Considerations for Working with Survivors of Sexual Violence

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Original Editor - Jeniffer Chepkemoi from The Center for Victims of Torture as part of the PREP Content Development Project

Top Contributors - Naomi O'Reilly, Jess Bell, Kim Jackson and Kirenga Bamurange Liliane  

Introduction to Sexual Violence

Sexual violence is a global concern which is occuring in every culture, in all levels of society and age groups throughout the world. It is a rising global issue as sexual violence can bring devastating consequences to the mental health and well-being of a person. Data on most aspects of sexual violence today are lacking in many countries. There is a huge need everywhere for more research to be done on all aspects of sexual violence. According to current available data, nearly every one in four women during her lifetime has suffered an attempted or completed rape by an intimate partner, whereas up to one-third of adolescent women reported their first sexual experience as being forced. Statistics from the United States reveal that 1 in every 3 women and 1 in every 4 men experienced sexual abuse involving physical contact in their lifetime. Sexual abuse is not limited to physical contact. It encompasses a range from verbal sexual abuse (for example; unwanted sexual comments) to forced penetration and coercion. The coercion can be in the form of blackmail and threats. Any sexual advance without consent is considered sexual abuse, including sexual acts performed on an individual who is intoxicated, drugged, mentally impaired or asleep.

Despite the vast majority of victims being women, men and children of both genders are also experiencing sexual violence. Between 8% and 31% of girls and 3% and 17% of boys experience Childhood Sexual Violence worldwide. In Southeast Asia, a recent review suggested that approximately 10% of boys and 15% of girls have experienced at least one form of sexual violence in their childhood. Sexual violence can take place within a variety of settings including home, workplace, schools and the community. In many cases, it begins in childhood or adolescence.

Sexual violence has a significant negative impact on the health of the population. The potential reproductive and sexual health consequences are numerous – unwanted pregnancy, sexually transmitted infections (STIs), human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and increased risk for adoption of adoption of risky sexual behaviours (for example; early and increased sexual involvement, and exposure to older and multiple partners). The mental health consequences of sexual violence can be just as serious and long lasting. Victims of child sexual abuse, for example, are more likely to experience depression, substance abuse, post-traumatic stress disorder (PTSD) and suicide in later life than their non-abused counterparts. Worldwide child sexual abuse is a major cause of PTSD, accounting for an estimated 33% of cases in females and 21% of cases in males.

Sexual Abuse and Exploitation in Humanitarian Settings

The occurrence of sexual abuse and exploitation is higher in armed conflict than in stable non- displaced settings. Sexual abuse occurs during the height of armed conflict, during displacement and post conflict. A study conducted on 288 women in East Timor found that 23% of the respondents were sexually abused during conflict and that 10% experienced abuse in the post-conflict period. Sexual exploitation occurs in the form of transactional sex, where sex is exchanged in order to be granted priority treatment in their case and faster release from detention centers, for food, money and to guarantee safe passage across closed borders by smuggler. The factors that contribute to the increased occurrence of sexual violence and exploitation in armed conflict and displacement include:

Breakdown of Services

Services such as law enforcement and the legal, health and educational systems, weakened or destroyed during war. Ongoing conflict leads to damaged infrastructure and essential staff are forced to flee.

Family Separation

Family separation puts women and unaccompanied children at an increased risk for sexual abuse and exploitation. Due to their gender and age, they may depend on other parties to get them to safety and this increases their vulnerability.

Conflict Scenarios

The conflict scenario may psychologically affect the men and their ability to perform their usual social, cultural and economic roles and provide protection as they usually do in the family and community settings.

Community and Societal Factors

Community and societal factors that continue to condone gender-based violence against women also play a part. Beliefs in society edging towards male superiority, gender inequality and discrimination continue to contribute to violence against women.

Women and girls are more vulnerable to sexual violence and exploitation both in stable and unstable environments as compared to men and boys. They are often abducted and held captive as sexual slaves by armed groups. Sexual abuse among male victims is rarely reported because it is associated with greater stigma as compared to sexual abuse among women and girls. Men and boys are particularly vulnerable when they are forcefully recruited by armed militia or when they are held in detention centers. Children can also be victims especially when abducted by rebel groups and often undergo abuse repeatedly.

Most perpetrators of sexual abuse are men, however, in some instances, such as the Rwandan Genocide, women have been found to instigate and participate in armed conflict sexual abuse. Forcibly recruited child soldiers in Liberia perpetrated sexual violence. Perpetrators of armed conflict sexual abuse and exploitation include: army and  state security officials; militia and rebel groups; civilians such as fellow refugees and displaced people within camps and asylum centers; humanitarian workers; border guards and bandits. Accurately determining the prevalence of sexual violence in conflict situations is difficult. Researchers are usually faced with security, methodological, ethical and scientific challenges.

