WHO/RHR/02.08

Clinical Management of Survivors of

A guide to the development of protocols for use in refugee and internally displaced person situations

An Outcome of the Inter-Agency Lessons Learned Conference: Prevention and Response to Sexual and Gender-Based in Refugee Situations 27-29 March 2001 • Geneva

Clinical Management of Survivors of Rape

A guide to the development of protocols for use in refugee and internally displaced person situations

An Outcome of the Inter-Agency Lessons Learned Conference: Prevention and Response to Sexual and Gender-Based Violence in Refugee Situations 27-29 March 2001 • Geneva © World Health Organization and High Commissioner for Refugees 2002

This document is not a formal publication of WHO or UNHCR. The document may be freely ii reproduced and translated, in part of in whole, but not for sale or for use in conjunction with commercial purposes. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO or UNHCR.

This guide is to be field-tested. Users are invited to submit comments to WHO at the address below.

For more information on this document or to obtain additional copies, please contact:

World Health Organization Department of Reproductive Health and Research 22, Avenue Appia, 1211 Geneva 27, Switzerland Fax: +41-22-791 4189; E-mail: [email protected] Website: http://www.who.int/reproductive-health

UNHCR Health and Community Development Section C.P. 2500, 1202 Geneva, Switzerland Fax: +41-22-739 7366 E-mail: [email protected] Website: http://www.unhcr.ch Contents

Preface ...... v

Acknowledgements...... vii

Abbreviations and acronyms...... viii

Introduction ...... 1

STEP 1 – Making preparations to offer medical care to rape survivors ...... 3

STEP 2 – Preparing the survivor for the examination ...... 7

STEP 3 – Taking the history ...... 8

STEP 4 – Collecting forensic evidence ...... 10

STEP 5 – Performing the physical and genital examination ...... 14

STEP 6 – Prescribing treatments ...... 17

STEP 7 – Counselling the survivor ...... 22

STEP 8 – Follow-up care of the survivor...... 24 iii Care for child survivors ...... 25

Special considerations for men ...... 28

Special considerations for pregnant women ...... 28

Special considerations for elderly women ...... 28

Annex 1 – Information needed to develop a local protocol ...... 29

Annex 2 – Sample consent form ...... 30

Annex 3 – Sample history and examination form ...... 31

Annex 4 – Pictograms ...... 35

Annex 5 – Protocols for treatment of STIs ...... 39

Annex 6 – Protocols for post-exposure prophylaxis of HIV infection ...... 41

Annex 7 – Protocols for emergency contraception ...... 42

Annex 8 – Minimum care for rape survivors in low-resource settings ...... 44

Annex 9 – Additional resource materials...... 46

Preface

Sexual and gender-based violence is a Refugees, 160 representatives of refugee, worldwide problem. Refugees and internally nongovernmental, governmental and displaced people are particularly at risk of intergovernmental organizations met in this violation of their human rights during Geneva to share experiences and lessons every phase of the refugee cycle. Rape – learned. This document is an outcome of one of the most extreme forms of sexual that conference. It was produced under violence – occurs in every society, country the leadership of the World Health and region. Rape as a weapon of is Organization’s Department of well documented, as is rape of refugees. Reproductive Health and Research, with support from the International Committee Over the past five years, humanitarian of the Red Cross and the United Nations agencies have been working to put in place High Commissioner for Refugees. systems to respond to sexual and gender-based violence as well as to A draft of this guide was distributed in a support community-based efforts to prevent variety of settings around the world and such violence. In March 2001, the field-tested at several sites. Feedback international humanitarian community came from these field-tests has been included in together to document what had been done the current revision. This version will be and what is still needed to prevent and circulated more widely and its use in the respond to sexual and gender-based field evaluated over a period of one to two violence towards refugees. Hosted by the years before being revised. Comments on United Nations High Commissioner for its use will be welcome. v

Acknowledgements

Special thanks go to all those who # Emergency and Humanitarian Action, participated in the review and field-testing # of this document: Essential Drugs and Medicines Policy, 5 Centers for Disease Control and # Gender and Women’s Health, Prevention (CDC), Atlanta, GA, USA; # HIV/AIDS, 5 Center for Health and Gender Equity (CHANGE), Takoma Park, MD, USA; # Injuries and Violence Prevention, 5 Département de Médecine # Mental Health and Substance Communautaire, Hôpital Cantonal Dependence, and Universitaire de Genève, Geneva, # Vaccines and Biologicals; Switzerland; 5 World Health Organization Regional 5 International Centre for Reproductive Office for Africa (AFRO); Health, Ghent, Belgium; 5 World Health Organization Regional 5 International Committee of the Red Office for South-East Asia (SEARO). Cross, Women and War Project, Geneva, Switzerland; A particular note of appreciation goes out 5 International Medical Corps, to the following individuals who Los Angeles, CA, USA; contributed to the finalization of this guide: 5 Ipas USA, Chapel Hill, NC, USA; 5 Dr Michael Dobson, John Radcliffe vii 5 Médecins Sans Frontières, Belgium, Hospital, Oxford, United Kingdom; The Netherlands, Spain, Switzerland; 5 Dr Coco Idenburg, Family Support 5 Physicians for Human Rights, Clinic, Harare, Zimbabwe; Boston, MA, USA; 5 Dr Lorna J. Martin, Department of 5 Reproductive Health for Refugees Forensic Medicine and Toxicology, Consortium (American Refugee Cape Town, South Africa; Committee, CARE, Columbia University’s 5 Dr Nirmal Rimal, AMDA PHC Center for Population and Family Health, Programme for Bhutanese Refugees, International Rescue Committee, Jhapa, Nepal; Research and Training Institute of John 5 Snow, Inc., Marie Stopes International, Dr Santhan Surawongsin, Nopparat Women’s Commission for Refugee Rajathanee Hospital, Bangkok, Women and Children); Thailand; 5 5 United Nations Population Fund, Ms Beth Vann, Reproductive Health for New York, NY, USA; Refugees Consortium, Alexandria, VA, USA. 5 United Nations High Commissioner for Refugees, Health and Community Thanks are also due to the Development Section, Geneva, nongovernmental organizations and Switzerland; UNHCR staff in the United Republic of Tanzania, especially Marianne 5 World Health Organization Headquarters Schilperoord, who organized the Department of Reproductive Health and field-testing of this guide. Research with support of the Departments of Abbreviations and acronyms used in this guide

ARV antiretroviral

DT diphtheria and tetanus toxoids

DTP diphtheria and tetanus toxoids and pertussis vaccine

ECP emergency contraceptive pills

ELISA enzyme-linked immunosorbent assay

HBV hepatitis B virus

HIV human immunodeficiency virus

IDP internally displaced person

IUD intrauterine device

PEP post-exposure prophylaxis viii RPR rapid plasma reagin STI sexually transmitted infection

Td tetanus toxoid and reduced diphtheria toxoid

TIG tetanus immunoglobulin

TT tetanus toxoid

UNHCR United Nations High Commissioner for Refugees

VCT voluntary counselling and testing

WHO World Health Organization Introduction

pronouns are therefore used in the guide to refer to rape survivors, except where This guide describes best practices in the context dictates oherwise. clinical management of people who have been raped. It is intended for adaptation to each situation, taking into account The essential components of national policies and practices, and medical care after a rape are: availability of materials and drugs. & collection of forensic evidence, & evaluation for sexually transmitted infections and preventive care, This guide is intended for use by qualified & evaluation for risk of pregnancy and health care providers (health coordinators, prevention, medical doctors, clinical officers, midwives & and nurses) in developing protocols for the care of injuries, management of rape survivors, based on & counselling and follow-up. available resources, materials, drugs, and national policies and procedures. It can also be used in planning care services and in training health care providers. How to use this guide The document includes detailed guidance on the clinical management of women, men This document is meant to be used by and children who have been raped. It health care professionals who are working explains how to perform a thorough with refugees or internally displaced 1 physical examination, record the findings persons (IDPs), or in other similar settings and give medical care to someone who has to develop specific protocols for medical been penetrated in the vagina, anus or care of rape survivors. In order to do this a mouth by a penis or other objects. It does number of actions have to be taken. not include advice on standard care of Suggested actions include (not wounds or injuries or on psychological necessarily in the following order): counselling, although these may be needed. Neither does the guide give 1 Identify a team of professionals and guidance on referral procedures to community members who are community support, police and legal involved in caring for people who services. Other reference materials exist have been raped. that describe this kind of care or give 2 Convene meetings with medical staff advice on creating referral networks; this and community members. guide is complementary to those materials. 3 Create a referral network between the Note: It is not the health care provider’s different sectors involved in caring for responsibility to determine whether a rape survivors (community, health, person has been raped. That is a legal security, protection). determination. The health care provider’s responsibility is to provide appropriate care, 4 Identify the available resources to record the history and other relevant (drugs, materials, laboratory facilities) information and, with the person’s consent, and the relevant national policies and to collect any forensic evidence that might procedures relating to rape (standard be needed in a subsequent investigation. treatment protocols, legal procedures, laws relating to abortion, etc.). See While it is recognized that men and boys Annex 1 for an example of a checklist can also be raped, most individuals who for the development of a local are raped are women or girls; feminine protocol. 5 Develop a situation-specific medical care protocol, using this guide as a Rape is a traumatic experience, both reference document. emotionally and physically. Survivors may have been raped by any number of 6 Train providers on use of the protocol, people in a number of different including what must be documented situations; they may have been raped by during an examination for legal soldiers, police, family members, purposes. friends, boyfriends, husbands, fathers or uncles; they may have been raped while collecting firewood, using the Steps covered in this latrine, in their beds or while visiting guide friends. They may have been raped by one, two, three or more people, by men or boys, or by women. They may have 1 Making preparations to offer medical been raped over a period of months or care to rape survivors. this may be the first time. Survivors can 2 Preparing the survivor for the be women or men, girls or boys; but examination. they are most often women and girls. 3 Taking the history. Survivors may react in any number of ways to such a trauma; whether their 4 Collecting forensic evidence. trauma reaction is long-lasting or not depends, in some part, on how they are 5 Performing the physical and genital treated when they seek help. By seeking examination. medical treatment, the survivor is 6 Prescibing treatments. acknowledging that physical and/or emotional damage has occurred. She 7 Counselling the survivor. most likely has health concerns. The 2 health care provider can address these 8 Follow-up care of the survivor. concerns and help survivors begin the recovery process by providing Special considerations needed when caring compassionate, thorough and for children, men, and pregnant and elderly high-quality medical care, and by women are also described. centring this care around the survivor and her needs and being aware of the setting-specific circumstances that may affect the care provided. Center for Health and Gender Equity (CHANGE) STEP 1 – Making preparations to offer medical care to rape survivors

