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For Roma women and girls in Romania, the struggle to access abortion care brings them into contact with horrific levels of racism and discrimination, hardwired into mainstream Romanian society and institutions over centuries. This discrimination prevents many of the country’s 2 million-strong Roma population from having adequate access to healthcare, education, housing, employment, and other aspects of daily life and rights. For women and girls, these challenges are magnified by sexism and chauvinism. In this Q&A, equal opportunity expert Roxana-Magdalena Oprea of E-Romnja, a Roma women’s rights organisation, discusses the experiences of Roma women and girls within Romania’s healthcare system and why far more must be done to uphold their rights.   Could you give a brief overview of systemic barriers to the rights of Roma women in Romania?  The Roma population has long been one of the most discriminated against groups in Romania. Five hundred years of Roma slavery, the Holocaust and deportations to Transnistria, eugenic policies, and the assimilation policies of the Communist period represent systems of oppression that generated historical and political contexts in which the Roma population was systematically persecuted, abused, or even decimated. In 2020, the European Commission launched an infringement procedure against Romania for the state's failure to implement the Framework Decision on combating racism through criminal measures. Roma women remain among the most vulnerable categories when it comes to access to education, health, housing, the labour market, social protection, and other aspects of daily life. All these systemic barriers reinforce inequalities between Roma women and the mainstream population, and perpetuate Roma women's vulnerabilities. Looking specifically at health – infant and maternal mortality are higher among the Roma population, and Roma women in particular face additional obstacles (obstetric violence, segregation in maternity hospitals, racist attitudes and behaviours from medical staff) that make them even more vulnerable. For Roma women, the intersection of ethnicity, gender, class, skin colour, and so on creates different experiences of discrimination, as systems of oppression overlap. To illustrate, I would mention the case of a young deaf Roma woman who was denied maternity care and gave birth on a pavement outside a hospital. What are the main cost barriers that Roma people face when trying to access abortion care? In Romania, the cost of an abortion on request varies, from more affordable in the public system to prohibitive in the private system. The problem is that within the public health system, there are very few medical units where abortions can be performed. Many doctors refuse to perform curettages – either by invoking the option to refuse a medical act on ethical or religious grounds, or by drawing attention to a lack of appropriate medical facilities. Some doctors direct patients to private clinics where the costs depend on the procedure (medical or surgical etc), but a Roma woman cannot afford the cost of private care. Frequently, doctors’ refusal to provide abortion on request is redoubled by all kinds of contemptuous attitudes towards women who seek this type of care. In addition to these barriers, in the case of Roma women, those from rural areas or other vulnerable groups face barriers related to access, as a trip to the nearest hospital can cost several hundred Romanian lei [$70-100]. Other barriers they encounter are poor quality insurance, lack of family planning clinics, lack of family practice physicians, and the refusal of family doctors to issue referral tickets for appointments. And let's not forget about racism. How do institutional racism and discrimination, as well as stigma and discrimination within society at large, affect access to abortion care and increase costs for Roma communities?  Institutional racism affects the access of Roma women in general to any type of public or private services. On the topic of abortion on request specifically – I don't feel there is necessarily a stigma associated with Roma women. At the same time, there is no quantitative data to demonstrate that Roma women face more obstetric violence or discrimination than majority women when accessing reproductive health services, but as a grassroots activist I know this is happening. It is debatable why there is no quantitative data on this topic and why, every time, Roma women are left out of research that could come up with this evidence. Change occurs by directly addressing the systemic problems, not masking them, not beautifying them, not making them invisible. It is also important to look at the reasons behind pleas of chauvinist politicians and other regressive actors to make contraception and abortion care accessible to vulnerable groups of women. Are their arguments of a socio-economic nature or are eugenicist ideologies behind their wish to control the bodies and birth rates of “undesirable” categories of people? It is a theme that we must reflect on! How does intersectional discrimination affect Roma women and girls and their access to abortion care?  