Posted on: Fri 19-06-2020

*Outline*

1. Introduction

2. Definition

3. Types

4. Factors increasing vulnerability

5. Factors increasing risk of commiting rape

6. Effects of rape on victims and society

7. Legislation

8. Clinical management of rape survivors

9. Recommendations

10. Conclusion

11. References

Introduction

The incidence of rape and gender related violence has become a  source of worry to governments, development planners and researchers  across the globe. In many developing countries such as India, Nigeria, South  Africa, etc, hardly a day passes without reported or rumoured cases of rape or gender violence. This has prompted, among other things, the passing of stringent legislations into law in some of these countries, with the hope of reducing the incidences of rape.

*Definition*

Rape: The word rape derives from the Latin verb rapere, which means 'to seize or take by force'. It is a forced, unwanted sexual intercourse; it is sometimes also called sexual assault, which can happen to both men and women of any age (Medhelp, 2008).

*Rape*, defined as physically forced or otherwise coerced penetration even if slight of the vulva or anus, using a penis, other body parts or an object. The attempt to do so is known as attempted rape. Rape of a person by two or more perpetrators is known as gang rape.

*Types of rape*

1. Acquaintance/ date rape: When the victim and the perpetrator knows each other e.g colleagues, schoolmates or friends.
2. Spousal rape: This is rape between legally married couple. It is not considered illegal in many countries.
3. Gang rape; This is when a group of two or more people raped a single person.
4. Minor rape: When a child is raped by an adult.
5. Campus rape: Rape within the college premises.
6. Statutory rape: Adult engaging in consensual sexual relationship with sexually mature minors under the age of consent.
7. Prison rape: Rape within the prison mainly homosexuals.
8. War rape: During war , rape is often used as a means of psychological warfare in order to humiliate the enemy and undermine their morale.
9. Rape within the military: When men and women are sexually harrasesd in the military.
10. Corrective rape: Where men rape lesbian women , purportedly as a means of curing the woman of her sexual orientation.

*Factors increasing  vulnerability*

• being young;
• consuming alcohol or drugs;
• having previously been raped or sexually abused;
• having many sexual partners;
• involvement in sex work;
• becoming more educated and economically empowered, at least where sexual violence perpetrated by an intimate partner is concerned;
• poverty

*Factors increasing risk of committing rape*

1. Individual factors

• Alcohol and drug use
• Coercive sexual fantasies and other attitudes and beliefs supportive of sexual violence
• Impulsive and antisocial tendencies
• Preference for impersonal sex
• Hostility towards women
• History of sexual abuse as a child
• Witnessed family violence as a child

2. Relationship factors

• Associate with sexually aggressive and delinquent peers
• Family environment characterized by physical violence and few resources
• Strongly patriarchal relationship or family environment
• Emotionally unsupportive family environment
• Family honour considered more important than the health and safety of the victim.

3.  Community factors

• Poverty, mediated through forms of crisis of male identity
• Lack of employment opportunities
• Lack of institutional support from police and judicial system
• General tolerance of sexual assault within the community
• Weak community sanctions against perpetrators of sexual violence.

4. Societal factors

• Societal norms supportive of sexual violence
• Societal norms supportive of male superiority and sexual entitlement
• Weak laws and policies related to sexual violence
• Weak laws and policies related to gender equality
• High levels of crime and other forms of violence

*Effect of Rape on Victims and Society*

1. Physical
2. Psychological
3. Sociocultural

1. Physical effects of rape: The physical effect of rape could be one or  more of the following:

• Injuries from beating or choking, such as bruises, scratches, cuts, and  broken bones
• swelling around the genital area
• bruising around the vagina
• Injury to the rectal-vaginal area (for example, tearing of the tissue that connects the anus to the vagina)
• Sexually transmitted infections (such as herpes, gonorrhoea, HIV/AIDS, and syphilis, etc)
• Possible pregnancy (in a regularly menstruating female).

2. Psychological effects on victims may include:

• Severe anxiety
• Depression
• Difficulty in concentrating or sleeping
• Dreaming about what happened
• Inappropriate guilt feelings
• Emotional numbness or irritability
• Flashbacks
• Nightmares
• Extreme fear, etc.

