A/HRC/31/57 (general comment No. 2). Discrimination against women, girls, and persons on the basis of sex, gender, real or perceived sexual orientation or gender identity and sex characteristics often underpins their torture and ill-treatment in health-care settings. This is particularly true when seeking treatments such as abortion that may contravene socialized gender roles and expectations. International human rights law increasingly recognizes that abuse and mistreatment of women seeking reproductive health services cause tremendous and lasting physical and emotional suffering, which is inflicted on the basis of gender (A/HRC/22/53). Health-care providers tend to exercise considerable authority over clients, placing women in a position of powerlessness, while the lack of legal and policy frameworks that effectively enable women to assert their right to access reproductive health services enhances their vulnerability to torture and ill-treatment. Access to abortion and related care 43. Unsafe abortion is the third leading cause of maternal death globally. 23 Where access to abortion is restricted by law, maternal mortality increases as women are forced to undergo clandestine abortions in unsafe and unhygienic conditions. Short- and long-term physical and psychological consequences also arise due to unsafe abortions and when women are forced to carry pregnancies to term against their will (A/66/254). Such restrictive policies disproportionately impact marginalized and disadvantaged women and girls. Highly restrictive abortion laws that prohibit abortions even in cases of incest, rape or fetal impairment or to safeguard the life or health of the woman violate women’s right to be free from torture and ill-treatment (A/HRC/22/53, CEDAW/C/OP.8/PHL/1). Nevertheless, some States continue to restrict women’s right to safe and legal abortion services with absolute bans on abortions. Restrictive access to voluntary abortion results in the unnecessary deaths of women (CAT/C/PER/CO/4). 44. In other cases, women and girls face significant difficulties in accessing legal abortion services due to administrative and bureaucratic hurdles, refusal on the part of health-care workers to adhere to medical protocols that guarantee legal rights, negative attitudes, official incompetence or disinterest (A/HRC/22/53). The denial of safe abortions and subjecting women and girls to humiliating and judgmental attitudes in such contexts of extreme vulnerability and where timely health care is essential amount to torture or illtreatment.24 States have an affirmative obligation to reform restrictive abortion legislation that perpetuates torture and ill-treatment by denying women safe access and care. Limited and conditional access to abortion-related care, especially where this care is withheld for the impermissible purpose of punishing or eliciting a confession, remains of concern (A/HRC/22/53). The practice of extracting, for prosecution purposes, confessions from women seeking emergency medical care as a result of illegal abortion in particular amounts to torture or ill-treatment. Forced and coerced sterilization 45. Forced sterilization is an act of violence and a form of social control, and violates a person’s right to be free from torture and ill-treatment. Full, free and informed consent of the patient herself is critical and can never be excused on the basis of medical necessity or emergency when obtaining consent is still possible (A/HRC/22/53). Gender often intersects with other characteristics such as race, nationality, sexual orientation, socioeconomic status, age and HIV status to render women and girls at risk of torture and other ill-treatment in the context of sterilization (CAT/C/CZE/CO/4-5, A/HRC/29/40/Add.2) The European Court of 23 24 12 Guttmacher Institute and World Health Organization, Facts on Induced Abortion Worldwide (2012). European Court of Human Rights, application No. 57375/08, P and S v. Poland, judgement of 30 October 2012.