(Adapted from the Peace Corps Volunteer Safety Council, January, 1998)
1. Administrative and Management Guidance
A) ON-SITE PREPARATIONS: PRE-ASSAULT
1) Administrative Considerations
a) Be informed about legal requirements and procedures. The Resident Director and designated medical doctor could establish an easily accessible file that contains a memorandum or other documents describing in detail current local forensic medical requirements and legal procedures for prosecution of the alleged assailant in the case of a rape or attempted rape. The documents should address how rape is locally defined in that country, what constitutes the requisite forensic material, who can collect forensic material, how the forensic material must be handled to preserve its value, and the timing required for collection of the material and other evidence as well as the statue of limitations for prosecution. This information can be gathered through a consultation with local counsel as discussed below. (See also "Questions for Local Counsel".)
The resident Director should be familiar with the general requirements for prosecution and for gathering evidence, since it is his or her responsibility to have in-depth and up-to-date knowledge of these requirements. Also these requirements should be verified and updated annually.
b) Identify a local attorney for consultation. The Resident Director could identify a local attorney who can be contacted for emergency consultation and who can provide knowledgeable and experienced criminal attorney. The U.S. Embassy may have a list of local attorneys available for this purpose. Every attempt should be made to build and maintain a relationship with an attorney before a crisis occurs. The attorney's name address and telephone numbers (office and home) should be kept with the forensic and legal information collected and updated annually. The resident director could also obtain a referral to and meet with a criminal lawyer before any assault occurs, for aid in compiling the specific information described above. (Again, see "Questions for Local Counsel")
2) Student and Staff Training
a) Address assault prevention at the Pre-departure Orientation and at the Orientation. Both orientations could address assault prevention. The Resident Director and the Director for the Women's Center, etc. could work together to develop appropriate training strategies.
Videos The safety and security needs of all students, the issue of confidentiality, and to urge prompt notifications to staff in case of rape and attempted rape could be discussed. Students should be made aware of the notification protocol. Their attention should be drawn to the obligation of a staff person who receives a report of a rape or attempted rape to report it immediately to the designated medical doctor. And the importance of such reports to preserving the safety of other students. They should also be advised of the fact that other staff members may have to be informed of the rape's location and pertinent circumstances, also in order to protect other students. The victim's name will be protected to the maximum extent possible.
b) Emphasize the importance of notification. It is important that a victim tell someone on the staff of a rape, so that she or he can receive appropriate support. It is also important to report an incident, so that staff can work to identify any steps available to reduce the risk to other students. For example, some areas of country (e.g., certain beaches, hostels or hotels) may be deemed unsafe as result of the report, and students should be so advised. These practical and positive results of notification should be emphasized in training.
1) Providing support to the victim.
a) Medical decisions. Medical decisions should be made with the help of a medical professional in the host country, the on-site resident director, and the study abroad administrator at the home institution in consultation with a medical professional at the home institution. The desires of the victim should be taken into account in any actions. Institutional policy and privacy issues may guide the amount of interaction with the victim's family and significant others.
b) What to communicate to the victim. All involved staff should give the victim, verbally and non-verbally, three messages:
I believe you;
You are not alone; and
We are sorry this happened to youIt is especially important never to blame the victim. Rather, staff should ask, "What can we do to help you?" The "victim" of rape will at some point also become a "survivor" of rape; staff should be cognizant of this transition. Host country staff unfamiliar with these issues may benefit from special training or discussion of supportive techniques. (A more complete discussion of the issues related to supporting the victim is contained in "Understanding and Supporting the Victim of a Rape.")
2) Keep notes of the report and all developments.
The Resident director could keep extensive and complete notes on the case because he or she will need to refer to them as the fog of memory thickens over time. The assaulted student should not be referred to by name in the notes; initials should be adequate.
3) Assessing the safety of the victim and other students.
The Resident Director could do the following to assure the safety of the victim and other students:
a) Make sure the victim is safe and feels safe. The Resident Director may consult with the victim, the US Embassy's Regional Security Officer (RSO) and others to determine how best to ensure the actual safety of the victim. The victim must also feel safe, however, and the Resident Director could take steps to allay the victim's fears to the extent possible.
1. In unusual cases, a security guard may be required at the location where the student is staying-possibly at the hospital. The Resident Director could authorize this expenditure. The RSO may need to be involved with this decision.
2. If the student's life is judged to be in danger for other than medical reasons, the Resident Director may institute emergency evacuation procedures to remove the victim from the country. The Resident Director could authorize this expenditure.
b) Assess any possible risk to other students and staff. If there is any reason to believe that other students or staff are at risk, the resident Director could immediately take appropriate action to ensure their safety.
4) Preserving the option to prosecute
a) Advise the victim of his or her legal rights and how best to preserve the option to prosecute. The Resident director is responsible for ensuring that the student has been advised of his or her legal rights, of the need for evidence, and other elements of preserving the option to prosecute. Local law may require that certain evidence be gathered and legal procedures be followed within a specified time frame after the assault; failure to carry out these procedures or to collect the evidence in a timely way could preclude prosecution at the later date. The possibility of prosecution, even though a final decision may not be made for some time thereafter. At all stages of investigation and prosecution, it is the victim's decision whether to participate in the legal proceedings; the victim cannot be compelled to participate in a prosecution.
b) Advise the victim of the public nature of the criminal proceedings. The victim should be advised that, if she or he decides to prosecute, the records will become public knowledge as the case proceeds though the judicial system. (The Resident Director should determine if there are any limits on this general rule in the applicable jurisdiction.)
