Iraq Without Water: The Cost of Oil to Italy

1. The Theft of Water

Basra, Iraq. When Saddam Hussein drained most of the Mesopotamian marshes in 1990 to punish rebels hiding among the reeds who opposed his regime, Mahdi Mutir took his few belongings, nets and small boat and fled to the Hammar marshes, north-east of Basra, where he thought he could continue to make a living from fishing. The Hammar Marshes are a large wetland complex in south-eastern Iraq and are part of the Mesopotamian Marshes, which originate from the Tigris and Euphrates River system.

These ancient rivers rise from the snow-capped headwaters of the Taurus Mountains in south-eastern Turkey, flow through valleys and gorges to the plateaus of Syria and northern Iraq, and then run parallel down to the floodplains of central Iraq. Like the arteries of the circulatory system, the rivers, joined by other tributaries, glide south and join at Al-Qurnah to form the majestic Shatt al-Arab, a river that travels two hundred kilometres before emptying into the Persian Gulf.

For millennia, the lives of the marsh dwellers have been closely linked to the Tigris, the Euphrates and the wetlands seasonally flooded by the rivers. Thanks to water and canals, these dwellers transported goods, navigated from one region to another, and they cultivated and lived from fishing in a symbiotic relationship with their environment.  Mutir also lived this way. Every day, at two o’clock in the afternoon, he would leave his house to cast his nets in a traditional mashuf — a long, narrow wooden canoe used by the fisherman of this area as a main mode of transport to navigate canals and marshes. He would wait for the sun to go down and leave the next day at first light to collect them. From the fish he caught, he managed to earn around 17,000 dinars a day, about 3 euros, a small amount but enough to feed his family.

Since the beginning of 2022, everything has changed for Mutir and the people of the area. His boat sits at a trickle of water surrounded by mudflats. It is a late afternoon in January when we meet him. The seasonal rains should have filled the canals and marshes but there is no water and no fish to be found. “Italian company. Italian company,” he repeats excitedly, pointing in the direction of the plant a few kilometres away. “Eni has taken away our water.” Mutir is a simple man with a mild gaze and a welcoming smile. He agrees to accompany us to the place he calls ‘the plant.’ After passing through a checkpoint, a structure under construction — surrounded by concrete walls and control towers around the perimeter — comes into view. At the entrance flies a tattered yellow flag with the six-legged dog, the symbol of the Italian energy company Eni. Opposite it, along the bank of a canal, a dam has been built to divert water to a recently constructed reservoir. And it is precisely this dam which will prevent the surrounding marshes from being flooded. “Before they built this dam, we had water,” Mutir explains, “it is not operational at the moment, but they will use the water to extract oil.”

The dam and the under-construction facility visited by IrpiMedia are part of a project Eni is implementing through the local contractor Iraq General Company for Execution of Irrigation Projects (IGC). This facility is intended to supply water needed to extract oil in the Zubair field. The field is one of Iraq’s largest and has been operated by the multinational Italian company Eni since 2010, under a ‘technical service contract.’  The contract provides for the development of the field with a production target of 700,000 barrels of oil per day.

Iraq is the second-largest producer in OPEC, the Organisation of the Petroleum Exporting Countries, and holds the world’s fifth-largest proven crude oil reserve, with approximately 145 billion barrels. Since the start of the war in Ukraine, and the subsequent rise in oil and gas prices, Iraq has increased the value of its oil exports by 9 percent. This resulted in revenues of $ 115.5 billion in 2022. At the same time, Iraq is ranked by the United Nations as the fifth most vulnerable country in the world when it comes to the climate and water crisis.

Rising temperatures, increasingly irregular rainfall, the construction of upstream dams in Turkey and Iran, and irrigation methods rendered obsolete have caused a drastic reduction in the flow of the Tigris and Euphrates rivers over the past decade. But the already serious situation due to the aforementioned factors is made critical by the oil industry. To extract crude oil, in fact, companies operating in Iraq use a technique involving water injection. On average, one and a half to three barrels of water are needed for each barrel of extracted oil.

Extracting oil by water injection is a standard technique that dates back to the 1950s. Often there is already water mixed with oil in the wells, and some of this water is normally extracted from the reservoir along with the oil. But that is not enough, so water is added from other sources such as reservoirs, aquifers or from the sea. Saudi Arabia, for example, built a desalination plant back in the late 1970s and uses water from the Persian Gulf to supply its wells.

In Iraq, it is not this way: in the absence of investment and infrastructure, water is taken from the rivers and diverted from other uses. The fields around Basra, where two-thirds of Iraq’s oil is extracted, daily consume 25% of all the water used in the Basra governorate.

In response to requests for clarification from IrpiMedia, Eni states that “there is no use of fresh water,” and that in general, “Eni Iraq has developed a Water Management Plan that provides guidance to minimise the use of water resources, particularly fresh water, according to the drivers of operational efficiency and reuse.”

The Al Khora plant, whose construction will be completed in 2025, “will draw water from the Main Outfall Drain (MOD) canal,” Eni stated to IrpiMedia. “The MOD is a canal that collects brackish and contaminated water resulting from the drainage of irrigation water, which, after a few kilometres, flows into the Persian Gulf west of Shatt el Arab.”

Currently, however, a third of the water used for injection at Zubair (equivalent to about 156,000 barrels per day) “is supplied by the ROO consortium through a brackish surface water collection canal called Qarmat Ali.”

Just like Zubair, most of the fields in southern Iraq obtain their water from the Qarmat Ali plant, located a few kilometres south of Al Khora. Built in the 1970s, it is currently managed by the Rumaila Operating Organisation (ROO), a consortium in which the British multinational British Petroleum holds a 47.7 percent stake. The water, drawn from a canal connected to the river of the same name, is first treated and then distributed through a system of above-ground pipes to the various fields in the south, including Rumaila and Zubair, where BP and Eni operate. IrpiMedia was denied access to the Qarmat Ali plant.

According to Eni, neither the water extracted from Qarmat Ali nor the “brackish and contaminated water taken from the MOD canal” have “any impact on reduction in the volumes of water potentially usable for other purposes.”

While it is true that the water from rivers and canals used by oil companies is of poor quality, due to the concentrations of salt and other pollutants, it is not true that it is not used for other purposes. If this water is purified, it can be used by citizens for domestic purpose.

Just downstream from the Al Khora and Qarmat Ali plants, as verified by IrpiMedia, the canals from which the companies draw their water flow into a public purification plant — known as R0 (R Zero). Thirty-five percent of the water used in Basra households comes from here. Additionally, the water, although saline, permitted navigation and fishing in what remained of the delicate marshland ecosystem where Mutir lived.

2. The Zubair Oil Field (Work, Rights?)

For Mutir, deprived of water and his sole source of income, the Zubair oil field is nearby and overwhelming presence in every way: on a clear day, the wells and their plumes of smoke are clearly visible from Mutir’s house and dot the entire horizon. It takes more than half an hour to get to the wells by car. The area takes the form of an immense expanse of barren land, densely populated areas, landfills, and car parks for oil trucks.

The Zubair field itself is completely militarised, with checkpoints, cameras and barbed wire at all entrances. Around two million people live in the area around the field. The promise of development that oil was supposed to bring has not been fulfilled. Most families have no access to electricity and the roads are in poor condition. Rubbish, plastic and debris are a constant. Agricultural lands, once cultivated with tomatoes—a typical product of Zubair—are now abandoned and contaminated by oil spills.

Zubayr, Iraq (Author: Daniela Sala)

Oil exploration in Iraq began in the early decades of the 20th century. Today, more than a century later, oil constitutes more than 90% of the Iraqi state’s revenue. With Saddam Hussein’s rise to power, and the nationalisation of the oil industry in 1972, things changed dramatically. Despite the Baathist slogan “Arab oil to the Arabs,” it was not the local communities who benefited from the oil revenues.

Moreover, due to international sanctions, the Iraqi fields were largely under-utilised. There was a lack of technology and investment, and Saddam Hussein’s attempts in the 1990s to strike deals with Chinese and Russian companies were of little or no use. The US-led invasion in 2003, followed by the fall of Saddam Hussein, definitively opened the way for multinational oil companies to enter the country.

