Clinical focus: Sexual and Gender-Based Violence (SGBV) is a health, human-rights and safeguarding emergency. This lesson defines the terms, forms, risk factors, health consequences and survivor-centred clinical principles. It does not replace current Ugandan law, Ministry of Health protocols or specialist sexual-assault and child-protection services.
Learning objectives
- Define gender, gender-based violence, sexual violence, rape, intimate-partner violence, harassment, exploitation and trafficking.
- Recognise physical, sexual, psychological, reproductive, social, economic, disability-related and technology-facilitated violence.
- Understand consent, coercion, capacity, power, intersectionality and why myths cause clinical harm.
- Provide safe first-line support using the WHO LIVES approach and make an immediate safety plan.
- Identify urgent medical, mental-health, safeguarding, forensic and referral priorities without blaming or retraumatising a survivor.
1. Core definitions
| Term | Definition for clinical teaching | Practical implication |
|---|---|---|
| Sex | Biological attributes associated with reproductive anatomy, physiology and chromosomes; sex characteristics vary naturally. | Do not assume anatomy, identity or risk from appearance; ask respectfully and privately. |
| Gender | Socially constructed roles, behaviours, expressions and expectations associated with being a woman, man, girl, boy or another gender. | Gender norms can create power imbalances and barriers to care. |
| Gender identity | A person’s internal experience of gender, which may or may not correspond with sex assigned at birth. | Use the person’s name and pronouns where safe and appropriate. |
| Sexual orientation | Pattern of emotional, romantic or sexual attraction. It is not a cause or justification for violence. | Provide non-discriminatory care to all survivors. |
| Gender-based violence (GBV) | Harmful acts directed against a person because of gender or acts that disproportionately affect a gender, including physical, sexual, psychological, economic and controlling behaviours. | GBV can occur in private or public, during peace or emergencies, and to any gender. |
| Sexual violence | Any sexual act, attempt, unwanted sexual comment/advance, or act directed at a person’s sexuality using coercion, regardless of relationship or setting. | Medical care is indicated even when there is no visible injury or penetration. |
| Rape | A legal term for non-consensual penetration; exact elements and terminology vary by jurisdiction. | Use local law for reporting and forms; clinically document the survivor’s account without deciding guilt. |
| Intimate-partner violence (IPV) | Physical, sexual, emotional or controlling violence by a current or former intimate partner. | Assess immediate danger, stalking, weapons, children and safe communication. |
| Domestic violence | Violence or coercive control within a household or family relationship; legal definitions differ. | Do not assume that returning home is safe; develop a survivor-led plan. |
| Violence against women and girls | Gender-based violence directed against women/girls or disproportionately affecting them, including public and private violence. | Women and girls are affected at high rates, but men, boys and gender-diverse people also require care. |
2. Consent, coercion and capacity
Consent is a voluntary, informed and specific agreement to a particular act. It can be withdrawn at any time, is not transferable to another act, and cannot be inferred from clothing, prior intimacy, marriage, payment or silence. Consent is absent when a person is asleep, unconscious, severely intoxicated, threatened, detained, deceived, under coercive control or unable to understand and communicate a choice.
- Freely given: no force, threats, intimidation, abuse of authority, economic pressure or fear of retaliation.
- Informed: the person understands what is proposed and its likely consequences.
- Specific and ongoing: agreement to one act does not authorise another; consent can stop at any time.
- Capacity: the ability to understand, weigh and communicate the decision. Capacity can be affected by age, disability, illness, intoxication or trauma. Follow current safeguarding law for children and adults lacking capacity.
- Coercion: pressure that removes meaningful choice, including threats to children, economic dependence, immigration status, social exclusion or exposure of private images.
Clinical rule: “No injury” does not mean “no violence,” and delayed disclosure, fragmented memory, calm affect or continued contact with the perpetrator do not disprove an account. Trauma responses vary widely.
