Clinical Management

of Rape Survivors
Developing protocols for use with refugees
and internally displaced persons

Revised edition
Clinical Management

of Rape Survivors
Developing protocols for use with refugees
and internally displaced persons

Revised edition
 WHO Library Cataloguing-in-Publication Data Free-of-charge copies of this document can
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Clinical management of rape survivors: developing
protocols for use with refugees and internally UNHCR - Technical Support Section
displaced persons -- Revised ed. C.P. 2500, 1202 Geneva, Switzerland
Fax: +41-22-739 7366
1. Rape 2. Refugees. 3. Survivors 4. Counseling E-mail: HQTS00@unhcr.ch
5.Clinical protocols 6.Guidelines Web site: http://www.unhcr.ch
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Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Abbreviations and acronyms used in this guide . . . . . . . . . . . . . . . . . . . . . viii

introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

STEP 1 – Making preparations to offer medical care to rape survivors . . . . . . . . . . 5

STEP 2 – Preparing the survivor for the examination . . . . . . . . . . . . . . . . . . . 9

STEP 3 – Taking the history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

STEP 4 – Collecting forensic evidence. . . . . . . . . . . . . . . . . . . . . . . . . . 12

STEP 5 – Performing the physical and genital examination . . . . . . . . . . . . . . . 16

STEP 6 – Prescribing treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

STEP 7 – Counselling the survivor . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

STEP 8 – Follow-up care of the survivor . . . . . . . . . . . . . . . . . . . . . . . . . 29

iii
Care for child survivors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

ANNEX 1 – Additional resource materials . . . . . . . . . . . . . . . . . . . . . . . . 35

ANNEX 2 – Information needed to develop a local protocol . . . . . . . . . . . . . . . 37

ANNEX 3 – Minimum care for rape survivors in low-resource settings . . . . . . . . . 38

ANNEX 4 – Sample consent form . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

ANNEX 5 – Sample history and examination form . . . . . . . . . . . . . . . . . . . . 42

ANNEX 6 – Pictograms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

ANNEX 7 – Forensic evidence collection . . . . . . . . . . . . . . . . . . . . . . . . 50

ANNEX 8 - Medical certificates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

ANNEX 9 – Protocols for prevention and treatment of stis. . . . . . . . . . . . . . . . 57

ANNEX 10 – Protocols for post-exposure prophylaxis of hiv infection . . . . . . . . . . 59

ANNEX 11 – Protocols for emergency contraception . . . . . . . . . . . . . . . . . . 63

Preface
Sexual and gender-based violence, nongovernmental, governmental and
including rape, is a problem throughout the intergovernmental organizations shared
world, occurring in every society, country their experiences and lessons learned.
and region. Refugees and internally
displaced people are particularly at risk of The first version of this document was an
this violation of their human rights during outcome of that conference. It was
every phase of an emergency situation. distributed in a variety of settings around
The systematic use of sexual violence as a the world and field-tested at several sites.
method of warfare is well documented and Feedback from these field-tests has been
constitutes a grave breach of international included in the current revised version,
humanitarian law. which is the result of collaboration
between the International Committee of
Over the past five years, humanitarian the Red Cross (Health Unit); the United
agencies have been working to put in place Nations High Commissioner for Refugees
systems to respond to sexual and (Technical Support Unit); the United
gender-based violence, as well as to Nations Population Fund (Humanitarian
support community-based efforts to prevent Response Unit); and the World Health
such violence. In March 2001, the Organization (Department of Reproductive
international humanitarian community came Health and Research, Department of
together to document what had been done Injury and Violence Prevention, and
and what still needed to be done to prevent Department of Gender and Women's
and respond to sexual and gender-based Health). This version has also been
violence towards refugees. In a conference updated to include the most recent
hosted by the office of the United Nations technical information on the various
v
High Commissioner for Refugees, Geneva, aspects of care for people who have been
160 representatives of refugee, raped.
Acknowledgements
This guide is an outcome of the Inter-Agency World Health Organization Headquarters
Lessons Learned Conference: Prevention and Departments of Reproductive Health and
Response to Sexual and Gender-Based Research, Injury and Violence Prevention,
Violence in Refugee Situations, 27-29 March and Gender and Women's Health, with the
2001, Geneva, Switzerland. support of the Departments of

Special thanks go to all those who 5 Emergency and Humanitarian Action,

participated in the review and field-testing of
this document: 5 Essential Drugs and Medicines Policy,

Centers for Disease Control and Prevention 5 HIV/AIDS,

(CDC), Atlanta, GA, USA; 5 Mental Health and Substance
Center for Health and Gender Equity Dependence, and
(CHANGE), Takoma Park, MD, USA; 5 Vaccines and Biologicals;
Département de Médecine Communautaire, World Health Organization Regional Office
Hôpital Cantonal Universitaire de Genève, for Africa;
Geneva, Switzerland;
World Health Organization Regional Office
International Centre for Reproductive Health, for South-East Asia.
Ghent, Belgium;
A particular note of appreciation goes out to
International Committee of the Red Cross, the following individuals who contributed to
Women and War Project and Health Unit, the finalization of this guide:
Geneva, Switzerland; vii
Dr Michael Dobson, John Radcliffe Hospital,
International Medical Corps, Los Angeles, Oxford, England;
CA, USA;
Ms Françoise Duroc, Médecins Sans
Ipas USA, Chapel Hill, NC, USA; Frontières, Geneva, Switzerland;
Médecins Sans Frontières, Belgium, The Dr Coco Idenburg, formerly Family Support
Netherlands, Spain, Switzerland; Clinic, Harare, Zimbabwe;
Physicians for Human Rights, Boston, MA, Dr Lorna J. Martin, Department of Forensic
USA; Medicine and Toxicology, Cape Town,
Reproductive Health Response in Conflict South Africa;
Consortium (American Refugee Committee, Ms Tamara Pollack, UNICEF, New York,
CARE, Columbia University's Center for NY, USA;
Population and Family Health, International
Rescue Committee, Research and Training Dr Nirmal Rimal, AMDA PHC Programme
Institute of John Snow, Inc., Marie Stopes Bhutanese Refugees, Jhapa, Nepal;
International, Women's Commission for
Ms Pamela Shifman, UNICEF, New York,
Refugee Women and Children);
NY, USA;
United Nations Population Fund,
Dr Santhan Surawongsin, Nopparat
Humanitarian Response Unit, Geneva,
Rajathanee Hospital, Bangkok, Thailand.
Switzerland;
Thanks are also due to the
United Nations High Commissioner for
nongovernmental organizations and UNHCR
Refugees, Technical Support Section,
staff in the United Republic of Tanzania,
Geneva, Switzerland;
especially Marian Schilperoord, who
organized the field-testing of this guide.
 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

ICRC International Committee of the Red Cross

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

UNFPA United Nations Fund for Population Assistance

UNHCR United Nations High Commissioner for Refugees

VCT voluntary counselling and testing

WHO World Health Organization

Introduction
Note: It is not the responsibility of the
health care provider to determine whether
This guide describes best practices in the a person has been raped. That is a legal
clinical management of people who have determination. The health care provider's
been raped in emergency situations. It is responsibility is to provide appropriate
intended for adaptation to each situation, care, to record the details of the history,
taking into account national policies and the physical examination, and other
practices, and availability of materials and relevant information, and, with the
drugs. person's consent, to collect any forensic
evidence that might be needed in a
subsequent investigation.

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

Special considerations needed when caring

for children, men, and pregnant or elderly
women are also described.
Human rights and medical 5 Right to non-discrimination: Laws,
policies, and practices related to access
care for survivors of rape to services should not discriminate
against a person who has been raped
Rape is a form of sexual violence, a public on any grounds, including race, sex,
health problem and a human rights colour, or national or social origin. For
violation. Rape in war is internationally example, providers should not deny
recognized as a war crime and a crime services to women belonging to a
against humanity, but is also characterized particular ethnic group.
as a form of torture and, in certain
5 Right to self-determination: Providers
circumstances, as genocide. All individuals,
should not force or pressure survivors
including actual and potential victims of
to have any examination or treatment
sexual violence, are entitled to the
against their will. Decisions about
protection of, and respect for, their human
receiving health care and treatment
rights, such as the right to life, liberty and
(e.g. emergency contraception and
security of the person, the right to be free
pregnancy termination, if the law allows)
from torture and inhuman, cruel or
are personal ones that can only be
degrading treatment, and the right to
made by the patient herself. In this
health. Governments have a legal
context, it is essential that the survivor
obligation to take all appropriate measures
receives appropriate information to
to prevent sexual violence and to ensure
allow her to make informed choices.
that quality health services equipped to
Survivors also have a right to decide
respond to sexual violence are available
whether, and by whom, they want to be
and accessible to all.
accompanied when they receive
information, are examined or obtain
Health care providers should respect the
other services. These choices must be
human rights of people who have been
respected by the health care provider.
raped. 3
5 Right to information: Information
5 Right to health: Survivors of rape and should be provided to each client in an
other forms of sexual abuse have a right individualized way. For example, if a
to receive good quality health services, woman is pregnant as a result of rape,
including reproductive health care to the health provider should discuss with
manage the physical and psychological her all the options legally available to
consequences of the abuse, including her (e.g. abortion, keeping the child,
prevention and management of adoption). The full range of choices
pregnancy and STIs. It is critical that must be presented regardless of the
health services do not in any way individual beliefs of the health provider,
"revictimize" rape survivors. so that the survivor is able to make an
informed choice.
5 Right to human dignity: Persons who
have been raped should receive 5 Right to privacy: Conditions should be
treatment consistent with the dignity and created to ensure privacy for people
respect they are owed as human beings. who have been sexually abused. Other
In the context of health services, this than an individual accompanying the
means, as a minimum, providing survivor at her request, only people
equitable access to quality medical care, whose involvement is necessary in
ensuring patients' privacy and the order to deliver medical care should be
confidentiality of their medical present during the examination and
information, informing patients and medical treatment.
obtaining their consent before any
medical intervention, and providing a 5 Right to confidentiality: All medical
safe clinical environment. Furthermore, and health status information related to
health services should be provided in the survivors should be kept confidential
mother tongue of the survivor or in a and private, including from members of
language she or he understands. their family. Health staff may disclose
 information about the health of the Health care providers, in collaboration
survivor only to people who need to be with workers in other sectors, may play a
involved in the medical examination and role in the broader community, by
treatment, or with the express consent of identifying and advocating for
the survivor. In cases where a charge interventions to prevent rape and other
has been laid with the police or other forms of sexual violence, and to promote
authorities, the relevant information from and protect the rights of survivors. Lack of
the examination will need to be conveyed recognition of rape as a health issue, and
(see Annex 4). non-enforcement of legislation against
rape, prevent any real progress towards
gender equality.

4
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, accredited or
workers should not prevent the health licensed medical doctor provide the
service providing care for survivors of rape. care and complete the official
documentation.
In setting up a service, the following
questions and issues need to be 5 What are the legal requirements with
addressed, and standard procedures regard to forensic evidence?
developed.
5 What are the legal requirements with
regard to reporting?
5
What should the 5 What are the national laws regarding
management of the possible medical
community be aware of? consequences of rape (e.g. emergency
contraception, abortion, testing and
Members of the community should know: prevention of human immunodeficiency
virus (HIV) infection)?
5 what services are available for people
who have been raped;
5 why rape survivors would benefit from What resources and
seeking medical care; capacities are available?
5 where to go for services;
5 What laboratory facilities are available
5 that rape survivors should come for care for forensic testing (DNA analysis, acid
immediately or as soon as possible after phosphatase) or screening for disease
the incident, without bathing or changing (STIs, HIV)? What counselling services
clothes; are available?
5 that rape survivors can trust the service 5 Are there rape management protocols
to treat them with dignity, maintain their and equipment for documenting and
security, and respect their privacy and collecting forensic evidence?
confidentiality;
5 Is there a national STI treatment
5 when services are available; this should protocol, a post-exposure prophylaxis
preferably be 24 hours a day, 7 days a (PEP) protocol and a vaccination
week. schedule? Which vaccines are
available? Is emergency contraception
available?
 5 What possibilities are there for referral of What is needed?
the survivor to a secondary health care
facility (counselling services, surgery,
paediatrics, or gynaecology/obstetrics 5 All health care for rape survivors should
services)? be provided in one place within the
health care facility so that the person
does not have to move from place to
place.
Where should care be
provided? 5 Services should be available 24 hours a
day, 7 days a week.
Generally, a clinic or outpatient service that 5 All available supplies from the checklist
already offers reproductive health services, below should be prepared and kept in a
such as antenatal care, normal delivery special box or place, so that they are
care, or management of STIs, can offer readily available.
care for rape survivors. Services may need
to be provided for referral to a hospital.
How to coordinate with
others
Who should provide care?
5 Interagency and intersectoral
All staff in health facilities dealing with rape coordination should be established to
survivors, from reception staff to health ensure comprehensive care for
care professionals, should be sensitized survivors of sexual violence.
and trained. They should always be
compassionate and respect confidentiality. 5 Be sure to include representatives of
social and community services,
6 protection, the police or legal justice
How should care be system, and security. Depending on the
services available in the particular
provided? setting, others may need to be included.