Today, in southern Iraq, multinational company presence includes Italy’s Eni in Zubair, British Petroleum (BP) in Rumaila, the US-based ExxonMobil in West Qurna, Lukoil in West Qurna 2, China’s National Offshore Oil Corporation (CNOOC) in Maysan, and also Korean company Kogas and Egypt’s General Petroleum Corporation.

The legal framework is complex and confusing, still referring to laws predating 2003. In practice, however, these companies operate mainly through a series of licensing agreements, in partnership with the state-owned Basra Oil Company. Foreign companies are entitled to a percentage of the profits per barrel of oil produced.

Regarding environmental protection obligations, there is a general provision in Articles 33 and 114 of the Iraqi Constitution introduced in 2005, stating that “the State is responsible for the protection, conservation of the environment, and its biological diversity” and “shall formulate environmental policies, in collaboration with regional governments, to ensure the protection of the environment from pollution and preserve its quality.”

***

In Shaibah, a neighbourhood in the north of the city of Zubair, sandwiched between the oil field and a refinery, the air is pungent and smelly. The only public health centre in the area, a dilapidated building lacking sufficient medical staff and medicines, has a non-functioning air monitoring system.  Nouri Sadeq Hassan Salman, 33, lives just around the corner. Salman worked at the Zubair wells until 2014, when he fell ill with chronic kidney failure. He is now waiting for a transplant. “I worked in the reservoir from 2011 to 2014. I left the job in 2014 because I got sick. The doctors told me that the illness was caused by air pollution and the conditions of the place where I work and live. There was smoke everywhere in the factory, I was paid by the day, without a contract and I earned $9 a day. When the doctors told me the probable cause of my illness, I was angry. How could I not be? I blamed myself for taking that job. But the truth is that there is no other option here.” His older brother and two cousins also work in the same wells. Salman receives no financial support, no pension and no insurance.

Like Salman, the vast majority of workers are subcontracted out, effectively exempting the multinational oil companies of from direct responsibilities in terms of pay and workplace safety.

In fact, the foreign companies responsible for developing the field and ensuring production can subcontract various parts of the production process to other companies, local or foreign, in agreement with the state company — the Basra Oil Company.

Only a minority of the workers in the field have direct contracts with international companies. They are almost exclusively engineers or managers, and most of them are non-Iraqis. In theory, 80% of jobs should be reserved for local workers, but as two Eni employees in Zubair and other sources close to BOC and the union confirmed to IrpiMedia, this obligation is never fulfilled.

The Zubair field and the surrounding urban areas, where Mutir, Salman and thousands of Iraqi families live, were the gateway to Iraq for US Marines and British soldiers in 2003. Fierce and violent battles were fought here, which, in addition to dead bodies and destruction, left behind mines, depleted uranium and, above all, a lasting legacy: the presence of foreign oil companies. This is what Abdilkarim Omran, president of the General Federation of Workers’ Unions in Iraq (GFWUI), thinks: “We believe that these companies have obtained contracts and licences thanks to their home countries’ participation in the war against Iraq. Firstly, because the contracts, including ENI’s for the Zubair field, made during the ‘licensing waves’ were not subject to parliamentary approval. These companies work against Iraq’s interests. Every year they promise us that they will put an end to gas flaring and instead they continue to pollute the air, water and land. The citizens are paying the price. Cancer rates are high. There are numerous cases of birth defects and stillborn children.”

Nahr Bin Umar, Iraq. Early in the morning, a group of fishermen from Qarmat Ali collect the nets on the Shatt al-Arab river. (Author: Daniela Sala)

At night, the outskirts of Basra are illuminated by a series of torches, visible from a satellite, brighter than the city itself. This is known as “gas flaring.” Along with the oil, a certain amount of naturally occurring gas escapes from the wells. In Iraq, companies that have not invested in recovering this gas, which could be stored and used to produce energy, are burning it. The companies thus release huge amounts of not only carbon dioxide into the atmosphere, but also other highly polluting substances which are harmful to public health, such as nitrogen dioxide (NO2) and sulphur dioxide (SO2).

In 2009, Shell estimated that if this gas would be used rather than burned, it would cover 70 percent of the country’s energy needs.

In 2018, within a 70-kilometre radius of Basra, more gas was burned than in all of India, China, Canada and Saudi Arabia combined. In the following years, until 2022, the trend remained unchanged.

In theory, Iraqi law prohibits gas flaring within 10 kilometres of homes, but in many areas visited by IrpiMedia, flares were observed burning gas within a few hundred metres of homes.

For years, multinational oil companies such as Eni and BP have promised to reduce flaring worldwide, but in reality, they are skirting their responsibilities. As documented in a recent Greenpeace investigation, British Petroleum’s annual emissions report does not count gas flares in the Rumaila field, claiming that it does not directly operate the field. If Rumaila were included in the report, BP’s reported emissions would double.

Even at Zubair, according to World Bank data, flaring is extremely high: In 2021, as much as 2.5 billion cubic metres of gas were burnt. However, Eni, which claims global flaring is 1.2 billion cubic metres, does not include emissions from the Iraqi field in its annual report.

In response to requests for clarification from IrpiMedia, Eni states that it “operates under a technical services contract signed with Basra Oil Company, BOC, in 2010 (…). Eni, therefore, does not control strategic decisions on the asset, including projects to reduce flaring.” For this reason, Eni would not be obliged to account for the gas flaring emissions produced at Zubair: all responsibilities, the company says, lie with BOC, including the emission count.

In any case, the details of responsibilities, environmental and otherwise, are contained in the licence agreements, signed between the foreign companies and the Ministry of Oil, which remain secret. Everything related to the companies goes through the powerful Ministry, to the point that the Department of the Environment — which in theory has the task of supervising their actions — can often do very little. ‘The government and the Ministry of Oil should oblige these companies to respect the law,” explains Walid Hamid, director of the Department of the Environment in southern Iraq. “Why don’t they burn the gas and spill the oil in other Gulf countries, but here they do? To save money. They do not want to spend or invest. It is more convenient for them to pollute, at the expense of the population.”

3. The Impact on Health: The Sick

While it is true that the data and research on the relationship between environmental aggression, pollution and public health are increasingly incontrovertible, it is equally true that epidemiological studies are needed to prove them. In Iraq, no studies have ever been conducted on the relationship between environmental pollution caused by multinational oil companies and the health of Iraqi citizens. Certainly, the political intention is not to raise the issue. According to the Ministry of Health, the official number of new cancer cases in Basra is about 2000 per year. But a document leaked by the same Ministry and viewed by IrpiMedia reports a figure of at least 8000 new cases per year. “We collect various data on occupational diseases from workers in the oil and gas industry, but it is confidential data. The information we collect must be sent directly to the Ministry and the oil companies. We know that there is an increase in tumours, but we have no power over the companies. That is up to the Ministry of Health,” explains Mai Taha Radi, director of the National Centre for Occupational Health and Safety, which is responsible for inspections inside the companies and conducting medical examinations of workers.

Those who fall ill with cancer in southern Iraq, an area inhabited by approximately seven million people, do not have much choice. Chemotherapy is provided by two public hospitals, one for children and one for adults. At the time of this writing, access to these hospitals has been suspended for all foreign journalists. Despite the lack of authorisation from the Ministry of Health, IrpiMedia was able to access and visit the oncology ward at Basra Children’s Hospital.

The hospital was built at the behest of Laura Bush, wife of former US President George W. Bush, after the 2003 invasion. Two signs are prominently displayed at the entrance. Both bear the logos of two oil companies: Italy’s Eni, and Korea’s Knoc, which are funding a new paediatric oncology ward as part of their so-called corporate social responsibility. Thirty extra beds in a hospital that currently has forty-five.

According to the contract, foreign companies are required to reinvest part of their profits in social utility projects and “local development “projects identified and managed by the Governor. Eni makes a big deal out of these projects: in Zubair, a few hundred metres from the entrance to the field, in a neighbourhood that lacks paved roads and drinking water, the company is building a school.

Then, in 2022, the company enthusiastically announced a project in partnership with the European Union and UNICEF dedicated to building a series of infrastructures to supply drinking water to more than 850,000 people. One of the projects supported by Eni, together with other companies, consists of refurbishing a water treatment plant on the Shatt Al Arab. Once completed, the plant will provide 19,200 cubic metres of water per day to the city. For comparison, in Zubair, just under 25,000 cubic metres of water per day are injected into wells, drawn from Qarmat Ali.

