Clinical overview
Gender-based violence (GBV) is violence directed at a person because of their gender or that affects one gender disproportionately. In South Africa it is endemic: intimate-partner violence, sexual assault, and femicide occur at rates among the highest recorded anywhere, and the clinic or labour ward is frequently the first — sometimes the only — point of contact a survivor has with a service that can name what is happening, treat it, document it, and open a door to safety. For the O&G registrar this is not a peripheral social problem; it is core clinical work. GBV presents as recurrent sexually transmitted infection, unwanted or concealed pregnancy, antepartum or postpartum haemorrhage from abdominal trauma, miscarriage, genital injury, chronic pelvic pain, "non-specific" gynaecological complaints, late or absent antenatal booking, depression, and self-harm. Pregnancy is itself a recognised period of heightened risk: violence may begin or escalate in pregnancy, and homicide is a meaningful contributor to maternal mortality.
To appraise a survivor — the verb that defines this objective — is to do considerably more than treat the presenting injury. It means recognising GBV behind a vague presentation, conducting a safe and trauma-informed enquiry, assessing acute medical and forensic priorities, weighing immediate danger to life, gathering and preserving evidence to a medico-legal standard, applying the correct South African statutory framework, and judging what each individual survivor actually needs — clinical, legal, psychological, and protective. The registrar must hold the clinical and the medico-legal in the same hand, never sacrificing safe care for paperwork, nor neglecting documentation that may later be the only objective record of the assault. Throughout, the survivor's autonomy and dignity are paramount: she decides, you enable. See informed-consent and sa-og-law for the statutory and consent scaffolding this chapter sits within.
Core knowledge
Defining the field
GBV is an umbrella term. The clinically relevant categories overlap and co-occur:
- Intimate-partner violence (IPV) — physical, sexual, emotional/psychological, or economic abuse by a current or former partner. It is typically chronic and escalating, with coercive control as its engine. It is the commonest form of GBV the gynaecologist meets.
- Sexual assault / rape — non-consensual penetration or sexual contact. May be a single acute event (the survivor presenting acutely) or part of ongoing IPV.
- Femicide — the gender-motivated killing of a woman, the lethal end of the GBV spectrum; intimate-partner femicide is the most common subtype in South Africa.
- Female genital mutilation (FGM) — partial or total removal of external genitalia for non-medical reasons; uncommon in South-African-born women but seen in migrant populations.
Why pregnancy matters
Violence and reproduction are bound together. Coerced sex causes unwanted pregnancy; pregnancy can trigger or intensify abuse; abuse causes obstetric harm (placental abruption from blunt trauma, preterm birth, low birth weight, miscarriage). Forced or coerced reproductive control — sabotaging contraception, forcing pregnancy or forcing termination — is itself a form of GBV. A woman who books late, conceals her pregnancy, attends antenatal visits accompanied by a partner who answers for her, or has injuries inconsistent with her account, warrants quiet consideration of IPV. The psychiatric sequelae in pregnancy (depression, anxiety, PTSD, suicidality) are substantial — see gbv-mental-health-pregnancy.
The South African statutory and service architecture
This is examinable and you must know it cold:
- Criminal Law (Sexual Offences and Related Matters) Amendment Act 32 of 2007 — the governing sexual-offences statute. It defines rape broadly and gender-neutrally, regulates compelled HIV testing of alleged offenders, and entrenches the survivor's right to post-exposure prophylaxis (PEP) and to be informed of it.
- Domestic Violence Act 116 of 1998 — provides for protection orders against an abuser; clinicians may need to support a survivor seeking one.
- Children's Act 38 of 2005 — abuse or neglect of a child is a mandatory report.
- The J88 — the statutory medico-legal form on which the clinical findings of a forensic examination are recorded for court.
- Thuthuzela Care Centres (TCCs) — one-stop, survivor-centred rape-care sites (typically attached to a designated hospital) integrating medical care, forensic examination, counselling, and the criminal-justice interface to reduce secondary trauma.
- National Department of Health Maternity / clinical service guidance — the National Integrated Maternal and Perinatal Care Guideline (NDoH, 2024), and the EML frame antenatal screening and the obstetric care that GBV survivors need; HIV PEP and STI management sit within the national HIV/ART and STI guideline framework.
Reporting duties — the distinction that is regularly tested
Reporting obligations are not uniform across all GBV:
- Abuse of a child or of a person with a mental disability is mandatorily reportable under the relevant statutes — this overrides confidentiality.
- For a competent adult woman, sexual assault and IPV are not generally mandatorily reportable by the treating clinician against her will; her autonomy is respected and she decides whether to open a criminal case. Treatment (including PEP, emergency contraception, and injury care) is never conditional on her reporting to police.
Confirm the precise current ambit of mandatory reporting and the relevant sections against the governing Acts before acting in a specific case — the principle is settled but section-level detail should be verified.
Figure H3.1 — Core GBV appraisal framework linking recognition, pregnancy-specific harms, consent, autonomy, and South African reporting duties.
Assessment
The appraisal is where the registrar's judgement is examined. Work in a logical order but let clinical urgency override sequence.