Care should be provided: 5 As a multisectoral team, establish

referral networks, communication
5 according to a protocol that has been systems, coordination mechanisms, and
specifically developed for the situation. follow-up strategies.
Protocols should include guidance on
medical, psychosocial and ethical
aspects, on collection and preservation of See Annex 3 for the minimum care that
forensic evidence, and on can and should be made available to
counselling/psychological support survivors even in the lowest-resource
options; settings.
5 in a compassionate and non-judgemental
manner;
5 with a focus on the survivor and her
needs;
5 with an understanding of the provider's
own attitudes and sensitivities, the
sociocultural context, and the
community's perspectives, practices and
beliefs.

Remember: the survivor's autonomy and right to make

her own decisions should be respected at all times.
Checklist of needs for clinical management of rape
survivors

1 Protocol Available?

# Written medical protocol in language of provider*

2 Personnel Available

# Trained (local) health care professionals (on call 24 hours/day)*

# For female survivors, a female health care 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, with access to a toilet or latrine)*

# Examination table*

# Light, 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 7

# Weighing scales and height chart for children

4 Supplies Available

# “Rape Kit” 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 needs for clinical management of rape
survivors

# Supplies for universal precautions (gloves, box for safe disposal of

contaminated and sharp materials, soap)*

# Resuscitation equipment*

# 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*

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

# Emergency contraceptive pills and/or copper-bearing 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 records confidential*

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
A person who has been raped has 5 Ask her if she has any questions.
experienced trauma and may be in an
agitated or depressed state. She often feels 5 Ask if she wants to have a specific
fear, guilt, shame and anger, or any person present for support. Try to ask
combination of these. The health worker her this when she is alone.
must prepare her and obtain her informed 5 Review the consent form (see Annex 4)
consent for the examination, and carry out with the survivor. Make sure she
the examination in a compassionate, understands everything in it, and
systematic and complete fashion. explain that she can refuse any aspect
of the examination she does not wish to
undergo. Explain to her that she can
To prepare the survivor delete references to these aspects on
for the examination: the consent form. Once you are sure
she understands the form completely,
ask her to sign it. If she cannot write,
5 Introduce yourself. obtain a thumb print together with the
5 Ensure that a trained support person or signature of a witness.
trained health worker of the same sex 5 Limit the number of people allowed in
accompanies the survivor throughout the the room during the examination to the
examination. minimum necessary. 9
5 Explain what is going to happen during 5 Do the examination as soon as
each step of the examination, why it is possible.
important, what it will tell you, and how it
will influence the care you are going to 5 Do not force or pressure the survivor to
give. do anything against her will. Explain
that she can refuse steps of the
5 Reassure the survivor that she is in examination at any time as it
control of the pace, timing and progresses.
components of the examination.
5 Reassure the survivor that the
examination findings will be kept
confidential unless she decides to bring
charges (see Annex 4).
 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 they are needed. happened. Allow her to speak at her
5 Before taking the history, review any own pace. Do not interrupt to ask for
documents or paperwork brought by the 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 Use a calm tone of voice and maintain tell you anything she does not feel
eye contact if culturally appropriate. comfortable with.
5 Let the survivor tell her story the way she 5 Survivors may omit or avoid describing
wants to. details of the assault that are
particularly painful or traumatic, but it is
5 Questioning should be done gently and
important that the health worker
at the survivor's own pace. Avoid
understands exactly what happened in
questions that suggest blame, such as
order to check for possible injuries and
"what were you doing there alone?"
to assess the risk of pregnancy and STI
5 Take sufficient time to collect all needed or HIV. Explain this to the survivor, and
information, without rushing. reassure her of confidentiality if she is
reluctant to give detailed information.
10 5 Do not ask questions that have already The form in Annex 5 specifies the
been asked and documented by other details needed.
people involved in the case.
5 Avoid any distraction or interruption
during the history-taking. History
5 Explain what you are going to do at every
step. 5 If the incident occurred recently,
determine whether the survivor has
A sample history and examination form is bathed, urinated, defecated, vomited,
included in Annex 5. The main elements of used a vaginal douche or changed her
the relevant history are described below. clothes since the incident. This may
affect what forensic evidence can be
collected.
General information 5 Information on existing health problems,
allergies, use of medication, and
5 Name, address, sex, date of birth (or age vaccination and HIV status will help you
in years). to determine the most appropriate
treatment to provide, necessary
5 Date and time of the examination and the counselling, and follow-up health care.
names and function of any staff or
support person (someone the survivor 5 Evaluate for possible pregnancy; ask for
may request) present during the interview details of contraceptive use and date of
and examination. last menstrual period.
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 suggests useful questions to ask the
survivor if a pregnancy test is not possible.

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)? 11

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
information on emergency arrive at an informed choice
contraception to help her (see Step 7)
arrive at an informed choice
(see Step 7)

1 Sexual assault nurse examiner (SANE) development and operation guide. Washington, DC,
United States Department of Justice, Office of Justice Programs, Office for Victims of
Crime, 1999 (www.sane-sart.com)

2 Checklist for ruling out pregnancy among family-planning clients in primary care. Lancet, 1999,
354(9178).
 STEP 4 – Collecting forensic
evidence
Forensic evidence may be used to
support a survivor's story, to confirm
The main purpose of the examination of a recent sexual contact, to show that force
rape survivor is to determine what or coercion was used, and possibly to
medical care should be provided. identify the attacker. Proper collection and
Forensic evidence may also be collected storage of forensic evidence can be key to
to help the survivor pursue legal redress a survivor's success in pursuing legal
where this is possible. redress. Careful consideration should be
given to the existing mechanisms of legal
The survivor may choose not to have
redress and the local capacity to analyse
evidence collected. Respect her choice.
specimens when determining whether or
not to offer a forensic examination to a
survivor. The requirements and capacity
of the local criminal justice system and the
Important to know before you capacity of local laboratories to analyse
develop your protocol evidence should be considered.
Different countries and locations have
different legal requirements and different
facilities (laboratories, refrigeration, etc.) Annex 7 provides more detailed
for performing tests on forensic materials. information on conducting a forensic
National and local resources and policies examination and on proper sample
12 determine if and what evidence should be collection and storage techniques.
collected and by whom. Only qualified and
trained health workers should collect
evidence. Do not collect evidence
that cannot be processed or that Collect evidence as soon
will not be used.
In some countries, the medical examiner
as possible after the
may be legally obliged to give an opinion incident
on the physical findings. Find out what the
responsibility of the health care provider is Documenting injuries and collecting
in reporting medical findings in a court of samples, such as blood, hair, saliva and
law. Ask a legal expert to write a short sperm, within 72 hours of the incident may
briefing about the local court proceedings help to support the survivor's story and
in cases of rape and what to expect to be might help identify the aggressor(s). If the
asked when giving testimony in court. person presents more than 72 hours after
the rape, the amount and type of evidence
that can be collected will depend on the
situation.
Reasons for collecting Whenever possible, forensic evidence
evidence should be collected during the medical
examination so that the survivor is not
A forensic examination aims to collect required to undergo multiple examinations
evidence that may help prove or disprove a that are invasive and may be experienced
connection between individuals and/or as traumatic.
between individuals and objects or places.
Documenting the case (see Annex 6). Health workers who
have not been trained in injury
interpretation should limit their role to
5 Record the interview and your findings at describing injuries in as much detail as
the examination in a clear, complete, possible (see Table 1), without
objective, non-judgemental way. speculating about the cause, as this can
5 It is not the health care provider's have profound consequences for the
responsibility to determine whether or not survivor and accused attacker.
a woman has been raped. Document 5 Record precisely, in the survivor's own
your findings without stating conclusions words, important statements made by
about the rape. Note that in many cases her, such as reports of threats made by
of rape there are no clinical findings. the assailant. Do not be afraid to
5 Completely assess and document the include the name of the assailant, but
physical and emotional state of the use qualifying statements, such as
survivor. "patient states" or "patient reports".

5 Document all injuries clearly and 5 Avoid the use of the term "alleged", as it
systematically, using standard can be interpreted as meaning that the
terminology and describing the survivor exaggerated or lied.
characteristics of the wounds (see Table 5 Make note of any sample collected as
1). Record your findings on pictograms evidence.

Table 1: Describing features of physical injuries

FEATURE NOTES 13
Use accepted terminology wherever possible, i.e. abrasion, contusion,
Classification
laceration, incised wound, gun shot.

Site Record the anatomical position of the wound(s).

Size Measure the dimensions of the wound(s).

Shape Describe the shape of the wound(s) (e.g. linear, curved, irregular).

Note the condition of the surrounding or nearby tissues (e.g. bruised,

Surrounds
swollen).

Colour Observation of colour is particularly relevant when describing bruises.

Comment on the apparent direction of the force applied (e.g. in

Course
abrasions).

Contents Note the presence of any foreign material in the wound (e.g. dirt, glass).

Comment on any evidence of healing. (Note that it is impossible

Age accurately to identify the age of an injury, and great caution is
required when commenting on this aspect.)

The characteristics of the edges of the wound(s) may provide a clue

Borders
as to the weapon used.

Give an indication of the depth of the wound(s); this may have to be

Depth
an estimate.

Adapted from Guidelines for medico-legal care for victims of sexual violence, Geneva, WHO, 2003.
 Samples that can be
Forensic evidence should be collected
collected as evidence during the medical examination and
should be stored in a confidential and
5 Injury evidence: physical and/or genital secure manner. The consent of the
trauma can be proof of force and should survivor must be obtained before
be documented (see Table 1) and evidence is collected.
recorded on pictograms. Work systematically according to the
medical examination form (see Annex 5).
5 Clothing: torn or stained clothing may be Explain everything you do and why you
useful to prove that physical force was are doing it. Evidence should only be
used. If clothing cannot be collected (e.g. released to the authorities if the
if replacement clothing is not available) survivor decides to proceed with a case.
describe its condition.
5 Foreign material (soil, leaves, grass) on
clothes or body or in hair may
corroborate the survivor's story. The medical certificate3
5 Hair: foreign hairs may be found on the
survivor's clothes or body. Pubic and Medical care of a survivor of rape includes
head hair from the survivor may be preparing a medical certificate. This is a
plucked or cut for comparison. legal requirement in most countries. It is
the responsibility of the health care
5 Sperm and seminal fluid: swabs may be provider who examines the survivor to
taken from the vagina, anus or oral make sure such a certificate is completed.
cavity, if penetration took place in these
locations, to look for the presence of The medical certificate is a confidential
sperm and for prostatic acid phosphatase medical document that the doctor must
14 analysis. hand over to the survivor. The medical
5 DNA analysis, where available, can be certificate constitutes an element of proof
done on material found on the survivor's and is often the only material evidence
body or at the location of the rape, which available, apart from the survivor's own
might be soiled with blood, sperm, saliva story.
or other biological material from the
assailant (e.g., clothing, sanitary pads, Depending on the setting, the survivor
handkerchiefs, condoms), as well as on may use the certificate up to 20 years
swab samples from bite marks, semen after the event to seek justice or
stains, and involved orifices, and on compensation. The health care provider
fingernail cuttings and scrapings. In this should keep one copy locked away with
case blood from the survivor must be the survivor's file, in order to be able to
drawn to allow her DNA to be certify the authenticity of the document
distinguished from any foreign DNA supplied by the survivor before a court, if
found. requested. The survivor has the sole right
to decide whether and when to use this
5 Blood or urine may be collected for document.
toxicology testing (e.g. if the survivor was
drugged).

