withdrawal of peacekeeping forces like the United Nations Organization Stabilization Mission in the DRC (MONUSCO) and the East African Community Regional Force (EAC-RF) has raised concerns about further escalating the humanitarian crisis[2].

In this report, Physicians for Human Rights (PHR) documents conflict-related sexual violence targeting adults and children in eastern DRC. These findings are based on semi-structured interviews with 16 health care professionals and humanitarian workers in conflict-affected areas of North and South Kivu. These interviews detail the experiences of health care workers as they provided care to survivors using survivor-centered research methodology.

PHR’s research findings establish widespread and severe conflict-related sexual violence – including rape and sexual slavery – and barriers in access to health care and accountability, indicating violations of international human rights law, as well as international humanitarian law.

Health care workers have reported a “massive influx of cases” of conflict-related sexual violence among adults and children. Survivors often sought care following very violent encounters with armed groups, which included armed sexual assault by multiple perpetrators, penetration with foreign objects, and forced captivity. The physical and emotional toll on survivors was complex and long-lasting. Survivors presented at health facilities with a range of medical and psychological needs, including lacerations, sexually transmitted infections, unwanted pregnancies, incontinence, paralysis, post-traumatic stress disorder, depression, and developmental delays. In describing the complex trauma seen in their clinic, one health care worker reported that survivors:“They may undergo physical traumas, organ [traumas], destruction…of the genitalia… sexually transmitted diseases that endanger their lives, their future. They can contract unwanted pregnancies. And with those unwanted pregnancies, face the risk of becoming disabled…”

Members of multiple armed groups, including those supported by the DRC’s neighbors and the DRC military itself, were identified by survivors as perpetrators who used sexual violence to instill fear, intimidate, and control affected communities. While violence and displacement caused by armed groups drove survivors away from their communities, clinicians received survivors living in IDP camps who had been forced to travel to insecure areas to access basic resources and who were attacked while searching for food or firewood around IDP camps. As one nurse recounted, “The child had told me that she went to the field in order to look for food. Then, arriving at the field, she ran into two soldiers. Then the soldier told her: I’m going to have sex with you. If you refuse, I will kill you.”

“They may undergo physical traumas, organ [traumas], destruction…of the genitalia… sexually transmitted diseases that endanger their lives, their future. They can contract unwanted pregnancies. And with those unwanted pregnancies, face the risk of becoming disabled…”

Children are frequent targets of sexual violence, with one health care professional reporting treating a survivor as young as three years old. While the patterns of violence against children are similar to those against adults, there are also some indications that the insecurity caused by conflict was seen as an opportunity for acquaintances and others to commit acts of violence against children.

Compounding these challenges, health care providers struggled to cope with the crisis as they experienced supply chain issues and severe human resource constraints which have left them without adequate training, supplies, staffing, or compensation to manage the acute influx of survivors.

The resurgence of violence and related displacement has led to staggering levels of sexual violence, with the UN reporting over 113,000 cases registered in 2023. Documented cases of conflict-related sexual violence more than doubled in the first half of 2024, compared to the same period in 2023.[3] Local health care workers have been central to the response to support survivors of sexual violence by providing medical and mental health care, including medicolegal documentation of sexual violence. However, the conflict has severely strained the DRC’s health care system, which already suffers from a lack of resources and personnel. Attacks on health care facilities have reduced access to essential services, particularly for survivors of sexual and gender-based violence[4]. The ongoing conflict has also increased the incidence of communicable diseases, including mpox – declared a public health emergency of international concern by the World Health Organization (WHO) in August 2024[5] – in the country’s growing internally displaced persons (IDP) camps. The capacity of the DRC health system to respond to sexual and gender-based violence has been compromised, with many survivors unable or unwilling to seek care due to stigma, facility closures, and fear of further violence.

“The child had told me that she went to the field in order to look for food. Then, arriving at the field, she ran into two soldiers. Then the soldier told her: I’m going to have sex with you. If you refuse, I will kill you.”

PHR’s research findings establish widespread and severe conflict-related sexual violence – including rape and sexual slavery – and barriers in access to health care and accountability, indicating violations of international human rights law, as well as international humanitarian law (IHL). The report calls for coordinated efforts by the DRC government, other parties to the conflict, regional and international actors to take urgent action to prevent the use of sexual violence in war and improve security and access to essentials in IDP camps. The study emphasizes the urgent need for better medical care, psychosocial support, and forensic documentation to address conflict-related sexual violence while highlighting the challenges faced in the health sector. Despite the DRC government’s creation and adoption of laws and policies to provide access to justice for survivors and reparations, no further steps have been taken to implement them. There is an immediate need to strengthen monitoring, investigation, and documentation of conflict-related sexual violence, and to promote accountability and justice for violations by all parties.

PHR makes the following recommendations:

To all parties:

• Fully comply with IHL and international human rights law (IHRL) in all aspects of operations throughout the conflict.
• Ensure that local armed forces and police forces, as well as various armed groups involved in the hostilities, do not engage in sexual violence, including by issuing clear directives prohibiting such violence, investigating and removing from service known perpetrators, and referring the perpetrators of these crimes to the appropriate courts to combat impunity.
• Implement the priority actions contained in regional diplomatic efforts, including the Luanda Process and the East African Community (EAC)-led Nairobi Process with a view to promote de-escalation and create the conditions for lasting peace in DRC, the repatriation of all foreign armed groups and foreigners, and compliance by local armed groups with the DRC’s Disarmament, Demobilization, Community Recovery and Stabilization programme.

To the government of the DRC:

• Take all measures to prevent sexual violence and establish conditions to enable IDPs to return to their living environments, including multisectoral coordinated care for survivors, emergency humanitarian aid and community recovery.
  • Immediately improve access to food and firewood or cooking fuel inside of camps to prevent sexual violence against IDPs that occurs outside of the camps.
  • Strengthen security in and around routes where displaced populations are fleeing and within the IDP camps to prevent sexual violence.
• Ensure survivors’ access to justice and reparation for conflict-related sexual violence.
  • Support survivors who wish to report conflict-related sexual violence.
  • Investigate, remove from service, and prosecute actors responsible for violations of IHL and IHLR including Congolese military and political figures, through the judicial services of the DRC.
• Ensure accessible, available, acceptable, and quality health care for survivors of sexual violence, including post-rape care and prophylaxis, sexual and reproductive health care including stigma-free abortion care, mental health care, and child- and adolescent-friendly care.
• Take all measures to cooperate with regional and international legislative bodies to seek accountability and justice for human rights violations.

To the international community:

• As committed by DRC in the June 2024 Security Council session, refrain from authorizing the withdrawal of MONUSCO in North Kivu until progress is made to de-escalate the fighting and instability and when violence has come down meaningfully. And ensure robust monitoring of the situation in South Kivu where MONUSCO withdrawal has occurred, including rates of conflict-related sexual violence in border areas between North and South Kivu.
• Fully fund the 2024 DRC Humanitarian Response Plan[6], including the prevention of sexual violence by strengthening the provision of basic necessities (food, cooking fuel, and others) in IDP camps and by supporting survivors’ healing and access to justice through materials and training for post-rape care, forensic documentation of sexual violence, and comprehensive health care for survivors including mental health, infectious disease including mpox and sexually transmitted infections, and sexual, and reproductive health care.
• Increase international human rights cooperation and support to the government of DRC to promote stronger documentation and evidence-gathering of grave human rights abuses, with a special focus on conflict-related sexual violence and medicolegal documentation and care.

Background

The DRC has a long history of internal conflict and regional tensions amongst numerous armed groups driven, in part, by struggles to control valuable mineral assets[7] , ethnic tensions[8], regional political dynamics[9], and aggravated by intervention by neighboring States[10], which have resulted in wide-reaching impacts including a death toll estimated to be in the millions[11], mass displacement[12], a weakened health system, food insecurity, and sexual and gender-based violence against men, women, and children.[13] Since 2022, the resurgence of the M23 rebel group has significantly escalated the conflict in the region and has pushed rates of displacement and sexual and gender-based violence to record levels. Originally active between 2012 and 2013, when the group occupied the city of Goma in eastern DRC, M23 re-emerged in late 2021 following failed peace discussions. Despite regionally led peace talks and ceasefire agreements, M23 has continued to be involved in ongoing clashes with the Congolese military, displacing thousands and exacerbating the humanitarian crisis. M23’s resurgence has drawn regional attention, with accusations of external support from other states, further complicating peace efforts in eastern DRC. In addition, the growth of foreign investment for the exploitation of natural resources in the DRC and the explosion of illicit trade of precious minerals has fueled territorial tensions in the region and financially funded the growth of rebel movements in recent years, notably, reports have said that M23 has also been accused of smuggling minerals out of the DRC.[14] The UN has expressed concern about “the heavy fighting …between M23, alongside the Rwanda Defence Force (RDF), and the Armed Forces of the Democratic Republic of the Congo (FARDC) together with the Wazalendo coalition of local armed groups, the sanctioned Forces démocratiques de libération du Rwanda (FDLR), and Burundi National Defence Force troops.” The UN Group of Experts on the DRC note that Uganda has not prevented the presence of M23 and RDF troops on its territory or passage through it and sources witnessed Ugandan soldiers crossing into the DRC … and operating in M23-controlled areas.[15] More armed groups have since moved into the region and now over 120 militia groups occupy the eastern DRC with the Congolese army (the FARDC) frequently employing them as proxies in close combat with M23[16]. They include the Nyatura (an umbrella term for predominantly Hutu self-defense militias who fight against M23, and various Mai-Mai groups opposed to the presence of Rwandophone Hutus in eastern DR Congo), Kinshasa-hired eastern European mercenaries[17]. Moreover, international stabilization and peacekeeping forces have also operated in the region, including MONUSCO, EAC-RF and more recently the Southern African Development Community Mission in the DRC (SAMIDRC)[18].

In November 2023, the newly elected Congolese government signed a memorandum calling for MONUSCO to cease operations in the DRC. As of June 30, 2024, MONUSCO had already pulled all but essential personnel from the province of South Kivu. There is widespread concern that MONUSCO’s departure, scheduled to be complete by the end of 2024, will further escalate the humanitarian emergency and leave vulnerable communities at increased risk.[19] This comes shortly after the EAC-RF began withdrawing from the region after the DRC government chose not to renew the force’s mandate in 2023. The EAC-RF was replaced at the end of 2023 by a force from the Southern African Development Community (SADC), but there have been concerns regarding the SADC’s ability to tackle M23 and the continued resistance to pursuing non-military solutions in the region.[20]

Public Health

The ongoing conflict has affected the health systems, rates of communicable diseases, maternal and child health, and access to services for survivors of sexual and gender-based violence.[21] The DRC has a ratio of 1.05 doctors, nurses and midwives per 1000 population, significantly lower than the Sustainable Development Goals index threshold of 4.45 physicians, nurses and midwives per 1000.[22] The health system has also been impacted by facility closures, reduced health care staffing, cost of care, and threat of violence. In 2022, there were 159 attacks on health care facilities, forcing these centers to reduce care provisions or cease operating for up to a month.[23] Attacks on health reduced the number of deliveries occurring at health facilities, decreased the quality of care, and lowered the number of child vaccinations.[24] The already understaffed health system is under additional pressure from previous mpox, yellow fever, cholera, and malaria.[25] In North Kivu, cholera and diarrheal diseases are on the rise in internally displaced persons (IDP) water, sanitation, and hygiene facilities are lacking. The conflict has also dramatically increased reports of sexual and gender-based violence; in the first quarter of 2023, reports of sexual and gender-based violence increased 37 percent as compared to that time in 2022.[26] Survivors of sexual violence often avoid seeking health care because of facility closures, reduced health care staffing, cost of care, threat of violence, stigma associated with sexual violence, and fear of jeopardizing their marriage or other social relationships. Survivors who are able to or choose to seek care often require specialized medical care, psychological care, prenatal or abortion services, and forensic documentation services, in addition to services provided by social, judicial, and legal actors.[27]

Conflict-Related Sexual and Gender-Based Violence

Civilians on the ground have also faced significant conflict-related sexual violence by Congolese forces as well as numerous other military actors as part of attacks on villages and communities, while fleeing violence, and in displacement camps. Due to many factors, including significant cuts in food assistance, gender-based violence cases have increased dramatically over the last year, and M23 has encircled Goma – a humanitarian hub – isolating the city from the rest of the province.[28] Women and children are particularly vulnerable. Women and girls accounted for almost 90 percent of all cases, with incidents of sexual violence against children increasing by 40 percent.[29] In the Bulengo IDP camp, a few miles from the city of Goma, one facility’s medical staff report that an average of five to seven survivors of sexual violence arrive every day for treatment, averaging six child and adolescent survivors of sexual violence under the age of 18 each week.[30] Increased crowding in IDP camps, insufficient humanitarian assistance, and aid distribution policies, as well as underlying poverty and food insecurity, have also exacerbated vulnerabilities to sexual violence and sexual exploitation, including survival sex, including with peacekeeping forces, is well documented and has continued to grow as a coping mechanism and a 2023 mapping project identified 145 brothels in eastern DRC, at least half of which are located in IDP sites.[31] Children are also frequently employed in these brothels and there have been reports of women and girls selling sex for as little as US$0.20.[32] Rates of sexual violence and exploitation have been increasing over recent years with a substantial increase in documented cases from about 40,000 in 2021 to over 113,000 in 2023.[33] Cases of sexual violence, particularly conflict-related sexual violence are expected to continue to rise in 2024 due to the resurgence in violence and increased displacement. United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA) estimates that a staggering 685,000 people are at risk of sexual and gender-based violence and may require specialized care in 2024.[34]

In the face of these staggering levels of sexual violence, local Congolese health workers mounted a robust response to support the health care needs of survivors of sexual violence in North Kivu and surrounding areas affected by conflict in the DRC. Local clinicians and the organizations that they work for are providing IDPs with a comprehensive suite of medical and mental health services, including reproductive health care, access to contraception, and psychological support for the mental health consequences of sexual violence.[35] Local and international organizations have also worked to meet survivors’ basic needs by deploying teams to provide food, hygiene and dignity kits to people living in camps near Goma.[36]

Health care workers have been central to the response to support survivors of sexual violence. Locally trained clinicians have expanded the forensic documentation of sexual violence, including through the introduction of MediCapt, a mobile application to collect and secure forensic evidence of sexual violence.[37] To support the needs of children, facilities have opened child-friendly spaces to help children access holistic care and referrals and children who have experienced sexual violence.[38]Besides, health care workers have joined forces with other sectors including legal and law enforcement professionals in multisectoral networks to collaborate on cases and better implement locally driven responses.[39]

Access to Justice

While the high levels of conflict-related sexual violence persist, access to justice has historically been limited or non-existent for these survivors. In 2023, the DRC government adopted a Draft National Transitional Justice Policy to establish judicial mechanisms to address human rights violations. However, no further steps have been taken yet to operationalize the commitments outlined in the policy.^[40] Following a request for investigations into alleged crimes committed by rebels in North Kivu, including M23, the Office of the Prosecutor of the International Criminal Court (ICC) committed to investigate all crimes in its jurisdiction, however it is unclear how these accountability efforts will take place in practice.[41]

Alongside a weak and overwhelmed national justice system, survivors of sexual violence have had limited access to reparations, despite continued promises from national and international actors. Even with the creation of the National Fund for the Reparation of Victims in 2022[42] and national consultations to develop a transitional justice policy, only interim reparations have been available to survivors of conflict-related sexual violence through a non-governmental organizations[43]. Ongoing challenges of victim identification and the lack of transitional justice systems have impeded the DRC government’s ability to address survivor needs and facilitate access to justice. Documentation of conflict-related sexual violence incidents and collection of forensic evidence is carried out but is scattered and often incomplete. There is a lack of coordination amongst the actors involved in the care of survivors and documentation of crimes, primarily due to insufficient training, staff shortages, and limited resources[44].

Against this backdrop of the intensifying conflict, PHR conducted research to understand the recent patterns of perpetration of conflict-related sexual violence in eastern DRC.[45] To document the rapidly deteriorating situation, PHR sought to capture the experiences and needs of health care professionals working to support survivors of sexual violence through their unique perspectives, expertise, and experience.

Methodology

PHR conducted one-on-one semi-structured interviews to capture the experiences of 16 health care professionals and staff working at IDP camps, employed at health facilities and humanitarian organizations, who provided direct services to survivors of sexual violence in the three key health zones in North Kivu and South Kivu provinces affected by conflict-related sexual violence and displacement since March 2022. Qualitative research approaches allowed for the study to capture the experiences, context, and depth of health care worker experiences in DRC, however, it is not able to provide estimates of prevalence or more generalizable typical of data collected using quantitative methods.

In addition, the team complemented these interviews with desk research. To summarize evidence from previously published and unpublished reports, news and media reports, and peer-reviewed studies on the nature and scale of conflict-related sexual violence, attacks on health care and IDP camps and possible associations between attacks on health care and IDP camps and conflict-related sexual violence the study team reviewed published reports in media and reviewed published and unpublished documents from international, national, governmental and non-governmental organizations.

The research team included PHR staff and external experts from the DRC, the United States of America, and France, and other nationalities with expertise in medicine, public health, law, human rights, and investigations as well as physicians who have experience documenting or responding to sexual and gender-based violence in the region. Data was collected in May and June 2024. The PHR Ethics Review Board reviewed and approved the study.

To mitigate vicarious trauma, the team implemented regular meeting sessions, allowing members to debrief their experiences and share emotional support. Interviewers in the field received vicarious trauma training prior to data collection. PHR staff involved in the project regularly participate in vicarious trauma training activities. These strategies helped to maintain the mental health and resilience of the team while navigating potentially traumatic subject matter.

Study Population 

Semi-structured qualitative interviews (16) were conducted with health care professionals, and staff working at IDP camps, or humanitarian aid workers in conflict-affected health zones in North or South Kivu such as Minova, Kirotche, and Goma. Inclusion criteria included being an adult health care worker of any discipline, staff working at an IDP camp, or humanitarian aid worker who also has experience working with a population in or around the health zones impacted by conflict after March 2022, the date identified as the start of the current phase of violence. As is standard in qualitative research, the final number of interviews collected as part of this study continued until ‘data saturation’ – or the point at which new themes or information ceased to emerge from the data – rather than quantitative methods for statistical representation to determine the final sample size of 16 health care workers.[46] The health care workers interviewed for this study represent three different health zones in North and South Kivu, six health specialties, and perspectives of both male and female health care workers, providing a diversity of experiences and insights, which are critical for understanding the nuanced impact of conflict on health care delivery in the region (see Table 1 for respondent demographic data).

 The selection of health care professionals was a deliberate strategy to capture the unique perspectives of professionals who provided support to survivors. The health care professionals interviewed for this study have extensive experience working with multiple survivors over extended periods, enabling them to identify patterns and trends across their patient populations. Their insights could corroborate and contextualize survivor experiences reported by other sources. This approach aligns with the principles in the Murad Code,[47] as it allows for data to be collected from other sources in a manner that “poses less risk for survivors, and …mitigate[s] over-reliance on survivor information.” Participants were not compensated for their participation in the study.

Informed Consent

Professionals interviewed by PHR as part of this project gave written or verbal informed consent prior to participating in the interview. Study subjects each received a written informed consent form, which was derived from the Global Code of Conduct for Gathering and Using Information about Systematic and Conflict-Related Sexual Violence, also known as the Murad Code.[48] The consent form introduced participants to the researcher collecting the data, outlined the purpose of the study, and explicitly stated the benefits and risks of participation. It was emphasized in the informed consent form that participation in the research was voluntary and based on active, ongoing consent.

Data Instruments

PHR developed a semi-structured interview guide to scaffold questions and ensure that they addressed the domains related to the key research questions. This guide drew from previously developed guides as part of completed projects and published reports in other settings such as Myanmar and Ethiopia.[49] The semi-structured interview guide included questions related to health care and humanitarian workers’ experiences treating patients, child and adolescent survivor experiences, perpetration of human rights violations, challenges in addressing trauma and care, and attacks on health. A brief demographic form was used to capture health professionals’ education, employment, and work experience.

Data Collection and Management

PHR identified and recruited an interviewer, prioritizing clinical experience and training in conflict-related sexual violence research and documentation, as well as familiarity with the methodologies employed. Before interviews began, the interviewer received training on procedures, confidentiality protocols, safety measures, ethical considerations during interviews to minimize re-traumatization, and the specific study aims and sampling methodology. The interviewer was also trained on all the tools and underwent practical training to familiarize themselves with them before interviews began. To ensure that emerging data iteratively informed the interviews with Congolese health care workers. PHR held regular meetings to review interview transcripts to identify additional probes, refine lines of questioning, and strategize ways to enhance the interviews with health care workers. These meetings also assessed the research’s progress towards reaching data saturation and collectively processing interview content, mitigating the potential trauma for the research team, including interviewers in DRC.

After obtaining informed consent, all interviews were recorded, transcribed in French and reviewed by at least two researchers to ensure accuracy. Recordings of interviews were immediately deleted to maintain the privacy, safety, and security of participants. Once transcribed, the interviews were de-identified.

Data Analysis

In accordance with common qualitative research methodology, de-identified interviews were uploaded to Dedoose, a qualitative data management and analysis software for analysis and review.[50] All interviews were coded by at least two researchers in the original language of the interviews, French. Coders used a coding dictionary to provide a consistent way to organize the content within the transcripts for review and analysis. The coding dictionary was flexible and iterative to allow for more codes to be added as new findings emerged from the data. All changes to the coding dictionary were discussed and implemented across coders.

The data analysis comprised a three-step process. First, open coding categorized data within and across interviews into common areas of interest. Second, data were compiled into theme tables to record key themes that emerged from the data. Finally, summaries were created to describe and integrate the key elements within each theme. This process enabled the research team to review the coded data, identify cogent themes and patterns, and create a cohesive narrative responsive to the project’s research objectives and reflective of the data. The analysis process was an iterative and collaborative effort, inclusive of all team members incorporating their diverse and broad areas of expertise.

Limitations

As a qualitative study, the interpretation and analysis of data is subject to interpretation biases introduced by the researchers. The research team was multidisciplinary, drawn from various cultural backgrounds, and worked collaboratively to address potential biases in the interpretation of results. A qualitative inter-rater reliability exercise to check for consistency in the application of codes in the data analysis phase was used to address this potential limitation.

This study is limited to the perspectives of health professionals interviewed for this study. Health professionals interviewed as part of this study can recount their experiences treating survivors of conflict-related sexual violence but are not able to directly share survivor experiences, as they were not typically present at the times when survivors had violent experiences. Study respondents were asked to recall patient histories and their experiences from events dating as far back as 2022, which means that recall bias is inherent in the data presented. However, professionals were able to review notes and other clinical materials at their disposal to refresh their memory.

This study may not be able to capture all forms of sexual violence experienced by survivors in this conflict, as all information may not be divulged to health care workers. For example, survival sex[51] may not be reported to health care workers because individuals may feel they are consenting or that they will face criminal charges for reporting it.

As with all qualitative research, our sample was relatively small and not random. Therefore, there are limitations in terms of the generalizability of this data regarding the experiences of the many health care workers and their organizations involved in the humanitarian efforts in the Democratic Republic of Congo.

Findings

Increase in Sexual Violence Cases

Many respondents in Minova, Kirotche, and Goma health zones interviewed for this study reported a stark increase in cases since 2022.

“If we go back in time, the conflict didn’t start today, obviously, but we started to see a massive influx of cases starting from the year 2023. That’s when the war started really taking on a larger scale… And that’s when we started receiving a lot of rape cases, victims of sexual violence and many other related assaults, but also injured persons… But it’s since 2023 that we’ve seen a real explosion of references to cases originating from these consequences of war.” Nurse working in Goma health zone

“The resemblance, the similarity that we’ve already observed is that during periods of conflicts, of clashes, there’s an influx in cases. The number of cases increases in comparison to the situation in a normal context.” Nurse working in Minova health zone

Survivor Characteristics

Age

The health professionals interviewed for this study described treating survivors of all ages, from adults to children as young as three years. There was a wide range of responses regarding the primary age of the survivors that health care professionals treated, and responses seemed to vary by facility. However, most respondents had experience treating both adults and children on a regular basis.

“Sometimes, it’s under 18 years old, sometimes, it’s 18 years old or older… almost every age is affected.” Public health expert working in Goma health zone

There was a broad age range reported in the patient population, with participants reporting seeing patients as young as three years old. Though most frequently the child survivors seen were between the ages of 12 and 17 years old.

“Children who are most affected by the… sexual violence… are the children at the age of puberty. That’s the age you find from… 13 to 18 years old.” Humanitarian specialist working in Goma health zone

“Well, sometimes, we get children who are victims of sexual assault that are three years old, four years old, five years old, eight years old, it depends” Public health expert working in Goma health zone

Most child survivors were girls although some health care professionals reported rare cases of treating boys who experienced sexual violence, though the general feeling was that boys experience sexual violence, but they do not report it.

“Up until now, since we’ve started the patient care, since the atrocities of the war, we have never found a man. Even though men can get raped, but they do not present themselves [to us].” Nurse working in Kirotche health zone

In general, health care professionals interviewed for this study were unable to speak to specific ethnic or linguistic groups being targeted.

Gender

Most of the health care professionals interviewed reported that the majority of conflict-related sexual violence survivors treated in their facilities were women and girls who had been internally displaced. Gender intersected with other factors, including labor roles, age, displacement status, and economic status to create vulnerabilities to sexual violence. The most common vulnerabilities described by respondents include the lack of firewood and food which forced women and children to go to the fields outside of the camps to gather these resources due to gendered labor roles.

“…many are linked to the conflict because as you know, we are close to the displaced persons camps. Where the displaced people go to get firewood in the park. And there, they run into many armed groups who take them and rape them while they are conducting their activities in the park.” Nurse working in Goma health zone

While male survivors sought services at some facilities, not every health care worker interviewed had received male survivors. Most health care workers described seeing limited or sporadic cases of conflict-related sexual violence against men and boys. However, many health care workers emphasized that they are aware that there are many men who have experienced sexual violence and choose not to come forward due to fear of stigma from health care workers or their community.

“What’s true is that there are men who get raped. But unfortunately, when you see yourself as a man, there are times where you hide a lot of things because you start developing the idea to say, no, maybe they’ll make fun of me as soon as I’ll tell my story, and all that. But I’ve at least seen one dad before…. He had been raped and it was a dad who came to the consultation… But predominantly, men do not come to the consultation, but they are also raped.” Psychologist working in Minova health zone

“Sometimes, we don’t ask for their origin … You see, when someone is traumatized, and you start going deeper into their origin. They’ll tend to wonder: ‘He’s asking me about my origin, what does that mean? Does he not want to treat me anymore, or is there something wrong?’ So, we limit way more the questions that seem more closed and that would cause the cut off of the dialogue.”

Psychologist working in Minova health zone

Survivor Demographics

The survivors seen by the respondents came from a variety of ethnic and linguistic groups. Some of these ethnic groups include Bahavu, Banyarwanda, Bashi, Batembo, Hunde, and Nande. Survivors were identified as speaking Kihunde, Kinyarwanda, Kirundi, and Swahili. However, several health care workers explained that it was challenging to identify a predominant ethnicity of conflict-related sexual violence survivors as they saw survivors from many backgrounds at their facilities.

“Ethnicity, it’s really… we can’t really say that there’s one ethnicity that’s affected, but it’s everybody. Because those that are raped, there are the Bahunde, there are the Banyarwandas, there are the Batembos, there are Bahavus. And so, the one who falls into the trap is always raped. So, we can’t really say that the violence is characterizing or choosing an ethnicity.” A nurse working in Kirotche health zone

“…on a general level, really, all the communities that are there are affected in a proportional manner, if I may say it that way.” Physician working in Minova health zone

Health care workers also sometimes choose not to collect information on ethnicity or geographic origins of the patients to avoid retraumatizing or alienating the survivor. One health care worker explained:

“Sometimes, we don’t ask for their origin … You see, when someone is traumatized, and you start going deeper into their origin. They’ll tend to wonder: ‘He’s asking me about my origin, what does that mean? Does he not want to treat me anymore, or is there something wrong?’ So, we limit way more the questions that seem more closed and that would cause the cut off of the dialogue.” Psychologist working in Minova health zone

Perpetrator Characteristics

All health care professionals interviewed as part of this study reported treating survivors who experienced violence at the hands of multiple perpetrator groups, including governmental military forces, rebel, and militia groups.

Some survivors identified members of FARDC as perpetrators of rape; one health care worker shared a story of a rape:

“There’s a displaced person who was here at the camp. And then there were some soldiers who met her at her home. They entered there and took this victim by force. Afterwards, the victim arrived here with soldiers accompanying her here. And we took care of this case… They were soldiers from the [FA]RDC…Here, in the camp… [of] displaced persons… The assault took place during the night… So, the soldiers had weapons. They were intimidating the victim with the weapons. All three of the soldiers had raped this woman… [The soldiers spoke] …Swahili.” Nurse working in Minova health zone

Some survivors reported rapes perpetrated by Wazalendo groups. Meaning patriots in Swahili, Wazalendo are local militia groups generally affiliated with the DRC government.[52] Some survivors identified Wazalendo as speaking Swahili when reporting to health professionals.

“What we can say with this, there really are rape cases… There are either soldiers, or Wazalendos who intimidate them, and they do whatever they please with them.” Psychologist working in Minova health zone

Other health professionals reported treating survivors who experienced rape at the hands of Nyatura militias,

“They say that it’s the soldiers or it’s the Wazalendos, or it’s the Nyaturas.” Nurse working in Kirotche health zone

Rebels associated with the M23 were reported by multiple health care workers as perpetrators of multiple forms of sexual violence.

“It was three soldiers… well-armed… from armed groups. That’s when she said they were soldiers of the M23… the soldiers had gone to war. She was left on her own… She ran away just like that, she left.” Psychologist working in Minova health zone

Health care workers reported a greater level of diversity of perpetrators of conflict-related sexual violence against children compared to adults. Reported perpetrators included armed soldiers from several armed groups identified above and a limited number of health care workers identified peacekeeping forces, or associated entities as perpetrators of sexual violence. [53]. Clinicians identified others who took advantage of vulnerability and instability to commit these acts. These included teachers, family members, peers, and employers. One health care worker below described UN MONUSCO forces giving “favors” to families in exchange for being allowed to have sexual relations with their children.[54]

“Yes, we admitted at least two who were raped. They came with pregnancies resulting from rapes by their parents.” Nurse working in Goma health zone

“Our military, the UN, MONUSCO. So, the MONUSCO too, sometimes, take the children and give favors to their family so that they consent to relations with the children. All of these are cases of sexual exploitation and sexual abuse.” General physician working in Goma health zone

Despite these accounts that contained specific information identifying perpetrator groups, many survivors were not able to identify perpetrators beyond affirming that they were armed strangers who were either uniformed or tried to conceal their identities.

