EMERGENCY CARE TREATMENT FOR RAPE VICTIMS Need of

EMERGENCY CARE & TREATMENT FOR RAPE VICTIMS – Need of Hour DUTIES & RESPONSIBILITIES OF GYNAECOLOGISTS & PRIVATE MEDICAL PRACTITIONER Dr. Sharda Jain

Sexual assault and rape cases are increasing at an alarming rate in India Sexual Assault can Happen to anyone shattering her life completely (She can be your Daughter, Sister, Girl Friend & Even Mother !!)

Sexual Assault is a serious problem and must not be taken lightly by DOCTORS

Recent Statistics 1 in 6 to 1 in 3 women will be raped during her lifetime (Anderson, 2009; Luce, 2010). Up to 40% of these women have been found to be sexually assaulted more then once (kilpatrick, 1992). Many rapes are unreported, ↑ 70% because of a victim’s feeling of shame and guilt. (India)

Delhi High Court - Judgment Following Judgment of division bench of DELHI HIGH COURT comprising of chief justice sh. D Murgeshan and justice sh. V. K. Jain stating that the government must issue direction to all hospital including those in Private sector - not to deny emergency treatment to rape victims. Dept of Health and Family welfare NCT of Delhi has directed nursing homes and private hospital not to refuse emergency treatment to rape Victims / give care Failing which face punishment.

We have to give up lou sy Medical ex amination & poor me dical care Medical Care to Rape Victim Needs to be changed in India

A brutal crime rape or sexual assault leaves the victim in an emotionally and physically vulnerable state Every Lady doctor has to get trained in Rape Victim exam & care

Lets Know the LAW New Definition Of RAPE (According to 2013 amendment) 1. Penetrates his penis, to any extent, into the vagina, mouth, urethra or anus of a women or makes her to do so with him or any other person; or • Insert, to any extent, any object or a part of the body, not being the penis, into the vagina, the urethra or anus of a women or makes her to do so with him or any other person;

Lets Know the LAW New Definition Of RAPE (According to 2013 amendment) Cond. • Manipulates any part of the body of a women so as to cause penetration into the vagina, urethra, anus or any part of body of such women or makes her to do so with him or any other person Or • Applies his mouth to the vagina, anus urethra of a women or makes her to do so with hem or any other person, under the circumstances falling under any of the following seven descriptions:

Lets Know the LAW Cond. New Definition Of RAPE (According to 2013 amendment) FIRST – Against her will SECONDLY – without her consent THIRDLY – with her consent, when her consent has been obtained by putting her or any person in women she is interested in fear of death or of hurt. FOURTH – with her consent, when the man knows that he is not her husband that her consent is given because she believes that he is another man to whom she is or believes herself to be lawfully married.

Lets Know the LAW New Definition Of RAPE (According to 2013 amendment) Cond. FIFTHLY – with her consent when, at the time of giving such consent, by reason of unsoundness of mind or intoxication or the administration by hem personally or through another of any stupefying or unwholesome substance, she is unable to understand the nature and consequences of that to which she gives consent. SIXTHLY – with or without her consent, when she is under eighteen years of age SEVENTHLY – when she is unable to commutate consent 2. INJURIES ON VICTIMS BODY HAS NO RELEVANCE

It is important that victims of sexual assault or rape is received by sympathetic and sensitive doctor, appropriate medical care & treatment and clinical evidence saved.

Most Important Adequate attention victims to emergency medical, emotional, and legal needs • Trained Doctor & her team • Special kit for examination • Treatment to prevent STD/ Pregnancy is crucial

What you can do before reaching hospital ? As soon as one comes across a victim Of Sexual assault, the first step is to ensure SAFETY • Take her to safe and secure place call the police if danger from the assailant is still there. • Call a close friend or relative- someone who will offer unconditional support.

Instructions to the Victim What you can do before reaching hospital ? • One must take care not to clean up before taking them to hospital. The victim should not bath, go to the bathroom, comb hair, change clothes or brush teeth before undergoing a medical examination. • This will help to preserve all the evidence.

Emergency Care The doctor’s job at the emergency room is not to determine if the rape has happened or not. Rape is a legal term – a crime – and whether this crime has been committed or not will be decided by the Honorable court.

Principle of Emergency Care • The attitude of the medical staff should be compassionate and not judgmental • Life threatening emergency, if present needs urgent attention

Our Aim should be • Immediate treatment of any physical injuries • Detailed physical examination – for abrasions , bruises and laceration. Presence or absence of injuries are no sign of protest on consent • Injuries are seen in only one third cases. • Common sites of extra genital trauma are mouth, throat, wrists, arms, breast and thighs. It is essential to do a careful recording of the findings if there presents.

Guidelines for Medical Examination As per new law 2013 • Victim : the first aid medical treatment to the victim of rape and vitriolage shall be provided promptly and free of cost by all hospital public or private • Medical examination of a female victim shall be conducted by a female registered medical practitioner, in absence there of , in presence of a female registered medical practitioner

Guidelines for Medical Examination As per new law 2013 • Police requisition /FIR is not mandatory for seeking medical care and treatment of the victim. • Two finger admissibility test on a women victim shall not be performed and • Recording of “victim is habituated to sexual inter course or not” shall not form a part of report at all.

