Denying humanitarian aid in a war zone: The intersecting impacts of the war on Gaza on adolescent girls’ and young women’s health

Abstract

Background:

Since the Hamas attack on 7 October 2023, Israel has carried out an intensive bombing campaign and implemented a complete siege on Gaza, permitting extremely limited humanitarian aid. This has created a humanitarian catastrophe, yet little evidence exists on how it is experienced by adolescent girls and young women. A critical but overlooked challenge in conflict-affected contexts is the specific health needs of girls and young women, including menstrual hygiene management and sexual and reproductive health. In conflict, women and girls often struggle to access contraceptives, menstrual products, clean water and healthcare services, leading to significant immediate and longer-term risks.

Objectives:

This article explored these challenges in Gaza, examining how the intersecting impacts of the humanitarian crisis are affecting adolescent girls’ and young women’s basic needs and health outcomes.

Design:

It draws on a sequential mixed methods cross-sectional research study undertaken between August and December 2024.

Methods:

The study combined data from a household survey (n = 1011) of young people aged 10–24, with qualitative data from in-depth interviews (n = 100) and key informant interviews (n = 24).

Results:

The findings underscore severe and intersecting financial, physical and social obstacles in fulfilling girls’ and young women’s basic health needs in the context of the hostilities in Gaza, threatening their physical and mental health. Restricted access to clean water, sanitation, hygiene services and menstrual products heighten health risks, while the collapse of maternal health services threatens mothers and children. These deprivations are exacerbated by poverty from disrupted livelihoods and conservative gender norms that hinder girls’ mobility and emphasise modesty, which is difficult to maintain in displacement contexts.

Conclusion:

The findings highlight the disproportionate impact of armed conflict on adolescent girls and young women and the urgency of preventative and responsive actions to address their health needs and uphold their rights to health.

Plain language summary

Denying humanitarian aid in a war zone: The overlapping impacts of the war on Gaza on adolescent girls’ and young women’s health

Since the Hamas attack on 7 October 2023, Israel’s military actions in Gaza and siege have produced a severe humanitarian catastrophe. This study looks specifically at how this situation affects the health and daily needs of girls and young women, especially around menstruation, pregnancy, and access to basic health care. Researchers collected information between August and December 2024 using a large survey of over 1,000 young people (aged 10–24) and interviews with girls, young women, and key professionals. The study found that girls and young women in Gaza face overlapping money problems, danger, and restrictive social rules that make it very hard to meet their basic health needs, harming their physical and mental health. Limited access to clean water, toilets, washing facilities, and menstrual products increases health risks, while collapsing maternity services endanger mothers and babies. These problems are made worse by deepening poverty and strict gender norms that restrict girls’ movement and make modesty hard to maintain in crowded displacement settings. Overall, the study shows that the conflict harms girls and young women in specific ways and that urgent action is needed to protect their health and rights.

Introduction

In response to the deadly Hamas attack on Israel on 7 October 2023, the former Israeli Defence Minister, Yoav Gallant, announced that ‘there will be no electricity, no food, no water, no fuel’ going into Gaza, and that ‘everything will be closed’. ¹ In the first weeks of the war, Israel did exactly this, preventing any humanitarian aid from entering Gaza, in contravention of Article 55 of the Fourth Geneva Convention. The blockade was partially lifted on 18 October 2023, but during the ongoing bombing campaign (temporarily halted with a ceasefire deal between January 2025 and March 2025), Israel has permitted only very limited humanitarian aid to enter the Gaza Strip.^2–5 This resulted in a famine (especially in the north), with nearly the entire population (96%) facing acute food shortages through September 2024. ⁶ Famine was increasingly imminent by March 2025, as Israel had fully blocked humanitarian aid since early March. ⁷ By mid-July, Gaza was experiencing widespread famine conditions, with an official famine confirmation on 22 August by the UN-approved Integrated Food Security Phase Classification. ⁸ As Palestinians struggle with widespread shortages of the most basic survival needs (water, food, medicine, shelter), the specific needs of girls and women are easily overlooked.

Although men often account for the majority of casualties during war, evidence suggests that women and children bear the brunt when it comes to indirect mortality.^9,10 This is in part because sexual and reproductive health (SRH) is often neglected in humanitarian crises. Living dangerously close to armed conflict increases the risk of sexual violence, unwanted pregnancy and poor reproductive and maternal health outcomes, which account for a significant share of female indirect mortality.^11–13 Material deprivations – including shortages of medicines, water, nutritious (and fresh) food, cooking oil, soap, toilets and menstrual products – compound these challenges for girls and women.^14,15

To manage their menstrual hygiene, women and girls need access to clean water, adequate housing, waste disposal systems and women-friendly water, sanitation and health (WASH) facilities,^16–18 but in conflict, these systems often fail, leading to significant health risks for females.^16–23 A systematic review of menstrual hygiene management (MHM) in humanitarian crises found that access to sanitary products and adequate disposal options was often very limited due to intersecting physical, financial and social barriers. ¹⁰ Poor menstrual health can cause reproductive and urinary tract infections, putting girls at risk of infertility and birth complications, and can also contribute to stress, anxiety and reduced self-esteem.^24–32 Qualitative data suggest that compounding these challenges is the fact that health workers may not only lack expert knowledge and be reluctant to discuss SRH issues due to cultural taboos or conservative gender norms, but also fail to prioritise SRH needs in a crisis.^18,33

Drawing on mixed-methods research with over 1000 young people (aged 10–24 years) from all five governorates of Gaza in 2024, this article explores the intersecting obstacles to healthcare – material, financial and social – facing adolescent girls and young women as a result of the (human-made) humanitarian crisis in Gaza. The central research question guiding this article is how the multi-level impacts of the war on Gaza have shaped the health outcomes of adolescent girls and young women, including their ability to fulfil their health-related basic material needs. The article begins with a brief overview of the Gazan context – both before the 7 October attack, and during the subsequent prolonged war, focusing on the health sector. In the method section, we discuss the sample and methods, before presenting our findings on the material deprivations that adolescent girls and young women have experienced, and how these have been compounded by financial, physical and social barriers to accessing appropriate health and SRH care. We conclude by discussing the implications of our findings for age-and gender-inclusive healthcare provisioning in humanitarian contexts.