The health care service must make What are the host preparations to respond thoroughly and country’s laws and compassionately to people who have been raped. The health coordinator should policies? ensure that health care providers (doctors, medical assistants, nurses, etc.) are trained 5 Which health care provider should to provide appropriate care and have the provide what type of care? If the person necessary equipment and supplies. Female wishes to report the rape officially to the health care providers should be trained as authorities, the country’s laws may a priority, but a lack of trained female health require that a certified or licensed workers should not prevent the service medical doctor provide the care and providing care for survivors of rape. complete the official documentation. 5 In setting up a service, the following What are the legal requirements with questions and issues need to be regard to forensic evidence? addressed, and standard procedures 5 What are the national laws regarding developed. management of the possible medical consequences of rape (e.g. emergency 3 contraception, abortion, testing and What should the preventive treatment for human community be aware of? immunodeficiency virus (HIV))?

Members of the community should know: What resources and 5 what services are available for people capacities are available? who have been raped; 5 5 why rape survivors would want to seek What laboratory facilities are available medical care; for forensic testing (DNA analysis, acid phosphatase) or screening for disease 5 where to go for services; (STIs, HIV)? What counselling services 5 that rape survivors should come are available? immediately after the incident without 5 Are there rape management protocols bathing or changing clothes; and “rape kits” for documenting and 5 that rape survivors can trust the service collecting forensic evidence? to treat them with dignity, maintain their 5 Is there a national STI treatment security, and respect their confidentiality; protocol, a post-exposure prophylaxis 5 that there is 24-hour access to services. (PEP) protocol and a vaccination schedule? Which vaccines are available? 5 What possibilities are there for referral of the survivor to a secondary health care facility (psychiatry, surgery, paediatrics, or gynaecology/obstetrics)? Where should care be What is needed? provided? 5 All health care for rape survivors should Generally, a health care clinic or outpatient be provided in one place within the service that already offers reproductive health care facility so that the person health services, such as antenatal care, does not have to move from place to normal delivery care, or management of place. STIs, can offer care for rape survivors. 5 Services should be available 24 hours a Referral services may need to be provided day, 7 days a week. at hospital level. 5 All available supplies from the checklist on page 5 and 6 should be prepared Who should provide care? and kept in a special box or place, so that they are readily available.

All staff in health facilities dealing with rape survivors, from reception staff to health care professionals, should be trained in How to coordinate with their care. They should always be others? compassionate and respect confidentiality. 5 Interagency and intersectoral coordination should be established to How should care be ensure comprehensive care for provided? survivors of . 5 Be sure to include representatives of Care should be provided: social/community services, protection, 4 the police or legal justice system, and 5 according to a protocol that has been security. Depending on the services specifically developed for the situation. available in the particular setting, others Protocols should include guidance on may need to be included. medical, psychosocial and ethical 5 As a multisectoral team, establish (responsibilities of the provider) aspects, referral networks, communication and on counselling options; systems, coordination mechanisms, and 5 in a compassionate manner; follow-up strategies. 5 with a focus on the survivor and her needs; See Annex 8 for the minimum care that 5 with an understanding of the provider’s can and should be made available to own attitudes and sensitivities, the survivors in the lowest-resource sociocultural context, and the settings. community’s perspectives, practices and beliefs.

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 same language 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)*

# Examination table*

# Lighting, preferably fixed (a torch may be threatening for children)*

# Magnifying glass (or colposcope)

# Access to an autoclave to sterilise equipment*

# Access to laboratory facilities/microscope/trained technician 5

# Weighing scales and height chart for children

4 Supplies Available

# “” for collection of forensic evidence, could include:

3 Speculum* (preferably plastic, disposable, only adult sizes)

3 Comb for collecting foreign matter in pubic hair

3 Syringes/needles (butterfly for children)/tubes for collecting blood

3 Glass slides for preparing wet and/or dry mounts (for sperm)

3 Cotton tipped swabs/applicators/gauze compresses for collecting samples

3 Laboratory containers for transporting swabs

3 Paper sheet for collecting debris as the survivor undresses

3 Tape measure for measuring the size of bruises, lacerations, etc*.

3 Paper bags for collection of evidence*

3 Paper tape for sealing and labelling containers/bags* Checklist of supplies for clinical management of rape survivors

# Supplies for universal precautions (gloves, box for safe disposal of contaminated and sharp materials, soap)*

# Resuscitation equipment for anaphylactic reactions*

# Sterile medical instruments (kit) for repair of tears, and suture material*

# Needles, syringes*

# Cover (gown, cloth, sheet) to cover the survivor during the examination*

# Spare items of clothing to replace those that are torn or taken for evidence

# Sanitary supplies (pads or local cloths)*

# Pregnancy tests

# Pregnancy calculator disk to determine the age of a pregnancy

5 Drugs Available

# For treatment of STIs as per country protocol*

6 # For post-exposure prophylaxis of HIV transmission (PEP)

# Emergency contraception pills and/or intrauterine device (IUD)*

# Tetanus toxoid, tetanus immuno-globulin

# Hepatitis B vaccine

# For pain relief* (e.g. paracetamol)

# Anxiolytic (e.g. diazepam)

# Sedative for children (e.g. diazepam)

# Local anaesthetic for suturing*

# Antibiotics for wound care*

6 Administrative Supplies Available

# Medical chart with pictograms*

# Forms for recording post-rape care

# Consent forms*

# 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 for examination and treatment of a rape survivor. STEP 2 – Preparing the survivor for the examination

The person who survives rape has 5 Reassure the survivor that the experienced trauma and may be in an examination findings will be kept agitated or depressed state. She often feels confidential. fear, guilt, shame and anger. The health 5 worker must prepare her for the Ask her if she has any questions. examination, and must carry out the 5 Ask if she wants to have a specific examination in the most compassionate, person present for support. systematic and complete fashion. 5 Review the consent form (see Annex 2) with the survivor. Make sure she To prepare the survivor understands everything in it, and explain that she can delete anything for the examination: she does not wish to consent to. Once you are sure she understands the form 5 Ensure that a trained support person or completely, ask her to sign it. If she trained health worker of the same sex cannot write, obtain a thumb print accompanies the survivor throughout the together with the signature of a witness. examination. 5 5 Explain what is going to happen during Limit the number of people allowed in each step of the examination, why it is the room during the examination to the important, what it will tell you, and how it minimum necessary. 7 will influence the care you are going to 5 Undertake the examination as soon as give. possible. 5 Reassure the survivor that she is in 5 Do not force or presssure the survivor control of the pace, timing and to do anything against her will. components of the examination. STEP 3 – Taking the history

General guidelines Description of the incident 5 If the interview is conducted in the treatment room, cover the medical 5 Ask the survivor to describe what instruments until use. happened. Allow the survivor to speak 5 Before taking the history, review any at her own pace. Do not interrupt to ask documents or paperwork brought by the for details; follow up with clarification survivor to the health centre. questions after she finishes telling her story. Explain that she does not have to 5 Let the survivor tell her story the way she tell you anything she does not feel wants to. comfortable with. 5 Questioning should be done gently and 5 It is important that the health worker at the survivor’s own pace. understands the details of exactly what happened in order to check for possible 5 Sufficient time should be allotted to injuries. Explain this to the survivor, and collect all needed information without reassure her of confidentiality if she is rushing. reluctant to give detailed information. 5 Do not ask questions that have already The form in Annex 3 specifies the been asked and documented by other details needed. people involved in the case. 8 5 Avoid any distraction or interruption during history-taking. History 5 Explain what you are going to do. 5 If the incident occurred recently, 5 Try to create a climate of trust. determine whether the survivor has bathed, urinated, vomited, etc. since the A sample history and examination form is incident. This may affect the collection included in Annex 3. The main elements of of forensic evidence. the relevant history are described below. 5 Information on existing health problems, allergies, use of medication, and vaccination and HIV status will help you General information to determine the best treatment to provide, counselling needed, and 5 Name, address, sex, date of birth (or age follow-up health care. in years). 5 Evaluate for possible pregnancy, ask for 5 Note the date and time of the details of contraceptive use, last examination and the names of any staff menstrual period, etc. or support person (someone the survivor may request) present during the interview and examination. In developed country settings, some 2% of survivors of rape have been found to be pregnant 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 age by a pregnancy test or by history and examination. The following guide may be useful if you do not have access to pregnancy tests.

A guide for confirming pre-existing pregnancy (adapted from an FHI protocol 2)

No Yes

1 Have you given birth in the past 4 weeks?

2 Are you less than 6 months postpartum and fully breastfeeding and free from menstrual bleeding since you had your child?