c) Preserve the evidence to the extent possible. The student's physical and mental health take precedence over a prosecution. Consistent with this understanding, however, the Resident Director and medical doctor should take immediate steps, to the extent they are able, to preserve clothing and any other relevant material for tests. (Physical evidence that must be obtained from the victim can only be obtained with the victim's consent, of course.) Because of the legal issues related to chain of custody, such material should be maintained under lock and key. Consult local counsel for specific rules applicable in the jurisdiction.
d) If prosecution seems likely, retain local criminal counsel on behalf of the Student
5) Notification of US home institution
6) Notification of Embassy personnel
a) The Resident Director notifies RSO in accordance with protocol or individual understanding with RSO. As reflected in the notification summary, above, the Resident Director could promptly notify the RSO of the incident and location, but should not give the name of the victim.b) Resident Director notifies Ambassador. The Resident Director should also inform the Ambassador of the assault, without giving the name of the student. Notification should be especially prompt if the victim wishes to prosecute or if the incident is likely to assume a high profile.
7) The Press
The Resident Director, in consultation with the Regional Director (if one exists) and US home institution Director, could discuss any press-related issues in-country with the Ambassador and/or the United States Information Service (USIS) public affairs officer. The Study Center staff should always encourage the press not to use the name or the initials of the student.
1) Providing support to the victim
a) Continue to provide emotional support to the victim. Consult the section called "Understanding and Supporting the Victim of a Rape" for a detailed description of the continuing issues related to the emotional state of the victim of a rape.
b) Urge the victim to agree to accept a suitable companion for a while. The Resident Director should urge the student to accept a suitable, constant companion who may be staff or another student of the student's choosing. The companion need not-and usually will not -be the Resident Director. The Resident Director could make every attempt to provide a suitable and constant companion for the victim, including in a hospital setting.
c) Offer other practical support to the victim. The resident Director could offer practical as well as emotional support to the victim. Practical support could include identifying and hiring a confidential interpreter; making oneself available (but not requiring) to accompany the victim to attorney meetings, depositions, examinations, suspect identification and other legal proceedings. Other useful support may include offering to obtain cash for expenses; providing clothes; providing a trip to the site to pick up belongings; finding a nice and safe place to stay temporarily; offering an escort to the site; making available at the Study Center expense phone calls to parents or other supportive individuals; offering to contact and obtain the company of other students who can provide support.
d) Support a decision to medevac. If the student is to be medevaced, the Resident Director should give full support to that decision and should not preclude future discussions about the student's subsequent return to the program.
e) Support the Student's family. The Resident Director should have the responsibility for supporting the student's family.
2) Communications between the study center and the US home institution.
a) The US home institution will designate a primary contact person at the home institution for use by US home institution in contacting the study center. One person in the US home institution will be designated the contact person. That person's task is to coordinate and centralize non-medical calls to the study center about the incident and to maintain one channel of communication. This is important to avoid confusion about the facts of the incident and the status of the matter. Regular, scheduled telephone calls between the study center and the US home institution to update those individuals with a need-to-know can be productive and can reduce the burden placed on the study center by repetitive calls from the US home institution.
b) Resident Director sets up direct telephone consultations with the US home institution as he or she needs. The Resident Director should call the US home institution staff directly as needed to receive specific information and counseling e.g. legal advice from university attorneys or investigate advice from the Study Abroad Director.
c) Press Coverage. The Resident Director should update the Office of Congressional relations and the Press Office regarding any press coverage in-country or in the US.
3) Involvement of Embassy personnel
a) Work with the RSO. The Resident Director could work with the RSO to ensure that the victim's needs and wishes are addressed and respected during any investigation or prosecution that results from the incident. They could also attempt to ensure that the victim is provided a confidential interpreter, an appropriate attorney, and is accompanied to any attorney or investigative meetings, suspect identification or legal proceedings (if the victim so desires).
b) Keep the Ambassador and USIS posted if there is press coverage. If the case has a high profile, the Ambassador and the USIA should be kept up-to-date on developments in the case. USIA can often work with the local press to reduce or suspend coverage, and to keep the name of the victim confidential, if there are compelling reasons for such a request.
c) The level of Embassy involvement can be expected to vary from incident to incident. The level of discussion and focus on the incident within the mission will vary, depending on how the mission collectively perceives the incident, e.g., if one or more other members of the program are concerned about their own well-being, there may be greater involvement.
d) Written communications should NOT contain the name of the victim. No cable or fax communications by the Resident Director, RSO or other embassy staff related to the incident should contain the victim's name.
4) Health and Security of Students and Staff
a) Work as a team at the Study Center, but preserve confidentiality. Given the many and possibly competing priorities in such a crisis, the Resident Director and staff should work as a team, holding regular update meetings to keep the team informed, while at the same time preserving the confidentiality of information unnecessary for the team to know.
b) Provide support to other students and staff. The resident Director should be aware that rapes and attempted rapes are potentially traumatic for others in addition to the actual victim. The Resident Director and other staff should be particularly aware that other students and staff may have been past victims of rape or attempted rape and may have special needs as a result of the assault and require additional support. This support will most often be sought from staff. For example some students may react to the incident without identifying the reaction as tied to the assault. (The document entitled "Understanding and Supporting the Victim of a Rape," contains relevant material related to delayed reactions that may be of use in considering how best to handle certain other students.)
c) Provide emotional support for staff. Supporting a rape victim is often stressful for the staff involved. The resident Director should be prepared for this possibility and offer or seek support as needed. The service of the State Department Regional Psychiatrist can be helpful in some circumstances for US staff. The Office of Special Services is also available to render support to staff.
d) Consider using State Department Training Resources as part of the response. The Mobile Training Team, which gives rape prevention and assault prevention training can be requested through the RSO. Such training can be a useful response to an assault that causes widespread concern.