The Israeli blockade of Gaza (pre-7 October)

Before 7 October 2023, the Gazan population was already living under siege. In June 2007, after Hamas was elected and took control of Gaza, Israel imposed a blockade, restricting the movement of goods and people in and out of the territory.^34,35 Israel maintained full control over Gaza’s land, air and sea access, rendering the multiple crossings – once vital for trade – largely inoperable. ³⁶ Without sufficient imports or exports, Gaza’s economy collapsed entirely, leading to shortages of all goods and rising unemployment levels. ³⁵

As of 2022, 80% of Gaza’s population were reliant on humanitarian assistance and 81.5% were living below the poverty line. ³⁷ Due to the blockade, as well as internal political conflict, lack of funding and intermittent bombing campaigns, Gaza’s health system was already under strain.^38,39 Before the war, only 55% of essential medications were available (on average); for a range of health complications, Palestinians were reliant on referrals to hospitals outside the territory, though the Israeli authorities often denied them access. ⁴⁰

In 2018, the United Nations had already predicted that Gaza could become unliveable by 2020. ⁴¹ Before October 2023, 96% of Gaza’s water was deemed undrinkable, with many people having to rely on trucked-in desalinated water. ⁴² Due to the blockade, malnutrition rates increased, with more than half of pregnant women and children (aged 6–23 months) classed as anaemic according to surveys conducted by the Ministry of Health between 2018 and 2020. ⁴³ Only one in four women in Gaza relied on exclusive breastfeeding (as recommended by the World Health Organization), and one-fifth of boys and girls were stunted by the age of 2. Some studies suggested higher rates for girls, possibly due to gender bias.^44,45

The war on Gaza (post-7 October 2023) and impacts on healthcare

As of April 2025, at least 60,000 Palestinians had been killed since the onset of the war on Gaza, although this number is likely under-reported.^46–49 Compared to other conflicts, in which most casualties are typically male, ⁹ the war on Gaza stands out in terms of levels of civilian mortality, ⁵⁰ and particularly among women and children.^49,51 Moreover, the destruction of essential services – such as food, water and healthcare systems – often results in ‘indirect’ deaths that outnumber direct conflict-related casualties (sometimes by a factor of 3–15).^52,53 In Gaza, systematic attacks on agriculture, water resources, civilian infrastructure, healthcare facilities and personnel and aid networks have severely compromised survival conditions.^54,55 Israel has also deliberately targeted Gaza’s water infrastructure, destroying wells, water desalination plants, wastewater treatment facilities and water tanks.^54–57 As a result, water usage per person has dropped from 83 L a day to 2–9 L, in contrast to Israelis who use around 247 L (on average). ⁵⁷ Most of Gaza’s sewage system has also either been destroyed or become inoperable due to a lack of fuel, electricity and the destruction of infrastructure.^57,58 There is sufficient evidence to conclude that the indiscriminate killing of civilians and the clear intent to make life in the Gaza Strip impossible for Palestinians amount to genocide.^57,59–62

Within this context, an estimated 690,000 girls and women in Gaza face multiple challenges in meeting their material health needs. This includes challenges managing their menstrual hygiene and receiving adequate maternity care.^63–65 Whereas before the war there was near universal antenatal and postnatal care, access is now very limited for approximately 155,000 pregnant or breastfeeding women, and miscarriage rates have increased by 300%.^57,66,67 In April 2024, UN Women surveyed 305 women across Gaza. Almost all pregnant women (99%) reported a lack of nutrition; 69% had experienced pregnancy complications, including urinary tract infections (92%), anaemia (76%), hypertensive disorders (44%) and preterm labour (28%), with little or no care available.^57,67 The war has also severely impacted mental health: 75% of surveyed women report experiencing depression, 62% struggle with sleep and 65% frequently experience anxiety and nightmares. ⁶⁷

Methods

This article draws on qualitative and quantitative research methods. Data was collected sequentially, with the initial survey findings helping to inform the design of the qualitative research tools. The tools were informed by a capabilities conceptual framework drawing on the work of Amartya Sen, Martha Nussbaum and Naila Kabeer but nuancing the approach to take into account age-specific dynamics during adolescence and early adulthood. ⁶⁸ The reporting of this study conforms to the STROBE and COREQ statement.^69,70

Data collection was undertaken as part of the Gender and Adolescence: Global Evidence (GAGE) longitudinal research programme. GAGE has collected data following young people’s lives since 2016 in the Gaza Strip, with a research team based at Al Quds University. The GAGE team has a robust network of local researchers, community-based organisations and policy-relevant stakeholders. These relationships allowed the team to continue conducting research under the current crisis conditions in Gaza.

