i
MINISTRY OF HEALTH
National Guidelines on
Management of Sexual
Violence in Kenya
3
rd
Edition, 2014
National Guidelines on
Management of Sexual
Violence in Kenya
3
rd
Edition, 2014
Printing supported by German Development Cooperation
through SGBV Networks Project
Table of Contents
Forward vii
Acknowledgements ix
Executive Summary xi
Acronyms xiii
Denition of Terms xv
Medical Management 1
Pyscho Social Support 19
Forensic Management of Sexual Violence 29
Humanitarian Issues 39
Quality Assurance and Quality Improvement 44
Annexes 47
vii
Forward
S
exual Violence is a serious public health and human rights concern in Kenya. It affects men
and women, boys and girls and has adverse physical and Psycho-social consequences
on the survivor. The post election violence experienced in 2008 following the disputed
2007 presidential elections, that saw a wave of sexual abuse targeted at women and girls,
was perhaps the clearest manifestation of the gravity of sexual violence in Kenya. Sexual
Violence and its attendant consequences threaten the attainment of global development goals
espoused in the Millennium Development Goals and national goals contained in Vision 2030
as well as the National Health Sector Strategic Plan II, as it affects the health and well being
of the survivor. Of concern is the emerging evidence worldwide that Sexual Violence is an
important risk factor contributing towards vulnerability to HIV infection. The National Plan
for Mainstreaming Gender into the HIV/AIDS strategic plan for Kenya has identied sexual
violence as an issue of concern in HIV transmission, particularly among adolescents. This calls
for comprehensive measures to address issues of Sexual Violence and more importantly meet
the diverse and often complex needs of the survivors and their families.
Comprehensive care for Sexual Violence ranges from medical treatment which includes
management of physical injuries, provision of emergency medication to reduce chances
of contracting sexually transmitted infections including HIV and provision of emergency
contraception to reduce chances of unwanted pregnancies. It also entails provision of psycho-
social support through counseling to help survivors deal with trauma and legal assistance to
assist the survivor access justice, as well as includes provision of evidentiary requirements for
the criminal justice system.
These National Guidelines have been designed to give general information about management
of sexual violence in Kenya and focus on the necessity to avail quality services that address
all the medical, psychosocial, legal needs of a survivor of sexual violence in both stable and
humanitarian contexts. Although these needs are interrelated, attempt has been made to group
the Guidelines into chapters that can easily be accessed for easy reference.
The Guidelines recognize the fact that children form a signicant proportion of survivors of
sexual violence and make special provisions for them that address their unique aspects, distinct
from those of female and male adults. The Guidelines also highlight the need to provide quality
services to perpetrators, as an effort towards HIV/STI management and provision of necessary
forensics evidence as required.
The Guidelines should be available in all health care facilities and it is our sincere hope that
their implementation will comprehensively address the needs of survivors of Sexual Violence
in Kenya.
Dr. Francis M. Kimani
Director of Medical Services
Ministry of Health
ix
T
hese guidelines are as a result of collaborative efforts of various government sectors,
partner organizations and individuals. I therefore take this opportunity to appreciate
the effort of the ofcers from the Ministry of Health, Division of Reproductive Health
(DRH) who coordinated and provided leadership to the development of these guidelines.
I especially acknowledge the Task Force on the Implementation of the Sexual Offences
Act (TFSOA), for the continued technical support and advice to the legal processes,
and the policy advocacy that saw the gazettement of the Sexual Offences Act Medical
(treatment) regulations, 2012.
The development and subsequent revisions to these guidelines were guided by the
Gender and Sexual Reproductive Health Rights Technical Working Group (GSRHR
TWG) of the DRH under the leadership of Dr Pamela Godia. This included members from
various government ministries, professional associations and civil society organizations
drawn from different sectors involved in sexual and gender based violence response,
all of whom contributed considerably to the production of these guidelines. I therefore
acknowledge the following organizations, government ministries and departments who
volunteered technical expertise and resources to facilitate the review process: Ministry
of Health, TFSOA, NGEC, LVCT Health, GIZ, MSF France, KNH, UNFPA, Population
Council, Abantu for Development, GVRC, KWCWC, FHI 360, CHUVREC, APHIA
Plus Nairobi- Coast, KMWA, Pathnder International, CDTD, SHOFCO and AOCASP
UNGASS Kenya.
I acknowledge former head of the Department of Family Health Dr. Josephine Kibaru
and current Head of RMHSU, Dr.Bartilol Kigen respectively. Dr. Nduku Kilonzo formerly
of (LVCT Health) and Dr. Klaus Hornetz (GIZ) for the technical support accorded to the
DRH and for spear heading the development of the rst edition of these guidelines.
I acknowledge the feedback received from the following through eld interviews:
Hon. Njoki Ndung’u, the architect of the Sexual Offences Act 2006, now a judge at
the Supreme Court of Kenya; Dr. Sam Thenya, the Chief Executive Ofcer, Nairobi
Women’s Hospital; Mr. John Kamau, Government Chemist, Dr Margaret Mak’anyengo,
Clinical Psychologist KNH, and Dr. Ian Kanyanya, Deputy Coordinator, GBVRC KNH.
I acknowledge the role of research evidence in informing the development and revision
of various components of these guidelines, including the PRC form, the PRC register and
the Rape kit. For this, I am grateful to the research studies funded by Trocaire, Population
Council, Norad, Swedish Embassy, Elton John AIDS Foundation and the United Nations
Trust Fund to End Violence Against Women.
I would like to acknowledge the Kenyatta National Hospital, Nairobi Women’s Hospital,
Moi Teaching and Referral Hospital, Coast Provincial General Hospital, Embu Provincial
General Hospital, Jaramogi Oginga Odinga Teaching and Referral Hospital, Thika Level
5 Hospital, Malindi District Hospital, Kitui Distict Hospital, Rachuonyo District Hospital,
Acknowledgements
x
Kianjokoma Sub-District Hospital, Turbo Health Centre, Government Chemist, Riruta
Health Center, Thika Police Station and Kisumu Police Station, for providing useful
feedback that enabled the revisions to these guidelines.
Finally, the production of this third edition was facilitated and coordinated by a core team
which spent a lot of time and effort to get this work done. Special acknowledgement
goes to Maureen Obbayi, Aboud Suhayla, David Nyaberi (late), Alice Mwangangi, Dr.
Lina Digolo, Dr. Vincent F. Buard, Dr. Jeldah Mokeira, Rukia Yassin, Dr. Shobha Vakil,
Hellen Chebet and Evelyne Ofwona for their commitment in compiling this edition.
The technical assistance to the process of reviewing these guidelines: meetings, retreats
and the various consultations could not have taken place without the secretariat and
nancial support from LVCT Health and GIZ. To them we are grateful.
Review Panel, 2009
Anne Njeru
Buluma Bwire
Catherine Maternowska
Carolyne Ajema
David Nyaberi (late)
Dr. Margaret Meme
Dr. Ian Kanyanya
Dr. David Oluoch
Dr. Nancy Cabelus
Dr. Essam Ahmed
Dr. Anne Weber
Dr. Paul Muganda
Dr. Angie Dawa
Dr. Lilian Otiso
Hadley Muchela
Lucy Kiama
Lucy Odhoch
Paul Ngone
Purity Kajuju
Rukia Yassin
Sarah Nduta
Violet Mavisi
Wangu Kanja
Review Panel, 2013
Aboud Suhayla Ahmed
Alice Mwangangi
Beatrice Nduta
Carolyne Ajema
David Nyaberi (late)
Damaris Mwanzia
Dr. Pamela Godia
Dr. Lina Digolo
Dr. Angie Dawa
Dr. Lilian Otiso
Dr. Jenniffer Othigo
Dr. Chi Chi Undie
Dr. Phenny Kachumbo
Dr. Dan Okoro
Dr. Vincent F. Buard
Dr. Lavussa Joyce
Dr. Margaret Mak’anyengo
Dr. Ian Kanyanya
Dr. Jeldah Mokeira
Faith Kabata
Getrude Kinyua
Hellen Chebet
Dr. William K. Maina
Head, Directorate of Preventive and
Promotive Health Services
Ministry of Health
xi
K
enya is a signatory to the international human rights instruments and standards such
as the International Conference on Population and Development (ICPD) and the
Millennium Development Goals (MDGs) that have been enshrined in the Constitution
enacted in 2010. These instruments obligate governments to put in place measures to
address sexual violence. Kenya has put in place provisions for laws and policy documents
emanating from specic sectors, including: The Sexual Offences Act 2006, the National
Policy on Gender and Development and National Reproductive Health Policy and the
National Reproductive Health Strategy. These policy documents have provided the
policy framework from which this specic guidelines have been developed. It is against
this background that the Ministry of Health in collaboration with other stakeholders
decided to develop comprehensive guidelines that can adequately respond to the
complex and often diverse needs of survivors of sexual violence and bridge the existing
gaps in the sector. The main goal is to ensure that the needs of survivors are addressed
as much as possible.
These guidelines have been designed to give general and easy to read information about
management of sexual violence in Kenya, and focus on the necessity to avail services
that address the needs of survivors and perpetrators, be they medical, psycho-social,
legal or referrals to additional support services. The guidelines cater for the needs of
children owing to the fact that they comprise a signicant percentage (about 60%) of
the cases that present in health facilities. In this regard, all aspects of child sexual abuse
management that differ from those of adults have been singled out, and where possible,
integrated into the content of the information outlined in each section. Sexual abuse of
children presents a unique phenomenon - the dynamics are often very different from
those of adult sexual abuse, and therefore abuse of this nature cannot be handled in the
same way as adults. For example, children tend to disclose as part of a process rather
than a single event. They do so over a longer period of time compared to adults.
Although these needs are interrelated, attempt has been made to group the guidelines
into chapters that can easily be accessed for ease of reference.
The clinical management chapter details out procedures relating to clinical management
of sexual violence from the rst point of contact with a survivor. Guidance to health
care providers on obtaining informed consent and assent has been provided. Treatment
options for various management have been updated and well-illustrated for ease of
reference. A section on follow up of survivors, beyond the rst clinical visit has also
been added.
The psychosocial chapter highlights the necessary considerations for psychosocial
support including preparation for treatment, prophylaxis, criminal justice system and
follow up counselling with clear ethical considerations. It further delves into the rape
trauma protocol to guide the delivery of trauma counselling and hopefully, enable health
Executive Summary
xii
care providers and counselors address psychosocial challenges faced by survivors as
comprehensively as possible, including providing information on the rights of survivors
of sexual violence.
Forensic management which is essential in helping survivors access justice by ensuring
availability of credible evidence that sexual violence indeed took place and help link or
delink the alleged perpetrator to the crime, is also elaborately covered in the guidelines.
Information on appropriate collection and preservation of specimens has been elaborated
upon as well as the need for proper documentation and the maintenance of the chain
of evidence. The importance and role of the health care provider as an expert witness
in court is strongly addressed, in accordance to the SOA medical (treatment) regulations
2012. These regulations states that sexual violence survivors should be treated free of
charge at public health facilities and also make it mandatory for a “designated person”
who examines survivors of sexual violence to ll the both the PRC and P3 forms. The
designated person can either be an enrolled or registered nurse, registered clinical
ofcer or medical doctor as dened by their respective registrations acts.
The guidelines further provide information on the humanitarian issues relating to sexual
violence and how best to manage sexual violence in crisis contexts. Key issues to
be considered in such contexts have been highlighted. Quality Assurance (QA) and
Quality Improvement (QI) which are a core component of any service delivery are also
covered in the guidelines, and a sample support supervision tool provided to aid in the
supervision of PRC services.
Additional annexes include the revised Post Rape Care register, a tool that is expected
to facilitate comprehensive data collection at the facility level; for this register to be
comprehensively lled in, close collaboration is required from the various PRC service
delivery points including the OPD, In-patient, Laboratory, Pharmacy and counselling
units. The PRC register is accompanied by a monthly and cohort summary to facilitate
the ow of data from facility to the national level.
xiii
ABC Abacavir
AIDS Acquired Immune Deciency Syndrome
ALT Alanine Aminotransferase
ART Anti Retroviral Therapy
ATV Atanovir
BD Twice a day
CCC Comprehensive Care Clinic
Cr Creatinine
D4T Stavudine
DNA Deoxyribonucleic Acid
DRH Division of Reproductive Health
EC Emergency Contraception
ECP Emergency Contraceptive Pills
GBV Gender Based Violence
GBVRC Gender Based Violence Recovery Centre
GVRC Gender Violence Recovery Center
Hb Haemoglobin
HCP Health Care Provider
HIV Human Immuno-Deciency Virus
HTC HIV Testing and Counselling
HVS High Vaginal Swab
IDPs Internally Displaced Persons
IRC International Rescue Committee
LFTs Liver Function Tests
LPV/r Lopinavir/ritonavir
LVCT Liverpool VCT Care and Treatment, Kenya
MDGs Millennium Development Goals
MOH Ministry of Health
MSF Medicins Sans Frontieres
Acronyms
xiv
NHSSP National Health Sector Strategic Plan
NVP Nevirapine
OB Occurrence Book
OPD Out Patient Department
PDT Pregnacy Diagnostic Test
PEP Post Exposure Prophylaxis
PRC Post Rape Care
PTSD Post Traumatic Stress Disorder
QA Quality Assurance
QI Quality Improvement
QID Four times a day
RTV Ritanovir
SDP Service Delivery Point
SGBV Sexual & Gender Based Violence
SGPT Serum Glutamate Pyruvic Transaminase
STIs Sexually Transmitted Infections
SOA Sexual Offences Act (2006)
SV Sexual Violence
TDF Tenofovir
TDS Thrice a day
TT Tetanus Toxoid
TIG Tetanus Immunoglobulin
U+Es Urea and Electrolytes
VCT Voluntary Counselling and Testing
VDRL Venereal Disease Research Laboratory
WHO World Health Organization
xiv
xv
Denition of Terms
Terms
Definition
Delement An act which causes
penetration
of a
c
hild
’
s
genital
organs
(A child is any one below the age of 18 y
ears).
Designated
persons
For purposes of the SOA, designated persons are
Nurses
and Clinical Ofcers registered under the various laws
and acts of
parliament.
Genital organs Includes the whole or part of male or female genital
organs and for
the
purposes of the act of sexual violence
includes the
anus.
Informed consent
(medical)
Where the health care provider has disclosed all relevant
information in regard to the proposed course of treatment to
the patient so that the patient can then arrive at a choice as
to whether or not to proceed with the same.
Informed consent
(legal)
Where a person has all relevant information in regard to a
certain course of action prior to agreeing to that action. For
this consent to be legally valid the person has to be an adult
of sound mind.
Post Rape
care form
This is a document that should be lled in triplicate by
medical practitioners or either of the designed persons for
purposes of medico- legal documentation following sexual
violence.
Penetration Partial or
complete
insertion of the genital organs of
a
person
or an object into the genital organs of another
person.
Rape An act done which causes
penetration
of one person’s
genital organs with the genital organs of another without
their consent or where
the
consent is
obtained
by force,
threats or intimidation of any
kind.
Survivor Any person who has undergone violence (in this case
sexual violence) and has
lived
through the
experience. A
survivor is also known
as a
‘victim’
according
to the SOA.
xvi
Sexual Assault Any act where a
person unlawfully
and purposely uses
an object or
any
part of his body (except his/ her private
parts) or any part of an
animal,
to penetrate the private
parts of another person without
permission.
(The only
exception
is where such
penetration
is carried
out for
proper
and professional hygienic or medical
reasons)
Sexual violence Any sexual act, attempt to obtain a sexual act,
unwanted
sexual
comments or advances, or acts to trafc
w
omen
’
s
sexuality,
using
coercion, threats of harm or physical force,
by any
person
regardless of relationship to the survivor, in
any setting, including
but
not limited to home and work
1
For the purpose of this guideline, sexual violence
refers to rape, attempted rape, defilement, attempted
defilement, sexual assault and attempted sexual assault.
1
1
Medical Management
1
1.
Introduction
2
2.
Obtaining Consent
2
3.
History Taking and Examination
3
3.1 History Taking for
Adults
4
3.2 Head to Toe Examination for
Adults
4
3.3 The Genito-Anal Examination for Adults
5
4.
History Taking and Examination for
Childr
en
6
4.1 History Taking for
Childr
en
6
4.2 Head to Toe Examination for
Childr
en
7
4.3 The Genito-Anal Examination for Girls
7
4.4 The Genito-Anal Examination for
Boys
8
4.5 Investigations for Clinical Management
8
5.
Management of Physical Injuries
10
6.
Post Exposure
Prophylaxis
(PEP)
12
6.1 Timing of PEP
12
6.2 ARV prophylaxis options in sexual violence
12
6.3 Recommended PEP Regimens for
Childr
en
12
6.4 Side Effects of PEP
14
7.
Pregnancy Prevention
14
8.
Management of Sexually Transmitted Infections
15
9.
Hepatitis B
16
10.
Medical Management of Perpetrators of Sexual Violence
17
11.