3 Did your last menstrual period start within the past 10 days?

4 Have you had a miscarriage or abortion in the past 10 days?

5 Have you gone without sexual intercourse since your last menstrual period (apart from the incident)? 9

6 Have you been using a reliable contraceptive method consistently and correctly? (check with specific questions)

If the survivor answers NO to If the survivor answers YES to all the questions, ask about at least 1 question and she is and look for signs and free of signs and symptoms of symptoms of pregnancy. If pregnancy, provide her with pregnancy cannot be information on emergency confirmed provide her with contraception to help her arrive information on emergency at an informed choice (see contraception to help her arrive Step 7) at an informed choice (see Step 7)

1 Sexual nurse examiner (SANE) development and operation guide. Washington, DC, Department of Justice, Office of Justice Programs, Office for Victims of Crime (www.sane-sart.com/SaneGuide/toc.asp).

2 Checklist for ruling out pregnancy among family-planning clients in primary care. Lancet, 1999, 354(9178). STEP 4 – Collecting forensic evidence Collect evidence as soon as possible after the The main purpose of the examination is to determine what medical care should incident (within 72 hours) be provided. However, forensic evidence may also be collected to help the survivor Documenting injuries and collecting pursue legal redress. samples, such as blood, hair, saliva and sperm, within 72 hours of the incident, The survivor may choose not to have may help to support the survivor’s story evidence collected. Respect her choice. and might help identify the aggressor(s). If the person presents more than 72 hours after the rape, the amount and type of evidence that can be collected will depend on the situation. Good to know before you develop your protocol Different countries and locations have Documenting the case different legal requirements and different facilities (laboratories, refrigeration, etc.) 5 for performing tests. National and local Record the interview and your findings resources and policies determine what at the examination in a clear, complete, 10 evidence should be collected. Do not objective, non-judgemental way. collect evidence that cannot be processed. 5 Completely assess and document the In some countries, the medical doctor may physical and emotional state of the be legally obliged to give an opinion on the survivor. physical findings. Find out what the role of 5 the health care provider is in reporting Record precisely important statements medical findings in a court of law. Ask a made by her, such as threats made by legal expert to write a short briefing about the assailant. Do not be afraid to the local court proceedings in cases of rape include the name of the assailant, but and what to expect to be asked when use qualifying statements, such as giving testimony in court. “patient states” or “patient reports”. 5 Avoid the use of the term “alleged”, as it can be interpreted as meaning that the survivor exaggerated or lied. Reasons for collecting 5 Note down exactly which samples you evidence take.

5 To confirm recent sexual contact. Samples that can be 5 To show that force or coercion was used. collected as evidence 5 To corroborate the survivor’s story. 5 5 Possibly, to identify the assailant. Injury evidence: physical and/or genital trauma is proof of force and should be documented. 5 Clothing: torn or stained clothing is useful to prove force was used. 5 Foreign material (soil, leaves, grass) on or provide a gown for her to cover clothes or body or in hair may herself. Collect torn and stained items corroborate the survivor’s story. of clothing, only if you can give her replacement clothes. 5 Hair: foreign hairs may be found on the survivor’s clothes or body. Pubic and 5 Document all injuries (see Step 5). head hair from the survivor may be 5 plucked or cut for comparison. Collect samples for DNA analysis from all places where there could be saliva 5 Sperm and seminal fluid: specimens may (where the attacker licked or kissed or be taken from the vagina, anus or oral bit her) or semen on the skin, with the cavity, if ejaculation took place in these aid of a cotton-tipped swab lightly locations, to look for the presence of moistened with sterile water. sperm and for prostatic acid phosphatase 5 analysis. The survivor’s pubic hair may be combed for foreign hairs. 5 DNA analysis can be done on material 5 found on the survivor’s body or at the If ejaculation took place in the mouth, place of aggression, which might be take samples and swab the oral cavity, soiled with blood, sperm, saliva or other for direct examination for sperm, and for biological material from the assailant DNA and acid phosphatase analysis. (e.g., clothing, sanitary pads, 5 Take a blood and urine sample if handkerchiefs, condoms), as well as on indicated. swab samples from bite marks, semen stains, and involved orifices, and on fingernail cuttings and scrapings. In this case blood from the survivor must be Inspection of the anus, drawn to allow her DNA to be perineum and vulva distinguished from foreign DNA found. 11 5 Blood or urine for toxicology testing (if the Inspect and collect samples for DNA survivor was drugged). analysis from the skin around the anus, perineum and vulva using cotton-tipped swabs moistened with sterile water. Forensic evidence should be collected during the medical examination. It is necessary to obtain the consent of the Examination of the survivor for the collection of evidence. Work systematically according to the vagina and rectum medical examination form (see Annex 3). Explain everything you do and why you are Depending on the site of penetration, doing it. examine the vagina and/or the rectum.

5 Lubricate a speculum with normal saline or clean water (other lubricants may Inspection of the body interfere with forensic analysis). 5 Collect some of the fluid in the posterior 5 Examine the survivor’s clothing under a fornix for examination for sperm. good light source before she undresses. 5 Take specimens of the posterior fornix Collect any foreign debris on clothes and and the endocervical canal for DNA skin or in the hair (soil, leaves, grass, analysis, using cotton-tipped swabs. Let foreign hairs). Ask the person to undress them dry at room temperature. while standing on a sheet of paper to collect any debris that falls. Do not ask 5 Collect separate samples from the her to uncover fully. Examine the upper cervix and the vagina. These can be half of her body first, then the lower half, analysed for acid phosphatase. 5 Obtain samples from the rectum, if If it is not possible to take the samples indicated, for examination for sperm, and immediately to a laboratory, precautions for DNA and acid phosphatase analysis. must be taken:

5 All clothing, cloth, swabs, gauze and Direct examination for other objects to be analysed need to be well dried at room temperature and sperm packed in paper (not plastic) bags. Samples can be tested for DNA many Put a drop of the fluid collected on a slide, if years after the incident, provided the necessary with a drop of normal saline material is well dried. (wet-mount), and examine it for sperm 5 under a microscope. Note the mobility of Blood and urine samples can be stored any sperm. Smear the leftover fluid on a in the refrigerator for 5 days. To keep second slide and air-dry both slides for the samples longer they need to be further examination at a later stage. stored in a freezer. Follow the instructions of the local laboratory. 5 All samples should be clearly labelled Screening for STIs with a confidential identifying code (not the name or initials of the survivor), Tests for sexually transmitted infections are date, time and type of sample (what it usually not used as forensic evidence. A is, from where it was taken), and put in pre-existing STI could be used against the a container survivor in court. 5 Seal the bag or container with paper tape across the closure. Write the In some settings screening for gonorrhoea, identifying code and the date and sign chlamydia, syphilis and HIV is done for your initials across the tape. 12 children who have a history of sexual abuse (see “Care for child survivors”, pages In the adapted protocol, clearly write down 25-27). the laboratory’s instructions for collection, storage and transport of samples. Maintaining the chain of evidence Evidence should only be released to the authorities if the survivor decides to proceed with a case. It is important to maintain the chain of evidence at all times, to ensure that the evidence will be admissible in court. This means that the evidence is collected, The survivor may consent to have labelled, stored and transported properly. evidence collected but not to have the Documentation must include a signature of evidence released to the authorities at the everyone who has possession of the time of the examination. In this case, evidence at any time, from the individual advise her that the evidence will be kept in who collects it to the one who takes it to the a safe, locked, secure space in the health courtroom, to prevent any possibility of centre for one month before it is tampering. destroyed. If she changes her mind during this period, she can advise the authorities where to collect the evidence. Reporting medical Conduct yourself professionally and confidently in the courtroom: findings in a court of law 5 Dress appropriately. If the survivor wishes to pursue legal 5 Speak clearly and slowly, and make eye redress and the case comes to trial, the contact with whomever you are health worker who examines her after the speaking to. incident may be asked to report on the findings in a court of law. Only a small 5 Avoid using medical terms. percentage of cases actually go to trial. 5 Many health workers may be anxious about Answer questions as thoroughly and appearing in court or feel that they have not professionally as possible. enough time to do this. Nevertheless, 5 If you do not know the answer to a providing such evidence is an extension of question, say so. Do not make an their role in caring for the survivor. answer up and do not testify about matters that are outside your area of In cases of rape, the prosecutor (not the expertise. health care provider) must prove three things:3 5 Ask for clarification of questions that you do not understand. Do not try to 1 Some penetration, however slight, of guess the meaning of questions. the vagina or anus by a penis or other object, or penetration of the mouth by a The notes written during the initial penis. interview and examination are the mainstay of the findings to be reported. It 2 That penetration occurred without the is difficult to remember things that are not consent of the person. written down. This underscores the need 3 The identity of the perpetrator. to record all statements, procedures and 13 actions in sufficient detail, accurately, In most settings the health care provider is completely and legibly. This is the best expected to give evidence as a factual preparation for an appearance in court. 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 and obtain information about the significant issues involved in the case.