“Often, the victim has no knowledge and doesn’t manage to identify them. I can just describe to you a little bit how he was dressed. Was it a man in a uniform, was it a civilian? But often, because she’s the one who’s coming from the fields, you get told that they’re hooded men. Hooded, maybe they couldn’t identify. The others are men, they had faces, but they don’t get found. They can describe how he was dressed, his body shape a bit, but oftentimes, they are people the victim has not been able to truly identify” Nurse working in Minova health zone

“The survivors, because today you can’t know to identify the armed groups on the ground. With the multiplicity of armed groups, they all are in military clothing, they all carry weapons. Now identifying them, you can say they may be FARDC soldier, while they are soldiers from Wazalendo or Nyatura, as there are more than 20 armed groups in this entity where women are raped.” Nurse working in Kirotche health zone

While survivors were not always able to specifically identify perpetrators, when asked by health care workers, they were still able to identify certain characteristics. Most commonly, survivors were able to report the language that perpetrators spoke, including Kinyarwanda, Swahili, and Lingala.

“He said that they are soldiers who speak Kinyarwanda. He did not identify this type of soldiers, but he said they speak Kinyarwanda only.” Nurse working in Kirotche health zone

“So, in many cases, the victims are not able to really provide the profiles… But there are some others who respond that the perpetrators spoke either Lingala, or Kinyarwanda… In many cases, we cannot detect the perpetrator’s profiles.” Psychologist working in Minova health zone

A common pattern of perpetration is the use of hoods or masks to conceal the perpetrator’s identity from the survivor.

“No, they don’t know the tormentor… Many say that the tormentors are masked. They are usually masked, and they don’t see the perpetrator, they don’t even see the face. So, they see that they are men wearing military outfits, armed with either rifles or machetes, for instance, but they don’t see the face.” Nurse working in Goma health zone

As noted in the quotation above, the use of weapons is also frequently mentioned in the survivor’s accounts of their experiences. Masked or hooded perpetrators carry out the assault with rifles, guns, machetes, or other bladed weapons. The perpetrator(s) would then often threaten to kill the victim(s) if they do not submit themselves to the rape.

“The survivors arrive, they have been assaulted by an armed man. And when the weapon is pointed at the head of the survivor, the survivor lets herself be used.” Physician working in Minova health zone

Types of Sexual Violence

Multiple Perpetrators

All health care workers interviewed by PHR universally reported having treated multiple survivors who experienced conflict-related sexual violence[55] with rape[56] reported by all respondents. In particular, patients who had experienced multiple perpetrator rape.

“The cases that we receive a lot, are rapes committed by several people and often, they are armed people, so soldiers and the likes of them. But there are also cases of forced sexual acts, without consent. That is found here also, but most oftentimes, they are cases linked to rapes with multiples partners, if I can put it that way, or multiples aggressors.” General physician working in Minova health zone

Use of Foreign Objects

Health care workers often reported survivors presenting with complex physical injuries. One described several physical injuries resulting from penetration with sharp objects:

 “Yes, there are injuries linked to sharp objects that can be used during the rape, as it is much more the case during conflicts, during war. There are those perpetrators who use sharp objects such as wood sticks. And from that, we get vaginal lesions, lesions on the perineum, and sometimes complete tear of the perineum. And really, it is the type of lesions that we receive most often.” General physician working in Minova health zone

Types of Sexual Violence against Children

Respondents reported frequently treating child survivors of conflict-related sexual violence to be mostly girls. Children who presented for health care after experiencing sexual violence commonly experienced vaginal rape. Cases of forced marriage, procuring or trafficking, harassment, and sexual assault were also mentioned.

 “…When I talk about sexual violence, it’s much more about penetration. … Because there are children who arrive, you see that perhaps…” General physician working in Goma health zone

“Rape, there are others… There is harassment. There are cases of harassment. There are… We also have cases of forced marriage. There are cases of pimping. There are so many forms of sexual violence.” Humanitarian worker working in the Goma health zone

Settings of Sexual Violence

Geographic Location of Reported Attacks

Health care workers interviewed by PHR frequently collect information related to the location of the attacks from the survivors that they treat. Over 18 different locations were flagged by these health care workers as locations where survivors had experienced sexual violence (see Table 2). These include the following: Bitonga, Butondo, Bweremana, Kabase, Kalehe, Karuba, Kashenda, Kituku, Minova, Mubimbi, Mungunga, Ndosho, Ngungu, Numbi, Rusayo, and Soko Boudondo. Within these geographic locations, the site of perpetration is often referenced generally as “the forest” and “the fields” surrounding the displacement camps; these are the most common sites of perpetration mentioned by survivors:

Table 2: Geographic locations identified by health care workers as sites of reported conflict-related sexual violence
North Kivu Attacks	North Kivu Origins	South Kivu Attacks	South Kivu Origins
Bitonga, Masisi	Kanya Bayonga, Rutshuru	Butondo, Kalehe	Buganga, Kalehe
Bulengo IDP Camp, Masisi Nyiragongo border	Karuba, Masisi	Bweremana, Kalehe	Bukavu, Kabare
Goma, Nyiragongo	Kiluki, Masisi	Market of Bweremana, Kalehe	Bushushu, Kalehe
Kabase (Bahunde chiefdom), Masisi	Health care zone of Kirotshe, Masisi	Market of Kashenda, Kalehe	Bweremana, Kalehe
Kanyaruchinya IDP Camp, Nyiragongo	Health care zone of Kitoyi, Masisi	Minova, Kalehe	Kalehe, Kalehe
Market of Kituku, Nyiragongo	Masisi, Masisi	Highlands of Minova, Kalehe	Minova, Kalehe
Lushagala IDP Camp, Nyiragongo	Mushaki, Masisi	Mubimbi IDP Camp, Kalehe
Masisi, Masisi	Mushenge, Lubero	Numbi, Kalehe
Mushaki, Masisi	Ngungu, Masisi
Ndosho, Nyiragongo	Rutshuru, Rutshuru
Rusayu IDP Camp, Nyiragongo	Shasha, Masisi
Rutshuru, Rutshuru

Rape While Fleeing Violence

Health care workers reported that women often experienced conflict-related sexual violence while fleeing their home and encountering militias, rebels, the FARDC and other armed groups in road to displacement camps.

“Lately, most of the victims confess that the incident happened, mostly in the conflict areas. While they are trying to flee and some others, while they are heading to the field to look for food, they encounter this difficulty there. And others, in their home, because there are victims who stayed in the conflict zones. And when the malefactor run into them there, they sexually assault them.” Nurse working in Minova health zone

“And you see, that with this conflict of war, when they flee, they head towards Minova, but they always tend to return to go look for food in their original environment. That’s how they fall into the hands of these bandits. They rape them in the bush, even on the way, in the bush. It happens sometimes even that they bring them back in their camp and they finish up with them for that many days and leave them.” Nurse working in Kirotche health zone

“Lately, most of the victims confess that the incident happened, mostly in the conflict areas. While they are trying to flee and some others, while they are heading to the field to look for food, they encounter this difficulty there. And others, in their home, because there are victims who stayed in the conflict zones. And when the malefactor run into them there, they sexually assault them.”

Nurse working in Minova health zone

Rape while Seeking Food or Cooking Fuel

Health professionals interviewed for this study frequently shared that survivors reported rapes after leaving camps or their communities to look for food or firewood for cooking in insecure areas nearby. One health care worker spoke about the large number of survivors they see who report sexual violence while looking for firewood.

“Most of them tell us that they were in the bush in order to look for firewood. Especially firewood. Because there are times when we receive even 10 cases of firewood, firewood.” Nurse working in Goma health zone

“There is a case we received the day before yesterday, just arriving from Bitonga. She had gone towards the forest to look for firewood. Once she got there, she ran into unidentified soldiers. Then, those soldiers forced, they took by force and really, they hurt even the outside part and even the inside part of this survivor. We saw that it was really severe [damage/injuries].” Nurse working in Kirotche health zone

Not limited to firewood, survivors also shared with health care workers that they were raped while looking for food. A participant spoke of one survivor in particular who was raped while looking for cassava leaves to eat.

“…a woman who came, who told me she had gone to get food in a field, to pick cassava leaves. And then she was caught by someone in charge, an individual she didn’t know, and he imposed sexual intercourse on her. There, he raped her. When I examined her, I did not find physical traces, but I found that since it had been already two, three days, it was more infections that were developing.” Nurse working in Minova health zone

Survivors frequently reported sexual violence occurring within camps. One health care worker shared a pattern of sexual violence occurring at night and particularly during periods of rain.

 “So, in the camps, it happens mostly at night. And when it rains, then it’s more serious because even twice, even three times during the night. Because it’s raining, there is no one to help and all that. It’s complicated in the camps.” Public health expert working in Goma health zone

“…it was raining. There’s a man who came sneaking into the little house, that is, thinking he wanted to take shelter there. But instead, he found the woman on her bed and jumped on top of her. While it was raining, the woman tried to scream, but the people around, as there was heavy rain, people around didn’t realize immediately.” Nurse working in Minova health zone

The lack of security in both communities and camps left survivors vulnerable to repeated experiences of sexual violence.

Rape While Deprived of Liberty

The majority of the health care workers interviewed also shared survivors experienced sexual violence in captivity. In one case, a survivor reported being held for five days and in another case a survivor reported being held in captivity for one month before escaping.

“…she had come from Minova to go look for food in their place of origin, in the high plateau. And as she was coming back, there was a hold-up by armed men who took her to their place of residence. She finished five days and during the five days, she suffered forced sexual intercourse, by five men per day and each according to his will. And when she was released, she found that she did not even have the strength to contain urines. So, she felt that she was already open. And when she came, we tried to run tests. Unfortunately for her, she had already contracted syphilis, that we took care of.” Nurse working in Kirotche health zone

Other forms of Gender-Based Violence

Health professionals interviewed for this study also identified cases of forced marriages happening within IDP camps.

“Forced marriages, there, we receive them starting from the… [prenatal consultation] … A young girl aged 15, she has already married in the camps. That, that’s already a forced marriage.” Public health expert working in Goma health zone

Settings of Sexual Violence Against Children

Often what left adults vulnerable to sexual violence left children at an even higher risk. Children were reportedly raped and experienced other forms of violence by members of armed groups and militants while fleeing their towns and villages on the way to IDP camps, and after having arrived at the camps. Like their adult counterparts, children were often attacked when gathering food or firewood for cooking in the forest or fields.

 “The child had told me that she went to the field to get food. Then, arriving at the field, she ran into two soldiers. After, the soldier told her: I will have sexual intercourse with you. If you refuse, I will kill you. Then the child accepted. The soldiers had forced the act.” Nurse working in Kirotche health zone

There were also accounts of children who had been raped alongside their mother while in the fields outside of the IDP camps. In other accounts, rebels and other militants have attacked IDP camps and children have been raped in their tents.

“Currently, in the displaced persons camps, there’s everything. So even children are raped in the tents there. There are others who go to the field with their mothers, they are raped there.” Nurse working in Goma health zone

Children not only experienced sexual violence while fleeing violence, but also faced sexual violence in internally displaced persons camps. Respondents reported that perpetrators of sexual violence against children in camps sometimes included a child’s family members, including parents.

“Yes, we have received at least two who were raped. They had come with pregnancies resulting from rapes by their parents. One had come from Kalehe, another had come from Mungunga. They had come alone to request an abortion.” Nurse working in Goma health zone

Children also experienced sexual violence from their friends, peers, and classmates.

“For the children, the tormentors are often their older friends. They are sometimes the pupils, their classmates. Most of them admit that it is their friends, their classmates, who are the tormentors.” Nurse working in Minova health zone

Several respondents noted that children may take employment in private homes and that their employers perpetrated sexual violence against children by taking advantage of their vulnerabilities, notably absent parents and economic poverty to demand sex in exchange for employment or benefits.

“Yes, we are seeing children that are now being used in environments such as the Ngandas, or they’re being used in homes, restaurants. And there, we think they can be used as workers, but we don’t know what happens in those homes, and since they do not have any means, they can concede their sex. That is a problem already.” Nurse working in Kirotche health zone

“Well, consequences of sexual violence, first of all we have… There are many diseases. There are a lot of diseases linked to sexual violence. There are children who… Well, there are children who are victims of rape. There is also famine because the women are afraid to go get food outside.”

Psychologist working in Minova health zone

Consequences of the Sexual Violence on Survivors

The experiences of sexual violence described above left survivors with numerous physical and psychological consequences.

“Beaten up. Yes, there are even fractures that arrive, even with fractures. Even from machete or from bullet.” Nurse working in Goma health zone

Other physical consequences included sexually transmitted infections, unwanted pregnancies, amongst other physical injuries and conditions:

“Consequences, those who arrive after 72 hours, they have a lot of infections. We see a lot of STIs, sexually transmitted infections. There are unwanted pregnancies that can occur, and much more on a psychological level. They really have psychological disorders. There are even those who go all the way to developing mental disorders to the point of going to psychiatric centers. … There are those who arrive, but who have been sexually and physically assaulted, they arrive with broken bones, with paralysis, with a lot of stuff.” Physician working in Goma health zone

“Even with HIV, we have a lot of cases here that we screen who already carry the HIV due to [sexual] violence.” Nurse working in Goma health zone

Health care workers routinely reported seeing patients displaying severe psychological consequences of violence. Health professionals interviewed for this study routinely reported seeing patients with signs of post-traumatic stress disorder, isolation, shame, self-blame, and depression.

“The consequences are obvious. The cases we see in consultation develop several pathologies. …They develop isolation issues after experiencing these problems. There are precursors that already give us an idea that the patient is already developing a mental problem: isolation, guilt, shame, fear that the event will happen again. From a pathological point of view, there are now major pathologies that are developing: depression. Aside from depression, we also encounter cases that develop post-traumatic stress disorders. There are also cases that develop many other problems, anxiety disorders.” Psychologist working in Goma health zone

While some survivors had complex physical injuries after their assault, many survivors presented without any physical injuries that could be documented.

“The survivors get here; they have been assaulted by an armed man. And when the weapon is aimed at the survivor’s head, the survivor lets herself be manipulated. So, sometimes, for older people that have had sexual relations in the past, maybe with their husband, it’s a little bit difficult to have lesions. Because with the weapon there, when told undress, they undress, sleep, they sleep, spread your legs, straight away they do it. It’s like they were ready to do that thing. So, sometimes many women can arrive and out of ten women, to have just two people who show lesions.” Physician working in Goma health zone

Survivors experienced many consequences of sexual violence that have been outlined above including famine because of fear of returning to the fields outside of the camps and being raped again.

 “Well, consequences of sexual violence, first of all we have… There are many diseases. There are a lot of diseases linked to sexual violence. There are children who… Well, there are children who are victims of rape. There is also famine because the women are afraid to go get food outside.” Psychologist working in Minova health zone

“…The impact of the conflict on children victims of sexual violence, in any case, the impact is too severe.You know, first of all, these children, apart from the fact that they may undergo physical traumas, organ [traumas], a nasty destruction of the genitals, they can develop, contract sexually transmitted diseases that endanger their lives, their future.”

Nurse working in Minova health zone

Impacts on Children

Children experienced complex patterns of violence with profound psychological and physical impacts. Physical effects included contracting sexually transmitted infections (notably syphilis), HIV, lesions on the vulva and vagina and other genital traumas.

“But in what happens in cases of minors who have never had sexual intercourse well before, there are so many lesions that can be observed. This is all that is done to a child under the age of 10, under 15, 10 or 12, like that. There are visible lesions, that can be seen in the vulva area. There are others that were traumatized, that were assaulted physically. They can arrive with wounds, bleedings.” Physician working in Goma health zone

“The impact of the conflict on children who are victims of sexual violence, in any case, the impact is too severe. You know, first of all, these children, aside from the fact that they undergo physical traumas, organ [traumas], a nasty destruction of the genitals, they can contract and develop sexually transmitted diseases that endanger their lives, their future.” Nurse working in Minova health zone

Pregnancy resulting from sexual violence was a particular concern for respondents who noted that since the resurgence of the conflict, there has been an increase in pregnancies in girls under age 18. Several health professionals reported treating child patients for unwanted pregnancies. Some participants reported girls being abandoned because they became pregnant following rape. Abortion access was, however, noted to be limited.

“A child who has been sexually abused without finding support, it’s a trauma that destroys their whole life. That destroys their whole life, that can even get to the point of defining their future. …The child thinks this is normal. We even get to… unwanted pregnancies, clandestine abortions, with everything it convenes.” Humanitarian worker working in Goma health zone

“Minors, they are accompanied by their parents. But this one time, a girl had just given birth in the hospital […] in case of a pregnancy resulting from rape, it becomes a headache for the hospital, because it is the hospital that covers this medical care and expenses… it’s as if the family has abandoned the young girl, because the pregnancy is a pregnancy resulting from rape. The perpetrator is not known […]. So, it’s the hospital that bears the weight on its back for the care of this child.” Public health expert working in Goma health zone

In addition to physical health effects, there were multiple psychological health consequences of sexual violence against children. Respondents discuss Post Traumatic Stress Disorder (PTSD), trauma, fears of abandonment, fear of being reattacked, fears of discussing the experience of violence, sadness, depression, anxiety, stress, isolation, distraction, inability to reason, low self-esteem, inability to express oneself, developmental delays, behavioral problems and changes among others.

“The impact on these children’s mental health is that these children seem to be abandoned to their sad fate because their mothers, sometimes, do not know the perpetrators of the rape[s]. These children now find themselves in situations where they are abandoned to their ill fate et sometimes they also develop mental illnesses.” Nurse working in Minova health zone

“Yes, there are definitely developmental delays. Because with the situation they’ve been through, there are some children who become absent-minded. There’s no concentration.” Psychologist working in Minova health zone

One participant described the interconnected and long-lasting impacts of sexual violence on child survivors’ physical, psychological and mental health.

“…The impact of the conflict on children victims of sexual violence, in any case, the impact is too severe. You know, first of all, these children, apart from the fact that they may undergo physical traumas, organ [traumas], a nasty destruction of the genitals, they can develop, contract sexually transmitted diseases that endanger their lives, their future. They can contract unwanted pregnancies. And with those unwanted pregnancies, they’re at risk of becoming disabled in their lives. They will no longer study. Especially since even studying is hard for displaced persons. When to all of this is added an unwanted pregnancy, the girl’s life becomes complicated. At the same time on the psychological level, some develop mental disorders, abnormal behaviors in the community, in life. And I believe that the impact, the consequences, there are numerous ones.” Nurse working in Minova health zone

These accounts speak to both the long-lasting mental health impacts and the stigma and social consequences child survivors may face. Finally, respondents discussed the potential impact of sexual violence on parents’ mental health.

 “The concerns are that the parents even have difficulties digesting [processing] these cases. They find that the child is traumatized. But sometimes, the parent or the guardian is also traumatized at the same time as their child because their child was the victim of a rape case. And you find that there is… There’s guilt on the one hand. For example, if a parent has sent the child to fetch firewood and the child becomes a victim, the parent will guilt themselves too. Why did I send them?” Humanitarian worker working in Goma health zone

Delays in Accessing Care

Besides, multiple health care workers spoke of significant delays related to the time of survivors presenting at facilities for care. Some survivors did not present until six months after the assault, due to insecurity related to the conflict and challenges accessing care and social barriers such as fear, stigma, or lack of understanding of the resources available.

“You will see a case, a victim to whom the rape occurred six months ago, who is showing up at the hospital now. … And it’s afterwards that we discover cases like that and so, who stay within the community, unfortunately. And when they get to the hospital, often it’s late and there are not many interventions we can proceed to about it.” Physician working in Minova health zone

“Those that are in society or in the community, many do not seek support. And we received some cases recently who told us: I resigned myself for at least two weeks before looking for support or seeking care. …There are many cases like that, that are referred to us late, beyond 72 hours. And there, taking care of them is a big issue for us, whether it’s on a medical level or a psychological level.” Psychologist working in Goma health zone

Drivers of Conflict-related Sexual Violence

Health care workers interviewed by PHR identified numerous drivers of conflict-related sexual violence that left survivors vulnerable to sexual violence, including insecurity, poverty, and food scarcity. Insecurity took many forms including banditry, troop movements, and militia presence along roadways. Survivors frequently reported having no choice but to enter insecure areas when fleeing, and due to a lack of basic resources in IDP camps.

Insecure areas in and around IDP camps were identified by health care workers as a key factor increasing the risk of vulnerability to sexual violence.

“Yes, because for now, the majority of our patients come from displaced persons camps. Because over there, there is insecurity, especially at night, it’s a bit complicated. So, in the morning, if there is a case that exceeds the plateau at the camp level…” Public health expert working in Goma health zone

Some health care workers also identified insecurity within communities as drivers of sexual violence in conflict-affected areas of North and South Kivu. Insecurity in terms of banditry, troop movements, and militia presence along roadways led to experiences of sexual violence.

“Cases of rapes exist a lot because as you will notice, there are women that can go to the field and on the way, there are either soldiers or Wazalendos who intimidate them, and they do whatever they want with them. So, in short, we really have women raped here and there. …there is a mother who came lately, here, she said that no, I was raped, because on her plot, there is a road that leads to the mountain where the soldiers keep their bombs, their heavy weapons, there. And as soon as they passed by, they found the mother and took the mother, they went up with her, on the way she was raped.” Psychologist working in Minova health zone

Response to Conflict-Related Sexual Violence: Access and Barriers to Care

Forensic documentation

Forensic documentation services are being provided to survivors by some local health care workers, but most facilities included in this study do not routinely collect forensic medical evidence. Multiple health care workers interviewed pointed to the need for further training and mentorship to support improved forensic documentation at their facility.

“We collect them on the basis of a medical certificate that we have, but the certificate of forensic evidence, we will maybe need accompaniment or training so we can reassure ourselves that really, we do it without failures… Yes, as I’ve said, we don’t have training on filling forensic documents, but also sometimes we face difficulties to fill some of the tools, but with the means we have on board, we try to do what we can.” Humanitarian worker in Goma health zone

Another health care worker described the lack of materials for collecting forensic evidence, including dignity drapes, medical certificates, supplies to collect forensic samples, in addition to the lack of training as a key barrier to the collection of forensic evidence.

“Yes, sometimes we face difficulties in collecting forensic evidence due to lack of equipment for sampling this evidence, but also due to lack of training. We are not informed on the ways to collect this evidence.” A nurse working in Minova health zone

“Consent forms, general information, all that. There aren’t any. There aren’t any.” Nurse working in Kirotche health zone

Even at facilities where the collection of forensic evidence was taking place, challenges related to the collection and analysis of samples due to lack of resources remained. Storage of forensic evidence posed problems for many health care workers interviewed for this study as facilities lacked secure places to store evidence, such as clothing, paperwork, and other important materials and supplies necessary for the forensic evidence collection process.

“You know, the survivors that arrive to you with clothes but already torn up, dirty, shredded. They would need to keep, conserve these clothes that they wear for evidence, but also to be given new clothes, for instance. They would need first of all to be accompanied, even maybe materially a bit, for a time so that she feels considered. But often, she comes… Us, we will only stop at the medication aspect. We only give treatment.” Nurse working in Minova health zone

“Document? I can say yes, because on the consultation form. There is the part where we talk about evidence. Keeping them, we don’t really have an appropriate place to keep them. … First, their collection poses a problem because we don’t have all the means, everything that is necessary to collect this evidence, but also their conservation.” Nurse working in Minova health zone

“Often, there are shortages of medication. Even PEP kits, sometimes, we can lack other means, logistical means.”

A sexual and gender-based violence nurse working in Minova health zone

Lack of Resources

Health care workers almost universally pointed to a lack of general resources in a number of areas that made comprehensive care and treatment of survivors of sexual violence more difficult. Supplies, including medicine, post-exposure prophylaxis (PEP) kits for HIV prevention, and forensic evidence collection supplies (discussed above) were frequently cited as missing. In particular, PEP kits were identified as sometimes missing.

“We’ve observed that if there is no assistance in PEP kits and other essential medicines, really, the population has to suffer from this bad behavior.” Nurse working in Kirotche health zone

“Often, there are shortages of medication. Even PEP kits, sometimes, we can lack other means, logistical means.” A sexual and gender-based violence nurse working in Minova health zone

Furthermore, one facility reported missing HIV testing kits for routine testing and treatment.

“Yes, well, difficulties in relation to medical care, for now, it does not pose a problem. But sometimes, we’re missing tests for HIV. When we need to do the tests and we do not have any, it is a difficulty. That is in relation to medical care.” Humanitarian specialist working in Goma health zone

In addition to the lack of funds for key supplies and materials, resource challenges also had an impact on the kinds of services available. One health care worker described how some facilities continue providing free care and support – despite the lack of resources for programming – even at great cost to the facility, however it was unclear how long facilities can continue to do so without additional funds.

“Fortunately, lately, since the war started, here, the care, we provide care to the displaced persons and all other categories for free without even support. That is also a difficulty we are facing, because with the structure not being supported, we do not know what to do. At the same time our brothers who came from Masisi and Rutshuru and elsewhere, they need care. They are unable, in a state of vulnerability where they cannot pay for care. Us, we sacrifice the care ourselves to tell them they do not pay today.” Nurse working in Minova health zone

Unwanted Pregnancy, Access to Abortion Care and Emergency Contraception

Pregnancy was noted as common amongst survivors. Health care workers reported multiple challenges in caring for survivors with children resulting from unwanted pregnancies, as well as facing malnutrition, housing barriers, lack of psychosocial support, and limited access to pre and antenatal care.

“During the consultation, the midwives, the nurses notice that the mother is crying. So, they wonder why. And while trying to dig deeper, they observe that the mother is crying because of the burden of this child. And that in truth, at home, she has nothing to eat. And no one is helping her to take care of that child. That’s when the nurse notices the child is the result of a rape. … The child is already six months old. He’s already six months old. And the need of the mother was what? To separate from this child because he is a burden now. She can’t take it anymore. There is nothing to give him, there is no food. Even housing, the mother relates that the child spends the nights with the mother under the stars, meaning next to the shops, in the street. So, she wanted this child to have a taker, someone who needs to adopt him at least, because she can’t stay with that child anymore… Psychologically, it had disturbed her.” Psychologist working in Goma health zone

Another health care worker pointed to the complex challenges mothers who have children born of rape face in their communities.

“They are almost discredited and abandoned. They are not acknowledged by their family. They are people that are always neglected. On the economic level, they have no activity because she was raped when she was a minor or here, she was even an adult woman of the household, but who was raped and was rejected by the husband. She remains alone trying to find ways to feed this child.” Nurse working in Minova health zone working

In the face of high levels of unwanted pregnancies and social stigma facing unwed mothers, health care workers reported some instances where survivors asked to terminate the pregnancy or expressed desire to no longer be pregnant. They reported that access to abortion care for survivors of sexual violence varied from site-to-site with services being offered at some locations and other locations did not have adequate supply of emergency contraception due to the lack of PE kits or for facilities with a religious affiliation they did not offer abortion care. At other health institutions where abortion access was unavailable, survivors may be referred to other places where they could access this service.

“If it happens that the survivor suggests an intervention, on our end, we make a referral to where there is a package in relation to care. That’s what we do. You know, religious faith, it’s a little complicated compared to other structures. So, we redirect, make a referral to where the package is available.” Public health expert working in Goma health zone

At some facilities, survivors were sometimes given counseling to discourage them from seeking an abortion if they expressed a desire to terminate the pregnancy. One health care worker described an example of this practice.

“… We put in place psychoeducation to show her that… We guided her, we can’t make the decision for her, but we guided her on how she could bring this child into the world. There is time, we even apply an acceptance therapy so she can settle with that. … we discourage them from aborting.” Psychologist working in Minova health zone

Impact of the Crisis on Health Care Workers and Human Resource Constraints

Health care workers frequently reported that the conflict’s scale and gravity has taken a toll on them. They described how they were overwhelmed with the number of patients they see.

“Sometimes, we are affected when we’re overwhelmed. We see cases that really overwhelm [us]. Because there are cases of sexual violence for which you start wondering: are they humans, are they animals. Sometimes, it suffuses, and it really affects the person’s mood.” Public health expert working in Goma health zone

One health care worker described how the volume of survivors they saw had a great impact on their own wellbeing and suggested mental health programming to help health care workers navigate how they are impacted by the crisis.

 “Yes, as a health care worker, really, I would like to add something. It is related to the psychological state of us also, staff, caregivers, because it affects us too, when you see the cases really increasing in high numbers like that, it affects us. It affects us a lot…” General physician working in Minova health zone

In addition to mental health care and support, health care workers often pointed to human resource challenges that affect their ability to provide patient care. Some health care workers pointed to lack of pay as a factor that is disincentivizing health care workers who support survivors.

“Yes, on the funding side, there is an impact. Because the human resources are available, the medicines are available, but there is no motivation for the staff who takes care of these victims.” Nurse working in Minova health zone

Pay was not the only factor impacting the ability of health care workers to treat survivors. The health care workers indicated that lack of clinical training on survivor care and forensic documentation is a key human resource constraint.

“Well, we have human resources, but who also lack training[s], because everyone, in this context should go through training…. We have personnel who should help to receive and know many cases or to have many cases who were raped and stay within the community, but who are not trained.” Nurse working in Kirotche health zone

Good Practices in Service Provision

Despite the immense challenges identified by health care workers – including lack of resources and a surge of cases – clinicians and health facilities have found collaborative and innovative ways to provide support and services to survivors. One emerging good practice to tackle the stigma and mental health challenges for survivors has been the development of safe spaces. One clinician shared the initiative their facility has taken to establish a safe space for women who have experienced sexual violence to meet and discuss their experiences:

“So, for the women, women didn’t have a place where they could go to discuss, to talk about their stuff. … So, that’s why our project thought of creating a space where women can come, talk about what’s happening to them and what they do, and feel safe. So, the safe space is where there is safety. They can talk about their stuff here and there’s not going to be any infiltrators or things that can leak out. That’s it. So, they feel good when they come here to discuss their matters.” Psychologist working in Minova health zone

Several clinicians also referenced the strong referral pathways to support services within their facilities and with other facilities and organizations. These referral pathways have made it possible for clinicians to send their patients to trained and specialized professionals to address their unique needs resulting from the conflict. This has allowed for more comprehensive care for survivors to address their needs – both physical and psychological.

“For the psychological state, thankfully, we organize it before the care, we must go through counselling always. We have the APS who are trained but also the organizations that help us in the care, they have APS too, they have psychologists. This is how we try to put the victims back in their own frame. But their psychological situation is not always good because they incriminate the fact that if the war wasn’t happening, they would not fall into these pictures of violence. So, they are not well at all, despite the fact that they are still in houses, in foster families, in schools. They are still in the entities, and they don’t know when they will be able to return to their original environment, with this war that does not want to end.” Nurse working in Kirotche health zone

And despite the growing needs for increased training and resources for forensic documentation, several facilities are establishing strong practices and policies for secure collection and documentation of medical-legal evidence. While there are still challenges to address, clinicians discussed the use of tools, such as the forensic medical certificate, that have helped them more comprehensively document forensic medical evidence. Another clinician spoke about using technology to support forensic medical documentation of sexual violence, as an innovative approach they use to document forensic evidence medical evidence of sexual violence.