Follow Up of Survivors of Sexual Violence
20
2
Medical Management
1. Introduction
Medical
management
of sexual violence survivors is essential in mitigating against
ad
v
erse
effects of the violence. It is aimed at managing any life
threatening
injuries
and
providing other post-rape services to reduce the
chances
of the survivor
contracting
an
y sexually related infections and
pregnancy.
The
management of any
life
threatening
injuries, and extreme distress should take precedence over all other
aspects of post-r
ape
care. However, the
management
of minor
cuts
and abrasions
should not delay the delivery of other more time
dependent treatments.
Health care providers should be aware that the Kenyan law entitles medical care
to survivors of sexual violence as well as suspects, convicts or witnesses of sexual
offences. Therefore, a perpetrator or alleged perpetrator seeking medical treatment
should be accorded the necessary treatment and care as would a survivor.
This chapter highlights the
procedures
of clinical
management
of sexual
violence
including
the ethical
considerations.
The
procedures
cover the needs of adult
males, adult females and children (boys and girls).
General
consider
ations
• Introduce yourself to the
survivor.
• Reassure the survivor that he/she is in a safe place
now.
• Explain the steps of the
procedures
you are about to
undertake.
• Obtain written informed consent or thumb
print.
• Obtain medical
history.
• Examine the survivor from head to
toe.
• Take both medical and forensic
specimens
at the same
time.
• Record your ndings in the PRC forms and register.
2. Obtaining Consent
Before a full medical
examination
of the survivor can be
conducted,
it is essential
that
informed
consent is
obtained
by ensuring that the survivor lls the consent form.
( annex
1).
In practice, obtaining informed consent means explaining all aspects of the
consultation
to
the
survivor. It is crucial that patients
understand
the options open
to them and are given
suf
cient
information to enable them make informed decisions
about their care. Particular
emphasis
should be placed on the matter of the release of
information to other parties, including
the
police. Examining a person without their
consent could result in the
healthcare
provider
in
question being charged with violence
or trespass of the survivor’s privacy. The results of
an
examination conducted
without
consent cannot be used in legal
proceedings.
Consent for children,
unco
nscious and
mentally ill survivors can be given by their care
giver.
3
Table 2.1: Informed consent/ assent guidelines (IRC 2012)
Age Group
(Years)
Child Caregiver
If No Caregiver Or Not In
Child’s Best Interest
Means
0-5 -
Informed
Consent
Other trusted adult’s or case-
worker’s informed consent
Written
Consent
6-11
Informed
Assent
Informed
Consent
Other trusted adult’s or case
worker’s informed consent
Oral
Assent,
Written
Consent
12-14
Informed
Assent
Informed
Consent
Other trusted adult’s or child’s
informed assent. Sufcient level
of maturity (of the child) can
take due weight.
Written
Assent,
Written
Consent
15-18
Informed
Consent
Obtain
informed
consent
with child’s
permission
Child’s informed consent and
sufcient level of maturity takes
due weight
Written
Consent
3. History Taking and Examination
History taking and
examination
of the survivor should be
undertaken
immediately in
a s
a
f
e
and trusting
environment.
For a survivor who cannot be
examined
immediately
because
of t
h
e
extent
of
the trauma
experienced,
s/he should be given rst aid and
then referred to a tr
auma
counselor for emotional
support.
B
e
f
o
r
e
starting and at every step of the physical
examination,
take time to explain to
the
survivor
all the procedures you will be performing and why they are necessary.
Show and explain to the survivor the instruments to be used and give her/ him a
chance to ask any questions. A family member or friend can be allowed to be present
throughout the
examination
if
the survivor so
w
is
h
e
s
.
If a survivor declines all or part
of the
ph
ysical
examination,
you must respect her/ his decision; allowing the survivor
a degree of control over the physical
examination
is important
for
her/ him r
ec
o
v
e
ry
.
Both medical and
f
o
r
e
n
si
c
specimens should be collected during the course
of t
h
e
examination. Make sure that the survivor understands that s/he can stop the procedure
at
a
n
y stage
if
it is
un
c
o
m
f
o
rt
a
b
l
e
. Always address t h e s
u
rviv
o
r’s questions and
concerns in calmly, in a
non-judgmental and
empathetic manner.
The ndings
of
medical history,
examination
and sample collection should be
ca
r
e
f
u
lly
and
precisely
documented
in the PRC form (Annex 5).
4
3.1 History Taking for Adults
In history taking, the health care provider should ask questions that will generate
the following information:
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
inicted
• 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
• 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
• Difculty or pain on passing urine or stool
3.2 Head to Toe Examination for Adults
A
systematic,
“Head-to-toe”
physical
examination
of the survivor should be
conducted
in
the
following manner: (The
genito-anal examination
is
described separ
ately).
• 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.
• 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 scalp.
5
• 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 and for abdominal examination, which includes
abdominal palpation to exclude any internal trauma or to detect pregnancy.
• While in the reclined position, examine the legs, starting with the front.
• If possible, to 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, bres, grass and soil).
3.3. The Genito-Anal Examination for
Adults
• Try to make the survivor 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
carefull
y
.
Please
tell me if anything feels
tender
.
”
• Examine the external areas of the genital region and anus, as well as
an
y
markings
on
the thighs and
buttoc
ks.
• 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 difcult to
see.
• If
any bright blood is present, gently swab in order to establish its origin,
i.e.
w
hether
it is vulval or v
aginal.
• Warm the
speculum
prior to use by immersing it in warm
water
.
• Insert the
speculum
along the
longitudinal
plane of the vulval tissues once the initial
muscle resistance has
relaxed.
• 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
6
4. History Taking and Examination for Children
General approach:
• Ensure
pri
v
ac
y
• Approach the child with extreme sensitivity and
recognize
their vulnerability
• Identify yourself as a helping
person
• Try to establish a neutral environment and rapport with the child
before
beginning the
interview
• Try
to establish the
c
hild
’
s
developmental
level in order to
understand
an
y
limitations
as well as
appropriate interactions.
It is important to realize
that
y
oung
children have little or no
concept
of numbers or time and that
they
ma
y
use terminology differently from adults making
interpretation
of
questions
and
answers a sensitive
matter
• Ask the child if s/he knows why s/he has come to see y
ou
• Ask the child to describe what
happened
or is
happening
to them in their
o
wn
words (where
applicable). Play therapy can be used where necessary.
• Always ask
open-ended
questions and avoid
leading questions. Only use direct
questioning when
open-ended qu
e
sti
ons
h
a
ve been
exhausted.
Structured
interviewing protocols can reduce interviewer bias
and
preserve
objecti
vity
• Prepare the child for examination by explaining the
procedure
and showing
equipment;
this helps to diminish fears and
anxiety
• Encourage the child to ask questions about the
examination
• If the child is old enough, and it is
deemed appropriate,
ask whom they
w
ould
like in the room for support during the
examination
• Stop the
examination
if the child indicates discomfort or withdraws permission
to
continue
• Consider interviewing the child and the care giver of the child separately
4.1 History Taking for Children
History should be
obtained
from a caregiver or
someone
who is
acquainted
with the
c
hild, or the child her/ himself.
I
t is important to gather as much medical information
as possible.
Older
children, especially
adolescents,
are often shy or embarrassed to talk
about
matters of sexual nature. It is therefore good to allow them to be seen alone as this may
encourage them to talk more freely.
When gathering history directly from a child, start with a number of general,
non-
threatening
questions to create rapport then move on to questions specic to the
incidence, as shown below.
7
• When did this
happen?
• Was this the rst time this happened or has it happened before?
• What t
hreats 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 difculty 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? (girls)
4.2. Head to Toe Examination for
Childr
en
The physical examination of children should be conducted according to the procedures
outlined for adults in section 3.2.
Before examination, ensure that consent has been obtained from the child and/ or the
caregiver as per the table 2.1. 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 ndings will be minimal and this coercion may
represent 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.
8
4.3. The Genito-Anal Examination for Girls
Whenever
possible, do not
conduct
a
speculum
examination on girls who have
not reached
pubert
y
.
It might be very painful and cause
additional tr
auma.
A speculum
may only be
indicated
w
hen
the child has internal bleeding arising
from a vaginal injury as a result of
penetr
ation. In this case:
• Help the child to lie on
her
bac
k or
side.
• Use a paediatric speculum and c
onduct t
he 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.
4.4 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.
The
information provided on collection of medical and forensic specimens in
adults (section 3.3) equally applies to
c
hildr
en.
• When did this
happen?
• Was this the rst time this happened or has it happened before?
• What t
hreats 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 difculty 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? (girls)
9
Summary of findings to be documented after examination of a survivor of
sexual violence:
General examination
• Document the state of clothes- the colour, whether stained or torn,
where they were taken to
• Document vital signs of the survivor
Mental assessment
Document as per the psychological assessment form, see Annex 5 section B
Systemic examination
Document details of the:
• Central nervous system- level of consciousness, affect
• Musculo-skeletal system- physical disabilities, posture control and
gait, swellings, bruises, lacerations, dislocations, bite marks, scratches
on the body of survivor from head to toe.
• Perineum- The perineum consists of the clitoris, labia majora and
minora, vagina, mons pubis, introitus, fossa navicularis, vestibule,
hymen, penis, prepuce, scrotum, urethra, anus, gluteal region, inner
medial thighs.
• In the above areas, document:
• Any tenderness, bruises, abrasions, cuts, teeth -marks, scratch
marks bleeding, discharge, old scars (question their source if
any)
• Details of the anus- shape, dilatation (sphincter muscle tone),
ssures, faecal matter on perianal skin, bleeding from rectal
tears.
• Details of the hymen- shape, position, colour, and type e.g.
Cribriform, septal, cresent shaped, carunculae.
• Position and size of tears e.g. At 3 o’clock 1 cm etc.
4.5 Investigations for Clinical Management
Hymen
urethra
Clitoris
Labias
Vestibule
Fourchette
10
Investigations are carried out for two purposes:
i. To know the general condition of the survivor
ii. For forensic evidence purposes
Investigations done on various specimens (urine, blood and swabs) will include:
Urine
• Urinalysis-
microscop
y
• Pregnancy test
• Spermatozoa
Blood
• HIV Test
• Haemoglobin (Hb) level
• Liver Function Tests (where
possible)
• VDRL
• Hepatitis B
Anal
Swab
High Vaginal Swab
Oral Swab
• For evidence of spermatozoa
Note: Specimens to check for spermatozoa should only be collected when a survivor
presents to the health facility within ve days of sexual violence.
On collection of the forensic evidence, the health care provider should preserve it
for
appropriate
storage
and
hand it over to the police for further investigations and
processing in the court of law.
More
information on forensic
evidence
is available
in Chapter
F
our
.
5 Management of Physical Injuries
General wound care
• Clean any tears, cuts and abrasions and remove dirt, faeces, and dead or
damaged tissue.
• Decide if any wounds need suturing. Suture clean wounds within 24 hours.
After this time they will have to heal by second intention or delayed primary
suture.
• Do not suture very dirty wounds. If there are major contaminated wounds,
consider giving appropriate antibiotics and pain relief.
• If there are any breaks in skin or mucosa, tetanus prophylaxis should be given
unless the survivor has been fully vaccinated.
11
Genital wound care
• Clean abrasions and supercial lacerations with antiseptic and either dress or
paint with tincture of iodine, including minor injuries to the vulva and perineum.
• If stitching is required, stitch under local
anaesthesia.
If
the
surv
iv
or
’
s
lev
el
of
anxiety does not permit, consider sedation or general
anaesthesia.
• High vaginal vault, anal and oral tears and 3rd/4th degree perineal injuries
should
be assessed under general
anaesthesia
by a
gynaecologist
or other
qualied
personnel
and repaired
accordingly.
• In cases of conrmed or suspected perforation, laparatomy should be performed
and any intra-abdominal injuries repaired in consultation with a general surgeon
• Provide analgesics to relieve the survivor of physical pain.
Post traumatic vaccination with Tetanus Toxoid
• Where any physical injuries result in breach of the skin and mucous membranes,
immunize with 0.5mls of tetanus toxoid according to the schedule table
• Use table 6.1 below to decide whether to administer tetanus toxoid (which
gives active protection) and anti -tetanus immunoglobulin (which gives passive
protection) if available.
• If the vaccine and immunoglobulin are given at the same time, it is important
to use separate needles and syringes and different sites of administration.
• Advise survivors to complete the vaccination schedule (second dose at 4
weeks, third dose at 6 months to 1 year).
Table 6.1 Tetanus toxoid schedule
This table applies to survivors who have not previously been vaccinated with TT.
Dosing
Sc
hedule
Administr
ation
Sc
hedule
Dur
ation
of
Immunity
conferr
ed
1
st
TT
dose At rst contact
Nil
2
nd
TT
dose 1 month after 1
st
TT 1-3 y
ears
3
rd
TT
dose 6 months after 2
nd
TT 5 y
ears
4
th
TT
dose 1 Year after 3
rd
TT 10 y
ears
5
th
TT
dose
1
Y
ear
after
4
th
TT
20
y
ears
Note: Do not give TT if the survivor has received 3 or more doses previously and the
last dose is within 5 years
12
6 . Post Exposure Prophylaxis (PEP)
Post Exposure Prophylaxis (PEP) for HIV is the administration of a combination of
anti- retroviral (ARV) drugs for 28 days after the exposure to HIV, and should be
started within 72 hours of sexual violence if a survivor tests HIV negative.
PEP is
given in the event of rape, delement and some cases of sexual violence; signicant risk
involves oral, vaginal and/ or anal penetration.
This guideline recommends the use of Triple therapy i.e. three ARV drugs as per
the National ART guidelines.
In the event that the survivor tests HIV positive, PEP IS NOT RECOMMENDED; the
survivor should be referred for HIV care, treatment and follow up.
In the event that the survivor declines to take a HIV test, counselling should be
continued and other management provided as per the health care provider’s
clinical judgment.
6.1 Timing of PEP for HIV
The efcacy of PEP decreases with the length of time from exposure to the rst dose,
therefore administering the rst dose is a priority. People presenting later than 72 hours
after sexual violence should be offered other aspects of post rape care, except PEP.
6.2 ARV
prophylaxis
options in sexual violence
All HIV exposures through sexual violence are
considered
to be high risk and
should
be treated as
indicated. The recommended triple therapy is as follows:
TDF + 3TC +ATV/r
Treatment Prescription
TDF + 3TC+ ATV/r
Tenofovir 300mg
Lamivudine 300mg
Lopinavir 200 mg/ ritonavir 50mg
Atanovir (ATV) 400 mg
Ritanovir (RTV) 199 mg
Once a day for 28 days
Once a day for 28 days
Twice a day for 28 days
Once a day for 28 days
Once a day for 28 days
6.3 Recommended PEP Regimens for Children
For children, the drugs slightly differ;
the recommended triple therapy is as follows:
ABC + 3TC +LPV/r
Children’s doses must be given
according
to weight as indicated below. Both syrups
and tablets can be
used.
13
Weight
Range
(kg)
Fixed dose combination Single formulation where FDCs are not
available
Abacavir
(ABC)
+
Lamivudine
(3TC)
Zidovudine
(ZDV)
+
Lamivudine
(3TC)
Zidovudine
(ZDV)
+
Lamivudine
(3TC)
+
Nevirapine
(NVP)
Efavirenz
(EFV)
Nevirapine
(NVP) (use weight
appropriate formulation)
Lopinavir/Ritonavir (LPV/r) Additional dosing for
Ritonavir for TB/HIV
co-infection
TWICE
Daily
TWICE
Daily
TWICE
Daily
ONCE
Daily
ONCE Daily for first 2
weeks then twice daily
TWICE Daily TWICE Daily
60mg ABC
+30mg 3TC
tablets
60mg ZDV
+ 30mg
3TC tabs
60mg ZDV
+ 30mg
3TC tabs
+ 50mg
NVP tabs
200mg EFV
tabs
10mg/ml
suspension
200mg tabs LPV/
t80/20mg
per ml
solution
LPV/r
200/50mg
tabs
RTV liquid
(80mg/ml as
90ml bottle)
RTV capsule
100mg
3.59 1 tab 1 tab 1 tab see notes 5ml - 1.5ml - 1ml -
6-9.9 1.5 tab 1.5 tab 1.5 tab see notes 8ml - 1.5ml - 1ml -
10-13.9 2 tab 2 tab 2 tabs 1 tab 10ml 0.5 2ml - 1.5ml -
14-19.9 2.5 tab 2.5 tab 2.5 tabs 1.5 tab 15ml 1 tab in am
0.5 tab in
pm
2.5ml 1 tab twice
daily
2ml 2 cap
20-24.9 3 tab 3 tab 3 tab 1.5 tab 15ml 1 tab in am
0.5 tab in
pm
3ml 1 tab twice
daily
2.5ml 2 cap
25-34.9 300 +
150mg
300 +150
mg
300/150/
200mg
2 tab - 1 tab 4ml 2 tab in am
1 tab in pm
4ml in am &
2ml in pm
2 cap in am &
3 cap in pm
Source: MoH guidelines on use of ARV drugs for treatment and prevention of HIV infection: Rapid advice, 2014.
