Neobook — clinical reference

Legislation and relevant legal definitions

Introduction

There are two aspects in the management of the patient, namely health care needs as well as the medico-legal needs, including forensic evidence collection and medico-legal documentation.

The patient’s rights should be respected – these include the rights to health, dignity, non-discrimination, self-determination (i.e. do not force to have examination or treatment against the patient’s will), information, privacy and confidentiality. It is very important to prevent secondary (vicarious) trauma to the patient.

The following persons may be present during the examination: medical examiner (preferably same sex as patient), attending nurse, trained support person with consent of the patient, close friend or relative on patient’s request. There is no medical or legal reason for a law enforcement representative of any gender to be present.

The case should be given priority as an emergency case where the patient presents within 72 hours of the alleged incident.

Management

The patient should open a case at the local police station, and SAPS should contact the relevant FCS unit (Family violence, Child protection, Sexual offences) to get involved. If the patient reports directly to a health care facility, you should contact the police.

The SAPS/FCS detective to provide the attending clinical with:

A SAP 308 form, signed by the patient and investigating officer. (This form gives the medical examiner consent to perform the examination, collect evidence and to release the completed J88 form, which contains confidential medical information to the investigating officer)
Sexual assault evidence collection kit with J88 form. (if the alleged offence occurred within 120 hours of presentation, and evidence collection is indicated by the history of the alleged incident)
J88 form. (if the alleged offence occurred more than 120 hours before presentation)
Affidavit 212 form; Affidavit to be signed and completed by the attending clinician.

The management of the survivor depends on the time that has lapsed since the alleged incident:

If the patient presents within 120 hours of the alleged incident, forensic evidence will be collected with the patient’s consent, a medical examination be done, medical tests will be performed, and prophylaxis against STDs, pregnancy and HIV if indicated, will be offered, if indicated.
If the patient presents after 120 hours of the alleged incident, a medical examination will still be conducted, however no forensic evidence will be collected. Medical advice and appropriate treatment should still be offered, as indicated.

The management of the survivor should consist of the following steps:

Preparation of the survivor, by explaining the procedure, and getting informed consent. Offer containment counselling, if available on site.
History taking, including medical history, surgical history, obstetric and gynaecological history, use of medication, drugs and alcohol, vaccination history, last sexual intercourse, history regarding the alleged incident.
General physical examination
- Describe all injuries and also draw these on the body diagrams on page 4 of the J88. (Refer to section 1.b for more information on the completion of the J88). Take note to use the correct wound terminology.
Specimen collection
- Take specimens as guided by the history – please also refer to the instruction booklets and guidelines provided in the evidence collection kit: (Relevant and currently used evidence collection kit indicated in brackets)
Always swab the following areas: (D1)
- External genital (vulva/scrotum)
- Vaginal/shaft/glans
- Peri-anal
Swab when indicated by type of rape:
- Ano-rectal (D1)
- Oral (D2)
- Any area with body fluids (D2)
Reference specimens to conduct DNA-analysis and to compare hair samples:
- Blood (D2)
- Pulled pubic hair (D3)
- Pulled head hair (D3)
Collect if present:
- Underwear, clothing (D1, D5)
- Fingernail debris (D2)
- Sanitary pad/tampon (D1)
- Loose pubic hair (D3)
- Loose head hair (D3)
- Debris (D2)
- Condoms
- Wipes/towels if used after the incident
Ano-genital examination
- Comfort patient, explain steps to be taken, get consent
- Start with inner thighs, perineum, anus, genitals
- Take external anal and ano-rectal specimens before examination of genitalia:
- Peri-anal:
  - Lightly moisten swab and carefully swab peri-anal area and perineum with swab
- Ano-rectal:
  - Lightly moisten swab, encourage patient to relax and apply gentle pressure and lateral traction to peri-anal area, carefully swab anal canal and rectum
  - Only take with history of definite anal penetration
Female genital examination
- Injuries are most commonly found in posterior fourchette and fossa navicularis (female)
- Examine and describe injuries (Useful acronym “TEARS”: Tears/Ecchymoses or bruising/Abrasions/Redness/Swelling)
- Describe the hymen: presence and condition
- External genital
  - Thoroughly swab external and internal surfaces of labia majora and minora, and the clitoral region with a lightly moistened swab
- Cervical os
  - Only use a speculum in survivors who have been sexually active, and if patient allows this.
  - Insert speculum and carefully swab and cervical os with a dry swab
- Vaginal vault
  - Swab posterior fornix with a dry swab
Male genital examination
- Scrotum
  - Lightly moisten swab and swab scrotum by applying gentle pressure
- Shaft
  - Lightly moisten swab and swab the shaft by applying gentle pressure
- Glans
  - Lightly moisten swab and swab the head of the penis by applying gentle pressure

Documentation of findings

Document findings in your clinical notes.
Complete the legal documentation (J88 Form, Evidence collection form and Affidavit 212 form) in duplicate. Place the top copy of the Evidence collection form(s) with the collected evidence in the kit(s), seal the kit, and hand the sealed evidence collection kit(s), J88 Form and Affidavit 212 form to the investigating officer.
Retain copies of the legal documentation.

