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Peace Corps

Technical Guideline 540


A RESOURCE GUIDE FOR THE CLINICAL MANAGEMENT
OF SEXUAL VIOLENCE
TABLE OF CONTENTS
1. Purpose
2. Background
Classifications, Resources, Statistics
Peace Corps Commitment to Sexual Assault Victims
3. PCMO Responsibilities
4. PCMO Administrative Preparations to Manage Sexually-Assaulted Volunteers
Training
Host Country Law and Resources Regarding Sexual Assault
Ordering and Maintaining Sexual Assault Kits (SAK)
Sexual Assault Medical Records
5. Managing the Initial Report of a Rape
Initial Assessment
Preparing the Volunteer for a Sexual Assault Examination by the PCMO
6. History Taking and Clinical Examination
Taking the History
Performing and Documenting the Clinical Exam
7. Standing Order Sets
Prevention of Pregnancy
Prevention of Sexually-Transmitted Infections
Drug Facilitated Sexual Assault (DFSA)
8. Discharge Information
Discharge Information and Instructions for Volunteers
127s for Close of Service
Sexual Assault Discharge Summary
9. Registered Nurse PCMO Privileges for Sexual Assault
10. Addendums
a. Preparations List
b. Guidelines for Responding to Rape and Sexual Assault Algorithm
c. Sexual Assault Exam Form
d. Sexual Assault Clinical Exam Form for Females
e. Sexual Assault Clinical Exam Form for Males
f. Strangulation Addendum
g. Instructions for Completing the Examination Forms
h. Standing Order Set and Medical Treatment Plan
i. Discharge Information and Instructions for Volunteers
j. Summary Chronologic Note Outline
k. SAFE Consultant Information Form

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TG 540
Management of Sexual Violence

1. PURPOSE
To establish procedures to provide trauma informed clinical care to Volunteers who have been
sexually assaulted. For guidance in meeting the emotional needs of Volunteers who have been
sexually assaulted, refer to Medical Technical Guideline 545 Sexual Assault: Counseling.

2. BACKGROUND
Sexual assault is a traumatic event that can be physically and psychologically devastating. Peace
Corps Medical Officers (PCMOs) are designated staff at post, and are generally first responders
to Volunteers who are victims of sexual assault. PCMOs are part of a Peace Corps system that is
prepared to respond immediately, effectively, and compassionately to victims. The clinical
components and approaches to examining and providing care to victims of sexual assault outlined
in this Technical Guideline are based on A National Protocol for Sexual Assault Medical Forensic
Examinations: Adults/Adolescents (DOJOVAW, 2004), Clinical Management of Rape Survivors
(WHO, 2005), Sexual Assault Nurse Examiner protocols, and Peace Corps Restricted Reporting
policy.

A. Classifications and Definitions

Peace Corps Sexual Assault Classifications according to CIRG, 2013:

Rape: The penetration, no matter how slight, of the vagina or anus with any body part or object,
or oral penetration by a sex organ of another person, without the consent of the Volunteer.

Aggravated sexual assault: Another person, without the consent of the Volunteer, intentionally or
knowingly:
(a) touches or contacts, either directly or through clothing, the Volunteers genitalia, anus,
groin, breast, inner thigh, or buttocks;
(b) kisses the Volunteer;
(c) disrobes the Volunteer; or
(d) causes the Volunteer to touch or contact, either directly or through clothing, another
persons genitalia, anus, groin, breast, inner thigh, or buttocks, or attempts to carry out any
of those acts, AND:
The offender uses, or threatens to use, a weapon OR
The offender uses, or threatens to use, force or other intimidating actions OR
The Volunteer is incapacitated or otherwise incapable of giving consent.

Sexual assault: Another person, without the consent* of the Volunteer, intentionally or
knowingly:
(a) touches or contacts, either directly or through clothing, the Volunteers genitalia, anus,
groin, breast, inner thigh, or buttocks,
or
(b) kisses the Volunteer on the mouth,
or
(c) attempts to carry out any of those acts.

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*Consent means words or actions that show a knowing and voluntary agreement to engage in
mutually agreed-upon activity. Consent is absent if force has been used against the
Volunteer, the Volunteer has been threatened or placed in fear, or the Volunteer is
incapable of appraising the nature of the conduct or is physically incapable of declining
participation in, or communicating unwillingness to engage in, that conduct.

The Peace Corps defines restricted reporting to mean a confidential report made to designated
staff by a Volunteer who is sexually assaulted during service in order to receive restricted
report services without further disclosure of the Volunteers PII or details of the sexual
assault except to the extent necessary and without automatically triggering an official
investigation (IPS3-13).

