I have anxiety…. I feel stress, I am affected mentally…. That moment comes to my mind every day…. I always remember that day.
—Tirhas S. (not her real name), 44-year-old sexual violence survivor, Tigray, March 16, 2021
The armed conflict that began in November 2020 in the Tigray region of Ethiopia has involved numerous grave abuses committed by Ethiopian and Eritrean armed forces, and regional Amhara militias allied to the Ethiopian army, including massacres, rape, and other sexual violence against women and girls; attacks on refugee camps; and destruction of crops and civilian infrastructure, including healthcare facilities and schools. Tigrayan militia forces have also committed serious abuses, including sexual violence, against Eritrean refugees in the region, and in the Amhara region as the fighting has expanded.
The armed conflict has also been characterized by the Ethiopian government’s obstruction of humanitarian assistance in Tigray, which the United Nations has characterized as a de facto blockade. The government is unlawfully restricting and denying desperately needed food, medical supplies, and fuel to the population of Tigray. The government has imposed unpredictable bureaucratic obstacles for aid agencies to obtain visas and permissions for goods; engaged in harassment, attacks, and expulsion of humanitarian workers; and shut down basic services in the region, including banking, electricity, and telecommunications.
Since Tigrayan forces retook control of most of the region in late June 2021, the Ethiopian government has effectively besieged Tigray, raising concerns that it is using starvation as a weapon of war, which is a violation of the Ethiopian criminal code and a war crime under international humanitarian law.
This report documents the health impacts of conflict-related sexual violence in Tigray as described by humanitarian agencies and other service providers. It details the devastation of the healthcare system in Tigray, and the lack of availability of post-rape health care and related psychosocial support services. It documents how insecurity, armed men’s presence in health settings, and Ethiopian government restrictions on communications, electricity, and humanitarian assistance have impeded the access to care for sexual violence survivors, including girls and women from 6 to 80 years old. It also describes how the government’s blocking of food, medical supplies, and fuel to the region has stymied the rehabilitation of the health sector and the ramping-up of a comprehensive response to gender-based violence.
An analysis of the prevalence and patterns of sexual violence in Tigray and more recent abuses in the Afar and Amhara regions is beyond the scope of this report.
For this report, between June and November 2021, Human Rights Watch interviewed, over secure channels, 21 local and international healthcare workers, service providers, humanitarian aid workers, members of community organizations, and government donor agencies. We reviewed 43 additional individual cases of sexual violence as documented through anonymized medical notes, intake notes, and written transcripts of interviews between sexual violence survivors and service providers. We drew from previous Human Rights Watch interviews conducted between January and June 2021 with two Eritrean refugee sexual violence survivors and five health workers, service providers, and witnesses.
Human Rights Watch conducted four written and telephone interviews with members of the Tigray Regional Health Bureau, and the Sexual and Gender-Based Violence Assessment and Rehabilitation Committee of the Tigray Women’s Affairs Bureau. On October 15, 2021, Human Rights Watch sent a summary of findings and requests for information to the Ethiopian Ministry of Health, the Ministry of Justice, the Ministry of Peace, the Ministry of Women and Social Affairs, and the National Disaster Risk Management Commission, but did not receive replies by the time of publication.
Gender-Based Violence in the Tigray Conflict
The armed conflict between the Ethiopian government and allied forces with the Tigray People’s Liberation Front (TPLF) has been accompanied by reports of widespread sexual violence across the region in areas controlled by different warring parties, including rape, gang rape, sexual slavery, and torture. Sexual violence took place alongside killings of family members, beatings, and psychological violence. Sexual violence—often accompanied with degrading and ethnic-based slurs—has been used as a weapon of war, particularly by Ethiopian, Eritrean, and Amhara forces against Tigrayan women and girls. These reports first emerged in late 2020 from community networks, healthcare workers, and humanitarian aid providers. By February 2021, conflict-related rape had been confirmed and condemned by Ethiopian authorities and UN officials.
Reliable estimates of the prevalence of sexual violence in the conflict, and comprehensive incident data do not exist. While information on numbers of survivors can contribute to understanding the scale of abuse and support the planning and provision of services, an overemphasis on establishing the extent of sexual violence or disclosing incident data can be counterproductive, including by putting pressure on survivors to report. Priority should be placed on developing safe spaces and confidential services where survivors can seek support voluntarily and at the time of their choosing.
The November 3, 2021 report from the joint investigation by the Ethiopian Human Rights Commission (EHRC) and the UN Office of the High Commissioner for Human Rights (OHCHR) on human rights abuses in Tigray committed by parties to the armed conflict found “a continuous rise in the use of SGBV [sexual and gender-based violence] services by survivors.” It cites data between November 2020 and May 2021 provided by Ethiopia’s Ministry of Women, Children and Youth and the Ministry of Health indicating 1,324 visits to hospitals in Tigray by survivors of sexual and gender-based violence, including in the cities and towns of Mekelle, Adigrat, Axum, Adwa, Shire, and Maichew. According to information provided to Human Rights Watch in October from the Tigray Bureau of Health, a regional government entity now under TPLF control, 2,204 survivors sought services for sexual violence at health facilities (a broader category inclusive of hospitals and health centers) across Tigray from November 2020 through June 2021.
Insecurity, deeply rooted social stigma, and the lack of functioning healthcare facilities mean that the actual number of cases of sexual violence far exceeds the number reported. In addition, certain groups of sexual violence survivors, including men, boys, older people, and people with disabilities, typically have fewer channels to seek confidential help from trained personnel equipped to provide support to them and for their specific needs.
During the first nine months of the conflict, Ethiopian and Eritrean government forces, as well as Amhara militias, pillaged and destroyed health facilities in Tigray, reducing survivors’ access to essential post-rape health care and mental health and psychosocial support services (MHPSS). An April 2021 UN humanitarian assessment reported that the Emergency Coordination Center, established by the Ethiopian government, found that only 29 of the nearly 230 health centers in Tigray were fully functional.
Human Rights Watch research showed that the healthcare needs of sexual violence survivors able to seek services have included testing, treatment, and termination of pregnancy, testing and treatment for sexually transmitted infections including HIV and Hepatitis B, and physical trauma, including broken bones, bruises, stab wounds, and traumatic fistula. They have also sought support for depression, anxiety, post-traumatic stress, and other mental health conditions. A doctor working in a hospital in an urban center told Human Rights Watch:
One day Ethiopian military men came to the hospital with a [teenage] girl…. We checked her and found that she was pregnant. She was one of the sex slaves in the Gereb Giba military camp [more than 12 kilometers from Mekelle, the provincial capital]. That was the first day in early December…. We [tested her,] she was hepatitis positive. With her consent we terminated her pregnancy. Gave her anti-hepatitis drugs. After that quite a lot of women and girls were coming in, seeking medication, and to terminate their pregnancies, raped by conflict actors, mainly by Eritrean troops and Ethiopian forces.
As of April 2021, the UN Population Fund (UNFPA), which is coordinating humanitarian response to gender-based violence in Tigray, reported that only 1 percent of health facilities in Tigray had the capacity to provide comprehensive gender-based violence services. It also identified critical shortages in medical supplies used in the clinical management of rape.
The presence of soldiers at checkpoints on the roads and near or inside health facilities also deterred survivors from seeking health services. The doctor above, noting both the military presence in the hospital where he worked and the lack of transportation for survivors, said they only came if they had severe injuries or suspected pregnancy. “They really feared to come,” he said. “We didn’t find anyone coming the day they were raped. [They came] after two weeks, after a month, and [longer].”
Service providers described soldiers coming into health facilities searching for specific rape survivors or health records. One humanitarian worker said: “In [location withheld] a [rape] survivor was admitted…. The alleged perpetrators, the Eritrean defense forces, came into the hospital a few times…looking for her.”
Human Rights Watch also collected reports of at least five instances in which armed groups threatened, harassed, or detained Tigrayan aid workers supporting sexual violence survivors or providing reproductive health services for local organizations or international organizations.
Health workers and humanitarian aid providers said that government-imposed restrictions on telecommunications, banking, and fuel, along with insecurity, impeded their ability to expand their operations, alongside insecurity due to active fighting. The presence of Ethiopian, Eritrean, and Amhara forces within communities in Tigray in the first half of 2021 also impacted the work of mobile clinics and community outreach programs. Humanitarian workers described situations in which soldiers warned community members of reprisals if they spoke to aid workers. They said they struggled to adhere to best practices for supporting survivors of gender-based violence, including to provide private and safe spaces for women and girls.
Ethiopian government shutdowns of telecommunications and electricity also affected survivors’ access to health information and services. Without functioning mobile phones, survivors could not find out from family or community members where they could go to seek help, call health facilities for information, or gather information on safe travel routes.
The lack of safety, information, health facilities, medications, trained staff, and transport prevented survivors of sexual violence from seeking or receiving time-sensitive treatments, including during the critical 72-hour window to administer post-exposure prophylaxis to prevent HIV and the 120-hour window for emergency contraception to prevent pregnancy. A humanitarian aid provider told Human Rights Watch that of the sexual violence cases handled by their agency, “More than 80 percent of victims and survivors didn’t present within the 72-hour window.”
Human Rights Watch interviews showed that social stigma around sexual violence undermined survivors’ ability and willingness to access psychosocial support and health care when available. Navigating social stigma is a pressing issue for women and girls who have become pregnant due to rape, and for children born of rape. A representative of a safehouse for women said they had 13 babies born of rape residing at the safehouse, and as of October, only 1 of these mothers had been able to return to the community with the support of the woman’s relatives. The other 12 women were afraid of returning home, due to stigma and to worries about financially supporting and feeding their babies. Another humanitarian worker said in November, “There is definitely abandonment of babies…. There is a lot of stigma.”
Mental health care and psychosocial support services, including community-based support and specialized services, are massive gaps in Tigray, as well as other conflict-affected regions. The need for mental health support also extends to healthcare providers, who have treated and worked with distressing cases with little support amidst enormous challenges. Tigrayan health workers have done so in the context of having their own lives and communities disrupted by conflict, displacement, and loss, and the shutdown of essential services.
Ethiopian Government Response and Obstruction of Aid
The Ethiopian government has acknowledged reports of sexual violence, but its response has been mixed. In January it created a joint governmental taskforce team to investigate allegations of conflict-related sexual violence and has since referred the findings to the Attorney General’s office. However, the investigations have been slow, and while senior officials, including Prime Minister Abiy Ahmed and Attorney General Gedion Timothewos, have personally acknowledged the occurrence of rape, senior officials have also downplayed media reporting around rape as sensational, referencing it as “TPLF propaganda.”
The joint investigation by the EHRC and OHCHR collected evidence of sexual violence accompanied by particular brutality, including gang rape and intentional transmission of HIV, and found that, “in many cases, rape and other forms of sexual violence have been used to degrade and dehumanize the victims.” It noted that these abuses, due to their widespread and systematic nature, may amount to crimes against humanity. The Ethiopian government responded to the report findings by defending the Ethiopian military’s disciplinary record and, despite the report’s evidence of significant increases in sexual violence survivors seeking assistance and identifying armed forces as perpetrators, suggested that sexual violence had been a major problem in the region prior to the conflict.
The Ethiopian government has engaged with the aid community on medical and psychosocial support, for example through initially co-chairing the humanitarian coordination cluster focusing on protection issues, including gender-based violence. The coordinated response included expanding One-Stop Centers, provision of “Dignity Kits” for nongovernmental organization (NGO) distribution, creation of women and girls’ safe spaces, and rebuilding the health infrastructure. Human Rights Watch requested information from the Ethiopian government to learn more about their response to conflict-related sexual violence but had not received a reply by time of publication.
However, these efforts pale in comparison to the effects of the severe restrictions to access and essential services that the Ethiopian government has imposed repeatedly on the Tigray region since the beginning of the conflict. These have included closing access to roads in and out of the region, and shutting down telecommunications, electricity, and banking.
Since Tigrayan forces retook control of the region on June 28, the government has tightened these restrictions by limiting access to Tigray to one route through Afar region, cutting off all basic services, and blocking humanitarian assistance, effectively besieging the region. The humanitarian community has been able to deliver only a small fraction of needed food, medical supplies, and fuel to civilians in the region, or to scale up their staffing and operations. The restrictions have remained in place despite an escalating crisis of food insecurity affecting 90 percent of Tigray’s population with 350,000 people already facing famine-like conditions before the government blocked aid to the region.
The Ethiopian government has also obstructed the access of senior international humanitarian officials and humanitarian agencies providing aid in the region. On July 30, the government ordered a three-month suspension on Médecins Sans Frontières (Doctors Without Borders, MSF) Holland and the Norwegian Refugee Council after accusing them of “misinformation” and failure to obtain appropriate work permits. On September 30, the government declared seven senior UN officials, including the country leads for the UN Office for the Coordination of Humanitarian Affairs (OCHA) and the UN Children’s Fund (UNICEF) and a lead OHCHR investigator, as “persona non grata,” or unwelcome in the country, further jeopardizing humanitarian operations.
The Ethiopian government’s obstruction of aid has severely constrained the rehabilitation of the health sector. On September 16, OCHA reported that proper case management of gender-based violence, including mental health and psychosocial support services, “remain insufficient in most locations in Tigray.” In late-September, OCHA reported that “health partners have not been able to rehabilitate and re-equip health facilities following the systematic looting by parties to the conflict,” and in mid-October, said that the government continued to block medical supplies and life-saving medicines.
In October, healthcare workers and service providers working in Tigray told Human Rights Watch they did not have adequate medicines and medical supplies and could not expand outside of urban centers for community-based outreach and services due to the lack of cash, transportation, and fuel. They described their challenges with confidential case management of gender-based violence cases and data protection from the lack of electricity and computers, meaning that some service providers had to rely on handwritten notes and files.
Humanitarian groups have been hobbled by the obstruction of aid, and told Human Rights Watch they have found it difficult to meet the minimum standards of care to ensure an appropriate and quality humanitarian response as laid out in the Sphere Standards and other international guidelines.
International humanitarian law applicable in Tigray requires parties to the conflict to allow and facilitate rapid and unimpeded impartial aid to civilians in need. The parties must consent to allow relief operations and may not refuse such consent on arbitrary grounds. They may take steps to control the content and delivery of humanitarian aid, for example to ensure it does not include weapons. The movement of relief workers may be temporarily blocked for reasons of imperative military necessity, such as security concerns in the midst of a military operation.