3 Brown, W.A. Obstacles to women accessing forensic medical exams in cases of sexual violence. Unpublished background paper to the Consultation on the Health Sector Response to Sexual Violence, WHO Headquarters, Departments of Injuries and Violence Prevention and Gender and Women’s Health, Geneva, June 2001. STEP 5 – Performing the physical and genital examination

# extensive trauma (to genital region, head, chest or abdomen), The primary objective of the # asymmetric swelling of joints (septic examination is to determine what arthritis), medical care should be provided to the survivor. Work systematically according # neurological deficits, to the medical examination form (see # respiratory distress. sample form in Annex 3). The treatment of these complications is not covered here. What is included in the physical examination will depend on how soon after 5 Obtain voluntary informed consent for the rape the survivor presents to the health the examination and to obtain the service. Follow the steps in Part A if she required samples for forensic presents within 72 hours of the incident; examination (see sample consent form Part B is applicable to survivors who in Annex 2). present more than 72 hours after the incident. The general guidelines below 14 apply in both cases. Part A: Survivor presents General guidelines within 72 hours of the 5 Make sure the equipment and supplies incident are prepared. 5 Always look at the survivor first, before you touch her, and note her appearance Physical examination and mental state. 5 5 Always tell her what you are going to do Never ask her to fully undress or and ask her permission before you do it. uncover. Examine the upper half of her body first, then the lower half; or give 5 Assure her that she is in control, can ask her a gown to cover herself. questions, and can stop the examination 5 at any time. Minutely and systematically examine the patient’s body, starting at the head. 5 Take the patient’s vital signs (pulse, Do not forget to look in the eyes, nose, blood pressure, respiratory rate and and mouth, and in and behind the ears, temperature). and to examine forearms, wrists and ankles. Take note of the pubertal stage. 5 The initial assessment may reveal severe medical complications that need to be 5 Look for signs that are consistent with treated urgently, and for which the patient the survivor’s story, such as bite and will have to be admitted to hospital. Such punch marks, marks of restraints on the complications might be: wrists, patches of hair missing from the back of the head, or torn eardrums, which may be a result of being slapped. 5 Note all your findings carefully on the adolescents (see “Care for child examination form and the body figure survivors”, pages 25-27). pictograms (see sample in Annex 4), # taking care to record the type, size, Take samples ac-cording to your colour and form of any bruises, local evidence collection protocol. If lacerations, ecchymoses and petechiae. collecting samples for DNA analysis, take swabs from around the anus and 5 Take note of the survivor’s mental and perineum before the vulva, in order to emotional state (withdrawn, crying, calm, avoid contamination. etc.). 5 If there has been vaginal penetration, 5 Take samples of any foreign material on gently insert a speculum, lubricated with the survivor’s body or clothes (blood, water or normal saline (do not use a saliva, semen, fingernail cuttings or speculum when examining children; see scrapings, swabs of bite marks, etc.) “Care for child survivors”, pages 25-27): according to the local evidence collection # protocol. Under good lighting inspect the cervix, then the posterior fornix and 5 Take a sample of the survivor’s own the vaginal mucosa for trauma, blood, if indicated. bleeding and signs of infection. # Take swabs and collect vaginal secretions according to the local Examination of the genital evidence collection protocol. area 5 If indicated by the history and the rest of the examination, do a bimanual Even when female genitalia are examined examination and palpate the cervix, immediately after a rape, there is uterus and adnexa, looking for signs of identifiable damage in less than 50% of abdominal trauma, pregnancy or 15 cases. Carry out a gynaecological infection. examination as indicated below. Collect evidence as you go along, according to the Note: In some , it is unacceptable local evidence collection protocol. Note the to penetrate the vagina of a woman who is location of any tears, abrasions and bruises a virgin with anything, including a on the pictogram and the examination form. speculum, finger or swab. In this case you may have to limit the examination to 5 Systematically inspect the mons pubis, inspection of the external genitalia, unless inside of the thighs, perineum, anus, there are symptoms of internal damage. labia majora and minora, clitoris, urethra, introitus and hymen: # Note any scars from previous female Examination of anus and genital mutilation. rectum # Look for genital injury, such as bruises, scratches, abrasions, tears (often 5 For the anal examination the patient located on the posterior fourchette). may have to change position. Write # down her position during the Look for any sign of infection, such as examination (supine for genital ulcers, vaginal discharge or warts. examination; supine, prone, knee-chest # Check for injuries to the introitus and or lateral recumbent for anal hymen by holding the labia at the examination). posterior edge between index finger 5 Note the shape and dilatation of the and thumb and gently pulling outwards anus. Note any fissures around the and downwards. Hymenal tears are anus, the presence of faecal matter on more common in children and the perianal skin, and possible bleeding from rectal tears. 5 If indicated by the history, collect 5 note size and colour of any bruises and samples from the rectum according to the scars; local evidence collection protocol. 5 note any evidence of possible 5 If indicated, do a rectovaginal complications of the rape (deafness, examination and inspect the rectal area fractures, abscesses, etc.); for trauma, recto-vaginal tears or fistulas, 5 bleeding and discharge. Note the note the survivor’s mental state (normal, sphincter tone. withdrawn, depressed, suicidal).

Laboratory testing Examination of the genital area No additional samples need to be collected for laboratory testing, other than those If the assault occurred more than a week collected for evidence, unless indicated by ago and there are no bruises or the history or the findings on examination. lacerations and no complaints (i.e. of Samples for testing for sexually transmitted vaginal or anal discharge or ulcers), there infections may be collected for medical is little indication to do a pelvic purposes. examination. However, if you are in a setting with laboratory facilities, samples 5 If the survivor has complaints that may be taken from the vagina and anus indicate a urinary tract infection, collect a for STI screening. urine sample to test for erythrocytes and leukocytes, and possibly for . 5 Do a pregnancy test, if indicated and Laboratory screening 16 available (see Step 3). 5 Screen for STIs if possible. Follow the Other diagnostic tests, such as X-ray and instructions of the local laboratory. ultrasound examination, may be useful in Screening might cover: diagnosing fractures and abdominal trauma. 5 rapid plasma reagin (RPR) test for syphilis; 5 Part B: Gram stain and culture for gonorrhoea; 5 culture or enzyme-linked immunoassay Survivor presents (ELISA) for chlamydia; more than 72 hours 5 screening for HIV (but only on a after the incident voluntary basis and after counselling).

Physical examination

It is rare to find any physical evidence more than one week after an assault. If the survivor presents within a week of the rape, or presents with complaints, do a full physical examination as above. In all cases: STEP 6 – Prescribing treatments

Treatment will depend on how soon after benzylpenicillin will be sufficient the incident the survivor presents to the treatment for gonorrhoea, chlamydial health service. Follow the steps in Part A if infection and syphilis. she presents within 72 hours of the 5 incident; Part B is applicable to survivors Be aware that women who are pregnant who present more than 72 hours after the should not take certain antibiotics, and incident. modify the treatment accordingly. 5 Examples of WHO-recommended STI treatment regimens are given in Annex 5. Part A: Survivor presents Prevent HIV transmission within 72 hours of the incident Good to know before you develop your protocol As of the date of publication of this document, there are no conclusive data Prevent sexually on the effectiveness of post-exposure transmitted infections prophylaxis in preventing transmission of HIV after rape. However, PEP is available 17 in some settings for rape survivors. Before you start your service, find out if Good to know before you develop PEP is available in your setting and make your protocol a list of names and addresses of providers Neisseria gonorrhoeae, the bacterium that for referrals. causes gonorrhoea, is widely resistant to several antibiotics. Many countries have 5 If PEP is available, it usually consists of local STI treatment protocols based on 1, 2 or 3 antiretroviral (ARV) drugs local resistance patterns. Find out the local given for 28 days (see Annex 6 for STI treatment protocol in your setting and examples). There are many problems use it when treating survivors. and issues surrounding the prescription of PEP, not the least of which is the difficulty of counselling the survivor on 5 Survivors of rape should be treated with HIV issues at a time like this. If you wish antibiotics to prevent gonorrhoea, to know more about PEP, see the chlamydial infection and syphilis. If you resource materials listed in Annex 9. know that other STIs are prevalent in the 5 area (such as trichomoniasis or If it is possible for the person to receive chancroid), give preventive treatment for PEP in your setting, refer her as soon these infections as well. as possible (within 72 hours of the rape) to the relevant centre. If she presents 5 Give the woman the shortest courses after this time, provide information on available in the local protocol, which are voluntary counselling and testing (VCT) easy to take. For instance:2gof services available in your area. azithromycin orally plus one injection of 2.4 million IU of benzathine 5 Prevent pregnancy If an early pregnancy is detected at this stage, either with a pregnancy test or from the history and examination (see 5 Taking emergency contraceptive pills Steps 3 and 5), make clear to the (ECP) within 72 hours of unprotected woman that it cannot be the result of the intercourse will reduce the chance of a rape. pregnancy by between 74% and 85%, 5 depending on the regimen chosen and There is no known contraindication to the time of starting the course (see giving ECPs at the same time as Annex 7). antibiotics. 5 Emergency contraceptive pills work by interrupting a woman’s reproductive cycle – by delaying or inhibiting ovulation, Provide wound care blocking fertilization or preventing implantation of the ovum. ECPs do not Clean any tears, cuts and abrasions and interrupt or damage a pregnancy and remove dirt, faeces and dead or damaged thus WHO does not consider them a tissue. Decide if there are any wounds method of abortion.4 that need suturing. Suture clean wounds within 24 hours. After this time they will 5 Some people believe that ECPs are have to heal by second intention or abortifacients. Health workers who delayed primary suture. Do not suture believe this may feel unable to provide very dirty wounds. If there are major this treatment. Women should be offered contaminated wounds, consider giving objective counselling on this treatment so appropriate antibiotics and pain relief. as to reach an informed decision. 5 A health worker who is willing to prescribe ECPs should always be 18 available to prescribe the treatment to rape survivors who wish to use it. If the survivor is a child who has reached menarche, discuss emergency contraception with her and her parent or guardian who can help her to understand and take the regimen as required.

