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A Training Course for Management of Sexual Violence Facilitatorâ€™s Manual

Ministry of Health Reproductive Health and Maternal Services Unit Second Edition, September, 2015 A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

Suggested Citation: Reproductive and Maternal Health Services Unit (RMHSU), Kenya: A Training Course for Clinical Management of Sexual and Gender Based Violence: Facilitator’s Manual. September, 2015.

All enquiries and feedback pertaining to this manual should be addressed to: Head, Reproductive and Maternal Health Services Unit (RMHSU), Kenya Old Mbagathi Road P.O. Box 43319 Nairobi, Kenya

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Table Of Contents

Table of Contents LIST OF ABBREVIATIONS AND ACRONYMS ..................................................................................

ACKNOWLEDGEMENTS ...........................................................................................................................

FOREWORD....................................................................................................................................................

1.0 INTRODUCTION ...................................................................................................................................

2.0 COURSE SYLLABUS .............................................................................................................................

Course Description...........................................................................................................................

Expected Learning Outcomes .......................................................................................................

Course Modules ................................................................................................................................

Training Methodology...................................................................................................................

Training Materials ...........................................................................................................................

Participants’ Selection Criteria ..................................................................................................

Methods of Evaluation ..................................................................................................................

Certification........................................................................................................................................

Course Duration ...............................................................................................................................

1 week .....................................................................................................................................................

Course Composition ........................................................................................................................

3.0 COURSE SCHEDULE ............................................................................................................................

4.0 TRAINING LOGISTICS: .......................................................................................................................

5.0 TRAINING MODULES: ........................................................................................................................

MODULE 1: INTRODUCTION TO GENDER BASED VIOLENCE ...............................................

U N I T 1: D E F I N I T I O N O F G E N D E R A N D R E L AT E D T E R M S .............................

U N I T 2: T Y P E S O F G E N D E R B A S E D V I O L E N C E ......................................................

U N I T 3 S I T UAT I O N/P R E VA L E N C E O F G E N D E R B A S E D V I O L E N C E .........

U N I T 4 C AU S E S, CO N T R I B U T I N G FAC TO R S, R I S K S, V U L N E R A B I L I T I E S A N D E F F E C T S O F G E N D E R B A S E D V I O L E N C E .......................................................

U N I T 5: S E L F - E X P LO R AT I O N/S E L F - AWA R E N E S S O N G E N D E R I S S U E S

A Training Course for Management of Sexual Violence - Facilitator’s Manual

MODULE 2: SEXUAL VIOLENCE AND THE LAW ............................................................................

U N I T 1: B AC KG R O U N D TO T H E S E X UA L O F F E N C E S AC T A N D D E F I N I T I O N O F T E R M S ..........................................................................................................................................

U N I T 2: S E X UA L O F F E N C E S A N D P U N I S H M E N T .................................................

U N I T 3: R I G H T S, D U T I E S A N D R E S P O N S I B I L I T I E S U N D E R T H E S E X UA L O F F E N C E S AC T ..............................................................................................................................

MODULE 3: MEDICAL/ CLINICAL MANAGEMENT ...................................................

U N I T1:

D E F I N I T I O N O F T E R M S .....................................................................................

U N I T2:

AT T E N D I N G TO T H E S U R V I V O R ..................................................................

101

U N I T3:

O BTA I N I N G I N F O R M E D CO N S E N T ...........................................................

104

U N I T4:

M A I N TA I N I N G CO N F I D E N T I A L I T Y ............................................................

107

U N I T5:

H I S TO RY TA K I N G ....................................................................................................

110

U N I T6:

E X A M I N AT I O N ..........................................................................................................

114

U N I T7:

CO L L E C T I N G F O R E N S I C E V I D E N C E .........................................................

119

U N I T8:

M A N AG E M E N T O F P H YS I C A L I N J U R I E S ...............................................

122

U N I T 9: P R O V I D I N G P R O H Y L A X I S F O R S T I S I N C LU D I N G H I V, OT H E R I N F E C T I O N S A N D P R E V E N T I O N O F P R E G N A N C Y .............................................

125

U N I T10:

P R O P E R D O C U M E N TAT I O N O F T H E F I N D I N G S ...........................

131

U N I T11:

O RG A N I S I N G F O R R E F E R R A L O F S U R V I V O R .................................

134

U N I T12:

CO M M U N I T Y H E A LT H P R O M OT I O N A N D S U P P O RT ...............

138

MODULE 4: FORENSIC MANAGEMENT .....................................................................

144

U N I T 1: D E F I N I T I O N O F T E R M S .......................................................................................

147

U N I T 2: T Y P E S O F E V I D E N C E .............................................................................................

150

U N I T 3: F O R E N S I C M E D I C A L E X A M I N AT I O N P R O C E S S .................................

153

U N I T 4: C H A I N O F C U S TO D Y .............................................................................................

161

U N I T 5: T Y P E S O F I N J U RY ....................................................................................................

164

U N I T 6: R O L E O F H E A LT H C A R E P R O F E S S I O N A L S I N E V I D E N C E P R E S E N TAT I O N

I N CO U RT ..........................................................................................................................................

166

MODULE 5: PSYCHOSOCIAL SUPPORT ......................................................................

170

U N I T1: I N T R O D U C T I O N TO P S YC H O S O C I A L C A R E A N D S U P P O RT .....

174

U N I T 2 P S YC H OT R AU M A .......................................................................................................

177

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

U N I T 3 P S YC H O LO G I C A L D E B R I E F I N G F O R T R AU M A S U R V I V O R S A N D C A R E G I V E R S ..................................................................................................................................

182

U N I T 4 B A S I C CO U N S E L L I N G S K I L L S ...........................................................................

185

U N I T 5 CO U N S E L L I N G E T H I C S ..........................................................................................

193

U N I T 6 T H E R O L E O F T H E CO M M U N I T Y I N P S YC H O S O C I A L C A R E A N D S U P P O RT ............................................................................................................................................

196

U N I T 7 CO U N S E L L I N G S U P P O RT S U P E R V I S I O N .................................................

202

MODULE 6: MANAGEMENT OF SEXUAL VIOLENCE IN CHILDREN AND ADOLESCENTS 204 U N I T 1: K E Y P R I N C I P L E S F O R W O R K I N G W I T H C H I L D R E N A N D P R E PA R AT I O N F O R M A N AG E M E N T O F C H I L D R E N A N D A D O L E S C E N T S. ............................

208

U N I T2: H I S TO RY TA K I N G .......................................................................................................

216

U N I T 3: P H YS I C A L E X A M I N AT I O N A N D P S YC H O LO G I C A L A S S E S S M E N T

227

U N I T 4: I N V E S T I G AT I O N A N D F O R E N S I C M A N AG E M E N T ...........................

237

U N I T 5: T R E AT M E N T A N D CO U N S E L L I N G ................................................................

242

U N I T 6: F O L LO W U P C A R E A N D R E F E R R A L ............................................................

256

MODULE 7: MONITORING AND EVALUATION IN SEXUAL VIOLENCE PROGRAMS

263

U N I T 1: M AG N I T U D E O F S G B V I N K E N YA ................................................................

266

U N I T 2: I N T R O D U C T I O N TO S G B V I N D I C ATO R S A N D DATA E L E M E N T S

268

U N I T 3: S G B V R E P O RT I N G TO O L S ..................................................................................

271

U N I T 4: U P LOA D I N G S G B V DATA O N T H E D H I S A N D A N A LYS I N G I T

273

U N I T 5: S G B V DATA F LO W A N D Q UA L I T Y ................................................................

275

MODULE 8: QUALITY MANAGEMENT AND REFERRALS IN SEXUAL VIOLENCE SERVICES..278 U N I T 1: Q UA L I T Y M A N AG E M E N T ...................................................................................

281

U N I T 2: R E F E R R A L A N D L I N K AG E S/ N E T W O R K I N P R O V I D I N G CO M P R E H E N S I V E P O S T R A P E C A R E S E R V I C E S ....................................................

295

MODULE 9: SEXUAL VIOLENCE IN HUMANITARIAN CRISIS SITUATIONS AND HUMAN303 U N I T1: G E N D E R V U L N E R A B I L I T Y I N H U M A N I TA R I A N C R I S I S S I T UAT I O N S

306

U N I T 2: H U M A N T R A F F I C K I N G .........................................................................................

309

U N I T 3: M I N I M U M I N I T I A L S E R V I C E PAC K AG E ( M I S P ) I N H U M A N I TA R I A N C R I S I S S I T UAT I O N S ...................................................................................................................

319

U N I T4: P R E PA R E D N E S S A N D CO N T I N G E N C Y P L A N N I N G F O R S G B V P R E V E N T I O N

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

A N D R E S P O N S E I N C R I S I S ...................................................................................................

322

U N I T 5: CO D E O F CO N D U C T A S A P P L I E D I N H U M A N I TA R I A N C R I S I S S I T UAT I O N S ..................................................................................................................................... U N I T 6:

329

S T R AT E G I E S F O R S E C U R I T Y A N D P R E V E N T I O N O F V I O L E N C E I N

H U M A N I TA R I A N C R I S I S S I T UAT I O N S ..........................................................................

332

ANNEX 1: PRE COURSE ASSESSMENT ..............................................................

335

ANNEX 2: END OF COURSE EVALUATION ........................................................

339

ANNEX 3: OBSERVED PRACTICE GUIDELINES .................................................

342

ANNEX 4: CHECKLISTS FOR ADULTS ................................................................

344

ANNEX 5: CHECKLISTS FOR CHILDREN ............................................................

355

ANNEX 6: JOB AIDES ............................................................................................

369

ANNEX 7: PRC FORM ............................................................................................

375

ANNEX 8: P 3 FORM .............................................................................................

379

ANNEX 9: CASE STUDIES ....................................................................................

384

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

List of Abbreviations and Acronyms AIDS

Acquired Immune Deficiency Syndrome

AZT

Zidovudine

Twice a Day

DNA

Deoxyribonucleic Acid

Emergency Contraception

FGM

Female Genital Mutilation

GBV

Gender Based Violence

GVRC

Gender Violence Recovery Centre

Haemoglobin

HCP

Health Care Providers

HIV

Human Immunodeficiency Virus

HVS

High Vaginal Swab

LVCT

Liverpool VCT, Care and Treatment

MOA

Mode of Action

MOH

Ministry of Health

Police Form 3

PEP

Post Exposure Prophylaxis

PRC

Post Rape Care

PSA2

Prostate specific antigen

PWD

People with Disability

Quality Assurance

Quality Improvement

QID

Six Hourly (four times a day)

SGPT

Serum Glutamic Pyruvic Transaminase

SLO

State Law Office

SOA

Sexual Offences Act

STI

Sexually Transmitted Infections

Sexual Violence

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

TDS

Eight Hourly (three time a day)

UNHCR

United Nations High Commissioner for Refugees

VAW

Violence against Women

VDRL

Venereal Disease Research Laboratory

WHO

World Health Organization

3TC

Lamivudine

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

Acknowledgements The development of this manual was a result of concerted efforts of several persons and organisations. The Ministry of Health through The Reproductive and Maternal Health Services Unit (RMHSU) wishes to thank the following individuals whose hard work, insights and dedication made it possible to produce this trainer‘s manual for management of survivors of sexual violence. We are highly indebted to Dr. Kigen Bartilol and Dr. Anne Ng’ang’a for providing leadership and policy direction to the process. Much appreciation to the consultant , Peter Shikuku of IntraHealth International, USAID/FUNZOKenya for providing technical assistance to the review of this training curriculum. The Ministry acknowledges the technical and financial support by the SGBV Networks Project, funded by the German Development Cooperation in the Health Sector and CapacityPlus Project for supporting the Child and Adolescent module. We also thank the World Health Organisation and International Organisation for Migration (IOM) for financial and technical assistance especially during the pilot stage of the curriculum development process. We also acknowledge LVCT Health through funding from Trocaire for the design and printing of the curriculum. RMHSU wishes to recognise the following individuals who served in the Technical Working Group that developed the training manual: (in alphabetical order) No.

ORGANIZATION

Alice N. Mwangangi

MOH-RMHSU

Angeline Wambanda

IOM

Anne Njeru

MOH-RMHSU

Anne W. Maina

Government Chemist

Annie Gituto

MOH-RMHSU

Baraza Joseph

MOH-Gender Division

Christine Alai

Physicians for Human Rights (PHR)

Clarice Okumu

MOH-RMHSU

Damaris Mwanzia

MOH-RMHSU

Delight Moyo

UNFPA

Denis Muya

MOH-RMHSU A Training Course for Management of Sexual Violence - Facilitator’s Manual

Dr. Alexandra Vandenbulcue

MSFF

Dr. Anne Ng’ang’a

MOH-RMHSU

Dr. Claire Nyambati

IOM

Dr. Donna Nyamunga

Forensic Division-MOH

Dr. Jean Patrick

RMHSU-MOH

Dr. Johansen Oduor

Forensic Division-MOH

Dr. Joyce Lavussa

WHO

Dr. Kizzie Shako

MOH-Pathology & Forensic Services

Dr. Margaret Makanyengo

KNH

Dr. Ndonga MaryAnne

MOH

Dr. Wangui Muthigani

MOH-RMHSU

Eunice Odongi

NACC

Joyce K. Onyango

MOH-RMHSU

Judge Stephen Githinji

Judiciary

Lillian A. Ouma

Govt. Chemist

Lydia Nyaga

LVCT Health

Maureen Muthinzi

Physicians for Human Rights (PHR)

Maureen Obbayi

GenderHealth Africa

Nancy Ngetha

Kenyatta National Hospital

Paul Kilonzo

Ministry of Devolution

Peter Milo

Peter Shikuku- CONSULTANT

Rebecca Gitau

IntraHealth International – USAID/FUNZO Kenya Project IntraHealth International – USAID/FUNZO Kenya Project GVRC/Nairobi Women’s Hospital (NWH)

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Peter Shikuku- CONSULTANT

IntraHealth International – USAID/FUNZO Kenya Project

Rebecca Gitau

GVRC/Nairobi Women’s Hospital (NWH)

Rose Mwongera

MOH

Rukia Yassin

SGBV Networks

Ruth Muia

MOH-RMHSU

Sophia Karanja

MOH

Suhayla A. Aboud

MSF

Teclar J. Kogo

MOH-RMHSU

Wilson Edung

Kenya Police Service

Stella Munyi

Kenya Red Cross Society

Hadley Muchela

East Africa Gender Associates

External Reviewers No. 1 2 3

NAME Dr. John Burton Dr. Digolo Florence Gachanja

Julia Hill-Mlat

Karen Naimer

Lincoln Ndogoni

ORGANIZATION UNHCR LVCT Health UNFPA IOM Regional Health support team Physicians for Human Rights (Boston) GVRC Nairobi Women’s Hospital

We appreciate the secretariat services provided by Florence Ireri.

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Foreword Sexual violence is a global problem that constitutes a violation of basic human rights. Women, children and even men are victims of this vice. Survivors of sexual violence suffer physical, psychological and social effects. The Ministry of Health through the Reproductive and Maternal Health Services recognizes these harmful effects of sexual violence and intends to equip health care workers with skills to effectively manage the survivors. The legal and policy environment in Kenya is favorable for Sexual and Gender Based Violence (SGBV) response, with the Constitution 2010 exhorting the right to the highest attainable standard of health. It is against this backdrop that this training manual has been revised to respond to the changed legal and policy environment. This curriculum addresses emerging issues such as the rising cases of children survivors of sexual violence. It incorporates a pediatric module that was absent in the previous curriculum in recognition of the special needs of children. This training manual will equip health care workers with skills to address not only the clinical management of sexual violence but also the psychosocial and legal aspects to ensure a holistic view of the survivors needs. I recommend all health care workers to undergo this training and stay current through refresher trainings. In particular I encourage them to use the skills learnt to recognize survivors of sexual violence as they interact with them as most cases go unrecognized or unreported due to stigma associated with sexual violence. Finally I encourage all stakeholders to support the roll out of this curriculum at all levels to ensure all survivors of sexual violence receive the highest attainable standard of care.

Dr. Jackson Kioko, Ag. Director of Medical Services, Ministry of Health, Kenya

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

Part 1 Introduction

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

Introduction 1.1

Background Information

Violence and in particular sexual violence is a serious, life-threatening issue primarily affecting women and girls. It proliferates in the context of conflicts, emergencies and natural disasters. It is recognized as a fundamental violation of human rights and a constraint to development. Women and girls are often targeted for abuse due to their vulnerability to exploitation and violence as noted in past conflicts in Kenya. Although few, cases of Sexual Gender Based Violence (SGBV) against men also go unreported or unrecognized. Linkages between gender equality and Sexual Reproductive Health Rights (SRHR) including GBV and HIV have not been adequately addressed in poverty reduction strategies and other national development frameworks. According to available country surveys in Africa, 15 to 76 per cent of women have experienced physical and/or sexual violence in their lifetime. In Kenya about 41% of women in reproductive age have experienced physical and sexual violence (KDHS, 2014). It is also important to recognize the fact that men and boys are also victims and survivors of GBV such as rape or sexual abuse.

Sexual violence is also a serious risk factor in HIV transmission that contributes to fueling of the AIDS epidemic. There are also reported cases of fistula attributed to sexual violence.

Violence against children and adolescents is also a global public health concern. The World Health Organization estimates that 150 million girls and 73 million boys experienced sexual abuse before attainment of 15 years. In Kenya, the Violence Against Children (VAC) Survey indicated that one in three females and one in five males experienced at least one episode of sexual violence before reaching age 18. This exposure has been found to influence the adoption of risky behaviors by children when they become adolescents.

The legal and policy environment in Kenya is favorable for Sexual and Gender Based Violence (SGBV)

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

response. The constitution 2010 exhorts the entitlement to the highest attainable standard of health; the social pillar of the vision 2030 emphasizes the need to improve the overall livelihoods of Kenyans, through provision of efficient and high quality health care systems with high standards. The Kenya Health Sector Strategic and Investment Plan (KHSSP, 2012 -2018) is designed to operationalize this vision. The National Policy for Prevention and Response to GBV recently developed, also assists in acceleration of implementation of legislation, policies and programmes.

Legal instruments like the Sexual Offences ACT, and MOH (RMHSU) policy guidelines, standards and protocols have been designed to support this response. The National Guidelines on Management of Sexual Violence (3rd edition, 2014) and Standard Operating Procedures (2014) have been revised to address the medical, psycho-social, forensic, legal and humanitarian aspects of sexual violence which includes information on psychosocial support as part of the comprehensive care package to a survivor and perpetrator of sexual violence.

Despite existence of legislation, administrative directives, judicial sanctions, and educational awareness efforts by a variety of agencies and governments, SGBV is still endemic in Kenya. According to the Kenya Demographic Health Survey (2014), SGBV trends have not changed significantly since 2003

The needs of survivors are often diverse and complex, necessitating holistic and comprehensive care, including medical treatment for physical injuries, emergency contraception, HIV Post exposure prophylaxis, treatment for sexually transmitted infections and psychosocial support for trauma and rehabilitation in community. The needs of children and adolescents are unique and require special attention.

This training manual, informed by the revised National Guidelines on Management of Sexual Violence 2014 in Kenya intends to build capacity of service providers in comprehensive Post Rape Care Services

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

to survivors of sexual violence including children and adolescents.

1.1

The Purpose of the Manual

This trainer’s manual has been written to provide guidance to the trainer on how to deliver the clinical training on management of sexual violence. It provides the trainer with all pertinent information to facilitate effective delivery of the course. This includes information about training approach, course syllabus, course schedule, training logistics and facilitator’s manual.

1.1

Structure of the Manual

This facilitator’ manual is divided into five parts as follows: • Part 1 – Introduction which includes background information and the rationale/justification for this training course. It also provides basic information on how to use this manual • Part 2 – Course syllabus • Part 3 - Course schedule • Part 4 – Training logistics • Part 5 – Facilitator’s manual with step by step guidance on how to deliver each session of the course

1.1

Training Approach

The training approach in this manual is hinged on the concept of mastery learning which states that all participants can master (learn) the required knowledge, skills and attitudes provided sufficient time is allowed and appropriate training methods are used. The approach to learning therefore employed is competency based that is distinctly different from traditional educational processes. Competency based training is learning by doing and focuses on the specific knowledge, skills and attitudes needed to carry out a procedure or activity. The training is geared towards ensuring that participants can perform the tasks for which they are trained. To ensure this happens the following processes are observed and are critical to the success of the training. • Proper identification and screening of participants, • Use of appropriate training methodology,

A Training Course for Management of Sexual Violence - Facilitator’s Manual

• Training schedule to guide programming and planning of training activities • Use of learning guides and checklists in training for skills mastery and assessment respectively • Use of appropriate assessment tools to assess both acquisition of knowledge, skills and attitudes required to perform the task and follow up of participants beyond training to assess effect of training at work after completion of training

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Part 2 Course Syllabus

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

1.1

Course Syllabus

Course Description This training program is designed to build capacity of Health Care Professionals to effectively and comprehensively manage survivors of sexual violence. The course comprises 9 modules covering a broad range of sexual violence management issues to be delivered in 40 hours. It derives its guidance from the National Guidelines on Management of Sexual Violence in Kenya, 3rd edition, 2014.

Course Goal/Purpose To build capacity of participants to provide comprehensive quality services in the management of sexual violence

Expected Learning Outcomes • To attain a thorough understanding of gender terms and issues to enable effective work with SGBV survivors • To apply the key provisions of the Sexual Offences ACT and and other relevant laws in provision of Sexual Gender Based Violence Services to Survivors • To attain the competence/ability (knowledge, skills and attitudes) to attend to clients of sexual gender based violence in a professional and comprehensive manner. • To attain competence in history taking, examination, collection, handling, storage/preservation and transportation – handing over of evidence. • To attain competence in providing various forms of psychosocial support to survivors of sexual violence, to facilitate their resumption to normal functioning and full integration into society • To manage children and adolescent survivors of SGBV • To apply quality management, monitoring and evaluation and referral skills in the provision of SGBV services • To manage a survivor of sexual violence in humanitarian settings as per Minimum Initial Service Package (MISP) and support victims of human trafficking Module 1 Introduction to Gender Based Violence

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Course Modules Unit 1: Definition of Gender and Related Terms Unit 2: Types of Gender Based Violence Unit 3: Situation/Prevalence of Gender Based Violence Unit 4: Causes, Risks, Vulnerabilities and Effects of Gender Based Violence Unit 5: Self-Exploration/Self-Awareness on Gender Issues

Module 2 Sexual Violence and the Law Unit 1: Background to the Sexual Offences Act and Definition of Terms Unit 2: Sexual Offences and Punishment Unit 3: Rights, Duties and Responsibilities under the SOA

Module 3 Medical/Clinical Management Unit 1: Identification of Survivors of SGBV Unit 2: Attend to a Survivor and Suspect Unit 3: Obtaining Informed Consent Unit 4: Maintaining Confidentiality Unit 5: History Taking Unit 6: Examination Unit 7: Collecting Forensic Evidence Unit 8: Management of Physical Injuries Unit 9: Provide Prophylaxis for STIs including HIV, other Infections and Prevention of Pregnancy Unit 10: Proper Documentation of the Findings Unit 11: Organise for Referral of the Survivor as needed Unit 12: Assess the Safety of the Survivor and Provider

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

Unit 13: Community

Module 4 Forensic Management Unit 1: Definition of Terms Unit 2: Types of Evidence Unit 3: Forensic Examination Process Unit 4: Chain of Custody of Evidence Unit 5: Types of Injury Unit 6: Role of Healthcare Professional in Evidence Presentation in Court Module 5 Psychosocial Support Unit 1: Introduction to Psychosocial Care and Support Unit 2: Basic Counselling Skills Unit 3: Types of Counselling in Management of Sexual Violence Unit 4: Psycho â€“ Trauma Unit 5: Psychological Debriefing for Trauma Survivors and Caregivers Unit 6: Counselling Ethics Units 7: The Role of the Community in Psychosocial Care support. Unit 9: Counselling Support Supervision Module 6 Management of Children and Adolescents Unit 1: Key principles for Working with Children and Preparation for Management of Children and Adolescents Unit 2: Taking History Unit 3: Physical Examination and Psychosocial Assessment Unit 4: Investigation and Forensic Management Unit 5: Treatment and Counselling Unit 6: Follow up Care and Referral Module 7 Monitoring and Evaluation in Sexual Violence programs Unit 1: Magnitude of SGBV in Kenya

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

Unit 2: Introduction to SGBV Indicators and Data Elements Unit 3: SGBV Reporting Tools Unit 4: Uploading SGBV data on the DHIS and its Analysis Unit 5: SGBV Data Flow and Quality Module 8 Quality Management and Referrals in Sexual Violence Services Unit 1: Quality Management Unit 2: Referral Module 9 Sexual Violence in Humanitarian Crisis Situations Unit 1: Gender vulnerability in Humanitarian crisis situations Unit 2: Human Trafficking and SGBV Unit 3: Minimum Initial Service Package (MISP) in humanitarian crisis situations Unit 4: Preparedness and Contingency planning for SGBV prevention and response in humanitarian crisis Unit 5: Code of conduct as applied in humanitarian crisis situations Unit 6: Strategies for security and prevention of violence in Humanitarian crisis situations

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

Training Methodology Training methodology employed in this training is experiential, participatory/interactive and didactic; to include • Illustrated lectures (Power – Point Presentations) • Role plays • Skills stations • Audio visuals - DVD • Group Works/discussions • Brain storming • Case studies • Question and answer sessions • Plenary discussions • Demonstration on physical examination and evidence collection

Training Materials • Audio visual equipment – LCD projector, Lap top • Flip charts • Marker pens • Writing pads for participants • Pens • PRC forms • P3 forms • Laboratory request form • Sexual and Gender Based Violence Register • Sexual and Gender Based Violence Monthly summary form • Consent forms • Psychological/Mental assessment forms

A Training Course for Management of Sexual Violence - Facilitator’s Manual

• Evidence collection kit- locally assembled • Drug kit – locally assembled • Job aides – client flow charts, Forensic evidence collection, care algorithms, referral pathways etc. • Humanistic models/Manikins • The Sexual Offences ACT

Participants’ Selection Criteria Participants of this training must be in any of the following professions: • Medical officer (may include a consultant e.g. family physician, gynaecologist, psychiatrist etc.) • Dentist • Clinical officer • Nurses • Laboratory personnel (Laboratory technicians and technologists) • Pharmacist and Pharmaceutical technologists • Health Records and Information Officers • Medical Social Worker • Clinical Psychologist NB. 2/3 of the training participants MUST be clinicians and 1/3 other cadres. The other cadres selected MUST be persons involved in service delivery for survivors of sexual violence. The agencies/organizations undertaking the training should work with health management teams for proper selection of participants for the training. It is advisable that interviews be done for prospective participants as part of this process.

Methods of Evaluation • Pre course questionnaire • Post course questionnaire • Learning guides • Checklists

A Training Course for Management of Sexual Violence - Facilitator’s Manual

• Training course evaluation to assess participants reaction to the course

Certification • Pass mark 80% • Full attendance of all sessions • Certifying body, Reproductive and Maternal Health Services Unit (RMHSU), Ministry of Health • A certificate of participation/attendance will be issued to all participants completing the training. A certificate of competence will ONLY be issued to participants who complete observed practice and pass as per guidelines in annex 3 of this training manual. Course Duration 1 week Course Composition • Facilitators with TOT training, proficient in medical/clinical, forensic management and psychosocial support for survivors of sexual violence • 30 participants

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Part 3 Course Schedule

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

2.0 CH Day

Day1

Course Schedule Topic

0800 – 900

Registration/introduction/Climate setting Housekeeping issues and expectations of participants and ground rules

0930 – 1030

Module1: Unit 1: Definition of Gender and Related Terms Unit 2: Types of Gender Based Violence Unit 3: Situation/ Prevalence of Gender Based Violence

1030 – 1100

Tea Break

1100 – 1200

1200 – 1300

Day 2

Person Responsible

Time

Remarks

Unit 4: Causes, Risks, Vulnerabilities, Effects and Contributing Factors to Gender Based Violence Unit 5: Self-Exploration/Self-Awareness on Gender Issues Module 2: Unit 1: Background to the Sexual Offences Act and Definition of terms Unit 2: Sexual Offences and Punishment

1300 – 1400

Lunch

1400 – 1700

Unit 3: Rights, Duties and Responsibilities under the SOA

0800- 0815

Recap of Day 1 and housekeeping issues

0815- 1030

Module 3: Medical/ Clinical Management of SGBV survivors Unit 1: Identification of survivors of SGBV Unit 2: Attending to a survivor and suspect Unit 3: Obtaining Informed Consent Unit 4: Maintaining Confidentiality

1030 – 1100

Tea Break

1100 - 1300

Unit 5: History taking Unit 6: Examination Unit 7: Collecting Forensic Evidence Unit 8: Management of Physical Injuries Unit 9: Providing prophylaxis for STIs including HIV other infections and prevention of pregnancy

1300-1400

Lunch

1400 - 1730

Unit 10: Proper documentation of the findings Unit 11: Organising for referral of the survivor when needed Unit 12: Assessing the safety of the survivor and the providers Unit 13: Community Health Promotion and support

A Training Course for Management of Sexual Violence - Facilitator’s Manual

0800 – 0815

Recap Day 2 and housekeeping issues

0815 – 1030

Module 4: Forensic Medical Management Unit 1: Definition of terms Unit 2: Types of Evidence Unit 3: Forensic Examination Process

1030 -1100

Tea Break

1100 - 1300

Unit 4: Chain of Custody of Evidence Unit 5: Types of Injury Unit 6: Role of Healthcare professionals in evidence presentation in Court: Role Play/Practical sessionModule 5: Psychosocial support Unit 1: Introduction to Psychosocial Care and Support

1300-1400

Lunch

1400 - 1700

Unit 2: Basic Counselling Skills Unit 3: Types Of Counselling In Management Of Sexual Violence Unit 4: Psychotrauma Unit 5: Psychological Debriefing for Trauma Survivors and Caregivers Unit 6: Counselling Ethics Units 7: The Role of the Community in Psychosocial Care support. Unit 8: Counselling Supervision

0800 – 0815

Recap of Day 3 and housekeeping issues

0815 – 1030

Module 6: Management of Children and Adolescents. Unit 1: Key Principles of Working with Children and Preparation for Management of Children and Adolescents Unit 2: Taking History Unit 3: Physical Examination and Psychological Assessment

1030 – 1100

Tea Break

1100 – 1300

UNIT 3 Cont’d: • Systemic examination • Psychological assessment • Documentation of findings • Practical session on physical examination of child and adolescent survivors using humanistic models • documentation filling of PRC form and other related documentation

1300 – 1400

Lunch

Day 3

Day 4

1400 – 1700

Unit 4: Investigation and Forensic Management • Collection of evidence for clinical management • Collecting handling, preserving evidence for legal purposes • Documentation for management and legal purposes Unit 5: Treatment and Counselling • Management of life threatening and other injuries

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Pregnancy Prevention and management Prevention of HIV STIs prophylaxis and treatment Hepatitis B prevention Psychosocial Support Documentation of treatment on PRC form and SGBV register Unit 6: Follow up Care and Referral • Referrals • Referral Mechanism • Follow up • Feedback • • • • • •

Day 5

0800 – 0815

Recap of Day 4 and Housekeeping issues

0815 – 1030

Module 7 Unit 1: Monitoring and Evaluation in the Provision of SGBV Services • Magnitude of SGBV in Kenya • Introduction to SGBV indicators and Data Elements • SGBV Reporting Tools • Uploading SGBV data in the DHIS2 and its Analysis • SGBV Data Flow and Quality

1030 – 1100

Tea Break

1100 – 1300

Module 8: Unit 1: Quality management • Definition of terms in quality management • quality improvement • quality assurance • quality improvement principles • dimensions of quality management • methods of monitoring quality • minimum standards for providing comprehensive sexual violence services Unit 3: Referral • What is an effective referral system and its importance • Flow of patients in the facility providing SV services • The different components and types of referral • Referral strategies • Resources required for referral • The role of community in referral of SGBV clients

1300 - 1400

Lunch

1400 - 1700

Module 8: Sexual Violence in Humanitarian Crisis and Human Trafficking Unit 1: Gender vulnerability in Humanitarian crisis situations Unit 2: Human Trafficking and SGBV Unit 3: Minimum Initial Service Package (MISP) in humanitarian crisis situations Unit 4: Preparedness and Contingency planning for SGBV prevention and response in humanitarian crisis Unit 5: Code of conduct as applied in humanitarian crisis situations Unit 6: Strategies for security and prevention of violence in Humanitarian crisis situations

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Part 4 Training Logistics

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

4.0 Training Logistics: General Logistics to Prepare for the Training Venue The training venue should be well lit, ventilated and comfortable. It should have ample space for both the theoretical and practical aspects of the course. Budgets and finances All courses cost money and a careful budget must be established before running any course. If possible, trainers should not be too involved with the financial aspects of the training. Before the course starts The letters should be drafted in consultation with the facility managers. Ensure that letters of invitation are sent well in advance (preferably at least 2 weeks prior) to all participants. These letters should include the length and structure of the course, details of the venue and the time they are expected to attend the course at the facility. When participants arrive Welcome the participants when they arrive. Give details of the specific venue where the training will be conducted, how the training will be done (the start time) and anything they will need to bring with them. It should also have the names and details of the trainers. How to structure the sessions Please read this section carefully before you start planning your course. The timetable for the course should be designed to suit the local learning needs at the facility Housekeeping issues At the beginning of each session time needs to be allocated to housekeeping tasks and burning issues. Reports can also be made from the course representatives and rapporteurs though it is recommended that these are kept to a maximum of 3 - 5 minutes. In general half an hour is more than adequate for this purpose. Agenda for the day: For each session, a brief outline of the topics to be covered should be given after the round. Prayer: Some groups may ask for a prayer at the start of each session. Remember, even if most

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

people indicate that they share the same religion, not everyone will be comfortable praying in the same way. The facilitator needs to be aware and sensitive to participantâ€™s religious beliefs and practices. Energizers: need to be included at least twice a day or more. Afternoons: If the weather is hot, the afternoon sessions need to encourage participation even more than the mornings. Trainers need to earmark group work, games and practical exercises rather than lectures for the afternoons.

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

Checklist for Preparation for Training Item

Packed (yes or no)

Remarks

1. Audio visual equipment – LCD projector, Lap top 2. Flip charts 3. Marker pens 4. Writing pads for participants 5. Pens 6. PRC forms – enough copies for participants 7. P3 forms – enou gh copies for participants 8. Laboratory request form – enough copies for participants 9. SV Register - enough copies for participants 10. SV Monthly summary form - enough copies for participants 11. Consent forms - enough copies for participants 12. Psychological/Mental assessment forms 13. Evidence collection kit- locally assembled 14. Drug kit – locally assembled 15. Job aides – client flow charts, Forensic evidence collection, care algorithms, referral pathways etc. 16. Humanistic models/Mannequins

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Part 5 Facilitatorâ€™s Manual Modules

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

Module 1 Introduction to Gender Based Violence

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

Module 1: Introduction to Gender Based Violence Module Description: Sexual violence, a form of GBV, is meted upon individuals due to gender inequity, abuse of power and lack of respect for human rights. This module aims at defining key gender concepts as well as identifying types, causes, risks and vulnerabilities contributing to sexual violence and the impact of sexual violence to survivors and society in general.

Purpose/Module Competence: To demonstrate understanding of gender based violence and related concepts, types, causes, risks and vulnerabilities and its impact on society

Expected Learning Outcomes:

By the end of this module the participant should be able to:

• • • • • •

Define gender and related terms Recognize the situation/prevalence of gender based violence globally, regionally and nationally Demonstrate understanding of the different types of gender based violence Discuss causes, risks and vulnerabilities to gender based violence Discuss effects of gender based violence To explore personal values and beliefs on gender

Content: Unit 1: Definition of Gender and Related Terms • Gender • Sex • Gender roles • Sex roles • Sexual orientation • Gender identity • Gender expression • Transgender • Gender transition • Gender based violence • Violence against women

A Training Course for Management of Sexual Violence - Facilitator’s Manual

• Sexual violence • Power relations • Perpetrator • Survivor/victim • Sexuality • Gender equity • Gender equality • Gender sensitivity • Gender responsiveness • Gender analysis • Gender mainstreaming • Practical gender needs • Strategic gender needs Unit 2: Types of Gender Based Violence • Sexual violence • Physical violence • Emotional and psychological violence • Harmful traditional practices • Socioeconomic violence • Intimate Partner Violence • Child Sexual Abuse Unit 3: Situation/Prevalence of Gender Based Violence • Globally • In Africa • In Kenya • Statistics of GBV among men Unit 4: Causes, Risks, Vulnerabilities and Effects of Gender Based Violence • Causes of GBV • Risks, Vulnerabilities of GBV • Effects of GBV Unit 5: Self-Exploration/Self-Awareness on Gender Issues • Myths and facts on GBV • Stigma and Discrimination A Training Course for Management of Sexual Violence - Facilitator’s Manual

UNIT 1: DEFINITION OF GENDER AND REL ATED TERMS

Purpose: • To attain a thorough understanding of gender terms and issues to enable effective work with SGBV survivors

Expected Learning Outcomes: • Demonstrate understanding of gender concepts and issues

Lesson Plan Guide:

Time: 40 Mins

Time 40 mins

Content

Resource Materials

Training methodology and learning activities

Definition of terms

• Define

Divide participants into the

• Flip charts

• Gender

gender terms

• Masking tape

• Sex

and concepts

two groups, separately to define the terms above.

• Marker pens

Group work should take 10

• Trainer’s Manual

minutes; each group takes

• LCD machine and

10 minutes to report back

laptop

• Sexual orientation • Gender identity • Gender expression • Transgender • Gender transition

Training Objectives

in plenary. The facilitator fills in the gaps by giving

• Gender roles

an illustrated lecture on the

• Sex roles

definitions.

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Training Objectives

Training methodology and learning activities

Time

Content

40 mins

• Sexual orientation

(Please note that not all

• Gender identity

the terms require to be

• Gender

defined…a select list of terms

expression

requiring definition can be

• Transgender

found in the slides.)

Resource Materials

• Gender transition • Gender based violence • Violence against women • Sexual violence • Power relations • Perpetrator • Survivor/victim • Sexuality • Gender equity • Gender equality • Gender sensitivity • Gender responsiveness • Gender analysis • Gender mainstreaming • Practical gender needs • Strategic gender needs

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Gender

Sex

Gender refers to the socially constructed roles This refers to biological attributes of men and and responsibilities assigned to men and women women - are universal and cannot be changed. It by society. These roles are learned, vary across is static, universal, innate and biological. cultures and change over time. In other words, gender is dynamic, geographical, learned, social and constructed Gender roles

Sex roles

Gender roles are reflected in activities ascribed to men and women on the basis of perceived differences which are reinforced through the gender division of labour. This arises from the socialization of individuals from the earliest stages of life through identification with specific characteristics associated with being male or female. They include rearing children, piloting, farming and care giving

Sex roles’ are from nature; they are genetically determined characteristics of male and female, such as pregnancy and childbirth, breastfeeding and impregnating.

Sexual orientation “Sexual orientation” is the preferred term used when referring to an individual’s physical and/or emotional attraction to the same and/or opposite gender. “Gay,” “lesbian,” “bisexual” and “straight” are all examples of sexual orientations. A person’s sexual orientation is distinct from a person’s gender identity and expression. Gender identity The term “gender identity,” distinct from the term “sexual orientation,” refers to a person’s innate, deeply felt psychological identification as a man, woman or some other gender, which may or may not correspond to the sex assigned to them at birth (e.g., the sex listed on their birth certificate). Gender expression Gender expression refers to all of the external characteristics and behaviors that are socially defined as either masculine or feminine, such as dress, grooming, mannerisms, speech patterns and social interactions. Social or cultural norms can vary widely and some characteristics that may be accepted as masculine, feminine or neutral in one culture may not be assessed similarly in another.

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Transgender Transgender – or trans – is an umbrella term for people whose gender identity or expression is different from those typically associated with the sex assigned to them at birth (e.g., the sex listed on their birth certificate). Not all people who consider themselves (or who may be considered by others as) transgender will undergo a gender transition. Gender transition Transitioning is the process some transgender people go through to begin living as the gender with which they identify, rather than the sex assigned to them at birth. This may or may not include hormone therapy, sex reassignment surgery and other medical procedures Gender equity- Is the process of being fair to women and men. To ensure fairness, measures must often be available to compensate for historical and social disadvantages that prevent women and men from otherwise operating on a “level playing field.” Gender equality- It refers to the absence of discrimination on the basis of a person’s sex in authority, opportunities, allocation of resources or benefits and access to services. It therefore describes the equal valuing by society of both the similarities and differences between men and women, and the varying roles that they play. Gender sensitivity- ‘Gender sensitivity’ is theoretical and refers to when a person or program recognizes that gender roles are socially constructed and can be changed. Gender responsiveness- ‘Gender responsiveness’ is a when a person or a program practises gender sensitivity. Actions address gender unfairness and discrimination, promote equity for women and men and include their empowerment and advancement. Gender analysis- This is the process of examining roles and responsibilities or any other situation in regard to women and men; boys and girls, with a view to identifying gaps, raising concern and addressing them; investigating and identifying specific needs of girls and boys, women and men for policy and programme development and implementation. Practical gender needs- These are needs related to the roles of reproduction, production and community work of men and women which, when met, do not necessarily change their relative position/condition in society. Meeting of practical needs tends to create dependency syndrome, for example, giving a person fish instead of teaching them how to fish.

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Strategic gender needs- Refers to higher level of needs of women and men which, when met, help change their status in society. Examples of such needs are decision making and access to information. Gender mainstreaming- It is the process of integrating a gender equality perspective into the development process at all stages and levels. Gender mainstreaming is a strategy (tool) for the achievement of gender equality. It may also be defined as the process of ensuring that gender is taken into account in all policies, processes and practices. It is an approach to achieving gender equality and supporting the advancement of women. Central to the process of mainstreaming and engendering processes and projects, are issues of capacity and skills development for gender analysis; availability of data and information for planning purposes

References and Recommended Reading

1. Heise, L. (1998) Violence against women: An integrated, ecological framework. 4(3): p. 262-290. 2. World Health Organization. (1997) Violence against women: a priority health issue. Geneva: WHO

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

UNIT 2: TYPES OF GENDER BASED VIOLENCE

Purpose:

Attain knowledge and understanding of the different types of GBV

Expected Learning Outcomes:

• Define violence • Discuss the different types of gender based violence • Relate gender based violence to human rights

Lesson Plan Guide:

Time: 40 Mins

Time 40 mins

Content

Training Objectives

Training methodology and learning activities

Define violence

Brainstorming session on the definition of violence

Types of GBV • Sexual violence • Physical violence • Emotional and psychological violence • Harmful traditional practices • Socioeconomic violence

•

Participants brainstorm on the different types of gender based violence as the facilitator writes them on a flip chart. The facilitator then gives an illustrated lecture to fill in gaps.

Discuss the different types of gender based violence

Resource Materials • • • • •

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Time

Content

Training Objectives

Intimate Partner Violence • Child Sexual Abuse GBV and Human Rights

Training methodology and learning activities

Resource Materials

•

Relate gender based • violence to human rights

40 mins

• • • Participants brainstorm • on the how gender based • violence violates human rights. The facilitator then gives an illustrated lecture to fill in gaps.

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop

Facilitator’s notes

What is Violence? The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation (WHO,2002)

Types of GBV •

Sexual violence is any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion,

A Training Course for Management of Sexual Violence - Facilitator’s Manual

threats of harm or physical force by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work (WHO, 2003) •

Physical violence includes punches, mutilation, burns, use of arms and domestic incarceration.

•

Emotional or psychological violence encompasses humiliation, exploitation, intimidation, psychological degradation, verbal aggression and deprivation of freedom and rights.

•

Harmful traditional practices include, FGM, Female sex slavery, Denial of rights to control one’s fertility, Sex discrimination, dowry-related murder, selective malnourishment of female children, and sexual abuse of female children, Early/forced marriages etc.

•

Socioeconomic violence, covers economic blackmail, taking away the money the woman earns so the male partner has an absolute control over the family income. Forced housewifeism or the denial of resources. NB. Men can also suffer from socioeconomic violence if the female partner is the one that has financial power

•

Intimate Partner Violence: This refers to behaviour by an intimate partner or ex-partner that causes physical, sexual or psychological harm, including physical aggression, sexual coercion, psychological abuse and controlling behaviours (WHO, Fact Sheet on Violence Against Women, 2014). It is the most pervasive form of gender violence is abuse of women by intimate male partners. Physical violence is often accompanied by psychological and sexual violence a third of these cases. A review of 50 population-based studies carried out in 36 countries indicates that between 10 and 60% of women who have ever been married or partnered have experienced at least one incident of physical violence from a current or former intimate partner (Heise, 1999). Although women can also be violent and abuse exists in some same-sex relationships, the vast majority of partner abuse is perpetrated by men against their female partners.

•

Child Sexual Abuse: Child sexual abuse refers to any sexual act that occurs between an adult or immediate family member and a child, and any nonconsensual sexual contact between a child and a peer. Laws generally consider the issue of consent to be irrelevant in cases of sexual contact byan adult with a child (Heise, 2002)

A Training Course for Management of Sexual Violence - Facilitator’s Manual

WHO Typology of Sexual Violence:

Source: WHO (2002) Global Report on Violence and Health. Geneva: WHO GBV and Human Rights Gender-based violence violates human rights principles enshrined in international human right instruments and in the Kenyan Constitution, Bill of Rights, these rights include: •

Right to life, liberty and personal security.

•

Right to the highest attainable mental and physical growth.

•

Right to freedom from torture or cruel, inhuman or degrading treatment or punishment.

•

Right to freedom of movement, opinion, expression and association.

•

Right to enter into marriage with free and full consent and entitlement to equal rights to marriage, during marriage and its dissolution.

•

Right to education, social security and personal development.

•

Rights to cultural, political and public participation with equal access to public services, work and equal pay for all work.

A Training Course for Management of Sexual Violence - Facilitator’s Manual

References and Recommended Reading 1. Heise, L. (1998) Violence against women: An integrated, ecological framework. 4(3): p. 262-290. 2. Heise L, Ellsberg M, Gottemoeller M. (1999) Ending violence against women. Population Reports: Baltimore: Johns Hopkins University. 3. Heise, L. Ellsberg, M, Gottmoeller, M. (2002) A global overview of gender-based violence. International Journal of Gynaecology and Obstetrics 78 Suppl. 1 S5â€“S14. 4. WHO (2003) Guidelines for Medico-Legal Care for Victims of Sexual Violence. Geneva: WHO 5. WHO (2002) Global Report on Violence and Health. Geneva: World Health Organization 6. WHO (2014) Fact Sheet on Violence Against Women. Geneva: World Health Organization

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

Unit 3 Situation/Prevalence of Gender Based Violence Purpose: •

Demonstrate understanding of the situation and prevalence of SGBV globally, regionally and nationally

Expected Learning Outcomes: •

Be familiar with the situation of gender based violence globally, regionally and nationally

Lesson Plan Guide:

T ime: 40 Mins

Time

Content

40 mins

Situation of SGBV

Training Objectives

Training methodology and learning activities

Resource Materials •

Flip charts

•

Globally

Appreciate the situation

Facilitator gives an

•

Masking tape

•

In Africa

of gender at different

illustrated lecture on the

•

Marker pens

•

In Kenya

levels and its impact to

situation of GBV globally,

•

Trainer’s Manual

individuals and society

regionally and nationally.