The Ethiopian authorities’ onerous restrictions on the delivery of humanitarian assistance to the Tigray region, which has blocked food, medical supplies, and fuel, without valid justification, is in violation of international humanitarian law. Moreover, the government’s curtailment of food aid may amount to the use of starvation as a weapon of war, which is a war crime.
Warring parties may take military action to restrict electricity or communications to opposing forces, so long as such actions do not cause disproportionate civilian harm. The government’s cutting off electricity and telecommunications in Tigray has had an enormous negative impact on the population.
In addition to its international obligations, the Ethiopian government should immediately provide full and unimpeded access for humanitarian aid to the Tigray region and restore essential services to meet the pressing healthcare and psychosocial support service needs of sexual violence survivors.
Since mid-2021, the European Union (EU), United States, and United Kingdom have made increasingly stronger calls for investigations into alleged abuses and unimpeded humanitarian aid. The US government authorized a targeted sanctions regime in September, allowing the US government to deny visas to and freeze the assets of individuals and entities responsible for or complicit in serious abuses and obstructing access to humanitarian aid.
On September 3, the African Union (AU) urged the Ethiopian government to step up efforts to ensure humanitarian access into Tigray. On October 7, the European Parliament adopted a resolution calling on national, regional, and local actors to “allow immediate and unimpeded relief into Tigray,” and an end to “the de facto blockade on humanitarian assistance and critical supplies, including food, medicine and fuel,” as well as targeted sanctions against those “responsible for actions prolonging the conflict and exacerbating the humanitarian situation.”
The United Nations Security Council did not hold its first public meeting on Ethiopia until June 2021 and has not placed Ethiopia—including the crucial issue of humanitarian access—on its formal agenda. On November 5, as the fighting in northern Ethiopia escalated and spread, the Security Council released a statement that called for “the respect of international humanitarian law, for safe and unhindered humanitarian access, the re-establishment of public services, and… the scaling up of humanitarian assistance.”
Human Rights Watch research from conflicts around the world, including the Central African Republic, Iraq, Myanmar, and South Sudan, have repeatedly documented the profound and long-term impacts of conflict-related sexual violence on women and girls, including their mental and physical health and ability to fully resume working, studying, participating in public life, and caring for their families. The availability, accessibility, and quality of support both in the immediate aftermath of violence, and in the long-term are essential for survivors’ healing and rebuilding their lives.
International donors should commit support and resources for the long-term rehabilitation of the healthcare system, including for clinical management of rape across the region, and for the short and long-term mental health and psychosocial service needs for survivors of gender-based violence, their families, and communities. This includes an emphasis on community-based outreach and services, and referrals and availability of specialized care.
Given the grave and expanding abuses by all parties to the conflict in Tigray, the United Nations Human Rights Council should urgently establish an independent, international investigation that examines the pattern and scale of violations, identifies those responsible for the worst crimes up to the present, and collects and preserves evidence to pave the way for future accountability and reparations.
Amhara Regional Police Special Forces
Combination of drugs used to treat HIV infection.
Dignity Kits help women and girls maintain proper hygiene after being displaced, and typically include menstrual pads, underwear, soap, washing powder, a flashlight, toothbrush, toothpaste, and comb.
Eritrean Defense Forces
Ethiopian Human Rights Commission
Ethiopian National Defense Forces
Amhara militia group
Gender-Based Violence Area of Responsibility. The GBV AoR coordinates humanitarian response to gender-based violence, including the work of NGOs, UN agencies, donors, academics, and independent experts.
Mental Health and Psychosocial Services
UN Office for the Coordination of Humanitarian Affairs
Centers that provide coordinated services and referrals for health care, legal assistance, mental health support services, shelter, and other protection needs for sexual violence survivors.
Tigray Defense Forces
Tigray People’s Liberation Front
An injury from rape leading to a hole between a woman’s vagina and bladder or rectum, or both, resulting in the leaking of urine and/or feces.
Women and Girls Safe Spaces (WGSS) or Women and Girls Friendly Spaces (WGFS)
A place where women and girls can go to feel physically and emotionally safer, access information and support, participate in activities, build their networks, and strengthen relationships with peers.
District-level administrative unit
Enforce zero tolerance for sexual violence and other violations of international human rights law and international humanitarian law.
All parties to the conflict should respect international law, including by enforcing a zero-tolerance policy for sexual violence and ensuring that anyone responsible for sexual violence be appropriately held to account. They should uphold international humanitarian law prohibitions against attacks on health workers and humanitarian aid personnel, health facilities, and medical transport.
Allow immediately rapid, full, safe, and unfettered access to humanitarian aid.
All warring parties should urgently allow access to humanitarian aid throughout conflict-affected areas in compliance with international law. This includes supplies and staff necessary for the rehabilitation of healthcare and psychosocial support infrastructure.
The federal Ethiopian government in particular should lift broad restrictions on banking, telecommunications, fuel, electricity, food, medicines, and humanitarian access in the Tigray region. Tigrayan forces should also ensure humanitarian access to areas under their control.
Strengthen and expand a comprehensive approach to preventing and responding to gender-based violence across Tigray and conflict-affected areas, including at the regional, woreda (district), and village levels.
The Ethiopian government and regional authorities, including the TPLF, should cooperate fully with humanitarian agencies to ensure the availability, accessibility, and quality of sexual and reproductive health services, including clinical management of rape, without discrimination. They should also ensure the availability, accessibility, and quality of mental health and psychosocial support services without discrimination, including community-level trainings on psychological first aid and provision of specialized services and counseling for sexual violence survivors and their families.
UN member countries should increase pressure on parties to the conflict to allow rapid and unfettered access to humanitarian aid, and should establish and support an independent international investigation into human rights abuses and war crimes in the Tigray conflict.
The United Nations Human Rights Council should establish an independent international investigation into human rights abuses and war crimes in conflict-affected areas of Tigray, Afar, and Amhara regions to ensure credible scrutiny, investigate and report on violations, collect and preserve evidence for future trials, and facilitate genuine accountability. The investigation should include all forms of gender-based violence, including rape as a weapon of war, attacks on health facilities, and obstruction of humanitarian assistance including starvation as a weapon of war.
This report focuses on access to health care and psychosocial support services for survivors of conflict-related sexual violence in the Tigray region of Ethiopia. This research includes documentation of the barriers that sexual violence survivors have faced in obtaining care and services during periods of active armed conflict as well as due to the Ethiopian government’s blocking of aid to the region since mid-2021. This research investigated healthcare and mental health and psychosocial support service needs as documented by service providers, obstacles faced by healthcare providers and humanitarian aid workers in delivering and expanding post-rape care, and individual cases of sexual violence as documented through anonymized medical notes, interview transcripts with service providers, and direct witness accounts.
Attempts to quantify the prevalence of conflict-related sexual violence, or to describe patterns of sexual violence by location or timeline are beyond the scope of this report. Documentation of conflict-related sexual violence in the Amhara region is also outside the scope of this report. This research did not set out to review or evaluate legal accountability efforts. Community-based gender-based violence, and domestic violence linked to the conflict and displacement are also outside of the scope of this report.
Due to physical access constraints and the government-imposed shutdown in telecommunications in Tigray, interviews were conducted remotely. For ethical and logistical reasons, particularly in a context with few functioning or accessible referral pathways for support services, we chose to focus the research on service-providers and did not seek interviews with sexual violence survivors.
For this report, from June through November 2021, Human Rights Watch researchers interviewed, over secure channels, 21 healthcare workers, service providers, humanitarian aid workers, members of community organizations, and international donors. Fifteen of the interviewees directly provided services to survivors of gender-based violence or helped to coordinate and oversee the response of their respective organizations in Tigray to gender-based violence in the period November 2020 to November 2021. Three were members of informal networks and community organizations responding to human rights abuses including sexual violence in Tigray, and three were staff members of international government donor agencies.
This report also draws from previous Human Rights Watch research conducted between January and June 2021 including interviews with two Eritrean refugee women about other topics who voluntarily disclosed their experiences of rape and interviews with five health workers, service providers, and witnesses.
Altogether, the organizations and health providers that we interviewed had treated more than 1,000 cases of sexual violence perpetrated by members of armed forces and non-state armed groups.
The research included review and analysis of 43 individual cases of sexual violence reported to and treated by service providers through anonymized intake notes, medical notes, and interview transcripts with survivors of sexual violence provided to Human Rights Watch. These cases included 38 women and 5 girls under the age of 18. Information from the anonymized intake notes and medical notes were reviewed for patterns and Human Rights Watch did not disclose any individual information in this report.
Survivors whose accounts were documented in the interview transcripts provided consent for their public use. Illustrative quotes, using pseudonyms that do not reflect survivors’ real names, from three of these interview transcripts have been included in this report.
Due to privacy and security considerations, Human Rights Watch has anonymized the names and identifying details of most interviewees, including specific locations of where they were providing health and gender-based violence support services in Tigray.
Human Rights Watch also reviewed internal and published reports from humanitarian organizations on gendered impacts of the crisis, media reports, official statements made by governmental and intergovernmental authorities, and publicly available data on humanitarian needs and response.
Human Rights Watch conducted four written and telephone interviews with members of the Tigray Regional Bureau of Health and the Sexual and Gender Based Violence (SGBV) Assessment and Rehabilitation Committee of the Tigray Women’s Affairs Bureau.
Human Rights Watch sent a summary of our research findings and written requests for information to federal Ethiopian authorities on October 15, 2021, including to the Ministry of Health, the Ministry of Justice, the Ministry of Peace, the Ministry of Women and Social Affairs, and the National Disaster Risk Management Commission. As of the date of publication, we had not received any responses.
Armed Conflict in Tigray
In the early hours of November 4, 2020, following years of growing tensions between Ethiopia’s federal government and the ruling party administering the Tigray region, the Tigray People’s Liberation Front (TPLF), Ethiopia’s Prime Minister Abiy Ahmed acknowledged on state television that he ordered the Ethiopian National Defense Forces (ENDF) to commence a “law and order operation” in Tigray in response to attacks by TPLF forces on Ethiopian military bases and federal forces in the regional capital of Mekelle, and at other camps in the Tigray region.
At the onset of fighting, the TPLF, supported by Tigray’s regional special police and local militias, said that it took over the assets of the Ethiopian military’s northern command in Tigray. The Ethiopian military soon carried out military operations in Tigray, which were supported by Amhara regional special police (ASF), Amhara militias, and irregular militia groups known as “Fano.”
Reports soon emerged that Eritrean Defense Forces (EDF) were participating in the conflict in support of the ENDF and its allied forces from the neighboring Amhara region. Human Rights Watch documented that on November 9, artillery attacks launched from Eritrea hit the Tigrayan town of Humera, in western Tigray. On November 14, TPLF officials acknowledged launching rockets at Eritrea’s capital, Asmara, asserting they were in retaliation for the EDF’s involvement in the fighting.
On June 28, Tigrayan forces recaptured the regional capital of Mekelle. That same day, the federal government unilaterally declared a ceasefire, citing many reasons, including to allow essential aid into Tigray. Since then, Ethiopian federal and regional forces have blocked roads into the region and limited humanitarian access. In July, the fighting expanded into the neighboring Amhara and Afar regions, with reports of civilian casualties and thousands displaced, and increasing reports of serious abuses against civilians in the Amhara region by Tigrayan forces, including sexual violence and summary killings.
The conflict, which is ongoing at time of writing, has been marked by serious violations of international humanitarian law, including large-scale massacres, summary executions, widespread rape and other sexual violence, indiscriminate shelling, pillage, attacks on refugee camps, destruction of crops and civilian infrastructure, such as factories, schools, and healthcare facilities, and the obstruction of humanitarian assistance. The blocking of humanitarian assistance has included bureaucratic obstacles to getting visas and permissions for goods; attacks against, harassment of, and expulsion of humanitarian workers; and shutdowns of basic services in the region, including banking, electricity, and telecommunications.
Gender-Based Violence in the Tigray Conflict
The conflict in Tigray has involved widespread sexual violence against Tigrayan women and girls accompanied by brutal beatings and psychological violence. Reports first emerged at the end of 2020 from community networks, healthcare workers, and humanitarian aid providers. The existence of conflict-related rape has since been confirmed and condemned by Ethiopian authorities and UN officials, although the scale of abuses remains unknown.
Amnesty International published a report in August 2021 that provides the most comprehensive documentation to date of rape, gang rape, sexual mutilation, and sexual slavery against Tigrayan women and girls. Perpetrators include the Eritrean Defense Forces (EDF), the Ethiopian National Defense Force (ENDF), the Amhara Regional Police Special Forces (ASF), and Fano, an informal Amhara militia group. Human Rights Watch has also documented incidents of sexual violence perpetrated by Tigrayan militias against Eritrean refugees.
In October, the Tigray Regional Bureau of Health provided Human Rights Watch with data from the One-Stop Center in Shire, which showed that of 173 women and girls seeking health services for rape between November 2020 and June 2021, 125 identified the profile of their attackers. Of these, 113 named Eritrean forces, Fano militia, and Ethiopian forces.
The Amnesty International report documented 63 individual accounts of sexual violence that corroborated media and other reports of rape and gang rape that were accompanied by killings, beatings, death threats, and use of ethnic slurs. In some cases, perpetrators held Tigrayan women and girls for days or weeks in conditions of sexual slavery. Some survivors were raped in front of their children and other family members.
A joint investigation by the Ethiopian Human Rights Commission (EHRC) and the UN Office of the High Commissioner for Human Rights (OHCHR) into abuses committed by parties to the armed conflict released its findings on November 3, 2021 and found that all parties to the conflict had perpetrated sexual and gender-based violence, and that, “in many cases, rape and other forms of sexual violence have been used to degrade and dehumanize the victims.” The Joint Investigation Team interviewed 30 survivors of rape, gang rape, and other forms of sexual violence. The report concludes that sexual violence in the conflict “may further constitute war crimes and, in view of their widespread and systematic nature, crimes against humanity.”
The report had shortcomings. Although it documented instances of women being held captive and repeatedly raped over long periods, it did not use the term “sexual slavery” to appropriately characterize these abuses. It documented brutal sexual violence by all warring parties, but did not acknowledge the scale of abuses by Ethiopian, Eritrean, and Amhara forces targeting Tigrayan women and girls.
Human Rights Watch independently reviewed information from 43 cases of sexual violence provided by the health and service providers that assisted the survivors directly. Each of these cases, some of which are described in detail below, shared consistent patterns as those acknowledged in official statements and documented by media reports and Amnesty International.