“…We do a collection correctly because we have elements for collection. We have our forensic certificate. We have… the… software… that helps us collecting forensic evidence. …we have our documents for the collection, so we still do it anyway.” Physician working in Goma health zone

Analysis

Clinicians interviewed for this study report that violence has increased dramatically in North Kivu and South Kivu since 2022. This has resulted in a surge of cases of conflict-related sexual violence in a region that has experienced over 30 years of these violations. Clinicians frequently report a growing trend of receiving patients who have experienced multiple forms of conflict-related sexual violence, including multiple perpetrator rape, rape with foreign objects, which has resulted in a host of physical and psychological impacts, including sexually transmitted infections, unwanted pregnancy, incontinence, isolation, and post-traumatic stress disorder in addition to other long term psychological impacts.

Despite the “massive influx of cases”[57] of sexual violence seen by clinicians interviewed by PHR, the study’s findings also point to a potentially large number of survivors who have experienced sexual violence but who have not accessed care, support, or medicolegal documentation services. Clinicians frequently reported that the survivors who presented at health facilities were typically in need of care for acute medical needs, such as prenatal care, pregnancy termination, HIV testing and treatment, mental health and psychosocial support for complex trauma. The fact that most clinicians reported survivors presenting at facilities with acute injuries combined with the intense stigma faced by survivors suggests that there may be many more survivors who could not access care or did not access care due to the lack of physical injuries following sexual violence. This implies that there may be a potentially large number of survivors who have not reported their experiences of sexual violence, have not sought medical care, or been able to access post-rape care or services.

While no one actor was identified as the sole perpetrator of the violence, clinicians interviewed by PHR identified multiple armed groups that used sexual violence to fuel fear, intimidation and exercise control amongst affected communities. Survivors reported conflict-related sexual violence as being committed by Swahili, Lingala and Kinyarwanda speaking perpetrators. Furthermore, clinicians also identified instances where the UN, MONUSCO forces, or their associated civilian agents committed sexual exploitation and abuse against children.[58] In addition to UN actors, clinicians interviewed by PHR also identified others, including teachers, family members, peers, and employers, who took advantage of vulnerability and instability to commit sexual violence against children. One respondent below described UN or MONUSCO forces giving “favors” to families in exchange for being allowed to have sexual relations with their children. These accounts are consistent with other reports, including the recent report that eight MONUSCO peacekeepers were accused of sexual misconduct in October 2023.[59] There were 224 documented reports of sexual exploitation and abuse by MONUSCO forces between 2010 and 2021.[60]

Additionally, armed actors took advantage of the vulnerability created by protracted fighting to commit sexual violence with impunity. Most notably, this study noted no difference in patterns of perpetration of the crimes across groups nor did the data show patterns of how specific groups targeted affected populations which points to a need for additional research. That being said, multiple drivers of conflict-related sexual violence, including insecurity in communities, on roadways, in and around camps, and economic insecurity placed survivors in situations where they were particularly vulnerable to violence. Clinicians almost universally reported that survivors experienced sexual violence while searching for food or firewood. This report shows that there are no safe spaces for civilians to go to as they face sexual violence in their communities, along the roadways as they seek safety, and in internally displaced person camps. The gendered vulnerabilities associated with gathering firewood are well-documented as women and girls are often exposed to sexual and gender-based violence when gathering food and firewood.[61] [62] In DRC, Médecins Sans Frontières has reported that the majority of survivors describe sexual violence occurring “while searching for food or firewood outside of the displacement camps.”[63] While sexual violence occurs at the hands of a variety of actors, the root factors that drive conflict-related sexual violence include the security of roadways and communities, food insecurity , and the security of displaced persons camps.

DRC has the world’s largest population of food insecure people with 6.5 million people experiencing food insecurity in Ituri, North Kivu, and South Kivu. Furthermore, the lack of services to support citizens experiencing insecurity and displacement due to conflict with necessary humanitarian aid such as food, cooking fuel, health services and other resources, creates a self-perpetuating cycle of vulnerability to sexual violence which we see in the number of respondents who shared stories of patients who had experienced sexual violence at multiple times.

This study draws important attention to the sexual violence experienced by children in this conflict. Clinicians reported treating children of all ages who have experienced rape, forced marriage, and forced pregnancy. The drivers of sexual violence against children in this conflict were similar to those of adults but were heightened by children’s specific vulnerabilities based on their age and gender. As well, the range of perpetrators shared by clinicians for cases of sexual violence involving children, indicates that in some instances the insecurity caused by conflict was seen as an opportunity for acquaintances and others to commit acts of violence against children. Clinicians interviewed for this study almost universally reported providing post-rape care to child survivors who experienced complex patterns of violence and presented with compounded physical and mental health impacts of the violence, including sexually transmitted infections, unwanted pregnancies, long-lasting trauma, and physical injuries, including on survivors’ genitals. Clinicians reported using emerging good practices for engaging with children, notably child-friendly spaces, but resources to support more child-focused programming to ensure children have access to tailored care and psychosocial support services to address the immediate and long-term impacts of the violence were still seen as lacking.

The study also provides insight into the profound needs related to medical care and services related to post-rape care and support for survivors of sexual violence. Many clinicians reported outages – ranging from sporadic to frequent – of key medical supplies that are key to patient care, such as HIV testing kits, PEP kits, and key medicines. These supply chain challenges are coupled with severe human resource constraints which leave health professionals without the training, staffing, and pay to manage such an acute influx of survivors. As of the date of publication, the United Nations Office for Coordination of Humanitarian Affairs is reporting a significant gap in the amount of funds needed for the humanitarian response in DRC versus the amount of funds allocated for the response underscoring the gap in resources needed to support survivors, prevent conflict-related sexual violence, and ensure millions of people can access the lifesaving support that they need.[64]

In particular, this study finds that forensic documentation of sexual violence is only happening at some – but not all – facilities where survivors seek care, pointing to challenges in documentation and a need for more investment in training and resources to facilitate medicolegal evaluations and evidence collection. Forensic documentation services are an essential part of post-rape care and are part of the United Nations Joint Global Programme on Essential Services for Women and Girls Subject to Violence, a partnership by UN Women, United Nations Population Fund (UNFPA), WHO, United Nations Development Fund (UNDP) and The United Nations Office on Drugs and Crime’s (UNODC) Essential Services package for women and girls subject to violence. To ensure that crucial forensic documentation services are routinely offered to survivors, training and funding are required to ensure clinicians are able to collect, document, preserve, and transfer key evidence. A forensic medical certificate of sexual assault – a standard documentation tool for clinicians to use to systematically document forensic medical evidence of sexual violence – was nationally recognized in the DRC in 2022. Additional support is needed to ensure that all professionals are trained in its use and have the requisite supplies to properly collect, document, store, and transfer forensic medical evidence. Moreover, some clinicians interviewed were not trained on the specificities of conducting medicolegal investigations with pediatric and adolescent populations- highlighting both a need for additional training for clinicians and the possibility that some children may not have access to appropriate forensic documentation, due to distance and lack of knowledge of the availability of those services.

In addition to the needs of survivors and the health system, support for clinicians who are front-line first responders engaging with survivors must be central to all responses to the conflict. Often working with little to no pay, clinicians report experiencing vicarious trauma from working with survivors of sexual violence who have experienced complex trauma and brutal injuries. To manage this exposure to trauma, clinicians requested psychosocial support and training on coping with exposure to trauma for themselves.

While access to abortion care is legal in the DRC, this study shows that these services are not always available to survivors who express a desire to terminate an unwanted pregnancy. A variety of factors contributed to the inability of survivors to avoid pregnancy or access abortion care, including a lack of emergency contraception at the facility or the referral of women expressing a desire for abortion care to counselling. These factors meant that pregnant survivors of conflict-related sexual violence who wish to terminate their pregnancy are not always able to access abortion care or pregnancy termination despite DRC’s obligations under the 2008 ratification of the Maputo Protocol and the 2018 Public Health Law.[65] The need for access to safe abortion for survivors of conflict-related sexual violence in DRC is great. The lack of services and supplies has a profound impact on women; the DRC has one of the highest maternal mortality rates in the world[66] and it is estimated at least 10 percent of maternal deaths each year are due to complications from unsafe abortions and 74 percent of Congolese women aged from 15 to 49 have an unmet need for contraception. As of September 2023, the United Nations Population Fund estimated that there were at least 220,000 pregnant and displaced women in this conflict who lack secure access to health care.[67] 2.2 million pregnant and breastfeeding mothers suffered from acute malnutrition in 2023 in Ituri, North Kivu and South Kivu provinces.[68]

Challenges in pursuing political solutions have prolonged the growing violence in the DRC. The Nairobi and Luanda processes provide opportunities to advocate for sustainable and non-militarized solutions to the humanitarian crisis.[69] Increased funding for the Humanitarian Response Plan for the DRC is also essential to reducing the risk of further violence for civilians and IDPs in North Kivu. As of September 2024, the Humanitarian Response Plan for the DRC was only 37 percent funded, at US$964.1M million.[70]

Legal Analysis

PHR’s research confirms that conflict-related sexual violence is perpetrated by a range of actors, including the FARDC, M23, which UN experts recently identified as being in the control and acting at the direction of Rwanda, and other Congolese and foreign rebel and militia groups. Our findings establish widespread and severe conflict-related sexual violence – including rape and sexual slavery – and barriers in access to health care and accountability, indicating violations of IHRL, as well as IHL.

This evidence of violations of international law gives rise to immediate obligations for the DRC and other state actors – including Rwanda, Burundi, and Uganda who the UN has identified as playing a role in this crisis – to prevent further atrocities, ensure documentation and investigation of harms, enable accountability and justice, and provide health care including sexual and reproductive health care to survivors. All armed groups must cease the use of sexual violence. To do so, they must issue clear directives prohibiting its use and remove and pursue accountability against members who have engaged in such acts.

Table 3: Status and Date of Human Rights Article Accession(a), Succession(d), Ratification (r) by Country
	DRC	Rwanda	Uganda	Burundi
International Convention on the Elimination of all Forms of Racial Discrimination (1965)	21 April 1976 a	16 April 1975 a	21 November 1980 a	27 Oct 1977
International Covenant on Economic, Social and Cultural Rights (1966)	1 November 1976 a	16 April 1975 a	21 January 1987 a	9 May 1990 a
International Covenant on Civil and Political Rights (1966)	1 November 1976 a	16 April 1975 a	21 June 1995 a	9 May 1990 a
Convention on the Elimination of All Forms of Discrimination against Women (1979)	17 October 1986	2 March 1981	22 July 1985	8 January 1992
Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (1984)	18 March 1996 a	15 December 2008 a	3 November 1986 a	18 February 1993 a
Convention on the Rights of the Child (1989)	21 September 1990	24 January 1991	17 August 1990	19 October 1990
Convention on the Rights of Persons with Disabilities (2006)	30 September 2015 a	15 December 2008 a	25 September 2008	22 May 2014
The Maputo Protocol	9 June 2008 r	29 December 2003 r	18 December 2003 r	X
The Rome Statute	11 April 2002	X	14 June 2002	Withdrew 27 Oct 2017
The Genocide Convention	31 May 1962 d	16 April 1975 a	14 November 1995 a	6 January 1997 a

Prohibition on Sexual Violence in War, Perpetrator and Command Responsibility, and Obligation to Protect IDPs

Conflict-related sexual violence is a violation of IHL[71], international criminal law[72], and IHRL[73]. In non-international armed conflicts such as DRC, all parties, including state and non-state armed groups, are required to prevent and address sexual violence in accordance with their obligations under IHL, including Common Article 3, Additional Protocol II to the 1949 Geneva Conventions, and relevant Security Council resolutions. Sexual violence in war is prohibited by the requirement of ‘humane treatment’, and by the prohibitions of ‘violence to life and person’, including ‘cruel treatment and torture’ and ‘outrages upon personal dignity’[74]. Serious violations of IHL may constitute war crimes.

Under IHL, states may prosecute individuals for serious violations of the Geneva Conventions.[75] International criminal law also recognizes that commanders of forces led by both state and non-state actors may be held criminally responsible for war crimes by their forces if they knew or should have known about such crimes and failed to prevent them or punish those responsible.[76] All military leaders, whether affiliated with a state or not, have the obligation to send clear directives to their members and subordinates that sexual violence is a violation of the laws of war and unacceptable, and can incur liability individually for ordering, failing to prevent, or failing to ensure accountability for sexual violence. All states involved in the conflict in DRC have the obligation to prevent and prosecute sexual violence by their own state forces as well as non-state actors acting under their control. Further, the DRC authorities have the obligation to pursue accountability even by other parties for all acts of conflict-related sexual violence. Finally, beyond states holding individuals accountable, a state may also be held responsible for the acts of non-state actors in certain circumstances, including where a state has exercised control over the non-state actor, such as where the non-state actor is in fact acting under its discretion.[77]

In addition to IHL, international and regional human rights law requires states parties -including the DRC and other states supporting rebel groups including M23 – to prevent, investigate, prosecute, punish, and provide remedy – including reparations – for sexual and gender-based violence in general, including in conflict[78]. Sexual violence violates several fundamental rights, including the rights to life, health, privacy, torture, and freedom from gender-based discrimination[79]. The DRC, Rwanda, Uganda, and Burundi have signed and ratified numerous human rights treaties (see Table 3) that prohibit sexual and gender-based violence, including the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW).[80] The UN Committee on the Elimination of Discrimination against Women (CEDAW Committee) has clarified in General Recommendations 19, 30, and 35 that CEDAW prohibits gender-based violence [81] including in international and non-international conflict and post-conflict periods^[82]. States parties must prevent and redress conflict-related sexual violence, including violence perpetrated by non-state actors^[83]. Similarly, the Protocol to the African Charter on the Rights of Women (the Maputo Protocol) establishes that states parties must, “in accordance with the obligations incumbent upon them under IHL, protect civilians including women, irrespective of the population to which they belong, in the event of armed conflict”^[84]. Further, the Maputo Protocol requires states parties to protect internally displaced women and girls from “all forms of violence, rape and other forms of sexual exploitation, and to ensure that such acts are considered war crimes, genocide and/or crimes against humanity and that their perpetrators are brought to justice before a competent criminal jurisdiction.”^[85]

The obligation to prevent sexual violence, including in conflict, requires addressing risk factors for sexual violence including insecurity, lack of food, and lack of cooking fuel. In particular, States have obligations under both IHL and IHRL to protect civilian populations and IDPs in particular, including specifically from violations of sexual and reproductive autonomy.[86] Furthermore, the African Union Convention for the Protection and Assistance of Internally Displaced Persons in Africa (Kampala Convention)[87], to which the DRC is a party, reinforces that the primary responsibility for supporting and protecting IDPs lies with the state. States must ensure comprehensive protection measures that include preventing sexual violence, providing essential services, and creating a secure environment for IDPs. IDPs are entitled to protection like all other civilians and must not be the object of attack provided they are not directly and actively taking part in hostilities.[88]

Places where IDPs are sheltered are considered protected civilian objects so long as IDP camps must be secured by national and local authorities in accordance with their primary obligation to protect civilians under IHL and in a manner that strictly adheres to international human rights law.[89] IHL specifically establishes that the life, dignity, and humane treatment of IDPs must be respected, requiring protection of their physical and mental well-being as well as freedom from rape and other sexual violence.[90] IDPs are also entitled to enjoy satisfactory conditions of shelter, hygiene, health, safety and nutrition.[91] Similarly, IHRL recognizes that displaced women and girls in particular face risks of human rights violations including sexual violence during flight and in displacement and calls upon states parties to ensure protection of displaced persons’ human rights by ensuring basic services and humanitarian assistance including in “all situations of massive influx of refugee and displaced populations.”[92]

Obligations to ensure survivors’ access to health care and reproductive autonomy

IHRL recognizes that women in conflict-affected areas face heightened risks of sexual violence, sexually transmitted infections, and unplanned pregnancy due to conflict-related sexual violence as well as disruptions in access to essential services. Even during conflict, states parties are obligated to provide basic health services and information, including mental health care and sexual and reproductive health care such as maternal health care, abortion care, STI treatment, and contraceptive services.[93]

Further, IHL requires all parties to a conflict to respect the protection, health, and assistance needs of women affected by armed conflict and establishes special protections for medical personnel and facilities to ensure the functioning of health care throughout a conflict.[94] Civilians in conflict areas have the right to receive humanitarian aid, including medical and other supplies essential to survival[95]. IHL allocates primary responsibility for meeting civilian needs to the state or party that controls the territory in which the civilians are located,[96] which in this case is the DRC.

The UN Security Council has passed several resolutions in the past 15 years relating to women and armed conflict.[97] Specifically, with regard to sexual and reproductive health rights in conflict settings, the Security Council has urged “United Nations entities and donors to provide non-discriminatory and comprehensive health services, including sexual and reproductive health” to survivors of sexual violence.[98]

Obligation to ensure effective documentation, accountability, and justice

States also have an obligation to provide victims of human rights violations, including specifically sexual violence, with an effective remedy in satisfaction of their rights to truth, justice, and reparation[99]. This obligation includes ensuring effective prosecution, punishment, and remedy for sexual violence committed by both state and non-state actors.[100] Concerning documentation and accountability for conflict-related sexual violence, states parties are obligated to include “training and the adoption, implementation and monitoring of legal provisions, administrative regulations and codes of conduct, and for investigating, prosecuting and applying appropriate legal or disciplinary sanctions, as well as providing reparation, in all cases of gender-based violence against women, including those constituting international crimes.”[101] Where existing national mechanisms lack the capacity to undertake independent impartial investigations and prosecutions, the international community should act to promote justice with input from affected local communities. The CEDAW Committee has stated that states must safeguard refugees and IDPs from sexual and gender-based violence, including child and forced marriage, provide them with immediate access to medical services, and create accountability mechanisms for sexual and gender-based violence in all displacement settings.[102]

The CEDAW Committee establishes that states parties’ measures to prevent sexual violence should “provide mandatory, recurrent and effective capacity-building, education and training for members of the judiciary, lawyers and law enforcement officers, including forensic medical personnel, legislators and health-care professionals.”[103] Further, the Committee calls on states parties to address conflict-related gender-based violence by adopting gender-sensitive investigative protocols, and taking steps to “develop and disseminate standard operating procedures and referral pathways to link security actors with clinicians on gender-based violence, including one-stop shops offering medical, legal and psychosocial services for sexual violence survivors, multipurpose community centers that link immediate assistance to economic and social empowerment and reintegration, and mobile clinic.”[104]

National Legal Context

The DRC national law also prohibits sexual violence and commits to accountability and justice for survivors. For example, the revised Constitution of 2011 commits to the elimination of sexual violence (Article 15).[105] This provision establishes the fight against sexual violence as a cross-cutting matter for the entire administration. Paragraph 2 establishes sexual violence as a serious crime if it has a specific intent.[106]

Further, Congolese legislation defines sexual violence as a serious crime which, in some instances, may constitute a war crime, a crime against humanity, and/or a crime of genocide[107]. In addition, the law commits to the provision of appropriate protection measures for victims and witnesses, including reparation and support mechanisms.[108] Under the penal code, sexual violence is a crime and punishable by 5 to 20 years imprisonment.[109] To strengthen the protection of children, it adopted a law on child protection in 2009. The DRC also specifically prohibits sexual offenses against children. Under the code of criminal procedure, the DRC government also commits to ensure timely adjudication, victims’ protection during the proceedings through closed sessions, and other supportive measures. [110]

In 2013, the Law on the Organization and Jurisdiction of the Judiciary was discussed, which, among other things, gives jurisdiction to the civil courts to try crimes against peace and security, bringing these offences before courts that are likely to offer more than guarantee a fair trial[111]. But also, to allow for better implementation of the Rome Statute, three harmonization laws were adopted in 2015 to amend and supplement the Military Criminal Code (15/023), the Criminal Code (15/022) and the Code of Criminal Procedure (15/024)[112].

Moreover, in 2020, the DRC revised and validated the National Strategy to Combat Gender-Based Violence and the Action Plan to Combat Gender-Based Violence in 2020, expanding the definition of gender-based violence to include domestic violence and gender-based violence in humanitarian contexts.[113] The revised national strategy is the reference framework for all actions related to prevention, victim care, and the fight against impunity for perpetrators of gender-based violence. It includes 124 activities to be carried out over five years, structured around seven main components, such as gender-based violence prevention, women’s empowerment, education, security and protection, justice, and data collection for monitoring and evaluation of interventions. While the action plan that accompanies this strategy for the period 2021-2025 aims to concretely implement the activities identified in the strategy. This action plan includes specific measures to improve holistic care for victims, strengthen justice mechanisms, and promote collaboration between different actors, including civil society organizations, government agencies, and international partners. These initiatives aim not only to reduce gender-based violence but also to provide adequate support to survivors and strengthen protection systems to prevent such violence in the future.

The DRC adopted Law No. 22/065 in 2022 which establishes the fundamental principles relating to the protection and reparation of victims of conflict-related sexual violence and victims of crimes against the peace and security of humanity[114]. This law is a major step forward in enshrining the rights of victims of serious crimes, fighting impunity and supporting them, including victims of conflict-related sexual violence. It has the merit of clarifying the concept of victim, adding administrative reparations alongside judicial reparations, setting up a Fund for the Benefit of Victims (FONAREV), among others. However, this measure has not yet resulted in reparations for many survivors.[115]

Conclusions and Recommendations

The findings of this report are a clarion call to the government of the DRC, other parties to the conflict, and regional and international actors to take urgent action to halt sexual violence as a tactic of war and to increase security and guarantee access to food and cooking fuel in IDP camps to prevent such violence. As funding for humanitarian aid and political will to negotiate diplomatic solutions are channeled to other crises, clinicians on the frontlines in the DRC report seeing “a massive influx” of survivors who have faced repeated acts of sexual violence during attacks and while displaced, including multiple perpetrator rape and rape with foreign objects. This violence has led to serious physical and psychological impacts, including sexually transmitted infections, unwanted pregnancy, incontinence, isolation, and post-traumatic stress disorder in addition to other long-term psychological harm. Yet, survivors also face significant barriers in accessing the health care they require to heal, as well as the materials and support necessary to have the evidence necessary to pursue accountability documented. Across North and South Kivu, clinicians have underscored the critical need for materials and training to support survivors’ healing and access to justice, including post-rape care, forensic documentation of sexual violence, and comprehensive health care for survivors including mental health and sexual and reproductive health care.

The sexual violence and resulting suffering experienced by civilians in eastern Congo indicate widespread violations of international law that merit monitoring and investigation. Stemming this crisis requires coordinated action by local, national, regional, and international actors. In particular, as MONUSCO continues to draw down its presence in eastern DRC, efforts must be redoubled to ensure that civilians do not face increased sexual violence and that survivors can pursue accountability and justice. Given these findings, PHR makes the following recommendations:

All parties to the conflict:

• Fully comply with IHL and IHRL in all aspects of operations throughout the conflict.

• Ensure that local armed forces and police forces, as well as various armed groups involved in the hostilities, do not engage in sexual violence, including by issuing clear directives prohibiting such violence, investigating and removing from service known perpetrators, and referring the perpetrators of these crimes to the appropriate courts to combat impunity.

• Implement the priority actions contained in regional diplomatic efforts, including the Luanda Process and the EAC-led Nairobi Process with a view to promote de-escalation and create the conditions for lasting peace in DRC, the repatriation of all foreign armed groups and foreigners, and compliance by local armed groups with the Disarmament, Demobilization, Community Recovery and Stabilization programme.[116]

The government of DRC:

• Take all measures to prevent sexual violence and establish conditions to enable IDPs to return to their living environments, including multisectoral coordinated care for survivors, emergency humanitarian aid and community recovery.

• Immediately improve access to food and cooking fuel inside of camps to prevent sexual violence against IDPs that occurs outside of the camps.

• Strengthen security in and around routes where displaced populations are fleeing and within the IDP camps to prevent sexual violence.

• Investigate, remove from service, and prosecute actors responsible for violations of IHL and IHRL including Congolese military and political figures, through the judicial services of the DRC.

• Ensure survivors’ access to justice and reparation for conflict-related sexual violence, including by:
  • Supporting survivors who wish to report conflict-related sexual violence,

• Carry out geographic mapping of where violations have occurred to ensure coherent, effective, and efficient holistic response,

• Prioritize the development of a policy for the National Fund for the Reparation of Victims to make the identification of survivors who are eligible for reparations more effective and secure, including the digitalization of medicolegal documentation, and

• Building upon the national consultations held throughout the country, the DRC should adopt a binding legal text to support the implementation of transitional justice mechanisms which have thus far remained inoperative in their entirety

• Ensure accessible, available, acceptable, and quality health care for survivors of sexual violence, including post-rape care and prophylaxis, sexual and reproductive health care including stigma-free abortion care, mental health care, and child- and adolescent-friendly care.
• Take all measures to cooperate with regional and international legislative bodies to seek accountability and justice for human rights violations.

United Nations and members of the international diplomatic community:

• Regional leaders should exert influence on all states involved in the conflict to promote peace and support a robust African Union led peace support operation, should a ceasefire be negotiated.

Support efforts to ensure adherence with international humanitarian, human rights, and criminal law, including by exercising diplomatic pressure on all parties to de-escalate tensions, cease engagement in conflict-related sexual violence, and pursue diplomatic solutions.

• As committed by DRC in the June 2024 Security Council session,[117] refrain from authorizing the withdrawal of MONUSCO in North Kivu until progress is made to de-escalate the fighting and instability and when violence has come down meaningfully.

• Ensure robust monitoring of the situation in South Kivu where MONUSCO withdrawal has occurred, including rates of conflict-related sexual violence in border areas between North and South Kivu.

• Mobilize additional resources urgently to bolster the work of UN agencies, as well as non-governmental development, humanitarian, and peace organizations which support state services in their sovereign missions, funds, and programs in preparation for MONUSCO’s departure.

• Fully fund the 2024 DRC Humanitarian Response Plan, including to prevent sexual violence by strengthening provision of basic necessities (food, cooking fuel, and others) in IDP camps and by supporting survivors’ healing and access to justice through materials and training for post-rape care, forensic documentation of sexual violence, and comprehensive health care for survivors including mental health and sexual and reproductive health care.

• Increase international human rights cooperation and support to the government of DRC to promote stronger documentation and evidence-gathering of grave human rights abuses, with a special focus on conflict-related sexual violence and medicolegal documentation and care; to take measures to address risk factors for sexual violence such as lack of food and cooking fuel; and to ensure survivors’ access to reparations and multisectoral coordinated care as guaranteed in national law.

International Criminal Court (ICC) Office of the Prosecutor (OTP):

• In line with the ICC OTP memorandum of understanding with the DRC, the OTP should work with the government to:
  • Continue to support efforts for accountability for past acts of conflict-related sexual violence to send a clear message that such violations will not be tolerated
  • Provide support to the DRC government not only for forensic documentation relating to mass graves but also for ongoing cases of conflict-related sexual violence
  • Investigate and prosecute perpetrators responsible for conflict-related sexual violence in violation of international law and ensure justice for survivors.

Acknowledgements

This report was researched and co-written by a team of Democratic Republic of the Congo (DRC) and United States-based PHR staff experts, with expertise on conflict-related sexual violence, public health, international human rights law, and research methodologies, including Thomas McHale, SM, PHR director of public health and Payal Shah, JD, director of legal, advocacy, and research, and additional co-authors who remain anonymous due to the severe and ongoing security risks in the eastern DRC.

PHR staff who contributed to the review of the report are: Saman Zia-Zarifi, JD, LLM, executive director; Karen Naimer, JD, LLM, MA, director of programs; Michele Heisler, MD, MPA, medical director; Payal Shah, JD, director of research, legal and advocacy; and Michael Payne, deputy director of advocacy; and Christian DeVos, JD, PhD, former director of research and investigations.

External review was provided by Ranit Mishori, MD, MHS, MSc, FAAFP, member of PHR advisory council; Adam Richards, MD, PhD, MPH, PHR board member and senior technical advisor at Community Partners International and Patrick Bigabwa, gynecologist in Panzi Hospital.

The research team would like to recognize the dedication and resilience of health care workers in the Democratic Republic of the Congo who have provided care and support for thousands of survivors of conflict-related sexual violence and whose experiences and stories are reflected in this report.

Citations and Endnotes

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[3] “Implementation of the Peace, Security and Cooperation Framework for the Democratic Republic of the Congo and the Region,” United Nations Security Council, April, 1, 2024, https://documents.un.org/doc/undoc/gen/n24/082/53/pdf/n2408253.pdf.

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[6] “Democratic Republic of the Congo,” OCHA, https://www.unocha.org/democratic-republic-congo

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[8] Council on Foreign Relations, “Violence in the Democratic Republic of Congo,” Global Conflict Tracker, Updated June 20, 2024, https://www.cfr.org/global-conflict-tracker/conflict/violence-democratic-republic-congo.

[9] Council on Foreign Relations, “Violence in the Democratic Republic of Congo,” Global Conflict Tracker, Updated June 20, 2024, https://www.cfr.org/global-conflict-tracker/conflict/violence-democratic-republic-congo.

[10] Council on Foreign Relations, “Violence in the Democratic Republic of Congo,” Global Conflict Tracker, Updated June 20, 2024, https://www.cfr.org/global-conflict-tracker/conflict/violence-democratic-republic-congo.

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[18] “In Eastern Congo, The Regional War is Already Here,” International Crisis Group International Crisis Group, Published July 16, 2024, https://www.crisisgroup.org/africa/great-lakes/democratic-republic-congo/dans-lest-du-congo-la-guerre-regionale-est-deja-la.

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[20] “Military Muscle Rather Than Mediation Prevails in DRC,” Institute for Security Studies, September 1, 2024, https://issafrica.org/iss-today/military-muscle-rather-than-mediation-prevails-in-drc.

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[24] “Attacks Against Healthcare in the Democratic Republic of the Congo,” International Rescue Committee, April 2024, https://www.rescue.org/sites/default/files/2024-04/ERSP%20UCB%20RIAH%20IRC%20-%20ATTACKS%20AGAINST%20HEALTHCARE%20DRC.pdf.

[25] “Disease Outbreak News: Democratic Republic of the Congo,” World Health Organization, October 25, 2023, https://www.who.int/emergencies/disease-outbreak-news/item/2023-DON493; “Disease Outbreak News: Democratic Republic of the Congo,” World Health Organization, August 10, 2023. https://www.who.int/emergencies/disease-outbreak-news/item/2023-DON441; “Yellow Fever – West and Central Africa,” World Health Organization, https://www.who.int/emergencies/disease-outbreak-news/item/yellow-fever—west-and-central-africa.

[26] “UNICEF Calls for Urgent Action to Respond to Alarming Levels of Increasing Sexual Violence,” UNICEF Press Release. September 3, 2024, https://www.unicef.org/press-releases/unicef-calls-urgent-action-respond-alarming-levels-increasing-sexual-violence-0#:~:text=Reports%20of%20gender%2Dbased%20violence,2022%20in%20North%20Kivu%20alone.

[27] “Essential Services Package for Women and Girls Subject to Violence: Module 1,” United Nations Population Fund (UNFPA), https://www.unfpa.org/resources/essential-services-package-women-and-girls-subject-violence-module-1#:~:text=The%20Essential%20Services%20Package%20is,services%2C%20police%20and%20justice%20sectors.

