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SAMJ: South African Medical Journal
versión On-line ISSN 2078-5135
versión impresa ISSN 0256-9574
SAMJ, S. Afr. med. j. vol.106 no.11 Pretoria nov. 2016
http://dx.doi.org/10.7196/samj.2016.v106i11.12064
CME
Current approaches to the management of adult survivors of sexual offences
M Tiemensma
MB ChB, Dip For Path (SA), FC For Path (SA), MMed (For Path), DOH, AHMP Clinical Forensic Unit, Victoria Hospital, Cape Town, South Africa
ABSTRACT
The adequate management of survivors of sexual offences is vital to ensure that both the healthcare and medicolegal needs of survivors are met. This article provides step-wise guidelines on current approaches to the management of adult survivors of sexual offences, which include the collection of evidence, medical management and treatment.
Recently, a number of sexual crimes committed in South Africa (SA) raised alarm both locally and internationally. The cases of Anene Booysen[1] and Sinoxolo Mafevuka[2] come to mind, as well as newspaper headings such as 'Rape victim turned away from hospital'. All of these contribute to the emotional discussions reverberating from these continued crimes, and emphasise the need for the proper management of survivors of sexual offences. Dedicated clinical forensic centres, such as Thuthuzela centres,[3] are available across SA; however, in many settings, there are no dedicated service centres, and survivors are seen in provincial day hospitals and emergency departments, among, and competing with, other patients waiting to receive medical care. Often, the attending clinician is an inexperienced junior doctor, who may not have received specific training in the management of survivors of sexual offences.
Objective
This article aims to provide clear guidelines to the attending clinician when managing adult survivors of alleged sexual offences. These include the dual responsibility of attending to the healthcare and medicolegal needs of the survivor.[4]
Definitions
It is helpful for the clinician to understand the legal definitions of sexual offences, as contained in the Criminal Law (Sexual Offences and Other Related Matters) Amendment Act No. 32 of 2007 (Table 1).[5]
However, it is imperative that the clinician should realise that rape is not a medical, but a legal definition and that the clinician can never testify or confirm whether 'rape' occurred or not. The clinician can collect evidence and give testimony on what was found during the physical examination, and merely present and explain the objective evidence to court.
It is vital to understand that in many instances no injuries are present, which does not exclude the possibility that forced penetration could have occurred. It is the role of the judge or magistrate to decide, after reviewing all available evidence and testimonies, whether a sexual crime was committed or not.
Approaches to survivors of alleged sexual offences
Anyone who reports an alleged sexual offence should be attended to in a non-judgemental way, ensuring the best outcome of the medicolegal investigation, while preventing secondary trauma. Survivors should be advised how to preserve DNA evidence prior to examination, especially if they are transferred to be seen, or while awaiting examination (Table 2).
Different scenarios
A survivor may present to a healthcare facility under various circumstances, and management should be guided by the presenting history and wishes of the survivor.
In most cases, a survivor will report to a police station first, in which case a detective from the Family Violence, Child Protection and Sexual Offences (FCS) unit of the SA Police Service (SAPS) should be contacted. The detective should assist the survivor to open a case and arrange examination and evidence collection, if applicable, at the relevant healthcare facility. The examination and evidence collection are time sensitive, with a general cut-off of 120 hours since the time of the alleged incident for the evidence collection, and 72 hours for the provision of post-exposure prophylaxis against HIV.
General comments
A mentally competent adult survivor has a choice to lay a charge with the police or not. If the survivor wishes to lay a charge, but reports to a healthcare facility first, the attending clinician should contact SAPS/ FCS to request an officer to attend to the survivor at the healthcare facility. This avoids sending the survivor back to the police station first to report the incident.
The Independent Police Investigative Directorate (IPID) should be contacted should the alleged perpetrator be a police official.
The SAPS/IPID official has to supply the relevant medicolegal documentation (SAP 308 form, Affidavit 212 form), the J88 form, and sealed, unopened sexual assault evidence collection kit(s) (SAECK(s)).
Survivor presents with severe injuries
If a survivor is admitted with severe injuries or is in a serious medical condition, the following guidelines apply:
• Forensic examination and evidence collection should be done only after stabilisation of the patient's condition.
• If a survivor has to be referred to the next level of care, ensure that the necessary information (such as forensic evidence that has not been collected yet) is communicated to the next facility and advise that, where possible, the survivor must not be bathed/washed prior to evidence collection.
• Collect any removed clothes/items from the scene that may be with the survivor, and hand these over to the investigating officer, or keep these in a safe and locked cupboard until collected by the investigating officer.
Survivor presents <120 hours after the alleged incident and wishes to lay a charge with the police
Give the case priority as an emergency, and attend to the survivor as soon as reasonably possible. Provide the survivor with the necessary privacy. The clinician is responsible for the following:
Step 1. Arrange containment counselling if available. Prepare the patient and obtain informed consent to proceed with the examination and evidence collection (SAP 308 form and consent form inside the evidence collection kit to be signed by the complainant/guardian, investigating officer and clinician).
Step 2. Take a detailed history, following the information requested on the J88 form, and add clinical notes in the hospital folder.
Step 3. Conduct a medical examination and collect evidence (guided by the details of the sexual offence) in the presence of a chaperone, who is preferably of the same sex as the survivor (more details on evidence collection are given below). If available and applicable, arrange or perform photographic recording of injuries.
Step 4. Carefully document findings in an objective and understandable manner on the J88 form, and sign and complete the Affidavit 212 form. Take care to describe the injuries, using accurate wound terminology.
Step 5. Perform medical tests (see Medical management below).
Step 6. Provide medical treatment (see Medical management below).
