Strengthening Health System Responses to Gender-based Violence in Eastern Europe and Central Asia

A resource package

3.2. Undertaking a medical examination and providing medical care

Following disclosure of GBV, health care professionals should undertake a medical examination and provide medical care. Even if a woman does not reveal GBV, health care providers should ensure examination and care, as required by the clinical symptoms observed.

Throughout the entire process of medical examination and care, health care providers need to take into account that survivors of sexual violence are often in a heightened state of awareness and very emotional after an assault, due to the circulation of stress hormones. While kindness of service providers may support the process of emotional recovery from sexual assault, conversely, inappropriate comments by police, doctors or other persons may contribute to patient distress during the examination and hinder long-term recovery. Please refer to chapter 3.1.4, table 10 for a list of “do’s and don’ts” in communicating with survivors of GBV that should be observed throughout the entire medical consultation.

3.2.1  First-line support

When a woman discloses violence,health care providers should offer immediate first-line support. If they are unable to do so, they should ensure that someone else (within their health-care setting or another that is easily accessible) is immediately available to provide first-line support (WHO 2013 Recommendation 1).

Box 18: Guidelines for women-centred care - elements of first-line response

First-line support includes:

  • being non-judgemental and supportive and validating what the woman is saying;
  • providing practical care and support that responds to her concerns, but does not intrude;
  • asking about her history of violence, listening carefully, but not pressuring her to talk (care should be taken when discussing sensitive topics when interpreters are involved);
  • helping her access information about resources, including legal and other services that she might think helpful;
  • assisting her to increase safety for herself and her children, where needed; and
  • providing or mobilizing social support.

Providers should ensure:

  • that the consultation is conducted in private and
  • confidentiality, while informing women of the limits of confidentiality (e.g. when there is mandatory reporting).

Source: WHO 2013 Recommendations 1, 10, 12, 24

3.2.2 Medical history and examination

Health care professionals first need to obtain informed consent from the patient on all aspects of the consultation. This means explaining all aspects of the consultation to the patient, so that she understands all her options and is able to make informed decisions about her medical care. In particular, health care professionals need to point out any limitations of confidentiality, such as any legal obligations to report GBV to the police or other authorities. If required by national legislation, the health care professional needs to ask the patient to sign or mark the consent form. Examining a person without her consent may result in criminal prosecution of health care professionals. Further, in some jurisdictions, the results of an examination conducted without the consent of the patient cannot be used in legal proceedings (WHO 2003).

The next step is to take a complete medical history, recording events to determine what interventions are appropriate. This should include a detailed description of the assault, its duration, whether any weapons were used (such as belts, household objects, knives or guns, as well as date and time of the assault (BMFWJ 2010). In cases of sexual violence, the following information should be added:

  • the time since assault and type of assault,
  • the risk of pregnancy,
  • the risk of HIV and other sexually transmitted infections (STIs), and
  • the woman’s mental health status (WHO 2013 Rec. 11).

For more information on taking the patient’s general medical history and gynaecological history, refer to the WHO 2003,  section 4.3.

When interviewing the patient about the assault, health care professionals should

  • ask her to tell in her own words what happened;
  • avoid unnecessary interruptions and ask questions for clarification only after she has completed her account;
  • be thorough, bearing in mind that some patients may intentionally avoid particularly embarrassing details of the assault, such as details of oral sexual contact or anal penetration;
  • use open-ended questions and avoid questions starting with “why”, which tends to imply blame; and
  • address patient questions and concerns in a non-judgemental, empathic manner, for instance, through using a very calm tone of voice, maintaining eye contact as culturally appropriate and avoiding expressing shock or disbelief.

After taking the history, health care professionals should conduct a complete physical examination (head-to-toe; for sexual violence also including the patient’s genitalia) (WHO 2013 Recommendation 11), observing the following general principles (Perttu/Kaselitz 2006, Warshaw/Ganley 1996, WHO 2003):

  • Explain the medical examination, what it includes, why it is done and how, to avoid the exam itself becoming another traumatic experience. Also, give the patient a chance to ask questions.
  • Ask the patient if she wishes a female doctor (especially in cases of sexual violence).
  • Do not leave the patient alone (e.g. when she is waiting for the examination).
  • Ask her to disrobe completely and to put on a hospital gown, so that hidden injuries can be seen.
  • Examine especially areas covered by clothes and hair.
  • If she has experienced sexual violence, examine her whole body – not just the genitals or the abdominal area.
  • Examine both serious and minor injuries.
  • Note emotional and psychological symptoms as well.
  • Throughout the physical examination inform the patient what you plan do next and ask permission. Always let her know when and where touching will occur. Show and explain instruments and collection materials.
  • Patients may refuse all or part of the physical examination. Allowing her a degree of control over the examination is important to her recovery.
  • Both medical and forensic specimens should be collected during the course of the examination. This should be done by a health care professional trained in forensic medicine. Providing medical and legal (forensic) services at the same time, in the same place and by the same person reduces the number of examinations that the patient has to undergo and can ensure the needs of the patient are addressed more comprehensively.

