Strengthening Health System Responses to Genderbased Violence in

Strengthening Health System Responses to Gender-based Violence in EECA: A resource package 6. Medical examination and care

Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Aim of this module • To provide an overview of the different steps involved in – providing first-line support to patients disclosing GBV – taking a medical history and undertake a physical examination – providing treatment and follow-up care, with a focus on patients who experienced sexual violence and/or suffer from pre-existing and GBV-related mental disorders 2

Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Outlook • • First-line support Medical history Physical examination Treatment and follow up care – Injuries – Unwanted pregnancies, STIs & HIV – Psychological/mental health interventions 3

Strengthening Health System Responses to Gender-based Violence in EECA: A resource package First-line support

Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Elements of first-line support (WHO 2013) • Be non-judgemental and supportive, validate what the woman is saying • Provide practical care and support that responds to her concerns, but does not intrude • Ask about her history of violence, listen carefully, but do not pressure her to talk • Help her access information about resources • Assist her to increase safety for herself and her children • Provide or mobilize social support • Ensure the consultation is conducted in private and inform women of the limits of confidentiality 5

Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Medical history

Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Steps for medical history 1. Obtain informed consent • Explain all aspects of consultation • Explain limits of confidentiality • Ask patient to sign or mark consent form, if required by law 2. Take complete medical history • the time since assault and type of assault • the risk of pregnancy • the risk of HIV and other STIs • the woman’s mental health status 7

Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Tips for interviewing • Ask her to tell in her own words what happened • Avoid unnecessary interruptions • Be thorough, some patients may purposely avoid embarrassing details (e. g. oral sexual contact, anal penetration) • Use open-ended questions and avoid questions starting with “why”, which tends to imply blame • Address questions and concerns non-judgementally (using a calm tone of voice, maintaining eye contact, and avoiding expressing shock or disbelief) 8

Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Physical examination

Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Checklist: general principles ü Explain the medical examination ü Ask her to disrobe completely and to put on a hospital gown, so that hidden injuries can be seen ü Examine both serious and minor injuries ü Throughout the physical examination inform the patient what you plan do next and ask permission, always let her know when and where touching will occur, show and explain instruments and collection materials H 24 ü Patients may refuse all or part of the examination ü Provide medical and legal (forensic) services at the same time, in the same place, by the same person, if possible 10

Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Treatment and follow-up care

Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Treatment of injuries • Refer patients with severe, life-threatening conditions for emergency treatment right away • Try to treat patients with less severe injuries (cuts, bruises, superficial wounds) in situ. • The following medications may be indicated: – antibiotics to prevent wounds from becoming infected – a tetanus booster or vaccination (according to local protocols) – medications for the relief of pain, anxiety or insomnia 12

Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Prevention of unwanted pregnancies, STIs & HIV • Emergency contraception • HIV post-exposure prophylaxis • Post-exposure prophylaxis for STIs H 25 13

Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Treatment of psychological/mental health outcomes (1) • Where referral possibilities are available: refer survivors with pre-existing diagnosed or IPV-related mental disorders to specialist health care providers for psychological/mental healthcare interventions • Some interventions may be performed by primary health care providers, in line with WHO mh. GAP guidelines that apply to non-specialized health care settings • In settings with limited or no referral possibilities, provide psychological first aid support 14

Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Treatment of psychological/mental health interventions (2) For survivors of IPV (or mental health outcomes of nonpartner violence) • For survivors with pre-existing diagnosed or IPV-related mental disorders: provide mental health care in line with WHO mh. GAP Intervention Guide • For women who are either breastfeeding or pregnant: consult with a specialist for use of psychotropic medicine • For women who no longer experience IPV but are suffering from PTSD: arrange for psychotherapy (cognitive behavioural therapy [CBT] or eye movement desensitization reprocessing [EMDR]) • Mother-child intervention (though not always feasible): offer children who are exposed to IPV a psychotherapeutic intervention, including sessions with and without their mother. 15

Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Treatment of psychological/mental health interventions (3) For survivors of sexual violence 1. During the first days of the assault • • continue providing first-line support, but not psychological debriefing provide written info on coping strategies for dealing with severe stress 2. Up to three months post-trauma • • continue first-line support apply “watchful waiting” for 1 -3 months after the event arrange CBT or EMDR interventions (only if necessary) provide care in line with the WHO mh. GAP Intervention Guide if the person has any other mental health problems 3. After three months post-trauma • • assess for mental health problems if suffering from PTSD, arrange for PTSD treatment with CBT or EMDR 16

Strengthening Health System Responses to Gender-based Violence in EECA: A resource package Treatment of psychological/mental health interventions (4)General Principles • Ensure patients’ informed consent and safety • Therapies should be implemented by a trained health care provider with a good understanding of sexual violence • Consider pre-existing mental health conditions – Higher likelihood in rape survivors • Consider pre-existing traumatic events (sexual abuse in childhood, IPV, war-related trauma) 17