The handling of a victim after Sexual and Gender Based Violence (SGBV) before a decision is taken to report can impact on the outcome. How the victim and the circumstance are handled should form part of the message for all stakeholders, especially the public.

1. Report as soon as possible: Late reportage is not uncommon. Late reportage or not reporting at all will allow all the possible consequences of Sexual and Gender Based Violence (SGBV) run their courses. It will also allow time for forensic evidence to disappear and for the culprit to escape.
2. Maintain confidentiality and do not create a scene: When sexual assault has been made known or discovered, the first person to know should keep the information as closed as possible. Making the knowledge public will increase the victim’s psychological trauma and get him/her more stigmatized in the society. Information should be limited to those who will act in place of the parents/guardian, necessary witnesses, medical personnel and the police. If the case gets to the police first before the hospital or medical facility, request to speak in confidence with the police on duty rather than talking loudly for everyone to hear when presenting the case. Encourage the police to get the victim to the hospital as soon as possible.
3. Provide cover/clothing for the victim after taking pictures for evidence.
4. Keep all evidence intact, like soiled/torn clothing.
5. Secure the crime site if possible.
6. MANAGEMENT IN HOSPITAL

Evaluate the victim in a room that satisfies the guiding principles of safety, confidentiality, etc and always get ready all you need for sample collection including rape kits.

Step One: A survivor-centred approach starts with preparing the survivor for evaluation. This includes the following:

• Introduce yourself.
• Limit the number of people in the room to the minimum necessary. If the survivor wishes, ensure that a trained support person or trained health worker of the same sex accompanies the survivor throughout the examination. Ask if they also want to have a specific person present (e.g., family member or friend).
• Determine the best way to communicate and adapt to the victim’s communication skill level and language. Avoid medical terminology and jargon.
• Obtain informed consent (or a parent’s informed consent in the case of a child).
• Explain what is going to happen during each step of the examination, why it is important, what it will tell you, and how it will influence the care you will give. Make sure the survivor understands everything.
• Reassure the survivor they are in control of the examination. Explain that they can refuse any aspect of the examination they do not wish to undergo, and that this will not affect their access to treatment or care, but may affect the extent of treatment or prevention if that is later decided. Document the victim’s decision.
• Reassure the survivor that the examination findings will be kept confidential unless the survivor decides to bring criminal charges.
• Provide psychological first aid.

Ask the survivor if they have any questions

Step Two: Obtain consent/assent and consent. Consent may be needed for most court cases. The table below is adapted from the IRC.

 Step Three: History

• The third step is to take the history. Ensure the following: If the history-taking is conducted in the treatment room, cover the medical instruments until they are needed.
• Before taking the history, review any documents or paperwork brought by the survivor. Do not ask questions that have already been asked and documented by other people involved in the case except to seek for more clarification.
• Avoid any distraction or interruption during the history-taking.
• Make sure the survivor feels comfortable. Use a calm tone. If culturally appropriate, maintain eye contact. Be aware of the survivor’s body language and your own.
• Be systematic. Proceed at the survivor ‘s own pace. Be thorough, but don‘t force the survivor.
• Let the survivor tell their story the way they want to. Document the incident in the survivor’s own words.
• Avoid questions that suggest blame (e.g., What were you doing there alone?).
• Be compassionate and non-judgmental.
• Explain what you are going to do at every step.

DEALING WITH VICTIM’S EMOTIONS

 Be ready to deal with their various emotions/feelings. The following are suggested responses:

Hopelessness: Reassure the person and tell her/him encouraging things

Despair: Focus on the strategies and resourcefulness through which the person will get better.

Powerlessness and loss of control: Say, “You have choices and options today on how to proceed.”

Flashbacks: Say, “These will resolve with the healing process.”

Disturbed sleep: Say, “This will improve with the healing process.”

Denial: Say, “I’m taking what you have told me seriously. I will be here if you need help in the future.”

 Guilt and self-blame: Say, “You are not to blame for what happened to you. The person who assaulted you is responsible for the violence.”

Shame: Say, “There is no loss of honour in being assaulted. You are an honourable person.”

