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Guidelines for Medico-Legal Care for Victims of Sexual Violence

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Guidelines for Medico-Legal Care for Victims of Sexual Violence GUIDELINES FOR MEDICO-LEGAL CARE FOR GUIDELINES FOR MEDICO-LEGAL CARE Guidelines for medico-legal care for victims of sexual violence VICTIMS OF SEXU AL VIOLENCE ISBN 92 4 154628 X WHO WORLD HEALTH ORGANIZATION GENEVA Guidelines for medico-legal care for victims of sexual violence GENDER AND WOMEN’S HEALTH, FAMILY AND COMMUNITY HEALTH INJURIES AND VIOLENCE PREVENTION, NONCOMMUNICABLE DISEASES AND MENTAL HEALTH WORLD HEALTH ORGANIZATION GENEVA WHO Library Cataloguing-in-Publication Data World Health Organization. Guidelines for medico-legal care of victims of sexual violence. 1.Sex offenses 2.Genitalia, Female – physiopathology 3.Genital diseases, Female – therapy 4.Wounds and injuries – classification 5.Delivery of health care- standards 6.Forensic medicine 7.Data collection – methods 8.Practice guidelines I.Title. ISBN 92 4 154628 X (NLM classification: W 795) Guidelines for medico-legal care for victims of sexual violence © World Health Organization 2003 All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: [email protected]). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: [email protected]). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distin- guished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Designed by minimum graphics, New Zealand Printed in France CONTENTS Contents Acknowledgements vii 1. Introduction 1 1.1 Sexual violence: a global problem 1 1.2 Why are these guidelines needed? 1 1.3 Aims of the guidelines 3 1.4 Using the guidelines 3 1.5 Reviewing the guidelines 5 2. Sexual violence: prevalence, dynamics and consequences 6 2.1 Definition of sexual violence 6 2.2 Types of sexual violence 7 2.3 Prevalence 8 2.4 Dynamics of sexual violence 9 2.4.1. Rape myths 10 2.4.2 Risk factors 11 2.5. Health consequences 12 2.5.1 Physical consequences 12 2.5.2 Psychological consequences 13 3. Service provision for victims of sexual violence 17 3.1. General considerations 17 3.1.1. Priorities 17 3.1.2 The setting 17 3.1.3 Timing 18 3.1.4 Service providers 18 3.1.5 Ethical issues 19 3.1.6 Local policies and laws 19 3.1.7 Relationship with investigators 20 3.1.8 Interaction with other services 20 3.2 Facilities 21 3.2.1 The location 21 3.2.2 Equipment 22 3.3 Establishing a service for victims of sexual violence 27 3.3.1. Initial considerations 27 3.3.2 Evaluation and monitoring 28 4. Assessment and examination of adult victims of sexual violence 30 4.1. Overview 30 4.2 The initial assessment 31 4.2.1. Assessing the priorities 31 4.2.2 How health workers should conduct themselves 32 4.2.3 Obtaining consent 34 iii GUIDELINES FOR MEDICO-LEGAL CARE FOR VICTIMS OF SEXUAL VIOLENCE 4.3 Taking a history 34 4.3.1 General medical history 35 4.3.2 Gynaecological history 35 4.3.3 The assault itself 36 4.4 The physical examination 37 4.4.1 General principles 37 4.4.2 The “top-to-toe” physical examination 39 4.4.3 The genito-anal examination 42 4.5 Recording and classifying injuries 44 4.5.1 Injury description 45 4.5.2 Classification of wounds 45 4.5.3 Genito-anal injuries related to penetration 48 4.5.4 Injury patterns and their interpretation 51 4.6 Diagnostic tests, specimen collection and forensic issues 55 5 Forensic specimens 57 5.1 The purpose of forensic specimens 57 5.2 Forensic specimen collection techniques 58 6Treatment and follow-up care 63 6.1 Physical injuries 63 6.2 Pregnancy prevention and management 64 6.2.1 Emergency contraception 64 6.2.2 Pregnancy testing and management 65 6.3 Sexually transmitted infections 67 6.3.1 STI testing 67 6.3.2 Prophylactic treatment for STIs 67 6.4 HIV/AIDS 68 6.4.1 HIV testing 69 6.4.2 Post-exposure prophylaxis 70 6.5 Hepatitis B 70 6.6 Patient information 71 6.7 Follow-up care 72 6.7.1 Medical review 72 6.7.2 Counselling and social support 73 6.7.3 Referrals 74 7 Child sexual abuse 75 7.1 Definition of child sexual abuse 75 7.2 Dynamics of child sexual abuse 76 7.2.1 Risk factors for victimization 76 7.2.2 Dynamics of disclosure 76 7.3 Physical and behavioural indicators of child sexual abuse 