GUIDELINES FOR MEDICO-LEGAL CARE FOR VICTIMS OF SEXUAL VIOLENCE4 Assessment and examination ofadult victims of sexual violenceSUMMARY In caring for victims of sexual violence the overriding priority must always be the health andwell-being of the patient. The physical examination of sexual assault victims must be thorough; it will inevitably beintrusive and time consuming. In the interest of avoiding multiple examinations and further distressfor the patient, the medical examination and forensic evidence collection should, when possible,occur simultaneously. Treating a victim of sexual assault with respect and compassion throughout the examinationwill aid her recovery. Obtaining informed consent for the examination and for the release of information to thirdparties is a crucial component of the service. All parts of the examination should be explained in advance; during the examination, patientsshould be informed when and where touching will occur and should be given ample opportunityto ask questions. The patient’s wishes must be upheld at all times. All findings must be documented carefully; to help ensure that no important details are omitted,the use of a standard examination form is recommended (see Annex 1).4.1 OverviewIndividuals who have suffered sexual violence, irrespective of the point at whichthey present within the health sector, should be offered a full medical-forensicexamination, the main components of which are as follows:— an initial assessment, including obtaining informed consent (see section4.2);— a medical history, including an account of the events described as sexualviolence (see section 4.3);— a “top-to-toe” physical examination (see section 4.4.2);— a detailed genito-anal examination (see section 4.4.3);— recording and classifying injuries (see section 4.5);— collection of indicated medical specimens for diagnostic purposes (seesection 4.6);— collection of forensic specimens (see section 5.2);— labelling, packaging and transporting of forensic specimens to maintainthe chain of custody of the evidence (see section 5.2);— therapeutic opportunities (see sections 6.1–6.5);— arranging follow-up care (see section 6.7);30

4 . A S S E S S M E N T A N D E X A M I N AT I O N O F A D U LT V I C T I M S O F S E X U A L V I O L E N C E— storage of documentation (see section 8.1.2);— provision of a medico-legal report (see section 8.3).Although these guidelines take the adult female as their subject, many of theprinciples and procedures described below apply equally to adult men. Specificconcerns as they relate to the care of men are highlighted in Box 4. The specialcase of children is, however, covered separately (section 7 Child sexual abuse).Rape victims need an unusual degree of professional reassurance, acceptanceand understanding in regard to the therapeutic examination (37). Dealing withpatients who have been subjected to sexual violence thus demands a broadrange of skills:— a knowledge of normal human sexual responses, genito-anal anatomyand physiology;— a knowledge of medical and colloquial terms for sexual organs and sexualacts;— good communication skills;— a basic knowledge of the dynamics of sexual violence;— an understanding of the legal issues surrounding sexual crimes;— an understanding of relevant cultural and/or religious issues;— empathy and sensitivity.BOX 4Medical management of adult male victims of sexual violenceWith regard to the physical examination and medical interventions: Male victims of sexual violence should be triaged in the same manner as female victims. The same procedures for obtaining consent, taking a history, conducting the physical examination(although the genital examination will be different) and ordering diagnostic laboratory tests shouldbe followed, that is:— perform a top-to-toe examination looking for any signs of injury;— conduct a thorough examination of the genito-anal area;— treat any injuries (men also need to be treated for STIs, hepatitis B and tetanus). Men need to be informed about, and offered, a HIV test and the option of post-exposure prophylaxis,if available. Men also need to receive follow-up care for wound healing, any prescribed treatments(including those for STIs), completion of medications and counselling.4.2 The initial assessment4.2.1 Assessing the prioritiesOn presentation, victims of sexual violence should be granted immediate accessto a trained health worker.Their acute health care needs are the primary concernat this early stage and should be assessed as soon as possible.In busy settings where several patients may present simultaneously, such ashospital emergency departments, it will be necessary to sort out the order of31

GUIDELINES FOR MEDICO-LEGAL CARE FOR VICTIMS OF SEXUAL VIOLENCEurgency in which patients are seen. Victims of sexual violence who have seriousor life-threatening injuries will need acute medical or surgical care, asappropriate. Under these circumstances, the safety, health and well-being ofthe patient always takes priority over all other considerations. It may not alwaysbe possible to attend to the medical needs of patients with less severe injuriesimmediately; if a wait is unavoidable, patients should not be left alone in awaiting room, but should have someone with them to offer comfort and supportuntil their medical needs can be attended to.4.2.2 How health workers should conduct themselvesA victim is often in a heightened state of awareness and very emotional afteran assault due to circulating stress hormones; events may be recalled in dramaticdetail. Many survivors of sexual assault have described the kindness of thetreating personnel as being beneficial to their recovery. Conversely, manydescribe comments made by police, doctors, counsellors and other personswith whom they have had contact as a result of the assault that have hauntedthem for years. For this reason, health workers must choose their words withgreat care when dealing with sexual assault patients and take care not tocontribute in any way to revictimization of the patient.Use of insensitive language may contribute not only to patient distressduring the examination but also hinder long-term recovery. Healthworkers are advised to choose words that are gentle and soothing; thereis no place for judgmental or critical comments. It is imperative thatall victims of sexual violence are treated with respect and dignitythroughout the entire examination irrespective of their social status,race, religion, culture, sexual orientation, lifestyle, sex or occupation.Some of the emotions and feelings that are commonly expressed by victims ofsexual violence, together with suggestions for appropriate responses, are listedin Table 5. Box 5 also offers advice on appropriate health care provider conductand demeanour.Many victims cite a fear of not being believed as a reason for not reportingsexual assault and, indeed, recovery can be hindered when others disbelieve orblame the patient for the assault. Validation of the patient’s feelings is thuscritical to recovery (52). Body language, gestures and facial expressions allcontribute to conveying an atmosphere of believing the patient’s account.However, this does not relieve the health worker from his/her duty to considercarefully what they are being told. There is a big difference between scepticismand naivete, and it is in between these polarities that the health worker canbest satisfy the differing needs of patient, law enforcement, criminal justicesystem and the wider society. To be seen to be impartial is vital for effectivecourt testimony.Health workers should also be aware of the impact on themselves of repeatedlyhearing, seeing and dealing with cases of interpersonal violence. Recognitionof the effects of exposure to what are inevitably, at least at times, extremely32

