GUIDELINES FOR MEDICO-LEGAL CARE FOR VICTIMS OF …

1 GUIDELINES FOR MEDICO-LEGAL CARE FOR VICTIMS OF sexual VIOLENCE62 sexual violence : prevalence , dynamics and consequencesSUMMARY sexual violence can take many different forms; it is not limited to acts of non-consensualintercourse but includes a wide range of sexual behaviours, including attempts to obtain a sexualact, sexual harassment, coercion, trafficking for sexual exploitation and female genital GUIDELINES , however, deal mainly with sexual assault (rape) and child sexual abuse. The vast majority of VICTIMS of sexual violence are female and most perpetrators are male. In most cases of sexual assault, the perpetrator is someone the victim knows, and perhapsknows well, such as a current or former intimate partner, or a relative.

2 sexual assault is an aggressive act motivated by power and control. sexual violence has both physical and psychological effects on health and well-being; thesecan be short- and/or long-term. The health consequences of, and the responses to, sexualviolence vary markedly between individuals and according to the nature of the abuse ( , severity, perpetrator). Definition of sexual violenceThe terms rape , sexual assault , sexual abuse and sexual violence aregenerally considered to be synonymous and are often used , these terms may have very different meanings (and implications) invarying situations and locations. More significantly, legal definitions of specifictypes of sexual violence may differ from the medical and social definitions,and furthermore, can vary between countries and even within countries.

3 It isimportant, therefore, that health care professionals are aware of the legaldefinitions of sexual violence within their own jurisdiction, particularly as itapplies to the age of consent and violence is defined as, any sexual act, attempt to obtain a sexual act,unwanted sexual comments or advances, or acts to traffic women s sexuality,using coercion, threats of harm or physical force, by any person regardless ofrelationship to the victim, in any setting, including but not limited to homeand work (1). According to this definition, a very wide range of behaviours,from rape at gun-point to sexual coercion under a threat of dismissal ( withfalse agreement), would be classed as an act of sexual agreement to sexual activity can be obtained in a variety of ways; forinstance, through threats of physical violence , threats of withholding benefits(such as a promotion at work or a good grade), psychological pressure orblackmail.

4 Agreement in such circumstances does not amount to freely givenconsent. The same is true in cases of sexual acts involving individuals who are72. sexual violence : prevalence , dynamics AND consequences unable to give consent, that is to say, individuals who are not capable ofunderstanding the significance of the act or of indicating their consent or refusal( those who are incapacitated due to the effects of alcohol and/or drugs, orthose with a mental disability); such acts would also be described as non-consensual (17). Types of sexual violenceSexual violence can take many forms and take place under very differentcircumstances. A person can be sexually violated by one individual or severalpeople ( gang-rapes); the incident may be planned or a surprise sexual violence occurs most commonly in the victim s home (or inthe perpetrator s home), it also takes place in many other settings, such as theworkplace, at school, in prisons, cars, the streets or open spaces ( parks,farmland).

5 The perpetrator of a sexual assault may be a date, an acquaintance, a friend,a family member, an intimate partner or former intimate partner, or a completestranger, but more often than not, is someone known to the victim. There is nostereotypical perpetrator; sexually violent men come from all backgrounds,rich and poor, academic and uneducated, religious and may be persons in positions of authority who are respected andtrusted ( a doctor, teacher, tourist guide, priest, police officer) and thusless likely to be suspected of sexual violence is common in situations of war and armed , rape and sexual torture are frequently used as weapons todemoralize the enemy; women are sometimes forced into temporarymarriages with enemy soldiers.

6 Women who are incarcerated may be subjectedto sexual violence by prison guards and police officers (18).Other forms of sexual violence include, but are not limited to (19): sexual slavery; sexual harassment (including demands for sex in exchange for jobpromotion or advancement or higher school marks or grades); trafficking for purposes of forced prostitution; forced exposure to pornography; forced pregnancy; forced sterilization; forced abortion; forced marriage; female genital mutilation; virginity perpetrators use drugs in order to facilitate sexual assault (20). A womanwho has been plied with drugs is easier to control, to the extent that physicalforce is not necessary, as the drugs will render her submissive and incapacitatedand, in some cases, unconscious.

7 In this respect, the increased use of so-called date rape drugs in recent years has received much attention. This and otheraspects of drug-facilitated sexual violence are discussed in greater detail inBox FOR MEDICO-LEGAL CARE FOR VICTIMS OF sexual VIOLENCE8 While sexual violence takes many forms, these GUIDELINES focus on providingcare for VICTIMS of sexual assault and VICTIMS of child sexual abuse. For thepurposes of these GUIDELINES , rape is defined as physically forced or otherwisecoerced penetration even if slight of the vulva or anus, using a penis, otherbody parts or an object (1). This definition includes coerced sexual activitythat may not be considered rape if the local legal definition of rape is narrow( confined to vaginal penetrtion with a penis).

8 PrevalenceSexual violence is a reality for millions of people worldwide, and for women inparticular. Research indicates that the vast majority of VICTIMS of sexual violenceare female, most perpetrators are male, and that most VICTIMS know their attacker(19, 21 23). This does not, however, negate that fact that sexual violence againstmen and boys is also it is generally acknowledged that sexual violence against women ispervasive in all countries and in all levels of society, reliable statistics concerningthe prevalence of sexual violence around the world are very limited. Population-based studies of abuse by intimate partners indicate that between 6% andBOX 1 Drugs and sexual violenceAlcohol has long been used to facilitate non-consensual sex and remains the most popular drug ofchoice.

9 In recent years, however, the use of date rape drugs has been implicated in an increasingnumber of cases of sexual violence . The most commonly used drugs are flunitrazepam (Rohypnol) andother benzodiazepines, gamma-hydroxybutyrate (GHB), ketamine, cocaine, methamphetamine andmarijuana (20). VICTIMS may be unaware that they have been drugged and that they have been double standard often exists between men and women in terms of drinking alcohol or using drugs. Ifa woman has been drinking or using drugs she is often blamed for her victimization. On the other hand,the perpetrator s behaviour is excused or justified because he was under the influence and thus notexpected to control his workers need to be aware of the signs that are suggestive of drug-facilitated sexual violence .

10 Ifpatients present with any of the following symptoms, the use of drugs or alcohol should be suspected: impaired conscious state, memory loss, disorientation or confusion; impairment of speech or coordination; unexplained signs of trauma, particularly genital trauma; apparent intoxication not corresponding to stated alcohol consumption; unexplained loss or rearrangement of clothing; talking about having an out-of-body experience .If drugs or alcohol are suspected, it is important to be aware of the following: any alteration in conscious state requires immediate access to full resuscitation facilities, such asthose available in emergency departments; the sooner specimens are taken ( blood, urine) the greater the likelihood of successfully detectingany substances not knowingly of women report that they have experienced attempted or completedforced sex by an intimate partner or ex-partner at some time in their lives (1).