• Gender based violence
• Rape
• Infanticide
• Fetocide

Gender based violence (GBV) is a preventable and serious human rights violation whereby an individual is harmed based on their gender.1 The violence can be perpetrated physically, sexually, mentally or financially. This includes domestic violence, rape, feticide/infanticide and female genital mutilation. As is to be expected, victims of GBV often suffer from life-long consequences and at times even death.

The equation of GBV is significantly skewed against women and girls. Due to the sensitive and taboo nature of the topic, exact prevalence numbers of GBV remain difficult to ascertain with a global paucity of data on the matter.² The World Health Organisation (WHO) estimates that 1 in 3 women will experience sexual or physical violence in their lifetime.¹ This article will highlight 2 major forms of GBV in sexual violence and female feticide.

A national survey from the United States of America found that 14.8% of women over 17 years of age had been raped in their lifetime.³ The most common form of sexual violence is forced penetration with male genitalia but sharp objects, chemicals and even firearms are used. Perpetrators of sexual violence can often a time be well known to the woman, with the act being conducted in familiar settings like schools, healthcare facilities or as part of a cultural initiation. Unfortunately, sexual violence tends to be exacerbated during times of conflict and even employed as a weapon of war. The brutality of sexual violence leads to numerous pelvic floor complications like fistulae, urinary/faecal incontinence, dyspareunia, post-traumatic stress disorder. At the world renowned Panzi Hospital (Democratic Republic of Congo), over 56,050 victims of sexual violence have been treated. An alarming trend over the past decade has been the increase in the rape of girls under the age of ten, which has increased from 3% to 6% of all treated cases.⁴ Sexual violence remains a prominent yet poorly understood cause of gynaecological morbidity. The taboo nature of the injury, fear of further marginalization, vulnerability of patients and often complex anatomical disruption means that quality holistic services are required to appropriately manage patients.

From an urogynaecological perspective, reconstructive pelvic surgery following GBV remains an incredibly complex aspect of clinical practice. Although the post-operative success rates of genital fistulas repair can be high,⁵ optimal outcomes require a highly refined skill set in specialized centres. A primary prognostic factor in reconstructive surgeries for genital fistulae are the degree in fibrosis.⁵ The longer patients wait to present for care, the greater the degree of fibrosis and this makes the tissue friable and more likely to dehisce post operatively. The reasons behind the delays in patient presentation are multifactorial; the taboo nature of GBV to the pelvic floor means that patients often hesitate to access care. In addition, the vast majority of GBV related fistulae occur in remote settings where healthcare facilities are simply not available and a general low medical literacy rate persists. A recent retrospective review found that vesicovaginal fistulae were most likely to have high post-operative success rates if sutured vertically and in two layers.⁵ Due to the complex interplay of variables, we recommend that reconstructive surgeries in the context of GBV be repaired at highly specialized centres, providing holistic patient care.

The selective abortion of female fetuses or even female infants in some cases remains a troublesome proponent of GBV. It is estimated that in India alone, around 1 million female fetuses are aborted every year, solely because of their gender.⁶ The practice is fuelled by the cultural stigma of girls being considered both a social and financial burden. In certain traditions, sons alone inherit property, are the beneficiaries of marriage dowry and expected to look after their elderly parents. This unfortunate perspective drives a preference for sons and the consequential selective feticide of female fetuses. If a woman pushes ahead with her right to have a daughter, she may face abandonment or even violence. To further compound the issue, the daughter herself may face neglect and a lack of opportunity.⁷

With the rise of technology allowing for the antenatal detection of gender, over the decades the disincentive to have daughters and their selective feticides, has had major epidemiological and social consequences. Around 140 million women are considered ‘missing’ or believed to have been aborted due to gender biased sex selection.⁷ This has significantly skewed the biological normal sex ratio. It is expected that for every 100 females born there will be 102–106 males. This figure has skyrocketed in certain regions, with up to 130 males being born for every 100 females.⁷ This gender imbalance has far reaching social consequences. The disparity places undue pressure on marriage numbers. In addition, female feticide has been speculated to be linked to an increase in sexual violence and human trafficking.⁷

While the global picture of GBV may seem like a story of resounding doom and gloom, there are some positive facets looking to the future. While a solid legal framework is part of the picture, the issue extends much deeper and needs to be addressed at its core. Primarily, this comes down to empowering women. A change of culture can be instigated through increased access for women to education and healthcare. As a means of secondary prevention, the Federation of International Gynaecologists and Obstetricians (FIGO) fistula surgery training initiative has made great inroads towards addressing GBV. FIGO developed a structured curriculum for training of fistula surgeons, who often a time surgically mend pelvic floor trauma caused by sexual violence. The program thus far has facilitated for the administration of appropriate equipment, facilities and trained personnel to some of the most vulnerable women on earth. As a means of tackling GBV, this initiative has provided life restoring treatment and dignity to over 6000 women thus far.⁸ The final step towards addressing GBV, as with any interventional measure is raising awareness. GBV and the disempowerment of women remains a contentious and somewhat taboo topic despite it affecting millions of vulnerable women worldwide.

Through a sustained effort of highlighting inequalities and the promotion of interventional strategies, GBV and its widespread ramifications can slowly but surely be changed.