From 2018 to 2022, Eni, as conveyed to Irpi Media by the company, has invested “over 60 million in various social projects to support the health, water, and education sectors and strengthen infrastructure.”

In the meantime, however, with the ongoing war in Ukraine and the Russian fuel embargo, exports from Iraq are expected to increase steadily. And the major fossil fuel companies have already posted record profits: Eni has announced a group operating profit of 20.4 billion EUR for the 2022 financial year, more than double the figure for 2021. The same goes for BP, with 28 billion EUR in 2022.

***

In the early hours of the morning, the ward is still sleepy. All the beds are occupied by patients arriving from more distant cities such as Nassiriya, Amarah, and nearby Zubair. The mothers and grandmothers accompanying the sick children sleep on the floor on improvised beds. Ward nurses report a lack of chemotherapy drugs for this hospital, as well as insufficient equipment and personnel to carry out bone marrow transplants. In addition to the patients interviewed inside the hospital, IrpiMedia met with dozens of people who are ill or have lost a family member in the area around Zubair. Among them is Falah Hassan Sajed, son of Hassan Sajed, who died of liver cancer in July 2022. “The pollution killed my father. My wife has asthma, my eight children are growing up in this polluted environment. We can’t even get a job in the fields without a recommendation, and we don’t even have oil to light the stove. How can we think of fighting these companies?” he asks resignedly.

Zubayr, Iraq. (Author: Daniela Sala)

And yet there is a new generation of young Iraqis who are carrying out numerous campaigns and mobilisations to protect the air and water in Iraq, even at with the risk of losing their lives or being made to disappear. Ahmed (the name is fictitious), 32, is one of them. After the massive protests in Basra in 2018 due to the water crisis and the lack of basic services for the population, he decided to get involved and denounce the alleged crimes of the oil companies. He has already received a death threat for helping journalists document the pollution, but says, “I am doing it for my son and future generations.” Ahmed is a member of Humat Dijlah, an environmental organisation dedicated to defending the Tigris and Euphrates rivers and the Mesopotamian marshes. In recent years, many Iraqi environmentalists have been threatened, killed, kidnapped or forced to flee abroad. The latest was Jassim Al Asadi, a well-known face of the Nature Iraq organisation, who was kidnapped on 1 February 2023 and released after two weeks.

Meanwhile, despite the risks and threats, it is precisely Ahmed’s generation, born or raised in the wake of the 2003 US invasion, that is trying to start anew and has decided to do so from the water. It is Friday morning, a public holiday in Iraq. In front of the Shatt al-Arab, where the Tigris and Euphrates rivers meet, a group of environmentalists talk to passers-by about pollution and the problems caused by a lack of water resources. The rivers and canals of what was once nicknamed “the Venice of the Middle East” are open sewers, filled with waste and used for domestic and industrial discharges. If once their grandparents and parents, despite the conflicts and Saddam’s dictatorship, were able to live off the river, fish, and drink from the river — today this generation, which grew up in an oil-rich country with theoretically medium-high incomes, — no longer has access to clean, drinkable water. “Here in this land, civilisation was born. And here, if we remain silent and do nothing, we will see its end,” says Ahmed.

Contributors:

• Lina Issa, local producer. Lina Issa is a Syrian journalist, producer and fixer based between Prague and Erbil and working in Syria and Iraq since 2015. She worked for NBC, MBC , RTL, RTE , Paris match, New York Times, CNN , CBC, among others.
  
• Essam El Sudani, local producer.The investigation was supported by the Journalismfund Europe: https://www.journalismfund.eu/supported-projects/price-oil

Further Media publication:

• The Guardian
• The Guardian portfolio 
• Alternatives Economiques
• Aftenposten, November 2023 issue
• Geographical

“How Am I Going To Ask a Hospital for Help if the Abuse Happens in the Hospital?”: Sexual Violence in Hospitals and Doctor’s Offices

Find the original publication by Público here, find the original publication by Setenta e Quatro here.

Hospitals and doctors’ offices should be safe places, but they were not for the 47 women Setenta e Quatro spoke to. They were subjected to sexual abuse by doctors, nurses, and operational assistants and live with that trauma to this day. How has this happened over the past two decades? What are the failures of the system? Of the Justice? Of the Hospitals?

by Ana Patrícia Silva, Setenta e Quatro

She had been having unbearable menstrual pain for many months. The best solution was really to go to the doctor. She went to one appointment, then to a second. The doctor’s behavior did not arouse any suspicion in her; I would even say that the consultations were trivial. He prescribed medication and the pain stopped. But the success of the treatment required a third visit. Sandra booked it for 2023.

It was scheduled for 4 pm. It was the third time Sandra had been to that private practice in the Lisbon Metropolitan Area. She had started a treatment that was having positive results and for the first time the bleeding (and pain) had stopped. Sandra has endometriosis. It is a disease in which the endometrial tissue – the tissue that lines the uterus – grows outside the uterine cavity. It affects one in ten women of childbearing age and causes pain and possible bleeding. “Despite the pain, I was happy that something positive was happening,” she says.

She went into the office and the doctor told her to go to “the little room,” a specific room for exams. He wasn’t supposed to do tests: The appointment was for a discussion about the success of the medication. In that room, the doctor asked Sandra to take off her blouse. She was not wearing a bra.

She lay down on the couch and the doctor approached. “He brought his hands to my breasts and started groping them,” Sandra recounts. “He wasn’t supposed to examine my breasts, I hadn’t complained at any point.” For her, the type of touch was sexual, not clinical. “His gaze never crossed with mine, but I know and felt that something was going on and I wasn’t sure what it was about.” Sandra froze, or as mental health professionals say, froze. Not knowing where to look, she fixed her attention on the blue walls of the office and stayed that way, static, until the end of those two minutes that “seemed like hours” to her. It was the same blue that she used to draw pictures of doctors’ offices as a child; she liked to draw office rooms and doctors seeing patients. It’s a detail that she won’t forget now.

“Then he asked me if I had [pubic] hair on my vagina.” Sandra said no with her head. “He gestured with his hand for me to take off my panties — I had my pants undone — touching my crotch,” she explains, uncomfortable. Not knowing how to react, feeling repulsion, she turned to her left side, but the doctor, not realizing or ignoring this sign, continued. He insisted even more.

“He insisted that I take off my pants, because it was necessary to do a pelvic ultrasound on me with an endovaginal probe.” The decision to have this examination was made on the spot, Sandra says, since neither the ultrasound machine nor the necessary materials were previously prepared. But Sandra obeyed. She undressed and the next thing she knew the doctor had already inserted the probe, without even wearing gloves. “It was only yesterday that I realized that the machine wasn’t even on,” she says via video call three weeks ago.

The doctor never looked her in the eye. “He looked at the computer, changed the subject, and the appointment was over,” says the woman in her late 30s. What remained from this appointment was a prescription that itemized three packets of the medication she would have to continue taking. She never had access to the report of the supposed examination, nor did it ever appear in her medical file. It is as if it never happened.

Sandra’s case was not a “serious breach” of conduct, but, she says, sexual abuse. Generally, a gynecological ultrasound is not a test that is done routinely. “But there are many gynecologists who in private [offices] do the exam in the context of consultation, almost as an objective examination,” explains a gynecologist-obstetrician who prefers not to be identified for fear of reprisals.

Sandra has suffered a “hideous malaise” since the day she suffered the abuse. “With each passing day, the disgust I felt for myself was indescribable.” It took her a few days before she told her husband what happened: “I was abused.” Only after two months of therapy was she able to acknowledge it out loud.

Consecutive baths followed. “I felt so dirty,” she admits. Her husband couldn’t understand why she was constantly washing herself.

The act allegedly committed by the doctor falls under the crime of sexual coercion, as defined in Article 163 of the Penal Code. Sandra can still file a complaint. She has two months to do so until she reaches the maximum limit allowed by law: six months. She has been advised to do so by her psychologist and her husband, but the fear and shame she feels take up a place that still remains unattainable.