Paedriatic ARV Drug Dosing Chart
14
6.4 Side Effects of PEP
Patients taking PEP should be forewarned about the possibility of experiencing the side-
effects below, and
prepared
on how
to
deal with them should they occur. They should
for instance be informed that they can reduce the intensity
b
y taking the pills with food.
Side-effects usually diminish with time and do not cause
an
y long-term
damage.
Extreme side effects are rare due to the short duration of PEP treatment.
Drug Possible side effects
Tenofovir Renal toxicity and bone mineral loss.
Zidovudine
Anaemia, gastrointestinal side-effects, and proximal muscle
weakness.
Abacavir Skin rash, cough, fever, headache, asthenia, diarrhoea
Lamivudine gastrointestinal side-effects, anaemia,
Lopinavir/
ritonavir
gastrointestinal side-effects
7. Pregnancy Prevention
• Emergency Contraception (EC) should be readily available at all times during
the day and night, and should be provided free of charge for survivors of sexual
violence in all health facilities.
EC
should be given within 120 hours/ 5 days of
sexual violence; ideally as early as possible to maximize effectiveness
• EC
should be given to all females who have experienced
menarche except
those on menses, pregnant or on reliable contraceptive methods.
• EC does not harm an early pregnancy
• EC is not a form of
abortion
• There are no known medical conditions for which EC use is contraindicated.
Medical conditions that limit the continuous use of oral contraceptive pills do
not apply for the use of EC.
Table 7.1 Options for Emergency
Contr
aception
Regime
Pill composition
(per dose)
Examples of
brand names
1st dose –no
of pills
2nd dose no
of pills
Levornogestrel
only
LNG 750 μg
Postinor-2
Plan B
2 NA
Combined
Estrogen-
progesterone pills
EE 30 μg + LNG
150 μg
Microgynon 30,
Nordette
4 4
15
Note
Emergency
contraception
is to prevent pregnancy and is
NOT
a form of abortion
.
Unless a woman is
obviously
pregnant, a baseline pregnancy test should be
performed.
However, this
should
not delay the rst dose of EC as these drugs are not known to be
harmful to an
early
(unknown)
pregnanc
y
.
A follow-up
pregnancy
test at four weeks should be offered to all women who return
,
regardless of whether they took EC after the sexual violence occurrence or not.
If
a
survivor intends to terminate a
pregnancy
which resulted from the
sexual violence,
the
health
care provider
and the survivor should be aware of the
Constitutional
provision
in
reference to abortion, thus ``Abortion is not permitted unless, in the opinion of a
trained
health
professional,
there is need for
emergency
treatment, or the life or health of the
mother is
in
danger, or if permitted by any other law (Kenya
Constitution 2010).
”
8. Management of
Sexually
Transmitted Infections
• STI prophylaxis should be offered to all survivors of sexual violence.
• The HVS performed at initial presentation is done for forensic reasons and not for
screening for STIs or to guide antibiotic administration.
• Survivors with a “normal” HVS result should still be offered STI prophylaxis.
• Survivors of sexual violence should be given antibiotics to treat gonorrhoea,
chlamydial infection and syphilis.
• Preventive STI regimens can start on the same day as emergency contraception
and post-exposure prophylaxis for HIV (PEP), although the doses should be spread
out (and taken with food) to reduce side-effects, such as nausea.
Table 8.1 Options for STI Management
STI Dosage Alternative Regimen
Males and non-
pregnant adult
females
Cexime 400 mg stat OR
Ceftriaxone 250 mg IM stat
PLUS
Azithromycin 1 g stat OR
Doxycycline 100 mg B.D for 7 days
PLUS
Tinidazole 2 g stat
Noroxacin 800mg stat
Doxycycline 100mg b.d.
for 7 days
Pregnant
females
Cexime 400 mg stat OR
Ceftriaxone 250 mg IM stat
PLUS
Azithromycin 1 g stat
PLUS
Tinidazole 2 g stat
Spectinomycin 2g stat
PLUS
(Amoxil 3g stat +
Probenecid 1g stat)
PLUS
Erythromycin 500mg QID
for 7 days
9. Hepatitis B
16
Children’s prophylactic treatment for STI’s
Children Product
Presen-
tation
Strength Dosage Duration
5-12kg
Cexime Powder
for sus-
pension
100mg/5ml 8mg/kg stat
Azithromycin 200mg/5ml 20mg/kg
12-25kg
Cexime
Tablet or
capsule
200mg 200mg
Azithromycin 250mg 500mg
25-45kg
Cexime 200mg 400mg
Azithromycin 250mg 2g
Alternative treatment
Amoxicillin 15mg/ kg TDS for 7 days PLUS Erythromycin 10mg/kg QID for 7 days
Children’s prophylactic treatment for trichomoniasis
Children Product
Presen-
tation
Strength Dosage Duration
<45kg
Tinidazole
Tablet
+/-pow-
der for
suspen-
sion
500mg
50mg/kg
(max 2g)
stat
Metronidazole
250mg or
500mg or
125mg/ml
30mg/kg/
day in 3
dosages
7 days
9. Hepatitis B
Hepatitis B vaccination is intended to provide
protection from
future Hepatitis B virus
infe
ction. It is not meant to treat an already existing infection.
It is much less costly
to
vaccinate
all survivors of
rape/sexual violence,
rather than to test everyone for
Hepatitis B
antibodies
to see who might benet. Ideally, if Hepatitis
B
Vaccines is
available, it should be
considered
for survivors of sexual
violence
according
to the
schedule in the table
belo
w
.
Dosing schedule Administration schedule Duration of
immunity
conferred
1
st
dose At rst contact
Nil
2
nd
dose 1 month after rst dose 1-3 y
ears
3
rd
dose
5
months
after
second
dose
10
y
ears
If a survivor has been vaccinated before and completed the full series of vaccinations
as scheduled, there is no need to re-vaccinate. If s/he did not complete the full series,
they should complete as scheduled.
17
Table 11. Treatment summary table
√ Drug should be administered X Drug should not be administered
Interventions/ Time after the
sexual violence
<72 hours >72 hours
but < 1 month
1 month to
3 months
> 3
months
PEP √ X X X
Cexime √ √ X X
Ceftriaxone √ √ X X
Azithromycin √ √ √ X
Doxycycline √ √ √ X
Tinidazole √ √ X X
Noroxacine √ √ X X
Spectinomycin √ √ X X
Amoxycilline √ √ X X
Probenecid √ √ X X
Erythromycin √ √ √ X
Hepatitis B immunization √ √ √ X
Tetanus immunization √ √ X X
.
10. Medical Management of Perpetrators of Sexual Violence
Survivors of sexual violence should be encouraged to report to the police
immediately after medical treatment. It is however an individual’s choice and he/
she should not be forced. Police should encourage and assist anyone presenting
at the police station following rape/sexual violence, to attend the nearest health
facility as soon as possible, preferably before legal processes commence as both
PEP and EC become less effective with the passing of time.
11. Follow Up of Survivors of Sexual Violence
The follow-up visits for survivors who receive post-exposure prophylaxis for HIV
and those who do not, only differ slightly.
2
nd
visit- 2 weeks
• Provide PEP rell
• Assess adherence to treatments previously given
• Evaluate for STIs and treat if necessary
• Evaluate mental and emotional status; treat or refer as needed
• Provide adherence and trauma counselling
3
nd
visit- 4 weeks
• Check for PEP completion
• Repeat PDT and refer for care if necessary
18
• Do follow up vaccinations
• Evaluate for STIs and treat if necessary
• Evaluate mental and emotional status; treat or refer as needed
• Provide trauma counselling
4
rd
visit- 6 weeks
• Evaluate for STIs and treat if necessary
• Evaluate mental and emotional status; refer or treat as needed.
• Provide trauma counselling
5
rd
visit- 3months
• Retest for HIV and refer for care if necessary
• Evaluate for STIs and treat if necessary
• Evaluate mental and emotional status; refer or treat as needed.
• Provide trauma counselling
19
1. Introduction 20
2. Survivor-Centred Approach to Counselling 20
3.
Counselling
Different Groups Affected by Sexual
Violence
21
4. Core Conditions Essential to a Productive Counselling
Session
22
5. Obtaining Informed Consent 22
6. The Counselling Environment 22
7. Trauma Counselling 22
8. Rights of a Survivor of Sexual Violence 26
9. What The Survivor Should Expect At The Police
Station
26
10. Referrals 27
11. Support Supervision, Debrieng and
Care of the Health Care Provider
27
Pyscho Social Support
19
20
1. Introduction
Survivors of sexual violence react differently to the ordeal. Some survivors
experience
immediate psychological
distress, others short-term and/or long-term
psyc
hological
problems.
The amount and length of social support and/or
psychological counselling
required
by survivors of sexual violence varies
enormously, depending
on the
degree of
psyc
hological
trauma suffered and the
surv
iv
or
’
s individual coping skills
and
abilities.
This chapter highlights the
procedures
of
psycho-social
care for survivors of
sexual
violence
including ethical consideration. Efforts are made to address the
distinct
psycho-social
needs of adult male and females and children- boys and girls, persons
with
disabilities and perpetrators of sexual
violence.
• It is
recommended
that all counselors providing trauma counselling to
survivors
of
s
e
x
ual
violence may be trauma
counselors
and should also
have basic professional training
(
e
.
g
.
nurses, clinical ofcers, doctors,
psychological
counselors, social workers,
p
sy
c
hiat
r
ists)
.
• They should be members of an
accredited counselling association
e.g.
Kenya Counselling Association (KCA), Kenya Psychologists Association
(KPA) or
be
recognized
by Ministry of Public Health and Sanitation or
Ministry of
Medical
Services
as rape trauma
counselors.
2. Survivor-Centred Approach to Counselling
The
counselor
should apply the principles of doing “good” and not “doing harm”
in
counselling a
surv
iv
or
.
When providing services to survivor of sexual violence, counselors should adhere to
the
following
fundamental
principles of
counselling:
• Autonomy
:
The right of patients to make decisions on their own behalf (or in the
case of patients under 18 years of age, individuals acting for the child, i.e. parents
or
guardians).
All steps taken in providing services are based on the informed
consent of the
surv
iv
or
.
• Benecence
:
The duty or obligation to act in the best interests of the
survi
v
or
• Non-malecience : The duty or obligation to avoid harm to the survivor. Justice or
fairness
:
Doing and giving what is rightfully due to the
surv
iv
or
.
These principles have practical implications on the manner in which services are
provided,
namely:
• Awareness of the needs and wishes of the
survivor;
• Displaying sensitivity and
compassion;
• Maintaining objectivity (WHO
2003).
Pyscho Social Support
21
3.
Counselling
Different Groups Affected by
Sexual
Violence
Male Survivors of Sexual
Violence
When counselling male survivors of sexual violence, counselors need to be aware that
men have the same physical and psychological responses to sexual violence as women.
Men experience Rape Trauma Syndrome (RTS) in much the same way as women.
However,men are likely to be particularly concerned about their masculinity; their
sexuality; opinions of other people (i.e. afraid that others will think they are homosexual);
the fact that they were unable to prevent the rape.
Children Survivors of Sexual Violence
The dynamics of child sexual abuse differ from those of adult sexual abuse. In particular,
children rarely disclose sexual abuse immediately after the event. Moreover, disclosure
tends to be a process rather than a single episode and is often initiated following a
physical complaint or a change in behaviour (WHO 2003). The counselor should make
an effort to believe in and trust the child, create rapport, let the child go at her/his own
pace and listen carefully with understanding. The counselor needs to be familiar with
the protocol on counselling children.
Persons with Disabilities - Survivors of Sexual Violence
Counselors need to be aware that people with developmental disabilities who have
been sexually violated have challenges to “work through” or talk about their traumatic
experiences in a treatment or therapeutic setting. Guardians may also need assistance
as caretakers of the abused. Counselors should not have prejudices about people with
disabilities. For example, the benet of psychotherapy for people with mental retardation
as well as the impact of the abuse should not be questioned. Counselors should debrief
the guardian and/or family members and make appropriate referrals.
Perpetrators of Sexual Violence
Counselors need to be aware of their own fears about how they would counsel a
suspected perpetrator. When a perpetrator enters the clinic escorted by police or a
relative, the counselor should let them know that everything discussed between them
(counselor and the perpetrator) is condential and the counselor is not under obligation
to disclose any test results to these parties, except when required by law. However,
for purposes of clinical management of the perpetrator, shared condentiality will still
apply.
22
4. Core Conditions Essential to a Productive Counselling Session
• Unconditional Positive Regard: Counselors should perceive and deal with
the
survivor as s/he is while
maintaining
a sense of their innate dignity and
personal
worth.
• Non-judgmental attitude: Counselors should not assign guilt or
innocence
or
a
degree of survivor responsibility for
causation
of the problem, and they
should
not make evaluative judgments about the attitudes, standards or actions of
the
survi
v
or/perpetrator
.
• Genuineness or Congruence: Counselors should freely and deeply be able
to
relate
to
survivors/perpetrators
in a sincere and
non-defensive
w
a
y
.
• Empathy:
The
counselor
should be able to
understand
the
survivor
’
s reactions
from
the
inside, with a sensitive awareness of the emotions and the situation of
the
survivor. (Rogers 1967
304-311)
5. Obtaining Informed Consent
The
counselor
should obtain written consent from the survivor before starting any
sessions.
If
the survivor is below the age of 18, refer to Table 2.1
6. The Counselling Environment
The room should have privacy;
unauthorized
people should not be able to view or
hear
any
aspects of the
consultation. Hence,
the ideal
examination
room should
be a private
area
with walls and doors, not just curtains, to ensure privacy. It should
be clear when
counselling
is in process,
indicated
on the door with a sign such as:
“Counselling in Process: Please do
not
Disturb!”
Make the room friendly,
comfortable
and clean. There should be a small cabinet
that
can be locked and secured for condentiality where les are stored. The room should
be
child-friendly with toys and other relevant play material. Ensure that all forms (consent
and
case notes) are readily available. Tissues should be made available if possible.
When
the
survivors/perpetrators
are leaving the
counselling
room, please ensure to
pro
vide
them
with
additional
material to read as further
reference.
7. Trauma Counselling
Trauma counselling entails:
• Contracting with the survivor and initial de-brieng
• HIV pre-test counselling
• HIV post-test counselling
• Adherence counselling for PEP, STI prophylaxis and treatment, and other
management
23
• Counselling on Emergency Contraception and unwanted pregnancies
• Psycho-education
• Adherence to follow-up sessions
• Psychosocial support e.g. support groups for survivors, family and relatives
• Information giving on survivors’ rights, legal redress and referral linkages
The recommended minimum period of trauma counselling is ve sessions.
The rst session should include psycho-education and information on the nature
and symptoms of post traumatic stress disorder (PTSD).
The stabilization of the survivor is an important step at the beginning of the
counselling process.
Stabilization means that the person gets a sense of “being
grounded”
back on their feet
again,
emotionally
and socially. Emotional stabilisation means mending the identity of
the
traumatised person.
Note: The
counselor
should assess the safety of the environment to which the
survivor is returning in case of domestic sexual violence and make referrals as
appropriate.
Table 7.1 Rape-Trauma Counselling Protocol
There is need for counselors to be aware of the need for exibility with the protocol
and adapt to t individual survivors who present to them. All issues must however be
covered.
PROTOCOL CONTENT
Contracting
with the
survivor and
initial de-
brieng
• Ensure there’s a conducive environment
• Introduce yourself and your role as a counselor
• Assure the survivor of shared condentiality
• Establish the survivor’s reason(s) for coming
• Contract time with the survivor; mention that several sessions may
be required
• Obtain informed consent
• Explain the survivor’s freedom to terminate the session at any time
• Respect the survivor’s preference to be attended to alone or
accompanied.
• Assess whether the survivor qualies for PEP, ECP and STI
management
• Establish whether the survivor has received any health services,
including examination, PEP, ECP and STI management and PRC
form lled elsewhere
• (If these have not been done, refer survivor to the clinician for PRC
before proceeding with counselling)
24
PROTOCOL CONTENT
HIV Pre-test
counselling.
• Provide
basic HIV-information.
• Explain the benets of HIV testing
• Discuss
t
he possible implications of the HIV test results i.e. if
positive or negative
• Explain the HIV testing
process
• Risk assessment and risk reduction- consider:
• Survivor’s age and implications for him/her
• Survivor’s parents’ HIV status (for under 5 year olds)
• Perpetrators’ HIV status if known
• Discuss the window period (up to 6 weeks)
• Address survivor’s concerns on HIV testing
• Review survivor’s understanding and readiness for HIV test and
subsequent management
• Conduct HIV test (can be done on site or at the lab based on
facility set up)
A survivor who
tests
HIV negative at the rst visit should be retested
after six weeks.
Post HIV test
counselling.
For HIV negative results & HIV positive results:
• Re-contract, assess survivor’s readiness for the results, Give results.
• Discuss result’s implications; risk reduction.
