A Proposal for a Follow-Up Algorithm for Survivors of Sexual Violence in the Context of a Humanitarian Crisis

The World Health Organization (WHO) defines Sexual Health as a “physical, emotional, mental and social state of well-being related to sexuality”, considering it a major concept beyond the absence of disease or dysfunction.^1,2,3 This major definition of Sexual Health “requires a positive and respectful approach, as well as the possibility of having safe and pleasurable sexual relations, free from coercion, discrimination and violence”.^1,2,3 Sexual and Reproductive Health (SRH) is one of the central aspects of the individual, fundamental for their health and well-being, as well as for the respective families and social and economical development of communities.^1,2,3,4 SRH is relevant throughout an individual’s entire life and not just in their reproductive window.^1,2,3,4 It is determined and influenced by the quality and safety of the relationships that the individual has with himself, other individuals, family and friends and with the society in which they live, which includes gender standards that model the individual’s experiences and perceptions.^1,3

Sexual violence is defined as any sexual act or attempt to obtain a sexual act, unwanted sexual comments or acts to sexually traffic a person, through the use of coercion, threats of harm or physical force, by any person, regardless of the relationship with the victim, in any environment.^1,5 Sexual violence is, therefore, a continuum of actions that include sexual harassment, rape, forced pregnancy/abortion, sexual exploitation and trafficking.^1,5 It is, undoubtedly, an attack on the health of an individual.^1,5

As a violation of Fundamental Human Rights — especially Refs. 3, 6–8 — this public health problem is aggravated in situations of conflict, forced migration and natural disasters, particularly due to the loss of a safe residence, limited economic opportunities and instability inherent to the context.^1,5,9 Worsening the problem, the national systems and community and social support networks are often weakened, which leads to an environment of impunity.^6,7,10,11 Furthermore, in some conflict or post-conflict settings, sexual violence is used as a war tactic.^6,7 Sexual violence may inflict and condition long-term consequences both at an individual and community level, such as an increase in the prevalence of sexually transmitted infections, unwanted pregnancies, depression, anxiety, social exclusion and practices such as early and/or forced marriage and an increase in intimate violence and female genital mutilation.^1,6 Thus, there is an undeniable need for action in the field of SRH from the early stage of a humanitarian crisis.^1,6

In 1999, the United Nations Interagency Working Group on Reproductive Health in Crisis conceived and elaborated the Inter-Agency Field Manual (Reproductive Health in Refugee Situations: An Inter-Agency Field Manual), which included the Minimum Initial Service Package for SRH, a manual and training aimed at increasing the knowledge of humanitarian SSR actors and which should be initiated at the onset of a humanitarian crisis.^6,12

In the context of a humanitarian crisis, the approach to survivors of sexual violence must be based on four guiding principles: safety, confidentiality, respect and non-discrimination — and respect for their rights — to health, human dignity, non-discrimination, confidentiality, privacy, information and self-determination.^1,6,8,12 A Code of Conduct, established by the sector/group responsible for SRH, must be applied and respected by all humanitarian agents.^1,6,12

The approach to a survivor of sexual violence should, besides support and psychosocial counseling, address and guarantee emergency contraception and post-exposure prophylaxis for the Human Immunodeficiency Virus (HIV) as soon as possible after the incident, as long as the victim consents.^1,6,12 It is extremely important that during all contact with the survivor, he is sure that he is autonomous and independent and that he is in control.^1,6,12

Health care is often the first point of contact with help for survivors of sexual violence, so all health providers must be prepared for a first-line approach and to provide the first line of psychosocial support.^1,6,13 This approach should be holistic and take into account the biological, psychological and social characteristics, considering the inherent dolence and centered on the survivor, inferring that the perceptions, expectations, rights, needs and desires of the survivors are always the priority.^1,6,13

In order to systematize the best practices for approaching a survivor of sexual violence, the group of authors proposes the application of the algorithm conceived and explained (Figures 1 and 2), as stipulated by WHO, IAWG for SRH and United Nations Population Fund (UNFPA).

