MODULE TWO

Management of GBV and

VAC Survivors

1
 Overview of Module Two
This module consists of five sessions:
 Session 2.1: Interpersonal Communication, Values, and
Attitudes of Health Care Providers
 Session 2.2: Principles and Procedures for Management
of GBV and VAC Survivors
 Session 2.3: Physical Examination and Treatment of
Survivors
 Session 2.4: Forensic Sample/Evidence Management
 Session 2.5: Approaches in the Provision of Psychosocial
Care and Support
SESSION 2.1
Interpersonal Communication,
Values, and Attitudes of Health
Care Providers
 Learning Tasks
At the end of this session participants are
expected to:

 Use principles of interpersonal communication

skills in managing GBV and VAC survivors.
 Communicate effectively with children and
adolescents who have experienced abuse and
violence.
 Learning Tasks
 Identify personal strengths, weaknesses, and
values in provision of care and support to child
and adolescent survivors of GBV and VAC.
 Identify positive attitudes in service provision for
GBV and VAC survivors.

 Explain strategies for improving attitudes

towards GBV and VAC survivors.
 Role Play Activity
 Observe the role play and note whether the following
communication skills emerge:

 Building rapport

 Active listening skills

 Questioning skills

 Answering skills

 Summarization

 Paraphrasing
 Principles of Communication

 Interpersonal communication is the process by which

people exchange information, feelings, and meaning
through verbal and nonverbal messages.

 Interpersonal communication is not just about what is

actually said (the language used), but also how it is said
and the nonverbal messages sent through tone of voice,
facial expressions, gestures, and body language.
 Principles of Communication
 Types of interpersonal communication:
 Verbal communication employs words, which can be said, written, or read.

 Nonverbal communication uses gestures, body expressions, tone of voice,

and posture.

 Correct mixture of verbal and nonverbal communication makes

sharing information and feelings complete.
 Influences on interpersonal communication:
 Attitudes

 Feelings

 Values

 Social norms

 Environment
 Components of Interpersonal
Communication Skills
 Build rapport:
 Establish a harmonious relationship.
 Implies building trust
 Having each other’s best interests in mind
 Mutual respect.
 Definition of listening:
 Listening is the absorption of the meanings of words
and sentences by the brain.
 Listening is the ability to accurately receive messages
in the communication process.
 Active Listening Skills

Active listening is a major tool for the provision of GBV/VAC

services. You need to:
 Maintain eye contact.
 Exhibit affirmative nods and appropriate facial expressions.
 Avoid distracting actions or gestures.
 Ask questions.
 Paraphrase what the client says.
 Avoid interrupting the client.
 Do not talk unnecessarily.
 Steps of Listening
 Know what you are listening for.
 Listen to specific content (who, what, where, when, why).
 Suspend your personal judgment.
 Resist distractions, thoughts, imaginings which take your
attention from the client.
 Use verbal expressions such as: “Um-hum,” “Yes,” “Go on,” and “I
see.”
 Maintain eye contact.
 Use a well-modulated voice: such a tone is reassuring and
comforting.
 Match your body language with your verbal language.
 Questioning Skills

 Know what you are looking for before asking the

question.
 Minimize use of closed-ended questions, such as, in
medical history, for example, “How many injections have
you been given?”
 Use open-ended questions: to learn about the client’s
feelings, beliefs, and knowledge; for example, “What
have you heard about gender-based violence?” or “Can
you tell me more about why you think positive living is
important?”
 Answering Skills

 Understand the question and give the correct answer.

 Use both body language and verbal language to convey
your message.
 Self-Awareness

 Self-awareness means having a clear perception of your

personality, including strengths, weaknesses, thoughts,
beliefs, motivation, and emotions.
 It also allows us to look at ourselves and gain a better
understanding of our strengths, weaknesses, and
values and how these issues can impact our
interactions with GBV/VAC survivors.
Conceptual Model for Assessing Self-
Awareness
 Techniques for Self-Assessment

 There are several techniques of assessment

for self-awareness.
 One is the Johari Window model:
 Behavior model
 Four-square grid representing four different areas
of interaction between people.
 KNOWN TO MYSELF UNKNOWN TO MYSELF
OPEN/FREE AREA BLIND AREA
KNOWN TO OTHERS

This is the information about the person: This is the information of what is known about a
behaviors, attitudes, feelings, emotions, person by others, but is unknown by the person
knowledge, experience, skills, views, etc., him/herself.
known by the person (“the self”) and
• Feedback solicitation from others
known by others.

HIDDEN AREA UNKNOWN AREA

UNKNOWN TO

This is the information that is known to the This is the information, feelings, latent abilities,
person but kept hidden from, and aptitudes, experiences, etc., that are unknown to the
OTHERS

therefore unknown to others. person him/herself and unknown to others.

• Self-disclosure/exposure (self- • Shared discovery

assessment) • Self-discovery
• Others’ observation
 Application of Johari Window Model

 Working openly with others helps one become

more self-aware and be at his/her most effective
and productive condition.
 Expand the open area by soliciting feedback from
others.
 Moving relevant hidden information and feelings,
etc., through disclosure increases the open area.
 Application of Johari Window Model
 Reducing hidden areas also reduces the potential for
confusion, misunderstanding, poor communication, etc.
 Reduce the unknown area through:
 Observation

 Self-discovery

 Mutual enlightenment

 Discussion
 Why is Self-Awareness Important for Service
Providers?

 Self-reflection and self-awareness are integral to the

service provision and professional relationship.

 If we want to be effective in what we do, we need to

know how we function emotionally.

 If we do not know our strengths and weaknesses we

cannot effectively help.
 Developing Self-Awareness

Developing self-awareness means:

 The provider has a realistic view of his/her strengths
and weaknesses.
 The provider is able to capitalize on strengths to
overcome or manage weaknesses.
 The provider does not exaggerate weaknesses or
allow others to look down on them.
 The provider understands that s/he exists as an
individual person separate from other people.
 Developing Self-Awareness

Developing self-awareness means:

 The provider is able to differentiate between
what belongs to the client and to him/herself.
 This reduces burnout and provides a better
understanding of the survivor’s needs.
 The provider can be more objective toward
GBV and VAC survivors and provide better
services.
 The provider is genuine in providing services.
 Developing Self-Awareness

Developing self-awareness means:

 Self-awareness helps service providers:
 Avoid establishing a dependent relationship with the survivor.
 Communicate better.
 Encourage survivors to take responsibility for themselves.

 Self-awareness is developed through the

following strategies:
 Self-disclosure
 Being introspective
 Accepting feedback.
Values and Attitudes in Provision of
Services to GBV and VAC Survivors

Values Clarification Exercise

 Values

 Values are a measure of one’s inner worth or one’s judgment

of what is important in their life.
 Values are developed while growing up.
 They are influenced by:
 Family
 Environment
 Culture
 Religion
 Education
 Values will differ for people who come from different families,
societies, and countries.
 Importance of Values

 Values:
 Guide a person’s beliefs and opinions.
 Determine a person’s identity, decisions, and behavior.
 Result in peace of mind when decisions are guided by
them.
 Result in respect, love, good health, cooperation,
development, comfort, unwavering decisions, and
good habits when properly applied.
How Values Govern Decision Making in GBV and
VAC Service Provision
 Service providers deal with all types of people,
tribes, races, and ages.
 Growing up, people can develop certain
stereotypes and prejudices about others that
have a major impact on their social and
interpersonal interactions.
 Providers need to have some understanding of
how stereotypes, prejudices, beliefs, and culture
may impact service provision.
 How Values Govern Decision Making in
GBV and VAC Service Provision
 The following elements can have a great impact
on service provision
 Ethnicity: What is seen as appropriate behavior in one
ethnic tribe may not be seen as appropriate in another
group.
 Culture: Different cultures have different ideas of what
is appropriate.
 Stereotyping: A set of usually negative generalizations
about a group (e.g., gender, race, or national origin).
 Challenges for Talking about GBV and VAC

 Belief that GBV and VAC are private matters and

should not be discussed in public.

 Rationalization of GBV and VAC as something

that is acceptable under certain conditions.

 Silencing of survivors by perpetrators/family/

community.

 Blaming the survivor.

 Child-Friendly Values and Beliefs

 Health and psychosocial service providers must:

 Put child-friendly values and beliefs into practice.
 Ensure child-friendly attitudes are communicated
during the provision of care.
 Values that are essential for service providers working
with children include the recognition that:
 Children are resilient individuals.
 Children have rights, including the right to care,
love, support, and healthy development.
 Child-Friendly Values and Beliefs

• Children have the right to be heard and be

involved in decisions that affect them.