Further medical management

Treatment:
- Treat all acute injuries evident on presentation
- Treatment of physical injuries:
  - i.Anti-tetanus toxoid 0.5mL IM if open wounds present and last vaccination >10 years ago, or vaccination status unknown.
  - ii.Treat any other physical injuries as appropriate, or refer for further treatment if indicated.
- Treat established complications – infections or pregnancy
Investigations:
- Pre- and post HIV test counselling
- Rapid HIV test
- Rapid RPR test
- Urine pregnancy test
- Further STI testing if indicated
- Screening for Hepatitis B if the immunisation status of the individual is unknown

STD prophylaxis

Ceftriaxone 250mg IMI stat AND Metronidazole 2g stat po AND Azithromycin 1g stat po
Anti-retroviral prophylaxis
- HIV negative:
  
  Note: Give the 1^st dose of antiretroviral medication as soon as possible.
  - 1^st choice: Tenofovir 300mg + Emtricitabine 200mg: one tablet once a day for 28 days
  - Note: Tenofovir is contra-indicated in renal disease or with concomitant use of nephrotoxic medicines e.g. aminoglycosides (check baseline creatinine clearance first if this is to be prescribed). Where tenofovir is contraindicated, switch to the 2^nd choice. If zidovudine is not tolerated, consult or refer to a specialist HIV clinic for further management.
- OR
  - 2^nd choice: Zidovudine 300mg + Lamivudine 150mg: one tablet 12-hourly for 28 days
- AND
  - Add a protease inhibitor: Lopinavir/ritonavir (Aluvia) 2 tablets 12-hourly for 28 days
  - Note: Lopinavir/ritonavir often causes diarrhea. If lopinavir/ritonavir is not tolerated, switch to atazanavir/ritonavir.
- HIV positive (confirmed)
  - Refer for further counselling and HIV care at an appropriate health care facility.

Emergency contraception (<5 days/120 hours after incident)1st choice: Escapelle (1.5mg levonorgestrel) 1 tablet stat po

(If not available - Ovral 2 tablets stat and 2 tablets 12 hours later OR Norlevo 2 tablets stat).

Note:

Add an anti-emetic and repeat dose if vomiting occurs within two hours after ingestion of medication.

For women already using enzyme-inducing drugs, including ARVs, or within 30 days of stopping them, the dose should be increased by 50%, e.g. Escapelle 2 tablets stat OR Norlevo 3 tablets stat OR Ovral 3 tablets stat and 3 tablets 12-hours later

Alternatively - Copper-bearing intrauterine contraceptive device (<5 days after incident)

Anti-emetic medication:

Metoclopramide 10mg tds po, take 30 minutes before a meal.

Simple analgesics:

Offer simple analgesics if necessary and no contra-indications, such as Paracetamol 500mg qid po or Ibuprofen 200mg tds po (with or after a meal).

Refer for counselling

Arrange follow-up visits(one week, 6 weeks and 3 months after the alleged incident)

At follow-up visits:

Document whether the survivor experience any post-traumatic stress syndrome symptoms at each visit, and give advice regarding medication and blood results. b.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 HIV and RPR test at 6 weeks and 3 months.
Enquire about menstruation and repeat pregnancy test if indicated at 6 weeks and 3 months.
Treat sexually transmitted infections if indicated.
If the survivor becomes pregnant as a result of the 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

Legislation and relevant legal definitions

Sexual offences are governed by the Criminal Law (Sexual Offences and Related Matters) Amendment Act, No. 32 of 2007.

The medical practitioner should take note of the following definitions contained within this Act:

“Sexual penetration”

Any act which causes penetration to any extent whatsoever by-
- The genital organs of one person into or beyond the genital organs, anus, or mouth of another person
- Any other part of the body of one person, or any object, including any part of the body of an animal, into or beyond the genital organs or anus of another person
- The genital organs of an animal, into or beyond the mouth of another person

“Genital organs”

Includes the whole or part of the male and female genital organs, and further includes surgically constructed or reconstructed genital organs

“Rape”

Any person (“A”) who unlawfully and intentionally commits an act of sexual penetration with a complainant (“B”), without the consent of B, is guilty of the offence of rape

“Compelled rape”

Any person (“A”) who unlawfully and intentionally compels a third person (“C”) without the consent of C, to commit an act of sexual penetration with a complainant (“B”), without the consent of B, is guilty of the offence of compelled rape.

References

Jina R, Jewkes R, Munjanja SP, Mariscal JDO, Dartnall E, Gebrehiwot Y. Report of the FIGO Working Group on Sexual Violence/HIV: Guidelines for the management of female survivors of sexual assault. Int J Gyn Obs2010;109:85-92

Criminal Law (Sexual Offences and Related Matters) Amendment Act No. 32 of 2007.

National Instruction 3. of 2008 Government Notice 865 of Government GazetteNo. 31330

Provincial Policy on the Management of Survivors of Rape and sexual assault: adults. Department of Health: Western Cape Province. March 2006

Management of Adult Cases of Alleged Sexual Assault - Detail

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