Firstly, the survivors are reluctant to report either to the police or healthcare workers in both conflict and stable environments due to feelings of shame, guilt, fear of retaliation, assumption they will not be believed, lack of support structures and social stigma.

Secondly, armed conflict is a political issue. Many governments fear condemnation and resulting sanctions from the international community on the violation of human rights that thrive in conflict situations. Governments and other state agencies therefore tend to downplay reports of sexual violence.

Thirdly, it is unethical to ask individuals about sexual violence while conducting research without the provision of the required care. In most humanitarian crisis situations, the access and provision of care to survivors of sexual violence is often inadequate limited by factors such as distance, cost and stigma. Lastly, conducting research on sexual abuse in unstable environments poses a security threat to both the researcher and the respondent.

Nature of Sexual Abuse in Armed Conflict

The nature of sexual violence perpetrated in conflict situations falls into 2 main categories:

• Sexual violence is utilized as a weapon of warfare due to consequences on the survivor as well as its far- reaching effects on the survivor’s family and community. Rebels and militia in the Democratic Republic of Congo (DRC) used sexual abuse against men to emasculate the men and break down the family unit because in their culture a man is considered the head of the household. This abuse against men usually leads to social stigma and discrimination of the entire family. Sexual violence has also been used to terrorize communities and as a tool of genocide in countries such as  Rwanda.
• The perpetrators of sexual violence in conflict settings also include abusers who exhibit opportunistic behavior in the climate of impunity found in war zones. These perpetrators take advantage of the breakdown in social and legal systems for sanctioning sexual violence.

Motives Behind Armed Conflict Sexual Abuse

The motives behind armed conflict sexual abuse include:

• To advance military agenda, instill terror and cause flight from a particular target territory
• To torture and humiliate victims in order to ensure compliance among captives
• To punish and humiliate enemy groups
• To destroy family and community structure by the perpetrators publicly raping victims, forcing the victims to view rape of their family members or forcing the victims to rape their own family members.
• To affirm their aggression and brutality. Some perpetrators consider it a boost to their morale or a “reward for their bravery”
• Sexual abuse can also be used as an act of genocide-targeting a specific ethnic/social group as was the case in the Rwandan genocide of 1994.
• Specific cultural beliefs e.g. some rebel groups in Democratic Republic of Congo believe raping a virgin leads to invincibility.

Root Causes and Risk Factors for Sexual Abuse

According to the ecological model, Sexual abuse is a complex issue that occurs as a result of the interaction of four factors: individual, relationship, societal and community factors. The individual and relationship factors have been identified as risks for sexual abuse against women and have been found to increase the likelihood of men perpetrating sexual violence. Community and societal factors consist of the acts society has normalized that may condone sexual violence against women.

Armed Conflict Sexual Abuse Against Males

There is a higher occurrence of sexual abuse against women and girls compared to sexual abuse of males in scenarios of conflict and forced displacement. Consequently, a lot of literature is available and numerous studies have been conducted on armed conflict sexual abuse against women and girls. Limited studies have been conducted on sexual abuse of male survivors. Sexual abuse is however common among male survivors in forced displacement and conflict as well.

The extent of armed conflict sexual violence against males varies across different conflict affected zones. For instance in Eastern DRC, the prevalence of sexual violence against males in was 23.6%, whereas in Sudan 46.9% men reported either witnessing sexual violence against a man or being subjected to sexual violence. The numbers are underestimated due to underreporting by the survivors, as well as the inability of healthcare providers and humanitarian workers to identify the survivors who are reluctant to self-identify. Most survivors choose not to report because of stigma, fear, guilt and confusion.

Male survivors are subjected to sexual abuse and exploitation in the countries of origin, during migration and in the countries of asylum. Sexual violence against males happens to a range of survivors including young boys, adolescents, straight adult men, transgender men and women, gay and bisexual men and boys. Unaccompanied adolescent boys aged 14-17 years are at a particularly high risk of sexual abuse. Gay and transgender survivors are also at an increased risk and have reported being sexually abused by multiple perpetrators. Men have been found to be particularly vulnerable to sexual abuse while in detention centers and when they are forcefully recruited by rebel groups.

The forms of sexual abuse in men include but are not limited to:

• Genital Violence for example; electrocution, tying heavy objects on the genitalia, beatings on the genitalia
• Enforced Nudity accompanied by verbal sexual threats
• Enforced Masturbation
• Forced Sterilization (castration) usually performed through crude means for example; fellow captives biting off each other’s testicles
• Oral and Anal Rape (including with objects)
• Sexual Slavery
• Forced Sexual Activity with other people, animals or corpses

There are various motives for sexual violence of men in scenarios of armed conflict.

Firstly, sexual violence  is used to assert power and dominance over the victims. It is meant to empower the perpetrators and disempower the victims, their families and the community at large. Public sexual abuse is used to spread terror across communities and prove the men are powerless and unable to protect both themselves and their community.