• Children have the right to live a life free from

violence.

• Information should be shared with children in a

way they understand.
 Child-Friendly Values and Beliefs

 Necessary beliefs for service providers working

with child sexual abuse survivors:
 Children tell the truth about sexual abuse.
 Children are not at fault for being sexually abused.
 Children can recover and heal from sexual abuse.
 Children should not be stigmatized, shamed, or
ridiculed for being sexually abused.
 Adults, including caregivers and service providers,
have the responsibility to help a child heal by
believing them and not blaming them for sexual
abuse.
Interviewing a Survivor of Child Sexual Abuse

 Health workers responsible for investigative

interviewing of children in cases of alleged sexual
abuse need to bear in mind that:
 Child survivors should be approached with extreme
sensitivity and their vulnerability recognized and
understood.
 They should try to establish a neutral environment and
rapport with the child before beginning the interview.
 Things to Consider When Interviewing a
Child Survivor of Violence
 Approach all children with sensitivity and recognize their
vulnerability.
 Try to establish a neutral environment and rapport with the child
before beginning the interview.
 Try to determine the child’s developmental level in order to
understand any limitations as well as appropriate interactions.
 It is important to realize that young children have little or no
concept of numbers or time and that they may use terminology
differently than adults, making interpretation of questions and
answers a sensitive matter.
 Always identify yourself as a helping person.
Things to Consider When Interviewing a
Child Survivor of Violence
 Ask the child if s/he knows why s/he has come to see you.
 Establish ground rules for the interview, including permission
for the child to say s/he doesn’t know, permission to correct
the interviewer, and the difference between truth and lies.
 Ask the child to describe what happened, or is happening, to
them in their own words.
 Always begin with open-ended questions. Avoid the use of
leading questions and use direct questioning only when
open-ended questioning/free narrative has been exhausted.
 Structured interviewing protocols can reduce interviewer bias
and preserve objectivity.
Things to Consider When Interviewing a
Child Survivor of Violence

 When planning investigative strategies, consider

other children (boys as well as girls) who may
have had contact with the alleged perpetrator.
 For example, there may be an indication to examine
the child’s siblings.

 Also consider interviewing the caretaker of the child

without the child present.
 Guiding Principles for Interviewing a
Child Victim of Violence
 Be nurturing, comforting, and supportive.

 Reassure the child.

 Do no harm: Be careful not to traumatize the child further.

 Speak so the child understands.

 Help the child feel safe.

 Tell the child why you are talking with him/her.

 Use appropriate people.

 Use nonverbal communication and pay attention to body language.

 Respect the child’s opinions, beliefs, and thoughts.

 Empower the child.

 Key Points

 Principles of interpersonal communication

for effective provision of services to GBV
and VAC survivors.
 Importance of self awareness and values in
provision of services.
 Evaluation

What key skills does a health worker need to

have in order to effectively communicate
with children and adolescents?
Questions?

40
Thank you for
your attention

41
SESSION 2.2
Principles and Procedures for
Management of GBV and VAC
Survivors

42
 Learning Tasks

By the end of this session participants are

expected to be able to:
 Screen for GBV and VAC survivors.
 Obtain consent from the client.
 Conduct comprehensive history from GBV/VAC
survivors.

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Basic Principles for Providing Care to
GBV and VAC Survivors

 Ensure the safety of the survivor.

 Ensure confidentiality.
 Respect the wishes, rights, and dignity of
the survivor.
 Ensure nondiscrimination.
Importance of GBV/VAC Screening

 Survivors of violence tend to use health care

services and average more visits than the
general population.
 Providers often fail to correctly detect the real
cause of the health problems presented by
survivors of violence.
 Screening improves quality of survivor care.
Importance of GBV/VAC Screening

 Early identification of survivors allows the provider

to help survivors before the violence escalates.
 Early recognition significantly reduces the
morbidity and mortality that results from violence.
 Screening enables the provider to accurately
diagnose the problem.
 Screening enables links between the survivor with
other services.
Importance of GBV/VAC Screening
 Service providers can document the survivor’s history of
abuse which can be important in a legal case.
 The MOHCDGEC of URT recommends selective screening for
GBV and VAC survivors which means asking an individual
about violence when a health care provider has some reason
to suspect violence/abuse based on certain signs and
symptoms.
 Asking all individuals in a given health care setting about
experiences of violence/abuse, whether or not they have signs
or symptoms (universal screening) is not recommended.
Steps for Screening for GBV and VAC

 Attend to the client’s current needs.

 Engage the client in the screening
process.
 Screen the patient.
 Address safety and referral measures.
 Obtaining Consent
In the context of GBV and VAC, informed consent should give
adequate information to the survivor, including:
 What the history-taking process will involve
 Types of questions that will be asked and the reason those
questions will be asked
 What the physical and pelvic examination will involve
 Examination will be conducted in privacy and in a dignified
manner
 S/he will lie on an examination couch/bed during
examination.

49
 Obtaining Consent
 Genital and anal examinations will require
her/him to lie in a position where genitals can be
adequately seen with the correct lighting.
 Specimen collection (where needed) involves
touching the body and body openings with
swabs and collecting body materials such as
head hair, pubic hair, genital secretions, blood,
urine, and saliva.

50
 Obtaining Consent
 Clothing may be collected.
 Not all of the results of the forensic analysis may be made
available to the survivor.
 S/he can refuse any aspect of the examination that s/he does
not wish to undergo.
 S/he will be asked to sign a form that documents consent.
 Inform the survivor that information discussed during the
examination will be conveyed to relevant legal authorities ONLY
if s/he decides to pursue legal action (with the exception of
mandated reporting).

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Obtaining Consent from Child Survivors
 According to the Tanzania Law of the Child Act child
protection regulations, the social welfare officer shall seek
alternative consent for the examination and any necessary
treatment of the child, in cases where the following three
things pertain:
 There is reasonable cause to believe that a child is suffering or
is at risk of suffering significant harm.
 The Social Welfare Department has decided that a medical
examination of the child or any other child in the household
should be undertaken.
 The parents, guardian or carer refuse to consent to such an
examination.
Obtaining Consent from Child Survivors

 In such cases:
 Consent may be provided by the child, where he
or she is of sufficient maturity to understand why
a medical examination and treatment should be
undertaken.
 The determination of whether the child is of
sufficient maturity shall lie with the doctor
undertaking the examination.
 Obtaining Consent from Child Survivors
 In all other cases, where consent is not forthcoming, the Social
Welfare Officer may seek an order from the juvenile court under
section LCA 95(3)(a) permitting the medical examination to take
place. Any such application shall be heard on the day that the
application is made.
 Children 16 years and older are generally sufficiently mature to
make decisions.
 Children between ages 14 and 16 are presumed to be mature
enough to make a major contribution. Children between ages 9
and 14 can meaningfully participate in the decision-making
procedure, but maturity must be assessed on an individual basis.
 Obtaining Consent from Child
Survivors
 Children younger than age 9 also have the right to give their informed opinion.
 Involve the children’s department, social welfare workers, and police so
investigations can start while the child is in a safe place.
 Consent for a child survivor is signed by the child’s parent or legal guardian, unless
the child’s parent/guardian is the suspected perpetrator.
 If the parent/guardian is the suspected perpetrator, a consent form may be signed
by a social welfare officer, head of facility, or three health facility staff members,
keeping in line with the Tanzania’s Law of the Child Act 2009.
 However, the most crucial thing to remember about consent is that, while legally
children cannot give consent to examination and services, they shall not be
compelled or forced to undergo an examination or treatment, unless it is necessary
to save the life of the child.
Guidelines for Taking History
ACTIVITY: Brainstorming
What types of information will you collect
when taking history from a GBV/VAC
survivor?
 Guidelines for Taking History
 Introduce yourself to the survivor and explain your
role.
 Explain what you are going to do at every step.
 Ask if the survivor wants to have a specific support
person of his/her choice present.
 Cover the medical instruments until they are needed if
the interview is conducted in the treatment room.
 Avoid any distractions or interruptions while you are
taking the history.
 Guidelines for Taking History
 Limit the number of people allowed in the room during the
examination. If others are present, explain their role and ask
permission from the survivor.
 Reassure the survivor that any information given or found during
examination will be kept confidential.
 Provide relevant information on the GBV incident and the need
for medicolegal documentation.
 Review any documents or paperwork brought by the survivor to
the health center before taking the history. This may include
referral notes.
Guidelines for Taking History
 Use a calm tone of voice and maintain eye contact if culturally
appropriate.
 Let the survivor tell her/his story the way s/he wants to.
 Explain to the survivor that s/he is in control of the pace and
timing during the conversation.
 Avoid questions that suggest blame or judgment, such as:
“What were you doing there alone?”
 Take sufficient time to collect all needed information without
rushing.
 Do not ask questions that have already been asked and
documented by other people involved in the case.
Guidelines for Taking History
 Have the survivor sign the consent form if the situation dictates,
otherwise the survivor may wish to sign later during the course of
treatment.
 In case of medicolegal issues, you must obtain history after the
survivor consents. Note that the survivor may wish to get medical
services only and opt not to pursue legal redress—respect that!
 When interviewing children, the age and cognitive development of
the child will influence the way in which the interview is conducted.
 Every effort should be made to minimize the number of times the
child is interviewed.
 Refer participants to session on communication with children.
 Steps for History Taking