[28] “Ensuring Women’s Protection Amid Rising Conflict in Eastern DRC, Refugees International,” https://www.refugeesinternational.org/reports-briefs/ensuring-womens-protection-amid-rising-conflict-in-eastern-drc/.

[29] “Gender-Based Violence Cases Surge in Conflict Zones, UN Reports,” United Nations News, July 25, 2024, https://news.un.org/en/story/2024/07/1151846#:~:text=Gender%2Dbased%20violence-,Ms.,increasing%20by%2040%20per%20cent.

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[31] Baker, Sarah, et al., “Addressing the Health Needs of Conflict-Affected Populations: Evidence from Eastern Democratic Republic of the Congo,” BMJ Global Health 6, no. 10 (2024): e006631. https://doi.org/10.1136/bmjgh-2024-006631; “Ensuring Women’s Protection Amid Rising Conflict in Eastern DRC,” Refugees International, https://www.refugeesinternational.org/reports-briefs/ensuring-womens-protection-amid-rising-conflict-in-eastern-drc/.

[32] “Ensuring Women’s Protection Amid Rising Conflict in Eastern DRC,” Refugees International, Published April 2024, https://www.refugeesinternational.org/reports-briefs/ensuring-womens-protection-amid-rising-conflict-in-eastern-drc/.

[33] “Implementation of the Peace, Security and Cooperation Framework for the Democratic Republic of the Congo and the Region,” United Nations Security Council, April, 1, 2024, https://documents.un.org/doc/undoc/gen/n24/082/53/pdf/n2408253.pdf.

[34] “Democratic Republic of the Congo,” OCHA, accessed 5 April, 2024, https://www.unocha.org/democratic-republiccongo; “Humanitarian Response Plan Democratic Republic of the Congo 2023,” OCHA Financial Tracking Service, https://fts.unocha.org/plans/1113/summary.

[35] “Why Sexual Violence is Rising in Goma’s Displacement Camps,” Doctors Without Borders, September 18, 2023, https://www.doctorswithoutborders.org/latest/why-sexual-violence-rise-gomas-displacement-camps.

[36] “Support for Refugee Camps in North Kivu,” Panzi Foundation, https://panzifoundation.org/support-for-refugee-camps-in-north-kivu/.

[37] “Innovative E-Health Tool Scales in the Democratic Republic of Congo: Medicapt Launches HEAL Africa in Goma, DRC,” Relief Web, June 7, 2022, https://reliefweb.int/report/democratic-republic-congo/innovative-e-health-tool-scales-democratic-republic-congo-medicapt-launches-heal-africa-goma-drc.

[38] “Care in the Midst of Conflict: Heal Africa in Eastern Democratic Republic of the Congo,”Physicians for Human Rights, https://phr.org/our-work/resources/care-in-the-midst-of-conflict-heal-africa-in-eastern-democratic-republic-of-the-congo/

[39] “Visual Diary: Caring for Child Survivors of Sexual Violence in Eastern Democratic Republic of Congo,” 

Physicians for Human Rights, July 19, 2024, https://phr.org/our-work/resources/visual-diary-caring-for-child-survivors-of-sexual-violence-in-eastern-drc/  

[40] “Democratic Republic of the Congo 2023,”Amnesty International, https://www.amnesty.org/en/location/africa/east-africa-the-horn-and-great-lakes/democratic-republic-of-the-congo/report-democratic-republic-of-the-congo/.

[41] “Democratic Republic of the Congo 2023,”Amnesty International, https://www.amnesty.org/en/location/africa/east-africa-the-horn-and-great-lakes/democratic-republic-of-the-congo/report-democratic-republic-of-the-congo/; This was the DRCs second referral to the International Criminal Court – the first was made in 2004, https://www.amnesty.org/en/location/africa/east-africa-the-horn-and-great-lakes/democratic-republic-of-the-congo/report-democratic-republic-of-the-congo/; The International Criminal Court Office of the Prosecutor has now signed an Memorandum of Understanding with the DRC government to deliverable concrete deliverables through a framework of complementarity. domestic efforts through cooperation/complementarity, https://www.icc-cpi.int/news/prosecutor-international-criminal-court-karim-aa-khan-kc-concludes-his-first-visit-democratic.

[42] Democratic Republic of the Congo. Law n°22/065 in date of the 26^th of December 2022 setting the foundational principles related to protection and reparations for victims of conflict-related and for victims of crimes against peace and security of humanity. Published December 26, 2022, https://leganet.cd.

[43] “Democratic Republic of the Congo,” Global Survivors Fund, https://www.globalsurvivorsfund.org/our-work/democratic-republic-of-the-congo/.

[44] “Minimal Norms for Prevention and Response to Gender-Based Violence in Emergency Situations,”United Nations Population Fund, November 2015, https://www.unfpa.org/sites/default/files/pub-pdf/16-092_Minimum_Standards_Report_FRENCH_proof.FINAL__1.pdf.

[45] “Eastern DRC at Breaking Point as Security, Humanitarian Crises Worsen,” Al Jazeera, March 29, 2024,

https://www.aljazeera.com/news/2024/3/29/eastern-drc-at-breaking-point-as-security-humanitarian-crises-worsen.

[46] Morse, Janice M, “The Significance of Saturation,” Qualitative Health Research 5, No. 2 (1995): 147-149. https://doi.org/10.1177/104973239500500201.

[47] “The Global Code of Conduct for Gathering and Using Information about Systematic and Conflict-Related Sexual Violence,” Murad Code, June 2020, https://www.muradcode.com/murad-code.

[48] “The Global Code of Conduct for Gathering and Using Information about Systematic and Conflict-Related Sexual Violence,” Murad Code, June 2020, https://www.muradcode.com/murad-code.

[49] “Sexual Violence, Trauma, and Neglect: Observations of Health Care Providers Treating Rohingya Survivors in Refugee Camps in Bangladesh,” Physicians for Human Rights, October 22, 2020, https://phr.org/our-work/resources/sexual-violence-trauma-and-neglect-observations-of-health-care-providers-treating-rohingya-survivors-in-refugee-camps-in-bangladesh/?utm_term=hero.

[50] Dedoose Version 9.2.12, cloud application for managing, analyzing, and presenting qualitative and mixed method research data (2024). Los Angeles, CA: SocioCultural Research Consultants, LLC,  www.dedoose.com.

[51] “What Is Survival Sex?”, Changing Lives, December 2023, https://www.changing-lives.org.uk/insights/what-is-survival-sex.

[52] “The Wazalendo Patriots at War in Eastern DRC,” Le Monde, December 19, 2023, https://www.lemonde.fr/en/international/article/2023/12/19/the-wazalendo-patriots-at-war-in-eastern-drc_6356363_4.html.

[53] Rohwerder, Briony, “The Impact of Conflict on Health Care Provision and Access in the Democratic Republic of the Congo,” Conflict and Health 15 (2021): Article 14, https://doi.org/10.1186/s13031-021-00414-0.

[54] “UN Suspends Some Peacekeepers in Congo, Denounces Sexual Abuse,” Reuters, October 12, 2023, https://www.reuters.com/world/africa/un-suspends-some-peacekeepers-congo-denounces-sexual-abuse-2023-10-12/.

[55] Physicians for Human Rights uses the definition used by the United Nations to define conflict related sexual violence as “rape, sexual slavery, forced prostitution, forced pregnancy, forced abortion, enforced sterilization, forced marriage and any other form of sexual violence of comparable gravity perpetrated against women, men, girls or boys that is directly or indirectly linked to a conflict. That link may be evident in the profile of the perpetrator, who is often affiliated with S/2019/280 2/35 19-04552 a State or non-State armed group, which includes terrorist entities; the profile of the victim, who is frequently an actual or perceived member of a political, ethnic or religious minority group or targeted on the basis of actual or perceived sexual orientation or gender identity; the climate of impunity, which is generally associated with State collapse, cross-border consequences such as displacement or trafficking, and/or violations of a ceasefire agreement. The term also encompasses trafficking in persons for the purpose of sexual violence or exploitation, when committed in situations of conflict.” S/2019/280

[56] The International Criminal Court Elements of Crimes defines rape as: “The perpetrator invaded the body of a person by conduct resulting in penetration, however slight, of any part of the body of the victim or of the perpetrator with a sexual organ, or of the anal or genital opening of the victim with any object or any other part of the body” and “the invasion was committed by force, or by threat of force or coercion, such as that caused by fear of violence, duress, detention, psychological oppression or abuse of power, against such person or another person, or by taking advantage of a coercive environment, or the invasion was committed against a person incapable of giving genuine consent.”

[57] A quote from a psychologist in the Goma health zone working with survivors of CRSV since 2021

[58] Rohwerder, Briony, “The Impact of Conflict on Health Care Provision and Access in the Democratic Republic of the Congo,” Conflict and Health 15 (2021): Article 14, https://doi.org/10.1186/s13031-021-00414-0.

[59] “UN Urges Action to Address Sexual Violence and Exploitation in Conflict Zones,” United Nations News, October 10, 2023, https://news.un.org/en/story/2023/10/1142247.

[60] “UN Suspends Some Peacekeepers in Congo, Denounces Sexual Abuse,” Reuters, October 12, 2023, https://www.reuters.com/world/africa/un-suspends-some-peacekeepers-congo-denounces-sexual-abuse-2023-10-12/.

[61] “Gender and Clean Cooking: A Summary of Key Issues,”Clean Cooking Alliance, July 2021, https://cleancooking.org/wp-content/uploads/2021/07/CCA-gender-sheet-ENGLISH.pdf.

[62] Mulumba, D. (2011), “The Gendered Politics of Firewood in Kiryandongo Refugee Settlement in Uganda,” African Geographical Review, 30(1), 33–46. https://doi.org/10.1080/19376812.2011.10539134

[63] “DRC: Alarming Numbers of Sexual Violence Victims in Camps Around Goma,” Médecins Sans Frontières, https://www.msf.org/drc-alarming-numbers-sexual-violence-victims-camps-around-goma.

[64] “Democratic Republic of the Congo,” United Nations Office for the Coordination of Humanitarian Affairs, https://www.unocha.org/democratic-republic-congo.

[65] “Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa (Maputo Protocol),” African Union, adopted July 11, 2003, entered into force November 25, 2005.

Law n° 18/035 in date of the 13^th of December 2018 setting the foundational principals related to the organization of Public Health.

[66] “Gender Data: Democratic Republic of the Congo,”World Bank, https://genderdata.worldbank.org/en/economies/congo-dem-rep.

[67] “Beating the Odds: Resilience, Hope, and Safe Births with UNFPA’s Mobile Clinic in the Democratic Republic of the Congo,” United Nations Population Fund, https://www.unfpa.org/news/beating-odds-resilience-hope-and-safe-births-unfpa-mobile-clinic-democratic-republic-congo.

[68] “WFP Delivers Nutrition Assistance to People Affected by Conflict in Eastern DRC,” ReliefWeb, https://reliefweb.int/report/democratic-republic-congo/wfp-delivers-nutrition-assistance-people-cut-conflict-eastern-drc.

[69] Remadji Hoinathy, “Eastern DRC: Peace Processes Miss the Mark,” Institute for Security Studies, https://issafrica.org/iss-today/eastern-drc-peace-processes-miss-the-mark; East African Community (EAC). “The EAC-Led Nairobi Process on Restoration of Peace and Security in Eastern DRC,” East African Community https://www.eac.int/nairobiprocess.

[70] “UN Warns of Escalating Humanitarian Crisis in Eastern DRC as Conflict Intensifies,” United Nations News, July 4, 2024. https://news.un.org/en/story/2024/07/1151701; “Democratic Republic of the Congo,” UNOCHA, 2024, https://www.unocha.org/democratic-republic-congo.  

[71] Fourth Geneva Convention, article 27 (2). Article 76 of Protocol I extend this protection of protected persons to all women. Protocol I, article 76; Protocol II, article 4 (2) (a), (e), and (f).

[72] Statute of the International Criminal Court (1998), articles 7(1)(g); 8(2)(b)(xxii); 8(2)(e)(vi)

[73] United Nations General Assembly Rape as a grave, systematic and widespread human rights violation, a crime and a manifestation of gender-based violence against women and girls, and its prevention G21/089/99, https://documents.un.org/doc/undoc/gen/g21/089/99/pdf/g2108999.pdf; Office of the High Commissioner for Human Rights. General Comment No. 30 on Women in Conflict Prevention, Conflict, and Post-Conflict Situations. CEDAW/C/GC/30. https://www.ohchr.org/sites/default/files/Documents/HRBodies/CEDAW/GComments/CEDAW.C.CG.30.pdf.

[74] Article 3 common to the Geneva Conventions (CA3); ICRC, Commentary on GCI, 2016, CA3, paras. 696, 699, 701.

[75] Geneva Conventions Rule 158 Prosecution of War Crimes Rule 158. States must investigate war crimes allegedly committed by their nationals or armed forces, or on their territory, and, if appropriate, prosecute the suspects. They must also investigate other war crimes over which they have jurisdiction and, if appropriate, prosecute the suspects.

[76] “Command Responsibility and Failure to Act,” International Committee of the Red Cross, April 2014, https://www.icrc.org/sites/default/files/external/doc/en/assets/files/2014/command-responsibility-icrc-eng.pdf.

[77] “Draft Articles on Responsibility of States for Internationally Wrongful Acts, with Commentaries, International Law Commission, October 18, 2013, https://www.ohchr.org/sites/default/files/Documents/HRBodies/CEDAW/GComments/CEDAW.C.CG.30.pdf.

[78] United Nations General Assembly. “Convention on the Elimination of All Forms of Discrimination against Women (A/RES/34/180) Adopted 18 December 1979; Committee on the Elimination of Discrimination against Women; Rome Statute of the International Criminal Court Done at Rome on 17 July 1998, in force on 1 July 2002, United Nations, Treaty Series, vol. 2187, No. 38544, Depositary: Secretary-General of the United Nations, http://treaties.un.org; “Common Article 3 of the Geneva Conventions, 1949,”; Protocol Additional to the Geneva Conventions of 12 August 1949, and Relating to the Protection of Victims of International Armed Conflicts (Protocol 1); Protocol Additional to the Geneva Conventions of 12 August 1949, and Relating to the Protection of Victims of Non-International Armed Conflicts (Protocol II); Geneva Convention Relative to the Protection of Civilian Persons in Time of War of 12 August 1949;  

[79] United Nations Declaration on the Elimination of Violence Against Women (1993); See, example, Declaration on the Elimination of Violence Against Women; CEDAW Committee, General Recommendation No. 35 on gender-based violence against women, updating general recommendation No. 19, para. 15, U.N. Doc. CEDAW/C/GC/35 (2017); https://documents.un.org/doc/undoc/gen/g21/089/99/pdf/g2108999.pdf para. 20.

[80] “Sexual and other forms of gender-based violence are prohibited as violations of autonomy, sex and gender discrimination, and as forms of torture,” See UN General Assembly, Convention on the Elimination of All Forms of Discrimination Against Women, December 18, 1979, United Nations, Treaty Series, vol. 1249, p. 13, http://www.un.org/womenwatch/daw/cedaw/cedaw.htm, Article 1; ICCPR, articles. 2 (1) and 26; UN General Assembly, Declaration on the Elimination of Violence against Women, article 4.

https://www.ohchr.org/en/countries/burundi, Status of Ratifications, CEDAW, 07 Feb 1992

[81] As clarified by the Committee on the Elimination of Discrimination against Women (CEDAW Committee) in General Recommendations 19, 30, and 35; “General Recommendation No. 19: Violence against Women,” Committee on the Elimination of Discrimination against Women, https://www.refworld.org/legal/resolution/cedaw/1992/en/96542; “General Recommendation No. 30 on Women in Conflict Prevention, Conflict, and Post-Conflict Situations,” Committee on the Elimination of Discrimination against Women,” https://www.refworld.org/legal/general/cedaw/2013/en/53711; “General Recommendation No. 35 (2017) on Gender-Based Violence against Women, Updating General Recommendation No. 19 (1992),” Committee on the Elimination of Discrimination against Women, https://www.ohchr.org/en/documents/general-comments-and-recommendations/general-recommendation-no-35-2017-gender-based.

[82] United Nations General Assembly, supra note 7

[83] Committee on the Elimination of Discrimination against Women (CEDAW Committee). General Recommendation No. 35 on Gender-Based Violence Against Women, Updating General Recommendation No. 19. CEDAW/C/GC/35, para. 24(b). https://www.ohchr.org/sites/default/files/Documents/HRBodies/CEDAW/GComments/CEDAW.C.CG.35.pdf.

[84] “Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa. Article 11(2),” African Union, 2003, https://au.int/en/treaties/protocol-african-charter-human-and-peoples-rights-rights-women-africa.

[85] “Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa. Article 11(3),” African Union, 2003, https://au.int/en/treaties/protocol-african-charter-human-and-peoples-rights-rights-women-africa.

[86] “Guiding Principles on Internal Displacement, second edition, OCHA/IDP/2004/01, New York,” United Nations, 2004, https://www.unhcr.org/protection/idps/43ce1cff2/guiding-principles-internal-displacement.html. In 1998 the UN Commission on Human Rights adopted a resolution taking note of the Guiding Principles on Internal Displacement, which are not legally binding but contain numerous rules that are part of existing international human rights law (IHRL) and IHL. Furthermore, the Guiding Principles have enjoyed wide support from the international community, and many states have incorporated them into their domestic legal systems.

[87] “African Union Convention for the Protection and Assistance of Internally Displaced Persons in Africa (Kampala Convention),” African Union, Adopted October 23, 2009. Entered into force December 6, 2012.

[88] Geneva Convention (IV) Relative to the Protection of Civilian Persons in Time of War, Articles 3, 4, and 27, International Committee of the Red Cross, August 12, 1949, https://ihl-databases.icrc.org/en/ihl-treaties/geneva-convention-iv; Additional Protocol I to the Geneva Conventions of 12 August 1949, and Relating to the Protection of Victims of International Armed Conflicts. Articles 51 and 75, International Committee of the Red Cross, June 8, 1977, Accessed September 4, 2024. https://ihl-databases.icrc.org/en/ihl-treaties/additional-protocol-i; Additional Protocol II to the Geneva Conventions of 12 August 1949 and Relating to the Protection of Victims of Non-International Armed Conflicts. Articles 4 and 5, International Committee of the Red Cross, June 8, 1977, Accessed September 4, 2024, https://ihl-databases.icrc.org/en/ihl-treaties/additional-protocol-ii; Customary International Humanitarian Law. Rules 1 and 7, International Committee of the Red Cross, https://ihl-databases.icrc.org/en/customary-ihl/v1/rule1; https://ihl-databases.icrc.org/en/customary-ihl/v1/rule7.

[89] Additional Protocol II to the Geneva Conventions of 12 August 1949 and Relating to the Protection of Victims of Non-International Armed Conflicts. Articles 4 and 5, International Committee of the Red Cross, June 8, 1977. Accessed September 4, 2024. https://ihl-databases.icrc.org/en/ihl-treaties/additional-protocol-ii; Customary International Humanitarian Law. Rules 1 and 7, International Committee of the Red Cross, https://ihl-databases.icrc.org/en/customary-ihl/v1/rule1; Customary International Humanitarian Law, Rules 1, 7, 14, 15, and 22, International Committee of the Red Cross, https://ihl-databases.icrc.org/en/customary-ihl/v1/rule1; https://ihl-databases.icrc.org/en/customary-ihl/v1/rule7; https://ihl-databases.icrc.org/en/customary-ihl/v1/rule1; https://ihl-databases.icrc.org/en/customary-ihl/v1/rule7; https://ihl-databases.icrc.org/en/customary-ihl/v1/rule14; https://ihl-databases.icrc.org/en/customary-ihl/v1/rule15; https://ihl-databases.icrc.org/en/customary-ihl/v1/rule22.

[90] “Geneva Convention (IV) Relative to the Protection of Civilian Persons in Time of War, Articles 3, 4, and 27,” International Committee of the Red Cross, August 12, 1949, https://ihl-databases.icrc.org/en/ihl-treaties/geneva-convention-iv; “Additional Protocol I to the Geneva Conventions of 12 August 1949, and Relating to the Protection of Victims of International Armed Conflicts, Articles 51 and 75,” International Committee of the Red Cross, June 8, 1977, Accessed September 4, 2024, https://ihl-databases.icrc.org/en/ihl-treaties/additional-protocol-i; “Additional Protocol II to the Geneva Conventions of 12 August 1949, and Relating to the Protection of Victims of Non-International Armed Conflicts, Article 4,” International Committee of the Red Cross, June 8, 1977, Accessed September 4, 2024. https://ihl-databases.icrc.org/en/ihl-treaties/additional-protocol-ii; “Customary International Humanitarian Law, Rules 87, 89, and 93,” International Committee of the Red Cross, https://ihl-databases.icrc.org/en/customary-ihl/v1/rule87;

https://ihl-databases.icrc.org/en/customary-ihl/v1/rule89; https://ihl-databases.icrc.org/en/customary-ihl/v1/rule93;

[90] “Geneva Convention (IV) Relative to the Protection of Civilian Persons in Time of War, Article 49(3),” August 12, 1949, International Committee of the Red Cross, https://ihl-databases.icrc.org/en/ihl-treaties/geneva-convention-iv; “Geneva Conventions of 12 August 1949, Common Article III,” International Committee of the Red Cross, August 12, 1949, https://ihl-databases.icrc.org/en/ihl-treaties/geneva-convention-i-iv; “Additional Protocol II to the Geneva Conventions of 12 August 1949, and Relating to the Protection of Victims of Non-International Armed Conflicts, Article 17(1),” International Committee of the Red Cross, June 8, 1977, https://ihl-databases.icrc.org/en/ihl-treaties/additional-protocol-ii; “Customary International Humanitarian Law, Rule 131,” International Committee of the Red Cross, https://ihl-databases.icrc.org/en/customary-ihl/v1/rule131.

[92] General Recommendation No. 30 on Women in Conflict Prevention, Conflict and Post-Conflict Situations. Para. 57. October 18, 2013, https://tbinternet.ohchr.org/_layouts/15/treatybodyexternal/Download.aspx?symbolno=CEDAW%2fC%2fGC%2f30&Lang=en.

[93] Committee on the Elimination of Discrimination against Women. General Comment 30, paragraphs 50(c)-(d)

The CEDAW Committee has stated that the failure to provide services that only women require to meet their reproductive health needs is a form of discrimination and has emphasized that state obligations under the Convention “are non-derogable and continue to apply during conflict situations.” CEDAW Committee, General Recommendation No. 24: Article 12 of the Convention (Women and Health), paras. 17, 26, U.N. Doc. A/54/38/Rev. 1 (1999) [hereinafter CEDAW Committee, Gen. Recommendation No. 24]; CEDAW Committee, Concluding Observations: Central African Republic, para. 13, U.N. Doc. CEDAW/C/CAF/CO/1-5 (2014). See also CEDAW Committee, Gen. Recommendation No. 28, para. 11; CEDAW Committee, Gen. Recommendation No. 30. 4. For women and girls affected by conflict, the CEDAW Committee has called on state parties to [e]nsure that sexual and reproductive health care includes access to sexual and reproductive health and rights information; psychosocial support; family planning services, including emergency contraception; maternal health services, including antenatal care, skilled delivery services, prevention of vertical transmission and emergency obstetric care; safe abortion services; post-abortion care; prevention and treatment of HIV/AIDS and other sexually transmitted infections, including post-exposure prophylaxis; and care to treat injuries such as fistula arising from sexual violence, complications of delivery or other reproductive health complications, among others. CEDAW Committee, Gen. Recommendation No. 30, para. 52(c).

[94] See, e.g., William H. Boothby and Michael N. Schmitt, The Law of Targeting (Oxford: Oxford University Press, 2013), 233.

[95] See Fourth Geneva Convention, Articles 16–18, 21–23, 38, 50, 89, 91 and 127 (ibid., §§ 76–80); Additional Protocol I, Article 70(1) (adopted by consensus) (ibid., § 81) and Article 76(2) (adopted by consensus) (ibid., § 82).

[96] “Guiding Principles on Internal Displacement,” See principles 3 and 25 of UNOCHA, 1998, https://www.unhcr.org/43ce1cff2.pdf.

[97] UN Security Council Resolutions: Normative Frameworks, https://peacemaker.un.org/wps/normative-frameworks/un-security-council-resolutions.

[98] United Nations Security Council. Resolution 2106, para. 19. U.N. Doc. S/RES/2106. June 24, 2013, https://undocs.org/S/RES/2106(2013).

[99] “About Transitional Justice and Human Rights,”Office of the United Nations High Commissioner for Human Rights (OHCHR), https://www.ohchr.org/en/transitional-justice/about-transitional-justice-and-human-rights#:~:text=Transitional%20justice%20is%20rooted%20in,truth%2C%20justice%2C%20and%20reparation;

United Nations. Draft Articles on Responsibility of States for Internationally Wrongful Acts, with Commentaries. 2001, Accessed https://www.un.org/law/ilc/texts/state_responsibility/responsibility_articles.pdf; General Recommendation No. 35 on Gender-Based Violence against Women, Updating General Recommendation No. 19. Para. 2. November 14, 2017. https://documents.un.org/doc/undoc/gen/n17/231/54/pdf/n1723154.pdf.

[100] CEDAW Committee. General Recommendation No. 35 on Gender-Based Violence against Women, Updating General Recommendation No. 19. Para. 2, November 14, 2017. https://www.ohchr.org/en/documents/general-comment-or-recommendation/general-recommendation-no-35-gender-based-violence.

[101] CEDAW Committee, General Recommendation No. 35 on Gender-Based Violence against Women, Updating General Recommendation No. 19. Para. 23. November 14, 2017, Accessed September 4, 2024, https://www.ohchr.org/en/documents/general-comment-or-recommendation/general-recommendation-no-35-gender-based-violence.

[102] CEDAW Committee, General Recommendation No. 30 on Women in Conflict Prevention, Conflict and Post-Conflict Situations, Para. 57, October 18, 2013, https://tbinternet.ohchr.org/_layouts/15/treatybodyexternal/Download.aspx?symbolno=CEDAW%2fC%2fGC%2f30&Lang=en.

[103] CEDAW Committee, General Recommendation No. 35 on Gender-Based Violence against Women, Updating General Recommendation No. 19. Para. 30(e). November 14, 201, https://www.ohchr.org/en/documents/general-comment-or-recommendation/general-recommendation-no-35-gender-based-violence.

[104] CEDAW Committee. General Recommendation No. 30 on Women in Conflict Prevention, Conflict and Post-Conflict Situations. Para. 35(f). October 18, 2013. https://tbinternet.ohchr.org/_layouts/15/treatybodyexternal/Download.aspx?symbolno=CEDAW%2fC%2fGC%2f30&Lang=en.

[105] Congo (Democratic Republic of the) 2005 (rev. 2011) Article 15

[106] Congo (Democratic Republic of the) 2005 (rev. 2011)

[107] Congolese Penal Code Official Journal Special issue 30^th of November 2004

Code of Criminal Procedure, 1959, Democratic Republic of the Congo, Decree in date of the 6^th of August 1959

Congo (Democratic Republic of the) 2005 (rev. 2011)

[108] The Democratic Republic of Congo – Act No. 22/065 of 26 December 2022

[109] Congolese Penal Code Official Journal Special issue 30^th of November 2004

Code of Criminal Procedure, 1959, Democratic Republic of the Congo, Decree in date of the 6^th of August 1959

[110] Congolese Penal Code Official Journal Special issue 30^th of November 2004

Code of Criminal Procedure, 1959, Democratic Republic of the Congo, Decree in date of the 6^th of August 1959

“Democratic Republic of the Congo,” the U.S. Department of State, 2023,

https://www.state.gov/reports/2023-country-reports-on-human-rights-practices/democratic-republic-of-the-congo

[111] “Magistrates Discuss Dual Jurisdiction of Military and Civilian Courts for International Crimes in DRC,” International Center for Transitional Justice (ICTJ), October 9, 2015, https://www.ictj.org/news/drc-magistrates-discuss-dual-jurisdiction-military-civilian-courts-international-crimes.

[112] Law n° 06/018 in date of the 20^th of July 2006 modifying and adding to the «sentence». Decree in date of the 30^th of January 1940 regarding the Congolese Code of Criminal Procedure.

[112] Law n° 06/019 in date of the 20^th of July 2006 modifying and adding to the «sentence». Decree in date of the 30^th of January 1940 regarding the Congolese Code of Criminal Procedure.

Organic Law n°13/011-B in date of 11 April 2013, regarding the organization, functioning and competencies of jurisdictions of the legal Order.

[113] “DRC Takes a Step Towards Zero Tolerance Against Gender-Based Violence,” UN Women Africa, September 1, 2020, https://africa.unwomen.org/en/news-and-events/stories/2020/09/drc-takes-a-step-towards-zero-toleranceagainst-gender-basedviolence#:~:text=This%20revision%20aims%20to%20eliminate,of%20GBV%2C%20including%20domestic%20violence.

[114] Human Rights Committee

Information received from the Democratic Republic of the Congo on follow-up to the concluding observations on its fourth periodic report *[Date received: 4 September 2023]

[115] “Amnesty International Report 2022/23: The State of the World’s Human Rights,” Amnesty International, accessed April 5, 2024, https://www.amnesty.org/en/location/africa/east-africa-the-horn-and-great-lakes/democraticrepublic-of-the-congo/report-democratic-republic-of-the-congo/.

[116] “DRC: MONUSCO Supports New Demobilization Program for Ex-Combatants,” United Nations Peacekeeping, April 1, 2024, https://peacekeeping.un.org/en/drc-monusco-supports-new-demobilization-program-ex-combatants.

[117] “Military Group’s Expansion in Democratic Republic of Congo ‘Carries Very Real Risk of Provoking Wider Regional Conflict’, Mission Head Tells Security Council, Press Release: SC/15760,”United Nations, Meetings Coverage and Press Release, July 8, 2024, https://press.un.org/en/2024/sc15760.doc.htm.

Cover Photo: Women and children are at risk of experiencing sexual violence while searching for food or firewood outside of the Bulengo Internally Displaced Persons (IDP) camp near Goma, DRC in 2024. Photo: Alexis Huguet/AFP via Getty Images

Since the conflict in Ethiopia began in 2020, the Tigray region has seen horrific atrocities committed against civilians. Physicians for Human Rights (PHR) and others have documented egregious human rights violations, including attacks on health care and conflict-related sexual violence  – abuses that did not stop even after the Cessation of Hostilities Agreement (CoHA) was signed in November 2022. In response to atrocities occurring largely in Tigray, the UN Human Rights Council (UN HRC) created the Independent Commission of Human Rights Experts on Ethiopia (ICHREE) in 2021.  