Service providers told Human Rights Watch that many rape survivors reported gang rapes. According to one, “More than 25 percent of reports [made to us]…involved multiple perpetrators, or gang rape.” The Tigray Women’s Affairs Bureau provided information to Human Rights Watch that of 166 survivors admitted to a safehouse between April and August 2021, the majority reported gang rape from anywhere between 3 and 21 assailants. Of 125 women and girls providing information about their attackers at the One-Stop Center in Shire during the period between November 2020 and June 2021, 59 reported gang rape by armed forces personnel.
A significant number of the survivors reporting sexual violence are girls under the age of 18. One health worker noted that of more than 500 rape cases coming to their facility, roughly 150 included children under age 18. Of 166 rape survivors admitted to a safehouse between April and August 2021, 40 were under 18, 96 were between 19 and 25, and 30 were between 36 and 65. In early November, a humanitarian worker working in cooperation with the One-Stop Centers supporting survivors of gender-based violence said that at least one-third of those seeking help were children.
The reports by Amnesty International and journalists have included accounts from survivors and the doctors who treated them that indicated an ethnic motivation for the sexual assault. These accounts describe soldiers telling their victims they wanted to infect them with HIV, to cleanse the Tigrayan bloodline, and that girls can make Amhara babies. A health worker in Tigray told Human Rights Watch that survivors told her that Eritrean soldiers who had used objects to rape them would use “bad words… about their identity, that Tigrayan women must be [made] sterile.”
Sexual Violence against Men, Boys, Older People, and People with Disabilities
There is limited information on sexual violence against men and boys, older people, and people with disabilities in the Tigray conflict. In a March 2021 UN briefing, the deputy humanitarian coordinator for Ethiopia at the time, Wafaa Said, stated they had received accounts of men being forced to rape their own family members under threat of violence. The EHRC/OHCHR joint investigation report described three incidents of rape and gang rape of men and boys, including a 16-year-old boy who later died by suicide. It also documented sexual violence against older people, and against a woman with a physical disability. Healthcare providers interviewed by Human Rights Watch said the rape survivors they treated included older women, including between 65 and 80 years old.
Sexual violence involving men and boys, either by forcing them to rape family members or other forms of sexual assault by armed soldiers and fighters, carries deep social stigma and impedes reporting or seeking out health services and psychosocial support. Community members, aid workers, healthcare providers, and law enforcement may have little awareness or training about sexual violence against men and boys. Research on various conflicts around the world shows that in conflict and forced displacement settings, men and boys are subject to rape and other forms of sexual violence, including forced nudity, genital violence, enforced rape of others, forced witnessing of sexual violence, threat of rape, castration, and sterilization.
Given that the vast majority of victims are women and girls, many community outreach and health programs focusing on sexual violence are not accessible to men and boys, for example through Women and Girls Safe Spaces, or through reproductive health services. Men and boy survivors of sexual violence typically have fewer channels to seek confidential help from trained personnel equipped to provide support to them and for their specific needs.
People with disabilities also may be at high risk of being undercounted because they do not have support to reach protection services and they may face obstacles to accessibility and confidentiality in seeking services. One humanitarian organization operating in Tigray documented through individual and focus group interviews cases of older people and people with disabilities being left behind during episodes of violence because they were unable to flee and hide along with their family members.” Human Rights Watch has documented the heightened risk that people with different types of disabilities and older people may face in armed conflict due to specific obstacles to fleeing violence, including lack of availability of assistive devices such as wheelchairs, finding accessible refuge, and obtaining basic services.
Estimates of Sexual Violence
Given the lack of access in Tigray to functioning healthcare facilities, insecurity, and social stigma, the number of cases of sexual violence reported to health facilities or legal authorities is most likely a significant underestimate of the actual number.
The Ethiopian government, regional authorities, international bodies, donors, humanitarian agencies, community organizations, and the media may feel pressure—from each other and from the public—to assess the prevalence of sexual violence, or to collect and disclose the number of sexual violence survivors seeking legal or health assistance. While this information can help establish the scale of abuse and support the planning and provision of services, an overemphasis on reporting and numbers may be counterproductive, including through pressure on survivors to report.
Survivors should not feel pressured to disclose their experience, and it may take years for them to choose to do so. The Women’s Refugee Commission, which has longstanding expertise on prevention and response of gender-based violence in humanitarian settings, states:
It is not essential for survivors to explicitly disclose sexual victimization to enable healing or recovery. The priority is to create a safe, supportive, and trusting environment where confidentiality and non-judgement are prioritized, and where staff are trained in receiving disclosures and do not pressure, force, or rush a survivor to disclose…. Disclosure—if, when, how, and to whom—is an individual preference. 
Even prior to the conflict in Tigray, social stigma and other factors have meant only a fraction of sexual violence survivors come forward to seek assistance. In the Tigray sample of a 2016 Demographic and Health survey of women and girls ages 15-49, only 24 percent of those who had experienced physical or sexual violence sought help, 14 percent told someone but did not seek help, and 62 percent did not tell anyone and did not seek help. No comparable data is available for older women, girls under 15, people with disabilities, or men and boys. In the context of the current conflict, including insecurity, fear of retaliation from perpetrators, displacement, and the devastation of healthcare facilities described below, the obstacles to reporting sexual violence and seeking support have only increased.
Avenues to report sexual violence have been limited. The police were not functioning in conflict-affected areas during the first half of the year, and one humanitarian assessment noted that, “official reporting at medical facilities remains limited…. It is expected that many cases remain unreported.” Amnesty International reported that most of the rape survivors they interviewed had not sought or received treatment at health facilities and would not be counted in available numbers.
The EHRC/OHCHR joint investigation report notes the government, a UN agency, and service providers reporting “a continuous rise in the use of SGBV services by survivors” since the beginning of the conflict. It cites data between November 2020 and May 2021 provided by the Ministry of Women, Children and Youth and the Ministry of Health indicating 1,324 visits to hospitals by survivors of sexual and gender-based violence, including in the cities and towns of Mekelle, Adigrat, Axum, Adwa, Shire, and Maichew. In October, the Tigray Bureau of Health said that 2,204 survivors reported sexual violence to health facilities (a broader category inclusive of hospitals and health centers) across Tigray from November 2020 through June 2021.
Written communication from personnel who had worked at Ayder Referral Hospital in Mekelle said they treated 553 survivors of rape between November 2020 and June 2021. These included girls as young as 6 and up to 80 years old. A medical worker in another part of Tigray said that they treated between 76 and 80 cases of sexual and gender-based violence between the end of March and early June. The media reported that the public hospital in Adigrat treated at least 174 rape survivors between early November and March 2021. In its humanitarian briefings, OCHA reported at least 504 cases of gender-based violence, including rape, in May 2021, including 69 cases against girls under 18, and 129 cases during the first week of June 2021 alone.
The total number of people subject to conflict-related rape and other gender-based violence may well be much higher because many survivors do not report their abuse. A humanitarian worker noted that in one area they were receiving about 30 women and girls reporting sexual violence per month, however they suspected that others who sought family planning or counseling services were survivors of conflict-related rape but not counted in these numbers because they did not report the abuse.
Factors that impede survivors from seeking support, including lack of availability and access to health care and the social stigma surrounding rape, are discussed in greater detail below.
Ethiopian Government Response to Conflict-Related Sexual Violence
The Ethiopian government’s response to reports of sexual violence has been mixed. It created a joint taskforce team to investigate allegations of conflict-related sexual violence and has referred the findings to the attorney general’s office. On February 11, 2021, the then Ethiopian minister of women, children and youth, Filsan Abdullahi, was the first federal official to confirm conflict-related rape in the region, tweeting that, “We have received the report back from our Taskforce team on the ground in the Tigray region, they have unfortunately established rape has taken place conclusively and without a doubt.” Her Twitter thread urged domestic and international partners to support the government in providing mental health and social assistance. In a February 18 statement, Ethiopian President Sahle-Work Zewde also confirmed conflict-related sexual violence in the region.
Public statements by other government officials, however, raise concerns about the government’s commitment to acknowledge and seriously address the scale and severity of reports of sexual violence committed by armed forces in Tigray, including by government forces. On March 23, 2021, Prime Minister Abiy Ahmed told parliament and tweeted, “Regardless of the TPLF propaganda of exaggeration, any soldier responsible for raping our women & looting communities in the region will be held accountable.”
There is little information about the timeline of the investigations and other senior officials have downplayed media reporting around rape. In a written response to Reuters in April 2021, the Ethiopian information minister, Yemane Gebremeskel, accused TPLF activists of “coaching ‘sympathizers’ to create false testimonies.” In August, the Ministry of Foreign Affairs released a statement in response to Amnesty International’s report documenting sexual violence, acknowledged that “some members of the armed forces engaged in conduct that is contrary to the rules of engagement and the orders they were given,” but accused the organization of “sensationalized attacks and smear campaigns against the government.”
In a June 3, 2021 press conference, Attorney General Gedion Timothewos stated that criminal investigations into rape were being carried out by the military court and prosecutors, regional police and prosecutors, and federal police and investigators. He added that military prosecutors had pressed charges against 25 soldiers for sexual violence, and their trials were underway while three soldiers had been convicted of rape.  He did not share information about their sentences.
The governmental EHRC released a brief monitoring report in February recognizing the absence of local structures and health facilities where survivors of sexual violence could turn to report abuses. In March, it launched the joint investigation with OHCHR on abuses in Tigray.
In November, the Ethiopian government responded to the EHRC/OHCHR joint investigation report findings on sexual and gender-based violence by defending the Ethiopian military’s disciplinary record and alleging that sexual and gender-based violence had been a major problem in the region prior to the conflict. It asserted that the release of prisoners following the outbreak of conflict “aggravated the situation” and the scale of crimes. The assertion that sexual violence had been a problem before the conflict does not address the evidence presented in the report of significantly increased numbers of sexual violence survivors seeking services during the reporting period, with the vast majority identifying members of warring parties as the perpetrators.
In its response, the government said, “a small number of rogue ENDF members have been convicted of the heinous crimes,” affirmed its commitment to ending impunity, and made a point of noting the report made no claims that the ENDF systematically used rape to dehumanize civilians. Finally, the government underscored its cooperation with stakeholders to provide medical and psychosocial support to survivors, including through One-Stop Centers and a safehouse.
The Ethiopian government engaged with the aid community, for example through initially co-chairing the humanitarian coordination cluster focusing on protection issues, including gender-based violence. The coordinated response included expanding One-Stop Centers, the provision of “Dignity Kits” for NGO distribution, the creation of safe spaces for women and girls, and rebuilding the health infrastructure. Human Rights Watch requested information from the Ethiopian government, including the Ministry of Health and the Ministry of Women and Social Affairs, to learn more about their response to conflict-related sexual violence but had not received a reply at the time of publication.
However, other actions by the Ethiopian government and armed forces deeply undermined and ran counter to these efforts, including access restrictions to the region, prolonged shutdowns on telecommunications, electricity, and banking. Humanitarian agencies described how these affected their response, and reported bureaucratic challenges in obtaining visas, including for experts on protection issues.
Conflict-Related Devastation of Health Infrastructure in Tigray
[We found] a huge amount of destruction of healthcare facilities in most places we looked at. A half to a third being completely destroyed or demolished or looted to the extent that it’s a shell of a building and can’t be used as a health post anymore. One-third being degraded so that they could only be used for a few things. And traveling for outreach was limited, because of insecurity. The area of coverage shrinks to right around the health post.
—Humanitarian worker, August 17, 2021
The destruction, pillage, and military use of hospitals and health centers by Ethiopian and Eritrean federal forces, and Amhara forces in Tigray between November 2020 and late June 2021 has severely curtailed civilian access to functioning health care.
In early 2021, ongoing looting and insecurity hampered the proper functioning of remaining health facilities, the rehabilitation of the health sector, and the ability of humanitarian organizations to expand the geographic reach of their operations. Witnesses described Eritrean forces looting health facilities, such as St. Mary’s Hospital in Axum and the Adigrat Referral Hospital and a pharmaceutical factory in Adigrat. In March 2021, MSF teams in northwestern Tigray “found destroyed equipment, smashed doors and windows, and medicine and patient files scattered across floors.” In April 2021, OCHA reported twelve incidents of looting of health facilities by armed personnel in a two-week period and the delay or halting of several humanitarian missions.
In January 2021, doctors from Mekelle, Adigrat, and elsewhere in Tigray described the shortages of medicines and medical supplies. One doctor said, “We didn’t have antibiotics, we didn’t have gloves, IV fluid, insulin, cancer drugs, everything. A doctor in Adigrat said that, “we were in difficulty to take care of patients of chronic medical illnesses like HIV, DM [diabetes] and TB [tuberculosis] patients as there was no way of providing medical supplies nearly for 40 days since the onset of war and the hospital drug was stock out.”
Ongoing assessments throughout 2021 by the World Health Organization (WHO) and humanitarian organizations have documented the damage to buildings and equipment, and lack of staffing, medical supplies, and medications.
In March 2021, the WHO found that 141 of the 198 assessed hospitals and health centers were either partially or fully damaged. An April assessment found that only 29 of the nearly 230 health centers in Tigray were fully functional, and that they all urgently needed more medical supplies, drugs, and equipment. As of May, only 7 out of 40 referral hospitals in Tigray were fully functional. A doctor in Tigray said, “we faced a shortage of equipment and medications and even for primary healthcare services [in May].”
One humanitarian worker noted, “It will take years to rebuild the healthcare system of Tigray, it’s really dependent on external support to do so. When [we were] going through facilities… [t]here were literally pillboxes opened and emptied. [There was] really deliberate destruction.”
Obstruction of Humanitarian Aid
Fuel and medical supplies are still denied entry into Tigray. Lack of fuel is one of the major impediments for delivering humanitarian assistance…. Consequently, several UN and NGO partners had to severely reduce or suspend humanitarian response activities.
—Northern Ethiopia Humanitarian Update, OCHA, September 30, 2021
Between November 2020 and late June 2021, the Ethiopian government repeatedly imposed restrictions on access and services in the region, cutting off Tigray from essential services and infrastructure, including by closing roads in and out of the region, and shutting down telecommunications, electricity, and banking. Since Tigrayan forces retook control of most of the region at the end of June, the government has tightened these restrictions, by limiting access to Tigray to one route through Afar, cutting off all these basic services and blocking humanitarian assistance that has obstructed the delivery of fuel, food, and all medical supplies.