The provider may not necessarily follow the order

provided here. However, it is necessary to make sure all
the elements in the history-taking are well-covered and -
-documented in the GBV and VAC form. History
comprises the following:
 General information
 Incident description
 Sexual and gynecologic history
 Mental health history
 Past medical and surgical history.
 General Information in History Taking
 Ask and document:
 Name
 Address
 Sex
 Date of birth
 Date and time of the examination
 Names and function of any staff or support person
present during the interview and examination.
 Description of the Incident
 Ask the survivor to describe what happened.
 Allow survivor to speak at his/her own pace.
 Do not interrupt to ask for details.
 Follow up with clarification questions after
s/he finishes telling her/his story.
 Explain that s/he does not have to tell you
anything s/he does not feel comfortable with.
 Description of the Incident

 Reassure her/him of confidentiality if s/he is reluctant to

give detailed information.
 Obtain information about the perpetrator.
 Determine whether the survivor has
 Bathed, urinated, defecated, vomited, used a vaginal douche.
 Changed his/her clothes since the incident, if the incident
occurred within 72 hours.
 This may affect what forensic evidence can be collected.
 Sexual History
 Obtain history of prior sexual encounters, as well as
whether or not they were consensual.
 Find out if the survivor has a sexual partner (or
partners). Determine the last time the survivor had
sexual intercourse prior to the incident.
 Determine if the survivor has had STIs before and if
s/he was treated.
 Determine if the survivor has ever been tested for
HIV before and his/her HIV status.
 Gynecological History

 Inquire if the survivor had attained menarche.

 Obtain the date of the first day of her last menstrual
period.
 Determine if the survivor has ever been pregnant. If so,
when and what was the outcome.
 Determine if the survivor uses contraception. If so, the
type, since when, and her compliance, when relevant.
 Evaluate for possible pregnancy.
 Mental Health History
 Obtain a mental health history, including:
 Previous and current psychiatric diagnoses
 Prior hospitalization
 Previous and current medication
 Drug use
 Family history of mental illness
 Symptoms of depression, anxiety, suicidal
behaviors, or substance abuse.
 Medical History
 Ask about:
 Medical conditions
 Allergies
 Use of alcohol/drugs
 Vaccination
 HIV status
 Previous surgery
 These questions can help determine the best
treatment, counselling and referrals.
 Safety Planning for Survivors of GBV
and VAC
 Safety plan is developed collaboratively by a health care
provider/social welfare officer and GBV or VAC survivor. It contains
specific activities and measures to be taken to keep a survivor safe
from an offender.
 It is an essential step to be completed with all adult and child
survivors of violence.
 It allows individualized planning for situations the survivor and
children or family may encounter while planning for their next steps.
 Age-appropriate safety planning is also important for child
survivors/witnesses of domestic violence.
 Safety Planning for Survivors of GBV
and VAC
 Things to consider:
 Keep a record of phone numbers of important people,
that is, those who can help if violence occurs.
 Plan an escape route out of your home. Teach your
children the route too.
 Put away some money—even if it is just enough for
public transport.
 Keep copies of your ID, student ID, maternal and child
health clinic cards, and birth certificates in a safe place.
 Safety Planning for Survivors of GBV
and VAC
 Things to consider:
 Put together a bag/basket/pouch of essential
clothing and medicines. Leave it with a trusted
friend.
 Have the numbers of the shelters handy, but hidden.
 In a violent situation, avoid rooms with access to
weapons (e.g., kitchen).
 Teach children not to intervene in a violent situation.
The most important thing is for the children to be
protected and to protect themselves.
 Safety Planning for Survivors of GBV
and VAC
 Things to consider:

 Teach your children a code and use it to signal when you need them to
go get help.

 Change your routine, schedule, or the route you take your children to
school when you decide to leave or have already left the abusive
relationship.

 Alert school authorities of the situation.

 Talk to your neighbors and request that they call the police if they feel
you may be in danger.

 Safety plan should not be documented anywhere.

 Safety Planning for Survivors of GBV
and VAC
 Safety and referral measures:
 For clients who turn out to be GBV or VAC survivors,
different needs will arise from their narrations/stories.

 Health care providers should ask additional questions to

understand and address a survivor’s needs.

 Screening for GBV or VAC and then not addressing the

needs is unethical and may put the survivor in more
danger.
 Safety Planning for Survivors of GBV
and VAC

When you talk about safety with the victim, start with
the following questions:

 How can I help you?

 What do you need to feel safe?

 What have you tried in the past to protect yourself

(and your children)?

 What worked? What did not work?

 Safety Planning for Survivors of GBV
and VAC
If the survivor is separated from the perpetrator and living alone, discuss the
following options:

 Changing the locks; installing a better security system.

 Talking to schools and about the danger and giving them clear
directions about who has permission to pick up the children.

 Teaching the children how to call the police or other persons who can help
(family members, friends, etc.).

 Finding a victim support service that can help them and inform them of their
rights and available legal protection.

 Finding a competent lawyer.

 Applying for a protection order at the court.

 Asking somebody to move into the house so that they are not alone.
 Safety Planning for Survivors of GBV
and VAC
If the victim is planning to leave the perpetrator:
 How and when can the victim (and the children) leave
most safely?
 Do they have a car or other transportation? Money?
 Do they have a safe place to go to?
 What can the victim and others do to make sure they
will not be located by the perpetrator?
 What should they take?
 Key Points

 Screening should be conducted for

individuals presenting with symptoms of
abuse.
 Consent needs to be explained to and
obtained from the client.
 Obtaining a comprehensive GBV/VAC
history is important for medical and legal
reasons.
 Evaluation

 Explain the steps for obtaining consent

from an adult survivor and from a child
survivor.
 Explain the screening process.
 Identify considerations that need to be
made when safety planning with survivors.
Questions?

79
Thank you for
your attention

80
SESSION 2.3
Physical Examination and
Treatment of Survivors

81
 Learning Tasks
• Perform physical examination of GBV/VAC survivors
for medical and medical-legal purposes.
• Conduct investigations and gather evidence for
medical and medicolegal purposes while maintaining
sample integrity (move to session on forensic sample
collection).
• Provide post-trauma medical treatments (pain, wound
care, surgeries, antibiotics, etc.).
• Provide preventive therapy (PEP, ECP, TT, STI-PT).
• Provide appropriate referral(s).
 Demonstration

 Discuss and repeat demonstration as needed.

 Observe while the facilitator demonstrates the following

examinations:
 Head-to-toe examination

 Mental status assessment

 Genital-anal examination

 Discuss and repeat demonstration as needed.

Procedure for Comprehensive Physical
Examination of Adult GBV Survivors
 Inform the survivor that at any point during the
physical examination, s/he can ask the provider to
stop.

 Tell the survivor what to expect at every step of the

physical examination and what will happen next.

 Collect specimens as the physical examination is

being conducted.

 Examine the GBV survivor systematically.