Public policies do not pay enough attention to the intersectional dimensions of discrimination and the causal link between systemic racism and health inequalities faced by Roma women. This lack of consideration can lead to a shallow understanding of the issues, and means that inequalities are treated in isolation, without considering the complex interactions between gender, ethnicity, class and other dimensions of oppression. In general, the problems faced by Roma women in accessing the public health system in Romania are: prolonged waiting times; poor quality medical interventions; reluctance or refusal of doctors to consult or admit Roma patients; and humiliation, classism, and discrimination. Racism is so pronounced that even if Roma women urgently need medical services, they avoid going to hospital. Recently, an organisation that E-Romnja works with contacted us to ask us to accompany a Roma woman to the hospital for an abortion on request, to ensure that the woman would not be discriminated against. What impact do developments at EU level have on the Roma community's sexual and reproductive health and rights? The rise of the far right, the lack of representation of Roma women in national or international politics, anti-Gypsyism, pandemics, wars, social inequities – these are cyclical realities that cause irreparable damage to the Roma community and remain a challenge on the human rights agenda. The fear is that the Roma minority will become a target again, as happened for example during the pandemic, when the wave of hatred against the Roma intensified. When it comes to reproductive rights, Roma women are over-represented in a negative sense. In recent history, we have plenty of examples of Romanian politicians who have spoken publicly about Roma women’s bodies and their supposed hyperfertility – their fear being that the Roma population will outnumber the majority population. Let’s not forget that in neighbouring countries (Czech Republic, Slovakia, Hungary, Bulgaria), forced sterilisation of Roma women was state policy implemented by doctors until very recently. History also indicates that in extremist regimes, sexual violence against women – especially women from vulnerable minority groups – increases and their rights are more often violated. How does E-Romnja support women and girls' access to abortion care? What are your priority focus areas, and what do you see as main current and future threats ? We support Roma women and girls with money – for travel expenses, medicine, and even for abortion. We also organise workshops on reproductive health topics for Roma girls and women in the communities where we work, as well as workshops with medical professionals and public authorities to raise awareness of the problems and barriers in the system encountered by Roma girls and women. Our current and long-term priorities are challenges around sexual violence and child marriage, access to reproductive health and social services, and community development. As for the main threats – beyond those already mentioned, I would add the lack of interest among donors/funders for this cause, and the interference of the Church in political decision-making on the subject. *** Read more about the how high costs and a broken health system are freezing many people out of abortion care in Romania, in this recent interview with IPPF's Romanian Member Association, SECS.  Photo of protest banner by E-Romnja. The slogan reads “Who is afraid of the Roma woman’s womb?”. Roxana explains that this question results from "our historical, collective, political, and vindictive anger addressed to all racists, abusers, and aggressors, who feel disturbed and threatened by our colours, bodies, and fertile uteruses." Article by Imogen Mathers for IPPF EN   This content is funded by the European Union through the Citizens, Equality, Rights and Values Programme. Disclaimer: Views and opinions expressed are those of IPPF EN and do not necessarily reflect those of the European Union or the European Commission. Neither the European Union or the European Commission can be held responsible for them.                   

Hitting the road in the desperate search for abortion care For thousands of women and girls in Croatia, getting an abortion involves travelling for hours, even days, across this small but poorly connected country in search of appointments. Whether by ferry, bus, or both, these journeys mark the beginning of an arduous and expensive ordeal – one that piles stress and costs onto people needing an abortion and forces many to leave Croatia altogether. On paper, a very different picture emerges. “By the law, abortion is quite accessible in Croatia,” says Marija Trcol of human rights and civic participation organisation PaRiter. Abortion on request is legal for up to ten weeks, and all public hospitals with obstetrics and gynaecology departments should provide care. But dig a little deeper and the extent of the crisis quickly reveals itself. “Actually there is no hospital with accessible abortion in Croatia,” Marija says. “There’s a really big discrepancy between [law and reality], which is why Croatia is perceived as a state with accessible abortion.” Different factors push people to travel far from home for care – from shortages in medical staff and problems rife within Croatian healthcare overall, to stigma and discrimination attached to abortion in this deeply Catholic country, where the growing influence of the church and chauvinist campaigners is intensifying structural violence against women. Scrutiny of these factors – among others – reveals catastrophic issues within Croatian healthcare and social attitudes to women, and why the struggle for abortion care is increasingly expensive and traumatic. Abortion’s hefty price tag For many people, the first barrier is Croatia’s complex geography: there is no abortion care in the islands or rural communities, and people must travel to mainland cities for appointments. In a nation of islands, mountains, and creakingly slow bus networks, this can be time-consuming and expensive. “It’s a small country but it’s really complicated to [reach] certain hospitals,” says Marija. “Public transport in Croatia is the worst – cities are not well-connected with buses, and it takes half of a day to a whole day just to travel to the hospital.” Ferries are expensive, costing €30-100 one-way. There are also no sick days for abortion care on request: people must book a day off, which can be complicated to arrange and lose you a day or more’s pay. Then there is the price of the abortion itself. Abortions on request are around €300 in public hospitals and up to €800 in private clinics. People with rhesus negative blood must pay an extra €50-80 euros for anti-D injections. Almost everyone has to fund their own care: the state only pays in specific cases of medical indication or rape, and the process for rape cases is deeply flawed, exacerbating trauma. These costs are “a massive chunk of your salary, especially if you are not economically stable, like women in some violent relationships,” says Marija. “For people with low socioeconomic status, I would say it’s impossible.” “The median salary in Croatia is around €900,” and women often work in low paid sectors or roles, she says. The country has a 12% gender pay gap, and 21% of women are at risk of poverty – shooting up to 48% for single women and 32% for single parents.  