3 Adapted from Medical care for rape survivors, MSF,December 2002

The medical certificate may be handed over
to legal services or to organizations with a
protection mandate only with the explicit
agreement of the survivor.

See Annex 8 for examples of medical

certificates. These should be adapted to
each setting in consultation with a legal
expert.

A medical certificate must

include:
& the name and signature of the exam-
iner;*
& the name of the survivor;*
& the exact date and time of the exami-
nation;*
& the survivor's narrative of the rape, in
her own words;
& the findings of the clinical examina-
tion;
& the nature of the samples taken;
& a conclusion.
* If the certificateis more than one page, these
elements should be included on every page of the
document.
15
If the certificate is shared with human
rights organizations for advocacy
purposes, without the consent of the
survivor, her name must be removed
from every page.
 STEP 5 – Performing the
physical and genital
examination
# extensive trauma (to genital region,
head, chest or abdomen),
The primary objective of the physical
# asymmetric swelling of joints (septic
examination is to determine what
arthritis),
medical care should be provided to the
survivor. # neurological deficits,
Work systematically according to the
medical examination form # respiratory distress.
(see sample form in Annex 5).
The treatment of these complications is
not covered here.
What is included in the physical 5 Obtain voluntary informed consent for
examination will depend on how soon after the examination and to obtain the
the rape the survivor presents to the health required samples for forensic
service. Follow the steps in Part A if she examination (see sample consent form
presents within 72 hours of the incident; in Annex 4).
Part B is applicable to survivors who
present more than 72 hours after the 5 Record all your findings and
incident. The general guidelines apply in observations as clearly and completely
16
both cases. as possible on a standard examination
form (see Annex 5).

General guidelines
Part A:
5 Make sure the equipment and supplies
are prepared. Survivor presents
5 Always look at the survivor first, within 72 hours of the
before you touch her, and note her incident
appearance and mental state.
5 Always tell her what you are going to
do and ask her permission before you Physical examination
do it.
5 Assure her that she is in control, can ask 5 Never ask the survivor to undress or
questions, and can stop the examination uncover completely. Examine the upper
at any time. half of her body first, then the lower half;
or give her a gown to cover herself.
5 Take the patient's vital signs (pulse,
blood pressure, respiratory rate and 5 Minutely and systematically examine
temperature). the patient's body. Start the examination
with vital signs and hands and wrists
5 The initial assessment may reveal severe rather than the head, since this is more
medical complications that need to be reassuring for the survivor. Do not
treated urgently, and for which the patient forget to look in the eyes, nose, and
will have to be admitted to hospital. Such mouth (inner aspects of lips, gums and
complications might include: palate, in and behind the ears, and on
 the neck. Check for signs of pregnancy. # Look for genital injury, such as
Take note of the pubertal stage. bruises, scratches, abrasions, tears
(often located on the posterior
5 Look for signs that are consistent with the fourchette).
survivor's story, such as bite and punch
marks, marks of restraints on the wrists, # Look for any sign of infection, such as
patches of hair missing from the head, or ulcers, vaginal discharge or warts.
torn eardrums, which may be a result of
being slapped (see Table 1 in Step 4). If # Check for injuries to the introitus and
the survivor reports being throttled, look hymen by holding the labia at the
in the eyes for petechial haemorrhages. posterior edge between index finger
Examine the body area that was in and thumb and gently pulling
contact with the surface on which the outwards and downwards. Hymenal
rape occurred to see if there are injuries. tears are more common in children
and adolescents (see "Care for child
5 Note all your findings carefully on the survivors", page 30).
examination form and the body figure
pictograms (see Annex 6), taking care to # Take samples according to your local
record the type, size, colour and form of evidence collection protocol. If
any bruises, lacerations, ecchymoses collecting samples for DNA analysis,
and petechiae. take swabs from around the anus and
perineum before the vulva, in order to
5 Take note of the survivor's mental and avoid contamination.
emotional state (withdrawn, crying, calm,
etc.). 5 For the anal examination the patient
may have to be in a different position
5 Take samples of any foreign material on than for the genital examination. Write
the survivor's body or clothes (blood, down her position during each
saliva, and semen), fingernail cuttings or examination (supine, prone, knee-chest
scrapings, swabs of bite marks, etc., or lateral recumbent for anal 17
according to the local evidence collection examination; supine for genital
protocol. examination).
# Note the shape and dilatation of the
anus. Note any fissures around the
Examination of the genital anus, the presence of faecal matter
area, anus and rectum on the perianal skin, and bleeding
from rectal tears.
Even when female genitalia are examined # If indicated by the history, collect
immediately after a rape, there is samples from the rectum according to
identifiable damage in less than 50% of the local evidence collection protocol.
cases. Carry out a genital examination as
indicated below. Collect evidence as you 5 If there has been vaginal penetration,
go along, according to the local gently insert a speculum, lubricated with
evidence collection protocol (see Annex water or normal saline (do not use a
7). Note the location of any tears, abrasions speculum when examining children; see
and bruises on the pictogram and the "Care for child survivors", page 30 ):
examination form.
# Under good lighting inspect the
cervix, then the posterior fornix and
5 Systematically inspect, in the following
the vaginal mucosa for trauma,
order, the mons pubis, inside of the
bleeding and signs of infection.
thighs, perineum, anus, labia majora and
minora, clitoris, urethra, introitus and # Take swabs and collect vaginal
hymen: secretions according to the local
evidence collection protocol.
# Note any scars from previous female
genital mutilation or childbirth.
 5 If indicated by the history and the rest of # Look for hyperaemia, swelling
the examination, do a bimanual (distinguish between inguinal hernia,
examination and palpate the cervix, hydrocele and haematocele), torsion
uterus and adnexa, looking for signs of of testis, bruising, anal tears, etc.
abdominal trauma, pregnancy or
infection. # Torsion of the testis is an emergency
and requires immediate surgical
5 If indicated, do a rectovaginal referral.
examination and inspect the rectal area
for trauma, recto-vaginal tears or fistulas, # If the urine contains large amounts of
bleeding and discharge. Note the blood, check for penile and urethral
sphincter tone. If there is bleeding, pain trauma.
or suspected presence of a foreign # If indicated, do a rectal examination
object, refer the patient to a hospital. and check the rectum and prostate
for trauma and signs of infection.
Note: In some cultures, it is unacceptable
to penetrate the vagina of a woman who is # If relevant, collect material from the
a virgin with anything, including a anus for direct examination for sperm
speculum, finger or swab. In this case you under a microscope.
may have to limit the examination to
inspection of the external genitalia, unless
there are symptoms of internal damage. Laboratory testing

Only the samples mentioned in Step 4

Special considerations for need to be collected for laboratory testing.
elderly women If indicated by the history or the findings
on examination, further samples may be
18 collected for medical purposes.
Elderly women who have been vaginally
raped are at increased risk of vaginal tears
5 If the survivor has complaints that
and injury, and transmission of STI and
indicate a urinary tract infection, collect
HIV. Decreased hormonal levels following
a urine sample to test for erythrocytes
the menopause result in reduced vaginal
and leukocytes, and possible for
lubrication and a thinner and more friable
culture.
vaginal wall. Use a thin speculum for
genital examination. If the only reason for 5 Do a pregnancy test, if indicated and
the examination is to collect evidence or to available (see Step 3).
screen for STIs, consider inserting swabs
only without using a speculum. 5 Other diagnostic tests, such as X-ray
and ultrasound examination, may be
useful in diagnosing fractures and
abdominal trauma.
Special considerations for
men

5 For the genital examination:

# Examine the scrotum, testicles, penis,
periurethral tissue, urethral meatus and
anus.
# Note if the survivor has been
circumcised.
Part B: Laboratory screening
Survivor presents Do a pregnancy test, if indicated and
more than 72 hours available (see Step 3). If laboratory
facilities are available, samples may be
after the incident taken from the vagina and anus for STI
screening for treatment purposes.
Screening might cover:
Physical examination
5 rapid plasma reagin (RPR) test for
syphilis or any point of care rapid test;
It is rare to find any physical evidence more
than one week after an assault. If the 5 Gram stain and culture for gonorrhoea;
survivor presents within a week of the rape,
or presents with complaints, do a full 5 culture or enzyme-linked
physical examination as above. In all immunosorbent assay (ELISA) for
cases: Chlamydia or any point of care rapid
test;
5 Note the size and colour of any bruises 5 wet mount for trichomoniasis;
and scars;
5 HIV test (only on a voluntary basis and
5 note any evidence of possible after counselling).
complications of the rape (deafness,
fractures, abscesses, etc.);
5 check for signs of pregnancy;
5 note the survivor's mental state (normal,
withdrawn, depressed, suicidal). 19

Examination of the genital

area

If the assault occurred more than 72 hours

but less than a week ago, note any healing
injuries to genitalia and/or recent scars.

If the assault occurred more than a week

ago and there are no bruises or lacerations
and no complaints (e.g. of vaginal or anal
discharge or ulcers), there is little indication
to do a pelvic examination.

Even when one might not expect to find

injuries, the survivor might feel that she has
been injured. A careful inspection with
subsequent reassurance that no physical
harm has been done may be of great relief
and benefit to the patient and might be the
main reason she is seeking care.
 STEP 6 – Prescribing treatment
Treatment will depend on how soon after presumptive treatment for gonorrhoea,
the incident the survivor presents to the chlamydial infection and syphilis.
health service. Follow the steps in Part A if
she presents within 72 hours of the 5 Be aware that women who are pregnant
incident; Part B is applicable to survivors should not take certain antibiotics, and
who present more than 72 hours after the modify the treatment accordingly (see
incident. Male survivors require the same Annex 9).
vaccinations and STI treatment as female 5 Examples of WHO-recommended STI
survivors. treatment regimens are given in Annex
9.
5 Preventive STI regimens can start on
Part A: the same day as emergency
contraception and post-exposure
Survivor presents prophylaxis for HIV/AIDS (PEP),
within 72 hours of the although the doses should be spread
out (and taken with food) to reduce
incident side-effects, such as nausea.