Secondly, sexual violence is used to emasculate the male victims. In many societies, it is assumed that a man should be able to resist any attack. When they are sexually abused the perpetrators do it in order to strip them of their masculinity. In the Democratic Republic of Congo (DRC) raping a man changes him into a woman in the eyes of his family and community, making the survivors question their sexuality and prevention of procreation through forced sterilization.

Lastly, sexual abuse against the men targeting specific ethnic, racial or religious can be used to symbolically assert dominance and disempowerment of the entire group.

Table 1 : Consequences of Sexual Abuse in Male Victims

Physical	Sexually Transmitted Infections Sexual Dysfunction Anal Pain Rectal Trauma (abscesses and fissures which may lead to painful sitting and coughing) Infertility Fecal Incontinence Genital Impairment
Mental	Post-traumatic Stress Disorder Sleeplessness Intrusive thoughts of torture and rape during intimacy Depression Anxiety Suicide Ideation
Scoioeconomic	Shame Stigma for self and family Self-exile from the community and the wife is consequently shamed and stigmatized when the husband leaves Unable to work or contribute to household income

Barriers to Accessing Healthcare

There are a number of factors that often come in the way of men accessing healthcare post sexual violence they include:

• Male survivors of sexual violence are less likely to seek healthcare as compared to female survivors of sexual violence due to shame, fear of retaliation, fear of discovery and consequent social stigma and the fear of arrest in countries where there are laws prohibiting same sex relations. Masculinity stereotypes also lead to under reporting of sexual violence. Men are expected to not be expressive and to “cope like a man”.
• Reluctance to self-identify in healthcare settings, as well as health care providers focus on anal rape only as opposed to looking out for other indicators such as sexual dysfunction, incontinence and genital scarring leads to male survivors not being easily identified and at risk of inadequate assessment and management.
• Some healthcare providers have a negative attitude towards male survivors of sexual violence. Some believe all male survivors of sexual abuse are gay or that men and boys cannot be sexually abused. Consent may be assumed because a man should have been able to defend themselves. Homophobia among healthcare workers interferes with the provision of quality healthcare.
• Most gender-based violence centers are linked to women health services and as a result of this, male survivors are not open to seeking assistance in such settings.
• Humanitarian agencies should strive to raise awareness of sexual violence against men among healthcare providers as well as first line responders in humanitarian crisis situations.

Armed Conflict Sexual Abuse Against Women

Over the past years, humanitarian organizations have recognized and taken steps to prevent armed conflict sexual violence and exploitation. Various guidelines have been developed by the United Nations High Commissioner for Refugees (UNHCR) and the Interagency Working Group for the Prevention and Response to Armed Conflict Sexual Abuse since 1995, however sexual abuse during armed conflict still remains a major problem. Women disproportionately bear the brunt of armed conflict sexual abuse since they are more vulnerable in comparison to men. The weighted prevalence of sexual violence among female refugees in 14 countries affected by conflict was estimated at 21.4%. One in every five refugees and displaced women in complex humanitarian settings experienced sexual violence, yet this is considered to be an under-estimate.

There are multiple barriers associated with disclosure. Survivors of sexual violence globally are reluctant to report to the authorities due to feelings of shame, guilt and fear of retaliation. The situation is no different for survivors in environments of conflict and forced displacement. In addition to their reluctance to report, female refugees may also be faced with language barriers, not knowing where to report to, fear of officials and deportation. Closure of borders in the countries of asylum leads to panic among refugees seeking asylum in European Union states and therefore instances of sexual violence are not reported due to fear of being delayed in their onward journey. The access and availability to reproductive health services can be hampered by cost, distance and stigma.

Women and girls experience sexual violence and exploitation during the conflict, during displacement and post conflict. The abuse happens in various settings such as fields, detention and asylum centers, camps for refugees and displaced people, military sites and their homes. Family violence during conflict is also prevalent. Women are likely to experience intimate partner violence due to trauma, elevated stress and loss of livelihood associated with armed conflict. Women and girls have also been abducted by armed militia and kept as sexual slaves. Within refugee camps women and girls have been attacked when performing their daily chores such as fetching water or collecting firewood.

In addition to sexual violence, women are also particularly vulnerable to sexual exploitation. Women are likely to be exploited when they are obtaining essential goods from men. Many female refugees are forced to engage in transactional sex with smugglers in order to ensure their safe passage into countries of asylum whose borders have been closed. Transactional sex was also reported in Detention Centers in Macedonia, where female refugees desperate to enter European Union states were required to have sex with male guards after they were promised priority treatment of their cases and faster release from the detention center.

During conflict and forced displacement, women are vulnerable to soldiers and armed combatants, bandits, border guards, human traffickers, smugglers, and humanitarian workers. Women are subjected to various violations such as rape, forced participation in the sex trade and sexual exploitation.

