“Thirty-four-year-old woman, from Cameroon. Pregnant, raped in Libya,” said Angelina Perri, a 59-year-old from Italy, reading her handwritten notes. She works for Doctors Without Borders — often known as MSF, the acronym for the nonprofit humanitarian group’s French name, Medecins Sans Frontieres — which is conducting rescue missions at sea between Libya and Italy. “Nineteen-year-old from Guinea, raped in Libya. Two Nigerian women, one 25 years old, one 24 years old, both raped.”

The Mediterranean waters between Libya and Italy are the current front line for Europe’s migrant crisis. At least 2,196 people have died at sea trying to reach Europe this year, more than double the rate of 2016. But the risk of death has not deterred people starting the journey: This year, more than 80,000 people have reached Italy on wooden and rubber boats, the majority traveling from countries in West Africa.

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The route to Libya is also perilous — and it is especially treacherous for women. On every rescue mission, Perri meets women who say they have endured sexual assault and rape. She spoke of cases in which women had contracted HIV from sexual violence while crossing borders, and listened to others as they told her how guns and other objects had been used to penetrate them.

Yet, despite the known perils on the journey to Europe, women are willing to risk their lives to escape equally dire sexual violence at home.

In 2016, the United Nations identified gender-specific violence — such as early and forced marriage and domestic violence — as reasons that women are leaving their countries of origin. The problem has persisted for some time in the region. In 2010, an MSF study on a sample of sub-Saharan women who had fled to North Africa found that 70 percent had left their countries because of violence or abuse. Almost one-third of the women said they had been raped in their country of origin.

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The perpetrators of sexual violence on the route to Libya can be anyone: security and police forces, smugglers out to exploit and traffic women, and sometimes even the men on rescue boats with them. In February, a UNICEF report said the levels of sexual violence, exploitation, abuse and detention along the Central Mediterranean migration route makes it “among the world’s deadliest and most dangerous migrant routes for children and women.”

One refugee charity described conditions on the route as “hell on Earth,” with sexual abuse occurring at “every stage of the journey” and affecting “almost all” female migrants and refugees. The report said some women choose to get contraceptive injections while traveling to prevent pregnancies, knowing that the likelihood of rape during the journey is high.

Aboard the rescue boat, Perri attended to 17 pregnant women, as well as women traveling alone and mothers caring for several children. Some said they had abandoned abusive partners at home; others were forced to engage in transactional sex to fund their travel. Several women asked Perri whether they could take a pregnancy test. “We then ask if being pregnant is a good thing or a bad thing,” she said. “If they say it’s a bad thing, we know to investigate further.”

Even when those in transit reach Libya, the conditions remain dire. Men, women and children are held indefinitely in detention centers, where many are tortured, raped and starved. Some are sold into the modern-day slave trade: The International Organization for Migration, a U.N. body, estimated that 80 percent of the 11,009 Nigerian women who arrived in Sicily from Libya in 2016 were trafficked.

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Women who work as maids in homes in Libya are sometimes kidnapped in the middle of the day to be smuggled into Europe. “Women are sitting there in homes eating their lunch, and the next minute they're grabbed, dragged, and thrown on a boat,” said Sarah Adeyinka, an MSF cultural mediator, whose own cousin from Nigeria had been trafficked.

Europe’s response to the issues faced by female refugees and migrants has been slow. In April, members of the Council of Europe recognized that “the gender dimension of the refugee crisis has been largely overlooked,” saying the protection of women “should be a priority, irrespective of their status.” Last month, the council ratified legislation to prevent and combat violence against women, highlighting a need for gender‐sensitive asylum procedures and refugee-status determination, as well as the presence of female social workers, interpreters, police officers and guards in transit facilities.

Still, some charities and organizations warn that sexual violence on migration routes is being gravely underestimated. They say that insufficient training of personnel and a lack of effective procedures to identify cases of sexual violence make migrant women reluctant to seek medical attention or report the crimes. As a result, according to the European Union Agency for Fundamental Rights, Europe is “currently not able to prevent or respond to survivors of sexual and gender-based violence in any meaningful way.”

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As the boat arrived in Italy, Perri handed out medical certificates to those who had experienced sexual violence, torture and trafficking, detailing their experiences and the medical advice they had received. They hope the certificates can help their asylum cases, but there is no guarantee.

“Some women refuse to take a certificate,” Perri said. “They’re afraid and don’t want to speak about it.”