Many groups face additional cultural or logistical barriers to care. The Roma community has long experienced stigma and discrimination when attempting to access state services, including abortion care, Marija says. People with disabilities are also more vulnerable. “For people who need assistance to go to a doctor, this is something that the state does not provide at all,” she explains. “If you are deaf, for example, I don’t see how you can have an abortion without huge expenses.” These restrictions underline how transformative abortion telemedicine would be in Croatia, where it is currently banned. Croatian abortion law was drawn up in 1978 when abortions were exclusively surgical, meaning lawmakers decreed that procedures must take place in hospital. Fast forward five decades, and millions of people globally now use abortion pills at home in line with WHO guidelines, making abortion cheaper and more accessible, and reducing stigma. Spiralling denial of care One of the most significant barriers is the dramatic fall in the number of doctors and hospitals providing abortion care. ‘Conscientious objection’ – the practice of refusing to provide care on grounds of personal beliefs – lies at the crux of this crisis, as in many European countries. Since being legalised in 2003, it is now “normalised”, Marija says. The law doesn’t just apply to gynaecologists: any member of an abortion care team can invoke it, and a procedure will be cancelled if most of the team object, Marija explains. Even if no one objects, senior management can stop procedures going ahead, and hospital managers have sometimes fired staff for providing abortions, Marija says. This has had a catastrophic impact. By 2018, 59% of health workers were refusing to provide abortions. According to recent research by the gynaecologist Jasenka Grujić, there are now two hospitals in Croatia where all staff refuse to provide abortion care, 12 hospitals where 50-100% of staff refuse, and 9 hospitals where 1-49% of staff refuse.  Another problem is that “there is no regulation of denial of care in hospitals at a state level at all,” Marija says. For example, hospitals should ensure there is always at least one team available to provide abortions, but currently there is no government pressure on them to do this, she explains. Many abortion facilities are only open a few hours a day, a few days a week, and certain gynaecologists have become so notorious for being “really harsh to women” that people avoid them altogether. Forced to travel abroad for care A notorious case from 2022 reveals how doctors use denial of care and evasion to suppress reproductive justice. Mirela Čavadja was in the 24th week of pregnancy when doctors told her the fetus was unlikely to survive. Every hospital she contacted in Zagreb refused to provide abortion care – some citing ‘conscientious objection’, others saying “they were not equipped with knowledge and equipment to perform this kind of abortion, although by law this needs to be accessible in Croatia,” Marija explains. Finally, Mirela had to go to Slovenia for an abortion – a familiar path for women with medical indication in later pregnancy. Marija says doctors frequently tell such women to travel to Slovenia and foot the €5,000 bill themselves, despite the state being legally obligated to reimburse costs if Croatia lacks capacity to deliver care when it is medically indicated. This is yet another example of doctors participating in reproductive violence against women. Women at different stages of pregnancy also travel to Bosnia and Herzegovina or as far afield as the Netherlands to access abortion care – a shocking indictment of the state of abortion care coverage in Croatia Dearth of data The lack of data on abortion coverage exacerbates the struggle for appointments. Hospitals are supposed to send annual data reports to the Institute of Public Health, but there are no sanctions if they don’t and no way to find out if reporting is accurate, Marija says. Many hospitals say they provide abortion care, “and then the woman comes and they won’t do it,” she explains.  For women's rights activists, unreliable data seriously hampers their work. For women and girls, it means they can spend hours ringing around trying to get appointments, or turn up for an appointment and be turned away. “So this is something that we are going to campaign for – give us the true data and please give us the list of teams who are doing the abortions.” Data leaks linked to abortion stigma  The leaking of confidential patient data by medical staff to “shame” women who have had abortions is another serious problem – and yet another reason why women seek care far from home, Marija says. “If you live in a smaller place, then you sometimes choose to travel to a big city, because even if care is accessible, there’s a big chance of data being leaked and the whole place will know that you had an abortion,” she explains. Such leaks are illegal but completely normalised, and “there are no sanctions.” Even government ministers are involved: in the uproar following Mirela Čavadja’s case, the minister of health – himself a doctor – “went public with all of [Mirela’s] medical data” to the media. He remains in post. Misogynistic networks target abortion Growing links between anti-abortion actors, politicians, the church, the far right, and healthcare providers are a major threat to abortion care in Croatia. Since the breakup of Yugoslavia in the early 1990s, the power