Management Guideline for Sexual Assault

Forward

The Ethiopian Society Obstetricians and Gynecologists has been selected by the International Federation of Gynecology and Obstetrics as one of the six countries to implement the Sexual and Reproductive Health Rights project which is now in its third and final phase. In the past two phases, awareness creation was made in the 10^th annual conference of ESOG by making violence against women its theme. A one-day training on management of violence against women was conducted. A national code of ethics on sexual and reproductive health for health providers was published.

One of the activities in this project is establishing a model clinic for management of victims of sexual violence. To this effect the society has secured space in the premises of Gandhi Memorial Hospital, Addis Ababa, which is the only women hospital in the country.

To provide quality care for victims of violence and to standardize the management, the society has developed this management guideline for health personnel practicing in the country. This guideline has brief introduction on violence against women, detailed outline of history taking and physical examination, relevant laboratory examination and clinical interpretation of findings. The management part emphasizes clinical care and schedules of follow-up. The importance of psychological care and the need for counseling is described. A format for recording and reporting clinical findings and the management provided is also part of this guideline.

Due attention is given to simplify this guideline such that all cadres of health workers can make best use of it. The society hopes that this guideline will contribute to the provision of quality and standard care, which these victims deserve and as this is the first edition, it will be updated as new knowledge is gained.

Solomon Kumbi, MD

President, ESOG     

Acknowledgment

The Ethiopian Society of Obstetricians and Gynecologists (ESOG) wishes to express its gratitude and appreciation to FIGO for its financial assistance to undertake this activity. Our special thanks goes to Dr. Dorthy Shaw and Prof. Anibal Faundes who were enthusiastic about the standardization of management of victims of sexual assault and have encouraged this" bold initiative." 

ESOG also acknowledges the commitment and hard work of Dr. Yirgu G/Hiwot, the lead person in this activity, Dr Eskinder Kebede and Dr Zufan Lakew who prepared this document on behalf of the society.  Dr Solomon Kumbi, the president of the society, deserves special acknowledgment not only for facilitating this activity but for also actively engaging in the development of the guideline and reviewing the manuscript extensively so that it achieves the present from the executive committee of ESOG.

Table of Contents

Introduction ....................................................................................................... 

Definition...........................................................................................................  

Evaluation of victims of sexual assault ........................................................ 

Medical Examination ....................................................................................... 

History Taking .................................................................................................. 

Physical Examination ...................................................................................... 

Forensic evidence and laboratory investigation ........................................ 

Management .................................................................................................... 

Follow up evaluation ...................................................................................... 

Legal obligations of providers ...................................................................... 

Sexual Violence Report form......................................................................... 

 Introduction

Rape is one of the conditions in which sexual and reproductive health rights of women is violated. The exact incidence of rape in Ethiopian setting is not known. Study of rape in two hospitals revealed that there were 182 cases of victims of sexual assault of whom 51.2% were under the age 15 and around 7% were preschool children. The injuries they sustained ranged from hymeneal tear to 4^th degree perineal tear.

The prevalence of rape among women who presented with abortion complications were 3% and among women with unwanted pregnancy the incidence of rape was 18%.   It is the observation of many clinicians working in major hospitals that not only it is becoming more common but the age of occurrence (the victim’s age) is dramatically decreasing. The revised draft penal law not only has put more rigorous sentences for those who are guilty of rape but has also unlike the previous penal code has given the opportunity to terminate a pregnancy, which is the outcome of rape or incest.

It is a widely known fact that victims are brought to the attention of the health worker to secure a medical certificate, which more often describes the status of the hymen. So far, there is no standardized management of rape; there is no uniform ways of documenting and reporting findings. There is no center in the country that caters to the physical and psychological needs of victims. 

Timely and proper collection of evidences, empathetic provider with knowledge of proper examination technique, administration of prophylactic and therapeutic measures and providing psychological and psychiatric support is the sine qua non of the management of sexual assault. Good evidence is not only a medical requirement but also help the judiciary deliver appropriate justice.

Therefore there is a great need to build consensus among the health professionals caring for the victims and standardize the management in Ethiopia. This is an initial step taken by the Ethiopian society of obstetricians and gynecologists to standardize the management of victims of assault. It is believed that the wider use of this manual creates a better condition for the management and care of victims, generating reliable data, as well as a comprehensive and understandable way of communicating evidences for legal use.

