Case 37

Violence at school in Nigeria


  1. Sexual violence of the girl child can occur at school and at any age
  2. Sometimes females are the perpetrators of such violence

Narrative Case

A three year old girl was sexually abused by her female teacher [1]. During break time at school, the female teacher took the girl to a hidden place [2], gave her sweets and biscuits as a bribe for her not to tell anyone and inserted her finger and pencil into the girl’s vagina [3].

The girl’s mother noticed when bathing her daughter that the vagina was tender. Though surprised, she asked her daughter if she has been touched by anyone there; the girl refused to talk initially but later told her mother what the female teacher had been doing.  

Learning Points

[1] Children can be abused by anyone, even female teachers and caregivers. However, the majority of perpetrators are still male (the proportion is about 1 to 20).

[2] School buildings and premises should be designed in such a way that there are no hidden corners or rooms for any form of immoral acts and/or sexual harassment.

[3] Most of the time sexual harassment of children is done by people that are well known to the child and who are responsible for looking after them. Giving a reward such as sweets or biscuits make the perpetrators feel better and believe they have compensated the child.

Sexual harassment of children can lead to long term bad memories. It can result in feelings of guilt and the loss of trust. Some victims can develop a post traumatic stress disorder or other problems for which psychological therapy might be necessary.

Further information:

“School-related gender-based violence” is a common problem in schools not only in Africa but worldwide. It is estimated that each year between 500 million and 1.5 billion children become the victim of this kind of violence. The case study clearly demonstrates that young age does not protect the child. The UN reported that nearly 50% of all sexual assaults are committed against girls younger than 16 years.

References: (8/27/2014) (8/27/2014)

Case 34

Sexual violence in the home in Japan


  1. To show that the care of a victimized child becomes difficult or even impossible when the parent/guardian is uncooperative.


  1. To show that when no organization takes responsibility for the care of a victimized child and the parent/guardian behaves in an unethical manner, the situation becomes unremediable.


Narrative Case

The victim is an 11 year-old girl with 4 older and 2 younger brothers of which the eldest was 16 years old. She was taken to the emergency department by ambulance due to severe abdominal pain and was found to be 30 weeks pregnant. It was suspected that one of the elder brothers had impregnated her, but the details were unclear. [1]


The parent refused an interview visit by the child consultation and protection centre and missed an opportunity for the girl to have help from agencies. [2]


When the girl was admitted to the paediatric department after delivery [3] her mother came and took her away without permission, and afterwards, returned to take the baby. The mother then moved out of her home without notice. Care for the victimized child could not be provided. [4]


Learning Points

[1] In cases of sexual abuse by a family member, it is difficult to clarify the details.

[2] The mother refused intervention by a public institution, and the responsible staff did not intervene because the mother insisted, “the girl is the baby’s mother, let her bring it up”

[3] Comprehensive teamwork by responsible sectors is important such as the departments of paediatrics, obstetrics and gynaecology and psychiatry, with expert government or NGO sector teams.

[4] The horizontal cooperation in [3] is difficult because of the vertical administration system, which prevents sharing of information.


Background information

  1. It is thought that there was domestic abuse.
  2. As there is no law in Japan requiring the reporting of the girl’s pregnancy to responsible sectors/organizations, the intention of the family is given priority over the care of the victimized child.
  3. Communication between the child consultation centres in different local governments does not occur because of independent management by the separate local governments. Therefore when a family moves to another city, follow up is virtually impossible.



As it is so difficult for victims of sexual abuse by a family member to report the crime, the full extent of these crimes is unknown.

  1. Record keeping of child abuse consultations began in 1990 in Japan. Consultations have increased over the years with 1,101 consultations in 1990, 11,631 in 1999, 37,323 in 2008 and 59,862 in 2011.
  1. Abuse by type in Japan (1999): Records of consultations and notifications of abuse provided by the child consultation centre.

