Submission to the Committee on the Elimination of Discrimination against Women on Italy

This submission derives from Human Rights Watch’s documentation of rights violations in Italy and focuses on access to reproductive health care and access to education, including during the Covid-19 pandemic, as well as complicity in abuses faced by migrants. All of the names used are pseudonyms to protect the identity of witnesses and victims.

Access to Reproductive Health Care (Article 16)

Italy is failing to fulfil its obligations to ensure women’s access to reproductive health care. Abortion is legal in Italy during the first 90 days of pregnancy for health, economic, social, or personal reasons. However, burdensome requirements as well as extensive use of “conscientious objection” by medical personnel function to deny care to women and girls, and leave them scrambling to find services within the legal time frame.

Barriers to Accessing Reproductive Health Care

Significant barriers to accessing abortion persist in Italy, such as the need for multiple clinical visits

and a seven-day waiting period – the longest in Europe – except in cases of emergency, and lengthy waits for appointments.[1] Such delays prevent access to medical or surgical abortion within the legal time frames and undermine women’s reproductive choice.

Additionally, access to later abortions in Italy is extremely limited. Beyond 90 days, abortion is legal if there is a serious threat to a woman’s life. It may be legal if there is a serious threat to her physical or mental health, including due to diagnosis of severe or fatal fetal anomalies, but the law requires

doctors to “take any appropriate action to save the life of the fetus.”[2] Activists and doctors in Italy told Human Rights Watch that delays in testing and diagnosis during pregnancy mean women are not always aware of fetal anomalies during the first trimester, and some anomalies cannot be identified until later in pregnancy.[3] In addition, few doctors in Italy are willing to perform abortions after the 90-day limit. Most people travel outside the country for later abortion.

Italy has also not taken adequate steps to ensure access to birth control.[4] Free contraception through the national health service stopped in 2016, and only six regions now provide free hormonal birth control.[5]  Experts noted the cost of contraception in Italy can be prohibitive for poor women and adolescents, creating “discrimination in access.”[6] Birth control pills cost around €150 to €200 a year, and an intra-uterine device (IUD) around €250 to €300.[7] Given the economic fallout of the Covid-19 pandemic, more people may face financial barriers to accessing birth control.

In 2017, both the UN Human Rights Committee and the CEDAW Committee raised concerns about such barriers to abortion in Italy and said that the government should ensure access to abortion services nationwide.[8] The CEDAW Committee specifically said that Italy should ensure that conscientious objection “does not pose an obstacle for women who wish to terminate a pregnancy.”[9] UN treaty bodies have also noted that mandatory waiting periods constitute barriers to abortion access and called for their removal.[10]””

Similarly, the European Committee on Social Rights ruled in 2013 and 2015 that Italy’s failure to ensure consistent access to abortion, including the overly broad practice of invoking conscientious objection, constitutes a failure to uphold the right to protection of health and nondiscrimination in violation of the European Social Charter.[11]

Access to Abortion During the Covid-19 Pandemic

The Italian government did not take adequate action to prevent the Covid-19 pandemic from exacerbating barriers to abortion access despite the statement by the Commissioner for Human Rights of the Council of Europe calling on all member states to ensure full access to reproductive health care, including abortion, in their pandemic responses and her call for member states to “urgently remove all residual barriers preventing access to safe abortion.”[12]

From May to July 2020, Human Rights Watch documented how the Italian government failed to ensure clear pathways to essential, time-sensitive medical care during the pandemic and how interruptions to services prevented some women from accessing abortion within legal time limits, exacerbating longstanding obstacles to safe and legal abortion in Italy.[13]

Lack of Guidance and Information

Italy’s government did not immediately deem abortion essential health care during the pandemic. Although the Health Ministry clarified on March 30 that abortion services were non-deferrable, lack of guidance on providing these services during the pandemic hindered compliance by hospitals and clinics. For example, on March 31, the ministry issued guidance for care of pregnant women, women who had recently given birth, and newborns, as well as breastfeeding, but no such guidance for abortion-related care.[14]