• Disclosure of SV and of HIV results.
• On-going counselling.
For HIV Negative Results include:
• Prevention counselling, continue trauma counselling, referral to
additional supportive services , PEP advised for repeat testing
after six weeks.
• Adherence, legal issues and referrals.
For HIV Positive results include;
• Positive living, continued trauma counselling and referral for
comprehensive HIV care.
• Plan of action.
Adherence
counselling
Adherence counselling for PEP and STI prophylaxis. Counsel on:
• Keeping appointments,
• Treatment regime and dosage
• Side effects of HIV drugs and their management without causing
unnecessary alarm.
• Potential barriers to adherence
• Positive living (e.g. good nutrition, safer sex practices, exercises
etc)
• Health consequences of STIs.
• Other management e.g. Tetanus Toxoid ,Hepatitis B vaccine,
Psychotherapy etc
25
PROTOCOL CONTENT
Counselling
on Adherence
to follow-up
sessions
Emphasize on importance of follow up care and the options for follow
up should be discussed.
Counselling
on Emergency
Contraception
and pregnancy
• Explain the importance of taking EC within 120 hours. However,
emphasize that there is still a risk of pregncy. The later EC is taken,
the higher the risk of a preg nancy.
• Explain the short and long term consequences in case of
pregnancy after rape. The survivor should be given information
on child adoption or any other available options. Heath care-
providers and the survivor should be aware of the Constitutional
provision about abortion
Psycho-
education
• Explore survivor’s issues, concerns, fears.
• Identify and normalize feelings of guilt, embarrassment, low self
esteem and hopelessness.
• Empower the survivor with information on coping mechanisms,
tips on how to avoid situations which make them vulnerable to
sexual violence in future.
Psychosocial
support
• Offer group
counselling
as an ongoing support for survivors.
• It helps to process trauma in a collective way and creates
supportive coping
mechanisms.
• Families need to be
counseled
and given relevant information to
enable them help the survivor cope
and
heal.
• The
counselor
should refer the survivor to an
appropriate
professional or agency that is skilled in this
area if need be.
• Mobilize community support to address the causes and
consequences
of violence, what to do if raped or violated
(including preservation of evidence), what to expect in the health
facility
and prevention
measures of sexual violence.
• Raising
awareness
around
c
hildren
’
s and women’s rights is
important while decreasing the stigma
associated
with sexual
violence.
Information
on survivors’
rights, legal
redress and
referral
linkages
• Give information on health, police, legal services, other linkages
and their purposes.
• Emerging legal issues for the survivor (reproductive health issues,
litigation, reporting, rights and responsibilities).
26
8. Rights of a Survivor of Sexual Violence
A survivor has a right to Sexual and Reproductive Health Rights (SRHR) which are
recognized by the law. These include the right to:
• Attain the highest standard of SRH
• Life and survival
• Liberty and security
• Freedom from torture, cruel, inhuman or degrading treatment
• Freedom from violence against women.
• Freedom from discrimination (on the basis of sex, gender, marital status, age,
race and ethnicity, health status, disability)
• Marry with free and full consent
• Enjoy the benets of scientic progress and to consent to experimentation
• Decide freely and responsibly the number and spacing of one’s children
• Access information
• Education
A survivor also has a right to:
• Willingly press a charge of rape with the police
• Be treated with as much credibility as victims of other crimes are
• Information on medical, community and legal services
• Legal representation
• Be notied of any scheduled court proceedings.
• Be represented in court by a relative, guardian or professional if physically
unable to in person
• Recover from the violation at their own pace
9. What the survivor should expect at the police station
At the police station, a report is entered into the
Occurrence
Book (OB) and the
survi
v
or
is issued with a P3 form. The P3 form should be provided free of charge. An OB
number
should
be
availed to the survivor.
If
the survivor has not been to the hospital, it
is important that
s/he
goes there immediately after reporting. Other
procedures
such
as writing a statement can
be
undertaken
after initial treatment has been received. The
police should record the statement of the survivor and any witnesses, and the survivor
should sign it only when s/he is
satised
with
what the police have written. The P3 form
should be
completed
by an
authorized health
care provider based on the clinical
notes found in PRC
F
orm.
27
10. Referrals
After acute
counselling
is done, the
counselor
should refer the survivor to
other
qualied
professionals as
appropriate
to the needs of the survivor. The referral
network for survivors is wide and includes social services, psychiatrists and other
medical
specialists,
legal services, the criminal justice system and shelters
etc
11. Support supervision, debriefing and care of the health care provider
Supportive supervision is important for preventing ‘burn out’ of the health care
privider and counselors and for
maintaining high
quality
communication
between
the counselors and the survivors. It provides
an
opportunity
for
counselors to come together with other professional
counselling
pro
viders
and
at least one trained supervisor, to discuss and process issues that arise during
counselling
of survivors of sexual violence and to monitor the quality of their own
service provision
o
v
er
time.
Regular personal therapy is also
recommended
to all practicing trauma counselors
in order
to
cope with
secondary traumatization.
28
29
1. Introduction 30
2. Types of Evidence 31
3. Exhibit Management 32
3.1 Collection and Handling of Specimen 32
3.2 Chain of Evidence 34
4. Documentation and
Reporting
35
4.1
The
Post Rape Care Form 35
4.2
The
Kenya Police Medical Examination P3 Form 35
5. Role of Health Care Provider in relation to the Sexual
Offences Act
36
5.1 Sexual Offences Act Medical Treatment Regulation 2012 36
5.2 Specic Roles of Health Providers 37
5.3 Role of The Expert Witness in Court 38
Forensic Management of Sexual Violence
29
30
Introduction
Forensic
management
is essential in helping survivors of sexual violence access
justice
through
judicial processes. Proper
management
of
evidence
helps in
presenting credible
evidence
to Court to prove that sexual violence indeed
occurred
and link the
perpetrator
to the
crime.
This chapter
elaborates
on the
procedures
of forensic
management
while highlighting
the
processes of collecting, handling and preserving
evidence.
1. Definitions
F
or
ensic
Examination is a medical assessment
conducted
in the knowledge of
the
possibility of judicial
proceedings
in the future requiring medical
opinion.
Medical practitioners: Medical practitioner means
a
practitioner registered in
accordance
with section 6 of the ‘Medical Practitioners
and
Dentists
A
ct
’
.
Designated persons: This includes a nurse registered under section 12(1) of
the
‘Nurses
A
ct
’
or clinical ofcer registered under section 7 of the
‘Clinical
Ofcers
(training, registration and licensing)
A
ct
’
.
Evidence: This is the means by which disputed facts are proved to be true or
untrue
in any trial in a court of law or an agency that functions like a
court.
F
or
ensic
evidence: This is the
evidence collected
during a medical
examination.
T
he
role
of forensic
evidence
in criminal investigation includes the following: (i) To
link
or
delink the
perpetrator
to the crime. (Aside from SV, including
deliber
ate
HIV/
AIDS
infection, which constitutes another crime on its own);
(ii)
To ascertain
that
SV
occurred;
(iii)
To help in
collection
of data on perpetrators of SV.
In most cases, forensic
evidence
is the only thing that can link the
perpetrator
to
the
crime. E.g. where the incident is reported a long time after it has
happened
or
w
here
the
survivor was
pregnant.
Physical evidence: This refers to any object, material or
substance
found
in
connection
with an investigation that helps establish the identity of the offender,
the
circumstances
of the crime or any other fact
deemed
to be important to the
process.
Physical
evidence
may include: used
condoms,
cigarette butts, ropes,
masking
tape
etc.
Physical
evidence
can be
collected
from the survivor as well as
the
en
vironment
(crime scene
location).
Forensic Management
31
Crime scene: This constitutes either a person, place or an object -
capable
of
yielding
physical
evidence
which has the potential of assisting in
apprehending or
exonerating the suspect. No one should interfere with a crime scene by
c
hanging
or
tampering with any of the objects. One should leave everything as it was. A survivor
is
considered
a crime scene as a lot of
evidence
can be
collected from
him/her.
For example suspects hair found on the survivor. There are 5 stages in
crime
scene
management:
(i) Identication; (ii) Protection;
(iii)
Search; (iv) Record; (v)
Retriev
al
2. Types of Evidence
There are two types of
evidence
that need to be
collected:
• Evidence to conrm that sexual violence has
occurred
e.g.
evidence
of
penetration
(torn hymen), if
obtained
by force there might be bruises, tears
and
cuts
around the vaginal area and the clothing may be
stained.
Locard’s
exchange
principle
States that, every contact leaves a tr
ace.........
‘Wherever he steps, whatever he touches, whatever he leaves, even
unconsciously,
will serve as a silent witness against him. Not only his
ngerprints or his
footsteps,
but
his
hair
,
the bre from his clothes, the glass he
breaks, the tool mark he leaves, the
paint
he
scratches, the blood or semen
he deposits or
collects
.
’
• Evidence to link the alleged assailant to the violence e.g. perpetrators torn
clothes,
used
condoms,
grass and blood stains, scratches and bite marks on
the
perpetr
ator
,
and eyewitness testimony i.e. people last saw the
perpetrator
walking away with
the
survivor (this is
because circumstantial evidence
can help the court
adduce
the
guilt
of the
accused).
• Forensic materials that can be
collected
include but not limited
to:
•
Suspect
’
s material
deposited
on an object, e.g. Cigarette
butt;
•
Suspect
’
s material
deposited
at a
location;
•
V i c t i m ’s
material
deposited
on the
suspect
’
s body or
clothing;
•
V i c t i m ’s
material
deposited
on an
object;
•
V i c t i m ’s
material
deposited
at a
location;
• Witness’ material
deposited
on a victim or
suspect;
• Witness material
deposited
on an object or at a
location.
32
3. Exhibit
Management
The following practices must be followed when handling an exhibit:
• Protect the exhibit from weather and
contamination;
• Use clean instruments and
containers;
• Wear protective devices eg gloves when
appropriate;
• Package, transport and store exhibit safely and
securely;
• Take special care with fragile and
perishable exhibits;
• Call on an expert if you lack
adequate
training to handle a particular type of
exhibit.
3.1 Collection and Handling of Specimen
When collecting
specimen
for forensic analysis, the following principles should
strictly be
adhered to:
Avoid contamination: Ensure that
specimens
are not
contaminated
by other
materials.
Store
each exhibit separately. Wear gloves at all times to
ensure
that the
exhibit is not
contaminated and also
for your own
protection.
Collect early: Try to collect forensic
specimens
as soon as possible. S
pecimens
should
be collected
within 24 hours of the violence; after 72 hours, yields are
reduced
consider
abl
y
.
Collect the same before requiring the victim to
bathe.
Handle appropriately: Ensure that
specimens
are packed, stored and tr
ansported
correctly.
As a general rule, the uids (e.g. urine) should be refrigerated;
an
ything
else should be kept dry. In some
instances,
blood can be dried on gauze and stored
as
suc
h.
Biological
evidence
material (e.g. body uids, soiled clothes) should be
packaged in
paper
envelopes or bags after drying, avoiding plastic
bags.
Label
accurately: All
specimens
must be clearly labelled with the
survi
v
or
’
s name
and date of birth, the health care provider name, the type of
specimen,
and the
date and time of
collection.
Ensure security: Specimens should be packed to ensure that they are secure and
tamper
proof. Only
authorised
people should be entrusted with
specimens.
Maintain continuity: Once a
specimen
has been
collected,
its
subsequent
handling
should be
recorded.
Details of the transfer of the
specimen between
individuals
should also
be
recorded.
An exhibit register should be
maintained
at each facility.
It is not a good
pr
actice
for the survivor to move any samples taken from them from
one facility to another for
an
y
analysis.
33
Specimen
Method of preservation
Test for Purpose for testing
Mouth s
w
ab
Air dry and store in a clean
dry
bottle with screw
top
Spermatozoa
DNA
Identify assailant/
victim
Urine of both
the
victim
and
the
suspect
Clean dry bottle with screw
up,
refriger
ated
Spermatozoa
Alcohol
and
drugs
To conrm recent
sexual intercourse.
Whether the
assailant/
victim abuses
drugs
Pubic
hair/
head
hair
Pick the hair using
non
po
wdered
gloves and store
in
an
envelop or lift using
tape
store
on acetate
sheet
DNA
T
r
ansfer
evidence
analysis
Identify assailant
and survivors
Foreign
bres/
gr
ass/
soil(1)
Hand pick the foreign
bre/
grass/soil using non
po
wdered
gloves and store
in a
khaki
envelope or lift
using
tape
Fibres
found
at the
incident
for tr
ansfer
evidence
analysis
Verify claim i.e.
corroborative
evidence
Liquid
blood
A clean sterile dry bottle
with
screw top or transfer
liquid
blood onto sterile
cotton
gauze
and air dry
(only for
control
samples)
DNA,
Alcohol/
drugs
Identify assailant
and survivors
For drug analysis, whole
liquid
blood should be taken
and
submitted
Whether the
assailant/ victim
abuses drugs
Ability of the survi-
vor to consent
Semen
HVS, dry semen stained
clothes
in open air. Do not
dry in
front
of re or articial
means
or
directly under the
sun. Preserve
in
khaki
paper
Avoid using plastic
bags
Spermatozoa
Secretor,
Blood
group
assailant
DNA
proteins in
semen
(PSA2
or
P30)
Identify assailant
F
ingernail,
scrapping
or
clippings(4)
Pick the nger nail
scr
apings/
clippings using
non
po
wdered
gloves and
store in an
en
v
elope
DNA Identify assailant
and victim
Table
3.2.1: Possible specimens, methods of preservation, tests and
purpose of
test
34
Blood
stained
clothes (2)
Dry blood stained clothes
in
open
air. Do not dry
in front of re or articial
means or
directly
under
the sun. Preserve in a
khaki
paper. Avoid
polythene
bags
DNA,
Alcohol/
Drugs
Identify assailant
and survivors
Bite
marks
Plasticine
Dental
impressions
Identify assailant
Note:
• All tests and results should be
recorded
in a laboratory register ( date,name,
registration number, age, sex,
in
v
estigations
done, results and a place for
anyone who takes
specimen
to sign in order
to
maintain a chain of custody
of
evidence).
The Laboratory register should be
kept
well locked away and
only
accessible
to
authorized
health facility
personnel
as
a
measure towards
preserving
condentialit
y and to avoid tampering with the results
.
• The above tests can be carried out on the survivor and also on the
perpetr
ator
.
• With regard to the
perpetrator,
the court can under section 26(2) and 36 of
the
SOA, order that certain specic samples be
collected.
Document collection: It is good practice to compile an itemized list in the
survi
v
or
’
s
medical notes or reports of all
specimens collected
and details of when, and to
whom,
they
were tr
ansferred.
Handling Exhibits
• Exhibits should not be exposed to direct light and sunshine. If wet, exhibits are
dried under shade or dark rooms;
• Exhibits should be marked properly and signed for immediately upon receipt and
stored;
• All exhibits including documents lled (e.g. PRC, P3) must be kept in places that
guarantee safety and condentiality.in of Custody of Evidence
3.2 Chain of Evidence
This refers to the process of obtaining, preserving and conveying evidence
through accountable tracking mechanisms from the community, health facility
and nally to the police. Also refers to a paper trail where the movement of
evidence is traceable through the different persons in the chain of sample
collection, analysis, investigation and litigation)
35
4. Documentation and Reporting
In general, most effort should be
expended
on
documenting evidence
that
can
corroborate
the
survi
v
or
’
s
evidence
in a court of law. Such
evidence include:
• Evidence that sexual intercourse (penetration) has taken place –
engorgement
of
the
genital and maybe
increased
epithelial cells in the urine and broken
hymen.
If
the
h
ymen
is not broken it does not mean that
penetration
didn’t
take
place.
• Evidence that
ejaculation
has taken place –
presence
of semen around
the
genitalia.
Semen inside the vagina is
evidence
that
ejaculation
did take place
inside
the vagina – hence the
importance
of a high vaginal swab.
It
is important
to know
that
ejaculation
doesn’t always have to take
place.
• Evidence that force was used – Torn clothes including
undergarments,
bruised genitalia.
Signicant levels of epithelial cells in the
urine.
• Evidence linking the suspect with the sexual offence. This will mainly be
police
work but the Health care provider will collect the various
specimens
as
detailed in the
F
orensic
chapter of these
guidelines.
4.1 The Post Rape Care (PRC) Form
The Post Rape Care form is a medical d o c u m e n t lled when attending to the
survivor. The form allows space for history taking,
documentation
and
examination.
It facilitates lling of the P3 form by
ensuring
that all relevant details are available
and were taken at the rst contact of the survivor
with
a
health facility. The PRC
form strengthens the
development
of a chain of custody of
evidence
by having a
duplicate
that can be used for legal purposes and showing what
specimen were
collected,
where it was sent and who signed for it. The PRC form can be lled by
a doctor,
a
clinical ofcer or a
nurse.
NOTE:
When the PRC form is lled and signed
completely:
• The Original form is to be given to the police for custody. This is the form that
is
produced
in court as
evidence;
• The
Duplicate
form is given to the
survi
v
or;
• The Triplicate form remains with the
hospital.
