6 Abuse of women

Verbal abuse is the use of language to control, frighten or insult someone. It usually involves shouting and swearing to criticise, humiliate, blame or order some task to be carried out.

Verbal abuse can result in fear and anxiety, a loss of self-confidence and sense of worth. The abused person may also feel ashamed and guilty and believe that they deserve abuse. They can become depressed.

This is the commonest form of abuse. Repeated verbal abuse may lead to physical abuse.

6-3 What is physical abuse?

This is the use of physical force to control someone. It often involves hitting and kicking and can cause serious injury and even death. Physical abuse also includes locking someone away, depriving them of food or forcing them to carry out physical tasks which they do not want to do.

6-4 What is sexual abuse?

Sexual abuse is the non-consensual (without permission) forcing of a person to be involved in a sexual act. Sexual abuse does not always include intercourse. It may involve unwanted touching, oral sex or masturbation.

6-5 What is rape?

Rape is penetration of the vagina, anus or mouth with a penis or an object without consent by forcing or threatening the victim, or if the victim is unable to resist because of sleep, intoxication or unconsciousness. Men, women and children can be raped.

6-6 Is abuse more common in women?

Yes. Most abuse involves a man abusing a woman. However, men can also be abused.

Gender-based violence

6-7 What is gender-based violence?

Gender-based violence is abuse directed at a woman because of her gender (because she is a woman). It includes threats or acts of physical, mental or sexual harm or suffering as well as depriving her of her liberty (such as economic deprivation).

Gender-based violence is abuse directed at a woman because of her gender.

6-8 Where does gender-based violence occur?

There are 3 main areas of gender-based violence:

In the family
In the general community
Violence perpetrated or condoned by the State

It occurs in every region, country and culture regardless of class, race or income.

Intimate-partner violence

6-9 What is intimate-partner violence?

Intimate-partner violence (IPV) is any form of gender-based violence in which the perpetrator is or was an intimate partner of the victim. It is one of the commonest causes of gender-based violence. It is the same as domestic violence.

It often takes the form of repeated slapping or hitting, verbal abuse, threatening, sexual assault, economic deprivation and stalking.

Intimate-partner violence is violence committed by a present or past partner of the victim.

6-10 How common is intimate-partner violence?

Very common. Exact statistics are difficult to obtain, especially because many women do not tell anybody about the abuse they are experiencing. However, many women living in South Africa have experienced abuse, and very often this abuse is committed by an intimate partner.

Note: In a nationally representative household survey 13% of all women and 31% of all married and co-habitating women said they had been physically abused by an intimate partner.

6-11 Who is at risk of intimate-partner violence?

Intimate-partner violence occurs in all socioeconomic, religious and racial groups. Any woman, irrespective of her circumstances or background can be a victim. However, women are especially at risk if they are:

Young
Unmarried
Poor
Pregnant
Immigrants or asylum seekers

Any woman, irrespective of her circumstances or background, can be a victim of intimate-partner violence.

6-12 What are risk factors for intimate-partner violence?

Although any women, irrespective of her cultural background or social circumstances may suffer from abuse, intimate partner abuse is more common if:

The woman or her partner have themselves experienced abuse in the home as children
The woman has little or no formal education
There is a lot of conflict in the home
The community accepts that violence is a way to deal with conflicts and arguments
Alcohol or illegal drugs are involved

6-13 How does intimate-partner violence affect a woman’s health?

Intimate-partner violence can affect a woman’s health in many different ways. A victim of intimate-partner violence may suffer from:

The direct consequences of trauma (bruises, cuts, burns, fractures)
Depression, anxiety and post-traumatic stress
Loneliness and social isolation
Wanting to or trying to commit suicide
Unwanted pregnancy
Substance abuse
Non-specific complaints such as headaches, dizziness and stomach ache

6-14 How is intimate-partner violence diagnosed?

It is often very difficult to diagnose intimate-partner violence. Many victims do not report abuse because they are afraid or ashamed. They may often be accompanied by their partner, but even when they are alone with a doctor or nurse they may not disclose their experiences or even deny them when directly questioned.

