Case 38

Violence Against Women


  1. To review the Istanbul Protocol
  2. To illustrate an application of the Istanbul Protocol

Narrative Case

A young recently married woman (31 years old) asked for divorce after 3 months of marriage. She complained that her husband frequently attacked her and physically hurt her. On examination, 2 months later, she was found pale, slimy and depressed. More than 20 skin lesions were seen, in the form of abrasions, bruises and lacerations, widely distributed on both upper limbs. Most of them were rounded or elliptical and some were brush-shaped indicating dragging of teeth on soft tissues of skin. The pattern of teeth marks were compared to bite marks of the wife to exclude being self-inflected bite-marks. A cast was prepared to the victim’s teeth while the husband refused to be examined for comparison. All lesions were old, dating to more than 3 weeks, showing discolored scars, brownish, coppery or paler than the surrounding normal skin. They appeared neglected, infected or badly treated and showed different stages of healing, and some showed keloid formation (massive fibrous tissue formation) with loss of sensation at certain parts of injured areas. All injuries were photographed with a scale to document these injuries with the proper measurements.


It was concluded that these bite marks dated back to the time of marriage, about 2 months before examination, and they were neglected. Healing was by secondary intension and there was keloid formation. These bite-marks were not self-inflicted. As the husband refused being examined for comparison, the victimized wife got divorced by the court considering his refusal as a confession of guilt and was convicted.  So, effective investigation and documentation according to Istanbul Protocol are important to prevent torture and abuse.

Learning Point

  1. The Istanbul Protocol can be an effective tool in clinical decision making, including appropriate investigations and record keeping in cases of Wife Abuse.


Background Information

The Manual of Effective Investigation and Documentation of Torture, and other Cruel, Inhuman or Degrading Treatment or Punishment, commonly known as the Istanbul Protocol, sets the international standard for legal and medical investigations of torture and other mistreatment, including intimate partner violence. Its development was the work of more than 75 physicians, lawyers, mental health professionals and human rights monitors from 15 nations representing 40 agencies or organizations. In 1999, the Istanbul Protocol became an official United Nations document.

The standard set by this document, when adhered to, ensures that the physician’s medical record can be used in the prosecution of crime.


  1. The Manual of Effective Investigation and Documentation of Torture, and other Cruel, Inhuman or Degrading Treatment or Punishment:


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 36

Interaction of domestic violence with the social determinants of health


  1. To consider the interaction of domestic violence with the social determinants of health.


Narrative Case

Mary is a 28 year old woman who suffered childhood abuse and neglect and then domestic violence (DV) in her adult life.  Her partner, Tom, is a 37 year old man who comes from a similar background.  He has never been employed and is chronically dependent on alcohol.

To review Mary’s history, Mary’s mother was addicted to drugs and had a variety of men in her life, many of whom abused Mary.  Being the oldest child, Mary took on the responsibility of getting her siblings fed and to school [1].

Mary did poorly at school and by the time she was in high school was associating with a group of her peers who were also not doing well in school.  She was using drugs herself. At age 14, she moved in with Tom who was 23, and showed her special attention [2]. Tom himself had been thrown out of his home at 14 by an abusive father and spent most of his teenage years in detention centres as a result of petty crimes [3].

The relationship between Mary and Tom developed a certain pattern.  They would drink for days at a time, then they would argue, this would escalate to the point of physical and verbal abuse [4]. Mary was often badly beaten by Tom and became frightened of him. He would tell her to ‘get out’ but the idea of being on her own frightened her even more. Tom would then apologize, they would make love and Mary would forgive him, believing that things would get better [5].

After a number of abortions, Mary had Katy, their first child [6].  Tom was violent towards her during the pregnancy and she became more frightened and moved out to stay with her mother [7]. Mary was very depressed after the birth [8].  She felt alone and abandoned.  She went back to Tom.  She hoped ‘that things would improve’ now that they had a child, but the drinking and violence and verbal abuse continued [9]. She found herself pregnant again, soon after returning to Tom.

Mary was now so depressed that she thought about suicide. She was afraid to leave and was always afraid that Tom would eventually kill her or the children or himself – or all of them [10]. She went to many doctors about her depression and was prescribed numerous anti-depressants, with little help [11]. She never told anyone about the abuse to which she was subjected [12]. She felt that she deserved the beatings, as Tom had told her so often that she was worthless and nobody else would have her, that she now believed this herself [13].