4 Emergency contraception: a guide for service delivery. Geneva, World Health Organization, 1998 (document no. WHO/FRH/FPP/98.19). 5 Prevent tetanus If there are any breaks in skin or mucosa, tetanus prophylaxis should be given unless the survivor has been fully vaccinated. Good to know before you develop 5 On the basis of the table below, decide your protocol whether to administer tetanus toxoid, & Tetanus toxoid is available in several dif- which gives active protection, and ferent preparations. Check local vaccina- antitetanus immunoglobulin, if available, tion guidelines for recommendations. which gives passive protection. & Antitetanus immunoglobulin (antitoxin) 5 is expensive and needs to be refriger- If vaccine and immunoglobulin are ated. It is not available in low-resource given at the same time, it is important to settings. use separate needles and syringes and separate sites of administration. TT – tetanus toxoid 5 DTP – triple antigen: diphtheria and Advise survivors to complete the tetanus toxoids and pertussis vaccine vaccination schedule (second dose at 4 weeks, third dose at 6 months to 1 DT – double antigen: diphtheria and year). tetanus toxoids; given to children up to 6 years of age Td – double antigen: tetanus toxoid and reduced diphtheria toxoid; given to individuals aged 7 years and over TIG – antitetanus immunoglobulin

19

Guide for administration of tetanus toxoid and tetanus immunoglobulin in cases of wounds5

History of If wounds are clean tetanus and <6 hours old All other wounds immunization or minor wounds (number of doses) TT* TIG TT* TIG

Uncertain or <3 Yes No Yes Yes

No, unless last dose No, unless last dose 3 or more No No >10 years ago >5 years ago

*For children less than 7 years old, DTP or DT is preferred to tetanus toxoid alone. For persons 7 years and older, Td is preferred to tetanus toxoid alone.

5 Adapted from: Benenson, A.S. Control of communicable diseases manual. Washington DC, American Public Health Association, 1995. Prevent hepatitis B Provide mental health care

Good to know before you develop 5 Social support and psychological your protocol counselling (see Step 7) are essential & Find out the prevalence of hepatitis B components of medical care for the in your setting, as well as the vaccina- rape survivor. Most survivors of rape tion schedules in the survivor’s country will regain their psychological health of origin and in the host country. through the emotional support and & Several hepatitis B vaccines are avail- understanding of people they trust, the able, each with different recom- community counsellor, and support mended dosages and schedules. Check groups. All rape survivors should be the dosage and vaccination schedule referred to the community focal point for for the product that is available in your sexual and gender-based violence. setting. 5 Occasionally a survivor may have severe symptoms of post-traumatic 5 stress disorder. These symptoms can Whether you can provide post-exposure include anxiety, nightmares, inability to prophylaxis against hepatitis B will sleep, and constant crying. depend on the setting you are working in. The vaccine may not be available as it is 5 In exceptional cases, if the level of relatively expensive and requires anxiety is such that it is disrupting the refrigeration. survivor’s everyday life, give one 10 mg 5 tablet of diazepam, to be taken at There is no information on the incidence bedtime. In this case she should be of hepatitis B virus (HBV) infection referred to a specially trained health 20 following rape. However, HBV is present professional and her symptoms in semen and vaginal fluid and is reassessed the next day. efficiently transmitted by sex. If possible, survivors of rape should receive hepatitis B vaccine within 14 days of the incident. 5 In countries where the infant Part B: immunization programmes routinely use Survivor presents hepatitis B vaccine, a survivor may already have been fully vaccinated. If the more than 72 hours vaccination record card confirms this, no after the incident additional doses of hepatitis B vaccine need be given. 5 The usual vaccination schedule is at 0, 1 Sexually transmitted and 6 months. However, this may differ for different products and settings. Give infections the vaccine by intramuscular injection in the deltoid muscle (adults) or the If laboratory screening for STIs has anterolateral thigh (infants and children). revealed an infection, or if the person has Do not inject into the buttock, because symptoms of an STI, treat according to this is less effective. the syndromic approach. Follow local protocols. 5 The vaccine is safe for pregnant women and for people who have chronic or previous HBV infection. It can be given at the same time as tetanus vaccine. HIV transmission Tetanus

While in some settings testing for HIV can Tetanus usually has an incubation period be done as early as six weeks after a rape, of 3 to 21 days, but it can be many it is recommended that the survivor is months. Refer the survivor to the referred for voluntary counselling and appropriate level of care if you see signs testing (VCT) after 3-6 months, in order to of a tetanus infection. If she has not been avoid the need for repeated testing. Check fully vaccinated, vaccinate immediately, the VCT services available in your setting no matter how long it is since the incident. and their protocols. If there remain major, dirty, unhealed wounds, consider giving antitoxin if this is available (see “Prevent tetanus” in Part A). Pregnancy

5 If the survivor is pregnant, try to ascertain Hepatitis B if she could have become pregnant at the time of the rape. If she is, or may be, Hepatitis B has an incubation period of pregnant as a result of the rape, counsel two to three months on average. If you her on the possibilities available to her in see signs of an acute infection, refer the your setting. (See Step 3, Step 7, and person if possible or provide counselling. Step 8). If the person has not been vaccinated and 5 it is appropriate in your setting, vaccinate, If the survivor presents within five days of no matter how long it is since the incident. the rape, insertion of a copper-bearing IUD is an effective method of preventing pregnancy (it will prevent more than 99% Mental health of subsequent pregnancies). The IUD 21 can be removed at the time of the woman’s next menstrual period or left in 5 Social support and psychological place for future contraception. Women counselling (see Step 7) are essential should be offered counselling on this components of medical care for the service so as to reach an informed rape survivor. Most survivors of rape decision. A skilled provider should will regain their psychological health counsel the patient and insert the IUD. through the emotional support and understanding of people they trust, the community counsellor, and support Bruises, wounds and scars groups. All rape survivors should be referred to the community focal point for sexual and gender-based violence. Treat, or refer for treatment, all unhealed wounds, fractures, abscesses, and other 5 Occasionally a survivor may have injuries and complications. severe symptoms of post-traumatic stress disorder. These symptoms can include anxiety, nightmares, inability to sleep, and constant crying. 5 In exceptional cases, if the level of anxiety is such that it is disrupting the survivor’s everyday life, give one 10 mg tablet of diazepam, to be taken at bedtime. In this case she should be referred to a specially trained health professional and her symptoms reassessed the next day. STEP 7 – Counselling the survivor

Survivors seen at a health facility 5 Tell the survivor that she has immediately after the rape will most likely experienced a serious physical and be experiencing psychological trauma and emotional trauma. Advise her about the may show signs of anxiety and/or post-traumatic symptoms (emotional depression. Survivors in this state are and physical) that she may experience. unlikely to remember counselling and 5 advice given at this time. It is therefore In most cultures, there is a tendency to important to repeat the counselling during blame the survivor in cases of rape. follow-up visits. It is also useful to prepare Assure the survivor that she did not standard advice and counselling deserve to be raped, that the incident information in writing, and give the survivor was not her fault, and that it was not a copy before she leaves the health facility caused by her behaviour or manner of (even if the survivor is illiterate, she can ask dressing. someone she trusts to read it to her later). 5 Advise the survivor that part of the care she needs is emotional support. Encourage her to confide in someone Give the survivor the opportunity to ask she trusts and to ask for this emotional questions and to voice her concerns. support, perhaps from a family member or friend. 5 22 Refer the survivor to a counselling service for psychosocial assistance. Psychological and 5 Ask the survivor if she has a safe place emotional trauma to go to, and if someone she trusts will accompany her when she leaves the 5 Medical care for survivors of rape health facility. If she has no safe place includes care and referral for to go to now, efforts should be made to psychological trauma. find her a safe place. Enlist the assistance of the counselling services, 5 The majority of rape survivors never tell community services provider, police or anyone about the incident. If the survivor security officer (see Step 1). has told you what happened, she has demonstrated that she trusts you. 5 In some cases, the survivor is seriously traumatized and experiences severe 5 Rape causes psychological and emotional or psychological dysfunction, emotional trauma as well as physical becoming unable to carry out injury. Survivors may experience a range day-to-day activities. Referral for of post-traumatic symptoms, including: psychological evaluation and more # self-blame; in-depth counselling may be needed. Find out what services are available in # uncontrollable emotions, such as fear, your area. anger, guilt, shame, anxiety; # mood swings; # nightmares and sleeping disorders; # eating disorders; # suicidal thoughts or suicide attempts. Pregnancy HIV

5 Emergency contraceptive pills cannot Both men and women may be concerned prevent pregnancy resulting from sexual about the possibility of becoming acts that take place after the treatment. If HIV-positive as a result of rape. While the the survivor wishes to use an additional risk of acquiring HIV through a single hormonal method of contraception, she sexual exposure is small, these concerns should start this on the first day of her are well founded. Compassionate and next period. Condom use for a period of careful counselling around this issue is 6 months should be recommended to essential. The health care worker may protect against transmission of STIs and also discuss the risk of transmission of HIV infection. HIV or STI to partners following a rape. 5 Female survivors of rape are likely to be 5 The survivor may be referred to an very concerned about the possibility of HIV/AIDS counselling service if becoming pregnant as a result of the available. rape. Emotional support and clear information are needed to ensure that 5 Condom use with all partners for a they understand the choices available to period of 6 months (or depending on the them if they become pregnant: result of HIV screening tests) should be recommended. # There may be services for adoption and/or foster care in your area. Find 5 Give advice on the signs and symptoms out what services are available and of possible STIs, and on when to return give this information to the survivor. for further consultation. # In many countries the law allows termination of pregnancy resulting from rape. Furthermore, local interpretation Other 23 of abortion laws in relation to mental and physical health may include 5 Give advice on proper care for any indications for rape survivors as well. injuries following the incident, infection Find out whether this is the case in prevention (including perineal hygiene, your setting. Determine where safe perineal baths), signs of infection, abortion services are available so that antibiotic treatment, when to return for you can refer survivors to this service if further consultation, etc. they so choose. 5 Give advice on how to take the # Advise survivors to seek support from prescribed treatments and on possible someone they trust – perhaps a side-effects of treatments. religious leader, family member, friend or community worker. Follow-up care at the health facility

