Clinical management of survivors of rape - a guide to the development of protocols for use in refugee and internally displaced person situations
Clinical Management of Survivors of Rape - A Guide to the Development of Protocols for Use in Refugee and Internally Displaced Person Situations Table of Contents Clinical Management of Survivors of Rape - A Guide to the Development of Protocols for Use in Refugee and Internally Displaced Person Situations
A guide to the development of protocols for use in refugee and internallydisplaced person situations
An Outcome of theInter-Agency Lessons Learned Conference:Prevention and Response to Sexual and Gender-Based Violence in Refugee Situations27-29 March 2001 Geneva
' World Health Organization and United Nations High Commissioner for Refugees2002
This document is not a formal publication of WHO or UNHCR. The document may befreely reproduced and translated, in part of in whole, but not for sale or foruse in conjunction with commercial purposes. The mention of specific companies orof certain manufacturers’ products does not imply that they are endorsed orrecommended by WHO or UNHCR.
This guide is to be field-tested. Users are invited to submit comments to WHO atthe address below.
For more information on this document or to obtain additional copies, pleasecontact:
World Health OrganizationDepartment of Reproductive Health and Research22, Avenue Appia, 1211 Geneva 27, SwitzerlandFax: +41-22-791 4189;E-mail: [email protected]: http://www.who.int/reproductive-health
UNHCRHealth and Community Development SectionC.P. 2500, 1202 Geneva, SwitzerlandFax: +41-22-739 7366E-mail: [email protected]: http://www.unhcr.ch
Sexual and gender-based violence is a worldwide problem. Refugees and internallydisplaced people are particularly at risk of this violation of their human rightsduring every phase of the refugee cycle. Rape -one of the most extreme forms ofsexual violence - occurs in every society, country and region. Rape as a weaponof war is well documented, as is rape of refugees.
Over the past five years, humanitarian agencies have been working to put in placesystems to respond to sexual and gender-based violence as well as to supportcommunity-based efforts to prevent such violence. In March 2001, theinternational humanitarian community came together to document what had been doneand what is still needed to prevent and respond to sexual and gender-basedviolence towards refugees. Hosted by the United Nations High Commissioner forRefugees, 160 representatives of refugee, nongovernmental, governmental and
intergovernmental organizations met in Geneva to share experiences and lessonslearned. This document is an outcome of that conference. It was produced underthe leadership of the World Health Organization’s Department of ReproductiveHealth and Research, with support from the International Committee of the RedCross and the United Nations High Commissioner for Refugees.
A draft of this guide was distributed in a variety of settings around the worldand field-tested at several sites. Feedback from these field-tests has beenincluded in the current revision. This version will be circulated more widely andits use in the field evaluated over a period of one to two years before beingrevised. Comments on its use will be welcome. Acknowledgements
Special thanks go to all those who participated in the review and field-testingof this document:
- Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA;
- Center for Health and Gender Equity (CHANGE), Takoma Park, MD, USA;
- DØpartement de MØdecine Communautaire, Hpital CantonalUniversitaire de GenŁve, Geneva, Switzerland;
- International Centre for Reproductive Health, Ghent, Belgium;
- International Committee of the Red Cross, Women and War Project,Geneva, Switzerland;
- International Medical Corps, Los Angeles, CA, USA;
- MØdecins Sans FrontiŁres, Belgium, The Netherlands, Spain,Switzerland;
- Physicians for Human Rights, Boston, MA, USA;
- Reproductive Health for Refugees Consortium (American RefugeeCommittee, CARE, Columbia University’s Center for Population andFamily Health, International Rescue Committee, Research and TrainingInstitute of John Snow, Inc., Marie Stopes International, Women’sCommission for Refugee Women and Children);
- United Nations Population Fund, New York, NY, USA;
- United Nations High Commissioner for Refugees, Health and CommunityDevelopment Section, Geneva, Switzerland;
- World Health Organization Headquarters Department of ReproductiveHealth and Research with support of the Departments of
- Emergency and Humanitarian Action,- Essential Drugs and Medicines Policy,- Gender and Women’s Health,- HIV/AIDS,- Injuries and Violence Prevention,- Mental Health and Substance Dependence, and- Vaccines and Biologicals;
- World Health Organization Regional Office for Africa (AFRO);
- World Health Organization Regional Office for South-East Asia(SEARO).
A particular note of appreciation goes out to the following individuals whocontributed to the finalization of this guide:
- Dr Michael Dobson, John Radcliffe Hospital, Oxford, United Kingdom;- Dr Coco Idenburg, Family Support Clinic, Harare, Zimbabwe;- Dr Lorna J. Martin, Department of Forensic Medicine and Toxicology,Cape Town, South Africa;- Dr Nirmal Rimal, AMDA PHC Programme for Bhutanese Refugees, Jhapa,Nepal;- Dr Santhan Surawongsin, Nopparat Rajathanee Hospital, Bangkok,Thailand;- Ms Beth Vann, Reproductive Health for Refugees Consortium,Alexandria, VA, USA.
Thanks are also due to the nongovernmental organizations and UNHCR staff in theUnited Republic of Tanzania, especially Marianne Schilperoord, who organized thefield-testing of this guide. Abbreviations and acronyms used in this guide
diphtheria and tetanus toxoids and pertussis vaccine
tetanus toxoid and reduced diphtheria toxoid
UNHCRUnited Nations High Commissioner for Refugees
Introduction
This guide describes best practices in clinical management of people who havebeen raped. It is intended for adaptation to each situation, taking into accountnational policies and practices, and availability of materials and drugs.
This guide is intended for use by qualified health care providers (healthcoordinators, medical doctors, clinical officers, midwives and nurses) indeveloping protocols for the management of rape survivors, based on availableresources, materials, drugs, and national policies and procedures. It can also beused in planning care services and in training health care providers.
The document includes detailed guidance on the clinical management of women, menand children who have been raped. It explains how to perform a thorough physicalexamination, record the findings and give medical care to someone who has beenpenetrated in the vagina, anus or mouth by a penis or other objects. It does notinclude advice on standard care of wounds or injuries or on psychologicalcounselling, although these may be needed. Neither does the guide give guidanceon referral procedures to community support, police and legal services. Otherreference materials exist that describe this kind of care or give advice oncreating referral networks; this guide is complementary to those materials.
Note: It is not the health care provider’s responsibility to determine whether aperson has been raped. That is a legal determination. The health care provider’sresponsibility is to provide appropriate care, to record the history and otherrelevant information and, with the person’s consent, to collect any forensicevidence that might be needed in a subsequent investigation.
While it is recognized that men and boys can also be raped, most individuals whoare raped are women or girls; feminine pronouns are therefore used in the guideto refer to rape survivors, except where the context dictates oherwise. The essential components of medical care after a rape are:
collection of forensic evidence, evaluation for sexually transmitted infections and preventive care, evaluation for risk of pregnancy and prevention, care of injuries, counselling and follow-up. How to use this guide
This document is meant to be used by health care professionals who are workingwith refugees or internally displaced persons (IDPs), or in other similarsettings to develop specific protocols for medical care of rape survivors. Inorder to do this a number of actions have to be taken. Suggested actions include(not necessarily in the following order):
1 Identify a team of professionals and community members who are involved in caring for people who have been raped. 2 Convene meetings with medical staff and community members. 3 Create a referral network between the different sectors involved in caring for rape survivors (community, health, security, protection). 4 Identify the available resources (drugs, materials, laboratory facilities) and the relevant national policies and procedures relating to rape (standard treatment protocols, legal procedures, laws relating to abortion, etc.). See Annex 1 for an example of a checklist for the development of a local protocol. 5 Develop a situation-specific medical care protocol, using this guide as a reference document. 6 Train providers on use of the protocol, including what must be documented during an examination for legal purposes. Steps covered in this guide 1 Making preparations to offer medical care to rape survivors. 2 Preparing the survivor for the examination. 3 Taking the history. 4 Collecting forensic evidence. 5 Performing the physical and genital examination. 6 Prescibing treatments. 7 Counselling the survivor. 8 Follow-up care of the survivor.
Special considerations needed when caring for children, men, and pregnant andelderly women are also described.
Rape is a traumatic experience, both emotionally and physically. Survivors mayhave been raped by any number of people in a number of different situations;they may have been raped by soldiers, police, family members, friends,boyfriends, husbands, fathers or uncles; they may have been raped whilecollecting firewood, using the latrine, in their beds or while visiting friends. They may have been raped by one, two, three or more people, by men or boys, orby women. They may have been raped over a period of months or this may be thefirst time. Survivors can be women or men, girls or boys; but they are mostoften women and girls.
Survivors may react in any number of ways to such a trauma; whether their traumareaction is long-lasting or not depends, in some part, on how they are treatedwhen they seek help. By seeking medical treatment, the survivor is acknowledgingthat physical and/or emotional damage has occurred. She most likely has healthconcerns. The health care provider can address these concerns and help survivorsbegin the recovery process by providing compassionate, thorough and high-qualitymedical care, and by centring this care around the survivor and her needs andbeing aware of the setting-specific circumstances that may affect the careprovided. Center for Health and Gender Equity (CHANGE)STEP 1 - Making preparations to offer medical care to rape survivors
The health care service must make preparations to respond thoroughly andcompassionately to people who have been raped. The health coordinator shouldensure that health care providers (doctors, medical assistants, nurses, etc.) aretrained to provide appropriate care and have the necessary equipment andsupplies. Female health care providers should be trained as a priority, but alack of trained female health workers should not prevent the service providingcare for survivors of rape.