Prevent sexually Prevent HIV

transmitted infections transmission
20

Good to know before you develop Good to know before you develop
your protocol your protocol
Neisseria gonorrhoeae, the bacterium As of the date of publication of this
that causes gonorrhoea, is widely document, there are no conclusive data
resistant to several antibiotics. Many on the effectiveness of post-exposure
countries have local STI treatment prophylaxis (PEP) in preventing
protocols based on local resistance transmission of HIV after rape.
patterns. Find out the local STI treatment However, on the basis of experience
protocol in your setting and use it when with prophylaxis after occupational
treating survivors. exposure and prevention of
mother-to-child transmission, it is
believed that starting PEP as soon as
5 Survivors of rape should be given possible (and, in any case, within 72
antibiotics to treat gonorrhoea, hours after the rape) is beneficial. PEP
chlamydial infection and syphilis (see for rape survivors is available in some
Annex 9). If you know that other STIs are national health settings and it can be
prevalent in the area (such as ordered with inter-agency emergency
trichomoniasis or chancroid), give medical kits Before you start your
preventive treatment for these infections service, make sure the staff are aware of
as well. the indications for PEP and how to
counsel survivors on this issue or make
5 Give the shortest courses available in the a list of names and addresses of
local protocol, which are easy to take. providers for referrals.
For instance: 400 mg of cefixime plus 1 g
of azithromycin orally will be sufficient
5 PEP should be offered to survivors and 93%, depending on the regimen
according to the health care provider's and the timing of taking the medication.
assessment of risk, which should be
based on what happened during the 5 Progestogen-only pills are the
attack (i.e. whether there was recommended ECP regimen. They are
penetration, the number of attackers, more effective than the combined
injuries sustained, etc.) and HIV estrogen-progestogen regimen and
prevalence in the region. Risk of HIV have fewer side-effects (see Annex 11).
transmission increases in the following 5 Emergency contraceptive pills work by
cases: If there was more than one interrupting a woman's reproductive
assailant; if the survivor has torn or cycle - by delaying or inhibiting
damaged skin; if the assault was an anal ovulation, blocking fertilization or
assault; if the assailant is known to be preventing implantation of the ovum.
HIV-positive or an injecting drug user. If ECPs do not interrupt or damage an
the HIV status of the assailants is not established pregnancy and thus WHO
known, assume they are HIV-positive, does not consider them a method of
particularly in countries with high abortion.4
prevalence.
5 The use of emergency contraception is
5 PEP usually consists of 2 or 3 a personal choice that can only be
antiretroviral (ARV) drugs given for 28 made by the woman herself. Women
days (see Annex 10 for examples). There should be offered objective counselling
are some problems and issues on this method so as to reach an
surrounding the prescription of PEP, informed decision. A health worker who
including the challenge of counselling the is willing to prescribe ECPs should
survivor on HIV issues during such a always be available to prescribe them to
difficult time. If you wish to know more rape survivors who wish to use them.
about PEP, see the resource materials
5 If the survivor is a child who has 21
listed in Annex 1.
reached menarche, discuss emergency
5 If it is not possible for the person to contraception with her and her parent or
receive PEP in your setting refer her as guardian, who can help her to
soon as possible (within 72 hours of the understand and take the regimen as
rape) to a service centre where PEP can required.
be supplied. If she presents after this
time, provide information on voluntary 5 If an early pregnancy is detected at this
counselling and testing (VCT) services stage, either with a pregnancy test or
available in your area. from the history and examination (see
Steps 3 and 5), make clear to the
5 PEP can start on the same day as woman that it cannot be the result of the
emergency contraception and preventive rape.
STI regimens, although the doses should
be spread out and taken with food to 5 There is no known contraindication to
reduce side-effects, such as nausea. giving ECPs at the same time as
antibiotics and PEP, although the doses
should be spread out and taken with
food to reduce side-effects, such as
Prevent pregnancy nausea.

5 Taking emergency contraceptive pills

(ECP) within 120 hours (5 days) of
unprotected intercourse will reduce the
chance of a pregnancy by between 56%

4 Emergency contraception: a guide for service delivery. Geneva, World Health Organization,
1998 (WHO/FRH/FPP/98.19).
 Provide wound care
TT - tetanus toxoid
Clean any tears, cuts and abrasions and DTP - triple antigen: diphtheria and
remove dirt, faeces, and dead or damaged tetanus toxoids and pertussis vaccine
tissue. Decide if any wounds need suturing. DT - double antigen: diphtheria and
Suture clean wounds within 24 hours. After tetanus toxoids; given to children up to
this time they will have to heal by second 6 years of age
intention or delayed primary suture. Do not Td - double antigen: tetanus toxoid and
suture very dirty wounds. If there are major reduced diphtheria toxoid; given to
contaminated wounds, consider giving individuals aged 7 years and over
appropriate antibiotics and pain relief.
TIG - antitetanus immunoglobulin

Prevent tetanus 5 If there are any breaks in skin or

mucosa, tetanus prophylaxis should be
given unless the survivor has been fully
Good to know before you develop vaccinated.
your protocol
5 Use Table 2 to decide whether to
& Tetanus toxoid is available in several administer tetanus toxoid (which gives
different preparations. Check local
active protection) and antitetanus
vaccination guidelines for recommen-
immunoglobulin, if available (which
dations.
gives passive protection).
& Antitetanus immunoglobulin (anti-
toxin) is expensive and needs to be re- 5 If vaccine and immunoglobulin are
frigerated. It is not available in given at the same time, it is important to
low-resource settings. use separate needles and syringes and
22
different sites of administration.
5 Advise survivors to complete the
vaccination schedule (second dose at 4
weeks, third dose at 6 months to 1 year).

Table 2: Guide for administration of tetanus toxoid

and tetanus immunoglobulin to people with 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 and psychological support,
your protocol including counselling (see Step 7) are
& Find out the prevalence of hepatitis B essential components of medical care
in your setting, as well as the vaccina- for the rape survivor. Most survivors of
tion schedules in the survivor's country rape will regain their psychological
of origin and in the host country. health through the emotional support
& Several hepatitis B vaccines are avail- and understanding of people they trust,
able, each with different recom- community counsellors, and support
mended dosages and schedules. Check groups. At this stage, do not push the
the dosage and vaccination schedule survivor to share personal experiences
for the product that is available in your beyond what she wants to share.
setting However the survivor may benefit from
counselling at a later time, and all
survivors should be offered a referral to
5 Whether you can provide post-exposure the community focal point for sexual
prophylaxis against hepatitis B will depend and gender-based violence if one
on the setting you are working in. The exists.
vaccine may not be available as it is 5 If the survivor has symptoms of panic or
relatively expensive and requires anxiety, such as dizziness, shortness of
refrigeration. breath, palpitations and choking
5 There is no information on the incidence of sensations, that cannot be medically
hepatitis B virus (HBV) infection following explained (i.e. without an organic
rape. However, HBV is present in semen cause), explain to her that these
23
and vaginal fluid and is efficiently transmitted sensations are common in people who
by sexual intercourse. If possible, survivors are very scared after having gone
of rape should receive hepatitis B vaccine through a frightening experience, and
within 14 days of the incident. that they are not due to disease or
injury.6 The symptoms reflect the strong
5 In countries where the infant immunization emotions she is experiencing, and will
programmes routinely use hepatitis B go away over time as the emotion
vaccine, a survivor may already have been decreases.
fully vaccinated. If the vaccination record
card confirms this, no additional doses of 5 Provide medication only in exceptional
hepatitis B vaccine need be given. cases, when acute distress is so severe
that it limits basic functioning, such as
5 The usual vaccination schedule is at 0, 1 being able to talk to people, for at least
and 6 months. However, this may differ for 24 hours. In this case and only when
different products and settings. Give the the survivor's physical state is stable,
vaccine by intramuscular injection in the give a 5 mg or 10 mg tablet of
deltoid muscle (adults) or the anterolateral diazepam, to be taken at bedtime, no
thigh (infants and children). Do not inject into more than 3 days. Refer the person to a
the buttock, because this is less effective. professional trained in mental health for
reassessment of the symptoms the next
5 The vaccine is safe for pregnant women and
day. If no such professional is available,
for people who have chronic or previous
and if the severe symptoms continue,
HBV infection. It may be given at the same
the dose may be repeated for a few
time as tetanus vaccine.
days with daily assessments.

6 Resnick H, Acierno R, Holmes M, Kilpatrick DG, Jager N. Prevention of post-rape

psychopathology: preliminary findings of a controlled acute rape treatment study. Journal of
anxiety disorders, 1999, 13(4):359-70.
 5 Be very cautious: benzodiazepine use effectiveness of emergency
may quickly lead to dependence, contraception after 120 hours.
especially among trauma survivors.
5 If the survivor presents within five days
of the rape, insertion of a
copper-bearing IUD is an effective
Part B: method of preventing pregnancy (it will
prevent more than 99% of subsequent
Survivor presents pregnancies). The IUD can be removed
more than 72 hours at the time of the woman's next
menstrual period or left in place for
after the incident future contraception. Women should be
offered counselling on this service so as
to reach an informed decision. A skilled
provider should counsel the patient and
Sexually transmitted insert the IUD. If an IUD is inserted,
infections make sure to give full STI treatment to
prevent infections of the upper genital
If laboratory screening for STIs reveals an tract (for recommendations see Annex
infection, or if the person has symptoms of 9).
an STI, follow local protocols for treatment.

Bruises, wounds and

HIV transmission scars
In some settings testing for HIV can be Treat, or refer for treatment, all unhealed
done as early as six weeks after a rape. wounds, fractures, abscesses, and other
24 Generally, however, it is recommended that injuries and complications.
the survivor is referred for voluntary
counselling and testing (VCT) after 3-6
months, in order to avoid the need for Tetanus
repeated testing. Check the VCT services
available in your setting and their protocols.
Tetanus usually has an incubation period
of 3 to 21 days, but it can be many
months. Refer the survivor to the
Pregnancy appropriate level of care if you see signs
of a tetanus infection. If she has not been
5 If the survivor is pregnant, try to ascertain fully vaccinated, vaccinate immediately,
if she could have become pregnant at the no matter how long it is since the incident.
time of the rape. If she is, or may be, If there remain major, dirty, unhealed
pregnant as a result of the rape, counsel wounds, consider giving antitoxin if this is
her on the possibilities available to her in available (see "Prevent tetanus" in Part
your setting (see Step 3, Step 7, and A).
Step 8).
5 If the survivor presents between 72 hours
(3 days) and 120 hours (5 days) after the Hepatitis B
rape, taking progestogen-only
emergency contraceptive pills will reduce Hepatitis B has an incubation period of
the chance of a pregnancy. The regimen 2-3 months on average. If you see signs
is most effective if taken within 72 hours, of an acute infection, refer the person if
but it is still moderately effective within possible or provide counselling. If the
120 hours after unprotected intercourse person has not been vaccinated and it is
(see Annex 11). There are no data on appropriate in your setting, vaccinate, no
matter how long it is since the incident.
Mental health duration of the treatment will vary with
the medication chosen and the
response.
5 Social support and psychological
counselling (see Step 7) are essential 5 If the assault occurred more than 2 to 3
components of medical care for the rape months ago and psychological
survivor. Most survivors of rape will counselling and support (see Step 7)
regain their psychological health through are not reducing highly distressing or
the emotional support and understanding disabling trauma-induced symptoms,
of people they trust, community such as depression, nightmares, or
counsellors, and support groups. All constant fear, and you cannot refer her;
survivors should be offered a referral to consider a trial of antidepressant
the community focal point for sexual and medication (see the bullet above).
gender-based violence if one exists.
5 Provide medication only in exceptional
cases, when acute distress is so severe
that it limits basic functioning, such as
being able to talk to people, for at least
24 hours. In this case, and only when the
survivor's physical state is stable, give a
5 mg or 10 mg tablet of diazepam, to be
taken at bedtime, no more than 3 days.
Refer the person to a professional trained
in mental health for reassessment of
symptoms the next day. If no such
professional is available, and if the
severe symptoms continue, the dose of
diazepam may be repeated for a few 25
days with daily assessments.
5 Be very cautious: benzodiazepine use
may quickly lead to dependence,
especially among trauma survivors.
5 Many symptoms will disappear over time
without medication, especially during the
first few months. However, if the assault
occurred less than 2 to 3 months ago and
the survivor complains of sustained,
severe subjective distress lasting at least
2 weeks, which is not improved by
psychological counselling and support
(see Step 7), and if she asks repeatedly
for more intense treatment and you
cannot refer her, consider a trial of
imipramine, amitriptyline or similar
antidepressant medicine, up to 75-150
mg at bedtime. Start by giving 25 mg
and, if needed, work up to higher doses
over a week or so until there is a
response. Watch out for side-effects,
such as a dry mouth, blurred vision,
irregular heartbeat, and light-headedness
or dizziness, especially when the person
gets out of bed in the morning. The
 STEP 7 – Counselling the
survivor
Survivors seen at a health facility 5 Provide basic, non-intrusive practical
immediately after the rape are likely to be care. Listen but do not force her to talk
extremely distressed and may not about the event, and ensure that her
remember advice given at this time. It is basic needs are met. Because it may
therefore important to repeat information cause greater psychological problems,
during follow-up visits. It is also useful to do not push survivors to share their
prepare standard advice and information in personal experiences beyond what they
writing, and give the survivor a copy before would naturally share.
she leaves the health facility (even if the
survivor is illiterate, she can ask someone 5 Ask the survivor if she has a safe place
she trusts to read it to her later). to go to, and if someone she trusts will
accompany her when she leaves the
health facility. If she has no safe place
to go to immediately, efforts should be
Give the survivor the opportunity to ask
made to find one for her. Enlist the
questions and to voice her concerns.
assistance of the counselling services,
community services provider, and law
enforcement authorities, including
police or security officer as appropriate
Psychological and (see Step 1). If the survivor has
emotional problems dependants to take care of, and is
26 unable to carry out day-to-day activities
as a result of her trauma, provisions
5 Medical care for survivors of rape must also be made for her dependants
includes referral for psychological and and their safety.
social problems, such as common mental
disorders, stigma and isolation, 5 Survivors are at increased risk of a
substance abuse, risk-taking behaviour, range of symptoms, including:
and family rejection. Even though
# feelings of guilt and shame;
trauma-related symptoms may not occur,
or may disappear over time, all survivors # uncontrollable emotions, such as
should be offered a referral to the fear, anger, anxiety;
community focal point for sexual and
gender-based violence if one exists. A # nightmares;
coordinated integrated referral system # suicidal thoughts or attempts;
should be put in place as soon as
possible (see Step 1 and the UNHCR # numbness;
guidelines7).
# substance abuse;
5 The majority of rape survivors never tell
# sexual dysfunction;
anyone about the incident. If the survivor
has told you what happened, it is a sign # medically unexplained somatic
that she trusts you. Your compassionate complaints;
response to her disclosure can have a
positive impact on her recovery. # social withdrawal.

