STEP 1 - Making preparations to offer medical care to rape survivors

The health care service must make preparations to respond thoroughly and compassionately to people who have been raped. The health coordinator should ensure that health care providers (doctors, medical assistants, nurses, etc.) are trained to provide appropriate care and have the necessary equipment and supplies. Female health care providers should be trained as a priority, but a lack of trained female health workers should not prevent the service providing care for survivors of rape.

In setting up a service, the following questions and issues need to be addressed, and standard procedures developed.

What should the community be aware of?

Members of the community should know:

- what services are available for people who have been raped;

- why rape survivors would want to seek medical care;

- where to go for services;

- that rape survivors should come immediately after the incident without bathing or changing clothes;

- that rape survivors can trust the service to treat them with dignity, maintain their security, and respect their confidentiality;

- that there is 24-hour access to services.

What are the host country's laws and policies?

- Which health care provider should provide what type of care? If the person wishes to report the rape officially to the authorities, the country's laws may require that a certified or licensed medical doctor provide the care and complete the official documentation.

- What are the legal requirements with regard to forensic evidence?

- What are the national laws regarding management of the possible medical consequences of rape (e.g. emergency contraception, abortion, testing and preventive treatment for human immunodeficiency virus (HIV))?

What resources and capacities are available?

- What laboratory facilities are available for forensic testing (DNA analysis, acid phosphatase) or screening for disease (STIs, HIV)? What counselling services are available?

- Are there rape management protocols and "rape kits" for documenting and collecting forensic evidence?

- Is there a national STI treatment protocol, a post-exposure prophylaxis (PEP) protocol and a vaccination schedule? Which vaccines are available?

- What possibilities are there for referral of the survivor to a secondary health care facility (psychiatry, surgery, paediatrics, or gynaecology/obstetrics)?

Where should care be provided?

Generally, a health care clinic or outpatient service that already offers reproductive health services, such as antenatal care, normal delivery care, or management of STIs, can offer care for rape survivors. Referral services may need to be provided at hospital level.

Who should provide care?

All staff in health facilities dealing with rape survivors, from reception staff to health care professionals, should be trained in their care. They should always be compassionate and respect confidentiality.

How should care be provided?

Care should be provided:

- according to a protocol that has been specifically developed for the situation. Protocols should include guidance on medical, psychosocial and ethical (responsibilities of the provider) aspects, and on counselling options;

- in a compassionate manner;

- with a focus on the survivor and her needs;

- with an understanding of the provider's own attitudes and sensitivities, the sociocultural context, and the community's perspectives, practices and beliefs.

What is needed?

- All health care for rape survivors should be provided in one place within the health care facility so that the person does not have to move from place to place.

- Services should be available 24 hours a day, 7 days a week.

- All available supplies from the checklist on page 5 and 6 should be prepared and kept in a special box or place, so that they are readily available.

How to coordinate with others?

- Interagency and intersectoral coordination should be established to ensure comprehensive care for survivors of sexual violence.

- Be sure to include representatives of social/community services, protection, the police or legal justice system, and security. Depending on the services available in the particular setting, others may need to be included.

- As a multisectoral team, establish referral networks, communication systems, coordination mechanisms, and follow-up strategies.

See Annex 8 for the minimum care that can and should be made available to survivors in the lowest-resource settings.

Remember: the wishes of the survivor should be respected at all times.

Checklist of supplies for clinical management of rape survivors

1	Protocol		Available
	- Written medical protocol translated in language of provider*
2	Personnel		Available
	- Trained (local) health care professionals (on call 24 hours/day)*
	- For female survivors, a female health provider speaking the same language is optimal. IF this is not possible a female health worker (or companion) should be in the room during the examination*
3	Furniture/Setting		Available
	- Room (private, quiet, accessible, access to a toilet or latrine)*
	- Examination table*
	- Lighting, preferably fixed (a torch may be threatening for children)*
	- Magnifying glass (or colposcope)
	- Access to an autoclave to sterilise equipment*
	- Access to laboratory facilities/microscope/trained technician
	- Weighing scales and height chart for children
4	Supplies		Available
	- "Rape Kit" for collection of forensic evidence, could include:
		- Speculum* (preferably plastic, disposable, only adult sizes)
		- Comb for collecting foreign matter in pubic hair
		- Syringes/needles (butterfly for children)/tubes for collecting blood
		- Glass slides for preparing wet and/or dry mounts (for sperm)
		- Cotton tipped swabs/applicators/gauze compresses for collecting samples
		- Laboratory containers for transporting swabs
		- Paper sheet for collecting debris as the survivor undresses
		- Tape measure for measuring the size of bruises, lacerations, etc*.
		- Paper bags for collection of evidence*
		- Paper tape for sealing and labelling containers/bags*
	- Supplies for universal precautions (gloves, box for safe disposal of contaminated and sharp materials, soap)*
	- Resuscitation equipment for anaphylactic reactions*
	- Sterile medical instruments (kit) for repair of tears, and suture material*
	- Needles, syringes*
	- Cover (gown, cloth, sheet) to cover the survivor during the examination*
	- Spare items of clothing to replace those that are torn or taken for evidence
	- Sanitary supplies (pads or local cloths)*
	- Pregnancy tests
	- Pregnancy calculator disk to determine the age of a pregnancy
5	Drugs		Available
	- For treatment of STIs as per country protocol*
	- For post-exposure prophylaxis of HIV transmission (PEP)
	- Emergency contraception pills and/or intrauterine device (IUD)*
	- Tetanus toxoid, tetanus immuno-globulin
	- Hepatitis B vaccine
	- For pain relief* (e.g. paracetamol)
	- Anxiolytic (e.g. diazepam)
	- Sedative for children (e.g. diazepam)
	- Local anaesthetic for suturing*
	- Antibiotics for wound care*
6	Administrative Supplies		Available
	- Medical chart with pictograms*
	- Forms for recording post-rape care
	- Consent forms*
	- Information pamphlets for post-rape care (for survivor)*
	- Safe, locked filing space to keep confidential records*

* Items marked with an asterisk are the minimum requirements for examination and treatment of a rape survivor.