1) Physical abuse constituted 53% of the child abuse consultations/notifications. The assault records showed:

  1. Contusions and bruises in 69.9%
  2. Burns in 13.4%
  3. Head trauma in 12.1%
  4. Fractures in 5.5%
  5. Stings in 2.7%


2) Negligence or refusal of protection (neglect) constituted 32% of the child abuse consultations/notifications. Neglect records showed

  1. Negligence in 60%
  2. Deserted child/left behind in 35%
  3. School ban in 4%


3) Psychological abuse constituted 9% of the child abuse consultations/notifications. This showed an increase by about 2.5 fold compared to other types of abuse. In most cases, psychological abuse overlapped with other types of abuse.

4) Sexual abuse constituted 6% of the child abuse consultation/notification. Around

6% of sexual abuse cases led to pregnancy

  1. Age Composition of abuse cases (2006). Total number 37,323 (100%)
  1. Type of abuse cases (2006)

In cases of child abuse, the parent/guardian generally does not give a detailed account of the abuse, so it is impossible to assess the situation fully.

An urgent task is the construction of a comprehensive network between the different agencies involved including police, medical departments such as paediatrics, obstetrics and gynaecology and psychiatry, and expert government teams to work as “The One Stop Centre” providing physical and mental support to child abuse victims.



  1. Child abuse statistics and types of abuse

Case 32

Sexual violence in a 14 year old girl in Japan


  1. To show an example illustrating that lack of knowledge about sex can lead to an unwanted pregnancy.
  1. To show adult exploitation of a mobile phone dating site to obtain sex with a child.


Narrative Case

A 14-year-old girl became pregnant after having sex with a man met through a mobile phone dating site [1].

The girl thought that intense physical exertion engaged in during a club activity at school was the cause of cessation of her menstruation and did not realize that she was pregnant. Her family did not notice anything amiss [2].

Her mother thought that her daughter had a bowel problem, not morning sickness, and brought her to the hospital. At the hospital, the physician failed to notice that the girl was pregnant. By the time it was realized that the girl was pregnant, she was beyond the upper limit of gestation for an abortion. She had to stop attending high school to give birth to the baby. Her family informed the school that she would be hospitalized, due to illness, until after graduation. The school, however, generously gave her a Graduation Certificate. A district welfare commissioner became aware of the situation and advised the family to consult with a lawyer; the man was accused of having sex with a minor and arrested, and found guilty in court. The baby was adopted and raised by the girl’s family [3].

Learning Points

[1] In Japan, there are many men having sex with girls met through mobile phone dating sites knowing that the girl is a minor.

[2] The high school girl was entirely ignorant of the risk of pregnancy after sex. Young people need to be urgently educated about sex, menstruation and pregnancy in school to prevent such incidences. There is a need for cooperation between schools, health centres and the police.

Background information

  1. Dating sites were introduced with the i-mode service of mobile phones in 1999, and the Child Prostitution and Child Pornography punishment law was enacted the same year. However, the prevalence of young girls carelessly dating and having sex has not yet improved.
  2. Sex education in schools in Japan is insufficient.
  3. Sexual violence perpetuated by adult males remains tolerated.  It should be categorically repudiated as a matter of social awareness and responsibility


  1. Teenagers giving birth:
  • 1985    17,877 live births
  • 2002 21,401 live births
  • 2007 15,250 live births (1.4% of the total live births; 5 teenagers/1000 total females gave birth; 39 teenagers 15 years old or younger gave birth).
  • 2010 13,546 births (1.2% of the total live births)
  1. Teenage abortions:
  • 1995   26,117 abortions (6.2 teenage abortions/1000 total females)
  • 2001   46,511 abortions (13 teenage abortions/1000 total females)
  • 2007   23,985 abortions (7.8 teenage abortions/1000 total females)
  • 2010   20,650 abortions
  • 2011   20,903 abortions      

After 2002, there was a decrease in teenage abortions. One possible factor was access to birth control pills. However, birth control pill usage was only 3% in women aged 16 to 49 years old in Japan. Another possible factor was support by local government.

In order to alleviate loneliness and to obtain money, young people including minors are easy prey to sexual predators. Society should protect the rights of boys and girls.


  1. Maternal and child health information. (2009). Responding to young pregnancy, childbirth and childcare. November: No 60.  
  2. Maternal and child health information. (2009). Responding to young pregnancy, childbirth and childcare. November: No 60
  4. Satako O. Way of life of the teenage mother.