•

LCD machine and laptop

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Facilitatorâ€™s notes

Global and regional context on sexual violence Globally, Gender Based Violence (GBV) remains a public health problem (WHO, 2005) An estimated 1.6 million people worldwide died as a result of self-inflicted, interpersonal or collective violence in 2000 (WHO, 2010) However, Sexual Violence (SV) remains the common form of GBV. Worldwide, an estimated 1 in every 3 women will experience some form of Sexual Gender-Based Violence (SGBV) in their lifetime. (Erulkar, A. S. 2004). A multi-country study conducted by the WHO in 10 developing countries found that 15-71% of the women reported experiencing either intimate partner or sexual violence at some point in their lives (WHO 2005) The highest levels of IPV were reported in Peru, Samoa, and the United Republic of Tanzania (Jewkes, R. 2002). A study conducted among high school students in Addis Ababa indicated that the prevalence of rape and attempted rape was 5% and 10% respectively (Mulugeta, E., Kassaye, M., & Berhane, Y. 1998). Prevalence of GBV: Forced Sexual Initiation

48%

Female adolescents reporting forced sexual initiation, as % of those having had sex (populationbased surveys 1993-99) 40%

37% 29%

28% 21%

19% 9%

Caribbean

Peru

Cameroon

United Republic of Tanzania

South Africa

Ghana

Mozambique

United States

New Zealand

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

Source: WHO’s World Report on Violence and Health, 2002

Prevalence of sexual violence after age 15, WHO multi-country study 59%

60%

Partner Non partner

50% 40%

20%

14% 10% 7% 6% 6% 4% 4%

17%

20%

23%

11% 5%

50%

37% 29%

30%

10%

47%

30%

31%

23%

10% 6%

11%

12% 8% 3%

Se rb ia

an d

Ja pa n

(c i ty )

on te ne gr Br o az i l( Br ci az ty il ) (p ro vi nc N e) am ib ia (c ity ) Sa m oa Pe ru (c Ta ity nz ) a ni Th a ai (c la ity nd ) (p ro vi nc Th e) ai la Ta n nz d (c an ity ia ) (p r Ba ov ng in ce la ) de sh Pe (c i ty ru Ba ) (p ng ro la vi de nc sh e) (p Et ro hi vi op nc e) ia (p ro vi nc e)

Child Sexual Abuse Child sexual abuse is a critical public health, human rights and a developmental issue that has severe consequences for the immediate and long-term health and well-being of children. The magnitude of child abuse remains a global problem with a serious impact on the victims’ physical and mental health, well-being and development and by extension, on society (WHO, 2006). Globally, approximately 7 to 36 per cent of girl children and 5 to 10 per cent of boy children will experience some form of sexual violation.( Finkelhor,D.1994) The World Health Organization estimates that 150 million girls and 73 million boys experienced sexual abuse before reaching 15 years of age. In many societies, the occurrence of SGBV is rooted in unequal gender dynamics and, certain social and cultural norms. (Etienne G.Krug et.al. 2002). In Sub-Saharan Africa, sexual violence is largely linked to the existing patriarchal societies, meaning that there is male domination and female submission, often leading to the increased vulnerability of women and girls towards SV (Tarayia, G. N. 2004).

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Prevalence of Child Sexual Abuse % of women who reported child sexual abuse before age 15 25% 21% 20%

18%

20%

14%

15% 12% 10%

7% 4%

12%

10%

oa M on Th te ai ne la gr nd o (p Et ro hi vi op nc ia e) (p r Ba ov ng in ce la de ) sh Br (c az i ty il ) (p ro vi nc Th e) ai la Ta n nz d (c an ity ia ) (p ro vi nc e) Br az il (c Ta ity nz ) an ia (c ity Ja ) pa n Pe (c i ty ru ) (p ro vi nc e) Pe ru (c N ity am ) ib ia (c ity )

an d Se rb ia

Ba ng la de

Sa m

(p ro vi nc e)

Refugee/Internally Displaced/Conflict-affected Statistics Refugees and internally displaced persons also experience SV often without appropraite response. A survey of displacement settings in 33 countries, comprised of 82 percent refugees and 18 percent IDPs, revealed that EC was available to survivors of rape in 60 percent of the sites (WHO, Lancet, 2006). A study by United Nations High Commissioner for Refugees (UNHCR) revealed that 54 percent of women that survived rape in refugee camps in seven countries did not receive emergency contraception within 120 hours of an incident in 2007 (Garcia Morena, C. et al., 2005) A January 2008 inter-agency rapid GBV assessment of selected sites in North Rift Valley, South Rift Valley, the Coastal Region, Nairobi and Central Provinces of Kenya found that while the health sector made an effort to quickly establish camp-based services, it was unable to adequately respond to survivors of sexual violence. None of the camps visited by the assessment team had post-exposure prophylaxis (PEP) or EC on site, and staff had not been trained on responding to survivors of GBV or the medical management of rape. (Speizer, I. S., A. Pettifor, et al.,2009)

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

Kenya In Kenya, according to the Kenya Health Demographic Survey (KDHS, 2014) 38 % of of ever-married women age 15-49 have ever experienced physical violence committed by their husband/partner. The results depict a slight negative relationship between the prevalence of physical violence and the education and wealth status of women. Women and men with incomplete primary level of education were more likely to have experienced physical violence. The data show that 49 percent of women have experience physical violence with one in three (28 percent) experiencing such violence in the 12 months preceding the survey. Women in the highest wealth quintile were least likely to have experienced violence, although the relationship between household wealth and experience of violence was not as clear for men. Women and men with incomplete primary level of education were more likely to have experienced physical violence The data also showed that divorced, separated, and widowed women and men are more likely to report having experienced physical or sexual violence than their currently married counterparts, ever and in the past 12 months. Among those who are currently married, however, women and men who have married more than once are more likely to have ever experienced physical or sexual violence than women and men who have married only once, ever and in the past 12 months. There are notable variations in the prevalence of physical and sexual violence across the regions. Women in Western, Nyanza and Nairobi reported a higher prevalence than the other regions, approximately one-half have ever experienced physical violence compared with the low reported in North Eastern region (12 percent). Similarly, men in these three regions also reported higher levels of physical and sexual violence committed by a spouse/partner compared with men in other regions. A joint report by the Teachers Service Commission (TSC) and the non profit making organisation Centre for Rights Education and Awareness (CREAW) has revealed that 12,660 girls were sexually abused by male teachers over a five-year period. The report captured data between 2003 and 2007 (Kenya Education Rights Update, 2009) Data from Nairobi Womenâ€™s hospital indicate that 55% of sexual assault survivors are girls aged 0-15 years (Munyui 2004). Boys and men have also been victims.

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

Kenya Violence Against Children Study (VACs) This study sought to examine four types of sexual violence meted aginst children, viz. 1. Unwanted touching in a sexual way, kissing, grabbing, or fondling; 2. Unwanted attempted intercourse but the assailant did not succeed in completing sexual intercourse; 3. Pressured intercourse 4. Physically forced intercourse The significant results are summarised in the illustrations below:

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

References and Recommended Reading

1. Erulkar, A. S. (2004). The experience of sexual coercion among young people in Kenya. Int Fam. Plan.Perspect., 30, 182-189. 2. Etienne G.Krug, Linda L. Dahlberg James A. Mercy Anthony B. Zwi Rafael Lozano (2002). World Report on Violence and Health. Geneva: World Health Organization. 3. Finkelhor,D.(1994) “The International Epidemiology of Child Sexual Abuse,” Child Abuse & Neglect 5 : 409 -417. 4. Government of Kenya (2014) Kenya Demographic Health Survey. Nairobi, Kenya. Kenya National Bureau of Statistics (KNBS) 5. Jewkes, R. (2002). ‘Intimate partner violence: causes and prevention’. Lancet, 359.1423-1429 6. Mulugeta, E., Kassaye, M., & Berhane, Y. (1998). Prevalence and outcomes of sexual violence among high school students. Ethiop.Med J, 36(3), 167-174. Retrieved from PM:10214457 7. Tarayia, G. N. (2004). Legal Perspectives of the Maasai Culture, Customs, and Traditions, The. Ariz.J.Int’l & Comp.L., 21, 183. 8. WHO(2010) Global Disease Burden Study 9. WHO. WHO multi-country study on women’s health and domestic violence against womensummary report of initial results on prevalence, health outcomes and women’s responses. WHO, Geneva, 2005, 6. 10. World Health Organization (2005). The World health report, 2000. Health systems: improving performance. Geneva: World Health Organization. 2000. URL: http://www.who.int/whr/2000/ en/index.html.

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Unit 4 Causes, Contributing factors, risks, vulnerabilities and Effects of Gender Based Violence

Purpose: Attain insight into the causes, risks vulnerabilities and effects of gender based violence

Expected Learning Outcomes: Attain knowledge on: • causes of gender based violence • risks vulnerabilities of gender based violence • effects of gender based violence

Lesson Plan Guide:

Time: 40 Mins

Time

Content • •

40 mins

•

Causes of GBV Risks, Vulnerabilities of gender based violence Effects of GBV

Training Objectives •

•

Discuss causes of gender based violence Discuss risks, vulnerabilities of gender based violence Discuss effects of gender based violence

Training methodology and learning activities Participants buzz in groups on causes, risks, vulnerabilities and effects of GBV, each group reports in turn followed by an interactive discussion. The facilitator gives an illustrated lecture to fill in gaps.

Resource Materials • • • • •

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Facilitator’s notes Causes of GBV There are many factors contributing to acts of gender-based violence in any setting. In general, the overriding causes are: •

Gender inequity

•

Abuse of power

•

Lack of respect for human rights

In situations of armed conflict and displacement, when community supports and social structures have broken down, women and children face additional risks and are the most vulnerable to gender-based violence. Risks and Vulnerabilities to GBV Culture: Traditional gender norms that support male superiority and entitlement and that tolerate and justify violence against women Poverty: Abuse occurs in all socio-economic groups. Although poverty alone does not cause abuse, poverty related factors such as stress, drug abuse and inadequate resources increases the likelihood of maltreatment. Alcohol and drug abuse: Higher use of alcohol and drug abuse is associated with increased violence. Media: Media (internet, TV, radio, magazines etc) perpetuate sexual and other forms of violence by commodifying women’s bodies and women’s sexuality. Exposure to this kind of media may lead to the development of thought patterns, sexual arousal patterns and other responses that support violence against women. Such media may teach the youth that sex is something that can be consumed and to which men are entitled. Illiteracy: the lower the education level, the higher the likelihood of experiencing gender based violence.

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Conflicts: Conflict situations are characterized by a breakdown of law and order and absence of systems that would curb Gender Based Violence. Further, there is absent or severely weakened accountability mechanisms which give rise to a climate of impunity for perpetrating all sorts of crimes, including GBV. Disability: Both men and women with disabilities are at an increased risk of violence based on their disability status. Women and girls with disabilities are more likely to face violence based on their gender and disability status. A Training Course for Management of Sexual Violence - Facilitator‘s Manual

Religion: Religion can be a factor in causing or perpetrating gender based violence. For example, not all Some religions support family which women the opportunity to marriage. religions may also planning perpetuate GBVdenies by promoting polygamy, a control their fertility. Religious leaders have been known to take advantage of their position of thatabusing may promote women‘s unequal within and powerpractice by sexually their congregants. Some status religions call marriage on women to society. obey and submit to their husbands which often means they cannot refuse sex or speak up against other forms of violence within the marriage. Some religions may also perpetuate GBV by promoting polygamy, a practice that may promote unequalby status within marriage and society. Developmental Paths women’s to Perpetration Men. Developmental Paths to Perpetration by Men.

Source: Source: Heise, Heise, (2011)(2011) Effects of SGBV Nonfatal outcomes Physical health outcomes: A Training Course for Management of Sexual Violence - Facilitator’s Manual

Effects of SGBV Nonfatal outcomes Physical health outcomes: •

Injury(from lacerations to fractures and

•

internal organs injury)

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Unwanted pregnancy

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Gynaecological problems

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STDs including HIV

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Miscarriage

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Pelvic inflammatory disease

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Chronic pelvic pain

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Headaches

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Permanent disabilities

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Asthma

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Irritable bowel syndrome

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Self-injurious behaviour (smoking, unprotected sex)

Fatal outcomes •

Suicide

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Homicide

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Maternal mortality

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HIV and AIDS

Mental health outcomes:

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Depression

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Fear

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Anxiety

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Low self-esteem

•

Sexual dysfunction

•

Eating problems

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Obsessive-compulsive disorder

•

Post-traumatic stress disorder

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Source: World Health Organization, Violence Against Women: A priority Health Issue, WHO Briefing on Violence and Health The Life Cycle of Violence Against Women and Its Effects on Health*

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

Violence Against Women : Direct and Indirect Pathways to HIV/AIDS/STIs and Unwanted Pregnancy*

Partner abuse Sexual violence Child abuse

• • • •

Emotional damage

Alcohol and drug abuse Depression Low self-esteem Post-traumatic stress

High risk sexual relations Early sexual relations Multiple partners Unprotected sex Prostitution

STIs, HIV/AIDS

Unwanted Pregnancy Suicide, homicide

Abortion, miscarriage

Maternal mortality

Neonatal morbidity/ mortality

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Reproductive morbidity/ mortality

Adverse pregnancy outcomes

References and Recommended Reading

1. Heise, L. (1998) Violence against women: An integrated, ecological framework. 4(3): p. 262-290. 2. Heise, L (2011) What works to prevent partner violence? An evidence review. UK Department for International Development. 3. Heise L, Ellsberg M, Gottemoeller M. (1999) .Ending violence against women. Population, Reports. Baltimore: Johns Hopkins University.

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

UNIT 5: SELF - E XPLORATION/SELF - AWARENESS ON GENDER ISSUES Purpose: Attain self – awareness and knowledge about personal beliefs, values and biases on gender to enable better work with clients

Expected Learning Outcomes: •

Attain self-awareness and knowledge on personal beliefs, values, biases and issues on gender to facilitate better practice

Lesson Plan Guide: Time: 1 Hour

Time

Content

Training Objectives

1 hour

•

Myths and facts on GBV

•

Stigma and Discrimination

To explore personal values and beliefs on gender

Training methodology and learning activities

Resource Materials

Explain to the participants that statements will be read out and they should decide whether a statement is TRUE or FALSE. After each statement, those who think the statement is true should move to the right of the room and those who think it is false should move to the left.

•

Flip charts

•

Masking tape

•

Marker pens

•

Trainer’s Manual

•

LCD machine and

Make a provision for those who are not sure

A Training Course for Management of Sexual Violence - Facilitator’s Manual

laptop

Facilitator’s notes STATEMENTS •

Women are raped by strangers in dark places outside the home.

•

Rape of men is more shameful than that of women.

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There is no rape in marriage.

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Women say ‘No’ when they mean ‘Yes’.

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Men rape because they are overcome by sexual urges.

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Men who rape are obviously not normal.

After this exercise, remind the participants that rape is about power and domination and that every man has self-control. The facilitator should also revisit controversial issues, such as dressing. Note: Different people will have differing views on the statements. The facilitator needs to stress there are no right or wrong answers because our values determine our responses. The facilitator then proceeds to explain myths about sexual violence and how they perpetuate sexual violence. Myths and facts Myth:

Women ask to be raped.

Fact:

Rape is violent and humiliating. The rapist often uses threats and life endangering force, so the survivor fears injury or death. No one asks for the fear and trauma of rape.

Myth:

‘Young attractive girls’ get raped.

Fact:

Rapists do not choose survivors by appearance or age. Any woman may be raped. The age range of survivors is from 2 days to 103 years.

Myth:

Rapists are strangers.

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Fact:

Studies show that 60–75% of rapists know their survivors. Acquaintance rape and date rape are a real danger, especially for teens and young adults.

Myth:

Sexual violence is impulsive, done for sexual gratification. Fact:

Most rapes are

planned in advance. The rapist stalks a victim or waits for a safe opportunity and finds a victim. Sexual gratification is not the motive for rape; it is an act of anger, aggression and control with sex used as a weapon. Myths about Date Rape Myth 1:

A woman who gets raped usually deserves it, especially if she has agreed to go to a man’s house or park with him

Fact:

No one deserves to be raped. Being in a man’s house or car does not mean a woman has agreed to have sex with him.

Myth 2:

If a woman agrees to allow a man to pay for dinner or drinks, it means she owes him sex.

Fact:

Sex is not an implied pay back for dinner or other expenses, no matter how much money has been spent.

Myth 3:

Acquaintance rape is committed by men who are easy to identify as rapists

Fact:

Women are often raped by “normal’’ acquaintances that resemble “regular guys’’

Myth 4:

Intimate kissing or certain kinds of touching mean that intercourse is inevitable.

Fact:

Every one’s right to say ‘no’ should be honoured, regardless of the activity which preceded it.

Myth 5:

Once a man reaches a certain point of arousal, sex is inevitable and they can’t help forcing themselves upon a woman.

Fact:

Men are capable of exercising restraint with sexual urges.

Myth 6:

Most women lie about acquaintance rape because they have regrets after consensual rape

Fact:

Acquaintance rape really happens to people one

Myth 7:

Women who say ‘no’ really means ‘yes’

Fact:

This notion is based on rigid and outdated sexual stereotypes.

Myth 8:

Certain behaviours such as drinking or dressing in a sexually appealing way make rape a woman’s responsibility

A Training Course for Management of Sexual Violence - Facilitator’s Manual

These myths •

Increase the trauma experienced by the survivor.

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Encourage prejudice about the legal liability of both the survivor and the accused.

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Slow down or prevent the recovery of the survivor.

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Discourage survivors from reporting the rape as a crime.

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Help lawyers assist offenders escape conviction or reduce their sentence.

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Hamper society’s understanding of sexual violence and the serious effect it has

•

on survivors.

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Survivors are denied the support and assistance they need to heal from sexual

•

violation.

References and Recommended Reading

None

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Module 2 Sexual Violence and the Law

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

Module 2: Sexual Violence and the Law

Module Description: Sexual violence (SV) is not only a serious health issue but also a human rights issue. SV violates fundamental human rights enshrined in Chapter 4 of the Kenyan constitution which includes the right to life, dignity, freedom and security of the person, economic and social rights. The substantive laws governing sexual violence are contained in the Sexual Offences Act (No. 3 2006), and other relevant laws such as International Crimes Act, Penal Code, Children’s Act, Human Trafficking ACT, and The protection Against Domestic Violence ACT. This module discusses relevant laws concerning sexual violence that all Health Care Professionals (HCPs) must be conversant with to provide quality services to survivors of sexual gender based violence.

Purpose/Module Competence: To apply the key provisions of the Sexual Offences ACT and and other relevant laws in provision of Sexual Gender Based Violence Services to Survivors

Expected Learning Outcomes: By the end of this module the participant should be able to: •

Demonstrate understanding of the common offences under the Kenyan law with emphasis on Sexual Offences Act, and their ingredients.

•

Explain key terminologies used in the Sexual Offences Act

•

Outline the different offences in the Sexual Offences Act

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Describe the ingredients of the different offences in the Sexual Offences Act

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Discuss the penalties attracted by the different offences

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Discuss sexual offences as domestic crimes and international crimes

•

Demonstrate understanding of victims, accused persons, and clinicians’ rights, duties and responsibilities under the Sexual Offences Act

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Content: UNIT 1: Background to the Sexual Offences Act and Definition of Terms •

Context and Background of the Sexual Offences Act

•

Key Terms in the Sexual Offences ACT − Child − Consent − Complainant − Genital organs − Indecent act − Penetration, − Person with mental disability − Intermediary − Vulnerable person − Intentional and unlawful act − Other terms

•

Sexual offences as international crimes

UNIT 2: Sexual Offences and Punishment UNIT 3: Rights, Duties and Responsibilities under the SOA

A Training Course for Management of Sexual Violence - Facilitator’s Manual

UNIT 1: BACKGROUND TO THE SE XUAL OFFENCES ACT AND DEFINITION OF TERMS Purpose: •

Attain knowledge on the laws used in prosecuting sexual offences in Kenya

Expected Learning Outcomes: • •

Discuss the context within which the sexual Offences Act was written Define key terms in the ACT, including: − Child − Consent − Complainant − Genital organs − Indecent act − Penetration, and other terms Other terms Explain the key provisions in the sexual offences Act and other relevant laws

Lesson Plan Guide:

Time: 1 Hour

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Time

Content

Training Objectives

Background to Sexual Offences Act and other related laws

Outline the specific provisions of the Sexual Offences Act and other related laws

Definitions of terms in the Acts

To define a terminologies used in the relevant Acts

20 mins

40 mins

Training methodology and learning activities Facilitator leads participants to brainstorm on the importance of understanding the law in clinical management of sexual violence and some of the reasons that led to enactment of the sexual offences act. Facilitator fills in gaps and gives an illustrated lecture.

Resource Materials • Flip charts • Masking tape • Marker pens • Trainer’s Manual • LCD machine and laptop • Training Manual for Judicial Officers on - The Sexual Offences Act. • National Guidelines on Management of Sexual Violence, 3rd Edition 2014 • Case Studies • Internet resources

Facilitator leads participants to brainstorm on the sexual offences they know about, and to define each term. S/he then gives an illustrated lecture to fill in the gaps.

• • • •

A Training Course for Management of Sexual Violence - Facilitator’s Manual

• •

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop Training Manual for Judicial Officers on The Sexual Offences Act and other related Acts

Facilitator’s Notes Begin session with participants expressing their views on the importance of understanding provisions of the law in clinical management of sexual offences. Highlight the following – the law provides: •

Clarity on what constitutes a sexual offence

•

Understanding of specific ingredients or elements required to prove commission of a sexual offence

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Understanding clinicians’ role in supporting investigations to prove specific ingredients of sexual offences

•

Articulation of victims, perpetrators and clinicians’ rights, duties and responsibilities

Background to Sexual Offences Act and other Related Laws •

Existing laws did not adequately deal with cases of sexual violence. Sexual offences were classified as offences against morality under the Penal Code, which affected how seriously the crimes were taken and there was no uniform sentencing policy.

•

Certain forms of abuse such as sexual harassment, child sex tourism and trafficking were not acknowledged and the laws presumed that men and boys could not be sexually violated.

•

The Sexual Offences Act was passed by the National Assembly on 31st May 2006, assented to by the president on July 14, 2006, and commenced operation on 21st July 2006.

•

Its purpose is to provide comprehensive legislation addressing sexual violence in Kenya.

Definitions of Key terms in the Act Child - any human being under the age of eighteen years ( SOA and Children’s Act Section 2) Consent - a person consents if he or she agrees by choice, and has the freedom and capacity to make that choice (Section 42 (1)( Sexual Offences Act) Complainant - the Republic or the alleged victim of a sexual offence and in the case of a child or a person with mental disabilities, includes a person who lodges a complaint on behalf of the alleged victim where the victim is unable or inhibited from lodging and following up a complaint of sexual abuse (Section 2 SOA) Genital organs - includes the whole or part of male or female genital organs, and includes the anus

A Training Course for Management of Sexual Violence - Facilitator’s Manual

for purposes of this Act. ( Section 2, Sexual Offences Act) Penetration - the partial or complete insertion of the genital organs of a person into the genital organs of another person ( Section 2, Sexual Offences Act) Juristic person- refers to a registered company which is recognized to have its own identity, and it can sue or be sued. ( Section 2, Sexual Offences Act) Sexual Offences refers to all offences prescribed under the Act. ( Section 2, Sexual Offences Act) A person with mental disability refers to a person affected temporarily or permanently with a mental disability irrespective of its cause to the extent that that person is unable to make decisions on the sexual act. E.g. they do not understand the consequences of the act, express unwillingness or resistance to participate in the act. ( Section 2, Sexual Offences Act) An Intermediary refers to a person given authority by the court to give evidence on behalf of a child, a person with mental disability or an elderly person. This person may be a parent, relative, psychologist, counselor, guardian, children’s officer or social worker. ( Section 2, Sexual Offences Act) Vulnerable person - child, person with mental disabilities or an elderly person, and “vulnerable witness” shall be construed accordingly (Section 2, SOA) Intentional and unlawful act (Section 43, SOA) refers to an act committedIn any coercive circumstances involving use of force against a complainant or his/her property or another person; threat of harm; abuse of power or authority Under false pretenses or fraudulent means, where a complainant is led to believe that the act is being committed with a different person or is something other than the act; or where a person intentionally fails to disclose to a person in respect of whom an act is being committed that he or she is infected by HIV or any other life threatening sexually transmissible disease In respect of a person who is incapable of appreciating the nature of an act which causes the offence, where such person is, at the time of commission of the act: a child, mentally impaired, asleep, unconscious, altered state of consciousness, or under the influence of drugs, medicine, alcohol or other substance that adversely affects the person’s judgment or consciousness Section 43(5) provides that the provisions on intentional and unlawful acts are not applicable in respect of persons lawfully married to each other. This provision appears to contradict Section 3 of the Protection against Domestic Violence Act of 2015, which defines “violence” under part (vii) to include sexual violence within marriage. This aspect of the law will need to be remedied in due course. Nonetheless, clinicians faced with cases involving sexual violence within marriage should

A Training Course for Management of Sexual Violence - Facilitator’s Manual

conduct thorough medical and forensic examinations and documentation, which would aid the police and prosecutors in determining the most suitable charge to proffer in any given case.

A summary table of sexual offences and where to locate them in the SOA Offence

Section

Sexual Assault

Acts which cause penetration committed within the view of the family

Gang Rape

Promotion of Sexual Offences with a Child

Child Sex Tourism

Child Prostitution

Child Pornography

Exploitation of Prostitution

Trafficking for Sexual Exploitation

Prostitution of Persons with Mental Disability

Sexual Harassment

Sexual Offences Relating to Position of Authority and Persons in Position of Trust

Deliberate Transmission of HIV or any other life Threatening Sexually Transmitted Disease

Administering a Substance with Intent

Distribution of Substance by Juristic Person

Cultural and Religious Offences

Non-Disclosure of Sexual Offences

Keeping Scene of Crime secure

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

References and Recommended Reading 1. Training Manual for the judicial Officers on sexual offences Act (unpublished) 2. National Council for Law Reporting with the Authority of the Attorney General. (2006). Sexual Offences Act No. 3 of 2006. Kenya 3. National Council for Law Reporting with the Authority of the Attorney General. (2001). Children Act No. 141 of 2001. Kenya 4. National Council for Law Reporting with the Authority of the Attorney General. (2011). Prohibition of Female Genital Mutilation Act No. 32 of 2011. Kenya 5. National Council for Law Reporting with the Authority of the Attorney General. (2012). Evidence Act No. 12 of 2012. Kenya 6. National Council for Law Reporting with the Authority of the Attorney General. (2008). International Crimes Act No. 16 of 2008. Kenya 7. United States Department of Justice (2013). A National Protocol for Sexual Assault Medical Forensic Examinations, Adults/ Adolescents (2nd Edition). United States of America.

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

UNIT 2: SE XUAL OFFENCES AND PUNISHMENT

Purpose •

Attain knowledge of penalties attracted by the different sexual offences

Expected Learning Outcomes •

Outline the different offences in the Sexual Offences Act

•

Describe the ingredients of the different offences in the Sexual Offences Act

•

Discuss the penalties attracted by the different offences

•

Demonstrate understanding of sexual offences as international crimes (International Crimes Act 2008)

Lesson Plan Guide: Time: 1 hour 30 Minutes

Time

Content

Training Objectives

1 hour 10 mins

Sexual Offences and their Punishment

Discuss common Sexual Offences and their punishment

Training methodology and learning activities

Resource Materials

Facilitator leads participants to brainstorm on the sexual offences they know about, that are in the act and to the accompanying punishment. S/he then facilitates/engages the students in an interactive session to fill in the gaps.

• • • • • •

• •

Charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop Training Manual for Judicial Officers on The Sexual Offences Act. National Guidelines Case Studies

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Time

Content

Training Objectives

20 mins

Sexual offences as international crimes

Discuss varying elements of sexual offences as international crimes, particularly when committed in the context of widespread, massive, and organized attacks against civilian populations

Training methodology and learning activities •

•

Brainstorming session on episodes of massive sexual violence in Kenya Use offences under the SOA to illustrate the manner in which sexual offences could rise to the level of international crimes

Resource Materials •

International Crimes Act of 2009

Facilitator’s Notes Sexual Offences and their Punishment Rape- a person commits rape if a) He or she intentionally and unlawfully commits an act which causes penetration with his or her genital organs and b) The other person does not consent to the penetration or rape c) The consent is obtained by force or by means of threats or intimidation of any kind. A person guilty of committing rape is liable upon conviction to imprisonment for a term which shall not be less than ten years but which may be enhanced to imprisonment for life.

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Attempted rape - Any person who attempts to unlawfully and intentionally commit an act which causes penetration with his or her genital organs is guilty of the offence of attempted rape and is liable upon conviction for imprisonment for a term which shall not be less than five years but which may be enhanced to imprisonment for life. Gang rape - rape or defilement in association with another or others, or any person who, with common intention, is in the company of another or others who commit the offence of rape or defilement is guilty of an offence called gang rape A person guilty of this offence is liable upon conviction to imprisonment for a term of not less fifteen years but which may be enhanced to imprisonment for life. Facilitator should highlight the key elements as noted below: •

Rape – Age over 18 years

•

Penetration refers to the slightest penetration of one sexual organ by another

•

Lack of consent

•

Gang Rape- As above, with more than one perpetrator

Defilement – 1) A person who commits an act which causes penetration with a child is guilty of an offence termed defilement. 2) A person who commits an offence of defilement with a child aged eleven years or less shall upon conviction be sentenced to imprisonment for life. 3) A person who commits an offence of defilement with a child between the age of twelve and fifteen years is liable upon conviction to imprisonment for a term of not less than twenty years. 4) A person who commits an offence of defilement with a child between the age of sixteen and eighteen years is liable upon conviction to imprisonment for a term of not less than fifteen years. It is a defense to a charge of defilement if:a) It is proved that such child, deceived the accused person into believing that he or she was over the age of eighteen years at the time of the alleged commission of the offence; and (b) The accused reasonably believed that the child was over the age of eighteen years.

A Training Course for Management of Sexual Violence - Facilitator’s Manual

The belief described above is determined having regard to all the circumstances, including any steps the accused person took to ascertain the age of the complainant. This defense does not apply if the accused person is related to such child within the prohibited degrees of blood or affinity. Where the person charged with this offence is below the age of eighteen years, the court may upon conviction, sentence the accused person in accordance with the provisions of the Borstal institutions Act and the Children’s Act.

Attempted defilement – A person who commits an Act attempting to penetrate the genital organs of a child using genital organs (Section 9 (9) of the Sexual Offences Act) A person guilty of this offence is liable upon conviction to imprisonment for a term of not less than ten years. Where the person charged with an offence under this Act is below the age of eighteen years, the court may upon conviction, sentence the accused person in accordance with the provisions of the Borstal Institutions Act and the Children’s Act. This defense shall not apply if the accused person is related to such child within the prohibited degrees of blood or affinity

Highlight the Key elements in defilement/attempted defilement: Consent is no defense − The act must be with a child (under 18) − Penetration/attempted penetration of sexual organs of the child using sexual organs. Sexual assault - Section 5 (1) Any person who unlawfully – (a) Penetrates the genital organs of another person with (i) Any part of the body of another or that person; or (ii) An object manipulated by another or that person except where such penetration is

A Training Course for Management of Sexual Violence - Facilitator’s Manual

carried out for proper and professional hygienic or medical purposes;

(b) Manipulates any part of his or her body or the body of another person so as to cause penetration of the genital organ into or by any part of the other person’s body, is guilty of an offence termed sexual assault.

A person guilty of this offence is liable upon conviction to imprisonment for a term of not less than ten years but which may be enhanced to imprisonment for life. The facilitator should highlight that there must be penetration by an object or another bodily organ other than a genital organ. Indecent act – Any person who commits an indecent act with a child is guilty of the offence of committing an indecent act with a child and is liable upon conviction to imprisonment for a term of not less than ten years.

It is a defense to this charge if it is proved that such child deceived the accused person into believing that such child was over the age of eighteen years at the time of the alleged commission of the offence, and the accused person reasonably believed that the child was over the age of eighteen years.

Compelled or induced indecent acts – A person, who intentionally and unlawfully compels, induces or causes another person to engage in an indecent act with a) The person compelling, inducing or causing the other person to engage in the act; b) A third person; c) That other person himself or herself; or d) An object, including any part of the body of an animal, in circumstances where that other

A Training Course for Management of Sexual Violence - Facilitator’s Manual

person i) Would otherwise not have committed or allowed the indecent act; or ii) Is incapable in law of appreciating the nature of an indecent act, including the circumstances referred to in section 43, is guilty of an offence and is liable upon conviction to imprisonment for a term which shall not be less than five years.

Incest by male – any person who commits an indecent act or an act which causes penetration with a female person who is to his knowledge his daughter, granddaughter, sister, mother, niece, aunt or grandmother and is liable to imprisonment for a term of not less than ten years. If it is alleged and proved that the female person is below eighteen years the accused shall be liable to imprisonment for life and it shall be immaterial that the act was obtained with the consent of the female person.

Incest by Female – has a corresponding meaning as incest by male person

Attempted incest – attempts by any person to commit the offence of incest. A person guilty of this offence is liable upon conviction to a term of imprisonment of not less than ten years. Test of relationship - In cases of the of incest, brother and sister includes half-brother, half-sister and adoptive brother and adoptive sister and a father includes a half father and an uncle of the first degree and a mother includes a half mother and an aunt of the first degree whether through lawful wedlock or not. “Uncle” means the brother of a person’s parent and “aunt” has a corresponding meaning; “nephew” means the child of a person’s brother or sister and “niece” has a corresponding meaning; “half-brother” means a brother who shares only one parent with another; “half-sister” means a sister who shares only one parent with another; and

A Training Course for Management of Sexual Violence - Facilitator’s Manual

“adoptive brother” means a brother who is related to another through adoption and “adoptive sister” has a corresponding meaning. Facilitator highlights that: Cousins are excluded Consent in not a defense Administering a substance with intent - (1) Any person commits an offence if he intentionally administers a substance to, or causes a substance to be administered to or taken by, another person with the intention of a) Stupefying; or b) Overpowering that person, So as to enable any person to engage in a sexual activity with that person.

The complainant has to prove that the accused person administered or caused the alleged victim to take any substance with a view to engaging in a sexual activity with the alleged victim.

A person guilty of this offence, in addition to any other offence under this Act, liable on conviction to imprisonment for a term of not less than ten years

Deliberate transmission of HIV & Sexually Transmitted Diseases (Sec. 26) • Any person with actual knowledge that he/she is infected with HIV or any other life threatening sexually transmitted disease (STD) • Intentionally, knowingly and willfully • Does anything or permits the doing of anything, which he/she knows or ought to reasonably know • will infect another person with HIV, or any life threatening or other STD • is likely to lead to another person being infected with HIV or any life threatening STD

A Training Course for Management of Sexual Violence - Facilitator’s Manual

• will infect another person with HIV, or any life threatening or other STD • is likely to lead to another person being infected with HIV or any life threatening STD • Penalty: 15 years to life imprisonment, irrespective of whether or not accused person is married to the victim • Person convicted of any other offence under the SOA and proved to have been infected with HIV or other life threatening STD at time of committing offence, whether or not he/she was aware of infection, and notwithstanding any other sentence, shall be liable to 15 years to life imprisonment • Presence of HIV antibodies or antigens, detected through appropriate tests, shall be prima facie proof that person concerned is infected with HIV • If it is proved that a person was infected with HIV after committing an offence referred to in the Act, it shall be presumed, unless the contrary is shown, that he or she was infected with HIV when the offence was committed Sexual harassment – Section 23 (1) SOA Any person, who being in a position of authority, or holding a public office, who persistently makes any sexual advances or requests which he or she knows, or has reasonable grounds to know, are unwelcome, is guilty of the offence of sexual harassment and shall be liable to imprisonment for a term of not less than three years or to a fine of not less than one hundred thousand shillings or to both. Promoting sexual offences with a child – manufacturing or distributing any article that promotes or is intended to promote a sexual offence with a child; or supplying or displaying to a child any article which is intended to be used in the performance of a sexual act with the intention of encouraging or enabling that child to perform such sexual act, A person guilty of this offence is liable upon conviction to imprisonment for a term of not less than five years Child Sex tourism - minimum sentence of ten years Child prostitution - minimum sentence of ten years Child pornography - minimum sentence six years and/or fine of not less than Ksh 500,000 Exploitation of prostitution – minimum sentence of five years and/or to fine of Ksh 500,000 Prostitution of persons with mental disabilities – minimum sentence of ten years

A Training Course for Management of Sexual Violence - Facilitator’s Manual

Sexual offences relating to position of authority or trust - minimum sentence of ten years. Cultural and religious sexual offences –. Any person who for cultural or religious reasons forces another person to engage in a sexual act or any act that amounts to an offence under this Act is guilty of an offence and is liable upon conviction to imprisonment for a term of not less than ten years. Sexual Offences as International Crimes: • International crimes are offences that transcend national borders, often prohibited in international treaties and conventions agreed upon by the international community of states. • Sexual violence is recognized as an international crime when it is committed in the context of massive or large scale attacks or violations against individuals and communities • Sexual offences as international crimes are prohibited in the International Crimes Act of 2009 • The main distinction between sexual offences as domestic crimes and international crimes lies in the contextual and criminal liability elements The table below provides a summary of some of the contextual issues and criminal responsibility

Rape

Specific elements

Contextual elements

Criminal Responsibility

Must be established to prove occurrence of sexual offence both as a domestic and international crime

• Rape committed as a domestic crime involve singular/ individual incidents

• Rape committed as a domestic crime places criminal liability on individuals directly involved in committing the offence as outlined in Sec. 3 of the SOA

a. Penetration

• Rape committed as International crimes • Rape committed as includes additional criminal liability for: international crimes involve widespread or massive number of a. Indirect and higher level criminal responsibility for those involved in incidents, committed ordering, organizing, financing or offering in a specific pattern other practical assistance to facilitate or organized manner, commission of the offences; and and in the context of attacks against b. Command responsibility, placing civilians e.g. during criminal liability on a person in a position civil strife or armed of superior authority, whether military or conflict civilian, for acts directly committed by his or her subordinates.

b. Lack of consent

A Training Course for Management of Sexual Violence - Facilitator’s Manual

References and Recommended Reading 1. Training Manual for the judicial Officers on sexual offences Act (unpublished) 2. United Kingdom Foreign and Commonwealth Office (2014). International Protocol on the Documentation and Investigation of Sexual Violence in Conflict: Basic Standards of Best Practice on the Documentation of Sexual Violence as a Crime under International Law. First Edition, June 2014. 3. Rome Statute of the International Criminal Court, 2002 http://www.icc-cpi.int/nr/rdonlyres/ea9aeff7-5752-4f84-be940a655eb30e16/0/rome_statute_english.pdf 4. National Council for Law Reporting with the Authority of the Attorney General. (2006). Sexual Offences Act No. 3 of 2006. Kenya 5. National Council for Law Reporting with the Authority of the Attorney General. (2012). Evidence Act No. 12 of 2012. Kenya 6. National Council for Law Reporting with the Authority of the Attorney General. (2008). International Crimes Act No. 16 of 2008. Kenya

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UNIT 3: RIGHTS, DUTIES AND RESPONSIBILITIES UNDER THE SE XUAL OFFENCES ACT Purpose •

Discuss legal underpinning of clinicians’ role and responsibilities in provision of medical treatment to victims, suspects, convicted persons and others as provided in the SOA.

Expected Learning Outcomes •

Demonstrate an understanding of clinicians’ duties and responsibilities vis-à-vis victims and accused persons’ right to medical treatment as provided in the SOA and related laws.

Lesson Plan Guide: Time: 30 Minutes

Time

Content

Training Objectives

50 mins

Rights, duties and responsibilities under the sexual

•

offences act

Demonstrate understanding of victims, accused persons, and clinicians’ rights, duties and responsibilities under the Sexual Offences Act

Training methodology and learning activities •

•

Buzz and plenary session on rights, duties and responsibilities of different persons under the sexual offences act Facilitator gives a brief lecture to fill in gaps

Resource Materials •

SOA

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Facilitator’s Notes This session is intended to provide a legal underpinning for clinicians’ role in provision of medical treatment to victims and accused persons, and supporting investigations and access to justice for sexual offences. It will make reference to the Sexual Offences (Medical Treatment) Regulations of 2012, which were promulgated pursuant to Section 35 of the SOA, which requires the Minister for Health to prescribe circumstances under which a victim of sexual offence may access treatment in any public hospital or institution. Section 3 of the Regulations articulates the right to medical treatment and provides that: • A victim, suspect, person convicted or witness of a sexual offence has a right to medical treatment in any public hospital, private hospital or any other medical facility • Expenses incurred for medical treatment in a public hospital are to be borne by the State • The Minister for Health may enter into agreements with private hospitals to be designated as public hospitals for purposes of the SOA • Victims are entitled to medical treatment whether or not they have reported the matter to the police • Section 4 of the Regulations require a police officer who receives a report that a sexual offence has been committed against any person, to notify and refer the victim to a “designated person” or “medical practitioner” in any health facility. Section 2 of the Regulations define a “designated person” to include” • A nurse registered under section 12(1) or enrolled under section 14(1) of the Nurses Act (Cap. 257); and • A clinical officer registered under section 7 of the Clinical Officers (Training, Registration and Licensing) Act (Cap. 260); • and a “medical practitioner” as one registered in accordance with section 6 of the Medical Practitioners and Dentist Act (Cap. 253) Section 6 of the Regulations provides that upon receiving notification from a police officer, a medical practitioner or designated person shall: • conduct a full medical-forensic examination on the victim and prescribe appropriate medical treatment • provide appropriate professional counselling to the victims of the sexual offence • complete the prescribed Post Rape Care form and psychological assessment form, and any

A Training Course for Management of Sexual Violence - Facilitator’s Manual

• •

• • •

other relevant records collect and preserve the necessary medical forensic samples in accordance with the national guidelines on management of sexual violence inform and forward to investigating officer or his/her representative collected samples, while maintaining a record of the chain of custody by appending his/her signature for the samples initiate appropriate referral for further relevant care provide medical treatment to a person suspected of committing a sexual offence conduct other examinations and treatment as he/she deems necessary

Under Section 5 of the Regulations, a designated person or medical practitioner will also be required to obtain samples from a person charged with a sexual offence, pursuant to a court order and as provided under section 36 of the SOA. Such samples will be obtained for the purpose of forensic and other scientific testing, including a DNA test, to prove or disprove whether the accused person committed the offence.

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References and Recommended Reading 1.

Sexual Offences Act No. 3 of 2006. Kenya

Sexual Offences (Medical Treatment) Regulations of 2012. Kenya

Children Act No. 141 of 2001. Kenya

Prohibition of Female Genital Mutilation Act No. 32 of 2011. Kenya

Evidence Act No. 12 of 2012. Kenya

International Crimes Act No. 16 of 2008. Kenya

Training Manual for the Judicial Officers on Sexual Offences Act

8. International Protocol on the Documentation and Investigation of Sexual Violence in Conflict: Basic Standards of Best Practice on the Documentation of Sexual Violence as a Crime under International Law. First Edition, June 2014. 9.

Rome Statute of the International Criminal Court, 2002

10. A National Protocol for Sexual Assault Medical Forensic Examinations, Adults/ Adolescents (2nd Edition). United States of America.

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Module 3 Medical / Clinical Management

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

Module 3: Medical/ Clinical Management Module Description: Medical management of survivors of sexual violence is essential in mitigating the adverse physical effects of sexual violence. This module facilitates attainment of competencies required to manage survivors of sexual violence.

Purpose/Module Competence: To attain the competence/ability to attend to clients of sexual gender based violence in a professional and comprehensive manner.

Expected Learning Outcomes: By the end of this module the participant should be able to: 1. Attend to a survivor and suspect 2. Obtain informed consent 3. Demonstrate understanding of the consequences of lack of consent for both survivor and suspect. 4. Maintain confidentiality and explain the circumstances in which confidentiality may be breached. 5. Take survivorâ€™s and suspectâ€™s history 6. Perform a complete physical, mental and emotional examination of a survivor 7. Collect forensic evidence and samples for laboratory investigations 8. Manage physical injuries sustained in SGBV 9. Provide prophylaxis for STIs including HIV, Hepatitis B, other infections and prevention of pregnancy 10. Document findings in PRC, P3 forms and medical certificate 11. Organise for referral of the survivor as needed 12. Assess the safety of the survivor and provider and respond appropriately

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Content: Unit 1: Definition of Terms • Survivor • Suspect Unit 2: Attend to a survivor and suspect • Attending to a survivor: being sensitive to the emotional reactions of survivors • Creating a safe and conducive environment for managing a SGBV survivor Unit 3: Obtaining informed consent • What is informed consent • The significance of informed consent • The procedure for obtaining informed consent for minors and adults Unit 4: Maintaining confidentiality • What is confidentiality • What are the consequences of breaching confidentiality • What are the circumstances under which confidentiality can be breached Unit 5: History Taking • What is history taking? • The significance of history taking for survivors • The procedure of history taking for children and adults • The procedure of history taking in gynaecology • Role play/practical session on history taking Unit 6: Examination

• • •

The procedure for general physical examination The procedure for systemic examination with emphasis on genital, oral and anal exam in adult males and females, boys and girls Physical examination of a survivor using mannequins

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Unit 7: Collecting forensic evidence

• • •

What is forensic evidence? Investigations undertaken for clinical management and forensic purposes Collection of specimen for both clinical and forensic purposes

Unit 8: Management of physical injuries

• • •

Injuries caused by sexual violence Clinical management procedures for the injuries Practical session on treating injuries caused by the assault

Unit 9: Provide prophylaxis for STIs including HIV, other infections and prevention of pregnancy

• •

Prophylaxis and treatment for STIs including prophylaxis for HIV and other infections as well as prevention of pregnancy Referral and follow-up care for the survivor/ suspect

Unit 10: Proper documentation of the findings

• •

The importance of proper documentation Documentation of examination and findings

Unit 11: Organise for referral of the survivor as needed

•

Referral, where, when and to whom to refer the survivor

Unit 12: Assess the safety of the survivor and provider

• • •

Survivor’s safety Signs of danger in survivor’s life Measures to ensure survivor’s safety

Unit 13: Community Health Promotion and Support

•

Mechanisms to establish and strengthen community SGBV preparedness and response

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UNIT1: DEFINITION OF TERMS Purpose To identify survivors at the health facility and community level

Expected Learning Outcomes 1. Define terms used in sexual violence. 2. Describe the roles and responsibilities of the health care provider

Lesson Plan Guide: Time: 30 minutes

Training methodology and learning activities

Resource Materials

Define survivor and suspect

Brainstorming and group discussion

National Guidelines, Flip chart paper, marker pens

Describe the roles and responsibilities of the health care provider

Brainstorming and group discussion

Flip chart paper, marker pens

Time

Content

Training Objectives

10 mins

Definition of survivor and suspect

20 mins

Roles and responsibilities of the clinician

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Facilitator’s notes Facilitator’s notes Definitions Definitions Survivor: Survivor: This This term term -- used used throughout throughout this this document document –– is is used used in in place place of of “victim” “victim” to to describe describe someone someone who who has has survived survived sexual sexual abuse abuse or or assault. assault. The The term term “survivor” “survivor” honors honors and and empowers empowers the the strength strength of of an an individual individual to to heal. heal. Suspect: - In criminal law, a suspect is someone who is under suspicion, often formally announced as

being under law enforcement cause for an arrest exists when theasfacts Suspect: - Ininvestigation criminal law, by a suspect is someoneofficials. who is Probable under suspicion, often formally announced and circumstances within the arresting officer’sofficials. knowledge are sufficient toan warrant prudent person to being under investigation by law enforcement Probable cause for arrest aexists when the facts believe that a suspect has the committed, committing, or is about to commit a crime. a prudent person to and circumstances within arrestingisofficer’s knowledge are sufficient to warrant It is the that clinical’s role tohas provide medical care and treatment and,to with informed consent, also conduct a believe a suspect committed, is committing, or is about commit a crime. forensic medical role evaluation. It is the clinical’s to provide medical care and treatment and, with informed consent, also conduct a It is not the clinician’s role to conclude whether or not rape occurred. That is the role of the judge. forensic medical evaluation. The clinician should provide about what careful usethe of judge. legal terms It is not the clinician’s role toinformation conclude whether or notthey rapeobserved, occurred.be That is theabout role of and their meanings, and desist from making conclusions The clinician should provide information about what they observed, be careful about use of legal terms and their meanings, and desist from making conclusions For roles and responsibilities of the clinician – see previous see module 2 on sexual violence, unit 3 Rights, Duties and Responsibilities The– Sexual Offences For roles and responsibilities of theUnder clinician see previous seeAct module 2 on sexual violence, unit 3 Rights, Duties and Responsibilities Under The Sexual Offences Act

References and Recommended Reading 1. Ministry of Health (2014). National Guidelines on Management of Sexual Violence in Kenya – 3rd Edition. German Development Cooperation. Kenya: Nairobi. 2. Medicins Sans Frontieres (2013).Care for Victims of Sexual Violence. Situation with Displacement of Population. MSF Belgium: Brussels

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UNIT2:

AT TENDING TO THE SURVIVOR

Purpose To attain the ability to create a conducive environment for the survivor to narrate their story in detail

Expected Learning Outcomes At the end of this unit the participants should be able to: 1. Demonstrate understanding and sensitivity to the emotional reactions of survivors 2. Create a safe and conducive environment for managing a SGBV survivor

Lesson Plan Guide:

Time: 1 hour Training methodology and learning activities

Resource Materials

Demonstrate how to be sensitive to the emotional reactions of survivors

Role play/ simulation

National Guidelines, role play, video clips

Describe a safe and conducive environment for managing a SGBV survivor

Discussion

National Guidelines, Flip chart paper, marker pens

Time

Content

Training Objectives

40 mins

Attending to a survivor: being sensitive to the emotional reactions of survivors

20 mins

Creating a safe and conducive environment for managing a SGBV survivor

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Facilitator’s notes This is a crucial time to start the healing process – the survivor’s autonomy and right to make decisions is paramount. The survivor must feel in control throughout the entire care process!