Experts told Human Rights Watch that lack of centralized information about available services also caused confusion and delays. Months into the pandemic, they said, activists and women themselves faced challenges in determining where services remained operational.[15]

Movement Restrictions

Human Rights Watch found that restrictions on movement also inhibited access to abortion. In areas declared “red zones” during the Covid-19 pandemic, people could travel outside the home for health emergencies, but had to provide justification to authorities if stopped and could face fines for violations.[16] Some women told Human Rights Watch that the prospect of telling authorities they were seeking an abortion was itself a deterrent.[17]

Pandemic-related movement restrictions further limited access to later abortion, which women often travel outside of Italy to access. One woman told Human Rights Watch she accessed a later abortion in France during the pandemic, but at a cost of 2,000 euros for the procedure and travel expenses. Thus, access may be further inhibited for women without financial resources.[18]

Lack of Available Services

Some reproductive health services were suspended or relocated to provide space for Covid-19 patients.[19] Reassignment of medical staff to Covid-19 wards and absence of personnel due to illness or self-isolation also led to reduced services.[20]

“Valentina” told Human Rights Watch that she searched for a doctor to authorize and perform her abortion in March 2020 in Lombardy:

I went to my gynecologist – he said I can’t see you because of Covid. I went to the hospital, they said we can’t see you because of Covid. I went to another hospital – they didn’t even let me in the door because they said they were only taking urgent cases. They told me to go to the consultorio [family planning clinic]. So I called the consultorio. They said they were closed because of the pandemic.

Valentina said she felt desperate: “The Italian state closed the door in my face.” She finally accessed an abortion at a hospital in another town.[21]

A doctor at a public hospital in Rome that receives referrals for the Lazio region said the number of women seeking abortion increased by around 20 percent during the pandemic, which she attributed to the fact that some local facilities had closed or stopped providing certificates or performing abortions.[22] Nongovernmental organizations facilitating access to abortion also said that demand for assistance increased significantly, in part due to reduced services and movement restrictions.[23]

While Italy’s abortion law, called Law 194, requires annual reports on its implementation, no data is available regarding denial of abortion services, so it is impossible to know how many people were unable to get a medical or surgical abortion within the legal time limits or were denied services multiple times before finding an abortion provider.

Conscientious Objection

Under Law 194, personnel at health facilities can refuse to provide abortion on grounds of “conscientious objection” unless the life of the woman is “in imminent danger.”[24] Official statistics for 2018 show that 69 percent of gynecologists and 46 percent of anesthesiologists nationally are self-declared conscientious objectors. In one-quarter of areas listed, over 80 percent of gynecologists and at least 60 percent of anesthesiologists are registered as conscientious objectors.[25] General anesthesia was used in over 52 percent of abortions in Italy in 2018, making the high rate of objecting anesthesiologists a notable obstacle.[26]

Law 194 obliges authorities to ensure that conscientious objection does not prevent fulfilment of legal requests for abortion, even if this necessitates relocating personnel. It also specifies that medical personnel cannot deny pre- or post-abortion care. However, activists and doctors told Human Rights Watch that these measures are not upheld or enforced, including during the pandemic. In some cases, this impacted women’s access not only to abortion but to other essential reproductive health care.

“Chiara” experienced pain and symptoms of infection in March 2020 following an abortion several months prior. Personnel at a family planning clinic she visited in Calabria told her their only non-objecting doctor was on vacation for an unknown period. “Then I went to a center in a nearby city and they said, ‘We don’t do visits related to abortion, not before and not after, because the head of the center is a conscientious objector,’” Chiara said.[27] According to the March 30 Health Ministry circular, non-deferrable care during the Covid-19 pandemic includes gynecological examinations for vaginal infections.