Quantitative data and sampling approach

The quantitative component of this study draws on the results of an observational, cross-sectional household survey carried out in August and September 2024 with 1011 young people (aged 10–24 years), proportionately sampled across the five governorates of the Gaza Strip. Due to the challenges of obtaining a probability sample in a conflict setting, participant selection relied on a convenient clustered proportionate sampling of all accessible neighbourhoods at the time of data collection, using a sampling frame suggested by the Palestinian Central Bureau of Statistics (PCBS) in 2020. ⁷¹

The study sample was calculated by using widely accepted sampling parameters (confidence level 95%; acceptable margin of error at 5%, design effect 1.5); the formula suggested 927 participants. To enhance representativeness and statistical strength, the research team increased the sample size to 1020 participants. Replacement households (in the case of lack of availability or ineligibility) were replaced following the same sampling procedures, resulting in a final total of 1011 participants; the remaining 9 although eligible and accessible declined to participate. The sampling strata included participants from all five governorates, representing diverse age groups and living conditions (i.e. displaced young people living in shelters, tents and among host communities). Eligibility criteria required participants to be aged 10–24 years, to have been living in Gaza for at least 1 year before the war, and to reflect diversity in age, gender, place of residency before the war, current displacement location, and type of residency. The sample also included purposely selected married young women (10% of the total) and young people with disabilities (12%) to understand the specific effects of the war on the well-being of these at-risk sub-groups. They were recruited through networking in coordination with community leaders, health clinics and disability rights organisations. Table 1 presents the characteristics of the study sample. In households with more than one eligible young person, a single individual was selected using the Kish Grid equal probability sampling method.

Table 1.

Distribution of study participants (young people aged 10–24 years) by characteristic variables (N = 1011).

Variable	Number	Percentage
Age (years)
10–14	304	30.1
15–19	397	39.3
20–24	310	30.7
Mean age: 17.14 (median 17)	—	—
Gender
Male	485	48
Female	526	52
Place of residence (before the war)
North of Gaza	234	23.1
Gaza	347	34.3
Middle area	132	13.1
Khan Younis	184	18.2
Rafah	114	11.3
Current place of living (governorates)
Gaza	225	23.3
North of Gaza	142	14
Middle area	280	27.7
Khan Younis	213	21.1
Rafah	151	14.8
Refugee status
Refugees	332	32.8
Non-refugees	679	67.2
Marital status
Married	181	17.9
Not married	830	82.1
Mean age at marriage: 17 years	—	—
Disabilities
Yes	123	12.2
No	888	87.8

Survey tool

The survey tool was designed based on established approaches and adapted to the local context. The research team adopted questions from other surveys applied in the Palestinian context, particularly from the PCBS-administered national Multiple Indicator Cluster Survey. The team also drew on tools developed by GAGE, particularly the survey tool used during the Covid-19 pandemic in Jordan and Palestine, which was designed to assess adolescent capabilities including those related to health, nutrition, mental health and bodily integrity in a crisis context. ⁷² Several internationally validated scales were used, including the Household Water InSecurity Experiences (HWISE) scale, which was particularly relevant for this article. It has proven to be an effective measure in low- and middle-income countries and (post-) conflict contexts, including countries in the Levant and Gaza (pre-October 2023).^73–78 A score of 5 or more indicates a high water insecurity experience in the past month.

Data collection

Over 2 days, 10 experienced female enumerators (aged 30–50 years) – residents of the targeted localities – were trained on data collection processes and administering the survey. The training covered the study’s objectives, ethical issues, safety protocols, participant recruitment procedures and the sensitivities of conducting face-to-face interviews with young people in a conflict context. The enumerators have been collaborating with GAGE since 2020 and bring outside experience conducting surveys – for instance, for PCBS. Tools were then piloted with 30 participants (3% of the total), resulting in further modifications. The Arabic version of the tool was used during face-to-face interviews, and answers were directly uploaded into the SurveyCTO programme. The response rate was high, with only nine households refusing participation. To ensure scientific rigour, the programming of the software incorporated several built-in quality control measures and checks. Two field supervisors also conducted validation visits and call-backs (152 calls).

Statistical analysis

Data were imported, cleaned, processed and analysed using SPSS 27 (IBM) and Stata v17 (StataCorp LLC). Data pertaining to scales were then checked for reliability and credibility using Cronbach’s alpha, which revealed high internal consistency. In the case of the HWISE-8 scale, the Cronbach alpha score was 0.870 whereby 1 denotes perfect reliability. The descriptive statistical analysis began with frequency distribution and central tendency measurements, followed by inferential statistical tests to identify significant differences among the variables. A p-value of less than 0.05 was regarded as statistically significant.

Qualitative data

The qualitative component of the study was conducted in November and December 2024. It involved in-depth interviews with 100 adolescents and youth (56 females and 44 males) selected from the quantitative sample (see Table 2). The team also conducted 24 key informant interviews with service providers and community leaders from northern and southern Gaza (see Table 3). Key informants were recruited based on a purposive snowball sampling technique to ensure a mix of participants from different localities, age groups, genders and socioeconomic backgrounds. For more details of the qualitative research sample, see Tables 2 and 3.

Table 2.

Adolescent qualitative research sample.

Adolescent characteristics	Girls/young women			Boys/young men			Sub-totals
	10–14	15–19	20–24	10–14	15–19	20–24
North Gaza, Gaza City, Middle Gaza, Khan Younis and Rafah (displaced versus not displaced, living in tents/shelters versus living in houses)	8	12	12	8	8	8	56
Married males and females	—	6	6	—	4	4	20
Adolescents with disabilities (both pre-existing disabilities and conflict-acquired disabilities)	4	4	4	4	4	4	24
Total	12	22	22	12	16	16	100

Table 3.

Key informant sample.

Key informant characteristics	North Gaza and Gaza City		South Gaza (Middle, Khan Younis and Rafah)		National	Subtotals
	Male	Female	Male	Female
Community leaders	1			1	1	3
NGOs (social protection sector) Aisha (combating violence)		1	1		1	3
Disability sector		1	1	—	1	3
Social assistance (UNRWA, Ministry of Social Development, UNICEF, World Food Programme)	1			1	1	3
School teachers/counsellors at formal and informal shelters, school e-learning services	1	1	1	1		4
Health workers (UNRWA, Ministry of Health)	1	1	1	1	1	5
Shelter managers	1			1	1	3
Total	5	4	4	5	4	24

Data collection

A team of six experienced local researchers (four females and two males), who have been working with GAGE in Gaza for at least 5 years, collected the data. The GAGE team in London provided remote technical support and guidance. Six pilot interviews (5%) were carried out, leading to refinements of the study tools. Local researchers used Arabic versions of the qualitative tools, which were revised, tested and adapted for contextual relevance. Interviews lasted around 90 min on average.