Step 7. Arrange follow-up visits at the appropriate healthcare facility, as indicated, at 1 week, 6 weeks and 3 months.
Step 8. Offer the survivor a comfort pack (if available) and bath/ shower if facilities are available.
Step 9. Hand over the completed medicolegal documentation (original) to the investigating officer and keep copies in the survivor's file, in a secure location as per local facility arrangement.
Survivor presents >120 hours after the alleged incident and wishes to lay a charge with the police
The same steps are to be followed as above, except:
• There should be no collection of evidence (except in the case of termination of pregnancy after alleged rape, where the products of conception should be retained for DNA analysis, using the appropriate Tissue Collection Kit to be provided by the FCS unit).
• HIV prophylaxis is prescribed up to 72 hours after the alleged incident.
• Emergency contraception should be provided, if indicated, up to 120 hours after the alleged incident.
Survivor does not wish to lay a charge with the police, but requests medical advice and treatment
A survivor does not forfeit her/his right to medical advice and treatment when no case is opened with the police.[6] Explain to the survivor that it may be of value to proceed with evidence collection if within the 120-hour period after the alleged incident in case s/he changes her/his mind about laying a charge. Obtain informed consent and proceed with the procedure in the same order as before, according to the time passed since the alleged incident. If the survivor consents, evidence may be collected (SAECK obtained from the FCS unit) and kept at the healthcare facility in a locked cupboard for 30 days in case the survivor changes her/his mind. Document your findings carefully in the survivor's clinical notes.
Evidence collection
Evidence collection is to be guided by the history and details of the alleged sexual offence. SAECKs are provided by the investigating officer. Never accept SAECKs if the seals are broken or any evidence of tampering is evident, and maintain the chain of evidence.
Previously, a single box that contained all the various steps/packages for forensic evidence collection was provided. This has been changed to separate evidence collection kits, which are to be used according to the type of assault.[7]
Consider the detailed history of the sexual assault and request the necessary and appropriate kits before starting with your examination of the survivor and evidence collection (Table 3).
Medical management
The medical management, similar to the evidence collection, is guided by the presenting history and the time elapsed since the alleged incident.
Investigations
The following investigations should be performed:
• pre- and post-HIV-test counselling and a rapid HIV test
• baseline rapid plasma reagin (RPR) test (for syphilis)
• urine pregnancy test
• further testing for sexually transmitted infections (STIs), if indicated
• screening for hepatitis B if the immunisation status of the individual is unknown.
Treatment
Treat all acute injuries evident on presentation, and provide antitetanus toxoid 0.5 mL intramuscularly if: (i) open wounds are present; (ii) the last vaccination was >10 years ago; or (iii) the vaccination status is unknown. Treat any other physical injuries as appropriate, or refer for further treatment if indicated. Treat established complications, such as infections or pregnancy, as applicable.
Prophylaxis and medication
Information on prophylaxis and medication is given in Table 4.
Follow-up visits
Document whether the survivor experiences any post-traumatic stress syndrome symptoms at each visit, and give advice regarding medication and blood results. Ensure that arrangements for counselling are in place. A repeat examination is only required if there was significant injury, and documentation regarding healing is required. Follow up blood results on hepatitis B serology (if this was indicated) and manage accordingly. Repeat the HIV and RPR tests at 6 weeks and 3 months. Enquire about menstruation and a repeat pregnancy test, if indicated, at 6 weeks and 3 months. Treat STIs if indicated. If the survivor became pregnant as a result of rape, and wishes to terminate the pregnancy, she should be referred to an appropriate facility for a safe termination of pregnancy as soon as possible.
Conclusion
As the prevalence of rape and sexual assault in SA is vast, clinicians can expect to be faced with providing relevant care for survivors of alleged sexual offences in an array of clinical settings. Meticulous and appropriate management of these survivors is paramount to assist their healing and the best possible judicial outcomes.
References
1. Eyewitness News. 2013. http://ewn.co.za/2013/10/31/The-Anene-Booysen-Stor (accessed 12 April 2016). [ Links ]
2. News24. 2016. http://www.news24.com/SouthArica/News/family-of-murdered-teen-sinoxolo-angry-with-cops-20160.11 (accessed 12 April 2016). [ Links ]
3. The National Prosecuting Authority of South Africa. 2016. https://www.npa.gov.za/node/4 (accessed 10 April 2016). [ Links ]
4. Jina R, Jewkes R, Munjanja SP, et al. Report of the FIGO Working Group on Sexual Violence/ HIV: Guidelines for the management of female survivors of sexual assault. Int J Gynaecol Obstet 2010;109(2):85-92. DOI:10.1016/j.ijgo.2010.02.001 [ Links ]
5. South Africa. Criminal Law (Sexual Offences and Other Related Matters) Amendment Act No. 32 of 2007. http://www.justice.gov.za/legislation/acts/2007-032.pdf (accessed 8 April 2016). [ Links ]
6. South Africa. National Health Act of 2003. Regulations: Rendering of clinical forensic services. Government Gazette No. 33655, 2010. (Published under Government Notice R929.) http://www.gov.za/sites/www.gov.za/files/33655_929.pdf (accessed 22 April 2016). [ Links ]
7. Manta Forensic. 2016. Collection kits. http://www.mantakits.co.za/?page_id=3753 (accessed 11 April 2016). [ Links ]
8. National Department of Health. Standard Treatment Guidelines and Essential Medicines List for South Africa - Primary Health Care Level. 5th ed. Pretoria: NDoH, 2014. [ Links ]
9. Western Cape Government. Circular H33/2016. Provincial Contraceptive Guidelines. Cape Town, DoH, 2016. [ Links ]
Correspondence:
M Tiemensma
marianne.tiemensma@westerncape.gov.za