For more information on the different steps to follow in the “top-to-toe” physical examination and the genito-anal examination of survivors of sexual violence, refer to WHO 2003, section 4.4.

3.2.3 Treatment and follow-up care

Treatment of injuries

Patients with severe, life-threatening conditions should be referred for emergency treatment immediately. Patients with less severe injuries, for example, cuts, bruises and superficial wounds can usually be treated in situ by the examining health care worker or other nursing staff. Any wounds should be cleaned and treated as necessary. The following medications may be indicated:

  • antibiotics to prevent wounds from becoming infected;
  • a tetanus booster or vaccination (according to local protocols); and
  • medications for the relief of pain, anxiety or insomnia (WHO 2003).

Prevention of unwanted pregnancies, HIV and sexually transmitted infections

Health care professionals should offer emergency contraception to survivors of sexual assault, based on the following guidelines:

  • Emergency contraception should be initiated as soon as possible after the assault. It is more effective if given within 3 days but can be given up to 5 days (120 hours).
  • Health-care providers should offer levonorgestrel (recommended: single dose of 1.5 mg).
  • If levonorgestrel is not available, the combined oestrogen–progestogen regimen may be offered, along with anti-emetics to prevent nausea, if available.
  • If oral emergency contraception is not available and it is feasible, copper-bearing intrauterine devices (IUDs) may be offered to women seeking ongoing pregnancy prevention. Taking into account the risk of STIs, the IUD may be inserted up to 5 days after sexual assault for those who are medically eligible, in line with the WHO medical eligibility criteria (WHO 2010a, cited in WHO 2013; WHO 2013 Recommendations 12, 13).

Availability of drugs may depend on existing country-specific regulations and thus vary in the region.

Safe abortion should be offered in accordance with national law, if

  • a woman presents after the time required for emergency contraception (5 days),
  • emergency contraception fails, or
  • the woman is pregnant as a result of rape (WHO 2013 Recommendation 14).

Health care professionals should consider offering HIV post-exposure prophylaxis (HIV PEP) for women presenting within 72 hours of a sexual assault. Health professionals and the survivor should use shared decision-making in order to determine whether HIV PEP is appropriate (WHO 2013 Rec. 15). When discussing the HIV risk, the following factors should be taken into account:

  • HIV prevalence in the geographic area,
  • limitations of PEP,
  • the HIV status and characteristics of the perpetrator if known,
  • assault characteristics, including the number of perpetrators,
  • side-effects of the antiretroviral drugs used in the PEP regimen, and
  • the likelihood of HIV transmission (WHO 2013 Recommendation 15, WHO 2007, cited in WHO 2013).

If HIV PEP is used, health care professionals should:

  • start the regimen as soon as possible and before 72 hours,
  • provide HIV testing and counselling at the initial consultation,
  • ensure patient follow-up at regular intervals, and
  • provide adherence counselling (WHO 2013 Recommendation 16). The latter is important, keeping in mind that many women survivors of sexual violence do not successfully complete the 28 days of the preventive regime required in order to be effective. This is because HIV PEP causes nausea and vomiting, may trigger painful thoughts of the rape and may be overtaken by other issues in the lives of the survivors.

Two-drug regimens (using a fixed dose combination) are generally preferred over three-drug regimens, prioritizing drugs with fewer side-effects. The choice of drug and regimens should follow national guidance. It is recommended that survivors of sexual violence undergo HIV testing prior to giving PEP, but should not preclude PEP from being offered. Persons with HIV infection should not use PEP; rather, they should receive care and antiretroviral therapy (WHO 2013 Recommendations 17, 18).

Health care professionals should offer women survivors of sexual assault post-exposure prophylaxis for the following sexually transmitted infections:

  • chlamydia,
  • gonorrhoea,
  • trichomoniasis, and
  • syphilis, depending on the prevalence.

The choice of drug and regimens should follow national guidance. In order to avoid unnecessary delays, presumptive treatment is preferable to testing for STIs; therefore, testing prior to treatment is not recommended (WHO 2013 Recommendation 19).

Hepatitis B vaccination without hepatitis B immune globulin should be offered according to national guidelines. Health care professionals should take blood for hepatitis B status prior to administering the first vaccine dose. If immune, no further course of vaccination is required (WHO 2013 Recommendation 20).

