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close this bookClinical Management of Survivors of Rape - A Guide to the Development of Protocols for Use in Refugee and Internally Displaced Person Situations (United Nations High Commissioner for Refugees (UNHCR) / Alto Comisionado de Naciones Unidas para los Refugiados (ACNUR) - WHO - OMS, 2001, 46 p.)
View the document(introduction...)
View the documentPreface
View the documentAcknowledgements
View the documentAbbreviations and acronyms used in this guide
View the documentIntroduction
View the documentSTEP 1 - Making preparations to offer medical care to rape survivors
View the documentSTEP 2 - Preparing the survivor for the examination
View the documentSTEP 3 - Taking the history
View the documentSTEP 4 - Collecting forensic evidence
View the documentSTEP 5 - Performing the physical and genital examination
View the documentSTEP 6 - Prescribing treatments
View the documentSTEP 7 - Counselling the survivor
View the documentSTEP 8 - Follow-up care of the survivor
View the documentAnnex 1 · Information needed to develop a local protocol
View the documentAnnex 2 · Sample consent form
View the documentAnnex 3 · Sample history and examination form
View the documentAnnex 4 · Pictograms
View the documentAnnex 5 · Protocols for treatment of STIs
View the documentAnnex 6 · Protocols for post-exposure prophylaxis of HIV infection
View the documentAnnex 7 · Protocols for emergency contraception
View the documentAnnex 8 · Minimum care for rape survivors in low-resource settings
View the documentAnnex 9 · Additional resource materials

STEP 6 - Prescribing treatments

Treatment will depend on how soon after the incident the survivor presents to the health service. Follow the steps in Part A if she presents within 72 hours of the incident; Part B is applicable to survivors who present more than 72 hours after the incident.

Part A: Survivor presents within 72 hours of the incident

Prevent sexually transmitted infections

Good to know before you develop your protocol

Neisseria gonorrhoeae, the bacterium that causes gonorrhoea, is widely resistant to several antibiotics. Many countries have local STI treatment protocols based on local resistance patterns. Find out the local STI treatment protocol in your setting and use it when treating survivors.

- Survivors of rape should be treated with antibiotics to prevent gonorrhoea, chlamydial infection and syphilis. If you know that other STIs are prevalent in the area (such as trichomoniasis or chancroid), give preventive treatment for these infections as well.

- Give the woman the shortest courses available in the local protocol, which are easy to take. For instance: 2 g of azithromycin orally plus one injection of 2.4 million IU of benzathine benzylpenicillin will be sufficient treatment for gonorrhoea, chlamydial infection and syphilis.

- Be aware that women who are pregnant should not take certain antibiotics, and modify the treatment accordingly.

- Examples of WHO-recommended STI treatment regimens are given in Annex 5.

Prevent HIV transmission

Good to know before you develop your protocol

As of the date of publication of this document, there are no conclusive data on the effectiveness of post-exposure prophylaxis in preventing transmission of HIV after rape. However, PEP is available in some settings for rape survivors. Before you start your service, find out if PEP is available in your setting and make a list of names and addresses of providers for referrals.

- If PEP is available, it usually consists of 1, 2 or 3 antiretroviral (ARV) drugs given for 28 days (see Annex 6 for examples). There are many problems and issues surrounding the prescription of PEP, not the least of which is the difficulty of counselling the survivor on HIV issues at a time like this. If you wish to know more about PEP, see the resource materials listed in Annex 9.

- If it is possible for the person to receive PEP in your setting, refer her as soon as possible (within 72 hours of the rape) to the relevant centre. If she presents after this time, provide information on voluntary counselling and testing (VCT) services available in your area.

Prevent pregnancy

- Taking emergency contraceptive pills (ECP) within 72 hours of unprotected intercourse will reduce the chance of a pregnancy by between 74% and 85%, depending on the regimen chosen and the time of starting the course (see Annex 7).

- Emergency contraceptive pills work by interrupting a woman's reproductive cycle - by delaying or inhibiting ovulation, blocking fertilization or preventing implantation of the ovum. ECPs do not interrupt or damage a pregnancy and thus WHO does not consider them a method of abortion.4

- Some people believe that ECPs are abortifacients. Health workers who believe this may feel unable to provide this treatment. Women should be offered objective counselling on this treatment so as to reach an informed decision.

- A health worker who is willing to prescribe ECPs should always be available to prescribe the treatment to rape survivors who wish to use it. If the survivor is a child who has reached menarche, discuss emergency contraception with her and her parent or guardian who can help her to understand and take the regimen as required.

- If an early pregnancy is detected at this stage, either with a pregnancy test or from the history and examination (see Steps 3 and 5), make clear to the woman that it cannot be the result of the rape.

- There is no known contraindication to giving ECPs at the same time as antibiotics.

4 Emergency contraception: a guide for service delivery. Geneva, World Health Organization, 1998 (document no. WHO/FRH/FPP/98.19).

Provide wound care

Clean any tears, cuts and abrasions and remove dirt, faeces and dead or damaged tissue. Decide if there are any wounds that need suturing. Suture clean wounds within 24 hours. After this time they will have to heal by second intention or delayed primary suture. Do not suture very dirty wounds. If there are major contaminated wounds, consider giving appropriate antibiotics and pain relief.

Prevent tetanus

Good to know before you develop your protocol

· Tetanus toxoid is available in several different preparations. Check local vaccination guidelines for recommendations.

· Antitetanus immunoglobulin (antitoxin) is expensive and needs to be refrigerated. It is not available in low-resource settings.