Definition

Sexual Violence is any act, attempted or threatened, that is sexual in nature and is done with force – physical, mental/emotional, or social – and without the consent of the affected person/survivor. This includes acts of forcing another individual, through violence, threats, deception, cultural expectations, weapons, or economic circumstances, to engage in behavior against his or her will.

Gender- Based Violence is physical, mental or social abuse (including sexual violence) including acts, attempted or threatened, done with some type of force, manipulation, or coercion and without the informed consent of the affected person/survivor.

Forms of gender violence include sexual violence, sexual abuse, sexual harassment, sexual exploitation, early or forced marriage, discrimination, and female genital mutilation.

Types of Gender based Violence and their definition 

Rape

Rape is an act of non-consensual sexual intercourse (penis-vagina or penis-anus). Any penetration is considered rape, and includes:

• Rape of an adult female

• Rape of a minor (male or female), including incest. Even if the minor was agreeing to the act, she/he cannot legally consent due to his/her age.

• Gang rape, if there is more than one assailant

• Male rape, sometimes known as sodomy

Sexual Assault

Sexual assault is an intentional act involving sexual organ. It includes acts like insertion of foreign objects into the genitals, forced removal of clothing, forcing someone to engage in sexual acts or positions, forcing someone to watch sexual acts.

Child Abuse

Involves a non accidental injuries in a child as result of acts of omission on the part of parents or guardians for which there is no reasonable explanation

Child sexual abuse

Child sexual abuse is defined as any use of a child for the sexual pleasure of adults. The sexual act can be penetrative or non penetrative. Non-penetrative acts include exhibitionism, fondling, use or exposure to pornography and solicitation to engage in sexual activity.

Under the Ethiopian penal law articles 620-631 have included sexual misconduct that is clearly punishable

1. The use of force or threat or rendering a woman unconscious or in a position unable to defend herself (620) to have sex

2. Sexual act on a person who is mentally incompetent (623)

3. Hospitalized persons, incarcerated or imprisoned persons  (624)

4. Taking advantage of material or psychological problems or moral superiority (625)

5. Children under 18 (626-7)

Under Ethiopian law the following are aggravating conditions  (628)

1. If pregnancy follows

2. If the victim sustained sexually transmissible infections

3. If the victim commits suicide out of physical or psychological distress

Evaluation of victims of sexual assault

Medical Examination

The medical management of the sexually abused child/adult is basically the same as that of any other patients. It consists of taking history, physical examination, investigations, treatment and follow-up. In addition attention must be paid to the medico-legal aspects, which includes the completion of the medical certificate.

Taking the history

A good history taking will help the attendant develop rapport and trust which is especially important with children.

a) Setting

• Wherever possible private and a quiet environment

• Minimize number of people present. Only the victim (if the victim is a child or wishes the presence of an accompanying person, it should be allowed), the doctor and one nurse

b) Introduction

• Explain who you are, the purpose of the interview and examination

• Explain that the victim has the right to know findings and to pose questions and express concerns

c) Interviewing skills

• Requires: empathy, non-judgmental attitude, respect, patience, gentleness, compassion and good listening skills.

• Ask open ended questions, start about general issues, slowly direct towards incident

• Face client squarely

• Adopt open posture (i.e. no crossed arms etc) 

• Lean towards client

• Maintain eye contact

• Try to be relaxed

• React neutrally, but with empathy to the story, don't show horror or disgust

History Taking

1. General medical history

Take a detailed medical history

2. Gynecological history

	Reproductive history (Gravidity, Parity, Abortion)
	Last menstrual period (LMP) - if the woman is pregnant; does the dates coincide with abuse.
	Previous STI and treatment
	Use of family planning

3. Sexual History

	Ask whether the victim is sexually active or not active
	Date and time of last consensual intercourse and number of partners in last 7 days especially important when collecting semen for forensic evidence

4. Details of incident

	Date, time and frequency of abuse, and date of last incident in cases of repeated abuse
	Location
	Number of assailants
	Details of perpetrator, is he/she still posing a threat?
	Details of physical/ sexual assault, was a weapon or object used
	Occurrence of ejaculation,
	Use of condoms
	Drugs or alcohol taken or given

Physical examination

	Have adequate light
	Have a swab ready. With children show them and explain what you might have to do
	Never have an adult or child completely undressed. First undress upper half, than bottom half
	Female genital examination

Position:

	'Frog leg' with hips flexed and soles of feet touching one another
	On mother's lap with a young child

NB:  when examining a child

	If very agitated, the child can be sedated with Diazepam 1 mg/kg of body weight
	If child uncooperative, delay examination or arrange for an examination under anesthesia

General Appearance

	Height/weight for children and if appropriate for adult
	General (nutritional) status
	Signs of neglect or physical abuse
	Obvious functional impairments

Extra-genital Injuries

	Describe type of injuries, their position, age and note whether 'lesion is consistent with injury caused by blunt/sharp object/burns/.
	Use a diagram to illustrate injuries.
	Clothing: Mainly relevant in acute cases, i.e. describe whether torn, type of dirt, blood etc.