7 Sexual and gender-based violence against refugees, returnees and internally displaced persons:
guidelines for prevention and response. Geneva, UNHCR, 2003.
5 Tell the survivor that she has Pregnancy
experienced a serious physical and
emotional event. Advise her about the
psychological, emotional, social and 5 Emergency contraceptive pills cannot
physical problems that she may prevent pregnancy resulting from sexual
experience. Explain that it is common to acts that take place after the treatment.
experience strong negative emotions or If the survivor wishes to use a hormonal
numbness after rape. method of contraception to prevent
future pregnancy, counsel her and
5 Advise the survivor that she needs prescribe this to start on the first day of
emotional support. Encourage her - but her next period or refer her to the family
do not force her - to confide in someone planning clinic.
she trusts and to ask for this emotional
support, perhaps from a trusted family 5 Female survivors of rape are likely to be
member or friend. Encourage active very concerned about the possibility of
participation in family and community becoming pregnant as a result of the
activities. rape. Emotional support and clear
information are needed to ensure that
5 Involuntary orgasm can occur during they understand the choices available
rape, which often leaves the survivor to them if they become pregnant:
feeling guilty. Reassure the survivor that,
if this has occurred, it was a physiological # There may be adoption or foster care
reaction and was beyond her control. services in your area. Find out what
services are available and give this
5 In most cultures, there is a tendency to information to the survivor.
blame the survivor in cases of rape. If the
survivor expresses guilt or shame, # In many countries the law allows
explain gently that rape is always the termination of a pregnancy resulting
fault of the perpetrator and never the fault from rape. Furthermore, local
interpretation of abortion laws in 27
of the survivor. Assure her that she did
not deserve to be raped, that the incident relation to the mental and physical
was not her fault, and that it was not health of the woman may allow
caused by her behaviour or manner of termination of the pregnancy if it is
dressing. Do not make moral judgements the result of rape. Find out whether
of the survivor. this is the case in your setting.
Determine where safe abortion
Special considerations for men services are available so that you can
refer survivors to this service where
5 Male survivors of rape are even less legal if they so choose.
likely than women to report the incident, # Advise survivors to seek support from
because of the extreme embarrassment someone they trust - perhaps a
that they typically experience. While the religious leader, family member,
physical effects differ, the psychological friend or community worker.
trauma and emotional after-effects for
men are similar to those experienced by 5 Women who are pregnant at the time of
women. a rape are especially vulnerable
physically and psychologically. In
5 When a man is anally raped, pressure on particular they are susceptible to
the prostate can cause an erection and miscarriage, hypertension of pregnancy
even orgasm. Reassure the survivor that, and premature delivery. Counsel
if this has occurred during the rape, it pregnant women on these issues and
was a physiological reaction and was advise them to attend antenatal care
beyond his control. services regularly throughout the
pregnancy. Their infants may be at
higher risk for abandonment so
follow-up care is also important.
 HIV/STIs
If the woman is pregnant as a
result of the rape
Both men and women may be concerned
about the possibility of becoming infected & A pregnancy may be the result of the
with HIV as a result of rape. While the risk rape. All the options available, e.g.
keeping the child, adoption and,
of acquiring HIV through a single sexual
where legal, abortion, should be dis-
exposure is small, these concerns are well
cussed with the woman, regardless of
founded in settings where HIV and/or STIs
the individual beliefs of the counsel-
prevalence are high. Compassionate and
lors, medical staff or other persons in-
careful counselling around this issue is
volved, in order to enable her to make
essential. The health care worker may also an informed decision.
discuss the risk of transmission of HIV or
STI to partners following a rape. & Where safe abortion services are not
available, women with an unwanted
5 The survivor may be referred to an pregnancy may undergo an unsafe
HIV/AIDS counselling service if available. abortion. These women should have
access to post-abortion care,
5 The survivor should be advised to use a including emergency treatment of
condom with all partners for a period of 6 abortion complications, counselling
months (or until STI/HIV status has been on family planning, and links to
determined). reproductive health services.
& Children born as a result of rape may
5 Give advice on the signs and symptoms
be mistreated or even abandoned by
of possible STIs, and on when to return
their mothers and families. They
for further consultation. should be monitored closely and sup-
port should be offered to the mother.
It is important to ensure that the fam-
28 Other ily and the community do not stigma-
tize either the child or the mother.
5 Give advice on proper care for any Foster placement and, later, adoption
injuries following the incident, infection should be considered if the child is re-
prevention (including perineal hygiene, jected, neglected or otherwise mis-
treated.
perineal baths), signs of infection,
antibiotic treatment, when to return for
further consultation, etc.
5 Give advice on how to take the
prescribed treatments and on possible
side-effects of treatments.

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
5 Evaluate mental and emotional status;
refer or treat as needed (see Step 7).
It is possible that the survivor will not or
cannot return for follow-up. Provide
maximum input during the first visit, as Follow-up visits of
this may be the only visit.
survivors who receive
post-exposure
The follow-up visits for survivors who prophylaxis
receive post-exposure prophylaxis for HIV
and those who do not differ slightly.
One-week follow-up visit

Follow-up visits for 5 Evaluate post-exposure prophylaxis

(side-effects and adherence).
survivors who do not
5 If not supplied at the first visit, provide
receive post-exposure the additional three-week supply of
prophylaxis post-exposure prophylactic medication.
5 Check that survivor has taken the full
Two-week follow-up visit course of any medication given for STIs
29
5 Evaluate for STI, treat as appropriate,
5 Evaluate for pregnancy and provide
and provide advice on voluntary
counselling (see Steps 3, 6, and 7).
counselling and testing for HIV (see
5 Check that survivor has taken the full Steps 6 and 7).
course of any medication given for STIs.
5 Evaluate mental and emotional status;
5 If prophylactic antibiotics were not given, refer or treat as needed (see Step 7).
evaluate for STI, treat as appropriate,
and provide advice on voluntary
counselling and testing for HIV (see Six-week follow-up visit
Steps 6 and 7).
5 Evaluate for pregnancy and provide
5 Evaluate mental and emotional status; counselling (see Steps 3, 6, and 7).
refer or treat as needed (see Step 7).
5 If prophylactic antibiotics were not
given, evaluate for STIs, treat as
Three-month follow-up visit appropriate, and provide advice on
voluntary counselling and testing for
5 Evaluate for STIs, and treat as HIV (see Steps 6 and 7).
appropriate.
5 Evaluate mental and emotional status;
5 Assess pregnancy status, if indicated. refer or treat as needed (see Step 7).

5 Test for syphilis if prophylaxis was not

given. Three-month follow-up visit
5 Provide advice on voluntary counselling
5 Evaluate for STIs, and treat as
and testing for HIV.
appropriate.
 5 Assess pregnancy status, if indicated. General
5 Test for syphilis if prophylaxis was not
given. A parent or legal guardian should sign the
consent form for examination of the child
5 Provide advice on follow-up voluntary
and collection of forensic evidence, unless
counselling and testing for HIV for those
he or she is the suspected offender. In
who had a negative test during the first
this case, a representative from the police,
week.
the community support services or the
5 Offer voluntary counselling and testing court may sign the form. Adolescent
for HIV to survivors that were not tested minors may be able to give consent
before. themselves. The child should never be
examined against his or her will, whatever
5 Evaluate mental and emotional status; the age, unless the examination is
refer or treat as needed (see Step 7). necessary for medical care.

The initial assessment may reveal severe

medical complications that need to be
Care for child treated urgently, and for which the patient
survivors will have to be admitted to hospital. Such
complications include:

5 convulsions;
Good to know before you develop 5 persistent vomiting;
your protocol
& If it is obligatory to report cases of 5 stridor in a calm child;
child8 abuse in your setting, obtain a 5 lethargy or unconsciousness;
30 sample of the national child abuse
management protocol and information 5 inability to drink or breastfeed.
on customary police and court proce-
dures. Evaluate each case individually - In children younger than 3 months, look
in some settings, reporting suspected also for:
sexual abuse of a child can be harmful
to the child if protection measures are 5 fever;
not possible.
5 low body temperature;
& Find out about specific laws in your
setting that determine who can give 5 bulging fontanelle;
consent for minors and who can go to
court as an expert witness. 5 grunting, chest indrawing, and a
breathing rate of more than 60
& Health care providers should be knowl-
breaths/minute.
edgeable about child development and
growth as well as normal child anat-
The treatment of these complications is
omy. It is recommended that health
care staff receive special training in ex- not covered in detail here.
amining children who may have been
abused.
Create a safe
environment

5 Take special care in determining who is

present during the interview and
examination (remember that it is

8 The United Nations Convention on the Rights of the Child (1989) defines a child as any individual
below the age of eighteen years.
 possible that a family member is the 5 who did it, and whether he or she is still
perpetrator of the abuse). It is preferable a threat;
to have the parent or guardian wait
outside during the interview and have an 5 if this has happened before, how many
independent trusted person present. For times and the date of the last incident;
the examination, either a parent or 5 whether there have been any physical
guardian or a trusted person should be complaints (e.g. bleeding, dysuria,
present. Always ask the child who he or discharge, difficulty walking, etc.);
she would like to be present, and respect
his or her wishes. 5 whether any siblings are at risk.

5 Introduce yourself to the child.

5 Sit at eye level and maintain eye contact. Prepare the child for
5 Assure the child that he or she is not in examination
any trouble.
5 As for adult examinations, there should
5 Ask a few questions about neutral topics, be a support person or trained health
e.g., school, friends, who the child lives worker whom the child trusts in the
with, favourite activities. examination room with you.
5 Encourage the child to ask questions
Take the history about anything he or she is concerned
about or does not understand at any
time during the examination.
5 Begin the interview by asking
open-ended questions, such as "Why are 5 Explain what will happen during the
you here today?" or "What were you told examination, using terms the child can
about coming here?" understand. 31
5 Avoid asking leading or suggestive 5 With adequate preparation, most
questions. children will be able to relax and
participate in the examination.
5 Assure the child it is okay to respond to
any questions with "I don't know". 5 It is possible that the child cannot relax
because he or she has pain. If this is a
5 Be patient; go at the child's pace; do not
possibility, give paracetamol or other
interrupt his or her train of thought.
simple painkillers, and wait for them to
5 Ask open-ended questions to get take effect.
information about the incident. Ask
5 Never restrain or force a frightened,
yes-no questions only for clarification of
resistant child to complete an
details.
examination. Restraint and force are
5 For girls, depending on age, ask about often part of sexual abuse and, if used
menstrual and obstetric history. by those attempting to help, will increase
the child's fear and anxiety and worsen
The pattern of sexual abuse of children is the psychological impact of the abuse.
generally different from that of adults. For
5 It is useful to have a doll on hand to
example, there is often repeated abuse. To
demonstrate procedures and positions.
get a clearer picture of what happened, try
Show the child the equipment and
to obtain information on:
supplies, such as gloves, swabs, etc.;
allow the child to use these on the doll.
5 the home situation (has the child a
secure place to go to?);
5 how the rape/abuse was discovered;
 Conduct the examination 5 All children, boys and girls, should have
an anal examination as well as the
genital examination. Examine the anus
Conduct the examination in the same order with the child in the supine or lateral
as an examination for adults. Special position. Avoid the knee-chest position,
considerations for children are as follows: as assailants often use it.