First: safety and consent
- Is she medically stable? Resuscitate first — major trauma, haemorrhage, head injury, and strangulation take absolute priority over history-taking and any forensic process.
- Is she safe right now? Is the perpetrator on the premises? Are children at risk?
- Consent governs everything. Separate and explicit consent is needed for: the medical examination, the forensic (medico-legal) examination, the taking of evidence, HIV testing, and any release of information to police. A survivor may accept treatment but decline forensic examination, or vice versa — honour that. Provide a chaperone and a private, uninterrupted space, and ideally see her alone (a controlling companion may be the abuser).
Trauma-informed history
Conduct the interview once, gently, without forcing detail, and without expressions of doubt. Establish:
- The assault: nature (vaginal/anal/oral penetration, objects, ejaculation, condom use), number of assailants, use of weapons or strangulation, loss of consciousness, possible drug-facilitated assault.
- Timing — the single most clinically decisive variable, because it drives PEP, emergency contraception, and forensic yield (see Management).
- Post-assault behaviour that degrades evidence: washing, douching, urinating, defaecating, changing clothes, eating/drinking, brushing teeth.
- Obstetric/gynaecological background: LMP, contraception, current pregnancy, prior pregnancies.
- Pattern, in suspected IPV: escalation, previous episodes, weapons in the home, threats to kill, strangulation history, controlling behaviour — these are recognised markers of lethality risk.
- Mental state: mood, suicidality, prior self-harm.
Examination — clinical and forensic together
Perform a head-to-toe examination, not just a genital one. Document, ideally with a body map and measurements:
- General injuries: bruises (note that dating bruises by colour is unreliable), abrasions, lacerations, bite marks, burns, patterned injuries.
- Strangulation signs — petechiae (conjunctival, peri-orbital, oral), neck bruising, voice change, dysphagia. Strangulation is a sentinel marker of near-lethal violence and may cause delayed airway compromise — treat it as serious even when external marks are minimal.
- Anogenital examination: external genitalia, introitus, posterior fourchette, hymen, vagina, cervix, perianal area and anus. Absence of genital injury does not exclude rape — most rape survivors have no anogenital injury, particularly parous women. Never let a "normal" examination be read, or recorded, as evidence that nothing happened.
- Forensic specimens where consented and within the relevant collection window: use the sexual-assault evidence collection kit, maintain an unbroken chain of custody, and label and seal every specimen. Swabs (vaginal, anal, oral, skin), clothing, debris, and reference samples are collected per the kit protocol.
Investigations
- Pregnancy test (urine βhCG) in all of reproductive age.
- Baseline HIV test (with consent and counselling) — a positive baseline result means the survivor was already living with HIV, which changes PEP to treatment; see hiv-counselling.
- STI screening / syndromic assessment and hepatitis B status as locally protocolised.
- Other bloods as the clinical picture dictates (FBC, U&E, toxicology if drug-facilitated assault is suspected, imaging for trauma).
The J88 and documentation
Complete the J88 contemporaneously, legibly, and factually. Record what you observe in objective, descriptive terms; quote the survivor's account in her own words where relevant and attribute it as history. Do not write conclusory opinions you cannot defend ("consistent with consensual intercourse"). The notes and the J88 may be read in court years later; their quality is the registrar's medico-legal responsibility.
Management
Acute management runs on parallel tracks — life-saving, infection/pregnancy prophylaxis, forensic, and protective — and the time-critical prophylaxis must not wait for the forensic process.
The acute sexual-assault drill (make this unmistakable)
For an acute sexual-assault presentation, work through, in order of clinical priority but largely concurrently:
- RESUSCITATE first. Major trauma, haemorrhage, strangulation/airway, and head injury take absolute precedence over forensics. Stabilise, then proceed.
- CONSENT — separately for treatment, examination, forensic collection, HIV testing, and police release.
- HIV PEP — START AS EARLY AS POSSIBLE, within the recommended post-exposure window (the sooner the better; the benefit falls steeply with delay). Test baseline HIV first; if the survivor is HIV-negative or status unknown, commence PEP per the current South African HIV/ART and PEP guidance for the guideline-recommended course, with adherence support and follow-up testing. Confirm the exact eligibility window, regimen, and duration against the current national PEP/ART guideline before prescribing — do not quote a regimen from memory.
- EMERGENCY CONTRACEPTION for any woman at risk of pregnancy who is not already pregnant — offered promptly, with efficacy falling as time elapses; the copper IUD is the most effective option where appropriate, oral methods otherwise. Verify the agent, dose, and time window against current guidance.
- STI prophylaxis / treatment per the current South African STI guidelines, and hepatitis B prophylaxis as protocolised.
- FORENSIC examination + evidence collection with the sexual-assault kit, chain of custody intact — but never let forensics delay PEP or emergency contraception.
- DOCUMENT on the J88, contemporaneously and factually.
- REFER to a Thuthuzela Care Centre / designated facility for integrated survivor-centred care, counselling, and the criminal-justice pathway.
- MENTAL HEALTH + SAFETY — psychological first aid, suicide-risk assessment, a safety plan, and arranged follow-up.