Tom had been drinking for days and there was no money in the house, Mary did not know how she was to feed the children or pay the rent.  There was yet another fight and Mary tried to lock Tom out of the house but he banged on the door and woke the neighbourhood.  The older child woke up crying and afraid that her father would come into the house. Katy then told her mother that Tom had sexually abused her on a number of occasions. Shocked by Katy’s disclosure, Mary then made a very serious attempt to kill herself and her two children.

Mary was charged with the attempted manslaughter of her children and they were removed from her care and placed with the Tom and his mother.


Learning Points

[1]  Female children especially become ‘parentified’, taking on the role of ‘little mother’ in the household.  This pattern of caring for others – no matter how dysfunctional or even abusive they are – becomes entrenched and is repeated in adult life. Generally it is reinforced by cultural prescriptions of appropriate female roles and behaviours.

[2]  Adolescent girls who have been abused and neglected are easily attracted to a man who seems able to take care of them and offer protection.  There was also the social imperative that she be attached to a man – in most cultures this is necessary to provide a woman with status and with ‘protection’. In some cultures a woman has no social and/or economic option but to remain with her male partner.

[3]  Most youngsters with this profile are running away from impoverished and/or neglectful and/or abusive families.  Their time spent in detention centres further stigmatizes them so that they are less able to secure employment and this often reinforces a criminal life style. Similarly, men like Tom are repeating behaviour that has been their own experience of family life.  They are impulsive and aggressive – they have a fragile sense of self worth and cultural mores of masculinity may dictate that they not acknowledge this fragility but rather that they express aggressive and challenging behaviours.

[4]  This is a typical pattern in DV: alcohol and/or drug abuse leads to fighting and then reconciliation.  Often the man feels overcome with remorse after beating the woman and there are pleas for forgiveness, promises to reform, lovemaking and then further cycles. The perpetrator is often very loving and repentant following a violent outburst and this intensifies the partner’s attachment to him.  In many cultures a woman had little option but to endure the situation since leaving the man may make her more stigmatized or vulnerable or she may have no economic support without him.

[5]  Her childhood background of neglect and abuse meant that Mary was unable to develop a sufficient sense of worthiness or entitlement to be treated any better.  In some cultures this is compounded by social mores, which marginalize women like Mary. Typically she remained in the relationship in spite of repeated violence, partly because her self-protective mechanisms were impaired by trauma and partly because whatever love and affection Tom provided her in between the episodes of violence simply reinforced her attachment to him and the hope that things would get better.

[6]  With little sex education she was vulnerable to pregnancy and STDs. Intravenous drug use compounds the vulnerability to blood borne viruses.  Her mother had no time to tell her about safe sex.

[7]  DV increases during a pregnancy and is the commonest cause of injury in pregnant women. Men like Tom often feel threatened by the prospect of having a child – economically they have little to offer and emotionally it means one more person to be cared for. This intensifies the man’s feelings of worthlessness and he defends against this by being more angry and violent.

[8]  Mary had two children in quick succession and was severely depressed following both births. Postpartum depression is common in women in situations of abuse and/or deprivation. There was insufficient follow up in spite of the fact that she was patently at high risk.

[9]  This is a typical pattern of hoping that a child will change him and not recognising that it may in fact worsen the situation.  With a history of teenage pregnancy with additional history of abuse and DV, Mary needed more vigorous follow up from the clinic (eg home visits).

[10]  This situation involves psychological entrapment and is sometimes referred to as a‘hostage’ situation (Herman, 1992).  It is common in situations of domestic violence where abused women usually feel helpless and powerless and unable to leave the situation and often they fear for their lives or for the welfare of their children if they attempt to leave.  This perception is actually quite accurate – homicide statistics show that women are most likely to be killed by their partners when they attempt to leave the relationship.  Walker’s concept of Battered Woman Syndrome is similar – the problem of the battered woman’s entrapment is described, as one of ‘learned helplessness’, meaning that the victim learns that to resist is pointless because it only leads to further abuse.  This leads to feelings of helplessness and surrender to the power of the abuser. These descriptions (both Walker and Herman) are psychological ones that assume a woman has a choice, socially and economically.  In Mary’s case this applies because she lives in a culture where she has social and economic support to leave the relationship. However, in many other cultural contexts a woman has no social or economic alternative and then psychological analyses are less important and the most compelling causes of the woman’s entrapment are social and/or economic.