The government claims these measures are to prevent the flow or diversion of resources to Tigrayan forces. In July, the state minister for foreign affairs, Redwan Hussein, accused aid agencies of “arming” rebel groups. On October 18, the Ministry of Foreign Affairs released a statement claiming that “the diversion of humanitarian resources by the TPLF for its military purposes has sputtered the delivery of humanitarian aid into the region,” and accused the international community of placing sole blame on the government. These statements were viewed with alarm by humanitarian agencies, which defended its neutrality and cited the risk such statements created for their staff.
These restrictions on aid have rendered humanitarian agencies unable to deliver a fraction of the needed food, fuel, and essential medical supplies to the civilian population, or to scale up their staffing and operations. The blocking of commercial supplies has also led to shortages and price hikes for essential commodities including food and fuel. The shutdown of banking has meant many Tigrayan health workers have been working without salaries for months. Several humanitarian organizations are halting or significantly reducing their programs due to operational constraints caused by lack of fuel, cash and supplies.
The restrictions have remained in place despite escalating food insecurity affecting 90 percent of Tigray’s population and 350,000 already feared starving as of June. A September assessment diagnosed 79 percent of screened pregnant and lactating women with moderate malnutrition, and 18 percent of screened children under 5, exceeding global emergency thresholds.
The Ethiopian government has mounted administrative and political obstacles impeding humanitarian access. On July 30, the government ordered a three-month suspension of MSF Holland and the Norwegian Refugee Council after accusing them of “misinformation” and failure to obtain appropriate work permits. In a September statement, MSF noted that patients have been discharged from MSF clinics, leaving people in these locations with even further limited access to health care. A team of nearly 1,000 Ethiopian staff are also on standby at home.
On September 30, the Ethiopian government declared seven senior UN officials, including the country leads for OCHA and UNICEF, as “persona non grata” or unwelcome in the country. In November, an aid worker told Human Rights Watch that the UN had begun reducing and relocating some of its staff from Tigray due to safety concerns. The expulsion of top officials from lead agencies coordinating and implementing the global humanitarian effort, and the need to evacuate UN staff, further jeopardizes aid operations.
On September 13, 2021, the UN high commissioner for human rights, Michelle Bachelet, said that the EHRC/OHCHR joint investigation had documented human rights violations including attacks on civilians, killings, and torture, and that, “[s]exual and gender based violence has been characterised by a pattern of extreme brutality, including gang rapes, sexualised torture and ethnically targeted sexual violence.” She also emphasized the need for government transparency around the prosecutions of sexual and gender-based violence. 
Several other international bodies and governments have also acknowledged and condemned the reports of sexual violence. In January 2021, Pramila Patten, the UN special representative to the secretary-general on sexual violence in conflict confirmed her office had received reports of sexual violence perpetrated by combatants in uniform, including holding women and girls captive for days and repeatedly assaulting them; and forcing individuals to watch the attack of family members.
Despite condemnations of the atrocities in the Tigray conflict, political action from the AU, UN, and influential governments has been slow and mixed. The United Nations Security Council did not hold its first public meeting on Ethiopia until June 2021 and has not placed Ethiopia—including the crucial issues of humanitarian access—on its formal agenda. The secretary-general has yet to adequately engage mechanisms on sexual violence in conflict, for example by deploying a team of experts on sexual violence in conflict, or by establishing monitoring and reporting arrangements (MARA) through Pramila Patten’s office.
In June, the African Commission on Human and Peoples’ Rights established a commission of inquiry. In September, the AU appointed former Nigerian president Olusegun Obasanjo as the AU high representative for the Horn of Africa. On September 3, the AU urged the Ethiopian government to step up efforts to ensure humanitarian access into Tigray.
Since mid-2021, the EU, US, and UK have made increasingly stronger calls for investigations into alleged abuses and unimpeded humanitarian aid. The US government authorized a targeted sanctions regime in September, allowing the US government to deny visas to and freeze the assets of individuals and entities responsible for or complicit in serious abuses and obstructing access to humanitarian aid. On October 7, the European Parliament adopted a resolution calling on national, regional, and local actors to “allow immediate and unimpeded relief into Tigray,” and an end to “the de facto blockade on humanitarian assistance and critical supplies, including food, medicine and fuel,” as well as targeted sanctions against those “responsible for actions prolonging the conflict and exacerbating the humanitarian situation.”
On November 5, as the conflict in northern Ethiopia escalated and spread, the Security Council released a statement that called for “the respect of international humanitarian law, for safe and unhindered humanitarian access, the re-establishment of public services, and… the scaling up of humanitarian assistance.”
There was a lag in analysis and identifying the issues, the extent of violations, the extent of needs, again largely the politics around the conflict…. The international response was not appropriate for the crisis unfolding…. There was significant dysfunction in responding in the first three to four months.
—Humanitarian aid provider, August 3, 2021
Human Rights Watch interviewed aid workers and donors who said that the initial humanitarian response in Tigray, particularly from the UN, was slow and disorganized. They attributed this partly to insecurity, but also to the orientation of many existing organizations toward economic development instead of humanitarian intervention. They compared the response in Tigray to their experiences working in other humanitarian emergencies and expressed outrage at the sluggishness in the scaling-up of operations and getting staff with appropriate training, experience, and skills on the ground.
A humanitarian specialist with a government donor agency said, “Some UN agencies were in a development mindset and couldn’t transition quickly…. Emergency access was difficult. [But] this was an excuse. These are humanitarian organizations that should have scaled-up more quickly.” These critiques do not apply to all humanitarian organizations—some showed greater agility in expanding the reach of their aid operations early in the conflict.
In July, the Emergency Directors Group (EDG), including representatives of operational UN agencies and some NGOs, and tasked with advising on humanitarian coordination, traveled to Tigray. Their internal report found:
Communities indicate a lack of assistance and protection, across the board…. Some communities indicated receiving only one round of assistance in eight months…. the gradual improvement in the deployment of senior emergency experienced staff to lead operations in Tigray by some agencies, are positive steps…. However, there is need for further enhanced capacities to lead, coordinate and deliver humanitarian assistance in the deep field…. Staff in Tigray are exhausted, often junior and without necessary tools and enablers to function including cash, communication, and fuel and feel.
Since then, most interviewees have described significant improvements in the humanitarian response, including in the profile of deployed staff, amidst an extremely difficult operating environment.
Health Impacts of Conflict-Related Sexual Violence
The impacts of conflict-related sexual violence can include physical and psychological trauma, pregnancy, sexually transmitted infections, short and long-term disabilities, and social stigma and exclusion. In some settings, a healthcare provider may be the first and only contact that a survivor has with services providing care for gender-based violence.
Clinical Management of Rape
Response to gender-based violence should include the availability of skilled healthcare workers and relevant supplies in all primary healthcare centers and mobile teams as well as referrals for additional health, psychological, legal, and social services. Time-sensitive care includes provision of post-exposure prophylaxis within 72 hours of exposure to prevent HIV, and emergency contraception with 120 hours to prevent pregnancy.  Other essential supplies and services include treatment of wounds, pregnancy testing, pregnancy options information including safe abortion referrals, treatment of sexually transmitted infections, and prevention of Hepatitis B.
Health Services Sought by Rape Survivors
Healthcare providers said that survivors of sexual violence who came to functioning clinics or hospitals for care had primarily been requesting abortions, testing for sexually transmitted infections, treatment for HIV and hepatitis, and mental healthcare support. A doctor working in a hospital in an urban center said:
When the conflict started in November, we saw lots of women and girls coming to the hospital asking for abortions…. We didn’t realize there was widespread rape in the region initially. One day Ethiopian military men came to the hospital with a [teenage] girl. They told us she needed medication. We checked her and found that she was pregnant. She was one of the sex slaves in the Gereb Giba military camp [around eight miles from Mekelle]. That was the first day in early December. Then we ask her and [tested her]—she was hepatitis positive. With her consent we terminated her pregnancy. Gave her anti hepatitis drugs. After that quite a lot of women and girls were coming seeking medication, and to terminate their pregnancies, raped by conflict actors, mainly by Eritrean troops and Ethiopian forces.
Another healthcare provider said that survivors of gender-based violence were approaching them seeking three main types of services: physical trauma and emergency gynecology, sexual and reproductive health consultations to check for infection and ask for contraception, and abortions after rape.
A medical worker described treating increasing numbers of rape survivors in March through the end of April:
One was a 45-year-old lady, who was raped by Eritrean troops, and she came for termination of pregnancy. And another lady was pregnant with excessive vaginal bleeding… at the time we didn’t have an established operation theater, and she needed immediate referral to Mekelle.
Healthcare providers working across different parts of Tigray reported that they were receiving survivors with similar types of health needs, injuries, and infections. These include pregnancy, HIV, hepatitis, psychological trauma, and physical injuries. A doctor at a referral hospital said, “Some of them sustained injuries. Some were raped by up to 15 individuals…. Also sodomized [anal rape]…. We give them a bed [at the hospital], and give treatment of fistula. At least a quarter of them had psychological disturbance and psychiatric problems.”
According to the Tigray Bureau of Health, a significant proportion of women and girls seeking services at One-Stop Centers between November 2020 and June 2021 were seeking pregnancy testing and termination of pregnancies. At the Shire One-Stop Center, 69 out of 173 women and girls reporting sexual violence were pregnant, and 65 of them received abortions. At the Adigrat One-Stop Center, 255 out of 499 survivors seeking health services were pregnant, of whom 252 received abortions. In Axum, out of 168 survivors seeking health services, 148 tested positive for pregnancy. Data on how many sought and obtained abortions was not provided or available.
The Shire One-Stop Center recorded that all 173 survivors seeking services during this period were tested for HIV, hepatitis B, and other sexually transmitted infections. Of these 3 tested positive for HIV, 13 tested positive for sexually transmitted infections, and none tested positive for hepatitis B.
From the medical notes of 10 cases, a doctor described specific injuries including vaginal bleeding, bruises, perineal tears, lacerations in the vulva, and removal of foreign objects from the vagina including nails, a condom, and a metal rod. A health worker outlined at least 80 cases of rape survivors out of more than 500 who came for treatment, who had tested positive for sexually transmitted infections, including HIV. The worker also noted that some survivors, “are psychologically disturbed, they can’t sleep, walk. Some have started psychiatric medications. They are not stable. They are still in suffering.”
Service providers reported that rape survivors often sustained physical injuries due to the violence of the rapes and gang rapes. For example, they described women with bruises all over their bodies, and survivors who could not control their bladder or bowel movements, one of the common consequences of traumatic fistula from rape. Other examples include stab wounds from knives requiring stitches, injuries from being stepped on, and bone fractures.
Injuries and consequences of rape and gang rape have long-term health implications. One service provider noted, “There are women having a lifetime injury. Some are pregnant…and they couldn’t get an abortion, others are HIV positive.” 
Survivors of sexual violence reported ongoing symptoms and injuries months after the rape. Seble G., a 22-year-old woman originally from Eritrea, said that on December 16, 2020, “They [Eritrean soldiers] forced us to have sexual intercourse and because of that I am still bleeding [two months later]. My wound is not in a normal situation, there is bleeding right now.”
Service providers noted that there was a high fear of rape in the civilian population, including when the region saw an uptick in fighting prior to the Tigrayan forces gaining control of much of Tigray at the end of June. The fear of rape was associated with demands for contraception. “In outreach sites, quite a high demand for family planning. A lot of women [were] afraid they would be raped by soldiers and wanted to have family planning to protect them from getting pregnant if they were raped.”
Service providers also told Human Rights Watch they suspected that many survivors sought family planning services and testing for sexually transmitted infections without reporting the rape. One service provider noted, “Girls, if they were accessing medical services, were asking for emergency contraception without mentioning they [needed it] because of assault.”
Mental Health and Psychosocial Support Services Needs
Many people in Tigray have experienced trauma related to the widespread abuses committed during the conflict and suffering from the humanitarian crisis. Mental health and psychosocial support services addressing the specific needs of survivors of rape and gang rape as well as family members, including spouses and children, who witnessed the assaults, is an important part of the mental health response.
Mental Health and Psychosocial Support Services (MHPSS)
International guidelines on mental health and psychosocial support services emphasize a “multi-layered” response, including 1) basic services and security, including food, shelter, water, and essential healthcare; 2) community and family supports, including family tracing and reunification; 3) focused, non-specialized supports, for example primary healthcare workers and community workers who can provide psychological first aid and livelihood supports; and 4) specialized services, including specialized psychological or psychiatric care. (See Appendix for more information)
Intake notes from service providers described survivors who were distraught, unable to focus, sometimes unable to talk or move, and who expressed hopelessness and depression.
In the individual cases that Human Rights Watch reviewed, survivors of sexual violence expressed deep and ongoing anguish. Seble G., quoted above, said, “What makes me cry is always I remember the situation, I can see the blood, I can see the way they raped us. I remember, thatʼs why I am crying. If I talk about the situation, I feel like I am in that situation.” A 27-year-old Eritrean woman who was raped by Tigrayan militia along with her 17-year-old sister said, “Because of what happened to us, we have nightmares. We have found a psychologist. He has given us [medicine] and we feel a bit better. I hope with time that we will feel better.”
Tirhas S., a Tigrayan woman, said that a soldier and civilians gang raped her in November, three months prior to the interview, and says she feels anxiety, guilt, and shame:
I am still praying to God—it has not helped. I repent but it has not helped…. Difficult situations overlap and I have anxiety…. I feel stress, I am affected mentally…. That moment comes to my mind every day…. I always remember that day.
A humanitarian worker expressed concern about adherence to standards in the combined Ethiopian government and humanitarian response: “Response has to be in line with protocols. The MHPSS [Community Based Mental Health and Psychosocial Support (CB MHPSS) Operational Guidelines] protocols…. The government, the Ministry of Health, for mental and psychosocial support reportedly send psychologists from Addis to Tigray, from the ethnic group that terrorized the population to offer support, and in a different language. This is not in line with [standards].”
Humanitarian workers interviewed consistently underlined the lack of and urgent need for community-based, culturally sensitive mental health and psychosocial support services to address the trauma experienced by survivors of sexual violence, their families, and communities. Service providers described several survivors who had to choose between access to ongoing psychosocial support services available in urban settings and returning home to their families and community.
