Clinical management of rape survivors
Sexual violence is a worldwide problem that requires a multipronged approach to provide survivors with the basic needs they require. Healthcare workers must know how to manage rape survivors to provide medical care, psychosocial first aid, and referral for further management and assessment if needed. The eight steps in managing rape are: Preparing to receive and offer medical care to rape survivor, Preparing the survivor for the clinical examination, History taking, Forensic evidence collection, Genital examination, Treatment of infection, Counselling and Follow-up.
Sexual violence is a worldwide problem, particularly in war and natural calamity areas. Rape is a type of sexual violence, a public health concern and a violation of human rights. Rape in war is internationally recognized as a war crime and a crime against humanity. It is also characterized as a form of torture and, in certain circumstances, as genocide. It is defined as physically forced or otherwise coerced penetration, even if slight -of the vulva or anus, using a penis, other body parts, or an object.
Sexual violence is a complicated matter that requires a multipronged approach to provide the survivors with the basic needs they require. Besides sexual violence being meted out against women and girls, boys and men are also often assaulted during natural and man-made catastrophes. Sexual violence predisposes the individual to sexual and reproductive health issues, which, even though treated, have immediate and long-term consequences. Therefore, the survivors of sexual assault will require urgent medico-legal, physical, and psychosocial support. As such, the medical and legal systems work together to serve sexual assault survivors and aid in healing.
Healthcare workers, especially those working in the developing world, must be well versed in managing rape survivors to provide medical care, psychosocial first aid, and referral for further management and assessment whenever necessary. Besides, a caring and empathic attitude is essential when offering clinical treatment to rape victims. The clinical management of rape depends entirely on the kind of injury sustained by the survivor. See Figure 1. Clinical Management of Rape Algorithm.
Figure 1. Clinical Management of Rape Algorithm 
Key: Y-Yes, N-No
MANAGEMENT OF RAPE SURVIVORS
Note that although there are male rape victims we use the female pronoun in this paper. There are eight steps in the clinical management of rape. These are:
Preparing to receive and offer medical care to rape survivor
Hospitals, primary healthcare centres, and units should make a deliberate provision to respond promptly and with empathy to individuals who have been sexually assaulted. In addition, the in-charge of the health facility should ensure that the healthcare team has been appropriately trained and have the essential supplies and equipment required for the job.
Preparing the survivor for the clinical examination
Because the rape survivor has undergone a traumatic experience, the healthcare worker needs to prepare and examine the survivor compassionately and dignifiedly. Informed consent needs to be obtained from the survivor before any examination takes place. The survivor is in charge of the examination process, not the doctor or nurse. Besides, the clinician needs to examine the survivor systematically and comprehensively.
The history must be taken in a quiet room without interruptions and noise. A chaperone and a support person for the survivor should be present during the history taking if she consents to them being there:
- The survivor’s bio data, time, and examination date are noted.
- The survivor is asked to describe in her own words, and without interruption, what exactly happened to her.
- The healthcare worker should check and confirm from the survivor if she sustained any injuries and their locations. The risk for STI and HIV should also be questioned during this time and reassured that this would be treated confidentially. In addition, if the rape occurred recently, the survivor should be asked if she bathed, changed clothes, urinated, defaecated, brushed her teeth, or even combed her hair after the incident, as doing any of these things will compromise the quality of forensic evidence that would be collected.
- A history of allergy, pre-existing illnesses, vaccination, HIV status, and the last normal menstrual period should be documented since they will guide the most appropriate treatment, counselling and follow-up.
Forensic evidence collection
Forensic examination is done to prove or disprove a link between suspects and places or objects. For example, forensic evidence may corroborate the survivor’s story, confirm a history of recent sexual intercourse, and probably identify an attacker. For the success of a case in court, specimen collection, transport, and storage must be done correctly. Evidence should be collected as soon as possible after the incident as time is of great essence, and this should be done preferably within 72 hours of the incident.
Before the physical examination, it is essential to ensure that all the equipment and instruments required are ready. After obtaining verbal informed consent and ensuring the survivor is relaxed a thorough examination is conducted. If the initial assessment shows serious complications such as massive trauma to the abdomen, genitalia, chest, neurological deficits, and respiratory distress, the survivor needs to be referred immediately to a health facility where she can be stabilized before the examination can be resumed.
The collection of samples and the examinations are done concurrently, and the samples collected are documented and clearly labelled. Urine for pregnancy tests and high vaginal swabs should be taken simultaneously with the examination. Furthermore, a smear can also be made from a swab to find sperms that will help identify culprits. By identifying the morphology of the sperms and quantity, the time since intercourse can be assessed. It will also add extra information on the crime scene by determining how the offender’s DNA came to be located at the site where it was found. Other tests, such as CXR and abdominal or pelvic ultrasonography, should be done when a rib fracture or haemoperitoneum is suspected. Finally, the mental state of the survivor, such as normal, withdrawn, depressed, or suicidal, needs to be noted.
Treatment of infection
The treatment given to rape survivors, whether male or female, depends on how soon after the incident they report to the hospital. In general, survivors are given prophylactic antibiotics to treat sexually transmitted infections, post-exposure prophylaxis to prevent the transmission of HIV, and emergency contraception to prevent pregnancy. In addition, they should receive post-exposure prophylaxis against Hepatitis B and vaccination against tetanus. Wounds and bruises must also be managed by dressing them with povidone-iodine or topical antibiotics.
Counselling of the survivor
Survivors of rape suffer from psychological and emotional issues; therefore, they need counselling and psychological first aid. Besides, they will require emotional support from trusted family members, friends, and the community. When they experience a severe mental and emotional breakdown, they must be referred to the appropriate professionals for further treatment and support. The survivor is then advised to return to the health facility if there is a question or any health concerns for evaluation.
Follow up of the survivor
In many cases, perhaps due to the stigma associated with rape and other challenges, the survivor of rape might not return for a follow-up visit. Therefore, the survivor must be provided with sufficient information to support her in making decisions since this might be her only chance. During the follow-up visits, ensure that the survivor has completed vaccination, treatment for sexually transmitted infections, post-exposure prophylaxis for HIV, and contraception. In addition, mental and emotional status is evaluated and referred to a counsellor or treated accordingly.
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