STEP 8 - Follow-up care of the survivor

It is possible that the survivor will not or cannot return for follow-up. Provide maximum input during the first visit, as this may be the only visit.

If the survivor is started on post-exposure prophylaxis with antiretroviral drugs, the follow-up schedule may be different from the one below. Discuss this with the PEP provider.

Two-week follow-up visit

- Evaluate for pregnancy and provide counselling (see Steps 3, 6, 7).

- Evaluate for STIs, treat as appropriate, provide advice on voluntary counselling and testing for HIV (see Steps 6, 7).

- Evaluate mental and emotional status; refer or treat as needed (see Step 7).

Six-month follow-up visit

- Evaluate for STIs, treat as appropriate.
- Provide advice on voluntary counselling and testing for HIV.
- Evaluate mental and emotional status; refer as needed (see Step 7).

If the woman is pregnant as a result of the rape · A pregnancy may be the result of the rape. All the options available, e.g. keeping the child, adoption and abortion, should be discussed with the woman, regardless of the individual beliefs of the counsellors, medical staff or other persons involved, in order to enable her to make an informed decision. · Where safe abortion services are not available, women with unwanted pregnancies may undergo unsafe abortions. These women should have access to post-abortion care, including emergency treatment of abortion complications, counselling on family planning, and links to reproductive health services. · Children born as a result of rape may be mistreated or even abandoned by their mothers and families. They should be monitored closely and support should be offered to the mother. It is important to ensure that the family and the community do not stigmatize either the child or the mother. Foster placement and, later, adoption should be considered if the child is rejected, neglected or otherwise mistreated.

Care for child survivors

Good to know before you develop your protocol · If it is obligatory to report cases of child abuse in your setting, obtain a sample of the national child abuse management protocol and information on customary police and court procedures. · Find out about specific laws in your setting that determine who can give consent for minors. · In settings where the health worker is expected to go to court as an expert witness, he or she should receive special training in examining children who have been abused. · Health care providers should be knowledgeable about child development and growth as well as normal child anatomy.

General

A parent or legal guardian should sign the consent form for examination of the child and collection of forensic evidence, unless he or she is the suspected offender. In this case, a representative from the police, the community support services or the court may sign the form. Adolescent minors may be able to give consent themselves. The child should never be examined against his or her will, whatever the age, unless the examination is necessary for medical care.

The initial assessment may reveal severe medical complications that need to be treated urgently, and for which the patient will have to be admitted to hospital. Such complications might be:

- convulsions;
- persistent vomiting;
- stridor in a calm child;
- lethargy or unconsciousness;
- inability to drink or breastfeed.

In children younger than 3 months, look also for:

- fever;
- low body temperature;
- bulging fontanelle;
- grunting, chest indrawing, and breathing rate of more than 60 breaths/minute.

The treatment of these complications is not covered here in detail.

Create a safe and trusting environment

- Introduce yourself to the child.

- Sit at eye level and maintain eye contact.

- Assure the child that he or she is not in any trouble.

- Ask a few questions about neutral topics, e.g., school, friends, who the child lives with, favourite activities.

- Take special care in determining who should be present during the interview and examination (remember that it is possible that a family member is the perpetrator). It is preferable to have the parent or guardian wait outside during the interview and have an independent trusted person present. For the examination, either a parent or guardian or a trusted person should be present. Always ask the child who he or she would like to be present, and respect his or her wishes.

Take the history

- Begin the interview by asking open-ended questions, such as "Why are you here today?" or "What were you told about coming here?"

- Assure the child it is okay to respond to any questions with "I don't know".

- Be patient, go at the child's pace, don't interrupt his or her train of thought.

- Ask open-ended questions to get information about the incident. Ask yes-no questions only for clarification of details.

The pattern of sexual abuse of children is generally different from that of adults. For example, there is often repeated abuse. To get a clearer picture of what happened, try to obtain information on:

- the home situation (has the child a secure place to return to?);
- how the rape/abuse was discovered;
- the number of incidents and the date of the last incident;
- whether there has been any bleeding;
- whether the child has had difficulty walking.

Prepare the child for examination

- As for adult examinations, there should be a support person or trained health worker whom the child trusts in the examination room with you.

- Encourage the child to ask questions about anything he or she is concerned about or does not understand at any time during the examination.

- Explain what will happen during the examination, using terms the child can understand.

- With adequate preparation, most children will be able to relax and participate in the examination.

- It is possible that the child has pain and cannot relax for that reason. If this is a possibility, give paracetamol or other simple painkillers to relieve pain. Wait for these to take effect.

- Never restrain or force a frightened, resistant child to complete an examination. Restraint and force are often part of sexual abuse and, if used by those attempting to help, will increase the child's fear and anxiety and worsen the psychological impact of the abuse.