Psychological/mental health interventions

Where referral possibilities are available, primary health care professionals should refer survivors with pre-existing diagnosed or intimate partner violence-related mental disorders to specialist health care providers for psychological/mental healthcare interventions. Some of the interventions may also be performed by primary health care providers themselves, in accordance with the WHO mhGAP guidelines that apply to non-specialized health care settings. In health care settings with limited or no referral possibilities, psychological first aid provides a very basic form of psychological support that is suitable for primary care level. Psychological first aid involves the following elements: providing practical care and support, which does not intrude; assessing needs and concerns; helping people to address basic needs (for example, food and water, information); listening to people, but not pressuring them to talk; comforting people and helping them to feel calm; helping people connect to information, services and social supports; and protecting people from further harm (WHO et al 2011, WHO 2013).

The following WHO recommendations refer to survivors of intimate partner violence; however, they may also be used as guidance when addressing psychological/mental health outcomes of non-partner violence.

  • Survivors of intimate partner violence with pre-existing diagnosed or intimate partner violence -related mental disorder (such as depressive disorder, alcohol use disorder) should receive mental health care in accordance with the WHO mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings (WHO 2010a), delivered by a health professional with a good understanding of GBV. For women who are either breastfeeding or pregnant, the use of psychotropic medicine requires specialist knowledge and should be provided in consultation with a specialist (WHO 2013 Recommendation 5).
  • Women who no longer experience intimate partner violence but are suffering from post-traumatic stress disorder (PTSD), should receive cognitive behavioural therapy or eye movement desensitization and reprocessing interventions (see glossary), delivered by a health professional with a good understanding of GBV (WHO 2013 Recommendation 6). According to WHO, there is insufficient evidence for providing such interventions to women who are still experiencing intimate partner violence (WHO 2013).
  • Mother-child intervention: Children who are exposed to intimate partner violence should be offered a psychotherapeutic intervention, including sessions with and sessions without the presence of their mother. The WHO observes that the extent to which this applies to low- and middle-income countries is unclear, given the cost of this type of intensive intervention, the lack of resources, and lack of trained providers in these countries (WHO 2013 Recommendation 9).

For survivors of sexual violence, health professionals need to observe three main stages after the assault when setting appropriate interventions:

  1.  During the first days of the assault, health care providers should
  • continue to provide first-line support (WHO 2013 Recommendation 21),
  • provide survivors with written information on coping strategies for dealing with severe stress (with appropriate warnings about taking printed material home if an abusive partner is there) (WHO 2013 Recommendation 22), and
  • not use psychological debriefing[1] (WHO 2013 Recommendation 23).

   2.    Up to three months post-trauma, health care providers should

  • continue to provide first-line support (WHO 2013 Recommendation 24);
  • apply “watchful waiting” for 1-3 months after the event (i.e. explaining the woman that she is likely to improve over time and offering her the option to come back for further support by making regular follow-up appointments), However, “watchful waiting” should not be applied if the woman is depressed, has alcohol or drug use problems, is suicidal or self-harming or has difficulties functioning in day-to-day tasks (WHO 2013 Recommendation 25);
  • arrange cognitive behavioural therapy or eye movement desensitization and reprocessing interventions in case the woman is incapacitated by the post-rape symptoms (i.e. she cannot function on a day-to-day basis), to be provided by a health care provider with a good understanding of violence (WHO 2013 Recommendation 26); and
  •  provide care in line with the WHO mhGAP Intervention Guide if the person has any other mental health problems, such as symptoms of depression, alcohol or drug use problems, suicide or self-harm (WHO 2013 Recommendation 27).

    3.    After three months post-trauma, health care providers should

  • assess for mental health problems (symptoms of acute stress/PTSD ,depression, alcohol and drug use problems, suicidality or self-harm) and treat depression, alcohol use disorder and other mental health disorders using the WHO mhGAP intervention guide (WHO 2013 Recommendation 28); and
  • if the survivor is suffering from PTSD, arrange for PTSD treatment with cognitive behavioural therapy or eye movement desensitization and reprocessing (WHO 2013 Recommendation 29).

When delivering psychosocial/mental health care, it is essential for health professionals to ensure the patients’ informed consent and her safety. Therapies should be implemented by a trained health care provider with a good understanding of sexual violence. Further, health care providers should consider pre-existing mental health conditions, keeping in mind that women with mental health and substance abuse problems may be at greater risk of rape than other women. Therefore, there is likely to be a disproportionate burden of pre-existing mental health and substance abuse problems among rape survivors. Pre-existing traumatic events such as sexual abuse in childhood, intimate partner violence or war-related trauma should also be considered (WHO 2013).

[1]Psychological debriefing involves promoting ventilation by asking a person to briefly, but systematically recount their perceptions (WHO 2010a and Sphere 2011, all cited in WHO 2011).