5 Note the child's weight, height, and 5 Record the position of any anal fissures
pubertal stage. Ask girls whether they or tears on the pictogram.
have started menstruating. If so, they
5 Reflex anal dilatation (opening of the
may be at risk of pregnancy.
anus on lateral traction on the buttocks)
5 Small children can be examined on the can be indicative of anal penetration,
mother's lap. Older children should be but also of constipation.
offered the choice of sitting on a chair or
5 Do not carry out a digital examination to
on the mother's lap, or lying on the bed.
assess anal sphincter tone.
5 Check the hymen by holding the labia at
the posterior edge between index finger
and thumb and gently pulling outwards Laboratory testing
and downwards. Note the location of any
fresh or healed tears in the hymen and
Testing for sexually transmitted infections
the vaginal mucosa. The amount of
should be done on a case-by-case basis
hymenal tissue and the size of the
and is strongly indicated in the following
vaginal orifice are not sensitive indicators
situations:9
of penetration.
5 Do not carry out a digital examination 5 the child presents with signs or
(i.e. inserting fingers into the vaginal symptoms of STI;
32 orifice to assess its size).
5 the suspected offender is known to
5 Look for vaginal discharge. In prepubertal have an STI or is at high risk of STI;
girls, vaginal specimens can be collected
5 there is a high prevalence of STI in the
with a dry sterile cotton swab.
community;
5 Do not use a speculum to examine
5 the child or parent requests testing.
prepubertal girls; it is extremely painful
and may cause serious injury. In some settings, screening for
5 A speculum may be used only when you gonorrhoea and chlamydia, syphilis and
suspect a penetrating vaginal injury and HIV is done for all children who may have
internal bleeding. In this case, a been raped. The presence of any one of
speculum examination of a prepubertal these infections may be diagnostic of rape
child is usually done under general (if the infection is not likely to have been
anaesthesia. Depending on the setting, acquired perinatally or through blood
the child may need to be referred to a transfusion).10 Follow your local protocol.
higher level of health care.
5 In boys, check for injuries to the frenulum
of the prepuce, and for anal or urethral
discharge; take swabs if indicated.

9 From Guidelines for the management of sexually transmitted infections, revised version. Geneva,
World Health Organization, 2003 (WHO/RHR/01.10).

10 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.
If the child is highly Treatment
agitated
With regard to STIs, HIV, hepatitis B, and
In rare cases, a child cannot be examined tetanus, children have the same
because he or she is highly agitated. Only if prevention and treatment needs as adults
the child cannot be calmed down, and but may require different doses. Special
physical treatment is vital, the examination protocols for children should be followed
may be performed with the child under for all vaccinations and drug regimens.
sedation, using one of the following drugs:
Routine prevention of STIs is not usually
5 diazepam, by mouth, 0.15 mg/kg of body recommended for children. However, in
weight; maximum 10 mg; low-resource settings with a high
prevalence of sexually transmitted
or diseases, presumptive treatment for STIs
should be part of the protocol (see Annex
5 promethazine hydrochloride, syrup, by 9 for sample regimens).
mouth;
Recommended dosages for
# 2-5 years: 15-20 mg post-exposure prophylaxis to prevent HIV
# 5-10 years: 20-25 mg transmission in children are given in
Annex 10.
These drugs do not provide pain relief. If
you think the child is in pain, give simple
pain relief first, such as paracetamol (1-5 Follow-up
years: 120-250 mg; 6-12 years: 250-500
mg). Wait for this to take effect. Follow-up care is the same as for adults. If
a vaginal infection persists, consider the 33
Oral sedation will take 1-2 hours for full possibility of the presence of a foreign
effect. In the meantime allow the child to body, or continuing sexual abuse.
rest in a quiet environment.
Annex 1 • Additional resource materials

Annex 1 • Additional resource materials

General information
Sexual and gender-based violence against refugees, returnees and internally displaced persons:
guidelines for prevention and response. Geneva, UNHCR, 2003 (http://www.unhcr.ch/ or
http://www.rhrc.org/resources/gbv/).

Guidelines for medico-legal care for victims of sexual violence. Geneva, WHO, 2003
(http://www.who.int/violence_injury_prevention/publications/violence/med_leg_guidelines/en/).

Sexual assault nurse examiner (SANE) development and operation guide. Washington, DC, United States
Department of Justice, Office of Justice Programs, Office for Victims of Crime, 1999, (www.sane-sart.com )

Reproductive health in refugee situations: an inter-agency field manual. Geneva, UNHCR, 1999
(http://www.who.int/reproductive-health/publications or http://www.rhrc.org/fieldtools or
http://www.unhcr.ch/).

Basta! A newsletter from IPPF/WHR on integrating gender-based violence into sexual and reproductive
health published in New-York, from 2000 to 2002,. International Planned Parenthood Federation,
(http://www.ippfwhr.org/publications/publication_detail_e.asp?PubID=10 )

Information on mental health 35

Mental health of refugees. Geneva, WHO, 1996 (http://www.unhcr.ch/).

Mental health in emergencies: psychological and social aspects of health of populations exposed to
extreme stressors. Geneva, WHO, 2003.
(http://www.who.int/mental_health/prevention/mnhemergencies/en/)

Information on sexually transmitted diseases

Guidelines for the management of sexually transmitted diseases, revised version. Geneva, WHO, 2003
(WHO/RHR/01.10) (http://www.who.int/reproductive-health/publications).

Information on emergency contraception

Emergency contraceptive pills: medical and service delivery guidelines. International Consortium for
Emergency Contraception, Washington DC, Second Edition, 2004.
(http://www.cecinfo.org).

Selected practice recommendations for contraceptive use, 2nd ed. Geneva, WHO, 2004
(http://www.who.int/reproductive-health/family_planning/index.html).
 Annex 1 • Additional resource materials

Information on post-exposure prophylaxis of HIV infection

PHS report summarises current scientific knowledge on the use of post-exposure antiretroviral therapy for
non-occupational exposures. Atlanta, GA, Centers for Disease Control and Prevention, 1998
(http://www.cdc.gov/hiv/pubs/facts/petfact.htm).

Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV,
HCV, and HIV and recommendations for post exposure prophylaxis. Morbidity and mortality weekly report,
2001, 50(RR-11), Appendix C, 45-52 (http://www.cdc.gov/hiv/treatment.htm#prophylaxis).

HIV post-exposure prophylaxis following non-occupational exposure including sexual assault, updated
July 2004. New York, State Department of Health AIDS Institute
(http://hivguidelines.org/public_html/center/clinical-guidelines/pep_guidelines/pep_guidelines.htm).

Detailed information on the abortion policies of countries

Abortion policies: a global review, New York, UN Department of Economic and Social Affairs, Population
Division, 2001 (http://www.un.org/esa/population/publications/abortion/profiles.htm).

Safe abortion: technical and policy guidance for health systems. Geneva, WHO. 2003
(http://www.who.int/reproductive-health/publications/safe_abortion/safe_abortion.html).

Information on protection
36
IASC Task Force. Activities of the Inter-Agency Standing Committee Task Force on Protection from Sexual
Exploitation and Abuse. June 2004.
( http://ochaonline.un.org/webpage.asp?Page=1139 )

Information on rights
Convention on the Rights of the Child. New York, United Nations, 1989
(http://www.unhchr.ch/html/menu2/6/crc/treaties/crc.htm).

Convention on the Elimination of All Forms of Discrimination against Women. New York, United Nations,
1979 (http://www.un.org/womenwatch/daw/cedaw/cedaw.htm).
 Annex 2 • Information needed to develop a local protocol

Annex 2 • 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, other)
37
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
Vaccine availability and vaccination schedules Ministry of Health
Location of voluntary HIV counselling and testing services National AIDS Control Programme, Ministry of Health
Confirmatory HIV testing strategy and laboratory services UNHCR, National AIDS Control Programme,
Ministry of Health, Regional Medical Officer
Possibilities/protocols/referral for post-exposure National AIDS Control Programme, Ministry of Health
prophylaxis of HIV infection
Clinical referral possibilities (e.g. psychiatry, surgery, Referral hospital at regional level
paediatrics, gynaecology/obstetrics)
 Annex 3 • Minimum care for rape survivors in low-resource settings

Annex 3 • 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 Set of replacement clothes
38 3 Tape measure for measuring the size of bruises, lacerations, etc.
# Supplies for universal precautions
# Resuscitation equipment for anaphylactic reactions
# Sterile medical instruments (kit) for repair of tears, and suture material
# Needles, syringes
# Gown, cloth, or 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 3 • 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.
39
 Annex 4 • Sample consent form

Annex 4 • Sample consent form

Notes on completing the consent form

Consent for an examination is a central issue in & That during part of the physical exam, the
medico-legal practice. Consent is often called patient will lie on an examination couch.
"informed consent" because it is expected that the
& That the health care provider will need to touch
patient (or his/her parent(s) or guardian) will receive
information on all the relevant issues, to help the her for the physical and pelvic examinations.
patient make a decision about what is best for & That a genitor-anal examination will require the
her/him at the time. patient to lie in a position where her genitals can
be adequately seen with the correct lighting.
It is important to make sure that the patient
understands that her consent or lack of consent to & That specimen collection (where needed)
any aspect of the exam will not affect her access to involves touching the body and body openings
treatment and care. with swabs and collecting body materials such
as head hair, pubic hair, genital secretions,
The health care provider must provide information blood, urine and saliva. That clothing may be
in a language that is readily understood by the collected. And that not all of the results of the
patient or his/her parent/guardian to ensure that forensic analysis may be made available to the
he/she understands: patient and why.
& That she can refuse any aspect of the
40 & What the history-taking process will involve.
examination she does not wish to undergo.
& The type of questions that will be asked and the
& That she will be asked to sign a form which
reason those questions will be asked.
indicatesthat she has been provided with the
& What the physical examination will involve. information and documents what procedures
ahe has agreed to.
& What the pelvic examination will involve.

& That the physical examination, including pelvic Inform the patient that if, and only if, she decides to
examination, will be conducted in privacy and in pursue legal action, the information told to the
a dignified manner. health worker during the examination will be
conveyed to relevant authorities for use in the
pursuit of criminal justice with her consent.
 Annex 4 • Sample consent form

Sample consent form

Name of facility - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Note to the health worker:

After providing the relevant information to the patient as explained on page 40 (notes on copleting the
consent form), read the entire form to the patient (or his/her parent/guardian), explaining that she can
choose to refuse 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 41

Conduct a medical examination A A

Conduct pelvic examination A A
Collect evidence, such as body fluid samples, collection of clothing, hair
combings, scrapings or cuttings of fingernails, blood sample, and photographs A A
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. A A

I understand that I can refuse any aspect of the examination I don’t wish to undergo.

Signature: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Date: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Witness: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
 Annex 5 • Sample history and examination form

Annex 5 • Sample history and examination form

Sample form, page 1 of 4

CONFIDENTIAL CODE:

Medical History and Examination Form – Sexual Violence

1. GENERAL INFORMATION

First Name Last Name

Address

Sex Date of birth Age

Date / time of examination / In the presence of

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

2. THE INCIDENT

Date of incident: Time of incident:

42
Description of incident (survivor’s description)

Physical violence Yes No Describe type and location on body

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).