Despite ICHREE’s critical work to independently document evidence of human rights violations in Ethiopia, Member States of the UN Human Rights Council bent to political pressure from Ethiopia and failed to renew the body’s mandate in 2023. They did so despite dire warnings from Ethiopian and international civil society groups including Health Professionals Network for Tigray (HPN4Tigray) and PHR, that the failure of the HRC to renew ICHREE’s mandate would prevent victims of human rights violations from any credible access to justice and could lead to further atrocities. Since that time, Tigray and many other regions of Ethiopia have faced an ongoing humanitarian and human rights crisis. Food shortages, inadequate medical supplies, and widespread insecurity have been compounded by the lack of comprehensive human rights monitoring, leaving little hope for justice or accountability 

One year after the international community failed the people of Ethiopia, PHR spoke with a representative of HPN4Tigray, one of the leading organizations working to support survivors of traumatizing violence, including the thousands of people who have survived conflict-related sexual violence during the conflict.  

Names have been withheld due to ongoing security risks faced by health professionals in Ethiopia and the diaspora. 

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PHR: What is happening now in Tigray? Give us a glimpse into daily life for communities who survived the conflict but continue to be impacted by this crisis.   

HPN4Tigray: Life in Tigray remains incredibly difficult for communities that have endured years of conflict and are still dealing with its devastating aftermath. Despite the signing of the Cessation of Hostilities Agreement (CoHA), the region continues to struggle with widespread insecurity and a painfully slow recovery. 

For survivors, daily life is a constant battle to access basic needs like food, clean water, and medical care. The destruction of infrastructure, including schools, health care facilities, and roads has made things even worse, cutting off many from essential services. Many families depend on the far too sporadic aid deliveries, and in addition, some roads are still unsafe or blocked, making this lifeline even more unreliable. Doctors in Tigray have told us of families who cannot afford health care are forced to take their children back home to die due to disease and malnutrition. Most schools, once a source of stability, are now either destroyed or serving as shelters for displaced families, leaving children without education or a safe space to heal.  

“Fear and uncertainty dominate life, with many unsure of what tomorrow will bring. Even though the conflict has faded from global headlines, the people of Tigray are still living under its shadow.” 

Over a third of Tigray remains occupied by non-Ethiopian National Defense forces from Eritrea and the Amhara region, and human rights abuses continue in these areas. Fear and uncertainty dominate life, with many unsure of what tomorrow will bring. Even though the conflict has faded from global headlines, the people of Tigray are still living under its shadow. 

HPN4Tigray is one of the organizations working to support survivors of traumatizing violence, including the thousands of people who have survived conflict-related sexual violence during the conflict. What challenges do they face, and how is HPN4Tigray working to provide support?  

In Tigray, survivors of conflict-related violence, including sexual violence, face serious challenges. With the widespread destruction of health care facilities and a shortage of mental health professionals, it is hard for survivors to get the medical and psychological support they need. In the Eastern zone of Tigray, I heard from our partners about survivors of conflict-related sexual violence traveling 12 hours to reach the nearest functioning clinic. By the time they arrive – often months after the incident  – they are dealing with severe health issues like fistulas and HIV, showing how more accessible health care is direly needed. 

Stigma is another huge barrier. Many survivors do not come forward because of the shame associated with sexual violence. Cultural barriers isolate them, and women who do speak out are sometimes rejected by their families or even divorced, adding to their trauma. 

“I heard from our partners about survivors of conflict-related sexual violence traveling 12 hours to reach the nearest functioning clinic. By the time they arrive – often months after the incident – they are dealing with severe health issues like fistulas and HIV.”

Despite these challenges, HPN4Tigray is dedicated to helping survivors heal and rebuild their lives. We work with local partners to provide trauma-informed care, addressing immediate medical needs and long-term psychological recovery. We are also raising awareness about the difficulties survivors face and pushing for international action to ensure they get the services they need. 

During the conflict in Tigray, health care was also targeted. How are health care workers there dealing with the aftermath of the violence, particularly now in the midst of the ongoing humanitarian crisis?   

Health care workers in Tigray have been profoundly impacted by the conflict, both personally and professionally. The health care system in Tigray was intentionally attacked during the conflict, with the majority of health care facilities being destroyed, looted, and vandalized. Additionally, a “de facto humanitarian aid blockade” was imposed on Tigray, with aid and medical supplies being blocked from entering the region, in addition to little to no access to telecommunications, electricity, and banking services.  

As a result, many health care professionals worked for several months without pay under dangerous and traumatic conditions. Often, they lost patients who could have been saved with proper supplies. Now, as they try to rebuild amid an ongoing humanitarian crisis, they face the daunting task of providing care with extremely limited resources.  

Many health care facilities still remain damaged and under-resourced, with critical shortages of medications and supplies, even for basic lab tests, which has led to the spread of preventable diseases. On top of this, health care workers are dealing with the psychological toll of the conflict, suffering from depression, burnout, and vicarious trauma. Some have lost colleagues, loved ones, and even their own homes. Despite these hardships, they continue to work long hours to treat patients suffering not just from war-related injuries, but also from the effects of malnutrition and disease. In the face of these overwhelming challenges, the resilience and dedication of these professionals stand out. They continue to provide life-saving care to their communities, even in the most difficult circumstances. 

PHR has been proud to partner with HPN4Tigray. What in your view has been the most impactful part of the collaboration with PHR?   

HPN4Tigray is deeply honored to partner with PHR. The most impactful aspect of our collaboration has been blending PHR’s expertise in documenting conflict-related sexual violence and other violations with HPN4Tigray’s commitment to providing survivors with comprehensive mental health and psychosocial support. This integrated approach not only shines a light on the atrocities but also ensures survivors get the care they need to heal. With our network of health care and mental health professionals in Ethiopia, along with our understanding of cultural context, we ensure all documentation protocols are culturally- and trauma-informed, as well as provide survivors access to essential referral networks. Our partnership has also been key in amplifying survivors’ voices, strengthening advocacy efforts, and pushing for stronger international action to address the ongoing crisis in Tigray. 

It has been a year since the Human Rights Council effectively closed ICHREE, the one international mechanism set up to independently monitor the situation in Ethiopia. What is HPN4Tigray calling for now a year later related to ongoing humanitarian needs, as well as for justice and accountability?   

HPN4Tigray was deeply disappointed by the disbandment of ICHREE. This closure undermined crucial efforts to address past and ongoing human rights violations in Ethiopia. On this one-year mark, we urge renewed international efforts to tackle the humanitarian crisis and ensure justice and accountability for the atrocities committed. We call on the international community to work with the Ethiopian government to secure unrestricted humanitarian access and ensure aid reaches all regions in need. 

“We urge the global community to remain focused on Ethiopia and continue to advocate for sufficient funding for humanitarian needs, rebuilding efforts, and initiatives aimed at justice and accountability”. 

Additionally, we advocate for international oversight of Ethiopia’s transitional justice process, ensuring that the voices of survivors are central to the implementation of the CoHA, including the safe return of internally displaced people. Ongoing monitoring and transparent reporting of humanitarian aid delivery and the CoHA’s implementation are essential, as is independent monitoring, investigation, and documentation of human rights violations across the country. 

It is crucial that future efforts prioritize justice for survivors, address their immediate needs, and provide long-term support for their recovery. We urge the global community to remain focused on Ethiopia and continue to advocate for sufficient funding for humanitarian needs, rebuilding efforts, and initiatives aimed at justice and accountability. 

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Learn more about Health Professionals Network for Tigray

Photo (top): Dr. Genet attends to a mother and child in Yechila, Tigray, who are beneficiaries of the HPN4Tigray-RecTOR program in partnership with Ayder Comprehensive and Specialized Hospital. This initiative addresses rising maternal and child mortality rates by delivering essential obstetric, gynecologic, and pediatric care to Tigray’s most affected areas. Courtesy of HPN4Tigray. 

Executive Summary

In June 2022, the U.S. Supreme Court’s ruling in Dobbs v. Jackson Women’s Health Organization overturned the federal constitutional right to abortion.[1] In July 2022, Florida enacted a ban on abortion care after 15 weeks of gestation from the first day of a pregnant person’s last menstrual period, with only limited exceptions.[2] Two years later, in April 2024 the Florida Supreme Court followed suit and overturned decades of precedent that the Florida Constitution’s Privacy Clause protects the right to abortion. This judgment cleared the way for a new, far more restrictive six-week abortion ban to take effect on May 1, 2024.[3] This ban shifted the legal limit for abortion from 15 weeks to six weeks from the first day of a pregnant person’s last menstrual period and included only very narrow exceptions that differed from those in the 15-week ban. The penalties for those who violate the ban are severe, including imprisonment, fines, and loss of medical licenses.[4] On the same day that the Florida Supreme Court revoked state constitutional protection of abortion rights, however, it also allowed a proposed amendment that would enshrine abortion rights into Florida’s Constitution to be included on the state’s November 2024 ballot for voters’ consideration.

Florida’s extreme abortion ban has created an unworkable legal landscape that endangers both patients and clinicians. The ban violates individual reproductive freedom, leads to preventable suffering, and compels clinicians to deviate from established standards of care and medical ethics. These denials constitute violations of Floridians’ fundamental rights, including their human rights to life, health, privacy, freedom from torture and cruelty, and equality.

In July and August 2024, PHR researchers conducted in-depth, semi-structured interviews with 25 reproductive health care clinicians and clinicians in training in Florida about their experiences caring for pregnant patients under the six-week ban. In these interviews, clinicians stated that while abortion clinics in the state continue to provide care where legally permitted, Florida’s six-week ban is creating insurmountable barriers to abortion care for many patients. Clinicians described how the unworkability of the ban’s narrow exceptions and the severe chilling effect on abortion provision caused by the sweeping criminalization of abortion from a very early stage of pregnancy are endangering patients’ health and survival and impairing clinicians’ ability to comply with their ethical obligations and medical standards of care.

Clinicians shared multiple examples of cases of delays and denials of reproductive health care including abortion care and miscarriage management, disruption of the patient-clinician relationship, deviations from standard medical care, impaired training of new clinicians, and an exodus of health care providers from the state, worsening Florida’s already severe health care provider shortages. Alarmingly, clinicians stated that patient care is being impeded by Florida’s broad abortion ban even in cases of ectopic pregnancy, molar pregnancy, and preterm premature rupture of membranes, despite state health agency rules that state that these conditions should not be considered abortion.[5]

Clinicians interviewed described the devastating consequences of the abortion ban for their patients. Many patients do not realize they are pregnant until after the legal limit – just two weeks after a missed period – and the required 24-hour waiting period between a first face-to-face appointment with an abortion provider and receiving an abortion further narrows the window for care. Patients are referred to tertiary care centers and abortion-providing facilities within the state as hospitals grapple with confusion about what the exceptions include and direct patients to seek more specialized clinicians’ authorization to avoid risk. Ultimately, the law’s narrow exceptions do not cover many serious conditions, forcing patients to either travel out of state for medical care or continue pregnancies with severe health risks. As clinicians deliberated whether they could legally offer care, patients experiencing medical emergencies requiring pregnancy termination, miscarriages where they needed medical intervention, and even cancer faced delays and even denials of treatment due to the ban. This disruption in medical care disproportionately impacts low-income and marginalized communities, who already face barriers to prenatal and maternal health care. Additionally, the emotional and physical toll on these patients is profound, as they are often left with few possible options for care.

The broader implications of Florida’s abortion ban are alarming. Clinicians’ testimonies highlight ways that Florida’s ban is jeopardizing prenatal care and will likely further worsen the state’s already poor maternal health outcomes.[6] The ban also threatens the future of reproductive health care in Florida, as medical training in essential procedures like dilations and curettages (D&C) and dilations and evacuations (D&E) after the first trimester is severely limited. This lack of training not only impacts abortion care but also the management of miscarriages and other pregnancy complications, posing a significant risk to patient safety. Reflecting on these devastating impacts, clinicians called for the lifting of the six-week ban.

Florida’s extreme abortion ban has created an unworkable legal landscape that endangers both patients and clinicians. The ban violates individual reproductive freedom, leads to preventable suffering, and compels clinicians to deviate from established standards of care and medical ethics. These denials constitute violations of Floridians’ fundamental rights, including their human rights to life, health, privacy, freedom from torture and cruelty, and equality. This research brief underscores the urgent need to ensure the right to comprehensive reproductive health care in Florida.

Introduction

The United States (U.S.) Supreme Court ruling on June 24, 2022, in Dobbs v. Jackson Women’s Health Organization (Dobbs) overturned the 50-year-old precedent set by Roe v. Wade and eliminated the federal constitutional right to abortion.[7] Two years after Dobbs, in April 2024 the Florida Supreme Court followed suit and overturned its own 1989 judgment and decades of precedent that the Florida Constitution’s Privacy Clause protects the right to abortion.[8]  On May 1, 2024, Florida’s six-week ban took effect, shifting the legal limit for abortion from 15 weeks to six weeks from the first day of a pregnant person’s last menstrual period.[9] [10]  The six-week ban punishes any person who “willfully performs, or actively participates in, a termination of pregnancy” in violation of the law as a third-degree felony with up to five years in prison, up to a US$5000 fine, loss of medical licenses, or all the above. Unlike many other states, Florida’s ban does not clearly exempt pregnant people themselves from criminal prosecution.[11]

The six-week ban in Florida criminalizes the termination of pregnancy before many individuals are aware that they are pregnant – typically two weeks after a missed period in a standard four-week menstrual cycle. The new Florida ban provides limited exceptions in situations of medical necessity to save a pregnant person’s life; to “avert a serious risk of imminent substantial and irreversible physical impairment of a major bodily function…other than a psychological condition;” in cases of fatal fetal impairment where a pregnancy has not reached the third trimester; and in pregnancies resulting from rape, incest, or trafficking prior to 15 weeks only if the patient provides “a copy of a restraining order, police report, medical record, or other court order or documentation providing evidence” that they are obtaining the termination of pregnancy because they are a victim of rape, incest, or human trafficking.

The six-week ban replaces the previous 15-week ban that was instituted on July 1, 2022.[12] Some of the new ban’s exceptions differ from those of the 15-week ban, exacerbating confusion about when abortion is legally permitted.[13]  For example, the 15-week ban’s  “fatal fetal abnormality” exception allowed abortion “before viability,” unlike the six-week ban that states the limit is “before the third trimester.”[14]

On the same day that the Florida Supreme Court revoked state constitutional protection of abortion rights, in 2024, it also allowed a proposed amendment that would enshrine abortion rights into Florida’s Constitution to be included on the state’s November 2024 ballot for voters’ consideration.[15] The proposed Florida amendment says, in part, that no “law shall prohibit, penalize, delay, or restrict abortion before viability or when necessary to protect the patient’s health, as determined by the patient’s health care provider.” It would need approval from 60 percent of voters to be enacted.[16]

In addition, the day after the six-week ban went into effect, the Florida Agency for Health Care Administration (AHCA) released emergency rules – stating that certain pregnancy terminations, including for premature preterm rupture of membranes (PPROM), ectopic pregnancy, and trophoblastic tumors, should not be considered abortion for reporting purposes. These guidelines lack medical clarity, further confusing clinicians.[17] [18] Compounding these laws and guidelines, targeted restrictions on abortion providers (TRAP) laws (procedural requirements on facilities and individuals who can provide abortion care), along with the 24-hour waiting periods between the two required in-person abortion care appointments in Florida, further complicate service delivery and lead to confusion on how providers can best care for their patients.[19]

After the six-week ban went into effect, PHR undertook fact-finding interviews from July to August 2024 with 25 clinicians and clinicians in training to document whether and, if so, how Florida’s abortion ban is impacting patients, health care workers, and access to health care. We interviewed clinicians in obstetrics and gynecology, maternal-fetal medicine, family medicine, reproductive endocrinology, certified nurse midwifery, medical students, and genetic counselors across the state, with representation in varied practice types that include public and private hospitals, academic medical centers, private practices, and free-standing abortion-providing facilities.

In these interviews, clinicians described the serious and manifold harms the ban is causing pregnant people in the state who seek reproductive health care. The six-week ban is unclear in its guidelines and introduces barriers to care, delays in emergency reproductive services, and deviations from standard medical care. Moreover, the steep penalties, particularly when combined with other laws, create intensified fear and confusion among health care providers who do not know in what cases they legally can or cannot provide abortion care, creating strain in the patient-clinician relationship and inducing providers and trainees to leave the state. Clinicians report receiving warnings from hospital administrators, legislators, and others that they may be targeted for providing necessary abortions and that these laws are being strictly enforced. This has led to an overall chilling effect on the provision of reproductive health care and has hindered access to abortion care for pregnant people, many of whom have a medical necessity for the procedure.[20] Thus, the six-week ban has rendered the already complex legal landscape for abortion in Florida even more unworkable in practice, with restrictions that endanger both clinicians and pregnant patients in the state.

Florida’s Reproductive Health Landscape

As of 2024, 20 percent of Florida’s population – 4.6 million women- are of reproductive age (between 15 and 44 years old).[21] Health care costs and accessibility create significant barriers in access to health care generally for people of reproductive age in Florida. Florida’s health care system ranks among the worst in the U.S. in terms of accessibility and affordability, especially for women’s health, possibly driven by the lack of Medicaid expansion.[22] [23] Florida is currently experiencing extensive shortages of physicians, dentists, and mental health providers compared to the needs of the state’s population.[24] Further, an estimated 13 of Florida’s 67 counties are maternity care “deserts,” or counties without access to hospital or birth centers offering obstetric care or without obstetric care providers. Another 11 counties have low or moderate access to maternity care.

Pregnant people in Florida have long faced delays in accessing prenatal care.[25] In 2021, before the Dobbs decision, fewer than two out of every three pregnant people received prenatal care within the first four months of pregnancy (64.7 percent).[26] Florida is rated the second worst in the nation currently for the provision of prenatal care, which creates serious risks for pregnant people in the state, including already marginalized populations who face higher barriers to quality maternal health care.[27] For example, in Florida, in 2020, Black and Hispanic women died from pregnancy-related death at nearly four times and one and a half times the rate of non-Hispanic white women, respectively. [28] Of concern, nearly one in five of these pregnancy-related deaths in Florida were attributed to systemic care issues, such as a lack of standardized policies, procedures and care coordination.[29]

Over the past decades until the recent bans, abortion care was available throughout Florida. Even under the 15-week ban, Florida provided crucial access to abortion for Floridians and others in the U.S. South who lived in states with more extreme laws.[30] Prior to the Dobbs decision in June 2022, abortion was legal in Florida up to the third trimester, defined as starting 26 weeks after the last menstrual period.[31] A 24-hour waiting period for abortions went into effect in April 2022, followed shortly by the 15-week ban that went into effect in July 2022. As of March 2024, Florida had 54 abortion clinics.[32]

Once the six-week ban went into effect in May 2024, there have been significant decreases in abortions within the state in May and June compared to comparable periods last year in Florida.[33] While abortion clinics in the state continue to provide crucial care within the legal limits, many Floridians have been forced to travel outside the state for abortion care. The National Abortion Federation, which runs the largest patient assistance fund in the country to help people afford abortion care, reported a 575 percent increase in callers requesting funding in the two months since the ban went into effect in May, compared to the same time last year.[34] This has contributed to more than a 30 percent increase in wait times at abortion clinics across North Carolina, Virginia, Maryland, and Washington, DC. North Carolina has seen the largest increase despite having a 72-hour waiting period, with wait times increasing in half of the state’s 16 clinics.[35] The long-term impact on abortion clinics in Florida remains uncertain, but in other states with severe abortion restrictions 66 clinics closed across 15 states, with 14 states losing all abortion-providing facilities[36] within 100 days[37] of the Dobbs decision. Clinics in states with bans face significant challenges in maintaining[38] staff and financial viability, and even if abortion rights are restored, reversing closures can be difficult, creating lasting impacts on access to care.[39]

The passage of the six-week ban raises serious questions about the impact on Florida’s existing challenges in the provision of health care and specifically care for pregnant patients. Health care worker shortages, barriers to prenatal care, and barriers to abortion currently contribute to significant health harms in the state. Against this backdrop, it is critical to understand reproductive health care clinicians’ experiences providing care to pregnant patients under the six-week ban.

Research Methodology

In July and August 2024, the PHR research team conducted outreach to reproductive health community-based organizations and professional networks in Florida. These contacts facilitated connections to reproductive health care providers (“clinicians”), medical students and genetic counselors who have provided reproductive or pregnancy health care in Florida post-Dobbs. The research team then used snowball sampling, an established sampling strategy for research on hard-to-reach populations or sensitive topics, which has been used to conduct qualitative research in comparable studies.[40] Clinicians consented to 30- to 60-minute, semi-structured, in-depth, confidential interviews. Interview guides were developed based on the expertise of the research team and conversations with partner organizations. Transcripts were de-identified and cleaned by interviewers, and data was stored on a password-protected server and only accessed by the research teams. Study recruitment ended when we reached concept saturation, the point at which no new themes emerged from additional interviews.[41] Thematic analysis was used to identify experiences across interviews. The two interviewers (WA and MH) read transcripts of the clinician interviews after a third of the interviews were completed; through a hybrid approach they identified key themes emerging from the data (inductive analysis) and based on the research questions (deductive analysis) to develop a codebook. One interviewer (WA) coded all the transcripts, adding more codes as they emerged from the data. Illustrative quotes were selected based on key themes.[42] PHR’s Ethics Review Board (ERB) approved the study with exempt status. See Appendix 1 for characteristics of the 25 clinicians interviewed.

Findings

Florida’s abortion ban and unworkable exceptions pose insurmountable barriers to abortion care for many patients

Abortion is currently legal in Florida only until six weeks after a pregnant person’s last menstrual period (LMP) with limited exceptions.[43] As one obstetrician-gynecologist said: “While it is limited, abortion is still legal. There has definitely been some confusion. It is still legal.” While health care facilities across the state continue to provide abortion care to pregnant patients within the laws’ narrow confines, as one clinician emphasized, the unworkable exceptions and extreme gestational limits mean many patients are barred from care:

“It is virtually a total abortion ban. Most people do not know that they are pregnant at six weeks. Considering the 24-hour waiting period, it is virtually a complete ban. So, do not be fooled that this is a compromise. It is not.” (14)

Many people do not know that the timeline for calculating the abortion ban begins from the first day of the last menstrual period (LMP) on ultrasound and not the estimated date of conception

 Many clinicians noted that many of their patients did not realize that pregnancy is dated from the first day of their last menstrual period. The American College of Obstetrics and Gynecology (ACOG) measurement guidelines, for example, are based on the first day of the patient’s last menstrual period confirmed with an ultrasound measurement.[44] Clinicians reported that since the six-week ban, their patients who come in seeking an abortion right when they discover that they are pregnant are often distraught that they are considered further along in their pregnancy than they had assumed and are unable to receive an abortion within Florida. A clinician at an abortion care facility described how often she faces this:

“There is at least one person a week who is really angry and does not trust the ultrasound [results]. What is behind it is that they do not understand how the dating of pregnancy works, which is fair. It is just so confusing. And, the person is explaining to me, ‘There is no way I am six weeks pregnant. There is no way I am seven weeks pregnant, because this is when I had sex, and this is when I got pregnant.’ And I am like, ‘You are 100 percent right. I agree. That is when you got pregnant. But here is how the law and the medical world define the time of pregnancy. I am so sorry.’” (4) 

Patients who have irregular periods may have no idea what they will measure on an ultrasound once they have discovered that they are pregnant. One obstetrician-gynecologist told us: “The other day, we had a 14-week [patient] just because she does not menstruate. And she was like, ‘I have no idea. I do not know when my period was. I do not know when I conceived.’” (21)

Six weeks pass before many people realize they are pregnant or can secure an appointment with a provider to confirm results of a positive home pregnancy test

As many clinicians explained, many of their patients do not find out they are pregnant until after six weeks, at which point they no longer have the option to have an abortion in Florida except in narrow circumstances.[45] An obstetrician-gynecologist in private practice described:

“With the six-week ban, I would say it is more like the inability to really offer anything at all now. I mean, we see patients for their new obstetrician-gynecologist visits usually around eight weeks, and sometimes we see them earlier, if they are having bleeding or other issues where we end up scanning them earlier. But I do not think I have ever had a viable pregnancy that was less than six weeks that I could offer a termination. They are never less than six weeks, so it is essentially impossible. By the time we see them for their first visit, that option is already gone.” (19)

Multiple clinicians explained that because of a shortage of obstetrician-gynecologists in Florida, people are rarely able to secure a prenatal appointment to confirm the results of a pregnancy test with a dating ultrasound before six weeks of gestation. In the words of another obstetrician-gynecologist in private practice:

“The patients that I see in the office for an initial prenatal visit are almost never less than six weeks. It is incredibly rare for somebody to be able to get in less than six weeks. I would say more often it is closer to twelve. And part of that is because of the demand, we do not have enough providers to see patients, and we are a very big practice… And then patients who are coming in for something else and then discover that they are pregnant, if they are lucky enough to be less than six weeks, just have so little time to consider their options and then hopefully get in with somebody who can provide abortion if that’s what they choose.” (17)

Another obstetrician-gynecologist explained how impossible this timeline makes the option of abortion care for many of her patients:

“Most women do not know that they are pregnant that early. Also [because of] the way that we label pregnancies as six weeks of pregnancy…. they have actually only been pregnant for four weeks, and most pregnancy tests do not turn positive for those first two weeks. So, they really only have two weeks. And that is total days, not business days. They have two weeks to figure out that they are pregnant, even have that on their radar. Call and get an appointment, and then get a second appointment all within six weeks and zero days’ time, which is really hard.” (20)

Florida’s 24-hour waiting period creates an additional barrier to receiving abortion care within legal time limits

 In Florida, the first abortion appointment consists of an ultrasound to measure gestational age, where patients are read the state-mandated consent information. Patients then return at least 24 hours later for a medication (mifepristone and misoprostol) or procedural abortion (for example, D&C). Clinicians noted that clinics have been penalized by AHCA for performing abortions up to 15 weeks and six days rather than 15 weeks and zero days, under the 15-week abortion ban. While clinicians did not name a public document stating this policy, these accounts of aggressive enforcement have led facilities to err on the side of caution, and assume the same is true for the six-week ban- that to be legally eligible for abortion care under the six-week ban, the first appointment must occur no later than five weeks and six days after the beginning of a patient’s last menstrual period ifthey can schedule the abortion for the next day. However, most abortion-providing facilities are not open or do not provide abortion procedures every day of the week. As a clinician who provides abortion care described:

“[In Florida] abortion clinics are not open seven days a week. [One clinic is] open on Tuesday, Wednesday, and Thursday. So, if you are seen on Thursday and you are five weeks and four days – we cannot provide for your care. And, like, maybe a [city] an hour and a half away, is booked up, and they do not have appointments for you. And so, a six-week ban is not a six-week ban, depending on what day you are getting seen. …If you are not open for four days, it is not a six-week ban, it is a five [week] and four [day] ban.” (4)

Several obstetrician-gynecologists described how harmful the impact is on their patients who must travel to facilities hours away to receive their abortion before the six-week deadline:

“I have definitely seen patients who I do the consent, and then the next day they drive [to another city across the state] for their appointment for their abortion. …I have talked with many patients who are confused about why they are being asked to drive across the state on a day’s notice and have to drop everything they are doing, leave work, find childcare, pay for gas, and all these things. And I have to explain to them – this is not a rule that we implemented. This is based on state law, and we are just trying to help as much as we can.” (14) 

Many fetal anomalies are unable to be detected on early ultrasound imaging before six weeks

Florida’s six-week ban only permits abortion for “fatal fetal abnormalities” where termination is sought before the third trimester. The law states that “a fatal fetal anomaly” is one that is “a terminal condition that, in reasonable medical judgment, regardless of the provision of life-saving medical treatment, is incompatible with life outside the womb and will result in death upon birth or imminently thereafter.”[46]  Clinicians shared that patients faced delays and denials of abortion due to confusion about which fetal anomalies could be terminated legally, including severe anomalies that would lead to death in weeks or months – not just hours – from birth.” Clinicians described their experiences caring for patients with severe but not clearly fatal fetal anomalies during pregnancy that cannot be detected on early ultrasound imaging. One certified genetic counselor said:

“When I started practicing, the legal limit to have an abortion was 23 weeks and six days. So, for the majority of our patients at that time, we were able to get them the care. Some patients who were late to care or things were found later on ultrasounds, we helped them go out of state, but that was few and far in between. So, then when the 15-week abortion ban came into place, obviously that made things a lot harder, but we were still able to get in, not necessarily the ultrasound findings, because those are just very hard to see anything super well under 15 weeks, but the very severe ones, we would still be able to get them in. And then we really pushed for, in our practice, [getting people in] for chromosomal screening right at the 10-week mark when they can do it or as early as possible. So, when the results are back that we would be able to do diagnostic procedures at 12 weeks and then we can get those results back before the legal timing limit to get abortions. But it was hard because there was no time to spare, essentially. Like things had to get in very quickly. …But anything past that, any anomalies had to go out of state.” (22)

Fear of criminal charges has caused delays and denials of emergency reproductive health care to patients

Clinicians repeatedly shared how Florida’s narrow exceptions to the overall criminalization of abortion has led to widespread fear that has hindered access to care and harmed patients. Clinicians at tertiary care centers reported receiving increased referrals from clinicians afraid to care for complicated pregnant patients under the current laws. One obstetrician-gynecologist told us:

“I have seen a surge in patients coming to me that I was not seeing before that were being handled by the community and getting care elsewhere. Patients [are] coming desperate, [saying] ‘They would not sign off on this. I do not know what to do. They just said, go to [tertiary care hospital].’ So, I get a lot of phone calls from my residents about patients in the ER, [telling me], ‘They are 18 weeks, and they have bilateral renal agenesis [lack of both kidneys which is usually fatal] in the fetus …and they are like, ‘I want an abortion.’” (11)

One maternal-fetal medicine (MFM) specialist explained one basis for this fear: “The state has come down very hard on a couple abortion centers that [the state argued had] deviated on the cutoffs as the law changed from 15 weeks to 6 weeks. And so, the fear is that the state is actually looking for a scapegoat to go after.” (13) This MFM also noted referrals from providers afraid that they would not fill out correctly the extensive and confusing required paperwork by the state for legally allowable abortions and would thus be prosecuted:

“We are seeing tons of referrals that would not have been made before [the abortion ban]. I even see doctors that are two blocks away from me going, I am too intimidated by all the state paperwork. I know exactly that this fits the criteria, but I just do not know how to fill it out, how to date it, how to sign it. There are all these rules. We are just sending the patient to you so you can do the paperwork.” (13)               

Several clinicians described how fear and lack of clarity about the narrow medical exceptions are leading to patients being sent out of state for abortions even in situations where abortion care could be considered to be legal. One obstetrician-gynecologist hospitalist stated:

“I would say 99 percent of MFMs in our state are not entirely aware of the laws or they are scared of the laws. So instead of calling a clinician who does abortions [in Florida] and asking them, ‘Would this qualify for an exemption?’ They just automatically refer the patient out of state. Because they do not want to be on record saying that they think this is a lethal anomaly or that they think that this is going to endanger maternal life…. And so, they just say, ‘Go to North Carolina or Virginia or whatever it is. …Since the six-week [ban] went in place, literally zero clinician sign off has occurred [at my hospital], because I think people are just being directed elsewhere. [It is] just an even more unnecessary burden on the patient. Like, it is bad enough she is going through this bad outcome that she did not sign up for, now you are making her travel out of state when she really does not have to. There is a multitude of doctors in Florida who remain who are capable of doing [abortions]. But people are just scared.” (21)