While living in Refugee Camps, female refugees are scared of other refugees. Inadequate accommodation and sanitary facilities in Asylum Centers place women at increased risk for sexual violence. There are few toilets to be shared among the male and female refugees, no running water thus the need to use outside taps, communal bathrooms with little or no privacy, which forces women and girls to shower after dark and overcrowded living arrangements. Some women do not leave their rooms at night even if they need to use the toilet for fear of their security. Women also experience family and conjugal violence. Conjugal violence often involves repeated violent episodes, and one partner taking control of the other person and engaging in harmful behaviours toward them. Conjugal violence differs from arguments within a couple, primarily because it involves an imbalance of power between partners, for instance, the controlling partner may include: forcing their partner to do things against their will (for example; wearing a certain type of clothing, not going out with friends, having sex, etc.). As a result, some women are unable to leave their abusive husbands for fear of continuing the journey to safety alone.

Health Consequences of Sexual Violence in Women

The health consequences of sexual violence against women can be grouped into either immediate or medium to long term consequences. Immediate consequences result directly from the sexual abuse incident, whereas medium to long term effects occur during the period after violation. The consequences may also be fatal or non-fatal depending on the extent of injuries.

Table.2 Health Consequences of Sexual Violence in Women

	Immediate Consequences	Medium to Long Term Consequences
Physical	Haemorrhage Shock Urinary Tract Infections Urinary Incontinence Urinary Retention Back Pain	Irritable Bowel Syndrome Gastrointestinal Symptoms e.g.nausea, bloatedness, diarrhea, abdominal pain Chronic Pain Syndromes Fibromyalgia Poor perception of health Cardiopulmonary and Neurological Type Symptoms e.g. hyperventilation, shortness of breath, palpitations, numbness and weakness Migraines and Headaches
Reproductive	Unintended Pregnancy Sexually Transmitted Infections Unsafe Abortions Genito-anal Trauma Fistulas	Pelvic Inflammatory Disease Infertility Painful Periods Pain with Sexual Intercourse
Psychological	Sleep Difficulties Panic Disorder	Depression PTSD Anxiety Suicide Ideation
Behavioural	High likelihood of engaging in risky behavior such as unprotected sex, multiple partners, alcohol and drug abuse Eating Disorders	Early consensual sexual initiation in cases of child sexual abuse At higher risk of re-experiencing sexual abuse
Fatalities	Femicide after Sexual Cbuse Suicide	Infanticide following conception from rape. Death from unsafe abortions Death from pregnancy related complications AIDS related deaths

Common Sequelae of Sexual Abuse

Sexual and gender-based violence results in many consequences ranging from physical, psychological, and social effects.

Common sequelae of sexual and gender-based violence can be categorized as follows:

1. Fatal Outcomes
2. Non-Fatal Outcomes
   • Physical Trauma
     • Injury
     • Sexual & Reproductive Health Issues
     • Somatoform Issues
   • Psychological Trauma
     • Mental Health Issues
     • Negative Health Behaviours

Common Sequelae of Sexual & Gender-based Violence

Physical Trauma includes:

1. Physical Injury
2. Somatoform issues such as functional impairment and chronic pain,
3. Sexual and reproductive health issues include unwanted pregnancy, miscarriages, abortion, HIV/STIs, low birth weight, pelvic inflammation, and various gynecological issues

Physical Injuries

The most common areas of physical injuries, whether it is bruising, fractures, broken bones, fissures, lesions, and hemorrhaging, were the face, neck, head, genital areas, and anus. It should be noted that quantifying the amount of injuries from sexual and gender-based violence remains a problem. The majority of those experiencing it fear more abuse, torture, violence, and possibly even death, from perpetrators if they disclose the Gender Based Violence to authorities.

Pelvic Inflammation and Chronic Pelvic Pain

It usually results from unprotected sex and rape. Pelvic inflammation occurs when a sexually transmitted disease (usually gonorrhea or chlamydia) reaches the fallopian tubes, uterus, and the ovaries; on rare occasions, it can also occur after childbirth, miscarriage, or abortion. The inflammation of the pelvis is due to bacteria and affects the normal functions of the reproductive system, which can sometimes lead to infertility. The same study also found out that pelvic inflammation is more common amongst female survivors of sexual and gender-based violence than male survivors.

Anal Fissures

An anal tear, refers to the raptures/ tears that are caused on the thin and smooth inner mucosal lining of the anus and rectum. The anal tears are caused by forceful anal sex. The anal tears result to difficulties in passing stool due to pain and inflammation of the anus. Furthermore, it can cause bacterial infection of the anus and hence escalate the pain. The prevalence of anal tears in male rape is higher than in female rape.