of the Catholic church has surged. “The church has a really big influence on politics and on the health system regarding reproductive health,” Marija says. With the entry of the far-right Homeland Movement into coalition government in April, Croatia’s government has shifted further right, and many in government have strong ties with the church and the growing anti-gender movement, Marija adds. She explains that different groups – including the ultraconservative Poland-linked ‘kneelers’, and ‘40 Days for Life’ abortion clinic picketers – target people providing or accessing abortion care, and are often backed by the church or global networks. The ‘kneelers’ are so entrenched that “they’re now part of the government,” Marija says. Women’s rights activists have been mobilising in response, including by calling for criminalisation of harassment of women seeking abortion care, but the threat remains dire, calling for massive, united efforts by campaigners. Mobilising to protect women This brings us back to the perception gap. Public support for abortion care is high at 65-75%, but this is a “quiet majority”, which hasn’t yet recognised the threats facing abortion access, Marija says. To galvanise people to speak up, campaigners need to expose gaps between perceptions and reality – and this calls for more trustworthy data. With this in mind, PaRiter is running a survey on abortion access and hopes that “through the next two years we’ll have established some kind of independent monitoring system on abortion,” with the support of other feminist organisations, within their capacities and means.   PaRiter is also scrutinising contradictions between Croatia’s stance on women’s rights and its European and international commitments, and plans to report yearly on findings. Despite the government’s shift rightwards, Marija says “our hope is that they are still going to want to look good in the EU’s eyes” and so constrain attacks on women’s rights, but “they are signing things like there is no tomorrow and are not doing anything to make things better.” Given the formidable forces lining up to attack women’s rights, civil society networks (national, regional and global) must work together to protect women’s rights, Marija says. For example, the Croatian coalition for My Voice, My Choice, a European citizens’ initiative calling for a financial mechanism to guarantee safe abortion access in the EU, has done a “fantastic job,” mobilising huge public support for safe abortion access, now and for generations to come. ***   Words by Imogen Mathers for IPPF EN Illustration by Alissa Thaler for IPPF EN   This content is funded by the European Union through the Citizens, Equality, Rights and Values Programme. Disclaimer: Views and opinions expressed are those of IPPF EN and do not necessarily reflect those of the European Union or the European Commission. Neither the European Union or the European Commission can be held responsible for them. 

For a country long reputed to have one of the more progressive healthcare systems in Europe, Germany’s law on abortion – a health issue affecting millions of people – remains firmly stuck in the past. “The law has negative impacts, and [these] are not accidental side-effects that need to be adjusted – they’re intentional,” says Stephanie Schlitt, board member of Pro Familia, an SRHR counselling and advocacy organisation and IPPF’s German Member Association. “By compelling women to do certain things, the law enforces abortion stigma.” Germany’s archaic law has a long and messy past, in which the trampling of women’s rights to reproductive justice has been a common thread. Abortion has been criminalised since 1871 and remains punishable with prison sentences for those obtaining and providing abortions (though prosecutions are rare). Exceptions are made up to 12 weeks of pregnancy under strict conditions, or where there is a medical necessity, or in cases of rape. The state’s longstanding treatment of abortion as a criminal rather than health issue has devastating repercussions. For people needing abortions, strict legislation makes accessing care a fraught process, involving high costs, complex paperwork, fear of criminalisation, and stigma. For doctors, the legal red tape, threat of prosecution, and growing harassment by anti-rights campaigners create “a huge disincentive for the provision of care”, Stephanie says. “What’s happening here simply isn’t good enough, because it goes completely against the needs of the people concerned and those who want to support them professionally – doctors and counsellors,” Stephanie says. “We can’t be surprised if, as a result of this law, [abortion] healthcare provision is difficult. Of course it will be – it’s geared towards making it difficult.” Outdated laws crush women’s rights    “Some of the barriers flow directly from the law as it’s framed, and some flow from the practice that results from that law,” Stephanie explains. Firstly, people seeking abortion care must undergo mandatory counselling at state-certified centres or online, and receive a certificate to present to their gynaecologist. Following counselling, there is a mandatory and medically unnecessary three-day waiting period – a delay that can affect treatment options for such a time-critical procedure and exacerbate stress. Making counselling a legal requirement creates difficult conditions for counsellor and client, Stephanie explains. Women “feel under pressure to justify themselves” during an already stressful period, while for counsellors, these conditions are “a huge burden because counselling should only happen on a voluntary basis.” Mandatory counselling and waiting periods contravene World Health Organization (WHO) advice on abortion care, and Germany is one of the few EU countries to impose both. “The point is that this law creates hurdles to good healthcare and actually makes the whole experience much more difficult than it needs to be,” Stephanie says. “An abortion needn’t be so emotionally, financially and socially burdensome.”