3. Sociocultural effects

• Stigmatization
• Divorced
• Social ostracization
• Death sentence

*Legislation*

We will focus on 5 specific laws that deal with rape:

The Criminal Code – this is applicable in all the Southern States

The Penal Code – this is applicable in all the Northern States

The Criminal Laws of Lagos – this is applicable only in Lagos State

The Violence Against Persons Prohibition Act – this is applicable in only the FCT Abuja.

The Child Rights Act – this is only applicable in the States which have domesticated it

Criminal Code (CC): Under the CC, rape is when any person has sexual intercourse with a woman or girl, without her consent, or incorrectly obtained consent. Consent can be incorrectly obtained where it is obtained:

• by force/threat/intimidation
• by means of false and fraudulent representation as to the nature of the act,
• by a person impersonating a married woman’s husband in order to have sex
• Under the CC, sexual intercourse with under aged girls or people with unsound mind is the offence of defilement, and so technically a person could be charged for rape and defilement.

Penal Code (PC): Under the PC, rape is when a man has sexual intercourse with a woman against her will, without her consent, or with incorrectly obtained consent. Consent can be incorrectly obtained where it is obtained:

• by putting her in fear of death or hurt
• by a person impersonating a married woman’s husband in order to have sex
• Further under the PC, sex with a girl under 14 years of age or who is of unsound mind is rape, irrespective of whether there is consent. Also the PC, explicitly states that sexual intercourse by a man with his wife is not rape.

Criminal Laws of Lagos (CLL): Under the CLL, rape is when a man has sexual intercourse with a woman or girl without her consent, or with incorrectly obtained consent. Consent can be incorrectly obtained where it is obtained:

• by force, impersonation threat or intimidation of any kind
• by means of false and fraudulent representation as to the nature of the act,
• As with the PC, the CLL explicitly states that sexual intercourse by a man with his wife cannot be unlawful, and therefore a man cannot rape his wife.

It is important to note here that in all 3 laws; rape can only occur when the vagina of the woman is penetrated. However, this does not mean that anal unlawful sexual intercourse is allowed. This is a crime, and is covered under different descriptions in each legislation. The penalty for rape across all the laws is life imprisonment (however this is not a mandatory sentence in all of them).

Violence Against Persons Prohibition Act (VAPPA): The VAPPA defines rape as when a person intentionally penetrates the vagina, anus or mouth of another person with any other part of his/her body or anything else without consent, or with incorrectly obtained consent. Consent can be incorrectly obtained where it is obtained:

• by force/threats/intimidation
• by means of false and fraudulent representation as to the nature of the act,
• by the use of substances capable of taking away the will of that person
• by a person impersonating a married woman’s husband in order to have sex

As you can see, the VAPPA seems like a very progressive piece of legislation. Unfortunately, the law is only applicable in the FCT, Abuja. It does not apply in of the other States of the Federation.

5. Child Rights Act (CRA): The CRA provides that sex with a child is rape, and anyone who has sexual intercourse with a child is liable to imprisonment for life upon conviction.

*Clinical management of rape survivors*

Steps include:

1. Making preparations to offer medical care to rape survivors.

2. Preparing the survivor for the examination.

3. Taking the history.

4. Collecting forensic evidence.

5. Performing the physical and genital examination.

6. Prescribing treatment.

7. Counselling the survivor.

8. Follow-up care of the survivor

1. Making preparations to offer medical care to rape survivors

The health care service must make preparations to respond thoroughly and compassionately to people who have been raped. The health coordinator should ensure that health care providers (doctors, medical assistants, nurses, etc.) are trained to provide appropriate care and have the necessary equipment and supplies. Female health care providers should be trained as a priority, but a lack of trained female health workers should not prevent the health service providing care for survivors of rape.

Generally, a clinic or outpatient service that already offers reproductive health services, such as family planning, antenatal care, normal delivery care, or management of STIs, can offer care for rape survivors.

Services may need to be provided for referral to a hospital.

2. Preparing the survivor for the examination

A person who has been raped has experienced trauma and may be in an agitated or depressed state. She often feels fear, guilt, shame and anger, or any combination of these. The health worker must prepare her and obtain her informed consent for the examination, and carry out the examination in a compassionate, systematic and complete fashion.

