|Clinical 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.)|
The primary objective of the examination is to determine what medical care should be provided to the survivor. Work systematically according to the medical examination form (see sample form in Annex 3).
What is included in the physical examination will depend on how soon after the rape 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. The general guidelines below apply in both cases.
- Make sure the equipment and supplies are prepared.
- Always look at the survivor first, before you touch her, and note her appearance and mental state.
- Always tell her what you are going to do and ask her permission before you do it.
- Assure her that she is in control, can ask questions, and can stop the examination at any time.
- Take the patient's vital signs (pulse, blood pressure, respiratory rate and temperature).
- 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:
- extensive trauma (to genital region, head, chest or abdomen),
- asymmetric swelling of joints (septic arthritis),
- neurological deficits,
- respiratory distress.
The treatment of these complications is not covered here.
- Obtain voluntary informed consent for the examination and to obtain the required samples for forensic examination (see sample consent form in Annex 2).
Part A: Survivor presents within 72 hours of the incident
- Never ask her to fully undress or uncover. Examine the upper half of her body first, then the lower half; or give her a gown to cover herself.
- Minutely and systematically examine the patient's body, starting at the head. Do not forget to look in the eyes, nose, and mouth, and in and behind the ears, and to examine forearms, wrists and ankles. Take note of the pubertal stage.
- Look for signs that are consistent with the survivor's story, such as bite and punch marks, marks of restraints on the wrists, patches of hair missing from the back of the head, or torn eardrums, which may be a result of being slapped.
- Note all your findings carefully on the examination form and the body figure pictograms (see sample in Annex 4), taking care to record the type, size, colour and form of any bruises, lacerations, ecchymoses and petechiae.
- Take note of the survivor's mental and emotional state (withdrawn, crying, calm, etc.).
- Take samples of any foreign material on the survivor's body or clothes (blood, saliva, semen, fingernail cuttings or scrapings, swabs of bite marks, etc.) according to the local evidence collection protocol.
- Take a sample of the survivor's own blood, if indicated.
Examination of the genital area
Even when female genitalia are examined immediately after a rape, there is identifiable damage in less than 50% of cases. Carry out a gynaecological examination as indicated below. Collect evidence as you go along, according to the local evidence collection protocol. Note the location of any tears, abrasions and bruises on the pictogram and the examination form.
- Systematically inspect the mons pubis, inside of the thighs, perineum, anus, labia majora and minora, clitoris, urethra, introitus and hymen:
- Note any scars from previous female genital mutilation.
- Look for genital injury, such as bruises, scratches, abrasions, tears (often located on the posterior fourchette).
- Look for any sign of infection, such as ulcers, vaginal discharge or warts.
- Check for injuries to the introitus and hymen by holding the labia at the posterior edge between index finger and thumb and gently pulling outwards and downwards. Hymenal tears are more common in children and adolescents (see "Care for child survivors", pages 25-27).
- Take samples ac-cording to your local evidence collection protocol. If collecting samples for DNA analysis, take swabs from around the anus and perineum before the vulva, in order to avoid contamination.
- If there has been vaginal penetration, gently insert a speculum, lubricated with water or normal saline (do not use a speculum when examining children; see "Care for child survivors", pages 25-27):
- Under good lighting inspect the cervix, then the posterior fornix and the vaginal mucosa for trauma, bleeding and signs of infection.
- Take swabs and collect vaginal secretions according to the local evidence collection protocol.
- If indicated by the history and the rest of the examination, do a bimanual examination and palpate the cervix, uterus and adnexa, looking for signs of abdominal trauma, pregnancy or infection.
Note: In some cultures, it is unacceptable to penetrate the vagina of a woman who is a virgin with anything, including a speculum, finger or swab. In this case you may have to limit the examination to inspection of the external genitalia, unless there are symptoms of internal damage.
Examination of anus and rectum
- For the anal examination the patient may have to change position. Write down her position during the examination (supine for genital examination; supine, prone, knee-chest or lateral recumbent for anal examination).
- Note the shape and dilatation of the anus. Note any fissures around the anus, the presence of faecal matter on the perianal skin, and possible bleeding from rectal tears.
- If indicated by the history, collect samples from the rectum according to the local evidence collection protocol.
- If indicated, do a rectovaginal examination and inspect the rectal area for trauma, recto-vaginal tears or fistulas, bleeding and discharge. Note the sphincter tone.
No additional samples need to be collected for laboratory testing, other than those collected for evidence, unless indicated by the history or the findings on examination. Samples for testing for sexually transmitted infections may be collected for medical purposes.
- If the survivor has complaints that indicate a urinary tract infection, collect a urine sample to test for erythrocytes and leukocytes, and possibly for culture.
- Do a pregnancy test, if indicated and available (see Step 3).
- Other diagnostic tests, such as X-ray and ultrasound examination, may be useful in diagnosing fractures and abdominal trauma.
Part B: Survivor presents more than 72 hours after the incident
It is rare to find any physical evidence more than one week after an assault. If the survivor presents within a week of the rape, or presents with complaints, do a full physical examination as above. In all cases:
- note size and colour of any bruises and scars;
- note any evidence of possible complications of the rape (deafness, fractures, abscesses, etc.);
- note the survivor's mental state (normal, withdrawn, depressed, suicidal).
Examination of the genital area
If the assault occurred more than a week ago and there are no bruises or lacerations and no complaints (i.e. of vaginal or anal discharge or ulcers), there is little indication to do a pelvic examination. However, if you are in a setting with laboratory facilities, samples may be taken from the vagina and anus for STI screening.
Screen for STIs if possible. Follow the instructions of the local laboratory. Screening might cover:
- rapid plasma reagin (RPR) test for syphilis;
- Gram stain and culture for gonorrhoea;
- culture or enzyme-linked immunoassay (ELISA) for chlamydia;
- screening for HIV (but only on a voluntary basis and after counselling).