Case 31

Growing Pains of the Samburu Girl


  1. To show how harmful traditional practices can violate young girls in Kenya and lead to permanent injury

Narrative Case:

Blossom, a 10 years old Samburu girl from Kenya was brought to the hospital with severe bleeding and close to death. After consulting her mother, Blossom was found to have suffered an incomplete abortion after being 6 months pregnant. The pregnancy had followed being picked at a beading ceremony [1]. She had a ruptured spleen and injuries to her reproductive system. Her mother performed the abortion [2]. Blossom later returned to the hospital one year later with severe pneumonia and learnt that she had also contracted HIV. She was treated with herbs but without any success [3].

Learning points:

[1]. Girls are circumcised and beaded between the ages of nine to twelve. They are targeted based on their good family reputation and picked during cultural dances, or while in the bush looking after livestock.

[2]. Traditional crude methods are employed to bring about an abortion including the location of the 2nd trimester fetal skull in the pelvis or abdomen and the girl’s mother crushing it using her knee or elbow. This rarely leads to a complete abortion and results in an incomplete abortion with complications. If abortion fails and the baby is born, then it is supposed to be thrown in the forest to be eaten by wild animals as the baby is an outcast.

[3]. There is limited access to knowledge about HIV, treatments and services with peers being used as the primary knowledge resource. Home treatments with herbs are commonly used. Condom use is associated with HIV positive people and sex workers and they are not accessible in interior regions of the Samburu country where most of the beading activity takes place. Mortality and morbidity are significant in this group.

Background information

Beading of pre-pubescent girls in Samburu, a predominantly nomadic community in the North Central part of Kenya is a form of initiation. Traditionally young strong men aged 15-19 years of age, referred to as “morans” or “warriors” in the community are not allowed to marry. Mothers of young girls are expected to adorn them with beads as early as 10 years of age as a sign of “sexual engagement” to the “morans”. A hut is then built outside the main house for this “service” without any consideration for the girl regarding exposure to pregnancy, sexually transmissible infections and HIV/AIDS. If the girl does get pregnant she is treated as an outcast and so it is the mother’s obligation to ensure the pregnancy does not get to term. This harmful traditional practice leads to permanent injury to the reproductive system, increase in the spread of sexually traditional infections including HIV/AIDS and the end of their school life. The other rite of passage is female genital cutting after which the girls are deemed ready for marriage. Other complications associated with this practice are i) early and risky sexual encounters and ii) an early marriage and early childbearing.

This harmful traditional practice demands in-depth community dialogue with wider stakeholder participation to raise further awareness of its negative implications. The longer the girls stay in school then the better access there is to offer alternative rites of passage to them and their families. Primary prevention of HIV/AIDS in a setting where young girls cannot negotiate for safe sex, would benefit from use of women-centered products such as microbicides. Opportunities exist for use of multipurpose prevention technologies in prevention of both HIV and pregnancies, as well as education and rescue centers.


There are various initiatives to help these girls:

  1. Samburu girl’s foundation:
  2. Samburu Project Well Drilling Initiative- Changemakers:
  3. Wasichana Wote Wasome Project 2013-2015(UKAID):

AFFILIATIONS:  Kenya Medical Women’s (KMWA)/THE UNIVERSITY OF NAIROBI(UON)/Coalition On Violence Against Women (COVAW)

Case 30

Case of Post-traumatic Stress Disorder as a Result of Childhood Sexual Abuse

Objective:  To illustrate the long term sequelae of childhood sexual abuse.

Narrative Case

Susan, who was aged 55 years, came to the medical review panel as her long term disability had been refused by her work disability insurance.  The review panel had difficulty in understanding the reason for her inability to work as there was no clear cut history in her medical record.  She was working as a care aide at a long term facility when she felt too anxious and depressed to work.

The review panel had the opportunity to interview Susan and find out the details of her disability.