5) During an investigation and prosecution
a) Consult with US home institution Study Abroad Director. During an investigation and prosecution, the Study Abroad Office is available to provide professional advice and guidance with respect to legal questions and investigative matters.
b) Retain and consult with local criminal lawyer. The Resident Director should identify and retain a criminal lawyer who is experienced, well-respected in legal and judicial circles, and able to manage and explain the intricacies of the local legal system to the student and to the Resident Director. This retention should be accomplished in consultation with the Study Abroad Center at the US home institution. Do not forget to consult the list of legal questions to discuss with local counsel.
c) Resident Director serves as the US home institution's point person for investigation and prosecution. The Resident Director should serve as the point person within the university. If the victim has left the program, completing the investigation may require a significant time commitment on the part of the Resident Director. It may also require support form the US home institution for contact with the victim, if she or he returns to the US.
d) A medically separated victim may return to the country, at the program's expense to provide testimony. A student who has been medically separated may return to the country at the program's expense to testify in a prosecution. The (former) student's travel should be coordinated through the US home institution.
e) Consider security implications of prosecution (and non-prosecution) for the victim, other students and staff. The Resident Director should consult with informed persons about whether prosecution (or failure to prosecute) and conviction (or failure of convict) would have any significant security implications for the victim or for other students. (For example, will family members of the perpetrator be inclined to take any retaliatory action?)
f) An outgoing Resident Director should ensure that an acting Resident Director or incoming Resident Director is fully informed about a prosecution or conviction. After completing the responsibility as a Resident Director or Program Director, in which a rape has occurred, an outgoing Resident Director/Program Director should ensure that the records of the incident are complete and current. He or she should also ensure that the acting Resident Director and the incoming Resident Director are fully briefed about the status of the case, including any sentence after conviction, and whether release of the assailant is pending. Such briefings may need to occur over the period of a number of years with each new Resident Director, depending on the length of any sentence that has been imposed on a convicted assailant.
2. Commentary on Rape/Assault Notification Protocol
The Peace Corps Volunteer Safety Council designed the rape notification protocol for use in the case of major sexual assault. It has been adapted to be used by study abroad administrators and resident directors. It is intended to help ensure that all appropriate staff at the Study Center abroad and the US home institution receive timely notice of such an assault so that they may perform their assigned functions, and to serve as a guide and resource for the Resident Directors. The protocol is designed to manage communications between the study center and the US home institution, minimize duplication of effort, keep necessary personnel up to date on developments, and relieve those most responsible for taking emergency action of unnecessary burdens of communication in the days and weeks after an assault has occurred. (While men may be victims of sexual assault, the vast majority of victims are, in fact, women. The language of this document reflects this overwhelming disparity.)
When a staff member of the study center learns that a student has been subject to a rape or attempted rape, that staff member should take the following steps with regard to notifying staff at the study center and in the US home institution. This protocol assumes that the assaulted student and the Staff member have spoken directly. (See one page summary of the protocol).
A. Notification
The staff member first informs the student that the staff member is required to inform the establish protocol on a college campus.
1) Notification Checklist
| ______ | a brief summary of the incident; |
| ______ | gender of the student; |
| ______ | country of study center and of occurrence; |
| ______ | type of assault, date of incident, time of incident; |
| ______ | date of report to in-country medical staff; |
| ______ | type of community where the incident occurred; |
| ______ | type of location; accompaniment of student; |
| ______ | whether program-related or not; use of weapon; |
| ______ | information on assailant, relationship of assailant; |
| ______ | suspect apprehended; |
| ______ | student's intention to prosecute; |
| ______ | whether medical treatment provided; |
| ______ | medevac plans; |
| ______ | police role and position; |
| ______ | local counsel retained; |
| ______ | whether Embassy notified |
B) DEFINITIONS FOR REPORTING ELEMENTS/CATEGORIES
1) Summary of Incident
Briefly describe the incident. Include information not included in the body of the report that provides greater description of the event. Include information on injuries sustained including broken bones, lost teeth, internal injuries, loss of consciousness, and if hospitalization was required. When indicated, include information on whether the assailant had been under the influence of alcohol or other mind altering substance; include the same information for the Student.
Demographics
| Name | Full Name of Student |
| SSN | Social security number of Student |
| Age | Age of Student on their last birthday |
| Gender | Indicate whether the Student is male or female |
| Country | Indicate the program location (country) of the student. If the incident occurred in a place other than the program location, also provide the country of occurrence. |
| Date of Report | Date of report to the Office of Medical Services |
2) Description of the Incident
Type of Assault
Indicate if the incident is a completed rape, other sexual assault, aggravated assault, or simple assault. Use the following case definitions as a guide. The definitions are the same as those used in the Epidemiologic Surveillance System, with the exception that here completed rapes are separated from other sexual assaults.
2.1 Rape
Rape is defined as sexual intercourse without the consent, and against the will of the victim. There is always force or the threat of violence involved. Threats of violence include the display of a weapon or a verbal threat to do physical harm. The victim submits out of fear. For the purposes of reporting, sexual intercourse is defined as penetration of the penis and the vagina or anus. Attempted rapes (i.e., where penetration did not occur) should be reported under "Other Sexual Assault."
2.2 Other Sexual Assault
Sexual activity without the consent, and against the will of the victim. There is always force or the threat of violence involved. Threats of violence include the display of a weapon or a verbal threat to do physical harm. The victim submits out of fear. Includes attempted rape and any assaults that involve sexual activity. For the purposes of reporting, sexual activity is defined as direct contact involving the genitals, breasts, mouth, or anus. Sexual assault can be distinguished from sexual harassment because, in sexual harassment, force or the threat of violence is usually not involved. Do not include incidents of sexual harassment.