3. Forms of SGBV
| Form | Examples | Possible health consequences |
|---|---|---|
| Physical violence | Hitting, kicking, burning, choking/strangulation, weapon injury, confinement | Fractures, head injury, internal bleeding, airway injury, chronic pain, disability and death. |
| Sexual violence | Rape, attempted rape, unwanted touching, forced sexual acts, sexual humiliation, reproductive coercion | STIs/HIV, pregnancy, genital/anal injury, pelvic pain, trauma, depression and PTSD. |
| Psychological/emotional abuse | Insults, threats, humiliation, intimidation, isolation, stalking and coercive control | Anxiety, depression, sleep problems, self-harm, suicidality and impaired functioning. |
| Economic violence | Withholding money, preventing work/school, taking earnings, property destruction | Dependence, inability to access food, medicines, transport or safe housing. |
| Neglect and deprivation | Withholding food, water, medical care or assistive devices; abandonment | Malnutrition, uncontrolled disease, pressure injury, infection and death. |
| Child sexual abuse/exploitation | Sexual contact, grooming, exposure, trafficking, online exploitation, transactional abuse | Injury, STI/pregnancy, developmental effects, behavioural change and long-term trauma. |
| Harmful practices | Female genital mutilation/cutting, forced marriage, child marriage, so-called “honour” violence | Acute bleeding, infection, obstetric complications, chronic pain and psychological harm. |
| Technology-facilitated violence | Image-based abuse, cyberstalking, threats, doxxing, location tracking and online grooming | Fear, isolation, reputational harm, sleep disturbance, self-harm and physical danger. |
4. Where and how violence occurs
- Partner/family: violence may be episodic, escalating or continuous coercive control; separation can increase danger.
- Community/public: assault by a stranger or acquaintance, school or workplace harassment, transport-related violence.
- Institutional/custodial: abuse in health facilities, prisons, police custody, refugee settlements, schools or care institutions.
- Conflict and humanitarian emergencies: displacement, loss of services, armed actors and dependency increase risk.
- Trafficking and exploitation: recruitment, transport or harbouring through force, deception or abuse of vulnerability for exploitation.
- Multiple perpetrators or repeated exposure: the survivor may present with cumulative injuries, pregnancy, infection or complex safety needs.
5. Risk and vulnerability are not blame
Violence is the responsibility of the perpetrator. Risk factors can guide safety planning but never justify harm.
| Level | Examples | Clinical action |
|---|---|---|
| Individual | Young age, disability, pregnancy, illness, substance dependence, prior violence, migration or economic dependence | Offer accessible communication, private care, support persons chosen by the survivor and safe referrals. |
| Relationship | Controlling partner, threats, weapon access, stalking, recent separation, violence toward children | Ask about immediate danger, safe contact, safe place and children; avoid contacting the partner without consent. |
| Community | Unsafe transport, school/workplace power imbalance, stigma, displacement, lack of services | Map trusted services and transport; protect confidentiality and continuity. |
| Structural | Gender inequality, poverty, discrimination, conflict, weak justice or health systems | Use multi-sectoral referral and advocate for survivor-centred systems. |
6. Health consequences
Immediate medical effects
- Airway compromise or voice change after strangulation; breathing difficulty, dysphagia, neck swelling or neurological symptoms are emergencies even with no external marks.
- Head injury, loss of consciousness, seizures, focal neurological deficit or repeated vomiting.
- Haemorrhage, shock, abdominal/chest injury, fractures, burns, poisoning or exposure to weapons.
- Genital, anal or oral injury; pregnancy risk; STI/HIV exposure; acute pain and urinary difficulty.
Longer-term effects
- Unintended pregnancy, unsafe abortion, infertility, chronic pelvic pain and obstetric complications.
- HIV, hepatitis B, syphilis, gonorrhoea, chlamydia, trichomoniasis and other infections.
- Depression, anxiety, PTSD, substance use, sleep problems, self-harm and suicide risk.
- Chronic pain, gastrointestinal/functional symptoms, disability, reduced school/work participation and social isolation.
- Health effects in children: regression, nightmares, enuresis, aggression, withdrawal, developmental delay and learning difficulties.