In setting up a service, the following questions and issues need to be addressed,and standard procedures developed. What should the community be aware of?
- what services are available for people who have been raped;
- why rape survivors would want to seek medical care;
- that rape survivors should come immediately after the incidentwithout bathing or changing clothes;
- that rape survivors can trust the service to treat them withdignity, maintain their security, and respect their confidentiality;
- that there is 24-hour access to services. What are the host country’s laws and policies?
- Which health care provider should provide what type of care? If theperson wishes to report the rape officially to the authorities, thecountry’s laws may require that a certified or licensed medicaldoctor provide the care and complete the official documentation.
- What are the legal requirements with regard to forensic evidence?
- What are the national laws regarding management of the possiblemedical consequences of rape (e.g. emergency contraception, abortion,testing and preventive treatment for human immunodeficiency virus(HIV))?
What resources and capacities are available?
- What laboratory facilities are available for forensic testing (DNAanalysis, acid phosphatase) or screening for disease (STIs, HIV)?What counselling services are available?
- Are there rape management protocols and "rape kits" for documentingand collecting forensic evidence?
- Is there a national STI treatment protocol, a post-exposureprophylaxis (PEP) protocol and a vaccination schedule? Which vaccinesare available?
- What possibilities are there for referral of the survivor to asecondary health care facility (psychiatry, surgery, paediatrics, orgynaecology/obstetrics)?
Where should care be provided?
Generally, a health care clinic or outpatient service that already offersreproductive health services, such as antenatal care, normal delivery care, ormanagement of STIs, can offer care for rape survivors. Referral services may needto be provided at hospital level. Who should provide care?
All staff in health facilities dealing with rape survivors, from reception staffto health care professionals, should be trained in their care. They should alwaysbe compassionate and respect confidentiality. How should care be provided?
- according to a protocol that has been specifically developed forthe situation. Protocols should include guidance on medical,psychosocial and ethical (responsibilities of the provider) aspects,and on counselling options;
- with a focus on the survivor and her needs;
- with an understanding of the provider’s own attitudes andsensitivities, the sociocultural context, and the community’sperspectives, practices and beliefs. What is needed?
- All health care for rape survivors should be provided in one placewithin the health care facility so that the person does not have tomove from place to place.
- Services should be available 24 hours a day, 7 days a week.
- All available supplies from the checklist on page 5 and 6 should beprepared and kept in a special box or place, so that they are readilyavailable. How to coordinate with others?
- Interagency and intersectoral coordination should be established toensure comprehensive care for survivors of sexual violence.
- Be sure to include representatives of social/community services,protection, the police or legal justice system, and security. Depending on the services available in the particular setting, othersmay need to be included.
- As a multisectoral team, establish referral networks, communicationsystems, coordination mechanisms, and follow-up strategies.
See Annex 8 for the minimum care that can and should be made available tosurvivors in the lowest-resource settings. Remember: the wishes of the survivor should be respected at all times. Checklist of supplies for clinical management of rape survivors 1 Protocol Available
- Written medical protocol translated in language of provider*
2 Personnel Available
- Trained (local) health care professionals (on call 24 hours/day)*
- For female survivors, a female health provider speaking the samelanguage is optimal. IF this is not possible a female health worker(or companion) should be in the room during the examination*
3 Furniture/Setting Available
- Room (private, quiet, accessible, access to a toilet or latrine)*
- Lighting, preferably fixed (a torch may be threatening forchildren)*
- Access to an autoclave to sterilise equipment*
- Access to laboratory facilities/microscope/trained technician
- Weighing scales and height chart for children
4 Supplies Available
- "Rape Kit" for collection of forensic evidence, could include:
- Speculum* (preferably plastic, disposable, only adult sizes)
- Comb for collecting foreign matter in pubic hair
- Syringes/needles (butterfly for children)/tubes for collectingblood
- Glass slides for preparing wet and/or dry mounts (for sperm)
- Cotton tipped swabs/applicators/gauze compresses for collectingsamples
- Laboratory containers for transporting swabs
- Paper sheet for collecting debris as the survivor undresses
- Tape measure for measuring the size of bruises, lacerations,etc*.
- Paper tape for sealing and labelling containers/bags*
- Supplies for universal precautions (gloves, box for safe disposalof contaminated and sharp materials, soap)*
- Resuscitation equipment for anaphylactic reactions*
- Sterile medical instruments (kit) for repair of tears, and suturematerial*
- Cover (gown, cloth, sheet) to cover the survivor during theexamination*
- Spare items of clothing to replace those that are torn or taken forevidence
- Sanitary supplies (pads or local cloths)*
- Pregnancy calculator disk to determine the age of a pregnancy
Available
- For treatment of STIs as per country protocol*
- For post-exposure prophylaxis of HIV transmission (PEP)
- Emergency contraception pills and/or intrauterine device (IUD)*
- Tetanus toxoid, tetanus immuno-globulin
6 Administrative Supplies Available
- Information pamphlets for post-rape care (for survivor)*
- Safe, locked filing space to keep confidential records*
* Items marked with an asterisk are the minimum requirements forexamination and treatment of a rape survivor.STEP 2 - Preparing the survivor for the examination
The person who survives rape has experienced trauma and may be in an agitated ordepressed state. She often feels fear, guilt, shame and anger. The health workermust prepare her for the examination, and must carry out the examination in themost compassionate, systematic and complete fashion. To prepare the survivor for the examination:
- Ensure that a trained support person or trained health worker ofthe same sex accompanies the survivor throughout the examination.
- Explain what is going to happen during each step of theexamination, why it is important, what it will tell you, and how itwill influence the care you are going to give.
- Reassure the survivor that she is in control of the pace, timingand components of the examination.
- Reassure the survivor that the examination findings will be keptconfidential.
- Ask if she wants to have a specific person present for support.
- Review the consent form (see Annex 2) with the survivor. Make sureshe understands everything in it, and explain that she can deleteanything she does not wish to consent to. Once you are sure sheunderstands the form completely, ask her to sign it. If she cannotwrite, obtain a thumb print together with the signature of a witness.
- Limit the number of people allowed in the room during theexamination to the minimum necessary.
- Undertake the examination as soon as possible.
- Do not force or presssure the survivor to do anything against herwill. STEP 3 - Taking the history General guidelines
- If the interview is conducted in the treatment room, cover themedical instruments until use.
- Before taking the history, review any documents or paperworkbrought by the survivor to the health centre.
- Let the survivor tell her story the way she wants to.
- Questioning should be done gently and at the survivor’s own pace.
- Sufficient time should be allotted to collect all neededinformation without rushing.
- Do not ask questions that have already been asked and documented byother people involved in the case.
- Avoid any distraction or interruption during history-taking.
A sample history and examination form is included in Annex 3. The main elements
of the relevant history are described below. General information
- Name, address, sex, date of birth (or age in years).
- Note the date and time of the examination and the names of anystaff or support person (someone the survivor may request) presentduring the interview and examination. Description of the incident
- Ask the survivor to describe what happened. Allow the survivor tospeak at her own pace. Do not interrupt to ask for details; follow upwith clarification questions after she finishes telling her story. Explain that she does not have to tell you anything she does not feelcomfortable with.
- It is important that the health worker understands the details ofexactly what happened in order to check for possible injuries. Explain this to the survivor, and reassure her of confidentiality ifshe is reluctant to give detailed information. The form in Annex 3specifies the details needed.
- If the incident occurred recently, determine whether the survivorhas bathed, urinated, vomited, etc. since the incident. This mayaffect the collection of forensic evidence.
- Information on existing health problems, allergies, use ofmedication, and vaccination and HIV status will help you to determinethe best treatment to provide, counselling needed, and follow-uphealth care.
- Evaluate for possible pregnancy, ask for details of contraceptiveuse, last menstrual period, etc.
In developed country settings, some 2% of survivors of rape have been found to bepregnant at the time of the rape.
1 Some were not aware of their pregnancy.
Explore the possibility of a pre-existing pregnancy in women of reproductive ageby a pregnancy test or by history and examination. The following guide may beuseful if you do not have access to pregnancy tests.
1Sexual assault nurse examiner (SANE) development and operationguide. Washington, DC, United States Department of Justice, Office ofJustice Programs, Office for Victims of Crime(www.sane-sart.com/SaneGuide/toc.asp).A guide for confirming pre existing pregnancy (adapted from an FHI protocol
2 Checklist for ruling out pregnancy among family-planning clients inprimary care. Lancet, 1999, 354(9178). STEP 4 - Collecting forensic evidence
The main purpose of the examination is to determine what medical care should beprovided. However, forensic evidence may also be collected to help the survivorpursue legal redress.
The survivor may choose not to have evidence collected. Respect her choice. Good to know before you develop your protocol
Different countries and locations have different legal requirements anddifferent facilities (laboratories, refrigeration, etc.) for performing tests. National and local resources and policies determine what evidence should becollected. Do not collect evidence that cannot be processed.
