DEPARTMENT OF HEALTH
UNIFORM NATIONAL HEALTH GUIDELINES FOR DEALING WITH SURVIVORS OF RAPE AND OTHER SEXUAL OFFENCES

The Department of Health needs to play a pivotal role in dealing with adult and child survivors of rape and/or other sexual assaults by developing an integrated and co-ordinated process which serves two main functions:

1. Providing for the case of the victim - both physical and psychological.
2. Collection of medico-legal evidence for the successful prosecution of the perpetrator in the criminal justice system.

A health practitioner is legally bound to report any case of physical, psychological or sexual abuse on children which comes to their attention (section 42 - Child Care Act).

1. Definitions

Victim/Survivor
A victim/survivor of rape or sexual assault may be -

1. A female/male of any age who claims to be a victim of rape/sexual abuse; or
2. A female/male on whose behalf another person claims that she/he is a victim of rape/sexual abuse where the victim is -

1. a minor person under 18 years of age, or
2. mentally retarded, or
3. a person under the influence of alcohol and/or drugs, or
4. an unconscious person

Accredited Health Care Practitioner (AHCP)

The term used throughout this document to describe the attending AHCP is an <AHCP'. For the purposes of these guidelines the terms have the following meanings -

1. Accredited - Proved to have the necessary skills and knowledge by means of formal and/or informal training and experience.
2. Health care practitioner - medical officer, specialist, specially trained nurse.

2. Protocol for management of victim/survivor

When a person presents at a health care facility alleging that they have been raped or sexually assaulted, the allegation should be assumed to be true and the victim should be allowed to feel confident that they believed and will be treated with dignity.

Many victims of rape/sexual abuse present at a health facility immediately after the assault because:

1. They do not wish to lay charges but need medical treatment
2. They do want to lay charges but require medical or psychological attention first
3. They are unaware of the processes to follow after being raped/abused

The victim may have laid charges at the SAPS first, made a preliminary statement, signed the SAP 308 - consent form and then have been brought to the AHCP.

The victim may have contacted an NGO first and may have then been to the SAPS.

In such cases, wherever possible, the medical examination and the health examination should be provided at the point of entry into the system.

The AHCP should then broadly follow these steps:

1. Introduce yourself - name and qualification
2. Take a detailed medical history on patient record card and a verbal history of the alleged incident

While it is desirable to elicit what allegedly happened to the victim so that the medical examination is appropriately focussed, it cannot be expectedd of the medical practitioner that a fully detailed statement, such as would be taken by an investigating officer, be taken and recorded. If any note is kept of what is said by the victim in that connection and questions arise concerning those notes at the trial, it should be made clear that the notes do not purport to be a full account of what occurred. For example, there could be a suggestion that an allegation made by the victim in court is a recent fabrication because no mention was made of that particular allegation in the notes.

3. Explain nature and purpose of examination:

• to collect evidence for court purposes
• full body medical examination including genital and anal areas
• need for possible samples/tests
• need for detailed medical information to be recorded

4. Obtain written consent

• on own consent form or SAP 308
• for medical evidence to be collected and disclosed in a court of law

5. Full medical examination
6. Take necessary samples (see Crime Kit protocol)
7. Record detailed findings on examination

• on J88 (in duplicate) and addendum (if space is limited on J88)

A copy of the J88 should be kept for a period of three years so that if the original is mislaid evidence of the medical notes made at the time is still available.

• patient record card - include sketches as it is easier to recall in court - years later.

After examination at least the following procedures should be followed:

1. Emergency medical treatment at primary health centre (PHC) or referral to appropriate centre. The appropriate procedure to follow in any area will have to be decided locally.
2. Prophylactic treatment against sexually transmitted diseases (PHC) should be given (with the consent of the victim). The syndromic management of STDs should be used.
3. Post-coital contraception should be given (with consent of victim).
4. The victim should also be given a letter to attend her nearest family planning centre following her next normal menstruation.
5. Information on follow-up services available should be given to the victim. In dealing with literate victims a booklet should be designed of all accessible services.
6. Referral to an appropriate counselling service should be given. Whilst ideally crisis counselling should be available on the premises, this is not always possible. Referral could for example be to an appropriate NGO (eg Rape Crisis, POWA) or to a local social worker.
7. Survivors should be counselled regarding the possibilities of HIV infection and referred for HIV counselling and testing.
8. Referral channels to provincial hospitals should be opened.
9. Medical certificates for school or work should be provided.
10. The victim should be informed of complaints mechanisms and how to use them.
11. If the victim arrived without referral by the SAPS but now indicates that she wishes to lay charges, the police should be called to the health centre.
12. Supply patient with information (preferably in a booklet form) regarding:

1. date and time of treatment; and
2. name, address and telephone number of doctor

13. Do not hand J88/patient record card to patient.
14. Until a trial takes place, access to the privileged confidential information contained in the J88 is restricted legally to the investigating officer and Justice Department. The J88 and crime kit are to be given only to the investigating officer who must sign a register and the J88 to acknowledge receipt.
15. The health worker should report any information which occurs in the consultation which could be useful to the case. This should include information on the physical condition and emotional and psychological state of the victim, the state of their clothes, evidence of rape as well as information provided verbally (and agreed by the victim to be used as evidence).

3. Optimal health resources

1. Health care practitioner

Special skills are required to provide proper health care plus forensic examination of survivors. These skills are only available at certain centres at present and thus extensive training programmes are required throughout the country to increase access for the victims.

1. Practitioners must understand the physical and psychological consequences of rape/sexual abuse and provide necessary treatment appropriate at the different levels of health care. Training should include issues of gender discrimination, promote gender sensitivity and include basic counselling skills.
2. The AHCP, including nurses, who need to collect forensic evidence for court presentation require additional specialised training. These practitioners must be:

1. Highly proficient in medico-legal knowledge
2. Credible to the justice system through accreditation of their skills and qualifications
3. Competent to give evidence in court confidently

Inappropriate acquittals occur on technical grounds because the evidence is poorly collected or presented. (Qualifications to be considered include the development of a diploma in Clinical Forensic Medicine).

3. Business plans need to be drawn up in each province to determine who will be providing accessible forensic and health services to survivors.

These AHCPs will need to go for initial training followed by continued in-service training. (From a practical perspective and because many practitioners are unsuited or unwilling to undertake forensic services, it is unwise to compel all practitioners to undertake these functions).

4. Non-accredited health care practitioners are not prohibited from seeing these victims. They must keep comprehensive patient records so as to give relevant evidence in court.

2. Location of services

1. Primary health care centres (PHC) or hospitals where an AHCP should be available and treatment facilities coexist. Each public facility should have a private room specifically fort the examination of these victiims.
2. At centres where no medical treatment facilities exist but the AHCP is available eg (full-time medico-legal clinics in larger towns/cities).
3. Where no public health facilities exist, an alternative venue in consultation with provincial/regional health authority should be found.
4. The location of health care facilities should be publicised in local communities.

3. Services should be available on a 24-hour basis with minimal delays in victim/survivor being seen for the following reasons:

1. Rape victims should be forwarded to the front of a health queue - though confidentiality should be maintained.
2. For forensic reasons, medical evidence need to be captures as quickly as possible.
3. The victim should be allowed to washy after the examination.
4. The medical/psychological problems should be dealt with quickly.

4. The intervention by the health professional should be sensitive to the experience that the victim has just been through and great care must be taken to ensure that secondary victimisation does not take place.

5. If possible, women who have been raped/abused, should be seen by a trained female health worker. Where this is not possible, another woman should be present when a male trained health worker examines the victim.

6. The victim should be allowed to speak in the language of her choice. If the practitioner is not proficient in this language, a translator should be made available.

7. The victim should be given brief information about the legal process and her right to lay charges. Details about the legal system at this stage is probably more than the victim can absorb but they require sufficient information to make a decision which will be appropriate for them.

8. If the victim comes into the consultation in a highly emotional state, she should be calmed down through appropriate counselling techniques before being given the physical examination. If necessary, the examination may need to be interrupted whilst the victim has an opportunity to regain her composure.

9. The consultation should be conducted in an environment conducive to confidentiality, privacy and dignity