Susan had been attending her general practitioner for ten years but felt uncomfortable in telling him about the sexual abuse she suffered as a child. [1] It was only when she was referred to a female psychiatrist that she was able to open up about her past.  She had a brother who was having sexual intercourse with her since the age of 12 years and although her mother knew about it, she did nothing to stop it. [2] Throughout her teenage years, she found herself partying and would overuse alcohol, smoke marijuana and use a bit of heroin.  She was devastated to find she had contracted hepatitis C.  She married young to get out of the house, but her husband was both verbally and physically abusive.  She really could not leave him as she had three young children and no means of support. [3]

As the children grew older, she was able to get a job as a care aide and finally left her husband.  She had a few boyfriends but they had drug and alcohol problems and were abusive towards her. [4] They blamed her for not being interested in sex but she found it difficult to enjoy intercourse without intrusive memories of her sexual abuse as a child. [5]

Work was becoming difficult.  She felt anxious all the time.  She was constantly tired due to nightmares and was surprised that the sexual abuse by her brother still turned up in these nightmares after all the years.  At work, she had found it difficult to concentrate as thoughts kept swirling around her head.  When the family of a patient complained about her care of their mother, she decided she could no longer work.  She went to her doctor and was prescribed antidepressants but did not find them helpful.  She found it difficult to complete the paperwork for the long term disability and when this was turned down she did not know what she was going to do.

Learning Points

[1]  Patients often present to their general practitioner but do not know how to bring up the topic of sexual abuse.  Likewise, physicians are often not sure how to ask, for fear that they do not know the proper management.

[2]  As a child she felt helpless and trapped.  If her own mother would not stand up for her, what was she to do.

[3]  Getting out of the house and away from the toxic environment is so important, that the choice of a husband is often poor and the selection is of one who continues to abuse her.

[4]  Due to low self-esteem, she chose partners who perpetuated her low self-esteem, treating her as if she was deserving of abuse.

[5]  Due to her PTSD, she tried to avoid sexual activity as it brought back the childhood memories of abuse.

Background Information

  1.  In the Diagnostic and Statistical Manual of Mental DisordersIV (Text Revision)(DSM-IV-TR), the diagnostic criteria for PTSD are:

A: Exposure to a traumatic event. This must have involved both (a) loss of “physical integrity”, or risk of serious injury or death, to self or others, and (b) a response to the event that involved intense fear, horror, or helplessness (or in children, the response must involve disorganized or agitated behaviour). (The DSM-IV-TR criterion differs substantially from the previous DSM-III-R stressor criterion, which specified the traumatic event should be of a type that would cause “significant symptoms of distress in almost anyone,” and that the event was “outside the range of usual human experience.”

B: Persistent re-experiencing. One or more of these must be present in the victim: flashback memories, recurring distressing dreams, subjective re-experiencing of the traumatic event(s), or intense negative psychological or physiological response to any objective or subjective reminder of the traumatic event(s).

C: Persistent avoidance and emotional numbing. 

This involves a sufficient level of:

  • avoidance of stimuli associated with the trauma, such as certain thoughts or feelings, or talking about the event(s)
  • avoidance of behaviours, places, or people that might lead to distressing memories as well as the disturbing memories, dreams, flashbacks, and intense psychological or physiological distress
  • inability to recall major parts of the trauma(s), or decreased involvement in significant life activities
  • decreased capacity (down to complete inability) to feel certain feelings
  • an expectation that one’s future will be somehow constrained in ways not normal to other people.

D: Persistent symptoms of increased arousal not present before. These are all physiological response issues, such as difficulty falling or staying asleep, or problems with anger, concentration, or hypervigilance. Additional symptoms include irritability, angry outbursts, increased startle response, and concentration or sleep problems.[18]

E: Duration of symptoms for more than 1 month. If all other criteria are present, but 30 days have not elapsed, the individual is diagnosed with Acute stress disorder.

F: Significant impairment. The symptoms reported must lead to “clinically significant distress or impairment” of major domains of life activity, such as social relations, occupational activities, or other “important areas of functioning”.

  1.  Posttraumatic Stress Disorder (PTSD) will be included in a new chapter in DSM-5 on Trauma- and Stressor-Related Disorders. This move from DSM-IV, which addressed PTSD as an anxiety disorder, is among several changes approved for this condition that is increasingly at the centre of public as well as professional discussion.

The diagnostic criteria for the manuals next edition identify the trigger to PTSD as exposure to actual or threatened death, serious injury or sexual violation. The exposure must result from one or more of the following scenarios, in which the individual:

  • directly experiences the traumatic event;
  • witnesses the traumatic event in person;
  • learns that the traumatic event occurred to a close family member or close friend (with the actual or threatened death being either violent or accidental); or
  • experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television or movies unless work-related).