Factors to consider when attending to a survivor and suspect •

Cultural background of survivor/ suspect

•

Language understood by the survivor/ suspect; consider interpreter/ translator where necessary, sign language

•

Beware of the link between SGBV and human trafficking – a trafficked person is highly likely to be a SGBV survivor

Factors in establishing rapport • Introduce yourself in a warm, friendly manner. • Maintain good eye contact. • Listen attentively. • Facilitate verbally and non-verbally. • Touch patients appropriately. • Discuss patients’ personal concerns. Use the SOLER approach in attending to the patient (see more details on this in the psychosocial support module) Sit squarely Open posture Lean forward to show interest Eye contact (being sensitive to cultural practices) Relax and let the survivor take control of the session Refer to psychosocial module for more discussion and practical sessions on attending. Creating a safe and conducive environment for management of sexual violence survivors

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Active Listening Do’s and Dont’s Do’s

Dont’s How you act

Be patient and calm

Don’t pressure her to tell her story

Let her know you are listening; for example, nod your head or say “hmm...”

Don’t look at your watch or speak rapidly. Don’t answer your telephone, look at a computer or write

Your Attitude

Acknowledge how she is feeling

Don’t judge what she has or hasn’t done or how she is feeling; Don’t say; “you shouldn’t feel that way” or “you should feel lucky you survived” or “poor you”

Let her tell her story at her own pace

Don’t rush her What you say

Give her the opportunity to say what she wants. Ask, “How can we help you”

Don’t assume you know what is best for her

Encourage her to keep taking if she wishes, ask “Would you like to tell me more“

Don’t interrupt. Wait until she has finished before Asking questionas

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UNIT3: OBTAINING INFORMED CONSENT

Purpose To attain/demonstrate ability to obtain informed consent Expected Learning Outcomes • Define informed consent • Explain the significance and consequences of informed consent in managing a survivor • Describe the procedure for consent taking for minors and adults Lesson Plan Guide: Time: 40 minutes

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Time

Content

Training Objectives

Training methodology and learning activities

Resource Materials

10 mins

What is informed consent

Define informed consent

Brainstorming/ Discussion

National Guidelines, PEPFAR Clinical Management for SGBV, Flip chart paper, marker pens

10 mins

The significance of informed consent

Discuss the significance of informed consent

Brainstorming/ Discussion

National Guidelines, Flip chart paper, marker pens

20 mins

The procedure for obtaining informed consent for adults

Describe the procedure for obtaining informed consent for minors and adults

Brainstorming/ Discussion Role play/ Simulation

National Guidelines, Training manual

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Facilitatorâ€™s notes Definition Informed consent Before a full medical interview and examination of the survivor can be conducted, it is essential that informed consent is obtained by ensuring that the survivor fills the consent form or thumb print if s/he cannot write or is impaired. Informed consent means explaining all aspects of the examination to the patient in a manner they can fully understand. This is the decision the survivor makes after a HCW has explained all aspects of clinical management on whether or not to continue with the management. There is a need to emphasize on shared confidentiality. Significance of informed consent Examining a survivor without consent could result in HCW being charged with offences of assault

and trespass of privacy. Particular emphasis should be placed on the matter of the release of information to other parties, including the police and other parties. This is especially important in settings where there is a legal obligation to report an episode of violence (and hence details of the examination) to relevant authorities. It is crucial that patients and parent/caregivers understand the options open to them and are given sufficient information to enable them to make informed decisions about their care. This is a fundamental right of all patients but has particular relevance in this setting where patients may have been subjected to a personal and intrusive event against their will. It is also important to ensure that a patient has a sense of control returned to them when in medical care. Above all, the wishes of the patient must be respected (WHO 2003) Procedure for obtaining an informed consent Consent for the examination should include information on the collection and disposition of any forensic samples that are collected in the course of the exam. The consent form should include what parties (e.g., the police, law enforcement, and other investigating authorities) the information and specimens obtained during the examination will be released to.

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References and Recommended Reading 1. Ministry of Health (2014). National Guidelines on Management of Sexual Violence in Kenya â€“ 3rd Edition. German Development Cooperation. Kenya: Nairobi. 2. Medicins Sans Frontieres (2010). Sexual Violence Guidelines for Medical and Psychosocial Care of Rape Survivors. MSF Operational Centre. Netherlands: Amsterdam. 3. AIDSTAR-One (2013). The Clinical Management of Children and Adolescents Who Have Experienced Sexual Violence. Technical Considerations for PEPFAR Programs. USA: Virginia.

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UNIT4:

MAINTAINING CONFIDENTIALIT Y

Purpose To attain competence in maintaining confidentiality in working with a survivor

Expected Learning Outcomes 1. Define confidentiality 2. Describe consequences in case of breach of confidentiality 3. Describe circumstances under which confidentiality can be breached

Lesson Plan Guide:

Time: 15 minutes Time

Content

Training Objectives

Training methodology and learning activities

Resource Materials

5 mins

What is confidentiality?

Definition of confidentiality

Brainstorming

National Guidelines on Management of Sexual Violence, Flip chart paper, marker pens

5 mins

What are the consequences of breaching confidentiality

Discuss the consequences of breaching confidentiality

Powerpoint presentation/ Illustrated lecture

National Guidelines On Management of Sexual Violence, Flip chart paper, marker pens

5 mins

What are the circumstances under which confidentiality can be breached

Discuss the circumstances under which confidentiality can be breached

Powerpoint presentation/ Illustrated lecture

National Guidelines on Management of Sexual Violence, Flip chart paper, marker pens

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Facilitator’s notes Definition of confidentiality As any breach of confidentiality could be extremely damaging for the person, and may discourage other survivors from coming for help, it is imperative that absolute confidentiality be observed. You should reassure the person that what they have revealed to you will remain confidential; however, some limitations exist that the person should be aware of, such as any legal obligation to inform authorities in the case of child sexual abuse. You must be aware of the law and policies around sexual violence before beginning your work. However, medical ethics always take precedence. Records of the interview should be stored safely in a locked drawer with extremely limited access. It is important to note that the confidentiality of sexual violence survivors must be given special attention while reporting. Where data entry is done by someone other than the health care worker directly involved in the care of the survivor, data entry must be done from an anonymised summary cover sheet rather than from the case history form itself. Consequences of breach of confidentiality • Survivor may miss an opportunity to seek help • Survivor may experience more violence in retaliation for having disclosed the situation to a health care provider • A partner/ family member may react with violence after learning the confidential information revealed at the health facility Lack of privacy and confidentiality • Survivors may not feel safe to disclose past experiences of sexual violence to health care providers • A violent family member may find out that the survivor told a health care provider about the sexual violence • A health care provider may reveal confidential information to a partner or family member without the survivor (e.g information about her pregnancy status, abortion history, HIV status, contraceptive use, STI diagnosis, experience of rape, sexual activity)

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References and Recommended Reading 1. Ministry of Health (2014). National Guidelines on Management of Sexual Violence in Kenya â€“ 3rd Edition. German Development Cooperation. Kenya: Nairobi. 2. Medicins Sans Frontieres (2010). Sexual Violence Guidelines for Medical and Psychosocial Care of Rape Survivors. MSF Operational Centre. Netherlands: Amsterdam. 3. Medicins Sans Frontieres (2013).Care for Victims of Sexual Violence. Situation With Displacement of Population. MSF Belgium: Brussels

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UNIT5:

HISTORY TAKING

Purpose To attain/demonstrate ability to take a comprehensive history of a survivor

Expected Learning Outcomes 1. 2. 3. 4. 5.

Define history taking Discuss the significance of history taking for survivors Describe procedure for history taking for children and adults Describe procedure for history taking in gynaecology Engage in a role play/practical session to take history

Lesson Plan Guide:

Time: 35 minutes Time

Content

Training Objectives

5 mins

What is history taking

Define history taking

10 mins The significance of history taking for survivors

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Training methodology Resource and learning activities Materials Brainstorming/ group work National Guidelines, Flip chart paper, marker pens

Discuss the significance PowerPoint presentation/ of history taking for illustrated lecture, video survivors

National Guidelines, Flip chart paper, marker pens

10 mins The procedure for Describe procedure for Brainstorming history taking for history taking for adults adults

National Guidelines, Flip chart paper, marker pens

10 mins The procedure for Describe procedure history taking in for history taking in gynaecology gynaecology

National Guidelines, Standard Operating Procedures, Flip chart paper, marker pens

Brainstorming, video

A Training Course for Management of Sexual Violence - Facilitatorâ€™s Manual

Facilitator’s notes History taking

Proper reception of the survivor begins from the moment the survivor arrives at the clinic. This means that it is vital for all staff to be sensitized and aware on how to talk to the survivor from the point of arrival. If the survivor is in crisis, the first responder at the clinic needs to ensure that the patient is placed in a safe place. The person to make first contact may give simple reassuring messages such as; “you are safe here”; “do you need anything?” “Do you have anyone with you are are you alone?”; “I can stay with you until the care provider comes”

It is important for the service provider to take as much time as possible with the survivor to optimize the process of history taking. The survivor needs to feel that s/he is in control of the medical interview The health care provider needs to understand what happened in order to help and treat the survivor correctly. During history taking, it is important to remember that the survivor has experienced profound trauma. Health care professionals need to approach clients of sexual violence in a professional manner. At this point, they may be agitated, depressed, ashamed, fearful, angry, feeling guilty etc. The HCP explains that s/he will work with another professional If the survivor needs to go to the examination room with a friend or family member, please allow this. Obtain history as completely as possible but with compassion, respect and sensitivity ensure privacy Restrict the number of people allowed into the examination room during the examination to the absolute minimum necessary Create a climate of trust Reassure confidentiality will be observed

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History taking for adults General history: During history taking, a HCP can use the following questions: Allow the survivor to describe exactly what happened in their own words, avoid interrupting, avoid signs of disapproval. Clarification of certain points should be done after the survivor is done describing the incident. • Date, Time and location of assault • Whether the suspect is known or unknown • If unknown whether their there are distinct descriptive characteristics noted on the person • Circumstances of the assault: Any injuries, blows, strangulation, weapons or other objects, verbal assault, threats • How the assault unfolded (penetration – oral, vaginal, anal, with or without foreign objects; use of condom) • Associated events- Loss of consciousness, toxic substances and drugs • Subsequent incidences/ activities by the survivor that may alter evidence e.g. Bathing, douching, wiping, the use of tampons and changes of clothing • Any symptoms that may have developed since the incident e.g. genital bleeding, discharge, itching, sores or pain, pain on passing urine or stool Gynecological history: • When was the first day of your last menstrual period? • Had you had any sexual intercourse prior to this incident? • Have you had any pregnancies? • Do you use contraception? What type? • Do you currently have a sexual partner? • When did you have the last consensual sexual intercourse? PRC form (MOH 363) The PRC form is filled in triplicate: • White(Original) copy with police-medical notes in court • Yellow(Duplicate) copy given to the survivor • Green(Triplicate) copy remains in the booklet at the facility • Ensure confidentiality in storage of medical records The following pieces of information are essential for medical history: • When do you say this happened? • When is the first time you remember this happening? • Threats that were made? • What area of your body did you say was touched or hurt?

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• • • • • •

Do you have any pain in your bottom or genital area? Is there any blood in your panties or in the toilet? Any difficulty or pain with voiding or defecating? First menstrual period and date of last menstrual period (girls only)? Details of prior sexual activity. History of washing/bathing since assault.

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UNIT6:

E XAMINATION

Purpose The HCP should attain competence to assess the nature, extent and severity of physical injuries

Expected Learning Outcomes By the end of this unit, the HCP should be able to: 1. Describe the procedure for general physical examination 2. Describe the procedure for systemic examination with emphasis on genital, oral and anal exam in adult males and females, boys and girls 3. Demonstrate ability to undertake a physical examination of a survivor using mannequins

Lesson Plan Guide:

Time: 1 Hour

Time

Content

Training Objectives

10 mins

What is physical examination?

Define Physical examination

Training methodology and learning activities

Resource Materials

Brainstorming

•

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National Guidelines, Flip chart paper, marker pens, MSF Guidelines for Medical and Psychosocial care of rape survivors 2010 IRC Clinical Care for sexual assault survivors – UCLA Centre for International Medical National Guidelines

Time

Content

Training Objectives

50 mins

The procedure for systemic examination with emphasis on genital, oral and anal exam in adult males and females,

Describe the procedure for systemic examination with emphasis on genital, oral and anal exam in adult males and females, boys and girls

boys and girls

Demonstrate ability to undertake a physical examination of a survivor using manikins

Training methodology and learning activities

Resource Materials

Discussion, video and anatomic models

•

Facilitator’s notes Be prepared. Have all needed supplies at hand. Before starting the physical examination, take time to explain all the procedures to the survivor and why they are necessary. It is important to respect the person’s modesty by uncovering the survivor partially as the examination goes along; be gentle Ensure to take forensic samples concurrently. Give the survivor a chance to ask any questions. Allow the survivor to have a family member or friend present throughout the examination, if s/he so wishes. Throughout the physical examination, inform the survivor what you plan to do next and ask for permission (informed consent). Both medical and forensic specimen should be collected during the course of the examination. Make sure that the survivor understands that s/he can stop the procedure at any stage if it is uncomfortable for her/him and give her/him ample opportunity to stop the examination, if necessary. Always address survivor‘s questions and concerns in a non-judgmental and empathic manner; use a calm tone of voice. Ensure a trained support person of same sex accompanies survivor throughout examination. Specimen collection process should be done during examination.

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Physical exam checklist Look at the following

Look for the record

•

General appearance

•

Hands and wrists, forearms, inner surfaces of upperarms, armpits Face, including inside of the mouth Ears, including inside and behind the ears Head

• • • • •

• • • • • • •

• • •

Active bleeding Bruising Redness or swelling Cuts or abrasions Evidence that hair has been pulled out and recent evidence of missing teeth

Neck • Injuries such as bite marks or gunshot Chest, including breasts wounds Abdomen • Evidence of internal traumatic injuries in the Buttocks, thighs, including inner thighs, legs abdomen and feet • Raptured ear drum Genito-anal examination Genitals (external) • Active bleeding Genitals (internal examination, using a specu- • Bruising lum) • Redness or swelling Anal region (external) • Cuts or abrasions • Foreign body presence

References and Recommended Reading 1. Ministry of Health (2014). National Guidelines on Management of Sexual Violence in Kenya – 3rd Edition. German Development Cooperation. Kenya: Nairobi. 2. Medicins Sans Frontieres (2010). Sexual Violence Guidelines for Medical and Psychosocial Care of Rape Survivors. MSF Operational Centre. Netherlands: Amsterdam. 3. International Rescue Committee (2008). Clinical Care for sexual assault survivors (DVD/ROM). UCLA Centre for International Medicine. USA: New York, NYa

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UNIT7:

COLLECTING FORENSIC E VIDENCE

Purpose To demonstrate ability to collect forensic evidence and samples for laboratory investigations

Expected Learning Outcomes 1. Define forensic evidence 2. Outline the investigations undertaken for clinical management and forensic purposes 3. Demonstrate ability to collect specimen for both clinical and forensic purposes

Lesson Plan Guide:

Time: 15 minutes Training methodology and learning activities

Resource Materials

Define forensic evidence

Brainstorming

National Guidelines, Flip chart paper, marker pens

Investigations undertaken for clinical management and forensic purposes

Discuss the investigations undertaken for clinical management and forensic purposes

Brainstorming, illustrated lecture using power point slides

MSF Guidelines for Medical and Psychosocial care of rape survivors 2010 National Guidelines, Flip chart paper, marker pens

Collection of specimen for both clinical and forensic purposes

Demonstrate ability to collect specimen for both clinical and forensic purposes

Demonstrations, role plays with anatomic models and real patients where possible

MSF Guidelines for Medical and Psychosocial care of rape survivors 2010 National Guidelines, Flip chart paper, marker pens

Time

Content

Training Objectives

5 mins

What is forensic evidence

5 mins

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Facilitator’s notes Investigations for Clinical Management of the Survivor Basic investigations to know the general condition of the survivor will include ‘mandatory investigations’ and ‘investigations where possible’ Mandatory

Where possible

HIV test

Blood for haemoglobin level/ packed cell volume

Pregnancy test

VDRL Liver Function Test Hepatitis B

Investigations Carried Out for Evidence Purposes Urine analysis for epithelial cells; High vaginal swab, anal swab or/ and swabs of other orifices for evidence of spermatozoa. A high vaginal swab is only necessary if there is fluid there that may include semen. The better practice is to swab fluid anywhere in the vaginal cavity (or anywhere else - on the body, survivor’s clothes) for possible semen. Only a qualified clinician is permitted to draw such samples (it is not permissible to ask the client to digitally draw these samples herself). DNA is not required to prove that rape occurred. DNA is just one more tool in the toolbox to inform investigations and prosecutions The health worker should collect the specimen, preserve it for appropriate storage and hand it over to the police for further investigations and processing in the courts. (Refer to module 3 for comprehensive forensic evidence capture)

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UNIT8:

MANAGEMENT OF PHYSICAL INJURIES

Purpose To manage physical injuries resulting from the sexual violence

Expected Learning Outcomes 1. Outline different injuries caused by sexual violence 2. Describe the clinical management procedure for the injuries 3. Demonstrate ability to treat injuries caused by the assault

Lesson Plan Guide:

Time: 20 min

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Training methodology and learning activities

Resource Materials

Outline different injuries caused by sexual violence

Brainstorming session, question and answer, facilitator asks the question? What are the physical injuries inflicted by SV? Then fills in gaps using illustrated lecture pictures, case studies and video

Video, TV, pictures flip chart marker pens National Guidelines, Standard Operating Procedures, MSF Guidelines for Medical and Psychosocial care of rape survivors 2010

Describe the clinical management procedure for the injuries

Brainstorming session, question and answer, facilitator asks, how are these injuries managed? Fills in gaps using illustrated lecture, pictures, case studies and video

Video, TV, pictures flip chart marker pens National Guidelines, Standard Operating Procedures

Time

Content

Training Objectives

10 mins

Injuries caused by sexual violence

10 mins

Clinical management procedures for the injuries

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MSF Guidelines for Medical and Psychosocial care of rape survivors 2010

Facilitator’s notes Management of injuries in sexual violence • to prevent risk of tetanus • to manage pain • management of any life threatening injuries takes precedence over all other aspects of postrape care. Immediately refer patients with life-threatening or severe conditions for emergency treatment. Complications that may require urgent hospitalization: • extensive injury (to genital region, head, chest or abdomen) • neurological deficits (for example, cannot speak, problems walking) • respiratory distress • swelling of joints on one side of the body (septic arthritis) Minor cuts and abrasions should not delay the delivery of other more time dependent treatments. Clean abrasions and superficial lacerations with antiseptic and either dress or paint with tincture of iodine, including minor injuries to the vulva and perineum. If stitching is required, stitch under local anesthesia. If the survivor‘s level of anxiety does not permit, consider sedation or general anesthesia. High vaginal vault, anal and oral tears and 3rd/4th degree perineal injuries should be assessed under general anesthesia by a gynecologist or other qualified personnel and repaired accordingly. In cases of confirmed or suspected perforation, laparatomy should be performed and any intraabdominal injuries repaired in consultation with a general surgeon Provide analgesics to relieve the survivor of physical pain. Where any physical injuries result in breach of the skin and mucous membranes, immunize with 0.5mls of tetanus toxoid. If the vaccine and immunoglobulin are given at the same time, it is important to use separate needles and syringes and different sites of administration. Advise survivors to complete the vaccination schedule (second dose at 4 weeks, third dose at 6 months to 1 year).

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UNIT 9: PROVIDING PROHYL AXIS FOR STIS INCLUDING HIV, OTHER INFECTIONS AND PRE VENTION OF PREGNANCY

Purpose To provide appropriate medical care to SGBV survivors

Expected Learning Outcomes By the end of this unit, the HCP should be able to: 1. Provide prophylaxis and treatment for STIs including prophylaxis for HIV and other infections as well as prevention of pregnancy 2. Organise referral and follow-up care for the survivor/ suspect

Lesson Plan Guide:

Time: 25 minutes Time

Content

Training Objectives

20 mins

Prophylaxis and treatment for STIs including prophylaxis for HIV and other infections as well as prevention of pregnancy

Provide prophylaxis and treatment for STIs including prophylaxis of HIV and other infections as well as prevention of pregnancy

Referral and follow-up care for the survivor/ suspect

Organise referral and follow-up care for the survivor/ suspect

5 mins

Training methodology and learning activities

Resource Materials

Participants brainstorm on the procedures for prevention of the following infections and pregnancy • HIV • STIs • Hepatitis B

Video, TV, pictures flip chart marker pens National Guidelines, Standard Operating Procedures, Clinical Guidelines on Antiretroviral Therapy, MSF Guidelines for Medical and Psychosocial care of rape survivors 2010

Facilitator fills in gaps through an illustrated lecture. Participants brainstorm on referral for certain conditions and after care why and where and to whom?

Flip chart marker pens National Guidelines

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Facilitator’s notes Management of STI STI prophylaxis should be offered to all survivors of sexual violence. • The HVS performed at initial presentation is done for forensic reasons and not for screening for STIs or to guide antibiotic administration. • Survivors with a “normal” HVS result should still be offered STI prophylaxis. • Survivors of sexual violence should be given antibiotics to treat gonorrhoea, chlamydial infection and syphilis. • Preventive STI regimens can start on the same day as emergency contraception and postexposure prophylaxis for HIV (PEP), although the doses should be spread out (and taken with food) to reduce side-effects, such as nausea.

Post Exposure Prophylaxis (PEP) for HIV This is the administration of a combination of anti-retroviral (ARV) drugs for 28 days after the exposure to HIV, and should bestarted within 72 hours of sexual violence if a survivor tests HIV negative. PEP isgiven in the event of rape, defilement and some cases of sexual violence; significant risk involves

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oral, vaginal and/ or anal penetration. This guideline recommends the use of Triple therapy i.e. three ARV drugs as per the National ART guidelines. In the event that the survivor tests HIV positive, PEP IS NOT RECOMMENDED; the survivor should be referred for HIV care, treatment and follow up. In the event that the survivor declines to take a HIV test, counselling should be continued and other management provided as per the health care provider’s clinical judgment. The efficacy of PEP decreases with the length of time from exposure to the first dose, therefore administering the first dose is a priority. People presenting later than 72 hours after sexual violence should be offered other aspects of post rape care, except PEP. All HIV exposures through sexual violence are considered to be high risk and should be treated as indicated. The recommended triple therapy is as follows: TDF + 3TC +ATV/r Treatment

Prescription

TDF + 3TC +ATV/r Tenofovir 300mg

Once a day for 28 days

Lamivudine 300mg

Once a day for 28 days

Lopinavir 200mg/ Ritonavir 50mg

Twice a day for 28 days

Atanovir (ATV) 300mg

Once a day for 28 days

Ritonavir (RTV) 100mg

Once a day for 28 days

Pregnancy Prevention • Emergency Contraception (EC) should be readily available at all times during the day and night, and should be provided free of charge for survivors of sexual violence in all health facilities. EC should be given within 120 hours/ 5 days of sexual violence; ideally as early as possible to maximize effectiveness • EC should be given to all females who have experienced menarche except those on menses, pregnant or on reliable contraceptive methods. • EC does not harm an early pregnancy • EC is not a form of abortion • There are no known medical conditions for which EC use is contraindicated. Medical conditions that limit the continuous use of oral contraceptive pills do not apply for the use of EC.

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Emergency contraception is to prevent pregnancy and is NOT a form of abortion. Unless a woman is obviously pregnant, a baseline pregnancy test should be performed. However, this should not delay the first dose of EC as these drugs are not known to be harmful to an early (unknown) pregnancy. A follow-up pregnancy test at four weeks should be offered to all women who return, regardless of whether they took EC after the sexual violence occurrence or not. If a survivor intends to terminate a pregnancy which resulted from the sexual violence, the health care provider and the survivor should be aware of the Constitutional provision in reference to abortion, thus `Àbortion is not permitted unless, in the opinion of a trained health professional, there is need for emergency treatment, or the life or health of the mother is in danger, or if permitted by any other law (Kenya Constitution 2010).” Hepatitis B Hepatitis B vaccination is intended to provide protection from future Hepatitis B virus infection. It is not meant to treat an already existing infection. It is much less costly to vaccinate all survivors of rape/sexual violence, rather than to test everyone for Hepatitis B antibodies to see who might benefit.

If a survivor has been vaccinated before and completed the full series of vaccinations as scheduled, there is no need to re-vaccinate. If s/he did not complete the full series, they should complete as scheduled.

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Follow up care 2nd visit- 2 weeks • Provide PEP refill • Assess adherence to treatments previously given • Evaluate for STIs and treat if necessary • Evaluate mental and emotional status; treat or refer as needed • Provide adherence and trauma counselling 3nd visit- 4 weeks • Check for PEP completion • Repeat PDT and refer for care if necessary • Do follow up vaccinations • Evaluate for STIs and treat if necessary • Evaluate mental and emotional status; treat or refer as needed • Provide trauma counselling rd 4 visit- 6 weeks • Evaluate for STIs and treat if necessary • Evaluate mental and emotional status; refer or treat as needed. • Provide trauma counselling rd 5 visit- 3months • Retest for HIV and refer for care if necessary • Evaluate for STIs and treat if necessary • Evaluate mental and emotional status; refer or treat as needed. • Provide trauma counselling

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ll:

HIV Prophylaxis

1st PEP dose (3 days) (see details at the bottom)

HIV Positive

Children â€“Dosage is as per the Kg body weight ABC +3TC + LPVr for 28 days (Check ART guidelines or paediatric dosing wheel )

HIV Prophylaxis

HIV Re-test 4 weeks, 12 weeks, 24 weeks

2 weeks clinical follow-up 2 weeks PEP re ll Adherence counseling

Continue PEP (2 weeks dose)

HIV Negative

Accepts HIV Test

Obtain informed consent Take history Examine & Document injuries Medical tests : HIV, PDT, Hb, HBV, HCV, CR, ALT , urinalysis and creatinine. Collect forensic samples: HVS, oral/anal-rectal swabs, hairs, semen, blood stained cothes Label, pack and store samples appropriately

History, Examination & Sample Collection

Tetanus Prophylaxis T.T injection as per TT schedule

Hepatitis B Prevention Hepatitis vaccine if indicated and available

STI Prevention As per MOH guidelines

Stop PEP

Declines HIV Test

HIV Care clinic Psychosocial support Police and legal care Shelters

Referrals to:

Trauma Pre and post HIV test Adherence

Counseling for:

Adult TDF 300mg + 3TC 300mg Once a day +ATV/r 300mg/100mg once a day for 28 days

Follow-up trauma counseling sessions: In 2 weeks, 4 weeks, 6 weeks and 12 weeks Repeat , Hb, ALTs in 2 weeks; repeat PDT in 4 weeks Trauma form lling PRC register lling

Discontinue PEP Refer to care clinic Psychosocial Support

Levonorgestrel (postinor 2) tabs 2 stat OR Eugynon OR Neogynon 4 tabs stat, OR Microgynon OR Nordette 8 tabs start. (to women/girls of reproductive age)

Pregnancy Prevention

Minimum Post Rape Care Package

Any life theatening injuries should take priority over other aspects of Post Rape Care

Survivor presents within 72 hours (Treat this as an Emergency)

> Regimen

> Duration

survivor consultation are documented

Documents to ll:

> Type

Pharmacy

Documents to ll:

Counselling

Documents to ll:

> Indicate results of each test

> Medical or Forensic

What is to be documented

This publication was adopted from LVCT

References: National Guidelines on Management of Sexual Violence in Kenya and Guidelines for Antiretroviral Therapy in Kenya 4th Edition 2011

Documents to

> Name and signature of health care provider handing over samples > Name and signature of police o cer receiving samples > Date of the evidence transfer

> Anterior and posterior view > Genitalia/anal-rectal (male and female)

> Types of samples > Whether survivor bathed or changed clothes > Name and signature of examining health care provider

> Presenting complaint > Date and time of the sexual violation > Details of perpetrators (Number; known or unknown) > Type of sexual violation reported (as per SOA de nitions)

> Marital status > Existence of any disability

Casualty /OPD

Demographic information must include

What is to be documented

Annex 3: Clinical Management Algorithm`

UNIT10:

PROPER DOCUMENTATION OF THE FINDINGS

Purpose To document examination findings correctly, accurately and completely

Expected Learning Outcomes By the end of this unit, HCP will be able to: 1. Demonstrate understanding of the importance of proper documentation 2. Properly document examination and findings

Lesson Plan Guide:

Time: 1 hour Time

Content

Training Objectives

Training methodology and learning activities

Resource Materials

10 mins

The importance of proper documentation

Demonstrate understanding of the importance of proper documentation

Brainstorming on the importance of documentation, facilitator fills in gaps

National Guidelines, Flip chart paper, marker pens

50 mins

Documentation of examination and findings

Properly document examination and findings

Use mock case studies or scenarios to record information on examination and findings

Examination and record tools, PRC form, psychological assessment form

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Facilitator’s notes The PRC form must be provided by the health facility while the P3 form must be provided by the police. These forms are free and therefore a survivor must not be requested to pay a fee. In cases where the designated forms to be completed are not available, the clinician can document findings (improvise using paper) properly – this evidence is permissible in the court of law Summary of findings to be documented after examination of a survivor of sexual violence: General examination • Document the state of clothes- the colour, whether stained or torn, where they were taken to • Document vital signs of the survivor Mental assessment Document as per the psychological assessment form Systemic examination Document details of the: • Central nervous system- level of consciousness, affect • Musculo-skeletal system- physical disabilities, posture control and gait, swellings, bruises, lacerations, dislocations, bite marks, scratches on the body of survivor from head to toe. • Perineum- The perineum consists of the clitoris, labia majora and minora, vagina, mons pubis, introitus, fossa navicularis, vestibule, hymen, penis, prepuce, scrotum, urethra, anus, gluteal region, inner medial thighs. In the above areas, document: • Any tenderness, bruises, abrasions, cuts, teeth -marks, scratch marks bleeding, discharge, old scars (question their source if any)

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Illustration of Clock Face documentation

• • • •

Details of the anus- shape, dilatation (sphincter muscle tone), fissures, faecal matter on perianal skin, bleeding from rectal tears. Details of the hymen- shape, position, colour, and type e.g. Cribriform, septal, cresent shaped, carunculae. Position and size of tears e.g. At 3 o’clock 1 cm etc.

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UNIT11:

ORGANISING FOR REFERRAL OF SURVIVOR

To attain the ability to assess safety of the survivor and manage her/him appropriately

Expected Learning Outcomes By the end of this unit 1. The HCP will be clear on how, where, when and whom to refer the survivor 2. Help the survivor who feels in danger to be put in safety 3. Identify when his/ her life is in danger 4. Take measures to ensure survivor’s safety

Lesson Plan Guide:

Time: 15 minutes

134

Training methodology and learning activities

Resource Materials

Discuss referral pathways, where, when and to whom to refer the survivor

Brainstorming, illustrated lecture, case studies etc.

National Guidelines, Flip chart paper, marker pens

Create an environment for a survivor who feels in danger to be put in safety

Brainstorming, question and answer, illustrated lecture

National Guidelines, SOPs Flip chart paper, marker pens MSF Guidelines for Medical and Psychosocial care of rape survivors 2010

Time

Content

Training Objectives

15 mins

The importance of referral within facilities; Referral to other non-health facilities Referral, where, when and to whom to refer the survivor Follow up care

5 mins

Survivor’s safety

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Time

Content

Training Objectives

Training methodology and learning activities

Resource Materials

10 mins

Signs of danger in survivor’s life

Identify signs of danger in the life of the survivor

Brainstorming, question and answer, illustrated lecture

National Guidelines, SOPs Flip chart paper, marker pens MSF Guidelines for Medical and Psychosocial care of rape survivors 2010

10 mins

Measures to ensure survivor’s safety

Take measures to ensure survivor’s safety

Simulation, role play

National Guidelines, SOPs Flip chart paper, marker pens, MSF Guidelines for Medical and Psychosocial care of rape survivors 2010

Facilitator’s notes The importance of referral, referral tracking and follow up care within health and other non-health facilities • To ensure that the survivor has a comprehensive management • To ensure coordinated preparedness and response to sexual violence cases

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Safety of the survivor Conditions for the survivor’s security need to be determined with the survivor and the most suitable solution found for the survivor’s particular situation depending on the environment and the possibilities. The survivor alone must decide when and how they wish to be helped. If the survivor is a child or an adolescent and the suspect is a member of the family still living in close proximity to the survivor, it is up to the designated person to take protective steps to initiate the process. Measures to take • Emergency accommodation (hospitalization, social groups etc.) • Immediately consult with the designated person on referral • There should be a process within every healthcare facility and a formal arrangement between the facility and the police. Prosecutors and judges should be part of this referral network as well (local SGBV coordination network). It is important to have the contacts and conduct meetings with these stakeholders.

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References and Recommended Reading • • •

1. Ministry of Health (2014). National Guidelines on Management of Sexual Violence in Kenya – 3rd Edition. German Development Cooperation. Kenya: Nairobi. 2. Medicins Sans Frontieres (2010). Sexual Violence Guidelines for Medical and Psychosocial Care of Rape Survivors. MSF Operational Centre. Netherlands: Amsterdam. 3. Medicins Sans Frontieres (2013).Care for Victims of Sexual Violence. Situation With Displacement of Population.

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UNIT12:

COMMUNIT Y HE ALTH PROMOTION AND SUPPORT

Purpose •

To apply principles in health promotion and networking to identify and support survivors at the community level

Expected Learning Outcomes •

By the end of this unit, the HCP will be able to put mechanisms in place to establish and strengthen community SGBV preparedness and response

Lesson Plan Guide:

Time: 20 minutes

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Time

Content

Training Objectives

20 mins

Mechanisms to establish and strengthen community SGBV preparedness and response

Discuss mechanisms to establish and strengthen community SGBV preparedness and response

Training methodology and learning activities

Resource Materials

Brainstorming, group work and illustrated lecture

National Guidelines, Flip chart paper, marker pens

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MSF, Guidelines for Medical and Psychosocial care of rape survivors 2010

Facilitator’s notes In many societies there is a “law of silence” surrounding sexual violence and often the survivors themselves refuse to report the assault for fear of reprisals or social stigma. Often the population, and in particular the victims of sexual violence, do not know about the services we offer. When survivors decide to approach the health facility, they often find it difficult to say what has happened to them and may complain of psychosomatic symptoms. Measures to take: 1.

Break the silence: - Awareness of the general population - men and women

We must show and let it be known that we are concerned for the victims of sexual violence and that we can offer them medical help.

(adults and adolescents), refugees/

displaced persons, as well as the native population should all be informed of the problem of sexual violence.

- Awareness of the most vulnerable - organise information sessions designed specifically for women (with adapted HP material): · at ante-natal and/ or reproductive health consultations · in nutritional centres · Within existing women’s groups, both within the refugee/displaced persons camps and the native population etc…

This activity is to be carried out in collaboration with: - home visitors and community health workers - matron from the community - male and female representatives of the refugees/displaced persons - “Influential” members of the community (schoolteachers, religious leaders, police,…) - male and female representatives of the native population The first step will, of necessity, consist in a full review of the various cultural and traditional rules which are observed in the operating context so that a common definition of what all understand by sexual violence can be established.

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1. Inform on the services offered at the health facility

The population must be informed on our offer of care stressing confidentiality. The message must be relayed in a manner appropriate to the context (message via homes visitors, community health workers, the radio, religious or other leaders, brochures, â€Ś) and should include the following : - What services are available - Why victims of sexual violence should attend the health centre - Guarantee of the confidentiality - The importance to come as quickly as possible after the attack - Where and who to ask for at the health centre - Accessibility (ideally 24/24h and 7/7 days) - Free care

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2. Make the survivor’s request for care easier

Self-help networks - Set up groups within the community (women’s groups already existing, or to be set up) and/or appoint key people to increase the number of reference points directing towards the health centre • Each member of the team must be able to be a referent if it is informed of sexual violence •

- To this end, all team members (included the guards who are the first people patients meet at the entrance to the health centre) will receive detailed information in the care to be provided. The risk of victims being stigmatised and the need for total confidentiality are to be stressed. •

Medical staff should encourage requests - In situations where sexual violence is frequent, members of the medical staff when recording a patient’s medical history during consultation, should question all women using a phrase such as : “Because sexual violence is so common, I am questioning all the women I see. Have you, too, been subject to this form of violence?”

•

Alternative patient’s circuit - Design the patient’s circuit so that victims : . do not have to explain to many people why they come . do not have to wait hours to be received

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1. Recognising survivors of sexual violence

Be alert to signs of physical violence. These may be the result of the actual assault or may be caused by subsequent aggression on the part of the family. Male members of a family sometimes assault a woman rape victim on the basis that she is no longer pure. Be alert to all physical abrasions (e.g. marks on the wrists of someone who has been held down by force) or symptoms (e.g. STI, adolescent pregnancy, incomplete abortion, fistula…) which may be the result of rape, or other wounds which do not tally with the explanation given by the patient (e.g. the mother who claims that a child is sore between her legs as a result of a fall from a bike?) • Be alert to vague complaints or chronic symptoms of no apparent physical origin. • Be alert to the warning signs of psychological problems (sleep problems, loss of appetite,…), and signs of acute or post-traumatic stress. • Listen carefully to a person who claims/is claimed to be possessed by evil spirits, or who has been accused, or accuses herself, of having broken a taboo or ancestral rule. Cultural elements, resulting from customs, religious or moral values, can be used as vectors for the expression of mental suffering.

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References and Recommended Reading 1. Medicins Sans Frontieres (2010). Sexual Violence Guidelines for Medical and Psychosocial Care of Rape Survivors. MSF Operational Centre. Netherlands: Amsterdam. 2. Medicins Sans Frontieres (2013).Care for Victims of Sexual Violence. Situation With Displacement of Population. MSF Belgium: Brussels

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Module 4 Forensic Management

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Module 4: Forensic Management Module Description: Forensic management acts as a link between the health facility and the justice system, it is essential in helping the survivor of sexual violence access legal justice through the judicial process. Proper management of evidence is vital in demonstrating that the violence indeed occurred and linking the suspect to the crime. This unit facilitates attainment of knowledge, skills and attitudes required during the collection, handling, storage/preservation and observation of chain of custody.

Purpose/Module Competence: To attain competence in history taking, examination, collection, handling, storage/preservation and observation of chain of custody

Expected Learning Outcomes: By the end of this modĂźle, the participant should be able to; 1. Take a focused and thorough forensic history 2. Conduct and document a forensic examination 3. Collect, handle, and document, store, preserve and observe chain of custody 4. Maintain a proper chain of custody 5. Attain the ability - skills and etiquette required to present evidence in court as an expert witness

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Content: Unit 1 Definition of terms • Forensic Examination • Medical practitioners • Designated persons • Evidence • Forensic evidence • Physical evidence • Crime scene Unit 2 Types of evidence • Types of evidence Unit 3 Forensic examination process • History taking • Examination • Collection handling, and preservation of specimens • Types of specimen, preservation methods, tests and reasons for testing • Principles of collecting and handling specimens • Emphasis on importance/relevance of photography Unit 4 Chain of custody of evidence • Chain of custody of evidence Unit 5 Types of Injury • Blunt force trauma • Sharp force trauma • Thermal Injury/Scalds/burns • Corrosive UNIT 6: Role of Healthcare professional in evidence presentation in Court • Skills and etiquette required to present evidence in court as an expert witness

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UNIT 1: DEFINITION OF TERMS Purpose To demonstrate understanding of the meanings of the terms

Expected Learning Outcomes The participants will have a thorough knowledge and understanding of relevant forensic terms.

Lesson Plan Guide:

Time: 1 Hour Time

Content

Training Objectives

1hr

Definition of terms • Forensic Medical Examination • Medical practitioners • Designated persons • Evidence • Forensic evidence • Physical evidence • Crime scene

To explain the relevant forensic terms.

Training methodology and learning activities

Resource Materials

Facilitator writes the following terms on a flipchart or power point slide and asks participants to define each at a time as s/he fills the gaps, (Facilitators can use any other effective methods of training, like brainstorming, and other innovative approaches)

• • • • • • •

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop Sexual Offenses Act National Guidelines

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Facilitator’s notes Definition of terms related to forensic management

148

Term

Definition

Forensic Medical Examination

A medical assessment conducted in the knowledge of the possibility of judicial proceedings in the future requiring medical opinion.

Medical practitioners

Medical practitioner means a practitioner registered in accordance with section 6 of the ‘Medical Practitioners and Dentists Act’.

Designated persons

This includes a nurse registered under section 12(1) of the ‘Nurses Act’ or clinical officer registered under section 7 of the ‘Clinical Officers(training, registration and licensing) Act’

Evidence

This is the means by which disputed facts are proved to be true or untrue in any trial in the court of law or an agency that functions like a court (i.e. Tribunals, and in case of inquest). There are two types of evidence: “direct evidence” and “indirect evidence”/ circumstantial evidence”. i.e., Direct evidence is what is usually perceived by the five senses, which proves or disapproves a fact in issue (e.g. “I saw him…., I smelled, I heard…. etc.). Indirect evidence is a set of facts which when considered together, proves or disapproves a fact in issue (e.g. “You were the last person seen with the deceased…..”)

Forensic evidence

This is the evidence collected during a medical examination. The role of forensic evidence in criminal investigation includes the following: (i) To link or delink the suspect to the crime. (ii) To ascertain that a sexual offence ; (iii) To help in collection of data on perpetrators and suspects of sexual offences. In some cases, forensic evidence is the only thing that can link the perpetrator to the crime. E.g. where the incident is reported long after it happened or where the survivor was pregnant and when other evidence is not available.

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Physical evidence This refers to any object, material or substance found in connection with an investigation that helps establish the identity of the offender, the circumstances of the crime or any other fact deemed to be important to the process. It may include: used condoms, cigarette butts, ropes, masking tape etc. and can be collected from the survivor, alleged offender as well as the environment (crime scene location) Crime scene

A scene can either be a person, place or an object - capable of yielding physical evidence which has the potential of assisting in apprehending or exonerating the suspect. There are 5 stages in crime scene management: (i) Identification; (ii) Protection; (iii) Search; (iv) Record; (v) Retrieval Note: No one should interfere with a crime scene by changing or tampering with any of the objects. One should leave everything as it was.

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UNIT 2: T YPES OF E VIDENCE Purpose Manage and transmit examination findings and forensic specimens to other parties in the chain of custody of evidence

Expected Learning outcomes 1. Identify different types of evidence 2. Describe different types of evidence

Lesson Plan Guide:

Time: 1 Hour

150

Time

Content

10 mins

Types of Evidence: • Evidence to demonstrate whether a sexual offence occurred or not • Evidence related to suspect’s identity

Training Objectives

• •

Identify different types of evidence describe different types of evidence

Training methodology and learning activities

Resource Materials

Facilitator leads a brainstorming session on the different types of evidence required to establish a sexual offence occurred. A power point slide is then used to fill in gaps.

• • • • •

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• •

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop Sexual Offenses Act National Guidelines Model Toys Photographs

Facilitator’s note Types of evidence There are two types of evidence that need to be collected: • Evidence to confirm whether or not that sexual offence has occurred e.g. evidence of penetration (torn hymen), if obtained by force, there may be bruises, tears and cuts around the vaginal area and the clothing may be stained. • Evidence to link or delink the alleged suspect to the offence e.g. suspect’s torn clothes, used condoms, grass and blood stains, scratches and bite marks on the perpetrator, and eyewitness testimony i.e. Witness (es) saw it happen, or the suspect was seen walking away with the survivor (this is because circumstantial evidence can help the court adduce the guilt or innocence of the suspect).

Locard’s exchange principle States that, every contact leaves a trace......... ‘Wherever he steps, whatever he touches, whatever he leaves, even unconsciously, will serve a silent witness against him. Not only his fingerprints or his footsteps, but his hair, the fibre from his clothes, the glass he breaks, the tool mark he leaves, the paint he scratches, the blood or semen he deposits or collects.’ Need to emphasize that a sexual offence can be committed by a female, and is not limited to males This would result in the following materials which can be used as evidence: • Suspect’s material deposited on an object, e.g. Cigarette butt; • Suspect’s material deposited at a location; • Suspect’s material deposited on a victim or witness; • Victim’s material deposited on the suspect’s body or clothing; • Victim’s material deposited on an object; • Victim’s material deposited at a location; • Witness’ material deposited on a victim or suspect; • Witness material deposited on an object or at a location Evidence is used to help confirm that there has been sexual contact in the recent past, to help identify the suspect, support the information given by the sexual offences survivor and also to show that force may have been used

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References and Recommended Reading 1. Ministry of Health. (2014). National Guidelines on Management of Sexual Violence (3rd Edition). Kenya. 2. National Council for Law Reporting with the Authority of the Attorney General. (2006). Sexual Offences Act No. 3 of 2006. Kenya 3. National Council for Law Reporting with the Authority of the Attorney General. (2010). The Evidence Act Chapter 80. Revised Edition 2012. Kenya 4. Department of Health Research. (2013). Forensic Medical care for Victims of Sexual Assault. India.