Access to Medical Abortion

Only in August 2020 did the Italian government revise national guidance to ease restrictions on medical abortion, allowing them on an outpatient basis up to the ninth week of pregnancy rather than the seventh.[28] The World Health Organization says that, up to the twelfth week of pregnancy, self-managed medical abortion is a safe alternative to procedures that are more invasive and require going to a medical facility, which may also increase risk of exposure to Covid-19 and put additional pressure on health systems.[29] Other European governments – including in France, England, Wales, Scotland, Ireland, Spain, and Germany – took steps to facilitate access to medical abortion early in the pandemic by extending legal time limits, permitting self-management of medical abortion at home, and conducting consultations via telemedicine.[30]

Reports indicate that few regions in Italy have implemented the new guidance on medical abortion, and access remains extremely limited due to lack of facilities offering outpatient medical abortion and extensive invocation of conscientious objection means that.[31]

Human Rights Watch recommends that the Committee ask the government of Italy:

• What measures is the Italian government taking to eliminate existing barriers to accessing legal abortion?
• What specific action is the Italian government taking to ensure that medical personnel’s invocation of conscientious objection does not hinder access to legal abortion, pre- or post-abortion care, or other reproductive health care?
• What steps is the Italian government taking to ensure that its Covid-19 pandemic and other emergency response plans include assurance of access to essential sexual and reproductive health care, including abortion, such as by ensuring availability of local services, up-to-date information regarding how to access such services, and clear guidance for medical professionals on provision of services?
• What steps is the Italian government taking to facilitate and ensure implementation of the updated guidance on medical abortion nationally?
• How does Italy plan to ensure that data collection on implementation of Law 194 includes information regarding denial of abortion services, such as inability to access a medical or surgical abortion within the legal time limits, or denial of services multiple times prior to accessing an abortion?

Safety of Migrant Woman and Girls (Articles 2 and 3)

Material and technical support from Italy has enabled the Libyan Coast Guard, under the UN-recognized Government of National Accord (GNA), to intercept thousands of people at sea and return them to Libya where they face arbitrary, indefinite detention and a high risk of exploitation and violence, including rape. [32]  Despite clear and abundant evidence of widespread human rights violations and abuses suffered by migrants in Libya, the Memorandum of Understanding that provides the framework for Italy-Libya migration cooperation automatically renewed for another three years on February 2, 2020.[33] To date, the GNA has not accepted cosmetic changes to the MoU, which Italy proposed shortly after its renewal, to increase protection for migrants, asylum seekers, and refugees in Libya.

Human Rights Watch recommends that the Committee ask the government of Italy:

• What steps is the Italian government taking to ensure that respect for the rights of migrants in Libya, including women and girls, is a condition for continued cooperation on migration control?

• What steps is the Italian government taking to promote the closure of all detention centers and the use of alternatives to detention?
• What programs does the Italian government support for migrants who experienced sexual violence prior to or during migration to Italy, including in Libya? 

Access to Education during Covid-19 Pandemic (Article 10)

By March 10, 2020, all schools across Italy were closed in an effort to slow the spread of the coronavirus, affecting almost 11 million students. In May and June 2020, Human Rights Watch interviewed students, parents, and teachers about the effects on children’s education. As of January 28, 2021, schools had been completely closed in Italy for 93 days during the pandemic, and closed either in particular areas or for certain grades for an additional 89 days.

During closures, schools offered distance learning alternatives, but some girls and young women said they found distance education less conducive to learning. Children with disabilities and children who had difficulty accessing devices or the internet for online learning were at a particular disadvantage in accessing education during school closures. These include girls, young women and trans and non-binary children and youth.

Impact of School Closures on Girls with Disabilities

School closures had disproportionate consequences for many students with disabilities, including girls, who often did not receive the accommodations they needed, making it harder for them to access the relevant tools and engage in remote classes.

