Executive Summary

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

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

Key Findings

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

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

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

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

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

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

Conclusions

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

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

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

Recommendations

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

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

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

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

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

To the Ethiopian government and federal regional authorities:

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

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

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

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

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

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

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

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

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

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

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

To the international community:

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

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

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

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

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

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

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

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

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

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

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

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

What We Do

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

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

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

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

Explore the Annual Report below or download it here.

Working to End Attacks on Health Workers and Hospitals

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

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

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

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

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

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

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

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

Naitore Nyamu-Mathenge, PHR Head of the Kenya Office

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

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

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

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

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

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Inspiring the Next Generation of Health and Human Rights Activists

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

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

Saman Zia-Zarifi, PHR Executive Director

This fact sheet summarizes the findings of the first published multi-sectoral consensus-building exercise on medico-legal affidavits in the U.S. immigration context. Medico-legal affidavits are underpinned by an expert medical evaluation which can objectively contextualize trauma and corroborate accounts of abuse; they are a critical component in immigration proceedings where somebody is seeking protection on the basis of said trauma or abuse. However, the lack of existing validated guidelines has led to inconsistencies in clinical evaluations’ format, structure, and content, causing confusion for practitioners and adjudicators alike. Drawing on expertise from adjudicators, attorneys, and clinicians, this Physicians for Human Right (PHR) research therefore aimed to pinpoint what experts viewed as the most crucial aspects of medico-legal asylum evaluations and their accompanying affidavits. By using a modified Delphi approach to collect and synthesize expert opinions, a consensus was reached on the defining features of a high-quality, comprehensive evaluation. The study identified seven key areas that were most agreed upon by participants, which serve as a foundation for future efforts to standardize and enhance the overall quality and consistency of medico-legal reports.

Executive Summary

Background

Sexual and gender-based violence (SGBV) is a global health crisis. More than 730 million women worldwide have experienced physical or sexual violence at least once in their lifetime.[1] In Kenya, the Demographic and Health Survey of 2022 showed that 34 percent of women and girls[2] surveyed reported having experienced physical violence at least once in their lifetime and 13 percent reported having experienced sexual violence, with many of these cases going unreported to authorities.[3] SGBV has profound impacts on a survivor’s physical and mental health.[4] Access to mental health care is a major challenge for survivors of sexual violence.[5]

In Kenya, 34 percent of women and girls aged 15-49 years surveyed have experienced physical violence at least once in their lifetime and 13 percent have experienced sexual violence, with many of these cases going unreported. SGBV has profound impacts on survivors’ physical and mental health, and access to mental health care is a major challenge for survivors of sexual violence.

Physicians for Human Rights’ Program on Sexual Violence in Conflict Zones began working in Kenya in 2011 to confront impunity for sexual violence committed during the unrest that followed the 2007 national elections.

From 2020 to 2022, PHR worked with partners, including the Survivors of Sexual Violence Network in Kenya (SSVKenya) convened by the Wangu Kanja Foundation, to address challenges faced by survivors. These included medical-legal documentation of the mental health impacts of sexual violence and access to quality mental health services in Kenya. The project, supported by the Comic Relief & UK Aid Mental Health Programme, aimed to enhance the capacities of health professionals and institutions in Kenya to provide post-rape mental health care and to forensically document the mental health impacts of sexual violence, as well as to strengthen the legal and policy framework on mental health care in Kenya.

This assessment arose out of PHR’s interest in understanding the impact of these interventions and related advocacy from the perspective of survivors of sexual violence, themselves. To ensure the voices of survivors remained at the heart of the assessment, PHR partnered with SSVKenya, an advocacy coalition comprised of survivors of sexual violence in Kenya.

Methodology

To conduct the assessment, PHR and SSVKenya jointly identified 10 survivors of sexual violence from across Nairobi who lived in areas that benefitted from the intervention, were active in SSVKenya, and were engaged in their communities as activists, human rights defenders, and volunteers helping other survivors access health services.

The assessment team selected Photovoice – a participatory action research (PAR) methodology through which community members document their experiences using photography – as well as voice recordings for this assessment.

The use of this methodology reflected a deliberate choice to empower survivors and mitigate the risk of re-traumatization that is inherent in traditional, interview-driven methodologies. The assessment team included self-selected survivors who were motivated to document issues important to them and their community and three PHR staff members. Using this methodology, survivors were equal partners in the assessment.[9]^,[10]

The assessment team selected Photovoice – a participatory action research (PAR) methodology through which community members document their experiences using photography. Using this methodology, survivors were equal partners in the assessment.

Findings

The assessment team took a total of 223 photos during a one-week period in October and November 2022 representing their experiences accessing mental health services in Nairobi. These photos were accompanied by a total of 99 WhatsApp voice notes.