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UNIT 3: FORENSIC MEDICAL E XAMINATION PROCESS Purpose To attain competence in proper and efficient forensic medical management

Expected Learning Outcomes For the participant to demonstrate knowledge and skills in: • History taking • Examination • Collection and handling of specimens • Types of specimen, preservation methods, tests and reasons for testing • Principles of collecting and handling specimens •

Emphasis on importance/relevance of photography

Lesson Plan Guide:

Time: 1 Hour

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Time

Content

10 mins

Forensic Examination Process •

History Taking

•

Examination

Training Objectives

•

Describe and apply the process of history taking

•

Describe and apply the process of examination Describe and apply the process of collecting and handling specimens Discuss specimen, preservation methods, tests and reasons for testing Describe and apply how preserve different types of evidence Identify the different components of a post rape kit Demonstrate ability to collect evidence

• •

•

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Collection and Handling of Specimens Types of specimen, preservation methods, tests and reasons for testing Principles of collecting and handling specimens

•

Training methodology and learning activities Participants in a buzz pairs, discuss • History taking • Examination • How to collect and handle each specimen and • The principles to observe in collecting each specimen Each pair then reports back in plenary. Facilitator gives an illustrated lecture to fill in gaps. • Brainstorming session A practical session ensues: • using a video that is Kenyan-specific • Simulation exercises (e.g. Mock crime scenes etc.) • use case studies and scenarios • mock-court sessions

Practical session on forensic medical examination

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Resource Materials

• • • • • • • • • • •

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop Sexual Offenses Act Sexual Offences Kit National Guidelines Camera and scales DVDs Photographs

Facilitator’s notes The Forensic Examination Process NB: Consent must be acquired before proceeding with every step of the forensic examination, from history taking, examination, photography, and evidence collection This process will include: History Taking Examination: 1. General Evidence • Debris • Clothing • Sanitary towels, panty liners etc. 2. Body Evidence (other than the perineal region) • Oral Swabs • Breast and thigh swabs • Foreign Material on the body • Semen-like stains on the body • Swabs from suspected or alleged bite marks, areas that were allegedly kissed/licked • Fingernail scrapings 3. Anogenital evidence (Pubic hair, vulva, swabs of the same) • Matted Pubic Hairs • Combing of Pubic hair • Labia majora Swabs • Labia minora swabs • Vaginal Swabs • Vaginal Smear • Perianal, anal, and rectal swabs and smear • Photographs and documentation of other body injuries (burns, scratches, bruises, lacerations etc.) Reference Sample: Reference samples are used by the crime laboratory to determine whether or not specimens of

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evidence collected are foreign to the survivor or alleged offender. Blood, buccal (inner cheek) swabbings, or saliva should be collected from the survivor or alleged offender for DNA analysis to distinguish their DNA. Collection of Clothing (NB. survivors will be requested to bring a changeover of clothes or ask their relatives to bring them) • Ask the survivor to remove his/her clothing while standing over a large sheet of paper. This is for the purpose of collecting evidence which the clothing may be carrying • The clothing is then put in paper bags (and not nylon bags) which will prevent decomposition of evidence. • Each evidential material should be packed separately to avoid cross contamination and transfer of evidence Collection of Hair Specimen • This is done by combing and plucking hair from various body parts, and where necessary slightly shaving. This is also for the purpose of collecting evidence which may be trapped in the hair strands. • This includes hair from the head, armpit, chest and pubic area. This hair is collected and put in an envelope which is then labeled. Swabs and Smears Swabbing various body parts can also help to collect evidence. • Cotton swabs may be used to collect specimen from the mouth, anal and vaginal areas as well as any other body part which may have dried body secretions (including semen). • Saliva secretions may also be taken from the neck or cheek, if there was kissing. Fingernail, Scrapping or Clipping Evidence of the perpetrator’s skin cells can be found under the survivors fingernails. Scrapings from the fingernails are collected and put in a labeled envelope. Fingernails may also be trimmed and also kept in the envelope as a source of specimen. Handling, Collection and Preservation of Evidence Handling of forensic evidence The following practices must be followed when handling an exhibit: • Protect the exhibit from weather and contamination;(a room with minimal/no human or animal traffic )

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• • • • • •

Use sterile instruments and containers; Wear gloves (powder free and sterilized) and the protective gear when appropriate; Change gloves when handling/collecting different specimens/exhibits Package, transport and store exhibit safely and securely; Take special care with fragile and perishable exhibits; Call on an expert if you lack adequate training to handle a particular type of exhibit.

Principles to be adhered to during specimen collection for forensic analysis: 1. Avoid contamination: Ensure that specimens are not contaminated by other materials. Store each exhibit separately. Wear gloves at all times for your own protection and to ensure that the exhibit is not contaminated. 2. Collect early: Try to collect forensic specimen as soon as possible. The likelihood of collecting evidentiary material decreases with the passing of time. Ideally, specimen should be collected within 24 hours of the assault; after 72 hours, yields are reduced considerably but specimen is still collected. Collect the same before requiring the victim to bathe. 3. Handle appropriately: Ensure that specimens are packed, stored and transported correctly. As a general rule, some of the 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 BAGS after drying, avoid plastic bags. 4. Label accurately: All specimen must be clearly labeled with the survivor’s name and date of birth, the health worker’s name (use full names and not initials), the type of specimen, and the date and time of collection. 5. Ensure security: Specimen should be packed to ensure that they are secure and tamper proof. Only authorized personnel (anyone authorized by the relevant authorities to handle the specimens) should be entrusted with specimens. 6. Maintain continuity: Chain of custody MUST be maintained. Provision of specimens to survivors for any reason is strictly prohibited. 7. Points to remember when handling exhibits: • Exhibits should not be exposed to direct light and sunshine. If wet, exhibits are dried under shade or dark rooms; • Exhibits should be marked properly and signed for immediately upon receipt and stored; • All exhibits including documents filled (e.g. PRC, P3) must be secured in places that guarantee safety and confidentiality.

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Types of Specimen, Preservation Methods, Tests and Reasons for Testing *Include diagrams/photographs of containers/storage modalities to illustrate further (this can be done by the professional editor and graphic designer with help from content experts)

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Specimen

Method of preservation

Test for

Purpose for testing

Mouth swab

Air dry and store in a sterile dry ventilated plastic casing

DNA

Identify assailant / victim

Urine of both the victim and the suspect

Sterile dry universal container refrigerated

Alcohol and drug

Identify the presence or absence of alcohol or substances

Pubic hair/ head hair

Pick the hair using nonpowdered gloves and store in an envelope or lift using tape store on acetate sheet

DNA Transfer evidence analysis

Identify assailant and survivors

Foreign fibres/grass/ soil

Hand pick the foreign fibre/ grass /soil using non-powdered gloves and store in a PAPER, and not plastic bag or lift using the specified lifting tape and place in a PAPER BAG/ENVELOPE

Fibres found at the incident for transfer evidence analysis

Verify claim i.e. corroborative evidence

Blood

• Liquid whole blood in an EDTA ( purple) top vaccutainer • Drops of blood onto sterile cotton gauze and air dry (only for control samples) • Use of FTA cards/sterile cotton gauze • Dry blood scrapings , should be swabbed with a moist sterile cotton swab (use distilled water/saline)

DNA, Alcohol/ drugs

Identify assailant and survivors

For drug analysis, whole liquid blood should be taken and submitted • DNA analysis

Whether the assailant / victim abuses drugs Ability of the survivor to consent

• DNA analysis

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Semen stain samples

HVS, dry semen stained clothes in open air. Do not dry in front of fire or artificial means or directly under sun. Preserve in PAPER and not plastic bags *Demonstrate how to carry out a HVS

Secretor, Blood group assailant DNA proteins in semen (PSA2 or P30)

Identify assailant

Fingernail, scrapping or clippings

Pick the finger nail scrapings/ clippings using a sterile wooden stick/toothpick and store in an envelope

DNA

Identify assailant and Victim

Blood stained clothes

Dry blood stained clothes in open air. Do not dry in front of fire or artificial means or directly under sun. Preserve in a khaki paper. Avoid polythene bags

DNA, Alcohol/ Drugs

Identify assailant and survivors

Bite marks

• Collect 3 swabs at bite wound using moist cotton swabs (distilled water/saline) • Take impressions with dental impressions material

Dental impressions

Identify assailant

Note: • All tests and results should be recorded in a laboratory sexual offences register that should contain information on: name, registration number, date, age, sex, investigations done, results and a place for anyone who takes specimen to sign in order to maintain a chain of custody of evidence. The Laboratory rape register should be kept well locked away and only accessible to authorized health facility personnel as a measure towards preserving confidentiality. • The above tests can be carried out on the survivor and also on the suspect. • With regard to the perpetrator, the court can under section 26(2) and 36 of the SOA, order that certain specific samples be collected. Document collection: It MANDATORY to compile an itemized list in the survivor’s medical notes or reports of all specimen collected and details of when, and to whom, they were transferred.

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Description of Sexual Offence Kit Sexual Offences Kit can be assembled to fit the description given below. Sexual Offence Kit Description Item

Kit Content

Powder free (latex gloves)

six stick swabs

Masking tape for use as labels

Brown envelopes for collecting specimen Clothes ,panty, pubic hair, etc.

Tape measures

Needles

Syringes

Vercutainer tube

6 doses of PEP,EC,STI prevention drugs Anti-emetic

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UNIT 4: CHAIN OF CUSTODY Purpose To demonstrate proper management, integrity and confidentially in handling specimens

Expected Learning Outcomes • •

To define chain of custody of evidence and its importance To describe the steps involved in chain of custody of evidence using relevant documentation tools and reporting mechanisms

Lesson Plan Guide:

Time: 30 Mins Time

Content

Training Objectives

30 mins

Chain of Custody

• • •

Define chain of custody Importance Steps in chain of custody of evidence

Training methodology and learning activities Facilitator gives a brief illustrated lecture describing • Chain of custody of evidence • Its importance and • The steps involved in chain of custody of evidence – Relevant documentation and reporting

Resource Materials • • • • • • •

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop Sexual Offenses Act Sexual Offence Kit Chain of custody tool

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Facilitator’s notes Chain of custody of evidence This refers to the process of obtaining, preserving and conveying evidence through accountable tracking mechanisms from the community, health facility and finally to the police. Also refers to a paper trail where the movement of evidence is traceable through the different persons in the chain of sample collection, analysis, investigation and litigation) Documentation and Reporting In general, most effort should be expended on documenting evidence that can corroborate the survivor’s evidence in a court of law. Such evidence includes: • Evidence that sexual intercourse (penetration) has taken place – Hymenal tears. It is crucial

•

to emphasis that an intact hymen, or lack of genital injuries does not mean penetration/an offence did not take place. Evidence that ejaculation has taken place – presence of semen around the genitalia. Semen inside the vagina is evidence that ejaculation did take place inside the vagina – hence the importance of a high vaginal swab. It is important to know that ejaculation doesn’t always have to take place. Evidence linking the suspect with the sexual offence. This will mainly be police work but the HCW will collect the various specimens as detailed in the Forensic chapter of the national guidelines.

i) The Post Rape Care (PRC) Form The PRC is a medical form filled when attending to the survivor. The form ensures that relevant information pertaining to survivors history, physical examination and investigation findings is documented It facilitates filling of the P3 form by ensuring that all relevant details are available and were taken at the first contact of the survivor with a health facility. The PRC form strengthens the development of a chain of custody of evidence by having a duplicate that can be used for legal purposes and showing what specimen were collected, where it was sent and who signed for it. The PRC form can be filled by a medical officer, a clinical officer or a nursing officer. NOTE: When the PRC form is filled and signed completely: • The Original form (white in color) is to be given to the police for custody. This is the form that is produced in court as evidence;

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• •

The Duplicate form (yellow in color) is given to the survivor; The Triplicate form (green in color) remains with the hospital.

ii) The Kenya Police Medical Examination P3 Form This is a Police form that is issued either at the police station or can be downloaded on the internet. It is filled by a police officer (part I) and health practitioner (part II) or the police surgeon as evidence that an assault has occurred. The P3 form is for all assaults and therefore not specific to sexual violence. It is therefore not as detailed as the PRC form. The P3 form is filled and returned to the police for custody. The filling of the P3 form in sexual violence cases is done free of charge. The survivor should get a copy of their PRC form when it is filled and signed and when the P3 form is being filled. The P3 form is the link between the health and the judiciary systems. The medical officer who fills the P 3 form or their representative will be expected to appear in court as an expert witness and produce the document in court as an exhibit.

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UNIT 5: T YPES OF INJURY Purpose To demonstrate ability to identify injuries caused by different trauma

Expected Learning Outcomes • •

To recognise injuries caused by different trauma To classify injuries caused by different trauma

Lesson Plan Guide:

Time: 30 Mins

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Time

Content

Training Objectives

30 mins

Types of Injury

•

To recognise and classify injuries caused by different trauma

Training methodology and learning activities • Facilitator gives a brief overview of different physical trauma related to sexual violence and indicates that injuries will vary depending on physical trauma inflicted. • Facilitator presents different pictures of trauma injuries and participants identify the injury and cause of trauma • After participant’s identification, facilitator provides guidance on appropriate identification injuries

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Resource Materials • • • • •

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop

Facilitator’s notes Types of Injuries • Blunt force trauma • Sharp force trauma • Thermal Injury/Scalds/burns (The images of the different types of injuries are found in the presentation slides for this unit).

References and Recommended Reading None

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UNIT 6: ROLE OF HE ALTHCARE PROFESSIONALS IN E VIDENCE PRESENTATION IN COURT Purpose To attain the ability - skills and etiquette required to present evidence in court as an expert witness

Expected Learning Outcomes • • •

To familiarize participants with the court proceedings To demonstrate court etiquette To use case studies to aid the identification of gaps in medicolegal documents, the consequences and how to avoid them.

Lesson Plan Guide:

Time: 1 .5 Hours Time

Content

Training Objectives

Training methodology and learning activities

Resource Materials

30 mins

Role of Health Care Professionals in Evidence Presentation in Court

•

• • • •

Discuss the role of HCPs in presentation of evidence in court

•

Participants buzz in pairs on the role of HCPs in presenting evidence in court and discuss findings in plenary. Facilitator wraps up session by giving a brief lecture on power point slides.

• • •

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Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop Evidence Act Internet resources

Time

Content

Training Objectives

Training methodology and learning activities

Resource Materials

1 hour

Role play/Practical session on presentation of evidence in court

•

• • • •

Engage in a practical session/ role play to learn the skill and etiquette of presentation of evidence in a court of law

Facilitator leads participants to role play a mock a court room session participant’s role play, presentation of evidence in court presentation. Case studies and scenarios depicting various cases are used to facilitate this. • Assign the following roles to participants: - The witness - public members • Assign the following roles to the facilitators: - Judge/ magistrate - Prosecutor - Defence lawyer - Suspect • Organize the room to simulate a court session. Note to facilitator: • Explain the expectations to each actor. ROLES • The defence lawyer should peruse through the medical document(s) and formulate his defence case. In case there is no defence lawyer the suspect can represent him/herself. • Magistrate should chair and maintain order in court; bear in mind the magistrate/judge can interrupt the proceeding at any point. • The prosecutor should introduce the case to the court, followed by the introduction of the witness. Once the witness has given his testimony, the prosecutor can examine before and after the defence counsel

• • •

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop Evidence Act Internet resources

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Time

Content

Training Objectives

Training methodology and learning activities

Resource Materials

• The 2 public members can break some of the court etiquette rules e.g. phone ringing in court, wearing a hat in court, talking during the court proceedings and not bowing on entry and exit from the court. This is to reinforce court etiquette proceedings.

The facilitator summarizes the session with emphasis on court etiquette and the importance of evidence collection and documentation.

Facilitator’s notes COURT ETIQUETTE • Bow as you enter the court and as you exit, facing the court (magistrate, judge) • Stand up as the Judge/magistrate enters or leaves the court • Address the Magistrate/judge as “Your Honor”. • ALWAYS address the court (not the state prosecutor or definite advocate) • After you have given your evidence, wait to be released by the court • Introduction, stating the HCP’s qualification and experience as an expert • Swear, as indicated below. • Be able to give facts the survivor presented – relate to the actual events presented by the client, and not interpret them. (not required by the court) • Look professional and dress appropriately. • Speak clearly, slowly, and loud enough. • Use plain language-not medical jargon, or elaborate/simplify the medical terms to the court • Do not give information beyond what one is asked. • Treat the legal practitioner(s) with respect.

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• • • • •

Not to be afraid to use the phrase “I don’t know”. Not to lose objectivity by wanting to please whoever called you Can refer to books, notes and written information, when presenting evidence. DO NOT DRAW CONCLUSIONS UNLESS THEY ARE CERTAIN. If giving evidence on behalf of another doctor, then restrict yourself to the report made by that doctor. Be confident. The HCW is the expert “ I swear, by the name of the Almighty God, that the evidence I shall give before this court, touching on the matter in question, shall be the truth, the whole truth, and nothing but the truth, so help me God”

References and Recommended Reading 1. United States Department of Justice (2013). A National Protocol for Sexual Assault Medical Forensic Examinations, Adults/ Adolescents (2nd Edition). United States of America. 2. National Council for Law Reporting with the Authority of the Attorney General. (2006). Sexual Offences Act No. 3 of 2006. Kenya 3. National Council for Law Reporting with the Authority of the Attorney General. (2012). Evidence Act No. 12 of 2012. Kenya

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Module 5 Psychosocial Support

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Module 5: Psychosocial Support

Module Description: Survivors of sexual violence suffer from profound emotional/psychological symptoms as a result of the trauma. Some develop serious mental disorders like Post Traumatic Stress Disorder (PTSD) and depression. In addition to clinical care, survivors require psychosocial care and support in order to attain full health. Psychosocial care and support includes psychological assessments, psychological counselling and follow up, social intervention and referral for specialized mental health services where appropriate. Some survivors may eventually be referred for psychiatric care and support groups to enable them to deal with a variety of emotions; both verbal and nonverbal. The ultimate goal is for the survivor to resume normal functioning and to be fully integrated into society

Purpose/Module Competence: To attain competence in providing various forms of psychosocial support to survivors of sexual violence, to facilitate their resumption to normal functioning and full integration into society

Expected Learning Outcomes: By the end of this modĂźle, the participant should be able to; 1. Appy counselling ethics and different forms of counselling support to survivors and suspects of SGBV 2. Identify trauma signals/signs in survivors, intervene and refer appropriately 3. Debrief survivors and care givers 4. Recognize the role of community in psychosocial care and rehabilitation of survivors 5. Appreciate the role of counselling support supervision in maintaining good counselling practice

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Content: Unit 1: Introduction to Psychosocial Care and Support • What is psychosocial support • Components of psychosocial support in SV interventions Unit 2: Psycho – trauma • What is psycho trauma? • Classifications of trauma • Post-Traumatic Stress Disorder (PTSD) and its symptoms • Psychological Responses/Effects of Trauma • Psychological Assessment • Interventions for Trauma Unit 3: Psychological Debriefing for Trauma Survivors and Caregivers • What is debriefing? • The objectives of debriefing • The different stages of debriefing and tasks of each stage • A practical debriefing session to a SGBV survivor and their care givers Unit 4: Basic Counselling Skills • Counselling and communication • Counselling Process • Basic counselling skills in Egan’s model relevant in intervening with SGBV clients • Types of counselling in management of sexual violence • Practical session on counselling skills in supporting/managing SGBV survivors Unit 5: Counselling Ethics • Basic principles in counselling practice • Ethical guidelines in counselling practice Units 6: The Role of the Community in Psychosocial Care support. • What is community based care. • The role of the community in supporting SGBV prevention, care and treatment. • Local structures that can implement community based SGBV services • Linkages between the community and the health facility for continuum of care • SGBV self-care tips for survivors • SGBV support tips for family, friends and neighbours to use

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Unit 7: Counselling Support Supervision • What is counselling supervision • The importance of counselling supervision. • How counselling supervision is done

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UNIT1: INTRODUCTION TO PSYCHOSOCIAL CARE AND SUPPORT Purpose: To demonstrate understanding of the concept of psychosocial support and types of psychosocial care interventions in management of survivors of SGBV

Expected Learning Outcomes: • •

Define Psychosocial support Identify different components of psychosocial support interventions for SV

Lesson Plan Guide

30 mins

174

Training methodology and learning activities

Resource Materials

Define psychosocial support

Brainstorming session to define psychosocial support and care

• • • • •

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop

To identify the different components of psychosocial support in SV interventions

Group to discuss different psychosocial components in SV interventions, groups present in plenary and facilitator makes an illustrated lecture by to fill in gaps

• • • • •

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop

Time

Content

Training Objectives

10 mins

What is psychosocial support

20 mins

Components of psychosocial support in SV interventions

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Facilitators Notes Definition of Psychosocial Care and Support The term psychosocial is used to emphasize the close connection between psychological aspects of the human experience and the wider social experience. • Psychological effects are those that affect different levels of functioning including cognitive (perception and memory as a basis for thoughts and learning), affective (emotions), and behavioural aspects of a person. • Social effects concern relationships, family and community networks, cultural traditions and economic status, including life tasks such as school or work. • The use of the term psychosocial is based on the idea that a combination of factors are responsible for the psychosocial wellbeing of people, and that these biological, emotional, spiritual, cultural, social, mental and material aspects of experience cannot necessarily be separated from one another. • The term directs attention towards the totality of people’s experience rather than focusing exclusively on the physical or psychological aspects of health and wellbeing, and emphasises the need to view these issues within the interpersonal contexts of wider family and community networks in which they are located.

Components of Psychosocial Support in SV Interventions • Self care • Family support • Friends • Neighbours • Psychosocial interventions • Debriefing • Counselling and psychotherapy • Social rehabilitation • Psychiatric care

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IASC (The Inter-Agency Standing Committee) (IASC) for Humanitarian Assistance Psychosocial Support Pyramid Model

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UNIT 2 PSYCHOTRAUMA

Purpose: Identify signs and symptoms of PTSD and refer appropriately

Expected Learning Outcomes: • • • • • • •

Define psychotrauma Classify psychotrauma Identify different psychological problems presented by SGBV survivors Describe Post Traumatic Stress Disorder (PTSD) and its symptoms Recognize psychotrauma responses/effects Perform a psychological assessment Identify interventions for psychotrauma

Lesson Plan Guide:

Time: 2 hours Time

Content

Training Objectives

1 hour

•

• • •

• •

•

What is psycho trauma Classifications of trauma PostTraumatic Stress Disorder (PTSD) and its symptoms Trauma responses/ effects

•

Define trauma Classify trauma Describe Post Traumatic Stress Disorder (PTSD) and its symptoms Recognize trauma responses/ effects

Training methodology and learning activities

Resource Materials

Participants are divided in 3 groups to discuss the following questions 1. What is trauma? 2. Discuss classifications of trauma 3. Describe PTSD and its symptoms 4. Discuss the effects of trauma

• • • • •

Flip charts Masking tape Marker pens Trainer’s Manual CD machine and laptop

Each group presents its findings in turn in plenary, facilitator fills in gaps by though slides – illustrated lecture.

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Time 1 hour

Content Psychological Assessment

Training Objectives •

•

Define Psychological assessment Perform a psychological assessment using PRC form

Training methodology and learning activities •

•

Brainstorming session on the meaning of a psychological assessment Role play on psychological assessment using PRC form

Resource Materials • • • • • •

Flip charts Masking tape Marker pens Trainer’s Manual PRC form part B CD machine and laptop

Facilitator’s notes Definition of Psychotrauma • The word ‘trauma’ comes from a Greek word meaning a ‘wound’ or a ‘piercing’ • Psychological trauma - an emotional or psychological injury, usually resulting from an extremely stressful or life-threatening situation • Freud – talks about Ego, a protective shield that protects individual from external stimuli that might otherwise overwhelm the ego - Trauma results in infringement of this Ego space Classification of Trauma • Primary - direct experience • Secondary • Second-hand (vicarious) experiences such as hearing accounts of violence • Refers to trauma affecting workers who help trauma and disaster survivors • Also known as compassion fatigue, secondary or vicarious traumatization, and “burn out • Professionals affected include mental health professionals, emergency workers, physicians, fire fighters, police, search and rescue teams, journalists exposed to overdose of survivor suffering • PTSD in workers offering services to survivors Post-Traumatic Stress Disorder Post-traumatic stress disorder (PTSD) once called ‘shell shock’ or ‘battle fatigue’ syndrome (after world war 1), is a serious condition that can develop after a person has experienced or witnessed a traumatic or terrifying event in which serious physical harm occurred or was threatened

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Causes of PTSD • PTSD is a lasting consequence of traumatic ordeals that cause intense fear, helplessness, or horror, causes include - a sexual or physical assault - the unexpected death of a loved one - an accident - war - natural disasters - Families of survivors can also develop posttraumatic stress disorder, as can service providers working with traumatized persons. Symptoms of PTSD • Re-living: People with PTSD repeatedly re-live the ordeal through thoughts and memories of the trauma. These may include flashbacks, hallucinations and nightmares. They also may feel great distress when certain things remind them of the trauma, such as the anniversary date of the event • Avoiding: The person may avoid people, places, thoughts or situations that may remind him or her of the trauma. This can lead to feelings of detachment and isolation from family and friends, as well as a loss of interest in activities that the person once enjoyed. • Increased arousal: These include excessive emotions; problems relating to others, including feeling or showing affection; difficulty falling or staying asleep; irritability; outbursts of anger; difficulty concentrating; and being “jumpy” or easily startled. The person may also suffer physical symptoms, such as increased blood pressure and heart rate, rapid breathing, muscle tension, nausea and diarrhoea Trauma psychological Responses/Effects of Trauma Response patterns are similar across different trauma types i.e. Sexual assault and rape, child sexual and physical abuse, domestic violence, environmental disasters, crime survivors, combat trauma e.g. Vietnam war, Iraq etc., Holocaust and torture Variations in response might vary due to vulnerabilities like age, psychological state at exposure etc. • Emotional Fear, anxiety and intrusion (nightmares etc. Depression Self-esteem disturbances

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Anger Guilt and shame • Cognitive Perceptual disturbances • Biological Physiological hyper arousal Somatic disturbances • Behavioural Aggressive behaviour Suicidal behaviour Substance abuse Impaired social functioning Personality disorders • Interpersonal Sexuality problems Relationship problems Revictimization Victim becomes victimizer What is Psychological Assessment? • Psychological assessment is a process of testing that uses a combination of techniques to help arrive at some hypotheses about a person and their behavior, personality and capabilities. The assessment may include interviews, observation, testing and consultation with other professionals • The assessment informs the management and subsequent follow up care of the survivor • Done at every visit, management is guided by the results of the evaluation • Documentation – Part 2 of the PRC form, can also be used as evidence

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References and Recommended Reading 1.

2. 3. 4.

5. 6. 7.

Campbell R. Mental health services for rape survivors: issues in therapeutic practice. Violence Against Women Online Resources, 2001:1–9 (http:// www.vaw.umn.edu/ documents/commissioned/campbell/campbell.html). Ministry of Health. (2014). National Guidelines on Management of Sexual Violence (3rd Edition). Kenya GBV and Child protection training manual- Gender Violence Recovery Centre (revised 2015) MOH (2014) National Health Sector Standard Operating Procedures on Management of Sexual Violence in Kenya. Nairobi, Kenya: German development Cooperation Campbell R. Mental health services for rape survivors: issues in therapeutic practice. Violence Against Women Online Resources, 2001:1–9 (http:// www.vaw.umn.edu/ documents/ commissioned/campbell/campbell.html). Ministry of Health. (2014). National Guidelines on Management of Sexual Violence (3rd Edition). Kenya GBV and Child protection training manual- Gender Violence Recovery Centre (revised 2015) MOH (2014) National Health Sector Standard Operating Procedures on Management of Sexual Violence in Kenya. Nairobi, Kenya: German development Cooperation

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UNIT 3 PSYCHOLOGICAL DEBRIEFING FOR TRAUMA SURVIVORS AND CARE GIVERS Purpose: Attain ability to conduct psychological debriefing for trauma survivors and their care givers

Expected Learning Outcomes: • • • •

Define debriefing Discuss the objectives of debriefing Identify the different stages of debriefing and tasks of each stage Perform a debriefing session to a SGBV survivor and their care givers

Lesson Plan Guide

Time: 1 Hour Time

Content

1 hour

• • •

•

182

What is debriefing? The objectives of debriefing The different stages of debriefing and tasks of each stage A practical debriefing session to a SGBV survivor and their care givers

Training Objectives • •

•

Define debriefing Discuss the objectives of debriefing Identify the different stages of debriefing and tasks of each stage Perform a debriefing session to a SGBV survivor and their care givers

Training methodology and learning activities

Resource Materials

Facilitator gives an illustrated lecture on the following: • Debriefing: What it is? • Objectives of debriefing • Stages of debriefing and tasks of each stage • Participants engage in a role play to practice debriefing of survivors of SGBV and care givers using case studies and case scenarios

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Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop

Facilitator’s notes Debriefing: What is it? Debriefing also known as critical incident stress debriefing (CISD) is a specific technique designed to assist individuals or groups in dealing with the physical or psychological symptoms that are generally associated with trauma exposure. Debriefing allows those involved with the incident to process the event and reflect on its impact. Ideally, debriefing can be conducted on or near the site of the event Why is it done? Evidence from crisis intervention indicates return to normal functioning and reduced likelihood of developing long term problems e.g. PTSD if debriefing is done. It is normally carried out after a shared trauma as a group procedure with not more than 15 participants best timed within 72 hours within the event, with a follow up 3 weeks later to make decisions on further interventions Objectives of Debriefing • To facilitate ventilation of impressions and reactions • Cognitive reorganization, through clear understanding of events and reactions/ Form a clear perspective of the events. • Decrease in sense of uniqueness or abnormality of reactions achieving normalization through sharing • Mobilization of resources within and outside the group, increasing group support, solidarity and cohesion • Preparation for experiences, such as symptoms or reactions which may arise • Identification of avenues of further assistance • Identify current or likely critical incident stress symptoms. • Access information about normal stress responses to abnormal experiences. • Mobilize problem-solving strategies. • Find avenues to address personal needs. Stages of Debriefing and Purpose of each Stage Initial stage • Immediate needs are met (Maslow’s)- practical help or support, comfort, protection from

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• further threat or distress Middle stage • Telling the story, making sense of the experience, ventilating feelings as appropriate, linking people to systems of support Final stage • Identification of needs for future intervention

References and Recommended Reading 1. Campbell R. Mental health services for rape survivors: issues in therapeutic practice. Violence Against Women Online Resources, 2001:1–9 (http:// www.vaw.umn.edu/ documents/ commissioned/campbell/campbell.html). 2. Ministry of Health. (2014). National Guidelines on Management of Sexual Violence (3rd Edition). Kenya 3. GBV and Child protection training manual- Gender Violence Recovery Centre (revised 2015) 4. MOH (2014) National Health Sector Standard Operating Procedures on Management of Sexual Violence in Kenya. Nairobi, Kenya: German development Cooperation

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UNIT 4 BASIC COUNSELLING SKILLS Purpose: Apply counselling skills in attending to survivors of sexual violence

Expected Learning Outcomes: • • • • • •

Define counselling Identify basic counselling skills in Egan’s model relevant in intervening for SGBV clients Describe the process of communication and counselling Describe the different types of counselling applicable in management of sexual violence Apply counselling skills in supporting/managing SGBV survivors Make an appropriate psychological intervention to a survivor of sexual violence

Lesson Plan Guide:

Time: 2 Hours 30 Mins Time

Content

Training Objectives

25 mins

Basic counselling skills in Egan’s model relevant in intervening with SGBV clients

Identify basic counselling skills in Egan’s model relevant in intervening for SGBV clients

1 hour

Practical session on counselling skills in supporting/ managing SGBV survivors

•

Practice basic counselling skills in a case scenario or case study on a SGBV survivor

Training methodology and learning activities Group work/ brainstorming session on counselling skills in Egan’s model

Demonstration, role plays, case scenarios and case studies

Resource Materials • Flip charts • Masking tape • Marker pens • Trainer’s Manual • LCD machine and laptop • Flip charts • Masking tape • Marker pens • Trainer’s Manual • LCD machine and laptop

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Time

Content

Training Objectives

30mins

Types of counselling in management of sexual violence

List and describe the different types of counselling in management of sexual violence

Training methodology and learning activities Facilitator leads participants to list and describe the different types of counselling in management of sexual violence. An interactive discussion ensues. S/he fills in gaps through a power point presentation.

Resource Materials • Flip charts • Masking tape • Marker pens • Trainer’s Manual • LCD machine and laptop

Facilitator’s notes

What is counselling? Counselling intervention is a helping relationship aimed at enabling a client to explore a personal problem; giving the client increased awareness of choices they have in dealing with the problem, and assisting her or him to make an informed decision about what to do about the problem. Counselling aims to help people to: • Understand their situation more clearly • Identify a range of options for improving the situation • Make choices which fit their values, feelings and needs • Make their own decisions and act on them • Cope better with an issue • Develop life skills such as being able to talk about sex with a partner • Provide support for others whilst preserving their own strength

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BASIC COUNSELLING SKILLS Egan’s Generic Model of Counseling Skills Stage: Aims/outcomes

Strategies

Exploration • Establish a working relationship • with the client • • To negotiate a contract • Explore the problem from client’s • frame of reference • To clarify and define problems • To focus on specific concerns

Skills

Supportive Skills Exploration • Attending Prioritizing and • Listening focusing • Reflective skills ( restating, paraphrasing/rephrasing, Communicating core mirroring, reflecting – conditions content and feeling) • Summarizing • Probing • Open – ended questions • Focusing • Concreteness • Silence NB. The skills above communicate the core conditions of empathy, unconditional positive regard and genuineness (congruence or being real or transparent)

Understanding • To reassess problems (help the client gain insight, clearer understanding of issues) • See himself/herself in new perspective • To maintain the working relationship • Continue working according to the contract • Focus on what s/he might do to cope more effectively • See what strengths/resources s/ he might use

• •

Challenging Skills • All the skills of exploration Communicating core stage conditions • Confrontation Challenging/offering • Giving feedback – letting clients a view or clients know how you perspective which experience them is different from • Giving information theirs and which • Self – disclosure stimulates them • Immediacy to reconsider their • Advanced level empathy position or view

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Action • To decide on appropriate change/ consider ways to act • To transfer learning – behaviour, feelings and experiences to real life situation • Plan action • Implement action • Evaluate action • End the counselling relationship

• • • •

Goal setting Action planning Evaluating Termination/ending

•

• • • • •

Creative thinking/ Brainstorming/exploration of options Problem solving Decision making Goal setting Implementation of plan of action Evaluation of plan of action

Note: This is a developmental model developed by Gerard Egan from a combination of a number of theories. It describes the process through which the counsellor helps client to identify and explore their problem, understand what they need to do and plan what to do and how to do it. It describes the supportive, challenging and action stage skills that counsellor uses in each stage • Non-verbal skills: 80% of our communication is non-verbal so the survivor can easily pick up on whether the helper is attentive to them or not. A simple way to convey this is to remember the acronym SOLER.

SOLER S – Sit Squarely on to the survivor, preferably at a 5 o’clock position to avoid the possibility of staring O – Maintain an Open posture at all times, not crossing your arms or legs, which can appear defensive L – Lean slightly in towards the survivor E – Maintain Eye Contact with the survivor without staring

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R – Relax. This should in turn help the survivor to relax. Physical contact In some cultures using physical touch, such as laying a hand on someone’s knee, to offer support to a friend is very acceptable. In other cultures physical touch is not appropriate. You should be aware of these cultural differences and try to respect them. No matter what the cultural differences are, we would generally encourage you not to use physical contact or touch to express support and concern to clients. This avoids any problems associated with clients misinterpreting the meaning of this contact or feeling uncomfortable as a result. The reluctant client: some clients will initially feel hesitant about talking to you. This may be for a range of different reasons, including: • Lack of trust • Mental health problems being taboo • Counselling being unknown in their culture • A lack of understanding or misperceptions about what counselling or psychological support actually is • A lack of understanding of your role as a helper • Being forced to attend the program by a family member • Feeling embarrassed about the experiences they have been exposed to • Feeling embarrassed about how they are coping now • Gender issues, such as speaking with someone of the opposite sex about personal things • Addressing topics that are a sexual taboo What to do with a reluctant client It is important for you to show readiness and openness to listen if they want to share private information about their distressing experiences, but the decision is entirely up to them. If a client refuses to talk further about a topic, it is important to your relationship with the client that you respect this. For instance, you may say, “I can see that this is upsetting for you to talk about and I want to respect that. However, if you do want to return to talking about this topic, I want you to know that I am ready to listen to you at any time. Or, if a client appears very distressed while discussing a particular topic but has not said they do not want to talk about it, you may want to let them know that it is ok for them to stop if they want to. Some clients may believe that there is an expectation that they have to do everything you suggest,

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including talking about sensitive and personal topics. For instance, you may want to say, “You seem very upset talking about this. I am very willing to listen to your story and help you talk about it but I want you to know that you can decide what we talk about and if you need to stop at any point or if you do not want to talk about a particular part of the story, then this is ok.” Three categories for special consideration 1. Male survivors - when handling male survivors of sexual violence, Helpers need to be aware that: • Men have the similar physical and psychological responses to sexual violence as women. • The after-effects of sexual violence in men are much the same as in women. • Men are likely to be particularly concerned about their masculinity; their sexuality; opinions of other people (i.e. afraid that others will think they are homosexual); the fact that they were unable to prevent the rape. • Male survivors are less likely than women to report the incident, because of: • Extreme embarrassment • Shame • Criminalization of same sex-relationships and • Slowness of institutions and health workers to recognize the extent of the problem 2. Child survivors - the dynamics of child sexual abuse differ from those of adult sexual abuse in that; Children rarely disclose sexual abuse immediately after the event. Disclosure tends to be a process rather than a single episode and is often initiated following a physical complaint or a change in behaviour. Helpers should therefore: • Develop a sense of trust, safety in the therapeutic setting a component of a working alliancecooperation. • Understand the child’s perception of the abuse. Let them be aware of what has happened and the impact. • Show sensitivity in handling of disclosure of diagnosis. Secrecy brings in dilemma for the child. Remember children want to remain loyal. If there is a lot of fear and/or pain, give reassurance. • Establish a safe environment - this refers to a sense of trust. Learn to tolerate delays and frustration. • Let the child know that you have a positive alliance with the positive care giver- this gives a sense of safety. • Create rapport, let the child go at her/his own pace and listen carefully. • The Helper should be aware of the developmental stage of the child 1. Persons with a disability • Helpers need to be aware that people with developmental disabilities and have been sexually abused have challenges to “work through” or talk about their traumatic experiences in a

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treatment or therapeutic setting. • It is therefore very important that the helper practice patience and like with child survivors, believe the client; impact of the abuse should not be questioned. • Helpers should not have prejudices about people with disabilities; for example, about the benefit of psychotherapy for people with mental retardation. • Guardians may also need assistance as caretakers of the abused; • Helpers should debrief the guardian and/or family members and make appropriate referrals. Alleged perpetrators of sexual violence Helpers need to be aware of their own fears about how they would handle an alleged perpetrator. When a suspected perpetrator enters the clinic escorted by police or a relative, the helper will let them know that everything discussed between them (helper and the alleged perpetrator) is confidential and the Helper is not under obligation to disclose any test results, except when the helper is required to do so by law. It is important to remember that regardless of their actions, they have the same rights to treatment as their victims. Therefore: PEP is required for perpetrators. Survivors’ rights  If willing, press a charge of rape with the police  Be treated with as much credibility as victims of other crimes are  Information on medical, community and legal services  Legal representation  Be notified of any scheduled court proceedings  Be represented in court by a relative, guardian or professional if physically unable to in person  Recover from the violation at their own pace What the survivor should expect at the police station  At the police station, a report is entered into the Occurrence Book (OB) and the survivor is issued with a P3 form. The P3 form should be provided free of charge.  An OB number should be availed to the survivor. If the survivor has not been to the hospital, it is important that s/he goes there immediately after reporting.  Other procedures such as writing a statement can be undertaken after initial treatment has been received.  The police should record the statement of the survivor and any witnesses, and the survivor should sign it only when s/he is satisfied with what the police have written.  The P3 form should be completed by an authorized health care provider based on the clinical notes found in PRC Form. Conclusion Psychosocial care is as important to the client as medical care as part of the trauma is psychological

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as much as it is physical.  Respect all clients and ask for clarifications in their story if there are details that sound contradictory.  As much as possible, prepare the client for the long process of recovery and always remind them that it will take a while.  Where possible refer the client to other kinds of aid: legal, shelter, etc. Types of counselling in management of sexual violence The following are services that a HCP can refer a survivor of sexual violence and their family or significant others for, they are: • Trauma counselling and psycho-education • Emergency Contraception counselling and unwanted pregnancies • Pre-and post-test HIV counselling • Adherence counselling for Post exposure prophylaxis (PEP) for HIV and other STIs • Follow-up sessions • Psychosocial support for groups and in the community • Counselling of the person(s) accompanying the survivor • Information on survivors’ rights, including legal care. Further information can be found in the National Guidelines on Management of Sexual Violence in Kenya, 4th edition, Pages 20 – 27 and also SOP on management of sexual violence in Kenya 2014 on page 25-28

References and Recommended Reading 1. Campbell R. Mental health services for rape survivors: issues in therapeutic practice. Violence Against Women Online Resources, 2001:1–9 (http:// www.vaw.umn.edu/ documents/ commissioned/campbell/campbell.html). 2. Ministry of Health. (2014). National Guidelines on Management of Sexual Violence (3rd Edition). Kenya. 3. Egan, G. (1986), ‘The Skilled Helper’, 3rd Ed., Brooks/Cole, Belmont, California

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UNIT 5 COUNSELLING E THICS Purpose: To apply counselling ethics in working with survivors of SGBV

Expected Learning Outcomes: • •

Recognize basic principles informing counselling practice Apply ethical principles and guidelines in counselling practice with SGBV clients

Lesson Plan Guide:

Time: 1 Hour Time

Content

Training Objectives

Training methodology and learning activities

Resource Materials

1 hour

•

Facilitator leads participants in discussing in an interactive discussion.

• • • • •

•

Basic principles in counselling practice Ethical guidelines in counselling practice

•

Recognize basic principles informing counselling practice Discuss and apply ethical guidelines in counselling practice

1. An experience in their work/practice when they faced an ethical dilemma 2. What was the ethical dilemma? 3. How did they resolve it? S/he then discusses principle informing counselling ethics and how the help in formulating ethical guidelines for practitioners.

•

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop National Guidelines on Management of Sexual violence in Kenya, 3rd Edition, 2014

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Facilitator’s notes Fundamental Principles of Counselling Autonomy: The right of patients to make decisions on their own behalf (or in the case of patients less than 18 years of age, individuals acting for the child, i.e. parents or guardians). All steps taken in providing services are based on the informed consent of the survivor. Beneficence: The duty or obligation to act in the best interests of the survivor. Non-maleficence: The duty or obligation to avoid harm to the survivor. Justice or fairness: Doing and giving what is rightfully due to the survivor. Ethical Guidelines for Counsellors • Counsellors need to be aware of what their own needs are, what they are getting from their work, and how their own behaviour and needs influence their clients. It is essential the counsellor’s own needs not to be met at the client’s expense. • Counsellors should have the training and experience necessary for the assessments they make and the interventions they attempt. • Counsellors need to become aware of the boundaries of their competence and seek qualified supervision or refer clients to other professionals when they recognize that they have reached their limit with a given client. They should make themselves familiar with the resources in the community so that they can make appropriate solutions. • It is important for counsellors to have some theoretical framework, of behaviour change to guide them in their practice. • Counsellors need to recognize the importance of updating their knowledge and skills through various forms of continuing educations • Counsellors should avoid any relationships with clients that could be a threat to therapy. • It is the counsellor’s responsibility to inform clients of any circumstances that are likely to affect the confidentiality of their relationship and of any other matters that may negatively influence the relationship. • It is imperative that counsellors be aware of their own values and attitudes, recognizing the role that their belief system plays in their relationships with their clients, and avoid imposing their beliefs, either subtly or directly. • It is important that counsellors inform their clients about matters such as the goals of counselling, techniques and procedures that will be employed possible risks associated with entering the relationship, and any other factors that are likely to affect the client’s decision to begin therapy.

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• •

•

Counsellors must realize that they teach their clients through setting an example. Thus they should attempt to practise in their own lives what they encourage in their clients. Counsellors bring their culture to the counselling relationship, and their client’s cultural values also operate in the process. Counselling takes place in the context of the interaction of cultural backgrounds. Counsellors need to learn how to think about and deal with ethical dilemmas, realizing that most ethical issues are complex and defy simple solutions. Willingness of a counsellor to seek consultation is a sign of professional maturity.

References and Recommended Reading 1. American Counselling Association (ACA) (2014) ACA Code of Ethics. Retrieved, May, 2015. http:// www.counseling.org/docs/ethics/2014-aca-code-of-ethics.pdf?sfvrsn=4 2. British Association for Counselling and Psychotherapy (2013) Ethical Framework for Good Practice in Counselling & Psychotherapy. Leicestershire, England: BACP 3. Ministry of Health. (2014). National Guidelines on Management of Sexual Violence (3rd Edition). Kenya 4. MOH (2014) National Health Sector Standard Operating Procedures on Management of Sexual Violence in Kenya. Nairobi, Kenya: German development Cooperation

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UNIT 6 THE ROLE OF THE COMMUNIT Y IN PSYCHOSOCIAL CARE AND SUPPORT Purpose: Identify and appreciate the linkages between the community and the health facility in psychosocial care and support of SGBV survivors

Expected Learning Outcomes: • • • • • • •

Define Community based care. Describe the role of the community in supporting SGBV prevention, care and treatment. Perform a psychosocial assessment to a survivor of SGBV Discuss the existing local structures that can implement community based SGBV services Recognize the linkages between the community and the health facility for continuum of care Describe SGBV self-care tips for survivors Discuss SGBV support tips for family, friends and neighbours to use

Lesson Plan:

Time: 1 Hour Time

Content

Training Objectives

1 hour

•

196

What is community based care. The role of the community in supporting SGBV prevention, care and treatment. Local structures that can implement community based SGBV services Linkages between the community and the health facility for continuum of care

•

Define Community based care. Describe the role of the community in supporting SGBV prevention, care and treatment. Describe the existing local structures that can implement community based SGBV services Recognize the linkages between the community and the health facility for continuum of care

Training methodology and learning activities Facilitator leads participants in discussing in an interactive discussion. • An experience in their work/practice with community around the objectives cited Facilitator uses power point presentations to fill in gaps

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Resource Materials • • • • • •

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop Directory of organization providing SGBV services

• •

SGBV self-care tips for survivors SGBV support tips for family, friends and neighbours to use

• •

Describe SGBV self-care tips for survivors Discuss SGBV support tips for family, friends and neighbours to use

Facilitator’s notes Definition of Community Types of Community based Care There are three types of community based care namely: • Home based care , • Home and community based care and • Community based treatment services Home Based Care Home Based Care is the provision of health services by formal and informal care givers in the patient’s home in order to promote, restore and maintain a person’s maximum level of comfort, function and health, including care towards a dignified death (WHO). Home Community Based Care Home-Community based care is an integrated, comprehensive, continuum of care for the survivors. Here there is a formal linkage with health facilities with the purpose of referrals for continuum of care. Here the community members can take on the responsibility of initiating and sustaining their own health. The community are involved in decision making, planning, organizing, implementing, monitoring and evaluation of services (MOH-NASCOP 2008) What is a Psychosocial Assessment? A formal evaluation of an individual or family intended to clarify their non-biomedical needs and priorities Important for diagnosis and documentation of issues of concern and for referral purposes What do we assess?