In some countries, the medical doctor may be legally obliged to give an opinionon the physical findings. Find out what the role of the health care provider isin reporting medical findings in a court of law. Ask a legal expert to write ashort briefing about the local court proceedings in cases of rape and what toexpect to be asked when giving testimony in court. Reasons for collecting evidence
- To confirm recent sexual contact. - To show that force or coercion was used. - To corroborate the survivor’s story. - Possibly, to identify the assailant. Collect evidence as soon as possible after the incident (within 72 hours)
Documenting injuries and collecting samples, such as blood, hair, saliva andsperm, within 72 hours of the incident, may help to support the survivor’s storyand might help identify the aggressor(s). If the person presents more than 72hours after the rape, the amount and type of evidence that can be collected willdepend on the situation. Documenting the case
- Record the interview and your findings at the examination in aclear, complete, objective, non-judgemental way.
- Completely assess and document the physical and emotional state ofthe survivor.
- Record precisely important statements made by her, such as threatsmade by the assailant. Do not be afraid to include the name of theassailant, but use qualifying statements, such as "patient states" or"patient reports".
- Avoid the use of the term "alleged", as it can be interpreted asmeaning that the survivor exaggerated or lied.
- Note down exactly which samples you take. Samples that can be collected as evidence
- Injury evidence: physical and/or genital trauma is proof of forceand should be documented.
- Clothing: torn or stained clothing is useful to prove force wasused.
- Foreign material (soil, leaves, grass) on clothes or body or inhair may corroborate the survivor’s story.
- Hair: foreign hairs may be found on the survivor’s clothes or body. Pubic and head hair from the survivor may be plucked or cut forcomparison.
- Sperm and seminal fluid: specimens may be taken from the vagina,anus or oral cavity, if ejaculation took place in these locations, tolook for the presence of sperm and for prostatic acid phosphataseanalysis.
- DNA analysis can be done on material found on the survivor’s bodyor at the place of aggression, which might be soiled with blood,sperm, saliva or other biological material from the assailant (e.g.,clothing, sanitary pads, handkerchiefs, condoms), as well as on swabsamples from bite marks, semen stains, and involved orifices, and onfingernail cuttings and scrapings. In this case blood from thesurvivor must be drawn to allow her DNA to be distinguished fromforeign DNA found.
- Blood or urine for toxicology testing (if the survivor wasdrugged).
Forensic evidence should be collected during the medical examination. It isnecessary to obtain the consent of the survivor for the collection of evidence. Work systematically according to the medical examination form (see Annex 3). Explain everything you do and why you are doing it. Inspection of the body
- Examine the survivor’s clothing under a good light source before she undresses. Collect any foreign debris on clothes and skin or in the hair (soil, leaves, grass, foreign hairs). Ask the person to undress while standing on a sheet of paper to collect any debris that falls. Do not ask her to uncover fully. Examine the upper half of her body first, then the lower half, or provide a gown for her to cover herself. Collect torn and stained items of clothing, only if you can give her replacement clothes.
- Document all injuries (see Step 5).
- Collect samples for DNA analysis from all places where there couldbe saliva (where the attacker licked or kissed or bit her) or semenon the skin, with the aid of a cotton-tipped swab lightly moistenedwith sterile water.
- The survivor’s pubic hair may be combed for foreign hairs.
- If ejaculation took place in the mouth, take samples and swab theoral cavity, for direct examination for sperm, and for DNA and acidphosphatase analysis.
- Take a blood and urine sample if indicated. Inspection of the anus, perineum and vulva
Inspect and collect samples for DNA analysis from the skin around the anus,perineum and vulva using cotton-tipped swabs moistened with sterile water. Examination of the vagina and rectum
Depending on the site of penetration, examine the vagina and/or the rectum.
- Lubricate a speculum with normal saline or clean water (otherlubricants may interfere with forensic analysis).
- Collect some of the fluid in the posterior fornix for examinationfor sperm.
- Take specimens of the posterior fornix and the endocervical canalfor DNA analysis, using cotton-tipped swabs. Let them dry at roomtemperature.
- Collect separate samples from the cervix and the vagina. These canbe analysed for acid phosphatase.
- Obtain samples from the rectum, if indicated, for examination forsperm, and for DNA and acid phosphatase analysis. Direct examination for sperm
Put a drop of the fluid collected on a slide, if necessary with a drop of normalsaline (wet-mount), and examine it for sperm under a microscope. Note themobility of any sperm. Smear the leftover fluid on a second slide and air-dryboth slides for further examination at a later stage. Screening for STIs
Tests for sexually transmitted infections are usually not used as forensicevidence. A pre-existing STI could be used against the survivor in court.
In some settings screening for gonorrhoea, chlamydia, syphilis and HIV is donefor children who have a history of sexual abuse (see "Care for child survivors",pages 25-27). Maintaining the chain of evidence
It is important to maintain the chain of evidence at all times, to ensure thatthe evidence will be admissible in court. This means that the evidence iscollected, labelled, stored and transported properly. Documentation must includea signature of everyone who has possession of the evidence at any time, from theindividual who collects it to the one who takes it to the courtroom, to preventany possibility of tampering.
If it is not possible to take the samples immediately to a laboratory,precautions must be taken:
- All clothing, cloth, swabs, gauze and other objects to be analysedneed to be well dried at room temperature and packed in paper (notplastic) bags. Samples can be tested for DNA many years after theincident, provided the material is well dried.
- Blood and urine samples can be stored in the refrigerator for 5days. To keep the samples longer they need to be stored in a freezer. Follow the instructions of the local laboratory.
- All samples should be clearly labelled with a confidentialidentifying code (not the name or initials of the survivor), date,time and type of sample (what it is, from where it was taken), andput in a container
- Seal the bag or container with paper tape across the closure. Writethe identifying code and the date and sign your initials across thetape.
In the adapted protocol, clearly write down the laboratory’s instructions forcollection, storage and transport of samples.
Evidence should only be released to the authorities if the survivor decides toproceed with a case.
The survivor may consent to have evidence collected but not to have the evidencereleased to the authorities at the time of the examination. In this case, adviseher that the evidence will be kept in a safe, locked, secure space in the healthcentre for one month before it is destroyed. If she changes her mind during thisperiod, she can advise the authorities where to collect the evidence. Reporting medical findings in a court of law
If the survivor wishes to pursue legal redress and the case comes to trial, thehealth worker who examines her after the incident may be asked to report on thefindings in a court of law. Only a small percentage of cases actually go totrial. Many health workers may be anxious about appearing in court or feel thatthey have not enough time to do this. Nevertheless, providing such evidence is anextension of their role in caring for the survivor.
In cases of rape, the prosecutor (not the health care provider) must prove threethings:
1 Some penetration, however slight, of the vagina or anus by a penis or other object, or penetration of the mouth by a penis. 2 That penetration occurred without the consent of the person. 3 The identity of the perpetrator.
3 Brown, W.A. Obstacles to women accessing forensic medical exams incases of sexual violence. Unpublished background paper to theConsultation on the Health Sector Response to Sexual Violence, WHOHeadquarters, Departments of Injuries and Violence Prevention andGender and Women’s Health, Geneva, June 2001.
In most settings the health care provider is expected to give evidence as afactual witness (that means reiterating the findings as he or she recorded them),not as an expert witness.
Meet with the prosecutor prior to the court session to prepare your testimony andobtain information about the significant issues involved in the case.
Conduct yourself professionally and confidently in the courtroom:
- Speak clearly and slowly, and make eye contact with whomever youare speaking to.
- Answer questions as thoroughly and professionally as possible.
- If you do not know the answer to a question, say so. Do not make ananswer up and do not testify about matters that are outside your areaof expertise.
- Ask for clarification of questions that you do not understand. Donot try to guess the meaning of questions.
The notes written during the initial interview and examination are the mainstayof the findings to be reported. It is difficult to remember things that are notwritten down. This underscores the need to record all statements, procedures andactions in sufficient detail, accurately, completely and legibly. This is thebest preparation for an appearance in court. STEP 5 - Performing the physical and genital examination
The primary objective of the examination is to determine what medical careshould be provided to the survivor. Work systematically according to the medicalexamination form (see sample form in Annex 3).
What is included in the physical examination will depend on how soon after therape the survivor presents to the health service. Follow the steps in Part A ifshe presents within 72 hours of the incident; Part B is applicable to survivorswho present more than 72 hours after the incident. The general guidelines belowapply in both cases. General guidelines
- Make sure the equipment and supplies are prepared.
- Always look at the survivor first, before you touch her, and noteher appearance and mental state.
- Always tell her what you are going to do and ask her permissionbefore you do it.
- Assure her that she is in control, can ask questions, and can stopthe examination at any time.
- Take the patient’s vital signs (pulse, blood pressure, respiratoryrate and temperature).
- The initial assessment may reveal severe medical complications thatneed to be treated urgently, and for which the patient will have tobe admitted to hospital. Such complications might be:
- extensive trauma (to genital region, head, chest orabdomen),- asymmetric swelling of joints (septic arthritis),- neurological deficits,- respiratory distress.