Designated Staff refers to PCMOs, Sexual Assault Response Liaisons (SARLs), Safety and
Security Coordinators (SSCs), a Victim Advocate in the Office of Victim Advocacy, and
Assigned Security Specialist for the Office of Safety and Security. Medical and
counseling staff at Headquarters may be provided with the Volunteers PII and details of
the assault for the procurement of victim services (IPS 3-13 Restricted Reporting).

Many of the procedures in this Medical Technical Guideline will be relevant for all types of
sexual assaults. However, certain procedures are determined by the nature of the event. In all
cases of sexual assault, the emotional needs of the victim should be cared for in accordance
with Technical Guideline 545 Sexual Assault: Counseling.

Note: For purposes of this document, the word Volunteer will be used to encompass both
trainees and Volunteers and the female pronoun will be used, although Peace Corps recognizes
that males can also be sexually-assaulted.

B. Resources
To effectively respond to the sexual assault of a Volunteer, PCMOs should follow this
Medical Technical Guideline and adhere to policies and procedures outlined in the
following documents:

Procedures for Responding to Rape and Sexual Assault;


Legal Environment Survey (LES) for the country in which the assault occurred;
Medical Technical Guideline 545 Sexual Assault Mental Health Assessment &
Support;
Volunteer Reporting of Sexual Assault IPS 3-13; and
Medical Technical Guideline 542 Sexual Assault Examination & Forensic Evidence
Collection, applies in circumstances when the PCMO may be authorized to collect
evidence.

C. Statistics
It is estimated that one in every six women in the United States has been the victim of an
attempted or completed rape during her lifetime (RAINN, 2009). About 1 in 33 men have
experienced attempted or completed rape in their lifetime (RAINN, 2009).

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It is the host countrys local judicial or legal systems responsibility to decide if the legal
definition of rape or sexual assault applies in a particular case. Regardless of how the law treats a
particular incident, if a Volunteer says that she has been sexually assaulted, she should be treated
as a victim of sexual assault for purposes of the Medical Technical Guideline.

Victims of sexual assault do not always present at the time of the incident, but may present at a
later date with incident-related symptoms (e.g., acute stress disorders, pregnancy, STD).
Individuals (men and women) who report that they have been sexually assaulted must be treated
in a compassionate, non-judgmental manner (see Technical Guideline 545 Sexual Assault:
Counseling.)

Typically, only 20 percent of assaulted victims have physical signs of abuse and less than 50
percent exhibit signs of trauma in the first 24 hours. Forty percent may never show signs of
trauma, but this does not mean that an assault did not occur. Victims of sexual assault are 3 times
more likely to suffer from depression, 6 times more likely to suffer from post-traumatic stress
disorder, 13 more times likely to abuse alcohol, 26 more times likely to abuse drugs and 4 times
more likely to contemplate suicide (RAINN, 2009).

D. Peace Corps Commitment to Sexual Assault Victims


The Peace Corps is committed to providing a compassionate and supportive response to
all Volunteers who have been sexually assaulted. To that end, the Peace Corps makes the
following commitment to our Volunteers who are victims of sexual assault.
1. Compassion. We will treat you with dignity and respect. No one deserves to be the
victim of a sexual assault.
2. Safety. We will take appropriate steps to provide for your ongoing safety.
3. Support. We will provide you with the support you need to aid in your recovery.
4. Legal. We will help you understand the relevant legal processes and your legal
options.
5. Open Communication. We will keep you informed of the progress of the case,
should you choose to pursue prosecution.
6. Continuation of Service. We will work closely with you to make decisions
regarding your continued service.
7. Privacy. We will respect your privacy and will not, without your consent, disclose
your identity or share the details of the incident with anyone who does not have a
legitimate need to know.
Peace Corps staff worldwide will demonstrate this commitment to the Volunteer through
our words and actions.

3. PCMO RESPONSIBILITIES
The general responsibilities of a PCMO when to prepare for and manage rape and sexual
assault are to:
Train Volunteers on information relating to sexual assault management in-country,
medevac options, and health care provider surveys.