Vaginal Fissures and Prolapse

Normally the vagina is supposed to lubricate itself if there is conducive environment before sex; however, during cases of sexual abuse, the vagina does not naturally lubricate and hence the forceful penetration of the penis or inserted object being used to rape causes vaginal tearing. In addition to vaginal tears or cuts, vaginal prolapses are also a common side effect. The prolapses refer to a condition where the reproductive parts such as the vagina, and the uterus, start to slide down from their normal positions. The integrity of the muscle networks around the reproductive system is compromised and weak, hence the organs seem to distend. Other organs linked to the reproductive tract such as the bladder are also affected.

Functional Impairment

The term functional impairment refers to the limitation of one’s normal psychological or physical bodily functioning, inability to carry out functions in their daily lives. In many cases, victims of sexual abuse are faced with stressful experiences and depression and are unable to carry on with their work due to diminished self-esteem, low morale, senses of isolation, loneliness, as well as suicidal thoughts and feeling worthless. A study done in Australia, found that while there were many outcomes from experiencing SGBV, the majority experienced an overall disability that impaired daily motor function.

Gynecological Issues

Gynecological issues that are related to sexual violence include pelvic pain, vaginal irritations, vaginal swelling, and infertility.

Female Genital Mutilation: Short-term & Long-term Sequelae

Female Genital Mutilation / Cutting (FGM/C) encompasses “all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or any other non-therapeutic reasons. Currently about 200 million women have undergone female genital mutilation in over thirty countries. Although many women and human right activists have universally indicated the intention to end the practice and to categorize it as a form of sexual and gender-based violence, several countries still categorise FGM as a cultural tradition or hygiene precaution (e.g. comparing it to male circumcision) even though there has never been conclusive evidence or data to confirm positive health reasoning.

Classification of FGM

Female genital mutilation can be classified into four major types:

Type I

Clitoridectomy; Removal of the prepuce, with or without cutting out of part of or the entire clitoris. Healing after the procedure can often be so complete that someone untrained in FGM/C may not detect this type of cutting.

Type II

Excision; Removal of the entire clitoris, with partial or total cutting of the labia minora. This is the most common form of FGM/C. Although no stitching takes place, deep cutting of the labia minora may result in raw surfaces that fuse together during healing, creating a false infibulation. In some places where Type II FGM is practiced, such fusion is accidental, while elsewhere it is deliberate.

Type III

Removal of the clitoris, the labia minora and the labia majora, followed by infibulation, the stitching together of the raw surfaces to create a small opening to ensure passage of urine and menstrual blood. In a few cases, infibulation has been done over an intact clitoris, and so care needs to be taken when they are performing surgical procedures for an infibulated woman.

Type IV

Includes pricking, piercing or incising of the clitoris and/or labia; stretching of the clitoris and/or labia; cauterization by burning of the clitoris and surrounding tissue; scraping of tissue.

Prevalence of FGM

Different states have different prevalence rates of FGM on girls and women aged between 5 to 49 years and it has been reported to be as high as 90%. As of February 2018, the World Health Organization declared a decrease in FGM practice, but with high prevalence still existing in countries located near the horn of Africa (e.g. Somalia, and West-African countries like Guinea).

Complications of FGM

Immediate Physical Complications due to the Procedure

• Injury to the adjacent tissue of urethra, vagina, perineum and rectum.
• Fracture or dislocation resulting from forceful holding down of girls and the girls’ struggle due to the resultant pain.
• Failure to heal as a result of wound sepsis.

Long-term Physical Complications

The most frequent complications include;

• Keloids, and vaginal narrowing due to scarring
• Some experience difficulty during sex and at delivery increased with the severity of cutting
• Damage to the perineum or anus
• Vulvar Tumours
• Infertility
• Prolapse

Gynaecological Complications

• Infertility
• Reproductive Tract Infections
• Vesico-Vaginal Fistula (VVF)
• Recto-Vaginal Fistula (RVF)
• Other Gynaecological Complications
  • Difficulty in passing urine as a result of partial blockage of urinary opening.
  • Difficulties in Menstrual Flow
  • Recurrent Urinary Tract Infections
  • Keloid Scarring
  • Vulval Cysts and Abscesses

Obstetric Complications

• Inability to become pregnant
• Reduced vaginal opening affects not only delivery, but appears to be the main factor responsible for other obstetric problems in women with FGM/C.
• Prolonged labour and/or obstruction which can lead to obstetric fistula
• Postnatal Genital Wound Infection

Physiotherapy for Survivors of Sexual Abuse

Victims of sexual assault therefore present with unique health care needs. Given the prevalence of sexual assault, physiotherapists are likely to encounter sexual assault patients and are often on the frontline of caring for these patients. Consideration for physiotherapy interventions that recognizes the complex impacts trauma can have on a person’s well-being is paramount. Trauma-informed care appreciates how a person’s life history may have impacted their development, their behaviors, and their current situation.