For these reasons healthcare workers should always think about the possibility of intimate-partner violence, especially if a woman presents with injuries. Ideally all adult women should routinely and repeatedly be asked about intimate-partner violence as in many instances women only speak about abuse with repeated inquiry and if they feel that they can trust the healthcare worker.

6-15 How should a woman be asked if she is a victim of intimate-partner violence?

Find a private and safe setting. See the woman alone without anybody who might be accompanying her, including children. Be kind, supportive and non-judgemental. Remember that she may feel very afraid or ashamed or believe that the abuse is her fault.

A helpful way of asking about intimate-partner violence is by making a general statement followed by a question. You could say ‘I have learned that it is important to ask all women about intimate-partner violence because it is so common and can be easily missed. By intimate-partner violence I mean any act by which a current or ex-partner hurts or threatens a woman physically, emotionally or sexually’. And then ask ‘Have you ever experienced anything like this?’ and ‘Do you feel safe with your partner?’.

If intimate-partner violence is suspected, the woman should be referred to a social worker.

If the woman denies intimate-partner violence but you are still concerned about it, share your concerns with her without stating that you do not believe her. Encourage her to come back to you. You could say ‘I am worried that I cannot find a convincing explanation for your injuries or complaints. Please come and see me again next week so I can see how you are doing’.

6-16 What help can be given to a woman who is a victim of intimate-partner violence?

Attend to injuries if needed. Depending on the degree of injury refer her for further care.
Do a safety check. Has she ever been threatened with a weapon or with murder? Does she feel safe going home? Are her children safe? If needed, help her to find a safe place with family, friends or in a woman’s shelter.
Provide supportive counselling and practical information. Tell the woman that intimate-partner violence is against the law and that nobody is allowed to hurt or threaten her. Assure her that abuse is not her fault. Ask her if she is or has been thinking of suicide. Ask her if she needs contraception.
Inform her of her right to report to the police and seek an interdict. Tell her that all forms of abuse are against the law and that intimate-partner violence is a punishable offense.
Inform her that there are safe houses which can be immediately accessed by women and children. Provide her with the address and telephone numbers of shelters, telephone hot lines and the police. Give her the necessary information or refer her to local support services (social worker, NGOs supporting women, FAMSA, NICRO).
Refer her to a social worker if she agrees.
Give her a pamphlet with information and contact numbers.

Note: An interdict is an instruction issued by a magistrate telling the abuser to stay away and have no contact with the victim.

Understand that she may feel unable to leave her partner and that it is her decision if and when to do so. Be aware that a woman may be in great danger when she tries or decides to end an abusive relationship. Continue to provide encouragement, care and support. Do not get frustrated or impatient because you see no change and cannot resolve the problem.

Women are often unable to leave their abusive partner, and if they do end the relationship they are at particular risk of violence.

6-17 What information should be documented?

Medical records can become legal documents. Therefore good documentation is of great importance. Document your suspicion of intimate-partner violence, your discussion with the woman and your advice and management. Carefully document any injuries using drawings or a ‘body map’.

Sexual assault

6-18 What is sexual assault?

Sexual assault refers to a range of unlawful sexual offenses including rape and attempted penetration of the vagina, anus or mouth.

6-19 How common is sexual assault?

Sexual assault (violence) is very common in South Africa. Each year thousands of cases are reported to the police. This is only the tip of the iceberg, as many more cases go unreported. Although men can also be sexually assaulted, men are far less often victims of sexual assault than women.

Note: According to the most recent statistics from the South African police, 68 332 cases of sexual assault were reported during 12 months in 2009/2010 resulting in a crime ratio of 138 per 100 000 population. However, only about 1 in 10 cases of sexual assault are reported to the police. In a study among pregnant women in Soweto the prevalence of physical and sexual violence from an intimate partner was estimated to be 55%. Other studies from South Africa have documented that approximately 1 in 5 men are perpetrators of sexual assault.

6-20 Which women are at risk of being sexually assaulted?