In the first contact (Appointment 1) after the episode of sexual violence, first of all, adequate communication of support should be ensured.^1,6,12,13 Communication of support to survivors of sexual violence implies precise, clear communication, free of judgments and/or false expectations, where empathy, active listening, autonomy and respect for the survivor prevail.^1,6,12,13 Communication should be developed in accordance with the LIVES model, advocated by WHO: Listen; Inquire, Validate, Enhance Safety and Support.^1,6,12,13 Therefore, this acronym means, to empathetically listen and to validate the emotions and feelings of the survivor, making sure he knows it’s not his fault; identify immediate emotional, psychological and physical needs and understand their necessities and concerns; identify and offer information from other support services; ensure the continuous safety/protection and immediate health of the survivor and support their decisions.^6,12,13 Regarding the anamnesis, the general medical history (user identification, date and time of observation), personal history, gynecological/obstetric history (if women), as well as information about the incident (Who? When? How? Where? Did you perform hygiene after the incident?) and assessment of the survivor’s mental and psychological state.^1,6,12,13

Before carrying out the objective examination, it is highly recommended that the survivor choose a person they trust to be present; in the case of children, their tutor or trained support person may be present, and the survivor may choose the biological sex of the support person (mandatory for children).^1,6,12 Furthermore, it is clinician’s responsibility to explain to the survivor the importance and pertinence of the objective examination, as well as to ensure that the survivor understands and accepts each stage of the objective examination before touching him.^1,6,13 The objective examination should include assessing vital signs and visible damage, performing a genital and anal examination and, where feasible, necessary and legal, collecting forensic evidence after the survivor’s consent and in accordance with the procedure in effect.^6,13 If the survivor does not consent to the objective examination, empirical treatment may be initiated without a complete objective examination, and complications must be treated according to stratified risk or referral to higher-level health units in cases of risk of life.^1,6,13 The treatment/intervention includes, if necessary, wound care (washing, cleaning, disinfection and suturing), tetanus prevention through vaccination and/or immunoglobulin, pregnancy test, emergency contraception, presumptive treatment of sexually transmitted infections, post-exposure prophylaxis against HIV and prevention of hepatitis B and human papillomavirus.^1,6,12,13

Emergency contraception should be performed within the first 120$$h after the incident using the pill (1.5$$mg levonorgestrel or 2100$$Ug ethinylestradiol $+$ 0.5$$mg levonorgestrel or 30$$mg ulipristal) or implantation of an intrauterine device (IUD).^1,6,12,13 The presumptive treatment of sexually transmitted infections should ensure coverage of the most frequent local etiological agents.^1,6,12,13,14 It is advised the treatment with ceftriaxone 250$$mg intramuscularly $+$ azithromycin 1$$mg or cefixime 400$$mg $+$ azithromycin 1$$mg and the use of metronidazole if there is a risk of infection by trichomonas.^1,6,12,13,14

For post-exposure prophylaxis against HIV, WHO recommends a 28-day cycle of tenofovir 300$$mg $+$ lamivudine 300$$mg $+$ dolutegravir 50$$mg.^1,6,12,13 However, for HIV antiretroviral treatment, local regulations in force must be complied with.^6,12 Prevention of hepatitis B and human papillomavirus should be carried out through vaccination, and vaccination against hepatitis B should occur within 14 days after the aggression.^1,6,12,13 Clinicians may also refer the survivor to other health services such as hospital health services (life-threatening situations), protection or social services (if the survivor does not have a safe place to go), health psychosocial or mental and community.^1,6,12,13 In the case of a pregnancy, it is the clinician’s obligation to provide accurate and impartial information about the pregnancy options and, in case the survivor chooses to have an abortion, safe abortion care or referral for this care must be carried out in accordance with the law in effect.^1,6,13 In most countries, induced abortion is legally permitted in at least some circumstances and abortion laws have liberalized it.¹⁵ In many countries, abortion is permitted if the pregnancy threatens the woman’s physical and mental health (legal in 190 countries to save the woman’s life) and when the pregnancy is the result of rape or incest (legal in 78 countries when resulting from rape).¹⁵

It is also the clinician’s obligation to plan follow-up after an episode of sexual violence, which should occur at 2 weeks, 1 month, 3 months and 6 months after the incident, keeping clinical records updated and confidential.^1,6,12,13 During this period, mental health needs, wound healing, monitoring of the vaccination schedule, evaluation of potential pregnancy, prophylaxis of sexually transmitted infections, adherence to treatments and the need for possible referrals should be monitored.^1,6,13

With the publication of this paper, it is intended, therefore, to present the proposal of this algorithm as a working tool in the follow-up of survivors of sexual rape, in the context of a humanitarian crisis, congregating the knowledge and skills inherent in the documents.

ORCID

Joana Gomes da Silva   https://orcid.org/0000-0003-0257-3593

Marta Regina Soares de Assunção   https://orcid.org/0000-0002-7537-4109

Regina Maria Ribeiro Belo   https://orcid.org/0009-0009-1945-0072