Delays in securing hospital approvals due to hospital concerns about violating Florida’s abortion ban in turn are delaying emergency care for pregnant patients

Multiple clinicians recounted how the abortion ban vaguely defined narrow exceptions had led to difficulties in securing approval for medically necessary abortion care from their health care facilities. Several clinicians described cases of being required by their hospitals to wait until patients become “sick enough” to qualify for care. One obstetrician-gynecologist told us about an incident which occurred under the 15-week ban:

“I strongly remember a patient who had severe kidney disease and was admitted to the hospital and was teetering on the edge of that 15 weeks. I think she was 14 weeks or so, and she got admitted, and we were trying to figure out how best to help her. She was getting sicker and sicker…. [We] had to bring it to the head people of the hospital and be like, ‘What are we allowed to do?’ And they were like, ‘She is not sick enough yet.’ And we had to wait for her to get sicker before we were even allowed to offer her termination. And she was past 15 weeks at that point. …I think it took over two weeks for us to get an answer from the hospital administrators. …So that hit very strongly, because it was kind of insane that we had to wait for her to become sicker. We had to wait for her creatinine to bump and her kidneys to be about to fail before we were allowed to even offer her [termination]. Then we had to jump through so many hoops to be able to do it. It really changed everything that we did in our practice.” (19)

Another obstetrician-gynecologist recounted another case of delay in care for a patient facing a potentially fatal pregnancy complication:

“[There] was a patient who was like 20 to 21 weeks and developed severe Hemolysis, Elevated Liver enzymes and Low Platelets [HELLP], a life-threatening liver and blood clotting disorder of pregnancy whose definitive treatment requires removal of the fetus and placenta …She also had COVID-19 and she was very isolated and her care got significantly delayed because we had to get approval to terminate her pregnancy in the hospital and she got pretty sick.” (18)

Another obstetrician-gynecologist described the impacts on pregnant patients of long delays in securing hospital approval for medically necessary abortions:

“There were times where we had to wait weeks before we had answers. And then that is just pushing the pregnancy further and further along for a sick patient or someone who is already struggling with those choices that they were having to make.” (19)

While the six-week ban allows terminations where there is a serious risk of substantial and irreversible physical impairment of a major bodily function of the pregnant person, clinicians described delays in the provision of abortion due to confusion about what constitutes a “serious” risk as well as the need for approval by hospital administrations. One obstetrician-gynecologist shared the account of a patient with a cardiac issue who had an increased risk of death postpartum:

“After [my patient’s] fifth pregnancy, she had a spontaneous coronary artery dissection. Almost died … and she is pregnant again…. I had to present her case, and she was, I think, 18 weeks pregnant…. There is no question her life would be at risk carrying this pregnancy and it is happening again, most likely postpartum. Well, then, is the pregnancy really putting her at risk? And, you know, I had to sit before five or six or seven hospital administrators and make an argument for this woman. And the data I could pull was that there probably was up to about a 10 percent chance of this happening again, but it is a 10 percent chance of dying because if she had another spontaneous coronary dissection, she’s dead. And I had to hear these people say, ‘Well, is 10 percent a lot? Is that enough?’ I said, ‘Are you kidding me? I guarantee if you ask her five children is 10 percent a lot, a big chance of losing your mom? Does that sound like a lot? They would say yes.’ But it is this back and forth, and it is just this kind of chaos. But who makes these decisions? It just leaves you in a stalemate sometimes. … I eventually got to a point where my hospital said, okay, yes, we can do this. It took me two to three weeks to get to that point. And you obviously know [that delay] matters. You are 15 weeks, 16, 17, or 18. The procedure changes a little bit, and the risk changes a little bit.” (11)

Preterm premature rupture of membranes (PPROM) and ectopic pregnancy care is still being delayed despite AHCA emergency rule

Following the six-week ban going into effect, AHCA, a state agency, issued a rule stating procedures to treat PPROM, ectopic pregnancy, and trophoblastic tumors would not be considered abortions for state reporting purposes. Despite this, several obstetrician-gynecologists reported that their patients are afraid that they will not be able to receive care for these conditions, which makes it incredibly “challenging,” as one clinician worded it, to provide care. In the words of one: “[for] molar pregnancies, ectopic pregnancies, even though the state has said in their AHCA emergency rule that those are not, “abortion care,” there is still so much confusion and fear on the part of our patients that they are not going to be able to get care or that they will get in trouble.” (1)

Indeed, these fears are not unfounded. One obstetrician-gynecologist told us that her hospital still required them to have a two-doctor signoff for PPROM to protect them in case the state decided to prosecute, even though PPROM should not count as abortion provision under the AHCA emergency rule:

“We did get guidance after the six-week law was passed…. So now we are able to discuss with patients what we call active management if their water is broken at a PPROM. So, we are lucky compared to other states in that regard. But still, it is so intrusive. Okay, here you are. Tragic your water is broken. We are worried about these things. You do not want to stay pregnant. Let us roll in with a brochure of state paperwork. Let us start filling it all out together, because even though you know what you want, we have to do all this paperwork. And the law is not that clear. So, we still do two signatures. Like there is still a delay that occurs with all of this that seems unnecessary in a situation where delay potentially could increase the chance of infection.” (13)

Clinicians at small rural hospitals and at religious-affiliated hospitals described how their hospitals were recommending that patients with PPROM to be transferred to larger, academic hospitals or tertiary care. These delays in care could result in additional health complications for patients, and this chilling effect extends to broader pregnancy care. One obstetrician-gynecologist described a case of a patient who developed complications due to delays in referring her to another hospital for termination that the obstetrician-gynecologist would have provided before the abortion ban:

“We had a patient who had PPROM, she was like 18 weeks and she desired termination. Basically, what we have to do is send a referral to our MFM, who then can refer her to [academic hospital] for care, and in that process [the patient] got infected, got chorioamnionitis and became septic and ended up needing admission and IV antibiotics at the academic hospital. So, yeah, just not being able to just admit that patient that day and proceed with an induction was unfortunate for her.” (18)

And, as another obstetrician-gynecologist at a rural hospital recounted, options in Florida for transfers requiring abortion procedures are increasingly limited: “I have thought about that – where do I send people? So, I know if I get somebody in who wants a D&E who is PPROM, I have to send them to that one hospital because I do not think any of the other ones would do the procedure.” (5)

We also heard similar accounts about ectopic pregnancy care. One obstetrician-gynecologist told us care was still being delayed in their ER for ectopic pregnancies, as ER clinicians were afraid to provide methotrexate to patients as it was an “abortive agent”:

“I was on call and we were trying to give methotrexate and were getting pushback from one of the emergency room providers. It was mostly from nursing, but I guess the physician assistant [PA] was the one that was mediating this between us. But we had a patient who had an evacuation already and was still having rising human chorionic gonadotropin [HCGs], a hormone indicating pregnancy and to everybody in the obstetric world, that is an ectopic unless proven otherwise. And she had come in specifically to get methotrexate. Like she had been sent in from [abortion-providing facility] to get methotrexate from our team. And so, we ordered it, and we had to have this back and forth. We were EPIC chatting [texting within the medical record], having this kind of disagreement back and forth. I actually printed out the AHCA code and [a resident] brought it down and there was still a lot of back and forth. It ended up being one of our labor and delivery nurses just went down and gave the medication. It is like a very big conversation on a bunch of email threads now because of this. And we had [another] recent case, [a] similar situation where they were refusing to give it because they were concerned about the legality of giving it as an – they kept calling it an abortive agent.” (25)

Narrow and unclear exception for “fatal fetal anomalies” is causing confusion and leading to denial of care to patients with severe diagnoses

Clinicians noted that the Florida law’s exception for fatal fetal anomalies does not cover many serious conditions. The state has defined “fatal fetal abnormalities” as “a terminal condition” that is “incompatible with life outside the womb and will result in death upon birth or imminently thereafter.”[47] As one MFM specialist explained:

“So, the actual term is “imminently lethal,” which is not a medical term…. So, a patient comes in or has a condition that is genetic, and let us say 100 percent of the time, the baby is going to die of a debilitating neurologic condition by age three or by three months of age even, they cannot terminate in the state of Florida. And so, that is an interesting conversation to have with people because many people … have no idea that their rights have been stripped away. And so, I end up having conversations where people get really angry with me because they cannot terminate.” (13)

A genetic counselor told us that their hospital had decided in consultation with the lawyers that “imminently lethal” meant “lethal, essentially, within the first day of life.” (22) Another genetic counselor recounted the case of a patient whose fetal diagnosis was not considered “imminently lethal”:

“A patient had two children who had a very rare genetic condition. They passed away four months of age. …The patient came to me in her third pregnancy, had already had diagnostic testing done, and just to talk a little bit about coordinating out of state abortion. All the providers who have seen her … nobody felt comfortable saying that this is lethal immediately post-delivery. Right, because is four months immediately post-delivery? And I think it is things like that where you are sitting there and you are like, what defines, you know, severity? And this is for, you know, a mother who lost two children who did not want to go through that suffering again or see them go through that again in her words, we could not give a time limit [for lethal].” (12)

Multiple clinicians described conditions in the gray area of the law that might be quite severe, but did not meet the criteria for being lethal immediately upon delivery. These patients who do not meet this narrow criterion for exceptions are forced to travel out of state or continue the pregnancy. As one obstetrician-gynecologist said:

“There is no amount of legal wording that can account for and pay respect to the complexities of medical care that can arise. …And so, what I have seen with these families [who] are in this area of gray is that they end up needing to travel out of state for abortion care because these exceptions are very narrow. And if they happen to be unlucky enough that their baby has a condition that does not necessarily meet this narrow exception, their health care team is going to be reluctant to care for them because they do not want to be prosecuted for not following the law. And so, in many instances, I have had patients travel out of state.” (2)

Pregnant people who do not qualify for narrow exceptions must travel out of state or continue pregnancies with severe health consequences

Due to the concentration of abortion bans in the southern U.S., patients in Florida have limited options for facility-based care. The closest states with higher gestational limits are North Carolina, which currently limits abortion provision to 12 weeks with exceptions for life-limiting fetal anomalies up to 24 weeks, and Virginia, which allows abortion until viability.[48] For many patients, traveling to another state is impossible. Out-of-state travel requires that people have significant resources such as financial means, travel experience, childcare for their other children, and time off from work. A clinician at an abortion care facility said:

“There are patients who come in at six weeks, zero days to sign their consent, and 24 hours later, they would be six weeks, one day. They come in with a stroller with two babies: ‘I cannot go to North Carolina. I am a single mom. I do not have any [paid time off]. What do you want me to do here?’ And, I mean, what I am asking of them is, ‘Hey, can you travel 300 miles for a five-minute procedure or 800 miles for a five-minute procedure?’ It is insane.” (3) 

Another obstetrician-gynecologist who provided reproductive health care to incarcerated patients pointed out that they now have no options for abortion care, as the prisons will not send incarcerated pregnant people out of state for abortion care: “My patients who were in the jail, they will take them to the clinic down the street, but they are not taking them out of state.” (5)

Clinicians described patients for whom English is a second language or who have recently immigrated to the U.S. as being among those most affected, as they were often less familiar with navigating the U.S. health care system. A clinician described the difficulties of non-English-speaking patients with fetal anomalies trying to navigate the American medical system to make health care appointments in another state.

“I just had a case this past week of a very nice couple. They did not speak English. The baby had a severe, debilitating abnormality that was not lethal. … a very large spinal bifida defect. They did not have it in them to stay pregnant. And absolutely, they were going to travel out of state to get care. I went through the long discussion with the translator about everything and about the options and pulled up a couple of out of state places. And at this point, I am 45 minutes behind in my schedule… [and the patient asks,] ‘Can you call the doctors at the top three centers and tell them about me? And can you set up those appointments for me?’ And I felt so bad. I said, ‘No, actually, I cannot do that. That is something you have to do for yourself.’…. [Afterwards] it haunted me. I left her with a really daunting task.” (13)

Being forced to travel out-of-state or continue pregnancies can result in compounding harms. A genetic counselor described the emotional impacts on patients who must travel out-of-state for pregnancies with life-limiting fetal diagnoses, where people reported post-traumatic stress disorder (PTSD) and grief that was compounded by the stress of needing to leave the state to receive abortion care.

“I had some patients who … had to travel out of state for medically indicated terminations. [It] was a really traumatizing experience. [Thinking of one patient seen last week], …. to have to travel out of state and have to do everything with doctors that she did not know in a state and in a health care system she did not know. It was really hard for her. She got good care. But it is a really sad thing to have these patients you have established relationships with have to leave and be off work and hopefully have somebody with them also supporting them and spend all that money. It is just that they report PTSD and, of course, grief. But I think that the grief is a lot more complicated than it could have been.” (17)

Multiple clinicians interviewed recounted the stories of patients unable to travel out of state for care who were forced to continue their pregnancies, even if they faced precarious social, financial, or health situations. A MFM specialist recalled one recent patient:

“I had a patient who was Spanish speaking, who had a trisomy 18-week pregnancy with a heart defect. Now, 30 percent of those babies will die prior to labor, 30 percent will die in labor, and the majority that are born will die in the subsequent hours to days to weeks after birth, with a small minority able to survive beyond a year. So, we made this diagnosis at about 18 weeks gestation, but these babies can live for hours or days. And so, I knew that just sending this case for review based on state laws was unlikely to be approved because there is so much fear. So, I sent the patient to the pediatric cardiologist. They said, it is a heart defect, and the baby has trisomy 18, but I cannot say that it is a lethal heart defect. I was the one that had the relationship with the patient, so I had to crawl back to her with a translator and tell her that we could not take care of her within our hospital system. So that left her with the only option of going out of state. And that is when she started to cry. And she told me that she is the only caregiver of her mother with severe Alzheimer’s. She had two small children …it would take [two to three days] to travel out of state to get the care and to terminate. But she was like, ‘There is no one that my mother will allow in her dementia to care for her. I am stuck in this state, so I am stuck staying pregnant.’ And she did. And two months later, the baby died in utero. And you can think of all the hurt there was for her in carrying a pregnancy for eight weeks for no reason other than state laws intimidating and altering patient care.” (13)

A genetic counselor said about patients whose fetuses have severe anomalies and who continue their pregnancies because they did not meet narrow criteria for lethal fetal anomalies and could not travel:

“I am seeing patients continuing because they must. Because they do not have the finances or sometimes not even finances. A patient last week could not get childcare. She is a single mom [who] cannot travel out of state for a couple of days, even though financially, we can with some of the funds and things like that make that happen. Somebody has to take care of her kids, and she does not have that. … I feel like my job has become panic coordinator for people as opposed to, truly, we are aligning values, we are making decisions. I feel like there is this sense of panic.” (12)

Florida’s abortion ban causes deviations from standard of medical care clinicians otherwise would provide to patients, including molar pregnancies, miscarriage management, and cancer treatment

Clinicians spoke to how the ban led to violations of patient autonomy, violations of pregnant people’s freedom to make decisions about their bodies, that themselves constituted deviations from the standard of care and ethical treatment of patients:

“The standard of care is that patients have bodily autonomy, and that is one of the main ethical pillars of medicine. And when you take that away, it absolutely impacts the standard of care.” (24)

For example, another obstetrician-gynecologist told us about delays in abortion care for a patient with terminal cancer:

“She had recurrent metastatic pancreatic cancer. She beat it two times, and this was her third recurrence, and it was stage four, terminal. And because she had been on and off chemotherapy and radiation for the better part of five years, because of her recurrences, her periods had been irregular for ages…. And she has always wanted to be pregnant, but never could because of her treatments. And it was on a routine PET scan that she found out she was pregnant, unimaginable. And she was over 20 weeks, like 21 weeks. [She] had no clue because of all of the reasons I just said. Her oncologist said, ‘We have to stop treatment unless you have an abortion, essentially because this poses a risk to the pregnancy.’

She came to us for an abortion after the six-week ban at around 21 weeks pregnant, and given the oncologist saying, we have to withhold treatment, I was like, certainly that is a health exception. And it took so, so much legal back and forth to ensure that we had all this really specific documentation from her oncologist…. [And then I realized she needed hospital-based abortion care due to her medical risks which took time to find.] I ultimately found one about an hour flight away, probably about a four-hour drive away, who was willing to do it. And then we had to go through all of the legal hoop jumping for that hospital [all over again]. And then we had to tell the patient, you have to drive 4 hours for this care while you are literally dying of cancer. She ultimately got [the abortion], and, like, thank God that we were able to set it up. …

In the middle of all that, you want to grab these Supreme Court judges and bring them in the room and say, look what you are doing to people. Let this woman be able to receive palliative chemotherapy, which is the least we can do for her, for Christ’s sake. What we put her through was so cruel and unnecessary. It took over a week for her to be able to get the procedure.” (3)

Some clinicians discussed how Florida’s current abortion ban pushed them to provide abortion care earlier, when they otherwise would have strongly recommended that patients wait for more information about the pregnancy. A gestational sac is not visible at all on ultrasound until approximately 4.5 to 5 weeks of pregnancy,[49] so even in cases where a possible abnormality may be observed that early, clinicians have a limited amount of time to try to determine severity before the patients will be ineligible for abortion care.

A clinician working at an abortion care facility gave an example of this deviation from standard of care for the treatment of possible or partial molar pregnancies, which require more time to diagnose than allowed by the six-week ban[50]:

“It is happening a lot around possible molar pregnancies where it is just a weird looking ultrasound, and in an ideal world, it would be like, all right, let us get some blood work. I am not 100 percent sure this is a molar pregnancy. Let us have you come back in a week and just see what is going on. And you cannot [with a six-week ban]. It pushes you to do, like, substandard medical care.” (4)

Rather than being able to wait and confirm the molar pregnancy before deciding on treatment, clinicians need to treat patients early, before being able to confirm this on an ultrasound.[51] Additionally, clinicians noted that the law limited treatment of patients who have a medication abortion failure and needed a second round of treatment but are now past the six-week limit. Patients might then be forced to continue the pregnancy, and continuing a pregnancy after exposure to misoprostol has a small increased risk of fetal malformations.[52] A clinician at an abortion facility described the problem: 

“The other thing that worries me is if a patient who comes in and they are going to do a [medication] abortion, say, at five weeks and four days, okay, if they are one of the two percent of failure, and now they come in [for a follow-up appointment] and they are six weeks and three days, what do we tell them? Sorry, it is now illegal. That is a terrible conversation to have with somebody.” (9) 

Several clinicians described patients experiencing miscarriages being turned away from emergency departments and then facing additional barriers to care due to fear of legal risks.[53] One obstetrician-gynecologist described how Florida’s abortion ban has caused a chilling effect, where staff in the emergency department (ED) are frightened and unsure about what care they can provide under state law.

“We had a patient who must have been 13 to 14 weeks, quite small still, who came in with concern about having a miscarriage. And we had seen her down in the ED, and we could tell that she was dilated, and her water had broken…. At that time, we had not yet confirmed if there was still a heartbeat in the fetus. When I reexamined her, [she was beginning to deliver] …., and she is not bleeding out or anything, but she is crying. She and her partner are very upset. They know that this baby is not going to survive, whether it has a heartbeat or not, and that this is going to end in a miscarriage. And she is looking at me and telling me, ‘I cannot mentally handle this anymore. I know, we all know, what is going to happen. Just pull it out. I want to be done.’ And the ED nurse put her hand on my arm and was like, ‘I do not think you can do that.’ And it was just so heartbreaking to have to look at a patient and say, ‘I can see how much pain you are in right now. We know from the medical perspective that this is not a pregnancy that is going to survive into anything, and that we should just take it out. But because of everything that is happening legally right now, I do not know if I can. I need to get some more information, some more help.’” (16)

Another obstetrician-gynecologist told us about being referred cases from nearby emergency rooms (ER):

“We have gotten received a couple of [miscarriages] where an ER would not treat them for whatever reason, and the patient does not totally understand. [The ER] just kind of insisted well, just let your body take care of it. Patients are in pain, they are bleeding, they are out of work, waiting to get an appointment at [an abortion clinic], and then we have to bother them with, ‘Wait, what medical records do you have?’ Because we must legally make sure, can we clearly defend that this is a miscarriage? While the patient is standing there, frustrated and it has been a week, and they are bleeding and not working or trying to take care of their kids.” (20)

Outpatient obstetrician-gynecologists described multiple cases where a patient was clearly having a miscarriage, but care was delayed to ensure exact diagnostic criteria for miscarriage were met so that providers were protected from prosecution. One obstetrician-gynecologist told us:

“What I am seeing is just by nature of our ban and by nature of being in an outpatient setting is someone with an obvious first trimester miscarriage, but who does not quite meet diagnostic criteria for a miscarriage. Meaning, the sac must measure yay big without a yolk sac, or there must be a fetal pole that is yay big without cardiac activity. And that is how you define miscarriage strictly. But there are patients in this gray area where you come in with a big sac, and it is clearly deformed because this patient has been bleeding, but it does not yet meet those exact criteria. But the patient is bleeding and cramping and in pain and wants it out. And there is obviously a risk if this has been going on for several weeks of sepsis – it is clearly not a viable pregnancy, but it does not yet meet those exact measurement criteria…. I am always like, I could document the heck out of this, but is it enough? …I could have her come back in a couple days, show that the sac is not growing to prove that it is a miscarriage. But in that time, she is miserable, she is bleeding, she is cramping, she could, God forbid, get infected. It makes no medical sense to delay care. But legally, it is really vague. Really, really vague.” (3)

Many clinicians discussed the importance of recognizing that miscarriage treatment and abortions both may require the same medical procedures. One obstetrician-gynecologist noted that both abortion and miscarriage care are part of the full spectrum of reproductive health care that people need access to:

“Abortion care is miscarriage care. They go together and you cannot really provide one without the other. And obviously, women who have a miscarriage, that is like one of the worst times in their entire lives. And now we are making that even harder. So, women really need to have their own autonomy and be able to make decisions [in consultation with their doctors].” (18)

Clinicians described distress experienced by their pregnant patients unable to receive care, and their own distress from being unable to care for patients and uphold medical ethics

Many clinicians described the frustration, distress, and anger their patients are experiencing. One obstetrician-gynecologist said of the six-week ban, “I have had a few patients, it is very few, which is surprising to me, who are just angry at me because they need to be angry at somebody. And I just take it because I know that they are angry and I am angry, too.” (7) Another obstetrician-gynecologist said, “There is a lot of crying and there is a lot of you know, the amount of people that tell me that ‘I almost died last time [I was pregnant], what am I supposed to do now?’ is just alarming.” (21)

Clinicians discussed how hard it was to communicate to patients that they will have to travel out of state for their abortion care:

“As a doctor, you watch these patients process all of this, like, in real time, and they are all kinds of frustrated. They are confused. A couple of them ended up at some legalized harassment clinic [anti-abortion centers that try to dissuade pregnant people from having abortions] that they thought was going to provide them abortion services, and it did not and wasted their time. And they need help, and financially, they need help. Just the whole idea of transportation, a lot of them already have kids. How do they make this work? It is really urgent. And they are really vocally very frustrated.” (20)

 One clinician at an abortion-providing facility described a clinic visit after the current abortion ban with a pregnant patient from Vietnam:

“I was trying to explain to her that she was like, eight weeks or something like that. And she pleaded with me, and she started to cry, and I said, ‘I cannot do anything. It is illegal.’ And she said, ‘Just sell me the medication under the table.’ And I am like, ‘I cannot do that.’ And then she fainted in my office, and we had to revive her, and I felt really bad, and she kept [saying] ‘Please, I cannot have this baby. Please help me. Please help me.’ You know, what do you do? You just have to be as understanding and supportive as possible. But I am not going to violate the law.” (9)

Several clinicians described the reactions of pregnant patients who did not know about the abortion ban until they requested an abortion at a clinic visit with them:

“When you have to tell them that it is not available to them in their state, their frustration turns on us. Like, we had a patient [say], ‘I cannot believe that. Like, you are telling me that I cannot get [an abortion]?’ And we were like, ‘You should go out and vote in November, because, we did not make this decision, and we agree with you. You should be allowed [to have an abortion].’ So, I have definitely had the animosity of patients who maybe either knew about the laws, but it did not affect them or who did not even know that these laws were being put in place until it affected them and being really frustrated by it.” (19)

Multiple clinicians in hospitals that required them to complete the 24-hour consent paperwork with patients who were experiencing medical emergencies or fatal fetal diagnoses described how distressful this was for their patients and them. One clinician explained that her hospital required this as an extra precaution to make sure they were complying with state law and told us:

“[The state-mandated 24-hour consent] form is really painful to go through with patients… It basically says, I have been given the opportunity to view a live ultrasound image of my baby, and they have shown me specifically the heartbeat. Or like, I have been given materials and gone over materials for adoption or, you know, like, quote unquote, alternatives to proceeding through with the pregnancy. And it is a difficult conversation, especially instances where, like, the parent may not actually want to go through with having a termination of pregnancy but medically, it is in their best interest. Like, we got a transfer from an outside hospital one time for this lady who had presented to that outside hospital for a heart failure exacerbation. She was very sick from her heart failure and found out in that admission in the ED there that she was pregnant with twins at like, 16 weeks. …. She has an extremely high chance of dying just from the pregnancy. And even at this conservative, religious outside hospital that she was at, the MFM there told her that she needs to go somewhere that will help her end her pregnancy. So, they transfer her to us, of course…. And she understood. She was very much on board with, like, ‘I want to be pregnant, but I also want to be there for my five other children and my partner.’ And it is hard to just have that conversation with a patient, let alone after that conversation be like, now, here is this form where we are going to talk about all these things that are going to make you feel bad about making the right decision for yourself and your family right now.” (16)

Clinicians stated that the ban violated their overall medical ethics and that they experienced moral distress by not being able to provide the full range of reproductive health care options for patients. One clinician told us:

“Basically, what we are being asked to do with these bans is throw out everything we have learned, our judgment, our clinical decision making, patient-centered care, advocacy, equitable health care, autonomy, and beneficence. We are basically being asked to throw every tenet of medicine out the window, and for me, abortion care is health care. It is the highest level of compassion and care and love that you can give to someone. …I am being told I cannot be a doctor, and if I want to be a doctor, I will go to prison for five years. It just puts patients in horrible situations that you would not wish upon your worst enemy. And that you definitely would never, ever want to go through yourself or have someone that you loved or cared about go through.” (11)

Another obstetrician-gynecologist said:

“I can provide [abortion care] up to essentially 24 weeks. I have the skills to do that. It feels, again, dumb. Like, so stupid that I have to go into six weeks, one day patient and be like, yeah, I cannot do anything. We have to help you get out of state…. Especially when, you know, there is no medical reason for it. There is no other field of medicine where people are like, oh, sorry, I cannot do your colonoscopy or whatever, because I just cannot. And that is tough on all [the doctors at her facility]. I think everyone has the skills. We cannot use them. We have the knowledge; we know it is safe. And so, you are turning people away for no real reason except to avoid going to jail, which is crazy.” (23)

An obstetrician-gynecologist described succinctly the conflicts she and other reproductive health care providers face between adhering both with Florida’s laws and her medical ethical obligations to her patients:

“I tend to err on the side of, if I do not comply with the law, then I cannot help the next patient that needs this help. But it is a hard situation to be in just trying to do what is legal but also do what is right. It is not always the same thing.” (24)

Florida’s abortion ban is exacerbating maternal health and mortality due to impacts on training new clinicians and trained clinicians leaving the state

Clinicians involved with medical student and resident training described how the inability to provide training in abortion care is detrimental to the future of maternal health care in the state. Several obstetrician-gynecologists told us stories about how the lack of comprehensive abortion training impacts the provision of broader reproductive health care and noted that this problem pre-dates the Dobbs decision. One obstetrician-gynecologist explained that the lack of providers trained in D&E procedures was already a problem in Florida before the abortion ban and that this shortage would likely worsen if current residents did not receive training in Florida:

“I have graduated a large number of residents who end up staying somewhere in the area and they all inevitably end up calling me, [saying] ‘I have this stillbirth at 20 weeks. She has a previa and three sections. She is really not a candidate for an induction.’ And they are going to section her. What, you are going to cut this woman open at 20 weeks? Like literally you are going to just split her uterus in half for no good reason. But this is what is being done to everybody across the state because nobody knows how to remove a fetus through the vagina anymore.” (21)

This is a problem as D&E procedures are important to broader obstetrics and gynecology practice. As one clinician stated: “Even if you decide you are never going to provide abortion care, you are going to be in a situation where you are going to need to evacuate a pregnant uterus at 14 to 16 weeks. And it is essential that you know this.” (7)

Clinicians further noted that trainees and established reproductive health care providers are choosing to leave the state and thus are further exacerbating existing shortages of providers. In the words of one obstetrician-gynecologist: “We are seeing providers leave. We are seeing residents not apply to the state of Florida because they want that training.” (10) Another obstetrician-gynecologist told us:

“We are going to lose doctors. There is zero question. And what is interesting as well, you know, the state might say, ‘Well, good riddance of abortion providers like, we do not want you, we do not need you.’ But I am talking about general obstetrician-gynecologists, MFMs who are like, I cannot provide the care and the counseling I need to understand these laws. I am going to leave. And we already have a shortage of obstetrician-gynecologists in Florida.” (11)

 Several clinicians emphasized the adverse effects of the abortion ban on training for miscarriage management. As an obstetrician-gynecologist explained:

“One in three women in their lifetime will have a miscarriage. One of three pregnancies end in miscarriage. And so many people can be affected by this because the medical term for miscarriage is spontaneous abortion. And people writing these laws are not looking at the medical terminology, the medical understanding. At the end of the day, if we are not training our clinicians to be able to care for patients, for the one in three pregnancies needing this kind of care, hopefully not all of them need surgical intervention. But if we are not able to train our providers to safely provide this care, we are doing a huge disservice to the state of Florida.” (10)

Additionally, obstetrician-gynecologists described the negative impacts the abortion ban will have on maternal health and mortality overall in Florida, a state that already had poor maternal health outcomes.