To prepare the survivor for the examination:

• Introduce yourself.
• Ensure that a trained support person or trained health worker of the same sex accompanies the survivor throughout the examination.
• Explain what is going to happen during each step of the examination, why it is important, what it will tell you, and how it will influence the care you are going to give.
• Reassure the survivor that she is in control of the pace, timing and components of the examination.
• Reassure the survivor that the examination findings will be kept confidential
• Ask her if she has any questions.
• Ask if she wants to have a specific person present for support. Try to ask her this when she is alone.
• Limit the number of people allowed in the room during the examination to the minimum necessary.
• Do the examination as soon as possible.
• Do not force or pressure the survivor to do anything against her will. Explain that she can refuse steps of the examination at any time as it progresses.

3.Taking the history

• Name, address, sex, date of birth (or age in years).
• Date and time of the examination and the  names and function of any staff or support person (someone the survivor may request) present during the interview  and examination.
• Ask the survivor to describe what happened. Allow her to speak at her own pace. Do not interrupt to ask for details; follow up with clarification questions after she finishes telling her story. Explain that she does not have to tell you anything she does not feel comfortable with.
• Survivors may omit or avoid describing details of the assault that are particularly painful or traumatic, but it is important that the health worker understands exactly what happened in order to check for possible injuries and to assess the risk of pregnancy and STI  or HIV. Explain this to the survivor, and reassure her of confidentiality if she is reluctant to give detailed information.
• If the incident occurred recently, determine whether the survivor has bathed, urinated, defecated, vomited, used a vaginal douche or changed her clothes since the incident. This may affect what forensic evidence can be collected.
• Information on existing health problems, allergies, use of medication, and vaccination and HIV status will help you  to determine the most appropriate treatment to provide, necessary counselling, and follow-up health care.
• Evaluate for possible pregnancy; ask for details of contraceptive use and date of last menstrual period.

4. Collecting forensic evidence

Forensic evidence may be used to support a survivor's story, to confirm recent sexual contact, to show that force or coercion was used, and possibly to identify the attacker. Proper collection and  storage of forensic evidence can be key to  a survivor's success in pursuing legal redress.

Documenting injuries and collecting samples, such as blood, hair, saliva and sperm, within 72 hours of the incident may  help to support the survivor's story and might help identify the aggressor(s).

Whenever possible, forensic evidence should be collected during the medical examination so that the survivor is not required to undergo multiple examinations that are invasive and may be experienced as traumatic.

Samples that can be collected as evidence:

• Injury evidence: physical and/or genital trauma can be proof of force and should be documented and recorded on pictograms.
• Clothing: torn or stained clothing may be useful to prove that physical force was used. If clothing cannot be collected (e.g. if replacement clothing is not available) describe its condition.
• Foreign material (soil, leaves, grass) on clothes or body or in hair may corroborate the survivor's story.
• Hair: foreign hairs may be found on the survivor's clothes or body. Pubic and head hair from the survivor may be plucked or cut for comparison.
• Sperm and seminal fluid: swabs may be taken from the vagina, anus or oral cavity, if penetration took place in these locations, to look for the presence of sperm and for prostatic acid phosphatase  analysis.
• DNA analysis, where available, can be done on material found on the survivor's body or at the location of the rape, which might be soiled with blood, sperm, saliva or other material from the assailant (e.g., clothing, sanitary pads, handkerchiefs, condoms), as well as on swab samples from bite marks, semen stains, and involved orifices, and on fingernail cuttings and scrapings. In this case, blood from the survivor must be drawn to allow her DNA to be distinguished from any foreign DNA found.
• Blood or urine  may be collected for toxicology testing (e.g. if the survivor was  drugged).

5. Performing the physical and genital examination

• Obtain voluntary informed consent for the examination
• Physical examination
• Never ask the survivor to undress or uncover completely. Examine the upper  half of her body first, then the lower half; or give her a gown to cover herself.
• Minutely and systematically examine the patient's body. Start the examination  with vital signs and hands and wrists rather than the head, since this is more reassuring for the survivor. Do not forget to look in the eyes, nose, and mouth (inner aspects of lips, gums and palate, in and behind the ears, and on the neck. Check for signs of pregnancy.