[11] Prescribed medication is unlikely to help while the situation is unaltered. Women are prescribed more psychotropic medication than men – often without attention to the underlying problem – this is especially true in DV.

[12] There is a pattern of consulting doctors but not disclosing.  Primary care physicians need to be alert to DV as a common precipitant of depression.  It is one of the commonest reasons for apparently accidental injury in females and presentation to Emergency Rooms.

[13]  Verbal abuse and attack on her self-image leading, typically, to false beliefs, ie ‘I am what he says I am’. For many women it may be true that no one else will have them – in many cultural groups a woman like Mary, with a child and seen as having ‘deserted’ her husband, will be outcast.

Background information on domestic violence

This is defined as abuse between persons in an intimate relationship, independent of gender, sexuality or marital status.  The term usually excludes abuse of children and the elderly.


  • 23% of women experience DV in their relationships at some time.
  • 45% female homicide victims are murdered by their partners. (Australian Bureau of Statistics: Women’s safety survey, 1996.)
  • Women presenting to ER 49% had experienced DV, 40% in the last 12 months (Australian study)
  • 25% had a history of childhood abuse plus adult DV (Roberts et al, 1998).

Psychiatric sequelae:

Women with acute psychiatric presentation to a community mental health service:

  • 40% have a history of abuse, 16% experienced it in the last 6/12
  • 24% have a history of DV, 8.6% in the last 6/12 (Tham et al 1995).

Domestic violence and substance abuse

  • 75% of women with drug and substance abuse problems have a history of sexual/physical violence.
  • 72% have experienced assaults in their adult life, mostly from partners. (Swift et al, 1996)

Effects of DV on children:

There is a strong association between witnessing DV and severe PTSD symptoms: withdrawal, clinging, regressive behaviour, hyperactivity, aggression, difficulties in concentration (Kilpatrick et al, 1997).  Child witnesses are much more likely to grow up to be either victims (females) or perpetrators (males).


  1. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition. Washington: American Psychiatric Association, 1994.
  2. Herman JL. Trauma and Recovery. New York: Basic Books, 1992.
  3. Kilpatrick DG, Acierno R, Resnick HS, Saunders BE, Best, CL (1997). A two year longitudinal analysis of the relationship between violent assault and alcohol and drug use in women. Journal of Consulting and Clinical Psychology, 65(5):834–847.
  4. Perry, B.D., Pollard, R.A., Blakely, T.L., Baker, W.L. and Vigilante, D. (1995) Childhood Trauma, The Neurobiology of Adaptation and ‘Use-dependent” Development of the Brain:  How “States” Become “Traits”. Infant Mental Health Journal 16:271-291.
  5. Roberts GL, O’Toole BI, Lawrence JM, Raphael B. (1993) Domestic Violence Victims in a Hospital Emergency Department. The Medical Journal of Australia,  159, 6 September
  6. Roberts, G.L., Lawrence, JM., Williams, GM & Raphael, B (1998) The Impact of Domestic Violence on Women’s Mental Health. Australian and New Zealand Journal of Public Health  22, No 7
  7. Schore, A.N. (1994) Affect Regulation and the Origin of the Self, pp. 261-268. Hillsdale, New Jersey: Erlbaum.
  8. Schore, A.N. (1996) The Experience-Dependent Maturation of a Regulatory System in the Orbital Prefrontal Cortex and the Origin of Developmental Psychopathology. Development and Psychopathology 8:59-87.
  9. Swift W, Copeland J, Hall W (1996.). Characteristics of women with alcohol and other drug problems: findings of an Australian national survey. Addiction 91(8):1141–1150.
  10. Tham, S., Ford, T. and Wilkinson, D. (1995).A survey of domestic violence and other forms of abuse. Journal of Mental Health 4: 317-321
  11. Van der Kolk B. Psychological Trauma. Washington: American Associated Press, 1986. van der Kolk, B., et al. Traumatic Stress. New York: The Guilford Press, 1996.
  12. Walker LE. The Battered Woman Syndrome. 3rd edition. New York: Springer Publishing Co Ltd, 2009.


Case 35

Staying in an abusive relationship may risk a woman´s life

Objective: To show that by staying in an abusive relationship women may risk their life.