Ejaculation

Condom used

If the survivor is a child, also ask: Has this happened before? When was the first time? How long
has it been happening? Who did it? Is the person still a threat? Also ask about bleeding from the
vagina or the rectum, pain on walking, dysuria, pain on passing stool, signs of discharge, any other
sign or symptom.
 Annex 5 • 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 or bathe

Brush teeth? Use tampon or pad

Contraception use
Pill IUD Sterilisation

Infectable Condom Other

Menstrual/obstetric 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

Obstetric history

History of consenting intercourse (only if samples have been taken for DNA analysis)
Last consenting intercourse within a week Date: Name of individual: 43
prior to the assault

Existing health problems

History of female genital mutilation, type

Allergies

Current medication

Vaccination status Vaccinated Not vaccinated Unknown Comments

Tetanus

Hepatitis B

HIV/AIDS status Know Unknown

 Annex 5 • Sample history and examination form

Sample form, page 3 of 4

4. Medical examination

Appearance (clothing, hair, obvious physical or mental disability)

Mental state (calm, crying, anxious, cooperative, depressed, other)

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

44 Eyes and ears Neck

Chest Back

Abdomen Buttocks

Arms and hands Legs and feet

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 5 • Sample history and examination form

Sample form, page 4 of 4

6. INVESTIGATIONS DONE

Type and location Examined/sent to laboratory Result

7. EVIDENCE TAKEN

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

8. TREATMENTS PRESCRIBED

Treatment Yes No Type and Comments

STI prevention/treatment 45
Emergency contraception

Wound treatment

Tetanus prophylaxis

Hepatitis B vaccination

Post-exposure prophylaxis for HIV

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 6 • Pictograms

Annex 6 • Pictograms

46
Annex 6 • Pictograms

47
 Annex 6 • Pictograms

48
Annex 6 • Pictograms

49
 Annex 7 • Forensic evidence collection

Annex 7 • Forensic evidence collection

As stated on page 12, the capacity of laboratories to Inspection of the anus,

analyse forensic evidence differs considerably. This perineum and vulva
annex describes the different types of forensic
evidence that can be collected and outlines
Inspect and collect samples for DNA analysis from
procedures for doing so. Health workers should
the skin around the anus, perineum and vulva using
familiarize themselves with national and local
seperate cotton-tipped swabs moistened with
protocols and resources. Different countries and
sterile water. For children, always examine both the
locations have different laws about rape and
anus and the vulva.
different guidelines on what is accepted as
evidence. Do not collect evidence that cannot be
processed. Examination of the vagina and
rectum
Inspection of the body
Depending on the site of penetration or attempted
& Examine the survivor's clothing under a good penetration, examine the vagina and/or the rectum.
light before she undresses. Collect any foreign
debris on clothes and skin or in the hair (soil, & Lubricate a speculum with normal saline or
leaves, grass, foreign hairs). Ask the person to clean water (other lubricants may interfere with
undress while standing on a sheet of paper to forensic analysis).
collect any debris that falls. Do not ask her to & Using a cotton-tipped swab, collect fluid from the
50 uncover fully. Examine the upper half of her posterior fornix for examination for sperm. Put a
body first, then the lower half, or provide a gown drop of the fluid collected on a slide, if necessary
for her to cover herself. Collect torn and stained with a drop of normal saline (wet-mount), and
items of clothing only if you can give her examine it for sperm under a microscope. Note
replacement clothes. the mobility of any sperm. Smear the leftover
& Document all injuries in as much detail as fluid on a second slide and air-dry both slides for
possible (see Step 4). further examination at a later stage.

& Collect samples for DNA analysis from all places & Take specimens from the posterior fornix and
where there could be saliva (where the attacker the endocervical canal for DNA analysis, using
licked or kissed or bit her) or semen on the skin, separate cotton-tipped swabs. Let them dry at
with the aid of a sterile cotton-tipped swab, room temperature.
lightly moistened with sterile water if the skin is & Collect separate samples from the cervix and
dry. the vagina for acid phosphatase analysis.
& The survivor's pubic hair may be combed for
& Obtain samples from the rectum, if indicated, for
foreign hairs. examination for sperm, and for DNA and acid
& If ejaculation took place in the mouth, take phosphatase analysis.
samples and swab the oral cavity for direct
examination for sperm and for DNA and acid
phosphatase analysis. Place a dry swab in the
spaces between the teeth and between the teeth
and gums of the lower jaw, as semen tends to
collect there.
& Take blood and/or urine for toxicology testing if
indicated (e.g. if the survivor was drugged) .
 Annex 7 • Forensic evidence collection

Maintaining the chain of The survivor may consent to have evidence

collected but not to have it released to the
evidence authorities at the time of the examination. In this
case, advise her that the evidence will be kept in a
It is important to maintain the chain of evidence at all secure locked space in the health centre for one
times, to ensure that the evidence will be admissible month and then destroyed. If she changes her mind
in court. This means that the evidence is collected, during this period, she can advise the authorities
labelled, stored and transported properly. where to collect the evidence.
Documentation must include a signature of
everyone who has possession of the evidence at
any time, from the individual who collects it to the Reporting medical findings in a
one who takes it to the courtroom, to keep track of court of law
the location of the evidence.
If the survivor wishes to pursue legal redress and
If it is not possible to take the samples immediately the case comes to trial, the health worker who
to a laboratory, precautions must be taken: examines her after the incident may be asked to
report on the findings in a court of law. Only a small
& All clothing, cloths, swabs, gauze and other percentage of cases actually go to trial. Many health
objects to be analysed need to be well dried at workers may be anxious about appearing in court or
room temperature and packed in paper (not feel that they have not enough time to do this.
plastic) bags. Samples can be tested for DNA Nevertheless, providing such evidence is an
many years after the incident, provided the extension of their role in caring for the survivor.
material is well dried.
In cases of rape, the prosecutor (not the health care
& Blood and urine samples can be stored in the
provider) must prove three things:1
refrigerator for 5 days. To keep the samples 51
longer they need to be stored in a freezer.
1 some penetration, however slight, of the
Follow the instructions of the local laboratory.
vagina or anus by a penis or other object, or
& All samples should be clearly labelled with a penetration of the mouth by a penis;
confidential identifying code (not the name or
2 that penetration occurred without the consent
initials of the survivor), date, time and type of
of the person;
sample (what it is, from where it was taken), and
put in a container. 3 the identity of the perpetrator.
& Seal the bag or container with paper tape across
In most settings the health care provider is expected
the closure. Write the identifying code and the
to give evidence as a factual witness (that means
date and sign your initials across the tape.
reiterating the findings as he or she recorded them),
not as an expert witness.
In the adapted protocol, clearly write down the
laboratory's instructions for collection, storage and
Meet with the prosecutor prior to the court session
transport of samples.
to prepare your testimony and obtain information
about the significant issues involved in the case.
Evidence should be released to the authorities
only if the survivor decides to proceed with a
legal case.

11 Brown WA. Obstacles to women accessing forensic medical exams in cases of sexual violence. Unpublished background paper
for the WHO Consultation on the Health Sector Response to Sexual Violence, Geneva, June 2001.
 Annex 7 • Forensic evidence collection

Conduct yourself professionally and confidently in & Ask for clarification of questions that you do not
the courtroom: understand. Do not try to guess the meaning of
questions.
& Dress appropriately.
The notes written during the initial interview and
& Speak clearly and slowly and, if culturally
examination are the mainstay of the findings to be
appropriate, make eye contact with whoever you reported. It is difficult to remember things that are
are speaking to. not written down. This underscores the need to
& Use precise medical terminology. record all statements, procedures and actions
in sufficient detail, accurately, completely and
& Answer questions as thoroughly and legibly. This is the best preparation for an
professionally as possible. appearance in court.
& If you do not know the answer to a question, say
so. Do not make an answer up and do not testify
about matters that are outside your area of
expertise.

52
 Annex 8 • Medical certificates

Annex 8 • Medical certificates

MEDICAL CERTIFICATE for a child

I, the undersigned: (NAME, first name) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

title (Indicate the function): - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

on this date and time (day-month-year, time) - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

certify having examined at the request of: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

(name of father, mother, legal representative)

child: (NAME, first name), - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

date of birth: (day, month, year) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

address: (exact address of the parents or place of residence of the child)

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 53
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

During the meeting, the child told me (repeat the child's own words as closely as possible)

During the meeting, (name of the person accompanying the child) stated:

This child presents the following signs:

General examination: (child's behaviour: prostrate, excited, calm, fearful, mute, crying, etc.)
 Annex 8 • Medical certificates

Physical examination: (detailed description of lesions, the site, extent, pre-existing or recent, severity)

During the genital examination: (signs of recent or previous defloration, bruises, tears, etc.)

During the anal examination:

54

Other examinations carried out and samples taken:

The absence of lesions should not lead to the conclusion that no sexual attack took place.

Certificate prepared on this day and handed over to (Name of father, mother, legal representative) as
proof of evidence.

Signature of the clinician

 Annex 8 • Medical certificates

MEDICAL CERTIFICATE for an adult

I, the undersigned: (NAME, first name) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

title (Indicate the function): - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

on this date and time (day-month-year, time) - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

certify having examined at his/her request Mr, Mrs, Miss: (NAME, first name):

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

date of birth: (day, month, year) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

address: (exact address of the parents or place of residence of the child)

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

She/He declared that she/he was the victim of a sexual attack on - - - - - - - - - - - - - - - - - - 55

(time, day, month, year)

at (place) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

by (known or unknown person): - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Ms, Mrs, Miss, Mr ____________________________________ presents the following signs:

General examination (behaviour: prostrate, excited, calm, afraid, mute, crying, etc.)

Physical examination (detailed description of lesions, the site, extent, pre-existing or recent, severity)
 Annex 8 • Medical certificates

Genital examination (signs of recent or previous defloration, bruises, abrasions, tears, etc.)

Anal examination

Other examinations carried out and samples taken

Evaluation of the risk of pregnancy

56

The absence of lesions should not lead to the conclusion that no sexual attack took place.

Certificate prepared on this day and handed over to the person concerned as proof of evidence.

Signature of the clinician

 Annex 9 • Protocols for preventiontreatment of STIs

Annex 9 • Protocols for prevention and

treatment of STIs

Based on WHO-recommended STI treatments for adults (may

also be used for prophylaxis)
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 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 azithromycin 1 g orally, in a single dose (not recommended in pregnancy)
or
doxycycline 100 mg orally, twice daily for 7 days (contraindicated in pregnancy)
Chlamydial infection erythromycin 500 mg orally, 4 times daily for 7 days
in pregnant woman or
amoxicillin 500 mg orally, 3 times daily for 7 days
57
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 14 days (contraindicated in pregnancy)
allergic to penicillin (Note: this antibiotic is also active against chlamydia)
Syphilis in pregnant erythromycin 500 mg orally, 4 times daily for 14 days
women allergic to (Note: this antibiotic is also active against chlamydia)
penicillin
Trichomoniasis 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)

*Note: benzathine benzylpenicillin may be omitted if the prophylactic treatment regimen includes azithromycin 1 g orally, in a single dose,
which is effective against incubating syphilis.

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:

& cefixime 400 mg orally + azithromycin 1 g orally

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 of 2 g of metronidazole orally.

 Annex 9 • Protocols for preventiontreatment of STIs

WHO-recommended STI treatments for children and adolescents

(may also be used for presumptive treatment)
Note: These are examples of presumptive 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),

< 45 kg
single dose
or (if > 6 months)

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

> 45 kg Treat according to adult protocol

Chlamydial < 45 kg azithromycin 20 mg/kg orally, single dose

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

> 45 kg erythromycin 500 mg orally, 4 times daily for 7 days

but or
58
< 12 years
azithromycin 1 g orally, single dose

> 12 years Treat according to adult protocol

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

Syphilis, patient allergic to Erythromycin 50 mg/kg of body weight daily, orally (up to a maximum of 2 g), divided into 4
penicillin doses, for 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

* Note: benzathine benzylpenicillin may be omitted if the presumptive treatment regimen includes azithromycin, which is effective against
incubating syphilis, unless resistance has been documented in the setting.