The treatment of these complications is not covered here.
- Obtain voluntary informed consent for the examination and to obtainthe required samples for forensic examination (see sample consentform in Annex 2). Part A: Survivor presents within 72 hours of the incident Physical examination
- Never ask her to fully undress or uncover. Examine the upper halfof her body first, then the lower half; or give her a gown to coverherself.
- Minutely and systematically examine the patient’s body, starting atthe head. Do not forget to look in the eyes, nose, and mouth, and inand behind the ears, and to examine forearms, wrists and ankles. Takenote of the pubertal stage.
- Look for signs that are consistent with the survivor’s story, suchas bite and punch marks, marks of restraints on the wrists, patchesof hair missing from the back of the head, or torn eardrums, whichmay be a result of being slapped.
- Note all your findings carefully on the examination form and thebody figure pictograms (see sample in Annex 4), taking care to recordthe type, size, colour and form of any bruises, lacerations,ecchymoses and petechiae.
- Take note of the survivor’s mental and emotional state (withdrawn,crying, calm, etc.).
- Take samples of any foreign material on the survivor’s body orclothes (blood, saliva, semen, fingernail cuttings or scrapings,swabs of bite marks, etc.) according to the local evidence collectionprotocol.
- Take a sample of the survivor’s own blood, if indicated. Examination of the genital area
Even when female genitalia are examined immediately after a rape, there isidentifiable damage in less than 50% of cases. Carry out a gynaecologicalexamination as indicated below. Collect evidence as you go along, according tothe local evidence collection protocol. Note the location of any tears, abrasionsand bruises on the pictogram and the examination form.
- Systematically inspect the mons pubis, inside of the thighs,perineum, anus, labia majora and minora, clitoris, urethra, introitusand hymen:
- Note any scars from previous female genital mutilation.
- Look for genital injury, such as bruises, scratches,abrasions, tears (often located on the posteriorfourchette).
- Look for any sign of infection, such as ulcers, vaginaldischarge or warts.
- Check for injuries to the introitus and hymen byholding the labia at the posterior edge between indexfinger and thumb and gently pulling outwards anddownwards. Hymenal tears are more common in children andadolescents (see "Care for child survivors", pages25-27).
- Take samples ac-cording to your local evidencecollection protocol. If collecting samples for DNAanalysis, take swabs from around the anus and perineumbefore the vulva, in order to avoid contamination.
- If there has been vaginal penetration, gently insert a speculum, lubricated with water or normal saline (do not use a speculum when examining children; see "Care for child survivors", pages 25-27):
- Under good lighting inspect the cervix, then theposterior fornix and the vaginal mucosa for trauma,bleeding and signs of infection.
- Take swabs and collect vaginal secretions according tothe local evidence collection protocol.
- If indicated by the history and the rest of the examination, do abimanual examination and palpate the cervix, uterus and adnexa,looking for signs of abdominal trauma, pregnancy or infection. Note: In some cultures, it is unacceptable to penetrate the vagina of a woman who is a virgin with anything, including a speculum, finger or swab. In this case you may have to limit the examination to inspection of the external genitalia, unless there are symptoms of internal damage. Examination of anus and rectum
- For the anal examination the patient may have to change position. Write down her position during the examination (supine for genitalexamination; supine, prone, knee-chest or lateral recumbent for analexamination).
- Note the shape and dilatation of the anus. Note any fissures aroundthe anus, the presence of faecal matter on the perianal skin, andpossible bleeding from rectal tears.
- If indicated by the history, collect samples from the rectumaccording to the local evidence collection protocol.
- If indicated, do a rectovaginal examination and inspect the rectalarea for trauma, recto-vaginal tears or fistulas, bleeding anddischarge. Note the sphincter tone. Laboratory testing
No additional samples need to be collected for laboratory testing, other thanthose collected for evidence, unless indicated by the history or the findings onexamination. Samples for testing for sexually transmitted infections may becollected for medical purposes.
- If the survivor has complaints that indicate a urinary tractinfection, collect a urine sample to test for erythrocytes andleukocytes, and possibly for culture.
- Do a pregnancy test, if indicated and available (see Step 3).
- Other diagnostic tests, such as X-ray and ultrasound examination,may be useful in diagnosing fractures and abdominal trauma. Part B: Survivor presents more than 72 hours after the incident Physical examination
It is rare to find any physical evidence more than one week after an assault. Ifthe survivor presents within a week of the rape, or presents with complaints, doa full physical examination as above. In all cases:
- note size and colour of any bruises and scars;- note any evidence of possible complications of the rape (deafness,fractures, abscesses, etc.);- note the survivor’s mental state (normal, withdrawn, depressed,suicidal). Examination of the genital area
If the assault occurred more than a week ago and there are no bruises orlacerations and no complaints (i.e. of vaginal or anal discharge or ulcers),there is little indication to do a pelvic examination. However, if you are in asetting with laboratory facilities, samples may be taken from the vagina and anusfor STI screening. Laboratory screening
Screen for STIs if possible. Follow the instructions of the local laboratory. Screening might cover:
- rapid plasma reagin (RPR) test for syphilis;- Gram stain and culture for gonorrhoea;- culture or enzyme-linked immunoassay (ELISA) for chlamydia;- screening for HIV (but only on a voluntary basis and aftercounselling). STEP 6 - Prescribing treatments
Treatment will depend on how soon after the incident the survivor presents to thehealth service. Follow the steps in Part A if she presents within 72 hours of theincident; Part B is applicable to survivors who present more than 72 hours afterthe incident. Part A: Survivor presents within 72 hours of the incident Prevent sexually transmitted infections Good to know before you develop your protocol
Neisseria gonorrhoeae, the bacterium that causes gonorrhoea, is widely resistantto several antibiotics. Many countries have local STI treatment protocols basedon local resistance patterns. Find out the local STI treatment protocol in yoursetting and use it when treating survivors.
- Survivors of rape should be treated with antibiotics to preventgonorrhoea, chlamydial infection and syphilis. If you know that otherSTIs are prevalent in the area (such as trichomoniasis or chancroid),give preventive treatment for these infections as well.
- Give the woman the shortest courses available in the localprotocol, which are easy to take. For instance: 2 g of azithromycinorally plus one injection of 2.4 million IU of benzathinebenzylpenicillin will be sufficient treatment for gonorrhoea,chlamydial infection and syphilis.
- Be aware that women who are pregnant should not take certainantibiotics, and modify the treatment accordingly.
- Examples of WHO-recommended STI treatment regimens are given inAnnex 5. Prevent HIV transmission Good to know before you develop your protocol
As of the date of publication of this document, there are no conclusive data onthe effectiveness of post-exposure prophylaxis in preventing transmission of HIVafter rape. However, PEP is available in some settings for rape survivors. Before you start your service, find out if PEP is available in your setting andmake a list of names and addresses of providers for referrals.
- If PEP is available, it usually consists of 1, 2 or 3antiretroviral (ARV) drugs given for 28 days (see Annex 6 forexamples). There are many problems and issues surrounding theprescription of PEP, not the least of which is the difficulty ofcounselling the survivor on HIV issues at a time like this. If youwish to know more about PEP, see the resource materials listed in
- If it is possible for the person to receive PEP in your setting,refer her as soon as possible (within 72 hours of the rape) to therelevant centre. If she presents after this time, provide informationon voluntary counselling and testing (VCT) services available in yourarea. Prevent pregnancy
- Taking emergency contraceptive pills (ECP) within 72 hours ofunprotected intercourse will reduce the chance of a pregnancy bybetween 74% and 85%, depending on the regimen chosen and the time ofstarting the course (see Annex 7).
- Emergency contraceptive pills work by interrupting a woman’sreproductive cycle - by delaying or inhibiting ovulation, blockingfertilization or preventing implantation of the ovum. ECPs do notinterrupt or damage a pregnancy and thus WHO does not consider them amethod of abortion.
- Some people believe that ECPs are abortifacients. Health workerswho believe this may feel unable to provide this treatment. Womenshould be offered objective counselling on this treatment so as toreach an informed decision.
- A health worker who is willing to prescribe ECPs should always beavailable to prescribe the treatment to rape survivors who wish touse it. If the survivor is a child who has reached menarche, discussemergency contraception with her and her parent or guardian who canhelp her to understand and take the regimen as required.
- If an early pregnancy is detected at this stage, either with apregnancy test or from the history and examination (see Steps 3 and5), make clear to the woman that it cannot be the result of the rape.
- There is no known contraindication to giving ECPs at the same timeas antibiotics.
4 Emergency contraception: a guide for service delivery. Geneva, World Health Organization, 1998 (document no. WHO/FRH/FPP/98.19). Provide wound care
Clean any tears, cuts and abrasions and remove dirt, faeces and dead or damagedtissue. Decide if there are any wounds that need suturing. Suture clean woundswithin 24 hours. After this time they will have to heal by second intention ordelayed primary suture. Do not suture very dirty wounds. If there are majorcontaminated wounds, consider giving appropriate antibiotics and pain relief. Prevent tetanus Good to know before you develop your protocol
Tetanus toxoid is available in several different preparations. Check local vaccination guidelines for recommendations.