7. First-line support: the WHO LIVES approach
Every health worker who receives a disclosure should provide a minimum supportive response, even when the service cannot provide a full forensic examination.
| Letter | Action | What it sounds like |
|---|---|---|
| L – Listen | Give time, privacy and attentive, non-judgemental listening; do not interrogate. | “I’m listening. You can tell me only what you are comfortable sharing.” |
| I – Inquire | Ask about immediate needs and concerns—physical injury, pregnancy, infection, emotional distress and safety. | “What concerns you most right now? Are you safe to go home?” |
| V – Validate | Acknowledge disclosure and remove blame. | “I believe that this was difficult to tell me. It was not your fault.” |
| E – Enhance safety | Assess danger, weapons, threats, stalking, children and a safe way to communicate. | “Is there someone who may harm you today? Where could you go safely?” |
| S – Support | Offer choices, medical care, psychosocial support and referrals; respect the survivor’s decisions within safeguarding law. | “We can discuss medical care, evidence options and support services. You choose what happens next.” |
Do not promise secrecy you cannot maintain, pressure for police reporting, ask “why did you not leave?”, confront the alleged perpetrator, or require a detailed narrative before treating injuries.
8. Safe clinical assessment
- Privacy and safety: separate the survivor from a partner, family member or alleged perpetrator when safe; use a trained interpreter rather than relatives where possible.
- Immediate danger: ABC, vital signs, glucose when indicated, injury assessment, strangulation red flags, poisoning, bleeding and suicide risk.
- History: ask permission, use open questions, record the survivor’s own words, clarify timing and body sites, and avoid repetitive questioning.
- Consent: explain each examination, test, photograph and specimen; allow refusal or pause without losing access to treatment.
- Examination: systematic, trauma-informed, chaperoned and culturally sensitive. A normal examination is common and does not exclude assault.
- Clinical care: pain relief, wound care, pregnancy and STI/HIV assessment, mental-health support and follow-up. Detailed management is covered in the separate rape-survivor post.
- Documentation: objective descriptions, diagrams, photographs with consent, test results, treatment, referrals, safety plan and what was declined.
9. Children and adolescents
Children cannot be expected to manage adult sexual decisions or safety. Follow current Ugandan child-protection law and institutional policy for consent, assent, mandatory reporting and referral. Use developmentally appropriate language, a child-friendly setting and a trained specialist where possible.
- Do not repeatedly interview the child or suggest answers. Record exact words and behaviour without interpretation.
- Assess immediate safety, caregiver capacity, injuries, pregnancy, STI/HIV risk, grooming, trafficking and online exploitation.
- Do not arrange a “reconciliation” meeting with an alleged perpetrator or return a child to an unsafe home.
- Recognise that normal genital findings are common in abused children; absence of injury does not disprove abuse.
10. Men, boys and gender-diverse survivors
SGBV can affect anyone. Men and boys may fear stigma, disbelief, criminalisation or being perceived as unable to be harmed; gender-diverse survivors may fear discrimination or disclosure of identity. Provide the same confidential, evidence-based care, ask about anatomy relevant to the examination without assumptions, and use appropriate referral pathways.
11. Forensic and legal interface
- Medical care takes priority over evidence collection. Evidence collection requires informed consent and local protocol; a survivor may accept treatment but decline forensic sampling.
- Evidence is time-sensitive but not limited to a single “cut-off.” Collect what is indicated by the history, timing and local kit; document washing, changing clothes, urination, eating, drinking or intercourse without suggesting these actions invalidate the examination.
- Label, seal, store and transfer samples with a complete chain-of-custody record. Keep clinical records separate from the forensic exhibit log where required.
- Write what was observed and what the survivor reported. Do not write that a test “proves rape,” identifies a perpetrator or establishes consent.
- Explain reporting choices and mandatory reporting limits before disclosure. Obtain legal/safeguarding advice for children, serious immediate risk or lack of capacity.
12. Psychological first aid and ongoing support
Stabilise the present moment, offer grounding and practical support, and avoid forcing a detailed trauma narrative. Assess suicide/self-harm, severe dissociation, psychosis, inability to care for self, substance withdrawal and danger from others. Arrange culturally acceptable psychosocial support, follow-up contact that is safe, and referral to specialised mental-health or protection services. Do not prescribe sedatives as a substitute for safety planning or psychological care.
13. Safety planning
- Ask whether the person feels safe leaving the facility and whether the alleged perpetrator knows where they are.
- Identify a trusted person, safe destination, transport, emergency contact and code word.
- Discuss children, dependants, medications, identity documents, money and essential items.
- Plan safer phone use, location sharing, passwords and online privacy if technology-facilitated abuse is present.
- Document the plan discreetly; do not give written material that could increase danger if discovered.
- Provide emergency referral pathways for shelter, police/protection, social work, legal aid and specialised medical care.