77 7.3.1 Sexualized behaviours 77 7.3.2 Genito-anal findings 78 7.4 Health consequences 80 7.5 Assessment and examination of children 81 7.5.1 General considerations 81 7.5.2 Consent and confidentiality issues 82 7.5.3 Interviewing the child 82 iv CONTENTS 7.5.4 Taking a history 84 7.5.5 The physical examination 85 7.6 Collecting medical and forensic specimens 87 7.7 Treatment 87 7.7.1 Children and STIs 87 7.7.2 HIV and post-exposure prophylaxis 90 7.7.3 Pregnancy testing and management 90 7.8 Follow-up care 90 7.8.1 Diagnostic conclusions 90 7.8.2 Reporting abuse 92 7.8.3 Follow-up treatment 92 7.8.4 Counselling and social support 92 8 Documentation and reporting 94 8.1 Documentation 94 8.1.1 How and what should be documented? 95 8.1.2 Storage and access to records 96 8.1.3 Epidemiological surveys 96 8.2 Photography 96 8.3 Providing written evidence and court attendance 97 References 99 Bibliography 103 Annex 1. Sample sexual violence examination record 105 Annex 2. Medical issues and sexual violence 129 Annex 3. Health worker education and training 142 v GUIDELINES FOR MEDICO-LEGAL CARE FOR VICTIMS OF SEXUAL VIOLENCE Acknowledgements The expertise and support of many people have made possible the development of these guidelines. WHO offers special thanks to David Wells, Victorian Institute of Forensic Medicine, Victoria, Australia, for his work as lead author, for his involvement in the peer review process, and for incorporating the recommendations arising from peer review. WHO also wishes to thank Wendy Taylor, University of Hong Kong, Hong Kong, Special Administrative Region of China, for her work as co-author and for her assistance during the peer review process and subsequent revising of the early drafts. The guidelines have benefited greatly from the contributions of others: particular acknowledgement is made to Tanya Smith, Hospital for Sick Children, Toronto, Canada, for writing the material on child sexual abuse, to Marcellina Mian, Hospital for Sick Children, Toronto, Canada, for reviewing the material on child sexual abuse, to Alexandra Welborn for her contribution to the adult sexual assault materials, to Joanne Peake for typing and layout of drafts and to Ann Morgan for copy-editing. Many thanks to the following individuals for their work as reviewers: Deborah Billings, Harendra Da Silva, Antonius Herkutanto, Coco Idenburg, Miguel Lorente, Margaret Lynch, Lorna Martin, Alex Olumbe and Fernando Pinilla. Participants in the June 2001 Consultation on the Health Sector Response to Sexual Violence were integral to the process: Abu Hassan Assari, Widney Brown, Artice Getton-Brown, Maria del Carmen Contreray, Alison Cunning- ham, Ravindra Fernando, Amal Abdel El Hadi, Rodney Hammond, Coco Idenburg, Hani Jahshan, June Lopez, Miguel Lorente, Bernie Madrid, Lorna Martin, Aida Elena Constantin Peña, Berit Schei, Margarita Quintanilla and Barbara Weibl. This work is a collaboration between WHO’s Department of Injuries and Violence Prevention and Department of Gender and Women’s Health. Special thanks to Magdalena Cerda and Alison Phinney, Department of Injuries and Violence Prevention, World Health Organization, who authored portions of the guidelines and were responsible for overall project co-ordination. The guidance and substantive input of Dr Claudia Garcia-Moreno, Department of Gender and Women’s Health, World Health Organization, was also integral to the process. The development and publication of these guidelines has been made possible by the generous financial support of the Governments of the Netherlands, Belgium and Sweden. vii 1. INTRODUCTION 1 Introduction 1.1 Sexual violence: a global problem Sexual violence is ubiquitous; it occurs in every culture, in all levels of society and in every country of the world. Data from country and local studies indicate that, in some parts of the world at least, one woman in every five has suffered an attempted or completed rape by an intimate partner during her lifetime. Furthermore, up to one-third of women describe their first sexual experience as being forced (1). Although the vast majority of victims are women, men and children of both sexes also experience sexual violence.
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