TT - tetanus toxoid

DTP - triple antigen: diphtheria and tetanus toxoids and pertussis vaccine

DT - double antigen: diphtheria and tetanus toxoids; given to children up to 6 years of age

Td - double antigen: tetanus toxoid and reduced diphtheria toxoid; given to individuals aged 7 years and over

TIG - antitetanus immunoglobulin

- If there are any breaks in skin or mucosa, tetanus prophylaxis should be given unless the survivor has been fully vaccinated.

- On the basis of the table below, decide whether to administer tetanus toxoid, which gives active protection, and antitetanus immunoglobulin, if available, which gives passive protection.

- If vaccine and immunoglobulin are given at the same time, it is important to use separate needles and syringes and separate sites of administration.

- Advise survivors to complete the vaccination schedule (second dose at 4 weeks, third dose at 6 months to 1 year).

Guide for administration of tetanus toxoid and tetanus immunoglobulin in cases of wounds5

History of tetanus immunization
(number of doses)

If wounds are clean and <6 hours old or minor wounds

All other wounds


TT*

TIG

TT*

TIG

Uncertain or <3

Yes

No

Yes

Yes

3 or more

No, unless last dose>10 years ago

No

No, unless last dose>5 years ago

No

*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

Good to know before you develop your protocol

· Find out the prevalence of hepatitis B in your setting, as well as the vaccination schedules in the survivor's country of origin and in the host country.

· Several hepatitis B vaccines are available, each with different recommended dosages and schedules. Check the dosage and vaccination schedule for the product that is available in your setting.

- Whether you can provide post-exposure prophylaxis against hepatitis B will depend on the setting you are working in. The vaccine may not be available as it is relatively expensive and requires refrigeration.

- There is no information on the incidence of hepatitis B virus (HBV) infection following rape. However, HBV is present in semen and vaginal fluid and is efficiently transmitted by sex. If possible, survivors of rape should receive hepatitis B vaccine within 14 days of the incident.

- In countries where the infant immunization programmes routinely use hepatitis B vaccine, a survivor may already have been fully vaccinated. If the vaccination record card confirms this, no additional doses of hepatitis B vaccine need be given.

- The usual vaccination schedule is at 0, 1 and 6 months. However, this may differ for different products and settings. Give the vaccine by intramuscular injection in the deltoid muscle (adults) or the anterolateral thigh (infants and children). Do not inject into the buttock, because this is less effective.

- The vaccine is safe for pregnant women and for people who have chronic or previous HBV infection. It can be given at the same time as tetanus vaccine.

Provide mental health care

- Social support and psychological counselling (see Step 7) are essential components of medical care for the rape survivor. Most survivors of rape will regain their psychological health through the emotional support and understanding of people they trust, the community counsellor, and support groups. All rape survivors should be referred to the community focal point for sexual and gender-based violence.

- Occasionally a survivor may have severe symptoms of post-traumatic stress disorder. These symptoms can include anxiety, nightmares, inability to sleep, and constant crying.

- In exceptional cases, if the level of anxiety is such that it is disrupting the survivor's everyday life, give one 10 mg tablet of diazepam, to be taken at bedtime. In this case she should be referred to a specially trained health professional and her symptoms reassessed the next day.

Part B: Survivor presents more than 72 hours after the incident

Sexually transmitted infections

If laboratory screening for STIs has revealed an infection, or if the person has symptoms of an STI, treat according to the syndromic approach. Follow local protocols.

HIV transmission

While in some settings testing for HIV can be done as early as six weeks after a rape, it is recommended that the survivor is referred for voluntary counselling and testing (VCT) after 3-6 months, in order to avoid the need for repeated testing. Check the VCT services available in your setting and their protocols.

Pregnancy

- If the survivor is pregnant, try to ascertain if she could have become pregnant at the time of the rape. If she is, or may be, pregnant as a result of the rape, counsel her on the possibilities available to her in your setting. (See Step 3, Step 7, and Step 8).

- If the survivor presents within five days of the rape, insertion of a copper-bearing IUD is an effective method of preventing pregnancy (it will prevent more than 99% of subsequent pregnancies). The IUD can be removed at the time of the woman's next menstrual period or left in place for 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 insert the IUD.

Bruises, wounds and scars

Treat, or refer for treatment, all unhealed wounds, fractures, abscesses, and other injuries and complications.

Tetanus

Tetanus usually has an incubation period of 3 to 21 days, but it can be many months. Refer the survivor to the appropriate level of care if you see signs of a tetanus infection. If she has not been fully vaccinated, vaccinate immediately, no matter how long it is since the incident. If there remain major, dirty, unhealed wounds, consider giving antitoxin if this is available (see "Prevent tetanus" in Part A).

Hepatitis B

Hepatitis B has an incubation period of two to three months on average. If you see signs of an acute infection, refer the person if possible or provide counselling. If the person has not been vaccinated and it is appropriate in your setting, vaccinate, no matter how long it is since the incident.

Mental health

- Social support and psychological counselling (see Step 7) are essential components of medical care for the rape survivor. Most survivors of rape will regain their psychological health through the emotional support and understanding of people they trust, the community counsellor, and support groups. All rape survivors should be referred to the community focal point for sexual and gender-based violence.

- Occasionally a survivor may have severe symptoms of post-traumatic stress disorder. These symptoms can include anxiety, nightmares, inability to sleep, and constant crying.

- In exceptional cases, if the level of anxiety is such that it is disrupting the survivor's everyday life, give one 10 mg tablet of diazepam, to be taken at bedtime. In this case she should be referred to a specially trained health professional and her symptoms reassessed the next day.