Punishment for non Compliance for we doctors Whoever, being in charge of a hospital , public or private , whether run by the central Government, local bodies or any other person, contravenes the provisions of sections 357 c of the code of criminal procedure , 1973(2 of 1974), shall be punished with imprisonment for a term which may extend to one year or with fine (166 B – IPC)

In sexual abuse victims screening recommended • Pregnancy test • HIV, STD TEST • Blood and urine for addiction or substance abuse such as: heroin , opium, benzodiazepine and alcohol

Collection of Evidence • The doctor should collect hair semen, clothing fibers and other evidence of the attacker. • Even if the victim is not sure, whether she wants to report the attack, it is still important to collect and preserve evidence so it can be accessed at a later date, if necessary. • Evidence not collect within 48 to 72 hours of the incident is often undercoverable or invalid.

Collection of Evidence • All specimens collected during the examination should be carefully sealed and dated. • Evidence should kept in a locked box in the emergency department until a police officer arrives. • The officer should transport the evidence to the nearest crime laboratory

Collection of Forensic Sample Followings samples are required to be collected in sexual abuse cases • Blood (blood grouping, testing drug intoxication) • Urine (to test for suspected pregnancy, drug testing) • Seminal stain (blood grouping) • Nail scrubbing (to look for epithelium of the assailant) • Hairs (to look for seminal stain, foreign hair) • Vaginal swab (vulva , low vaginal, high vaginal) to stress here that it should be made a routine • Microscopic examination of vaginal slides (motile and immotile sperm) • Ultraviolet test for detection of seminal and saliva stains

Swabs and Smears Vagina Take a dry or saline wet swab according to observation a. Labial Part b. External orifice c. Deep Vaginal Swab d. From Cervix e. From things public , rectal or affected area if required For spermatozoa, smear are prepared from the external genital Organs. The smears are fixed on the slide one drop of alcohol

Swabs and Smears • Mouth Swab from under the tongue and buccal area near molars. Take one swab from each area and prepare the smear • Rectum Take one sample from the external parts and another from the 2 -5 cm area external orifice

Essential for preparing smearing – instruction used to obtain a smear: • Clean microscopic glass slides of good quality, preferably with frosted ends (0. 96 -1. 06 mm. thickness). • Suitable glass marking pencil or a diamond marker for identification of slides. • Paper clips to separate the slides. • Fixative 95% ethy alcohol or 100% methy alcohol • Laboratory from with clear identification of the patients and history

Motility of Sperm – Prepare a hanging drop Preparation • Place a drop of vaginal pool secretion on a cover slip • Apply a circular band of clay over a glass slide • Put an inverted cove slip over it • Look under a microscope • Motile sperms can visualized up to four – five hours

Various Tests • Pregnancy test (Urine or serum) • Serum hepatitis B surface antigen (HBs. Ag) assay • VDRL test. • Culture for neisseria gonorrhoeae • Microscopic evaluation of vaginal discharge saline prep • If HPV PEP is planned, than CBC, serum liver function test, and serum creatinine level.

Treatment AIM • Pregnancy prevention • Sexually Transmitted Disease Prevention • Emotional Support

Prevention of pregnancy Emergency Pill : levonorgestrel 0. 75 mg one pill orally every 12 hours for two doses UPT : to be repeated at 1, 2 weeks & MTP if need be

Sexually transmitted diseases Incubation period of common infections • Gonorrhea 3 -4 days • Trichomonas 1 -4 weeks • Chlamydia 7 -14 days • Warts several months • Herpes 2 -14 days • Herpes vaginosis 2 -14 days • Syphilis 3 months

Universal STD Prophylaxis Metrogyl 2 gm orally - single dose Azithromycin 1 g - orally single dose Ceftriaxone 250 mg I/M single dose

Optional • Hepatitis B vaccination • Oral HIV pep for 4 weeks

Emotional support Sexual assault victim need unconditional emotional support as they may be struggling with emotions of Anger, Fear, Guilt, Shame and anxiety

Emotional Support The Victim May Suffer From • Sleep disturbances • Lack of appetite • Depression and nightmare • Physical pain

Counseling Most victims find counseling helpful in the process of recovering and moving on with their life. The care a patients initially receive influences her recovery from the trauma suffered due to rape Follow up is must

Please Remember Girls can not stop rape just by changing their own behavior violent never stop unless they are Punished Please join hands with Delhi Gynaecologists forum’s campaign to do great medical examination & care

Girls must learn self defense

Thank You

Top 13 reasons of increasing Sexual Assault & Rape Victims in India DR. Sharda Jain / Malti Slide share. net -----------------------------------FILM On Medical Examination of Rape Victim Prepared by MOWCD / IMA Youtube

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