2.3 Aggravated Assault
Attack or attempted attack with a weapon, regardless of whether or not an injury occurred, and an attack without a weapon when serious injury results. Serious injury includes broken bones, lost teeth, internal injuries, loss of consciousness, and any injury requiring two or more days of hospitalization.
2.4 Simple Assault
Physical attack or threat of attack. Attack without a weapon resulting either in minor injury (e.g., bruises, black eyes, cuts, scratches or swelling) or in undetermined injury requiring less than two days of hospitalization. Also includes attempted assault without a weapon.
| Date of Incident | Indicate the date of the incident. |
| Time of Incident | Indicate the exact time of the incident. If the time is unclear, estimate to the nearest hour. |
| Date of Report to Medical Staff |
Indicate the date that the incident was reported to the in-country medical staff. |
| Type of Community | Indicate the type of the community where the incident occurred based on estimated population. If the incident occurred outside the boundaries of a community, such as on a road, provide an estimate for the nearest community. Use the following classification:
|
| Type of Location | Indicate the type of location of the incident as follows:
|
| Accompaniment | Indicate whether or not the student was alone at the time of the incident. If the student was accompanied by another student(s), please state how many other students were present. |
| Program Related | Indicate whether or not the incident was program related. |
| Use of Weapon | Indicate if a weapon was used or threatened to be used against the student. |
| Type of Weapon | If a weapon was used, indicate the type of weapon(s) that was used or threatened to be used against the student. If more than one weapon was used, indicate all that apply.
Examples of other weapons that could be listed here include but are not limited to: drags given to a student against his/her will; use of a motor vehicle to attempt to run down a student. |
3) Information on Assailant
| Motive | Indicate the motive of the assailant, as perceived by the student who was assaulted, as follows:
|
| Relationship of Assailant | Indicate the relationship of the assailant to the student:
|
| Suspect | Indicate whether or not the assailant(s) has been apprehended by law enforcement agent |
| Intention to Prosecute | Indicate whether or not the student intends to press charges against the assailant at the present time. |
4) Personnel Notification
| U.S. Home Institution Staff Notified | Besides the medical staff, list other in-country staff who have been notified of the incident. The Resident Director or his/her designee must be advised that the assault has occurred (See Section 3B above). |
| Other U.S. | Besides the Home Institution staff, list the in-country U.S. officials (e.g., Embassy Personnel) who have been notified of the incident. |
| Local Authorities | List the local authorities (e.g., police, principal, mayor) who have been notified of the incident. |
5) Medical Treatment
| Medical Treatment Provided or Planned | Briefly describe the medical treatment provided and/or planned for the student. Include X-rays and other diagnostic procedures needed to rule out injuries. |
| Medical Evacuation | Indicate whether or not the student has or will be medically evacuated to the U.S. |
| Counseling Provided or Planned | Describe counseling provided and/or planned for the student. |
6) Assault Case Notification Fax Form
FROM:
To: DIRECTOR
NAME OF STUDENT
SSN
BRIEF SUMMARY OF INCIDENT
DEMOGRAPHICS
AGE:
GENDER:
COUNTRY:
DATE OF REPORT TO MEDICAL PROFESSIONAL:
DESCRIPTION OF THE INCIDENT
TYPE OF ASSAULT:
DATE OF INCIDENT:
TIME OF INCIDENT:
DATE OF REPORT TO MEDICAL STAFF:
TYPE OF COMMUNITY:
TYPE OF LOCATION:
ACCOMPANIMENT OF STUDENT:
JOB RELATED:
USE OF WEAPON:
TYPE OF WEAPON:
INFORMATION ON ASSAILANT
MOTIVE:
RELATIONSHIP OF ASSAILANT:
SUSPECT APPREHENDED:
INTENTION TO PROSECUTE:
PERSONNEL NOTIFIED
- STUDY ABROAD STAFF NOTIFIED:
- OTHER U.S. PERSONNEL NOTIFIED:
- LOCAL AUTHORITIES NOTIFIED:
MEDICAL TREATMENT
MEDICAL TREATMENT PROVIDED OR PLANNED:
MEDICAL EVACUATION PLANS:
COUNSELING PROVIDED OR PLANNED:
7) Sample Memorandum to Director from Resident Director for Notification of an Assault
MEMORANDUM
To: Director
From: Resident Director
Subject: Notification of an Assault
Date:
This is to report an assault involving a student. Details are as follows:
1) Demographics
Type of Assault:
Gender of student:
Country:
Date medical professional notified:
2) Characteristics of Assault
Date of the Incident:
Time of the Incident:
Location:
Number of Student's Involved:
Type of Weapon Used:
Motive:
Relationship of Assailant:
Intention to Prosecute:
3) Personnel Notified
Resident Director:
U.S. Embassy Staff:
Local Authorities:
4) Medical Treatment Provided
Treatment Provided:
Medical Evacuation Planned:
3. Management of Sexual Assault
To establish procedures for the appropriate medical and legal management of students who have been sexually assaulted.
Sexual assault is defined as any non-consentual sexual act and is a form of violent crime. Rape, attempted rape, or any unauthorized contact with genitals, breasts, or mouth should be reported to the Resident Director and managed as a sexual assault.
Victims of sexual assault do not always present at the time of the incident, but may present at a later date with incident-related symptoms (e.g. anxiety/depression, pregnancy, STD.) Individuals (men and women) who report that they have been sexually assaulted should be treated in a compassionate, non-judgmental manner (see "Sexual Assault: Counseling.")
It is estimated that one in every six women is raped during her lifetime. It is the court's responsibility to decide if the legal definition of rape applies in a particular case. The responsibilities of the designated medical doctor when managing a reported rape should be to:
- Assure the victim's physical safety.