Antitetanus immunoglobulin (antitoxin) is expensive and needs tobe refrigerated. It is not available in low-resource settings.
DTP - triple antigen: diphtheria and tetanus toxoids and pertussis vaccine
DT - double antigen: diphtheria and tetanus toxoids; given to children up to 6years of age
Td - double antigen: tetanus toxoid and reduced diphtheria toxoid; given toindividuals aged 7 years and over
- If there are any breaks in skin or mucosa, tetanus prophylaxisshould be given unless the survivor has been fully vaccinated.
- On the basis of the table below, decide whether to administertetanus toxoid, which gives active protection, and antitetanusimmunoglobulin, if available, which gives passive protection.
- If vaccine and immunoglobulin are given at the same time, it isimportant to use separate needles and syringes and separate sites ofadministration.
- Advise survivors to complete the vaccination schedule (second doseat 4 weeks, third dose at 6 months to 1 year). Guide for administration of tetanus toxoid and tetanus immunoglobulin in cases of wounds History of tetanus If wounds are clean and <6 All other wounds immunization hours old or minor wounds *For children less than 7 years old, DTP or DT is preferred totetanus toxoid alone. For persons 7 years and older, Td is preferredto tetanus toxoid alone.
5 Adapted from: Benenson, A.S. Control of communicable diseasesmanual. Washington DC, American Public Health Association, 1995. Prevent hepatitis B Good to know before you develop your protocol
Find out the prevalence of hepatitis B in your setting, as well as thevaccination schedules in the survivor’s country of origin and in the hostcountry.
Several hepatitis B vaccines are available, each with different recommendeddosages and schedules. Check the dosage and vaccination schedule for the productthat is available in your setting.
- Whether you can provide post-exposure prophylaxis against hepatitisB will depend on the setting you are working in. The vaccine may notbe available as it is relatively expensive and requiresrefrigeration.
- There is no information on the incidence of hepatitis B virus (HBV)infection following rape. However, HBV is present in semen and
vaginal fluid and is efficiently transmitted by sex. If possible,survivors of rape should receive hepatitis B vaccine within 14 daysof the incident.
- In countries where the infant immunization programmes routinely usehepatitis B vaccine, a survivor may already have been fullyvaccinated. If the vaccination record card confirms this, noadditional doses of hepatitis B vaccine need be given.
- The usual vaccination schedule is at 0, 1 and 6 months. However,this may differ for different products and settings. Give the vaccineby intramuscular injection in the deltoid muscle (adults) or theanterolateral thigh (infants and children). Do not inject into thebuttock, because this is less effective.
- The vaccine is safe for pregnant women and for people who havechronic or previous HBV infection. It can be given at the same timeas tetanus vaccine. Provide mental health care
- Social support and psychological counselling (see Step 7) areessential components of medical care for the rape survivor. Mostsurvivors of rape will regain their psychological health through theemotional support and understanding of people they trust, thecommunity counsellor, and support groups. All rape survivors shouldbe referred to the community focal point for sexual and gender-basedviolence.
- Occasionally a survivor may have severe symptoms of post-traumaticstress disorder. These symptoms can include anxiety, nightmares,inability to sleep, and constant crying.
- In exceptional cases, if the level of anxiety is such that it isdisrupting the survivor’s everyday life, give one 10 mg tablet ofdiazepam, to be taken at bedtime. In this case she should be referredto a specially trained health professional and her symptomsreassessed the next day. Part B: Survivor presents more than 72 hours after the incident Sexually transmitted infections
If laboratory screening for STIs has revealed an infection, or if the person hassymptoms of an STI, treat according to the syndromic approach. Follow localprotocols. HIV transmission
While in some settings testing for HIV can be done as early as six weeks after arape, it is recommended that the survivor is referred for voluntary counsellingand testing (VCT) after 3-6 months, in order to avoid the need for repeatedtesting. Check the VCT services available in your setting and their protocols. Pregnancy
- If the survivor is pregnant, try to ascertain if she could havebecome pregnant at the time of the rape. If she is, or may be,pregnant as a result of the rape, counsel her on the possibilitiesavailable to her in your setting. (See Step 3, Step 7, and Step 8).
- If the survivor presents within five days of the rape, insertion ofa copper-bearing IUD is an effective method of preventing pregnancy(it will prevent more than 99% of subsequent pregnancies). The IUDcan be removed at the time of the woman’s next menstrual period orleft in place for future contraception. Women should be offeredcounselling on this service so as to reach an informed decision. Askilled provider should counsel the patient and insert the IUD. Bruises, wounds and scars
Treat, or refer for treatment, all unhealed wounds, fractures, abscesses, andother injuries and complications.
Tetanus usually has an incubation period of 3 to 21 days, but it can be manymonths. Refer the survivor to the appropriate level of care if you see signs of atetanus infection. If she has not been fully vaccinated, vaccinate immediately,no matter how long it is since the incident. If there remain major, dirty,unhealed wounds, consider giving antitoxin if this is available (see "Preventtetanus" in Part A). Hepatitis B
Hepatitis B has an incubation period of two to three months on average. If yousee signs of an acute infection, refer the person if possible or providecounselling. If the person has not been vaccinated and it is appropriate in yoursetting, vaccinate, no matter how long it is since the incident. Mental health
- Social support and psychological counselling (see Step 7) areessential components of medical care for the rape survivor. Mostsurvivors of rape will regain their psychological health through theemotional support and understanding of people they trust, thecommunity counsellor, and support groups. All rape survivors shouldbe referred to the community focal point for sexual and gender-basedviolence.
- Occasionally a survivor may have severe symptoms of post-traumaticstress disorder. These symptoms can include anxiety, nightmares,inability to sleep, and constant crying.
- In exceptional cases, if the level of anxiety is such that it isdisrupting the survivor’s everyday life, give one 10 mg tablet ofdiazepam, to be taken at bedtime. In this case she should be referredto a specially trained health professional and her symptomsreassessed the next day. STEP 7 - Counselling the survivor
Survivors seen at a health facility immediately after the rape will most likelybe experiencing psychological trauma and may show signs of anxiety and/ordepression. Survivors in this state are unlikely to remember counselling andadvice given at this time. It is therefore important to repeat the counsellingduring follow-up visits. It is also useful to prepare standard advice andcounselling information in writing, and give the survivor a copy before sheleaves the health facility (even if the survivor is illiterate, she can asksomeone she trusts to read it to her later).
Give the survivor the opportunity to ask questions and to voice her concerns. Psychological and emotional trauma
- Medical care for survivors of rape includes care and referral forpsychological trauma.
- The majority of rape survivors never tell anyone about theincident. If the survivor has told you what happened, she hasdemonstrated that she trusts you.
- Rape causes psychological and emotional trauma as well as physicalinjury. Survivors may experience a range of post-traumatic symptoms,including:
- self-blame;- uncontrollable emotions, such as fear, anger, guilt,shame, anxiety;- mood swings;- nightmares and sleeping disorders;- eating disorders;- suicidal thoughts or suicide attempts.
- Tell the survivor that she has experienced a serious physical andemotional trauma. Advise her about the post-traumatic symptoms(emotional and physical) that she may experience.
- In most cultures, there is a tendency to blame the survivor in cases of rape. Assure the survivor that she did not deserve to be raped, that the incident was not her fault, and that it was not caused by her behaviour or manner of dressing.
- Advise the survivor that part of the care she needs is emotionalsupport. Encourage her to confide in someone she trusts and to askfor this emotional support, perhaps from a family member or friend.
- Refer the survivor to a counselling service for psychosocialassistance.
- Ask the survivor if she has a safe place to go to, and if someone she trusts will accompany her when she leaves the health facility. If she has no safe place to go to now, efforts should be made to find her a safe place. Enlist the assistance of the counselling services, community services provider, police or security officer (see Step 1).
- In some cases, the survivor is seriously traumatized andexperiences severe emotional or psychological dysfunction, becomingunable to carry out day-to-day activities. Referral for psychologicalevaluation and more in-depth counselling may be needed. Find out whatservices are available in your area. Pregnancy
- Emergency contraceptive pills cannot prevent pregnancy resultingfrom sexual acts that take place after the treatment. If the survivorwishes to use an additional hormonal method of contraception, sheshould start this on the first day of her next period. Condom use fora period of 6 months should be recommended to protect againsttransmission of STIs and HIV infection.
- Female survivors of rape are likely to be very concerned about thepossibility of becoming pregnant as a result of the rape. Emotionalsupport and clear information are needed to ensure that they
understand the choices available to them if they become pregnant:
- There may be services for adoption and/or foster carein your area. Find out what services are available andgive this information to the survivor.
- In many countries the law allows termination ofpregnancy resulting from rape. Furthermore, localinterpretation of abortion laws in relation to mental andphysical health may include indications for rapesurvivors as well. Find out whether this is the case inyour setting. Determine where safe abortion services areavailable so that you can refer survivors to this serviceif they so choose.
- Advise survivors to seek support from someone theytrust - perhaps a religious leader, family member, friendor community worker.
Both men and women may be concerned about the possibility of becomingHIV-positive as a result of rape. While the risk of acquiring HIV through asingle sexual exposure is small, these concerns are well founded. Compassionateand careful counselling around this issue is essential. The health care workermay also discuss the risk of transmission of HIV or STI to partners following arape.