What is hidden when the door closes

Sexual violence in hospital settings and doctors’ offices exists. Although there is little consistent public data on sexual abuse committed by doctors, nurses, and operational assistants, Setenta e Quatro heard the story of Sandra and 46 other women survivors of sexual abuse (coercion or rape) in hospitals, public and private, and doctor’s offices.

All of these women state that there was never consent. Of the 47 women we heard, who were sexually abused between 2000 and 2023, only 14 gave us permission to use their testimonies in this research, which we will recount in the coming weeks. The remaining 33 stayed with exploratory interviews: the fear and emotional vulnerability they were subjected to in remembering the trauma was enormous. They didn’t want to go through it. They did not want to expose themselves, much less denounce their attackers for fear of being discredited. It is also for this reason that the names of the women subjected to these abuses are fictitious, to which we add reasons of privacy and legal protection. The crimes of coercion and rape are semi-public, that is, a complaint by the victim is required, but the authorities and public officials are obliged to report them to the competent authorities.

Over the last 12 months, we’ve spoken to specialists and legal representatives, doctors, nurses, operational assistants, mental health professionals specializing in Sexual Violence and Post-traumatic Stress, NGOs, researchers, professional associations, unions and leaders of associations to understand how all these women survivors, victims and patients remain unprotected in health services in Portugal. But, above all, how can these abuses to women’s sexual freedom and self-determination be fought and prevented?

Author: Rafael-Medeiros

We analyzed case by case, spoke with people close to the survivors, consulted court cases, read national and international reports, and looked at the few numbers of complaints and claims that exist about this context that has had a significant increase since 2015.

Of the 14 accounts we heard and were allowed to tell, three women filed complaints, but only two went to court, resulting in the conviction with a suspended sentence of a nurse. This was not the only court case to which Setenta e Quatro had access, but it was the only one in which we were able to speak with all the survivors involved.

The inexistence of protocols for action or prevention of situations of sexual violence between health professionals and patients reveals a “serious negligence” with which the subject is treated by Portuguese health institutions, say various specialists. Complaints do not always reach the competent entities and internal inquiries are not always made.

Besides this, there is no national protocol for prevention and procedures in cases of sexual violence between users and health professionals. The same does not happen with moral and sexual harassment among health professionals: Each Health institution decides internally how to proceed when a health professional sexually violates a user, but by law it must open an internal investigation and report the complaint to the judicial authorities.

The same happens in Justice: from complaint to conviction, the process is very long. And because of this, many victims end up giving up or not coming forward at all — often the lack of material evidence leaves them in judicial limbo. There are no surveillance cameras inside health institutions (they are not allowed by the privacy law), material evidence is often not collected within the legal 72 hours, this is when there are material traces and in case they return to the place where they often suffered the abuse. Not all hospitals have rape kits prepared to collect evidence and this can result in women sometimes having to travel hundreds of miles to other health facilities.

In the case of the archipelagos of Madeira and the Azores, “the reality is much more difficult.”

Even so, Teresa Maria Magalhães argues that it all depends much more on the “victim than on Forensic Medicine”. “The victim doesn’t even need to file a complaint; if she wants to, she goes directly to the hospital’s emergency department, and the hospital should call the medico-legal expert. But if there are delays, it’s because most of them don’t arrive within the window of opportunity that we consider to be the adequate time to safely collect the evidence”, reiterates the professor of the Department of Public Health, Forensic and Medical Education at the Faculty of Medicine of the University of Porto. But these traces do not always exist. And these women survivors don’t always manage to get there.

Another possibility is to go to a Crisis Care Center, such as the EIR – Emancipation, Equality and Recovery Care Center, coordinated by UMAR, but there are only two in Portugal: in Porto and Lisbon.

Besides all these obstacles, the recognition of the abuse by the victims is a painful process. It involves phenomena of guilt, social stigmatization and even shame. The questions they ask themselves are constant: why they didn’t prevent or do something to prevent the abuse becomes a dead end.

“An issue that is given little relevance and that is more or less proven both in other European countries and in Portugal, and this is a similar physical phenomenon: many times the women do not present traces, because they enter in that frozen state, I will use the English expression: the freeze,” explained Helena Leitão, Prosecutor of the Republic who finished at the end of May her second term as a member of the Group of Experts on Combating Violence against Women and Domestic Violence (GRÉVIO) of the Council of Europe. “They authentically freeze, and that was often used by the opposition, because if there is no trace, it means there is no counter, almost as if it is ‘the woman’s fault’.”

Violence against women is widespread throughout the European Union: “one in three women suffers from sexual violence,” reads the directive proposed to the European Commission in March 2022 on combating violence against women and domestic violence.

A study done by the Emancipation, Equality and Recovery Care Center (EIR), coordinated by UMAR and to which Setenta e Quatro had first-hand access, goes even further: if health professionals, due to their proximity to patients, are in a strategic position to detect risks and identify possible victims of violence, 73.2% of the 325 respondents said they did not feel safe to respond to a request for help from a victim of sexual violence.

Asked whether they had specific training in sexual violence to intervene in such situations, 93.8% of the respondents answered they did not. In addition, 73.2% responded that they did not know about specialized support services for victims of sexual violence, says the study The Challenges in Intervening with Victims of Sexual Violence: A survey of professionals, which will be made public in the coming weeks.

Prescribing a stigma that makes sexual violence invisible

“Who would believe me?” is a question that soon comes up in the cases we heard: all the victims and women survivors we spoke to who did not press charges, citing the status that abusers have and the profession they work in (doctors, nurses, but also operational assistants) as the main reason for giving up. And the few women who did press charges felt at some point in the process that their word would be challenged, because it would always be the word of “a woman against that of a doctor or nurse,” or because they considered “something like this unlikely to happen inside a health care institution.”

“There are no professions or social statuses immune to sex offenders,” reiterates Catarina Barba, a specialist in Sexual Violence and Post-Traumatic Stress to Setenta e Quatro. There is an urgent need for social and cultural deconstruction: “it’s not because a doctor who supposedly ‘protects’ us, who ‘takes care of us’, who ‘studies hard’, stops being a potential sexual aggressor – or any other health professional”, she says.

The number of complaints from users reaching the Health Regulatory Authority (ERS) warns of this: complaints about violence, aggression and/or harassment have increased dramatically since 2015. In 2022, the total number of complaints was 149: 28 cases in private hospitals with hospitalization, 15 in private hospitals without hospitalization, 79 in public hospitals with hospitalization, 19 in public hospitals without hospitalization, seven in “social” (nursing homes or long-term/palliative care) and one in “social” without hospitalization.

Author: Rafael-Medeiros

Less than six months have passed since the year 2023 began and 58 complaints have already been filed, which is 69% of those of the previous year.

This reality was even more nebulous until 2014, when ERS started receiving complaints and claims from users against health professionals. However, the health regulator does not discriminate, because of the privacy law, in its statistics the situations of sexual violence, grouping them under the same heading: “violence, aggression or/and harassment”.

In statements to Setenta e Quatro about what procedure is carried out after receiving a complaint, it replied that, “when it detects evidence of non-compliance and fundamental requirements or procedures for patient safety, it proceeds to a more in-depth evaluation of the situation, through specific diligences with the providers and/or proceeds to the opening of a new process of inquiry, evaluation or even administrative offense.

As far as public hospitals are concerned, the investigation process is the responsibility of the Inspectorate General of Health Activities (IGAS). Setenta e Quatro insisted for several months with IGAS to be able to understand how many of the complaints resulted in the opening of an investigation and, of these, how many in court cases, but we did not get a response until the publication of this investigation.

Over the last month, Setenta e Quatro tried to find out from the Ministry of Health if it was aware of the complaints, what type of procedures are opened in hospitals, and what measures or regulations existed, but it did not get a response until the publication of this investigation.

If in the last decade the numbers have been growing with the ERS, the same is true both in number of cases and in number of criminal complaints. Let’s look at the Annual Homeland Security Report (RASI) of 2022. When it comes to serious violent crime and sexual crime, the report only highlights child sexual abuse (including child pornography) and the crime of rape.

Published in late April, the report indicates that there were 519 recorded cases of rape in 2022 alone. That’s a 30.7% increase compared to 2021, when there were 397 cases, a 72% rise since 2015 – there was also a peak in 2019 with 431 cases.