 Procedure for Comprehensive Physical
Examination of Adult GBV Survivors
 Collect clothes for forensic examination and put them
in a paper sheet/bag when sexual and physical
violence has occurred.
 Undress the survivor over a large sheet of paper to
collect debris such as vegetation, insects, dirt, and hairs
that would support her/his information about the assault
or violence.
 Record all findings appropriately in a GBV Medical
Form. If this form is not available, record findings on a
sheet of paper, following the GBV form format.
 Steps of Physical Examination

 Head-to-toe examination

 Mental status examination

 Genital and anal examination

 Head-to-Toe Examination
Conduct a head-to-toe examination, paying special
attention to the face, upper limbs, neck, breasts, thighs,
and perineum when sexual violence is involved.
 Note the general appearance of the survivor.
 Take vital signs.
 Examine the scalp for any injuries and signs of
inflammation.
 Inspect the face, eyes, and ears.
 Examine the upper limbs for signs of injuries.
 Head-to-Toe Examination
 Examine:
 Neck for bruises and life-threatening assaults

 Breasts and trunk for bites and other injuries

 Abdomen and chest for internal injuries/pregnancy

 Lower limbs.

 Collect forensic specimens as you examine the

survivor.
 Mental Status Assessment
The following are the components of mental status
examination:
 Appearance and behavior
 Mood
 Affect
 Speech
 Perception
 Thought
 Cognition and sensorium.
 Mental Status Assessment
Appearance and behaviour:
Appearance upon entering the interview
Changes in posture and motor activity
Record the survivor’s facial expressions and attitude toward the
examiner, including eye contact.
Note whether the survivor appeared interested during the interview
or bored.
Assess whether the survivor is hostile and defensive or friendly and
cooperative.
Record notes on grooming and hygiene.
 Mental Status Assessment
Mood

 Ask questions such as “How do you feel now and most of the days for the
past two weeks?” to trigger a response.

 Helpful answers include those that specifically describe the survivor’s mood,
such as “depressed,” “anxious,” “happy,” or “irritable.”

 These responses require further questioning for clarification.

Affect

 Observations made by the interviewer

 May be defined as expansive (happy and contagious), euthymic (normal),

constricted (limited variation), blunted (minimal variation), or flat (no
variation).
 Mental Status Assessment
Speech
 Document information on all aspects of
the survivor’s speech.
 If the survivor is depressed or anxious, the
speech could be low in tone and slow.
 Sometimes speech can be word salad
(nonsensical responses, i.e., jabberwocky)
or neologism (creating new words).
 Mental Status Assessment
Perception
 Determine if the survivor is experiencing
hallucinations.
 Ask about his/her experience of hearing
abnormal voices when no one else is around,
seeing abnormal things/images/people that
no one else can see, or other unexplained
sensations such as unusual smells, sounds, or
feelings.
 Mental Status Assessment
Thought Processes
 Record how the survivor processes
information: whether it is relevant to the
topic, contains racing or rapid thoughts, is
vague (beating around the bush) or limited
in content.
 Mental Status Assessment
Thought Content
 Note if a survivor is having delusions (fixed false beliefs about
something) or if other people have told her/him that his thoughts are
strange.
 Sometimes a survivor may report having special powers or abilities, or
receiving special messages through television or radio. All these indicate
delusions.
 Signs of ritualistic type behaviors should be explored further to
determine the severity of the obsession or compulsion.
 Determine if survivor has any fears that cause him/her to avoid certain
situations.
 Mental Status Assessment
Thought Content
• Assess for suicidal ideation or intent: start by inquiring if the
survivor feels like losing hope, thinking that they were better off
dead, or having thoughts of wanting to harm or kill themselves.
• If the reply is positive for these thoughts, inquire about specific
plans.
• Assess for any risk of homicidal ideation or intent: inquire from
the survivor if they have any thoughts about wanting to hurt
anyone or wishing that someone were dead.
• If the reply to one of these questions is positive, ask the survivor if
s/he has any specific plans.
 Mental Status Assessment
Cognition and Sensorium

 Consciousness

 Orientation to people, place, and time

 Impulsivity

 Reliability.
 Genital and Anal Examination
For women:
 Explain the procedure to the survivor, providing
details of each step.
 Examine the outer genitalia:
 Examine the pubic hair, labia majora and minora, urethral
meatus, introitus, and perineum.
 Look for swellings, mucosal injuries, bruises, lacerations,
bleeding, or other injuries.
 Gather pubic hair and any other pieces of physical
evidence that may be seen in the genitalia.
 Genital and Anal Examination
 Examine the inner genitalia:
 Examine the hymen, vagina, posterior fornix, portio, and
cervix.
 Look for swellings, mucosal injuries, bruises, lacerations,
bleeding, or other injuries.
 NOTE: Lubricate with water ONLY.

 Bimanual palpation of the cervix, uterus,

ovaries/oviduct:
 Look for tenderness when palpating and other abnormal
findings during palpation.
 Genital and Anal Examination
 Conduct speculum and digital examinations:
 This should be done after taking the external and
internal vaginal swabs.
 High vaginal swab should be taken during speculum
examination.

 Examine the anus for redness, swelling,

bleeding, mucosal lacerations or fissures,
scarring, sphincter injury, or pain to palpation.
 Look for secretions or foreign materials.
 Genital and Anal Examination
 Conduct proctoscopy if indicated (lubricate
with water only).
 Look for redness, swelling, bleeding, lacerations

 Document any wounds, giving the location,

size, and type (bruise, stab wound, incised
wound, or laceration).
 Control for bleeding, if any.
 Genital and Anal Examination
 Take the swabs in the following order:
 external vaginal swab

 internal vaginal swab

 high vaginal swab

 rectal swab.

 The other swabs are oral swabs for secretory factors in

cases where oral sex is implicated and skin swabs when
a suspicious seminal stain is present on the skin.
 Genital and Anal Examination
For men:
 Examine the outer genitalia
 Pubic hair, penis shaft, frenulum, glans, urethral
meatus, scrotum).
 Look for swellings, mucosal injuries, bruises,
lacerations, bleeding or other injuries.
 Obtain pubic hair and any other pieces of physical
evidence that may be seen in the genitalia.
 Genital and Anal Examination
For men:
 Examine the anus for redness, swelling,
bleeding, mucosal lacerations or fissures,
scarring, sphincter injury or pain to palpation:

 Document any wounds, giving the

location, size, and type.

 Look for secretions or foreign materials.

 Genital and Anal Examination
For men:
 Collect swabs from areas of contact and other
specimens as you conduct the physical
examination.
 Conduct proctoscopy if indicated (lubricate with
water ONLY).
 Look for redness, swelling, bleeding, and lacerations.
 Control bleeding, if any.
 Physical Examination of Children and
Adolescent Survivors

Steps for performing physical examination in

children and adolescents are sometimes
different than steps for performing physical
examination in adult survivors, although the
domains may appear the same.
 Physical Examination of Children and
Adolescent Survivors
 Record height and weight of the child.

 Note and describe the location and size of:

 Bruises

 Burns

 Scars

 Rashes on the skin.

 Physical Examination of Children and
Adolescent Survivors
 Examine mouth/pharynx; note for:
 Petechiae of the palate or posterior pharynx
 Tears to the frenulum.

 Examine neck and extremities:

 Signs that force and/or restraints were used.

 Record the child’s sexual development.

 Check the breasts for signs of injury.

 Physical Examination of Children and
Adolescent Survivors
Mental status examination in children is done in a few
aspects only, including:

 Appearance and behaviour:

 Anxious, extreme fearful, restless, hyperactive, hostile
or defensive.

 Mood and affect; it is important to record how the

child feels in his/her own words, and how s/he
expresses his/her feelings.
 Physical Examination of Children and
Adolescent Survivors
For girls:

 Explain each step of the examination.

 Examine the external genitalia.

 Examine the labia and other related structures.

 Examine the hymen and note the location of any fresh or healed tears
in the hymen and the vaginal mucosa.

 The amount of hymeneal tissue and the size of the vaginal orifice are not
sensitive indicators of penetration.

 Do not carry out a digital vaginal examination if the hymen is intact.

 Physical Examination of Children and
Adolescent Survivors
For girls:
 Speculum examination:
 Should be avoided, considered only if the child has
internal bleeding from a penetrating vaginal injury.

 If necessary, it should be done under general anesthesia.

 Use a pediatric or nasal speculum.

 Refer to a higher level health facility for this procedure.

 Physical Examination of Children and
Adolescent Survivors
For girls:

 Examine the anus with the child in the supine or lateral position.
 Avoid the knee-chest position, as assailants often use it.

 Look for bruises, tears, or discharge. Record the position of any

anal fissures or tears.

 Do not carry out a digital examination to assess anal sphincter

tone.

 Reflex anal dilatation can be indicative of anal penetration, but

also of constipation.
 Physical Examination of Children and
Adolescent Survivors
For boys:
 Check for injuries to the skin that connects the foreskin to
the penis.