- Document the pertinent history.
- Perform a careful physical examination.
- Promptly treat physical injuries.
- Inform the Resident Director of the assault.
- Maintain medical confidentiality.
- Contact the US home institution doctor.
- Provide and /or arrange psychological support (see "Sexual Assault: Counseling".)
- Prevent sexually transmitted disease.
- Prevent unwanted pregnancy.
- Collect legal evidence.
Students who have been sexually assaulted should be encouraged to go to a hospital/clinic as soon after the assault as possible. Students reporting rape should be asked not to urinate, defecate, rinse their mouths, or clean under their fingernails before examination, if possible. Inform the student that this request is to help obtain evidence which might later be used in court and is not in itself for medical reasons.
The designated doctor should tend, first and foremost, to the well-being of the student. The student should be taken to a quiet, comfortable, safe area and not be left alone. The student may prefer to be accompanied by a friend. Male doctors should arrange for a female chaperon when examining women. Consent must be given before examination and treatment. This also allows the student a sense of control over the examination.
Information should be carefully recorded in the student's medical record, with the history reflecting only the victim's account of the incident. For serious sexual assault or rape, a comprehensive history and examination are required (see below), with special attention to physical injuries, emotional distress, and the collection of appropriate evidence for future legal proceedings (see section 6.)
MANAGEMENT OF SERIOUS SEXUAL ASSAULT
SUBJECTIVE
-
History should include:
- Age and identifying information of the victim and the alleged assailant (if known)
- Date and time of the assault and examination
- Circumstances of the assault
- Details of the sexual contact (oral, vaginal, or anal intercourse, ejaculation or urination by the assailant)
- Type of physical abuse (use of weapons or restraints, drugs, alcohol)
- Victim's activities after the assault (change of clothing, bathing, douching, urination or defecation)
- Gynecological history:
Last menstrual period
Pregnancy history
Recent gynecological surgery or infections
Last voluntary sexual experience
Examination (see section 6 for more detail)
Carefully examine the entire body. Take photographs or make drawings of injured areas.
External (total body):
- Cuts
- Bruises
- Bite marks
Oral cavity:
- Secretions
- Injuries resulting from oral penetration
Genitalia:
- Hair combing
- Hair sample
- Vaginal secretions
- Check for gynecological pathology, trauma, and foreign objects
Rectal:
- Examine for trauma
Culture for chlamydia (cervix) and gonorrhea (cervix, rectum, and/or
pharynx, as appropriate) when possible. Non-culture testing is of limited
benefits.
Test for syphilis and repeated in 3 months
Counsel and test for HIV; repeat in 6 months
Perform pregnancy test
Assess the need for:
- Medical treatment/medevac
- Pregnancy prevention
- Hepatitis B prevention
- Psychological/psychiatric care. Medevac is generally recommended, but may not be immediately accepted by the student.
- Do not leave victim alone
- Notify US home institution doctor
- Arrange for medical treatment/medevac
- Provide STD & pregnancy prevention
- Arrange for close follow-up; continue to offer medevac (in most cases) and monitor for sequelae.
- Arrange subsequent periodic visits
- Arrange an emergency contact and support person
- Schedule follow-up at 3 months for syphilis testing and 6 months for HIV testing.
Pregnancy occurs as a result of rape in about five percent of female victims. Treatment to prevent pregnancy should be offered to victims, and prescribed only after a pregnancy test has been performed to rule out prior pregnancy. Following are the recommended doses of oral contraceptive pills to be taken within 72 hours of the alleged rape.
Protocol for post-coital contraception
(must be taken within 72 hours of intercourse, obtain a negative pregnancy
test first)
Two doses of two (2) contraceptive tablets containing 50mcg estrogen 12 hours apart or Two doses of three (3) oral contraceptives tablets containing 35mcg estrogen , 12 hours apart.
AND PROVIDE
Promethazine (Phenergan) 25mg suppositories (2)
Or
Tigan 200mg suppositories (2) (to be used every 3-4 hours for nausea, if
required.)
E) PREVENTION OF SEXUALLY TRANSMITTED DISEASES AFTER RAPE
Few studies are available which predict the risk of acquiring a STD as a result or rape.
E.1. CHLAMYDIA, GONORRHEAS, AND TRICHOMONAS
Treatment for the prevention of chlamydia, gonorrhea, and trichomonas is indicated.
Recommended regimen to prevent gonorrhea, chlamydia, and trichomonas
Ceftriaxone 125mg IM in a single dose
AND
Doxycycline 100mg orally 2 times a day for 10 days
Or
Azithromycin 1 gm orally in a single dose
AND
Metronidazole 2 gm orally in a single dose
Or
Trinidazole 2gm orally in a single dose
E.2 Prevention of Hepatitis B
Rape victims who are non-immune to hepatitis B should receive prophylaxis against hepatitis B. Unless the student has received a complete hepatitis B vaccine series or is immune due to prior hepatitis B infection (serologically confirmed), vaccination should be provided. Hepatitis B vaccine, when started within 14 days of exposure, is effective. Hepatitis B Immune Globulin .06ml/kg IM (HBIG human) can be given if available and offers additional protection.
Recommended post exposure immunization for hepatitis B (within 14 days of exposure, no prior immunity).
Hepatitis B vaccine 1.0 ml IM (deltoid) at months 0,1,6
E.3 HIV
The risk of acquiring HIV infection as a result of rape depends on the likelihood of the assailant having HIV, the sexual acts performed, and other factors (associated trauma, presence of other STD's, etc.) The estimated risk of HIV transmission in sexual assault by an HIV infected person (vaginal or anal intercourse, or exposure to ejaculate) is about 2 per 1000. The risk is higher if other factors are present.