4.2 The Kenya Police Medical Examination P3 Form
This is a Police form that is issued at the police station. It is lled by a health car e
provider and
the
police as evidence that an violence has
occurred.
The P3 form is
for all forms of violence
and
therefore not specic to sexual violence. It is therefore
not as detailed as the PRC form. The
P3
form is lled and returned to the police for
custody. The lling of the P3
f
o
r
m
in sexual vi
o
l
e
n
ce
cases is done
free of
charge.
The survivor should get a copy of their PRC form when it is
lled
and
signed and when
the P3 form is being
lled.
1. Introduction 30
2. Types of Evidence 31
3. Exhibit Management 32
3.1 Collection and Handling of Specimen 32
3.2 Chain of Evidence 34
4. Documentation and
Reporting
35
4.1
The
Post Rape Care Form 35
4.2
The
Kenya Police Medical Examination P3 Form 35
5. Role of Health Care Provider in relation to the Sexual
Offences Act
36
5.1 Sexual Offences Act Medical Treatment Regulation 2012 36
5.2 Specic Roles of Health Providers 37
5.3 Role of The Expert Witness in Court 38
36
The P3 form is the link
between
the health and the judiciary systems. The medical
off
icer who lls the P 3 form or their representative will be expected to appear in court
as an expert witness and produce the document in court as an exhibit.
5. Role of health care providers in relation to the
Sexual Offences Act
5.1 Sexual Offences Act Medical (treatment) regulations 2012
Introduction
Section 35 of the Sexual Offences Act contains progressive provisions on access to
free medical treatment for victim/ survivors of sexual offences in any public hospital or
institution or other designated/ gazzetted institution. According to Section 35 (3) these
provisions are to be operationalized through development of elaborate regulations by
the Minister responsible for health, prescribing the circumstances under which a victim/
survivor may access treatment.
Sexual Offences (Medical Treatment) Regulations 2012
Pursuant to the provisions of Section 35 (3), the Sexual Offences (Medical Treatment)
Regulations 2012 have been developed. The Regulations generally provide that:
1. Nurses, clinical ofcers and medical practitioners for purposes of the Sexual
Offences Act shall offer medical treatment (which includes counselling) to a
victim/ survivor of a sexual offence, a person who is suspected to have committed
a sexual offence or a person convicted or a witness of a sexual offence in a public
hospital.
2. The medical treatment expenses incurred by a survivor, a person suspected to
have committed a sexual offence, a person convicted or witness of a sexual
offence in a public hospital shall be borne by the Government.
3. A survivor of a sexual offence is entitled to receive medical treatment regardless
of whether they have reported the matter to the police.
4. Public hospital means a Government facility at all levels of health care or such a
health facility which the Minister responsible for health may gazette or designate
as a public hospital for purposes of offering medical treatment under the Sexual
Offences Act.
5. A police ofcer to whom a report of commission of a sexual offence has been
made shall notify a nurse, clinical ofcer or medical practitioner at any health
facility and refer the survivor accordingly for medical treatment.
37
6. A court may order collection of appropriate samples from any person who has
been charged with a sexual offence, specifying the place and conditions for such
collection of samples.
7. Once such an order for the collection of samples from an accused is received by
a police ofcer of a rank above the rank of a police constable, the police ofcer
shall request any medical practitioner, nurse or clinical ofcer to take appropriate
samples from the accused.
8. It is the duty of the medical practitioner, nurse or clinical ofcer to determine the
samples to take, part of the body from which the samples shall be taken and the
quantity that is reasonably necessary in accordance with the National Guidelines
for the Management of Sexual Violence.
5.2 Specific Roles of Health Care Providers
Once a police ofcer noties a nurse, clinical ofcer or medical practitioner of the
commission of a sexual offence and refers the victim/ survivor to the health facility, the
health care providers shall:
a. Conduct a full medical forensic examination on the survivor and prescribe the
appropriate medical treatment;
b. Provide appropriate professional counselling to the survivor of the sexual offence;
c. Complete the prescribed Post Rape Care form and psychological assessment
form as set out in the schedule and any other relevant records;
d. Collect and preserve the necessary medical forensic samples in accordance with
the National Guidelines on the Management of Sexual Violence;
e. Inform and forward to the investigating police ofcer or his or her representative
the samples collected while maintaining a record of the chain of custody by
appending his/her signature for the samples;
f. Initiate appropriate referral to the relevant areas or subsequent areas for the
necessary subsequent care;
g. Ensure safe custody of medical records relating to the treatment for use as evidence
before any court with regard to any offence under the Sexual Offences Act;
h. Where required produce the completed Post Rape Care form and other relevant
medical records in court as evidence in regard to any offence under the Sexual
Offences Act;
i. Provide the medical treatment prescribed in paragraph (a), (b), (d), (e) and (f) to a
person suspected to have committed a sexual offence;
j. Where they deem appropriate, conduct other examinations and treatment on the
victim/ survivor of sexual offence (s), witnesses or a person who is suspected to
have committed a sexual offence
38
5.3 Role of the Expert Witness in Court
Expert witness:
An expert witness, though often called by the prosecution, is really a witness of the
court. S/he is therefore primarily to assist the court reach certain conclusions. Their
evidence therefore is not to enable the prosecution to win the case, though often this
is the effect.
The court recognizes one as an expert witness if s/he has some special knowledge to
arrive at judgment. For one to be an expert witness, the expert must:
a. Be qualied in the subject.
b. Have a relevant experience.
Before the report of an expert witness is given, the court has to establish that the witness has
indeed some special knowledge which can assist the court. This is done by establishing:
1. The Name: Usually three names are required although on can give more names.
2. Academic/ Educational qualications
3. Occupation and experience: This is to establish what area one has been
specialization in. The length of experience in the eld is also very important. A
highly qualied expert with little knowledge cannot be taken seriously.
4. Employer: The organization one is working for should be of good reputation.
The prosecution calls witnesses to establish a prima facie case. The evidence adduced is
intended to show at rst sight (Prima facie) that a law has been broken by the accused.
If the case is not established at rst sight, then the accused has no case to answer and
is discharged.
Conduct of expert witnesses in
c
ou
r
t
•
Be able to give facts the survivor presented - relate to the actual
events presented by the survivor, and not interpret them.
• Look professional and dress appropriately.
• Speak clearly, slowly, and loud enough.
• Use simple language- not medical jargon.
• Do not give information beyond what one is asked.
• Treat the legal practitioner (s) with respect.
• Do Not to be afraid to say “I don’t know” when you don’t know
• Remain objective at all times avoiding bias
• Can refer to books, notes and written information, when presenting
evidence.
•
Do not draw conclusions unless they are
ce
rt
a
i
n
.
•
If
giving evidence on
b
e
ha
l
f
of another health care provider, then
restrict y
ou
rs
e
l
f
to the
r
e
port
made by that
provider
39
1. Introduction 40
2. Multi-Causal Nature of Sexual Violence in
Humanitarian Crisis
40
3. Minimum set of Interventions in Crisis Situations 41
4. The Need for Collaboration 44
5. Specic
Responsibilities
for the Health
Sector
45
Humanitarian Issues
39
40
1 Introduction
Understanding gender vulnerabilities in conict situations
• Age and gender are vulnerabilities that predispose women and girls
to
exploitation and
abuse;
• In early stages of conict, these vulnerabilities are further
increased
due
to:
• The
breakdown
of law and
order;
• The
absence
of systems that would respond to distress
signals;
• The lack of
adequate
services that would minimize the effects of
sexual
• violence.
• In the stabilized phases of conict, these vulnerabilities are
augmented
b
y:
• The
continual reproductive
roles of women and girls such as
fetc
hing
• rewood and/or water in
unsecure
areas which predispose them to
the
dangers
of being sexually
violated;
• The possible abuse of power by the security and
humanitarian
w
orkers
• who
demand
sexual favours in return of goods and
services.
• Harmful cultural practices are
exacerbated
- e.g. – forceful early marriage of
the
girls in order to meet the lack of resources in the
famil
y
.
During armed conict, women and girls are particularly vulnerable to all forms
of
sexual
violence
1
. Vulnerability to
exploitation
and abuse by virtue of their
age and gender is
further
increased
by conict and the prevailing
humanitarian
and security
conditions.
This
c
hapter
highlights the vulnerability factors to
sexual violence in conict situations. It
further
highlights interventions required in
addressing the needs of sexual violence survivors in such
situations.
2. Multi-Causal Nature of Sexual Violence in Humanitarian Crisis
Today’s
armed conicts mostly occur within state borders and typically drag on
for years,
ev
en
decades.
Multi-causal in nature, these crises are typically “highly
politicized”
a
nd
“
f
r
e
qu
e
n
tly
associated
with
non-conventional
w
a
r
f
a
r
e
”
.
National
accountability
mec
hanisms
are
characteristically
absent or severely
weakened
2
,
which
consequently
gives rise to a
climate
of impunity for perpetrating all sorts
of crimes. These conicts tend to
a
ff
ec
t the
c
ivili
a
n
s
ph
e
r
e
,
regardless
of
growing
international
emphasis on the protection
of
civilians in
c
on
i
c
t sit
u
a
ti
on
s
.
1 Derived from the GBV Sub-cluster Strategy and Action Plan developed in March 6, 2008
2 Development Assistance Committee. Guidance for Evaluating Humanitarian Assistance in
Complex Emergencies. 1996. http://www.the-ecentre.net/resources/e_library/doc/OECD.
pdf#search=%22complex%20emergencies%22
Humanitarian Issues
41
Understanding the nature of today’s conicts
• They occur within state
borders;
• They last for a long
time;
• They are highly
politicized;
• They are frequently
associated
with
unconventional war
-fare;
• National
accountability mechanisms
are
characteristically
absent.
Civilians are affected
accidentally
as they are not well
distinguishable
from
combatants.
T
hey
may
be
intentionally
targeted
because
“the goal of warfare
is not simply the
occupation
and
control of territory – it is about destroying the
identity and dignity of the
opposition”.
One of the strategies to achieve this goal
is by targeting
w
omen
’
s sexuality and
reproducti
v
e
capacity.
Sexual violence,
therefore, not only causes individual physical
and
psyc
hological
ill health and social
exclusion, but uproots families and
communities and
contributes
to the moral
and physical
destruction
of society
3
. In the
absence
of
go
v
ernmental
programmes
to mitigate the impacts of
sexual
violence,
humanitarian organizations
play a big
role in caring for rape
survi
v
ors.
3. Minimum Set of Interventions in Crisis Situations
Three
sets of activities are necessary in combating
SV
in emergency
situations:
• Overview of activities to be
undertaken
in the
preparedness phase;
• Detailed
implementation
of minimum
prevention
and response during
the
early stages of the emergency;
and
• Overview of
comprehensive
action to be taken in more stabilized
phases
and
during recovery and
rehabilitation.
These set of activities are
applicable
in any emergency setting, regardless of
whether the “known”
prevalence
of sexual violence is high or
low
.
It is important to
remember
that sexual violence is
under-reported
even
in
well-resourced
settings worldwide, and it will be difcult, if not impossible, to
obtain
an accurate measure of the
magnitude
of the problem in an emergency
situation.
All
humanitarian personnel
should therefore assume and believe that sexual
violence is
taking
place and is a serious and
life-threatening protection
issue,
regardless of the presence
or
absence
of
concrete
and reliable
evidence.
For effective short and long-term
protection
from sexual violence for women and
girls
in
Kenya, interventions must take place at three levels in order that structural,
systemic
and
individual
protections
are
institutionalized
4
.
3 Watts C, Zimmerman C. Violence against women: global scope and magnitude. The Lancet.
2002;359:1232–1237. doi: 10.1016/S0140-6736(02)08221-1
4 Adapted from A. Jamrozic and L. Nocella (1998) The Sociology of Social Problems: Theoretical Perspec-
tives and Methods of Intervention, Cambridge University Press, Melbourne.
42
Levels of interventions
• Structural level (primary protection): preventative measures to
ensure
rights are
recognized
and
protected
(through
international,
statutory
and
traditional laws and
policies);
• Systemic level (secondary protection): systems and strategies to monitor
and
respond when those rights are
breached
(statutory and traditional legal/
justice
systems, health care systems, social welfare systems and
community
mec
hanisms);
• Operative level (tertiary protection): direct services to meet the needs of
w
omen
and girls who have been
abused.
Addressing sexual violence among internally displace persons (IDP)
communities
in
Kenya therefore requires: measures to protect
w
omen
’
s and
girl’s
rights; intervention
when
those
rights are
breached;
and services and programs to meet the needs of
women and girls
w
ho
have suffered
violence.
4. The Need for Collaboration
Successfully protecting internally
displaced
women and girls from sexual violence
in
Kenya is
dependent
on the active
commitment
of, and collaboration
between,
all
actors,
including male and female
community
members. Sexual violence is a
cross-cutting
issue,
and no one authority,
organization
or agency alone possesses
the
knowledge, skills,
resources or
mandate
to respond to the complex needs of
the survivors or to tackle the
task
of preventing violence against women and girls,
yet all have a responsibility to work
together
to address this serious human rights
and public health
problem.
To save lives and maximize
protection,
a minimum set of activities must be
r
apidly
undertaken
in a
co-ordinated
manner to prevent and respond to sexual
violence from
the
earliest stages of an
emergenc
y
.
Minimal services needed
• Survivors of sexual violence need assistance to cope with
the
harmful
consequences
of this nature of
violence;
• They need health care,
psychological
and social support, security, and
legal
redress;
• Prevention activities must be put in place to address causes
and
contributing
factors to sexual violence in the
setting;
• Providers of all these services must be
knowledgeable,
skilled,
and
compassionate
in order to help the survivor, and to
establish
effective
preventive
measures;
• Prevention and response to SV requires
coordinated
action from actors
from
many
sectors.
43
5. Specific Responsibilities for the Health Sector
The health care
pro
vider
’
s responsibility is to provide
appropriate
care to survivors
of
sexual
violence as
documented
in these
guidelines.
This includes
collection
of any
forensic
evidence
that might be
needed
in a
subsequent
investigation
either during or post crisis
period.
It is not the responsibility of the health care
provider to
determine
whether a person has
been
sexually violated. That is a legal
determination.
However, all health care providers must
be
aware of relevant laws
and policies governing health care provision in cases of
sexual
violence.
The health care provider’s responsibility
• To provide
appropriate
care to survivors of sexual violence as is
documented
in
these
guidelines;
• To
collect forensic
evidence
that might be
needed
in a
subsequent
investigation
either during or post crisis
period.
44
Quality Assurance and Quality
Impr
ovement
The Quality Assurance and Quality control should be an essential part of all the
post r
ape
service. The objectives of quality
assurance
interventions
are:
• To ensure optimal quality of care and support services for
survivors;
• To establish the
relationships between
identied problems and quality of
care
issues
and their impact on the provision of
care;
• To
recommend
corrective action and regularly monitor the effect of
the
interv
entions.
45
Minimum Standards for Providing Comprehensive PRC in
Health Facilities
Minimum Standards for
Medical
management
of
survi
v
ors
Reporting/recording
requirements
for
health
facilities
Minimum
capacity
requirements at
health
facilities
All
health
facilities
without
a
labor
atory
(public
and
pri
v
ate)
Manage injuries as much
as
possible
Detailed history,
examination
and
documentation
(refer for
HVS,
PEP/EC,
STI)
Fill in PRC form
in
triplicate
Maintain PRC
register
Please ensure that
the
survivor has a copy of
the PRC form and
takes
it to the
labor
atory
A trained
nurse
All
health
facilities
with
a
functioning
labor
atory
(public
and
pri
v
ate)
Manage injuries as much
as
possible
Detailed history,
examination
and
documentation
(including HVS)
Ideally, 1
st
doses of PEP/
EC should be provided
(ev
en
where follow up
management
is not
possible)
Where HTC services
are
available, provide
initial
counselling
Fill in PRC form
in
triplicate
Maintain a PRC
register
Maintain a
labor
atory
register
Referral
to
comprehensive post
rape care
facility
A trained
nurse
and/or
a
clinical
ofcer
A tr
ained
counselor
(w
here
counselling
is
offered)
All
health
facilities
with
HIV, ARV
or a
com-
prehensi
v
e
care
clinic
(CCC)
w
here
ARV can
be
monitored
(compre-
hensive
post
rape
care
facilities
can
be
pro
vided)
(private
and
public
health
facilities)
Manage injuries as much
as
possible
Detailed history,
examination
and
documentation
Provide emergency and
on-
going
management
of PEP
Provide EC
Provide
STI
prophylaxis
or
management
Provide
counselling
for
trauma, HIV testing and PEP
adherence
Fill in PRC form
in
triplicate
Maintain PRC
register
Maintain a
labor
atory
register
Fill in PRC form
to
follow up
management
of
surv
iv
ors
1 medical
or
clinical
ofcer
trained in ARV/
PEP
management
1 tr
ained
counselor
(trauma, HIV testing
and
PEP
adherence
counselling
)
Laboratory for HIV and
HB
testing
Preservation of sperms
from
HVS
specimen
46
47
Annexes
Annex 1 PRC Consent Form 48
Annex 2 Survivor Flow Chart Form 49
Annex 3 Clinical Management Algorithm 50
Annex 4 Rape Kit 51
Annex 5 Post Rape Care Form (PRC)
52
Annex 6 Counsellng Form 55
Annex 7
Sexual Violence
Register MoH 365 57
Annex 8
P3 Form
67
Annex 9 PRC Support Supervision Tool
72
Annex 10 Sexual Offences Act Medical (Treatment)
Regulations, 2012
74
Annex 11 GBV Community Awarness Info Pack 76
Annex 12 Useful Resources
47
48
Annex 1:
PRC Consent Form
Name of
F
acility
Consent
form
Note to the health care provider: Read the entire form to the survivor, explaining
that
she
can choose any (or none) of the items listed. Obtain a signature, or
a thumb print
with
signature of a
witness.