On paper, abortion care is legal up to 14 weeks in Romania – though only free in emergencies – and should be provided by all hospitals with obstetrics and gynaecology departments. The reality is very different. Abortion care is increasingly expensive, provided by fewer and fewer clinics, involves a labyrinth of red tape, and tends only to be available in cities. “Today, we are in the worst-case scenario [seen] in recent years,” says Gabriel Brumariu, director of SECS, IPPF’s Romanian Member Association. In the 1990s and 2000s, abortion care had rapidly improved in Romania. The post-Communist government had inherited a brutal system for women and children – a near-total ban on abortion and contraception between 1966 and 1989 had brought devastating repercussions. Following the 1989 revolution, the new government swiftly legalised abortion up to 14 weeks, and introduced free contraception (though this ended unexpectedly in 2013). This progress is now being destroyed at pace, Gabriel says. Many factors are making abortion care more expensive and less accessible – including cuts to sexual and reproductive health and rights (SRHR) programmes, clinic closures, and a slump in the number of doctors willing to perform procedures. Overall, the country’s health system is crumbling, and women are particularly vulnerable. Evidence has emerged of people dying after being denied access to obstetric care, and the maternal mortality rate rose by 183% between 2018 and 2022 – “inconceivable” for an EU state, Gabriel says. And, with the far right on the march in Romania and European donor states, often bankrolled by US anti-rights campaign groups, the rights of women are under severe attack. Exorbitant costs For many in Romania, the high price tag for abortion puts it out of reach – and prices are rising fast year on year. In public hospitals, abortions on request cost around $200-300; in private clinics, between $250-1000. These prices are “a huge proportion of a monthly salary,” says Gabriel, and in some cases exceed it. The new national monthly minimum wage is 3,700 Romanian lei (RON) – around US$812, before tax and deductions of over 40%. Women’s median monthly salary is $582.24 net, with higher salaries concentrated in cities. For undocumented migrants, day workers, and those working without legal papers, salaries are much lower, at around US$300 per month, Gabriel explains.   Rural communities left high and dry Other costs swiftly stack up: on top of treatment costs, people often have to travel hundreds of kilometres to access care, partly because many rural clinics have shut down. Almost half (44.8%) of Romania’s 19 million population live in rural areas. For these communities, accessing abortion care requires cash for transport, accommodation, childcare, time off work – the list goes on. Repeat visits further drive up costs, and, unlike several other European countries, Romania does not allow abortion telemedicine for medical abortions (pills taken at home) at all.  As a result, abortion on request is becoming the preserve of wealthier, urban communities, says Gabriel: “Of course, the ones that have money will [be able to] access abortion [...] in a private clinic. But if you are from a marginalised community, it’s almost impossible for you.” Women on the fringes Some of the most marginalised people in Romania include the country’s 2 million-strong Roma community. Abortion access for the Roma is fraught, with geography and income playing a role here too: Roma people’s salaries tend to be far lower than average, and they often live in segregated areas on the geographical and cultural fringes of mainstream Romanian society. These barriers intersect with systemic racism, classism, and entrenched stigma towards the community from medical staff, as our recent interview with Roma feminist organisation E-Romnja explains in detail.   The approximately 77,900 Ukrainian refugees living in Romania are another group facing barriers to abortion care. Access is now so limited that “some of them prefer to go in a country at war because it’s easier in Ukraine to access abortion than in Romania,” Gabriel says. A 2023 report by the Centre for Reproductive Rights found that being unable to get appropriate care pushes many refugees to pursue unsafe avenues or return to Ukraine to access abortion. Gabriel says funding for care has dried up: SECS used to receive humanitarian funding to support Ukrainian refugees to access abortion, but “now, all the funds for Ukrainians disappeared […] and we don’t have funds to pay for Romanian people or Ukrainian refugees.” Public hospitals failing mandates One major factor cutting abortion access is the increasing refusal of doctors to provide care in public hospitals, Gabriel explains. Many doctors work in both public and private practice, but “tend to take their patients to private clinics because they earn a lot of money by doing … an abortion [there],” he says. “There are counties [...] which offer zero chance [of abortion] in public hospitals.” The data reveals a crisis spiralling downwards fast. In 2019, research by the Black Sea found that 60 of 190 public hospitals contacted did not offer abortions. The COVID-19 pandemic made a bad situation worse: only 12 of 112 public hospitals (11%) contacted by women's rights organisation Centrul Filia in 2020-2021 provided abortion on request. In 2021, an investigation by Romanian media revealed that 11 out of 42 Romanian counties provided no abortion on request, with 62% of such procedures taking place in private clinics. In 2023-2024, a telephone survey by the Independent Midwives Association found that over 80% of public clinics do not offer abortion services, while 90% refuse to refer women to another clinic on request, despite being required to by the medical ethics code.   