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Individual and family Household Extended family Social support – friends, neighbours etc. Psychological symptoms – Psychological assessment Social status, risks Other resources, church, community groups Community Based Treatment Services Defines and encompasses the “services “that we provide at health facility and the community with an emphasis on the latter. Key players in Home Community Based Care and their roles Key players include the client, family members, community, health worker and the government. Each one has a key role to play as outlined below The Client The client is a key player in his own care and his involvement in decisions making to optimize in safety and risk reduction. The client needs to comply and adhere to treatment prescribed and appointments made. The perpetrators need to be identified and arrested, potential perpetrators need to be identified also, referred for counselling, and monitored closely by the whole community. The client should be assisted to identify a safe place to stay or protective measures to take to, minimize further risks of sexual violence. The Family The family should be supported to accept and adjust to the situation especially in having a survivor of SGBV in the family. As a health care provider you need to give factual information to the family, the challenges they expect and how to deal with them. They should know the locally available services and collaborate with other service providers to ensure the client gets services when needed like legal services, spiritual care etc. Emphasis should be made on the importance of the family members to consult with the client on matters that concern them. They provide support by being there for the patient. Include the client in all matters that require decision making in a family. The Community The working definition of the community in this context refers to the families living in a locality and organisations (civil society ,faith based organizations ,community based organization and non-government organization) working in that locality . The health care worker should help the community understand the impact of having many of their members ill health and unable

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to contribute to the community development .You should educate the community to accept the situation of the client and collaborate with existing agencies to meet the needs of the client. You need to clarify to the community’s role in public stigma reduction. Let the community understand they have to support the families who have a client in terms of logistics as need arise. The Health Worker The role of the health workers is technical support on the relevant areas of care to the patient, family care giver and the community health worker who are in direct contact with the client on a daily basis .The initial diagnosis is made by the health worker either in a health facility or in a community setup. In implementation of the community activities the health worker follows national standard operating procedures. Enrols the patient to the HCBC Programme, identifies the patient’s needs and prepares the patient for discharge home. Initiate linkage referral and networking systems for the client. Clarify and advise on the available support services where the client is enrolled. The Government In this context the government consists of the different government ministries regulating service provision, professional bodies, and non-government organizations. The health care worker as the government representative has a responsibility to create a supporting policy environment for community level activity to optimize client care The Ministry of Health should assist in developing policies and guidelines to give direction for HCBC services. Provide checks and balances for maintenance of quality standard of care. Self-Care Tips for the Survivor Survivors who are already safe and have received the emergency medical interventions and psychological care need to be assisted to engage in wellness activities as part of rehabilitation. This information may need to be availed to the survivor on brochures, pamphlets or flyers that can allow them to read at home. How do I Take Care of Myself? Survivors need to be encouraged to engage in self-care or wellness activities as part of the healing process. They need to make a special effort to ensure that they take care of themselves at their own pace and in agreement with their own needs. The following are tips on how to do self-care: Physical self-care: • Maintain a balanced diet and drink a lot of clean water • Try to get enough sleep

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• Avoid overusing stimulants like caffeine, sugar, and nicotine. • Avoid depending on sleeping pills and tranquilizers • Use stress reduction techniques e.g. exercise ( jogging, aerobics, walking) or relaxation (yoga, massage, music, hot baths, prayer and/or meditation). • Seek medical care, if needed Emotional self-care: • Spend time with people who are positive and supportive. • Share your experience with a trusted person with whom you are comfortable with. • Give yourself “time outs.” Such as taking quiet moments to reflect, relax and rejuvenateespecially during times you feel stressed or unsafe. • Consider writing down your emotions on a piece of paper, this usually gives some relief and makes one feel better. One can destroy the piece of paper after ventilating. • Create time for hobbies or to do activities that one enjoys.

Spiritual Support Some survivors gain their strength from spiritual intervention. One can contact your local pastor/ priest/Imam to provide spiritual support Make your self-care a priority, not something that happens (or doesn’t happen!) by accident. How can I help/support someone who has been sexually assaulted? This may be useful for the family, friends and relatives of the survivor. This may be availed in the form of brochures, pamphlets or other IEC materials. It is also useful to the general public Recovering from a sexual assault or rape takes time. You will need to be very understanding and patient with the survivor who will need support after the frightening and violent experience. The following is a list of ways in which friends and family can help by:• Avoid overusing stimulants like caffeine, sugar, and nicotine. • Avoid depending on sleeping pills and tranquilizers • Use stress reduction techniques e.g. exercise ( jogging, aerobics, walking) or relaxation (yoga, massage, music, hot baths, prayer and/or meditation) Listening and being available Allow the survivors to talk about what happened and to express their feelings. Provide a safe environment and set aside some time to talk with the survivor. Sometimes just listen even if you may not have an answer. It helps alot.

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Acknowledge that the survivor may require several months to years for the recovery process to be complete. Encourage the survivor to seek the assistance of a trained professional health worker who can comprehensively manage them. Believing and not judging Some family and friends may not believe the survivor and may instead blame them for rape. This may be due to some of the rape myths – such as that is the victim somehow responsible for the incident. In a case of the wife being violated by the husband or his relative, many families take sides against the woman. There are instances where she is chased away from her marital home. The family and friends should support and believe the survivor. Offering a safe environment Some survivors are forced to leave their homes for a safer environment. Sometimes neighbours, relatives or friends accommodate the survivor into their homes or move into the survivor’s home to ensure that they remain safe. This is the correct thing to do temporarily until such a time when the matter is solved or an alternative place is found. Emotional support by friends and family Friends and family can assist by acknowledging the feelings the survivors are experiencing, and by reassuring the survivor that the feelings are a normal and that healing will take place. The decisions made by the survivor should be respected and referral for professional help should be done as soon as possible. How to cope with your own feelings As a family member or a friends, you may also be affected when someone close to you has been raped. Some of the reactions you may have include anger, rage, guilt, confusion, blame, and other types of emotions similar to what the survivor is experiencing. You will also need to see a professional counsellor who will be able to help you. How to support the survivor who is your spouse or intimate partner Sexual Partners: A Special Relationship. The spouse or the intimate partner of a survivor has a special role to play in supporting the survivor. Some of the interventions may include the following: • Listening, being available, Believing, not judging, Providing safety • Respecting the survivor’s decisions • Allowing recovery time--as long as is needed • Respecting in a sensitive manner the survivor’s wishes for affection or sexual contact • Addressing one’s own feelings of anger, rage, guilt, sadness, confusion, or blame.

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UNIT 7 COUNSELLING SUPPORT SUPERVISION Purpose: Utilize counselling support supervision for caring for self for professional practice

Expected Learning Outcomes: • • •

Define counselling supervision Recognize importance of counselling supervision. Discuss how counselling supervision is done

Lesson Plan:

Time: 1 Hour Time

Content

Training Objectives

Training methodology and learning activities

Resource Materials

1 hr

•

Participants discuss the following questions in 3 groups. 1. What is counselling supervision? 2. What is the importance of counselling supervision? 3. When is it done? 4. How is it done? Each group reports findings in plenary. Facilitator fills in gaps through an illustrated lecture.

• • • • •

•

What is counselling supervision? The importance of counselling supervision. How counselling supervision is done?

•

Define counselling supervision Recognize importance of counselling supervision. Discuss how counselling supervision is done

•

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop National Guidelines on Management of Sexual violence in Kenya, 3rd Edition, 2014

Facilitator’s notes Counselling Supervision What is it? Counsellor supervision is a forum where counsellors reflect on their work with clients and learn from that reflection through their interaction with an experienced counsellor who takes on the role of supervisor. It is a highly collaborative process. The welfare of the client is at the heart of the

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relationship. What is the Importance of counselling supervision? 1. It facilitates the personal and professional development of the counsellor. Helps relieve burnout 2. The educative function supports the development of counsellor competencies. 3. A competent counsellor will provide quality services; hence counselling supervision promotes provision of quality services. How is Counselling Supervision done? It can be done in any of the following ways: 1. Self 2. One to one 3. Co-supervision 4. Group supervision - leader led 5. Peer group 6. Team or Staff ( Could be internal or external) 7. Others - Mailing (post or email, telephone etc.) The following methods are used in presenting client work • Verbal reports • Written, Session notes • Audio taping • Video taping • Live supervision • one way mirrors • bug in the ear Sit in supervisor

References and Recommended Reading 1. Caroll, M. (2001). Counselling Supervision: Theory, Skills and Practice (Counsellor Trainer & Supervisor). London, United Kingdom: Sage Publication 2. Hawkins, P. & Shohet, R. (2012). Supervision in the Helping Professions (Supervision in Context) 4 edition. London. United Kingdom: Open University Press; 3. Ministry of Health. (2014). National Guidelines on Management of Sexual Violence (3rd Edition). Kenya 4. MOH (2014) National Health Sector Standard Operating Procedures on Management of Sexual Violence in Kenya. Nairobi, Kenya: German development Cooperation

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Module 6 Management of Children and Adolescents

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Module 6: Management of sexual violence in Children and Adolescents Purpose/Module Competence: To attain the competence to attend to children and adolescents survivors of sexual gender based violence.

Expected Learning Outcomes: By the end of this module the participant should be able to: 1. Prepare children and adolescent survivors of SGBV for clinical management, informed consent and assent 2. Take comprehensive history from a guardian/care giver and a survivor 3. Perform a thorough physical examination and assess the psychosocial status of children and adolescent survivors 4. Investigate and collect forensic evidence 5. Provide appropriate treatment and counselling 6. Manage follow up sessions and refer appropriately

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Content: Unit 1: Key principles for Working with Children and Preparation Management of Children and Adolescents. • A safe and trusting environment for the interview eventual examination • Promote the child’s best interest • The rule of confidentiality • Informed consent/assent • Psychosocial assessment Unit 2: Taking History • History taking • Survivor child and adolescent centred approach to obtaining history • Psychosocial history taking Unit 3: Physical Examination and Psychological Assessment • General physical examination • Systemic examination • Psychological assessment • Documentation of findings Unit 4: Investigation and Forensic Management

• Collection of evidence for clinical management • Collecting handling, preserving evidence for legal purposes • Documentation for management and legal purposes Unit 5: Treatment and Counselling

• • • • • • •

Management of life threatening and other injuries Pregnancy Prevention and management Prevention of HIV STIs prophylaxis and treatment Hepatitis B prevention Psychosocial Support Documentation of treatment on PRC form and SGBV register

Unit 6: Follow up Care and Referral

• • • •

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Referrals Referral Mechanism Follow up Feedback

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â€˘ Key Actors and services available for children and adolescent survivors

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UNIT 1: KEY PRINCIPLES FOR WORKING WITH CHILDREN AND PREPARATION FOR MANAGEMENT OF CHILDREN AND ADOLESCENTS.

Purpose: Establish a child-friendly environment and create rapport with survivor and care-giver

Expected Learning Outcomes By the end of the unit participants should be able to; 1. Create a safe and trusting environment for the interview and eventual examination 2. Apply the rule of confidentiality 3. Inform survivors about available services while respecting the survivors right of choice of services 4. Obtain Informed consent and assent

Lesson Plan Guide:

Time: 40min Time

Content

Training Objectives

10 mins

Key Principles of working with Children Best interest of the child Ensure child safety Treat every Child fairly and equally Requirements of an ideal/safe interview and examination room Warm conducive environment Children and adolescent rights equipment and supplies Privacy of the room Key principles of managing a child

Discuss the key principles of Brainstorming, working with children illustrated lectures

AIDSTAROne, Technical Considerations 2013

Discuss requirements of an ideal interview and examination room

National Guidelines, LCD, Flip chart paper, marker pens, ECSA, AIDSTAROne, Technical considerations 2013

10 mins

208

Training methodology and learning activities

Brainstorming, illustrated lectures

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Resource Materials

Time

Content

Training Objectives

Training methodology and learning activities

10 Mins

Privacy and Confidentiality Treat children and adolescents with respect and dignity Greetings & selfintroduction Reassure the survivors Privacy and confidentiality Shared confidentiality

Discuss privacy and confidentiality

Brainstorming/Q&A, illustrated lectures

Obtaining informed consent / assent Explaining what is informed consent/assent Importance of obtaining informed consent/assent in managing a survivor Procedure of informed consent Challenges in obtaining informed consent/assent

Explain how to obtain Group discussions informed consent Demonstration, Role Practical session to practice plays, mastery of skills

10 mins

Role plays/Practical session

Resource Materials National Guidelines, LCD, Flip chart paper, marker pens, ECSA, AIDSTAR-One, PEPFAR Technical considerations, Trainers guide on Clinical of management of Sexual Violence 2011

National Guidelines, LCD, Flip chart paper, marker pens, ECSA, AIDSTAROne, Trainers guide on Clinical of management of Sexual Violence 2011

Facilitatorâ€™s notes

Requirements of an ideal examination room For a child friendly room walls be coloured with atttractive colours,drawings on the walls toys,mats,calour pensils,drawing paper and well light .It should be clean and safe.

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Age Group (Years)

Child

If No Caregiver Or Not In Child’s Best Interest

Means

0-5

Informed Consent

Other trusted adult’s or caseworker’s informed consent

Written Consent

6-11

Informed Assent

Informed Consent

Other trusted adult’s or case worker’s informed consent

Oral Assent, Written Consent

12-14

Informed Assent

Informed Consent

Other trusted adult’s or child’s informed assent. Sufficient level of maturity (of the child) can take due weight.

Written Assent, Written Consent

Informed Consent

Obtain informed consent with child’s permission

Child’s informed consent and sufficient level of maturity takes due weight

Written Consent

15-18

Caregiver

Equipment Lockable cupboard for specimens and equipments Lockable cabinets for documents Room for the adolescents;TV, books, IEC materials Medical forensic examinations should take place at a medical site where there is optimal access to the full range of services that may be required by the child. This requires overall site preparation, examination site set up and equipment’s.

A child friendly room

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An adolescent friendly room Treat the survivor with respect and dignity throughout the entire examination irrespective of their social status, race, religion, culture, sexual orientation, lifestyle, sex or occupation • Greet the survivor by her/his preferred name: this will make her/him your central focus • Introduce yourself to the patient and tell her/ him your role, i.e. physician, nurse, health worker, counsellor • Aim for a respectful attitude and be quite professional within the boundaries of your patient’s culture • Have a calm demeanour; a survivor who has experienced fear wants to be in the company of people who are not frightened • Be unhurried; give time Maintain eye contact as much as is culturally appropriate • Secure physical and emotional safety (well-being) throughout care and treatment • Evaluate positive and negative consequences of actions with participation of the child and caregiver (as appropriate) •

The least harmful course of action is always preferred

•

All actions should ensure that the child’s/adolescent rights to safety and ongoing

•

development are not compromised

Guiding Principles for Caring for Children Who Have Experienced Sexual Violence (AIDSTAR – One Feb, 2010) Promote the child’s best interest • Secure physical and emotional safety (well-being) throughout care and treatment • Evaluate positive and negative consequences of actions with participation of the child and caregiver (as appropriate)

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• The least harmful course of action is always preferred • All actions should ensure that the child’s rights to safety and ongoing development are not compromised

Ensure the safety of the child • Ensure physical and emotional safety • All actions should safeguard the child’s physical and emotional well-being in the short and long term

Comfort the child • Offer comfort, encouragement, and support • Assure that service providers are prepared to handle the disclosure of sexual violence and exploitation appropriately • Believe the child when they have chosen to disclose sexual violence and exploitation • Never blame the child in any way for the sexual violence and exploitation they have experienced • Make the child feel safe and cared for as they receive services

Ensure appropriate confidentiality • Information about the child’s experience of sexual violence and exploitation should be collected, used, and stored in a confidential manner • Ensure the confidential collection of information during all aspects of care including interviews and history taking • Share information only according to local laws and policies and on a need to-know basis, after obtaining permission from the child and/or caregiver • Store all case information securely • If mandatory reporting is required under local law, inform the child and caregiver at the time they are seen • If the child’s health or safety is at risk, there may be limits to confidentiality to protect the child

Involve the child in decision making • Children have a right to participate in decisions that have implications in their lives • The level of a child’s participation in decision making should be appropriate to the child’s level of maturity and age, and local laws • Although service providers may not always be able to follow the child’s wishes (based on best-interest considerations), they should always empower and support children and deal with them in a transparent, open manner with respect • If a child’s wishes are not able to be followed, then the reasons behind not being able to follow them should be explained

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Treat every child fairly and equally • Utilize the principle of non-discrimination and inclusiveness for all children • All children should be offered the same high-quality care and treatment, regardless of their ethnicity, religion, sex, ability/disability, family situation, status of their parents or caregivers, cultural background, or financial situation, affording them the opportunity to reach their full potential • No child should be treated unfairly for any reason

Strengthen children’s resiliencies •

Each child has unique capacities and strengths, and possesses the capacity to heal

•

Identify and build upon the child’s and family’s natural strengths as a part of the recovery and healing process

•

Factors that promote the child’s resilience should be identified and built upon during the episode of care

•

Children who have caring relationships and opportunities for meaningful participation in family and community life and who see themselves as strong will be more likely to recover and heal from sexual violence and exploitation

Health care providers should be appropriately trained and skilled in managing children who have experienced sexual violence and exploitation. All providers responsible for caring for children who have experienced sexual violence and exploitation should: • Undergo training and orientation to the sexual violence/post-rape care clinic and referral protocols • Have specialized training on the medical forensic examination • Have advanced training on and understanding of emergency contraception based on national laws and protocols, where applicable and legal, as well as HIVnPEP, STI prophylaxis, hepatitis B vaccination, and the importance of timely intervention • Health care centres should: • Identify and train dedicated practitioners (doctors, forensic nurses, or clinic officers) to provide post-rape care and services for children

The health and welfare of the child takes precedence over the collection of evidence • Crisis intervention; treatment of serious injuries; and assessment, treatment, and prevention of HIV, pregnancy, and STIs are of primary importance • The welfare of the child ensures that they are able to maintain their dignity after sexual violence and exploitation, and do not feel coerced, humiliated, or further traumatized by the process of seeking services • Children should NEVER be forced to undergo the medical forensic examination against their will unless the examination is necessary for medical treatment.

Reporting to police should not be a prerequisite for obtaining medical care

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• The child’s decision regarding police involvement should be respected at all times • The child should not be pressured, coerced, or forced to report the sexual violence and exploitation as a condition of receiving their medical care • It is common for health care workers to tell the child that a police report must be made and they must obtain the report form before the facility will conduct the examination • Reporting is often tied to payment of fees, the hospital may only agree to provide free services if the patient has reported the violence to the police and is in possession of the official documentation forms. In most cases, these are procedural rather than legal requirements and should be changed at the facility level. • Efforts should be made by the facility to have a clear policy on reporting, consistent with national policy that affords the most patient-centered approach • Police forms should be kept ideally at the facility for children who present to the facility first and should be available free of charge • The child should be offered all available services including emergency contraception (EC) where legal, HIVnPEP, and other needed health services even if there is no physician available to sign medico legal forms, or if the child chooses not to report to the police

Use the person-first approaches to care •

Professionals working with children who have experienced sexual violence and exploitation must have a strong

understanding of current approaches to inclusive care of all patients regardless of ability •

Recognize that children with disabilities (physical as well as mental/emotional) are at increased risk for sexual

violence and exploitation, and have equal right to care and access treatment •

Ensure that someone who is trained is available when necessary for communication alternatives (e.g., sign

language) for patients who may require this approach

Informed consent and Assent Before a full medical examination of the survivor can be conducted, it is essential that informed consent is obtained by ensuring that the survivor fills the consent form or orally s/he cannot write or is impaired. This is the decision the survivor makes after a HCW has explained all aspects of clinical management on whether or not to continue with the management. There is a need to emphasize on shared confidentiality Examining a survivor without consent could result in HCW being charged with offences of assault and trespass of privacy

214

•

Be empathetic and non-judgmental as your patient recounts her/his experiences

•

Reassure the survivor that the examination findings will be kept confidential unless she decides to bring charges

•

Review the consent form with the survivor. Make sure she understands everything in it, and explain that she

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can refuse any aspect of the examination she does not wish to undergo. Explain to her that she can delete references to these aspects on the consent form. •

Once you are sure the survivor understands the form completely, ask her to sign it. If she cannot write, obtain

a thumb print together with the signature of a witness.

Informed consent /assent guidelines (IRC 2012)

References and Recommended Reading 1. AIDSTAR-One. (Feb. 2012) The Clinical management of Children and Adolescents who have Experienced Sexual Violence; Technical Considerations for PEPFAR Programs. 2. World Health Organization. (2003). Guidelines for medico-legal care for victims of sexual violence. Geneva, Switzerland: Gender and Women’s Health, Family and Community Health Injuries and Violence Prevention, Non-communicable Diseases and Mental Health 3. Ministry of Health. (2014). National Guidelines on Management of Sexual Violence (3rd Edition). Kenya 1. MOH (2014) National Health Sector Standard Operating Procedures on Management of Sexual Violence in Kenya. Nairobi, Kenya: German development Cooperation 2. International Rescue Committee (2012) Caring For Survivors of Sexual Abuse. New York USA. IRC

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UNIT2: HISTORY TAKING Purpose Obtain routine, background information and medical symptoms resulting from sexual violence.

Expected Learning Outcomes By the end of the unit participants should be able to; 1. Take history according to standard operating procedures for children and adolescent 2. Demonstrate survivor, child and adolescent centred interview skills in obtaining history 3. Take psychosocial history according to standard operating procedures for children and adolescents

Lesson Plan Guide:

Time: 1 hour Time

Content

Training Objectives

20 Min

History taking - Purpose of history in relation to SGBV - Procedure of history taking - Procedure for taking gynaecological history for girls and

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Describe the purpose and procedure of history taking Fill the PRC form Correctly and Completely

Training methodology and learning activities

Resource Materials

Brainstorming, illustrated lectures, case studies,

National Guidelines, SOPs, LCD, Flip chart paper, marker pens, ECSA,PRC form, Trainers guide, AIDSTAR-One PEPFAR Technical Considerations

Video, role plays, Check list, guided practice

examination Procedure for psychosocial assessment Documentationfilling PRC form

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Time

Content

Training Objectives

Training methodology and learning activities

Resource Materials

30Mins

Child and adolescent centered approach of obtaining history - History taking according to Developmental stage - Tanners staging

Discuss survivor, child and adolescent centered approach to history taking

Illustrated Lectures, group discussions,

National Guidelines, LCD, Flip chart paper, marker pens, ECSA, AIDSTAR-One

Practice history taking embracing this approach

Role play, case studies, check lists

Psychosocial History Family and community support

Take psychosocial history

Mini Lecture, Discussions

10 min

National Guidelines, SOPs, LCD, Flip chart paper, marker pens, ECSA,PRC form, Trainers guide, AIDSTAR-One

Facilitator’s notes

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Facilitator’s notes

History Taking for Children and adolescents • The purpose of history-taking is to obtain routine, background information relating to the medical history of the child, as well as information about any medical symptoms that have arisen, or may result from, the abuse. • It is important for the health worker to create a safe and trusting environment for the interview and eventual examination. • History should be obtained from a caregiver, or someone who is acquainted with the child, rather than from the child directly; however, this may not always be possible. Nonetheless, it is important to gather as much medical information as possible. • Older children, especially adolescents, are frequently shy or embar¬rassed when asked to talk about matters of a sexual nature. • It is a good idea to make a point of asking whether they want an adult or parent present or not; adolescents tend to talk more freely when alone. • History-taking from children, particularly the very young, requires special skills. • Health Care providers should try to establish the child’s developmental level in order to understand any limitations as well as appropriate interactions. • When gathering history directly from the child it may be worth starting with a number of general, non-threatening questions, for example, “What standard are you in at school?” and “How many brothers and sisters do you have?” before moving on to cover the potentially more distressing issues. • Be non-leading, non-suggestive and document all information as close to verbatim as possible, including observations, interactions, and emotional states of the child and his/her family. General approach: • Always ensure patients privacy. • Approach all children with extreme sensitivity and recognize their vulnerability. • Try to establish a neutral environment and rapport with the child before beginning the interview • Try to establish 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 from adults making interpretation of questions and answers a sensitive matter • Stop the examination if the child indicates discomfort or withdraws permission to continue;

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• •

• • • • •

• •

always prepare the child by explaining the examination and showing equipment; this has been shown to diminish fears and anxiety Encourage the child to ask questions about the examination If the child is old enough, and it is deemed appropriate, ask whom they would like in the room for support during the examination. Some older children may choose a trusted adult to be present Always identify yourself as a helping person 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 truths and lies Ask the child to describe what happened, or is happening, to them in their own words (where applicable) 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 Consider interviewing the caretaker of the child without the child presence. Before proceeding, ensure that consent/assent has been obtained from the child and/or the caregiver. If the child refuses the examination, it would be appropriate to explore the reasons for the refusal. Consider examining very small children while on their mother’s (or carer’s) lap or lying with her on a couch. If the child still refuses, the examination may need to be deferred or even abandoned. Never force the examination, especially if there are no reported symptoms or injuries, because findings will be minimal and this coercion may represent yet another assault to the child. Consider sedation or a general anesthetic only if the child refuses the examination and conditions requiring medical attention, such as bleeding or a foreign body, are suspected

History-taking is distinct from interviewing the child about allegations of sexual abuse. Ideally, history should be obtained from a caregiver, or someone who is acquainted with the child, rather than from the child directly; however, this may not always be possible. Nonetheless, it is important to gather as much medical information as possible. Older children, especially adolescents are often shy or embarrassed when asked to talk about matters of a sexual nature. It is a good idea to make a point of asking whether they want an adult or parent present or not; adolescents tend to talk more freely when alone. When gathering history directly from the child, start with a number of general, non-threatening questions before moving on to cover the potentially more distressing issues. • What grade are you in at school?” • How many brothers and sisters do you have?”

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The following pieces of information are essential for medical history: • When do you say this happened? • When is the first time you remember this happening? • Threats that were made? • What area of your body did you say was touched or hurt? • Do you have any pain in your bottom or genital area? • Is there any blood in your panties or in the toilet? • Any difficulty or pain with voiding or defecating? • First menstrual period and date of last menstrual period (girls only)? • Details of prior sexual activity. • History of washing/bathing since assault When the history has been completed, the health¬care provider can help the child to prepare for the examination by discussing the procedures, assuring the child that the examination is intended to ensure he/she is “all right,” and that no part of the body has been harmed. History taking according to the developmental stage and children with special needs and circumstances Developmental Stage Considerations for History-Taking Infants/toddlers/preschool (birth to 4 years old) • •

Children in this age group have limited to no verbal skills and should not be asked to provide any history (see communication techniques above). Non-offending caregivers or adults presenting with the child for care are the primary sources of information about the child and suspected sexual violence and exploitation.

School-aged children (5–9 years old) • Children in this age range should provide a history whenever possible. • Caregivers, parents, and guardians may provide supplemental information but should not be involved in the history-taking unless the child refuses to separate. • Providers should use non-leading language Early and later adolescents (10–18 years old) • Children in this age range should provide their own history. • Caregivers, parents, and guardians should not be involved in the history-taking to allow the

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•

child to express their own viewpoint on what has happened to them. Parents or guardians can inhibit this age group from sharing all information.

The child who will not speak • If a child cannot or will not speak to the provider, the provider should continue to talk with the child, and explain all of the examination process, but have no expectation that the child will give them a history. • It is not unusual for a child who initially will not speak to begin speaking as the examination progresses, and they begin to feel more comfortable with the examiner. • It is possible that children may present that have not experienced sexual violence and exploitation. • Some children may not be willing to talk about the sexual violence and exploitation—forcing them to talk about this is traumatizing and should not be done. Children with disabilities • Children with disabilities should be communicated with in the manner in which they are most comfortable (e.g., sign language, Braille, plain language/pictures, or audio aids). • It should never be assumed that because a child has some form of disability that they are not capable of communication. • Some disabilities affect the way that children and adolescents communicate. It can be difficult to understand them, and difficult for them to understand others, which can also lead to misunderstandings that further impede comprehension. • It is important to remember that children with disabilities are at greater risk of sexual violence and exploitation. • It is important to respect that some children with disabilities may not wish to have the physical exam as they may not want to share or expose their body with a stranger. • It is important to consider the best interest of the child and not use force when a child with disabilities may not be able to communicate on their own. Female genital mutilation/cutting (FGM/C) Children who have undergone FGM/C should be examined just as those without.

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• •

child to express their own viewpoint on what has happened to them. Parents or guardians can inhibit this age group from sharing all information.

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Stage I (Preadolescent) – Only the papilla is elevated above the level of the chest wall. • Stage II (Breast Bubbling) – Elevation of the breasts and papillae may occur as small mounds along with some increased diameter of the areolae. • Stage III – The breasts and areolae continue to enlarge, although they show no separation of contour • Stage IV – The areolae and papillae elevate above the level of the breasts and form secondary mounds with further development of the overall breast tissue. • Stage V – Mature female breasts have developed. The papillae may extend slightly above the contour of the breasts as a result of the recession of the areolae.

The stages for male genitalia development are as follows: • Stage I (Preadolescent) – The testes, scrotal sac, and penis have a size and proportion similar to those of early childhood. • Stage II – There is enlargement of the scrotum and testes and a change in the texture of the scrotal skin. The scrotal skin may also be reddened, a finding not obvious when viewed on a black and white photograph. • Stage III – Further growth of the penis has occurred, initially in length, although with some increase in circumference. There is also increased growth of the testes and scrotum. • Stage IV – The penis is significantly enlarged in length and circumference with further development of the glans penis. The testes and scrotum continue to enlarge, and there is distinct darkening of the scrotal skin. This is difficult to evaluate on a black and white photograph. • Stage V – The genitalia are adult with regard to size and shape.

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Pubic hair growth in females is staged as follows; • Stage I (Preadolescent) – Vellos hair develops over the pubes in a manner not greater than that over the anterior wall. There is no sexual hair. • Stage II – Sparse, long, pigmented, downy hair, which is straight or only slightly curled, appears. These hairs are seen mainly along the labia. This stage is difficult to quantitate on black and white photographs, particularly when pictures are of hairhaired subjects. • Stage III – Considerably darker, coarser, and curlier sexual hair appears.The hair has now spread sparsely over the junction of the pubes. • Stage IV – The hair distribution is adult in type but decreased in total quantity. There is no spread to the medial surface of the thighs. • Stage V – Hair is adult in quantity and type and appears to have an inverse triangle of the classically feminine type. There is spread to the medial surface of the thighs but not above the base of the The stages in male pubic hair development are as follows: • Stage I (Preadolescent) – Vellos hair appears over the pubes with a degree of development similar to that over the abdominal wall. There is no androgensensitive pubic hair. • Stage II – There is sparse development of long pigmented downy hair, which is only slightly curled or straight. The hair is seen chiefly at the base of penis. This stage may be difficult to evaluate on a photograph, especially if the subject has fair hair. • Stage III – The pubic hair is considerably darker, coarser, and curlier. The distribution is now spread over the junction of the pubes, and at this point that hair may be recognized easily on black and white photographs. • Stage IV – The hair distribution is now adult in type but still is considerably less that seen in adults. There is no spread to the medial surface of the thighs. • Stage V – Hair distribution is adult in quantity and type and is described in the inverse triangle. There

can be spread to the medial surface of the thighs.

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Psychosocial History Taking • Child survivors - the dynamics of child sexual abuse differ from those of adult sexual abuse in that; Children rarely disclose sexual abuse immediately after the event. Disclosure tends to be a process rather than a single episode and is often initiated following a physical complaint or a change in behaviour. Helpers should therefore: • Develop a sense of trust, safety in the therapeutic setting a component of a working alliancecooperation. • Understand the child’s perception of the abuse. Let them be aware of what has happened and the impact. • Show sensitivity in handling of disclosure of diagnosis. Secrecy brings in dilemma for the child. Remember children want to remain loyal. If there is a lot of fear and/or pain, give reassurance. • Establish a safe environment - this refers to a sense of trust. Learn to tolerate delays and frustration. • Let the child know that you have a positive alliance with the positive care giver- this gives a sense of safety. • Create rapport, let the child go at her/his own pace and listen carefully. • The Helper should be aware of the developmental stage of the child. Children and Adolescents with a disability • Helpers need to be aware that people with developmental disabilities and have been sexually abused have challenges to “work through” or talk about their traumatic experiences in a treatment or therapeutic setting. • It is therefore very important that the helper practice patience and like with child survivors, believe the client; impact of the abuse should not be questioned. • Helpers should not have prejudices about people with disabilities; for example, about the benefit of psychotherapy for people with mental retardation. • Guardians may also need assistance as caretakers of the abused; • Helpers should debrief the guardian and/or family members and make appropriate referrals.

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References and Recommended Reading 1. AIDSTAR-One. (Feb. 2012) The Clinical management of Children and Adolescents who have Experienced Sexual Violence; Technical Considerations for PEPFAR Programs. 2. World Health Organization. (2003). Guidelines for medico-legal care for victims of sexual violence. Geneva, Switzerland: Gender and Womenâ€™s Health, Family and Community Health Injuries and Violence Prevention, Non-communicable Diseases and Mental Health 3. Ministry of Health. (2014). National Guidelines on Management of Sexual Violence (3rd Edition). Kenya 4. MOH (2014) National Health Sector Standard Operating Procedures on Management of Sexual Violence in Kenya. Nairobi, Kenya: German development Cooperation

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UNIT 3: PHYSICAL E XAMINATION AND PSYCHOLOGICAL ASSESSMENT Purpose Carry out a thorough physical examination and psychological assessment for children and adolescents

Expected Learning Outcomes By the end of the unit participants should be able to; 1. Describe the procedure for general physical examination 2. Demonstrate ability to conduct physical examination 3. Describe the procedure for systemic examination with emphasis on genital and anal exam for girls and boys 4. Demonstrate ability to conduct and document psychological assessment 5. Document physical findings for purposes of clinical care and forensic examination.

Lesson Plan Guide:

Time: 3 Hours Time

Content

45 mins

General physical examination - General physical examination - Head to toe inspection and examination - Documenting physical forensic findings

Training Objectives

Training methodology and learning activities

Resource Materials

Perform general physical examination for children and adolescents according to SOPs

Brainstorming, experience sharing, illustrated lectures, Video, demonstration, role plays, Check list, guided practice

National Guidelines, SOPs, LCD, Flip chart paper, marker pens, ECSA,PRC form, Trainers guide, AIDSTAR-One

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Time

Content

45 mins

Systemic examination - Full /thorough review of systems ( injuries, site, depth,) - Thorough analgenital examination for girls and boys - Document results of the examination

45 mins

228

Psychological assessment - Assess for post traumatic reactions - Inappropriate sexual behaviors - Document psychological findings Documentation of findings - Document general physical findings - Document systemic findings including genital anal - Document findings in PRC form, SGBV register, Trauma counselling form - Document psychological findings

Training Objectives

Training methodology and learning activities

Resource Materials

Conduct a full systemic examination for children and adolescents according to SOPs Document results of the examination according to SOPs

Diagrammatic illustration Illustrated Lectures, group discussions, case studies, check lists

National Guidelines, SOPs, LCD, Flip chart paper, marker pens, ECSA, AIDSTAR-One

Recognize psychological signs and symptoms Conduct a psychological assessment

Diagrammatic illustration Illustrated Lectures, group discussions, case studies, check lists, role plays

National Guidelines, LCD, Flip chart paper, marker pens, ECSA, AIDSTAR-One

Competently document examination findings and observations on the forms

Practical filling of forms, samples of filled forms, scenarios, role plays

PRC form National Guidelines, LCD, Flip chart paper, marker pens, ECSA, AIDSTAR-One

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Facilitator’s notes

Physical examination of children and adolescents • Before starting the physical examination, take time to explain all the procedures to the survivor and why they are necessary. Give the survivor a chance to ask any questions. Allow the survivor to have a family member or friend present throughout the examination, if s/he so wishes. Throughout the physical examination, inform the survivor what you plan to do next and ask for permission (informed consent). • Both medical and forensic specimen should be collected during the course of the examination. Make sure that the survivor understands that s/he can stop the procedure at any stage if it is uncomfortable for her/him and give her/him ample opportunity to stop the examination, if necessary. Always address survivor’s questions and concerns in a non-judgmental and empathic manner; use a calm tone of voice. • Ensure a trained support person of same sex accompanies survivor throughout examination Head to toe examination for children • The physical examination of children can be conducted according to the procedures outlined for adults. Presence of mother, someone he/she trusts or a chaperone is important and should always be considered. When performing the head-to-toe examination of children, the following points are important: • Record the height and weight of the child, as well as the head circumference in children younger than 3 years. • In the mouth/pharynx, note petechiae of the palate or posterior pharynx, and look for any tears to the frenulum; Record the child’s Tanner stage of sexual development in either sex. • Assess for any injury or disease process on all surfaces of the skin, including the soles of the feet, behind the ears, the axilla, the eyes, and oral cavity/mouth. • Document the size, location, color, and type (abrasion, laceration, etc.) of any injuries or disease; photo-document if possible. • Document any injuries or disease process noted. • Once the full review of systems has occurred, the provider can focus on the anogenital examination of the child based on stage of development. The Genito-Anal Examination for Girls Remember that in most cases, a speculum exam is not indicated. It is only indicated when the child may have internal bleeding arising from a vaginal injury as a result of penetration.

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• • • •

In this case, a speculum examination should be done under general anesthesia Examine the anus. Look for bruises, tears or discharge. Help the child lie on her back or on her side. The child may need to be referred to a higher level health facility for this procedure. For small girls, a pediatric speculum is recommended. Whenever possible do not conduct a speculum exam on girls who have not reached puberty. It might be very painful and cause additional trauma.

INDICATIONS FOR INTERNAL SPECULUM EXAM IN PREPUBESCENT GIRLS • Bleeding from the vagina orifice • Suggestion that a foreign body may be present in the vagina • External genital injury requiring surgical repair Examination Positions and Techniques Supine frog-leg position Child lying on exam table or lap of a caregiver with feet close together and knees loosely apart. Allows for good visualization of the labia, and ease of use with labial separation and traction techniques Supine knee chest Child lying on exam table or lap of a caregiver, with feet and knees together holding knees to chest (may need assistance). Allows for good visualization of the anus and surrounding tissues. Prone knee-chest position Child on exam table in a prone position. Head and torso are flush with the table, knees separated and down on exam table with buttocks raised. Allows for excellent visualization of the anus, surrounding tissues, and rectal cavity during dilation. With use of labial separation and traction, allows for assessment and confirmation of hymenal discrepancy visualized while child was in supine frog-leg. Labial separation With the child in a supine frog-leg position, the provider gently separates the child’s labia with gloved hands allowing for visualization of the genital structures. Labial traction With the child in a supine frog-leg position, the provider gently holds the child’slabia majora bilaterally between thumb and forefingers with gloved hands, pulling out toward the examiner and down toward the anus of the child. The examiner should pay close attention to the area of the posterior fourchette before, during,and after the exam as examiner-induced injury may occur.With the child in prone knee-chest position, the provider gently holds the child’slabia majora bilaterally between thumb and forefingers with gloved hands, pulling out toward the examiner and

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• • • •

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up toward the anus of the child. The examinershould pay close attention to the area of the posterior fourchette before, during,and after the exam as examiner-induced injury may occur. In girls, assess the following external genital structures for injury or disease process: Mons pubis;Labia majora and minora ,Clitoral hood and clitoris,Urethra and periurethral tissuesâ€™ Posterior fourchette,Fossa navicularis, Hymen,Vaginal vestibule Perineum Illustration of the Female Genital Anatomy

Documentation of the genital structure assessment and findings should be done using the clock face analogy It is critical that the provider note the type of injury, size if possible, structure the injury is observed on, and color of the injury

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EXAMINATION OF THE POSTPUBESCENT FEMALE The adolescent girl who has reached puberty should receive a full pelvic examination in addition to the rest of the history and physical. The lithotomy (laying on their back, knees bent, feet in stirrups, and thighs apart) position will also be used as performance of a speculum examination is standard practice HYMENAL ASSESSMENT TECHNIQUES IN POSTPUBERTAL FEMALES • Use of a moistened cotton-tippedswab to sweep around the hymenal edge to look for hidden tears/lacerations. • Use of a small (8Fr) sterile Foley balloon catheter. The catheter is introduced through the hymenal opening into the vagina and the balloon is inflated to a degree that is tolerated (2-3 mL water in the balloon). The catheter is slowly and gently withdrawn until the balloon rests against the internal aspect of the hymen. The catheter is slowlyrotated around the clock face to allow full view of the hymenal edge Genito-Anal Examination for Boys • Check for injuries to the skin that connects the foreskin to the penis • Check for discharge at the urethral meatus (tip of 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; • Examine the anus. Look for bruises, tears, or discharge. Help the boy to lie on his back or on his side. The boy should not be placed on his knees as this may be the position in which he was violated. • Consider a digital rectal examination only if medically indicated, as the invasive examination may mimic the abuse. EXAMINATION OF THE MALE In boys, the genital examination should include the following structures and tissues, checking for

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signs of injury or disease process: • Prepuce of the glans, Glans penis and frenulum, Urethral meatus, Penile shaft, Scrotum, Testes, Inguinal region, Perineum. Illustration of the Male Genital Anatomy

ANAL EXAMINATION OF CHILDREN AND ADOLESCENTS Examination of the anus in children is best approached utilizing either the supine or prone kneechest positions. In either position, apply gentle traction to part the buttock cheeks. During the course of an anal examination the following tissues and structures should be inspected, again looking specifically for signs of injury or disease process: • Perianal area, paying particular attention to the perianal folds • Anal verge/margin • Anorectal canal • Anus • Gluteal cleft A digital examination should only be used in cases where laxity of the sphincter is observed during the exam..Anoscopy is not routinely utilized, unless there is bleeding, obvious trauma, or question of lodged foreign body. THE COLPOSCOPIC EXAMINATION A colposcope is a noninvasive binocular field microscope with adjustable light illumination that creates a magnified image. It may also provide photographic capability for taking still or video images. When available, colposcopes are utilized for magnification of the anogenital area of

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children who have experienced sexual violence and exploitation to aid in identification of injury or disease process. It allows for a permanent record of the genital examination findings and in obtaining a second opinion. It also facilitates peer review, teaching, and training. Because the cost of a colposcope is significant, many sites will not have them available. Providers can utilize any handheld magnifying device to aid in assessment of the genitalia. PSYCHOLOGICAL ASSESSMENT • The psychological assessment of the child should include the developmental stage of the child, and any signs of distress the child may be experiencing as a result of the sexual violence and exploitation they have experienced. • Often they will have experienced psychological pressure, threats of physical violence, and coercion to participate in the sexual violence and exploitation. • Children who experience sexual violence and exploitation need to feel they are in a safe environment, and the provider should assure that the child is not rushed or hurried through the examination. Children who have experienced sexual violence and exploitation should be assessed for : • Signs of depression • Anxiety Symptoms associated with posttraumatic stress disorder such as; avoidance, numbing, hyperarousal • Inappropriate sexual behavior • Loss of social competence • Cognitive impairment • Substance abuse • Alterations in body image • Suicidal ideations For prepubescent children, the examination should focus on the external genitalia. Generally speaking, no speculum or digital examination11 of prepubescent girls should occur. Documentation Summary of findings to be documented after examination of a survivor of sexual violence: General examination • Document the state of clothes- the colour, whether stained or torn, where they were taken to • Document vital signs of the survivor Mental assessment Document as per the psychological assessment form.

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Systemic examination Document details of the: • Central nervous system- level of consciousness, affect • Musculo-skeletal system- physical disabilities, posture control and gait, swellings, bruises, lacerations, dislocations, bite marks, scratches on the body of survivor from head to toe. • Perineum- The perineum consists of the clitoris, labia majora and minora, vagina, mons pubis, introitus, fossa navicularis, vestibule, hymen, penis, prepuce, scrotum, urethra, anus, gluteal region, inner medial thighs. • In the above areas, document: • Any tenderness, bruises, abrasions, cuts, teeth -marks, scratch marks bleeding, discharge, old scars (question their source if any) • Details of the anus- shape, dilatation (sphincter muscle tone), fissures, faecal matter on perianal skin, bleeding from rectal tears. • Details of the hymen- shape, position, colour, and type e.g. Cribriform, septal, cresent shaped, carunculae. • Position and size of tears e.g. At 3 o’clock 1 cm etc

References and Recommended Reading 1. AIDSTAR-One. (Feb. 2012) The Clinical management of Children and Adolescents who have Experienced Sexual Violence; Technical Considerations for PEPFAR Programs. 2. World Health Organization. (2003). Guidelines for medico-legal care for victims of sexual violence. Geneva, Switzerland: Gender and Women’s Health, Family and Community Health Injuries and Violence Prevention, Non-communicable Diseases and Mental Health 3. Ministry of Health. (2014). National Guidelines on Management of Sexual Violence (3rd Edition). Kenya 4. MOH (2014) National Health Sector Standard Operating Procedures on Management of Sexual Violence in Kenya. Nairobi, Kenya: German development Cooperation

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UNIT 4: INVESTIGATION AND FORENSIC MANAGEMENT Purpose: To demonstrate competency in collecting and handling specimen for both clinical and forensic purposes

Expected Learning Outcomes By the end of the unit participants should be able to; 1. Demonstrate skills to collect evidence for clinical management of children and adolescents 2. Collect, handle, preserve and transfer of forensic evidence for legal purposes 3. Document for management and legal purposes 4. Demonstrate ability to interpret injuries and link with observations made and obtained history

Lesson Plan Guide:

Time: 1 Hour Time

Content

10min

Collection of evidence for Clinical management -

Outline investigations for clinical management Discuss importance of investigations for clinical management

Training Objectives

Identify the range of investigations that are typically of interest in SV Practice the skills in collection of evidence

Training methodology and learning activities

Resource Materials

Diagrammatic illustration Illustrated Lectures, group discussions, case studies, check lists

National Guidelines, SOPs, LCD, Flip chart paper, marker pens, ECSA,PRC form, Trainers guide, AIDSTAR-One

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Time

Content

Training Objectives

Training methodology and learning activities

Resource Materials

30min

Collecting ,handling, preserving evidence for legal purposes

Demonstrate ability to collect, handle and preserve forensic evidence

Diagrammatic illustration Illustrated Lectures, group discussions, case studies, check lists

National Guidelines, SOPs, LCD, Flip chart paper, marker pens, AIDSTAR-One, WHO guidelines

Facilitator’s notes

The purpose of forensic specimens The objective of forensic evidence is to prove or exclude a physical connection between individuals and objects or places. Such evidence comprises a wide variety of substances or objects, the analysis of which requires specific, often specialized scientific skills. The close encounter of assailant, victim and crime scene may result in an interchange of traces of evidence (Locard’s principle). Biological traces (i.e. hair, blood, semen, skin fragments) may be found on both the victim and assailant; for instance, the victim’s blood could get onto the assailant’s clothes. Fragments from the scene (e.g. mud, vegetation) may link a victim and assailant to a particular location, or they may each have left traces of clothing or biological traces at the scene. On the basis of the facts available and information provided by the patient and investigators, the health worker must decide which specimens to collect from the individuals involved. When faced with such decisions, it is important to be mindful of what purpose the specimen will serve, what link is potentially going to be established and whether such a link may assist the investigation of the case. Specimen collection process Specimen collection should be done during examination. Basic investigations to know the general condition of the survivor will include urine specimen and blood tests as indicated below

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. FORENSIC SPECIMEN EVIDENCE COLLECTION SITE

Anus (rectum)

Blood

Clothing

MATERIAL

EQUIPMENT

SAMPLING INSTRUCTIONS

Semen

Cotton swabs and microscope slides

Use swab and slides to collect and plate material; lubricate instruments with water, not lubricant.

Lubricant

Cotton swab

Dry swab after collection.

Drugs

Appropriate tube

Collect 10 ml of venous blood.

DNA (victim

Appropriate tube

Adherent foreign(e.g. semen, blood, hair, fibres)

Paper bags

Collect 10 ml of blood. Clothing should be placed in a paper bag(s). Collect paper sheet or drop cloth. Wet items should be bagged separately. Use separate swabs and slides to collect and plate material collected from the external genitalia, vaginal vault and cervix; lubricate speculum with water not lubricant or collect a blind vaginal swab

Genitalia

Semen

Cotton swabs and microscope slide

Hair

Comparison to hair found at scene

Sterile container

Cut approximately 20 hairs and place hair in sterile container.

Semen

Cotton swabs, sterile container(for oral washings)

Swab multiple sites in mouth with one or more swabs. To obtain a sample of oral washings, rinse mouth with or dental flossing 10 ml water and collect in sterile container.

DNA (victim)

Cotton swab

Skin, blood ,fibres, etc. (from assailant)

Sterile toothpick or similar or nail scissors/clippers

Use the toothpick to collect material from under the nails or the nail(s) can be cut and the clippings collected in a sterile container

Sterile container

Collect if used during or after vaginal or oral penetration.

Semen

Cotton swab

Swab sites where semen may be present. 1

Saliva (e.g. at sites of kissing, biting or licking),blood

Cotton swab

Dry swab after collection.

Foreign material(e.g. vegetation, matted hair or foreign hairs)

Swab or tweezers

Place material in sterile container (e.g. envelope, bottle).

Mouth

Nails

Sanitary pads/ Foreign material(e.g. tampons semen, blood, hair)

Skin

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Urine.