A Trauma-Informed Approach to Sexual abuse care is important. The power differential between the health care professional and the patient, as well as an invasive physical examination, can cause victims of sexual assault to re-experience the trauma of an assault during health care interactions. In particular, the medical forensic examination and interview are invasive by nature and therefore have high potential for traumatization. Trauma-informed care is a framework that recognizes the impact of trauma and the role of health care providers in addressing trauma with their patients. Trauma-informed care advocates for patient safety and control by building patient-provider collaboration, with the long-term goal of supporting trauma recovery, making it essential to quality care for sexual assault patients. As rehabilitation professionals who frequently encounter clients who have experienced or are experiencing traumatic events, physiotherapists are in an excellent position to foster positive health care experiences and holistic rehabilitation by working from a trauma-informed perspective and supporting the health and resilience of both patients and therapists.

Table.3 Five Key Principles of Trauma Informed Care

Safety	The physiotherapist creates a therapeutic environment in which patients feel safe (physically and emotionally), respected, validated and understood. Safety is so vital that people usually can’t start processing their trauma until they feel safe. It is important for people to feel as safe as possible, so it is crucial that physiotherapists build a relationship of trust before they start the examination process,
Trustworthiness	It is often hard for survivors of trauma to trust people, and being touched can be very difficult, particularly for survivors of physical or sexual abuse. In situations where the treatment process involves touching the body and manipulating the joints, it is critical that physiotherapists not touch patients without permission. Therefore, the physiotherapist should work with a patient to develop a trusting relationship prior to undertaking any physical treatments.
Choice	The choice of the patient and the ability to control their physiotherapist treatments is important. Decisions about their treatment plan are not made for them, but with them.
Collaboration	Treatment effects are maximized by working with what the patient is already doing/knowing what works best for them.
Empowerment	Physiotherapists should priorities treatments that empower and build the patients skills and coping mechanism in managing their own health. Survivors often come from a place of being disempowered so it’s very important that they have major say input into their physiotherapy intervention, and that they have choices.

Physiotherapist should have a good understanding of pelvic anatomy and neurophysiology as this is critical to accurate diagnosis and management with appropriate physiotherapy techniques.

Goals of Physiotherapy for Survivors of Sexual Abuse

Main goals of physical therapy are to:

1. Increase patient awareness and proprioception of the affected musculature,
2. Improve ability to discriminate between muscles and to relax them,
3. Normalize muscle tone,
4. Increase elasticity at the vaginal opening and desensitize areas that are painful, and
5. Decrease fear of vaginal penetration.

Examples of other types of physiotherapeutic treatment recommended for relieving chronic pain and other physical complications in GBV survivors:

• Pelvic Floor Exercises
• Joint Mobilization Exercises
• Massage
• Vaginal Cones Exercises
• Biofeedback
• Hydrotherapy
• Thermotherapy 
• Myofascial Therapy
• Dance Therapy

Dyspareunia and Vaginismus

Dyspareunia is characterized by pain during sexual intercourse or vaginal penetration. Vaginismus is characterized by spasm of the perineal musculature which makes vagina penetration difficult.

Pelvic floor physiotherapy is an important treatment strategy in the multidisciplinary approach to dyspareunia and vaginismus as it improves muscle relaxation, normalize resting muscle activity, increases vaginal elasticity, muscle awareness and proprioception.

Methods such as manual therapy, Kegel exercise, posture, core stabilization, stretching, strengthening, flexibility and coordination exercises should also be included in the rehabilitation programme.

In males, instructing patients to isolate and identify the various trunk and pelvic muscles, as well as pelvic floor isometric strengthening exercises, biofeedback, and electrical stimulation can help with erectile dysfunction and improve control of the ejaculatory reflex.

In females, pelvic floor muscle training has been shown to improve quality of life and sexual function in women with urinary stress incontinence. This connection has prompted the recommendation that women with urinary problems should be asked about their sexual function.

Few physiotherapy studies have been done to explore treatment options for sexual abuse survivors. More research is needed about the topic areas below:

• Pelvic Floor Dysfunction
• Urine and Fecal Incontinence
• Vulva Hygiene
• Pelvic Inflammatory Disease
• Uterine Proplase
• Dyspareunia

When treating both male and female patients who are experiencing pain with sexual intercourse, there are a several guidelines to keep in mind for optimizing your patient’s well-being.

Take a thorough history of your patient presenting with pain during sexual intercourse

• Facilitate a therapeutic alliance that allows the patient to feel comfortable sharing with you.  Start with open-ended questions to give the opportunity for the patient to direct the conversation.
• Use close-ended questions to gain a more detailed understanding of the source of the pain. It may be a nearby mechanical or structural issue in the low back, hips, or legs.
• Asking the patient about specific positions in which their pain is evoked is essential to understanding the mechanism of their pain.
• Work to understand the role psychosocial factors and fear may be playing in the patient’s pain.