A humanitarian aid worker said that scaling-up community-based services is a priority, noting, “how widespread psychosocial trauma is. [Key actions should include] doing community-based PSS [psychosocial services] and psychological first aid trainings, spread skillsets into community.” Community elders, women’s development groups, and community-based health workers continue to hold trust among communities, and can play a positive role in disseminating health and counseling information and messages.
Many rape survivors whose cases Human Rights Watch reviewed recounted additional profound traumas that happened alongside the sexual violence, including women and girls seeing parents, spouses, and children killed in front of them, or being separated from their families.
Service providers and health providers also raised concerns about the trauma experienced by family members of sexual violence survivors, particularly children and spouses. Some “are raped in front of family, husbands, the whole family is disturbed.” A member of a community organization commented that psychosocial services are also needed for “the children made to witness this very brutal act. They are also the victims.”
A few interviewees mentioned the need for culturally specific counseling and psychosocial support that could address the suicidal thoughts that survivors of gender-based violence may be feeling. “Many women want to [die by] suicide. What kind of services can we give for those who want to do suicide? [Provision of services] needs religious and cultural context…. Usually people don’t take these measures, but people may be terrified, traumatized.”  These sentiments were echoed by another humanitarian worker: “Women and girls…[are] sufficiently afraid to [die by] suicide, in the local tradition, they can’t be buried with their families in the case of suicide…. The current [mental health] services are not equipped to deal with this.
Dr. Godefay Hagos, the head of the Tigray regional health bureau, called for quality and culturally sensitive mental health support for survivors and the community and suggested engaging with traditional and religious healers as well as, “availing non-specialized [m]ental health and psychosocial service to rape survivors and the community through capacitating the health care workers working at the primary health care. In addition, strengthening the referral of those in need [to] specialized service[s].”
Several interviewees noted a comprehensive response to gender-based violence means taking into account the impact of displacement, disruption of community networks, loss of livelihood, and economic pressures. A doctor said, “Most [rape survivors] have lost what they have, property, family. [They need] support financially to continue their life.”
The need for mental health support also extends to healthcare providers, who have treated and worked with distressed people with little support amidst enormous challenges. The doctor cited above said, “I have difficulty sleeping. For a whole month I could not sleep. I dropped my weight.” A service provider spoke of her colleagues working closely with survivors of gender-based violence: “Of course they are really traumatized…. I’ve been asking whether some organizations can [support] them…. They have seen all kinds of cases.” A humanitarian organization noted that health extension workers reported difficulty doing their jobs because of the stress and trauma from their work.
Effects of Stigma
At that time when… the rape happened to me I didn’t tell anybody because I am afraid people will insult me. I didn’t even tell my brother.
—Tirhas S., 44-year-old woman, sexual violence survivor
They say they have lost value. Some say they want to do suicide. Many will point fingers [saying] she has been raped. She cannot find a future husband. We must teach our community… [that these] are victims of conflict, everyone has to embrace them.
—Doctor formerly at a referral hospital in Tigray, August 12, 2021
Social stigma around sexual violence has a range of consequences for survivors of sexual violence, their families, and their communities. These include keeping the acts of sexual violence private, undermining a survivor’s ability or willingness to access social support and health care. It can also result in further stress for survivors, including for girls who fear their prospects for marriage are destroyed, for married women who are rejected or abandoned by their husbands, or for men and boy survivors, including those who were forced to rape their family members.
The individual cases that Human Rights Watch reviewed included women who sought help from healthcare providers but hid the rape from their families, and sometimes did not stay for full health care or follow-ups, fearing their families would suspect something was wrong. Human Rights Watch did not review individual cases of men or boys who were sexually assaulted during the conflict. Social stigma, the lack of general awareness or training around such abuses, and the lack of specific services may contribute to few survivors having a supportive environment to seek help.
An aid worker said their organization had found that in the communities they were working in, there are, “Generalized stigmatization and negative coping mechanisms imposed by family members or relatives…. Girls were afraid no one would marry them if they were known to be raped.” This was echoed by other interviewees. “I heard multiple times that for girls, mid-teens, families and communities really tried to protect them and keep it really quiet so that girls wouldn’t be affected [by social shaming].” Similarly, other healthcare providers reported situations in which girls sought emergency contraception but did not report a rape. The healthcare providers said they suspected that several of these cases may have been due to rape but that the girls were not reporting it for fear of stigma and losing their future prospects of marriage.
As discussed later, women and girls safe spaces are a critical strategy to creating supportive environments and combating the harmful impacts of stigma.
Several health workers and service providers mentioned that married women may face harsh judgment and even blame from their families and communities. One humanitarian worker said that in community consultations, “Several women mentioned those who became pregnant by rapists are turned out by their husbands because the husband doesn’t want anything to do with them.”
Another humanitarian worker said that that some of the women that she and colleagues had helped, the “husband would leave…if she had been attacked or raped… If they were married, [the rape was considered] almost their [survivor’s] fault.” A Tigrayan woman with a community-based organization said, “Some women [are] hiding, don’t want husbands or families to know. They walked for days, say I’m pregnant, I need to get this out before family finds out. Stigma and fear of these women are huge.”
A doctor observed that after receiving treatment, “Most of girls without pregnancy return to their families. Those who are [adult] women, really fear, [so they] stay away, because husband, relatives, kids, they will feel shameful to go back to the community.”
Fear of stigma could also prevent women from seeking support from religious leaders in their communities. Tirhas S., who described herself as religious, and who spent time praying after her rape, said, “I went to a priest, a religious father, in Axum. I don’t want to talk in my hometown to a priest. I am afraid they can insult me.” 
Navigating social stigma is a pressing issue for women and girls who have become pregnant due to rape, and for children born of rape. Human Rights Watch interviewed several service providers and healthcare workers who highlighted this concern. A service provider said they had 13 babies born of rape at a safehouse, and only 1 of these had been able to return to the community due to the support of the woman’s relatives. Safehouse staff said that the other 12 women were afraid of returning home, due to stigma, and due to worries about financially supporting and feeding their babies.
Another humanitarian worker said in November that, “There is definitely abandonment of babies…. We are hearing about these cases in coordination meetings…. There is a lot of stigma.” She added, “In the longer term, a very local solution where you’re supporting family-based care, alternative family based care or family-based care in the bigger kinship family in Tigray is the best solution. It requires a peacebuilding intervention around it because of the stigma.”
A Tigrayan gender-based violence specialist said, “We need to have organizations working from now to raise awareness in the community so children [of rape] are not stigmatized.” One service provider noted, “If it’s not addressed straight away, [whether] it’s on hold for another three years or [three] months, there will be more issues, more problems.” Experiences from other conflicts show that support for mothers, community sensitization, and stigma reduction are key for improving social acceptance and integration of children born of rape.
One worker from a community-based organization said that there have also been positive responses and support: “Knowing the culture and the stigma that comes with being a sexual violence survivor in our society…. There have been husbands who had their wives held hostage for weeks and come back home. The husbands say, ‘It’s okay, it’s not your fault, you’re home now.’” A health worker at a referral hospital also said that some husbands were accompanying and supporting their wives to seek post-rape care.
Availability and Accessibility of Health Services
Limited Availability of Services for Survivors of Gender-Based Violence
The widespread destruction of health facilities in Tigray during the fighting has played a significant role in preventing many women and girls from accessing essential sexual and reproductive health care. As one humanitarian aid worker stated, “There were only 13 percent of health facilities functioning. It means [in many places] family planning, maternal health care didn’t exist. Many reports of women delivering at home.”
For example, one doctor said that for survivors who managed to reach the hospital where he worked, “the medications required for the prevention of sexually transmitted diseases including HIV were not available and the hospital was understaffed as many of the workers fled to a nearby village after frequently [being] intimidated and terrorized by the forces.” A humanitarian aid worker said:
In the beginning it was tricky. We had to improve [the procurement] in the first medical order that we’re doing, everything with sexual violence, drugs for safe abortion care, contraceptives. The package… [i]t was done but not realizing the volume and the spread of sexual violence. There was a shortage. In places, [we faced] the issue of not being able to offer the treatment, because we didn’t have medicine or contraceptives.
A man who assisted women from his community who were raped by Amhara militia said that some who went to Sheraro were able to get medical services, but those who returned to their hometown had not been treated. “We haven’t been able to get care in hospitals and medical centers, sometimes we get care from mobile healthcare.”
In April 2021, international humanitarian organizations expressed concern that their “analysis of the situation in Tigray is that the response remains wholly inadequate to the scale of need. In the first half of 2021, response to conflict-related sexual violence was heavily concentrated in Mekelle, with an identified “urgent need for partners to start and scale up response across the region.” As of April 2021, only 1 percent of health facilities in Tigray had the capacity to provide comprehensive gender-based violence services.
UNFPA coordinates the humanitarian protection response to gender-based violence. They identified gaps in essential medical supplies in Mekelle for clinical management of rape, and in May 2021 noted that the continuing “lack of medical supplies (43%) and medical equipment (16%) due to the looting and vandalism of health facilities has left access to life-saving commodities highly inadequate, with critical shortages of essential drugs like antibiotics, family planning commodities or anti-retroviral therapy for HIV patients.” These supplies are essential for post-rape care.
As highlighted above, specialized services, including time-sensitive health care to prevent pregnancy and HIV infection from rape, and both short and long-term treatments for physical and mental health traumas are critical for post-rape care.
The Health Resources and Services Availability Monitoring System (HeRAMS) reported that out of 72 facilities with information, 15 percent did not previously provide clinical management of rape, 56 percent were not providing them at all, and 29 percent were providing them partially. Thirty-seven out of 72 health facilities were able to provide post-exposure prophylaxis fully and 27 out of 72 health facilities were able to provide emergency contraception.
During this period, healthcare workers also grappled with shortages in medications. One health worker at a referral hospital described the situation in June:
There are many, many shortages, especially with medications. Hepatitis prophylaxis is very expensive, one vial is 600 Ethiopian Birr [US$12.63], it’s too expensive, they can’t [afford it]. Before the war [treatment cost] 30 [Ethiopian Birr] to 40 a month [$0.63 to $0.84], now it’s 200 to 300 a month. Now there is a shortage of medication, staffing.
As of June 2021, only 26 percent of health services were fully functioning, and only 29 percent offer clinical management of rape. Nineteen of the 28 organizations providing some sort of gender-based violence response, such as creating safe spaces, community outreach on gender-based violence, or clinical management of rape, were operating in and around Mekelle, while other parts of the region remain severely under-served.
The destruction of healthcare infrastructure, through which mental health support services are typically provided, has contributed to a lack of specialized psychosocial support services. In a May 2021 update, UNFPA pointed to assessments conducted by the WHO on health infrastructure and highlighted, that:
Of particular concern is also the lack of comprehensive mental health and psychosocial support (MHPSS) by GBV survivors with only 7% of health facilities having the full capacity to provide psychosocial first aid. There is an urgent need to increase capacity of the existing health facilities, re-stocking of medical supplies and equipment, as well as expansion of comprehensive GBV and MHPSS services to survivors across the region.
These shortages are particularly pronounced outside of Mekelle. While updated figures are challenging to obtain for specific health facilities, as of May 2021, there was only one psychiatrist at Mehoni hospital, located near Maychew.
Presence of Armed Personnel and Intimidation in Health Settings
Health and service providers interviewed by Human Rights Watch shared several instances of harassment and intimidation by Ethiopian and Eritrean soldiers and Amhara fighters over the first six months of 2021. These included their presence at checkpoints and health facilities, and because they took targeted actions against rape survivors, health workers, and other service providers. The presence of soldiers at health facilities also deterred survivors from seeking health services, as their presence was frightening and retraumatizing.
One doctor said, “We were not allowed to work in the hospital, because it was a military base…. So I started working in a health center…. I saw it with my naked eye, that [the hospital] was a military base by ENDF.”
An aid worker recounted what a colleague said about an encounter with a shopkeeper in the area of the organization’s office. The shopkeeper told a member of their team that she “was being bribed to provide info to [Eritrean Defense Forces] about who on our team [was] working on sexual violence. This made our health workers really scared.… Made community health workers terrified of doing their job.”
The aid worker also noted challenges with Ethiopian and Eritrean forces: “Our difficulties were with both. Hospital intrusions, harassment of hospital staff. That has been run of the mill.” Several interviewees described soldiers coming into health facilities searching for specific rape survivors or health records. One humanitarian worker said, “A couple times in [location withheld] hospital, soldiers came in looking for specific people, sometimes patients, sometimes staff…. In [location withheld] Tigray, where [other humanitarian workers] were working, this happened multiple times, soldiers looking for victims of violence.” 
Another humanitarian worker described similar incidents in late February and early March 2021:
There were some visits to hospitals [by soldiers] to ask for medical records…. In [location withheld] a [rape] survivor was admitted, there was a breach of confidentiality [in which someone shared information about her presence in the hospital], which put her at risk. The alleged perpetrators, the Eritrean Defense Forces came into the hospital a few times. At the beginning, two or three people came in pretending to do consultations…Next day more coming, looking for her. We realized how hard it was to find a safe space for them. 
The same worker also described a few instances in early March at another location of soldiers asking for medical records of sexual violence survivors but said that the medical director [pushed back] and succeeded in not sharing with them. 
Several interviewees noted that the lack of ambulances or other transport, the fear of meeting soldiers on the way to health centers, and the presence of armed soldiers in many health centers deterred survivors from seeking help right away, or at all. A member of a community organization described talking to a survivor who had been given a referral for treatment in Mekelle. He said:
I [told her] we can help with transportation. She said, “I am afraid. On my way they will stop the car.” She was referring to Ethiopian or Eritrean soldiers. “They will check and find the referral paper. They will read I am a victim of rape. They will kill me because they think I will speak to the media. I don’t want to risk my life. I will stay here.”
In January, UNICEF said there were only 30 functional ambulances in the region compared to 280 prior to the conflict, with the rest damaged or looted. In Adigrat, for example, 20 ambulances were taken from the hospital and nearby health centers and MSF teams reported seeing some of them being used by soldiers to transport goods.
In some instances, humanitarian workers received reports of Tigrayans seeking health care who were stopped at checkpoints, threatened with death, and turned away. One service provider, talking about the period before Tigrayan forces retook control of Mekelle on June 28, 2021, said it was difficult for them to send rape survivors to Ayder Referral Hospital: “Ayder was surrounded by soldiers, some [survivors were ] turned back by soldiers, others did not want to approach.”
Human Rights Watch interviews with health workers and review of service provider intake notes described the fear and suspicion that survivors would exhibit due to the presence of soldiers around the health center.”