- It is useful to have a doll on hand to demonstrate procedures and positions. Show the child the equipment and supplies, such as gloves, swabs, etc.; allow the child to use these on the doll.

Conduct the examination

Conduct the examination as for adults. Special considerations for children are as follows:

- Note the child's weight, height, and pubertal stage. Ask girls whether they have started menstruating. If so, they may be at risk of pregnancy.

- Small children can be examined on the mother's lap. Older children should be offered the choice of sitting on a chair or on the mother's lap, or lying on the bed.

- Examine the anus with the child in the supine or lateral position. Avoid the knee-chest position, as assailants often use it.

- Check the hymen by holding the labia at the posterior edge between index finger and thumb and gently pulling outwards and downwards. Note the location of any fresh or healed tears in the hymen and the vaginal mucosa. The amount of hymenal tissue and the size of the vaginal orifice are not sensitive indicators of penetration.

- Digital examination (assessing the size of the vaginal orifice by the number of fingers that can be inserted) should not be carried out.

- Look for vaginal discharge. In prepubertal girls, vaginal specimens can be collected with a dry sterile cotton swab.

- Do not use a speculum to examine prepubertal girls; it is extremely painful and may cause serious injury.

- A speculum may be used only when you suspect a penetrating vaginal injury and internal bleeding. In this case, a speculum examination of a prepubertal child is usually done under general anaesthesia. Depending on the setting, the child may need to be referred to a higher level of health care.

- In boys, check for injuries to the frenulum of the prepuce, and for anal or urethral discharge; take swabs if indicated.

- Conduct an anal examination in both boys and girls.

- Record the position of any anal fissures or tears on the pictogram.

- Reflex anal dilatation (opening of the anus on lateral traction on the buttocks) can be indicative of anal penetration, but also of constipation.

- Digital examination to assess anal sphincter tone should not be done.

Laboratory testing

In some settings, screening for gonorrhoea and chlamydia (by culture), syphilis and HIV is done for all children presenting with a history of rape. The presence of these infections may be diagnostic of rape (if the infection is not likely to have been acquired perinatally or through blood transfusion).⁶ Follow your local protocol.

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

If the child is highly agitated

In rare cases, a child cannot be examined because he or she is highly agitated. Only if the child cannot be calmed down and treatment is vital, the examination may be performed with the child under sedation, using one of the following drugs:

- diazepam, by mouth, 0.15 mg/kg of body weight; maximum 10 mg;

or

- promethazine hydrochloride, syrup, by mouth;

- 2-5 years: 15-20 mg
- 5-10 years: 20-25 mg

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 years: 120 - 250 mg; 6-12 years: 250 - 500 mg). Wait for this to take effect.

Oral sedation will take 1 to 2 hours for full effect. In the meantime allow the child to rest in a quiet environment.

Treatment

Routine prevention of STIs is not usually recommended for children if screening can be done. However, in low-resource settings with a high prevalence of sexually transmitted diseases, presumptive STI treatment may be part of the protocol (see Annex 5 for sample regimens).

Follow-up

Follow-up care is the same as for adults. If a vaginal infection does not clear, consider the possibility of the presence of a foreign body, or continuing sexual abuse.

Special considerations for men

Counselling

- Male survivors of rape are even less likely than women to report because of the extreme embarrassment that they typically experience. While the physical effects differ, the psychological trauma and emotional after-effects for men are similar to those experienced by women.

- When a man is anally raped, pressure on the prostate can cause an erection and even orgasm. Reassure the survivor that, if this has occurred during the rape, it was a physiological reaction and was beyond his control.

Genital examination

- Examine the scrotum, testicles, penis, periurethral tissue, urethral meatus and anus.

- Note if the survivor is circumcised.

- Look for hyperaemia, swelling (distinguish between inguinal hernia, hydrocele and haematocele), torsion of testis, bruising, anal tears, etc.

- Torsion of the testis is an emergency and requires immediate referral.

- If the urine contains large amounts of blood, check for penile and urethral trauma.

- If indicated, do a rectal examination and check the rectum and prostate for trauma and signs of infection.

- If relevant, collect material from the anus for direct examination for sperm under a microscope.

Treatment

Men need the same STI preventive treatment and vaccinations as described in Step 6.

Special considerations for pregnant women

Women who are pregnant at the time of a rape are physically and psychologically especially vulnerable. In particular they are susceptible to miscarriage, hypertension of pregnancy and premature delivery.

Counsel pregnant women on these issues and advise them to attend antenatal care services regularly throughout the pregnancy.

Special considerations for elderly women

Elderly women who have been vaginally raped are at increased risk of vaginal tears and injury, and transmission of STI and HIV. Decreased hormonal levels following the menopause result in a reduction in vaginal lubrication and cause the vaginal wall to become thinner and more friable. Use a thin speculum for genital examination. If collecting evidence or screening for STIs is the only indication for the examination, consider inserting swabs only without using a speculum.