To ensure scientific rigour, the research team participated in two training sessions focused on reviewing, understanding and finalising (through input by the local team) the study tools and guidelines. The research supervisor audited a subset of interview recordings from each team member to ensure consistency in implementation of the tools. The relatively large sample size for qualitative interviews, the diversity of respondents and the use of a variety of tools facilitated effective triangulation and enabled the team to secure in-depth and diverse insights into the research questions. Data saturation was achieved when interviews no longer generated new themes or insights, and additional data simply confirmed patterns already identified in the earlier stages of analysis.

Analysis of qualitative data

All interviews were audio-recorded and supplemented by written notes taken during and immediately following the interview to record any pertinent observations about the process. Interviews were then transcribed, reviewed and thematically coded. Coding was completed using MAXQDA 24 software (VERBI software), by four experienced coders who received tailored training. Weekly meetings of coders were held to ensure consistent and accurate application of codes across transcripts. The thematic coding structure was informed by the GAGE conceptual framework (see Table 4).^72,79 After coding, quotes were grouped by theme, and those presented in this article were chosen because they exemplify the broader trends identified.

Table 4.

Snippet of the codebook (conflict-related codes).

Recent conflict: Codes related to the conflict in Gaza since 7 October 2023	Impacts on household and community infrastructure
	Impacts on living location (own home, shelter, with family, on street, etc.)
	Impacts on housing conditions
	Impacts on household composition
	Impacts on household livelihoods and earned income
	Access to emergency aid/social protection
	Impacts on access to drinking water
	Impacts on access to food/adequate nutrition
	Impacts on sanitation including MHM
	Impacts on transport
	Access to electricity
	Impacts on internet
	Impacts on adolescent physical health
	Impacts on physical health ex SRH and nutrition
	Impacts on access to health services ex SRH
	Impacts on SRH
	Impacts on access to SRH services
	Impacts on adolescent mental health
	Impacts on relationships with family
	Impacts on relationships with peers
	Impacts on mental health
	Impacts on coping strategies
	Impacts on access to psychosocial services
	Impacts on adolescent bodily integrity
	Adolescent exposure to violence
	Family exposure to violence
	Broader exposure to violence
	Impacts on child marriage
	Impacts on access to legal/protection services
	Impacts on mobility and other decision-making
	Intersectional impacts
	Impacts on gender norms/expectations – including for married and unmarried adolescents
	Nexus of conflict and disability all domains

SRH: sexual and reproductive health; MHM: menstrual hygiene management.

Research ethics

Ethical approval was obtained through the Helsinki Committee (PHRC/HC/1245/24) and the Ministries of Health and Education in Gaza, and from the ODI Global Ethics Committee (ODI R025002). Strict adherence to the international code of ethics (including to the principles of informed consent, privacy, confidentiality and voluntary participation) was ensured throughout data collection. Consent was obtained from participants aged over 18; participants under the age of 18 provided verbal assent, accompanied by consent from their caregivers. Due to security concerns, in lieu of written consent, participants were asked to verbally confirm, on tape, that they understood the terms of their participation, including the right to withdraw from the study at any time without repercussions, and that they consented to be interviewed.

All data were anonymised and securely stored on a cloud-based, password-protected platform. To mitigate safety risks, both quantitative and qualitative interviews were conducted in the participant’s household. Sign language interpreters facilitated communication with young people with a hearing impairment. For the qualitative data collection, a small cash payment was provided to cover hospitality costs so as to preserve the dignity of the participants and ensure that they were not incurring any costs for participation. The risk of coercion was deemed minimal, as participants appeared genuinely willing and motivated to participate and share their experiences.

Results

We now turn to discuss our findings, including on girls’ and women’s access to water and sanitation services, MHM and healthcare infrastructure and supplies. We foreground girls’ and young women’s unmet material needs but also explore how these intersect with financial and physical barriers as well as restrictive social and gender norms.

Water, sanitation and hygiene

Water

Although access to clean freshwater was already severely restricted due to the Israeli blockade, the war destroyed Gaza’s water infrastructure. Quantitative data using the Household Water Insecurity Experience Scale from August and September 2024 show that 87% of participants were classified as highly water insecure. Nearly half reported worrying about having enough water more than 10 times during the past 30 days. Approximately 75% cited lack of sufficient water, and about half had experienced going to bed thirsty. Only 14% of participants reported never having to worry about water access. Participants in the south experienced particularly high levels of water insecurity. The qualitative data confirmed these challenges. Whereas before the war, as a health worker explained, ‘every area had a large water tank’, during the war they ‘were all targeted by the occupation army. Every water source was deliberately targeted’. Similarly, a 15-year-old girl in north Gaza stated:

We need water to drink. For hygiene, too. These things used to be readily available, the easiest things. . . And suddenly, we found ourselves wishing for water, waiting for it to flow from the tap. . . It’s a terrible feeling. This made access to clean water extremely difficult.

Qualitative data also indicate that water became expensive, and according to a health worker, the price of fresh water ‘has increased many times over’, affecting the poorest families the most. Even salty water has become expensive, as a 15-year-old girl living in a tent in the south Gaza noted:

The water crisis was also really hard. At first, we had running water, and my brothers and dad used to fill roof water storage tanks. But now, there’s no water. They had to travel to far places to buy salty water. Can you imagine? A small 10-litre bottle of untreated water costs 4 shekels. It’s beyond belief. It’s hard to describe how tough and strange this situation is.