Drugs

Sterile container

Collect 100 ml of urine

Urine • Urinalysis – microscopy • Pregnancy test • Spermatozoa Blood • HIV Test • Haemoglobin level • Liver Function Tests • VDRL /HBSAg, Hep C, The health professional should collect the specimen, preserve it for appropriate storage and hand it over to the police for further investigations and processing in the courts. Recording and classifying injuries Clinicians and pathologists are frequently required to respond to questions about injuries from investigators, lawyers or the courts. The sorts of things that investigating teams want to know about are: — the age of an injury; — how (i.e. the mechanism by which) the injury was produced; — the amount of force required to produce the injury; — the circumstances in which the injury was sustained; — the consequences of the injury. Injury interpretation is, however, both a complex and challenging matter. Without accurate documentation and expert interpretation of injuries, any conclusions drawn about how injuries occurred might be seriously flawed. This will have profound consequences for both the victim and the accused. DESCRIBING FEATURES OF PHYSICAL INJURIES Classification/type Use accepted terminology whenever possible; such as, abrasion, bruise, laceration, incised wound Site Record the location of the wound/injury Size

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Measure the wound (using a ruler or other standardized method such as a coin) Shape Describe the shape of the wound(s): linear, curved, irregular Surrounds Note the condition of nearby tissues: bruised, swollen, tender Color Observe any changes in color: redness, bruising, pallor Contents Note the presence of foreign material in the wound: dirt, debris, glass Age Note any healing injuries, such as cuts that are scabbed; use great caution in this area, do NOT date or attempt to date bruising Borders Characterize wound margins: ragged, smooth Depth Give an estimate of the depth of the wounds, if present

References and Recommended Reading 1. AIDSTAR-One. (Feb. 2012) The Clinical management of Children and Adolescents who have Experienced Sexual Violence; Technical Considerations for PEPFAR Programs. 2. World Health Organization. (2003). Guidelines for medico-legal care for victims of sexual violence. Geneva, Switzerland: Gender and Womenâ€™s Health, Family and Community Health Injuries and Violence Prevention, Non-communicable Diseases and Mental Health 3. Ministry of Health. (2014). National Guidelines on Management of Sexual Violence (3rd Edition). Kenya 4. MOH (2014) National Health Sector Standard Operating Procedures on Management of Sexual Violence in Kenya. Nairobi, Kenya: German development Cooperation

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UNIT 5: TRE ATMENT AND COUNSELLING

Purpose Apply appropriate treatment protocols for management of children and adolescents survivors of SV.

Expected Learning Outcomes By the end of the unit participants should be able to; 1. Demonstrate ability to identify and manage life threatening injuries Pregnancy prevention and management 2. Provide ART prophylaxis 3. STIs prevention and management 4. Hepatitis B prevention 5. Provide basic psychosocial support

Lesson Plan Guide:

Time: 2 Hours

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Time

Content

Training Objectives

Training methodology and learning activities

Resource Materials

20 mins

Management of life threatening and other injuries - stabilize patients with life threatening injuries - Treatment of life threatening injuries and other physical injuries - Immunization

Demonstrate ability to manage life threatening and other injuries utilizing standard protocol • Describe management of different injuries

Diagrammatic illustration Illustrated Lectures, group discussions, case studies, check lists

National Guidelines, SOPs, LCD, Flip chart paper, marker pens, ECSA,PRC form, Trainers guide, AIDSTAR ONE

•

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Time

Content

Training Objectives

Training methodology and learning activities

Resource Materials

10 mins

Pregnancy Prevention and Management - Timing - Regimen

• Describe protocols for preventing unwanted pregnancy

Diagrammatic illustration Illustrated Lectures, group discussions, case studies, check lists

National Guidelines, SOPs, LCD, Flip chart paper, marker pens, PRC forms, FP guidelines AIDSTAR-one

10 mins

Prevention of HIV - Mode of transmission - HTC - PEP

• Apply relevant protocols for HIV testing and administration of PEP

Illustrated lectures, brainstorming

National Guidelines, SOPs, LCD, Flip chart paper, marker pens, PRC forms, Algorithms AIDSTAR-one

- 10 mins

Adherence

STIs prophylaxis and treatment - Diagnosis - Types of STIs & symptoms - Treatment - Regimen

•

Apply knowledge for STIs prophylaxis using the standard protocols to manage children and adolescents

Illustrated Lectures, group discussions,

National Guidelines, SOPs, LCD, Flip chart paper, marker pens, PRC forms, Algorithms AIDSTAR-one

Apply relevant protocols for Hep B prevention for children and adolescents

Illustrated Lectures, group discussions,

National Guidelines, SOPs, LCD, Flip chart paper, marker pens, PRC forms, Algorithms AIDSTAR-one

Brainstorming, minilectures, role plays

Trainers manual, GVRC training manual

Diagrammatic illustration Illustrated Lectures, group discussions, case studies, check lists

National Guidelines, SOPs, LCD, Flip chart paper, marker pens, PRC forms, AIDSTAR-One

10 mins

Hepatitis B prevention - History of Hep B vaccination

•

45 min

Psychosocial Support

Apply the basics of counselling children

15 mins

Documentation of treatment on PRC form ,SGBV register and trauma counseling form - Document all the treatment offered in the PRC form in PRC form, registers etc.

•

Competently document treatment on PRC form

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Facilitator’s notes

Management of injuries in sexual violence Management of any life threatening injuries takes precedence over all other aspects of post-rape care. Minor cuts and abrasions should not delay the delivery of other more time dependent treatments Clean abrasions and superficial lacerations with antiseptic and either dress or paint with tincture of iodine, including minor injuries to the vulva and perineum. • If stitching is required, stitch under local anesthesia. If the survivor’s level of anxiety does not permit, consider sedation or general anesthesia. • High vaginal vault, anal and oral tears and 3rd/4th degree perineal injuries should be assessed under general anesthesia by a gynecologist or other qualified personnel and repaired accordingly. • In cases of confirmed or suspected perforation, laparatomy should be performed and any intra-abdominal injuries repaired in consultation with a general surgeon • Provide analgesics to relieve the survivor of physical pain. Where any physical injuries result in breach of the skin and mucous membranes, immunize with 0.5mls of tetanus toxoid. • In a previously unvaccinated child, it may be necessary to administer anti tetanus serum and start a course of tetanus toxoid vaccine . For children younger than 7 years old, Diptheria, Tetanus and pertussis (DPT) or Diptheria and Tetanus (DT) is preferred to tetanus toxoid alone. For children 7 years and older, Td is preferred to tetanus toxoid alone. Prevention of pregnancy: Pregnancy as a consequence of sexual violence and exploitation should be a concern for any female child (Tanner stage III ) irrespective of menarche. Even a single exposure can result in pregnancy. Depending on the legality, as well as national protocols that guide the provision to minors, EC should be offered up to five days (120 hours) after the sexual violence and exploitation. Recommended dosage is 1.5 mg of progestin-only contraceptive in a single dose. The efficacy of this regimen is best if used within 72hours; however, it can be administered up to 120 hours. If the assault occurred outside the 120-hour window for EC, then pregnancy testing can be offered. An alternative EC regimen that is effective up to 120 hours post-exposure is ulipristal acetate, 30 mg orally as a one-time dosage. It has been found to be more effective than levonorgestrel, especially up to the 120 hour limits (Glasier et al. 2010). • There are limited side effects to EC. Nausea and vomiting may occur, but is more likely to been countered in the estrogen-based medications no longer recommended. Other side effects

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may include breast tenderness, spotting or bleeding, and menstrual irregularities. Antiemetic medications can be offered if the patient is experiencing nausea prior to taking EC. Children who are pregnant at the time of the examination should be offered information on any options available to her. Prevention of HIV: The risk for HIV can be reduced if a child is evaluated for and offered HIV post-exposure prophylaxis within 72 hours of the assault. Children might be at higher risk for HIV transmission than adults because the sexual violence and exploitation of children is frequently associated with multiple episodes of violence and might result in mucosal trauma. Specific circumstances of sexual violence and exploitation (e.g., bleeding, which often accompanies trauma) might increase risk for HIV transmission in cases involving vaginal,anal, or oral penetration. Site of exposure to ejaculate, viral load in ejaculate, and the presence of anSTI or genital lesions in the assailant or child who has experienced sexual violence and exploitation also might increase the risk for HIV infection. HIV counseling and testing (HCT) should always be offered as part of the PEP service package based on informed consent with standard pre-test and post-test counseling according to national or local protocols. HIV testing should not be mandatory or prerequisite for providing PEP, and the results should be treated in the strictest confidence. If HTC is not available at the service site and the child falls within the guidelines for PEP, then the medications should be started as soon as possible. It is not recommended that children be referred to programs for preventing mother-to-child transmission, as the drug regimens prescribed in such circumstances are inappropriate for PEP. Whenever possible, confidential HCT should be done onsite.In the absence of this option, the child should be referred to an HCT center. Regardless of where the child is tested, appropriate counseling services should be made available before and after HIV testing. The child, caregiver, and health worker must evaluate the risks and benefits of initiating or refraining from PEP treatment and decide together the best option for the child. If PEP is offered, the following information should be discussed with the child and caregiver: • The unproven benefits of antiretrovirals • The known toxicities of antiretrovirals • The importance of close follow-up • The benefit of adherence to recommended dosing

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• The necessity of early initiation of PEP to optimize potential benefits (i.e., as soon as possible after and up to 72 hours after the assault) Providers should emphasize that PEP appears to be well-tolerated in children and that severe adverse effects are rare. Recommended PEP Regimens for Children and adolescents For children and adolescents, the recommended triple therapy regimen is as follows: ABC + 3TC +LPV/r Children’s doses must be given according to weight as per the National guidelines. Both syrups and tablets can be used. The sooner PEP is initiated after the exposure, the higher the likelihood that it will prevent HIV transmission,if HIV exposure occurred. However, distress after an assault also might prevent the child from accurately weighing exposure risks and benefits of PEP and from making an informed decision to start such therapy. If prescribed, PEP should be initiated within 72 hours of the sexual violence and exploitation and be given for 28 days. Patient liver enzyme levels and renal function should be measured and a complete blood count made prior to the commencement of PEP (to establish baseline values) and then monitored at regular intervals until the treatment has been completed. If the initial test results for HIV were negative, children should have the test repeated at 6, 12, and 24 weeks after the assault. If the initial testing was not accepted at the time of the examination, the child should still be told that they can return for testing. If available, a professional specializing in HIV infection in children should be consulted prior to prescribing PEP. Side Effects of PEP Patients taking PEP should be forewarned about the possibility of experiencing the side-effects below, and prepared on how to deal with them should they occur. They should for instance be informed that they can reduce the intensity by taking the pills with food. Side-effects usually diminish with time and do not cause any long-term damage. Extreme side effects are rare due to the short duration of PEP treatment.

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Drug

Possible side effects

Tenofovir

Renal toxicity and bone mineral loss.

Zidovudine

Anaemia, gastrointestinal side-effects, and proximal muscle weakness.

Abacavir

Skin rash, cough, fever, headache, asthenia, diarrhoea

Lamivudine

gastrointestinal side-effects, anaemia,

Lopinavir/ ritonavir

gastrointestinal side-effects

A Training Course for Management of Sexual Violence - Facilitator’s Manual

THE OPTIONS FOR DISPENSING PEP AT THE INITIAL CONSULTATION ARE AS FOLLOWS: • An initial supply of medicine to last 1–7 days (starter packs) •Medicine provided every week or two weeks to encourage follow-up and to minimize possible waste of medicine(incremental dosing) • The full 28-day course of medicine supplied at the initial visit (maximizing the likelihood of completion if follow-up is aconcern STI prevention and Managemnt In prepubertal children a “dirty urine” (or random voided urine specimen) or nucleic acid amplification test (NAAT) is superior to genital swabs. The NAAT is also appropriate for the adolescent population. In the absence of NAAT, genital swabs in prepubescent children should be taken from the vulva and beside the vaginal orifice. Cervical specimens are only required in adolescents (i.e., those at Tanner stage II of puberty or later), as adolescents may have asymptomatic infections. Presumptive treatment for infection should be offered in children who have experienced sexual violence and exploitation according to local policies. Children and adolescents who test positive for STIs should be treated according to national protocols. Specimens may be required to test for STIs and pregnancy (in the case of the postpubertal female). If a provider tests for STIs, testing for HIV should also be offered. The diagnosis of an STI in a prepubertal child or adolescent who has not become sexually active may be evidence that the child has experienced sexual violence and exploitation. Which diagnostic testing is necessary should be determined on a case-by-case basis. Which tests are performed and the results of any testing should be documented in the medical record. The following diagnostic tests may be necessary to complete in children: • NAAT urine test for Chlamydia trachomatis and Neisseria gonorrhea. This specimen can be obtained as a “dirty” (a random voided, non–clean catch specimen). • Trichomoniasis testing of a portion of the “dirty” urine specimen. • Human papilloma virus (HPV) testing using swabs of the vulva, perineum, and surrounding genital tissues. This may be done with or without the presence of warts. • Herpes simplex virus (HSV) cultures may be obtained by unroofing a vesicle and sending the fluid for culture. Autoinoculation may occur, and may not be diagnostic for sexual abuse. Viral culture can distinguish between type 1 and type 2. • Serologic baseline HIV testing should be offered at the time of the exam, and done if consent is given. • Vertical transmission (acquired intrauterine) of HIV and other STIs can occur. Transmission can also occur from the birth process through cervical secretions of the mother (gonorrhea,chlamydia, HPV, HSV). • Implications of commonly encountered STIs for diagnosis and reporting of sexual violence and

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• exploitation among infants and prepubertal children. When using diagnostic testing for STIs in children, it is important to know the timing of the sexual violence and exploitation, as STI cultures are likely to be negative, unless the child has a preexisting infection.Follow-up testing may be necessary in acute sexual violence and exploitation cases to repeat testing done at the initial examination. Alternative treatment Children’s prophylactic treatment for STI’s PresenChildren Product tation Cefixime Powder 5-12kg for susAzithromycin pension Cefixime 12-25kg Azithromycin Tablet or capsule Cefixime 25-45kg Azithromycin

Strength

Dosage

Duration

100mg/5ml

8mg/kg

stat

200mg/5ml

20mg/kg

200mg 250mg 200mg 250mg

200mg 500mg 400mg 2g

Amoxicillin 15mg/ kg TDS for 7 days PLUS Erythromycin 10mg/kg QID for 7 days HEPATITIS B VIRUS (HBV) Children’s prophylactic treatment for trichomoniasis PresenChildren Product Strength tation Tinidazole <45kg

• • • • •

• •

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Metronidazole

Tablet +/-powder for suspension

500mg 250mg or 500mg or 125mg/ml

Dosage 50mg/kg (max 2g) 30mg/kg/ day in 3 dosages

Duration stat 7 days

There is no information on the incidence of HBV following sexual violence and exploitation. However, HBV is present in semen and vaginal fluid and is sexually transmitted. If possible, the hepatitis B vaccination should be administered to unvaccinated children who have experienced sexual violence and exploitation within 6 weeks of the last incident. Children who have experienced sexual violence and exploitation are at increased risk of contracting HBV if they have not been immunized against it. If there is vaccine available, and the child has not been immunized, they should be treated with the appropriate type of vaccine and dosage. The first dose should be given at the time of the examination, as a component of the treatment. Once the vaccine is initiated, then the child (or caregiver as appropriate) should be instructed to complete the series of three doses and encouraged to have a booster after one year.

A Training Course for Management of Sexual Violence - Facilitator’s Manual

PSYCHOSOCIAL SUPPORT Counselling Children and Adolescents Children require action oriented approaches to facilitate the counselling process Because some children may have no experience of an adult listening to them and Therefore may react with suspicion or resistance to the counsellor. Communicating about Sensitive Issues The dynamics of child sexual abuse differ from those of adult sexual abuse in that; Children rarely disclose sexual abuse immediately after the event, due to the fact that most are threatened, intimidated and confused, Disclosure tends to be a process rather than a single episode and is often initiated following a physical complaint or a change in behaviour. Helpers should therefore: • Develop a sense of trust, safety in the therapeutic setting a component of a working alliancecooperation. • Understand the child’s perception of the abuse. Let them be aware of what has happened and the impact. • Show sensitivity in handling of disclosure of diagnosis. Secrecy brings in dilemma for the child. Remember children want to remain loyal. If there is a lot of fear and/or pain, give reassurance. • Establish a safe environment - this refers to a sense of trust. Learn to tolerate delays and frustration. • Let the child know that you have a positive alliance with the positive care giver- this gives a sense of safety. • Create rapport, let the child go at her/his own pace and listen carefully. • The Helper should be aware of the developmental stage of the child. The Language of Children To communicate to children you must be able to speak and understand their language. Children speak 3 languages: • The language of the body • The language of play • Spoken language Along with these languages, there are four indirect methods that can help children express their feelings: • Drawing • Story-telling • Drama • Play

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Drawing Drawing can be a powerful activity for opening hidden cupboards in a child’s life. Drawing enables children to communicate their emotional state without having to put it into words. Most children enjoying drawing and it is a useful practical tool for counselling. After a child has drawn something gently follow up by asking the child to describe what is happening in their drawing. Example: Jane drew a picture of a man who used to do “bad things” to her. When the counsellor asked her about her drawing, she told how she used to be defiled by an uncle who ended up infecting her with HIV. Storytelling Children usually do not like to answer lots of direct questions or listen to long lectures. When they are finding it difficult to talk about painful issues, asking them to tell a story may help them express themselves. A story can also serve as a useful tool for problem solving. Example: A counsellor could ask children to tell a story about their school, home, friends or parents. They could be asked to tell a story about things that bother them in their lives. Drama Drama or role-play is an excellent way for children to raise issues they want to communicate with others but find it difficult to discuss directly.

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Example: Children could be asked to act out how they spend their time at home, or to act out their relationships with parents or siblings. Children who are abused at home could demonstrate their situation through drama. Play Adults often think play serves no serious purpose. But play is an important way that children express their feelings about events and make sense of their world. When children play, much of their activity involves imitation or acting out things that concern them in their lives. By watching children play, adults can begin to understand what emotions they are experiencing. Example: Four HIV positive children were told to go play before going to see the doctor. They started acting out a situation in which a person had died in the home. One of the children acted as a dead body and 2 other children were crying. One child cried, “Who have you left me with?” the oldest child was trying to move the body and telling the others to be strong: “It is God’s decision.” The counsellor watched what was happening and then asked for an explanation. The children explained why they were acting out this situation. When using play as a way to understand what children are feeling, always observe what the children are doing and follow up afterwards. Do not try to direct their playing. In conclusion, innovative, creative and child-friendly methods of communicating are very important to help children feel involved and express their feelings and emotions. With older children you can engage in non-play therapeutic counselling. Knowledge needed to communicate with Children • Knowing the developmental stage of a child • Knowing how to assess the child’s understanding • Knowing what the likely reactions and questions are and how to handle them • Knowing what difficult questions children may ask and how to handle them • Knowing how to handle your feelings and reactions during the process of counselling. Adolescents • Understand the developmental stage of the adolescent • Understand their language • Be very patient with them • Be up-to –date on their lifestyle and current activities • Be youth friendly • Be available • Accept the youths the way they are

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• •

Non-judgemental Be able to impact or strengthen life and social skills

Tone of Voice When dealing with children it is important to pay attention to your tone of voice. • The tone indicates your thoughts and attitudes. • If you speak too quietly or hesitantly the caller may find it hard to have confidence in you as a helper. • It would be counterproductive to be forceful. • Try to talk clearly at a fairly steady level rather than mumble or stumble • Avoid sounding rushed or excited. • Try to mirror the tone of the child to help them hear the emotion conveyed Do’s for communicating with children: • Do take a “one down position,” which means showing the child that he/she knows more about certain things than an adult? • Use minimal encouragers. This means using brief words and gestures to encourage the child to go on talking. • Be as fully present as possible. “The whole of you should be there.” • Externalizing. This involves separating the problem from the child e.g. not labelling a child a truant, bed wetter or orphan. • Call children by their names not by colour, height, size or place of origin and most importantly not by labelling them in relation to bad behaviour. • Reframe (or re-label). Reframing involves restating the situation the child has described in a more positive way. For example, if a child says that a playmate has told him that his mother has AIDS because she is a sinner, the counsellor can explain that AIDS affects all kinds of people and that AIDS is not a sin. • Be patient. There is no need to rush; children will tell or show you what they are ready to show or tell you. Even if they are quiet, there are thoughts going through their head. Try to move at their pace. • Show interest in the child. Children will feel valued if you show interest in their lives. • Be open and honest with facts. If you give information be accurate and precise. • Maintain a non-judgmental attitude. Counsellors are not trained to be judges of children but to offer badly needed emotional support. • Be empathetic. Put yourself in the shoes of the children and feel with them. • Maintain confidentiality and privacy. Don’t share sensitive information except when necessary

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to help the child. Handle it within your community. • Maintain a calm and approachable attitude • Maintain a caring attitude. • Show acceptance of the child and what he/she is telling you. • Factor in differing perceptions, especially, if the child and counsellor have different backgrounds, knowledge and experience. • Use the local language which the children and their families can understand. • Understand and maintain control of your own emotions. Refer the child to someone else if you feel your emotional involvement is endangering your ability to help him/her. • Network with other counsellors for personal support and guidance. • Know your limits and strengths. • Try to develop good listening skills and attending behaviour • Develop good question and answer techniques. Use open-ended questions. Make sure you understand a child’s question before answering. • Summarize and clarify what a child has told you. • Explain what you will do with the information • Take children seriously • Treat children as equals • Be nice and model good kind behaviours. • Say “yes” a lot. In fact, for each “no” find two or three things that are “yes”. • Word things in positive terms • Tell them their feelings are okay. • Set boundaries that keep them safe. • Allow the feelings but redirect any dangerous, destructive, or abusive actions. • Be honest, but keep adult information with adults. • Present options when they seek your counsel (limit options for younger children). • When giving choices try to give two choices that will both accomplish what needs to be done. (Peter, you can do your homework and then watch your show or do your homework and then go outside, which would you like better) • Delight in their discoveries, share their excitement. • Discuss their dreams and nightmares. • Laugh at their jokes. • Be relaxed, calm, loving, and nurturing as much as possible. • Answer their questions, or even better, help them answer them. • Use your ears more than your mouth. • Apologize when you’ve done something wrong.

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• Keep the promises you make. • Thank them for calling • Refer to professional help when they need it. Don’ts of communicating with children: • Don’t have a judgmental attitude. • Don’t speak in a commanding manner. • Don’t compare children. • Don’t make empty promises. • Don’t talk too much. • Don’t interrupt when a child is talking. • Don’t blame the child as he/she tries to express his/her feelings. • Don’t look down upon the child. • Don’t ignore the child. • Don’t allow emotions like anger, jealousy and fear to develop. • Don’t form a sexual relationship with the child you are helping. • Don’t use negative body language such as negative facial expressions or sitting postures. • Don’t evaluate the situation too quickly. • Don’t give the child too much information all at once. • Don’t patronize the interview process • Don’t sit or stand at higher level than children • Don’t put words in the child’s mouth or let other adults do so • Don’t interrupt the child • Don’t talk too much about yourself (unless asked) • Don’t continue with the interview if a child gets upset (stop and take break, ask if it’s ok to go on).

Documentation of treatment on PRC form and SGBV register The child or adolescent who reports to the clinic for care should have a written record of the encounter. This record should include a medical forensic report, diagrams or body maps of any findings, and, if available, photographs. All aspects of the care should be documented including consent forms, the medical forensic history, findings from the physical assessment, evidence collected, any testing or treatment rendered, photographic images obtained during the examination,and any follow-up care and referrals given. If the health care provider is called to testify in any criminal justice proceedings, they may use this

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report to recall the patient encounter. The written record should accurately reflect the child’s demeanor, any statements made by the child during the course of treatment, and any caretaker history of events. All information documented should be legible and accurate. Any statements made by the child should be put in quotations, verbatim, rather than making an interpretation of what is said. It is generally preferable to use a standard form to document the examination, for convenience and reliability. All injuries should be documented clearly, using standard terminology and descriptive language. At a minimum all injury or wound descriptions should include the type of injury (bruise, laceration,etc.), the size of the injury, the color, and the location. Describe the injury without making speculation on the cause of the injury; however, if the child details where the injury is from, it is appropriate to document their words, in quotations. Make note of any samples collected from injuries. Wounds should be photographed prior to interventions such as cleaning or suturing. When care is provided to a child who has experienced sexual violence and exploitation, the possibility exists that the health care provider may need to produce documentation and testimony regarding that care.

References and Recommended Reading 1. AIDSTAR-One. (Feb. 2012) The Clinical management of Children and Adolescents who have Experienced Sexual Violence; Technical Considerations for PEPFAR Programs. 2. World Health Organization. (2003). Guidelines for medico-legal care for victims of sexual violence. Geneva, Switzerland: Gender and Women’s Health, Family and Community Health Injuries and Violence Prevention, Non-communicable Diseases and Mental Health 3. Ministry of Health. (2014). National Guidelines on Management of Sexual Violence (3rd Edition). Kenya 4. MOH (2014) National Health Sector Standard Operating Procedures on Management of Sexual Violence in Kenya. Nairobi, Kenya: German development Cooperation

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UNIT 6: FOLLOW UP CARE AND REFERRAL Purpose: Effectively utilize existing referral mechanisms for successful follow up care and integration/rehabilitation of the survivor back into the community

Expected Learning Outcomes By the end of the unit participants should be able to; 1. Identify referral needs 2. Refer for specialized treatment 3. Identify appropriate service providers for holistic care 4. Describe referral and networking mechanism for SV survivors 5. Monitor adherence to treatment and psychosocial support 6. Monitor psychological state of the survivor 7. Include the role of the healthcare provider in follow up care 8. Inform survivors about key actors to be involved in their management

Lesson Plan Guide:

Time: 30 min

256

Time

Content

5min

Referrals -Definition of effective referral - Importance of referral systems - Referral components - Referral mechanisms

Training Objectives

Identify the need for referral and appropriately refer Correctly and completely fill referral forms

Training methodology and learning activities Illustrated Lecture

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Resource Materials National Guidelines, SOPs, LCD, Flip chart paper, marker pens, ECSA,PRC form, Trainers guide, AIDSTAR-oneâ€™ Referral form ,Kenya Health sector referral guidelines

Time

Content

15 min

Follow up -Role of community in referral systems -Resources required for referral -Follow up care -Counselling and social support - Role of HCPs in follow up care - Key actors

10 min

Training Objectives

Training methodology and learning activities

Employ effective follow up care and management

Brainstorming, Discussions

National Guidelines, SOPs, LCD, Flip chart paper, marker pens, PRC forms, Algorithms AIDSTAR-one

Identify available key actors

Discussions, Brainstorming

AIDSTAR-one

Resource Materials

Facilitator’s notes

Definition of Effective Referral In the context of sexual violence service provision, referral is the process by which client’s immediate needs for care, prevention, and supportive services are assessed, prioritized and the client is provided with assistance in accessing the necessary services. Referral also includes reasonable follow-up efforts necessary to facilitate initial contact with prevention, care, and psychosocial services and to solicit clients’ feedback on satisfaction with services. Importance of Referral Systems Referral helps provide better services. When a referral is appropriately and properly executed it can aid recovery, psychological and emotional support, diagnosis, treatment, and specialized care. Referral Components • Problem identification • Problem assessment • Problem diagnosis • Referral counselling • Communication • Transfer

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• Facility feedback • Community feedback The Community in the Referral System • Community involvement in planning, designing, developing and supporting the referral system affects its population. • Community education gives information to understand and appreciate referral systems and participate in the referral • Community participation may provide finances and transport, give feedback, accept clients back into the community and promote referral. Follow-up care Medical review Follow-up visits are recommended at 2 weeks, 3 months and 6 months post Assault. The 2-week follow-up visit As part of the 2-week post-assault visit, the following routine tasks and checks should be performed: ● Examine any injuries for proper healing. ● Photograph injuries if indicated (i.e. to document healing, comparisons in court). ● Check that the patient has completed the course of any medications given for STIs. ● Obtain cultures and draw blood to assess STI status, especially if prophylactic antibiotics were not given at the initial visit. ● Discuss results of any tests performed. ● Test for pregnancy if indicated. If pregnant, advise about options. ● Remind patients to return for their hepatitis B vaccinations in 1 month and 6 months, other immunizations as indicated, and HIV testing at 3 and 6 months or to follow-up with their usual health care provider. ● Make follow-up appointments. ● Assess the patient’s emotional state and mental status, and encourage the patient to seek counselling if they have not yet done so. The 3-month follow-up visit At 3 months post assault: ● Test for HIV. Make sure that pre- and post-testing counselling is available or make the appropriate referral. Assess pregnancy status and provide advice and support.

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● Discuss results. ● Draw blood for syphilis testing if prophylactic antibiotics were not given previously. ● Assess patient’s emotional state and mental status and encourage the patient to seek counselling if they have not yet done so. Counselling and social support While the initial medical assessment may not reveal any immediate psychological problems, it is important that a further assessment be conducted to ensure that any issues that may arise are addressed and dealt with appropriately. Counselling services should be provided in a coordinated fashion, and considered in conjunction with similar services provided by schools and other community groups. Thought must also be given to providing support and/or counselling to those caring for the child. This may be required even if the child itself is not assessed as needing therapy. In general: • Abuse-specific cognitive behavioural treatment is generally the most effective form of therapy for post-traumatic stress reactions. • Group therapy for children is not necessarily more effective than individual therapy. • Many sexually abused children may have co-morbid conditions that require • specific treatment. • Younger children may not understand the implication of abuse and therefore may appear to be less distressed than older children. • A believing and supportive mother or non-offending caretaker can be a strong determinant for a good prognosis. Key actors and Services available for survivors Although the main role of health service providers is to lead medical management for the child,making sure children and families are aware of, appropriately referred to, and able to access additional support services located outside of the health facility is also an important responsibility. Community support services are often provided by a variety of sources including nongovernmental organizations, organizations representing people with disabilities, and faith-based organizations.They may be individuals who provide direct services to children who have experienced sexual violence and exploitation and their families, including police, prosecutors, social services, community shelters and safe havens, legal advice centers, local clinics, women’s organizations, and organizations providing psychosocial care. Ensuring strong referral linkages to and from these providers is a critical, yet often

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underdeveloped element of clinical post-rape care services. Communications and Referral Between Health Care and Community Resources

HCPs Role Health care providers, as professionals with an established infrastructure and scientific base, must take the lead in educating community partners and referral resources on the well-rooted stigma, discrimination, myths, and silence regarding sexual violence and exploitation against children and its life-threatening health consequences. Acute medical forensic examination and treatment can effectively address prevention of pregnancy, STIs, and HIV, but much of the childâ€™s psychological recovery will occur in the months and sometimes

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years following the sexual violence and exploitation through their ongoing work with advocacy, social welfare, and counseling services. The following list outlines suggested interventions to be implemented by health service providers in order to establish or strengthen referral linkages to existing community-based psychological and social support services. • Encourage and provide routine exchange visits with expert providers in child sexual violence and exploitation with the goal of improving the health response. • Conduct participatory community mapping to identify service providers in the community to whom and from whom children who have experienced sexual violence and exploitation can be referred for services. • Develop a formal community directory for sexual violence and exploitation services for children and distribute copies to all health providers working with children. • Build and formalize relationships with referral institutions, including setting up formal referral and counter-referral systems. • Develop formal and informal protocols regarding standards for confidentiality, service delivery, data collection, and/or collaborating more closely on projects and activities. • Set up formal referral systems with built in tracking mechanisms. • Develop algorithms of care that include follow-up appointments and referrals to external service providers. • Develop referral systems to facilitate and track use of referral services. • Conduct community outreach activities to ensure that communities are aware of services available to children who have experienced sexual violence and exploitation and how to access them. • Develop communication material for community and clinic-based awareness. • Create community and service provider education to increase sensitivity and understanding of appropriate response. Health providers serve as gatekeepers for children who have experienced sexual violence and exploitation. These children require intervention from a coordinated and skilled team of health professionals, social workers, and nongovernmental organizations, including organizations representing people with disabilities, staff, and volunteers for psychological and social support.

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References and Recommended Reading 1. AIDSTAR-One. (Feb. 2012) The Clinical management of Children and Adolescents who have Experienced Sexual Violence; Technical Considerations for PEPFAR Programs. 2. World Health Organization. (2003). Guidelines for medico-legal care for victims of sexual violence. Geneva, Switzerland: Gender and Womenâ€™s Health, Family and Community Health Injuries and Violence Prevention, Non-communicable Diseases and Mental Health 3. Ministry of Health. (2014). National Guidelines on Management of Sexual Violence (3rd Edition). Kenya 4. MOH (2014) National Health Sector Standard Operating Procedures on Management of Sexual Violence in Kenya. Nairobi, Kenya: German development Cooperation

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Module 7 Monitoring and Evaluation

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Module 7: Monitoring and Evaluation in Sexual Violence Programs Module Description: This module introduces participants to SGBV indicators and the processes of recording and reporting for SGBV programs. Participants are introduced to the data tools used in the program, viz. • PRC form MOH 363- PRC Form, • Sexual Violence register MOH 365- Sexual Violence Register, • Sexual Violence Monthly summary MOH 364- SGBV Monthly Summary • MOH 711- Integrated tool MOH, 711. • MOH 705A – OP Outpatient under 5 summary • MOH 705B – OP Outpatient over 5 summary Participants engage in practical sessions to develop competence in the use of these forms and comprehension of data flow systems. Since data entry is currently done in the SGBV registers indicated above thereafter the health records officer inputs the information directly into the DHIS2. It is therefore crucial that the participants are introduced to the system for familiarity and appreciation of its functions.

Purpose/Module Competence: •

Record and report on SGBV services

Expected Learning Outcomes: • • • • • •

264

Appreciate the magnitude of SGBV in Kenya Be familiar with the SGBV indicators Attain ability to record and report on SGBV services using national data tools Utilize the SGBV data flow mechanism Apply quality data management principles in managing SGBV data Define the roles of different players on SGBV data management

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Content: Unit 1: Magnitude of SGBV in Kenya • National data on incidence and prevalence • County data on incidence and prevalence Unit 2: Introduction to SGBV Indicators and Data Elements • SGBV indicators •

SGBV data elements

Unit 3: SGBV Reporting Tools • Sexual Violence register MOH 365 • PRC form MOH 363 • Sexual Violence Monthly summary MOH 364 • MOH 705A – OP Outpatient Under 5 summary • MOH 705B – OP Outpatient Over 5 summary • Role Definition on SGBV data management Unit 4: Uploading SGBV data on the DHIS and its Analysis •

SGBV data elements in DHIS II

•

Uploading data in the DHIS II

•

Analysing data in the DHIS II

Unit 5: SGBV Data Flow and Quality •

SGBV data flow mechanism

•

SGBV data quality

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UNIT 1: MAGNITUDE OF SGBV IN KENYA

Purpose:

Appreciate magnitude of SGBV in Kenya and utilise information in service provision

Expected Learning Outcomes: • •

Discuss national SGBV data on incidence and prevalence Discuss county SGBV data on incidence and prevalence

Lesson Plan Guide:

Time: 30 minutes

266

Time

Content

Training Objectives

30 mins

Magnitude of SGBV in Kenya • National SGBV data on incidence and prevalence • County SGBV data on incidence and prevalence

Training methodology and learning activities

Discuss national and county data on SGBV prevalence and incidence

Illustrated lecture

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Resource Materials Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop KDHS, other population surveys and data sources

Facilitatorâ€™s notes National SGBV data on incidence and prevalence (See Module 1 unit 3 Situation/Prevalence of Gender Based Violence) County SGBV data on incidence and prevalence (This information is not available in the KDHS, however different partners have undertaken surveys in different counties and have county specific reports, if survey reports are available they can be presented at this stage )

References and Recommended Reading 1. Government of Kenya (2014) Kenya Demographic Health Survey. Nairobi, Kenya. Kenya National Bureau of Statistics (KNBS)

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UNIT 2: INTRODUCTION TO SGBV INDICATORS AND DATA ELEMENTS Purpose

Recognize/know SGBV national indicators and relate them to service provision and recording and reporting

Expected Learning Outcomes • •

Be familiar with SGBV national indicators Discuss other data elements for the SGBV programme

Lesson Plan Guide:

Time: 1 Hour Training methodology and learning activities

Resource Materials

Discuss the SGBV national indicators

Brainstorming

National Guidelines on management of Sexual violence, DHIS2

Discuss other data elements for the SGBV programme,

Illustrated lectures -Power – Point Présentations -Brain storming -Question and answer sessions

National Guidelines on management of Sexual violence, DHIS2

Time

Content

Training Objectives

30 minutes

SGBV national indicators

30 minutes

Data elements for the SGBV programme

Facilitator’s notes SGBV Indicators An ‘indicator’ is a measurable statement program objectives and activities. An indicator set includes at least one indicator for input, output, process, outcome and effect.

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Characteristics of good indicators • • • • •

Valid: measures the effect it is supposed to measure Reliable: gives same result if measured in the same way Precise: is operationally defined so people are clear about what they are measuring Timely: can be measured at an interval that is appropriate to the level of change expected Comparable: can be compared across different target groups

Expressing an indicator • A number: refers to number of cases of a disease or other phenomenon being studied such as the number of sexual violence clients who received post exposure prophylaxis in a set time. • A ratio: a fraction without a specified relationship between the numerator and denominator. Compares two or more variables such as comparing HIV incidence in 12–15-year-olds with 16–21-year-olds. • Percentage: compares two numbers and is usually used as an outcome indicator, such as the percentage survivors presenting within 72 hours out of total reported cases Qualitative indicators: • Friendly attitude towards clients • Implementing protocols in the right sequence • User-friendly physical environment SGBV National Indicators • Number of survivors presenting at a health facility • Number of survivors presenting within 72 hours • Number of survivors completing Post Exposure Prophylaxis • Number of survivors receiving comprehensive services The national SGBV program responds to several key indicators: Indicators Disaggregated by: County, Age, Sex. • SGBV prevalence rates • Total SGBV cases seen • Percentage of Survivors completing PEP • Percentage of SGBV survivors who sero-converted 3 months after exposure ( HIV+) • Percentage of SGBV survivors received EC within 120 hours • Percentage of survivors pregnant

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References and Recommended Reading 1. MOH (2014) Kenya Health Sector Referral Implementation Guidelines (1st Edition). Nairobi. Kenya. 2. Ministry of Health (2006).Trainerâ€™s Manual on Clinical Care for Survivors of Sexual Violence. Unpublished 3. Ministry of Health. (2014). National Guidelines on Management of Sexual Violence (3rd Edition). Kenya 4. Violence register MOH 365, 5. PRC form MOH 363, Sexual Violence 6. Monthly summary MOH 364 7. Integrated tool MOH 711 8. Outpatient over 5yrs and Under 5 yrs. Registers MOH 705A & 705B

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UNIT 3: SGBV REPORTING TOOLS

Purpose: To attain competence in using SGBV data tools to record and report on SGBV services

Expected Learning Outcomes • •

Practice documentation and presentation of SGBV data. Populate/fill SGBV data tools

Lesson Plan Guide:

Time: 1 hour Time

Content

Training Objectives

1 hour

SGBV reporting tools • Sexual Violence register MOH 365 • PRC form MOH 363 • Sexual Violence Monthly summary MOH 364 • Integrated tool MOH 711

•

• •

Role Definition on SGBV data Management

Be familiar with SGBV tools, know the content, instructions and data elements and requirements for populating Populate SGBV data tools Discuss the role of different officers in the SGBV data management process

Training methodology and learning activities

Resource Materials

Illustrated lecture Case Studies/scenarios Question and answer sessions Practical session populating data tools - The facilitator utilises the case studies used to fill the PRC form. The team should be put into groups thereafter each team presents. Lastly they should go through the data collection tool on the problematic areas.

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and lap top SGBV data tools (Sexual Violence register MOH 365, PRC form MOH 363, Sexual Violence Monthly summary MOH 364)

•

Brainstorm on the roles of different officers, facilitator fills in gaps

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Facilitator’s notes

The facilitator will make available hard copies of data tools, Sexual Violence register MOH 365, PRC form MOH 363, Sexual Violence Monthly summary MOH 364 and utilize these in a practical session with participants. S/he will use case scenarios and examples of already filled SGBV data tools( comparing good and bad practice). Participants will populate the tools and review their peformance based on set standards Role Definition of SGBV Data Management

Type of Tool

Person filling the tool

SGBV Register (MOH 365)

Health Care worker attending to the patient.

Monthly data summary (MOH 364)

Health Records officer.

Integrated tool ( MoH 711)

Filled by the records officer.

Inpatient and outpatient register

Filled by the health care provider.

References and Recommended Reading 1. MOH (2014) Kenya Health Sector Referral Implementation Guidelines (1st Edition). Nairobi. Kenya. 2. Ministry of Health (2006).Trainer’s Manual on Clinical Care for Survivors of Sexual Violence. Unpublished 3. Ministry of Health. (2014). National Guidelines on Management of Sexual Violence (3rd Edition). Kenya 4. Violence register MOH 365, 5. PRC form MOH 363, Sexual Violence 6. Monthly summary MOH 364 7. Integrated tool MOH 711

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UNIT 4: UPLOADING SGBV DATA ON THE DHIS AND ANALYSING IT

Purpose: Upload data on the DHIS2

Expected Learning Outcomes • •

Attain ability to upload data on the DHIS2 Be familiar with some basic analysis underatken using DHIS2

Lesson Plan Guide:

Time: 1 hour Training methodology and learning activities

Time

Content

Training Objectives

1 hour

Uploading SGBV Data on The DHIS2

•

Upload data into the DHIS2

•

Basic Analysis on SGBV Using DHIS

•

Perform basic analysis of data on the DHIS2

•

Illustrated lecture, Live session on the DHIS2 to demonstrate how to upload data into the DHIS2 Illustrated lecture, Live session on the DHIS2 to demonstrate how to analyse data in the DHIS2

Resource Materials Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and lap top SGBV data tools (Sexual Violence register MOH 365, PRC form MOH 363, Sexual Violence Monthly summary MOH 364) Internet connection

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Facilitator’s notes The facilitator will ensure there is internet connection to facilitate live demonstration of how to upload data and perform some basic analysis in the DHIS2. The facilitator also must have right of access into the DHIS2. It is important that the faciltator is familiar with the DHIS II. A good approach would be to utilize the county heath record officers to facilitate this demo.

References and Recommended Reading 1. MOH (2014) Kenya Health Sector Referral Implementation Guidelines (1st Edition). Nairobi. Kenya. 2. Ministry of Health (2006).Trainer’s Manual on Clinical Care for Survivors of Sexual Violence. Unpublished 3. Ministry of Health. (2014). National Guidelines on Management of Sexual Violence (3rd Edition). Kenya 4. Violence register MOH 365, 5. PRC form MOH 363, Sexual Violence 6. Monthly summary MOH 364 7. Integrated tool MOH 711 8. Outpatient Registers- MOH 705A & MOH 705B

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UNIT 5: SGBV DATA FLOW AND QUALIT Y Purpose: Observe data quality principles in management of SGBV and Know about SGBV data flow mechanisms

Expected Learning Outcomes • •

Apply data quality principles in management of SGBV data Be familair with SGBV data flow system

Lesson Plan Guide:

Time: 30 Minutes Time

Content

Training Objectives

30 mins

SGBV data flow mechanism •

Discuss SGBV data flow system

SGBV data Quality •

Discuss quality considerations for data management

Training methodology and learning activities • Buzz in pairs to draw graphic of data flow from site to national level, share in plenary, facilitator fills in gaps using an Illustrated lecture. • Brainstorming session, facilitator gives an Illustrated lecture to fill in gaps

Resource Materials Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and lap top

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Facilitator’s notes

Quality Considerations in Data Management • Completion • Correctness • Typing errors • Consistency • Timeliness • Security

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Module 8 Quality Management and Referral in SGBV Programs

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Module 8: Quality Management and Referrals in Sexual Violence Services Module Description: Quality service provision is dependent on accountability both in terms of quality of services and performance. Strict adherence to service standards and accountability for results ensures quality services. This module discusses the mechanisms that have been put in place in sexual violence response programs to monitor quality. The World Health Organization (WHO) stresses the importance of strengthening referral linkages between various service delivery points to ensure comprehensive and holistic delivery of sexual violence services. The issue of effective referral mechanisms is also addressed in this module.

Purpose/Module Competence: The purpose of this module is to enable providers of SGBV services to: • Apply quality management in the provision of SGBV services • Use referral skills in providing comprehensive post rape care services

Expected Learning Outcomes: By the end of this module the participant should be able to: • Demonstrate skills in quality management of SGBV services • Refer clients using the standard guidelines • Use existing linkages for client management

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Content: Unit 1: Quality Management • Quality management Concepts o Quality o Quality improvement o Quality assurance o Why quality management • Quality improvement principles • Dimensions of quality management • Methods of monitoring quality • The minimum standards for providing comprehensive sexual violence services • Quality improvement model in management of SGBV clients Unit 2: Referral • • • • • • •

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What is an effective referral system and its importance Flow of patients in the facility providing SV services The different components and types of referral Referral strategies Resources required for referral The role of community in referral of SGBV clients Use of SGBV referral form

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UNIT 1: QUALIT Y MANAGEMENT Purpose:

Integrate/apply quality principles and approaches in the provision of SGBV services to clients

Expected Learning Outcomes: •

• • • • •

Definition of terms in quality management o quality o quality improvement o quality assurance Explain quality improvement principles Describe the dimensions of quality management Outline methods of monitoring quality Discuss the minimum standards for providing comprehensive sexual violence services Apply quality improvement model in management of SGBV clients

Lesson Plan Guide:

Time: 1 Hour Time

Content

Training Objectives

20 mins

Definition of terms in quality management o Quality o Quality improvement o Quality assurance

Definition of terms

Training methodology and learning activities

Resource Materials

Participants discuss the definition of the following terms in buzz pairs and report findings in plenary. • Quality • Quality management • Quality improvement • Quality assurance

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop SOPs SV Guidelines

Facilitator fills in gaps, through an illustrated lecture.

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Time

Content

Training Objectives

Training methodology and learning activities

Resource Materials

10 mins

Quality improvement principles

Explain quality improvement principles

Illustrated lecture on principles of quality improvement

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop

10mins

Dimensions of quality management -Technical competence -Access to services -Effectiveness of services -Interpersonal relations -Efficiency -Continuity -Safety -Amenities/Physical infrastructure

Describe the dimensions of quality management

Participants discuss the different dimensions of quality they know about in 3 groups and report findings in plenary.

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop

Methods of Monitoring quality - Suggestion boxes - Immediate feedback - Rumors - Self-assessment - Client satisfaction tools - Counsellor support supervision - Checklist - Data analysis - Giving feedback

Discuss methods monitoring quality

Minimum standards for providing Comprehensive sexual violence services

Discuss the minimum standards for providing Comprehensive sexual violence services

10mins

Facilitator fills in gaps, through an illustrated lecture.

Participants brainstorm on different methods of monitoring quality and the tools used in these different methods Facilitator fills gaps in knowledge and shows participants samples of the tools used in the different methods of monitoring quality. Participants discuss in 3 groups what they conceive the minimum standards are in provision of PRC services. Facilitator reminds that previous sessions on medical management, forensic examination and psycho social support should inform their discussion. They should also indicate the person responsible for implementing each service at the facility. Facilitator fills gaps in knowledge through an illustrated lecture.

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Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop SV Guidelines SOPs

Facilitator’s notes Quality Management • Quality Management (QM) is an ongoing effort to provide services that are in line with stipulated service standards and that meet or exceed clients’ expectations, in an equitable and acceptable manner and within the available resources. The objectives of quality management interventions are: o To ensure optimal quality of care and support services for survivors; o To establish the relationships between identified problems and quality of care issues and their impact on the provision of care; o To recommend corrective action and regularly monitor the effect of the interventions. Quality Quality is a comprehensive and multifaceted concept. Quality means different things to different people. It might mean: reputation, durability of a product, right price, prompt service, high standard, friendly reputation, availability of services, honesty and trustworthy in relationships etc. Others have described quality as follows; “Doing the right thing right, right away” (Deming 1982) “It is that which makes a thing what it is; nature, character, attitude, grade of goodness, excellence…” (Chambers Dictionary, 1980) Quality Improvement QI is the determined effort to continuously do things better until they are done right the first time, every time (Berwick, Godfrey, & Roessner, 1990). QI involves both prospective and retrospective reviews i.e. planning for the future and reviewing the past. It is aimed at improvement, measuring where you are, and finding out ways to make things better. It specifically attempts to avoid attributing blame, and to create systems to prevent errors from happening.