Analysis of these materials, conducted by the assessment team and the survivor-collaborators, showed that survivors perceived gaps in the availability, accessibility, acceptability, and quality (AAAQ) of mental health services. As the AAAQ are the essential elements to realizing the right to health, they provide a powerful framework to understand sexual violence-related mental health services from a rights-based perspective.[12]

Availability

Survivors said mental health services for survivors of sexual violence are often unavailable in their communities, due to closed facilities, missing staff, or infrastructure challenges. They said there is minimal prioritization of mental health care services in general, and specifically of services targeting survivors of SGBV and other vulnerable groups.

Accessibility

Survivors identified difficulties accessing mental health services across Nairobi, with transportation a major challenge. They also experienced challenges accessing private facilities, primarily due to the high cost of mental health services and medication.

Acceptability

Survivors felt that many services being offered were not acceptable for their particular needs, including lack of private spaces for counselling sessions. They feared breaches of confidentiality and others learning about their history of sexual violence. They also noted challenges in accessing survivor-centered care, including the fact that providers multitasked during care.

Survivors said mental health services for survivors of sexual violence are often unavailable in their communities, due to closed facilities, missing staff, or infrastructure challenges.

Quality

Survivors frequently reported challenges related to the quality of services being offered. They shared their doubts regarding the skill level of health professionals on providing mental health services and how to engage with survivors of sexual violence. Survivors saw challenges in the implementation of existing policies and standards ensuring quality care in their areas.

Kenya has a clear obligation under national laws and policies to address these gaps and provide high quality, accessible, acceptable, and available mental health care. The Constitution of Kenya affirms that “every person has the right to the highest attainable standard of health.”[13] The Mental Health Amendment Act’s 2022 revisions state that survivors of sexual violence are entitled to access affordable mental health services in Kenyan health facilities.[14] The Sexual Offences Act Medical Regulations operationalize the provisions of the Sexual Offences Act and provide a legal foundation for access to no-cost post-rape care, which includes mental health services (i.e., counselling) for survivors of sexual violence.[15] The National Guidelines on Management of Sexual Violence in Kenya[16] provide guidance on the survivor-centered implementation of health services for survivors, including mental health services. This solid legal framework provides a robust platform from which Kenya’s national and local governments can implement existing laws to realize the right to mental health of survivors of sexual violence. Despite the strong domestic legal and policy landscape for the provision of mental health care for survivors of sexual violence, there is a gap in the implementation of these policies.

Finally, the government of Kenya, as a party to international human rights treaties and obligations – including the International Covenant on Economic, Social and Cultural Rights, the Convention on the Elimination of All Forms of Discrimination against Women, the African Charter on Human and Peoples’ Rights, and the Protocol to the African Charter on the Rights of Women in Africa (the Maputo Protocol) – is obligated to ensure that all sexual violence-related care (including mental health care) is provided in line with the AAAQ framework and should address obstacles to the realization of these standards.

Survivors perceived gaps in the availability, accessibility, acceptability, and quality of mental health services. They said there is minimal prioritization of mental health care services in general, and specifically of services targeting survivors of SGBV and other vulnerable groups.

Conclusion and Recommendations

This assessment not only deepened understanding of the perceptions of survivors of sexual violence about the challenges they face in accessing mental health services, but it also prioritized the engagement of survivors in advocating for change in their communities. This enables the results of this assessment to contribute to action and advocacy efforts. Finally, this assessment shows that Photovoice, as an example of a participatory research and evaluation method, can be a powerful tool to ensure that survivors of sexual violence can remain in the center of assessments, research, and evaluations conducted to understand their experiences.

Based on the assessment’s results, PHR and the Survivors of Sexual Violence Network in Kenya offer the following recommendations:

To all stakeholders, including national and county governments and civil society organizations:

▪ Ensure that measures are taken to engage survivors’ perspectives and ensure that their voices are included, listened to, and heard in processes to improve mental health services for survivors. This includes ensuring that survivors of sexual violence are able to engage at public meetings at the sub-county, city, national and other levels. Stakeholders must proactively engage survivor networks, such as the Survivors of Sexual Violence Network in Kenya, when developing laws, policies, and programs meant for survivors. Finally, stakeholders should leverage participatory methods to engage survivors to integrate survivor priorities in the design of polices and legislation.

▪ Engage in reparations and transitional justice processes to ensure the inclusion of mental health care and services for survivors of sexual violence, as part of survivor-centered and holistic reparations.

To the Nairobi City County Government:

▪ Prioritize the establishment of the Mental Health Council as per the provisions of the Mental Health Amendment Act. The council should include experts in mental health and representatives of survivors’ groups to ensure that the specific mental health needs of survivors of sexual violence are represented on the council. They should be required to maintain a register of all private mental health facilities operating within their counties and submit these to the Mental Health Board annually. They should also be mandated to inspect these facilities and report their findings to the Mental Health Board for remedial action that may be necessary.