Always verify the precise PEP window/regimen, emergency-contraception agent/window, and STI prophylaxis against the current SA national guidelines at the point of care — these are the most frequently updated numbers in this chapter and must not be quoted from memory.
Figure H3.2 — Acute sexual-assault drill showing concurrent resuscitation, consent, prophylaxis, forensic documentation, TCC referral, and safety planning.
Managing intimate-partner violence (the chronic presentation)
Most GBV the gynaecologist meets is not an acute rape but chronic IPV surfacing through gynaecological or obstetric care. Here the registrar's role is to recognise, validate, assess danger, document, and connect rather than to "rescue":
- Ask directly and routinely in a safe setting — many survivors disclose only when gently asked. Antenatal care is a key opportunity (see antenatal-booking and respectful-care).
- Validate ("this is not your fault; you are not alone; help is available") and do not pressure her toward any single course of action.
- Assess lethality — strangulation history, escalating violence, weapons, threats to kill, recent separation, and pregnancy itself all raise risk.
- Support, do not coerce. Offer information on protection orders (Domestic Violence Act 116 of 1998), shelters, and social work; respect her timing and autonomy. Document the disclosure and findings carefully.
- Children in the household who are being abused or neglected trigger the mandatory reporting duty under the Children's Act — this is the key situation where the clinician's hand is forced.
Figure H3.3 — Chronic IPV presentation: hidden O&G clues, lethality red flags, survivor-centred response, and protective referrals.
Respecting autonomy
For a competent adult, the survivor decides whether to report to police, whether to accept forensic examination, and what care to accept. Treatment is unconditional. The registrar's job is to make every option genuinely available and to make none of it a precondition for care. This is the autonomy principle of informed-consent applied at its most demanding.
Red flags / pitfalls
- Never make treatment conditional on reporting to police. PEP, emergency contraception, and injury care are provided regardless of whether she opens a case.
- Never let the forensic process delay time-critical prophylaxis. PEP and emergency contraception lose efficacy with every hour; the evidence kit can follow.
- "Normal genital examination" is not evidence that nothing happened. Most rape survivors have no genital injury. Recording or implying otherwise is a serious medico-legal error that can be used to discredit a true account.
- Missing strangulation. Minimal external signs can accompany life-threatening or delayed airway/neurological injury; petechiae, voice change, and any loss of consciousness are red flags.
- Forgetting the baseline HIV test before PEP, and failing to arrange adherence support and follow-up HIV testing.
- Quoting PEP/EC/STI regimens or time windows from memory instead of the current national guideline — these change and are heavily tested; verify at the point of care.
- Breaking the chain of custody — unlabelled, unsealed, or improperly handled specimens are forensically worthless.
- Examining or interviewing in the presence of the accompanying partner. The companion answering for her is itself a warning sign.
- Over-reaching on the J88 — write observations, not unsupportable conclusions. Conversely, sparse or illegible documentation fails the survivor in court.
- Forgetting the mandatory-reporting duty for an abused child in the household.
- Treating GBV as a social, not clinical, problem — re-presentations (recurrent STI, unwanted pregnancy, late booking, chronic pelvic pain, unexplained injury) are missed opportunities; pregnancy is a window of both risk and access.
- Neglecting your own and colleagues' safety and well-being, and arranging no follow-up — a single encounter without a safety plan and onward linkage leaves the survivor exposed.
Evidence anchors
- Criminal Law (Sexual Offences and Related Matters) Amendment Act 32 of 2007 — the governing South African sexual-offences statute; underpins PEP entitlement, compelled-testing provisions, and the forensic/criminal-justice interface.
- Domestic Violence Act 116 of 1998 — protection orders and the civil-protective framework for IPV.
- Children's Act 38 of 2005 — mandatory reporting of child abuse/neglect.
- The J88 form — statutory medico-legal documentation of forensic findings.
- Thuthuzela Care Centres — the South African one-stop, survivor-centred model for integrated post-rape medical, forensic, psychosocial, and criminal-justice care.
- National Integrated Maternal and Perinatal Care Guideline (NDoH, 2024), NDoH — the SA obstetric source of truth for antenatal care and the obstetric management of survivors in pregnancy.
- South African National HIV / ART Consolidated Guidelines and national PEP guidance + SAHCS 2023 Adult ART Guidelines — for post-exposure prophylaxis eligibility, regimen, and follow-up (verify the current window and regimen before prescribing).
- South African STI Management Guidelines (SAHCS 2022 STI Guidelines + NDoH STG/EML) — for STI prophylaxis/treatment after sexual assault.
- HPCSA ethical guidelines and the four principles (autonomy, beneficence, non-maleficence, justice) — the ethical scaffolding for consent, confidentiality, and survivor autonomy.
Note on hedged facts: the specific HIV-PEP time window and regimen, emergency-contraception agent/dose/window, and STI prophylaxis regimens are stated cautiously here and must be confirmed against the current South African national guidelines at the point of care — they are not quoted as fixed numbers because they are updated and are not line-itemed with exact thresholds in the verified-sources reference. The breadth of the sexual-offences definition and the precise section-level ambit of mandatory reporting should likewise be confirmed against the governing Acts.