Narrative case:

Marie is 45 years old, married for the last 12 years with two children and has a very busy life with an interesting job. She seems very happy but unexpectedly told her family that she had left her husband and moved with the children to a flat and filed for divorce. The family is understandably upset: “ Is there another man? Is the husband unfaithful?”
Finally she admitted that her husband had beaten her for many years. Each time this had happened he told her that he is very sorry, it is the last episode and he offered her a gift or flowers. She thought that she was guilty of something and never spoke about this to her family. However, her husband became increasingly violent, sometimes pushing her out of the flat and closing the door so she was obliged to seek the help of her neighbours. She decided to go to the police to lodge a complaint against her husband but was still not ready to leave him [1]. One evening, she was taking a bath, her husband came into the bathroom and was very angry. He put his hands on her head and tried to drown her. She was really afraid. He stopped just before she fainted [2]. This time it was really too much and she finally managed to leave him, got a divorce and got custody of the children [3].

Learning points

  1. This woman needs help: she must talk to her family or to a close friend. She can get in contact with services and associations specialized in that kind of help and can ask for legal aid. However she needs to have proof such as an account from neighbours , medical certificate etc describing injuries. The law can then decide and make the violent spouse move away.
  2. A woman beaten by her husband is in danger of death: even if he does not want to really kill her   he can go too far
  3. A message to women is to never tolerate the first slap in the face, as it can be the beginning of more violence.

Background information

  • In France every three days a woman dies due to the violence of her husband, her partner or ex partner.
  • A national number can be called in France to get help 3919.


Reference :

Lutte contre les violences faites aux femmes – Grande Cause Nationale 2010 (the Great National Cause 2010 against violence against women)


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 33

Sexual violence in a 17 year old girl in Japan


  1. To show that the victim of domestic violence often has poor knowledge about such violence.
  2. To show that, in many cases, young people do not realize that their date partner has treated them violently.
  3. To show the importance of notifying organisations working to prevent domestic violence

Narrative case

A 17-year old high school girl visited an obstetrics and gynaecology clinic for the prescription of oral contraceptives accompanied by a partner. After several visits for repeat prescriptions, the clinic staff noticed unusual behaviour by the girl’s partner. He always phoned the clinic to ask how the girl behaved and what she said in the clinic. After talking with the girl, the staff noticed signs of domestic violence [1].

The clinic decided to give the girl only short term prescriptions thereby aiming for more frequent visits and to have more time to talk with her. After many visits, she finally told them that she received frequent violence such as hitting, kicking, shooting by an air gun, and being forced to have sex without contraception [2].

The clinic notified a nonprofit organization (NPO) acting against domestic violence about this case. After 4 months, the NPO and the girl contacted her elder brother, the most intimate and reliable person of her relatives, for approval for the NPO’s intervention in this matter [3]. As she did not confide in her brother initially, her abusive relationship was prolonged.

With concrete advice and support by the NPO, the girl could behave in a more independent manner and finally separated from her partner after painstaking effort [4].

Learning Points

  1. Without an understanding of domestic violence, people, especially young people, do not recognize that they are victims of domestic violence. Educating pre-teens, teenagers, and young and older adults about domestic violence is essential
  2. There are many young people who do not recognize that violence from a date partner is domestic violence. There is a need for all healthcare workers to be able to recognize domestic violence as victim rarely come forward.
  3. An adviser close to the victim of domestic violence is important.
  4. In many cases, consultation with a specialized organization is important in changing the victim’s awareness of domestic violence and finding a solution to it. It is vital that staff in sectors which come into contact with victims of domestic violence are educated about it.

Background information

Sex education in Japanese schools is insufficient.


  1. Positive responses from 3,293 adults to a domestic violence questionnaire concerning such violence when 20 years old or younger (2012) showed:
  • Physical assault and/or psychological attack and/or sexual coercion:14% for females, 6% for males.
  • Physical assault: 8% for females, 4% for males.
  • Psychological attack: 8% for females, 4% for males.
  • Sexual coercion: 7% for females, 1% for males.

2. Responses to a domestic violence questionnaire 4413 responders out of 5000 questionnaires for high school and university students in Gifu Prefecture (2013)

  • Physical assault: 10% for females, 6% for males.
  • Psychological attack:34% for females, 24% for males
  • Sexual coercion: 16% for females, 3.% for males



  1. Survey on violence between men and women
  2. Women’s counselling centre. A year’s worth of consultations.
  3. Dating and domestic violence.