 In an older child, the foreskin should be gently pulled back

to examine the penis.

 Do not force it since doing so can cause trauma,

especially in a young child.

 Check for discharge at the urethral meatus (tip of penis).

 Physical Examination of Children and
Adolescent Survivors
For boys:

 Examine the anus, looking for bruises, tears, or discharge, and help the boy to lie
on his back or on his side.

 Avoid knee to chest position as this may mimic abuse.

 Consider a digital rectal examination only if medically indicated.

 Check for injuries to the frenulum of the prepuce and for anal or urethral
discharge.

 Take swabs if indicated. Record the position of any anal fissures or tears.

 Reflex anal dilatation can be indicative of anal penetration, but also of

constipation.
 Providing Post-Trauma Medical
Treatments
Guiding Points for Providing Medical Treatment to
GBV and VAC Survivors
 Treat all GBV and VAC cases as emergencies and do
not allow them to queue in the intake line.
 Attend to life threatening injuries as a first priority
before all other aspects of GBV care.
 Any medical officer, clinical officer, or nurse who is
trained in GBV and VAC may manage a survivor and be
able to fill in the GBV documentation forms.
 Providing Post-Trauma Medical
Treatments
 Preventive treatments should be provided concurrently with other medical
procedures, including post-exposure prophylaxis (PEP), emergency
contraception, and tetanus toxoid. Presumptive treatment for STIs should
be given if indicated.

 All GBV survivors require GBV psychosocial assessment, counseling,

psychosocial support, and follow-up once they are stable.

 Health care providers should ensure proper documentation and

safekeeping of medical records for purposes of security and for future use.

 All health institutions providing GBV services should have a network

directory of GBV service providers within their locality for purposes of
referral.
 Physical Injury Management
Procedures for physical injury management
 Abrasions and lacerations:
 Clean wound with antiseptic solution.

 Stitch under local anesthesia.

 Genital injuries:
 Speculum examination and high vaginal swab require the
patient to be in lithotomy position.

 Consider sedation or general anesthesia if the survivor is

anxious, has major injuries, or requires sutures.
 Physical Injury Management
Procedures for physical injury management:
 Vaginal injuries with cuts requiring sutures should be managed under
sedation or anesthesia.

 In cases of confirmed or suspected perforation, laparotomy should be

performed and any intra-abdominal injury repaired.

 Other supportive medication should be given, including analgesics and

antibiotics (when required).

 All these must be done in a room with privacy.

 For life-threatening conditions like severe injuries or shock, procedures

should be done in a place with the capacity to conduct them.
 Preventive Therapies
 Perform counseling and testing at baseline
before administering PEP. It is important to
establish the survivor’s baseline.
 Determine HIV status before administering
PEP in order to prevent the potential for
developing drug resistance if the
individual is found to be HIV-positive.
 Preventive Therapies
 If a rape survivor is HIV negative,
 Administer the first dose of PEP as early as possible. The efficacy of
PEP decreases with the length of time after an assault.
 Offer PEP promptly, preferably within 2 hours but not later than 72
hours after survivor was raped.

 If the rape survivor is HIV positive,

 Refer the person to HIV Care and Treatment Center (CTC) for
enrollment and further management.
 Do not offer PEP.

 Rape survivors presenting later than 72 hours after being raped

should not be offered PEP.
 Preventive Therapies
If the rape survivor is not psychologically ready:
 The baseline HIV test can be delayed by up to 3 days after
commencement of PEP.
 If the test result is positive, PEP should be stopped and the
patient should be referred to a CTC.
 It should also be explained to the rape survivor that the HIV
infection is not the consequence of the sexual assault but from
previous exposure.
 Provide psychosocial support and ensure adherence to PEP
regime. The loss rate is high in this group of patients.
 Monitor for antiretroviral drug toxicity and manage the conditions
(if present) accordingly.
 PEP Regimen for Adults
The recommended HIV PEP (post-exposure
prophylaxis) regimen is:
 Tenofovir 300 mg PO od, + lamivudine 300 mg PO
od + efavirenz 600 mg once a day for 4 weeks.
 Alternatively, the following regimens can be given,
but they are not recommended for routine PEP:
 Zidovudine 300 mg bd + lamivudine 150 mg PO bd +
efavirenz 600 mg PO od
 Tenofovir 300 mg PO od, + lamivudine 300 mg PO od
+ ritonavir100 mg PO od— boosted Lopinavir (400
mg).
 PEP Regimen for Children
Medicine Application
First Line • Tenofovir/lamivudine/efavirenz Once a day PO for
(tab/cap) 75/75/150 mg 28 days (dose
• Tenofovir (oral powder/tabs) + depends on body
lamivudine (syrup) + efavirenz weight)
(tab/cap)
Second • Lopinavir/Ritonavir (80/20 mg per ml) Twice a day PO for
Line • Lopinavir 10 mg per kg/RTV 2.5 mg 28 days
per kg up to 400/100 mg (5 mls)
 Emergency Contraception
According to national guidelines, the options for emergency
contraception (EC) are:
 Progestin only pills; Postinor 2® (Levonogestrel) 1 tab bd stat (or 2 tabs
stat)
 Progestion only pills; POP (Levonogestrel/Norgestere) 20 every 12
hours (total 40 tabs per day) for 1 day
 Combined oral contraceptive pills with high dose of estrogen (50 μg);
Ovral® 2 tabs every 12 hours (total 4 tabs per day) for 1 day
 Combined oral contraceptive pills with high dose of estrogen (30 μg);
Nordette® 4 tabs every 12 hours (total 8 tabs per day) for 1 day
 Emergency Contraception
 Hormonal methods of contraception can be used to prevent
pregnancy if taken within 120 hours following an unprotected act
of sexual intercourse.
 When initiated within 24 hours after unprotected sexual
intercourse they prevent pregnancy by 95 percent; if used
between 24 and 48 hours they prevent pregnancy by 85 percent.
The sooner ECPs (Levonorgestrel 0.75mg, Postnor 2) are taken
after unprotected sexual intercourse, the better the prevention of
pregnancy.
 First dose: ECP method should be taken as soon as possible within
120 hours of unprotected intercourse.
 Second dose: Taken 12 hours after the first dose.
 EC Regimes and Doses
 Progestin only pills; Postinor 2® (Levonogestrel) 1 tab
bd stat (or 2 tabs stat)
 Progestin only pills; POP (Levonogestrel/ Norgestere)
20 every 12 hours (total 40 tabs per day)
 Combined oral contraceptive pills with high dose of
estrogen (50 μg); Ovral® 2 tabs every 12 hours (total
4 tabs per day)
 Combined oral contraceptive pills with high dose of
estrogen (30 μg); Nordette® 4 tabs every 12 hours
(total 8 tabs per day)
 Tetanus Prevention

 Two reasons for giving tetanus toxoid to a

GBV/VAC survivor are:
 breaks in skin

 break in mucosa.

 Tetanus prophylaxis is not needed for the

survivor who has been fully vaccinated.
 Tetanus Toxoid Vaccine (TT)
Schedule

Duration of
Administration
Dosing Schedule Immunity
Schedule
Conferred
1st TT dose At first contact Nil
2nd TT dose 1 month after 1st 1–3 years
TT
3rd TT dose 6 months after 2nd 5 years
TT
4th TT dose 1 Year after 3rd TT 10 years
 Treatment of STIs of GBV and
VAC Survivors
 A presumptive treatment for STIs/RTIs should be provided in accordance with the
National Sexually Transmitted Infections/Reproductive Tract Infections (STI/RTI)
guidelines to all victims of rape or sexual assault among GBV and VAC survivors as
follows:
 Non-pregnant adults, male or female:
 Norfloxacin 800 mg stat plus
 Doxycycline 100 mg bd X 7 days
 Pregnant women:
 Spectinomycin 2 g stat and
 Amoxil 3 g stat and
 Probenecid 1 g stat and
 Erythromycin 500mg qds X 7 days
 Children:
 Amoxil 15 mg/kg tds X 7 days and
 Erythromycin 10 mg/kg qds 7 days
 Procedures for Conducting
Laboratory Investigations
Laboratory tests include: HIV testing, pregnancy tests, urinalysis, and screening for STIs, but
additional tests can be done according to the clinician’s opinion and recommended
procedures for the level of health facility.
GBV survivors may contract an STI as a direct result of the assault. Infections most frequently
contracted by the survivors, and for which there are effective treatment options, are as
follows:
 HIV
 Chlamydia
 Gonorrhea
 Syphillis
 Trichomoniasis
 Human papilloma virus (HPV)
 Herpes simplex virus type 2
 Hepatitis B and C
 Key Points
 Treat all GBV and VAC cases as an emergency
and do not let survivors wait in a queue

 Attend to all life-threatening injuries as a first

priority before other aspects of GBV/VAC care.