Any woman can be sexually assaulted. It is not true that victims cause the sexual assault by behaving or dressing in a certain way. Sadly, the majority of sexual assaults are committed by a person who is known to the victim, such as a current or ex-partner, a friend, an acquaintance, or a relative.

6-21 Why is immediate and effective management of a woman who has been sexually assaulted important?

All sexual assault survivors must receive immediate and skilled attention. This may save their life. It has been shown that empathy and effective immediate management are very important for long-term recovery. Delayed or poor early management makes the effects of sexual assault worse. Under no circumstances should a woman be ignored, blamed, made to wait for other staff to arrive or be told to get help from another institution. Although she may require referral, immediate care is still called for.

Empathy and good clinical care have a big influence on how women recover from a sexual assault.

6-22 Who should attend to a survivor of sexual assault?

According to the South African National Guidelines for Sexual Assault Care healthcare workers at all levels of care should be able to manage women who have been sexually assaulted. This means they should be competent to attend to physical and emotional needs, provide prevention against sexually transmitted infections and pregnancy, collect forensic information and, if required, give evidence in court.

6-23 Are there protocols for the management of victims of sexual assault?

Yes. All healthcare facilities should have a protocol in place on how to manage victims of sexual assault and how to conduct a forensic examination. Wherever possible, they should also have a dedicated room with all equipment and supplies for the management of a rape survivor. Sexual assault examination kits must be available.

6-24 How should a sexual assault survivor be managed?

The following steps should be taken:

Treat physical injuries. If severe or life threatening, stabilise the patient and refer to the nearest casualty or trauma unit. Emergency care must be provided before a forensic examination can be conducted.
Respond to the woman’s emotional needs. Even if she is physically stable or uninjured she is often in emotional shock. She needs to know that she is safe and will be cared for. Attend to the patient in a private room and, if possible, let a friend or family member be present.
Take a careful history and conduct a thorough clinical examination, including a forensic examination.
Exclude the possibility of pregnancy.
Provide protection against pregnancy and sexually transmitted diseases.
Document all findings carefully. Use a body map or make drawings to record any injuries.
Keep all specimens and records in a safe place.

6-25 What is a forensic examination?

A forensic examination includes a careful history, physical examination and the collection of specimens to provide evidence which may be later used by the police and in court. This evidence is critical for the abuser to be convicted and for justice to be served.

Even if the victim does not want to lay a charge, a forensic examination should still be conducted in case the woman later changes her mind. If she refuses a forensic examination respect her wishes, but make sure that she really understands the importance of the forensic examination.

6-26 How is a forensic examination conducted?

Ask the woman if she has laid a charge with the police or if she wants to lay a charge. Call the police to see the woman at the health facility if she wants to report the crime. If she does not want to call the police make sure she understands the implications, but respect her decision.
Obtain written informed consent to conduct a forensic examination and to release the report and evidence to the police or referral centres. Even if she does not want to lay a charge, a forensic examination should still be conducted with her permission in case she changes her mind at a later stage.
Sexual assault examination kits should be available at all health service facilities. They contain instructions, documentation and equipment for taking specimens (including how to handle and store collected evidence).
Only after the examination is completed and all forensic evidence has been collected allow the patient to shower and provide her with a change of clothing wherever possible.

6-27 What protection should be given against pregnancy?

If she is not pregnant and she was raped within the last 5 days give 2 tablets of Norlevo (levonorgestrel) immediately as emergency contraception.

6-28 What prophylaxis against sexually transmitted diseases is needed?

The standard prophylaxis is all 3 of the following:

Ciprofloxacin 500mg orally immediately
Doxycycline 100mg orally 12-hourly for 7 days
Metronidazole orally 2 g immediately

Note: In pregnant women use intramuscular ceftriaxone 125 mg and oral metronidazole 2 g immediately plus oral erythromycin 500 mg 6-hourly for 7 days instead. Ciprofloxacin and doxycycline are contraindicated as these drugs may be harmful to the fetus.

Provide Hepatitis B vaccination and test for Hepatitis B antibodies. If the patient is Hepatitis B antibody negative repeat the vaccination 4 and 8 weeks later.