5 Tell the survivor that she can return to the health service at any time if she has questions or other health problems. Encourage her to return in two weeks for follow-up evaluation of STI and pregnancy (see Step 8). 5 Give clear advice on any follow up needed for wound care or vaccinations. STEP 8 – Follow-up care of the survivor

It is possible that the survivor will not or If the woman is pregnant as a cannot return for follow-up. Provide result of the rape maximum input during the first visit, as & A pregnancy may be the result of the this may be the only visit. rape. All the options available, e.g. keeping the child, adoption and abor- tion, should be discussed with the If the survivor is started on post-exposure woman, regardless of the individual prophylaxis with antiretroviral drugs, the beliefs of the counsellors, medical staff follow-up schedule may be different from or other persons involved, in order to the one below. Discuss this with the PEP enable her to make an informed deci- provider. sion. & Where safe abortion services are not available, women with unwanted preg- Two-week follow-up visit nancies may undergo unsafe abortions. These women should have access to post-abortion care, including emer- 5 Evaluate for pregnancy and provide gency treatment of abortion complica- counselling (see Steps 3, 6, 7). tions, counselling on family planning, 5 Evaluate for STIs, treat as appropriate, and links to reproductive health ser- 24 provide advice on voluntary counselling vices. and testing for HIV (see Steps 6, 7). & Children born as a result of rape may 5 be mistreated or even abandoned by Evaluate mental and emotional status; their mothers and families. They refer or treat as needed (see Step 7). should be monitored closely and sup- port should be offered to the mother. It is important to ensure that the family Six-month follow-up visit and the community do not stigmatize either the child or the mother. Foster placement and, later, adoption should 5 Evaluate for STIs, treat as appropriate. be considered if the child is rejected, 5 Provide advice on voluntary counselling neglected or otherwise mistreated. and testing for HIV. 5 Evaluate mental and emotional status; refer as needed (see Step 7). 5 Care for child inability to drink or breastfeed. survivors In children younger than 3 months, look also for:

5 fever; Good to know before you develop 5 low body temperature; your protocol 5 bulging fontanelle; & If it is obligatory to report cases of child abuse in your setting, obtain a sample 5 grunting, chest indrawing, and breathing of the national child abuse manage- rate of more than 60 breaths/minute. ment protocol and information on cus- tomary police and court procedures. The treatment of these complications is & Find out about specific laws in your not covered here in detail. setting that determine who can give consent for minors. & In settings where the health worker is Create a safe and expected to go to court as an expert trusting environment witness, he or she should receive spe- cial training in examining children 5 who have been abused. Introduce yourself to the child. & Health care providers should be knowl- 5 Sit at eye level and maintain eye edgeable about child development and contact. growth as well as normal child anat- omy. 5 Assure the child that he or she is not in any trouble. 5 Ask a few questions about neutral 25 topics, e.g., school, friends, who the General child lives with, favourite activities. 5 Take special care in determining who A parent or legal guardian should sign the should be present during the interview consent form for examination of the child and examination (remember that it is and collection of forensic evidence, unless possible that a family member is the he or she is the suspected offender. In this perpetrator). It is preferable to have the case, a representative from the police, the parent or guardian wait outside during community support services or the court the interview and have an independent may sign the form. Adolescent minors may trusted person present. For the be able to give consent themselves. The examination, either a parent or guardian child should never be examined against his or a trusted person should be present. or her will, whatever the age, unless the Always ask the child who he or she examination is necessary for medical care. would like to be present, and respect his or her wishes. The initial assessment may reveal severe medical complications that need to be treated urgently, and for which the patient will have to be admitted to hospital. Such Take the history complications might be: 5 Begin the interview by asking 5 convulsions; open-ended questions, such as “Why 5 are you here today?” or “What were you persistent vomiting; told about coming here?” 5 stridor in a calm child; 5 Assure the child it is okay to respond to 5 lethargy or unconsciousness; any questions with “I don’t know”. 5 Be patient, go at the child’s pace, don’t often part of sexual abuse and, if used interrupt his or her train of thought. by those attempting to help, will 5 increase the child’s fear and anxiety Ask open-ended questions to get and worsen the psychological impact of information about the incident. Ask the abuse. yes-no questions only for clarification of details. 5 It is useful to have a doll on hand to demonstrate procedures and positions. The pattern of sexual abuse of children is Show the child the equipment and generally different from that of adults. For supplies, such as gloves, swabs, etc.; example, there is often repeated abuse. To allow the child to use these on the doll. get a clearer picture of what happened, try to obtain information on: Conduct the examination 5 the home situation (has the child a secure place to return to?); Conduct the examination as for adults. 5 how the rape/abuse was discovered; Special considerations for children are as follows: 5 the number of incidents and the date of the last incident; 5 Note the child’s weight, height, and 5 whether there has been any bleeding; pubertal stage. Ask girls whether they have started menstruating. If so, they 5 whether the child has had difficulty may be at risk of pregnancy. walking. 5 Small children can be examined on the mother’s lap. Older children should be Prepare the child for offered the choice of sitting on a chair or on the mother’s lap, or lying on the bed. 26 examination 5 Examine the anus with the child in the 5 supine or lateral position. Avoid the As for adult examinations, there should knee-chest position, as assailants often be a support person or trained health use it. worker whom the child trusts in the examination room with you. 5 Check the hymen by holding the labia at 5 the posterior edge between index finger Encourage the child to ask questions and thumb and gently pulling outwards about anything he or she is concerned and downwards. Note the location of about or does not understand at any time any fresh or healed tears in the hymen during the examination. and the vaginal mucosa. The amount of 5 Explain what will happen during the hymenal tissue and the size of the examination, using terms the child can vaginal orifice are not sensitive understand. indicators of penetration. 5 5 With adequate preparation, most children Digital examination (assessing the size will be able to relax and participate in the of the vaginal orifice by the number of examination. fingers that can be inserted) should not be carried out. 5 It is possible that the child has pain and 5 cannot relax for that reason. If this is a Look for vaginal discharge. In possibility, give paracetamol or other prepubertal girls, vaginal specimens can simple painkillers to relieve pain. Wait for be collected with a dry sterile cotton these to take effect. swab. 5 5 Never restrain or force a frightened, Do not use a speculum to examine resistant child to complete an prepubertal girls; it is extremely painful examination. Restraint and force are and may cause serious injury. 5 A speculum may be used only when you 5 diazepam, by mouth, 0.15 mg/kg of suspect a penetrating vaginal injury and body weight; maximum 10 mg; internal bleeding. In this case, a speculum examination of a prepubertal or child is usually done under general 5 anaesthesia. Depending on the setting, promethazine hydrochloride, syrup, by the child may need to be referred to a mouth; higher level of health care. # 2-5 years: 15-20 mg 5 In boys, check for injuries to the frenulum # 5-10 years: 20-25 mg of the prepuce, and for anal or urethral discharge; take swabs if indicated. These drugs do not provide pain relief. 5 Conduct an anal examination in both If you think the child is in pain, give boys and girls. simple pain relief first, such as paracetamol (1-5 years: 120 – 250 mg; 5 Record the position of any anal fissures 6-12 years: 250 – 500 mg). Wait for this to or tears on the pictogram. take effect. 5 Reflex anal dilatation (opening of the Oral sedation will take 1 to 2 hours for anus on lateral traction on the buttocks) full effect. In the meantime allow the child can be indicative of anal penetration, but to rest in a quiet environment. also of constipation. 5 Digital examination to assess anal sphincter tone should not be done. Treatment

Routine prevention of STIs is not usually Laboratory testing recommended for children if screening can be done. However, in low-resource 27 In some settings, screening for gonorrhoea settings with a high prevalence of sexually and chlamydia (by culture), syphilis and transmitted diseases, presumptive STI HIV is done for all children presenting with treatment may be part of the protocol (see a history of rape. The presence of these Annex 5 for sample regimens). infections may be diagnostic of rape (if the infection is not likely to have been acquired perinatally or through blood transfusion).6 Follow-up Follow your local protocol. Follow-up care is the same as for adults. If a vaginal infection does not clear, If the child is highly consider the possibility of the presence of agitated a foreign body, or continuing sexual abuse.

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:

6 American Academy of Pediatrics Committee on Child Abuse and Neglect. Guidelines for the evaluation of sexual abuse of children: subject review. Pediatrics, 1999,103:186-191. Special considerations Special considerations for men for pregnant women

Counselling Women who are pregnant at the time of a rape are physically and psychologically especially vulnerable. In particular they 5 Male survivors of rape are even less are susceptible to miscarriage, likely than women to report because of hypertension of pregnancy and premature the extreme embarrassment that they delivery. typically experience. While the physical effects differ, the psychological trauma Counsel pregnant women on these issues and emotional after-effects for men are and advise them to attend antenatal care similar to those experienced by women. services regularly throughout the 5 When a man is anally raped, pressure on pregnancy. the prostate can cause an erection and even orgasm. Reassure the survivor that, if this has occurred during the rape, it Special considerations was a physiological reaction and was beyond his control. for elderly women

Genital examination Elderly women who have been vaginally raped are at increased risk of vaginal tears and injury, and transmission of STI 5 Examine the scrotum, testicles, penis, and HIV. Decreased hormonal levels 28 periurethral tissue, urethral meatus and following the menopause result in a anus. reduction in vaginal lubrication and cause 5 Note if the survivor is circumcised. the vaginal wall to become thinner and more friable. Use a thin speculum for 5 Look for hyperaemia, swelling genital examination. If collecting evidence (distinguish between inguinal hernia, or screening for STIs is the only indication hydrocele and haematocele), torsion of for the examination, consider inserting testis, bruising, anal tears, etc. swabs only without using a speculum. 5 Torsion of the testis is an emergency and requires immediate referral. 5 If the urine contains large amounts of blood, check for penile and urethral trauma. 5 If indicated, do a rectal examination and check the rectum and prostate for trauma and signs of infection. 5 If relevant, collect material from the anus for direct examination for sperm under a microscope.