Many Palestinians, especially young people, have to queue for long hours to obtain water, which leads to stress and feelings of humiliation, as a 19-year-old young man in the south reported: ‘I have to wait in a long queue until I finish filling the water. Honestly, I feel humiliated. Before the war, I was never humiliated, but during the war, I have been’. Water distribution is often chaotic, with skirmishes among those queueing. As a 24-year-old young man with a visual disability explained: ‘When getting water, there’s always violence’. Families have to make hard choices when it comes to water, and as a 16-year-old girl said, ‘Sometimes, we anticipate that there won’t be water the next day, so we ration our drinking. We drink less to make the supply last longer until my father can go and refill it’.

Young people with a disability are especially affected due to their limited mobility. As a 13-year-old boy in south Gaza with a physical mobility impairment reported:

I go in the morning. I start limping till I get there, I wake up and take the gallon with me and I run as fast as I can so I can have a turn. It’s true that my legs hurt, but I have to get water because it’s the essence of life.

The destruction of freshwater basins and water treatment facilities means the quality of water in Gaza has also quickly deteriorated, with many people forced to drink contaminated or ‘salty’ water. Most participants regularly collected water from potentially contaminated sources. The quantitative data showed that around 75% had consumed unsafe water, putting them at risk of diarrhoea and other diseases. One 15-year-old girl in the south said, ‘Sometimes we drink water and feel like we’re drinking chlorine, not water’. The authorities and aid organisations have been compelled to use unconventional methods to provide ‘drinkable’ water such as using chlorine tablets to decontaminate water.

Drinking contaminated or salty water can cause serious health complications, which a 14-year-old girl in the North with a hearing disability attests to:

[T]he water was contaminated, and it caused her [sign interpreter translating the sign language of the respondent] to have jaundice. . .she got hepatitis and was very sick. She went to the hospital because they didn’t have clean water to drink. She told them there was no clean water or anything sweet to consume, because they asked her to eat sweet food, and she couldn’t find anything.

Some girls even experienced prolonged periods without access to water, often when certain areas were under siege, with the Israeli army blocking all aid and vehicles used for transporting water. A 15-year-old girl from the north described witnessing the siege of Khalifa Ben Zaid school in Beit Lahia:

Honestly, [it was] terrifying. We couldn’t even step out of the classroom door. . . There was absolutely no water. . . It got to the point where they used hookah [waterpipe] water. . . hookah water! They used syringes to extract the water and give it to the children.

The qualitative findings also revealed that the chronic shortage of drinking water resulted in loss of life, including among relatives of the study cohort. The same 15-year-old girl explained that:

In that month, I suffered from dehydration. . . My little cousin suffered from dehydration, and it led to her death. . . Many of our relatives died because of dehydration. . . That little girl suffered from dehydration, and we couldn’t do anything. . . Because of the bombing and because we were surrounded by tanks. . . She was a baby, and when her mother tried to breastfeed her, there was no milk in her breast.

As a key informant working in the disability sector stated, scarcity of water means girls and young women face additional challenges for MHM:

Due to the lack of hygiene supplies, adolescent girls and young women need more sanitation, more water, menstrual hygiene products, personal hygiene items, and protection against infections. So, they are even more affected.

Similarly, a boy in the south aged 17 said, ‘Girls are prioritized. . . Honestly, it’s their right. They go through a lot more struggles. We, as young men, can eat anything and drink anything’. In short, the qualitative data suggest that it is widely recognised by programme implementers and adolescent girls and boys alike that girls face particular challenges regarding water shortage due to MHM.

Sanitation

The quantitative data show that following the onset of the conflict, nearly a third of young people reported living in dwellings without access to a toilet, and 21% had to defecate without using one. On average, participants shared a single toilet with about 12 others. As a 22-year-old man living in southern Gaza asserted:

Accessing a toilet in the places we live in is very difficult, due to the large gatherings. Relieving oneself is very difficult, to the point that a person tries to control himself until his last breath, until he can’t. . . even. . . until he doesn’t go to this place. But in the end, we are forced to go to this place, of course, which is too dirty. . .

Many WASH facilities have been destroyed, whereas demand has risen due to frequent displacements and mass destruction of homes. A 23-year-old woman in the north described having to use a half-destroyed toilet:

You need to recite verses from the Quran before going into the bathroom [for divine protection] . . . The roof is half destroyed; it is half open. . . Before arriving in [specific location], the quadcopter threw bombs. It threw a bomb behind us. Thank God no one was in the bathroom. . . due to the impact of the bomb. I am telling you, it is half destroyed, and when it rains, you can get wet [there].

Whereas boys have more freedom to urinate in public spaces, girls face many more challenges, not least their restricted mobility due to conservative gender norms and safety concerns. As an 11-year-old girl noted: ‘Going at night. I feel scared, so I wake my mother to come with me’. A key informant further attested to the impact of lack of sanitation facilities on girls and women, noting that particularly in the late afternoon or evening, they:

. . .almost do not drink water so that they do not have to go to the bathroom at night because the bathrooms are far away and they are unable to reach them, and sometimes they are scolded by their families if they go to the bathroom at night because their brother or father will go with them and it will be a burden on them.

Qualitative data suggest that young people with a disability face additional burdens. A 14-year-old girl with a hearing disability from the north of Gaza described, through an interpreter, how she ‘doesn’t go to the bathroom alone. The bathroom is next to her, but she doesn’t go. . . Because she’s afraid someone will come and open the door, and she won’t hear them. Since she has a hearing impairment, she takes her mother with her to the bathroom’. The qualitative findings indicate that girls with disabilities face compounded challenges as visual, physical or hearing impairments can exacerbate issues of mobility, privacy and safety.

