The Shadow of Gynecological Violence in the Health Management of Survivors of Sexual Assault

Sexual violence has been defined as “any sexual act, attempt to obtain a sexual act, or other act directed against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting.”1 It constitutes a violation of the sexual and reproductive health and rights of individuals and has a profound impact on the victim’s health, causing morbidity, disability, and mortality in the short and long term.2,3 This complex trauma requires a multidisciplinary health care approach, as the needs of victims go beyond clinical and psychological care and include forensic aspects for legal support and the protection of their rights.4,5 Emergency department staff are often the first point of contact and have a dual responsibility: (1) to provide essential physical and psychological care, and (2) to manage forensic procedures by documenting the event, performing clinical-forensic examinations, recording injuries, and collecting biological evidence. During this medical process, patients are at risk of obstetrical-gynecological violence, defined as “any act perceived as sexist or disrespectful of human dignity during gynecological examinations.”6 This includes violations of privacy, derogatory behavior, misogynistic comments, and inadequate information about treatments or health care pathways. Health care facilities must establish clear protocols for gynecological examinations and procedures for survivors of sexual violence. Despite difficult working conditions, it is essential to promote empathy and trust between personnel and victims. It is essential to minimize the presence of non-essential staff and create a safe environment enabling the survivor to express herself without fear of being judged and to ensure her dignity and privacy are respected. Health care facilities should have dedicated staff with the time and capacity to fully support survivors. Another key point is the importance of training for health care personnel to avoid subjecting survivors to multiple medical and forensic examinations. The purpose of the examination is to assess the woman’s state of health and document the injuries and their consequences. Clinical and forensic aspects must be assessed simultaneously, based on the patient’s description of the violence, thus avoiding further violation of the body. Medical staff should conduct a thorough head-to-toe examination, ensuring that the patient is never fully undressed, following World Health Organization (WHO) recommendations, to minimize discomfort and protect the patient’s dignity. They should also be able to interpret non-verbal cues and refrain from judging the survivor. Obtaining consent for clinical-forensic interventions is particularly important for victims of sexual violence. Informed consent for any diagnostic or therapeutic treatment is a legal requirement. In the context of violence, consent becomes not only a duty but also a therapeutic and ethical choice to restore the integrity, dignity, and respect of a violated body and to avoid gynecological violence. In conclusion, for sexually abused women, the lack of a dedicated path in health facilities and of decision-making power, not having the possibility to choose the gender of the health personnel managing their case, and the possible judgment expressed by health staff through verbal or non-verbal language can constitute a further form of violence.