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Figure 2: Quality improvement cycle (Adapted from the Trainerâ€™s Manual on Clinical Care for Survivors of Sexual Violence, 2006) Quality Assurance Quality Assurance (QA) refers to a systematic and planned approach to monitoring, assessing and improving the quality of services on a continuous basis. QA can also be defined as all the activities that contribute to defining, designing, assessing, monitoring, and improving the quality of healthcare. QA is basically a simple idea. Standards are set for a certain service, the Quality Assurance team QA and improved quality of care requires more than a technical approach of tools and methods. Sustained improvements often require a change in attitude and sense of ownership for the quality of services provided by all.

ensures that the service is delivered in such a way that these standards are met consistently, and the client is therefore assured of the quality of the service. Quality Improvement Principles Quality improvement should be based on the right and needs of the clients. These principles include:

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Dimensions of Quality Experts generally recognize several distinct dimensions of quality that vary in importance depending on the context in which QA efforts take place. These dimensions of quality are a useful framework that helps health teams to define and analyse their problems and to measure the extent to which they are meeting program standards. These dimensions of quality are as appropriate for clinical care as for management services that support service delivery. ( 1. Technical Competence Technical competence refers to the skills, capability, and actual performance of health providers, managers, and support staff. For example, to provide technically competent SV related services, a SV service provider must have the skills and knowledge (capability) to carry out specific tasks and to do so consistently and accurately (actual performance). Technical competence relates to how well providers execute practice guidelines and standards in terms of dependability, accuracy, reliability, and consistency. Competence in health management on the other hand requires in addition to the above; skills in supervision, training, and problem solving. The requisite skills of support staff depend on individual job Descriptions. A lack of technical competence can range from minor deviations from standard procedures to major errors that decrease effectiveness or jeopardize client safety. 2. Access to Services Prompt access to sexual violence services especially by the survivor is critical. Access means that health related services are unrestricted by the following; â€˘ Geographic Access; may be measured by modes of transportation, distance, travel time, and any

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• other physical barriers that could keep the client from receiving services. • Economic Access; Affordability of products and services for clients. • Social or Cultural Access: Acceptability within the context of the client’s cultural values, beliefs, and attitudes. • Organizational Access; The extent to which services are conveniently organized for prospective clients, and encompasses issues such as clinic hours and appointment systems, waiting time, and the mode of service delivery. • Linguistic access; means that the services are available in the local language or a dialect in which the client is fluent. 3. Effectiveness of Services The quality of health services depend on the effectiveness of service delivery norms and guidelines. Assessing the dimension of effectiveness answers the question, does the procedure or treatment, when correctly applied, lead to the desired results or outcome? 4. Interpersonal Relations The dimension of interpersonal relations refers to the interaction between health care professionals and clients, managers, and the community. Good interpersonal relations establish trust and credibility through demonstration of respect, confidentiality, courtesy, responsiveness, and empathy. Effective listening and communication are also important. Sound interpersonal relations contribute to effective service provision and to a positive rapport with clients. Inadequate interpersonal relations can reduce the effectiveness of a technically competent health care service provider. Clients who are poorly treated may be less likely to heed the health care provider recommendations, or may avoid seeking support. 5. Efficiency The efficiency of health services is an important dimension of quality because it affects products and service affordability and because resources are usually finite/ limited. Efficient services provide the greatest benefit within the resources available. Efficiency demands that necessary or appropriate care is provided. Poor care resulting from ineffective norms or incorrect delivery should be minimized or eliminated. In this way, quality can be improved while reducing costs. Harmful care, besides causing unnecessary risk and client’s discomfort, is often expensive and timeconsuming to correct. It would be misleading, however, to imply that quality improvements never require additional resources. But by analysing efficiency, health program managers may select the most cost-effective interventions. 6. Continuity Continuity means that the client receives the complete range of health related services that he or she needs without interruption, cessation, or unnecessary repetition of diagnosis or treatment. It is important to note that continuity of services does not preclude the possibility of services being

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offered on an ongoing basis. A client must also have access to timely referral for specialized services and to complete follow - up care. Continuity is sometimes achieved by ensuring that the client always sees the same HCP; in other situations, it is achieved by keeping accurate records so that a new provider knows the client’s history which the provider can build up to make a sound decision. The absence of continuity can compromise effectiveness, decrease efficiency, and reduce the quality of interpersonal relations. 7. Safety As a dimension of quality, safety means minimizing the risks of injury, infection, harmful side effects, or other dangers related to service delivery. Safety involves protecting the HCP as well as the client. While safety may seem most important when complex clinical services are provided, there are safety concerns in the provision of basic health services as well. For example, it is crucial that disposal of bio hazard material such as contaminated sharps, gloves, swabs etc. be done appropriately in order to avoid exposing clients and the community to injuries, infections etc. 8. Amenities/Physical infrastructures Amenities refer to the features of services that do not directly relate to clinical effectiveness but may enhance the client’s satisfaction and willingness to return to a facility for subsequent support. Amenities are also important because they may affect the client’s expectations about and confidence in other aspects of the service or product. Where cost recovery is a consideration, amenities may enhance the client’s willingness to pay for services. Amenities relate to the physical appearance of facilities, personnel, and materials; as well as to comfort, cleanliness, and privacy. Other amenities may include features that make the wait more pleasant such as music, educational or recreational videos, and reading materials. While some amenities such as clean, accessible toilets; and privacy curtains in examination rooms are considered luxuries in most rural based settings, they are nevertheless important for attracting and retaining clients and for ensuring continuity and coverage. Four Core Principles of Quality Management QA focuses on four core principles namely; 1. The client 2. Systems and processes 3. Measurement 4. Teamwork The Client A focus on the client examines how and whether each step in a process is relevant to meeting client needs and eliminates steps that do not ultimately lead to client satisfaction or desired client outcomes.

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It refers to both external customers and internal customers. External customers include the people receiving the end product, or output, of a system. For example, SV clients are external customers. Internal customers on the other hand are organizational members involved in the processes necessary to produce the output: service providers, health care managers, and supportive staff are all examples of internal customers and each is important in achieving the overall goal of quality service provision. Internal customers benefit from system efficiency by being able to perform their jobs better, thereby better meeting the needs of external customers. Systems and Processes Quality management views all work in the form of processes and systems. Systems are arrangements of organizations, people, materials, and procedures that together are associated with a particular function or outcome. A system consists of inputs, processes, and outputs/outcomes. A process is defined as “a sequence of steps through which inputs from suppliers are converted into outputs for customers”. Processes include how client flows from one point to the next as they receive sexual violence services, service delivery protocols that HCP must observe in order to provide standardized services etc. Tools such as a flowchart help people understand the steps in a process. By increasing understanding of the processes and systems of service provision, QA activities can identify weaknesses and change processes in ways that make them produce better results. Measurement In quality assurance, data is used to analyze processes, identify problems, test solutions, and measure performance. Data is important because it ensures objectivity. For example comparing data from before and after an intervention can allow us to verify that the changes have actually led to improvements. Data is derived from the various methods of monitoring quality of services that are described further below Data in QA is used to: • Identify opportunities for improvement to initiate QA and QI efforts • Detect and assess problems • Verify possible causes of problems • Inform decision making • Show if a quality intervention yielded improvement and by how much • Monitor processes over time to see if the change or improvement is maintained

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The degree to which data is collected and analyzed varies with different quality assurance tasks. Data may be quantitative in nature, such as number of clients seen, or qualitative, such as customer feedback or comments on perception on services received. Focus on Teamwork Teams are important to QA for several reasons. First, processes consist of co-dependent steps that are carried out by different people... The participation of different people in decision making and carrying out tasks enriches decision making and helps to build consensus about changes, and reduces resistance to change. Moreover, mutual support and cooperation arise from working together within a health facility, leading to increased commitment to improvement. Such an atmosphere of support discourages blaming others for problems. Finally, the accomplishment of a team often increases the membersâ€™ self-confidence and facilitates improved health outcomes of the patients/clients. This empowers staff to work towards the goal of quality by motivating them to contribute their knowledge and skills to improve organizational and individual performance. Methods of Monitoring Quality Different methods can be utilized to monitor quality of sexual violence services provided, all of which have their advantages and setbacks. Below are commonly used methods for quality monitoring. Suggestion Boxes A suggestion box is a device for obtaining additional comments, questions, and requests. The box is used for collecting slips of paper with input from consumers of a service. Some of the advantages of suggestion boxes are; there is freedom of expression, it is accessible at all times, and secrecy is maintained. Drawbacks of suggestion boxes are; they can be misused to target certain HCPs, false information can be forwarded and is only limited to people who can read and write and there is no direct feedback. Health facilities need to make arrangements to strategically place the suggestion box where clients/patients easily give their feedback. Materials like pens and papers for writing needs to be provided also. Confidentiality of the information from patients must be maintained and deliberate efforts must be put in place not to victimize service providers adversely mentioned in the feedback but to focus on quality issues raised and how to best address them. Immediate Feedback Immediate feedback is information about performance that leads to action to affirm or develop performance. It is about reinforcing effective and strong performance and identifying areas of potential improvement on the part of the HCP and the facility at large. When feedback is given

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immediately and positively, room for improvement is created. The downside to feedback is that the feedback may be interpreted as criticism therefore creates resistance to change. Clients/patients and/ or HCPs should always be encouraged to give their candid feedback to facilitate quality improvement and HCP and management needs to be open and objective to this feedback provided. Rumors These are unfounded facts based on hearsay. At times rumors have truth in them, as the saying goes‘where there is smoke there is fire.’ The problem with rumors is that they do not have an originator and might be used as slander. Rumors therefore should objectively be investigated and responded to, to identify the underlying quality issues being raised. Self-Assessment This takes the form of a questionnaire set for the health care professionals to assess quality of SV services that they provide to client. Specific indicators in relation to the services that are offered are used as questions to ensure that the service provider adheres to the set standards. Where the service provider is biased, room for improvement is limited. The same is true if the service provider over criticizes themselves and see nothing good in what they offer. Client Satisfaction Tools For client exit interviews, the interviewer interviews clients as they leave the service site after they have received the requisite services. The questionnaire is usually short; the interview should take only 5-15 minutes. They sit in a private, quiet place for the 5-15 minutes necessary to complete the questionnaire. Interviewers can be drawn from staff. Some of the advantages of exit interviews include the fact that they are fast, easy to administer and that the information is readily available. Draw backs to the interviews include the fact that at times, due to a third party administering the questionnaire, truth may not be revealed or at times the respondent may not express themselves freely and some respondents may want to fill the questionnaire by themselves. One of the other disadvantages of using interview administered CEI’s include cost. This is especially so where independent interviewer are engaged for objectivity. Counselor Support Supervision According to British Association of Counselors, counselling supervision is a formal mutually agreed arrangement for counsellors to discuss their work regularly with someone who is normally an experienced and competent counsellor supervisor. The task is to work together to ensure and develop the efficacy of supervision in counselling practice. The overall aim of counselling supervision is to

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safeguard client’s’ welfare. In this context support supervision is very supportive as opposed to line management supervision which is usually perceived as a fault finding process. Supervision is also useful in that it improves services and reduces burn out and provides room for correction. It’s setback is however that it is time consuming and is an expensive venture. Checklist A check list is a tool used as an aid to memory. It helps to ensure consistency and completeness in carrying out a task. A basic example is a ‘to do’ list. It is suitable for monitoring quality as it is accurate, and aims to ensuring that specific aspects are not forgotten as they are written down, and the person checking carrying out specific task only needs to tick along the variable in question to confirm its availability or unavailability. The set back is that it can be very mechanical and limit user’s ability to think beyond the checklist. The checklist also becomes irrelevant if it not constantly updated to reflect what is actually on the ground. Data Analysis Data analysis is a process of gathering, modelling, and transforming data with the goal of highlighting useful information, suggesting conclusions, and supporting decision making. Through data collection, variances can be detected thus a reliable way of monitoring quality. A plus for data analysis include the fact that it is accurate, data can be analysed using different indicators like by age, sex, uptake, resources, etc. At the same time, identifying problems is easy. Setback for data analysis is that it is time consuming and requires a person with data analysis skills. Giving Feedback It is important to ensure that feedback on findings from analysed data is given to relevant stakeholders including staff, the community, managers etc. to facilitate communal decision making on QI measure’s to be implemented as well as to disseminate information on QA and QI activities. Methods used to present data will depend on the target audience and forum used to give feedback. The following are channels/fora through which feedback can be given include • Displaying information analyzed from data on notice board (at the facility) • Chief’s baraza / community meetings • Schools • Churches • Seminars • Staff meetings • Media (electronic & print)

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Minimum Standards for Providing Comprehensive post SV in Health Facilities Minimum Standards for Medical Management of Survivors

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Reporting/ recording requirements for health facilities

All health facilities without a laboratory (public and private)

Manage injuries as much as possible. Detailed history, examination and documentation provide EC, Hep B TT if indicated (refer for other missing services e.g. HVS, PEP/, STI and pregnancy test) Provide counselling

Fill in PRC form (part A and B) in triplicate.

All health facilities with a functioning laboratory (public and private)

Manage injuries as much as possible. Detailed history, examination and documentation (including HVS, STI screening and pregnancy test) Provide Hep. B, STI prophylaxis, PEP, ECP if indicated, TT if indicated. N/B 1st dose of PEP should be provided (even where follow up management is not possible). Where HTC services are available, provide initial counseling

Fill in PRC form (part A and B) in triplicate.

Minimum capacity requirements at health facilities A trained nurse

Maintain SGBV register. Please ensure that the survivor has a copy of the PRC form (part A and B) and takes it to the laboratory

Maintain SGBV register. Maintain a laboratory register. Referral to comprehensive post rape care facility

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A trained nurse and/or a clinical officer.

A trained counselor (where counseling is offered)

All health facilities with HIV, ARV or a comprehensive care clinic (CCC) where ARV can be monitored (comprehensive post sexual violence care facilities can be provided) (private and public health facilities)

Manage injuries as much as possible. Detailed history, examination and documentation. (HVS STI screening HIV testing and counseling Pregnancy test) Provide emergency and ongoing management of PEP. Provide Hep B, ECP if indicated, TT if indicated. Provide STI prophylaxis or management. Provide counseling for trauma, HIV testing and PEP adherence.

Fill in PRC form (part A and B) in triplicate. Maintain SGBV register. Maintain a laboratory register. Fill in PRC form (part A and B) to follow up management of survivors

1 medical or clinical officer trained in ARV/PEP management. 1 trained counselor (trauma, HIV testing and PEP adherence counseling ) Laboratory for HIV and HB testing. Preservation of sperms from HVS specimen

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References and Recommended Reading 1. Ministry of Health. (2014). National Guidelines on Management of Sexual Violence (3rd Edition). Kenya 2. MOH (2014) National Health Sector Standard Operating Procedures on Management of Sexual Violence in Kenya. Nairobi, Kenya: German development Cooperation

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UNIT 2: REFERRAL AND LINKAGES/ NE T WORK IN PROVIDING COMPREHENSIVE POST RAPE CARE SERVICES Purpose: To refer SGBV clients appropriately and effectively

Expected Learning Outcomes By the end of this unit the participants should be able to: • Define an effective referral system and its importance • Describe Flow of patients in the facility providing SV services • Explain the different components and types of referral • State different referral strategies • İdentify the resources required for referral • Describe the role of community in referral of SGBV clients • Use SGBV referral form

Lesson Plan Guide:

Time: 1Hour Time

Content

Training Objectives

10mins

What is an effective referral system and its importance

Define an effective referral system and its importance

10mins

Flow of patients in the facility providing SV services

Describe Flow of patients in the facility providing SV services

Training methodology and learning activities Illustrated lectures -Power – Point présentations -Group work/discussions Case Studies/scenarios -Brain storming -Question and answer sessions

Resource Materials Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop Referral forms

Illustrated lectures -Power – Point Présentations -Group Works/discussions -Brain storming Case study/scenario -Question and answer sessions -Plenary discussions

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop Client Flow chart

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Time

Content

Training Objectives

10 Mins

Components and Explain the different types of referral components and types of referral

10 Mins

Referral strategies State different referral strategies

10Mins

Resources required for referral

İdentify the resources required for referral

10 Mins

Role of community in referral of SGBV clients

Describe the role of community in referral of SGBV clients

10 Mins

SGBV referral form

Practice the use of SGBV referral form

Training methodology and learning activities Illustrated lectures -Power – Point Présentations -Group Works/discussions -Brain storming -Question and answer sessions -Plenary discussions Illustrated lectures -Power – Point Présentations -Group Works/discussions -Brain storming -Question and answer sessions -Plenary discussions

Resource Materials Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop Referral guidelines Client referral charts(interagency framework) Illustrated lectures -Power – Point Flip charts Présentations Masking tape -Group Works/discussions Marker pens -Brain storming Trainer’s Manual -Question and answer sessions LCD machine and laptop -Plenary discussions

Illustrated lectures -Power – Point Présentations -Group Works/discussions -Brain storming -Question and answer sessions -Plenary discussions

Flip charts Masking tape Marker pens Trainer’s Manual LCD machine and laptop Community health volunteers manual 2013 Referral strategy Illustrated lectures -Power – Point Flip charts Présentations Masking tape -Group Works/discussions Marker pens -Brain storming Trainer’s Manual Role play LCD machine and laptop -Question and answer sessions Referral form -Plenary discussions

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Facilitator’s notes

Client flow for Post Rape Care Services within a Health Facility The following is a diagrammatic representation of referrals in different service delivery points

Definition of Effective Referral In the context of sexual violence service provision, referral is the process by which client’s immediate needs for care, prevention, and supportive services are assessed, prioritized and the client is provided with assistance in accessing the necessary services. Referral also includes reasonable follow-up efforts necessary to facilitate initial contact with prevention, care, and psychosocial services and to solicit clients’ feedback on satisfaction with services (CDC’s Revised Guidelines). Importance of Referral Systems Referral helps provide better services. When a referral is appropriately and properly executed it can aid recovery, psychological and emotional support, diagnosis, treatment, and specialized care. Referral Components • Problem identification

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• • • • • • •

Problem assessment Problem diagnosis Referral counselling Communication Transfer Facility feedback Community feedback

Referral Mechanisms ‘Referral mechanism’ is client transfer from a service point or community to another service or back to the community. Referral Types • Vertical referral: a client is transferred to a higher or lower service delivery. • Horizontal referral: the client is transferred to a similar facility because there is a temporary lack of certain services or for a second opinion. • Consultancy referral: a client is referred for specialized care. • Central referral: a client is referred to a central point for commonly shared services. • Community referral: the client is referred from the community to the health facility or vice versa. Referral Strategies The World Health Organization (WHO) has repeatedly acknowledged the importance of strengthening links between HIV testing and HIV treatment sites, stating that explicit mechanisms are necessary to promote referral to onward medical and psychosocial support for those testing positive (WHO 2009). The following referral strategies can be useful in ensuring it is effectively done. • Clients-held card • Client- referral form • Provider assisted referral • Verbal referral Client- held card A card with five prevention messages (P5 card) is given to a client who has been tested to invite the partner. Client- referral form This is a strategy which involves the use of a referral form. Provider assisted referral This strategy involves engaging level 1 actors in facilities to escort the client to referral points and there after follow them up in the community.

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Verbal referral This involves oral direction of individuals requiring services to the place where the services are offered. Broadly all the community members are encouraged to do this. In all these strategies confidentiality must be observed The Community in the Referral System • Community involvement in planning, designing, developing and supporting the referral system affects its population. • Community education gives information to understand and appreciate referral systems and participate in the referral • Community participation may provide finances and transport, give feedback, accept clients back into the community and promote referral. Resources Required for Referral • Transport • Communication system • Qualified personnel • Equipment and supplies • Emergency support • Willing and understanding community • Empowered community

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Client Referral Form Date……………………… Time………………………… Facility code……………… Client Details: Name …………………………………………….. Age ………........ Sex……….. IP/OP number: ………………………

ID number: …………………………

NHIF Number: …………………………… Telephone Number(s)………………. Physical Address………………………

County………………………………..

Sub County………………………………. Sub Location…………………………. Next of Kin Details: Name …………………………………… Relationship to client …………………. Telephone Number………………………….......................... Referring from Facility/Department ………………………… Referral to Facility/Department ………………………………………………………………. History/Investigations……………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… Diagnosis: …………………………………………………………………………………………. Reasons for Referral: ……………………………………………………………………………………………………… ………………………………………………………………………………………………………

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Referring Officer Details: Name………………………………………..Telephone Number ……………………………….. Designation……………………… Signature……………………… Referral Back Details (Tracking Slip): Name of the Facility or Department…………………… Date Client Reported…………………Referred from Facility/Department ……………… Clinical Details: …………………………………………………………………… .............................................................................................................................................. Clinician Name………………………………Telephone Number…………………………… Designation……………………Signature…………………………Date…………………………

References and Recommended Reading 1. MOH (2014) Kenya Health Sector Referral Implementation Guidelines (1st Edition). Nairobi. Kenya. 2. Ministry of Health (2006).Trainer’s Manual on Clinical Care for Survivors of Sexual Violence. Unpublished 3. MOH (2009) Kenya Quality Assurance Model for Health (KQAMH) Department of Standards and Regulatory services 4. Ministry of Health. (2014). National Guidelines on Management of Sexual Violence (3rd Edition). Kenya

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Module 9 Sexual Violence in Humanitarian Crisis Situations and Human Trafficking

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Module 9: Sexual Violence in Humanitarian Crisis Situations and Human Trafficking Module Description: A humanitarian crisis is an event or series of events which represents a critical threat to the health, safety, security or wellbeing of a community or other large group of people, usually over a wide area. Examples of humanitarian crisis include drought, floods, and armed crisis among others. Women and girls are particularly vulnerable to all forms of GBV including sexual violence especially during armed crisis. This is exacerbated further by their age and gender as well as prevailing humanitarian and security conditions. This module highlights the vulnerability factors related to sexual violence in crisis situations and elaborates on the interventions to be undertaken during conflict situations including the types of services required in addressing the needs of sexual violence survivors in such situations

Purpose/Module Competence: By the end of the module, participant will be able To manage a survivor of sexual violence in humanitarian setting as per Minimum Initial Service Package (MISP) and InterAgency

Standing Committee (IASC) guidelines and the Sphere standards.

Expected Learning Outcomes: 1. 2. 3. 4.

Describe gender vulnerabilities in Humanitarian crisis situations Appreciate the global, regional and local situation of human trafficking Describe the role of Health Care Providers in assisting victims of human trafficking Demonstrate ability to provide clinical services to SGBV survivors in line with the national protocol 5. Demonstrate skills to develop strategies for security and prevention of violence 6. Apply Minimum Initial Service Package (MISP) for integration of SRH/HIV services in Humanitarian crisis situations 7. Demonstrate skills necessary for assisting victims of human trafficking

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Content: Unit 1: Gender vulnerability in Humanitarian crisis situations • Definitions of gender vulnerabilities • Vulnerability Factors related to SV • Interventions on SV Unit 2: Human Trafficking and SGBV • Definition of Human Trafficking • The global, regional and local situation of human trafficking • The link between Human Trafficking and Sexual Violence • Health consequences of human trafficking • Key features of trauma informed care associated with human trafficking • The role of Health Care Providers in assisting victims of human trafficking Unit 3: Minimum Initial Service Package (MISP) in humanitarian crisis situations • Minimum Initial Service Package (MISP) in Humanitarian crisis situations Unit 4: Preparedness and Contingency planning for SGBV prevention and response in humanitarian crisis • SGBV minimum prevention and response services in humanitarian crisis • Practice using different contingency planning tools

Unit 5: Code of conduct as applied in humanitarian crisis situations • Definition of code of conduct • Code of conduct principles in humanitarian crisis Unit 6: Strategies for security and prevention of violence in Humanitarian crisis situations • Protection • Security systems to prevent violence • Health services put in place to manage cases during crisis time

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UNIT1: GENDER VULNERABILIT Y IN HUMANITARIAN CRISIS SITUATIONS Purpose: To develop knowledge and skills on gender vulnerabilities in humanitarian crisis situations

Expected Learning Outcomes By the end of this unit participants should be able to: 1. Define human crises 2. Describe Vulnerability Factors related to SV 3. Recognize Interventions on SV

Lesson Plan Guide:

Time: 20 minutes

306

Training methodology and learning activities Define humanitarian crisis Brainstorming

Resource Materials National Guidelines, Flip chart paper, marker pens

Vulnerability Factors related to SV

Describe Vulnerability Factors related to SV

Group discussion

Interventions on SV

Discuss the interventions on SV

Handouts,

National Guidelines, Flip chart paper, marker pens, facilitatorâ€™s manual, photos (who is vulnerable?) National Guidelines

Time

Content

5 mins

Definition of humanitarian crisis

10 Mins

5 Mins

Training Objectives

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Facilitator’s notes Gender Vulnerabilities during crisis 1. Definition of humanitarian crisis A humanitarian crisis is an event or series of events which represents a critical threat to the health, safety, security or wellbeing of a community or other large group of people, usually over a wide area. A humanitarian emergency arises when such an event affects vulnerable populations who are unable to withstand the negative consequences by themselves. Humanitarian crisis include drought, floods, terrorism and armed conflict among others. Women and girls are particularly vulnerable to all forms of GBV including sexual violence especially during armed conflict. This is exacerbated further by their age and gender as well as prevailing humanitarian and security conditions. The use of rape and other forms of sexual violence to humiliate and terrorise civilians is now recognised as an international crime. Sexual violence is also included in the Statute of the International Criminal Court. 2. Vulnerability Factors related to SV GBV is a widespread international public health and human rights issue, Adequate, appropriate, and comprehensive prevention and response are inadequate in most countries worldwide. Gender-based violence is especially prevalent in the context of complex emergencies and natural disasters, where civilian women and children are often targeted for abuse, and are the most vulnerable to exploitation, violence, and abuse simply because of their gender, age, and status in society. However men can also be victims of SV.Throughout any emergency, many forms of GBV occur. During the early stages — when communities are first disrupted, populations are moving, and systems for protection are not fully in place — most reported GBV incidents are sexual violence involving female survivors/victims and male perpetrators. Sexual violence is the most immediate and dangerous type of gender based violence occurring in acute emergencies. Later— in a more stabilised phase and during rehabilitation and recovery — other forms of GBV occur and/or are reported with increasing frequency. These include, among others, harmful traditional practices (female genital mutilation, forced early marriage, honour killings, etc.) (WHO,2004). Rape is a form of sexual violence, a public health problem and a human right s violation. Rape in war is internationally recognized as a war crime and a crime against humanity, but is also characterized as a form of torture and, in certain circumstances, as genocide. All individuals, including actual and potential victims of sexual violence, are entitled to the protection of, and respect for, their human rights, such as the right to life, liberty and security of the person, the right to be free from torture and inhuman, cruel or degrading treatment, and the right to health (Clinical management of rape survivors (WHO/UNHCR 2004).

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The continual reproductive role of women and girls such as fetching water and firewood/ in unsecure areas predisposes them to being sexually violated 3. Recommended interventions during crisis situations The types of services required in addressing the needs of sexual violence survivors in such situations include: 1. Provision of Contraceptives, post exposure prophylaxis? 2. Provision of Emergency Neonatal and Maternal Health 3. Reproductive health services 4. Social support, security and legal redress 5. Prevention activities must be put in place to address causes and contributing factors to sexual violence in the setting 6. Evacuation and airlifting 7. Rapid situation anlaysis

References and Recommended Reading 1. Inter-agency Working Group (IAWG) on Reproductive Health in Refugee Situations. (1996) .Minimum Initial Service Package for Reproductive Health (RH) in Crisis Situation. Retrieved from www.who.int/reproductivehealth/publications/interagency_manual_on_RH_in_refugee_ situations/full_text.pdf 2. Heise, L, Pitanguy, & L., Germain, A. (1994). Violence against Women. The Hidden Health Burden, World Bank Discuss. Pp. No. 255, pp. 171â€“195. Washington, DC: World bank 3. World Health Organization and the United Nations High Commissioner for Refugees. (2004). Clinical Management of Rape Survivors: A guide to the development of protocols for use in refugee and internally displaced person situations, (revised edition)

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UNIT 2: HUMAN TRAFFICKING Purpose: Manage SGBV clients who experience human trafficking

Expected Learning Outcomes: • •

Define Human trafficking Describe the global, regional and local situation of human trafficking

• • •

Identify Health consequences of human trafficking Recognize key features of trauma and prompt care associated with human trafficking Describe the role of Health Care Providers in assisting victims of human trafficking

Lesson Plan Guide:

Time: 30 minutes Time

Content

Training Objectives

5 mins

Define Human trafficking

Define Human trafficking Describe the global, regional and local situation of human trafficking

Describe the global, regional and local situation of human trafficking Explain Link Between Human Trafficking and Sexual Violence

Training methodology and learning activities • Brainstorm • Lecture

Resource Materials Flip chart paper, marker pens Hand outs:

• Video • Group discussion • Group discussion • Lecture

Flip Chart, Marker pens, handouts: Risks and Vulnerabilities

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Training methodology and learning activities • Case study on scenarios on Human Trafficking • Short exercise on identifying health consequences from the case study • Lecture

Resource Materials Case Study, Flip Chart paper, Makers, Pens, handout- health consequences of human trafficking

Time

Content

Training Objectives

10 mins

Identify Health consequences of human trafficking

Brainstorm on the health consequences of human trafficking

5 mins

Key features of trauma informed care associated with human trafficking

Recognize key feature of trauma informed care for VOT

• Brainstorm • Lecture

Handout – Trauma Informed Care, Flip chart paper, makers, pen

10 mins

The role of Health Care Providers in assisting victims of human trafficking

Identify possibilities and limitations of the role of the HCP

• Brainstorming • Role plays • Lecture

Flip chart paper, makers, pen, LCD projector, laptop; Handout- Guiding Principles ,

Facilitator’s notes Human Trafficking: Human Trafficking is “The recruitment, transportation, transfer, harbouring or receipt of persons, by means of threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labour or other services, or removal of organs” . This definition is also adopted by Kenya Counter Trafficking in Persons Act 2010. In order for trafficking to have occurred, the following elements must be present. Only one element from each of the three categories needs be present:

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a) The consent of a victim of trafficking in persons to the intended exploitation is irrelevant where any of the means have been used. b) The recruitment, transportation, transfer, harbouring or receipt of a child for purposes of exploitation is considered “trafficking in persons” even if this does not involve the means outlined. c) A child shall mean any person under eighteen years of age Recruitment • Word of mouth, personal contacts, trusted friends or family • Newspaper or internet advertisement, social networking websites • Often using deceit,fraud or coercion Transportation • Origin, transit and destination communities • Can be Legal or illegal border crossings, or within a country • Travel by land, air or sea. • Often accompanied (documents retained) Coercion and Abuse • Sexual abuse and rape • Excessive working hours

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• Freedom of movement totally denied/partially denied • Not allowed to keep earned money, debt bonding • Forced substance abuse • Deprivation of adequate food/water • Lack of access to health car Link Between Human Trafficking and sexual Violence There are common misconception that sexual violence occurs only in sex trafficking. Not all people who work in the sex industry are trafficked, those that are engaged in the commercial sex industry, including trafficking victims, are at an extremely high risk of sexual assault. However, the unfortunate truth is that sexual violence occurs in almost every type of trafficking situation including the commercial sex industry, servile marriages, and in cases of forced labor. In all of these situations it is important to remember that no one agrees to be sexually assaulted or trafficked despite appearances of consent at various stages of the trafficking or sexual assault. Examples of the ways in which sexual assault can occur and be overlooked during the course of different types of trafficking situations include: Commercial Sex Industry: Although not all people who work in the sex industry are trafficked, those that are engaged in the commercial sex industry are at an extremely high risk of sexual assault. Because sex work is so stigmatized, sexual assaults suffered by sex workers are both underreported and undervalued. Domestic Violence and Servile Marriage: There are an increasing number of cases in which traffickers force their intimate partners and spouses to perform services and labor, such as domestic work, working at family businesses, or sex work. Often, the trafficking victim is emotionally manipulated, coerced, or forced into having sex with his or her intimate partner/trafficker and/or other individuals. For the Lesbians, Gay, Bisexual and Transgender( LGBTI) communities in particular, marital rape and intimate partner sexual violence are under-identified and underreported. Workplace: Sexual assault in formal and informal workplaces is under-reported and under-identified. Workplace sexual harassment occurs when the perpetrator of the assault and/or the trafficker is also the victim’s employer (or an agent of the employer) and the harmful act occurs on the job. This definition encompasses situations in which the perpetrator is a co-worker, or even a non-employee such as a customer, if the employer “knew or should have known of abuse that involved the workplace and failed to take prompt and appropriate remedial action.”4 Sexual assault and/or harassment of trafficking victims is common in restaurants, bars, domestic work, factories, agriculture, and home care industries Risk Factors and Vulnerabilities for human trafficking Individual •Age and Sex (i.e. young girls); •Orphans and runaways;

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•School drop-out; •Low self-esteem; •Negative peer pressure Family •Marginalized families/ clans; •Poor single parent families; •Large family in poverty; •Power relations within households – e.g. Son/male preference; •Divorce, domestic violence and sexual abuse Destination / Workplace •Unsupervised hiring of workers (e.g. in border areas); •Poor labour protection and enforcement; •Unregulated poor working conditions – 3D jobs (dangerous, dirty, demanding); •Male demand for sex with girls; •Undercover entertainment (hairdresser, massage); •Public tolerance sex trade, begging External •War / armed conflict; •Poor infrastructure and lack of social amenities; •Weak legal framework and enforcement •Natural disaster (e.g. draught, flooding, earthquakes); •Globalization and improved communication systems Vicious Cycle of Exploitation Risk & vulnerability lead to trafficking

More Exploitation

Trafficking leads to exploitation

Exploitation implies lack of opportunities

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1. Human trafficking in Kenya • Kenya is source, transit, and destination country for men, women, and children subjected to forced labor and sex trafficking • Children forced to labor in domestic service, agriculture, fishing, cattle herding, street vending, and begging • Children exploited in prostitution throughout Kenya, including: a) in the coastal sex tourism industry, b) in eastern khat cultivation areas, and c) near Nyanza’s gold mines As a source • Kenyans migrate to other East African nations, South Sudan, Europe, the US, and the Middle East— particularly Saudi Arabia, Qatar, Kuwait, the UAE, Lebanon, and Oman in search of employment, • At times exploited in domestic servitude, massage parlors and brothels, or forced manual labor • Gay and bisexual Kenyan men lured from universities with promises of overseas jobs, only to be forced into prostitution in Qatar and the UAE As a destination • Children from Burundi, Ethiopia, South Sudan, Tanzania, and Uganda subjected to forced labor and prostitution in Kenya. • Some children in Kenya-based refugee camps, the majority of whom are Somali, may encounter exploitation in prostitution while others are taken outside the camps and forced to work on tobacco farms. • Vehicles transporting khat to Somalia return carrying Somali girls and women, who often end up in brothels in Nairobi or Mombasa. Assistance of victims/Survivors • Counter-trafficking in persons Act, 2010-gazetted in 2012. • 24 toll free –hotline at MOG • In 2012, the hotline received 59 reports of child trafficking, 21 of child prostitution, and 646 of child labor. • hotline’s local call centers in Eldoret and Garissa • MOG operates four drop-in referral centres in Eldoret, Garissa, Malindi, and Mombasa • Rescue centers in Garissa, Malindi, Thika, and Machakos 3. Health consequences of human trafficking Trafficked persons may have health problems which range from minor to severe, some health risks occur prior, during and after the trafficking process. Amongst the most prevalent health risks are: • Physical abuse and deprivation

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• Threats, intimidation, abuse • Sexual abuse • Substance misuse • Social restriction, manipulation and emotional abuse • Economic exploitation • Legal insecurity • Occupational hazards • Marginalisation Participants will brainstorm the consequences of these health risks. Of particular importance is to note that violence is often present during human trafficking process. Examples include physical and sexual violence or both especially to women and adolescents. Victims of trafficking like other victims of torture have similar psychological symptoms. The uncontrollable and unpredictable events experienced by VoT result in traumatic stress responses which may include: Sense of helplessness, hopelessness and hyper-active, ‘all-or-nothing” response mechanism This has negative mental health consequences which may lead to reactions such as reliance and subservience to the traffickers and reluctance to trust. Health care providers should be aware of this when interacting with the victims of trafficking. As such HCPs need to emphasize on trust-building, providing clear information, giving options and control over decisions. Key features of trauma informed care associated with human trafficking Trauma informed care is about: • Recognising violence in patient encounters and in your clinical practice • Learning about and being accepting of the effects that traumatic events can have on people’s attitude, behaviour and perceptions of their body • Making time and space for individuals to disclose and describe traumatic events • Addressing violence in sensitive and safe ways • Being prepared to facilitate referral to other medical and non-medical services. The objective of trauma informed care is to make a clinical accounter more predictable and help the person feel they are not helpless and out of control. The trauma informed care approach outline 5 key features and these include: • Create a clinical ‘safe space’ for disclosure and discussion • Promote patient decision-making • Establish and maintain patient safety • Establish and maintain provider safety • Ensure informed consent.

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Role of Health Care Providers in assisting victims of human trafficking Health Care Providers being part of a network of other services providers are more likely to encounter VoTs. HCPs can encounter VoTs in the following services; accident and Emergency, Sexual and reproductive health and outreach, mental health and psychosocial, part of a counter trafficking referral network. There are two situations in which the HCPs is likely to encounter VoTs, that is, you may suspect someone might be a victim of trafficking in persons (someone is still in the trafficking situation / just escaped from the trafficking situation) or someone is referred to you for care that is already recognized as a trafficked person ( just after the trafficking experience / years later). The goal in both situations is to respond safely and appropriately. Scenario 1: When you suspect • Prioritize safety • Try to find a way to talk to the person alone • Apply the trauma-informed care approach • Ask a few questions related to the symptoms to ascertain the situation e.g. if very pale, ask: Can you tell me about your diet? What have you eaten this week? Over the last month? And referral seems possible: • Apply the trauma-informed care approach • Offer to provide information or to refer the person (e.g. hotline number) • Be careful they are alone! • Communicate clearly • Be mindful of traceable documentation; be discrete • Act only with informed consent And referral is not possible (the situation is unsafe or the patient does not want referral): • Provide as much information as possible • Be careful they are alone! • Communicate clearly • Be mindful of traceable documentation; be discrete • Provide as much treatment as possible Provide a complete regimen of prescribed medication and a medical summary • Use single dose therapy when possible • Apply the trauma-informed care approach • Try to arrange a follow-up visit if possible When urgent assistance is required: • Ensure your own safety • For emergency care, persuade by focusing on health status and not the cause

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• If person is alone and police contact is desired or seems necessary, discuss slowly and clearly. Make sure this is the person’s preferred course of action. • Apply the trauma-informed care approach Scenario 2: Caring for a recognized trafficked person Person has been identified as trafficked (has been screened and interviewed, and has most likely received some kind of assistance) Always be equipped with a list and contact details for available services (social services, housing, legal aid,) and first points of contact Whether receiving a referral or referring: • Know how information and data will be transferred • Know how the first contact will be arranged (Logistics) • Know how trafficked person will be released and received • Apply the trauma-informed care approach • Inform patient and obtain consent • Communicate (to the other agency) only information required for care and security • Assess risks with person and with experts in the field The Don’ts • Do not try to rescue a patient yourself • Do not inquire about trafficking-related circumstances in front of others • Do not disclose your personal address or attempt to shelter patient in yourown home • Do not contact the authorities (e.g., police, immigration) without explaining this option and gaining patient’s permission • Do not ask anyone accompanying individual to assist with interpreting or be present examination • Do not make promises you can’t keep

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References and Recommended Reading 1. IASC. (2015) Guidelines for Gender-Based Violence Interventions in Humanitarian Settings: Focusing on prevention of and response to sexual violence in emergencies. Geneva. 2. 3. WHO. (2005). Resource Book on Mental Health, Human Rights, and Legislation. Geneva. 4. London School of hygiene and Tropical Medicine. (2009). Caring for Trafficked persons. Guidance for Health Providers. Geneva: International Organization for Migration 5. Freedom Network USA (2012): Human Trafficking and Sexual Assault Watts, C ., 6. Zimmerman,C. 2002. Violence against women: global scope and magnitude. Retrieved from Lancet. www.lancet.thelancet.com/pdfs

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UNIT 3: MINIMUM INITIAL SERVICE PACKAGE ( MISP ) IN HUMANITARIAN CRISIS SITUATIONS Purpose: Attain ability to provide minimum service package in humanitarian situations to SGBV survivors

Expected Learning Outcomes: Administer minimum service package to survivors of SGBV in humanitarian situations

Lesson Plan Guide:

Time: 45 minutes

Training methodology and learning activities Brainstorming, illustrated lecture

Resource Materials National Guidelines, Flip chart paper, marker pens

Components of MISP Describe components of MISP

Brainstorming, illustrated lecture

National Guidelines, Flip chart paper, marker pens, handouts

5 mins

Components of comprehensive reproductive health

Identify the components of comprehensive reproductive health

Brainstorming, illustrated lecture

National Guidelines, Flip chart paper, marker pens, handouts

20 mins

Requirements of MISP

Discuss MISP requirements

Brainstorming, illustrated lecture

National Guidelines, Flip chart paper, marker pens, handouts

Time

Content

Training Objectives

5 mins

Definition of MISP

Define MISP

15 mins

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Facilitatorâ€™s notes Minimum Initial Service Package (MISP) in Humanitarian crisis situations What is the Minimum Initial Service Package MISP? The MISP is a coordinated set of priority activities designed to: prevent excess maternal and neonatal mortality; reduce HIV transmission; prevent and manage the consequences of sexual violence; coordination of reproductive health services; and plan for comprehensive reproductive health services in the early days and weeks of an emergency Components of the MISP 1. Prevent maternal and neonatal mortality 2. Prevent HIV/AIDS 3. Prevent and manage the consequences of sexual violence 4. Plan for comprehensive RH services 5. Coordination: need for an organization or individual to facilitate implementation Features of Comprehensive Reproductive Health Program (CRH) Needs to start as soon as feasible Needs to be context specific Needs to be informed by a comprehensive needs assessment Need to Prevent Maternal and Neonatal Mortality Requirements of MISP 1. Provide Clean delivery kits for pregnant women - the six cleans 2. Provide Midwife delivery kits at facility level. 3. Ensure that Neonatal resuscitation kit is part of midwife kit 4. Organize a referral system for Obstetric and neonatal emergencies 5. Ensure that there is quality emergency services at the referral center 6. Respect for Universal Precautions- Staff understand and practice universal precautions; clean health facility; reduce unnecessary procedures; use protective barriers (disposable gloves); use disposable syringe and needle (sharp management system); have incinerator and sterilization facilities 7. Ensure safe blood transfusions- Blood transfusions should be done in health facilities where laboratory facilities exist to screen donors for HIV and other infection, to cross-match blood and to manage complications due to blood transfusions 8. Ensure availability of free condoms 9. Continuation of ART and PMTCT

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UNIT4: PREPAREDNESS AND CONTINGENCY PL ANNING FOR SGBV PRE VENTION AND RESPONSE IN CRISIS Purpose: Demonstrate the ability to provide clinical services to SGBV survivors in line with the national protocol

Expected Learning Outcomes: • •

Participants attain skills to provide SGBV minimum prevention and response in humanitarian crisis Practice using different contingency planning tools for response to humanitarian crisis

Lesson Plan Guide:

Time: 40 minutes Time

Content

Training Objectives

15 mins

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Discuss SGBV Minimum Prevention and Response in Humanitarian crisis situations Demonstrate skills in SGBV Minimum Prevention and Response in Humanitarian crisis situations

Training methodology and learning activities

Resource Materials

-Lecture

MISP manual and guide, Red Cross Disaster Management guide, WHO guide Handout( checklist for supplies)

-Role play

10mins

Preparedness in Humanitarian crisis

Discuss needs for clinical management of rape survivors

Brainstorming, Lectures

15 mins

Special considerations during crisis:

Discuss special Role plays considerations for managing a rape survivor during humanitarian crisis

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Handout: Checklist of needs for clinical management of rape survivors National Guidelines Contingency planning Tools

Facilitator’s notes

Role of the health team in preparedness and minimum response in Humanitarian crisis situations Health teams Local communities, district and national representatives, and humanitarian and disaster agencies should prioritize RH in health emergency and crisis situations management policies, including emergency preparedness and contingency plans. 1. Preparedness and contingency plans include: a) Training national, local and community-based health workers in the MISP and the Sphere Standards in relation to GBV and multisectorial approach. b) Identifying a system to map available services at the onset of an emergency c) Identifying coordination and communication strategies d) Emergency human resource planning e) Developing logistics plans for stockpiling f) Ordering and disseminating MISP supplies. g) Instituting security mechanisms h) Assessment and monitoring 2. Tools for Contigency preparedness • Early warning/risk monitoring • Standard operating procedures for response • Contingency planning • Emergency training • Drills and simulations 1. Health care minimum response in humanitarian crisis situations Requirements: • The essential components of medical care after a rape are: • Documentation of injuries, • collection of forensic evidence, • treatment of injuries, • evaluation for sexually transmitted infections (STIs) and preventive care • evaluation for risk of pregnancy and prevention, • psychosocial support, counsel ling and follow-up In addition to the national protocol the following should be considered: Creating a clinical ‘safe space at the site during crisis’

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Aim to provide care in a rights-based environment: • The clinical environment is welcoming (trained staff and literature available in multiple languages). • Patients’ rights are communicated clearly, verbally and In writing. • Patients’ rights are respected at all times (for example,by ensuring systems are in place for protecting the confidentiality of patient files and providing private spaces for taking histories and for the physical exam). • In order to approach patients from a consistently supportive and empowering stance, staff and provider training should focus on describing the impact trauma may have on people’s behaviours, including ways in which patient’s post-trauma reactions may manifest as anger, irritability and belligerence, or withdrawal and avoidance. • Every encounter – even with clerical or medical support staff – can have a positive or negative impact on a person’s health. • Always strive to do no harm – inadvertent disclosures of the history, breaches of confidentiality, judgmental comments or probing unnecessarily or in an insensitive manner about the patient’s abuse history may contribute to individuals’ mistrust and fear of health care settings. Providers can minimize the potential for re-traumatizing persons by having well-trained personnel and clear protocols for supporting patients through acute and ongoing care. For example, it may be helpful to show patients how their records will remain locked in filing cabinets or access-coded computer files and to explain that a professional code of ethics prevents others from seeing these files without the patient’s permission or a court order. • Communicate slowly and clearly throughout the visit – this includes knowing how to respectfully assess patients’ level of literacy and language comprehension, and how to use visual aids to ensure that an individual understands what is happening. This may also involve working with interpreters • Provide accurate and easy-to-understand information to patients regarding what will happen during the exam – before it happens – it is crucial to keep patients informed and empower them to make well-considered decisions. This is particularly important given trafficked persons’ lack of information and control during trafficking experiences. • Be prepared to discuss informed consent using verbal, visual and written tools. Throughout the visit, providers should reiterate the voluntary nature of the clinical history-taking, exam and other services or treatment. • Provide information both verbally and in writing; offer multiple opportunities for patients to ask questions. • Always empower patients – clinical services are voluntary and patients have the right to decide what they are comfortable with (or not) based on a clear explanation of the procedures, exam or