No preventative treatment is available.
F) COLLECTING FORENSIC EVIDENCE
Physical evidence useful during legal proceedings includes the presence of semen, genital and other injuries, and pubic hair obtained from medical examinations. Evidence should be collected and handled in a manner acceptable to local courts. Procedures standard in the U.S. for handling evidence are generally acceptable (see below.) However, doctors should be familiar with local laws and procedures and should adapt U.S. procedures to conform with local ones.
Following are standard procedures for collecting evidence during a rape examination:
- Maintain a log of evidence collected. Anyone who handles the evidence should sign and date the log indicating when they had possession of the item and how it was stored.
- Avoid contamination by allowing only the victim to handle her clothing. Send all of the victim's clothing (if she has not changed) to crime laboratory in sealed and labeled paper bags.
- Prepare careful and complete photographs and /or drawings of the physical findings.
- Examine the perineal and thigh area with a Wood's lamp to detect semen stains.
- Comb the pubic hair over a sheet of paper (for possible material traceable to the assailant), and pluck and store a few of the victim's pubic hairs.
- Perform a vaginal examination with speculum lubricated only with water. Note the condition of the hymen and examine the vaginal walls and cervix for lacerations and abrasions.
- Aspirate or collect vaginal secretions on a saline-soaked swab. Sperm remain motile for about three hours after ejaculation. Non-motile sperm may be found for up to 72 hours.
- Swab areas involved in oral and anal intercourse, if appropriate. Spermatozoa have been recovered from the mouth up to six hours after the event-even after the victim had brushed her teeth or used a mouthwash.
- Carefully seal and date all specimens collected.
References
Hampton, H.L. (1995) Care of the Woman Who Has Been Raped. New England Journal of Medicine. 332, 234-7.
ACOG Technical Bulletin Number 172-September 1992. International Journal of Gynecology and Obstetrics, 1993: 42; 67-72.
Memorandum
To: Resident Directors
From: Administrator, Study Abroad Office
Subject: Medical Confidentiality
It is important to clarify the role of the Resident Director with respect to medical confidentiality. The Resident Director is responsible for the safety and security of students and the medical professional in the host country is responsible for the health and well-being of the student.
Medical confidentiality is important so that students can feel safe to discuss their medical problems openly with the medical professional. Thus, for routine student health care the medical professional shall not share medically confidential information with study abroad staff. However, because the Resident Director is responsible for overall program management to ensure a safe and secure environment for students, he or she has a need to know certain information students safety, security or programs. When such information is given to the Resident Director, he or she is bound by the Privacy Act and rules of medical confidentiality.
The Privacy Act protects information about individuals which is maintained in an agency system of records, including medical information and medical records. The Act provides a serious criminal and civil penalties for the unauthorized release of information contained in a protected file.
The Privacy Act authorizes the release of certain information by the keeper of the record to another agency employee on a need to know basis. The Resident Director has a legitimate need to know certain information in order to properly perform his or her duties.
For example, in the case of any physical or sexual assault, the Resident Director must be given timely notification that an incident has occurred, the type of assault, where it occurred, the date and time of day it occurred, whether the assailant was known, whether there was more than one assailant, whether any weapons were involved, and any other information which pertains to the safety and security of that student or other students. This is an extension of medical confidentiality to the Resident Director based on a need to know in order to carry out his or her responsibilities.
There are no circumstances in which extension of medical confidentiality to the Resident Director may be appropriate. These include situations in which there is a serious threat to student health and safety. Examples of these situations may include life threatening communicable diseases; child or spouse abuse; drug use; potential suicide or psychotic or violent behavior; alcohol abuse if it impairs the students health, safety, or ability to perform effectively; or any other condition or situation that would prevent a student from attending class. Only information that affects the well-being, safety, and security of the student or other students needs to be shared with the Resident Director.
The guidelines provided describe the nature and extent of the confidential relationship that exists between student and medical doctor. The limitations on medical confidentiality and the extension of medical confidentiality to non-medical staff are also outlined.
The purpose of medical confidentiality is to ensure that the patient can be completely open with his or her health care provider and not withhold important information for fear that it will be released to others who do not have a need to know. Responsible handling of confidential and private medical information obtained by the health care provider during a course of diagnosis or treatment of a student is an important part of an effective student health program.
In addition to medical confidentiality, the Privacy Act protects information about individuals, which is maintained in an agency system of records. The medical information maintained about a student is a protected Privacy Act record.
C) MEDICALLY CONFIDENTIAL INFORMATION
To be covered by medical confidentiality, information must be of a medical nature about an individual student and must be held by a medical provider (except when medical confidentiality has been extended to a non-medical personnel as discussed in Section 5.) Medical information shared by a student with a non-medical staff is not medically confidential.
The following types of information are considered medically confidential:
- Medical records. All medical records must be stored in a locked file cabinet with access limited to medical unit personnel.
- Information of a medical nature obtained from the student by a health care provider.
- Cables, faxes, or telexes marked medically confidential or "Med Eyes Only."
D) SHARING NON-CONFIDENTIAL INFORMATION
The following situations are examples of cases where, without revealing the underlying medical information, the doctor would appropriately share information with the Resident Director, or designee, and others who have a programmatic need to know about a student's status.
- When a student will be absent due to illness or injury, program staff need be advised of the student's absence and projected return.
- If limitations on activity would impair the student's ability to function as a student.
- During a medical evacuation, program staff need information on the probability of return to country.
- Behavioral problems are usually of concern to all staff and can be discussed in terms of the observed behavior and potential risk to the student and others.