- The survivor may be referred to an HIV/AIDS counselling service ifavailable.
- Condom use with all partners for a period of 6 months (or dependingon the result of HIV screening tests) should be recommended.
- Give advice on the signs and symptoms of possible STIs, and on whento return for further consultation.
- Give advice on proper care for any injuries following the incident,infection prevention (including perineal hygiene, perineal baths),signs of infection, antibiotic treatment, when to return for furtherconsultation, etc.
- Give advice on how to take the prescribed treatments and onpossible side-effects of treatments. Follow-up care at the health facility
- Tell the survivor that she can return to the health service at anytime if she has questions or other health problems. Encourage her toreturn in two weeks for follow-up evaluation of STI and pregnancy(see Step 8).
- Give clear advice on any follow up needed for wound care orvaccinations. STEP 8 - Follow-up care of the survivor
It is possible that the survivor will not or cannot return for follow-up. Provide maximum input during the first visit, as this may be the only visit.
If the survivor is started on post-exposure prophylaxis with antiretroviraldrugs, the follow-up schedule may be different from the one below. Discuss thiswith the PEP provider. Two-week follow-up visit
- Evaluate for pregnancy and provide counselling (see Steps 3, 6, 7).
- Evaluate for STIs, treat as appropriate, provide advice onvoluntary counselling and testing for HIV (see Steps 6, 7).
- Evaluate mental and emotional status; refer or treat as needed (seeStep 7). Six-month follow-up visit
- Evaluate for STIs, treat as appropriate. - Provide advice on voluntary counselling and testing for HIV. - Evaluate mental and emotional status; refer as needed (see Step 7). If the woman is pregnant as a result of the rape
A pregnancy may be the result of the rape. All the options available, e.g. keeping the child, adoption and abortion, should be discussed with the woman,regardless of the individual beliefs of the counsellors, medical staff or otherpersons involved, in order to enable her to make an informed decision.
Where safe abortion services are not available, women with unwantedpregnancies may undergo unsafe abortions. These women should have access topost-abortion care, including emergency treatment of abortion complications,counselling on family planning, and links to reproductive health services.
Children born as a result of rape may be mistreated or even abandoned by theirmothers and families. They should be monitored closely and support should beoffered to the mother. It is important to ensure that the family and thecommunity do not stigmatize either the child or the mother. Foster placementand, later, adoption should be considered if the child is rejected, neglected orotherwise mistreated. Care for child survivors Good to know before you develop your protocol
If it is obligatory to report cases of child abuse in your setting, obtain asample of the national child abuse management protocol and information oncustomary police and court procedures.
Find out about specific laws in your setting that determine who can giveconsent for minors.
In settings where the health worker is expected to go to court as an expertwitness, he or she should receive special training in examining children whohave been abused.
Health care providers should be knowledgeable about child development andgrowth as well as normal child anatomy.
A parent or legal guardian should sign the consent form for examination of thechild and collection of forensic evidence, unless he or she is the suspected
offender. In this case, a representative from the police, the community supportservices or the court may sign the form. Adolescent minors may be able to giveconsent themselves. The child should never be examined against his or her will,whatever the age, unless the examination is necessary for medical care.
The initial assessment may reveal severe medical complications that need to betreated urgently, and for which the patient will have to be admitted to hospital. Such complications might be:
- convulsions;- persistent vomiting;- stridor in a calm child;- lethargy or unconsciousness;- inability to drink or breastfeed.
In children younger than 3 months, look also for:
- fever;- low body temperature;- bulging fontanelle;- grunting, chest indrawing, and breathing rate of more than 60breaths/minute.
The treatment of these complications is not covered here in detail. Create a safe and trusting environment
- Sit at eye level and maintain eye contact.
- Assure the child that he or she is not in any trouble.
- Ask a few questions about neutral topics, e.g., school, friends,who the child lives with, favourite activities.
- Take special care in determining who should be present during theinterview and examination (remember that it is possible that a familymember is the perpetrator). It is preferable to have the parent orguardian wait outside during the interview and have an independenttrusted person present. For the examination, either a parent orguardian or a trusted person should be present. Always ask the childwho he or she would like to be present, and respect his or herwishes. Take the history
- Begin the interview by asking open-ended questions, such as "Whyare you here today?" or "What were you told about coming here?"
- Assure the child it is okay to respond to any questions with "Idon’t know".
- Be patient, go at the child’s pace, don’t interrupt his or hertrain of thought.
- Ask open-ended questions to get information about the incident. Askyes-no questions only for clarification of details.
The pattern of sexual abuse of children is generally different from that ofadults. For example, there is often repeated abuse. To get a clearer picture ofwhat happened, try to obtain information on:
- the home situation (has the child a secure place to return to?);- how the rape/abuse was discovered;- the number of incidents and the date of the last incident;- whether there has been any bleeding;- whether the child has had difficulty walking. Prepare the child for examination
- As for adult examinations, there should be a support person ortrained health worker whom the child trusts in the examination roomwith you.
- Encourage the child to ask questions about anything he or she isconcerned about or does not understand at any time during theexamination.
- Explain what will happen during the examination, using terms thechild can understand.
- With adequate preparation, most children will be able to relax andparticipate in the examination.
- It is possible that the child has pain and cannot relax for that reason. If this is a possibility, give paracetamol or other simple painkillers to relieve pain. Wait for these to take effect.
- Never restrain or force a frightened, resistant child to complete an examination. Restraint and force are often part of sexual abuse and, if used by those attempting to help, will increase the child’s fear and anxiety and worsen the psychological impact of the abuse.
- It is useful to have a doll on hand to demonstrate procedures andpositions. Show the child the equipment and supplies, such as gloves,swabs, etc.; allow the child to use these on the doll. Conduct the examination
Conduct the examination as for adults. Special considerations for children are asfollows:
- Note the child’s weight, height, and pubertal stage. Ask girlswhether they have started menstruating. If so, they may be at risk ofpregnancy.
- Small children can be examined on the mother’s lap. Older childrenshould be offered the choice of sitting on a chair or on the mother’slap, or lying on the bed.
- Examine the anus with the child in the supine or lateral position. Avoid the knee-chest position, as assailants often use it.
- Check the hymen by holding the labia at the posterior edge between index finger and thumb and gently pulling outwards and downwards. Note the location of any fresh or healed tears in the hymen and the vaginal mucosa. The amount of hymenal tissue and the size of the vaginal orifice are not sensitive indicators of penetration.
- Digital examination (assessing the size of the vaginal orifice bythe number of fingers that can be inserted) should not be carriedout.
- Look for vaginal discharge. In prepubertal girls, vaginal specimenscan be collected with a dry sterile cotton swab.
- Do not use a speculum to examine prepubertal girls; it is extremely painful and may cause serious injury.
- A speculum may be used only when you suspect a penetrating vaginal injury and internal bleeding. In this case, a speculum examination of a prepubertal child is usually done under general anaesthesia. Depending on the setting, the child may need to be referred to a higher level of health care.
- In boys, check for injuries to the frenulum of the prepuce, and foranal or urethral discharge; take swabs if indicated.
- Conduct an anal examination in both boys and girls.
- Record the position of any anal fissures or tears on the pictogram.
- Reflex anal dilatation (opening of the anus on lateral traction onthe buttocks) can be indicative of anal penetration, but also ofconstipation.
- Digital examination to assess anal sphincter tone should not be done. Laboratory testing
In some settings, screening for gonorrhoea and chlamydia (by culture), syphilisand HIV is done for all children presenting with a history of rape. The presenceof these infections may be diagnostic of rape (if the infection is not likely tohave been acquired perinatally or through blood transfusion).
6 American Academy of Pediatrics Committee on Child Abuse andNeglect. Guidelines for the evaluation of sexual abuse of children:subject review. Pediatrics, 1999,103:186-191. If the child is highly agitated
In rare cases, a child cannot be examined because he or she is highly agitated. Only if the child cannot be calmed down and treatment is vital, the examination may be performed with the child under sedation, using one of the following drugs:
- diazepam, by mouth, 0.15 mg/kg of body weight; maximum 10 mg;
- promethazine hydrochloride, syrup, by mouth;
- 2-5 years: 15-20 mg- 5-10 years: 20-25 mg
These drugs do not provide pain relief. If you think the child is in pain, give simple pain relief first, such as paracetamol (1-5 years: 120 - 250 mg; 6-12 years: 250 - 500 mg). Wait for this to take effect. Oral sedation will take 1 to 2 hours for full effect. In the meantime allow the child to rest in a quiet environment. Treatment
Routine prevention of STIs is not usually recommended for children if screeningcan be done. However, in low-resource settings with a high prevalence of sexuallytransmitted diseases, presumptive STI treatment may be part of the protocol (seeAnnex 5 for sample regimens). Follow-up
Follow-up care is the same as for adults. If a vaginal infection does not clear,consider the possibility of the presence of a foreign body, or continuing sexualabuse. Special considerations for men Counselling
- Male survivors of rape are even less likely than women to reportbecause of the extreme embarrassment that they typically experience. While the physical effects differ, the psychological trauma andemotional after-effects for men are similar to those experienced bywomen.