4 . A S S E S S M E N T A N D E X A M I N AT I O N O F A D U LT V I C T I M S O F S E X U A L V I O L E N C ETable 5 Management of victims of sexual violence: helping patients to deal with their emotionsTHE FEELINGSOME WAYS TO RESPONDHopelessnessSay, “You are a valuable person.”DespairFocus on the strategies and resourcefulness that the person used tosurvive.Powerlessness and loss of controlSay, “You have choices and options today in how to proceed.”FlashbacksSay, “These will resolve with the healing process.”Disturbed sleepSay, “This will improve with the healing process.”DenialSay, “I’m taking what you have told me seriously. I will be here if youneed help in the future.”Guilt and self-blameSay, “You are not to blame for what happened to you. The person whoassaulted you is responsible for the violence.”ShameSay, “There is no loss of honour in being assaulted. You are anhonourable person.”FearEmphasize, “You are safe now.” You can say, “That must have been veryfrightening for you.”NumbnessSay, “This is a common reaction to severe trauma. You will feel again. Allin good time.”Mood swingsExplain that these are common and should resolve with the healingprocess.AngerA legitimate feeling and avenues can be found for its safe expression.Assist the patient in experiencing those feelings. For example, “Yousound very angry.”AnxietyTell the patient that these symptoms will ease with the use of theappropriate stress management techniques and offer to explain thesetechniques.HelplessnessSay, “It sounds as if you were feeling helpless. We are here to help you.”Source: adapted from references (50, 51).BOX 5Dealing with victims of sexual violence: useful techniquesYou may find the following strategies and techniques helpful when dealing with victims of sexual violence: Greet the patient by name. Use her preferred name. Make her your central focus. Introduce yourself to the patient and tell her your role, i.e. physician, nurse, health worker. Aim for an attitude of respectful, quiet professionalism within the boundaries of your patient’s culture. Have a calm demeanour. A victim who has been frightened and has experienced fear wants to be inthe company of people who are not frightened. Be unhurried. Give time. Maintain eye contact as much as is culturally appropriate. Be empathetic and non-judgmental as your patient recounts her experiences33

GUIDELINES FOR MEDICO-LEGAL CARE FOR VICTIMS OF SEXUAL VIOLENCEdistressing events and an ability to develop mechanisms for coping are essentialfor maintaining one’s personal health and well-being while working long-termin this field. Health service managers need to be aware of this and to ensuresupport is available to staff. There are a number of fora, both formal andinformal, that can assist health workers address any issues they may have; theseinclude psychological debriefing sessions and discussions with fellowworkers.4.2.3 Obtaining consentBefore a full medical examination of the patient can be conducted, it is essentialthat informed consent be obtained. In practice, obtaining informed consentmeans explaining all aspects of the consultation to the patient. Particularemphasis should be placed on the matter of the release of information to otherparties, including the police. This is especially important in settings wherethere is a legal obligation to report an episode of violence (and hence details ofthe consultation) to the relevant authorities.Thus, having determined the medical status of the patient, the next step inthe assessment process is to inform the patient of her options. It is crucial thatpatients understand the options open to them and are given sufficientinformation to enable them to make informed decisions about their care. It isimportant that the correct environment is provided, i.e. one in which the patientfeels secure and does not feel pressurized or intimidated in any way. This is afundamental right of all patients but has particular relevance in this settingwhere patients may have been subjected to a personal and intrusive event againsttheir will. It is also important to ensure that a patient has a sense of controlreturned to them when in medical care. Above all, the wishes of the patientmust be respected.Informed consent is a central issue in medico-legal matters. Examininga person without their consent could result in the medical officer inquestion being charged with offences of assault, battery or trespass. Insome jurisdictions, the results of an examination conducted withoutconsent cannot be used in legal proceedings.4.3 Taking a historyOnce you are satisfied that your patient has sufficient information to provideinformed consent, ask her to sign or mark the consent form (if a consent formis required in your jurisdiction). Explain to the patient that should she decideto pursue legal action against the perpetrator, any information she discloses toyou in the course of the examination may become part of the public record. Ifmandatory reporting is required in your jurisdiction, make sure the patientunderstands this. It is worth spending time obtaining consent as this may wellhelp to develop the patient’s trust in you. It will benefit everyone if you canmake your patient feel safe and secure in the environment in which you areworking, as well as with yourself, as her examiner.34

4 . A S S E S S M E N T A N D E X A M I N AT I O N O F A D U LT V I C T I M S O F S E X U A L V I O L E N C E4.3.1 General medical historyThe primary purpose of taking a medical history is to obtain information thatmay assist in the medical management of the patient or may help to explainsubsequent findings, e.g. easy bruising or loss of consciousness or memoryloss. Health professionals are advised to refer to national guidelines or standardsfor conducting clinical examinations to ensure that they are in compliance.As a minimum, the medical history should cover any known health problems(including allergies), immunization status and medications. In terms ofobtaining information about the patient’s general health status, useful questionsto ask would be: Tell me about your general health.Have you seen a nurse or doctor lately