If the cases seem rare at first glance, the director alerts to a reality that is worrying: the survivors, victims of sexual violence, who contact the service center have a very different number compared to those of domestic violence. The center received 153 complaints of sexual violence in 2022, and was only aware of one case in a hospital setting.

“What we have noticed is that because sexual violence is still a very invisibilized violence, women do not seek help from the center. There is a lot of stigma,” adds Marisa Fernandes, a psychologist at UMAR’s service center and one of the authors of the report on the challenges of intervening with victims of sexual violence. The number of requests for help has indeed increased, but this increase has not been observed in the opening of legal proceedings or even in effective monitoring of survivors, say Marisa Fernandes and Ilda Afonso.

Although 154 countries have passed laws on sexual violence, they do not always apply the internationally implemented standards and recommendations. Portugal is one such case. “The Council of Europe since 2008 has recommended the existence of at least one Crisis Center for every 200,000 women and currently there are two specialized centers for women victims of sexual violence, one in Porto and another in Lisbon,” says Marisa Fernandes, with Ilda Afonso corroborating it.

“It is notorious that both in the process of denunciation and in the support to victims there are failures and difficulties in providing answers, especially by the professionals who intervene directly with the victims. It is necessary to review intervention practices, increase the number of specialized care and follow-up responses and train professionals who intervene in the field of sexual violence,” warns Ilda Afonso.

If sexual violence in hospital settings is seen as “isolated acts” because of the scant numbers that are publicly revealed, it becomes even more difficult to prove how in these cases a person’s trauma can “link the victim to the aggressor.” “There may even be ‘just’ something in the treatment that makes us feel uncomfortable, but we were. Why? Because we need the doctor, we need that consultation, we need that treatment that only ‘that’ person can define”, stresses psychologist Catarina Barba, a specialist in Post Traumatic Stress.

Rui Ferreira Nunes, a psychologist who has worked extensively with people who have suffered sexual abuse, stresses that in clinical terms we know that there is a compulsion to repeat. “A person who has been abused may be abused again in a context that somehow replicates the experience of the first abuse. In a situation where there is a power differential, the person is somewhat at the mercy of the other, since they are usually in a position of vulnerability.”

The psychologist’s consideration is not at all distant from what Catarina Barba tells us about such acts happening in hospital settings. All these circumstances “discredit a woman: the one who was touched and the one who was raped. And it discredits her, “especially in a hospital setting where other people circulate, where there is the awareness and the feeling that one is not alone and at any moment someone might see or hear,” Barba concludes.

A patient’s word against a doctor’s

In her home in the central region of the country, Paula tells how being a mother is a challenging process. Ten years later she realized what had happened to her: “I was sexually abused by a doctor who was 20 years older than me.”

“Therapy helped,” she begins by saying by video call.

One summer, when she was 20, she decided to take her mother’s suggestion and went to her gynecologist and had two appointments. Even then she suspected she might have endometriosis, but she had to wait months for an appointment at the public hospital in her area of residence. Worried, she wanted to be examined as soon as possible, because the menstrual pains were very strong.

The medical office was divided into two parts: the place by the window where the doctor sat with his back to his desk with his computer and some important tools. On the opposite side was a small place reserved by a curtain, around a couch, which clustered on the left side a small island of medical instruments and the ultrasound scanner.

Paula entered, took about five minutes to explain to the doctor what was going on, and he asked her to lie down on the bed to examine her. “I was being watched by him, on the stretcher, and I asked him if it was normal to have pain during [sexual] penetration,” Paula says. What followed left Paula not knowing what to do and how to react: “He started penetrating me with his fingers and kept, over and over, trying to give me an orgasm.” She didn’t have one.

He kept going and she couldn’t react, the “shock was so great” that Paula remained inert, completely blocked, without moving. “I just wanted it to be over so I could get up and leave,” she admits, anguished. After that, she can’t remember if she said anything else to him. But she does remember one detail that haunts her to this day: he wasn’t wearing gloves. “I panicked,” she says.

This case touches on several issues raised in this investigation. Let’s start with gloves. The standard issued in January 2012 by the Directorate-General of Health (DGS) — a joint proposal between the Department of Quality in Health, the Program for Prevention and Control of Infection and Antimicrobial Resistance, and the Medical Association — leaves no room for doubt. “Gloves must be worn when contamination with blood or other organic fluids is anticipated,” reads the document. In other words, gloves must be worn when touching mucous substances, because they secrete fluids. Anything of this nature cannot be touched without some kind of protection.

In 2009, the World Health Organization (WHO) also recommended it in the Glove Use Information Leaflet. The document reads: “the use of medical gloves is recommended to reduce the risk of health professionals’ hands becoming contaminated with blood and other body fluids.”

But these are far from being unique cases of doctors not wearing gloves when examining patients. All the reports from women we heard about the specialty in Gynecology reported not having been examined with gloves. And this data is relevant because it shows the predominance of a “sexualization of an act that is clearly premeditated,” says Catarina Barba, the psychologist in Sexual Violence and Post Traumatic Stress.

Author: Rafael-Medeiros

Paula’s discomfort grew greater and greater as the doctor approached. She has become so immobilized that her legs are no longer strong. Her voice trembles as she struggles to remember what it took her a year to try to forget. She swallows hard. She knows that after this conversation she will spend a week anxious about having relived everything, but most of all about having verbalized it.

After what happened, Paula began to feel guilt. “Guilt for asking something that somehow could have induced some act.” The way she dealt for a decade with this memory — even if repressed in some details — was that “the doctor was showing me something that I was supposed to know and that was not sexual abuse, because the way they represented these moments in the movies was something violent, with a stranger, where a person does not give consent,” she adds.

For Marisa Fernandes, this is a “belief” that needs to be deconstructed. The number of rape crimes committed by strangers is lower, as we verified in the RASI, 36.3% of cases in 2022. “Rape and abuse cases are perpetrated less and less by strangers, we need to demystify this belief that the culprit is a man standing there on a corner, ready to attack the victim. When, in fact, the aggressors walk among us. They are people who transmit this confidence and in whom we trust to a certain extent,” explains the psychologist.

Unlike Sandra, Paula was not alone. Her mother had accompanied her and was waiting for her in the waiting room. She was also the one who encouraged Paula to talk to Setenta e Quatro about what had happened to her. “I feel safe doing this for me and for her,” Paula says, as she joins her hands with her mother’s and adjusts a bracelet.

“As soon as I saw her [leaving the office room], I knew something bad had happened,” shares her mother. Her eyes filled with tears as she recalled one of the most traumatic episodes in her daughter’s life. “I ran to get her, she was very disoriented. She was limping, she almost fell. When we got in the car, she started rocking back and forth, crying hysterically,” she continues in anguish. The mother didn’t know what to do. Paula just asked them to leave. She couldn’t be there.

Since then she has never been back to a male gynecologist, has never been seen by male doctors, not even in other specialties, and is extremely anxious every time she thinks about going to a hospital, to a doctor’s office, or even about having tests done. Paula had her daughter with much fear and caution. The doctor who accompanied her during pregnancy was a long-time friend and all the obstetric exams were done with professionals she knew. Otherwise “I would not have returned to a hospital or a doctor’s office.”

Taking a denunciation forward is a process that carries several complex stages and, for this reason, many victims end up giving up or not going forward at all. “These are extraordinarily fragile and painful crimes for the victims and for all the actors who have to come into contact with them,” explains Helena Leitão, a prosecutor who is finishing her second term as a member of the Council of Europe’s Group of Experts on Combating Violence against Women and Domestic Violence (Grévio).

Sandra’s and Paula’s stories are two of the 47 collected by Setenta e Quatro against doctors, nurses and operational assistants from hospitals (public and private) and private practices. The vast majority of health professionals (doctors and nurses) have not been removed from their positions, even when there are lawsuits in court.

Paula’s mother encouraged her to go ahead with the complaint, but the feelings of guilt and shame weighed heavily again: they gave up because they realized it was a “one-way street.” “When I tried to figure out what to do, a lawyer friend said she wouldn’t stand a chance.” It was the word of Paula, then 20 years old, against that of the doctor, a socially respected professional.