- When a man is anally raped, pressure on the prostate can cause anerection and even orgasm. Reassure the survivor that, if this hasoccurred during the rape, it was a physiological reaction and wasbeyond his control. Genital examination
- Examine the scrotum, testicles, penis, periurethral tissue,urethral meatus and anus.
- Note if the survivor is circumcised.
- Look for hyperaemia, swelling (distinguish between inguinal hernia,hydrocele and haematocele), torsion of testis, bruising, anal tears,etc.
- Torsion of the testis is an emergency and requires immediatereferral.
- If the urine contains large amounts of blood, check for penile andurethral trauma.
- If indicated, do a rectal examination and check the rectum andprostate for trauma and signs of infection.
- If relevant, collect material from the anus for direct examinationfor sperm under a microscope. Treatment
Men need the same STI preventive treatment and vaccinations as described in Step6. Special considerations for pregnant women
Women who are pregnant at the time of a rape are physically and psychologicallyespecially vulnerable. In particular they are susceptible to miscarriage,hypertension of pregnancy and premature delivery.
Counsel pregnant women on these issues and advise them to attend antenatal careservices regularly throughout the pregnancy. Special considerations for elderly women
Elderly women who have been vaginally raped are at increased risk of vaginaltears and injury, and transmission of STI and HIV. Decreased hormonal levelsfollowing the menopause result in a reduction in vaginal lubrication and causethe vaginal wall to become thinner and more friable. Use a thin speculum forgenital examination. If collecting evidence or screening for STIs is the onlyindication for the examination, consider inserting swabs only without using aspeculum. Annex 1 Information needed to develop a local protocol Checklist developed for refugee camps in the United Republic of Tanzania
Certain information is needed before a local protocol can be developed. Thefollowing table shows the information collected in the United Republic ofTanzania and where this information was found. Information needed Where the information was found Medical laws and legal procedures
Foster placement and adoption laws and procedures
Ministry of CommunityDevelopment, Women Affairs andChildren
Crime reporting requirements and obligations, for
Forensic evidence
Which medical practitioner can give medical
evidence in court (e.g. doctor, nurse, etc)
examination (of adult or child survivors)
Evidence allowed/used in court for adult and
child rape cases that can be collected by medicalstaff
Forensic evidence tests possible in country (e.g.
How to collect, store and send evidence samples
Forensic laboratory incapital; laboratory atregional level
Existing "rape kits" or protocols for evidence
Medical protocols
Location of voluntary HIV counselling and testing
Confirmatory HIV testing strategy and laboratory
Program, Ministry of Health,Regional Medical Officer
Possibilities/protocols/referral of post-exposure
Clinical referral possibilities (e.g. psychiatry,
surgery, paediatrics, gynaecology/obstetrics)
Annex 2 Sample consent form Name of facility _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Note to the health worker: Read the entire form to the survivor, explaining thatshe can choose any (or none) of the items listed. Obtain a signature, or a thumbprint with signature of a witness.
I, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , (printname of survivor)
authorize the above_named health facility to perform the following (tick theappropriate boxes):
Conduct a medical examination, including pelvic examination Collect evidence, such as body fluid samples, collection of clothing, hair combings, scrapings or cuttings of fingernails, blood sample, and photographs Provide evidence and medical information to the police and/or courts concerning my case; this information will be limited to the results of this examination and any relevant follow_up care provided.
Signature:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Witness: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _
Annex 3 Sample history and examination form CONFIDENTIAL CODE: Medical History and Examination Form - Post-Sexual Violence 1. GENERAL INFORMATION In case of a child include: Name of school, name of parents and/or guardian 2. THE INCIDENT Date of incident: Time of incident:
Description of incident (survivor’s description)
Physical violence No Describe type and location
Type (beating, biting, pullinghair, etc.)
Penetration No Not sure Describe (oral, vaginal, anal, type of object) No Not sure Location (oral, vaginal, anal, other location). If use of restraints, drugs/alcohol involved and if the survivor is a child, also ask: Has this happened before, for how long, who is the perpetrator, is (s)he still a threat, etc. Also ask about bleeding from the vagina or the rectum, pain on walking, dysuria, pain on passing stool, signs of discharge, etc. 3. MEDICAL HISTORY After the incident, did the survivor Contraception use Menstrual history History of consenting intercourse (only if samples have been taken for DNA analysis) Existing health problems History of female genital cutting, typeVaccination Vaccinated Comments vaccinated HIV/AIDS 4. Medical examination
Appearance (clothing, hair, etc., obvious physical ormental disability?)
Mental state (calm, crying, anxious, cooperative, etc.)
Pubertal stage (pre-pubertal,pubertal, mature):
Physical findings Describe systematically, and draw on the attached body pictograms, the exact location of all wounds, bruises, petechiae, marks, etc. Document type, size, colour, form and other particulars. Be descriptive, do not interpret the findings. 5. GENITAL AND ANAL EXAMINATION Position of patient (supine, prone, knee-chest, lateral, mother’s lap)6. INVESTIGATIONS DONE Type and location Examined/sent to lab 7. EVIDENCE TAKEN Type and location Sent to./stored Collected by/date 8. TREATMENTS PRESCRIBED Treatment Yes No Type and Comments 9. COUNSELLING, REFERRALS, FOLLOW-UP
Survivor plans to report to police OR has
Name of health worker conducting examination/interview:__________________ Title: __________________ Signature: ______________ Date: ______________ Annex 4 Pictograms Annex 5 Protocols for treatment of STIs WHO-recommended treatments for adults Note: These are examples of treatments for sexually transmitted infections. There may be other treatment options. Always follow local treatment protocols for sexually transmitted infections. Treatment Gonorrhoea azithromycin
2 g orally (not recommendedin pregnancy)(Note: in this case you donot have to give furthertreatment for chlamydialinfection)or ciprofloxacin
500 mg orally, single dose(contraindicated inpregnancy)or cefixime or ceftriaxone Chlamydial infection doxycycline
100 mg orally, twice dailyfor 7 days (contraindicatedin pregnancy)or azithromycin
1 g orally, in a single dose(not recommended inpregnancy)erythromycin or amoxicillin Syphilis benzathine
2.4 million IU,intramuscularly, once only
benzylpenicillin (give as two injections inseparate sites.)doxycycline
for 15 days (contraindicatedin pregnancy)or tetracycline
500 mg orally, 4 times dailyfor 15 days (contraindicatedin pregnancy)(Note: both theseantibiotics are also activeagainst chlamydia)erythromycin
for 15 days(Note: this antibiotic isalso active againstchlamydia)Trichomonas metronidazole
2 g orally, in a single doseor as two divided doses at a12-hour interval(contraindicated in thefirst trimester ofpregnancy)
Give one easy to take, short treatment for each of the infections that areprevalent in your setting.
Presumptive treatment for gonorrhoea, syphilis and chlamydial infection for awoman who is not pregnant and not allergic to penicillin
azithromycin 2g orally + benzathine benzylpenicillin 2.4 million IUintramuscularly,
ciprofloxacin 500 mg orally + benzathine benzylpenicillin 2.4million IU intramuscularly + doxycycline 100 mg orally, twice dailyfor 7 days
If trichomoniasis is prevalent, add a single dose of 2 g of metronidazole orally. WHO-recommended treatments for children and adolescents Note: These are examples of treatments for sexually transmitted infections. There may be other treatment options. Always follow local treatment protocols for sexually transmitted infections and use drugs and dosages that are appropriate for children. Treatment Gonorrhoea ceftriaxone or spectinomycin
40 mg/kg of body weight,intramuscularly (up to a maximum of 2g), single dose
or (if > 6 months) cefixime Chlamydial erythromycin infection
(up to a maximum of 2 g), divided into4 doses, for 7 days
erythromycin or azithromycin doxycycline or azithromycin or erythromycin Syphilis benzathine penicillin Erythromycin or doxycycline in the dosages recommendedfor chlamydial infection for 14 days Trichomoniasis metronidazole
Based on: Tailoring clinical management practices to meet the special needs ofadolescents: sexually transmitted infections. Geneva, World Health Organization(document WHO/CAH 2002, WHO/HIV/AIDS 2002.03), in print. Annex 6 Protocols for post-exposureprophylaxis of HIV infection
The following are examples of post-exposure prophylaxis (PEP) protocols used insome settings for preventing HIV infection after rape. There may be otherexamples. These examples do not outline all the care that may be needed. If it ispossible in your setting to provide PEP, refer the survivor as soon as possible(within 72 hours) to the relevant centre. Example 1
From: Treatment guidelines for the use of AZT (zidovudine) for the prevention ofthe transmission of human immunodeficiency virus (HIV) in the management ofsurvivors of rape. The Department of Health, Western Cape Province, South Africa. Treatment regimen (28 days)
Survivors are given a one-week supply of the drug and an appointment to return for reassessment in one week.
Survivors are seen at one week for evaluation and to obtain theresults of their blood tests. They are given the remainder of their28-day course of zidovudine.
The next visits are at 6 weeks and 3 months after the rape. HIVtesting is performed at both these visits.