Treatment

Men need the same STI preventive treatment and vaccinations as described in Step 6. Annex 1 • Information needed to develop a local protocol

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. The following table shows the information collected in the United Republic of Tanzania and where this information was found.

Information needed Where the information was found Medical laws and legal procedures Abortion laws Ministry of Health Emergency contraception regulations Ministry of Health Foster placement and adoption laws and procedures Ministry of Community Development, Women Affairs and Children Crime reporting requirements and obligations, for adult or Ministry of Justice child survivors Police and other forms required Ministry of Home Affairs Forensic evidence Which medical practitioner can give medical evidence in Ministry of Justice court (e.g. doctor, nurse, etc) 29 Training for medical staff in forensic examination (of adult Ministry of Health or child survivors) Evidence allowed/used in court for adult and child rape Ministry of Justice cases that can be collected by medical staff Forensic evidence tests possible in country (e.g. DNA, acid Forensic laboratory in capital phosphatase) How to collect, store and send evidence samples Forensic laboratory in capital; laboratory at regional level Existing “rape kits” or protocols for evidence collection Referral hospital at regional level or in capital Medical protocols National STI protocol Ministry of Health Vaccination availability and schedules Ministry of Health Location of voluntary HIV counselling and testing services National AIDS Control Program, Ministry of Health Confirmatory HIV testing strategy and laboratory services UNHCR, National AIDS Control Program, Ministry of Health, Regional Medical Officer Possibilities/protocols/referral of post-exposure prophylaxis National AIDS Control Program, Ministry of Health of HIV infection Clinical referral possibilities (e.g. psychiatry, surgery, Referral hospital at regional level paediatrics, gynaecology/obstetrics) Annex 2 • Sample consent form

Annex 2 • Sample consent form

Name of facility ------

Note to the health worker: Read the entire form to the survivor, explaining that she can choose any (or none) of the items listed. Obtain a signature, or a thumb print with signature of a witness.

I, ------, (print name of survivor)

authorize the above-named health facility to perform the following (tick the appropriate boxes):

Yes No

30 Conduct a medical examination, including pelvic examination AA

Collect evidence, such as body fluid samples, collection of clothing, hair combings, scrapings or cuttings of fingernails, blood sample, and photographs AA

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. AA

Signature:------

Date: ------

Witness: ------Annex 3 • Sample history and examination form

Annex 3 • Sample history and examination form

Sample form, page 1 of 4

CONFIDENTIAL CODE:

Medical History and Examination Form – Post-Sexual Violence

1. GENERAL INFORMATION

First Name Last Name

Address

Sex Date of birth Age

Date / time of exam / In the presence of

In case of a child include: Name of school, name of parents and/or guardian

2. THE INCIDENT

Date of incident: Time of incident: 31 Description of incident (survivor’s description)

Physical violence Yes No Describe type and location

Type (beating, biting, pulling hair, etc.)

Use of restraints

Use of weapon(s)

Drugs/alcohol involved

Penetration Yes No Not sure Describe (oral, vaginal, anal, type of object)

Penis

Finger

Other (describe)

Yes No Not sure Location (oral, vaginal, anal, other location).

Ejaculation

Condom used

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. Annex 3 • Sample history and examination form

Sample form, page 2 of 4

3. MEDICAL HISTORY

After the incident, did the survivor Yes No Yes No

Vomit Rinse mouth

Urinate Change clothing

Defecate Wash/bathe

Brush teeth Use tampon/pad

Contraception use

Pill IUD

Injection Other (specify)

Menstrual history

Last menstrual period Menstruation at time of event Yes A No A

Evidence of pregnancy Yes A No A Number of weeks pregnant _____ weeks

History of consenting intercourse (only if samples have been taken for DNA analysis)

Last consenting intercourse within a week Date: Name of individual: 32 prior to the assault Existing health problems

History of female genital cutting, type

Allergies

Current medication

Vaccination status Vaccinated Not vaccinated Unknown Comments

Tetanus

Hepatitis B

HIV/AIDS status Know Negative Unknown Annex 3 • Sample history and examination form

Sample form, page 3 of 4

4. Medical examination

Appearance (clothing, hair, etc., obvious physical or mental disability?)

Mental state (calm, crying, anxious, cooperative, etc.)

Weight: Height: Pubertal stage (pre-pubertal, pubertal, mature):

Pulse rate Blood pressure Respiratory rate Temperature

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.

Head and face Mouth and nose

Eyes and ears Neck 33

Chest Back

Abdomen Buttocks

Upper extremities Lower extremities

5. GENITAL AND ANAL EXAMINATION

Vulva/scrotum Introitus and hymen Anus

Vagina/penis Cervix Bimanual/rectovaginal examination

Position of patient (supine, prone, knee-chest, lateral, mother’s lap) For genital examination: For anal examination: Annex 3 • Sample history and examination form

Sample form, page 4 of 4

6. INVESTIGATIONS DONE

Type and location Examined/sent to lab Result

7. EVIDENCE TAKEN

Type and location Sent to…/stored Collected by/date

8. TREATMENTS PRESCRIBED

Treatment Yes No Type and Comments 34 STI prevention Emergency contraception

Wound treatment

Tetanus prophylaxis

Hepatitis B vaccination

Other

9. COUNSELLING, REFERRALS, FOLLOW-UP

General psychological status

Survivor plans to report to police OR has already made report Yes A No A

Survivor has a safe place to go Yes A No A Has someone to accompany her/him Yes A No A

Counselling provided:

Referrals

Follow-up required

Date of next visit

Name of health worker conducting examination/interview: ______

Title: ______Signature: ______Date: ______Annex 4 • Pictograms

Annex 4 • Pictograms

35 Annex 4 • Pictograms

36

Left Right Annex 4 • Pictograms

37 Annex 4 • Pictograms

38

Left Right Annex 5 • Protocols for treatment of STIs

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.

STI Treatment Gonorrhoea azithromycin 2 g orally (not recommended in pregnancy) (Note: in this case you do not have to give further treatment for chlamydial infection) or ciprofloxacin 500 mg orally, single dose (contraindicated in pregnancy) or cefixime 400 mg orally, single dose or ceftriaxone 125 mg intramuscularly, single dose

Chlamydial infection doxycycline 100 mg orally, twice daily for 7 days (contraindicated in pregnancy) or azithromycin 1 g orally, in a single dose (not recommended in pregnancy) 39

Chlamydial infection in erythromycin 500 mg orally, 4 times daily for 7 days pregnant woman or amoxicillin 500 mg orally, 3 times daily for 7 days

Syphilis benzathine 2.4 million IU, intramuscularly, once only benzylpenicillin (give as two injections in separate sites.)

Syphilis, patient doxycycline 100 mg orally twice daily for 15 days (contraindicated in pregnancy) allergic to penicillin or tetracycline 500 mg orally, 4 times daily for 15 days (contraindicated in pregnancy) (Note: both these antibiotics are also active against chlamydia)

Syphilis in pregnant erythromycin 500 mg orally, 4 times daily for 15 days women allergic to (Note: this antibiotic is also active against chlamydia) penicillin Trichomonas metronidazole 2 g orally, in a single dose or as two divided doses at a 12-hour interval (contraindicated in the first trimester of pregnancy)

Give one easy to take, short treatment for each of the infections that are prevalent in your setting.

Example

Presumptive treatment for gonorrhoea, syphilis and chlamydial infection for a woman who is not pregnant and not allergic to penicillin

& azithromycin 2g orally + benzathine benzylpenicillin 2.4 million IU intramuscularly, Annex 5 • Protocols for treatment of STIs

or

& ciprofloxacin 500 mg orally + benzathine benzylpenicillin 2.4 million IU intramuscularly + doxycycline 100 mg orally, twice daily for 7 days

If trichomoniasis is prevalent, add a single dose of2gofmetronidazole 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.

STI Weight Treatment or age

Gonorrhoea ceftriaxone 125 mg intramuscularly, single dose or

spectinomycin 40 mg/kg of body weight, intramuscularly (up to a maximum of 2 g), <45kg single dose or (if > 6 months)

cefixime 8mg/kg of body weight orally, single dose

40 < 45 kg Treat according to adult protocol

Chlamydial <45kg erythromycin 50 mg/kg of body weight daily, orally (up to a maximum of 2 g), divided infection into 4 doses, for 7 days

> 45 kg erythromycin 500 mg orally, 4 times daily for 7 days but or < 12 years azithromycin 1 g orally, single dose

doxycycline 100 mg orally, twice daily for 7 days or

> 12 years azithromycin 1 g orally, single dose or

erythromycin 500 mg orally, 4 times daily for 7 days

Syphilis benzathine 50 000 IU/kg IM (up to a maximum of 2.4 million IU), single dose penicillin

Syphilis, patient allergic to Erythromycin or doxycycline in the dosages recommended for chlamydial infection for penicillin 14 days

Trichomoniasis < 12 years metronidazole 5 mg/kg of body weight orally, 3 times daily for 7 days

> 12 years Treat according to adult protocol

Based on: Tailoring clinical management practices to meet the special needs of adolescents: sexually transmitted infections. Geneva, World Health Organization (document WHO/CAH 2002, WHO/HIV/AIDS 2002.03), in print. Annex 6 • Protocols for post-exposure prophylaxis of HIV infection

Annex 6 • Protocols for post-exposure prophylaxis of HIV infection

The following are examples of post-exposure Example 2 prophylaxis (PEP) protocols used in some settings for preventing HIV infection after rape. There may be From: Bamberger, J.D. et al. Postexposure prophylaxis other examples. These examples do not outline all for human immunodeficiency virus (HIV) infection the care that may be needed. If it is possible in your following sexual assault. American Journal of Medicine, setting to provide PEP, refer the survivor as soon as 1999, 106: 323-326. possible (within 72 hours) to the relevant centre.