Author: Rafael-Medeiros

The unthinkable for any victim of sexual violence happens, and not infrequently in Portugal: being abused in the place where you should feel safest – in a hospital or doctor’s office. The testimonies, the numbers, the legal implications and the stigmas associated with a problem that has been in the news in recent weeks.

by Cláudia Marques Santos, Público

Manuela left the emergency room in a hurry, but in an effort, with small steps. They even made her sign a waiver and she walked out the door. She couldn’t stay there for another second. Two months ago, Manuela was lying on a stretcher in the emergency room of a public hospital in Portugal’s Centro region because of hypothermia – Manuela is  immunosuppressed – when she recognised the voice of the nurse who raped her, she was 16 years old. “I was in the emergency room for seven hours. At shift change,  I recognised the voice,” says Manuela, now 34. She had never been back to that emergency room again. But this time she hoped that her rapist was retired.  She pretended to sleep, pulled up the blankets, and covered her face with one arm.  The nurses stopped in front of the bed where she was. “If he had any doubts about  who I was, he didn’t anymore. When I was sure he was far away, I called the doctor and said I wanted to leave,” Manuela explains, noting that the doctor advised her  against it because they needed to do more tests. “While they went to get the consent form, he passed my stretcher seven or eight times, teasing me.” Manuela is sure he recognised her. She hid the catheter for fear that he would take it out. She got up slowly because if she fainted, she would stay in hospital. She started walking as best she could and got out of there. She removed the catheter herself, at home. “I thought  I’d got over it and it turned out that everything was still inside.”

Publico (c) Joana F. Bastos

“He” is the nurse who raped her 22 years ago. It wasn’t the first time that Manuela had tried to kill herself by taking an excessive dose of pills. Autistic, Manuela was very thin and was constantly  bullied by her classmates at school. Her relationship with her mother didn’t help either.  At the hospital, her stomach was pumped, and she was put in a ward to recover.  A man in scrubs approached her, he had a name written on his lapel, which she still  remembers today, as well as his face, voice, and smell. “I was in a room with more  beds and this man took care to look around before entering,” says Manuela. “It was the kind of conversation he approached me with… to see how I would react if I would shout, push him. He was trying to understand who he was dealing with. And he realised that there was someone there who was extremely vulnerable. ‘You deserve to live’ and he petted my hair.” He sedated her. She woke up the next day with blood  and pain in her vagina.  

Numbers on the rise  

The act perpetrated by this nurse may constitute several crimes: rape (foreseen and  punishable by article 164 of the Penal Code [CP]), in which there was vaginal  copulation or the introduction of objects into the vagina; sexual abuse of a person  incapable of resistance (article 165 of the CP); sexual abuse of a person in hospital  (article 166 of the CP); and, as Manuela was 16 years old at the time of the events,  sexual abuse of minors – between 14 and 18 years old – who are dependent or in a  particularly vulnerable situation (Article 172 of the Criminal Code) can also be considered to have taken place.  

Manuela still tried to file a complaint, but gave up when her mother wasn’t  allowed into the Public Prosecutor’s office, where the abuser and his lawyer would  also be.  

There have been several news reports about recent cases of rape and sexual  coercion. This Wednesday, for example, there were many reports about a radiologist  with a private practice in Bragança who was brought before an investigating judge  accused of two counts of rape. In 2022, the Health Regulatory Authority (ERS)  received 149 complaints of “violence/aggression/harassment”, without distinction:  28 cases occurred in private hospitals with inpatient care; 15 in private hospitals  without inpatient care; 79 in public hospitals with inpatient care; 19 in public hospitals without inpatient care; 7 in “social” care (nursing homes or long-term/palliative care); and 1 in “social” care without inpatient care.  

In the last decade, the number of rapes has been growing, both in terms of  cases and complaints. The recently published Annual Internal Security Report (RASI)  for 2022 indicates that in 2015 there were 375 cases of rape and in 2019, 431 cases.  In 2022, there were 519 cases, which means an increase of 30.7% compared to the  previous year (397).  

As for complaints from victims of aggressors who are health professionals – and according to ERS data – while 58 complaints were filed in 2015, this number has  already been equaled in 2023 and up to May. “It should be noted that (…) the ERS is  carrying out a more in-depth assessment of the situation, through specific steps with  service providers and/or the opening of a new investigation process,” the ERS replied  in writing, along with the latest figures. PÚBLICO insisted on finding out from the General Inspectorate for Health Activities, which is responsible for taking steps when  complaints are lodged with public hospitals, how many of these complaints resulted  in an investigation being opened and, of these, how many went on to trial. There was  no reply.  

For this work, we contacted 47 victims of sexual abuse – coercion or rape – in  a hospital setting, both public and private, or in a doctor’s surgery. Of these 47, only  14 agreed to share their experience. The remaining victims stuck to exploratory  conversations and gave up talking to us: all of them out of fear – of exposure, of  possible reprisals – and many out of an emotional inability to live through what happened again.  

Of these 14 victims, three filed complaints, two of which were charged and tried in  court and resulted in the perpetrators being sentenced to suspended prison  sentences. All the victims we spoke to who didn’t press charges mentioned the  “social status” of the abusers – doctors and nurses – as the main reason. Their word  would “always be worth more” in court than theirs. But there are other causes: the coldness of the rooms in hospitals and police stations to deal with them, the lack of training for professionals to deal specifically with their situation, and also the legal  time to file a complaint, which is very short. Victims only have six months to do so. “How am I going to ask a hospital for help if the abuse happens in the hospital?” asks psychologist Catarina Barba. “And sexual violence always has these characteristics:  it’s someone in a relationship of power – be it a parent, a teacher, a neighbour, the babysitter, the doctor.” This psychologist specialising in sexual violence and post traumatic stress makes a point of stressing that there are no professions or social  statuses immune to the profile of a sexual aggressor. “But we have these prejudices:  a doctor is ‘someone who looks after us’, who ‘protects us’. Someone who has  ‘studied a lot’ and therefore ‘has a different way of being’,” she adds. “This skews  our ability to understand that this doesn’t mean that a doctor can’t be a sexual  aggressor.”  

The victim, from trauma to awareness  

The first thing her mother told her about the psychiatrist she had just been referred  to was that he was known for being a womaniser. Her father had committed suicide when Sara was 13, because her mother wanted to separate, and from the age of 15,  Sara was regularly sexually abused by her stepfather. When she went to college, she met a boy and they started dating. Sara says she used this “ruse” to try to get rid of  her stepfather. She remembers the terror she felt whenever she was left alone at home  with her mother’s new partner. He wasn’t working at the time. All she could think was:  “Let’s get this over with”, so that she could free herself from the feeling of terror for the rest of the day. “It was as if I knew I would just stand there, static and… just  waiting for it to be over. There was no subtlety there.” She calls it the “terror without a name”.  

When she was 19 or 20 – she can’t remember exactly – Sara and her boyfriend broke up. “I was devastated. I’d been going through that violence for years,” says  Sara, now 48. We’re in the consulting room of her current psychologist, whom she  made a point of accompanying for this interview. “For the first time, I really fell apart.”  She went to the psychiatrist her mother suggested, “well known in the area”, with a private practice in the Lisbon Metropolitan Area. He’s no longer alive. She was given medication and Sara got better. “He was a very cultured person,” she describes,  explaining her fascination with the man: “He spoke to me about things that were  much more erudite than people my age.” Once, the psychiatrist took the book Moderato Cantabile by Marguerite Duras and started reading it to her during his consultation. “It’s a book about a married woman from the early 20th century who  starts going to a tavern where she meets a man and drinks glasses of wine.” She remembers that, sometime later, she was walking down the street and trying to convince herself that it wasn’t the same as what had happened with her stepfather. “But  what I felt was the same. So I didn’t feel well, I didn’t,” Sara admits. “Obviously because it wasn’t really a free choice on my part. I was manipulated and led to a certain place to make it happen.” It wasn’t until she was 30 that she realised it was  abuse.  