The increasing use of ‘conscientious objection’ laws that allow doctors to refuse care has also hit numbers of care providers. Data from Centrul Filia revealed that 70 out of 136 public hospitals use these laws as a basis for refusing to perform abortions. Doctors who refuse care are supposed to refer patients to another doctor or hospital, but often the personnel and infrastructure simply isn’t there, Gabriel says. Some doctors refuse to provide care in public hospitals on ‘conscience’ grounds but then offer the service privately, for a much higher fee. Chauvinist forces attack rights by stealth Many different groups are fomenting anti-abortion sentiment, Gabriel explains. As in other EU countries, abortion is a key battleground issue for Romania’s growing far right – “a more extreme far right party that’s bigger now and more powerful.” Meanwhile, ultra-conservative lobbying groups and evangelical Christian groups, often with US backing, have been consolidating influence on political parties, policies, and grassroots services. They often work covertly because public support for abortion is strong, Gabriel explains. Rather than pushing for a referendum on abortion and “making waves” – likely leading to public “revolt” – they focus on gaining political traction, influencing doctors, and lobbying for reducing gestational limits for abortion. Another tactic is to target women at the grassroots. ‘Pregnancy crisis centres’ run by Christian organisations – often with US links – are springing up across the country, often embedding themselves in public services, with the aim of dissuading women from having abortions. Romania’s powerful orthodox church – particularly strong in rural areas – is also a strong force opposing abortion. Far right influence also threatens SRHR organisations like SECS, Gabriel says. Such NGOs receive no government funding but rely on European donors and international organisations like IPPF, within an SRHR funding landscape that is already very constrained. Gabriel worries that if major European donor governments lurch rightwards, it will further diminish funding for SRHR and abortion care programmes in countries in east and southern Europe. Working together to protect future generations Fighting to protect and advance women’s rights within such an embattled landscape calls for strong partnerships, Gabriel says: “The most effective ways [for ensuring abortion access] are the advocacy interventions done by the civil society, united.” SECS is focusing on reviving an NGO advocacy platform that worked very hard to defeat the country's 2018 anti-LGBTI referendum. Such networks allow organisations to divvy up responsibilities and work strategically towards common goals. Through this “united” approach, SECS and partners plan to run robust campaigns backed by the collection and analysis of better data (currently, public data on many SRHR issues is often poor or non-existent). Working together, the focus is to mobilise public opinion, protect “good laws”, push for legislative change, and “facilitate real access to abortion services all around the country.” For example, SECS is currently pushing for the legalisation of abortion telemedicine, to make care more affordable and accessible to thousands of people – particularly those in remote rural areas, hundreds of kilometres from clinics – in the challenging years ahead. *** Words by Imogen Mathers for IPPF EN Illustration by Alissa Thaler for IPPF EN   This content is funded by the European Union through the Citizens, Equality, Rights and Values Programme. Disclaimer: Views and opinions expressed are those of IPPF EN and do not necessarily reflect those of the European Union or the European Commission. Neither the European Union or the European Commission can be held responsible for them. 

We can only achieve equal societies and access to sexual and reproductive health and rights for all if we ensure that sex workers are included. This has been the stance since 2012 of IPPF's French member, Le Planning Familial. Since then, the organisation has been defending sex workers’ rights and access to health, including the right to autonomy and bodily integrity and the right to work and live free from violence and discrimination. It describes itself as an ally, listening to and supporting sex worker organisations and adding its voice to calls for decriminalisation as the only way to respect human rights. Since the introduction of the Nordic Model in France in 2016, which criminalised the purchase of sex, reports of violence against sex workers have almost doubled. Criminalisation of clients has had a detrimental impact on the lives and safety of people who do sex work. Mel Noat from Le Planning Familial acknowledged that even now there is confusion about the law: “It is not illegal to be a sex worker but because clients have been criminalised, sex workers can’t work. Police often fine sex workers despite it being legal.” Because of criminalisation, clients want to avoid being fined, which in turn pushes sex workers underground into dangerous situations. With the current legal framework, they are more exposed to violent exploitation, precarious working conditions and are involved in high-risk behaviour just to earn basic wages. Mel said: “People work in dark places, without anyone around to witness violence from clients like stealing money, physical and sexual abuse, sometimes even murder. Sex workers have no choice over their customers, no choice of working hours, and no customer screening.” He added that sex workers face negotiating difficulties due to dwindling clientele. This, she argues, makes it harder to enforce the basics of sexual risk reduction like condom use. Whether it comes to access to healthcare, exposure to violence, discrimination and stigma, or financial insecurity, the harms of the 2016 law have been far greater for groups experiencing intersecting forms of exclusion, such as migrant and trans sex workers.   