I…………………………………….....……...(print name of survivor/care
giver/guardian)
authorize
the
above-named
health facility to perform the following (tick the
appropriate boxes):
Yes
No
Conduct a medical
examination,
including
pelvic
examination
Collect
evidence,
such as body uid samples,
collection
of
clothing, hair combings, scrapings or cuttings of nger
nails,
blood samples, and
photographs
Provide
evidence
and medical information to the
police
and law courts
concerning
my case; this information
will
be
limited to the results of this
examination
and any
relevant
follow-up
care
provided
Client’s
Signature………………………………
Date………………………………………………………
Name of witness……………………………… Signature
…………..............
Date.............................................................................
Initials of HCP
................................................ Signature …………..............
Date.............................................................................
49
Annex 2
: Survivor Flow Chart
50
Any life theatening injuries should
take priority over other aspects of
Post Rape Care
HIV Negative
Continue PEP (2 weeks dose)
HIV Re-test
4 weeks, 12 weeks, 24 weeks
HIV Positive
Discontinue PEP
Refer to care clinic
Psychosocial Support
Stop PEP
HIV Prophylaxis
Children –Dosage is as per the Kg body weight
ABC +3TC + LPVr for 28 days (Check ART guidelines
or paediatric dosing wheel )
Adult
TDF 300mg + 3TC 300mg Once a day +ATV/r
500mg twice daily for 28 days
Survivor presents within 72 hours
(Treat this as an Emergency)
HIV Prophylaxis
1st PEP dose
(3 days)
(see details at the
bottom)
History, Examination &
Sample Collection
Obtain informed consent
Take history
Examine & Document injuries
Medical tests : HIV, PDT, Hb, HBV,
HCV, CR, ALT , urinalysis and
creatinine.
Collect forensic samples: HVS,
oral/anal-rectal swabs, hairs,
semen, blood stained cothes
Label, pack and store samples
appropriately
Declines HIV Test
Pregnancy Prevention
Levonorgestrel (postinor
2) tabs 2 stat OR
Eugynon OR
Neogynon 4 tabs stat, OR
Microgynon OR
Nordette 8 tabs start.
(to women/girls of
reproductive age)
STI Prevention
As per MOH
guidelines
Hepatitis B
Prevention
Hepatitis vaccine
if indicated and
available
Tetanus
Prophylaxis
T.T injection as
per TT schedule
Minimum Post Rape Care Package
Counseling for:
Trauma
Pre and post HIV test
Adherence
Referrals to:
HIV Care clinic
Psychosocial
support
Police and legal care
Shelters
Accepts HIV Test
2 weeks clinical follow-up
2 weeks PEP re
ll
Adherence counseling
Follow-up trauma counseling sessions: In 2 weeks, 4 weeks,
6 weeks and 12 weeks
Repeat , Hb, ALTs in 2 weeks; repeat PDT in 4 weeks
Trauma form
lling
PRC register
lling
References: National Guidelines on Management of Sexual Violence in Kenya and Guidelines for Antiretroviral Therapy in Kenya 4th Edition 2011
This publication was adopted from LVCT
What is to be documented
> Marital status
> Existence of any disability
> Presenting complaint
> Date and time of the sexual violation
> Details of perpetrators (Number; known or unknown)
> Type of sexual violation reported (as per SOA de
nitions)
> Types of samples
> Whether survivor bathed or changed clothes
> Name and signature of examining health care provider
> Anterior and posterior view
> Genitalia/anal-rectal (male and female)
> Name and signature of health care provider handing
over samples
> Name and signature of police o
cer receiving samples
> Date of the evidence transfer
Documents to ll:
> Medical or Forensic
> Indicate results of each test
Documents to ll:
Documents to ll:
> Type > Regimen > Duration
Documents to ll:
Demographic information must include
survivor consultation are documented
What is to be documented
Counselling
Pharmacy
Casualty /OPD
Annex
3: Clinical Management Algorithm
51
Description of Item Item Use-
Powder free gloves (Clean
gloves)
To avoid contamination.
Sterile gloves For the sterile procedures such as collecting HVS
Six stick swabs For taking the HVS and/or anal swabs from the
survivor.
Masking tape For sealing the brown envelopes in which the
specimens have been stored.
Brown envelopes for
collecting samples
For proper storage of collected specimens.
Tape Measure. For measuring the physical injuries found on the
survivor, if any.
Needles & syringes For collection of blood samples.
Urine bottles For collection of urine samples.
Vercutainer tubes For collection of blood samples.
Speculum For collection of specimens from the vaginal
cavity.
Labels For labelling the brown envelopes with the details
of the specimens stored inside.
Pregnancy testing kit To test for pregnancy
Seal lock bags
For proper storage of collected specimens
Green towels One for wiping hands during the sterile procedure
One for placing beneath the patient’s buttocks
Annex
4: Rape Kit
52
MOH 363
PART A & B
POST RAPE CARE FORM (PRC)
MINISTRY OF HEALTH
County: ___________________________________________________
Sub-County: _______________________________________________
Facility: ___________________________________________________
Start Date: ___________________ End Date:__________________
Annex
5: Post Rape Care form
53
Day Month Year
County Code Sub-county Code OP/IP No.
Name(s) (Three Names)
Date
of
birth
Day Month Year
Male
Female
Contacts (Residence and Phone number) ____________________________________________________
Date and time of Examination
Date and Time of Incident
Alleged perpetrators
Unknown
Known (specify the relationship) _______________________________________
Where incident occurred
Administrative location: County ______________ Sub-county______________ Landmark_____________
Chief complaints: Indicate what is observed ________________________________________________
Indicate what is reported _________________________________________________
Circumstances surrounding the incident (survivor account) remember to record penetration (how, where,
what was used? Indication of struggle?)
_____________________________________________________________________________________
_____________________________________________________________________________________
Type of Sexual
Violence
Use of condom?
Incident already reported to police?
Yes
Oral
Vaginal
Unknown
Anal
Attended a health facility before this one?
Were you
treated?
Were you given
referral notes?
Other (specify)
____________
____________
No
Yes Yes
No
No
Yes (Indicate name of facility)
________________________
Comments: Indicate additional information provided by the client or observed by clinician
Ministry of Health National Rape Management Guidelines: Examination documentation form for
survivors of rape/sexual violence (to be used as clinical notes to guide filling in of the P3 form)
D
a
t
e
Day Month Year Hr Min
AM
PM
Day Month Year Hr Min
AM
PM
Yes (indicate name of police station)
______________________________________
No
Significant medical and/or surgical history
Day Month Year Hr Min
AM
PM
Day Month Year Hr Min
AM
PM
D
a
t
e
Date and time of
report
Citizenship ________________
Marital Status (specify)
__________________________
Disabilities (Specify) ______________________________________
Orphaned vulnerable child (OVC)
No. of
perpetrators
Male Female
Estimated Age ____________
POST RAPE CARE FORM (PRC)
Post Rape Care Form
PRC
PRC FORM IS NOT FOR SALE
PART A
Yes No
MOH 363
Facility Name
MFL Code
No
FORENSIC
Did the survivor change clothes?
State of clothes (stains, torn, color, where were the worn clothes taken)?
How were the clothes transported? a) Plastic Bag
Were the clothes handed to the police?
b) Non Plastic Bag
Yes No
Did the survivor have a bath or clean themselves?
Did the survivor go to the toilet?
Long call?
Short call?
Did the survivor leave any marks on the perpetrator?
OB /GYN
History
Parity
Contraception type
LMP Known Pregnancy?
Date of last consensual sexual
intercourse
General
Condition
BP
Pulse Rate
RR
Temp
Demeanor /Level of anxiety (calm, not
calm)
NoYes
Yes
No
No Yes (Give details)____________________________________________________
No Yes (Give details) _______________________________________________________
GENITAL EXAMINATION OF THE SURVIVOR-indicate discharges, inflammation, bleeding
Describe in detail the physical status
Physical injuries (mark in the body map) __________________________________________________
Outer genitalia _______________________________________________________________________
Vagina ______________________________________________________________________________
Hymen _____________________________________________________________________________
Anus _______________________________________________________________________________
Other significant orifices _______________________________________________________________
Immediate
Management
PEP 1st dose
Stitching /surgical toilet done
ECP given
STI treatment given
No
Yes
No
Comments
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
No
Yes (No of
tablets)
Yes(Comment)
______________________
No
Yes(Comment)
_________________
MOH 363
c) Other (Give details) ____________________________________________________________
Please use the body map below to indicate injuries, inflammations, marks on various body parts of the survivor
BODY MAP
Female Genitalia
Male Genitalia
Comments
Posterior view
Anterior View
PHYSICAL EXAMINATION [indicates sites and nature of injuries bruises and marks outside the genitalia]
Any other treatment / Medication given /management?
Referrals to
Police Station
HIV Test
Laboratory
OPD/CCC/HIV Clinic
Trauma Counseling
Other (specify)
Sample Type Test Please tick as is applicable Comments
National
government Lab
Health Facility
Lab
Outer Genital swab
Anal swab
Skin swab
Oral swab
Specify
Wet Prep Microscopy
DNA
Culture and
sensitivity
High vaginal swab
Urine
Pregnancy Test
Microscopy
Drugs and alcohol
Other
Blood
Haemoglobin
HIV Test
SGPT/GOT
VDRL
DNA
DNA
DNA
Pubic Hair
Nail clippings
Foreign bodies
Other (specify)
L
A
B
O
R
A
T
O
R
Y
S
A
M
P
L
E
S
CHAIN OF CUSTODY
These /All / Some of the samples packed and issued (please specify)
By
To
Police Officer's Name
Name of Examining Officer (Doctor/Nurse/Clinical officer)
Signature
Signature
Day Month Year
Day Month Year
Wet Prep Microscopy
DNA
Legal
Safe Shelter
PSYCHOLOGICAL ASSESSMENT
Complete psychological assessment section in Part B
54
POST RAPE CARE FORM (PRC)
Post Rape Care Form
PRC
PRC FORM IS NOT FOR SALE
PART B
MOH 363
PSYCHOLOGICAL ASSESSMENT
Part B is intended to assess the mental status of a client in order to be able to offer holistic care.
This should inform the management and subsequent follow up of the client and hence should be
filled in at presentation.
Psychological assessment should be done by trained health care providers including Medical
Officers, Nurses, Clinical Officers, Psychiatrists, Psychological Counselors and Medical Social
Workers duly recognized by the Ministry of Health.
The Medical Officers and other persons designated by law as expert witnesses in court (Nurses
and Clinical Officers) should be the ones to sign off both the Part A and B of the PRC form.
General appearance and behavior
Note appearance (appear older or younger than stated age), gait, dressing, grooming (neat or
unkempt) and posture.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Rapport
Easy to establish, initially difficult but easier over time, difficult to establish.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Mood
How he/she feels most days (happy, sad, hopeless, euphoric, elevated, depressed, irritable,
anxious, angry, easily upset).
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Affect
Physical manifestation of the mood e.g. labile (emotions that are freely expressed and tend to
alter quickly and spontaneously like sobbing and laughing at the same time), blunt/ flat,
appropriate/ inappropriate to content.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Speech
Rate, volume, speed, pressured (tends to speak rapidly and frenziedly), quality (clear or
mumbling), impoverished (monosyllables, hesitant).
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Perception
Disturbances e.g. Hallucination, feeling of unreality (corroborative history may be needed to
ascertain details)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Thought content
Suicidal and Homicidal Ideation (Ideas but no plan or intent; clear/unclear plan but no intent;
ideas coupled with clear plan and intent to carry it out); any preoccupying thoughts.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Thought process
Goal-directed/ logical ideas, loosened associations/ flight of ideas/ illogical, relevant,
circumstantial (drifting but often coming back to the point), ability to abstract, perseveration
(constant repetition, lacking ability to switch ideas).
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
(For children use wishes and dreams, and art/ play therapy to assess the thought process and
content.
-Through drawing and play (e.g. use of toys). Allow the child to comment on the drawing and
report verbatim.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
-Assess the unconscious world of the child by asking about feelings e.g. ask the child to report the
feeling that he/she commonly experiences and ask what makes him/her feel that way
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Cognitive function-
a. Mem
ory: Recent memory, long-term and short term memory (past
several days, months, years).
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
b. Orientation: to time, place, person i.e. ability to recognize time, where they are,
people around e.t.c.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
c. Concentration: ability to pay attention e.g. counting or spelling
backwards, small tasks
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
d. Intelligence: Use of vocabulary (compare level of education with case presentation;
above average, average, below average).
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
e. Judgment: Ability to understand relations between facts and to draw
conclusions; responses in social situations.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Insight level: Realizing that there are physical or mental problems; denial of illness, ascribing
blame to outside factors; recognizing need for treatment (Indicate whether insight level is;
present, fair, not present)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Recommendation following assessment Referral point/s
Referral uptake since last visit e.g. other medical services, children's department, police, legal
aid, shelter e.t.c.
___________________________________________________________________________
___________________________________________________________________________
MOH 363
By
To
Police Officer's Name
Name of Examining Officer (Doctor/Nurse/Clinical officer)
Signature
Signature
Day Month Year
Day Month Year
55
57
Annex 5
Counseling Form
SEXUAL VIOLENCE - TRAUMA COUNSELING DATA FORM
Date:
Facility Name:
District Code: Site Code:
Survivor Name: Parents/Guardian Name:
Phone Number: __________________________
Serial No. or OP/IP No.: ___________________________
DATE:
First Visit: Counselor Name:
Second Visit: Counselor Name:
Third Visit: Counselor Name:
Fourth Visit: Counselor Name:
Fifth Visit: Counselor Name:
(For children)
Annex 5. SV Counseling Form
Annex
6: Counselling Form
56
58
RAPE TRAUMA COUNSELING DATA FORM
Sex
0 No 1 Yes
1 Male 2 Female
Has the client reported to the
police?
If not, name reason(s)
Age (years)
0 No
1 Yes
If not, name reason(s)
2
nd
Visit
Education a) Is the client willing to report
to the police?
a) Disclosure of SV
0 None 0 No
1 Yes 0 No 1 Yes
1 Primary If not, name reason(s) b) Disclosure HIV results
2 Secondary
Client referred from?
0 No 1 Yes
3 Post Secondary/Technical 1 VCT services 2 Police stations c) PEP adherence
Marital Status
3 Health Facilities 9 Other 0 No 1 Yes
0 Never 1 Married
Was the 1
st
dose of PEP
administered?
If not, name reason(s)
2 widowed 3 Separated/Divorced 0 No 1 Yes d) Still taking PEP
Type of assault
If not, name reason(s) 0 No 1 Yes
1 Penile anal rape 2 Penile vaginal rape 1 Presented after
72 hours
2 Client declined
3
rd
Visit
3 Use of objects in vagina 9 Other Is disclosure done so far ?
4 Use of objects in anus
Was EC administered?
0 No 1 Yes
9 Other 0 No 1 Yes 2 N/A Comments
Client seen
If not, name reason(s)
4
th
Visit
1 Individual 2 With partner Comments
3 With guardian/parent 4 With friend/relative
Did client know HIV status
before the assault?
5
th
Visit
9 Other 0 No 1 Yes HIV Test done
Services required by client
If Yes, 0 Negative 1 Positive
Was the PRC 1 form filled?
0 Negative 1 Positive Disclosure of SV
0 No 1 Yes
1
st
Visit
0 No 1 Yes
a) HIV test done Disclosure of HIV Results
0 No 1 Yes 2 Declined 0 No 1 Yes
If not, name reason(s)
If Yes, 0 Negative 1 Positive Pregnancy Test done
0 No 1 Yes 2 N/A b)Pregnancy Test done
Results 0 Negative 1 Positive
Who is the assailant?