▪ Allocate more financial resources to mental health service provision and increase the number of staff offering mental health services. Dedicate additional funding and conduct annual capacity development for all health care providers on the provision of mental health services to ensure all are equipped with the skills to provide trauma-informed, survivor-centered initial mental health support, forensic psychological documentation, and referrals as needed.

▪ Strengthen the integration of mental health service provision into routine and primary health care, including ensuring that primary health care providers can identify and refer survivors of sexual and gender-based violence (SGBV) to mental health services.

▪ Fully implement the National Guidelines on Management of Sexual Violence in Kenya at health facilities that provide post-rape care, with particular emphasis on provisions of the guidelines that enhance the survivor-centered aspects of mental health-related service delivery, including ensuring privacy.

▪ In line with the Sexual Offenses Act Medical Regulations and The Nairobi City County SGBV Management and Control Bill, allocate county health funds to guarantee no-cost post-rape care and affordable mental health care for priority populations.

▪ Ensure that mental health providers are available to provide services during the hours of clinic operation.

▪ Train and engage community mental health workers to offer appropriate first-line mental health services to and referrals for survivors of sexual violence. This should include new and formal programs with survivors’ networks to provide peer support and engagement with other survivors.

▪ Conduct public education campaigns to create awareness on the importance of mental health care, psychosocial support, and the mental health impacts of SGBV in order to address community level stigma, discrimination, and negative attitudes related to mental health care and treatment that prevent many survivors from accessing services. This should include dissemination of information on the mental health services that are available to survivors, which clinics offer mental health services, hours of operation, and which services are free of charge.

▪ Develop new programs to ensure mental health services are more accessible to survivors of sexual violence. This should be done by providing transportation or transportation stipends to ensure survivors can return for mandated follow-up counselling sessions. Develop programs to offer home-based, online, virtual, or phone-based counselling services or at the community level to reduce the physical, logistical, and financial barriers to accessing mental health services.

▪ Ensure that health facilities and locations for mental health services are accessible and user-friendly. Additionally, provide wheelchairs, ramps, and signs that indicate where facilitates are located, and update publicly available information about when service providers will be available to provide services.

▪ Ensure that the privacy of survivors of sexual violence seeking mental health is protected at all public facilities, in line with the National Guidelines on Management of Sexual Violence. This should include access to private and separated treatment rooms where survivors can access services without fear of disclosure or interruption.

To the Ministry of Health:

▪ Prioritize the provision of trauma-informed, survivor-centered mental health services for survivors of SGBV, including, specifically, mental health counseling and access to psychological assessments, where needed, to capture critical evidence of sexual violence.

▪ Further develop and implement guidelines and protocols for the health sector on the provision of comprehensive mental health services to SGBV survivors. Specifically, expedite the adoption of the rules and regulations that will operationalize the Mental Health Amendment Act 2022, including ensuring access to mental health care without discrimination.

▪ Design, fund, and implement comprehensive training, campaigns, and awareness-building on the importance of mental health care for survivors of sexual violence for all health care workers, as well the scope and nature of legal obligations and national and international standards on the provision of such care. Develop standardized training materials and continuous medical education courses for health care workers to provide survivor-centered, trauma-informed mental health services and psychosocial to support survivors of sexual violence. This training should be conducted simultaneously with the development/implementation of facility and community health protocols to support the management of SGBV survivors.

▪ Through the National Treasury, allocate resources to county governments for the training, recruitment, and deployment of well-trained mental health service providers.

▪ Ensure the availability of funds at the county level and undertake monitoring to ensure survivors can meaningfully access no-cost services for post-rape care, including psychological assessments and mental health care, as mandated by the Sexual Offenses Act Medical Regulations. Increase the budgetary allocation to mental health services to, at a minimum, the recommended WHO standards at the national level.

▪ Undertake and fund additional assessments, research, and data collection on the impact of sexual violence on survivors’ mental health to be used to increase the accessibility, availability, acceptability, and quality of mental health services for survivors of sexual violence.

▪ Implement accountability processes at the national and county levels to monitor and evaluate the provision of high-quality, acceptable, available, and accessible mental health care for survivors of SGBV, without discrimination, and provide redress and remedy where survivors face barriers in accessing such care, including investigations by the Kenya National Commission on Human Rights where there are suspected violations of rights related to the mental health care of survivors.

▪ Ensure targeted implementation of the existing laws, including the Constitution of Kenya (article 43) and the Mental Health Amendment Act, to ensure that the right to the highest attainable standard of health is realized.

To Donors:

▪ Continue to support survivor’s groups and programs that provide mental health care for survivors, including capacity development for service providers on mental health care, survivor-centered approaches, and psychological documentation.