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treatment beforehand. The right to refuse should be reiterated at regular and appropriate stages during complicated, lengthy or stressful procedures. • Providers and office staff must understand the limits of confidentiality. Clinical settings have different mandates for reporting certain behaviours or situations, including suicidal or homicidal tendencies or reports of sexual abuse. Patients should be made aware of these limits to confidentiality prior to any delivery of clinical services. The following are steps for managing a rape survivor. Health workers should conduct procedures as per the national protocol for rape management. Special considerations are needed when caring for children, men, and pregnant or elderly women. A Prepare the survivor • Before starting a physical examination, prepare the victim/survivor. Insensitive examinations may contribute to the emotional distress of the victim/survivor. • Introduce yourself and explain key procedures(e.g. pelvic exam). • Ask if she wants to have a specific support person present. • Obtain the consent of the victim/survivor or a parent if the victim is a minor. • Reassure the victim/survivor that she is in control of the pace of the examination andthat she has the right to refuse any aspect of the examination she does not wish to undergo. • Explain that the findings are confidential. • Consider the cultural norms, language, religion of the survivor-e.g some survivors may prefer same sex providers to examine them. • Ensure to have translation service B. Perform an Examination • At the time of physical examination, normalise any somatic symptoms of panic or anxiety,such as dizziness, shortness of breath, palpitations and choking sensations that are medically unexplained (i.e. without organic cause). This means explaining in simple words that these body sensations are common in people who are very scared after having gone through a very frightening experience, and that they are not due to disease or injury; rather, that they are part of experiencing strong emotions, and will go away over time when emotion becomes less. • Conduct the medical examination only with the survivor’s consent as per the national guideline. C. Provide compassionate and confidential treatment as follows • Treatment of life threatening complications and referral if appropriate • Treatment or presumptive treatment for STIs • Post-exposure prophylaxis for HIV (PEP), where appropriate. Consider providing a full dose. • Emergency contraception • Care of wounds • Supportive counselling

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• Discuss immediate safety issues and make a safety plan • Make referrals, with survivor’s consent, to other services such as social and emotional support, security, shelter, etc. • Ensure that survivors/victims of sexual violence have safe shelter; • Provide community-based psychological and social support for survivors/victims.) D. Collect minimum forensic evidence • Follow national protocols for forensic evidence collection • Counsel the survivor about taking evidence if she may eventually want to take the case to court. Ensure their that the information will only be released to the authorities with theirconsent. • For all cases of sexual violence a careful written recording should be kept of all findings of the medical examination that can support the survivor’s story, including the state of her clothes. The medical chart is part of the legal record and can be submitted as evidence if the survivor decides to bring the case to court. E. Referral Promote access to a network of resources to support patients’ various needs. Providers should be familiar with the established procedures for contacting other health services, police, legal aid and support organizations to address needs such as food, housing, shelter, Education and legal aid. Special considerations during crisis: • Do not permit individuals who state that they are friends, family, employers or associates of the violated people in crisis, or have accompanied them, to interpret for them. These persons may be part of the situation or may provide information to the violaters. • Create a safe space for the patient where care is individualized, supportive, non-judgmental and integrated • Describe to the patient the reasons for the exam, how the exam will be conducted, how the results will be communicated and who will have access to the results. • Conduct a comprehensive health assessment, because this clinical encounter may be the only contact the violated person has with the health care system (e.g., individual may return to the hostile situation, may be in the camp.This includes a thorough and systematic review of symptoms, a careful ‘head to toe’ exam and appropriate laboratory testing, recognizing that the persons present with conditions that are co-morbid with other complex and chronic disorders. • Focus the clinical encounter as much as possible on those medical problems identified by the patient. Questions that simply serve the curiosity of the provider are not appropriate. • Refer the client to a mental health provider to offer a detailed assessment necessary to identify specific mental health diagnoses and treatment needs. The impact of traumatic experiences on

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•

• •

patients’ symptoms, adherence to treatment and outcomes cannot be overstated. Try to ensure that there is a consistent, certain and secure communications mechanism to inform patients of the results of any testing and a convenient means for patients to receive ongoing care, including preventive care.e.g provision of Drugs for longer times like 3 months Confirm that patients are connected to resources and services to address multiple needs whenever possible, including food, shelter, legal advocacy, mental health support, education and which are all crucial to the health, safety and well-being of the individual Ensure that the camps are well lit and toilets are in a close proximity to avoid violation. For cases of sexual violence, a careful written record should be kept of all findings of the medical examination, including the state of the patient’s clothes. The medical chart may be part of the legal record and in most locations can be submitted as evidence in a court case

Checklist of supplies 1.Follow the medical Protocol The written medical protocol should be in a language that the provider can understand 2. Personnel Available • Trained (local) health care professionals (on call 24 hours a day) • A “same language” same sex health worker or companion in the room during examination 3. Furniture/Setting Available • Room (private, quiet, accessible, with access to a toilet or latrine) • Examination table • Light, preferably fixed (a torch may be threatening for children) • Access to an autoclave to sterilise equipment 4. Supplies Available • “Rape Kit” for collection of forensic evidence, including:  Speculum  Tape measure for measuring the size of bruises, lacerations, etc.  Paper bags for collection of evidence  Paper tape for sealing and labelling  Set of replacement clothes  Resuscitation equipment for anaphylactic reactions  Sterile medical instruments (kit) for repair of tears, and suture material  Needles, syringes  Cover (gown, cloth, sheet) to cover the survivor during the examination  Sanitary supplies (pads or local cloths) 5. Drugs Available

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• For treatment of STIs as per country protocol • PEP drugs, where appropriate • Emergency contraceptive pills and/or IUD • For pain relief (e.g. paracetamol) • Local anaesthetic for suturing • Antibiotics for wound care Duration: Preferably stock for 3 months 6. Administrative supplies Available • Medical chart with pictograms • Consent forms • Information pamphlets for post-rape care (for survivor) • Safe, locked filing space to keep confidential records

References and Recommended Reading 1. WHO/UNHCR. (2004). Clinical Management of Rape Survivors. Developing protocols for use with refugees and internally displaced persons, revised edition. Italy: WHO/UNHCR Publishers 2. Inter-agency Working Group on Reproductive Health in Refugee Situations (2004). Reproductive Health Service for Refugees and Internally Displaced Persons: Report of an Inter-agency Global Evaluation. Retrieved from http://gbvaor.net/wp-content/uploads/ sites/3/2012/10/Minimum-Initial-Service-Package-MISP-for-Reproductive-Health-in-CrisisSituations-A-Distance-Learning-Module.pdf 3. World Health Organization. (2000). Reproductive Health during Crisis and Displacement: A Guide for Program Managers: Geneva

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UNIT 5: CODE OF CONDUCT AS APPLIED IN HUMANITARIAN CRISIS SITUATIONS Purpose: Apply code of conduct in working with SGBV clients as well as displaced population in humanitarian situations

Expected Learning Outcomes • •

Define code of conduct Discuss Principles in humanitarian crisis

Lesson Plan Guide

Time: 15 minutes Time

Content

Training Objectives

5 mins

Definition of code of conduct

Define code of conduct

10 mins

Discuss Principles of

Discuss Principles in humanitarian crisis

code of conduct in humanitarian crisis

Training methodology and learning activities Brainstorming

Resource Materials National Guidelines, Flip chart paper, marker pens

Handouts

MISP manual and guide, Red Cross Disaster Management guide, WHO guide

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Facilitatorâ€™s notes

1. Defining codes of conduct The Code of Conduct, like most professional codes, is a mandatory tool that needs to be signed by all humanitarian actors. It lays down ten points of principle which all humanitarian actors should adhere to in their disaster response work, and goes on to describe the relationships that agencies working in disasters should seek with donor governments, host governments and the UN system. The code is self-policing. There is as yet no international association for disaster-response NGOs which possesses any authority to sanction its members. The Code of Conduct continues to be used by the International Federation to monitor its own standards of relief delivery and to encourage other agencies to set similar standards. It is hoped that humanitarian actors around the world will commit themselves publicly to the code by becoming a signatory and by abiding by its principles. Governments and donor organizations may want to use the code as a yardstick against which to measure the conduct of those agencies with which they work. Disaster-affected communities have a right to expect that those who assist them measure up to these standards The code promotes respect for fundamental human rights, social justice, human dignity and respect for the equal rights of women, men and children as well as accountability to the beneficiary. Implementing MISP activities appropriately means that each agency has a CoC in place and all humanitarian actors are committed to adhering to the guidelines and have been oriented to their responsibilities to prevent sexual abuse and exploitation. The CoC is not only for staff of international agencies. International agencies must also ensure that any staff hired from local organizations or people contracted from the local community or displaced population are oriented to the CoC. All humanitarian actors who have been oriented should sign their agencyâ€™s CoC. Good Practice One agency conducts an orientation on its CoC for its entire staff and then six weeks later provides a brief refresher session so that staff may share examples from their work of issues discussed during

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the orientation. This is a promising way to ensure that staff do understand the CoC and can assist the agency in making any necessary modifications to the local context. 2. Principles of code of conduct in humanitarian situations a) The humanitarian imperative comes first. b) Aid is given regardless of the race, creed or nationality of the recipients and without adverse distinction of any kind. Aid priorities are calculated on the basis of need alone. c) Aid will not be used to further a particular political or religious standpoint. d) Endeavor not to act as instruments of government foreign policy. e) Respect culture and custom. f) Ensure attempt to build disaster response on local capacities. g) Ways shall be found to involve programme beneficiaries in the management of relief aid. h) Relief aid must strive to reduce future vulnerabilities to disaster as well as meeting basic needs. i) Observe accountability to both those we seek to assist and those from whom we accept resources j) Provide information, publicity and advertizing activities, which recognize disaster victims as dignified human beings, not hopeless objects.

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UNIT 6: STRATEGIES FOR SECURIT Y AND PRE VENTION OF VIOLENCE IN HUMANITARIAN CRISIS SITUATIONS Purpose: Apply knowledge and strategies of protection for SGBV clients

Expected Learning Outcomes: • • •

Define protection Identify security systems to prevent violence Integrate health services put in place to manage cases during crisis time

Lesson Plan Guide:

Time: 30 minutes

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Time

Content

Training Objectives

5 mins

Protection

Define protection

15 mins

Security systems to prevent violence

Identify security systems to prevent violence

10 mins

Health services put in place to manage cases during crisis time

Describe integration of GBV services in existing health services

Training methodology and learning activities Brainstorming/ illustrated lecture

Resource Materials National Guidelines, Flip chart paper, marker pens

Group work discussion through videos/ case studies videos/ case studies

MISP, National Guidelines

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Facilitator’s notes 1. Definition of protection (Protection as rights-based) Protection is widely defined as a concept that encompasses all activities aimed at obtaining full respect for the rights of a person in accordance with the letter and the spirit of the relevant bodies of law, i.e. human rights law, international humanitarian law and refugee law., and involve either removing individuals or groups from a risk, which adversely affects their fundamental human rights and freedoms, threat, and humanitarian law; or intervening at the source of or situation of the individual in accordance to the-violence. The principle of humanity recognises human beings as much more than physical organisms in need of the means of survival. As such, humanitarian work extends beyond physical assistance to the protection of ahuman being in their fullness. This means a concern for a person’s safety,dignity and integrity as a human being. 2. Systems to prevent violence in place: • Identify the challenges faced by single women, adolescent boys and girls,older women and men, persons with disability and men excluded from work. • Involve the community in Putting in place measures to ensure their safety and security and to reduce the risk of violence. • In shelters and emergency centers: ensure that womenand girlswithout male companions and unaccompanied minors are provided with safe spaces separate from unrelated men; that access to latrines is well-lit and close to the camp; that the distribution of aid is safe for all who are eligible to obtain it; and that the risk of exploitation for internally displaced persons, in particular, women, children, aged and persons with disability to have their needs met is minimized. • Work with men and boys in advocacy and mitigation of SGBV 3. Health services put in place to manage cases: • Emergency Contraceptives (within 7days) • Post Exposure Prophylaxis (PEP) for HIV/AIDS (72hours) • Hepatitis B vaccination • Presumptive treatment for STIs • Tetanus toxoid and tetanus immunoglobulin

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References and Recommended Reading 1. Sphere Project (2004).Sphere Project Humanitarian Charter and Minimum Standards in Disaster Response (revised edition). Retrieved from www.sphereproject.org 2. Inter-agency Standing Committee Task Force on Gender and Humanitarian Assistance. (2005). Guidelines for Gender-based Violence Interventions in Humanitarian Settings: Focusing on prevention of and response to sexual violence in emergencies. Retrieved from www.rhrc.org/ pdf/GBV_guidelines_Eng_09_13_05.pdf 3. Hugo Slim Andrew Bonwick. Protection. An ALNAP guide for humanitarian agencies. Overseas Development Institute 2005

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Annexes Annex 1

Pre/Post Course Assessment

Annex 2

End of Course Evaluation

Annex 3

Observed Practice Guidelines

Annex 4

Checklists for Adults

Annex 5

Checklists for Children and Adolescents

Annex 6

Job Aides a) Clinical Site Preparation and Set up b) Forensic Specimen Evidence Collection c) Care Algorithm for Children and Adolescents d) Referral Algorithm for Children and Adolescents

Annex 7

PRC form

Annex 8

P 3 Form

Annex 9

Case studies

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Annex 1: Pre Course Assessment TRAINING ON MANAGEMENT OF SEXUAL AND GENDER BASED VIOLENCE PRE/POST COURSE ASSESSMENT Please read the following statements carefully tick appropriately if the statement is ‘true’ or ‘false’ in the space provided at the end of every statement. Do not consult. QUESTION

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A perpetrator of sexual violence should not be offered counselling

The PRC Form can only be filled by the Medical Officer

HIV PEP can be administered up to 120hrs following sexual violence

Urine may be analysed for epithelial cells

Survivors of sexual violence require to be vaccinated with Tetanus toxoid

Mandatory laboratory examination after sexual violence include pregnancy test

The community plays a role in prevention of sexual violence

A survivor who presents at the health facility 3 months after the incident does not require any kind of care

It is important to collect forensic evidence during physical examination (concurrently)

Good quality data is the responsibility is the facility in-charge

Documentation and data collection for SGBV services is the responsibility of HMIS officer

Rumours is one of the methods of monitoring quality

Men are particularly vulnerable to all forms of Gender based violence including sexual violence especially during armed conflict

The health care worker is not necessarily concerned with Reproductive health/family planning integrated services during humanitarian crisis

Minimum Initial Service Package activities are limited to reproductive health

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True

False

Physical violence is a type of Gender Based Violence

Informed consent should be obtained from all children aged 12-14 years

All children and adolescent survivors reporting SGBV should undergo a speculum examination

A provider should obtain history from the caregiver without the presence of the child.

Evidence collection in a post pubertal adolescent can be collected within less than 168hrs

Admission should be considered during the treatment of children and adolescents.

Both boys and girls should be examined on lithotomy position

All female children Tanners stage III and above should get Emergency Contraceptive pills

Most perpetrators of sexual violence are known to the survivor

Gender based violence means violence against women

Sex roles and gender roles are different

Sexual Offences Act was enacted because of common cases of men raping their wives

You cannot convict a person for an offence under Sexual Offences Act without doctor’s evidence

A HIV-positive person who knowingly engages in sex with his wife, commits an offence under the Sexual Offences Act

In the offences of “defilement”, “rape”, “indecent act” and “sexual assault”penetration is a fundamental ingredient

Having sex with your first cousin, amounts to an offence of “incest”

Shock, irritability, sadness, anxiety are some of the psychological effects displayed by a SGBV survivor.

Counselling intervention is aimed at directing and advising clients on what to do with their personal problems.

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Psychological debriefing reduces chances of developing Post Traumatic Stress Disorder (PTSD).

Male survivors have similar physical and psychological responses to sexual violence as their female counterpart.

Administering alcohol to your friend with intent of making them drunk so as to have sex with them is a crime

Forensic medical examination is meant for acquiring medical treatment and evidence for justice

Without DNA related evidence, a suspect can hardly be convicted

Locard’s principle is rarely applied in crime investigation

High Vaginal Swab is necessary as evidential material in all sexual offences

Where there is evidence of “forceful penetration” to an adult, it is right for a doctor to make an opinion that the offence of “rape” was committed

Forensic evidence links or delinks the perpetrator to the sexual violence crime

Pubic hair ,grass and blood on survivors body are forensic specimens

Age and gender are vulnerabilities that predispose women and girls to exploitation and abuse.

A suspected perpetrator of sexual violence does not deserve health care services

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Annex 2: End of Course Evaluation Name (optional): Too easy 1. How easy or difficult was this workshop for you?

Too difficult

Not at all 2. To what extent, before coming to the workshop, were you informed about the purposes of the workshop?

3. Was the content of the workshop consistent with the stated objectives?

Not at all

4. To what extent do you expect this workshop will make a difference in the way you do your job?

None

5. Overall how would you rate the usefulness of this workshop?

Not Useful Useful

1 6. To what extent did the workshop provide the following: a. Applicable theory

Completely 3

Substantial 2

Very 3

Not at all Completely 1

7. Did the workshop meet your expectations?

1 2 Not at all Completely

8. How would you rate the following aspects of the workshop? • Workshop content

1 2 Very poor Excellent 1 2

b. Practical examples c. Time for discussion

•

Organization of workshop materials

•

Organization of the workshop

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Please rate the following aspects:

Very poor

Excellent

a. Workshop venue

n/a

b. Handouts

n/a

c. Demonstrations

n/a

d. Group discussions

n/a

10.

Comments (on the facility, rooms, materials, approach to workshop, etc.):

11.

If you were given the task of redesigning the workshop, what would you change?

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12.

Any additional comments or suggestions?

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Annex 3: Observed Practice Guidelines OBSERVED PRACTICE GUIDELINES FOR SGBV PRACTICUM Rationale Observed practice sessions will be conducted post training in order to establish provider competency in delivering various components of the clinical management for child and adolescent survivors of sexual violence. Observed practice sessions provide an opportunity for the trainee to receive immediate feedback from a trainer, mentor or supervisor on how to improve on management of survivors. The tools to be used during these sessions with real clients/patients are meant to support attainment of competency in SGBV services. Observed practice is intended as a continuation of the learning process and not fault finding. When is done? Observed practice will be undertaken at the end of the training, but before the provider is certified by the training institution as competent. Number of sessions The number of sessions recommended to attain mastery of the skills is a minimum of three. Where Efforts will be made by trainers to have the observed practice session carried out in high volume health facilities providing SGBV services to enable all trainees attain competency before being certified to provide the service in their duty stations. By whom? Sessions will be observed by SGBV Trainer of Trainees (ToT’s) from National and/or County level who have also undergone the same training. The ToTs will be sensitized on the use of the different set of tools The following will be adhered to by the observer to during the sessions: 1. Consent will be obtained from survivors or care givers once they are informed that this is part of the training being undertaken by the providers. Sessions will only be observed for where survivors or care givers give consent. 2. Maintain confidentiality by not interfering with the survivor- provider relationship, except in situations where the safety of the child is at risk 3. The ToTs will duly fill in all sections of the tools in use 4. Provide immediate feedback to provider on what went well during the session and areas of improvement Tools to be used:

• Physical examination checklist • Forensic evidence collection checklist • Counselling checklist • Psychological assessment checklists

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Conclusion: Upon successful completion of the observed sessions and satisfactory performance, providers will receive certification from the Ministry of Health. Providers who display unsatisfactory performance will be required to attend further mentorship sessions on specific aspects of care, until they attain mastery before they are certified.

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Annex 4: Checklists for Adults

Checklist for Clinical Management of Adult Survivors of Sexual Violence INSTRUCTIONS Place a √ if in the appropriate box as per the instructions below; place N/O if not observed Satisfactory: performs the step or task according to the standard procedure or guidelines. Scores 1 Unsatisfactory: Unable to perform the task or task according to the standard procedure or guidelines. Scores 0 Not observed: Step or task or skill not performed by participant during observation by trainer. Scores 0 Participant’s Name________________________ Date_____________________

Competency area Climate setting

Task (step by step)

Satisfactory

Introduced self to the survivor and caregiver and explains his/her role in management of the survivor. Allowed the survivor to introduce him/ herself, where he/she comes from Provided appropriate information to allow giving of informed consent Obtained informed consent from survivor Provided information on available services Reassured survivor about safety and explained procedure of service Assured the survivor/caregiver on confidentiality throughout the clinical management processes

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Unsatisfactory

Not Observed

Obtained appropriate history: Demographic information(name, age, sex, marital status) Complaint presented (nature of assault-oral, vaginal, anal or other)) place of assault Time of assault Number of perpetrators Date of reporting and examination Medical and surgical history Contact information (phone/physical residential address Administrative location where assault occurred Reported to another health facility

History taking

Took the vital signs-BP, PR,RR, records the height and weight of the adult and documents in the PRC forms Gave the survivor the option of choosing if he/she is comfortable with the opposite gender attending to him/her. Enquired if survivor and/or care giver had any questions on procedures to be undertaken Enquired survivor if s/he wanted to have a specific person to be present to provide support during session Documented the following information in the PRC form: •

Full names of survivor and gender

•

Presenting complaint

•

Time and place of assault

• Past medical/ surgical history (Existing health problems, allergies, use of medication, vaccination and HIV status) • Family history(size, physical residence) and safety of survivor Obtained gynaecological history (where applicable)

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Explained the examination procedure to the survivor and gave them all the information needed to make an informed decision Conducted a head to toe exam

Head to Toe Physical Examination

Took note of the survivor’s mental and emotional state (withdrawn, crying, calm etc.) Systematically examined the survivor’s body, starting with the upper half of the body, then lower half while covering the survivor with a gown Assessed for injuries Documented injuries Examined external genitalia(both male and female)for injuries Collected clothes worn by survivor during the assault as evidence Recorded all findings carefully in the PRC form and body maps to include type, size, colour and form of any bruises, lacerations, etc. Explained the positions that would be used to examine the Genito-anal organs. •

Genito-Anal Examination for Female adult survivors

Lithotomy

• Anal position Explained and showed survivors instruments or equipment(s) to be used for examination and their purpose Systematically inspected the mons pubis, inside of the thighs, perineum, anus, labia majora and minora, clitoris, urethra, introitus and hymen Used a speculum (where appropriate) and under anaesthesia where applicable Used sterile gloves Observed for genital injury, such as bruises, scratches, abrasions, tears Observed for any sign of infection, such as ulcers, vaginal discharge etc. Collected evidence during the examination •

High Vaginal Swab

•

Oral swab

•

Anal swab

• Swab any human bite. Documented findings of examination and samples collected in the PRC form Properly labelled the specimen and forwarded it to the lab for further investigation.

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The provider explained the positions that will be used to examine the Genito-anal organs.

Genital-Anal Examination for Male adult survivors

• Knee chest position Explained and showed survivors instruments or equipment(s) to be used for examination and their purpose Observed for injuries to the skin that connects the foreskin to the penis Observed for discharge at the urethral meatus (tip of penis) Checked out for ano-genital injury, such as bruises, scratches, abrasions, tears Collected evidence during the examination •

Oral swab

•

Anal swab

• Swab any human bite. Documented findings of examination and samples collected in the PRC form Properly labelled the specimen and forwarded it to the lab for further investigation. The provider explained to the survivor the need of admission (where applicable). Explained treatment available in a language understood by survivors Dressed any existing wounds Provided treatment for tetanus prevention according to the recommended guidelines for adults, where applicable Provided PEP stat dose (where eligible)according to the recommended guidelines for adults Explained procedure for PEP continuation post HIV test (implication of a positive or negative result)

Prescribing Treatment

Explained PEP side effects and adherence Provided pregnancy prevention or management services according to the recommended guidelines for adults, where applicable Determined eligibility for EC and testing for pregnancy Referred survivor for antenatal care in case pregnancy test is positive Provided treatment for STI management according to the recommended guidelines for adults Provided treatment for Hepatitis B prevention according to the recommended guidelines for adult survivors Discussed follow up plan with survivor Referred appropriately (lab, pharmacy, counselling, ,legal aid, shelter, etc.)

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Completed all sections of the PRC form and appropriately Filled in P3 form Documentation

Filled SGBV register Filled lab register Filled informed consent form Discussed referral options Referred appropriately Referred to shelter/safe house Referred for legal aid

Referral and linkages

Referred to CBO/NGO for continued psychosocial support Referred to police Referred to Lab Referred for counselling services Referred to pharmacy Referred to for maternity services Referred to paediatric or adolescent clinic

Total Score

Evaluatorâ€™s Signature__________________ Date _______________________________

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Checklists for General Counselling and Communication Skills INSTRUCTIONS Place a √ if in the appropriate box as per the instructions below; place N/O if not observed Satisfactory: performs the step or task according to the standard procedure or guidelines. Scores 1 Unsatisfactory: Unable to perform the task or task according to the standard procedure or guidelines. Scores 0 Not observed: Step or task or skill not performed by participant during observation by trainer. Scores 0

Participant’s Name: __________________________Date_____________________

Task(step by step)

Introduction

Privacy and safety

Confidentiality

welcomed client by introducing self and explaining his/her role Allowed for client to introduce themselves Introduced the client to the room/setting. Created rapport by using a language understood by the client. Stated session outline and approximate time to be spent. Used a door tag indicating “session in progress” and

Satisfactory

Unsatisfactory

Not observed

curtains Discussed with client about confidentiality. Discussed about shared confidentiality. Discussed about need for disclosure

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Used open ended questions to allow client tell his/her story Utilized appropriate communication skills such as listening and questioning with the Communication survivors

skills

Communicated effectively using verbal and nonverbal communication modes Used open ended questioning. Maintained eye contact and right posture Enabled client make decisions on the issue at hand Engaged the client in a sensitivte manner, by use of attending skills.

Exploration of the problem

Total Score

Used observation skills to identify the emerging emotions and feelings during the session Listened actively, reflected and gave back appropriate feedback in a manner easily understood by the client Reassured of the client safety.

Evaluatorâ€™s Signature__________________ Date _______________________________

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Checklist for Collection of Forensic Evidence for Adults INSTRUCTIONS Place a âˆš if in the appropriate box as per the instructions below; place N/O if not observed Satisfactory: performs the step or task according to the standard procedure or guidelines. Scores 1 Unsatisfactory: Unable to perform the task or task according to the standard procedure or guidelines. Scores 0 Not observed: Step or task or skill not performed by participant during observation by trainer. Scores 0 Participantâ€™s Name: __________________________Date_____________________ Competency area

Climate setting

General preparations

Task(step by step)

Satisfactory

Not satisfactory

Not observed

Introduced self and explained procedure Obtained informed consent from care giver Ensured privacy during evidence retrieval Prepared client for the procedure by appropriate positioning Prepared self by wearing sterile non-powdered gloves Collected adequate specimen immediately using a standardize kit Collected oral specimens Collected anal evidence(where necessary) Collected genital evidence

Specimen collection

Air dried specimen (where applicable) Obtained survivor clothes and undergarments and passed them to police Transferred all evidence collected to the laboratory Documented evidence collected in the PRC form

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Name of patient Labelled specimen appropriately

Packaging

Documentation

Type of specimen Date and time collected Health care providers full name Person receiving specimen and time Ensured proper package of specimen Labelled and sealed each package Recorded the following information in the lab rape register and PRC form • Name • Registration number • Date • Age • Sex Investigations done, results and persons handling the specimen

Maintain the chain of custody

Kept all documentation in a lockable cupboard accessible only to authorised personnel for confidentiality Ensured proper storage of evidence Maintained a proper and correct chain of evidence

Total Score Evaluator’s Signature__________________ Date _______________________________

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DATA MANAGEMENT ASSESSMENT CHECKLIST INSTRUCTIONS Place a √ if in the appropriate box as per the instructions below; place N/O if not observed Satisfactory: performs the step or task according to the standard procedure or guidelines. Scores 1 Unsatisfactory: Unable to perform the task or task according to the standard procedure or guidelines. Scores 0 Not observed: Step or task or skill not performed by participant during observation by trainer. Scores 0 Participant’s Name: __________________________Date_____________________

Competency area

Task(step by step)

Satisfactory

Not satisfactory

Not observed

Record all the patients of sexual violence to the sexual violence register Record all the data elements in the sexual violence register correctly as per the given instructions Recording

Fill the PRC form for all clients of sexual violence Record all the entries in the PRC form correctly Generate the daily activities from the register and fill in the Sexual Violence Monthly summary Aggregates and compiles the sexual violence monthly summary

Reporting

Submits the sexual violence monthly summary to the sub-county level for uploading to the DHIS2 Upload the sexual monthly violence monthly summary to the DHIS2 Ensures proper storage of data

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Examines the data to ascertain quality Analysis

Transforms the data into information for consumption at the facility level Presents the information in graphical form and displays as appropriate

Total Score

Evaluatorâ€™s Name _________________Signature__________________ Date ____________

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Annex 5: Checklists for Children

Checklist for Clinical Management of Child and Adolescent Survivors of Sexual Violence INSTRUCTIONS Place a √ if in the appropriate box as per the instructions below; place N/O if not observed Satisfactory: performs the step or task according to the standard procedure or guidelines. Scores 1 Unsatisfactory: Unable to perform the task or task according to the standard procedure or guidelines. Scores 0 Not observed: Step or task or skill not performed by participant during observation by trainer. Scores 0 Participant’s Name________________________ Date_____________________ Competency area Climate setting

Task (step by step)

Satisfactory

Unsatisfactory

Not Observed

Introduced self to the survivor and caregiver and explains his/her role in management of the survivor. Allowed the survivor to introduce him/ herself, how he/she is, where he/she goes to school, where he/she comes fromProvided appropriate information to allow giving of informed consent Obtained informed consent from survivor Obtained assent from children(where appropriate) Provided information on available services Reassured survivor about safety and explains procedure of service

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Assured the survivor/caregiver on confidentiality throughout the clinical management processes Discussed disclosure with child/ adolescent/care giver Obtained appropriate history: Demographic information(name, age, sex, marital status) Complaint presented (nature of assaultoral, vaginal, anal or other)) place of assault Time of assault Number of perpetrators Date of reporting and examination Medical and surgical history Contact information (phone/physical residential address Administrative location where assault occurred Reported to another health facility

History taking

Took the vital signs-BP, PR,RR, records the height and weight of the child and documents in the PRC forms Gave the survivor the option of choosing if he/she is comfortable with the opposite gender attending to him/her. Enquired if survivor and/or care giver had any questions on procedures to be undertaken Enquired survivor if s/he wanted to have a specific person to be present to provide support during session Documented the following information in the PRC form:

â€˘ Full names of survivor and gender

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• •

Presenting complaint Time and place of assault

• Past medical/ surgical history( Existing health problems, allergies, use of medication, vaccination and HIV status) • Family history(size, physical residence) and safety of survivor • Developmental milestones and history of immunizationo

Level of education

Immunization received

Obtained gynaecological history (where applicable) Explained the examination procedure to the child/adolescent and gave them all the information needed to make an informed decision, using child-friendly approaches Conducted a head to toe exam Took note of the survivor’s mental and emotional state (withdrawn, crying, calm etc.)

Head to Toe Physical Examination

Established developmental stage of the child/adolescent(Tanner stage) Systematically examined the patient’s body, starting with the upper half of the body, then lower half while covering the patient with a gown Assessed for injuries Documented injuries Examined external genitalia(both male and female)for injuries of disease progression Collected clothes worn by survivor during the assault as evidence

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Recorded all findings carefully in the PRC form and body maps to include type, size, colour and form of any bruises, lacerations, etc. Explained the positions that would be used to examine the Genito-anal organs. •

Lithotomy

•

Anal position

Explained and showed survivors instruments or equipment(s) to be used for examination and their purpose

Systematically inspected the mons pubis, inside of the thighs, perineum, anus, labia majora and minora, clitoris, urethra, introitus and hymen

Genito-Anal Examination for Girls

Used a speculum (where appropriate) and under anaesthesia Used sterile gloves Observed for genital injury, such as bruises, scratches, abrasions, tears Observed for any sign of infection, such as ulcers, vaginal discharge etc Collected evidence during the examination •

High Vaginal Swab

•

Oral swab

•

Anal swab

•

Swab any human bite.

Documented findings of examination and samples collected in the PRC form Properly labelled the specimen and forwarded it to the lab for further investigation.

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The provider explained the positions that will be used to examine the Genito-anal organs. •

Knee chest position

•

Dorsal spine lithotomy

Explained and showed survivors instruments or equipment(s) to be used for examination and their purpose

Genital-Anal Examination for Boys

Observed for injuries to the skin that connects the foreskin to the penis Observed for discharge at the urethral meatus (tip of penis) Checked out for ano-genital injury, such as bruises, scratches, abrasions, tears Collected evidence during the examination •

Oral swab

•

Anal swab

•

Swab any human bite.

Documented findings of examination and samples collected in the PRC form Properly labelled the specimen and forwarded it to the lab for further investigation. The provider explained to the survivor the need of admission (where applicable).

Prescribing Treatment

Explained treatment available in a language understood by child/ adolescent survivors and their care givers Dressed any existing wounds Provided treatment for tetanus prevention according to the recommended guidelines for children

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Provided PEP stat dose (where eligible) according to the recommended guidelines for children Explained procedure for PEP continuation post HIV test (implication of a positive or negative result) Explained PEP side effects and adherence Provided pregnancy prevention or management services according to the recommended guidelines for children

Used tanner staging to determine eligibility for EC and testing for pregnancy Referred child/adolescent for antenatal care incase pregnancy test is positive Provided treatment for STI management according to the recommended guidelines for children Provided treatment for Hepatitis B prevention according to the recommended guidelines for children Discussed care follow up plan with survivor and care giver Referred appropriately (lab, pharmacy, counselling, ,legal aid, shelter, etc.) Completed all sections of the PRC form and appropriately Documentation

Filled in P3 form Filled SGBV register Filled lab register Filled informed consent form

Referral and linkages

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Discussed referral options Referred appropriately

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Referred to shelter/safe house Referred for legal aid Referred to CBO/NGO for continued psychosocial support Referred to police Referred to Lab Referred for counselling services Referred to pharmacy Referred to for maternity services Referred to paediatric or adolescent clinic

Total Score Evaluatorâ€™s Signature__________________ Date _______________________________

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Checklist for General Counselling and Communication Skills for Children and Adolescents INSTRUCTIONS Place a √ if in the appropriate box as per the instructions below; place N/O if not observed Satisfactory: performs the step or task according to the standard procedure or guidelines. Scores 1 Unsatisfactory: Unable to perform the task or task according to the standard procedure or guidelines. Scores 0 Not observed: Step or task or skill not performed by participant during observation by trainer. Scores 0 Participant’s Name: __________________________Date_____________________ Task(step by step)

Satisfactory

welcomed child/adolescent and care giver by introducing self and explaining his/her role

Allowed for child/adolescent and care giver to introduce themselves Introduction Introduced the child/adolescent to the room/setting. Created rapport by using a language understood by survivor and caregiver

Privacy and safety

Used a door tag indicating “session in progress” Used curtains for privacy

Confidentiality

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Discussed with survivor and caregiver about confidentiality. Discussed about shared confidentiality.

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Unsatisfactory

Not observed

Discussed about need for disclosure Used open ended questions to allow survivors/care giver tell his/ her story

Communication skills

Utilized appropriate communication skills such as listening and questioning depending with the survivors developmental stage. Communicated effectively (verbal communication, play therapy, drawing etc.) Used open ended questioning Maintained eye contact and right posture Enabled survivor/care giver make decisions on the issue at hand Engaged the child and the caregiver in a sensitive manner, by use of attending skills.

Exploration of the problem

Used observation skills to identify the emerging emotions and feelings during the session

Listened actively, reflected and gave back appropriate feedback in a manner easily understood by the caregiver and the survivor.

Total Score

Reassured of the child safety.

Evaluatorâ€™s Signature__________________ Date _______________________________

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Checklists for General Psychological Examination for Children and Adolescents INSTRUCTIONS Place a √ if in the appropriate box as per the instructions below; place N/O if not observed Satisfactory: performs the step or task according to the standard procedure or guidelines. Scores 1 Unsatisfactory: Unable to perform the task or task according to the standard procedure or guidelines. Scores 0 Not observed: Step or task or skill not performed by participant during observation by trainer. Scores 0 Participant’s Name: __________________________Date_____________________

Competency area

Task(step by step)

General appearance and behaviour

Observed the child/ adolescent’s appearance and behaviour.

Satisfactory

Provider establishes survivors mental outlook and feelings Undertook mental assessment of survivor

Reaction post assault

Assessed immediate and long term effects of abuse on survivor Discussed common reactions to trauma with care giver or survivor Addressed PTSD Discussed possible trauma related symptoms

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Unsatisfactory

Not observed

Established safety of survivor Speech

Assessed the child/ adolescent speech pattern

Perception

Identified any disturbance of perception by probing on the five senses such as smell, taste, hearing, and taste

Thought content

Identified thoughts the child/ adolescent was harbouring such as hopelessness, helplessness and self-harm.

Explored the cognitive function of the child by asking appropriate questions of the recent happenings such as birth day of close family member Cognitive function

Established level of concentration during session Explored the childâ€™/ adolescentâ€™s understanding of complaint presented

Non-threatening session

Utilized child friendly approaches during the session -Play therapy, art

Total Score

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Checklist for Collection of Forensic Evidence for Children and Adolescents INSTRUCTIONS Place a âˆš if in the appropriate box as per the instructions below; place N/O if not observed Satisfactory: performs the step or task according to the standard procedure or guidelines. Scores 1 Unsatisfactory: Unable to perform the task or task according to the standard procedure or guidelines. Scores 0 Not observed: Step or task or skill not performed by participant during observation by trainer. Scores 0 Participantâ€™s Name: __________________________Date_____________________

Competency area

Task(step by step)

Satisfactory

Introduced self and explained procedure Climate setting

Obtained informed consent from care giver Obtained assent from child/adolescent Ensured privacy during evidence retrieval

General preparations

Prepared client for the procedure by appropriate positioning Prepared self by wearing sterile nonpowdered gloves Collected adequate specimen immediately using a standardize kit

Specimen collection

Collected oral specimens Collected anal evidence(where necessary)

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Not satisfactory

Not observed

Collected genital evidence Air dried specimen (where applicable) Obtained survivor clothes and undergarments and passed them to police Transferred all evidence collected to the laboratory Documented evidence collected in the PRC form Labelled specimen appropriately

Name of patient Type of specimen Date and time collected Health care providers full name Person receiving specimen and time Ensured proper package of specimen

Packaging Labelled and sealed each package

Recorded the following information in the lab rape register and PRC form

Documentation

•

Name

•

Registration number

•

Date

•

Age

•

Sex

Investigations done, results and persons handling the specimen Maintain the chain of custody

Kept all documentation in a lockable cupboard accessible only to authorised personnel for confidentiality

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Ensured proper storage of evidence

Maintained a proper and correct chain of evidence

Total Score Evaluatorâ€™s Signature__________________ Date _______________________________

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Annex 6: Job Aides CLINICAL SITE PREPARATION AND SET-UP This job aid can be used as a checklist to assist health facilities in determining their readiness towards effective response to medical management of children and adolescents who have been sexually violated Available OVERALL SITE PREAPARATION

Yes

Services available for 24 hours to all child and adolescent survivors ☐

☐

Providers are educated and trained on child and adolescent SV and exploitation

☐

SGBV national policies and protocols ( guidelines, PRC form,P3 form, PRC registers, Trauma counselling forms and Informed consent forms) and job aids available

☐

A secure medical record storage system in place

☐

SV data tracking system in use

☐

Optimal range of services required by child and adolescent survivors of SV available

☐

An appropriate location for private examination identified

☐

Identify appropriate location for private examination

☐

Resources to create an aesthetically child friendly environment available

☐

Proper lighting, soap and water and toilet facilities available

☐

A staffing plan that encourages availability of trained health care professional, 24hrs per day developed

☐

Plan for availability of a chaperone/companion to be present in the examination room during medical examination and evaluation, in place

☐

Examination table for the clinician and 3 seats.

☐

Powder free non-sterile examination gloves

☐

Examination couch that allows for lithotomy position

☐

Specula- for post pubertal children only

☐

Examination Site Set Up

Equipment needed

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Culture supplies

☐

Lubricants

☐

Evidence collection kit

☐

Forensic supplies

☐

Sharps disposal container

☐

Water for injection, normal saline

☐

Patients gowns , bed linen/sheets

☐

Basic medical supplies for injury treatment- sutures, bandages, splints, scissors

☐

Patient comfort suppliers- sanitary towels, food, drinks, toiletries and any extra clothing/under garments

☐

Resuscitation equipment’s

☐

Digital camera and related supplies such as memory cards, batteries, flash and a ruler

☐

Hand held magnifying glass

☐

Access to autoclave for sterilizing equipment’s if necessary

☐

Laboratory facilities/testing access

☐

Weighing scale, height chart and tape measure

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FORENSIC SPECIMEN EVIDENCE COLLECTION JOB AID*1 SITE

MATERIAL

EQUIPMENT

SAMPLING INSTRUCTIONS

Anus (rectum)

Semen

Cotton swabs and microscope slides

Use swab and slides to collect and plate material; lubricate instruments with water, not lubricant.

Lubricant

Cotton swab

Dry swab after collection.

Drugs

Appropriate tube

Collect 10 ml of venous blood.

DNA (victim

Appropriate tube

Collect 10 ml of blood.

Clothing

Adherent foreign(e.g. semen, blood, hair, fibres)

Paper bags

Clothing should be placed in a paper bag(s). Collect paper sheet or drop cloth. Wet items should be bagged separately.

Genitalia

Semen

Cotton swabs and microscope slide

Use separate swabs and slides to collect and plate material collected from the external genitalia, vaginal vault and cervix; lubricate speculum with water not lubricant or collect a blind vaginal swab

Hair

Comparison to hair found at scene

Sterile container Cut approximately 20 hairs and place hair in sterile container.

Mouth

Semen

Cotton swabs, sterile container(for oral washings)

DNA (victim)

Cotton swab

Nails

Skin, blood ,fibres, etc. (from assailant)

Sterile toothpick or similar or nail scissors/ clippers

Sanitary pads/ tampons

Foreign material(e.g. semen, blood, hair)

Sterile container Collect if used during or after vaginal or oral penetration.

Blood

Swab multiple sites in mouth with one or more swabs. To obtain a sample of oral washings, rinse mouth with or dental flossing 10 ml water and collect in sterile container. Use the toothpick to collect material from under the nails or the nail(s) can be cut and the clippings collected in a sterile container

*Adapted from WHO guidelines on medico-legal care for victims of sexual violence

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Skin

Semen

Cotton swab

Swab sites where semen may be present. 1

Saliva (e.g. at sites of kissing, biting or

Cotton swab

Dry swab after collection.

Foreign material(e.g. vegetation, matted hair or foreign hairs)

Swab or tweezers

Place material in sterile container (e.g. envelope, bottle).

Drugs

Sterile container Collect 100 ml of urine

licking),blood

Urine.

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CARE ALGORITHM FOR CHILD AND ADOLESCENT SURVIVORS OF SEXUAL VIOLENCE Child and adolescent

POLICE

Obtain informed Consent Obtain history Undertake physical exam Psychological exam Health facility

Clinical Investigation Initial treatment

HIV counselling and testing

Pregnancy testing

Documentation (PRC form, P3 forms, Registers)

If negative offer PEP & retest after 12weeks If positive Refer to CCC

Offer EC when appropriate

If pregnant refer to ANC clinic

R e f e r r a l

For all patients: Immediate counselling if suicidal Trauma counselling

Follow up for medical care /treatment

Collection of forensic evidence

< 168hours since last known contact

Collect all the relevant forensic evidence

Referral to: >168hours since last known contact

• Police • Safe house placement/rehabili tation

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Referral Algorithm for Children and Adolescents Social welfare and child protection

• Most children are abused by someone known to them and their families • These services provide safety planning

The short and long term effects of sexual violence can be minimized through ongoing counselling

Psychosocial services

• Children who are initiated on PEP require follow up testing and side effect management • Children who test HIV positive after SV require ongoing care

HIV services Child and Caregiver

NGOS,FBOS,C BOs

• Offer shelter to survivors • Offer legal aid • Provide community based follow up care • Offer education and training opportunities for providers • Undertake community advocacy

Police Investigates cases of child sexual violence Other health facilities

Provide further medical care (Surgical, Gynaecological ) and psychological support

Health facilities should provide appropriate referral of child and adolescent survivors of sexual violence

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Annex 7: PRC Form

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Annex 8: P 3 Form

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Annex 9: Case Studies Case 1 Irene comes to the SGBV centre with a complaint of having been abducted and taken to a nearby house by three men who were waiting at the bus stop when she alighted at 7pm in the evening. They raped her in turns for 2 hours. They later left her alone. She was rescued by some neighbours who heard her scream. They took her to hospital where she was given emergency medical care and post rape care. After 2 weeks, as she came for review, she complained of insomnia, irritability, nightmares and suicidal thoughts,. She was reluctant to take her PEP and she was withdrawn. What are the main psychological problems and how would you manage this client?

Case 2 A 5 year old child was brought by an auntie with history of restlessness and she was quiet more than usual, performing poorly in nursery and being withdrawn for 1 month. She was well until her mother passed away 3 months ago. She was left with an uncle and house help. Questions: What are your immediate concerns about the child? How will you perform psychological assessment? What types of interventions may you do as part of the treatment? Case 3 A young woman calls the clinic emergency phone number and reports that something terrible has happened to her. She identifies herself as Shiro and says that she is 24years old and needs help. The ambulance is released to go and pick her up and she is brought to the clinic at around 10. 30 am. On arriving at the clinic, she is shaking and looks very anxious and afraid. When seen by the counselor she reports that she is a newspaper vender and that she was out very early today morning at 5.15am, her normal routine to sell newspapers. She says that; as she walking along the street in town looking for customers, three men called her. She didn’t know them; they looked drunk so she ignored them. They quicken their steps and approach her. They then pull her around and say that they are not to be ignored. She says that they were very strong men, as old as his father and that she felt powerless and couldn’t fight them. They then drag her to a nearby vacant unfinished building where they threaten to kill her if she screams. She says that they had a pistol and a knife so she kept silent and obeyed their orders. She says that they then forced her to perform oral sex on two of them, and when they got an erection each of them took turns to sexually violate her penal vaginally and one of them violated her penal anally. She says that they then left her bleeding and in severe pain and took off. On Examination

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o She was sad and was crying. Her blue dress was torn at the back and had stains of fresh blood on it. o Her vital signs were as follows: BP -130/90 PULSE -125 TEMP-37 RR-20 o She had fresh bruises on her left arm around her elbow joint. She also had few bruises around her left thigh. On Genital Exam o She has normal female external genitalia. i.e. her clitoris, her labia majora and labia minora are normal o She has fresh superficial lacerations at the vaginal fourchette, o Her hymen is red; it has fresh tears at the 3, 7 and 9 oâ€™clock position, there is some minimal bleeding on touching. o Her anal opening is normal; there are no visible fresh bruises or tears; however her anal sphincter muscle tone is lose. Questions 1. You are a male healthcare provider and Shiro has presented to your clinic. What are the important considerations before you attend to her? 2. What forensic evidence will you collect from this client? 3. How will you collect the forensic evidence? 4. Fill in a PRC Form and SGBV register for this survivor and discuss the management.

Case 4 Bernard an 11year old boy is brought to your clinic by his mother on an early morning on Saturday , the mother reports that she suspected that something bad happened to her son last night; as she noticed him walking in a an uncomfortable way and that he reported to be having pains in his anus. She says that on asking the boy, he insists that nothing happened to him. When the counselor talked to the boy he confessed that last evening he was late to go back home and he remembered that his mother had warned him that if he ever goes back home late in the evening she will severely punish him. So he opted to sleep out. He had nowhere to go, so he went to a nearby market in the shunts and found a spot to sleep. He says that he was woken up at around midnight by a man he has seen around in their neighbourhood. This man told him not to scream or else he will hurt him. He then pulled down his pants and made him bend over on his knees and hands. He said that he then felt him inserting something in his anal opening. He says that it was very painful and that he felt some wetness on himself when he was done.

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The boy reports that he has not showered. Questions 1. Describe your intervention with this patient

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Ministry of Health Reproductive Health and Maternal Services Unit Second Edition, September, 2015

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