Example 1

From: Treatment guidelines for the use of AZT Treatment regimen (28 days) (zidovudine) for the prevention of the transmission Zidovudine, 300 mg twice a day or 200 mg 3 of human immunodeficiency virus (HIV) in the times per day, and management of survivors of rape. The Department of Health, Western Cape Province, South Africa. lamivudine,150 mg twice a day Alternative regimen (28 days) Didanosine, 200 mg twice a day, and Treatment regimen (28 days) staduvidine, 40 mg twice a day Zidovudine (AZT), 300 mg twice a day Consider adding:* 41 & Survivors are given a one-week supply of nelfinavir, 750 mg three times a day, or the drug and an appointment to return for indinavir, 800 mg three times a day reassessment in one week. & Although antiretroviral medications rarely & Survivors are seen at one week for cause important laboratory abnormalities, evaluation and to obtain the results of their baseline tests may be useful. blood tests. They are given the remainder & Monitoring should include complete blood of their 28-day course of zidovudine. count and liver enzyme levels as clinically & The next visits are at 6 weeks and 3 indicated. months after the rape. HIV testing is & HIV antibody testing is recommended at performed at both these visits. baseline, 6 weeks, 3 months, and 6 months & Routine testing, with full blood count and following the assault. liver enzymes is not recommended for * In the rare case where the assailant is known to be infected patients on zidovudine. Any blood tests are with HIV that is resistant to reverse transcriptase inhibitors, it is performed only if indicated by the recommended to add a protease inhibitor, such as nelfinavir or indinavir. An HIV specialist should be consulted to determine survivor’s clinical condition. 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 of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. Morbidity and mortality weekly report, 2001, 50(RR-11), Appendix C. Annex 7 • Protocols for emergency contraception

Annex 7 • Protocols for emergency contraception

Emergency contraceptive pills & Make it clear to the survivor that there is a small risk that the pills will not work. Most patients will & There are two emergency contraceptive pill have a normal menstruation within 21 days after (ECP) regimens that can be used: the the treatment. Menstruation may be up to a levonorgestrel-only regimen (this is the week early or a few days late. If she has not had recommended regimen) or the combined a period within 21 days after the treatment, she estrogen-progesterone regimen (Yuzpe). should return to have a pregnancy test or to discuss the options in case of pregnancy. & In both regimens, a first dose should be taken as soon as convenient, but not later than 72 hours & Side effects: especially if the Yuzpe regime is after the rape, and a second dose 12 hours later. used, nausea can occur. If vomiting occurs There are products that are specially packaged within 2 hours of taking a dose, repeat the dose. for emergency contraception, but at present they & Precautions: ECPs will not be effective in the are registered only in a limited number of case of a confirmed pregnancy. ECPs may be countries. If pre-packaged ECPs are not given when the pregnancy status is unclear and available in your setting, emergency pregnancy testing is not available, since there is contraception can be provided using regular oral no evidence to suggest that the pills can harm contraceptive pills which are available for family the woman or an existing pregnancy. There are planning purposes (see the table below for no other medical contraindications to use of 42 guidance). ECPs. & Counsel the survivor about how to take the pills, what side-effects may occur, and the effect the pills may have on her next period. ECPs do not prevent pregnancy from sexual acts after treatment. If needed, provide her with condoms for use in the immediate future. Annex 7 • Protocols for emergency contraception

a Second dose Formulation Common First dose Regimen 12 hours later (per pill) brand names (number of tablets) (number of tablets)

Levonorgestr 750 µg Levornelle-2, NorLevo, el only Plan B, Postinor, 11 Postinor-2, Vikela

30 µg Microlut, Microval, 25 25 Norgeston

37.5 µg Ovrette 20 20

Combined EE 50 µg + LNG 250 µg Eugynon 50, Fertilan, or Neogynon, Noral, EE 50 µg + NG 500 Nordiol, Ovidon, Ovral, Ovran, 22 Tetragynon/PC-4, Preven, E-Gen-C, Neo-Primovlar 4

EE 30 µg + LNG 150 µg Lo/Femenal, or Microgynon, Nordete, 44 Ovral L, Rigevidon EE 30 µg + NG 300 µg a EE = ethinylestradiol; LNG = levonorgestrel; NG =norgestrel.

(Adapted from: Consortium for Emergency Contraception, Emergency contraceptive pills, medical and service delivery guidelines. Seattle, WA, 2000). 43

Use of an intrauterine device (IUD) as an emergency contraceptive

& If the survivor presents within five days after the & A skilled provider should counsel the patient and rape, insertion of a copper-bearing IUD is an insert the IUD. effective method of emergency contraception. It & will prevent more than 99% of expected The IUD may be removed at the time of the subsequent pregnancies. woman’s next menstrual period or left in place for future contraception. & Women should be offered counselling on this service so as to reach an informed decision. Annex 8 • Minimum care for rape survivors in low-resource settings

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 room during examination 3. Furniture/Setting Available # Room (private, quiet, accessible, with access to a toilet or latrine) # Examination table # 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: 3 Speculum 3 Tape measure for measuring the size of bruises, lacerations, etc. 44 3 Paper bags for collection of evidence 3 Paper tape for sealing and labelling containers/bags # Supplies for universal precautions # Resuscitation equipment for anaphylactic reactions # Sterile medical instruments (kit) for repair of tears, and suture material # Needles, syringes # Cover (gown, cloth, sheet) to cover the survivor during the examination # Sanitary supplies (pads or local cloths) 5. Drugs Available # For treatment of STIs as per country protocol # Emergency contraceptive pills and/or IUD # For pain relief (e.g. paracetamol) # Local anaesthetic for suturing # Antibiotics for wound care 6. Administrative supplies Available # Medical chart with pictograms # Consent forms # Information pamphlets for post-rape care (for survivor) # Safe, locked filing space to keep confidential records Annex 8 • Minimum care for rape survivors in low-resource settings

Collecting minimum forensic Minimum examination evidence A medical examination should be done only with Evidence should only be collected and released to the survivor’s consent. It should be the authorities with the survivor’s consent (see Step 4). compassionate, confidential, and complete, as indicated and described in Step 5. & A careful written recording should be kept of all findings during the medical examination that can Minimum treatment support the survivor’s story, including the state of her clothes. The medical chart is part of the Give compassionate and confidential treatment as legal record and can be submitted as evidence follows (see Step 6): (with the survivor’s consent) if the case goes to court. & treatment and referral for life threatening complications; & Keep samples of damaged clothing (if you can give the survivor replacement clothing) and & treatment or preventive treatment for STIs; foreign debris present on her clothes or body, & which can support her story. emergency contraception; & & If a microscope is available, a trained health care of wounds; care provider or laboratory worker can examine & supportive counselling; wet-mount slides for the presence of sperm, which proves penetration took place. & referral to social support and psychosocial counselling services. 45 WHO/RHR/02.08

Clinical Management of Survivors of Rape

A guide to the development of protocols for use in refugee and internally displaced person situations

An Outcome of the Inter-Agency Lessons Learned Conference: Prevention and Response to Sexual and Gender-Based Violence in Refugee Situations 27-29 March 2001 • Geneva

Annex 9 • Additional resource materials

Annex 9 • Additional resource materials

General information Information on post-exposure prophylaxis (PEP) of HIV Sexual assault nurse examiner (SANE) development and operation guide. Washington, infection DC, United States Department of Justice, Office of Justice Programs, Office for Victims of Crime Management of possible sexual, (http://www.sane-sart.com/SaneGuide/toc.asp). injecting-drug-use, or other nonoccupational exposure to HIV, including considerations related Reproductive health in refugee situations: an to antiretroviral therapy: Public Health Service inter-agency field manual. Geneva, UNHCR, 1999 Statement. Morbidity and mortality weekly report, (http://www.who.int/reproductive-health/publications 1998, 47(RR17):1-14 or http://www.rhrc.org/fieldtools or (http://www.cdc.gov/hiv/treatment.htm#prophylaxis). http://www.unhcr.ch/). PHS report summarises current scientific Basta!: A newsletter from IPPF/WHR on knowledge on the use of post-exposure integrating gender-based violence into sexual and antiretroviral therapy for non-occupational reproductive health. International Planned exposures. Atlanta, GA, Centers for Disease Parenthood Federation Control and Prevention, 1998 (http://www.ippfwhr.org/whatwedo/basta.html). (http://www.cdc.gov/hiv/pubs/facts/petfact.htm).

46 Sexual violence against refugees: guidelines on Updated U.S. Public Health Service guidelines for prevention and response. Geneva, UNHCR, 1995 the management of occupational exposures to (http://www.unhcr.ch/). HBV, HCV, and HIV and recommendations for postexposure prophylaxis. Morbidity and mortality Mental health of refugees. Geneva, World Health weekly report, 2001, 50(RR-11), Appendix C, Organization, 1996 (http://www.unhcr.ch/). 45-52 (http://www.cdc.gov/hiv/treatment.htm#prophylaxis). Information on sexually Detailed information on the transmitted diseases abortion policies of countries Guidelines for the management of sexually transmitted diseases. Geneva, World Health Abortion policies: a global review. New York, UN Organization, 2001 (document number Department of Economic and Social Affairs, WHO/RHR/01.10) Population Division, 2001 (http://www.who.int/reproductive-health/publications). (http://www.un.org/esa/population/publications/ abortion/profiles.htm). Information on emergency contraception

Emergency contraception: a guide for service delivery. Geneva, World Health Organization, 1998 (document no. WHO/FRH/FPP/98.19) (http://www.who.int/reproductive-health/publications).