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Maintain hard copy information of host country sexual assault medico-legal resources for
quick reference and to provide for temporary duty medical officers providing clinical care
coverage on a short term basis.
Identify and maintain professional relationships with facilities or host country providers
recognized in the host country to perform SAFE exams.
Provide orientation to community back-up providers to Attachment L, A Step-by-Step
Guide to a Sexual Assault Report By a Volunteer to the Medical Duty Phone.
Fulfill the duties as a designated staff member as outlined in IPS3-13, Volunteer
Reporting of Sexual Assault and The Guidelines for Responding to Rape and Sexual
Assault
Assess the Volunteers physical safety, which is a shared responsibility among
designated staff.
Maintain medical confidentiality.
Explain to the Volunteer the policies and procedures for Restricted Reporting of Sexual
Assaults, the option to make either a Restricted Report or a Standard Report, and the
services that are available to the Volunteer, as well as IPS 1-11 Immunity from Peace
Corps Disciplinary Action for Victims of Sexual Assault. Use The Volunteer Reporting
Preference Form
If the Volunteer wants to report to local law enforcement, explain the local procedures
regarding a Sexual Assault Forensic Examination (SAFE) and the potential for such an
exam to lead to a standard report.
Ascertain how the Volunteer wants to report an incident (Restricted or Standard).
If necessary, contact the OMS Sexual Assault Nurse Examiner (SANE), International
Health Coordinator (IHC), or Counseling and Outreach Unit staff for clinical consults.
Perform a mental status exam and Acute Stress Disorder/Post Trauma Stress Disorder
screening and arrange for appropriate psychological support (see Technical Guideline
545 Sexual Assault Mental Health Assessment and Support)
Document the Volunteers pertinent history, injuries, and care in a separate file labeled
SA (Sexual Assault) attached to the Volunteers general medical file.
Provides a choice of medical and mental health providers to the extent practicable including a
Health Care Provider/Consultant Satisfaction Survey to evaluate the providers
Develop a treatment plan in conjunction with OMS and the Volunteer according to the
mental and medical health needs of the Volunteer.
Arrange for a medevac upon the Volunteers request or if the PCMO determines a clinical
need for medevac (MS 264).
If the Volunteer is going to be medevacd ensure that the Volunteer understands that she may
request an escort. Normally the PCMO should serve as the escort unless this will create a
hardship for post. In this case the SARL or another staff member may serve as an escort.

Additional PCMO responsibilities specific to a Restricted Report:

Offer a clinical exam to ascertain medical and mental health needs for a treatment plan.
Treat physical injuries.
Provide medication for the prevention of sexually transmitted infections including HIV.
Note: **PCMOs should know local resistant strains of sexually transmitted infections
and identify appropriate alternative therapies in-country with OMS approval.**

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Provide medication for the prevention of unwanted pregnancy.


Notify the SSC and notify the SARL (if requested).
Notify the Victim Advocate (VA) if the Volunteer declines SARL services at post.
Notify the CD to report that an incident occurred without sharing any PII

Additional PCMO responsibilities specific to a Standard Report:

Notify the Country Director to coordinate a response plan with the CD serving as the
team lead.
Determine if the Volunteer wants to undergo a SAFE and explain its purpose, the process
for conducting an examination, who is authorized to conduct the exam in country, and
where it will be conducted. A SAFE may require notification to local law enforcement.
When legally permissible and when requested by the Volunteer, the PCMO should
accompany the Volunteer to and during a SAFE exam. If Volunteer declines a SAFE
exam, offer a clinical exam and medical treatment as for a restricted report.
If a SAFE is to be performed by an authorized local authority, the PCMO should refrain
from providing medical treatment to the Volunteer unless waiting for the SAFE may
compromise health care outcomes of the Volunteer (e.g. providing PEP, Plan B, or STI
prevention, frank wounds that need immediate attention). After the SAFE, the PCMO
should then develop the treatment plan to include STI and pregnancy prevention, medical
treatment of injuries, counseling, and medevac options.

Specific circumstance when the PCMO might conduct the SAFE:

For Volunteer on Volunteer or Staff on Volunteer Sexual Assaults, the incident may be
prosecutable under U.S. law. In cases that satisfy all of the following requirements, explain to
the Volunteer that there is a possibility that the crime could be prosecuted in the
U.S. and determine if the Volunteer wishes to have a SAFE conducted by the PCMO. The
requirements are:
The perpetrator is another Volunteer, a U.S. direct-hire Peace Corps staff member, a
U.S. citizen Peace Corps contractor (including a personal services contractor), or a
U.S. citizen embassy employee;
This incident is a rape or aggravated sexual assault; and,
The assault took place in a building or on land used by the U.S. government; or in
a residence used by a Volunteer, a U.S. government employee or other U.S.
government personnel.

If the Volunteer has expressed interest in reporting to law enforcement in the U.S., explain to the
Volunteer it would be necessary for the Volunteer to have a SAFE in accordance with U.S. law, rather
than host country law.