Your physical examination of the patient should allow you to gain an understanding of mechanical and soft tissue limitations that may affect the patient during sex. Always explain why you need to touch a patient in sensitive areas and gain their consent before proceeding with your exam. If possible, patients should be referred to a physiotherapist who specializes in pelvic physiotherapy. An internal physiotherapy examination (of vagina or anus) should NOT be conducted by physiotherapists without advanced training in pelvic floor physiotherapy. However, even when there are not qualified pelvic floor therapists available and thus an internal examination or even detailed external palpation of genital musculature is NOT conducted, physiotherapists can still provide skilled evaluation and treatments.

Provide a treatment plan consistent with the patient’s goals. Example areas to focus treatment goals:

• Increase patient awareness and proprioception of the affected musculature
• Improve ability to discriminate between muscles and relax them
• Normalize muscle tone
• Increase elasticity at the vaginal opening and desensitize areas that are painful
• Decrease fear of vaginal penetration

Treatment tools that may be utilized are:

• Education: providing anatomical and physiological information to improve patient’s understanding of their own body.
• Cognitive behavioral: vaginal dilators
• Rehabilitative: pelvic floor muscle strengthening and relaxation, (with tools to facilitate biofeedback if available).
• Palliative: to decrease pain and improve mobility

Manual techniques such as stretching, massage, soft tissue and joint mobilisation may be utilised as appropriate in order to achieve patient goals.

Chronic Pelvic Pain (CPP)

Chronic pelvic pain (CPP) in women is a complex condition, with a high prevalence globally. CPP is defined as “chronic or persistent pain for at least 6 months, perceived in structures related to the pelvis, and often associated with negative cognitive, behavioral, sexual and emotional consequences and symptoms of lower urinary tract, sexual, bowel, pelvic floor or gynecological dysfunction” (34).

Compared with the general female population, women with Chronic pelvic pain report poorer total health, a higher number of surgeries in the pelvic area, and more incidences of physical, sexual, and psychological abuse. Altered movement and respiratory patterns are observed, and pain-related fear of movements among other issues are often present.

Sexual Dysfunction in Men

Much of the research on male sexual dysfunction has previously been focused on neurological or vascular causes. More recently, studies have turned their focus to the involvement of the pelvic floor (35). The pelvic floor helps to stabilize the internal organs and gives bowel and bladder control. Research has shown that physical therapy intervention in treatment of the pelvic floor musculature is a safe and conservative method for treatment of male sexual dysfunction and pelvic pain. The causes of sexual dysfunction and pelvic pain that can be managed by physical therapy include erectile dysfunction, ejaculatory/orgasmic dysfunction, and chronic prostatitis/chronic pelvic pain syndrome.

Erectile Dysfunction

Muscles involved are bulbospongiosus and ischiocavernosus. Both of these muscles contribute to increased engorgement and expulsion of seminal fluid. These muscles need strength and coordination in order to properly contribute to erection. Pelvic floor exercise has been found to be effective in men with mild to moderate veno-occlusive dysfunction. Literature has suggested that voluntary contraction of the ischiocavernosus can increase penile pressure, thus increasing penile hardness. Literature has suggested that relaxation techniques of the pelvic floor muscles may resolve erectile dysfunction caused by high resting muscle tone.

The following are exercises that can be done with patients to help them gain strength of the pelvic floor muscles and are recommended for treating erectile dysfunction (www.medicalnewstoday.com, “Do Erectile Dysfunction Exercises Help?)  

Knee Fallouts:

• Have the patient lay supine with their knees bent, feet flat on the floor, and arms by their sides; instruct them to keep their back in a neutral position
• Have the patient contract their pelvic floor muscles while exhaling. Then have them slowly lower one knee out to the side, keeping the pelvic floor muscles contracted. The muscles or letting their pelvis lift off the floor.
• Next have the patient bring their knee back to where it started while inhaling and relaxing the pelvic floor muscles.
• Repeat with the other knee.
• Have the patient start with 4-5 reps on each side, working towards a goal of 10 reps per side.

Supine Foot Raises:

• Have the patient lay supine with their knees bent, feet flat on the floor, and arms by their sides
• Instruct the patient to contract the pelvic floor muscles while exhaling, then lift one foot in the air and straightening their knee
• Next the patient will lower their foot back to the floor while inhaling and relaxing the pelvic floor muscles
• Repeat on the other side
• Start with 4-5 reps on each side, working towards 10 reps on each side

Pelvic Curl

• Patient lies supine with the knees bent, feet flat on the floor, and arms by their sides
• Make sure the patient keeps their spine in a neutral position
• Have the patient contract their pelvic floor muscles and exhale
• The patient next will push their back flat against the floor
• They will then slowly lift their buttocks off the floor while pushing their heels into the floor
• Patient contracts their buttocks as they lift it off the floor; they should lift until they are in a bridge position
• While keeping their buttocks in the air, have them take 3 breaths in and out and contract the buttock and pelvic floor muscles
• Next have the patient slowly lower their buttocks to the floor, rolling one vertebrae at a time.
• Start by doing 3-4 reps, and work towards doing 10 reps as the patient gets stronger

Constipation

Constipation is a condition where bowel movements become difficult, painful, and infrequent. Normal bowel movements can occur anywhere from 3 times/day to 3 times/week. Constipation affects multiple aspects of a person’s health, including health-related quality of life. Constipation is influenced by a multitude of factors including an overactive pelvic floor, a diet low in fiber, improper hydration, and certain medications. Other risk factors associated with constipation include history of trauma, history of depression, females, lower socioeconomic status, regular use of constipation medications, and decreased activity (36).