Fear: Emphasize, “You are safe now.” You can say, “That must have been very frightening for you.”

Numbness: Say, “This is a common reaction to severe trauma. You will feel well again. All in good time.”

Mood swings: Explain that these are common and should resolve with the healing process. A legitimate feeling and avenues can be found for its safe expression. Assist the patient in experiencing those feelings. For example, “You sound very angry.”

Anxiety: Tell the patient that these symptoms will ease with the use of the appropriate stress management techniques and offer to explain these techniques.

Helplessness: Say, “It sounds as if you were feeling helpless. We are here to help you.”

SEXUAL VIOLENCE HISTORY

• The date and time of the sexual violence
• The location and description of the type of surface on which the violence occurred
• The name, identity and number of assailants
• The nature of the physical contacts and detailed account of violence inflicted
• Use of weapons and restraints
• Use of any medications/drugs/alcohol/inhaled substances
• Use of condoms and lubricants
• Any subsequent activities by the survivor that may alter evidence e.g. Bathing, douching, wiping, the use of tampons and changes of clothing
• Any symptoms that may have developed since the violence e.g. Genital bleeding, discharge, itching, sores or pain
• Current sexual partner/s (be tactical about this especially for singles/divorced/widowed/separated)
• Last consensual sexual intercourse

Gynaecological history:

• Last menstrual period
• Number of pregnancies
• Use (and type) of current contraception methods

 Male- specific history

• Any pain or discomfort experienced in the penis, scrotum or anus
• Any urethral or anal discharge
• Difficulty or pain on passing urine or stool

Ask questions to elicit risk factors. These may include

• lower levels of education (perpetration of sexual violence and experience of sexual violence);
• a history of exposure to child maltreatment (perpetration and experience);
• witnessing family violence (perpetration and experience);
• antisocial personality disorder (perpetration);
• harmful use of alcohol (perpetration and experience); 
• harmful masculine behaviours, including having multiple partners or attitudes that condone violence (perpetration);
• community norms that privilege or ascribe higher status to men and lower status to women; 
• low levels of women’s access to paid employment; and
• low level of gender equity (discriminatory laws, etc.). past history of exposure to violence;
• marital discord and dissatisfaction;
• difficulties in communicating between partners; and
• male controlling behaviours towards their partners.
• beliefs in family honour and sexual purity;
• ideologies of male sexual entitlement; and
• weak legal sanctions for sexual violence.
• Walking at odd times / places unaccompanied
• one female heads of household
• children and young adults
• children in foster care
• physically and mentally challenged persons
• persons in prison or detention
• persons with mental illness or under the influence of alcohol or drug
• single parent homes
• persons with a history of rape or sexual abuse
• persons involved in prostitution
• persons in an abusive intimate or dependent relationship
• victims of war or armed conflict situations
• the homeless or impoverished

For children, the questions may be a little different.

• When did this happen?
• Was this the first time this happened or has it happened before?
• What threats were made? Or incentives were given?
• What part of your body was touched or hurt?
• Do you have any pain in your bottom or genital area?
• Is there any blood in your panties?
• Do you have difficulty or pain with voiding or defecating?
• Have you taken a bath since the sexual violence?
• When was the last time you had sexual intercourse? (explain why you need to ask about this).
• When was your last menstrual period? (girl)

Step four: PHYSICAL EXAMINATION

The fourth step is the physical examination (which includes the genital examination and forensic evidence collection)

• Reassure the survivor again and seek further consent
• Try to make the victim feel comfortable and relaxed as much as possible.

A systematic ‘’Head to Toe’’ approach may ensure all is covered.