Refer to TG 542 for more information regarding the PCMO performing the SAFE exam.

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4. PCMO ADMINISTRATIVE PREPARATIONS TO MANAGE VOLUNTEERS WHO


HAVE BEEN SEXUALLY ASSAULTED

PCMOs must plan ahead to be able to clinically support a Volunteer who has been sexually
assaulted. Administrative preparations to assist PCMOs in preparing for management of
sexual assault are listed below. The PCMO must:

Participate in the facilitation of the required Pre Service Training Modules that outline:
o Services available to Volunteers including medevac options and health provider
surveys
o Where to go if assaulted
o Benefits from seeking medical care and emotional support, both immediate and long-
term
o Trust in the PCMO and management system
o Peace Corps protocols and policies regarding support to Volunteers who have been
victims of sexual assault

Know basic host country laws and policies regarding sexual assault:
o Participate in the development of the Legal Environment Survey especially portions
that pertain to the SAFE
o Complete the SAFE Consultant Information Form (Attachment K) and update
annually.
o Have a basic understanding of the legal requirements for reporting and for a SAFE
exam for evidence collection. Be able to explain the SAFEs purpose, the process
for conducting the SAFE, who is authorized to conduct the exam in country, and
where it will be conducted.
o Know if the PCMO can accompany and support a Volunteer during the SAFE exam

Identify and maintain relationships with local sexual assault health care resources:
o Official facilities and/or clinicians in country that perform SAFE exams
o Official arrangement with the local SAFE facility or official provider if possible
(recommended)
o Health care facilities for gynecological and general trauma
o Mental health care providers that work with sexual assault or trauma victims
o Laboratory services that can provide basic required laboratory analysis (e.g., CBC,
STI screening, and pregnancy testing) as well as laboratories that provide drug
screening.
o Infectious Disease specialists to know STI drug resistances in country

Maintain a readily accessible sexual assault resource binder in the medical office that
contains written protocols, guidance, and information regarding host country laws,
facilities, and resources. Post-specific information should be updated at least yearly.
o TG 540 Sexual Assault Management and attachments
o TG 542 SAFE and Forensic Evidence Collection
o TG 545 Sexual Assault Mental Health Assessment and Support
o Guidelines for Responding to Rape and Sexual Assault
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o Legal Environment Survey In-Country
o IPS 3-13, Volunteer Reporting of Sexual Assault and Reporting Preference Statement
o IPS 1-11, Immunity Policy

o MS 461
o Official or unofficial agreements with forensic examiners in-country
o Information regarding host country laws, facilities, and resources
o Post Incident Assessment Tool

Maintain Sexual Assault Kits (SAK) in the health unit


PCMOs must ensure that they maintain at least 1-2 unexpired SAKs from Sirchie
(www.sirchie.com) #VEC100 at all times. Peace Corps posts are responsible for the
inventory and purchase of these SAKs. Keeping SAKs in stock allows the Peace Corps
to provide an evidence kit to local authorities to assist in evidence collection for a
Volunteer case if the local authorities do not have such supplies in stock. All medical
staff at post must know where the SAKs are stored. SAKs can be obtained through the
Overseas Support Specialist at Peace Corps Headquarters, directly from HHS
(www.hhs.gov) or SIRCHIE (www.sirchie.com. In an emergency, SAKs may be
available through the RSO or U.S. Embassy Health Unit.

Maintain a Sexual Assault Go Bag that contains the following items to better respond
to a Volunteer away from the Peace Corps office setting:
o Items listed in the Peace Corps Sexual Assault Supply Checklist (Attachment A)
o SAK
o Sexual assault resource binder as outlined above

Maintain separable Sexual Assault Medical Records on Volunteers who are victims of
sexual assault.
o The PCMO should have materials on hand to develop a separable sexual assault
medical record for EACH incident.
o The first Sexual Assault File should be labeled SA/A. Subsequent files should be
labeled sequentially (e.g., SA/B, SA/C, etc.)
o The PCMO should staple the Sexual Assault Medical Record to the back of the
regular medical record.
o Documents that should be put in this record are:
Chronological SOAP notes and consultant reports related to the incident,
medical care, counseling, and medevac
the Reporting Option Form
Sexual Assault Clinical Exam Form
Clinical Order Set and Medical Treatment Plan
Discharge Summary Info for the Volunteer
Copies of reports from forensic examiners pertaining to the sexual assault.
Correspondence with the Office of Victim Advocacy, Office of Safety &
Security, Office of General Counsel, Office of Inspector General, or any other
Peace Corps staff directly related to health and safety of the Volunteer specific
to the sexual assault case.
Lab results specific to the sexual assault
o Example of separable Sexual Assault Medical Record