“You, the bearer of the uterus, are 14 times more likely to die from being pregnant and delivering full term than from having an abortion. 14 times more likely to die. Forget hemorrhage, psychiatric dysfunction, infections, lacerations. I am not talking about morbidity. I am talking about mortality. And that is based on a study of a maternal mortality ratio of 8.8 to 100,000. Florida is in the low twenties. And that is even worse for people of color. So, we are actively condemning people to death by instituting these bans. And I feel like nobody understands this. Why are we trying to make our mothers die? That makes no sense. And I promise you that both Republican and Democratic mothers will die because this is not a partisan issue. This is medicine. …You need to be on alarm about the kind of training your doctor is getting because there are simply no doctors who can do this anymore. And the entire public should be alarmed because when a bad and weird and an unexpected thing happens in your pregnancy, your doctor will not know how to help you. And that is alarming.” (21)

Florida’s abortion ban interferes with individual freedom to access health care

When asked what they wished people knew about Florida’s abortion ban, many clinicians emphasized that the abortion ban interferes with individual freedom to access reproductive health care. International human rights law recognized that legal restrictions on abortion can violate numerous human rights, including the rights to life, health, equality, freedom from torture and cruelty, and reproductive autonomy.[54] The World Health Organization has found that the criminalization and penalization of abortion care – even with an exception for medical necessity – is fundamentally inconsistent with evidence-based, ethical, and patient-centered health care.[55] In the words of one Florida obstetrician-gynecologist: “It is really interfering in something that should never get interfered with, which is somebody’s private health care.” Another obstetrician-gynecologist said:

“I think I would like the public to see that abortion care is part of pregnancy care and basic health care. And when it comes to basic health care decisions, Floridians and Americans deserve the right to make these private medical decisions based on science within the context and support of their health care team and without politicians telling them what to do. That is the key thing. I would almost argue that it is not about abortion. You can choose to have an abortion, you can choose to continue the pregnancy and parent, you can choose to continue the pregnancy and make an adoption plan. It is about privacy and choice for your family and your body. Abortion is a part of that, but it is about the fundamental right to choice and privacy.” (2)

Several physicians emphasized the importance of recognizing the manifold physical harms of this governmental interference in private medical decisions between pregnant patients and their physicians. In the words of one obstetrician-gynecologist:

“Being able to provide this type of care without the fear of not only affecting your patient,     but your institution, your own license, it goes a very long way. And that this care that we are providing is lifesaving. I just feel like people have such a limited perception of what abortion care is and having seen the scary side of people being denied it, it is scary. And I am thankful that some people do not have to know the reality of that, but I sometimes wish that they did know the reality of the implications of limiting this.” (25)

Another obstetrician-gynecologist discussed how the bans on abortion also impact other reproductive health care, like in-vitro fertilization (IVF) and contraception:

“There is fear in the IVF community that fertility treatments will be the next to be banned because at the end of the day, whether it is abortion, fertility treatments, or contraception, it is all about bodily autonomy. Do women have autonomy over their own bodies? Who has control? It is clearly not about supporting families and children, because if you wanted families, then you would let IVF happen because that is creating more lives.” (10)

Multiple clinicians also discussed that they wanted people to know that abortion care is safe and should not be restricted through criminal bans. One obstetrician-gynecologist told us:

“Abortion is really safe, and there is this strange misconception that it is dangerous, but the risks of an abortion are lower than the risks of pregnancy at baseline. It is medical care, and we should not be restricting any type of medical procedure.” (17)

Conclusion

The findings of this research brief illustrate the urgent need to reverse Florida’s abortion ban and restore decision-making on individual health care to patients in consultation with their health care providers. The health care providers interviewed by PHR described multiple adverse effects of Florida’s abortion ban on pregnant people’s health, well-being, and human rights. They reported delays and denials of reproductive health care including in medical emergencies, deviations from standard medical care, disruption of the patient-clinician relationship, the need for patients to seek care outside of Florida, negative impacts on training new clinicians and retention of health care providers in the state, and adverse effects on individual freedom and bodily autonomy. Social determinants of health and racial and ethnic disparities significantly exacerbate these issues for many women in the state of Florida.

Florida’s current abortion ban has broadly impaired physicians’ ability to provide the proper standard of health care. Even the narrow exceptions to the ban have proven unworkable in practice, due to the confusion caused by non-medical terminology in the laws and fear arising from the significant penalties for violations of the ban. While physicians do continue to provide care where allowable under state law, the current abortion ban affords patients only a very narrow time frame to identify the pregnancy and access abortion care before five weeks and five days after the first day of a patient’s last menstrual period, the last day to make the first abortion appointment to be seen at six weeks with Florida’s 24-hour waiting period. Patients who receive severe fetal diagnoses later in pregnancy that are not deemed “imminently lethal” upon delivery are not able to receive abortion care in Florida and are being forced to leave the state for that care.

Furthermore, the fear of punishment for violating Florida’s abortion law by providing care to patients who are not experiencing an immediate risk of death has led clinicians to feel unable to provide treatment until patients develop additional health complications. Multiple clinicians at rural or religiously affiliated hospitals discussed having to refer patients to tertiary care centers for medical emergencies, due to hospital concerns about providing abortion care under Florida’s current laws. This included referring cases of miscarriage management and patients with conditions that were deemed exempt from Florida’s abortion ban.

These accounts demonstrate the extreme chilling effect caused by Florida’s unclear, punitive, and sweeping abortion ban on the provision of reproductive health care. Clinicians stated that Florida’s unworkable medical exceptions are leading to widespread fear and confusion that significantly threatens Floridians’ ability to access even routine medical care and jeopardizes their health and well-being. Clinicians stated that the abortion ban limits an individual’s reproductive freedom to make decisions about their reproductive health care. They reported feeling anguish that their inability to provide their patients with options for the full spectrum of standard medical care constituted a violation of their medical ethics and professional obligations to their patients. Many clinicians told us that they were considering leaving Florida and mentioned their colleagues who had already left the state due to this governmental infringement on their practice of medicine. They also expressed concerns about the impacts of the ban on training for residents and medical students, who need sufficient training in D&C and D&E procedures not just for abortion provision, but also for miscarriage management and emergency care later in pregnancy.

These concerns highlight that the state’s abortion ban has adverse consequences not just for the current landscape of abortion access but also for health care more broadly in Florida. It is essential to remedy the insurmountable barriers to care and devastating harm to Floridians caused by the state’s extreme abortion restrictions. Health care providers must be able to again meet their professional obligations to provide comprehensive reproductive health care for their patients, including termination of pregnancy.

Acknowledgements

This research brief was researched and written by Physicians for Human Rights (PHR) Consultant Whitney Arey, PhD; PHR staff members Michele Heisler, MD, MPA, medical director; and Payal Shah, JD, director of research, legal, and advocacy; and PHR intern Danielle Whisnant.

The brief was reviewed and edited by PHR staff members Saman Zia-Zarifi, JD, LLM, executive director; Karen Naimer, JD, LLM, MA, director of programs; Wacera Wathigo, MA, publications and communications manager; and by Elizabeth Singer, MD, MPH, PHR medical expert. Karla Torres, Elisabeth Smith, and Caroline Sacerdote also provided invaluable external reviews.

PHR is grateful to all the Florida clinicians who shared their time and experiences with our research team and to Dr Samantha Baer for assisting with recruitment.

Glossary of Terms

Cesarean birth: The birth of a fetus from the uterus through an incision (cut) made in the pregnant person’s abdomen.

Chorioamnionitis or intraamniotic infection: An acute inflammation of the membranes the placenta, typically due to bacterial infection after rupture of the membranes.

Dilation and Curettage (D&C): A procedure in which the cervix is opened (dilated) and a thin instrument is inserted into the uterus to remove tissue from inside the uterus (curettage). It is used for both diagnostic and therapeutic purposes, including for first-trimester abortion or after a miscarriage to remove all pregnancy tissue.

Dilation and Evacuation (D&E): The most common method of abortion after about 14 weeks pregnancy in which the cervix is opened (dilated) and the contents of the uterus are removed (evacuated) using instruments and a suction device. It is also a common procedure used after a miscarriage to remove all pregnancy tissue.

Ectopic pregnancy: A pregnancy in a place other than the uterus, usually in a fallopian tube.

Family Medicine: A medical specialty within primary care that provides continuing and comprehensive health care for the individual and family across all ages, genders, diseases, and parts of the body, including obstetric care.

Vacuum aspiration: The removal of the contents of the uterus using a suction device.

Maternal-Fetal Medicine (MFM) specialist: Also known as a perinatologist, an obstetrician-gynecologist with additional training in caring for pregnant patients with high-risk pregnancies.

Medical management of miscarriage: There are three main treatments for early pregnancy loss aimed at removing any pregnancy tissue left in the uterus: expectant management (letting the tissue pass on its own); medication; or a procedure (dilation and curettage).

Medication abortion: The use of medications to induce abortion. The World Health Organization endorses two regimens: one is the combination of mifepristone and misoprostol and the other uses misoprostol alone.

Obstetrics-gynecology (ob-gyn): The medical specialty that encompasses the two subspecialties of obstetrics (care of pregnant patients) and gynecology which focus on reproductive health and pregnancy. These clinicians are often called “ob-gyns” and the specialty of obstetrics is often called “OB.”

Preterm premature rupture of membranes (PPROM): A condition where the pregnant person’s amniotic sac (bag of water) breaks prior to 37 weeks’ gestation and prior to the onset of labor. Delivery occurs within one week of PPROM in 50 percent of patients.

Qualitative research: A type of research that gathers and analyzes nonnumerical data in order to gain an understanding of individuals’ social reality, including understanding their perceptions of their experiences, attitudes, beliefs, and motivations.

Self-managed abortion: Where a pregnant person performs their own abortion outside the formal health care system.

Spontaneous abortion: Also called a miscarriage, it is the loss of a pregnancy before 20 weeks’ gestation.

Standard of care: Treatment that is accepted by medical experts as the most appropriate for a certain type of disease in a particular setting and is widely used by health care professionals. Also called best practice, standard medical care, best available therapy, and standard therapy.

References

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[1] Dobbs v. Jackson Women’s Health Organization. No. 19-1392, 597 U.S. (2022), https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf

[2] Fla. Stat. § 390.0111(1)(d). Access: http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0300-0399/0390/Sections/0390.0111.html

[3] Planned Parenthood of Southwest and Central Florida, et al. v. State of Florida et al. No. SC2022-1050 (2022), https://supremecourt.flcourts.gov/content/download/2285280/opinion/Opinion_SC2022-1050

[4]  Fla. Stat. § 390.0111(1)(d). Accessed September 9, 2024.    http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0300-0399/0390/Sections/0390.0111.html

[5] “Florida Administrative Code and Florida Administrative Register,” Florida Department of State, May 2, 2024, https://www.flrules.org/bigdoc/view_section.asp?Issue=4132&Section=4

[6] “Maternal Deaths in Florida: Report by Month,” FL Health Charts, 2022, https://www.flhealthcharts.gov/ChartsDashboards/rdPage.aspx?rdReport=InfantDeath.DataViewer&cid=0392

[7] Dobbs v. Jackson Women’s Health Organization. No. 19-1392, 597 U.S., https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf

[8] Planned Parenthood of Southwest and Central Florida, et al. v. State of Florida et al. No. SC2022-1050, (2022) https://supremecourt.flcourts.gov/content/download/2285280/opinion/Opinion_SC2022-1050

[9] “Why is a 6-week abortion ban nearly a total ban? It’s about how we date a pregnancy,”NPR, May 1, 2024. https://www.npr.org/sections/health-shots/2024/05/01/1248416546/6-week-abortion-ban-explainer-pregnancy-lmp

[10] Fla. Stat. § 390.0111(1)(d). Accessed September 9, 2024. http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0300-0399/0390/Sections/0390.0111.html

[11] Florida Senate. Bill 300, An Act Relating to Abortion. 2023. https://www.flsenate.gov/Session/Bill/2023/300/BillText/er/PDF

[12] “Florida Abortion Ban Upheld by State Supreme Court,” AP News, May 1, 2024.  https://apnews.com/article/florida-abortion-ban-supreme-court-ruling-6a4949fc7459afe9b5e298086a793126

[13] “Florida Gov. Ron DeSantis signs a bill banning abortions after 15 weeks,” NPR, April 14, 2022, https://www.npr.org/2022/04/14/1084485963/florida-abortion-law-15-weeks

[14] http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0300-0399/0390/0390.html

[15] “Florida’s 6-week abortion ban is now in effect, curbing access across the South,” NPR, May 1, 2024, https://www.npr.org/2024/05/01/1247990353/florida-6-week-abortion-ban-south

[16] “Florida Amendment 4, Right to Abortion Initiative (2024),” Ballotpedia, Accessed September 9, 2024. https://ballotpedia.org/Florida_Amendment_4,_Right_to_Abortion_Initiative_(2024)

[17] “Florida clarified abortion rules after enacting ban. Doctors say it’s ‘gaslighting’ and unhelpful,” Salon, May 8, 2024. https://www.salon.com/2024/05/08/florida-clarified-abortion-rules-after-enacting-ban-doctors-say-its-gaslighting-and-unhelpful/

[18] “Florida Administrative Code and Florida Administrative Register,” Florida Department of State, May 2, 2024, https://www.flrules.org/bigdoc/view_section.asp?Issue=4132&Section=4

[19] “TRAP Laws: A Threat to Abortion Rights You Don’t Know About,” ACLU of Florida, Accessed September 9, 2024. https://www.aclufl.org/en/news/trap-laws-are-threat-abortion-rights-you-dont-know-about

[20] “Number of Florida Abortions Are Down After the 6-Week Limit Goes into Effect,” Health News Florida, published August 12, 2024, https://health.wusf.usf.edu/health-news-florida/2024-08-13/number-of-florida-abortions-are-down-after-the-6-week-limit-goes-into-effect

[21] “Interactive Map: US Abortion Policies and Access After Roe,” Guttmacher, policies current as of September 5, 2024, https://states.guttmacher.org/policies/florida/demographic-info

[22] Radley, David C., Jesse C. Baumgartner, and Sara R. Collins. “2022 Scorecard on State Health System Performance: How Did States Do During the COVID-19 Pandemic?” Commonwealth Fund, June 2022, https://doi.org/10.26099/3127-xy78;

Radley, David C., Jesse C. Baumgartner, and Sara R. Collins. “The Commonwealth Fund 2023 Scorecard on State Health System Performance: Americans’ Health Declines and Access to Reproductive Care Shrinks, But States Have Options.” Commonwealth Fund, June 2023. https://doi.org/10.26099/fcas-cd24;

[23] “Interactive Map: US Abortion Policies and Access After Roe,” Guttmacher, policies current as of September 5, 2024,

https://states.guttmacher.org/policies/florida/demographic-info

[24]“Addressing Florida’s Escalating Physician Shortage: Strategies and Solutions,” Florida Tax Watch, published January 10, 2024, https://floridataxwatch.org/Research/Full-Library/addressing-floridas-escalating-physician-shortage-strategies-and-solutions

[25] March of Dimes. Perinatal Data Center State Summaries: Florida. 2022. https://www.marchofdimes.org/peristats/state-summaries/florida?lev=1&obj=3&reg=99&slev=4&sreg=12&stop=55&top=3

[26] “Adequate Prenatal Care in United States,” America’s Health Rankings, United Health Foundation, accessed September 9, 2024. https://www.americashealthrankings.org/explore/measures/prenatalcare_adquate

[27] “Adequate Prenatal Care in United States,” America’s Health Rankings, United Health Foundation, accessed September 9, 2024. https://www.americashealthrankings.org/explore/measures/prenatalcare_adquate

[28] “Pregnancy-Associated Mortality Review Update, 2020,” Florida Department of Health, Accessed September 9, 2024, https://www.floridahealth.gov/statistics-and-data/PAMR/FLMMRC-2020-update.pdf

[29] Pregnancy-Associated Mortality Review Update, 2020,” Florida Department of Health, Accessed September 9, 2024, https://www.floridahealth.gov/statistics-and-data/PAMR/FLMMRC-2020-update.pdf

[30] “Monthly Abortion Provision Study,” Guttmacher, Accessed September 9, 2024, https://www.guttmacher.org/monthly-abortion-provision-study

[31] Florida Senate. Bill 5, An Act Relating to Reproductive Health and Pregnancy. 2022.   https://www.flsenate.gov/Session/Bill/2022/5/BillText/er/PDF (showing how 2022 SB 5 modified the prior ban).

[32] “The Number of Brick-and-Mortar Abortion Clinics Drops, as US Abortion Rate Rises: New Data Underscore the Need for Policies that Support Providers,” Guttmacher Institute, June 2024, https://www.guttmacher.org/report/abortion-clinics-united-states-2020-2024

[33] “Number Of Florida Abortions Are Down After The 6-Week Limit Goes Into Effect”, Health News Florida, August 12, 2024. https://health.wusf.usf.edu/health-news-florida/2024-08-13/number-of-florida-abortions-are-down-after-the-6-week-limit-goes-into-effect

[34] “The Fallout Of Florida’s Abortion Ban Has Been ‘Chaos,’ Experts Say,” Salon, August 8, 2024, https://www.salon.com/2024/08/08/the-fallout-of-floridas-abortion-ban-has-been-chaos-experts-say/

[35] “How Florida’s Abortion Law Is Affecting East Coast Abortion Clinics,” Washington Post, published May 24, 2024, https://www.washingtonpost.com/nation/2024/05/24/abortion-clinics-wait-time-florida-law/

[36] “Clear and Growing Evidence That Dobbs Is Harming Reproductive Health and Freedom,” Guttmacher, May 2024,

https://www.guttmacher.org/2024/05/clear-and-growing-evidence-dobbs-harming-reproductive-health-and-freedom

[37] Quotes have been edited for clarity and conciseness. 

[38]  “Why Providers Say Abortion Ban Exceptions Continue to Cause Confusion,” NPR, published June 14, 2024, Access: https://www.npr.org/2024/06/06/nx-s1-4995739/abortion-exceptions-life-mother-florida#:~:text=That%20law%20includes%20an%20exception,could%20face%20felony%20criminal%20charges; Supreme Court of Florida, Planned Parenthood of Southwest and Central Florida, et al. v. State of Florida et al. Available at: https://supremecourt.flcourts.gov/content/download/2285280/opinion/Opinion_SC2022-1050

[39] “Post-Dobbs, abortion clinics find new ways to serve patients in states with bans,” CNN, published June 19, 2024,

 https://www.cnn.com/2024/06/19/health/abortion-clinics-in-banned-states-pivot/index.html; Hawkins SS, Ghiani M, Harper S, Baum CF, Kaufman JS. Impact of State-Level Changes on Maternal Mortality: A Population-Based, Quasi-Experimental Study. American Journal of Preventive Medicine. 2020;58(2):165-174. doi: 10.1016/j.amepre.2019.09.012

[40] Whitney Arey et al., Abortion Access and Medically Complex Pregnancies Before and After Texas Senate Bill 8, 141 Obstetrics & Gynecology 995 (2023); Whitney Arey et al., A Preview of the Dangerous Future of Abortion Bans – Texas Senate Bill 8, New England J. of Med. (Aug. 4, 2022), https://www.nejm.org/doi/full/10.1056/NEJMp2207423;

Carolyn Payne & Angela Frankel, Changes in Young Pro-Choice Physicians’ Attitudes Towards Abortion Provision in Residency and Early Practice [05J], 135 Obstetrics & Gynecology 104s (2020), DOI:10.1097/01.AOG.0000664264.55609.56 https://journals.lww.com/greenjournal/abstract/2020/05001/changes_in_young_pro_choice_physicians__attitudes.362.aspx;

J.A. Reeves et al., Anesthesia providers’ perspectives on abortion provision: deductive findings from a qualitative study, 49 Int’l J. of Obstetric Anesthesia 103239 (2021), https://doi.org/10.1016/j.ijoa.2021.103239;

Catherine Marshall & Gretchen B. Rossman, Designing Qualitative Research (6th ed. 2015).

[41] John W. Creswell, Research Design: Qualitative, Quantitative, and Mixed Methods Approaches (2nd ed. 2022).

[42] Quotes have been edited for clarity and conciseness.

[43] “Why Providers Say Abortion Ban Exceptions Continue to Cause Confusion,” NPR, published June 14, 2024, https://www.npr.org/2024/06/06/nx-s1-4995739/abortion-exceptions-life-mother-florida#:~:text=That%20law%20includes%20an%20exception,could%20face%20felony%20criminal%20charges;

Supreme Court of Florida, Planned Parenthood of Southwest and Central Florida, et al. v. State of Florida et al. Available at: https://supremecourt.flcourts.gov/content/download/2285280/opinion/Opinion_SC2022-1050

[44] “Methods for Estimating the Due Date,” American College of Obstetricians and Gynecologists (ACOG), May 2017, https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/05/methods-for-estimating-the-due-date

[45] “The Frequency of Pregnancy Recognition Across The Gestational Spectrum and Its Consequences in The United States,” National Library of Medicine, published May 16, 2022; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9321827/

[46] Fla. Stat. § 390.011(6).

[47] ROA  15-16 (citing HB  5, §§ 3(6), 4 (codified at §§ 390.011(6), 390.0111(1)(a)-(c), Fla. Stat.)).  http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0300-0399/0390/0390.html

[48] “Florida Abortion Ban Prompts Two Southern States to Prep for an Influx of Patients,” NBC News, April 4, 2024, https://www.nbcnews.com/health/womens-health/florida-abortion-ban-other-states-prepare-influx-rcna146130

[49] Richardson A, Gallos I, Dobson S, Campbell BK, Coomarasamy A, Raine-Fenning N. Accuracy of First-Trimester Ultrasound in Diagnosis of Intrauterine Pregnancy Prior to Visualization of The Yolk Sac: A Systematic Review and Meta-Analysis. Ultrasound Obstet Gynecology, 2015 August; 46(2):142-9.

[50] “Epidemiology, Diagnosis, and Treatment of Gestational Trophoblastic Disease: A Society of Gynecologic Oncology Evidenced-Based Review And Recommendation,” Gynecologic Oncology, December 2021, https://www.gynecologiconcology-online.net/article/S0090-8258(21)01421-9/fulltext; Zhang RQ, Zhang JR, Li SD. Termination of a Partial Hydatidiform Mole and Coexisting Fetus: A Case Report. World J Clin Cases. 2019 Oct 26;7(20):3289-3295. doi: 10.12998/wjcc. v7.i20.3289. PMID: 31667181; PMCID: PMC6819279.

[51] Soper, John T. MD. Gestational Trophoblastic Disease: Current Evaluation and Management. Obstetrics & Gynecology 137(2): p 355-370, February 2021. | DOI: 10.1097/AOG.0000000000004240

[52] “Risk of Fetal Malformations,”Clinical Updates in Reproductive Health, last reviewed: September 23, 2022,https://www.ipas.org/clinical-update/english/recommendations-for-abortion-before-13-weeks-gestation/medical-abortion/risk-of-fetal-malformations/; Grossman, Daniel et al. “Continuing Pregnancy After Mifepristone and ‘Reversal’ of First-Trimester Medical Abortion: A Systematic Review.” Contraception 92 (2015): 206–211

[53] “Dozens of Pregnant Women, Some Bleeding or In Labor, Being Turned Away from ERs Despite Federal Law,”

Associated Press, updated August 14, 2024, https://www.wusf.org/health-news-florida/2024-08-12/dozens-pregnant-women-bleeding-in-labor-turned-away-er-despite-federal-law-florida-abortion-bans

[54] “Office of the United Nations High Commissioner for Human Rights (OHCHR)”, Abortion: Information Series on Sexual and Reproductive Health and Rights (Geneva: OHCHR, 2020),  https://www.ohchr.org/sites/default/files/INFO_Abortion_WEB.pdf; See Commission on Economic, Social and Cultural. Rights, General Comment No. 22: On the right to sexual and reproductive health (Article 12 of the International Covenant on Economic, Social and Cultural Rights) UN Doc. E/C, 12/GC/22 (May 2, 2016); e UN Human Rights Commission, General Comment No. 36: On Article 6 of the International Covenant on Civil and Political Rights, on the right to life, UN Doc. CCPR/C/GC/36, at 8 (September 3, 2019), https://www.ohchr.org/sites/default/files/Documents/HRBodies/CCPR/_CCPR_C_GC_36.pdf ; Human Rights Commission, Siobhán Whelan v Ireland: Views Adopted by the Committee Under Article 5 (4) of the Optional Protocol, Concerning Communication No. 2425/2014, 7.5–7.7, 7.9, 7.11–7.12, U.N. Doc. CCPR/C/119/D/2425/2014 (2017); Human Rights Commission, Amanda Jane Mellet v Ireland: Views Adopted by the Committee under Article 5 (4) of the Optional Protocol, Concerning Communication No. 2324/2013, 7.4–7.6, 7.8, 7.10–7.11, UN Doc. CCPR/C/116/D/2324/2013 (2016); Brief for UN Mandate Holders as Amici Curiae Supporting Respondents, Dobbs v. Jackson Women’s Health Organization, No. 19-1392 (U.S. September 20, 2021), at 31-32.

[55] World Health Organization (WHO), Abortion Care Guideline, pp13-14 (2022), https://www.who.int/publications/i/item/9789240039483; CRR, WHO’s New Abortion Guideline: Highlights of Its Law and Policy Recommendations (March 2022), https://reproductiverights.org/wp-content/uploads/2022/03/CRR-Fact-sheet-on-WHO Guidelines.pdf.

Summary

Survivor-centered, trauma-informed, and rigorous medico-legal documentation is essential to offer survivors a pathway to justice, with standardized forensic medical evaluations playing a key role in documenting and corroborating accounts of sexual violence and torture. To support Ukrainian government officials, civil society, and international partners in building systems to support survivors, Physicians for Human Rights (PHR) assessed the medico-legal documentation pathway in Ukraine to identify opportunities to strengthen systems to center survivors’ well-being, autonomy, and access to remedies.

Physicians for Human Rights assessed the medico-legal documentation pathway in Ukraine to identify opportunities to strengthen systems to center survivors’ well-being, autonomy, and access to remedies.

Building on the numerous efforts by Ukrainian authorities and their partners to address challenges to medico-legal documentation, this policy brief outlines current obstacles that impede justice and healing for survivors and sets forth actionable opportunities for the Ukrainian government and other stakeholders for reform. The recommendations put forward in the brief emphasize the need to expand the pool of qualified professionals authorized to conduct forensic medical evaluations in cases of conflict-related sexual violence and torture. They also call for legislative reforms to empower survivors in the justice process, the development of standardized medico-legal documentation tools, and implementation of capacity-building initiatives to ensure trauma-informed, survivor-centered approaches. Together, these efforts can transform the experience of survivors as they seek remedy and reparation and ultimately facilitate greater accountability and healing.

Introduction

The Need for Effective Pathways to Justice for Crimes of Torture and Sexual Violence

There is strong and growing evidence that torture and sexual violence have been perpetrated on a widespread scale since Russia launched its full-scale invasion of Ukraine in February 2022.[1] As the UN Independent International Commission of Inquiry concluded, “In the context of their full-scale invasion of Ukraine, Russian authorities have committed a wide array of violations of international human rights law and international humanitarian law, as well as war crimes … of torture, willful killing, rape and sexual violence […]. The evidence gathered reinforced the Commission’s previous findings that Russian authorities had used torture in a widespread and systematic way.”[2] As of August 2024, the Prosecutor General’s Office of Ukraine has registered 310 cases of conflict-related sexual violence since the start of the full-scale invasion.[3]

At every stage of the pathway to justice, survivors should receive trauma-informed care and be provided with resources for treatment and support.

The thousands of people who have survived this torture and conflict-related sexual violence are entitled to (a) equal and effective access to justice; (b) adequate, effective, and prompt reparation for harm suffered; and (c) access to relevant information concerning violations and reparation mechanisms.[4] To achieve such accountability, it is essential that effective laws and protocols are in place to guide rigorous documentation and investigation of torture and other cruel, inhuman, and degrading treatment or punishment, including where it takes the form of sexual or other gender-based violence.[5]  The pathways for survivors of these violations to initiate access to justice can vary, with survivors initially reporting the harm they suffered to police officers, prosecutors, non-governmental organization representatives, or health care providers. However, at every stage of the pathway to justice, survivors should receive trauma-informed care and be provided with resources for treatment and support.  Trauma-informed approaches to medical care and treatment as well as access to justice must be paramount, centering on the well-being, dignity, and autonomy of the survivor.[6]

This policy brief, developed within the framework of the project “Strengthening capacities to fight impunity for torture and related crimes in Ukraine”, implemented by the World Organization Against Torture, the Media Initiative for Human Rights, Human Rights Centre ZMINA and Physicians for Human Rights, draws on an assessment of the capacity for medico-legal documentation of conflict-related sexual violence and torture undertaken by PHR[7] to provide actionable recommendations for strengthening medico-legal documentation of sexual violence, torture and other cruel, inhuman, degrading treatment or punishment, and other human rights violations in Ukraine. Its purpose is to guide policymakers, government stakeholders, law enforcement representatives, international justice actors, legal professionals, medical practitioners, and humanitarian aid actors in implementing trauma-informed and survivor-centered practices that enhance the quality and credibility of forensic evidence.  

The Critical Importance of Rigorous Medico-Legal Documentation

Medico-legal evaluations are a critical tool, among others, for documenting evidence and corroborating accounts of sexual violence, torture and other cruel, inhuman, degrading treatment or punishment, and other human rights violations. Such evaluation is a systematic medical and psychological evaluation of survivors. A trained clinician conducts a thorough interview with the survivor in which the survivor recounts their pre-trauma social, medical, and psychological history, describes the violent events they experienced, the course of their physical symptoms and signs since the violent events and at the time of the interview. The clinician then performs a physical, mental health, and psychological examination and documents physical and psychological findings and symptoms, collects physical evidence as well as biological samples such as blood or semen as feasible for lab testing, and brings all the findings together to provide an interpretation of their consistency with the reported incident/s. Because poorly conducted evaluations can re-traumatize the survivor and deter the pursuit of justice, it is essential that clinicians conducting them be well-trained in trauma-informed, survivor-centered approaches.[8]

The success of investigations of torture and conflict-related sexual violence depends on the quality of documentation, and collecting medico-legal evidence can be an integral part of this process.[9] Medico-legal documentation can have a significant value as part of the justice process concerning cases of conflict-related sexual violence and torture even when the evaluations are conducted weeks or months after the alleged criminal acts were carried out. Often, the documentation of mental health harms experienced by the survivor is the only evidence available to show the presence of ongoing trauma and other psychological injuries.

Physical and mental health documentation of these violations can also provide critical evidence that links perpetrators to the crimes they have committed and shows patterns of abuse. Identification of patterns can help establish where crimes are widespread and systematic and prove other important elements such as criminal intent, common purpose, command, or superior responsibility. Forensic reports can further support civil claims, reparations, and other justice efforts.

Current Context for Documentation and Investigation of Torture and Sexual Violence in Ukraine

In 2023, PHR assessed the clinical, legal, and technological capacity in Ukraine to conduct medico-legal documentation of conflict-related sexual violence and cases of torture, cruel, inhuman and degrading treatment or punishment, encompassing trauma-informed and survivor-centered approaches and patient privacy protections. [10] Our assessment and analysis, based on in-person and remote interviews[11] as well as desk research, has mapped the specific and persisting challenges survivors and medical and legal professionals are experiencing in Ukraine in implementing survivor-centered and trauma-informed practices for documenting forensic evidence of sexual violence and torture. It also revealed several promising opportunities for strengthening the forensic documentation system.