• First, note the survivor’s general appearance and demeanor.
• Take the vital signs, i.e. pulse, blood pressure, respiration and temperature.
• Inspect both sides of both hands for injuries. Examine the wrists for signs of ligature marks.
• Inspect the face and the eyes. If there is pain in a particular area, reassure and perform that examination last.
• Gently palpate the scalp to check for tenderness, swelling or depression.
• Inspect the ears, not forgetting the area behind the ears, for evidence of shadow bruising; shadow bruising develops when the ear has been struck onto the mastoid.
• Carefully examine the neck. The neck area is of great forensic interest; bruising can indicate life-threatening violence.
• Examine the breasts and trunk with as much dignity and privacy as can be afforded.
• Inspect the forearms for defense related injuries. These are injuries that occur when the subject raises a limb to ward off force to vulnerable areas of the body, and include bruises, abrasions, lacerations and incised wounds.
• Examine the inner surfaces of the upper arms and armpit or axilla for bruises.
• Recline the position of the survivor for abdominal examination, which includes abdominal palpation to exclude any internal trauma or detect pregnancy.
• While in the reclined position, examine the legs, starting with the front.
• If possible, ask the survivor to stand for inspection of the back of the legs. An inspection of the buttocks is also best achieved with the survivor standing.
• Collect any biological evidence with moistened swabs (for semen, saliva, blood) or tweezers (for hair, fibres, grass and soil).

The Genito-Anal Examination for Adults

• Try to make the victim feel as comfortable and as relaxed as possible.
• Explain to them each step of the examination. For example, say, “I’m going to have a careful look. I’m going to touch you here in order to look a bit more carefully. Please tell me if anything feels tender.”
• Examine the external areas of the genital region and anus as well as any markings on the thighs and buttocks.
• Inspect the mons pubis; examine the vaginal vestibule, paying special attention to the labia majora, labia minora, clitoris, hymen or hymenal remnants, posterior fourchette and perineum.
• Take a swab of the external genitalia before attempting any digital exploration or speculum examination. Gently stretch the posterior fourchette area to reveal abrasions that are otherwise difficult to see. If any bright blood is present, gently swab in order to establish its origin, i.e. whether it is vulval or vaginal.
• Warm the speculum prior to use by immersing it in warm water. Insert the speculum. Inspect the vaginal walls for signs of injury, including abrasions, lacerations, and bruising.
• Collect any trace evidence, such as foreign bodies and hairs, if found. Suture any tears, if indicated.
• Remove the speculum. Remember: Prepare/assemble the PRC kit before the survivor comes in.
• If available, ensure a trained support person of same sex accompanies the survivor throughout the examination.

Head to Toe Examination for Children

 The physical examination of children should be conducted according The physical examination of children should be conducted according to the procedures outlined for adult’s section. Before examination, ensure that consent has been obtained from the child and/or the caregiver as appropriate. If the child refuses the examination, it would be appropriate to explore the reasons for refusal.

When performing the head-to-toe examination of children, the following points are important:

• Record the height and weight of the child.
• In the mouth/pharynx, note petechiae of the palate or posterior pharynx and look for any tears to the frenulum.
• Record the child’s sexual development and check the breasts for signs of injury.
• Note: Consider examining very small children while on their mother’s or care giver’s lap. If the child still refuses, the examination may be deferred or even abandoned. Never force the examination, especially if there are no reported symptoms or injuries because findings will be minimal, and any coercion may mean yet another violence to the child.
• Consider sedation or a general anaesthetic, only if the child refuses the examination and conditions requiring medical attention, such as bleeding or a foreign body, are suspected.

The Genito-Anal Examination for Girls

 Whenever possible, do not conduct a speculum examination on girls who have not reached puberty. It might be very painful and cause additional trauma. A speculum may only be indicated when the child has internal bleeding arising from a vaginal injury as a result of penetration. In this case:

• Help the child to lie on her back or side.
• Use a paediatric speculum and conduct the examination under general anaesthesia.
• Check for blood spots or trauma to the urethra.
• Examine the anus for bruises, tears or discharge. You may need to refer the child to a higher-level health facility for this procedure.

 The Genito-Anal Examination for Boys

• Check for injuries to the skin that connects the foreskin to the penis.
• Check for discharge at the urethral meatus (tip of penis).
• In older boys, pull back the foreskin to examine the penis. Do not force it since doing so can cause trauma, especially in younger boys.
• Help the boy to lie on his back or on his side and examine the anus for bruises, tears or discharge.
• Avoid examining the boy in a position in which he was violated as this may mimic the position of abuse.
• Consider digital rectal examination only if medically indicated.