Asses Mental State

1. Assess ability to consent, i.e. drunk, mentally retarded etc.

2. When you feel patient is 'slow', 'can't quite hold a normal conversation,' it is advisable to seek expert opinion from a psychiatrist/clinical psychologist

3. In children describe whether child is anxious, fearful, tearful, happy, withdrawn etc. These observations may complement the story and/or physical findings.

Genital findings

Breasts

1. Write sexual maturation, either use: Tanner stage

1-5

Or: 'pre-pubertal,' 'pubertal,' 'mature'

2. Any injury, bruising, bite etc

Describe any change noticed on

§         Labia Majora

§         Labia Minora

§         Vestibule

§         urethra   

§         fossa navicularis

§         Posterior fourchette

§         Perineum

§         Hymen

Hymeneal examination

	Look at hymen with gentle traction at posterior edge of labia majora out wards and downwards. You may ask the patient to 'push against' your fingers, this will generally open up the hymeneal orifice if not visible on traction
	A cotton swab inserted through the hymeneal orifice may also be used to look at the hymeneal rim. It can then be used as a specimen for laboratory examination.
	Describe - shape

                      estrogenation

                      irregularity, distortion ,etc in normally smooth margin

                      narrowing of hymeneal rim (attenuation)

Vaginal Examination is rarely indicated if vaginal examination is done. Note the following:

	Discharge: Physiological, infection, color, odor, consistency
	Hemorrhage: Traumatic/menstrual
	Uterine size by palpation / by dates

Anal examination

Left lateral position with flexed knees

Gentle parting/ separation of buttocks (30 seconds only)

Describe

 

	Acute changes /TEARS (see page 9)
	Fresh tears at 'x' o'clock
	Anal margin - look for irregularities, deficits, distortion, etc
	Fissures - at 'x' o'clock
	Acute fissures can occur in young children who have not been abused, they tend to occur in the mid line, either posterior or anterior.

Forensic evidence and laboratory investigation

Vaginal swab for spermatozoa

Take a swab for semen before doing the internal/speculum examination in the adult, as KY jelly interferes with the forensic analysis.

Time limits to detect the following:

Voluntary counseling and confidential testing (VCT)

Refer to a person trained in VCT for pre test counseling, testing and post test counseling for HIV. Testing for HIV should be done at initial encounter, at three months and six months for a victim who is negative to HIV test at initial encounter 

Screen for sexually transmissible infections

The following tests should be done to screen for STIs other than HIV

§         Hepatitis B surface antigen

§         VDRL/RPR

§         Grams stain for intra cellular diplococci (ICDC)

§         Saline mount for Trichomonas Vaginalis

Confirm or exclude pregnancy

If menses is overdue in a woman who has had a regular cycle or a period has been missed do urine for HCG to confirm pregnancy and if need be do ultra-sonography to confirm pregnancy and also ascertain gestational age.

Management

Purpose of management

·         To prevent acute life threatening conditions like suicide

·         To identify and treat acute genital injury

·         To give prophylactic management for sexual transmitted infections and prevention of pregnancy

·         To provide evidences of sexual assault

·         To provide psychological care or refer as appropriate

1.      Appropriate medical or surgical treatment for acute injuries.

Treatment of wounds

·         Baths in plain or salted warm water for superficial abrasions.

·         Surgical suturing for larger and actively bleeding laceration (general anesthesia  may be required)

·         Analgesics for pain

2.      Pregnancy prevention

A.           Emergency contraception

a)      Progestin only Pills

· Levonorgesrel 0.75mg one tab 12 hours apart within 72    hours of incident   eg. Postinor

·  Levonorgesrel 0.0375 mg containing oral contraceptives

              20 tabs per dose 12 hours apart eg. Ovrette

b)      Combined oral contraceptive pills with High dose of estrogen  (50µg) E.g. Ovral: 2-tabs 12 hours apart (total 4 tabs) within 72 hours

c)      Combined oral contraceptive pills with low dose of estrogen  (30µg) E.g. Nordette 4 tabs 12 hours apart (total 8 tabs) within 72 hours of incident

d)      IUD (copper IUDs are preferable) insertion up to 5 days post incident

N.B  If vomiting occurs as side effect within 2 hours of ingestion of the pills the dose should be repeated with advice of antiemetic before the replacement and the second dose

Though the effectiveness of pills decreases after 72 hours it can be administered up to 3-5 days.