 Preventive therapy should be provided

concurrently with other medical procedures.
 Evaluation

What are the preventive therapies that can

be offered to a GBV and VAC survivor?
Questions?

133
Thank you for
your attention

134
SESSION 2.4
Forensic Sample/Evidence
Management

135
 Learning Tasks
 Define the term “forensic evidence” and give examples.
 Facilitate chain of custody and documentation of
sample/evidence related to GBV and VAC survivors.
 Interpret findings from GBV and VAC survivors before the court
of law.
 Explain procedures for collecting and handling specimens and
other relevant information for medical legal evidence.
 Explain procedures for storage and transportation of samples of
forensic evidence.
 Explain roles of health care providers and social welfare officers
as factual or expert witnesses.
 Introduction to Forensic Evidence
 Chain of evidence: The process of obtaining, processing, and
conveying evidence whereby movement of evidence is traceable
through the different persons in the chain of sample collection,
analysis, investigations, and legal action.
 Evidence: A piece of information indicating whether a belief is true or
valid to establish facts in a legal investigation or admissible as
testimony in a court of law.
 Forensic evidence: (also known as medicolegal evidence) Evidence
collected during a medical examination using scientific methods. This
includes biological materials such as blood, hair, urine, sperm and
seminal fluid, nails, and DNA, where available, which can be used in
court to link the suspect to the crime.
 Introduction to Forensic Evidence
 Crime: An act committed or omission that
constitutes a serious offense against an individual or
the state and is punishable by law.
 Physical evidence: An exhibit in the form of
objects, material, or substances (e.g., condoms,
ropes, cigarette butts, masks) that support the
investigation process in identifying the suspect in
the crime.
 Witness: A person who sees an event take place or
gives sworn testimony to a court of law or the
police.
 Introduction to Forensic Evidence
 Purpose of forensic evidence: Forensic evidence is used to link the suspect to the
crime (or de-link the suspect from the crime), to ascertain that violence occurred,
and to help in collection of data on the perpetrator of violence.
 Two types of evidence
 Evidence to confirm that assault has occurred, for example:
• Evidence of penetration (torn hymen)

• Bruises, tears, and cuts around the genitalia/anus

• Stained clothes.

 Evidence to link the alleged perpetrators to the assault, for example:

• Perpetrator’s torn clothes

• Used condoms

• Grass and blood stains

• Scratches and bite marks on the perpetrator

• Eye witness testimony.

 Introduction to Forensic Evidence
Forensic materials to be collected
 Mouth swab
 Urine of both the victim and the suspect
 Pubic and/or head hair
 Foreign fibers, grass, soil
 Blood
 Semen
 Fingernails, scrapings or clippings
NOTE: Different materials can be collected from objects, the body, or at a
crime location. Material collected can be from the perpetrator, victim, or
witness.
 Clinical Procedures for Collecting and
Handling Specimens as Forensic Evidence
 Strictly adhere to the following principles when collecting
specimens for forensic analysis:
 Avoid contamination: Ensure that specimens are not contaminated
by other materials. Store each exhibit separately using clean
containers and ensuring protection from weather and other
contamination. Wear gloves at all times for your own protection and
also to ensure that the exhibit is not contaminated.

 Collect early: Try to collect forensic specimens as soon as possible

after the assault. The likelihood of collecting evidentiary material
decreases with the passing of time. Ideally, specimens should be
collected within 24 hours of the assault. After 72 hours, yields are
reduced considerably.
 Clinical Procedures for Collecting and
Handling Specimens as Forensic Evidence
 Handle appropriately: Ensure that specimens are packed, stored, and
transported correctly. As a general rule, some fluids (e.g., urine) should be
refrigerated; anything else should be kept dry. In some instances, blood
can be dried on gauze and stored as such. Biological evidence material
(e.g., body fluids, soiled clothes) should be packaged in paper envelopes
or bags after drying. Avoid use of plastic bags.
 Label accurately: All specimens must be clearly labeled with the survivor’s
name and date of birth, the health care worker’s name, the type of
specimen, and the date and time of collection.
 Ensure security: Specimens should be packed to ensure that they are
secure and tamperproof. Only authorized people should be entrusted with
specimens.
 Clinical Procedures for Collecting and
Handling Specimens as Forensic Evidence
 Maintain continuity: Once a specimen has been
collected, its subsequent handling should be recorded.
Details of the transfer of the specimen between
individuals should also be recorded. Maintain an
exhibit/evidence register at each facility. Ensure that
the survivor does not move any samples taken from
one facility to another for any analysis.
 Document collection: It is good practice to compile
an itemized list in the survivor’s medical notes/reports
of all specimens collected and details of when and to
whom they were transferred.
 Clinical Procedures for Collecting and
Handling Specimens as Forensic Evidence

General considerations for collection of various forensic

materials
 If specimens are collected within 72 hours of the incident,
injuries should be documented.
 Samples collected during this period, such as broad hour
saliva and sperm, may help to support the survivor’s story
and identify the perpetrator.
 After 72 hours of the incident, the amount and type of
evidence that can be collected will depend on the situation.
 Clinical Procedures for Collecting and
Handling Specimens as Forensic Evidence
When using swabs for the collection of various materials for forensic analysis:
 Use only sterile cotton swabs (or swabs recommended by your laboratory).
 Do not place the swabs in medium as this will result in bacterial overgrowth and
destruction of the material collected by the swab. Swabs placed in medium can
only be used for the collection of bacteriological specimens.
 Moisten swabs with sterile water or saline when collecting material from dry
surfaces (e.g., skin, anus).
 If microscopy is going to be performed (e.g., to check for the presence of
spermatozoa), a microscope slide should be prepared. Label slide and after
collecting the swab, rotate the tip of the swab on the slide. Both swab and slide
should be sent to the laboratory for analysis.
 All swabs and slides should be dried before sealing them in appropriate
transport containers. A hole or cut may be made in the swab sheath to allow
drying to continue.
 Clinical Procedures for Collecting and
Handling Specimens as Forensic Evidence

Foreign material attached to a victim’s skin

There are a number of ways in which foreign material attached to a survivor’s

skin or clothing can be collected:
 If there is a possibility that foreign materials have adhered to the
survivor’s skin or clothing, s/he should be asked to undress over a large
sheet of paper. Any loose material will fall onto the paper and can either
be collected with a pair of tweezers, or the entire sheet of paper can be
folded in on itself and sent to the laboratory.
 Alternatively, the survivor’s clothing can be collected and sent to the
laboratory. If the clothing is wet, however, it should be dried before
being packaged up and should be sent to the laboratory without delay.
 Clinical Procedures for Collecting and
Handling Specimens as Forensic Evidence

Scalp and pubic hair Materials from the mouth

 Collection of scalp hair is rarely  Firmly wiping a cotton swab on the inner
required, but may be indicated if hair is aspect of a cheek (i.e., a buccal swab) will
found at the scene. About 20 hairs can collect enough cellular material for
be plucked or cut. Ask for guidance analysis of the survivor’s DNA.
from the laboratory regarding the Alternatively, blood may be taken. Buccal
preferred sampling techniques for swabs should be dried after collection.
scalp hair.  Buccal swabs should not be collected if
 The survivor’s pubic hair may be there is any possibility of foreign
combed if you are looking for the material being present in the survivor’s
assailant’s pubic hair. The combings mouth (e.g., if ejaculation into the
should be transported in a sterile survivor’s mouth occurred).
container.
 Clinical Procedures for Collecting and
Handling Specimens as Forensic Evidence
Toxicological analysis

 This may be indicated if there is evidence that a survivor may have been
sedated for the purpose of a sexual assault. In cases where the survivor
presents within 12–14 hours after possible drug administration, blood
samples should be taken. Urine samples are appropriate when there are
longer delays.

 Seek the advice of the laboratory regarding suitable containers for

specimens of this type.

Other materials

 If the survivor scratched the assailant, material collected from under the
survivor’s nails may be used for DNA analysis.