Hygiene

Quantitative data show that nearly half (46%) of the participants lacked access to a bathroom for showering, and 90% of WASH facilities were not gender-segregated, contravening cultural norms. The findings indicate that as a result of the humanitarian blockade, Gazans have only limited access to hygiene products such as soap and shampoo, leading to a huge price increase. An 18-year-old girl in the north reported that:

We tried to use very small quantities of shampoo, because it was very expensive in the market. The cheapest shampoo was sold for 50 shekels [around USD15]. We bought it last time with quite a difficulty, for 54. . .The bottle we bought for 54 shekels was sold for 8 shekels before the war.

Other respondents explained that the lack of gas or electricity to warm water for bathing makes people reliant on limited firewood, which in turn poses additional physical and financial difficulties for maintaining hygiene. A 23-year-old married man in the south explained:

The fact is that we’re experiencing cold weather [referring to the time of the interview during the Gazan winter]. You need to go get some firewood, a kilo of firewood costs 4 shekels, just to warm a little bit of water. You’re going to get exhausted with your life.

During displacement, or when Israeli soldiers lay siege to a certain area, hygiene was accorded a low priority. A 20-year-old woman in the north described how:

We were showering with cold water in very cold weather and sometimes you stay a long time without showering, the first time [when we were displaced to schools for shelter], we stayed for a whole month without showering. . . a whole month, 27 days.

Maintaining even basic hygiene is extremely difficult in shelters for displaced people, where privacy is non-existent. This affects girls and women especially; 92% of girl respondents reported additional pressures to wear ‘modest’ clothing. An 18-year-old young woman staying in a shelter reported that:

The hijab is on the head all the time, it is never taken off, it is never removed. It affects everything, especially hair cleanliness, and hygiene. There is no personal hygiene, methods are non-existent.

A 15-year-old girl from the south of Gaza added:

As a female, I love cleanliness. During the war, and because of living in a tent, cleanliness has decreased. I no longer care about myself as much. I’ve lost hope in maintaining personal hygiene as it was before the war. When I shower, the area around me is unclean. I try to clean it often, but it just doesn’t get any cleaner. . . I stopped caring for myself. I’ve lost hope and passion for being clean, combing my hair, and caring for myself. I’ve lost hope of ever achieving this.

Qualitative data enriched the findings by showing how the erosion of the ability to maintain personal hygiene not only undermines physical health but also contributes to a profound sense of despair and loss of dignity among displaced girls and women.

Menstrual health

Some 72% of girls reported difficulties accessing menstrual hygiene supplies and commodities, primarily due to a lack of money or limited availability in the market. Many also faced challenges accessing essentials such as soap, water and toilets. Although 30% had received menstrual hygiene kits from humanitarian organisations, most kits were incomplete and did not contain all the necessary supplies. These challenges were particularly pronounced among girls in the south, and among girls with a disability, who have faced increased barriers to accessing menstrual hygiene products since the onset of the war. A health worker noted that:

. . .after October 7, the issue went beyond just poverty or having money. The pads simply aren’t available in the market anymore. And when they are, the prices are ridiculously high. So, people started resorting to alternatives. . . For example, if someone has diapers, they cut them up and use them as pads. Even baby diapers are being cut and used for menstruation. Girls and women have started using cloth and strips of fabric during their periods.

An 18-year-old young woman reported that these challenges were exacerbated by the lack of facilities for washing clothing and disposing of menstrual waste:

In our house. . . there was a Western bathroom, cleanliness, a sink, we washed our underwear with soap, but now. . . no water, no cleanliness. . . I mean where do you wash. . . where do you change, for example?. . . Also pads and their availability, and so on. . . when we move, we leave everything behind, we don’t know what to take every time we move, including cleaning materials.

More than half of girls (57%) cited a lack of privacy for managing their menstrual hygiene. Girls frequently reported having to share spaces and a bathroom with (male) family members or even strangers, leading to feelings of embarrassment and shyness when it comes to menstrual health due to widespread cultural taboos. The same 18-year-old young woman added: ‘There is no privacy. For example, I am a girl, and I have an older [male] cousin in the same room, so I feel there is something wrong in the room’. Another 18-year-old displaced girl attested to this discomfort, saying ‘I used to have the freedom to use my own toilet at my house. I don’t have such freedom here’.

Sharing a room with family also affects girls’ privacy, with a 15-year-old girl from the north explaining:

For example, in the room – if I want to change, my siblings might be sitting there, or the window might be open, and I have to find a way to cover myself. . . The bathroom is shared, so there’s no privacy to sit in there for a while.

Girls with disabilities face additional barriers. The qualitative data highlight their concerns, showing they are less mobile, need more time, require support from others and have additional needs concerning privacy. For instance, they are not able to hear or see when someone wants to enter the room, as one 14-year-old girl from the north with a hearing impairment noted:

She [interpreter speaking] says sometimes she doesn’t feel comfortable, as she is using a [menstrual hygiene] pad, and her father might come in [as she is not able to hear a knock on the door], and she feels embarrassed about this.

More than half of the girls surveyed also reported feeling embarrassed to ask their family for support with menstrual hygiene needs. This was in part due to a cultural taboo, but was also because of the outbreak of war, which has put enormous strain on the financial situation of many households, as a key informant noted: ‘A girl might feel shy to ask her father for these supplies when he can’t even afford flour and bread’. A 20-year-old young woman replied, when asked which supplies are essential, ‘Definitely the sanitary pads, because they are a necessity. . . Because if they weren’t available, I’d be too embarrassed to ask my father for them’. In sum, these findings show how the blockade and displacement severely compromise girls’ ability to manage their menstrual health with dignity, reinforcing both physical discomfort and emotional distress.

SRH services and supplies

According to health workers in the field, before the war, SRH-related topics were often considered controversial or even immoral, and only married women could access SRH care (with approval of the husband). As a key informant highlighted: ‘A girl does not visit a gynaecologist unless she is married. If she does, it becomes an issue’. The war has made it much more difficult for women to access SRH services due to the destruction of health facilities and infrastructure. Many health workers have fled, or been killed or displaced, and many are being held indefinitely in Israeli prisons. As one health worker noted:

A significant number of doctors and skilled professionals have left. Many who worked in primary and secondary care, UNRWA, government, or private sector, have left. That has impacted the quality of care.