An overactive pelvic floor hinders normal bowel movement. The pelvic floor surrounds the colon and rectum, aiding in the conscious control of elimination of feces. If the pelvic floor muscles are hyperactively contracting, passing a bowel can be difficult leading to pain, straining, hemorrhoids, anal fissures, fecal impaction, or rectal prolapse. Someone with a history of trauma, postural problems, and psychological/emotional factors can experience an overactive pelvic floor. While this handout can help to teach ways of relaxation of the pelvic floor, it will also be important to treat the underlying causes.

Physiotherapy is a very effective way of reducing the symptoms of constipation and optimising your recovery. Physiotherapists are equipped with knowledge and skills to do a thorough assessment and treatment programme specific to patient needs and goals.

Diaphragmatic Breathing

Diaphragmatic breathing is a good way to bring about general relaxation of the mind and body as well as relaxation of the pelvic floor. It stimulates the parasympathetic nervous system (rest and digest) and relaxes the sympathetic nervous system (fight or flight). The parasympathetic system promotes movement of the GI tract, and relaxation of the sympathetic system aids in relaxation of the surrounding back, pelvis, and trunk muscles which may be tense and causing pain. Teaching diaphragmatic breathing can be easy using DASS–Deep, Abdominal, Slow, and Smooth.

• Have patients lie comfortably with eyes closed. Have them focus on their breathing and eliminate any outside or stressful thoughts.
• Have them place one hand on their abdomen and the other on their chest, and have them observe which hand moves more with breathing. Guide them to focus on breathing primarily with the abdomen.
• Breathe in slowly through the nose, deep to the abdomen so it expands with inhalation. Hold for a second or more, and then exhale slowly through pursed lips, allowing the abdomen fall inward.
• The entire movement should be smooth instead of choppy. If they are experiencing choppy breathing, it may be helpful to breathe more slowly. Try having patients breathe in for 2 counts, then out with three. Numbers can be changed as needed but generally exhalation should be longer than inhalation.
• This can be done for 3-4 minutes at a time, multiple times each day.

Abdominal Self-Massage

Teaching patients to massage themselves at home can be an effective way to move stool along in the colon. The massage will follow the path of the colon.

• Have patients lie in a comfortable position on their back either with knees flexed or extended.
• Direct patients to the right side of their abdomen just above the iliac crest of the hip. Gently massage the abdomen, moving straight up from the hip until reaching the ribcage.
• Next, have patients move straight across the abdomen until reaching the left side of the ribcage.
• Then massage down the left side of abdomen from the ribcage until reaching the left iliac crest of the hip.
• Finish massaging by moving from the left hip until they reach you reach the center of the abdomen where the 
• Repeat this pattern for about 10 minutes at a time.

Tips for Massage:

• Use fingertips to move in a circular motion. The pressure can be gradually increased as tolerated.
• Spend about 1 minute moving through each direction
• Always start on the right side and go in a clockwise direction, as the direction that feaces travels through the colon.

Additional Lifestyle Tips for Reducing Constipation:

1. Diet;
   • Drink lots of water and tea to help soften stool for easier bowel movements
   • Limit consumption of drinks like soda, coffee, and alcohol. These can remove water fromyour bowels and cause stool to harden. 
   • Eat food rich in fiber like vegetables, ripe fruits, grains, and nuts.
2. Toilet Posture
   • Use a step-stool or box under your feet to bring your knees higher than your hips. This will put the body in an easier position for passing bowel movements.
3. Exercise
   • Moderate aerobic activity such as walking, biking, and swimming can help stimulate the bowels to move.

Feacal Incontinence

The Role of Physiotherapy in Treatment and Management. Information about fecal incontinence is included as this can be common sequelae for those who have experienced anal rape. Fecal incontinence or accidental bowel leakage (ABL) is defined as the inability to control bowel movements resulting in the loss of liquid or solid stool. The cause is often multifactorial including factors such as damage to muscles or nerves, rectal changes, aging, medication and child birth. This condition can have detrimental effects on the quality of life, daily activities and social interactions of those affected. Fecal incontinence is a complex issue often associated with psychological effects and can be a sensitive topic for many. Physical therapists have the ability to reassure their patients that they are not alone and implement accessible, evidence-based interventions and recommendations to help manage their patient’s condition and increase their quality of life (37) (38).<div

Resources

References