How the current law creates obstacles to protecting sex workers’ health and rights As a result of the 2016 law, sex workers are moving away from the traditional spaces where they would find and meet clients. Sometimes they have to venture to hidden places, such as apartments, which jeopardises their safety, as they are more isolated if subjected to violence or if a client refuses to pay. Many turn to intermediaries (pimps or sex websites) and end up paying back part of their income, which makes their situation even more precarious and reduces their autonomy over their work. Sex workers are often pushed into homelessness as they are forced to travel to different cities every few weeks to look for clients, now that these are more difficult to find. This affects their health and welfare as, for example, they don’t know where the closest hospital is, or where they can find condoms or information centres. People are also working more online, due to both the law change and the subsequent COVID-19 crisis. This reduces contacts with the community associations supporting sex workers’ rights, making it more difficult to provide information about healthcare and support. Sex workers are highly stigmatised and often face discrimination by medical staff. They find it difficult to talk about the reality of their work for fear of being judged, or for those who are undocumented, being reported to the authorities. However, there are spaces where sex workers can access healthcare. Some branches of Le Planning Familial are supporting people engaged in sex work through outreach and service delivery. In one region they undertake night patrols, offer condoms and rapid diagnostic tests and provide education on sexual and reproductive health. Elsewhere, the organisation collaborates with STRASS, the sex workers’ union, which provides peer-to-peer services in some of Le Planning’s clinics, as community-led services are proven to be one of the most effective way to deliver care to a key population group like sex workers.   The ‘exit programme’ is limiting and tokenistic The French government wrongly conflates sex work with human trafficking and has done little to review the impact that the legislation has had on sex workers. On the contrary, they are planning to implement a national strategy against human trafficking, which wrongly includes sex work. Measures in the 2016 law that are intended to provide a ‘pathway out of prostitution’ are not adapted to the realities and needs of sex workers. The allowance provided as part of this pathway is a measly €343 a month (three times lower than the French poverty line, which is €1,102). People can be granted a provisional residence permit, but only for six months, which makes it difficult for them to access accommodation, particularly social housing, as landlords often require longer residence permits. On top of this, professional opportunities are severely limited and tend to be in precarious sectors such as in cleaning or the hotel trade. The committee that is supposed to monitor the implementation of the law has only met twice in seven years and only those associations promoting the 2016 law were invited to the table, while sex worker-led community associations were excluded from the process. It is shocking that the government has refused to listen to the voices of the people concerned by the legislation, and to organisations that denounce its negative effects.   Partnerships for sex workers’ SRHR in the face of backlash The data is unambiguous: where sex work is criminalised, sex workers are at a much higher risk of violence. Yet, many pro-decriminalisation organisations face intense backlash, not only from conservative, anti-rights groups but also from well-intentioned organisations that claim to want to protect sex workers. This hostility can pose a challenge to advocacy efforts. To help overcome this challenge and speak with one common, stronger voice, Le Planning Familial has formed alliances with like-minded organisations. In conjunction with Médecins du Monde, Act Up-Paris and AIDES, it co-signed an alternative report in the context of the review of France’s implementation of the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW). This explained that the 2016 French law criminalising clients negatively impacts sex workers and is counterproductive. The organisation also widely shared and supported a European Court of Human Rights preliminary decision in August 2023, which recognised the admissibility of complaints by sex workers, confirming that the mere existence of the French law has harmful consequences for them.   Mel said: “We do not support the criminalisation or regulation of any aspect of sex work. Le Planning Familial acts and fights to help build an egalitarian society, free from commodification and violence. We are firmly opposed to human trafficking, violence, rape, pimping and slavery. We believe everyone has the right to autonomy and bodily integrity, the right to work and to live free from violence and discrimination. We support everyone's right to make their own choices through informed consent.” *** Mel Noat is the focal point for issues relating to sex work in the Board of Le Planning Familial. Read more about IPPF’s global policy position on sex work, which strongly supports decriminalisation of all aspects of sex work, together with social policies that address structural inequalities, as the only way to protect the health, safety and lives of those who do sex work. Photo by Loïc Fürhoff on Unsplash    

