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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 7 - Counselling the survivor

Survivors seen at a health facility immediately after the rape will most likely be experiencing psychological trauma and may show signs of anxiety and/or depression. Survivors in this state are unlikely to remember counselling and advice given at this time. It is therefore important to repeat the counselling during follow-up visits. It is also useful to prepare standard advice and counselling information in writing, and give the survivor a copy before she leaves the health facility (even if the survivor is illiterate, she can ask someone she trusts to read it to her later).

Give the survivor the opportunity to ask questions and to voice her concerns.

Psychological and emotional trauma

- Medical care for survivors of rape includes care and referral for psychological trauma.

- The majority of rape survivors never tell anyone about the incident. If the survivor has told you what happened, she has demonstrated that she trusts you.

- Rape causes psychological and emotional trauma as well as physical injury. Survivors may experience a range of post-traumatic symptoms, including:

- self-blame;
- uncontrollable emotions, such as fear, anger, guilt, shame, anxiety;
- mood swings;
- nightmares and sleeping disorders;
- eating disorders;
- suicidal thoughts or suicide attempts.

- Tell the survivor that she has experienced a serious physical and emotional trauma. Advise her about the post-traumatic symptoms (emotional and physical) that she may experience.

- In most cultures, there is a tendency to blame the survivor in cases of rape. Assure the survivor that she did not deserve to be raped, that the incident was not her fault, and that it was not caused by her behaviour or manner of dressing.

- Advise the survivor that part of the care she needs is emotional support. Encourage her to confide in someone she trusts and to ask for this emotional support, perhaps from a family member or friend.

- Refer the survivor to a counselling service for psychosocial assistance.

- Ask the survivor if she has a safe place 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 now, efforts should be made to find her a safe place. Enlist the assistance of the counselling services, community services provider, police or security officer (see Step 1).

- In some cases, the survivor is seriously traumatized and experiences severe emotional or psychological dysfunction, becoming unable to carry out day-to-day activities. Referral for psychological evaluation and more in-depth counselling may be needed. Find out what services are available in your area.

Pregnancy

- Emergency contraceptive pills cannot prevent pregnancy resulting from sexual acts that take place after the treatment. If the survivor wishes to use an additional hormonal method of contraception, she should start this on the first day of her next period. Condom use for a period of 6 months should be recommended to protect against transmission of STIs and HIV infection.

- Female survivors of rape are likely to be very concerned about the possibility of becoming pregnant as a result of the rape. Emotional support and clear information are needed to ensure that they understand the choices available to them if they become pregnant:

- There may be services for adoption and/or foster care in your area. Find out what services are available and give this information to the survivor.

- In many countries the law allows termination of pregnancy resulting from rape. Furthermore, local interpretation of abortion laws in relation to mental and physical health may include indications for rape survivors as well. Find out whether this is the case in your setting. Determine where safe abortion services are available so that you can refer survivors to this service if they so choose.

- Advise survivors to seek support from someone they trust - perhaps a religious leader, family member, friend or community worker.

HIV

Both men and women may be concerned about the possibility of becoming HIV-positive as a result of rape. While the risk of acquiring HIV through a single sexual exposure is small, these concerns are well founded. Compassionate and careful counselling around this issue is essential. The health care worker may also discuss the risk of transmission of HIV or STI to partners following a rape.

- The survivor may be referred to an HIV/AIDS counselling service if available.

- Condom use with all partners for a period of 6 months (or depending on the result of HIV screening tests) should be recommended.

- Give advice on the signs and symptoms of possible STIs, and on when to return for further consultation.

Other

- Give advice on proper care for any injuries following the incident, infection prevention (including perineal hygiene, perineal baths), signs of infection, antibiotic treatment, when to return for further consultation, etc.

- Give advice on how to take the prescribed treatments and on possible side-effects of treatments.

Follow-up care at the health facility

- 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).

- Give clear advice on any follow up needed for wound care or vaccinations.