3.      Prophylaxis for STDs:

Adults

All new cases of abuse should be given empirical anti-microbial therapy for chlamydia, gonococcus and trichomonal infection

Ø            Ceftriaxone 250 mg IM in single dose, plus

Ø            Metronidazole 2 gm orally in single dose, plus

Ø            Doxycycline 100mg orally two times a day for 7 days.

Children or pre-pubertal cases

Erythromycin 30-50mg/kg/day in divided doses every 6 hours. Use Erythromycin in patients who are allergic to tetracycline.

N.B: other appropriate antibiotics can be used according to local sensitivity pattern

4.      Hepatitis B Prophylaxis (vaccine if indicated)

Post exposure hepatitis B vaccination adequately protect against HBV

Hepatitis B vaccine should be administered to victims of sexual assault at the time of initial examination and should be repeated one month and 6 month after the first dose

5.      Tetanus (passive and active immunization)

Key

1         TT=tetanus toxoid,

2         TIG=tetanus immunoglobulin,

3         TAT=tetanus antitoxin

TT schedule

Dose 1: At the first contact to the clinic

Dose 2: 4 weeks after the first dose

Dose 3: 6-12 months after the second dose

Booster: all 10 years

Dose: TIG 250 -500 units IM

          : TAT 3000-6000 units IM after skin test

7.     Provide appropriate counseling and psychological support and referral

In case patient is agitated or have any indication of possible consequences due to her mental state give diazepam 5-10 mg per os (PO) daily at bed time and refer for psychosocial care.

Follow up evaluation two weeks and 12 weeks later

n       Screen for pregnancy and manage

n       Screen for STI and treat

n       Asses emotional status

n       Repeat serum test for RPR/TPHA

n       Repeat serum test for HIV at 3 and 6 months

n       Refer for psychiatric support

n       Refer for social support

n       Assess community resources

Legal obligations of sexual assault

n       Record events accurately

n       Document injury with diagrams

n       Collect sample to be sent for forensic examination whenever possible

n       Provide medico legal certificate using reporting format

Sexual Violence Report Form

Name of the health institution .................................................................

Card number ..........................................................................................

Date & Time..........................................................................................

Date and time incident occurred ...........................................................

Patient Name .........................................................................................

Sex .........................................................................................................

Age .........................................................................................................

Caretaker’s name ..................................................................................

Relation to survivor ................................................................................

Address .................................................................................................

Occupation ............................................................................................

Marital status ..........................................................................................

Parity ......................................................................................................

Previous Sexual experience ..................................................................

Menstrual history ....................................................................................

LMP ........................................................................................................

Description of incident in survivor’s words

On clinical Examination

Patient’s Appearance:

Vital Signs

BP…………Pulse……………Respiration rate………Temp…........

Description of Wounds and Injuries

Use pictogram and mark exact location of wounds also

Genital exam

Labia majora...............................................................

Labia minora............................................................................

Vestibule...................................................................................... Perineum......................................................................................

Discharge.....................................................................................

Hemorrhage.................................................................................

Genital Examination

Use pictogram and mark exact location

Examination: easy/painful........................................other juries...................................

Anus(in sodomy cases)................................................................................................

General remarks ..........................................................................................................

Remarks as to whether penetration effected ..............................................................

......................................................................................................................................

......................................................................................................................................

......................................................................................................................................

......................................................................................................................................

Laboratory results

Vaginal swab

Sample for motile spermatozoa ......................................................

Gram stains......................................................................................

Wet amount......................................................................................

Chlamydia test..................................................................................

Culture specimen from the cervix.....................................................

Pregnancy test..................................................................................

Serology

VDRL...................................................................................................

HBsAG................................................................................................

Serology for HIV..................................................................................

Management Given

Referral

Referral for psychotherapy                            Yes                     No

Referral for other reasons (specify)              Yes                     No

Follow up Recommended                             Yes                     No

Other comments

      Name of health care provider.......................................

      Signed  ........................................................................

      Date      ........................................................................