The disturbance, regardless of its trigger, causes clinically significant distress or impairment in the individuals social interactions, capacity to work or other important areas of functioning. It is not the physiological result of another medical condition, medication, drugs or alcohol.

Changes in PTSD Criteria

Compared to DSM-IV, the diagnostic criteria for DSM-5 draw a clearer line when detailing what constitutes a traumatic event. Sexual assault is specifically included, for example, as is a recurring exposure that could apply to police officers or first responders. Language stipulating an individuals response to the eventintense fear, helplessness or horror, according to DSM-IVhas been deleted because that criterion proved to have no utility in predicting the onset of PTSD.

DSM-5 pays more attention to the behavioural symptoms that accompany PTSD and proposes four distinct diagnostic clusters instead of three. They are described as re-experiencing, avoidance, negative cognitions and mood, and arousal.

Re-experiencing covers spontaneous memories of the traumatic event, recurrent dreams related to it, flashbacks or other intense or prolonged psychological distress. Avoidance refers to distressing memories, thoughts, feelings or external reminders of the event.

Negative cognitions and mood represents myriad feelings, from a persistent and distorted sense of blame of self or others, to estrangement from others or markedly diminished interest in activities, to an inability to remember key aspects of the event.

Finally, arousal is marked by aggressive, reckless or self-destructive behaviour, sleep disturbances, hypervigilance or related problems. The current manual emphasises the flightaspect associated with PTSD; the criteria of DSM-5 also account for the fightreaction often seen.

The number of symptoms that must be identified depends on the cluster. DSM-5 would only require that a disturbance continue for more than a month and would eliminate the distinction between acute and chronic phases of PTSD.








Case 24

Long-term Physical & Psychological Sequelae of Childhood Sexual Abuse


  1. To highlight the longterm physical and psychological effects of childhood sexual abuse (CSA)
  2. To emphasise the doctor’s important role in identifying patients with a history of CSA so that victim-survivors are treated holistically, using a multifactorial perspective with a biopsychosocial lens, which sees a complex interplay between past and present; physiological, psychological and social factors [1]
  3. To underline that holistic, rather than symptomatic treatment will help prevent retraumatisation of victim-survivors (victims of CSA are much more likely to be raped as adults) [2] as therapy helps them develop a stronger, more positive sense of themselves. Inadvertent iatrogenic retraumatisation by doctors eg with painful Pap smears will also be avoided by doctors who understand the aftermath of CSA


Narrative Case:

When Elyse, a 28 year old nurse developed debilitating irritable bowel syndrome (IBS), she went to a new doctor. In response to the doctor’s detailed questions as part of initial assessment, Elyse told her that work was okay but she was having a few problems with her boyfriend. Sex was sometimes painful, but she tried not to show it. She had occasional migraines, her periods were heavy and painful and she was treated with antidepressants for 3 years in her early twenties. She was a binge drinker as a teenager. She’d only ever had one Pap smear 8 years ago and it was excruciating.

The doctor said to Elyse that when women had a range of painful and debilitating symptoms like she did, sometimes something emotionally painful had happened to them in the past – physically or sexually. Elyse, to her surprise, felt safe enough to tell this doctor what she hadn’t told anyone in over 20 years. Then again, no-one had ever asked. Her uncle had sexually abused her: but she couldn’t see how what her uncle had done could be connected to any of her symptoms – it happened over 20 years ago.

After talking about the abuse for the first time, Elyse became anxious. The doctor was very supportive. She told Elyse that she was suffering from a form of posttraumatic stress, likening her experiences to a soldier. She said Elyse must never blame herself; the shame belonged to the perpetrator. Having kept it all in for so long, Elyse had developed a range of physical and psychological symptoms as well as having the emotional pain of abuse to deal with. The doctor said that first they needed a plan to deal with the painful aftermath of disclosure, and then she wanted to see Elyse regularly to make sure that her physical and psychological health were attended to and treated holistically.