14. Myths that cause clinical harm
| Myth | Correct clinical understanding |
|---|---|
| “A survivor would have obvious injuries.” | Many assaults cause no visible injury; fear, anatomy, delayed care and healing affect findings. |
| “A spouse cannot rape their partner.” | Marriage or a prior relationship does not create permanent consent; use local legal definitions. |
| “Delayed reporting means it did not happen.” | Fear, threats, dependence, trauma and stigma commonly delay disclosure. |
| “Calm behaviour means the person is lying.” | Freeze, dissociation, emotional numbing and culturally shaped responses are common. |
| “Clothing, alcohol or sexual history caused the assault.” | Responsibility lies with the person who used violence; these factors do not establish consent. |
| “A negative STI test excludes assault.” | Timing, prophylaxis, organism and test sensitivity matter; clinical care should not depend on a positive test. |
15. Multidisciplinary referral package
| Need | Possible service | What to communicate |
|---|---|---|
| Urgent injury/medical care | Emergency, surgery, obstetrics/gynaecology, paediatrics | Immediate findings, treatments, allergies, pregnancy, medications and red flags. |
| Forensic examination | Trained clinician/forensic service | Timing, consent, samples collected, chain of custody and what remains outstanding. |
| Protection/safeguarding | Social worker, child-protection team, shelter/protection service | Immediate danger, safe contact, children/dependants and mandatory-reporting status. |
| Mental health | Counsellor, psychologist, psychiatrist | Symptoms, suicide risk, consent and safe follow-up method. |
| Legal and justice | Police, legal aid, victim-support service | Only with consent unless a lawful reporting duty applies; avoid sharing unnecessary clinical details. |
16. Worked cases
Case 1: IPV with escalating danger
A patient presents with repeated bruises and says their partner recently acquired a weapon and threatened to kill them. Do not call the partner or send the patient home without discussing safety. Treat injuries, assess immediate danger and suicide risk, offer a private safety plan, and involve safeguarding/protection services according to consent and law.
Case 2: No visible injury after sexual assault
A survivor presents two days after an assault and has no genital injury. Provide LIVES support, pregnancy/STI/HIV assessment, mental-health support and an informed choice about forensic examination. Document the normal findings accurately; they do not disprove assault.
Case 3: Child disclosure
A 10-year-old gives a partial disclosure while a relative answers for them. Speak with the child privately in an age-appropriate manner, avoid leading questions, assess immediate safety, follow mandatory safeguarding procedures and arrange specialist examination. Do not conduct repeated interviews.
17. Quick self-test
- What does LIVES stand for?
- Can a survivor withdraw consent for part of an examination after consenting to another part?
- Does absence of injury exclude sexual violence?
- Name three immediate danger questions in IPV.
- What is the clinician’s first priority when forensic evidence and a life-threatening injury compete?
Answers
- Listen, Inquire about needs/concerns, Validate, Enhance safety, Support.
- Yes. Consent is specific, ongoing and may be withdrawn at any time.
- No. Many survivors have no visible injury, and findings are affected by timing and healing.
- Is the person safe now? Are there threats/weapons/stalking? Is it safe to go home and communicate? Are children or dependants at risk?
- Stabilise and treat the life-threatening condition; evidence collection comes after or alongside safe care where possible.
Key take-home points
- SGBV is any gender-related harm, including sexual, physical, emotional, economic, controlling and technology-facilitated violence.
- Consent must be free, informed, specific and ongoing; silence, marriage or prior intimacy is not consent.
- Every disclosure deserves compassionate first-line LIVES support, regardless of whether the person reports to police.
- Absence of injury or delayed disclosure does not exclude violence.
- Protect privacy, assess danger, provide choices and follow safeguarding duties—especially for children and people lacking capacity.
- Use objective documentation and maintain chain of custody; never turn a clinical finding into a verdict.
References and further reading
- WHO: Clinical management of rape and intimate partner violence in emergencies
- WHO: Responding to intimate partner violence and sexual violence
- WHO: Caring for women subjected to violence
- WHO: Health-sector response to GBV
- UN Women: Types of violence against women and girls
- Uganda/WHO-aligned SGBV and violence-against-children trainee manual
Educational note: Follow current Ugandan laws, Ministry of Health guidance, safeguarding procedures and local referral directories. This resource is for clinical education, not legal advice.