E) EXTENSION OF MEDICAL CONFIDENTIALITY
Medical confidentiality may be extended to non-medical personnel in any of the following circumstances. Persons with whom confidential medical information is shared are required to protect the information in the same way as medical staff.
The student has authorized in writing the release of some or all of his/her medical information.
If, in the opinion of the doctor, failure to release the information would pose a significant threat to the life or physical safety of the student or others, or if the doctor believes a student is likely to be threat to him/herself or the physical safety of others, or the program, the doctor should extend medical confidentiality to non-medical staff and share any information concerning the condition, diagnosis, or treatment of the student that is appropriate to the role and responsibilities of the other staff. Examples may include life-threatening communicable diseases, child or spouse abuse, drug abuse, or potential suicidal or violent behavior.
The Resident Director must be notified immediately when a student has been physically or sexually assaulted. This notification must include the following information,
- Type of assault.
- Date and time of day and the name of the town or city the assault occurred (and whether it occurred on the study center).
- Whether the assault was related to the program.
- Whether assailant was known.
- Whether there was more than one assailant.
- Whether a weapon (s) was involved.
- Any other information concerning the safety and security of this or other students.
The Resident Director's need to know the name of the student depends upon the situation. When the Resident Director believes that there is a need to know the name of the student, providing the name to the Resident Director is appropriate.
Staff at the study center may need to know or may be able to surmise confidential information from circumstances surrounding an incident or medevac. In such cases, they are also bound by the rules of confidentiality and privacy.
F) INQUIRIES FROM FAMILY MEMBERS AND OTHERS
When authorized by the student, confidential medical information may be released to family members or others. Written authorization should be obtained and filed in the student's health record. In cases where it is not possible to get written documentation, verbal authorization must be documented by the doctor in the health records. Even when faced with concern expressed by family and friends, confidentiality of medical information must be ensured.
Notification of a student's condition without the student's consent may be made only by Resident Director in cases where a student is incapable of providing consent and is considered to have a serious or life threatening condition. Notification is made to the individuals whom the student designated in writing for notification in case of emergency.
G) MEDICAL CONFIDENTIALIY IN COMMUNICATIONS
Cables
Communications which identify an individual student and contain medical information should receive the "Medical Eyes Only" designation.
Cables are more secure than the telephone or the fax. Telephone transmissions and fax transmission can be intercepted and understood by a third party. Cables are encrypted, so that they may not be understood if intercepted.
Fax
A cover sheet indicating that medically confidential information follows should be used in all transmissions.
Telephone
Doctors should be able to conduct telephone conversations without being overheard so that student's privacy and confidentiality can be maintained.
Rather than sending out individual cables for each assault, the following could serve as a permanent guidance on how to proceed in cases of sexual assault for a student in your country. Refer to it immediately whenever a sexual assault is reported to you. We believe this procedure will both speed the process by which the study center can receive guidance on retaining counsel in sexual assault cases as well as furthering confidentiality for assault victims.
As the Resident Director, you may retain an attorney to advise you regarding the legal process in your country for prosecution of the assailant. A list of questions has been included that you may wish to ask the attorney in order to identify for the students all aspects of the prosecution process and any possible alternatives. While the student might not be interested in pursuing prosecution immediately after the assault, we feel that she/he cannot make an educated decision regarding prosecution without adequate information about the process. In addition, there are often actions (for example, forensic exams) which must be taken immediately after the assault or chances of conviction of the assailant may be reduced. Therefore, it is important to be aware of the prosecution process in advance.
Once the victim has been informed about the legal process and has made a firm commitment to pursue prosecution, you should retain an attorney to represent and advise the student during prosecution. This attorney may be the same as the attorney you consulted or a different attorney, if appropriate.
Differences between legal systems make it difficult to generalize as to the form of assistance the student may take. However, the intent is that you should retain an attorney to provide legal support short of assuming the government's responsibility to prosecute the case. However, assistance may not include pursuit of civil remedies.
To provide guidance in meeting the emotional needs of students who have been sexually assaulted. The vast majority of sexual assaults are assaults on women, and for the purposes of this guideline it is assumed that the victim is a women. The same principles should be used when responding to a sexual assault on a man.
"Management of Sexual Assault", provides background information concerning sexual assaults and describes the medical and legal procedures appropriate in managing reported assaults. This guideline provides more specific information on the emotional support of victims of sexual assaults.
The medical doctor has a responsibility to the student to assist them in preventing sexual assaults by including the following topics in Pre-departure orientations and on-site orientations.
- Students should be informed about when and where sexual assault is more likely to occur. The institution could consider keeping information on these types of incidents on a database.
- When threatened with sexual assault, the initial response is an individual decision and may include verbal tactics such as conversation, joking, or screaming; and physical actions such as struggling, biting, or kicking.
- A review of cultural do's and don'ts can help students understand what might make them targets for attack. The review may include discussions on behavior in the street, manner of dress, and areas to avoid (for men and women.)
- Students can learn from watching host country women handle various forms of harassment such as unsolicited verbal comments, facial expressions, gestures, touching, and fondling. For some students, attitudes and behaviors will need to change significantly to avoid and/or cope with harassment.
The medical doctor should identify local physicians and trained counselors available for managing cases of sexual assault. Staff members should agree on how medical confidentiality should be preserved and student privacy respected.
D) INITIAL RESPONSE TO A SEXUAL ASSAULT
After a sexual assault, the student may seek out someone she trusts and from whom she expects to receive support. All staff should be trained to fulfill this role. Students who report a rape or other serious assault should not be left unaccompanied.
The emotional and physical needs of the victim should be attended to immediately. For serious assaults, the designated medical doctor should:
- Assure the student of her physical safety.