Note: Hepatitis B vaccination can be started up to 3 weeks after the assault because the virus has a long incubation period.

6-29 Should the woman be tested for HIV infection?

All survivors of sexual assault should receive counselling on the possibility of HIV infection as part of the immediate management. If the woman is not able to absorb the information, or is too emotionally upset to deal with the additional stress of HIV testing, this can be delayed for 3 days.

If the patient is willing to be tested, proceed after appropriate pre-test counselling. Do a rapid test where available and ensure that she receives the result together with post-test counselling.

Women who are HIV negative should have a repeat test at 6 weeks and again at 3 months after the assault.

6-30 Does the woman require HIV post-exposure prophylaxis?

This depends on the result of her HIV test, on the nature of the assault and on when she was assaulted. Women who are HIV positive or who present more than 72 hours after being raped do not benefit from HIV post-exposure prophylaxis (PEP).

Women who are HIV negative and who present within 72 hours of the assault, should be given HIV post-exposure prophylaxis.

If she is not able or unwilling to take the HIV test immediately, or needs to return for her result, a 3-day antiretroviral therapy starter pack should be provided. Women who test HIV positive should stop the treatment. Women who are HIV negative require treatment for 28 days.

6-31 What post-exposure-prophylaxis should be given?

The standard regimen is all three of the following:

Truvada (tenofovir 300 mg/ emtricitabine 200 mg)
Atazanavir 300 mg
Ritonavir 100 mg

Start as soon as possible. All drugs are taken orally for 28 days.

6-32 What follow-up care should be provided?

If the patient can be discharged, try and contact a relative or friend to accompany her home or to a safe place. Provide her with information and, if required, referral letters to local support services (such as NICRO, social worker, mental healthcare, rape crisis centres or legal aid).

Ask her to return for follow-up at 3 days, 6 weeks and 3 months. Follow-up is essential to evaluate, support and monitor physical and emotional healing. It is also important to:

Give her the results of all tests
Check adherence to prophylaxis for sexually transmitted infections, including HIV
Promote condom use
Ask about menstruation and repeat a pregnancy test if needed
Provide the second and third dose of Hepatitis B vaccine if indicated
Assess whether she has accessed and used support services including medico-legal support
Ensure that the woman is well-informed about all aspects of her care and her recovery process

Note: Condoms are important to prevent new HIV infection or pregnancy which may confuse the medico-legal process.

6-33 How should a woman who reports sexual assault that happened months or even years ago be managed?

Sometimes a woman may speak about an incident of sexual assault that happened in the past so that issues around physical injuries, HIV prevention and pregnancy prevention no longer apply. Listen to her story with empathy and without judgement. Ask her if she has reported the case to the police or if she wishes to do so now. Also ask her if she has received counselling in the past and if she would like to be referred for counselling now. Tell her about services available in the community and how to access them. Do not push her into a referral unless she is willing and ready to accept this intervention. Invite her to see you for follow up.

Case study 1

A mother of 3 small children tells a nurse at a primary-care clinic that her boyfriend shouts and swears at her if the house is not tidy and the supper not ready when he comes from work in the evening. He has never hit her, but forces her to have oral sex with him if he returns home drunk over the weekend.

1. Is this woman being abused?

Yes. She is being verbally and sexually abused.

2. Why is verbal abuse bad for this woman?

Because it is used to control, frighten or insult her. She will feel humiliated, anxious and lose self-confidence and her sense of self-worth. She may become depressed. The verbal abuse will also frighten the children.

3. Can verbal abuse be dangerous?

Yes, because it does a lot of harm and may lead to physical abuse.

4. Is verbal abuse common?

Yes. This is the commonest form of abuse. It is so common that it is often not recognised as abuse.

5. What is sexual abuse?

Any form of sexual act which is forced on a person without their permission.

6. Is this woman being raped?

Yes, as rape is defined as penetration of the vagina, mouth or anus with a penis or object without consent. Even though the abuse is carried out by her boyfriend in their own home, this is still rape.