This abuse is defined as a crime in Article 165 of the Penal Code and concerns “anyone who engages in a sexual act with a person who is unconscious or otherwise  incapable of resisting, taking advantage of their state or incapacity.” In court, judges  even question why there are no physical marks of a struggle on the victim’s body. In  a dangerous situation, present in any violent act, our brain reacts automatically to protect us, explains psychotherapist Rui Ferreira Nunes. “There are three possible  responses on the part of the victim: the fight, which is a reaction of struggle towards  the dangerous stimulus; the flight, almost like a reaction of flight in the face of danger;  and the freeze, seen as a reaction of paralysis in the face of the dangerous situation,  which is often questioned from a legal point of view,” says Ferreira Nunes. “These are behaviors that can be reproduced both during and after the abuse.” Juliana feels ashamed to have been a victim of sexual coercion in a private hospital in the central  region of the country. “I feel ashamed that anyone knows I was in a situation like that.  Shame is the dread behind exposure.”  

Juliana is now 32 and was abused by a doctor when she was pregnant at the age of  29. She has never been to therapy, although she is aware that she should have. “I  thought it would pass. But I’m not getting over anything. To get over something, I  have to go to therapy, to talk.” Juliana told us that the fact that she shared her story  with us relieved her, in a way.” Awareness is always a complex and very time consuming process, I would even say delayed, for various reasons. One of them is  the shame inherent in the situation. The victim often feels guilty about what happened,  thinking they could have done anything to prevent the abuse: run away, said no,”  explains Rui Ferreira Nunes. “Shame becomes a very toxic feeling.” 

Some people take years to deal with the trauma. That’s why, from legal experts to  Non-Governmental Organizations (NGOs) linked to victim support, the argument is  unanimous: the maximum time of six months after the abuse to file a complaint is  too short and the crime should not be semi-public, but public. “It’s absurd,” agrees public prosecutor Helena Leitão. “If the crime is public, it’s not even necessary to discuss the deadline for filing a complaint. It means that, as long as the crime doesn’t  lapse – and a crime of this nature can take up to 15 years to lapse – the investigation  can go ahead regardless of the victim’s or family’s wishes,” explains Helena Leitão. “The truth is that the victim may not want to press charges for various reasons,  ranging from wanting to forget what happened to her once and for all, to the shame and guilt she mistakenly feels, to pressure from her family who may say, ‘we’ll be  marked’. And even on the part of boyfriends or husbands, there can be a lack of  understanding.”  

One day, a few weeks into her pregnancy, Juliana had a headache and went to the health center. There, she was told that she should have already had her prenatal  tests. As there was no immediate vacancy at the public hospital, she decided to pay  for the ultrasound out of her own pocket and went to a private hospital, also in the central region of the country. “The doctor gave me the touch test, the test where he  puts his finger in my vagina, and I was surprised,” says Juliana. “I thought this test  was only done when a pregnant woman was about to give birth. But as it was the  doctor, I didn’t question it.” He didn’t wear gloves. The doctor then asked her to get  on the scales to weigh herself. As she passed him, he brushed his hand across her  bottom and let it rest there for a moment. Juliana was only wearing the gown she had  been given by the hospital. Juliana ended up pushing his hand away. “You think you  can have 1001 reactions, like ‘I’d hit him’, ‘I’d make a fuss’, but I was paralysed.” She  remembers the doctor’s lecherous smile well. As soon as she could, she left the  hospital. She didn’t even take the test. “If I was thinking of having a second child, I’m  not anymore,” she confesses. “I can’t go back to that place, the place of being pregnant.”  

Publico (c) Joana F. Bastos

Abuse situations are similar to panic situations, explains Rui Ferreira Nunes. “The  person doesn’t know how to react. They’re taken by surprise and their brain stops  thinking, stops using its cognitive functions in the direction of action, because  emotionally it’s blocked.” Catarina Barba says that sexual violence is something  that takes away all sense of control.  

Little support for the victim, little training  

Porto’s Service Center of the NGO UMAR – União de Mulheres Alternativa e Resposta  (Union of Alternative and Responsive Women) only became aware of one case of sexual abuse in a hospital setting last year. UMAR’s president and psychologist, Ilda  Afonso and Marisa Fernandes, warn of a worrying reality: the number of women who  are victims of sexual violence who contact the service centre is very low compared to  victims of domestic violence. Marisa Fernandes ventures an explanation: “What we’ve  noticed is that, because sexual violence is still very invisible, women don’t seek help  from the center. There’s a lot of stigma.” Marisa Fernandes is also one of the authors  of the UMAR report entitled The Challenges of Intervening with Victims of Sexual  Violence: A study with health and education professionals in the district of Porto.  Dated March, this report – not yet available online – presents the results of a survey  of health professionals in that district, in which 29.7% say they have major problems  with the external articulation of the action protocol defined for situations of sexual  aggression and 26.1% report difficulty in identifying the situations themselves. When  asked if they had specific training to intervene in this type of situation, 93.8% said  they had not. “It is notorious that, both in the process of reporting and in supporting  victims, there are shortcomings and difficulties in providing a response, especially on  the part of the professionals who intervene directly with the victims. There is a need  to review intervention practices in the field of sexual violence, increase the number of specialised care and follow-up services and train professionals,”  argues Ilda Afonso.  

The European Council Convention on preventing and combating violence  against women and domestic violence, signed in May 2011 in Istanbul (Istanbul  Convention), is a binding international legal instrument that establishes a legal  framework of measures to be implemented by participating states to protect women  from violence. This convention was ratified in Portugal in February 2013 and entered  into force in August 2014.  

“Since 2008, the Council of Europe has recommended that there should be at least  one crisis center for every 200,000 women. In Portugal, there are currently two  specialised centres for women victims of sexual violence, one in Oporto and the  other in Lisbon,” denounce Ilda Afonso and Marisa Fernandes.  

Until the end of last month, public prosecutor Helena Leitão was one of the  fifteen independent experts responsible for monitoring the application of the Istanbul  Convention in the various member states, as part of the so-called GREVIO  committee. “When I came back from the meetings in Strasbourg and started to see Lisbon from the plane, I admit that I was thinking almost unconsciously: ‘for a few weeks I’m going to be better with myself and with life’, because I’m aware that,  unfortunately, the situation in the other countries of Europe is no better than in  Portugal.”  

The Shadow Report presented in 2022 to the GREVIO committee by the NGOs Associação de Mulheres Contra a Violência, Plataforma Portuguesa para os Direitos das Mulheres and European Women’s Lobby, considers that – and taking into account the committee’s General Recommendation no. 35 – neutrality in laws is no longer acceptable. In her book Medusa no Palácio da Justiça ou uma História da  Violação Sexual (Medusa in the Palace of Justice or a History of Sexual Violation), sociologist Isabel Ventura corroborates the presence of patriarchal culture in the law  itself. “The difficulty (or even inability) to think of women as authors, decision makers  and holders of an active sexuality that is not dependent on (and at the service of) male  actions is continually present in the speeches of Portuguese penalises, before and after the 2007 penal reform. This is what Figueiredo Dias says, when he assures that ‘rape always requires the intervention of the male sexual organ’, or that  ‘copulation is thus only the penetration of the vagina by the penis’, and even that ‘the  common meaning of coitus requires a conjunction of bodies with other organs or with  any objects’.”  

Furthermore, the precept is that the intensity of the crime is proportional to the  victim’s reaction. “All this clearly indicates that the victim is still obliged to present antagonism. They are only exempted from this imposition if they are prevented  from doing so, in other words, if they are unconscious or semi unconscious,” the book also states.  

Lack of harassment kits in hospitals  

“I only realised yesterday that the machine wasn’t even on,” Sandra said via video  call three weeks ago. In April last year, she went to a gynaecologist with a private  practice in the Lisbon Metropolitan Area for the third time because of endometriosis problems. Endometriosis is a disease in which endometrial tissue, the tissue that lines  the uterus, grows outside the uterine cavity and can spread to other organs.  Sandra entered the office and the doctor asked her to go to the examination room.  He told her to take off her upper garment and lie down on the couch. The World Health Organization recommends that two health professionals be present for  gynaecological examinations, which was not the case. “He took his hands to my  breasts and started to feel them,” says Sandra, 32. “I felt something was happening and I wasn’t sure what it was.” Sandra froze.  

