Terrified children, men left behind, sex trafficking: Women in Ukraine fight a different kind of war

• For women in Ukraine, gender-based inequality can compound traumatic experiences of the conflict
• Women and girls face heightened risks due to displacement and risks of sexual exploitation
• Experts say women need access to reproductive healthcare services, childcare and police

You've seen the pictures. A mother carrying a child bundled in blue, her eyes fixed on nothing, her expression withdrawn. A young girl on the train, palms pressed against the window as she looks longingly at the father who will not board. A pregnant woman on a stretcher holding her swollen belly, smoke rising from the shelled-out maternity hospital behind her. The world learned Monday the woman had died, and the baby never got to breathe. 

They are glimpses of suffering generated by war, but they do not tell the full story of the women and girls caught in the Ukraine crisis, a story of displacement and trauma, with risks for abuse and exploitation that can have myriad impacts on their health and well-being during this conflict and beyond.

The United Nations warned that Russia's invasion of Ukraine could be the largest humanitarian crisis in Europe since World War II, one which experts predict will hit women and girls particularly hard. 

"Women and girls face heightened risks due to displacement and the breakdown of normal protection structures and support," U.N. Women told USA TODAY in a statement. "The contraction of routine health services and restrictions creates barriers to the provision of services and access to justice. In past conflicts, we have seen parties to armed conflict use sexual violence as a cruel tactic of war, terror, torture and political repression in order to advance their strategic objectives."

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More than 70% of women have experienced gender-based violence in some crisis setting, according to U.N. Women. The Lancet medical journal published research showing women and girls affected by armed conflict are exposed to an increased level of traumatic experiences, which is associated with an increased prevalence of anxiety disorders and depression. Though it's too early to know the specific long-term impacts on Ukrainians, experts said the stress of sudden displacement, separation from family members, loss of home and livelihood are taking a toll. 

Women lose services and protections

When conflict breaks out, women with daily health care needs and those who rely on government protections often lose access to crucial services, either because infrastructure collapses or it's no longer safe to access them. 

The image of the pregnant woman on the stretcher underscores the vulnerabilities, for example, of those who require prenatal care.

"Just because war breaks out doesn't mean that women's need for sexual and reproductive health care is suspended," said Kim Thuy Seelinger, director of the Center for Human Rights, Gender and Migration at Washington University in St. Louis.

Women who are victims of violence may not have protections enforced, and those seeking new ones may not be able to access them as institutions break down. Experts said women living in refugee camps are at an increased risk of gender-based violence, which can affect their physical, mental and reproductive health in the short and long term.

When men stay behind, many women lose their family units

Men in Ukraine ages 18-60 are banned from leaving the country because they could be conscripted to fight. The majority of people fleeing Ukraine are women with children and unaccompanied minors, who have unique risks and needs. 

When the family unit is fractured, many women face new and stressful caregiving responsibilities. in 2006, a paper in the medical journal World Psychiatry on the mental health consequences of war found that if "the household is facing disaster, this may overload women's capacity to cope, as preoccupation with the needs of the family may lead to that they are not able to consider their own needs."

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Seelinger said it's heartening to see the support from individual citizens in neighboring countries, many of whom are opening their homes in support of refugees. This is essential, she said, to help protect Ukrainians from immediate harm, but it's unclear how long the compassion will last, and she fears Ukrainian women may be harmed by those with ill -intent. 

"It's uncontrolled, unregulated compassionate response, which always has some chance of risk," she said. "There's no vetting of people who are opening up their homes."

Women may be vulnerable to sexual exploitation and abuse

A growing body of evidence shows women and girls in displacement situations are at higher risk of gender-based violence and abuse, according to U.N. Women. 

"We know that displaced women and minors are often at greater risk of sexual exploitation and even trafficking – and there certainly have been sophisticated trafficking networks in operation in Eastern Europe for decades," Seelinger said.

U.N. Women said economic desperation and collapse can make women and girls more vulnerable to exploitation and negative coping mechanisms, such as child marriage and “survival sex," when a person engages in prostitution to meet basic needs. 

Seelinger said there are contexts in which women who must cross borders experience violence, either transactional sex or sexual humiliation, often in front of their children and sometimes in front of their husbands.

Gender-based inequality can exacerbate the trauma of conflict. Seelinger said activation of the European Union's Temporary Protection Directive was critical, as it allows Ukrainian refugees to move freely within the EU and to obtain work authorization, which can reduce vulnerability to sexual exploitation, though authorities must pay attention to intelligence about upticks in trafficking.  

Individual citizens offering ad hoc support should make sure they do so safely and should report questionable situations, Seelinger said. Countries housing refugees must support access to sexual and reproductive health care, child care, police services and counseling with language access support, she said. 

"It's quite early to point to all of the gendered harms and long-term impacts," Seelinger said. "If we look at other conflicts, we see how things happen in stages and how the violence can be compounded with ongoing movement and insecurity. At the same time, many of these women's husbands, fathers, brothers are still at home. The daily worry as they watch the news, having to reassure their children that their father is OK and not knowing that for sure. The level of stress is tremendous."