Based on: Tailoring clinical management practices to meet the special needs of adolescents: sexually transmitted infections. Geneva, World
Health Organization, 2002 (WHO/CAH 2002, WHO/HIV/AIDS 2002.03).
 Annex 10 • Protocols for post-exposure prophylaxis of HIV infection

Annex 10 • Protocols for post-exposure

prophylaxis of HIV infection

The following are examples of post-exposure Post-exposure prophylaxis

prophylaxis (PEP) protocols used for preventing using two antiretroviral drugs
HIV infection after rape. These examples do not
outline all the care that may be needed. If it is not
& Use this regimen in settings where triple-ARV
possible in your programme to provide PEP, refer
AIDS treatment is not widely available.
the survivor as soon as possible (within 72 hours) to
a clinic where this service can be provided. & This preventive treatment consists of two ARV
drugs, to be taken twice a day for 28 days. The
Good to know before you start drugs are zidovudine (ZDV or AZT) and
lamivudine (3TC). These drugs are available
In settings where ARV drugs are widely
combined in one tablet called Combivir.
available for treatment of AIDS, it is more
likely that HIV virus will be resistant to one of & Gastrointestinal side-effects may occur in up to
these drugs. In this case you need to use 50% of people taking ZDV/3TC, but they are
three drugs in your PEP protocol. Find out if relatively minor. Appropriate counselling will help
ARV drugs are widely available and which people take the full treatment. There are no
drugs are used to treat AIDS patients. Also contraindications to starting PEP on the same
find out if there is a national PEP protocol and day as emergency contraception and STI
use this in your service. prophylaxis, although the doses should be
spread out, and if possible taken with food, to 59
reduce side-effects such as nausea.
There are currently no conclusive data on the & All survivors should be offered voluntary
effectiveness of post-exposure prophylaxis (PEP) in counselling and HIV testing. HIV testing is not
preventing transmission of HIV after rape. mandatory. Survivors who cannot or do not want
However, based on experience with PEP for to undergo HIV testing and who are not already
occupational exposure and mother to child known to be HIV -positive, should be offered
transmission, experts believe that starting PEP as PEP if indicated. A short PEP treatment is not
soon as possible (but only within 48-72 hours after expected to do harm in someone of unknown
the rape) is beneficial. PEP for rape survivors is HIV status who is actually HIV-positive.
available in some national health settings. Before Administration of PEP must never be made
you start your service, make sure staff is aware of conditional on the person agreeing to have
the indications for PEP and how to counsel an HIV test.
survivors on this issue or make a list of names and
addresses of providers for referrals. WHO does not & Survivors who are known or found to be
yet have an official policy or specific HIV-positive should not be offered PEP. While it
recommendations on PEP regimens. Expert is not likely to do harm, there is no expected
opinion on the best regimens to use in different benefit. Such people should be appropriately
settings is divided. A consultation will be held in counselled and referred to special programmes
2005 to recommend appropriate regimens. for people living with HIV/AIDS (PLHA), such as
home-based care, supplementary feeding, and
treatment of opportunistic infections.
 Annex 10 • Protocols for post-exposure prophylaxis of HIV infection

& Counselling for HIV testing may be particularly # The efficacy of PEP in preventing
difficult with a person who has just gone through seroconversion after rape is not known, but
the ordeal of sexual assault. The survivor may there is evidence from research on
not be ready for the additional stress of prevention of mother-to-child transmission
HIV-testing and receiving the result. If the and prophylaxis after occupational exposure
survivor does not want to be tested immediately, to indicate that PEP is very likely to be
PEP can be initiated and HIV-testing can be effective in reducing the risk of transmission
addressed again at the one-week follow-up visit. of HIV after rape.
& Pregnancy is not a contraindication to PEP, and # Explain the common side-effects of the drugs,
it should be prescribed to pregnant women in such as feelings of tiredness, nausea and
the same manner as to non-pregnant women. flu-like symptoms. Reassure her that these
Women who are less than 12 weeks pregnant side-effects are temporary and do not cause
should be informed that the possible effects of long-term harm. Most side-effects can be
the drug on the fetus are not known. (Ensure relieved with ordinary analgesics, such as
that pregnant women are referred for paracetamol.
appropriate antenatal care.)
# Provide the survivor with a patient information
& The following points should be covered when leaflet, adapted and translated in the local
counselling the survivor on PEP: language.
# The level of risk of HIV transmission during & Routine blood testing, with full blood count and
rape is not exactly known, but the risk exists, liver enzymes, is not recommended for patients
particularly in settings where HIV prevalence on zidovudine and lamivudine. Blood tests
is high. should be performed only if indicated by the
survivor's clinical condition.
60 # It is preferable to know the survivor's HIV
status prior to starting antiretrovirals, so the & Survivors may be given a one-week's supply of
best possible recommendation can be made PEP at the first visit, with the remainder of the
for her. drugs (another 3-weeks' supply) given at the
one-week follow-up visit. For survivors who
# The survivor is free to choose whether or not
cannot return for a one-week assessment for
to have immediate HIV-testing. If she prefers,
logistic or economic reasons, a full supply
the decision can be delayed until the
should be given at the first visit.
one-week follow-up visit.
 Annex 10 • Protocols for post-exposure prophylaxis of HIV infection

Adolescents > 40 kg and adults, including pregnant and

lactating women

Treatment Prescribe 28 days supply

Combined tablet containing zidovudine (300 mg) and 1 tablet twice a day 60 tablets
lamivudine (150 mg) or or
or 1 tablet twice a day 60 tablets
zidovudine (ZDV/AZT) 300 mg tablet plus plus
plus 1 tablet twice a day 60 tablets
lamivudine (3TC) 150 mg tablet

Children*

Weight or age Treatment Prescribe 28 days supply

< 2 years zidovudine (ZDV/AZT) syrup** 7.5 ml twice a day = 420 ml ( i.e.5 bottles of 100
10 mg/ml ml or 3 bottles of 200 ml)
or plus plus plus

5 – 9 kg lamivudine (3TC) syrup** 10 2.5 ml twice a day = 140 ml (i.e. 2 bottles of 100
mg/ml ml or 1bottle of 200 ml)

10 - 19 kg zidovudine (ZDV/AZT) 100 1 capsule three times a day 90 capsules

mg capsule 61
plus plus plus
lamivudine (3TC) 150 mg 1/2 tablet twice a day 30 tablets
tablet

20 - 39 kg zidovudine (ZVD/AZT) 100 2 capsules two times a day 120 capsules

mg capsule
plus plus plus
lamivudine (3TC) 150 mg 1 tablet twice a day 60 tablets
tablet

* From: Medical care for rape survivors, MSF draft guideline. December 2002

** A bottle of syrup should be discarded 15 days after being opened.

 Annex 10 • Protocols for post-exposure prophylaxis of HIV infection

Post-exposure prophylaxis using three antiretroviral drugs

Some experts recommend a third drug (protease Side-effects are common with indinavir. Any of the
inhibitor) to be added to the PEP protocol of ZDV following may occur: nausea, vomiting, diarrhoea,
and 3TC where possible, particularly in settings loss of appetite, stomach pain, headache, rash,
where there is widespread access to ARVs, to kidney stones with blood in the urine, muscle pains,
prevent transmission of HIV resistant to one of the general malaise, fever, jaundice, raised blood sugar
drugs. Adherence to the triple regimen may be and haemolytic anaemia. The patient should drink
more difficult than to the two-drug regimen. lots of water (at least 2 litres per day)

One recommended regimen2 is: Because of the potential side-effects of indinavir,

the survivor should be referred to a doctor
zidovudine (300 mg) and lamivudine (150 mg) experienced in HIV treatment. Nelfinavir and
combined tablet; one tablet two times per day Lopinavir/ritonavir are also other PI options that can
be considered.
plus
Note: Nevirapine is not recommended for use as
indinavir, 800 mg three times per day post-exposure prophylaxis.3

62

12 World Health Organization Health and Medical Service. Post Exposure Preventive Treatment Starter Kits. WHO Geneva,
November 2004

13 Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and
recommendations for post exposure prophylaxis. Morbidity and mortality weekly report, 2001, 50(RR-11), Appendix C.
 Annex 11 • Protocols for emergency contraception

Annex 11 • Protocols for emergency

contraception

Emergency contraceptive pills & Counsel the survivor about how to take the pills,
what side-effects may occur, and the effect the
& There are two emergency contraceptive pill pills may have on her next period. ECPs do not
regimens that can be used: prevent pregnancy from sexual acts that take
place after their use. Provide her with condoms
1 the levonorgestrel-only regimen: 1.5 mg of for use in the immediate future.
levonorgestrel in a single dose (this is the
recommended regimen; it is more effective and & Make it clear to the survivor that there is a small
has fewer side-effects), or risk that the pills will not work. If they work,
menstruation will occur around the time she
2 the combined estrogen-progestogen would normally expect it. It may be up to a week
regimen (Yuzpe): two doses of 100 early or a few days late. If she has not had a
micrograms ethinylestradiol plus 0.5 mg of period within a week after it was expected, she
levonorgestrel taken 12 hours apart. should return to have a pregnancy test and/or to
& Treatment with either regimen should be started
discuss the options in case of pregnancy.
as soon as possible after the rape because Explain to her that spotting or slight bleeding is
research has shown that efficacy declines with common with the levonorgestrel regimen and
time. Both regimens are effective when used up that it is nothing to worry about. This should not
to 72 hours after the rape, and continue to be be confused with a normal menstruation.
63
moderately effective if started between 72 hours & Side-effects. The levonorgestrel regimen has
and 120 hours (5 days) after. Longer delays been shown to cause significantly less nausea
have not been investigated. and vomiting than the Yuzpe regimen. If
& The levonorgestrel-only regimen can be taken
vomiting occurs within 2 hours of taking a dose,
as a single dose of 1.5 mg of levonorgestrel as repeat the dose. In cases of severe vomiting, EC
soon as convenient, ideally not later than 120 can be administered vaginally.
hours after the rape. With the combined & Precautions. ECPs will not be effective in the
estrogen-progestogen regimen, a first dose case of a confirmed pregnancy. ECPs may be
should be taken as soon as convenient, but not given when the pregnancy status is unclear and
later than 120 hours after the rape, and a pregnancy testing is not available, since there is
second dose 12 hours later. There are products no evidence to suggest that the pills can harm
that are specially packaged for emergency the woman or an existing pregnancy. There are
contraception, but at present they are registered no other medical contraindications to use of
only in a limited number of countries. If ECPs.
pre-packaged ECPs are not available in your
setting, emergency contraception can be
provided using regular oral contraceptive pills
which are available for family planning (see the
table below for guidance).
 Annex 11 • Protocols for emergency contraception

Second dose
Pill compositiona Common First dose
Regimen 12 hours later
(per dose) brand names (number of tablets)
(number of tablets)
Levonorgestrel 750 µg Levonelle,
only NorLevo, Plan B, 2 0
Postinor-2, Vikela

30 µg Microlut, Microval,
50 0
Norgeston

37.5 µg Ovrette 40 0

Combined EE 50 µg + LNG 250 µg Eugynon 50, Fertilan,

or Neogynon, Noral,
EE 50 µg + NG 500 µg Nordiol, Ovidon, Ovral,
Ovran, 2 2
Tetragynon/PC-4,
Preven, E-Gen-C,
Neo-Primovlar 4

EE 30 µg + LNG 150 µg Lo/Femenal,

or Microgynon, Nordete, 4 4
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, second
edition. Washington, DC, 2004).

64

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 (and if there was no earlier unprotected insert the IUD. If an IUD is inserted; make sure
sexual act in this menstrual cycle), insertion of a to give full STI treatment, as recommended in
copper-bearing IUD is an effective method of Annex 9.
emergency contraception. It will prevent more
& The IUD may be removed at the time of the
than 99% of expected subsequent pregnancies.
woman's next menstrual period or left in place
& Women should be offered counselling on this for future contraception.
service so as to reach an informed decision.
Clinical Management

of Rape Survivors
Developing protocols for use with refugees
and internally displaced persons

Revised edition