0 No 1 Yes 2 N/A
0 Known 1 Unknown Results 0 Negative 1 Positive
c) Disclosed SV
If known, specify relationship
0 No 1 Yes
Comments
57
Annex
7: SV Register
StartDate:
EndDate:
REPUBLICOFKENYA
MINISTRYOFHEALTH
SEXUALGENDERBASEDVIOLENCE(SGBV)
MOH365
SpecificServiceDeliveryPoint(SDP)
Ver.July2014
FacilityName
MasterFacilityList(MFL)Code
SubcountyName
CountyName
:
:
:
:
SEXUAL VIOLENCE REGISTER
58
Column DATA DEFINITIONS / EXPLANATIONS
a Serial No. This is the identication number given to the client on the rst attendance and
is facility specic. Usually written serially. 1, 2, 3, …..
b Out patient
Number
“This is a unique identication number given to a survivor on rst attendance at
the out patient ( Out patient number)
c Arrival Date Record the day the client visits your health facility as a new client, or revisit
(recorded as DD:MM:YYYY)
d Calculated hours Hours taken from the time the incident occurred to the time the client reported
to the health facility.
e Name (S) (Three
Names)
Record at least THREE names of the client as appears in the National
Identication documents (e.g. ID, birth certicate, pass port)
k Sex Record M for Male and F for Female
j Age Record the actual stated age of the client expressed in years, If client is below
one, Indicate Age in Months. Age here must be indicated in years and NOT ‘A’
or “C”(A for adult and C for child)
f Survivor/
Perpetrator (S/P)
Record S for Survivor and P for perpetrator
h Sub Location and
landmark
Record the client’s residential location and/ or landmark to enable tracing or
follow-ups
i Telephone Number Record the client’s telephone number or guardian’s in the case of children
g Type of Case: New
/ Repeat
Record the type of case, If a New Case indicate N, If it is Repeat Case indicate
R
l Marital Status Record 1-Single, 2-Married, 3-Divorced, 4-Separated, 5-Widowed
m Referred from Record 1= Health Facility , 2= Police, 3= Schools, 4= Community health
worker, 5= Chief , 6= Other
n Disability Record 1-Hearing impairement,2-Visual impairement,3-Physical impairment,
4- Mental, 5- Others, 6- Not applicable
o OVC-Orphan or
vulnerable child
Record Y = Survivor is an orphan or vulnerable child (OVC), N = survivor is not
an OVC
p Type of sexual
violence
Record type of reported sexual violence 1- Rape, 2- Attempted Rape, 3-
Sexual assault, 4-Delement, 5-Attempted delement
q Date of sexual
violence
Record date when the sexual violence occurred (recorded as DD:MM:YYYY)
r Time of sexual
violence
Record time when the sexual violence occurred (recorded as HH:MM)
s Date Post rape
care form(PRC)
form lled
Record date when Post rape care form(PRC) form was lled (recorded as
DD:MM:YYYY)
u HIV test Record the HIV test results for those tested during the visit, as negative (-ve)
or positive (+ve).(Record N for negative and P for positive tests, KP for Known
Postive, ND for Not done)
v Pregnancy
Diagnostic Test
(PDT)
Record the Pregnancy diagnostic test test results for those tested during the
visit, as negative (-ve) or positive (+ve), N/A , Not applicable, ND Not done.
Record N for negative and P for positive tests, ND, N/A
w Anal Swab Record the anal swab test results for those tested during the visit, as negative
(-ve) if results show absence of spermatozoa or positive (+ve) if results show
presence of spermatozoa -Record N for negative and P for positive tests) and
NA for tests not done
x High vaginal swab
(HVS)
Record the HVS test results for those tested during the visit, as negative
(-ve) if results show absence of spermatozoa or positive (+ve) if results show
presence of spermatozoa-Record N for negative and P for positive tests) NA
for test not done
The SGBV register is used to record services provided to of survivors of sexual violence at the health facility.
These include rape, delement, incest, attempted rape, gang rape and sexual assault. The register is also
used to capture data on alleged perpetrators of sexual violence attended to at the health facility.
For this register to be comprehensively lled in, information is required from various PRC service delivery
points including i.e. OPD, IPD, Lab, Pharmacy and counseling units.
59
Column DATA DEFINITIONS / EXPLANATIONS
y Urinalysis Record the urinalysis test results for those tested during the visit, as negative
(-ve) if results show absence of spermatozoa or positive (+ve) if results show
presence of spermatozoa- Record N for negative and P for positive tests)NA
for test done
z Hepatitis- B Record the Hepatitis B test results for those tested during the visit, as negative
(-ve) or positive (+ve).Record N for negative and P for positive tests), NA for
test not done
aa Hb(Hemoglobin) Indicate the specic value for Hb (Haemoglobin)
ab Alanine Amino
Transferase (ALT)
Indicate the specic value for ALT
ac Creatinine Indicate specic value for Creatinine
ad Venerial disease
research
Laboratory (VDRL)
Indicate P if Positive or N for negative
ae Emergency
contraceptive
prevention given
within 120 hours
Record Y if client was given dose of ECP (Emergency Contraceptives) within
120 hours, Only applicable to Females, N if not given.ECP SHOULD only be
given to eligible clients presenting within 120 hours. N/A where not applicable
ie Not to Women reproductive age or a Male Survivor.
af Post Exposure
Prophylaxis given
within 72 hours
Record Y- if the client was given dose of PEP within 72 hours. N if not given.
PEP SHOULD only be given to clients presenting within 72 hours.
ag Sexual transmitted
infections
Treatment (STI)
Indicate in this column whether STI (Sexual transmitted infections) Treatment
were given (‘Y’ if given or ‘N’ if not given).
ah Tetanus Toxoid
(TT)
Indicate in this column whether TT (Tetanus Toxoid) was given (‘Y’ if given or
‘N’ if not given).
ai Hepatitis-B vaccine Indicate in this column whether Hepatitis B vaccine was given (‘Y’ if given or ‘N’
if not given).
aj Trauma counseling Indicate in this column ‘Y’ if the client was given Trauma counseling or ‘N’ if
not given.
ak Adherence
Counseling
Indicate in this column ‘Y’ if the client was given Adherence counseling or ‘N’
if not given.
al Referred to Record 1- Health Facility ,2- Children’s Department, 3- Legal Aid, 4- Police, 5-
HIV care, 6-Shelter, 7-Support group, O8-Other,9- Not Applicable
t Date P3 Form lled Record date in full ( if not lled indicate NOT Done when P3 form was lled
(recorded as DD:MM:YYYY)
am Date of next
appointment
Record the next appointment give to the client (dd/mm/yy)
an Actual return date Record the actual date the client came for the next appointment (dd/mm/yy)
ao Post Exposure
Prophylaxis Rell
Indicate if client is given Post Exposure Prophylaxis at 2nd visit: Record ‘Y’ or
‘N’ , N/A-Not applicable for who seroconvert.
ap Adherence to
PEP Counseling
(Post Exposure
Prophylaxis)
Indicate if client is adhering to Post Exposure Prophylaxis at 2nd visit: Record
‘Y’ or ‘N’
ar Adherence
Counseling
Indicate in this column ‘Y’ if the client was given Adherence counseling or ‘N’
if not given.
aq Trauma counseling Indicate in this column ‘Y’ if the client was given Trauma counseling or ‘N’ if
not given.
as Referral uptake at
2nd visit
Indicate whether the client took up any of the refferal services : Record ‘Y’ or
‘N’
at Hb (Hemoglobin) Indicate the specic value for Hb (Hemoglobin) for test results at 2nd visit
au Alanine Amino
Transferase (ALT)
Indicate the specic value for ALT for test results at 2nd visit
av Date of next
appointment
Record the next appointment give to the client (dd/mm/yy)
60
Column DATA DEFINITIONS / EXPLANATIONS
aw Actual return date Record the actual date the client came for the next appointment (dd/mm/yy)
ax Pregnancy
Diagnostic Test
(PDT)
Record the Pregnancy diagnostic test test results for those tested during the
visit, as negative (-ve) or positive (+ve), N/A , Not applicable, ND Not done.
Record N for negative and P for positive tests, ND, N/A
ay Trauma counseling Indicate in this column ‘Y’ if the client was given Trauma counseling or ‘N’ if
not given.
az Referral uptake at
3rd visit
Indicate whether the client took up any of the refferal services : Record ‘Y’ or
‘N’
aaa Date of next
appointment
Record the next appointment give to the client (dd/mm/yy)
aab Actual return date Record the actual date the client came for the next appointment (dd/mm/yy)
aac Hepatitis-B vaccine Indicate in this column whether Hepatitis B vaccine was given (‘Y’ if given or ‘N’
if not given).
aad Trauma
Counseling 4th
visit
Indicate in this column ‘Y’ if the client is given Trauma and Adherence
counseling in the 4th visit or ‘N’ if not given.
aae Referral uptake at
4th visit
Indicate whether the client took up any of the refferal services : Record ‘Y’ or
‘N’
aaf Date of next
appointment
Record the next appointment give to the client (dd/mm/yy)
aag Actual return date Record the actual date the client came for the next appointment (dd/mm/yy)
aah HIV test- 5th visit Record the HIV test results for those tested during the visit, as negative (-ve)
or positive (+ve).(Record N for negative and P for positive tests, KP for Known
Postive, ND for Not done)
aai Trauma
Counseling 5th
visit
Indicate if client is given Trauma counseling at 3rd visit: Record ‘Y’ or ‘N’
aaj Referral uptake at
5th visit
Indicate whether the client took up any of the refferal services : Record ‘Y’ or
‘N’
Patient outcome Indicate the patient health outcome.Indicate 1-Alive, 2-Dead
aak Remarks Any relevant comment about the client or management should be documented
here.
61
Sexual Violence Register MOH 365
A
C
B
D
SV Register depicted is longitudinal (the sections: A, B, C and D are continuous).
62
Sexual Violence Register MOH 365
SV Register depicted is longitudinal
(the sections: A, B, C and D are continuous).
A
63
Sexual Violence Register MOH 365
B
64
Sexual Violence Register MOH 365
SV Register depicted is longitudinal
(the sections: A, B, C and D are continuous).
65
Sexual Violence Register MOH 365
66
MOH 364
Revised July 2014
Facility Name:________________________
Reporting Month:_______________ Reporting Year:_________________________
INDICATOR
M F M F M F M F M F
Section A
Number of rape survivors
Number presenting within 72 hours
Number initiated PEP
Number given STI treatment
Number eligible for Emergency Contraceptive Pill
Number given Emergency Contraceptive Pill
Number tested for HIV
Number HIV positive at 1st visit
Total survivors with disability
Number of perpetrators
Section B
M F M F M F M F M F
1st visit
2nd visit
3rd visit
4th visit
5th visit
Number completed PEP
Number seroconverted
Number pregnant
Number completed trauma counseling
Report Complied by:
Designation:
Report Checked by:
Designation:
This from should be completed at facility in duplicate; Original copy sent to the Sub-County level by 5th of every month for entry into DHIS and duplicate copy remains at the facilty record
0-11 Yrs
Signature:
Sub-county:_____________
12-17Yrs
Total
The purpose of section B is to assess programme success by capturing data on treatment outcomes and retention of rape/ defilemnt survivors.
Extract data from the SGBV register for three months within which the survivor(s) are expected to have completed their visits. Note that the
target group should fall in the bracket of 90 days counted from the first day of enrollment for services. E.g. the January cohort will be reported in
the April report; the February cohort in the May report etc.
Grand Total
REPUBLIC OF KENYA
Signature:
0-11 Yrs
SEXUAL GENDER BASED VIOLENCE (SGBV)
12-17Yrs 18-49 Yrs
Date:
MONTHLY SUMMARY
Date:
50 yrs+
Total
Grand Total
MINISTRY OF HEALTH
18-49 Yrs 50 yrs+
COHORT SUMMARY
MFL Code:______________
County:______________
SEXUAL VIOLENCE
MONTHLY SUMMARY
67
49
Annex 3 P3 Form
This P3 Form is free of charge
THE KENYA POLICE P3
MEDICAL EXAMINATION REPORT
PART 1-(
To be completed by the Police Of ficer Requesting Examination)
From_____________________________________Ref____________________________________
_________________________________________Date___________________________________
To the___________________________________________________________Hospital/Dispensary
I have to request the favour of your examination of:-
Name__________________________________Age__________(If known)
Address________________________________________________________________________.
Date and time of the alleged offence__________________________________________________
Sent to you/Hospital on the__________________20__________
Under escort of___________________________________________________________________
and of your furnishing me with a report of the nature and extent of bodily injury sustained by him/her.
Date and time report to police________________________________________________________
Brief details of the alleged offence
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Name of Officer Commanding Station Signature of the Officer Commanding Station
Annex 3: P3 Form
Annex
8: P3 Form
68
50
PART 11-MEDICAL DETAILS - (
To be completed by Medical Of ficer or Practitioner car r ying out
e
xamination)
(Please type four copies from the original manuscript)
SECTION ‘’A’’-THIS SECTION MUST BE COMPLETED IN ALL EXAMINATIONS
Medical Officer’s Ref. No.____________________________________________________________
1. State of clothing including presence of tears, stains (wet or dry) blood, etc.
_________________________________________________________________________________
_________________________________________________________________________________
2. General medical history (including details relevant to offence)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
3. General physical examination (including general appearance, use of drugs or
Alcohol and demeanour)
_________________________________________________________________________________
__________________________________________________________________________________________
This P3 Form is free of charge
SECTION ‘’B’’- TO BE COMPLETED IN ALL CASES OF ASSAULT INCLUDING
SEXUAL ASSAULTS
COMPLETION OF SECTION ‘’A’’
1. Details of site, situation, shape and depth of injures sustained:-
a) Head and neck
_________________________________________________________________________________
_________________________________________________________________________________
b) Thorax and Abdomen.
_________________________________________________________________________________
_________________________________________________________________________________
c) Upper limbs
_________________________________________________________________________________
_________________________________________________________________________________
d) Lower limbs
_________________________________________________________________________________
_________________________________________________________________________________
69
51
_________________________________________________________________________________
2. Approximate age of injuries (hours, days, weeks)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
3. Probable type of weapon(s) causing injury
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
4. Treatment, if any, received prior to examination
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
5. What were the immediate clinical results of the injury sustained and the assessed degree, i.e.’
harm’’, or’ grievous harm’’.*
DEFINITIONS:-
‘’Harm’’ Means any bodily hurt, disease or disorder whether permanent or temporary.
‘’Maim’ means the destruction or permanent disabling of any external or organ, member or sense
‘’Grievous Harm’’ Means any harm which amounts to maim, or endangers life, or seriously or permanently injures health, or which is likely
so to injure health, or which extends to permanent disfigurement, or to any permanent, or serious injury to external or organ.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Name & Signature of Medical Officer/Practitioner_____________________________________
Date______________________________________
70
52
This P3 Form is free of charge
SECTION “C”-TO BE COMPLETED IN ALLEGED SEXUAL OFFENCES
AFTER THE COMPLETION OF SECTIONS “A” AND “B”
1. Nature of offence_________________________________Estimated age of person
examined________________________________________________________________________
2. FEMALE COMPLAINANT
a) Describe in detail the physical state of and any injuries to genitalia with special reference to labia
majora, labia minora, vagina, cervix and conclusion
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
b) Note presence of discharge, blood or venereal infection, from genitalia or on body externally
_________________________________________________________________________________
_________________________________________________________________________________
3. MALE COMPLAINANT
b) Describe in detail the physical state of and any injuries to genitalia
_________________________________________________________________________________
_________________________________________________________________________________
c) Describe in detail injuries to anus
_________________________________________________________________________________
_________________________________________________________________________________
d) Note presence of discharge around anus, or/ on thighs, etc.; whether recent or of long standing.
_________________________________________________________________________________
_________________________________________________________________________________
71
53
This P3 Form is free of charge
SECTION “D”
4. MALE ACCUSED OF ANY SEXUAL OFFENCE
a) Describe in detail the physical state of and any injuries to genitalia especially penis
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
b) Describe in detail any injuries around anus and whether recent or of long standing
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
5. Details of specimens or smears collected in examinations 2 ,3 or 4 of section “C” including
pubic hairs and vaginal hairs
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
6. Any additional remarks by the doctor
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Name & Signature of Medical Officer/Practitioner_____________________________________
Date____________________________________
72
Annex
9: PRC Supervision Tool
1
POSTRAPECARESUPPORTSUPERVISIONTOOL
NAMEOFHEALTHFACILITY:................................................DATEOFVISIT.............................
PRCSERVICEPOINTSVISITED...................................................................................................
Namesofserviceproviderspresent
…………………………………………………………………………..