The presence of armed soldiers in some hospitals and health facilities deterred not only patients, but also health workers who were afraid to go to work. A doctor said that “Our hospital was occupied by the military, it was a base of the military…. Sometimes at night there were gunshots in the hospital. That frustrated the colleagues [health staff], they asked not to [have to work] at night, only during the daytime.”
Health workers also became victims to violence. In March 2021, federal police raped two medical students at Ayder hospital. According to a health worker who spoke with the students: “One [assailant] said, ‘You look Tigrayan, we are allowed to rape you.’”
A doctor brought a complaint and the two federal police were removed from the hospital, but it was unclear whether they were investigated or faced prosecution.
The EHRC/OHCHR joint investigation report did not pay sufficient attention to the deliberate and extensive destruction and pillaging of health facilities and did not document military use of and interventions into hospitals and health centers.
Delays in Seeking Treatment
Between March and mid-July 2021, only 40 rape cases had been clinically managed in Tigray within the recommended 72-hour window.
—UNFPA Ethiopia Response to the Tigray Crisis, Situation Report, 1 to 15 July 2021
The devastation of health centers, combined with the fear created by the presence of armed personnel on the roads and near or in many health facilities deterred survivors of sexual violence from seeking help for time-sensitive treatments within the necessary timeframe, including the critical 72-hour window to administer post-exposure prophylaxis to prevent HIV transmission and the 120-hour window for emergency contraception to prevent pregnancy. One aid provider said that of the sexual violence cases handled by their agency, “More than 80 percent of victims and survivors didn’t present within 72-hour window.”
Immediately after incidents of sexual violence, survivors were sometimes fleeing or in hiding, also delaying their access to health care.
Sexual violence survivors also delayed seeking treatment for fear of retaliation from perpetrators. A doctor in Adigrat said, “I witnessed around six women who came to the hospital psychologically traumatized after they were sexual abused by the Eritrean forces…Upon asking why they came [a few days] late, they reported that they were told not to report to anyone or seek medical help otherwise their life will be in danger.” 
Some survivors were raped while in detention and could not access services until they were released. Zewdi T., a 30-year-old Tigrayan woman, said she was detained in a prison in November 2020 in [location withheld] where she was gang raped by three Amhara Special Forces fighters. She was only able to seek health care after her release at the end of February.
The shutdown in telecommunications has been another major obstacle to obtaining care. Without mobile phones, survivors of rape are not able to receive or share critical information, such as finding out from family or community members where they could go to seek help, calling health facilities for information, or finding out about safe routes to travel. For example, one humanitarian worker said: “When you cut down the telecommunications network…. what that does to a woman’s agency seeking shelter for that night…. It removes extension of agency.”
Ethio-Telecom, the national telecom provider, repeatedly stated from December 2020 that they were working to restore communication services and infrastructure notably in urban centers in Tigray. Communication remained restricted outside of urban areas. Communications was restored in parts of Tigray, but continued to be sporadically cut off, including for periods spanning several weeks, notably during bouts of heavy fighting, through to June 28.
Human Rights Watch received reports of concern from service providers and health providers about women and girls with disabilities who had been raped by soldiers, and faced additional barriers to travel to health facilities due to inaccessible roads and lack of accessible transportation when roads were open.
One doctor, noting both the military presence in the hospital where he worked and the lack of transportation for survivors, said they only came if they had severe injuries or suspected pregnancy: “They really feared to come…. We didn’t find anyone coming the day they were raped. [They came] after two weeks, after a month, and [longer].” In some cases, so much had time had passed that survivors with pregnancies as a result of rape were no longer within a time range to obtain an abortion.
One health worker working in an urban center said that she and colleagues were treating up to 15 patients a day, though the numbers would drop especially when roads were closed [due to fighting]. “Most of our Tigrayan women, most of our girls, are raped in the rural areas, in villages, they can’t come to hospitals, because there is no safety [along the way],” she said. “They are very late when they arrive in hospital, after two or three weeks, there is not accessibility of transport…. So we are doing treatment, but can’t [give them] prophylaxis within 72 hours…. The only patients that reach on time are in [the city] or around [the city].
Harassment and Intimidation of Health Workers and Community Outreach Programs
Health workers and humanitarian aid providers described threats and intimidation linked to their work on sexual violence, and their fear of reprisals from Ethiopian authorities. They also said that the presence of armed forces and groups in communities, including Ethiopian, Eritrean, and Amhara forces, impeded their ability to protect privacy and confidentiality, and to run mobile clinics and community outreach programs.
Fear of threats, intimidation, and reprisal were felt by aid workers at the field level, including at health posts. One service provider noted their staff had limited access to many areas in the first half of 2021, and when they were able to visit specific health posts, for example:
Our teams would find 20 files of SV [sexual violence] [that had been previously treated] in a health center. The staff that remained didn’t want to share [these records] with us because they didn’t want to get in trouble [with Ethiopian authorities or the military] …. Even service providers in that environment, were terrified of speaking about sexual violence.
Human Rights Watch also collected reports of at least five instances in which Tigrayan aid providers supporting sexual violence survivors or providing other reproductive health services for local organizations or international organizations were harassed, detained, or threatened by the Ethiopian, Eritrean and Amhara armed forces and groups. In at least three such incidents, the aid workers were accused of working with the TDF. A safehouse run by the Women’s Association of Tigray in Mekelle, the only such functioning shelter for rape survivors for many months of the conflict, described a three-day raid on their facilities in late March 2021, a few weeks after a visit by President Sahle-Work Zewde brought publicity to the facility and the work it was doing with conflict-affected rape survivors. A representative said:
The first day [March 23], 22 [federal] soldiers [and police], with guns knocked with guns. They were ordered to search the place. The reason they are searching the place, [they accused us]...saying “Why are you serving the junta, those fighting the war?”… The soldiers came in and searched for documents and looked through the documents…. While they were there, they locked the 37 survivors in the living room. And they are once again retraumatized, some even peed themselves.”
Police detained one staff member for several hours at the police station and questioned her.
Human Rights Watch spoke to a service provider coordinating response to gender-based violence in Tigray who said, “About safety, in some places where we were doing mobile clinics, armed actors [were] still there. For women there, it was very difficult to come [to the clinic].” She said this was a significant barrier, including in places they visited where women were telling them sexual violence had been widespread, but they would only receive a few cases.
Another humanitarian worker said, “We did hear in the community, soldiers in community had called a meeting, [instructing them] when we showed up, not to talk to us or there would be repercussions.”
A humanitarian aid worker coordinating response to gender-based violence said, “Our teams had a lot of problems accessing many regions.” This has prevented critical community outreach efforts that make it possible for rape survivors to seek assistance. One humanitarian worker, when describing the number of sexual violence cases they treated in different villages and towns, said, “It made a big difference where community health workers could operate freely, [without security forces in the vicinity,] more GBV [gender-based violence] survivors coming forward.” The inability to conduct effective community outreach affects the ability to provide services in a time-sensitive manner.
Aid workers said that without clear, consistent access, they struggled to adhere to best practices for supporting survivors of gender-based violence, including to provide private, women-friendly spaces. One service provider said:
Confidentiality…was a huge problem. We did mobile clinics wherever we can find space to meet. A perfect [world] would be where consultation can be done respecting confidentiality, we train staff not to ask too many questions at triage [when survivor arrives], and passing messages to the community to use a [special] code [to indicate they need privacy to seek help for sensitive issues] and we tried to implement as soon as possible. In some places we are just in a community building [phase]. We have three tables and two clinicians and doing a [confidential] consultation was just impossible.
UNFPA coordination reports have also highlighted the lack of private, women-friendly spaces as a consistent barrier to reporting and treatment of gender-based violence in the first six months of 2021. For example, in April, UNFPA reported that community representatives in Mai Tsebri identified key gaps in their response, including lack of safe spaces for undertaking protection counseling for gender-based violence cases.
Impact of Ethiopian Government Obstruction of Aid
Partners are saying [the blocking of aid is] impacting their work, they don’t have fuel, cash, they don’t have medicines, kits, staff moving in and out. What I’ve heard lately is really fuel, that’s hampered them from being able to do any outreach. And communications. They can’t call – it has an enormous [impact] on collecting data on the needs.
—Donor representative, October 25, 2021
Since Tigrayan forces retook Mekelle on June 28, Ethiopian federal authorities have tightened their effective siege of the Tigray region, including shutting down of essential services such as banking, telecommunications, and electricity. They are severely restricting the entry of food, fuel, cash, and medical supplies, hobbling the humanitarian aid effort in Tigray, including the rehabilitation of the health sector.
The Ethiopian government has largely blocked the entry of medicine or medical supplies into Tigray since the end of June, with some exceptions such as a limited amount of UNICEF health and drug kits. By the end of September, the government began allowing increased numbers of trucks into the region to deliver food, nutrition, water, sanitation and hygiene, and shelter supplies, but continued to block fuel, medical supplies, and medicines. According to an OCHA update, “health partners have not been able to rehabilitate and re-equip health facilities following the systematic looting by parties to the conflict.”
On October 22, Ethiopian government airstrikes on Mekelle forced a UN humanitarian flight to abandon its landing. Referring to the incident, a UN spokesperson said it “illustrates just one more example of the direct impact of the conflict on our humanitarian operations, plain and simple. Right now, our flights are suspended.” The flights, which operated twice per week, also carried limited cash into the region. According to one humanitarian worker: “Cash is no longer coming into the region. There is no fuel. Very little fuel left. Without cash and fuel, it’s really difficult to reach the people in need.”
Aid actors told Human Rights Watch that in late September the Tigrayan authorities temporarily stopped providing limited fuel supplies to aid agencies.
Several interviewees said that health workers and other service providers reliant on cash salaries have not been paid in months. One doctor said that “Even all staff in the hospital didn’t get pay for the last three months. No salary, no bank, no communication, and no electricity.” Another aid provider said, “Regional government staff and some of our partner staff have not been paid if there isn’t cash on the ground.”
In September, humanitarian officials working on protection also highlighted “administrative impediments concerning visas and work permits, delaying staff recruitment and deployment,” as a key operational challenge. For example, in October, during the twice a week UN Humanitarian Air Service flights—suspended at the time of publication—10 to 15 international humanitarian workers have been denied the ability to board each flight due to new requirements for resident IDs and approvals by diverse government entities.
A government donor said there is a “lack of capacity of the organizations in-country. Partly due to the government PNGs [persona non grata] and ensuring that [lack of capacity] with visas.”
While interviewees suggested that alleged sexual violence cases in Tigray were decreasing, there is ongoing reporting of previous cases that had so far gone unreported. A humanitarian agency cited in an August OCHA update said that “about 70 unrecorded new rape cases were reported at the Adigrat IDP [internally displaced persons] camps alone last week. The survivors reportedly cited the slow pace of their reporting to fear of reprisal from the alleged perpetrators.”
Impact on Gender-Based Violence Response
Proper GBV case management services, including MHPSS (Mental Health and PsychoSocial Services) remain insufficient in most locations in Tigray. In Axum, for instance, GBV coverage is limited to only one partner covering four sites.
—OCHA humanitarian update, September 16, 2021
By July 2021, UNFPA reported that the majority of the target woredas in Tigray and surrounding conflict-affected areas still did not have access to comprehensive gender-based violence response services, with only three woredas (8 percent of the target) covered.  An October 22 OCHA update highlighted ongoing gaps in the gender-based violence response caused by the lack of: fuel for transportation, specialized services and partners outside of Shire and Mekelle, telecommunications, and dignity kits. It underlined needs to strengthen staff capacity on clinical management of rape, community engagement on gender-based violence, and mental health and psychosocial support services.
Service providers told Human Rights Watch they could not expand outside of urban centers for community-based outreach and services due to lack of cash, transportation, and fuel. Without community-based services, survivors confront rising transportation costs and lack of temporary shelter impeding their travel to health centers.
A central strategy for gender-based response has been the expansion of One-Stop Centers outside of Mekelle. As of October, there were at least six One Stop Centers in Tigray, all located in hospital settings in urban centers. These include in Mekelle General Hospital and Ayder Referral Hospital in Mekelle, Lemlem Karl General Hospital in Maychew, Adigrat General Hospital, St. Mary General Hospital in Axum, and Sihul Shire General Hospital in Shire. Some of these offer mental health support through clinical psychologists provided by the Tigray Regional Health Bureau and through psychiatric nurses and social workers provided by UNICEF. These One Stop Centers have access to police and a prosecutor, but they focus on legal counseling and do not conduct investigations given the lack of a functioning policing system and judiciary.
All service providers that Human Rights Watch interviewed said that the One-Stop Centers do not have adequate staffing, supplies, or quality of services. Dr. Hagos from the Tigray Bureau of Health noted that most of them do not have a permanent, separate room in the health facilities where they are located, proper data management, and that the centers are only functional on workdays.
One-stop facilities are often inaccessible for survivors outside of urban centers. A humanitarian aid provider supporting gender-based violence response said one-stop centers are, “really important…. But it’s a level that’s not close to the community. It always has to be accompanied by district and woreda level professionals who are able to detect and refer for highly specialized services.”
However, an OCHA update from October 21, 2021 reported that One-Stop Centers had halted their activities, including outreach and assistance.
Lack of Cash, Fuel, and Communications
Even though partners are on the ground and operational and we want to keep delivering, the fact there is no cash and fuel makes it difficult to provide the services that we need not only in the capital but around the province…. Cars don’t have fuel and you can’t go far.
—Humanitarian aid provider, location withheld, November 4, 2021
Humanitarian aid workers described to Human Rights Watch their inability to implement programming or scale-up their response due to the government’s blocking of supplies.
Many interviewees said that the lack of communications affected information-sharing, logistics, planning, and general implementation of their programs. A humanitarian aid provider said, “Communications is a challenge. The serious disruption of internet and telephone communication—that really complicates matters to reach beneficiaries and report back.”
Aid providers have not been able to spend the funds they have been provided for gender-based violence response, and some said they are planning to ask for no-cost extensions. A government donor agency supporting the response to gender-based violence said, “We’re not spending down in Tigray as much as we had planned.”
A representative from SGBV Assessment and Rehabilitation Committee of the Tigray Women’s Affairs Bureau said that the humanitarian organizations, “registered to work on GBV in Tigray, none are in a position to help us…. They cannot help us mobilize resources [such as fuel and communications] for grassroots discussion and community mobilization which they had budgeted for and agreed they would be doing.”