▪ Support programs that use participatory approaches to engage survivors in assessments, research, and monitoring and evaluation.

To organizations conducting assessments, research, and monitoring and evaluation with survivors of sexual violence:

▪ Use participatory research and evaluation methods, such as Photovoice, to leverage their utility as powerful tools that ensure survivors of sexual violence remain in the center of assessment, research, and monitoring and evaluation conducted with the aim of understanding survivor experiences and producing recommendations that will result in changes in spaces that matter most to survivors.

Acknowledgements

This assessment was written by staff members of Physicians for Human Rights’ (PHR) Program on Sexual Violence in Conflict Zones, Thomas McHale, SM, deputy director, Suzanne Kidenda, senior program officer- Kenya, and Olivia Dupont, MPH, program manager; and Millicent Akinyi, Jane Alfayo, Mercy Etole, Grace Kamau, Beatrice Karore, Margaret Kinyua, Ashura Mciteka, Diana Mushiyi, Lorraine Ong’injo, and Bonila Sisia, members of the Survivors of Sexual Violence in Kenya Network.

The assessment benefitted from review by PHR staff, including Erika Dailey, MPhil, director of advocacy and policy, Christian De Vos, JD, PhD, director of research and investigations, Lindsey Green, MA, senior program officer, Karen Naimer, JD, LLM,
MA, director of programs, Naitore Nyamu-Mathenge, LLM, MA, Kenya head of office, Dr. Ranit Mishori, MD, MHS, FAAFP, senior medical advisor, Payal Shah, JD, director, Program on Sexual Violence in Conflict Zones, Kevin Short, deputy director of media and communications, and Saman Zia-Zarifi, JD, LLM, executive director. The assessment was strengthened through external review by Donna Shelley, MD, MPH. It was reviewed, edited, and prepared for publication by Claudia Rader, MS, PHR senior communications consultant, with assistance from Samantha Peck, PHR executive and program associate and board liaison.

PHR would like to thank Rutgers International for sharing curriculum materials that were adapted and used for Photovoice trainings in this project. This innovative assessment would not have been possible without the generous support of the Comic Relief & UK Aid Mental Health Programme.

Above all, PHR is grateful to partners from the Survivors of Sexual Violence in Kenya Network (SSVKenya) who shared their time, stories, and photographs with us, and for the partnership with SSVKenya, whose members continue to passionately represent the priorities of survivors in Kenya and beyond.

Citations and Endnotes

[1] “Facts and Figures: Ending Violence against Women,” UN Women – Headquarters, https://www.unwomen.org/en/what-we-do/ending-violence-against-women/facts-and-figures.

[2] This statistic only includes women and girls aged 15-19 who were usual members of (or slept at the night before) households sampled as part of the Kenya Demographic and Health survey, 2022.

[3] Kenya National Bureau of Statistics, Ministry of Health/Kenya, National AIDS Control Council/Kenya, Kenya Medical Research Institute, and National Council for Population and Development/Kenya, 2023, Kenya Demographic and Health Survey 2022, Rockville, MD, USA: Available at https://dhsprogram.com/pubs/pdf/PR143/PR143.pdf.

[4] “WHO Multi-Country Study on Women’s Health and Domestic Violence against Women,” n.d.

[5] Nikram Patel, Neerja Chowdhary, Atif Rahman, and Helen Verdeli, 2011, “Improving Access to Psychological Treatments: Lessons from Developing Countries,” Behaviour Research and Therapy 49 (9): 523–28. https://doi.org/10.1016/j.brat.2011.06.012.

[6] Survivor-collaborator quote, Data collection period October 28 – November 4, 2023.

[7] Survivor-collaborator quote, Data collection period October 28 – November 4, 2023.

[8] Survivor-collaborator quote, Data collection period October 28 – November 4, 2023.

[9] M. Candace Christensen, 2017, “Using Photovoice to Address Gender-Based Violence: A Qualitative Systematic Review,” Trauma, Violence, & Abuse, July, 152483801771774, https://doi.org/10.1177/1524838017717746.

[10] “Using Photovoice to Address Gender-Based Violence: A Qualitative Systematic Review.”

[11] Survivor-collaborator quote, Data collection period October 28 – November 4, 2023.

[12] Office of the UN High Commissioner for Human Rights, “The Right to Health Fact Sheet,” https://www.ohchr.org/Documents/Issues/ESCR/Health/RightToHealthWHOFS2.pdf.

[13] Constitution of Kenya 2010, Article 43(1). n.d., http://kenyalaw.org/kl/index.php?id=398.

[14] “The Mental Health Act,” Kenya, 2022.

[15] “Sexual Offences Act Medical (Treatment) Regulations,” Kenya, 2020.

[16] Nairobi, Ministry of Health, 2014, National Guidelines on Management of Sexual Violence in Kenya.