Aspect
Whatisworkingwell
Gapsidentified
Comments
1. VisibilityMaterials
PRCIECsandsignagestrategicallydisplayed/
available
PRCservicesinservicecharter
ClientflowchartsdisplayedatOPDandother
waitingbays/strategicpointsatthefacility
2. PRCServiceDelivery
• OPD/Consultationrooms
Private,quietaccessibleexaminationroom
Examinationtable,lighting
Accesstoautoclave/sterilizedequipment
DisplayedIECs,SOPflowcharts,forensiccharts
Consentforms
Localanaesthesia,suturepacks
AssembledPRCkit
Cloth,orsheettocoverthesurvivorduring
examination;Sanitarysupplies
PRCformavailable,accuratelyandcompletely
filled;Copiesissuedoutcorrectly
PRCdrugkitinplace1
st
PEPdose,ECP
Lockablecabinetsforstorageofdatatools,
commoditiesandevidence
Referraltonextservicedeliverypoint
Laboratory
DisplayedIECs,SOPflowcharts,forensiccharts
Labtestsdone:HIV,PDT,Hb,HepBandC,HVS
STItestsforlatepresentingsurvivors
Functionalrefrigerator
HTClabregistercompletelyandaccuratelyfilled
Labregistersinplaceandfilled
ReferraltonextSDP
Counselling
Private,quietaccessible,welllitroom
DisplayedIECs,CounselingSOPs
Traumaforms
PRCregister:completely&accuratelyfilled;
‘Adopted from LVCT’
73
2
agreeswithPRCform
PRCdrugkit1
st
PEPdose,ECP
Lockablecabinetsforstorageofdatatoolsand
commodities
Referraldirectory
Pharmacy
DisplayedIECs,SOPflowcharts
Drugs:PEP,STIdrugs,ECP,analgesicsand
antibiotics
PEPregisters
3. Qualitymanagement
QMteamsaddressPRCissues
AvailabilityandadherencetoPRCguidelines,
SOPs,protocols
Clientsatisfactionsurveysdoneandanalyzed
Supervisionandprovidermentorshipgivenby
QMteam
DataflowfromSDPtorecords;timelyreporting
4. CapacitybuildingforPRCproviders
AllPRCservicedeliverycadrestrained
Traumacounselors
CMEforPRCproviders
5. Managementinvolvementandsupport
RecognizedPRCcoordinatingteaminplace
PRCissuesdiscussedandaddressedbyHMT
ManagementsupervisionofPRCservices
UtilizationofPRCdatainplanning
Site support supervision done by:
.....................................................................................................Signed……………………
……………………………………………………………………Signed…………………..
ActionPoints
Responsible
Person
Bywhen
74
IN THE EXERCISE of the powers conferred by section 35(3) of the Sexual Offences Act, 2006,
the Minister for Public Health, makes the following Regulations:
Citation:
1. These Regulations may be cited as the Sexual offences (MedicalTreatment) Regulations,
2012
Interpretation:
2. In these Regulations, unless the context otherwise requires- “Act” means the Sexual
Offences Act, 2006; and
“Designated Person” includes-
i. A nurse enrolled or registered under section 12(1) and 14(1) of the Nurses Act;or
ii. A clinical of cer registered under section 7 of the Clinical Ofcers (Training,
Registration and Licensing); Act and “Medical Practitioner” means a medical
practitioner registered in accordance with section 6 of the Medical Practitioners and
Dentist Act.
“Medical Treatment” includes professional counselling
“Public hospital or institution” means a government health facility at all levels of healthcare,
or such other institution that may be designated by notice in the Gazette as a public health
facility for the purposes of this Act.
Access to Health:
3. (1) (i) every victim of sexual violence is guaranteed the right to medical treatment in
a public or private hospital or any other institution
(ii) every witness is guaranteed the right to medical treatment in a public or
private hospital or any other institution
(iii) every suspect or convicted person to a sexual offence is guaranteed the right
to medical treatment in a public or private hospital or any other institution
(2) Any expenses incurred by the victim, witness, suspect or convicted person under
medical treatment in a public hospital shall be borne by the state
(3) A victim of sexual violence shall receive medical treatment at any health facility
whether or not they have reported the matter to the police
(4) The minister may at any time enter into arrangements with private hospitals or other
health facility as public hospitals for purposes of implementation of section 35(3) of
the Act Notication: a police ofcer of the rank of inspector and above, shall where
an allegation of sexual violence having been committed against anyone, notify and
refer the victim of sexual violence to a medical practitioner or a designated person at
any health facility
Annex 10: Sexual Offences Act Medical (Treatment) Regulations, 2012
75
Annex 10: Sexual Offences Act Medical (Treatment) Regulations, 2012
Specimen Collection: 5
(1) a court may make an order for the collection of appropriate samples from a person
charged with committing an offence under the act at such place and subject to
such conditions that the court may direct
(2) upon receiving the order made, a police ofcer above the rank of a constable shall
request any medical practitioner or designated person to take appropriate sample
or samples from the accused person concerned
(3) the medical practitioner or designated person shall determine what sample or
samples to take, from what body part and in such quantity as is reasonably
necessary for analysis, as per the national guidelines on management of sexual
violence
Treatment: 6
(1) medical practitioner or designated person shall-
(a) Conduct a full medical-forensic examination on the victim of sexual violence and
prescribe the appropriate medical treatment.
(b) Provide professional counselling to the victim of sexual violence
(c) Complete a prescribed Post Rape Care Form , and any other relevant records.
(d) Collect and preserve the necessary medical forensic samples as per the national
guidelines on management of sexual violence.
(e) Inform and forward to the Investigation Ofcer or his/her representative the
collected forensic samples while maintaining chain of custody by signing for them.
(f) Initiate appropriate referral to relevant areas for subsequent care.
( 2) a medical practitioner or designated person shall provide medical treatment
prescribed in 6(1) (a), (b), (d), (e) and (f) to a suspect of sexual violence
(3) the medical practitioner or designated person may, where they deem appropriate,
conduct other examinations and treatment on the victim of sexual violence, witnesses
or the alleged perpetrator of sexual violence.
Dated the ………………June, 2012
Signed for gazettement by Minister of Health
76
Annex 4. SV Community Awareness Info Pack
What is rape?
Rape is sex (sexual intercourse) that is obtained by use of
force, coercion, intimidation of any kind or threats. It
includes penetration in the vagina, the anus or any other
body orifice. Rape happens to persons when they do not
give consent to have sex
Rape happens to women and girls as well as men
and boys
In Kenya, sex with children below 18 years is called
defilement and is a criminal offence
Rape is often done by people we
know and may at times
be close to us.
Rape is about violence and the abuse of power by a
person. It is not about love.
What should l do if l am raped?
Get to a safe place and go the nearest health
facility within 72 hours.
Note: The national, Provincial and District
Hospitals provide Post Rape Care Services.
At the hospital you will get:
1. medical evaluation and attention for your
injuries
2. counseling support for yourself and your family
3. treatments to prevent infection with HIV,
pregnancy and other sexually transmitted
infections
4. referral for other services you may require
What should l NOT do if l am raped?
Do not wash yourself no matter how much you want to
bef
ore you visit a hospital and are examined by a
medical officer
Do not destroy or wash your clothing. Wrap them in a
non polythene bag or in plain cotton clothes.
Do not put them in a plastic bag. This may destroy the
evidence
Take them to the hospital with you and let the doctor
examine them.
After rape you may experience feelings of shame,
guilt and blame.
Remember: It is the person that raped you who is
wrong. What has happened is NOT your fault
What happens at the hospital?
• A health care provider will examine your whole
body for marks, bruises and wounds.
The examination may be
uncomfortable, embarrassing and sometimes painful,
but it is necessary
• The health care provider will ask questions about
the rape experience. You will need to answer all
questions asked frankly
• The health care provider will record this information
in detail in a book (that you may be required to
buy) or in a form already available at the
hospital. The health care provider will need to sign
this
•
if possible take a family member or a friend with
you to support you
Remember: keep the medical notes and any
documents that the doctor writes in a safe place. You
may require them at a later date.
What treatment do l need if l have been raped?
Treatment of your physical injuries (if there are any) is
most important
Drugs that could reduce chances of infection with HIV
after rape are available
• These anti-retroviral (ARV) drugs are
referred to as PEP (Post Exposure
Prophylaxis)
• PEP must be started soonest possible after
rape and certainly with 72 hours
• PEP is taken for a period of 28 days
• PEP is prescribed and managed by a
qualified medical officer
• PEP will
benefit you ONLY if you were
HIV negative before being raped
• Taking PEP when you are HIV positive is
not useful and increases your body
resistance to any future ARV treatment
• A HIV test is therefore necessary to
determine whether or not you can take PEP
Drugs to prevent pregnancy (emergency contraception).
These drugs are also available in pharmacies.
The most commonly used drug is called
postinor 2.
• If this is not affordable or availabl
e, ask
your pharmacist to give you a combination
for emergency contraception from normal
oral contraceptive pills
Drugs to reduce the possibility of infection with sexually
transmitted diseases (STIs)
•
Annex
11: SGBV Community Awareness Info Pack
77
You will also be referred:
• For counseling at the VCT site for support and
preparation to undertake a HIV test
• To the laboratory for necessary blood tests
What tests do l need to take if l am raped?
Tests to be done right away include
;
A vaginal swab or an anal swab in case of sodomy– will
attempt to show sperm in your vagina/anus. This can be
used as evidence. However, the absence of sperms does
not mean you were not raped
A pregnancy test – to make sure you are not already
pregnant. If a pregnancy test cannot be done, you should
get emergency contraception (Pregnancy prevention). If
you suspect that you may already be pregnant it is alright
to take emergency contraception since it does
not
interfere with established pregnancies.
Tests to be done later include:
Test for Sexually Transmitted infections. (these tests are
not very necessary if drugs to reduce the possibility of
STI infections are provided)
HIV test
Why do l need a HIV test?
PEP drugs reduce the chances of HIV transmission.
PEP drugs do not cure HIV. PEP is only useful to
someone who is HIV negative. It is important to
establish HIV status for PEP to be provided.
You can get PEP for 3 days before taking a HIV test as
you decide whether you wish
to proceed with it. It is
important to remember that:
• You will get counseling to support you through your
trauma and in making your decision to take a HIV
test.
• PEP may have some uncomfortable side effects. You
may need to discuss these with your
clinician/doctor.
Do not stop PEP without consultation with your
Clinician/ Health Care Provider
It is very important to take all the drugs as prescribed
throughout the 28 day period.
The HIV test and necessary blood test will be
undertaken in
a laboratory
Remember: it is entirely an individual’s choice to be
tested for HIV and is only necessary in hospitals and
clinics where PEP is available
If l was raped and did not take PEP does it mean l
have HIV?
Many people who have been raped do not get HIV. It
is hard to say exactly what the risk is but it is dependent
on a number of things:
• There is a chance that the person who raped
was not infected or was not infectious (has a
low load of HIV virus in his blood)
• If the person who raped did not ejaculate the
risk is also less
• The risk is more if there were many people
penetrating
and there were injuries
What if l tested HIV positive?
If you are in hospitals mentioned above, you will be
referred to the HIV care clinic. You will be offered:
• Counseling support that is on-going
• Information about available treatment for
management of HIV related illness
• Preventive treatment
• Treatment for other infections
• Referral to other support infections
Many other places also have HIV care clinics or can
provide some of the se
rvices mentioned above.
What if l choose to report to the police?
At the police station, you will report and a record will
be made in the occurrence book (OB). You will get an
OB number.
You will be asked questions about the incident. The
police will cross-examine what you say in detail and
may sometimes ask questions that are difficult for you.
It may be uncomfortable or even painful, but necessary.
You may speak the absolute truth of the situation.
If you have no
t been to the hospital, it is important
that you go there immediately after reporting.
Other procedures such as writing a statement or
obtaining a P3 form can be undertaken after you
have received initial treatment.
You will also be asked to recorded a statement and sign
it. Do not sign this statement until you are happy and
comfortable with what has been written in it.
You will be provided with a P3 form. This is a legal
document that the w
ill be provided for you to sign. If
you have already been to the hospital, take it back with
you to the health care provider to fill in. You may be
accompanied by a police officer. Remember to carry
the notes written by the medical officer as they will
be used to fill in the P3 form
78
Remember: you have the right to ask for a female
or male police officer to go with you.
The P3 form should be completed and signed only
when you have fully recovered from all your injuries
Remember: the P3 form is an important document
that provides a link between your statement and
prosecution, where the perpetrator is arrested. The P3
form is a free document and this should not be paid
for
What are my likely reactions to rape?
There are reactions commonly referred to as rape trauma
syndrome (RTS):
• Shock can make you cry, laugh, shake or stay
very calm
• Guilt and shame – you may feel and think that
you could have done things differently to avoid
or stop the rape. You may feel that others are
faulting you
• Fear – this may immobilize and dysfunction you
and can be triggered by different things – a
word, a film, a book, a smell etc
. Counseling
support can help your fear go away
• Silence – you may feel like you want to keep
quiet and may be afraid of disclosing rape
Remember: you have done nothing wrong. It is not
your fault. It is OK to be angry and feel what you are
feeling.
Some people may also experience:
• Nightmares, hallucinations and depression
• Anger and sense of loss – you may have lost your
sense of safety, being in control and certainly the
right to your bodily integrity. It is important to
speak to someone to begin to heal. Your counselor
will maintain confidentially. Breaking the silence
will help you and others to conquer the fear and
regain strength.
What are my rights as a survivor of sexual
violence?
You have a right to:
• Choose when, where, how and with whom to have
sex
• Engage in consensual sex in all situations at all
times
• Have your choice respected and protected by
society and the law
• Willingly decide to lay a charge of rape with the
police
• Access termination of pregnancy and post
abortion care in the event of pregnancy from rape
• Legal representation
Myths and facts about rape
Myth: Fact
Rapists are strangers in the dark streets Rapists are more often than not people known to the survivors. They
include husbands, boyfriends, relatives, neighbours, friends or dates
When a woman says “NO” to sex, she
means “YES
This belief is based on some cultures where women are expected to
be shy and resist when approached by a man. A “NO” means “NO”
and it has to be firm
Men cannot be raped Men and particularly young boys are vulnerable to rape and require as
much care and support as women who have been raped
Men cannot control themselves when
they get proved and excited
All men and women can control themselves and their sexual activity.
Rapists CHOOSE to use sex as a weapon of power
It does not matter how women are dressed whether they are children
in nappies and women in long robes. Women have the right to dress as
they so wish
Husbands cannot rape their wives Both women and men have a right to bodily integrity and choose
when to have sex. Whether they are married or not
79
Annex
12: Useful Resources
General information
• Ajema C, Mukoma W, Mugyenyi C, Meme M, Kotut R, and aMulwa R (2012)
Improving the collection, documentation and utilisation of medico-legal evidence
in Kenya; LVCT Kenya.
• Guidelines for medico-legal care for victims of sexual violence, World Health
Organization 2003, (http://www.who.int/violence_injury_ prevention/publications/
violence/med_leg_guidelines/en/inde)
• Clinical Management of Survivors of Rape. A Guide to the Development
• of Protocols for Use in Refugee and Internally Displaced Person Situations, World
Health Organization 2005, (http://www.unhcr.org/refworld/ docid/403b79a07.
html)
• Download guidelines for management of sexual violence of Kenya (2003) (http://
www.liverpoolvct.org/index.php?PID=172&showsubmenu=172)
• Family planning Guidelines for service providers 2005(http://www. maqweb.org/
iudtoolkit/policies_guidelines/kenyafpguidelines.pdf)
• Community Practices post sexual Violence Implications on the uptake of services
and the implementation of care (http://www.aidsportal.org/repos/
• Community Responses To Sexual Violence.pdf
Information on sexually transmitted diseases
• Guidelines for the management of sexually transmitted diseases. Geneva, World
Health Organization, 2001 (document numberWHO/RHR/01.10) (http://www.
who.int/reproductive-health/publications).
• Information on emergency contraception: a guide for service delivery. Geneva,
World Health Organization, 1998 (document no. WHO/FRH/ FPP/98.19). (http://
www.who.int/reproductive-health/publications).
• Practice Guidance on the supply of Emergency Hormonal Contraception as a
pharmacy medicine, Royal Pharmaceutical Society of Great Britain,
• 9/2004 (http://www.rpsgb.org.uk/pdfs/pr040922.pdf)
Information on post-exposure prophylaxis (PEP) of HIV infection
• Post-exposure prophylaxis to prevent HIV infection: joint WHO/ILO guidelines on
post-exposure prophylaxis (PEP) to prevent HIV infection, World Health Organization
2007 (http://www.who.int/hiv/pub/guidelines/en/)
80
Information on psychosocial issues
• Campbell R. Mental health services for rape survivors: issues in therapeutic practice.
Violence Against Women Online Resources, 2001:1–9 (http:// www.vaw.umn.edu/
documents/commissioned/campbell/campbell.html).
Information on humanitarian issues
• Inter Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial
Support in Emergency Settings (http://www.humanitarianinfo.org/iasc/content/products)
Information on legal and forensic issues
• The Sexual Offences Act. No 3 of 2006. Revised Edition 2007 (2006) (http://
• www.kenyalaw.org/.../download.php?...Sexual%20Offences%20Act )
• Community Practices Post Sexual Violence. Implications on the uptake of services and
the implementation of care (http://www.aidsportal.org/repos/
• COMMUNITY%20RESPONSES%20TO%20SEXUAL%20VIOLENCE.pf
• The Constitution of Kenya, 2010.
82
MINISTRY OF HEALTH
REPRODUCTIVE & MATERNAL HEALTH SERVICES UNIT