Providing healthcare and support to the sex worker community has been part of the work of APF, IPPF's Portuguese member, for over 20 years. The organisation’s northern regional delegation, APF Norte, has been operating Espaço Pessoa – a service providing care to sex workers and people who use drugs - in Porto since 1997. We spoke to Alexandra Ramos and Jorge Martins from APF Norte about Espaço Pessoa’s work. Espaço Pessoa has both a community centre and a street team working on the ground with people who do sex work. In addition to specialised psychology, nursing and social services, the centre’s users have access to changing rooms, clothing, and laundry facilities. Meanwhile, the street team provide sex workers with contraceptive care, information, and advice on STIs, as well as essential screening tests for syphilis, HIV and Hepatitis C, and vaccinations. By listening actively to the concerns and difficulties of the communities they support, they are able to build trust, to talk to people about their social rights, provide crucial psychosocial support and make referrals to more formal support services when necessary. Over the last decade, Espaço Pessoa’s team has observed a massive shift from people working on the street to indoor sex work. This is particularly true for trans sex workers, who face multiple layers of stigma and high levels of violence. Alexandra Ramos said, ‘Although when they are inside, sex workers are more protected from the everyday verbal abuse they face on the street, in many ways their vulnerability has increased; there is little to no protection from violent clients when working alone in an apartment.’ Legal framework falls far short of protecting sex workers Sex work is not criminalised within the Penal Code in Portugal. However, the law states that third parties are not permitted to profit from, promote, encourage or facilitate prostitution, which was originally intended to prohibit brothels and pimping. In some cases, this can be problematic for sex workers wishing to work together or in collective settings. Public and political discourse is very much focused on defining women who do sex work as victims, or conflating sex work with trafficking, despite these being two distinct issues. This perpetuates the notion that sex work can never be a choice; the reality is it is still not recognised as work. The Constitutional Court issued a statement in May 2023 in favour of sex workers’ rights, stating that criminalising all third parties without distinguishing between exploitative and non-exploitative ones is unconstitutional. Although this is a welcome move, APF believes that the national legal framework still has a long way to go to support sex workers, and underlines that there is still a lot of social and political division. Language plays a big part, and APF explains that the term sex work, preferred by the people who do the work, affirms the agency of sex workers and helps to destigmatise both the work and those who do it.  Sex workers experience many, often intersecting, systemic inequalities and oppressions, and the criminalisation of aspects of their work exposes them to high levels of violence and rights violations. APF explains that in Portugal, undocumented sex workers are at particular risk because of their lack of access to social rights, together with the current legal context and the social stigma that they face. These factors mean that they rarely report incidents to police for fear of repercussions. Many of those now engaging in sex work are non-nationals, predominantly from Brazil, which means most fall through the cracks. Jorge Martins underlined the difficulty in providing care for those excluded by the system: ‘Undocumented people face the greatest difficulties in accessing social and healthcare services. Unfortunately, referral becomes very difficult, which places them in increasingly marginalised, hidden and helpless spaces.’ At least, according to APF, migrant sex workers are rarely targeted by law enforcement and a service providing some healthcare for sex workers is provided within Portugal’s national healthcare system, although access becomes much more complicated in cases where coordination and referral to other services is required.   Adapting to the changing needs of sex working people Sex workers are some of the most marginalised and socially stigmatised groups in Portugal. The transient nature of their work means some lead extremely solitary lives. Alexandra said: “People are socially isolated, and many of them move from city to city, and room to room, without creating any links outside of the local bus station or airport. Opportunities to establish social support networks are increasingly few, particularly outside of the sex work circuit. Homelessness has also become an increasingly big problem with rent hikes making access to housing a massive barrier.” In response to changing needs, APF Norte has considerably increased the number of shifts of its street team, and initial contact is typically made through consulting sex workers’ adverts online.  Through their continuous presence, they have established a good level of trust with the sex worker community. Crucial to that is the presence in their team of a peer educator who has firsthand experience of sex work and is therefore able to play the role of trusted mediator with some members of the community, working in close collaboration with the technical team. APF’s approach has enabled it to support people with interventions that go beyond the delivery of contraceptives. Empowerment and education are key to eradicating stigma Espaço Pessoa tends to reach sex workers who have no other support system, so their outreach places a great deal of emphasis on empowerment. Sex workers navigate legally precarious territory, which means many have internalised stigma. Ingrained perceptions make some more likely to accept being subjected to sexual and physical violence, and/or non-consensual sexual practices. The Espaço Pessoa team works to build awareness of these issues amongst sex workers by educating them on their human rights, teaching them to recognise harmful behaviour, as well as deconstructing the myths and underlying prejudices surrounding sex work, always with a commitment to supporting the needs and autonomy of each person they reach. *** Read more about IPPF’s global policy position on sex work, which strongly supports decriminalisation of all aspects of sex work, together with social policies that address structural inequalities, as the only way to protect the health, safety and lives of those who do sex work.  Photo by Mario Gogh on Unsplash