Routine testing, with full blood count and liver enzymes is notrecommended for patients on zidovudine. Any blood tests areperformed only if indicated by the survivor’s clinical condition. Example 2 From: Bamberger, J.D. et al. Postexposure prophylaxis for human immunodeficiencyvirus (HIV) infection following sexual assault. American Journal of Medicine,1999, 106: 323-326.Treatment regimen (28 days)
Zidovudine, 300 mg twice a day or 200 mg 3 times per day, and lamivudine, 150 mg twice a day Alternative regimen (28 days)
Didanosine, 200 mg twice a day, and staduvidine, 40 mg twice a day Consider adding:* nelfinavir, 750 mg three times a day, or indinavir, 800 mg three times a day
Although antiretroviral medications rarely cause importantlaboratory abnormalities, baseline tests may be useful.
Monitoring should include complete blood count and liver enzymelevels as clinically indicated.
HIV antibody testing is recommended at baseline, 6 weeks, 3months, and 6 months following the assault. * In the rare case where the assailant is known to be infected with HIV that isresistant to reverse transcriptase inhibitors, it is recommended to add aprotease inhibitor, such as nelfinavir or indinavir. An HIV specialist should beconsulted to determine the appropriate regimen.Note: Nevirapine is not recommended for use as post-exposure prophylaxis after rape. 1
1 Updated U.S. Public Health Service guidelines for the management ofoccupational exposures to HBV, HCV, and HIV and recommendations forpostexposure prophylaxis. Morbidity and mortality weekly report,2001, 50(RR-11), Appendix C. Annex 7 Protocols for emergency contraception Emergency contraceptive pills
There are two emergency contraceptive pill (ECP) regimens that canbe used: the levonorgestrel-only regimen (this is the recommendedregimen) or the combined estrogen-progesterone regimen (Yuzpe).
In both regimens, a first dose should be taken as soon asconvenient, but not later than 72 hours after the rape, and a seconddose 12 hours later. There are products that are specially packagedfor emergency contraception, but at present they are registered onlyin a limited number of countries. If pre-packaged ECPs are notavailable in your setting, emergency contraception can be providedusing regular oral contraceptive pills which are available for familyplanning purposes (see the table below for guidance).
Counsel the survivor about how to take the pills, what side-effectsmay occur, and the effect the pills may have on her next period. ECPsdo not prevent pregnancy from sexual acts after treatment. If needed,provide her with condoms for use in the immediate future.
Make it clear to the survivor that there is a small risk that thepills will not work. Most patients will have a normal menstruationwithin 21 days after the treatment. Menstruation may be up to a weekearly or a few days late. If she has not had a period within 21 daysafter the treatment, she should return to have a pregnancy test or todiscuss the options in case of pregnancy.
Side effects: especially if the Yuzpe regime is used, nausea canoccur. If vomiting occurs within 2 hours of taking a dose, repeat thedose.
Precautions: ECPs will not be effective in the case of a confirmedpregnancy. ECPs may be given when the pregnancy status is unclear andpregnancy testing is not available, since there is no evidence tosuggest that the pills can harm the woman or an existing pregnancy. There are no other medical contraindications to use of ECPs. Formulation Common brand names First dose Second dose (per pill) (number of tablets) later (number of tablets) Levonorgestrel Combined a EE = ethinylestradiol; LNG = levonorgestrel; NG =norgestrel.(Adapted from: Consortium for Emergency Contraception, Emergency contraceptivepills, medical and service delivery guidelines. Seattle, WA, 2000). Use of an intrauterine device (IUD) as an emergency contraceptive
If the survivor presents within five days after the rape, insertionof a copper-bearing IUD is an effective method of emergencycontraception. It will prevent more than 99% of expected subsequentpregnancies.
Women should be offered counselling on this service so as to reachan informed decision.
A skilled provider should counsel the patient and insert the IUD.
The IUD may be removed at the time of the woman’s next menstrualperiod or left in place for future contraception. Annex 8 Minimum care for rape survivors in low-resource settings Checklist of supplies 1. Protocol Available
- Written medical protocol in language of provider
2. Personnel Available
- Trained (local) health care professionals (on call 24 hours a day)
- A "same language" female health worker or companion in the roomduring examination
3. Furniture/Setting Available
- Room (private, quiet, accessible, with access to a toilet orlatrine)
- Light, preferably fixed (a torch may be threatening for children)
- Access to an autoclave to sterilize equipment
4. Supplies Available
- "Rape Kit" for collection of forensic evidence, including:
- Tape measure for measuring the size of bruises, lacerations, etc.
- Paper tape for sealing and labelling containers/bags
- Resuscitation equipment for anaphylactic reactions
- Sterile medical instruments (kit) for repair of tears, and suturematerial
- Cover (gown, cloth, sheet) to cover the survivor during theexamination
- Sanitary supplies (pads or local cloths)
Available
- For treatment of STIs as per country protocol
- Emergency contraceptive pills and/or IUD
6. Administrative supplies Available
- Information pamphlets for post-rape care (for survivor)
- Safe, locked filing space to keep confidential records
Collecting minimum forensic evidence
Evidence should only be collected and released to the authorities with thesurvivor’s consent (see Step 4).
A careful written recording should be kept of all findings duringthe medical examination that can support the survivor’s story,including the state of her clothes. The medical chart is part of thelegal record and can be submitted as evidence (with the survivor’sconsent) if the case goes to court.
Keep samples of damaged clothing (if you can give the survivorreplacement clothing) and foreign debris present on her clothes orbody, which can support her story.
If a microscope is available, a trained health care provider orlaboratory worker can examine wet-mount slides for the presence ofsperm, which proves penetration took place. Minimum examination
A medical examination should be done only with the survivor’s consent. It shouldbe compassionate, confidential, and complete, as indicated and described in Step5. Minimum treatment
Give compassionate and confidential treatment as follows (see Step 6):
treatment and referral for life threatening complications; treatment or preventive treatment for STIs; emergency contraception; care of wounds; supportive counselling; referral to social support and psychosocial counselling services. Annex 9 Additional resource materials General information
Sexual assault nurse examiner (SANE) development and operation guide. Washington,DC, United States Department of Justice, Office of Justice Programs, Office forVictims of Crime (http://www.sane-sart.com/SaneGuide/toc.asp).
Reproductive health in refugee situations: an inter-agency field manual. Geneva,UNHCR, 1999 (http://www.who.int/reproductive-health/publications orhttp://www.rhrc.org/fieldtools or http://www.unhcr.ch/).
Basta!: A newsletter from IPPF/WHR on integrating gender-based violence intosexual and reproductive health. International Planned Parenthood Federation
(http://www.ippfwhr.org/whatwedo/basta.html). Sexual violence against refugees:guidelines on prevention and response. Geneva, UNHCR, 1995(http://www.unhcr.ch/).
Mental health of refugees. Geneva, World Health Organization, 1996(http://www.unhcr.ch/). Information on sexually transmitted diseases
Guidelines for the management of sexually transmitted diseases. Geneva, WorldHealth Organization, 2001 (document number WHO/RHR/01.10)(http://www.who.int/reproductive-health/publications). Information on emergency contraception
Emergency contraception: a guide for service delivery. Geneva, World HealthOrganization, 1998 (document no. WHO/FRH/FPP/98.19)(http://www.who.int/reproductive-health/publications). Information on post-exposure prophylaxis (PEP) of HIV infection
Management of possible sexual, injecting-drug-use, or other nonoccupationalexposure to HIV, including considerations related to antiretroviral therapy:Public Health Service Statement. Morbidity and mortality weekly report, 1998,47(RR17):1-14 (http://www.cdc.gov/hiv/treatment.htm#prophylaxis).
PHS report summarises current scientific knowledge on the use of post-exposureantiretroviral therapy for non-occupational exposures. Atlanta, GA, Centers forDisease Control and Prevention, 1998(http://www.cdc.gov/hiv/pubs/facts/petfact.htm).
Updated U.S. Public Health Service guidelines for the management of occupationalexposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. Morbidity and mortality weekly report, 2001, 50(RR-11), Appendix C, 45-52(http://www.cdc.gov/hiv/treatment.htm#prophylaxis). Detailed information on the abortion policies of countries
Abortion policies: a global review. New York, UN Department of Economic andSocial Affairs, Population Division, 2001(http://www.un.org/esa/population/publications/ abortion/profiles.htm).
Antimicrobial activity of Epilobium spp. extractsLucia Battinelli, Beatrice Tita, Maria Grazia Evandri, Gabriela Mazzanti * Department of Pharmacology of Natural Substances and General Physiology , Uni 6 ersity ‘ La Sapienza ’, P . le Aldo Moro , 5, 00185 Rome , Italy Received 31 October 2000; accepted 10 January 2001 Abstract The antimicrobial activity of the Epilobium angu
VHS 42 02566 16 min, Farbe das Medieninstitut der Länder stattfindet, wird vorgestellt. Höhepunkt istErfahren, wann und wie in einer jüdischen Familieder Sabbat gefeiert wird. Den Sabbat als einenaus der festlich geschmückten Torarolle, dieTag der Ruhe, der Freude und des Gedenkenskennen lernen. Die Bräuche und Riten bei einerSabbatfeier kennen und verstehen lernen. Nach-e