 Sanitary pads or tampons should be air-dried if possible. They should then

be wrapped in tissue and placed in a paper bag.
 Clinical Procedures for Collecting and
Handling Specimens as Forensic Evidence
 All tests and results should be recorded on a laboratory form and/or
register that includes name, registration number, date, age, sex,
investigations done, specimens collected, results, and a place for
anyone who takes possession of the specimens to sign in order to
maintain a chain of custody of the evidence.

 All GBV and VAC registers, including those that contain laboratory
results, should be kept locked up and accessible only by authorized
health facility personnel as a measure to preserve confidentiality.

 The above tests can be carried out on the survivor and also on the
perpetrator.

 With regard to the perpetrator, the court can order that certain
specific samples be collected.
 Clinical Procedures for Collecting and
Handling Specimens as Forensic Evidence
Procedures for Storage and Transportation of Samples for Forensic Evidence

 Forensic evidence must be stored in a manner that ensures its integrity and maintains its
availability while criminal investigations and judicial proceedings continue.

 Each item should be properly filed and marked.

 Biological samples should be dried before packaging to minimize sample degradation.

 Packing in paper is preferred, but liquid samples should be packed in glass or plastic
containers.

 Dry stains, swabs, hairs, clothes, and nails are stored at room temperature.

 Wet samples and DNA extracts are stored frozen at –200C.

 During transportation, avoid keeping evidence in a vehicle for a long time. Heat, cold and
humidity can damage and destroy evidence.
Chain of Custody and Documentation of
Forensic Evidence

 Health care providers are required document evidence that

can corroborate the survivor’s account in a court of law.

 All the evidence collected should be recorded in the client

case note file and on the GBV Medical Form.

 All GBV and VAC registers, including those that contain

laboratory results, should be kept locked up and accessible
only by authorized health facility personnel as a measure to
preserve confidentiality.
Chain of Custody and Documentation of
Forensic Evidence

 Health care providers, as expert witnesses, are required to file

the Police Medical Form Number 3 (PF3).
 The PF3 form is a form that police use to request medical
examination of a survivor of an alleged offense. The form is
also linked to the victim receiving medical attention.
Chain of Custody and Documentation of
Forensic Evidence

After a review of the PF3 and the procedures for

receiving medical treatment when a PF3 is required to
be filed, it was decided that survivors are required to
get medical services immediately after the act, rather
than having to go to a police station first to acquire a
PF3 before they can receive medical attention. Police
are required to provide the PF3 to the medical staff and
victim at the health facilities.
 Chain of Custody and Documentation of
Forensic Evidence
 Other forms to document forensic evidence include:
 GBV and VAC Health Facility Register

 GBV and VAC Consent Form for Adult and Child

 Pictograms: Pictorial documentation is best to describe findings of physical

examination, laboratory investigations, and results (Refer to National
Guidelines for Health Sector Prevention and Response to GBV, 2011)

 Evidence should be released to the authorities only if the survivor

decides to proceed with a legal case.
 All test and results should be recorded on a laboratory form and register
that contains the name, registration number, date, age, sex,
investigations done, evidence collected, results, and a place for anyone
who moves the specimen to sign in order to maintain a chain of custody
of evidence.
 Demonstration
Observe while the facilitator demonstrates
the collection and documentation of
evidence on the GBV Medical Form and the
Police Form Number 3.
Steps to Maintain the Chain of Custody of
Forensics

 Preserve sample/evidence integrity, the sample

should be properly collected, packaged, and stored.
 Avoid tampering with the sample/evidence.
 Properly label and seal the sample to prevent
tampering.
 The chain of custody form and the right and
assurance form should be completed across all the
levels of sample/evidence management.
Steps to Maintain the Chain of Custody of
Forensics
Other forms to document forensic evidence include:
 GBV and VAC Health Facility Register
 GBV and VAC Consent Form for Adult and Child
 Pictograms
 Pictorial documentation is best to describe findings
of physical examination, laboratory investigations,
and results.
 Evidence should be released to the authorities only
if the survivor decides to proceed with a legal case.
 Role of Health Care Provider and Social
Welfare Officer as Factual or Expert Witness
Responsibilities of health care providers and social
welfare officers
 Collecting and handling the evidence and documenting
all the forensic information that can be used as exhibit.
 Reporting medical findings in a court of law. The health
worker who examines the survivor after the incident may
be asked to report on the findings in court . Providing
such evidence is an extension of their role in caring for
the survivor.
NOTE: It is the duty of the prosecutor to link the suspect to
the crime, not the health worker or social welfare officer.
 Role of Health Care Provider and Social
Welfare Officer as Factual or Expert Witness
How to appear in court as witness
• As a general rule, all witnesses must be examined in open court
under oath or affirmation. This means that they must swear or
affirm (depending on their religious beliefs) to tell the whole truth
and nothing but the truth.
• Use precise medical terminology.
• Answer questions as thoroughly and professionally as possible.
• If you do not know the answer to a question, say so. Do not make
up an answer and do not testify about matters that are outside
your area of expertise.
• Ask for clarification of questions that you do not understand. Do
not try to guess the meaning of a question.
 Role of Health Care Provider and Social
Welfare Officer as Factual or Expert Witness

Three stages in the examination of a witness:

1. Examination-in-chief
2. Cross-examination
3. Re-examination
NOTE: Examination of a witness must follow well-
defined rules of evidence and must not be done
haphazardly.
 Key Points
 Forensic evidence is the evidence (also
known as medicolegal evidence) collected
during a medical examination using scientific
methods.
 This includes biological materials such as
blood, hair, urine, sperm and seminal fluid,
nails, and DNA where available, which can be
used in court to link the suspect to the crime
 Evaluation

List materials and describe procedures for

collection of forensic evidence.
Questions?
SESSION 2.5
Psychosocial Care And Support

165
 Learning Tasks
By the end of this session participants are
expected to be able to:
 Describe psychosocial care and support and the
different approaches for provision of this service to
GBV and VAC survivors.
 Describe the importance of psychosocial care and
support to GBV and VAC survivors.
 Identify psychosocial needs of GBV and VAC survivors.

166
 Definition of Psychosocial Care and Support

Psychosocial care and support is the process of

meeting a person’s emotional, social, mental, and
spiritual needs that are essential elements of
positive human development. This support is
intended to help the individual achieve well-being
with regard to his/her connections within the
community, as well as to determine how a person,
adult or child, feels and thinks about him or
herself and about life.
 Definition of Psychosocial Care and Support

 Survivors of GBV and VAC often develop

psychological problems. The extent of
psychological consequences depends on several
factors including the individual degree of trauma
and resilience.
 Appropriate psychosocial care and support helps
VAC and GBV survivors and their families
overcome challenges and builds coping
mechanisms, trust, and hope for their future.
mportance of Psychosocial Care and Support for
GBV and VAC Survivors
 Helps to meet emotional and spiritual needs in
addition to meeting GBV and VAC survivors' other
material needs such as food, clothes, shelter, and
medical care.
 Helps in the development of the survivor’s self-
esteem.
 Creates psychological autonomy of GBV and VAC
survivors.
 Brings about a sense of personal mastery/control and
capacity for behavioral regulation.
 mportance of Psychosocial Care and Support for
GBV and VAC Survivors

Facilitates negotiation and bargaining life skills to approach

problems in an adaptive and acceptable manner.
Brings a sense of self-acceptance and confidence to survivors.
Helps reduce the impact of stigma as a result of the survivor's
socioeconomic status.
NOTE: Psychosocial care and support to GBV and VAC is
ssential to provide psychological assistance, which requires the
raining and supervision of social workers, health workers,
ommunity service workers, the police, and justice workers, who
onfidentially gather and document client data and facilitate
eferrals for other services.
 Importance of Psychosocial Care and
Support for GBV and VAC Survivors
Remember:
Social workers are case managers; they are skilled in how to handle
a survivor's case and to manage linking and referring survivors
accordingly.
These case managers also make use of multisectoral collaboration
between local and international nongovernmental organizations to
provide medical, legal, security/protection, and psychosocial and
community support services; to build the capacity of individuals
and systems to address the causes of GBV and VAC through a
coordinated, integrated multidisciplinary approach among the
health, psychosocial, protection, and legal justice sectors; and to
promote the full participation of the target communities.
 Basic Psychosocial Needs
 Physiological needs: These are basic needs that include
food, nutrition, shelter, health services, and care (especially
for a child survivor), which a survivor may not be able to
easily access on his/her own. These are the primary or
material needs any human being should receive.
 Safety and security needs: This is the second category of
needs that any survivor must be assured of, especially child
survivors. Many children have problems that derive from
their past experiences of insecurity. These children need
protection and care from their parent/caregivers. Women
may be also vulnerable due to cultural influences that force
them to suffer in silence.
 Basic Psychosocial Needs