Local civil society organizations are critical for an effective and sustainable response to gender-based violence. However, many of them are directly affected by the conflict, including through displacement, shortages of food, and the shutdown of essential services. A donor government representative said, “Long-term CSOs [civil society organizations] are affected by the conflict, many of them women-led. They are grappling with how to operate in this context and even if we could fund them, cash cannot get through.” Another donor said, “In the women and girls’ safe spaces, there are volunteers who get stipends, but haven’t received cash in so many months, how can you expect them to provide a quality response?”
Confidential case management of gender-based violence cases and data protection is hampered by the lack of electricity and inability to rely on computers. The shutdown in telecommunications and the obstacles to physical movement due to the lack of cash and fuel have also impaired the coordination of the response to gender-based violence.
An aid worker described how lack of cash and food are affecting the response to support children born of conflict-related rape. She said:
You need very specific, very localized solutions as soon as agencies are able to operate again. All these different complications of lack of access are impeding something that is already an issue surrounded with such stigma. There is the practical challenge of foster care provided without cash and without extra food. It’s very difficult for organizations to find foster parents in that situation.
Visas and Staffing
Local health workers, international aid providers, and Tigrayan authorities all pointed to a need for increasing the number of appropriately trained staff, including those specializing in gender-based violence, psychology, and psychiatry, as part of a multi-layered gender-based violence response and complementing community-level efforts. They noted both that skilled health workers had fled or been killed, and that the need for specialized services had grown significantly as a result of the conflict.
Aid workers said the principal staffing challenges on gender-based violence were related to capacity, experience, and technical know-how. Another aid provider provided an example: “Clinical management of rape requires dedicated skills for doing a different type of medical examination with a child then a woman married for 10 years. That kind of skill is really important.”
A staff member from a donor government said:
On the psychosocial support piece—the needs are also among the responders…. It’s their community, their crisis, they’ve had to run for their lives… We need outside support to support the primary first response, also because this is a technically heavy issue. These are the worst kinds of GBV [gender-based violence] We need technical psychosocial experience.
Several aid workers highlighted challenges and delays their colleagues faced in getting visas to enter the country and permission to enter Tigray. These hindered efforts to scale-up humanitarian response and to address gaps in staff capacity.
Shortage and Unpredictability of Supplies
In October and early November 2021, a representative from the Tigray Women’s Affairs Bureau and donors supporting service providers working in Tigray told Human Rights Watch they did not have adequate medical supplies and medications, or enough “dignity kits.”
In a written communication to Human Rights Watch, the head of the Tigray Bureau of Health wrote that gaps in post-rape care included a shortage of medications, basic supplies such as IV equipment, syringes, and gloves, sexual and reproductive health kits, and dignity kits, as well as gaps in comprehensive abortion care including of Mifepristone and Misoprostol tablets, vacuum aspiration with electric pumps, and manual vacuum aspiration with cannula.
The federal government has obstructed, including through arbitrary regulations, the rapid, consistent, and smooth delivery of aid to Tigray. Interviewees described needing to obtain approvals for supplies, but encountering a lack of clarity on processes, including multiple changes to the procedures, and a lack of consistency in granted permissions. For example, one donor representative said: “One part of government will give approval [for humanitarian goods], but at a checkpoint, someone with a gun will say no and it’s unclear.”
Another aid worker said, “We have delays of supplies. We have warehouses in different places, but it is difficult to stock up, to dispatch, where access no longer granted.”
A representative of the regional Tigrayan authorities’ sexual and gender-based violence committee wrote, “The economy being crippled, the blockage [of aid], and the destruction of the pharmaceutical factories in Tigray have resulted in a severe shortage in medical supplies and medication.” She added, “A lot of survivors are asked to buy medications with their own money and many can’t afford it. Medications are free for survivors if available within the institutions, but with no medical supplies coming in most medication left now is in private pharmacies.”
Concerns about Heightened Risk of Sexual Exploitation and Abuse
Several humanitarian aid workers flagged their concerns about humanitarian conditions contributing to a heightened risk of sexual exploitation and abuse (SEA), and the lack of an adequate prevention and monitoring response. SEA refers to the abuse or attempted abuse of power for sexual purposes, for example, situations in which aid workers or community members demand sex in exchange for food, jobs, basic commodities, or other goods and services.
Numerous assessments, including by CARE International, the International Rescue Committee, and Refugees International have noted that food insecurity and widespread displacement has disrupted protective factors such as economic livelihoods and community networks. The shutdown in electricity, fuel, telecommunications, and banking drastically reduces the ability of women to reestablish their livelihoods. The obstruction of humanitarian aid means preventive actions, such as improving supply and distribution of food, access to water and sanitation, safe and private shelter, and livelihood supports are also stymied.
Humanitarian agencies, including UN Women, UNFPA, and NGOs have coordinated with the Ethiopian government around a Protection against SEA workplan and created a network of focal points and training around SEA. Interviewees raised concerns that both focal points and community members have little awareness about SEA and how to make complaints. Furthermore, monitoring and accountability systems remain vague—the website for protecting against SEA in Ethiopia says that safe and accessible complaint channels are “in progress” and that the approximate time for an investigation to be initiated, upon receipt of an allegation, is “unknown.”
Impact on Mental Health and Psychosocial Support Services
Overall in Tigray, people are incredibly traumatized. It’s always good to remember faces behind the numbers…. Such trauma of girls and boys, who have lived through such atrocities…. The sheer number of people in need. Access is a big worry.
—Humanitarian aid provider, location withheld, November 4, 2021.
The government’s blocking of humanitarian assistance has slowed the rehabilitation of the mental health services sector. As of September 2021, an OCHA humanitarian update highlighted that, “Mental health and psychosocial support (MHPSS) and tailored health services to survivors of GBV are ongoing critical needs.” A doctor said, “We don’t have many psychiatrists in Tigray. It would be good to [expand the] spectrum of psychologists and psychiatrists, and away from Mekelle…. Survivors of gang rape need [specialized] psychological and psychiatric services.”
A representative of the SGBV committee of the Tigray Women’s Affairs Bureau said that in a recent meeting they had a “discussion about the lack of medication to treat survivors who come with mental health conditions, they can’t get enough medication in. They psychologists or psychiatrists, they didn’t have enough medication on hand to help treat depression and anxiety.”
In a written communication to Human Rights Watch, the head of the Tigray Bureau of Health emphasized the need for family and community social support—currently disrupted by widescale displacement—and for non-specialized psychological and mental healthcare support to be integrated into health services.  He noted major gaps in the availability of specialists, noting:
There are only 5 clinical psychologist[s], 3 psychiatrists, and 13 MSc [masters degree in science] in psychiatry working in one teaching hospital. According to an assessment which had been done to 200 health facilities which includes General hospital, Primary hospital and health Center in July/2021, 31 psychiatric nurses are available, but prior to war there were 45. There is no psychologist in those 200 facilities which were included in the assessment. 
Human Rights Watch research from conflicts around the world, including Central African Republic, Iraq, Myanmar, and South Sudan, have repeatedly documented the profound and long-term impacts of conflict-related sexual violence on women and girls, including their mental and physical health and ability to fully resume working, studying, participating in public life, and caring for their families. The availability, accessibility, and quality of support both in the immediate aftermath of violence, and in the long-term are essential for survivors’ healing and rebuilding their lives.
International Donor Funds
Efforts to scale-up and meet the humanitarian needs in Tigray and other conflict-affected areas, including healthcare and psychosocial support services for sexual violence survivors, are stymied on multiple fronts. These include the inability to use existing funds for proper delivery of services and goods due to the government’s blocking of assistance as well as, looking forward, funding shortfalls to meet projected implementation costs and programming to meet needs if restrictions ease.
The shutdown in banking has affected the ability of humanitarian organizations and national service providers to receive and spend funds. For example, an international donor designated funds for a local organization providing services to gender-based violence survivors, but the organization has no way to collect the funds without a functioning banking system. Another international donor addressing the humanitarian situation said that due to the obstruction of basic services including banking, telecommunications, and delivery of essential supplies, “funded organizations are struggling to spend.”
Donors have identified case management, technical capacity of staff, data protection, and coordination as ongoing critical needs. They have earmarked a portion of their funds designated for the Tigray humanitarian crisis to case management for survivors of gender-based violence, coordination and information-sharing with respect to gender-based violence response, training for social workers, medical staff, and community case workers, service centers to provide gender-based violence screenings and referrals, and safe spaces and psychosocial support for children affected by the conflict. But as the US government has noted, humanitarian organizations “face a constant stream of bureaucratic delays, demands for additional approvals, and ongoing conflict.”
United Nations Mechanisms
The UN Security Council has established mechanisms to monitor and address sexual violence in conflict and grave violations against children in situations of armed conflict.
Sexual Violence in Conflict
In 2009, the adoption of Security Council Resolution 1888 on conflict-related sexual violence established the Office of the Special Representative of the Secretary-General on Sexual Violence in Conflict (SRSG-SVC), Women’s Protection Advisers, and the UN Team of Experts on the Rule of Law and Sexual Violence in Conflict who support the investigation and prosecution of perpetrators, legal reform, and protection of survivors and witnesses.
The Office of the SRSG-SVIC can use joint communiqués or frameworks of cooperation with states to develop specific, timebound commitments on priority interventions. UN Security Council Resolution 1960 requests the UN secretary-general to establish monitoring, analysis and reporting arrangements (MARA) on conflict-related sexual violence to ensure the systematic gathering of timely, accurate, reliable, and objective information on conflict-related sexual violence. This information can be used as a basis for Security Council action including sanctions and protection mandates.
UN Security Council resolution 1960 also requests the UN secretary general to include detailed information on parties to armed conflict credibly suspected of committing or being responsible for acts of sexual violence in his annual report on conflict-related sexual violence and to list these parties in annexes to the report. Listed parties must address violations in order to be de-listed.
Children’s Rights and Armed Conflict
At the request of the UN Security Council, the UN secretary-general has presented an annual report on the situation of children affected by armed conflict since 2000. The annual reports include both situations on the Security Council’s formal agenda, as well as other “situations of concern” where violations against children in armed conflict are taking place. With its Resolution 1379 of 2001 and subsequent resolutions on children and armed conflict, the Security Council mandated the secretary-general to include in the annexes of his annual reports a list of parties to armed conflict—often called the “list of shame”—that commit the following grave violations against children: recruitment and use; killing and maiming; rape and other forms of sexual violence; attacks on schools and hospitals; and abductions.
To further strengthen this system, the Security Council in 2005 established a unique global Monitoring and Reporting Mechanism (MRM) to collect and rigorously verify information on the grave violations against children in armed conflict. Once a party is listed in the secretary-general’s annexes, the UN establishes a Country Task Force on Monitoring and Reporting (CTFMR) co-chaired by UNICEF and the highest UN representative in the country, with the mandate to systematically monitor, document, and report on these violations. The CTFMR also informs UN service provision to affected children and engages with the parties to halt violations and comply with international standards.
International Human Rights and Humanitarian Law
Both international humanitarian law, or the laws of war, and international human rights law apply during the armed conflict in Tigray that began in November 2020.
The conflict between the Ethiopian government and allied forces against the TPLF is a non-international armed conflict governed by the body of international humanitarian law applicable to internal conflicts. Ethiopia is a party to the Geneva Conventions of 1949 of which Common Article 3, which sets forth minimum standards for all parties to a non-international armed conflict, applies. All the parties are also bound by Additional Protocol II to the Geneva Conventions relating to the Protection of Victims of Non-International Armed Conflict and by customary laws of war.
The parties to the conflict are responsible for complying with the requirements of international humanitarian law. They must respect the requirements whether or not the opposing side abides by them. It also does not depend on the reason underlying the conflict or why any party has resorted to using force, whether government forces or non-state armed groups. And all parties to an armed conflict are held to the same standards, regardless of any disparity in the harm caused by alleged violations.
Ethiopia is a party to core international human rights treaties, which remain in effect during wartime. These include the International Covenant on Civil and Political Rights (ICCPR), the International Covenant on Economic, Social and Cultural Rights (ICESCR), the Convention on the Rights of the Child (CRC), the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), and the Convention on the Rights of Persons with Disabilities (CRPD). These treaties outline guarantees for fundamental rights, many of which correspond to the rights that civilians and combatants are entitled under international humanitarian law, such as the prohibitions on torture and rape.
Obligations to Allow Unhindered Humanitarian Aid
The Ethiopian government’s onerous restrictions on the delivery of food, medical supplies, and fuel, along with delays and challenges to obtaining necessary approvals and travel documents such as visas, have significantly obstructed access to adequate life-saving humanitarian supplies in Tigray. The shutdown of essential services including banking, electricity, and telecommunications have caused further serious harm to Tigray’s civilian population. These restrictions violate the Ethiopian government’s obligations under international humanitarian law.
International humanitarian law prohibits attacks that could be expected to cause disproportionate harm to civilians compared to the military advantage anticipated. Therefore, even otherwise lawful attacks or actions, such as cutting off the electrical capacity or telecommunications to opposing military forces, are unlawful when they cause disproportionate civilian harm.
International humanitarian law requires all parties to the conflict to allow and facilitate the rapid and unimpeded passage of impartially distributed humanitarian aid to the population in need. Deliberately impeding relief supplies is prohibited. The use of starvation as a method of warfare is prohibited and amounts to a war crime. In addition, attacking, destroying, or rendering useless objects indispensable to the survival of the population are prohibited.
Ethiopia’s Criminal Code in article 270, “War Crimes against the Civilian Population,” states that anyone who during an armed conflict “organizes, orders or engages in, against the civilian population and in violation of the rules of public international law and of international humanitarian conventions … wilful reduction to starvation [or] destitution” faces 5 to 25 years in prison, or life imprisonment or death in more serious cases.”
While the parties must consent to allow relief operations, they may not refuse such consent on arbitrary grounds. The withholding of consent is considered arbitrary when the resulting circumstances violate international law with respect to the civilian population; exceed what is necessary for achieving the ends sought in withholding consent or is disproportionate to achieving those ends; or lead to injustice, lack of predictability, or are otherwise inappropriate.
They may take steps to control the content and delivery of humanitarian aid, such as to ensure that consignments do not include weapons. International humanitarian law also requires parties to ensure the freedom of movement of humanitarian workers essential to the exercise of their functions. This movement may be restricted only temporarily for reasons of imperative military necessity, such as security concerns in the midst of a military operation.