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 29

To show the value of Domestic Violence Perpetrator Programmes (DVPPs) in dealing with the cause of the problem


1. To show how Domestic Violence Perpetrator Programmes, in association with a support

service for partners, can successfully manage ongoing risk in a relationship


  • DVPP – Domestic Violence Perpetrator Programme
  • ISS – Independent Support Service, part of DVPP
  • Contacts all partners, relevant ex-partners, and new partners of every DVPP participant
  • MARAC – Multi Agency Risk Assessment Conference

Narrative Case

Zoe and Ben had approached Relate couples’ counselling agency, saying they were having difficulties in their relationship but wanted to stay together. During the screening process, it became clear that Ben was violent and abusive to Zoe. Ben was referred to a DVPP (1). The ISS contacted Zoe (2) Both were assessed using a risk assessment tool. Ben’s account was significantly minimised in comparison to Zoe’s (3). While on the DVPP Ben began talking about various controlling behaviours he was continuing to use, as well as past abuse against Zoe. It became apparent that Ben was extremely jealous and controlling (4). During the session on sexual abuse he talked about coercing Zoe into sex and sexual acts. Ben seemed unaware that this was abusive and continued to show no understanding that this was unacceptable. The DVPP worker, the ISS worker and their manager identified a much higher risk than previously assessed. The ISS met with Zoe and carefully discussed the things which Ben had mentioned in group. Zoe had felt too ashamed of what had happened (5) to mention the sexual abuse previously and was very upset, but confirmed that Ben was regularly abusive and continued to be so. She admitted she was very scared of Ben and he’d recently started saying that he’d never let her go. She agreed that it would be a good idea to involve other agencies through a Multi Agency Risk Assessment Conference (MARAC) (6) and the ISS worker helped her to start planning for her safety. Ben found out that he had been referred to a MARAC without his knowledge and threatened Zoe (7). He then aggressively confronted the DVPP workers. However, by the time he did this, Zoe had phoned the ISS worker saying she wanted to leave. The jealous and controlling behaviours, coupled with Ben’s statement about not letting Zoe leave, led the DVPP and ISS workers to believe there was a high risk of violence or even homicide. The ISS worker arranged a refuge place for Zoe immediately (8). The DVPP worker knew that Ben was likely to be angry and upset when he discovered that Zoe had left and rang to offer extra support. They talked to him about letting go and helped him plan strategies to keep him from harming himself, Zoe or others. Ben remains a high risk to Zoe and any future partners, but by focusing support on him the DVPP was able to contain the risk he posed at this critical time.

Learning Points

  1. Careful selection of participants into a Domestic Violence Perpetrators’ Programme (DVPP)  is essential.
  2. Support for partners, relevant ex-partners, and new partners (ISS), with advocacy, information about the programme and their partners’ attendance, is an integral part of any DVPP
  3. Many men on DVPPs do not initially realise the extent and severity of the abuse which they are inflicting on their partners.
  4. Coercive control is a form of abuse, which is not physical or sexual, but rather emotional and psychological.
  5. Victims are often reluctant to admit they are being sexually abused because they are ashamed.
  6. Many different sectors are involved in preventing, detecting and treating domestic violence (police, social services, health, education, probation and housing). Often communication between the sectors is poor, and the contribution that health professionals could make has not been developed and fostered. A MARAC is a way of ensuring good communication.
  7. Victims of domestic violence are vulnerable while treatment of the perpetrator is ongoing, and support for them is very important
  8. Refugees are an important part of domestic abuse services, especially if there is a risk of homicide or serious injury. Adequate funding for refuges must be ring-fenced.


Background information

There has been a failure in the past decade to adequately address the subject of violence against women, with the focus largely on women as victims. There has been growing interest in the involvement of men as perpetrators or potential perpetrators, but conclusive evidence of the effectiveness of perpetrator programmes is still lacking. An evaluation tool has been developed, and programmes must be properly accredited. It is very important that focusing on men does not overshadow work with women and girls. In the UK, funding for Refuges is under threat unless they are shown to accept male victims, who form only a very small proportion of those affected, and are at low risk of violence.


  1. Jewkes R, Flood M, Lang J. From work with men and boys to changes of social norms and reduction of inequities in gender relations: a conceptual shift in prevention of violence against women and girls. Lancet 2014. Published online Nov 21.
  2. National Institute for Health and Care Excellence. Domestic violence and abuse: how health services, social care and the organisations they work with can respond effectively. NICE, 2014