Publico (c) Joana F. Bastos

“Then he asked me if I had hair on my vagina.” Sandra nodded no. “He gestured with  his hand for me to take off my underwear, touching me on the groin,” she explains  uncomfortably. Sandra even turned to her left as a sign of refusal. “He insisted that I  take off my underwear because I needed a pelvic ultrasound with an endovaginal probe,” a decision that, according to Sandra, was made on the spot, because  nothing was prepared for that examination. She obeyed, took off her underwear and  the next thing she knew, the doctor was inserting the probe without even wearing  gloves.  

Washing themselves because they feel dirty is a common reaction among victims of sexual abuse. This means that the presence of the abuser’s fluids in the victim’s body is drastically reduced. This examination is carried out by a forensic doctor,  who is called to the hospital, and it is recommended that the victim comes forward within a maximum of 72 hours.  

“Most of the victims don’t arrive within that window of opportunity that we consider to be the right amount of time to collect traces safely,” explains Teresa Maria Magalhães, coordinator of the Forensic Medicine and Forensic Sciences unit of the  Department of Public Health Sciences, Forensics and Medical Education at the  Faculty of Medicine of the University of Porto. “They often wonder if they’re going, if  they’re not, and they come back three, four, five days later, sometimes much longer.  And they come after they’ve urinated, after they’ve eaten, after they’ve washed  themselves, washed their clothes, thrown their clothes away. After a series of things  that have resulted in nothing less than the destruction of traces.” For adult victims,  the law on medico-legal examinations stipulates that the doctor in the emergency  room can receive the person and take the samples, explains this forensic medicine  specialist. “And the person is seen at the Institute of Legal Medicine and Forensic  Sciences the next working day. The material collected goes to the genetics  laboratory.” But these cases carry a risk. “When forensic medicine specialists don’t  take the samples according to the rules, they may not be done as well and sometimes  a poorly taken sample, a poorly preserved sample or a poorly sent sample can be worthless in terms of evidence.”  

From conviction to suspended sentence  

She has passed her attacker several times in the street. Today, Carlota no longer looks away when she passes the nurse who abused her in the emergency room of  the public hospital in a small town in the Alentejo region 14 years ago. Carlota filed a complaint, which went to court and resulted in a conviction. She believes that she  only won the case because her abuser was the target of another lawsuit brought by  Ana and Joana for the same reasons. 

In a small town, Ana and, above all, Carlota were victims of threats and  bullying. They were booed, called liars on the way in and out of court. They would  pass Carlota’s house and shout abuse at her. His family also threatened her. They  sometimes told her if she wasn’t ashamed that she was “ruining life” for the boy. The courtroom was always full. Seven years passed between the filing of the  complaint and the judgment of the Court of Appeal – he appealed against the  conviction at first instance.  

One day, she began to lose strength in her legs. She went to the emergency room, taken by her sister. “You go to the hospital, and you feel safe. You’re sick and  you go there to get well,” says Carlota. She begins: “The nurse came in and closed  the curtain. I didn’t suspect.”  

The nurse took blood from Carlota and then told her he was going to give her  pain medication. In court, it was proven that she had been drugged. “We’ve lost our  sight and hearing and all physical strength. We were blocked,” explains Carlota. “He  warned me, saying: ‘Don’t worry, you’ll start to feel light and everything is fine. Just  relax’. He left and then came back.” The nurse used Carlota’s hands to masturbate while repeating phrases like: “Do you like anal sex?”; “Do you like blow jobs?” in her  ear. “I have the idea that I only had my eyes open, as if I was shouting, but I couldn’t do it. I’m sure that if he didn’t drug people, he wouldn’t touch anyone, least  of all me,” she says assertively. “When he started touching my body, I thought: ‘I want to die right now’. And I felt a force in me that made me black out.”

Carlota was outraged as soon as she remembered what had happened to her in the emergency room, and was already in her sister’s car returning home. They immediately went back to the hospital to file a complaint. “I got there and told a nurse that I wanted to complain. She arrogantly told me to start talking while she tore up some paper to write  it down,” says Carlota. “If I was already completely lost in my life, having that insensitivity killed me.” She filed a complaint and returned home. Her mother got the  whole family together and all her uncles came home. “This was a huge wave of love  for me. But at the same time, a huge shame.” Carlota took a shower, she felt dirty.  The family decided that Carlota would go to the police. It was late at night when she  entered a PSP police station. The officer, says Carlota, was in shock and felt her pain. He became her witness in court.

Later that night, he took her to hospital for a blood test. “They wouldn’t let my family in. So he stayed by my side the whole time, he never left me alone,” Carlota says emotionally. “When we got there, he said: ‘The victim made a complaint that she was sexually abused in this hospital in the afternoon and  we wanted to do a blood test to see what kind of drug it is, because this counts in court’.” The doctor she told claimed that Carlota could have arrived at the hospital on  drugs. “The policeman freaked out. He said it was shameless. They did urine and blood tests. “I went into the bathroom alone and this officer was always at the door. I felt safe.” Carlota spent three years in court. “They were the worst years of my life,” she says. She never walked alone and was always looking everywhere. “It was a  mixture of shame, humiliation, revolt and injustice. All at the same time. Not least because he filed a libel suit against me.”  

The Victim’s Statute, approved in September 2015 and in parallel with the Code of  Criminal Procedure (CPP), establishes that the questioning of victims must be carried out by a person of the same sex, unless it is carried out by a public prosecutor or a  judge. Measures must also be taken to avoid eye contact between victims and defendants in the courtroom. A particularly vulnerable victim can even  give their statement in advance, recorded and used for “future memory”. “Until  recently, judges understood that it was indispensable to the discovery of the truth for  victims to repeat their testimony at trial. Fortunately, this practice is being reversed,”  says public prosecutor Helena Leitão. “Things will tend to move in a positive direction. But these processes take time. Neither laws nor mentalities evolve quickly. There may also be a tendency for the legislator to seek to safeguard the stability of  the certainty of the law, particularly criminal law and criminal procedure.”  

Carlota felt a lot of shame in court. “I felt like I was being judged for being there.  Everyone knew who I was, the exposure…”, she explains. Some people even spat at her as she left the hearing. “It was horrible in court. I could see the attacker from the front. I could see him laughing as I spoke. It was as if I was on a terrace.” Carlota’s  case resulted in a conviction, a four-year suspended prison sentence and payment of  compensation. The defendant appealed against the decision, but the Court of Appeal  increased his suspended sentence to five years and the amount of compensation to  be paid doubled.”It’s very rare for an aggressor’s first conviction in a criminal case to  be a prison sentence,” says Helena Leitão. “Between a prison sentence or a sentence  to be served in freedom, Article 70 of the Portuguese Penal Code is clear when it  stipulates that preference should be given to the latter, whenever it ‘adequately and  sufficiently fulfils the purposes of the punishment’. In other words, whenever a judge  considers that it is sufficient for the defence of public order, as well as for the socialisation of the aggressor, to impose a sentence to be served in freedom,”  explains the public prosecutor. “In systematic terms, the criminal law is structured like  this: the perpetrator should be given a second chance whenever possible. But there  are clearly cases and types of crime were giving a second chance is not justified.  Above all, the victim has to feel that the legal and social system protects her.”  

Carlota still suffers from vaginismus today. “There are causes of sexual problems in  adult survivors that are related to the mind-body dissociation that occurred during  sexual abuse, a defence that arises as a way of preventing pain during the sexual act,  but which ends up also preventing pleasure,” explains psychotherapist Rui Ferreira Nunes. “Another mechanism is the loss of sensitivity in different parts of the body, as if they were anesthetised, particularly in sexual positions or practices associated with the abuse. They may even have vaginismus,  pain on penetration, a psychological symptom, but which is felt as physical pain”, he says.  

“I got vaginismus. It’s an emotional pain that’s stuck there, it’s not real,” says  Carlota. “The body somatises. I’ve never been to the doctors to prove it, but I feel my body myself and I know my body before and after.”  

* All the victims’ names are fictitious.  

** The Ministry of Health and the Judiciary Police were contacted several times to answer questions from PÚBLICO and Setenta e Quatro, but we did not receive a  reply by the time this text went to press. 

Further Credits:

Rafael Medeiros, Joana F. Bastos, illustrations

Ricardo Cabral Fernandes, Sérgio B. Gomes, editor

Pulitzer Center