Our assessment noted the following challenges:

• Existing legal, regulatory, and policy limitations in Ukraine restrict the pool of experts permitted to conduct forensic documentation and can create barriers for survivors. Medico-legal documentation in Ukraine happens through the forensic service where only state-certified forensic experts in state specialized institutions[12] are authorized to conduct forensic evaluations and draw up expert reports based on their results in distinct domains: forensic postmortem, medical, psychiatric, and psychological examinations.[13] Because these four domains are considered distinct in Ukraine, this can lead to fragmentation across different evaluations with the survivor subjected to multiple exams. Furthermore, the resulting need for multiple examinations combined with the limited numbers of state-certified forensic experts can lead to delays and deter survivors from pursuing follow-up.
• Currently, there is no standardized medico-legal form to guide forensic evaluations to ensure that comprehensive data is documented in a standardized manner.
• If the survivor’s entry point to the justice process is through their health care provider (by a medical professional reporting to law enforcement agencies), the results of the primary evaluation performed and documented by the provider by their very nature cannot be considered admissible evidence because only designated forensic experts who work in state specialized facilities are allowed to conduct forensic exams; while a forensic expert may include a high-quality evaluation as an addendum to their report or it can be added to the case at the request of a survivor for the court’s consideration, to date the clinical documentation provided by many first responders in Ukraine, like family doctors and gynecologists, that is submitted to forensic specialists is sometimes perceived as low quality and therefore excluded.
• In the absence of Ukraine using a standardized medico-legal form, clinicians sometimes utilize an existing medical form for documenting the results of medical examinations of survivors of domestic violence or persons who are likely to be survivors of domestic violence for cases of conflict-related sexual violence. Use of this form leads to gaps in documentation of sexual violence and subjects survivors of conflict-related sexual violence to procedural requirements for domestic violence such as mandatory reporting.
  • While the domestic violence documentation framework includes some forensic elements, it is not designed to capture the comprehensive evidence necessary for the prosecution of conflict-related sexual violence including detailed information about incidents and perpetrators.  Moreover, the current domestic violence framework requires evidence of physical harm. Thus, cases of conflict-related sexual violence in which physical signs and symptoms have otherwise been resolved or where other forms of conflict-related sexual violence such as forced nudity are committed may not be recognized. The Prosecutor General’s Office has developed new guidelines for the identification of various forms of conflict-related sexual violence. This information is not immediately available to clinicians through the Ministry of Health distribution channels.
  • The domestic violence framework requires clinicians to mandatorily report domestic violence to law enforcement. No such requirement exists for survivors of conflict-related sexual violence and government policies, particularly the recently adopted Strategic Plan on the Implementation of Powers of the Prosecutor’s Office in the Field of Criminal Prosecution for Conflict-Related Sexual Violence,[14] affirm the need to respect such survivors’ will and right to informed consent. Yet, where clinicians are utilizing domestic violence protocols for documentation of conflict-related sexual violence, there is confusion amongst providers about whether these survivors must mandatorily be reported.
• The adoption of a new form entitled the Certificate for the Documentation of Bodily Injuries[15] holds promise in allowing non-forensic expert clinicians to conduct and transmit standardized documentation of all forms of sexual violence and torture, including conflict-related. However, measures are necessary to build support and skills amongst the health and legal sectors to utilize the form effectively. Further, key amendments to the form could significantly improve its usefulness in capturing evidence for prosecution, referrals, and remedies. See box: Certificate for the Documentation of Bodily Injuries
• Fragmentation of documentation into separate domains and the necessity to establish the severity of bodily injuries can add harmful delay to accountability efforts. For instance, survivors who might take weeks or months to come forward, as is often the case, or who may not have immediate access to law enforcement, will likely not be interviewed by forensic experts. Their cases may also not be reviewed seriously due to the perception by both physicians and survivors that little can be gained medically from an evaluation in the post-acute phase.
• To date, there are insufficient practitioners in Ukraine trained in conducting rigorous, trauma-informed FMEs and individuals trained in trauma-informed practices and survivor-centered approaches at all stages of the pathway to justice.
• There is currently a lack of coordination across sectors, with medical, judicial, law enforcement, and legal professionals working in silos. There is also a lack of multi-sectoral training to encourage effective collaboration among these sectors, including building the capacity of lawyers and judges to understand the full scope of information that can be gathered in forensic evaluations and how to interpret forensic evidence.

Current Legislative and Policy Efforts in Ukraine

Since February 2022, Ukrainian authorities have implemented positive steps to improve interaction with survivors and to strengthen the capacity to document crimes, including, for example, the establishment of a new, specialized unit within the Prosecutor General’s Office to investigate cases of conflict-related sexual violence as well as a Coordination Center for Victim and Witness Support, and the launch of a reform of the forensic service.^[16]

In addition to Order No. 278[17], which regulates the documentation of medical exam results for survivors of domestic violence and serves as a significant framework for documentation, the Ministry of Health has also adopted a new standardized form: the Certificate for the Documentation of Bodily Injuries.[18] Based on the Istanbul Protocol, internationally renowned guidelines for documentation of torture, it is supposed to be rolled out to all doctors opening up documentation of sexual violence and torture to non-forensic experts.

Furthermore, certain legislative initiatives are registered in the Verkhovna Rada of Ukraine, which have a direct impact on the specifics of forensic evaluation. For example, the draft law No. 10420 on the implementation of the Istanbul Convention further proposes amendments to Article 242 of the Criminal Procedural Code of Ukraine (grounds for conducting an evaluation) regarding the immediate evaluation of survivors of criminal offences under Articles 152, 153, 155 and 156 of the Criminal Code of Ukraine at the request of the survivor (not voted by the Verkhovna Rada of Ukraine).[19]

The draft laws “On Forensic Expert Activity” No. 6284 from November 5, 2021,[20] and its alternatives No. 6284-1, 6284-2 and 6284-3 as well as No. 6285[21] from November 5, 2021, and its alternative No.6285-1, are aimed at changing approaches to forensic expert activity, determining the status, rights and duties of forensic experts and relevant institutions. Processing in the committees of the Verkhovna Rada of Ukraine and consideration by the Verkhovna Rada of Ukraine of relevant legislative initiatives will result in changes in the organization and conduct of forensic evaluations.

Civil society initiatives and international organizations are supporting the efforts to improve medico-legal documentation. Together with national and international advisors, the Prosecutor General’s Office developed and approved Standards for the Investigation of Torture which include basic guidelines for prosecutors and investigators on forensic evaluations.[22] Standard operating procedures are being drafted that would include guidelines for strengthening forensic pathways.[23]

International Standards

There are now global standards and benchmarks for forensic medical evaluations for conflict-related sexual violence, torture and other cruel, degrading treatment or punishment developed through robust international consultations and peer-reviewed evidence. These good practices are all built on the foundation of the principles outlined in three manuals to which PHR and our partners have contributed. These are:

1. The Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (Istanbul Protocol), [24]which provides guidance for the investigation and documentation of all forms of torture, including sexual torture, and promotes the protection of torture survivors and advocacy work of civil society on behalf of survivors;
2. The International Protocol on the Documentation and Investigation of Sexual Violence in Conflict, which highlights best practices in the medico-legal evaluation of survivors of conflict-related sexual violence;[25] and
3. The Murad Code for Gathering and Using Information About Systematic and Conflict-Related Sexual Violence which focuses on cross-sectoral trauma-informed practices and survivor-centered approaches to engagement with survivors of sexual violence.[26]

These manuals are widely considered global references for the medico-legal evaluation of survivors and are used in conflict settings worldwide.  

According to the Istanbul Protocol, any licensed clinician can be trained to carry out forensic evaluations. The Istanbul Protocol notes (para 303): “Conducting evaluations in accordance with the Istanbul Protocol does not require certification as a forensic expert, even though this may be the normative practice in some States and is sometimes used to intentionally exclude the testimony of independent clinicians from court proceedings.”[27]  

Similarly, the World Health Organization’s guidelines for medico-legal care for victims of sexual violence explicitly state that “district medical officers, police surgeons, gynecologists, emergency room physicians and nurses, general practitioners, and mental health professionals” should be able to carry out such evaluations.[28] According to these guidelines, “It will be of great benefit to the patient if any forensic evidence, if relevant, is collected during the medical examination; ideally, the health worker performing the medical assessment should also provide the forensic or medico-legal service, if properly trained to do this.”[29]

For effective medico-legal documentation, whether it is an in-depth evaluation according to the Istanbul Protocol or a brief evaluation at the primary level, it is crucial to train front-line clinicians on effective documentation and referral protocols.[30] Clinicians should be trained in obtaining informed consent; in documenting current symptoms and signs, and in communicating how patients can report to local, national, or international entities for further investigation.[31]

Along with training, clinicians need standardized documentation tools and procedures, including medico-legal certificates, to ensure that collected evidence can be used in legal processes. Standardized documentation has been shown to lead to better outcomes for survivors in courts.[32] Standardized protocols such as the Istanbul Protocol for interviewing and examining survivors should be followed to enhance the quality, comprehensiveness, and accuracy of evidence collected on sexual violence and torture.

It is also important to reinforce that even when it is not possible to secure an evaluation, a strong case for establishing the veracity of a violation can still be made. As the International Protocol declares: “In international criminal practice, the use of medico-legal evidence to prove Conflict and Atrocity-Related Sexual Violence is not necessary. Such a requirement would impose an impossible barrier to justice for most victims who do not have access to medical services close to the time the sexual violence was perpetrated. This is particularly true in cases where the sexual violence has been perpetrated in the context of detention or forcible displacement, sexual slavery, and where ongoing violence makes mobility and access to health services impossible.”[33] While forensic evaluations are helpful when possible and can play an important part in an investigation, their absence should not be on their own an obstacle for survivors, prosecutors, investigators, and judges to proceed with a case.

Recommendations

The Government of Ukraine and Verkhovna Rada of Ukraine, as well as the Prosecutor General’s Office, National Police and other stakeholders should:

• Take measures to allow forensic medical evaluations from trained clinicians in addition to state-affiliated forensic experts, to be admissible in cases concerning conflict-related sexual violence as well as torture, cruel, inhuman, and degrading treatment or punishment or punishment brought by the Prosecutor General’s Office or other domestic or hybrid mechanisms. These measures should include allowing clinicians – including non-physicians (for instance, nurses) – to be trained on forensic documentation and permitted to conduct forensic medical evaluations and to allow international non-Ukrainian experts to be authorized to conduct evaluations where national capacity is insufficient.

• Amend Article 7 of the Law of Ukraine “On Forensic Expertise” by deleting the provision: “forensic expert activities related to forensic, forensic medical and forensic psychiatric expertise are carried out exclusively by state specialized institutions” with the aim of increasing health workforce capacity to document and utilize medico-legal evidence of conflict-related sexual violence and torture.

• Clarify that investigators have discretion to determine when forensic medical evaluations are necessary, including but not limited to the grounds listed in the Criminal Procedure Code of Ukraine, and ensure survivors’ consent is obtained before performing an examination.

• Review the grounds for mandatory forensic medical examination in war crimes proceedings in the event of the objective impossibility of conducting it in a timely manner to ensure compliance with the criminal procedure during the investigation of war crimes (art. 242, art. 615 of the Criminal Procedure Code of Ukraine). Part 2 of Art. 242 in its current version threatens the parties’ right and opportunity to choose the evidence they wish to present and poses a risk of acquittal of war criminals in the future in case of a failure to carry out an evaluation.

• Develop, adopt, and roll out comprehensive standardized forensic documentation to support clinicians and forensic experts in documenting conflict-related sexual violence, torture, cruel, inhuman and degrading treatment or punishment in a trauma-informed and survivor-centered manner, including requiring the use of the Certificate for the Documentation of Bodily Injuries with recommendations made by PHR. 

Certificate for the Documentation of Bodily Injuries. The adoption of this form has been a major improvement, but critical provisions still need to be strengthened. The following recommendations have been provided by PHR to the Ministry of Health:   The medico-legal documentation form requires some enhancements to ensure comprehensive and survivor-centered documentation. First, it should incorporate a section addressing patient informed consent at the outset, aligning with ethical principles and legal requirements. Additionally, to facilitate a thorough understanding of the patient’s history, the form should include a dedicated section describing the circumstances of the assault or encounter. This would allow health care professionals to gather pertinent information before proceeding to the physical examination, ensuring a holistic approach to documentation. To streamline the documentation process and accommodate multiple examinations, it is essential to include fields capturing both the examination date and the certificate date. This would align with trauma-informed practices, recognizing that victims may require breaks during examinations. Also, by adding an “Other” category under the “Gender” section, the form can better accommodate diverse patient populations. Similarly, asking for “Nationality” would allow to document wider groups of the population.   Expand the form to encompass psychological assessments and behavioral observations is imperative. This expansion would enable health care professionals to document not only physical health complaints but also the psychological impact of the assault or encounter. Additionally, incorporating fields for recording the circumstances of injuries, description of perpetrators, and injury context would ensure the form is aligned with international protocols and ensures thorough documentation.  Relocate the “Diagnosis” section to the end of the form and redefine it as an “Assessment.” This adjustment would underscore the evaluative nature of the documentation, rather than prematurely assigning diagnoses. Furthermore, leaving descriptions of bruises and abrasions open-ended, rather than restricting them to specific categories, would prevent errors and enhance accuracy in documentation.  Explicitly mention pregnancy and sexually transmitted infections (STI) tests in the form’s additional tests and examinations section to ensure comprehensive health care provision for survivors. Similarly, considering the inclusion of a children-specific chart would cater to the unique needs of pediatric patients, enhancing the form’s applicability across diverse demographics. Furthermore, incorporating sections for referrals and treatment/therapy plans would promote continuity of care and facilitate collaboration among health care providers.  Specify each health care provider’s examination role and utilize higher-quality pictograms to enhance clarity and accountability in the documentation. It is also advised to expand the circle of those allowed to fill out the form from doctors to (trained) health care workers. The instructions accompanying the form should reflect all these changes. Clinicians should receive clear guidelines on how to incorporate the evaluation into their routine patient admissions and be trained on its implementation.

• Prioritize capacity-building for all clinicians, including non-forensics experts, on survivor-centered, trauma-informed forensic documentation of sexual violence, and torture, cruel, inhuman and degrading treatment or punishment in line with international standards, including through immediate training programs to respond to current cases as well as the adoption of such training into pre-service training for all clinicians. Legislative changes will have limited impact without their practical application, therefore, the National School of Judges, the Higher School of Advocacy, and the Training Center for Prosecutors should be supported to introduce training programs that would cover expert scientific methodology and how to effectively collaborate with forensic experts and the medical sector.

• Update the procedure for conducting and documenting the results of medical examinations of survivors by amending the relevant regulations[34] or adopting a new bylaw, defining the specifics of reporting cases of sexual violence in a broad sense (which may fall under the scope of criminal offences against sexual freedom and integrity or conflict-related sexual violence), taking into account informed consent.

Procedure for Conducting and Documenting the Results of Medical Examination of Victims of Domestic Violence or Persons Who Are Likely to Be Victims of Domestic Violence and Providing Them with Medical Care.[35] The medical certificate documentation form should be revised to include space for detailed injury descriptions, use of pictograms, and comprehensive information about the incident and perpetrator. It should also outline referral plans to ensure proper follow-up care and support. The form needs to account for STIs and pregnancy, ensuring a complete health assessment. While the domestic violence documentation framework is useful, it is incomplete for conflict-related sexual violence and should be adapted.

Other specific legislative changes are recommended to ensure a survivor-centered approach:

• Amend Part 1 of Article 242 of the Criminal Procedure Code of Ukraine, providing the survivor the legal possibility to engage an expert in criminal proceedings.
• Amend clauses 1 and 2 of Part 1 of Article 243 of the Criminal Code of Ukraine, giving the survivor the right to apply to the investigating judge in the presence of the circumstances provided for in Part 1 of Article 243 of the Criminal Code of Ukraine.
• Include the survivor among the parties that can independently collect samples, petition the investigator, and investigating judge for the collection of biological samples.
• Amend Part 1 of Article 244 of the Criminal Procedure Code in terms of conducting a forensic evaluation at the expense of the State Budget for survivors of war crimes without the need to prove the fact impossibility of attracting an expert independently due to lack of funds.

The international community and civil society actors should provide technical and financial resources to support the national efforts outlined above, as well as:

• Support the introduction and dissemination of standardized forms for forensic documentation that align with international best practices and national regulations.
• Support multisectoral and advanced specialized training to introduce standardized forensic documentation forms, build skills in high-quality survivor-centered forensic documentation and how to interpret such evidence, and promote collaboration, cooperation, and clarity concerning roles and protocols.
• Introduce training for clinicians, social workers, and other providers across the system on vicarious trauma, as well as ensure the necessary resources for ongoing support.

Conclusion

Supporting survivors in their healing, recovery, and pursuit of justice requires innovative approaches and collaboration across sectors and among stakeholders. Addressing this crisis demands collective effort, particularly in strengthening medico-legal documentation, to ensure that survivors have access to comprehensive care and justice they deserve.

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[1] Human Rights Council, Report of the Independent International Commission of Inquiry on Ukraine, U.N. A/HRC/55/66, March 18, 2024, para. 86, https://www.ohchr.org/sites/default/files/documents/hrbodies/hrcouncil/coiukraine/a-hrc-55-66-aev.pdf.   

[2] See footnote 1. 

[3] “310 cases of wartime sexual violence documented in Ukraine,” Mezha, August 8, 2024, https://mezha.net/ua/bukvy/v-ukraini-zadokumentovano-310-faktiv-seksualnoho-nasylstva-vchynenoho-v-umovakh-viiny/

[4] Committee on the Elimination of Discrimination against Women, General Recommendation No. 35 on Gender-Based Violence Against Women, U.N. Doc. CEDAW/C/GC/35 (2017); Committee on the Elimination of Discrimination against Women, General Recommendation No. 30 on Women in Conflict Prevention, Conflict, and Post-Conflict Situations, U.N. Doc. CEDAW/C/GC/30 (2013); Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment arts. 13-14, Dec. 10, 1984, 1465 U.N.T.S. 85; Basic Principles and Guidelines on the Right to a Remedy and Reparation for Victims of Gross Violations of International Human Rights Law and Serious Violations of International Humanitarian Law, General Assembly resolution 60/147, 15 December 2005, VI. Treatment of victims, https://www.ohchr.org/en/instruments-mechanisms/instruments/basic-principles-and-guidelines-right-remedy-and-reparation#:~:text=Victims%20should%20be%20treated%20with%20humanity%20and%20respect%20for%20their,as%20those%20of%20their%20families.

[5] The prohibition on torture and CIDT has been recognized as including sexual and other forms of gender-based violence by numerous UN human rights bodies and international courts. Sexual and gender-based violence can amount to torture and cruel, inhuman, and degrading treatment where the requisite elements are met (severity, purpose, public official involvement and intent). It can also include “acts or threats as forced nudity, verbal sexualized threats, sexualized degrading or humiliating mocking and other verbal or physical treatment, sexual assault by touching intimate parts of the body, digital penetration, forced masturbation, forced insertion of an object into the vagina or anus, oral rape, anal rape and vaginal rape, ejaculation or urination onto the victim, sexual slavery, forced pregnancy and enforced sterilization.” Please see https://www.ohchr.org/en/calls-for-input/2024/identifying-documenting-investigating-and-prosecuting-crimes-sexual-torture. This brief will include a discussion of the full breadth of torture and ill-treatment, including where it manifests as sexual or other forms of gender-based violence such as reproductive violence. While we recognize that sexual and gender-based violence is a form of torture and ill-treatment, given that in many sectors torture and sexual and gender-based violence may be handled by different actors, this brief utilizes the term “torture and sexual violence.”

[6] General comment no. 3, 2012: Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment: implementation of article 14 by States parties. See https://www.ohchr.org/en/documents/general-comments-and-recommendations/catcgc3-general-comment-no-3-2012-implementation; CEDAW General Recommendation 35, paragraph 28: All measures should be implemented with an approach centered around the victim/survivor, acknowledging women as right holders, and promoting their agency and autonomy, including the evolving capacity of girls, from childhood to adolescence. In addition, the measures should be designed and implemented with the participation of women, taking into account the particular situation of women affected by intersecting forms of discrimination. See https://www.securitycouncilreport.org/atf/cf/%7B65BFCF9B-6D27-4E9C-8CD3-CF6E4FF96FF9%7D/s_res_2467.pdf; UN Security Council Resolution 2467 (2019), S/RES/2467(2019): Strengthens justice and accountability and calls for a survivor-centered approach in the prevention and response to conflict-related sexual violence. See https://documents.un.org/doc/undoc/gen/n19/118/28/pdf/n1911828.pdf?token=TET993ahakTl1wPKnd&fe=true

[7] The initial assessment was undertaken with the support of the Dr Denis Mukwege Foundation.

[8] Office of the United Nations High Commissioner for Human Rights, “Istanbul Protocol: Manual on the Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment,” HR/P/PT/8/Rev. 2, 2022, https://www.ohchr.org/sites/default/files/documents/publications/2022-06-29/Istanbul-Protocol_Rev2_EN.pdf; Sara Ferro Ribeiro and Danaé van der Straten Ponthoz, “International Protocol on the Documentation and Investigation of Sexual Violence in Conflict: Best Practice on the Documentation of Sexual Violence as a Crime or Violation of International Law,” UK Foreign & Commonwealth Office, March 2017, https://www.un.org/sexualviolenceinconflict/wp-content/uploads/2019/06/report/international-protocol-on-the-documentation-and-investigation-of-sexual-violence-in-conflict/International_Protocol_2017_2nd_Edition.pdf.

[9] Office of the United Nations High Commissioner for Human Rights, “Istanbul Protocol: Manual on the Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment,” HR/P/PT/8/Rev. 2, 2022, https://www.ohchr.org/sites/default/files/documents/publications/2022-06-29/Istanbul-Protocol_Rev2_EN.pdf.

[10] “Strengthening Forensic Documentation of Torture and Conflict-Related Sexual Violence in Ukraine: Technical Assessment and Key Recommendations,” Physicians for Human Rights, May 2024, https://phr.org/wp-content/uploads/2024/07/PHR-Strengthening-Forensic-Documentation-of-Torture-ENG.pdf

[11] There were 21 semi-structured interviews conducted with stakeholders in Kyiv and Lviv, including health facility representatives, civil society organizations, survivors’ groups, legal experts, law enforcement, and government agencies. Several interviews involved multiple participants or representatives of several departments and were conducted uninterruptedly and are thus counted as one interview.

[12] Article 7 of the Law of Ukraine “On Forensic Examination” stipulates that forensic activities that are part of a criminal, medical, or psychiatric forensic evaluation are carried out exclusively by specialized governmental agencies, including by forensic medical experts.

[13] The organizational aspects of forensic expert activity are defined in the Law of Ukraine “On Forensic Expertise,” from February 25, 1994, № 4038-XII, https://zakon.rada.gov.ua/laws/show/4038-12#Text. Article 7 of the Law stipulates that forensic activities that are part of a postmortem, medical, or psychiatric forensic evaluation are carried out exclusively by specialized governmental agencies, including by forensic medical experts. In addition, psychological evaluations can also be carried out by other experts who are not necessarily part of state agencies but still have to be registered in the State Register of Certified Forensic Experts.

[14] Strategic Plan on the Implementation of Powers of the Prosecutor’s Office in the Field of Criminal Prosecution for Conflict-Related Sexual Violence, Prosecutor General’s Office of Ukraine, 2023, https://www.gp.gov.ua/ua/posts/specializovani-dokumenti

[15] On Amendments to Clause 1 of the Order of the Ministry of Health of Ukraine No. 110 dated 14 February 2012, Ministry of Health of Ukraine; Order, Certificate, Form […] from February 2, 2024, No. 186, https://zakon.rada.gov.ua/laws/show/z0243-24#n4

[16] “The Government has allocated a subvention for the functioning of forensic services during the transitional period of their reform,” Cabinet of Ministers of Ukraine, June 27, 2023, https://www.kmu.gov.ua/news/uriad-vydilyv-subventsiiu-na-funktsionuvannia-sudovo-medychnykh-sluzhb-pid-chas-perekhidnoho-periodu-ikh-reformuvannia; Order of the Ministry of Health of Ukraine dated 29.09.2023 No. 1712 “On Approval of the Action Plan for the Transformation of the Forensic Medicine System of Ukraine”, https://moz.gov.ua/article/ministry-mandates/nakaz-moz-ukraini-vid-29092023–1712-pro-zatverdzhennja-planu-zahodiv-z-realizacii-transformacii-sistemi-sudovo-medichnoi-ekspertizi-ukraini. In addition, in 2023, the Ministry of Health called for implementation of training on the Istanbul Protocol – international guidelines for the documentation of medical evidence of torture and its consequences – into the curriculum as part of the educational program “Health Care” at higher education institutions. See Report of the Ministry of Health of Ukraine on the implementation in 2022 of the Action Plan for the implementation of the National Human Rights Strategy for 2021-2023, approved by the Order of the Cabinet of Ministers of Ukraine No. 756-r dated June 23, 2021, https://moz.gov.ua/uploads/8/44409-dokument_no118_0_70_23_id3934000.pdf 

[17] Order 278 “On Approval of the Procedure for Conducting and Documenting the Results of Medical Examination of Victims of Domestic Violence or Persons Allegedly Affected by Domestic Violence and Providing Medical Care to Them,” February 1, 2019, https://zakon.rada.gov.ua/laws/show/z0262-19#Text.

[18] On Amendments to Clause 1 of the Order of the Ministry of Health of Ukraine No. 110 dated 14 February 2012, Ministry of Health of Ukraine; Order, Certificate, Form […] from February 2, 2024, No. 186, https://zakon.rada.gov.ua/laws/show/z0243-24#n4

[19] Draft Law “On Amendments to the Criminal Procedure Code of Ukraine on Examination and Expertise, Conclusion of Reconciliation Agreement and Criminal Proceedings in the Form of Private Prosecution in connection with the Ratification of the Council of Europe Convention on Preventing and Combating Violence against Women and Domestic Violence (Istanbul Convention),” No. 10420 from January 22, 2024, https://itd.rada.gov.ua/billInfo/Bills/Card/43531

[20] Draft Law “On Forensic Expertise,” No. 6284 from November 5, 2021, https://w1.c1.rada.gov.ua/pls/zweb2/webproc4_1?pf3511=73154

[21] Draft Law “On Amendments to the Criminal Procedure Code of Ukraine on Improving Certain Provisions Related to the Procedure for Appointing an Expertise,” No. 6285 from November 5, 2021, https://w1.c1.rada.gov.ua/pls/zweb2/webproc4_1?pf3511=73155

[22] “Standards for the investigation of war crimes. Illegal deprivation of liberty and torture,” Prosecutor General’s Office of Ukraine, 2023, https://justgroup.com.ua/wp-content/uploads/2023/05/standart-rozsliduvannya_katuvannya.pdf

[23] Standard Operation Procedures are being drafted by Global Rights Compliance, a nongovernmental organization and a law firm advising the Prosecutor General’s Office.

[24] See footnote 8.

[25] Sara Ferro Ribeiro and Danaé van der Straten Ponthoz, “International Protocol on the Documentation and Investigation of Sexual Violence in Conflict: Best Practice on the Documentation of Sexual Violence as a Crime or Violation of International Law,” UK Foreign & Commonwealth Office, March 2017, https://www.un.org/sexualviolenceinconflict/wp-content/uploads/2019/06/report/international-protocol-on-the-documentation-and-investigation-of-sexual-violence-in-conflict/International_Protocol_2017_2nd_Edition.pdf.

[26] Nadia’s Initiative, Institute for International Criminal Investigations, and United Kingdom Foreign, Commonwealth & Development Office, “Murad Code: Global Code of Conduct for Gathering and Using Information About Systematic and Conflict-Related Sexual Violence,” April 13, 2022, https://static1.squarespace.com/static/5eba1018487928493de323e7/t/6255fdf29113fa3f4be3add5/1649802738451/220413_Murad_Code_EN.pdf.

[27] Istanbul Protocol, p. 75. Paragraph 304 also stipulates the necessary qualifications of health practitioners who document violations: “Documentation of clinical evidence of torture requires specific knowledge by qualified health practitioners. Knowledge of torture and its physical and psychological consequences can be gained through publications, training courses, professional conferences and experience. In addition, knowledge about regional practices of torture and ill-treatment is important because such information may corroborate an individual’s accounts of these regional practices. Experience interviewing and examining individuals for physical and psychological evidence of torture or ill-treatment and documenting findings under the supervision of experienced clinicians is highly recommended.”

[28] Guidelines for medico-legal care for victims of sexual violence, World Health Organization, p. 3, 2003, https://iris.who.int/handle/10665/42788

[29] Ibid.

[30]Naimer K, Volpellier M, Mukwege D., “The case of Kavumu: a model of medicolegal collaboration,” Lancet,  Volume 393, Issue 10191, p.2651-2654, June 29, 2019, https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30649-X/abstract;

Mishori R, Naimer K, McHale T, Johnson K, Fateen D, Gillette-Pierce Z., “To confront sexual violence, we must train non-forensic experts to perform medico-legal evaluations,” Medicine, Science and the Law, Volume 62, Issue 2, June 29, https://journals.sagepub.com/doi/abs/10.1177/00258024211029075

[31] Christian De Vos, et. al, “Torture beyond carceral settings against individuals from marginalized communities: the important role for clinical documentation,” Torture Journal 33, no. 2 (2023), https://doi.org/10.7146/torture.v33i2.135272.    

[32] Naimer K, Volpellier M, Mukwege D., “The case of Kavumu: a model of medicolegal collaboration,” Lancet,  Volume 393, Issue 10191, p.2651-2654, June 29, 2019, https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30649-X/abstract; Rachel Jewkes et al., “Medico-Legal Findings, Legal Case Progression, and Outcomes in South African Rape Cases: Retrospective Review,” PLOS Medicine 6, no. 10 (2009), doi: 10.1371/journal.pmed.1000164; Margaret J. McGregor, Janice Du Mont, Terri L. Myher, “Sexual assault forensic medical examination: is evidence related to successful prosecution?” Annals of Emergency Medicine 39, no. 6 (2002); 639-647, doi: 10.1067/mem.2002.123694; Kelly Gray-Eurom et al., “The prosecution of sexual assault cases: correlation with forensic evidence,” Annals of Emergency Medicine 39, no. 1 (2002): 39-46, doi: 10.1067/mem.2002.118013; Mette Louise B. G. Kjærulff et al., “The significance of the forensic clinical examination on the judicial assessment of rape complaints – developments and trends,” Forensic Science International 297 (2019): 90–99, https://doi.org/10.1016/j.forsciint.2019.01.031.   

[33] Ribeiro and Straten Ponthoz, “International Protocol on the Documentation and Investigation of Sexual Violence in Conflict,” p. 158, https://www.un.org/sexualviolenceinconflict/wp-content/uploads/2019/06/report/international-protocol-on-the-documentation-and-investigation-of-sexual-violence-in-conflict/International_Protocol_2017_2nd_Edition.pdf

[34] Order 278 “On Approval of the Procedure for Conducting and Documenting the Results of Medical Examination of Victims of Domestic Violence or Persons Allegedly Affected by Domestic Violence and Providing Medical Care to Them,” February 1, 2019, https://zakon.rada.gov.ua/laws/show/z0262-19#Text

[35] Ibid.