Background information

Prevalence: One in three women are affected by a history of SV (in Australia). The overwhelming majority do not tell anyone, including their treating health professionals, for decades, if at all [3].

Learning points and Background

  1. The long-term health consequences of sexual trauma in women include a range of psychosomatic symptoms including IBS, headaches, gynaecological and obstetric problems, various mental health problems and health risk behaviours as well as avoidance of preventative health examinations such as Pap smears. Such avoidance is of concern as these women have an increased risk for sexually transmitted infections, cervical dysplasia, and an increased prevalence of invasive cervical cancer  [2]
  2. Depression, anxiety, stress and posttraumatic stress disorder (PTSD) associated with historical SV may increase affected women’s risk for other problems including alcohol abuse, binge drinking and substance abuse. CSA victim-survivors also have a greater risk for suicide and accidental fatal drug overdose [2]
  3. A biopsychosocial model of diagnosis and treatment conceptualises symptoms such as IBS, vaginismus (pain with sex and/or Pap smears), recurrent headaches and gynaecological symptoms as psychosomatic symptoms: the symptom, expressed in the body (soma), has its origins in mind (psyche) and body and alerts us to painful feelings. Based on this understanding, an integrated approach which addresses painful feelings as well as treating bodily symptoms is required [4]
  4. Patients should be asked about a history of SV if they present with multiple psychosomatic symptoms or health problems, have a history of engaging in health-risk behaviours eg drugs, alcohol or unprotected sex, or avoid or have difficulty with medical examinations or procedures [5] eg pain with Pap smears or avoidance of Pap smears [6]. Given that the biggest risk factor for cervical cancer is not being screened regularly, it is important to ask women if they have had their routine health checks, and if not, find out why not.
  5. Most victim/survivors do not tell their treating practitioners about a history of SV unless they are asked [3]
  6. Patients should only be asked after a good rapport and trust have been established between patient and doctor.
  7. The doctor should only ask if she feels comfortable discussing these sensitive matters and dealing with the aftermath of disclosure. Undergraduate and postgraduate teaching should have modules to help doctors feel competent in this important area of practice [3]. The doctor needs to know of appropriate professionals she can refer to if she is not going to do the counselling herself [5] as well as providing ongoing medical care to treat and prevent health problems.
  8. Many patients think that they should have sex even if it hurts. Some doctors and patients believe that “getting a Pap smear over quickly” will shorten the duration of pain and therefore be helpful. However, doing this can inadvertently re-traumatize a patient who has a history of sexual abuse (iatrogenic traumatic examination). To avoid this, doctors should never proceed with a Pap smear if the patient says it is painful or if she is afraid. Similarly, patients should be encouraged not to participate in painful penetrative sex, whilst still maintaining a sexual relationship. In both cases the pain or fear need to be treated first.

In Australia, a referral can be made to a psychotherapist who can help the patient make connections between the physical (how it feels) and emotional (what has happened/ is happening in her life and how it has affected her). She can also be referred to a specially-trained physiotherapist with skills in patient education (anatomy, physiology of sexual response) and gentle examination. Penetrative sex can be resumes and a Pap smear can be done when the patient feels comfortable emotionally and physically (confident there will be no pain).


  1. Boyer SC, Goldfinger C, Thibault-Gagnon S, Pukall CF. Management of female sexual pain disorders. Adv Psychosom Med 2011; 31: 83-104
  2. Taylor,SC, Pugh J, Goodwach R, Coles J. Sexual trauma in women. The importance of identifying a history of sexual violence. Australian Family Physician 2012;41:538-541
  3. Australian Women’s Coalition, Australian Federation of Medical Women, Victorian Medical Women’s Society. Happy Healthy Women Not Just Survivors Consultation Report: Advocating for a long-term model of care for survivors of sexual assault. 2010.
  4. Goodwach,R. Sex Therapy: Historical Evolution, Current Practice. Part 2. ANZJFT 2005; 26,4,178-183
  5. Leserman J. Sexual abuse history: Prevalence, health effects, mediators, and psychological treatment. Psychosom Med. 2005;67:906-15.
  6. Farley M, Golding JM, Minkoff JR. Is a history of trauma associated with a reduced likelihood of cervical cancer screening. J Fam Pract 2002, 51: 827-31