Case study 2

A young woman complains to her family doctor that she is unhappy at work as her male employer has been threatening that she will not get a promotion unless she has sex with him. She has not told anyone else at work or at home. She cannot sleep at night and is afraid of going to work.

1. What form of abuse is this?

Gender-based violence. Her male employer is abusing her because she is a woman.

2. Does this form of abuse always take place at work?

No. It may also occur in the family or in the community.

3. Can men be the victims of gender-based abuse?

Yes, but usually women are the victims.

4. Is it surprising that she has no told anyone else about the abuse?

No, because victims of any form of gender-based abuse are often embarrassed or afraid to tell anyone else.

5. What help should be offered to this woman?

She needs counselling to help her manage the situation. Provide her with the phone numbers of a local hotline or support service. She may want to speak to the police.

Case study 3

A young, unmarried woman who is 28 weeks pregnant attends an antenatal clinic. The nurse notices that she has a bruised face. Only on direct questioning does she admit that her partner frequently hits her. She cannot leave him as she is financially dependent on him.

1. Is this a case of intimate-partner violence?

Yes. This is one of the commonest forms of gender-based violence where a man abuses a woman.

2. Why is she at risk of intimate-partner violence?

Because she is young, unmarried, poor and pregnant. However anyone can become a victim of intimate partner abuse.

3. How is intimate-partner violence diagnosed?

By taking a careful history. It is important to ask relevant questions using simple language that will expose intimate-partner violence as women often will not report violence unless asked. It is important to write careful clinical notes and accurate record any injuries.

4. Why does she not simply leave her partner?

There are many reasons why abused women do not leave their partners. This woman is financially dependent on her partner. But even if she was economically independent she may not have the emotional and personal resources to end the relationship. She may also feel scared because trying to leave an abusive relationship can be very dangerous.

5. What help can be offered to this woman?

If she wishes, refer her to a social worker. She should be offered a place of safety if she or the healthcare worker feels she is at risk of injury or death, or if she has contemplated committing suicide. If she returns home she should be given counselling. Reassure her that the abuse is not her fault. Give her another appointment soon so that you can support her.

6. Can she ask for police protection?

Yes. Abuse is a punishable offence. The police can issue an immediate interdict which requires the abuser to stop all contact with the woman.

Case study 4

A young woman is brought to a district hospital outpatient department by a friend after being raped a few hours before. The doctors says he is not experienced in managing a rape victim and asks her to return after the weekend when more senior staff will be on duty. She is given no treatment as she has no obvious signs of injury.

1. Why is this bad management?

A victim of a sexual assault must always be given immediate and skilled attention. A delay in treatment makes the effects of the assault worse and the opportunity to prevent infections and pregnancy may be missed. All healthcare workers should be trained in managing a victim of sexual assault. Management protocols and sexual assault examination kits must be available at all healthcare facilities. She also needs a forensic examination before she showers or takes a bath.

2. What is a forensic examination?

A careful history, examination and the collection of specimens to provide evidence which may later be used in court.

3. What immediate tests should be done?

She should have a pregnancy test, rapid HIV test and Hepatitis B test. All tests should be done with her permission, and the HIV test must be done with pre- and post-test counselling.

4. What medical treatment may she need?

If she is not pregnant, she needs emergency contraception. If she is HIV negative she requires HIV post-exposure prophylaxis. She should be immunised against Hepatitis B with repeat doses 1 and 2 months later if she is Hepatitis B negative. She should also receive treatment for sexually transmitted infections.

5. What medication is used for HIV post-exposure-prophylaxis?

AZT and 3TC for 28 days.

6. What further care should she receive?

She should see a social worker before being discharged. Help her contact a friend or family member who can take her home or to a safe place. Also provide her with the contact details and a referral letter to a local support group. She needs to be followed-up after 3 days, 6 weeks and 3 months to evaluate whether she is recovering physically and emotionally, and to check the results of all tests, assess adherence to medical treatment and encourage condom use. She may also need repeat testing for pregnancy and HIV infection.