Take note of the pubertal stage.

• Look for signs that are consistent with the  survivor's story, such as bite and punch marks, marks of restraints on the wrists, patches of hair missing from the head, or torn eardrums, which may be a result of being slapped. If the survivor reports being throttled, look in the eyes for petechial hemorrhages.
• Examine the body area that was in contact with the surface on which the rape occurred to see if there are injuries.
• Note all your findings carefully on the examination form and the body figure pictograms, taking care to record the type, size, colour and form of any bruises, lacerations, ecchymoses and petechiae.
• Take note of the survivor's mental and emotional state (withdrawn, crying, calm, etc.).
• Take samples of any foreign material on the survivor's body or clothes (blood, saliva, and semen), fingernail cuttings or scrapings, swabs of bite marks, etc., according to the local evidence collection protocol.

Examination of the genital area, anus and rectum

Systematically inspect, in the following order, the mons pubis, inside of the thighs, perineum, anus, labia majora and minora, clitoris, urethra, introitus and hymen.

For the anal examination the patient may have to be in a different position than for the genital examination. Write down her position during each examination (supine, prone, knee-chest or lateral recumbent for anal examination; supine for genital examination).

• If indicated by the history and the rest of the examination, do a bimanual examination and palpate the cervix, uterus and adnexa, looking for signs of abdominal trauma, pregnancy or infection.
• If indicated, do a rectovaginal examination and inspect the rectal area for trauma, recto-vaginal tears or fistulas, bleeding and discharge. Note the sphincter tone. If there is bleeding, pain or suspected presence of a foreign object, refer the patient to a hospital.

Special considerations for men

-For the genital examination:

-Examine the scrotum, testicles, penis, periurethral tissue, urethral meatus and  anus.

-Note if the survivor has been circumcised.

-Look for hyperaemia, swelling (distinguish between inguinal hernia, hydrocele and haematocele), torsion of testis, bruising, anal tears, etc.

-Torsion of the testis is an emergency and requires immediate surgical referral.

-If the urine contains large amounts of blood, check for penile and urethral trauma.

-If indicated, do a rectal examination and check the rectum and prostate for trauma and signs of infection.

-If relevant, collect material from the anus for direct examination for sperm under a microscope.

Laboratory testing

-If the survivor has complaints that indicate a urinary tract infection, collect a urine sample to test for erythrocytes and leukocytes, and for possible culture.

-Do a pregnancy test.

-Rapid plasma reagin (RPR) test for syphilis or any point-of-care rapid test;

-Gram stain and culture for gonorrhoea;

-Culture or enzyme-linked immunosorbent assay (ELISA) for Chlamydia or any point-of-care rapid test;

-Wet mount for trichomoniasis;

-HIV test (only on a voluntary basis and after counselling).

-Other diagnostic tests, such as X-ray and ultrasound examinations, may be useful in diagnosing fractures and abdominal trauma.

