Gynaecologic
In many countries, acts of sexual violence are a common method of torture or inhuman treatment inflicted on women. It is found that female victims of torture are raped more often than men, although men are also frequently subjected to rape.
Women of any age may be raped, including women over 60 years of age or children. It must be emphasised that gender-based violence and rape may be only one among many traumas that women have suffered, and that physical consequences are often accompanied by psychological and social consequences.
A detailed medical, obstetric and gynaecological history should be taken, including questions on sexual activity, menstruation and contraception. Physical signs after sexual violations and rape depend very much on the interval between the assault and the examination. Immediately after the rape of a woman, semen may be detected. She may have injuries all over her body. There may be bruises and bite marks, on the lips, neck, shoulders, buttocks and breasts. The vulva, vagina, anus and the urethra should be carefully examined and special attention should be paid to the perineum. There may be external signs of perineal tears, with laceration of the margin of the vaginal introitus or anus. Where injuries are gross, fistulae between vagina and the rectum may be seen.
After electrical torture and/or blows in the genital region, haematuria may be found, due to injuries to the urethra and bladder.
Most acute symptoms disappear over time, and it may not be possible to differentiate scars of the perineum from scars after child- birth or scars following a sexually transmit- ted disease.
Later, women may present themselves with complaints of vaginal bleeding, decreased sexual desire, genital irritation, pain during intercourse and urinary tract infections. Sexual torture may leave traces in the musculo-skeletal system, structural injuries, functional disturbances and dysfunctioning of the pelvic joints in women. They often have lumbar pain, and complain of pains in the genitalia, menstrual disturbances and sexual problems.
Damage to the genitals is most severe in girls under 15 years of age, and in girls and women who have previously been subjected to female genital mutilation. These girls and women are also at higher risk of contracting sexually transmitted diseases (STDs). Health care workers should always consider sexually transmitted diseases after rape. Soldiers, even during peacetime, have STD infection rates two to five times higher than those of civilian populations. The chance of infec- tion is therefore considerable for women who have been raped by soldiers .
Consequences of pregnancy and delivery, as well as of an unsafe abortion, must be con- sidered. The most frequent complications are incomplete abortion, sepsis, haemorrhage and intra-abdominal injury, such as puncturing or tearing of the uterus.
If genital examination is necessary, it must be performed only with the specific consent of the alleged victim and may need to be postponed to a later examination. A chaperone must be offered if the examining physician’s gender is different from that of the patient. Ultrasonography, kidney function tests, urinalysis and dynamic scintigraphy can be used for detecting genito-urinary trauma.
Examine breasts for bites, inflammation, redness, bruises, cuts etc. The inner thighs should be examined for bruises, cuts, burns, incisions, scars or hematoma. Do the vaginal examination last after consent and explain to the person what and why you are doing it. Vaginal examination includes macro examination for discharge, redness, inflammation, tenderness, ulcers, swellings. Swabs can also be taken to look for sexually transmitted diseases (especially gonorrhoea, chlamydia, syphilis and trichomoniasis) as well as reproductive tract infections.
Pregnancy tests can be done with consent and offer emergency contraception if there has been penetrative rape. If there is advanced pregnancy, she should be offered the routine antenatal services. Other Sexually Transmitted diseases like Hepatitis B, HIV/AID can be screened with consent. If rape occurred within the previous seventy-two hours, consideration must be given to the administration of post-exposure prophylaxis (PEP) of anti-retrovirals (ARVs) for preventing infection by HIV and this depends on a detailed assessment of the nature of the sexual assault. The risk of infection with HBV should be assessed and the need for immunisation determined.
Lesions on the breasts, particularly from bites, should be enquired about in women who have been sexually assaulted. When the legs are examined, the inner thighs should be inspected thoroughly. Where women have had their legs forced apart, there may be finger bruising, scratches, cigarette burns, incisions and other wounds, or their late consequences.
The vaginal examination is generally the last part of the physical examination. The doctor must seek specific consent prior to a genital examination, even if consent for the physical examination has already been given. Prior notice of an intention to conduct a detailed physical examination that may include a genital examination could be reassuring to the person and help her to give informed consent. A clear, unambiguous explanation of the reason for the genital examination should be given while the victim is fully clothed. Rape victims in particular may feel disempowered, and may feel that they cannot refuse a request from the doctor, who should make every effort to ensure that any consent given is real and informed.
If the victim refuses consent, the doctor should record any relevant observations on the victim’s demeanour, such as embarrassment or fear. It is unwise to draw conclusions about a refusal to consent to genital examination. Lying prone on an examination table, exposed and with legs apart in front of a relative stranger, can trigger powerful recall of the rape. The victim may be anxious, and shame can be profound, making genital examination unacceptable to her.
If informed consent is obtained, the woman should be made at ease, reassured and explained the procedures that are going to be performed. The genitals should be inspected for the presence of a hymen, the likelihood of having been pregnant, and evidence of genital mutilation. Is there vaginal discharge or tenderness, or spasm of the vaginal muscles?
If the woman is being examined shortly after the rape, it is important to discuss issues of pregnancy and emergency contraception, and however long has passed since the assault, sexually transmitted diseases (especially gonorrhoea, chlamydia, syphilis and trichomoniasis) and other infectious diseases such as Hepatitis B (HBV) and HIV must be considered (see below), and treated where present if the necessary facilities are available. If rape occurred within the previous seventy-two hours, consideration must be given to the administration of post-exposure prophylaxis (PEP) of anti-retrovirals (ARVs) for preventing infection by HIV and this depends on a detailed assessment of the nature of the sexual assault. The risk of infection with HBV should be assessed and the need for immunisation determined.
Some women are raped persistently over a long period which increases the likelihood of becoming pregnant; in some cases they are then detained until it is too late to consider termination of pregnancy (if that would otherwise be an option). In such cases routine ante-natal examinations should be performed including, if possible, ultrasounds. This will enable the time of conception to be estimated.
“Deprivation of liberty … has devastating consequences for women’s lives, putting them at risk of torture, violence and abuse, unsafe and unsanitary conditions, lack of access to health services and further marginalization. It cuts women off from educational and economic opportunities, from their families and friends, and from the possibility of making their own choices and directing the course of their lives as they see fit.”
Working Group on discrimination against women and girls, Istanbul Protocol, 2022
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