- Provide psychological support through a warm, non-judgmental approach.
- Help the student identify people and things that she would find supportive and comforting.
- Offer calm acceptance of the student's range of feelings, and reassure her that these are normal reactions to trauma.
- After obtaining consent, record the medical history, perform a physical examination and evaluate the student's psychological condition. Refer to "Management of Sexual Assault." Medevac is generally recommended, but may not be immediately accepted by the Student (see below.)
- Suggest a warm bath or shower and a change of clothes (after the appropriate physical evaluation has been completed.)
Assault Reporting
Students who are sexually assaulted may be reluctant or unwilling to report the assault. Reasons for this reluctance include guilt, denial, shame, distrust of staff, and concerns about confidentiality. Reporting is more likely to occur if the assailant is a stranger or if the student is injured as a result of the assault. Assault reporting is important both to provide care and support for the victim and to assist other students through the in-country safety program.
E) RECOVERY FROM SEXUAL ASSAULT
The recovery from sexual assault may be long and complicated. To assist, the designated medical doctor should:
- Continue to help the student work through the experience by offering emotional support. Suggest professional counseling as appropriate.
- Offer medical evacuation for counseling, recuperation, consideration of withdrawing from the program or preparation to return to country. This brief return to one's own culture greatly facilitates the healing and emotional reorganization. Medical evacuation should be encouraged.
- Assist her in making her own decisions. She needs to regain control of her life, starting with the small decisions, such as what to take home with her.
- Gradually begin to discuss options with her.
Does she want to go home for additional medical or psychological support?
Does she want her family or friends notified?
Is there another student in the program able to provide companionship and support who should be notified?
Are there any concerns about returning to her program?
- Offer support to the students who may be experiencing guilt, anger, or anxiety.
- Recognize that the sense of belonging to the program can be therapeutic.
- Be aware that there is the potential for an anniversary reaction the following year.
The psychological condition of the student should be evaluated at all visits. Encourage the student to talk. Listen carefully and notice how she acts. Her body language will give clues as to how she feels. Following are suggestions for helping the student talk about her experience.
- Encourage her to tell you what happened. Start with general questions and gradually move to more specific ones. These might include questions about the circumstances before, during and after the assault, the assailant, any conversation that took place, the sexual details, physical and verbal threats, whether there was a struggle, alcohol or drug use (by assailant or student) and her reactions. Find out about her social network and whether she has been supported or not.
- Empathize and do not blame. Blaming and judgmental attitudes greatly interfere with the helping process. She needs and deserves confirmation that she has been assaulted. Support the fact that she was victimized.
- Share her pain. Let her know she's no longer alone. It will emotionally strengthen her.
- Encourage her to keep talking. Through it she will gain perspective and help herself. If she is not verbal and her style of expression is hard to understand, try to avoid getting frustrated-silence communicates, too. Allow periods of silence.
- Let her cry if she needs to. This is a grieving process. She's been hurt and has lost a sense of safety and security and thus a way of life. That is a severe loss.
- She will need to hear that it wasn't her fault. Assure her that she can get through this. If she took risks, assure her that she can avoid risks in the future.
- Encourage her to express all feelings regarding the assault, the assailant, and the situation. Assist her in clarifying and defining these feelings which may be overwhelming. Assure her that her feelings are the understandable reaction to such as trauma.
- Recognize her fear and respect it. She needs it, especially if threatened. It is real.
- Recognize her rage and help her to identify and respect it. Rage at being important and helpless should be directed toward the assailant and not toward herself (i.e. self-blame and recrimination.) It may be slow incoming because it is usually constricted. To assist, you may need to help her express anger at the assailant.
- Know that it will take time for her to get over this, but that she can learn to live with it. Tell her this.
- Recognize and support her strength every step of the way (e.g., her coping mechanisms during the assault, her getting help.)
G) LONG-TERM EMOTIONAL REACTIONS
Reactions to sexual assault vary. However, there are several common ones that may recur for weeks or even months after the attack. These include:
- Fear of remaining in the same residence or site.
- A need for continuous support from family or close friends.
- Difficulty in sleeping, recurrent nightmares, intrusive thoughts about the event.
- Fear that the assailant will return.
- Fear of crowds but also fear of being alone.
- Fear of being either indoors or outdoors, depending on where the rape occurred.
- Fear of sex or lack of sexual desire.
- Periods of depression or anger.
- Feelings of guilt.
- Feelings of being damaged or unclean.
- Feelings of paranoia that other people are talking about her or laughing at her.
- Feelings that she can't trust anyone, particularly men.
The student should be assured that her feelings are normal. She should be encouraged to regain control of her life. As she does so she should begin to experience a lessening of her fears and begin to accept that the rape has occurred and that it can be placed in perspective along with other bad things that occurred in her life.
Many students are worried about what to say and how to handle the reactions of people who know about their experience. The utmost care must be taken in observing medical confidentiality requirements.
The designated medical doctor should be aware of his or her own response to the student who has been sexually assaulted:
- One common response is denial, downplaying the trauma, and telling the student that things really aren't so bad.
- Another common response to a student is to focus on what went wrong, what she might have done differently or what mistakes she made. Explain to the student that people who respond in such a way probably do not mean to judge as much as they need to deal with their own anxiety about the event.
- Some may respond with criticism or judgment of the student. In particular, some men may be dealing with their own anxiety about the aggressive use of sexuality by members of their own sex. Men who are able to respond with sensitivity and understanding may have particularly helpful effect in providing support.
(Adapted from the Peace Corps Volunteer Safety Council, January, 1998)
 Copyright © 1999 by Gary Rhodes. All rights reserved. Copyrights and trademarks are property of their respective owners. |
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