6. Prescribing treatment

• Prevent sexually transmitted infections: Survivors of rape should be given antibiotics to treat gonorrhoea, chlamydial infection and syphilis. If you know that other STIs are prevalent in the area such as trichomoniasis or chancroid, give preventive treatment for these infections as well
• Prevent HIV transmission:  PEP should be offered to survivors according to the health care provider's assessment of risk, which should be based on what happened during the attack (i.e. whether there was penetration, the number of attackers, injuries sustained, etc.) and HIV prevalence in the region. Risk of HIV transmission increases in the following cases: if there was more than one assailant; if the survivor has torn or damaged skin; if the assault was an anal assault; if the assailant is known to be HIV-positive or an injecting drug user.
• Prevent pregnancy: Taking emergency contraceptive pills (ECPs) within 120 hours (5 days) of unprotected intercourse will reduce the chance of a pregnancy by between 56% and 93%, depending on the regimen and the timing of taking the medication.
• Provide wound care: Clean any tears, cuts and abrasions and remove dirt, faeces, and dead or damaged tissue.
• Decide if any wounds need suturing, Suture clean wounds within 24 hours, After this time they will have to heal by second intention or delayed primary suture. Do not suture very dirty wounds. If there are major contaminated wounds, consider giving appropriate antibiotics and pain relief.
• Prevent tetanus: If there are any breaks in skin or mucosa, tetanus prophylaxis should be given unless the survivor has been fully vaccinated.
• Prevent hepatitis B : There is no information on the incidence of hepatitis B virus (HBV) infection following rape. However, HBV is present in semen and vaginal fluid and is efficiently transmitted  by sexual intercourse. If possible, survivors of rape should receive hepatitis B vaccine within 14 days of the incident.
• Provide mental health care: Social and psychological support, including counselling are essential components of medical care for the rape survivor. Most survivors of rape will regain their psychological health through the emotional support and understanding of people they trust, community counsellors, and support groups. At this stage, do not push the survivor to share personal experiences beyond what she wants to share.
• However, the survivor may benefit from counselling at a later time, and all survivors should be offered a referral to the community focal point for sexual and gender-based violence, if one exists.
• Provide medication only in exceptional cases, when acute distress is so severe that it limits basic functioning, such as being able to talk to people, for at least 24 hours. In this case and only when the survivor's physical state is stable, give a 5 mg or 10 mg tablet of diazepam, to be taken at bedtime, no more than 3 days. Refer the person to a  professional trained in mental health for reassessment of the symptoms the next  day. If no such professional is available, and if the severe symptoms continue, the dose may be repeated for a few days with daily assessments.

7. Counselling the Survivor

• Survivors seen at a health facility immediately after the rape are likely to be extremely distressed and may not remember advice given at this time. It is therefore important to repeat information during follow-up visits. It is also useful to prepare standard advice and information in writing, and give the survivor a copy before she leaves the health facility (even if the survivor is illiterate, she can ask someone she trusts to read it to her later).
• Tell the survivor that she has experienced a serious physical and emotional event. Advise her about the psychological, emotional, social and physical problems that she may experience. Explain that it is common to experience strong negative emotions or numbness after rape.
• Advise the survivor that she needs emotional support. Encourage her – but do not force her - to confide in someone she trusts and to ask for this emotional support, perhaps from a trusted family member or friend. Encourage active participation in family and community activities.
• Involuntary orgasm can occur during rape, which often leaves the survivor feeling guilty. Reassure the survivor that, if this has occurred, it was a physiological  reaction and was beyond her control.
• In most cultures, there is a tendency to blame the survivor in cases of rape. If the  survivor expresses guilt or shame, explain gently that rape is always the fault of the perpetrator and never the fault of the survivor. Assure her that she did not deserve to be raped, that the incident  was not her fault, and that it was not caused by her behaviour or manner of dressing. Do not make moral judgements  of the survivor.

8. Follow up care of the Survivor

• Evaluate post-exposure prophylaxis (side-effects and adherence).
• If not supplied at the first visit, provide the additional three-week supply of post-exposure prophylactic medication.
• Check that survivor has taken the full course of any medication given for STIs.
• Evaluate for STI, treat as appropriate, and provide advice on voluntary counselling and testing for HIV.
• Evaluate mental and emotional status; refer or treat as needed
• Evaluate for pregnancy and provide counselling.

*Recommendation*

1. Public enlightment

2. Education

3. Institutional Framework

4.Emphasis on Primary Prevention

5.Pre-assault Self-Defence/Assertiveness Training

6. Recognizing Vulnerable Groups

7. Stiffer legislation.

8. Practice safety measures

*Conclusion*

Rape is a form of sexual violence, a public health problem and a human rights violation.

All individuals, including actual and potential victims of sexual violence, are entitled to the protection of, and respect for, their human rights, such as the right to life, liberty and security of the person, the right to be free from torture and inhuman, cruel or degrading treatment, and the right to health.

Governments have a legal obligation to take all appropriate measures to prevent sexual violence and to ensure that quality health services equipped to respond to sexual violence are available and accessible to all.

*References*

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4111066/I

2. https://lawpadi.com/laws-rape-every-nigerian-know/

3.https://www.msdmanuals.com/professional/gynecology-and-obstetrics/domestic-violence-and-rape/medical-examination-of-the-rape-victim

4. https://emedicine.medscape.com/article/806120-followup

5. Clinical management of rape survivors: developing protocols for use with refugees and internally displaced persons -- Revised ed.

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