 Need for a sense of belonging: Children who are

separated from their biological parents can experience
pain. This deprivation compels them to seek a sense of
belonging.
 Achievement needs: A child needs to be given
opportunities where s/he can see the achievement of
his/her own deeds. This crucial psychological need can
only be fulfilled by the parent or a substitute caregiver
who plays the role of parent. Deprivation of opportunity
constrains development of the child's potential or can
delay her/his full development. Therefore, this need is
very important for the child's intellectual development.
 Basic Psychosocial Needs
 Self-esteem: These are the resources that enable an individual to
develop feelings about herself or himself. People with good self-
esteem have confidence in their abilities and the expectation that
they will be successful. Children develop their own way of
thinking, making decisions, and behaving. Thus if not properly
guided, they become a source of problems rather than joy in their
families.
 Self-actualization: Psychologically, humans are driven by an urge
or desire to perform well. Through this an individual affirms what
he has achieved and that he expects to be successful. However,
this is largely influenced by the existing home or community
environment. In this regard, families play a crucial role in ensuring
that the child grows up positively.
Conducting Trauma Counseling for GBV and VAC
Survivors
 Trauma counseling is a short-term intervention when a person has suffered
a traumatic incident.

 Trauma comes in degrees of severity; it can include events such as divorce,

job loss, death, mugging, armed robbery, rape, car accident, illness, failing
an exam, losing one's car or house—in fact any event that a person regards
as negative and that changes his/her view of his/herself and the world.

 Trauma counseling supports a person in identifying and coming to terms with the feelings
and emotions s/he may feel during and after a traumatic experience. These emotions will
vary from individual to individual, but the most commonly experienced emotions are
anger and fear.

 Medical care for survivors of rape or sexual violence includes referral for psychological and
social problems, such as common mental disorders, stigma, isolation, substance abuse,
risk‐taking behavior, and family rejection.
 Steps in Trauma Counseling
 Establishing therapeutic alliance
 Remembrance and mourning
 Story-telling transforming
 Traumatic memories.
 Reconnection
 Reconnecting with self, family, community, and support
networks.
 Assessing and focusing on strengths, interests, goals.
 Building confidence, self-worth, self esteem.
 Establishing and developing positive coping strategies.
 Steps in Trauma Counseling
 Establishing therapeutic alliance

 Remembrance and mourning

 Storytelling transforming

 Traumatic memories

 Reconnection

 Reconnecting with self, family, community, and support networks

 Assessing and focusing on strengths, interests, goals

 Building confidence, self worth, self-esteem

 Establishing and developing positive coping strategies.

Techniques for Facilitating and Optimizing
Communication
 Nonverbal language: Provides information on the emotional state
of the client as well as the relationship established with her/him,
including:

 Facial expressions

 Body posture

 Physical distance between the counselor and the client

 Tone of voice

 The appearance of the counselor, how s/he is dressed.

178
 Techniques for Facilitating and
Optimizing Communication
 Questioning
 Open-ended questions
 Closed-ended questions
 Resuming
 Reframing
 Events
 Ideas/thoughts
 Emotions/feelings
Techniques for Facilitating and
Optimizing Communication
→ Greet
→ Ask
→ Tell
→ Help
→ Educate
→ Refer, Return, Review
180
Techniques for Facilitating and
Optimizing Communication
→ GREET
• Establish rapport

• Clarify goals of meeting

• Explain confidentiality

181
Techniques for Facilitating and Optimizing
Communication

 Begin by saying what you already know

about the person, such as “I know you were
sent to me by the women’s group…”

 Acknowledge that you are a stranger, a new

person in his/her life, but that you are ready
to listen and to make sure that s/he is ok.

182
 Techniques for Facilitating and
Optimizing Communication

 Start with broad questions, followed by

specific questions for clarification.
→ASK  Ask for a brief explanation of:
 How you may assist him/her
 Why she/he is seeking assistance
 Specific questions about the
experience of violence.

183
 Techniques for Facilitating and
Optimizing Communication

 Offer validation and support.

 Reassure him/her that you will try to
assist him/her.

→TELL  Reflect back to the survivor

 what you have understood.
 what you have heard as possible
stress reactions.
 Use small support statements when
needed.

184
 Techniques for Facilitating and
Optimizing Communication

…I am not sure if
I am doing the
right thing…its
all my fault……
It’s good you are
telling me these
things.

You aren’t
responsible for
what happened.

185
 Techniques for Facilitating and
Optimizing Communication

• Identify the basic concerns

of the survivor
₋ Understand her experiences
of GBV
₋ Identify related needs.
→HELP

186
 Techniques for Facilitating and
Optimizing Communication

…If you remember

anything else we …That is all I
will stop what we’re remember…
doing and talk.

…I am so angry
right now…
Your feelings are
not any different
than other women
(girls, boys, men).

187
 Techniques for Facilitating and
Optimizing Communication

• Work with the survivor to

identify coping mechanisms to
respond to stress.

• Reassure the survivor that his/her

feelings and needs are normal.

• Emphasize also his/her strengths.

→EDUCATE

188
 Techniques for Facilitating and Optimizing
Communication
…I am
powerless…I
can’t do
anything to
help myself…
You had the courage
to come here today.

You managed to tell

your story and to
tell me what you
need.

189
 Techniques for Facilitating and
Optimizing Communication

• Be prepared with a list of referrals

that may assist the survivor.
• Schedule a follow-up if possible.
• Review the plan with the survivor.

→ REFER, RETURN, REVIEW

190
 How to Manage Resistance
 Accept the client (and her/his ambivalences and contradictions).
 Highlight the client's ambivalence (ask suggesting question,
analyze good and bad reasons).
 Highlight contradictions through reframing.
 Reconstruct the reality (the facts and the feelings) in order to
construct a more realistic point of view.
 Invite the client to take into consideration other points of view.
 Empower her/his self-efficacy.
 Facilitate self-motivating assumptions.
 Accept failure.
 Role Play Activity
 OBSERVE the role play about trauma
counseling.
 STOP the role play when skills for trauma
counseling have emerged.
 DISCUSS the role play and aspects of trauma
counseling.
 Guidelines for Follow-Up
Appointments
 Receive the client in a welcoming manner.
 Let her/him tell you if there are changes in her/his
situation by starting with an open-ended question.
 Evaluate changes in physical, psychological, and
socioeconomic circumstances, coping strategies, and
actions taken and their results.
 Let the person express feelings, memories, ideas,
needs, desires, and projects.
 Acknowledge and empower the client, reflect with
her/him on what is helpful and what is not.
Guidelines for Follow-Up Appointments

 Assist the client to redefine the problem, set up

new priorities or review the same priorities, and
reach viable solutions.
 Define the agreement.
 Explain your feedback modality (how you will
provide feedback to the client).
 Thank the client.
 Register the case.
 Key Points
 Psychosocial care and support to GBV and VAC is essential to
provide ongoing psychological assistance.
 Psychosocial counseling follows the same format typical of
counseling sessions, but goes deeper in the phases of listening,
analyzing, and giving feedback.
 You should always seek to refer the survivor to other services, if s/he
agrees to them.
 Creating a good referral network prevents you from feeling like you
must meet all the survivor's needs alone. It also helps the survivor to
integrate or reintegrate into her/his community.
 Evaluation

 What is psychosocial care and support?

 What is the importance of psychosocial care
and support to GBV and VAC survivors?
 What is counseling?
 What are the types of counseling?
 Questions

resentation is made possible by the generous support of the American people through the U.S. President’s Emergency Plan for
Relief (PEPFAR) with the U.S. Agency for International Development (USAID) under the Cooperative Agreement Strengthening High
t Interventions for an AIDS-free Generation, number AID-OAA-A-14-00046. The information provided does not necessarily reflect
ews of USAID, PEPFAR, or the U.S. Government. AIDSFree is implemented by JSI Research & Training Institute, Inc. with partners
ssociates Inc., Elizabeth Glaser Pediatric AIDS Foundation, EnCompass LLC, IMA World Health, The International HIV/AIDS Alliance,
go Corporation, and PATH. The authors' views expressed in this publication do not necessarily reflect the views of USAID, PEPFAR
U.S. Government.