SEXUAL ASSAULT AND FEMALE

GENITAL MUTILATION
By hana (c2)
Moderator : Dr. Temesegen,MD,Obstetrician and Gynecologist
content
• Introduction
• Approach to Sexual assault
• Female genital mutilation
Introduction
• Violence against women includes a number of different acts to which
girls and women may be subjected during their lifetimes.
• Violence against women— particularly intimate partner and sexual
violence—has been characterized by the World Health Organization
(WHO) as a major public health problem and a violation of women’s
human rights.
Cont…
• Global estimates by WHO indicate that approximately 35% of women
worldwide have experienced either intimate partner, or nonpartner,
physical or sexual violence or sexual violence from a nonpartner in
their lifetime
• as many as 38% of murders of women are committed by a male
intimate partner
Definition of sexual violence
• Sexual violence is defined as, “any sexual act, attempt to obtain a
sexual act, unwanted sexual comments or advances, or acts to traffic
women’s sexuality, using coercion, threats of harm or physical force,
by any person regardless of relationship to the victim, in any setting,
including but not limited to home and work”.
Types of sexual violence
Sexual violence can take many forms and take place under very
different circumstances.
• sexual assault,
• sexual slavery;
• sexual harassment (including demands for sex in exchange for job
promotion or advancement or higher school marks or grades);
• trafficking for purposes of forced prostitution;
• forced exposure to pornography;
Cont…
• forced sterilization;
• forced pregnancy;
• forced abortion;
• forced marriage;
• female genital mutilation;
• virginity tests.
Sexual Assault
Sexual assault is any sexual act performed by one person on another
without consent.
May result from:
1. Use of force
2. Threat of force or
3. Victims inability to give consent
Who are the victims of Sexual Assault?
Cont…
• It encompasses a continuum of sexual activity that ranges from sexual
compulsion to contact abuse (unwanted kissing, touching, or
fondling) to forcible rape.
• After a sexual assault, women have many concerns, including
pregnancy and STDs (such as HIV infection).
• Rates of rape-related pregnancy among girls and women aged 12 to
45 years have been estimated at 5%
Rape
• Recognized forceful vaginal penetration of a woman by a man’s penis
as rape to a definition recognizes that rape survivors and perpetrators
may be female or male, and that oral and anal penetration with an
object are defined as rape.
 Types of rape
Acquaintance rape: refers to those sexual assaults committed by
someone known to the victim. More than 75% of adolescent rapes
are committed by an acquaintance of the victim
Incest rape: When the acquaintance is a family member, including
step-relatives and parental figures living in the home.
Date rape: When the forced or unwanted sexual activity occurs in
the context of a dating relationship.
Statutory rape: refers to sexual intercourse with a female under an
age specified by state law (ranging from 14–18 years of age).
Marital rape: is defined as forced coitus or related sexual acts within
a marital relationship without the consent of a partner.
INTIMATE PARTNER VIOLENCE

• IPV is the term that is used to refer to assaultive and coercive

behavior such as physical abuse, psychological or emotional abuse,
sexual assault, progressive isolation, stalking, intimidation, and
reproductive coercion by a current or former intimate partner.
• Beyond injuries, about one in six murder victims is killed by an
intimate partner; 40% of female homicide victims in the United States
is killed by an intimate partner.
• “date rape” ?
Cont…
Medical assessment of sexual assault victims include:
1. Assessment & treatment of physical injuries
2. Psychosocial assessment & support
3. Pregnancy assessment & prevention
4. Evaluation, treatment & prevention of STD
5. Forensic evaluation
History
1. Exact history in a sensitive & supportive manner
2. Explicit details of sexual assault that help to guide trauma
assessment & to assess pregnancy risk & STD risk
Cont..
• Circumstance of the assault
• Loss of consciousness or memory loss
• Assailant’s description
• Specifics: site of contact/ penetrations, ejaculations, use of
protections
• Areas of trauma
• Recent consensual sexual act
• Activities of the victim following the assault
Physical examination
Examine in presence of guardians/ chaperone
• Assess emotional state
• Note the patient’s general appearance and mental functioning.
• Examine the patient from head-to-toe, concluding with the genito-
anal area (Examine the breast, genitalia, anus, oral area & rectum
carefully)
• Note and describe in detail any physical injuries,
• Photograph any injuries,
• Wood’s lamp examination (semen/debris)
Posterior fourchette lacerations and bruised hymen
Trainline bruising on the back
Forensic evaluation
Collected samples:
• Victim’s clothing
• Swabs & smears from buccal mucosa, vagina, rectum & other sites
• Combed specimen from victim’s pubic & axillary hair
• Finger nail scrapping
• Whole blood sample
• Blood & urine sample for drugs
Investigations
• Laboratory evaluation should focus on trauma assessment, testing for
STI’s & pregnancy testing
• Base line tests: VDRL, HBSAg, HIV , pregnancy testing
• Smear for semen, and other sexually transmitted infections
• Drug screening
• Order diagnostic tests (e.g. X-rays, CT scan, ultrasound) to aid in
diagnosing
Treatment
• Treat initial injuries
• Treatment/ prevention of STD
• Prevention against pregnancy(i.e. emergency contraception)
• abortion services (where legal)
• Psychosocial support: extensive emotional support
• Prevention of HIV transmission: for high risks
FEMALE GENITAL MUTILATION
• FGM, also known as female genital cutting (FGC) or female
circumcision, is genital alteration performed on girls and young
women for non therapeutic indications .
• The WHO estimates that approximately 200 million girls and women
worldwide have been cut in the 30 countries in Africa, the Middle
East, and Asia, the primary areas where FGM occurs .
Cont..
• FGM typically is performed between infancy and age 15, and has been
characterized by the WHO as a violation of the human rights of girls
and women.
Cont…
FGM has been classified into four types
Type I FGM, often referred to as clitoridectomy, involves removing
part or all of the clitoris and prepuce.

Type II, often referred to as excision, is removal of part or all of the

clitoris and the labia minora with or without excision of the labia
majora.
Cont...
 Type III is known as infibulation and is the most extreme form,
involving narrowing the vaginal orifice and stitching the adjoining
labia minora and or labia majora with or without including the clitoris.
There are other “lesser” procedures often noted as

Type IV, such as pricking, piercing, incising, scraping, or cauterizing

the female genitalia.
Cont…
• Deinfibulation or defibulation refers to the practice of cutting open
the sealed vagina of a woman who has been infibulated, which is
necessary to allow intercourse or facilitate delivery
Cont..
• Although some 85% of FGC are Types I and II and 15% are Type III,
recent immigration and refugee resettlement from countries where
Type III predominates, such as Somalia, resulted in many more
women with Type III FGC in North America and Europe.
Cont..
Immediate complications of FGM are
• severe pain,
• hemorrhage,
• genital swelling,
• fever, and
• infections including tetanus, sepsis, urinary problems, poor wound
healing, injury to surrounding genital tissue, shock, or even death.
Cont..
Long-term complications include
• painful urination,
• urinary tract infections,
• urinary retention,
• vaginal infection,
• painful menstruation,
Cont..
• scar and keloid formation,
• sexual pain,
• increased risks of childbirth or hemorrhage,
• need for later surgeries, and
• psychological problems including depression, anxiety, PTSD, or low
self-esteem .
Cont…
Surgery is recommended for women with Type III FGC complications
such as
• dysmenorrhea,
• a desire for vaginal birth that would not be possible without surgery,
• apareunia,
• dyspareunia, or difficulty voiding.
Reference
Berek and novak’s gynecology 16th ed
Williams gynecology 4th ed
WHO guideline