Married participants (male and female) reported the worst overall health scores in the survey. Of the married girls in our sample, 39% reported being pregnant since the onset of the war but only half (45%) reported receiving any form of care during pregnancy. The main reasons for not receiving antenatal care included: could not reach the health centre because of war (40%); did not have money to go (34%); and health centres were closed or unavailable (31%). The main reasons for not receiving postnatal care were: could not reach the health centre because of war and insecurity (58%); health centres were closed or unavailable (33%); did not have money to go (25%); and could not find transportation (25%). One 18-year-old married woman from the north described how their financial situation made it difficult to attend a health clinic for seeking reproductive health services:

[M]y husband is currently unemployed. . . But we manage. We pay for transportation – 5 shekels for me, 5 for him, 10 in total. . . 10 for going and 10 for returning, so we know we need 20 shekels monthly for doctor visits.

With no permanent ceasefire in sight, it was frequently reported that married couples fear becoming pregnant and are increasingly turning to abstinence, considering limited access to modern contraceptive methods as a health worker noted:

People are deliberately avoiding pregnancy given the current context. They’re not confident about the future, how can they bring a child into this world now? Especially while living in a tent, moving from one place to another, struggling with costs, diapers, no income, and, most importantly, war.

Younger, unmarried participants also attested to this growing trend, as a 15-year-old girl reported:

I really want to have children, but I am afraid because of the food situation. . . There is no food or drink available. I mean, I haven’t eaten in three days. If I have a baby inside me, how will it survive?

The Israeli blockade of humanitarian aid means that lack of nutrition is a serious threat for mothers and babies. As one 18-year-old pregnant woman in the north explained, before the war, ‘At home, everything was normal. If I craved something, we’d get it. Now, if I crave something due to pregnancy, it’s not available’. A 12-year-old girl from the north added, ‘During the famine [September-October 2024] there was no food, my brothers and I were hungry, and there was no milk or diapers for my little brother either’. Qualitative data show that parents also find it difficult to access essential baby products like diapers and milk. As one married 22-year-old man said, ‘A pack of diapers costs 250 shekels [55 GBP], and baby formula costs 170 shekels [37 GBP]’. A 23-year-old father explained: ‘We run to associations [providing food rations], here and there. Today, my whole direction and my life go to my daughter [her needs]. I get her diapers; I get her milk. That’s all, really’.

However, despite fears of coping with pregnancy amidst war, contraceptive availability is very limited and unmet family planning needs have escalated, as one health worker commented: ‘Currently the pills are available but it’s not existing all the time, and the condoms, sometimes it’s available and sometimes not. . . If it was available, it’s at unrealistic prices, no one could afford it’. Another health worker suggested that accessing condoms had already become increasingly difficult during and after the Great March of Return protests (2018–2019), ‘because they used regular balloons and put flammable liquids in them. And they let them fly. When the balloons ran out, they started using condoms. Israel came and said, “By God, you won’t see them again.” Even now, it’s very difficult for them [condoms] to enter’. Although qualitative data highlight the demand for contraceptive methods, the blockade has severely restricted access, potentially leading to an increase in unplanned pregnancies under extreme conditions.

Discussion

Our mixed-methods findings provide rare insights into the health needs of girls and young women in the Gaza Strip post-7 October 2023. Given the enormous levels of death and destruction in modern conflicts (such as in Ethiopia, Iraq, Sudan and Ukraine), the impacts of war on female health are easily overlooked; qualitative analyses are especially scarce.^16,21,23 This study in Gaza sheds light on the experiences of girls and young women in managing personal hygiene, sanitation, menstrual health, and SRH, which is essential to understand the types of humanitarian interventions needed at scale. Our findings underscore the significant and intersecting threats to girls’ and young women’s access to basic material needs and related health supplies and services in Gaza due to the hostilities, with important implications also for other humanitarian contexts.

Before 7 October 2023, young females in Gaza already struggled with period poverty, menstrual stigma, inadequate information and lack of private WASH facilities. ⁸⁰ Because of social taboos, many girls begin menstruating without prior knowledge or preparation.^80,81 However, despite the pre-war challenges, the invasion and siege of Gaza have greatly exacerbated the situation. Findings from both quantitative and qualitative data align with earlier research on MHM in conflict and humanitarian settings, highlighting issues such as shortages of menstrual products, limited disposal options, insufficient humanitarian aid, prioritisation of other needs, inadequate water supply, lack of WASH facilities, privacy and mobility concerns and the social stigma surrounding MHM.^16–18,33 At a most basic level, essential MHM products (menstrual pads, soap and underwear) have not been allowed to enter Gaza due to the Israeli-imposed blockade on international aid. The resulting scarcity means that prices skyrocketed, making them only accessible for those with sufficient financial means or those that have prioritised menstrual health over other needs. In addition, girls and young women reported that humanitarian assistance was insufficient to meet their menstrual health requirements; aid kits with menstrual materials were scarce and often lacked essential items. As in other contexts, girls often must find alternatives to menstrual pads (cloth, diapers, etc.), which can increase the risk of urogenital infections. ²⁴ The lack of clean water and (private) WASH facilities in Gaza exacerbated by the widespread destruction of WASH infrastructure has made MHM challenging and especially for girls and young women who have been displaced to temporary shelters which afford scant privacy.