A support teacher in a vocational secondary school in Milan told Human Rights Watch that “for many students with learning difficulties, it’s difficult to participate in an online class…. What is missing is the personal relationship, which in the world of disability is fundamental.” In May 2020, she said that some of her students with disabilities “have never connected for online classes and this is horrible…. Already we have students who gave up and we haven’t managed to bring them back.” [34]

Italy’s 1992 Framework Law for the Assistance, Social Inclusion, and the Rights of Persons with Disabilities, sometimes referred to as “Law 104,” which guarantees the right to education for children with disabilities, provided some additional protection for children during school lockdowns.[35] The law also offered some parents of children with disabilities additional time off work to support their children during school lockdowns.[36] However, some parents told Human Rights Watch this was insufficient and that more support was needed for parents of children with disabilities.[37]

Insufficient Access to Internet-Connected Devices

Limited access to the internet or connected devices negatively affected students’ and teachers’ ability to use online platforms or benefit from technology-dependent distance learning, particularly in communities that struggle with a lack of infrastructure and the means to afford access.

A teacher in Emilia-Romagna, said, “One thing was clear from the beginning: continuing education during the lockdown would have increased existing inequalities in accessing education…. Just think, almost all my students have been doing their distance learning with a smartphone all the time.” [38]

“Sophia”, a mother of two school-aged children in Macherio, said that her daughters’ school provided devices to families who could not afford them, but by the time students received the devices and the necessary mobile internet keys, only a week remained in the school year. “Sophia” said: “I know of a couple of children who have actually disappeared. They haven’t participated in [distance learning] classes… We didn’t know if this was happening because they had technical problems, internet connection issues… or because they were just not participating in distant learning at all.”[39]

Gender Disparities in Unpaid Work and Impact on Distance Learning

The Covid-19 pandemic dramatically increased caregiving duties and time spent doing unpaid care and domestic work.[40] Globally, women do two and a half times as much unpaid care and domestic work as men.[41]

A science teacher in Emilia-Romagna, said: “There have been training opportunities…aimed to guide the teacher in how to do remote learning… I didn’t manage to take those courses because I didn’t have the time. I have a small child to take care of.”[42] In Italy, more than 90 percent of primary school teachers are women.[43]

A 19-year-old student in Milan said her family expected her to do domestic chores and did not understand that, although she was at home, she needed to focus on studying: “[My mother] didn't understand that if I was in front of the computer I was doing something and I couldn’t do anything else.”[44]

Human Rights Watch recommends that the Committee ask the government of Italy:

• How does the government plan to remedy learning time lost by all students due to Covid-19 related school closures, in particular for girls and young women with disabilities or from low-income families?
• What is the government doing to ensure equal access to learning for students with disabilities, for whom remote learning may create further learning barriers?
• What is the government doing to increase access to reliable and affordable internet services and internet-accessible devices as part of realizing the right to education?
• How is the government ensuring that all students, including girls and young women, return to school as soon as it is safe in accordance with public health standards?
• How is the government working to ensure that unpaid care and domestic work does not disproportionately impact access to education for girls and young women or access to training and support for teachers?

Protection of Education from Attack (Article 10)

Attacks on students and schools, and the use of schools for military purposes, disproportionately affect girls, who are sometimes the focus of targeted attacks and are more likely to be kept out of school due to security concerns.[45]

In May 2015, Italy was among the first countries to endorse the Safe Schools Declaration, an inter-governmental political commitment to better protect students, teachers, and schools during times of armed conflict.[46]

As of December 2020, Italy was contributing 1039 troops to UN peacekeeping operations in Lebanon. Peacekeeping troops are required to comply with the “UN Infantry Battalion Manual,” which includes the provision that “schools shall not be used by the military in their operations.”[47] Moreover, the UN Department of Peacekeeping Operation’s child protection policy notes: “peace operations should refrain from all actions that impede children’s access to education, including the use of school premises.”[48]

Human Rights Watch recommends that the Committee ask the government of Italy:

• Do any Italian laws or policies provide explicit protection for schools and universities from military use during armed conflict?
• Does pre-deployment training for Italian peacekeepers include the ban on using schools in military operations?