Restrictions on humanitarian aid affect the rights of individuals to life, to the highest attainable standard of health, and to an adequate standard of living. Authorities are obliged to ensure minimum essential levels of health care.
The Ethiopian authorities’ onerous restrictions on the delivery of humanitarian assistance to the Tigray region violate international humanitarian law and may amount to using starvation as a weapon of war. The restrictions on electricity, telecommunications, and other essential services have had an unlawful disproportionate effect on the civilian population. These actions have profoundly slowed and frustrated attempts to rehabilitate the health sector in Tigray.
Sexual and Reproductive Health Rights
International and regional treaties ratified by Ethiopia protect the right to health for all in Ethiopia, including the rights of women and girls to comprehensive post-rape care, psychosocial support services, and family planning. These include the ICESCR, CEDAW, the CRC, the CRPD, and the African Charter on Human and Peoples’ Rights. 
The ICESCR articulates the right to health as “the right to the enjoyment of the highest attainable standard of physical and mental health.” The 1981 African Charter on Human and Peoples’ Rights also recognizes this right. Governments have an obligation to take concrete and targeted steps to realize this right using available resources, including international assistance, as expeditiously and effectively as possible.
In its General Recommendation No. 30 on women and conflict, the Committee on the Elimination of Discrimination against Women (the CEDAW Committee), states that as a consequence of disruptions to healthcare systems and prevalence of sexual violence in conflict, women and girls face higher risks of reproductive health-related illness and injury, such as unplanned pregnancy, pelvic injuries, and sexually transmitted infections including HIV. It adds that the “breakdown or destruction of health services, combined with restrictions on women’s mobility and freedom of movement, further undermines women’s equal access to health care.” To meet the needs of sexual violence survivors in conflict-affected areas, the CEDAW Committee calls for states to ensure that sexual and reproductive health care includes emergency contraception, post-exposure prophylaxis and other medication to treat and prevent sexually transmitted infections, safe abortion services, psychosocial care, and care for sexual-violence related injuries. Displaced and refugee women should also have access to such services.
In its General Comment No. 22, the Committee on Economic, Social and Cultural Rights has underlined the importance of the availability, accessibility, affordability, and acceptability of sexual and reproductive health care. It highlights ensuring an adequate number of functioning healthcare facilities, availability of trained and skilled health providers, and essential medicines:
Including a wide range of contraceptive methods, such as condoms and emergency contraception, medicines for abortion and for post-abortion care, and medicines, including generic medicines, for the prevention and treatment of sexually transmitted infections and HIV. 
It also stipulates that an adequate number of healthcare providers willing and able to provide such services should be available at all times in both public and private facilities and within reasonable geographical reach.
To the Government of Ethiopia, Tigray People’s Liberation Front (TPLF), Donors, and Humanitarian Aid Providers
- Scale-up and expand the geographic reach of a comprehensive gender-based violence response across Tigray and conflict-affected areas at the woreda (district) level, including through:
- increased support to improve quality of services and adherence to international standards and national protocols, including through local staff training and capacity building, supervision, and mentoring;
- accessible safe spaces for women and girls, including for older women and those with disabilities;
- community outreach and engagement, including dissemination of information on services and combating stigma in a variety of accessible formats, and targeting those who are most marginalized;
- mobile clinics equipped with adequate medicines, supplies, and staff trained to identify and care for survivors of sexual violence;
- availability of mental health and psychosocial support services;
- financial livelihood support;
- training of health workers and service providers on forms of sexual violence affecting men and boys and equipping them to provide appropriate support;
- strengthened capacity and quality of One-Stop Centers, including through private rooms that ensure confidentiality, staff trained in clinical management of rape, including for children, and specialized psychosocial support services; and
- strengthened referral pathways for specialized services, while maintaining the safety, confidentiality, and privacy of survivors.
- Strengthen the availability, accessibility, and quality of sexual and reproductive health services without discrimination, including post-rape care, across Tigray and other conflict-affected areas.
- These services should include the Minimum Initial Service Package (MISP), clinical management of rape, safe abortion and post-abortion care, treatment of sexually transmitted infections (STIs), support for continued treatment for those on antiretroviral drugs, and Basic Emergency Obstetric and Newborn Care (BEmONC).
- Provide adequate funding and logistical support to ensure unfettered and speedy procurement, management, and distribution of all essential sexual and reproductive health commodities, including Inter-Agency Emergency Reproductive Health kits.
- Strengthen the availability, accessibility, and quality of mental health and psychosocial support services without discrimination, including specialized services and counseling for sexual violence survivors and their families, across Tigray and conflict-affected areas. This includes:
- training staff at all levels, including at the community level, on psychological first aid, supportive communication, and referral pathways; and
- expanding availability of trained and qualified mental health support service providers including counselors, social workers, psychologists, and psychiatrists.
- All agreements around programs funded or partly funded by donors should include robust provisions for independent monitoring.
- Enforce a zero-tolerance policy on sexual exploitation and abuse (SEA) including through: training of all humanitarian workers involved in the Tigray response with information on SEA, its consequences, and by strengthening reporting and accountability mechanisms.
To the Government of Ethiopia
- Immediately provide full, rapid, safe, and unimpeded access for humanitarian aid to the Tigray region and other conflict areas.
- Direct the armed forces to enforce a zero-tolerance policy for sexual violence and ensure that anyone committing sexual violence be appropriately held to account.
- Uphold international humanitarian law prohibitions against attacks on health workers and humanitarian aid personnel, health facilities, and medical transport.
- Cooperate fully with requests for independent, international investigations into the conflict in northern Ethiopia.
- Sign a joint communique to establish a framework of cooperation with the special representative of the UN secretary-general on sexual violence in conflict, including for the special representative and a team of experts to visit Tigray, Afar, Amhara, and other conflict-affected areas and through meaningful engagement with civil society organizations, with clear and transparent benchmarks for accountability, monitoring, and prevention.
- Invite the UN special rapporteur on violence against women, its causes and consequences, and the AU special envoy on women, peace, and security to conduct country visits to Ethiopia, including Tigray, Afar, Amhara, and other conflict-affected areas pursuant to their UN and AU mandates.
- Make public the findings of the task force set up by the minister of women, children and youth to investigate accounts of sexual violence in Tigray.
To the Government of Eritrea
- Cooperate with international investigations on sexual violence committed by Eritrean forces. Direct the armed forces to enforce a zero-tolerance policy for sexual violence and ensure that anyone committing sexual violence be appropriately held to account.
- Invite the UN special rapporteur on violence against women, its causes and consequences, and the AU special envoy on women, peace, and security to conduct country visits to Eritrea pursuant to their UN and AU mandates.
To the Tigray People’s Liberation Front (TPLF)
- Direct the armed forces to enforce a zero-tolerance policy for sexual violence and ensure that anyone committing sexual violence be appropriately held to account.
- Immediately provide full, rapid, safe, and unimpeded access for humanitarian aid to the Tigray region and other conflict areas under Tigrayan forces control, including in the Amhara and Afar regions.
- Cooperate with international investigations on sexual violence committed by Tigrayan forces.
To the African Union
- Hold regular AU Peace and Security meetings on the human rights and humanitarian crisis in Ethiopia.
- Request for the AU special envoy to the Horn of Africa, in collaboration with other regional intergovernmental institutions like IGAD, to build an inclusive mediation strategy that ensures the full, equal, and meaningful participation of women at all stages.
- Request for the AU special envoy to the Horn of Africa to meet with health workers and service providers working in response to gender-based violence in Tigray and other conflict-affected areas in Ethiopia.
- Request the AU special envoy on women, peace and security to visit Ethiopia, and press for access to Tigray, Amhara, and Afar regions. Request the special envoy to provide a briefing to the AU Peace and Security Council and report on the findings.
To the African Commission on Human and Peoples’ Rights (ACHPR)
- Incorporate into the ACHPR Inquiry on Tigray the investigation of conflict-related sexual violence, destruction of health infrastructure, and Ethiopian government restrictions on telecommunications, electricity, banking, fuel, and humanitarian assistance that have stalled the rehabilitation of the health sector and gender-based violence response.
- As a follow-up measure to the AACHPR Inquiry, and to boost an AU gender-focused response, urge the Ethiopian government to grant access to the ACHPR special rapporteur on the rights of women in Africa, to carry out a fact-finding mission on sexual violence, its impacts, and the availability and accessibility of support provided to survivors. The ACHPR should publish the report’s findings.
- In collaboration with the AU Panel of the Wise and the AU Department of Health, Humanitarian Affairs and Social Development, hold a High-Level Meeting on the health and social impacts of conflict-related sexual violence in Ethiopia.
To the UN Human Rights Council
- Establish an independent international investigation into human rights abuses and war crimes in conflict-affected areas of Tigray, Afar, and Amhara regions to ensure credible scrutiny, investigate and report on violations, collect and preserve evidence for future trials, and facilitate genuine accountability. The investigation should include all forms of gender-based violence, including rape as a weapon of war, attacks on health facilities, and obstruction of humanitarian assistance including starvation as a weapon of war.
To the UN Security Council
- Demand the Ethiopian government allow full, rapid, safe, and unimpeded humanitarian access to the Tigray region.
- Add the human rights and humanitarian crisis in Ethiopia to the Security Council’s formal agenda, request regular briefings from the UN secretary-general and Office for the Coordination of Humanitarian Affairs (OCHA), and the Office of the UN High Commissioner for Human Rights.
- Hold public sessions to address the humanitarian crisis in Ethiopia, including sexual violence and other conflict-related abuses; access to health care; attacks against medical facilities; and risks to children, people with disabilities and older people. Raise these issues in meetings of the working groups of the council, including the Informal Expert Group on Women, Peace, and Security.
- Adopt a global arms embargo on Ethiopia and Eritrea and targeted sanctions against Ethiopian, including Tigrayan, and Eritrean individuals and entities implicated in serious human rights abuses and violations of international humanitarian law in Tigray, including impeding humanitarian access.
To the UN Secretary-General
- Establish monitoring, analysis and reporting arrangements (MARA) on conflict-related sexual violence in Ethiopia.
- Include Ethiopia in the 2022 annual report to the Security Council on conflict-related sexual violence, and include all parties credibly suspected of committing or being responsible for sexual violence in the annexes of the report.
- Include Ethiopia in the 2022 annual report to the Security Council on children and armed conflict, place parties responsible for grave violations against children in the conflict in northern Ethiopia in the annexes of the 2022 report (the “list of shame”); and initiate the establishment of a country-level task force on monitoring and reporting.
To the Special Representative of the Secretary-General on Sexual Violence in Conflict
- Establish a framework of cooperation to foster compliance with international human rights law and international humanitarian law through a joint communiqué with the government of Ethiopia, including for:
- a visit to Tigray, Afar, Amhara, and other conflict-affected areas by the special representative and a team of experts;
- implementation of a survivor-centered approach to strengthening services, accountability, and prevention; and
- Development of timebound, specific commitments and action plans for the military and police to prevent, investigate, and ensure accountability for gender-based violence.
To All of Ethiopia’s International Partners including Canada, the European Union and its Member States, United Kingdom, and United States
- Use private and public channels at the highest possible political level to press the government of Ethiopia for full and unimpeded access for humanitarian aid to the Tigray region.
- Press for an independent investigation into human rights abuses and war crimes in northern Ethiopia, including the Tigray, Afar, and Amhara regions. The investigation should include rape as a weapon of war and all forms of conflict-related gender-based violence, attacks on health facilities, and obstruction of humanitarian aid, including starvation as a weapon of war.
- Immediately adopt an arms embargo halting the transfer and sale of arms and all other military equipment to Ethiopia and Eritrea and suspend all defense cooperation with these governments.
- Adopt, and coordinate among likeminded countries, targeted sanctions against Ethiopian, including Tigrayan, and Eritrean individuals and entities responsible for serious human rights abuse and violations of international humanitarian law in Tigray, including impeding humanitarian access to all areas in the region.
- Support through financial and technical resources the rehabilitation of Tigray’s health sector, including comprehensive sexual and reproductive health services as well as mental health and psychosocial support services.
- Include in all agreements with the Ethiopian government provisions for robust independent monitoring of all programs funded or partly funded by donors.
- Support community-based organizations, including diverse women’s groups, organizations of persons with disabilities, older people’s associations, and youth groups including through flexible and sustainable funding and trainings.
To Humanitarian Agencies, including UNFPA, UNICEF, OCHA
- Implement services in adherence to core humanitarian standards, including Inter-Agency Standing Committee (IASC) Guidelines on gender-based violence and mental health and psychosocial support services, and ensure robust monitoring and feedback mechanisms.
- Scale-up and expand the geographic reach and accessibility of a comprehensive gender-based violence response, including through One-Stop Centers, psychosocial services, public campaigns disseminating information on access to services and combating stigma, livelihood support, and community engagement.
- Expand geographic coverage and accessibility of gender-based violence services across Tigray to the woreda level, especially in hard to reach and underserved communities, including through building capacity of health extension workers, teachers, and other community workers, and strengthen referral pathways for specialized services.
- Include in all agreements with the Ethiopian government provisions for robust independent monitoring of all programs.
- Support community-based organizations, including diverse women’s groups, organizations of persons with disabilities, older people’s associations, and youth groups including through flexible and sustainable funding and trainings.
This report was researched and written by Nisha Varia, advocacy director in the Women’s Rights Division, with contributions from Laetitia Bader, Horn of Africa director and other Human Rights Watch staff. Erika Nguyen, senior coordinator in the Women’s Rights Division provided research assistance.
The report was reviewed by Laetitia Bader, Macarena Sáez, executive director of the Women’s Rights Division, Amanda Klasing, associate director in the Women’s Rights Division, Juliane Kippenberg, associate director in the Children’s Rights Division, Kyle Knight, senior health editor, Jane Buchanan, deputy director of the Disability Rights Division, Emina Ćerimović, senior researcher in the Disability Rights Division, Bridget Sleap, senior researcher on the rights of the older people, and Tom Porteous, deputy program director.
James Ross, legal and policy director, provided legal review.
Production and editing assistance was provided by Erika Nguyen. Layout and production were coordinated by Travis Carr, senior coordinator in the digital department, Fitzroy Hepkins, senior administrative manager, and José Martinez, administrative officer.
Human Rights Watch expresses deep gratitude and appreciation to the many individuals who spoke to us and shared information for this report, despite a complex and volatile environment in northern Ethiopia, and associated personal and organizational risks.