The findings underscore that compounding the challenges of these unmet health needs, social stigma vis-à-vis menstruation or ‘menstrual shame’ that stems from conservative gender norms forces girls to maintain secrecy on menstrual topics, even around trusted adults,^76,82 and inhibits many girls and young women from asking their families to cover the costs of sanitary products, especially in a context of high unemployment and poverty. This article also provides novel evidence around MHM among adolescent girls and young women with disabilities in conflict areas. Our findings show that young people with disabilities experience compounding challenges around mobility and privacy in the makeshift WASH facilities and sometimes need additional support that due to family injury, death, poverty and/or psychosocial stress is not always available.

Although conflict often results in a shortage of clean water, ⁸³ the war on Gaza stands out in that attacks on water infrastructure have been deliberately and systematically carried out by Israel to make life in the Gaza Strip impossible.^54–57 This destruction has created an acute water crisis, which has caused a severe public health emergency, at times resulting in death.^55,57,58 Before the war, 96% of water from the Gaza sole aquifer was already deemed unfit for human consumption. ⁸⁴ Our findings show that since 7 October 2023, accessing water has become expensive and time-consuming, as people must gather water from central distribution points, often experiencing long queues and a tense atmosphere – heightened by the risk of leaving empty-handed, being subjected to physical violence and/or the constant threat of aerial bombardment.^85,86 In this context, girls and young women face intersecting challenges as limited mobility often prevents them from travelling the necessary distances to access water under these circumstances. Moreover, in line with other research on conflict-affected settings,^12,16–18 the findings highlight that water needs to be heavily rationed within households – making overall hygiene and MHM particularly difficult.

Before the war, access to sanitation facilities (including flushable toilets) was nearly universal in Gaza (99.9%). ⁸⁷ However, the widespread destruction of private homes and WASH services has forced girls to share toilets or bathrooms with other (sometimes unknown) individuals, which can threaten their safety. Given prevailing conservative gender norms in Gaza, boys have greater freedom to seek out alternative restrooms or relieve themselves outdoors, whereas girls face severe restrictions in accessing WASH facilities. Evidence from other low-resource settings indicates that females often fear going to the toilet by themselves or inadvertently exposing themselves when managing their hygiene, which can lead to stress and anxiety.^26–33 In our findings, girls reported similar fears, especially at night. Our analysis expands on earlier observations and contributes new evidence by documenting that because of displacement and the need to share dwellings with males outside their immediate family, girls and young women feel obliged due to social mores to always wear a covering dress and hijab in the household. ⁸⁶ This constant need for covering, even in the heat of the summer, does not only impact their physical comfort and personal hygiene, but also their mental health ⁸⁸ ; the findings indicate that being unable to secure a decent level of hygiene negatively affects girls’ sense of self-worth, dignity and impacts their mental health.^26–33

In line with the broader literature that indicates that SRH services tend to be under-prioritised in humanitarian settings,^20–22 our findings show that as a result of the continues aggression, SRH facilities have ceased operations and skilled health workers have been killed, imprisoned, or left the Gaza Strip, leaving women and girls with severely limited access to essential SRH services. Attacks on health facilities and ongoing security risks have made it extremely difficult for girls and young women to access antenatal and postnatal care (despite near-universal access before the war).^89–92 As barriers to antenatal care, young women cite the security risks due to the war, lack of financial means and limited operational health facilities. This is a serious risk to the health of mothers and infants alike, and potentially a major contributor to indirect deaths.^12,13,93 Moreover, qualitative data from this study indicate that following the rapid deterioration of living conditions since 7 October,^54–62,94 many participants have become more hesitant to have children. This trend stands in contrast to historically high fertility rates in Gaza (for instance, between 2017 and 2019, the total fertility rate was 3.9 children per woman, compared to 3.8 in the West Bank). ⁹⁵ These high fertility rates can be explained by limited access to SRH services and rights for women, and family and societal pressure, as procreation is considered an effective strategy to resist occupation, especially after times of conflict.^81,96 However, despite shifting desires around childbearing during the war, family planning methods are extremely limited due to the humanitarian blockade imposed by Israel.

Study limitations

Due to military incursions and security concerns at the time of data collection in the second half of 2024, selecting a random probability sample was challenging. To overcome the limitations of the non-probability sampling and to enhance the study’s representativeness, the research team applied a multi-stage quota sampling approach, incorporating different clusters and diverse strata. As with all cross-sectional surveys, it assesses a specific point in time; while this makes it difficult to adjust for constantly changing circumstances that are especially pronounced during war, given that the data collection for this article took place prior to the further deterioration in the Gaza Strip in 2025, the findings can be interpreted as capturing widely experienced effects.

Another potential limitation is that the data relied solely on self-reported responses, which may lead to some under-reporting as participants are sometimes unable to be candid when describing their experiences, attitudes or feelings – especially when they are distressed. Since the surveys and interviews were administered in each participant’s household, responses may also have been influenced by the setting or the presence in a minority of cases of other household members. However, enumerators tried, wherever possible, to talk to participants in private. The absence of baseline data for this specific population prior to the war made it difficult to precisely attribute findings to the consequences of the ongoing conflict, although based on a wealth of other data collection with young people pre-war that the research team has undertaken in Gaza, the authors were well placed to disentangle such changes.^81,97–99

Conclusion

Israel’s war on Gaza has destroyed much of its water and health infrastructure, while its blockade of food and other essential supplies means that Palestinian girls and young women in Gaza lack the basic materials with which to manage their personal hygiene and general health. This study demonstrates how Israel’s actions have obstructed access to MHM products, SRH services, WASH facilities and clean drinking water. These deprivations pose significant risks to girls and young women as they struggle to find food and clean water, manage their hygiene and preserve a sense of dignity and mental well-being amidst widespread destruction. In the struggle for survival in humanitarian settings, the health needs of girls and young women quickly become dispensable, risking serious health complications in the short and longer terms. This research contributes to the growing body of evidence on the disproportionate impact of armed conflict and humanitarian crises on adolescent girls and young women’s health, and the need for urgent action so as to meet international rights and standards to health for all.