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LEFT SIDE OF SEXUAL ASSAULT RIGHT SIDE OF SEXUAL ASSAULT MEDICAL


MEDICAL RECORD (Top to Bottom) RECORD (Top to Bottom)
Post Service Documents related to the case Discharge Information and Instructions for Volunteers
Medevac Reports Chronologic Notes including Discharge Summary
Medevac Chronologic Notes from IHC Reports/Various Correspondence
Medevac Notes from COU/Counselors Clinical Order Sets and Treatment Plan
Correspondence between PCMO and HQ Sexual Assault Clinical Exam Form
regarding medevac Strangulation Addendum
Copy of Reporting Option Form

o In order to promote continuity of care, PCMOs should:


Document SA on the problem list in the regular medical record along with
date (s) in which the Volunteer consults with the medical office for care related
to the sexual assault. Do not use terms such as sexual assault, rape,
aggravated sexual assault in the problem list to identify the incident.
Document any diagnosis and need for follow up on the problem list as a result
from the sexual assault by identifying the diagnosis in conjunction with SA.
For example, SA/Pregnancy, SA/HIV+, SA/PTSD, SA/medevac to
Washington, DC
List any prescribed medications in the regular medical record where other
medications are listed.
Any immunizations given related to the sexual assault should be documented
on the immunization record in the regular medical record.
Maintain medical supply inventory in accordance with Peace Corps policy and
procedure for health unit medications prescribed to a Volunteer as a result of a
sexual assault.

5. CLINICAL MANAGEMENT
A. Managing the Initial Report of a Sexual Assault
1. Follow the Procedures for Responding to Rape and Sexual Assault
2. Refer to the Sexual Assault Notification Flow Chart (Attachment B)
3. Sexual Assaults should be considered a priority.

B. Initial Assessment
Assess Volunteers Vital signs and pain level. Respond to any acute injuries, trauma, and/or safety
needs of the Volunteer before performing a more thorough examination.

C. Preparing the Volunteer for the Clinical Exam and Obtaining Consent
(Sharkansky, 2011).

1. Greet the Volunteer in your office, and not the exam room (if possible), while she is still
fully dressed, and tell her that you are there to help her. Im here to help you, examine
you, and provide the physical and emotional support you need to get through this
situation. Im so sorry this happened to you. I want you to know that what has happened
to you is not your fault.

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2. Explain what is going to happen during each step of the exam. If the Volunteer asks,
explain why it is important, what it will tell the examiner and how the PCMO will use
the information obtained during the exam to determine treatment.

3. Reassure the Volunteer that she is in control of the pace, timing, and components of the
exam.

4. Reassure the Volunteer that the clinical exam findings will be kept confidential unless
she decides to revert to a standard report and pursue legal action.

5. Ask if she has any questions about the examination. Ask the Volunteer what she
imagines will be the most difficult parts of the examination. Listen carefully to any
concerns. Ask her what might help reduce her stress during the procedures. Provide the
Volunteer with as much choice as possible.

6. Ask the Volunteer who she would like to be in the room serving as a chaperone. A
chaperone is required to provide support to the Volunteer and is bound by
confidentiality. A chaperone can be the SARL, medical assistant/secretary, or any other
person the Volunteer would prefer to have in the room for support.

7. Discuss the exam consent form (Attachment C) with the Volunteer. Let her know that
she can refuse any aspect of the examination and that she can delete references to these
aspects on the consent form. When the Volunteer states she understands the consent
form, have her initial and sign.

8. Provide a secure, private location for the examination. During the exam, the only people
who should be in the room are the PCMO, the chaperone and/or SARL with the
Volunteer.

9. Perform the examination as soon as possible but only at the time agreed by the
Volunteer.

10. Do not force or pressure the Volunteer to do anything against her will. Explain that she
can refuse steps of the examination at any time but can still continue with other steps of
the exam.

D. Taking the History Using the Peace Corps Sexual Assault Clinical Exam Form
(Attachment D (Female) or E (Male))
1. Interview the fully-dressed Volunteer in the examination room.

2. Use a calm tone of voice and maintain eye contact. Speak clearly and directly to the
Volunteer. Do not stand over the Volunteer. Sit equal or lower than the level of the
Volunteer and begin gathering the medical history.

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3. Start by letting the Volunteer tell the history of events the way she wants to. Do not
interrupt. Explain that she does not have to tell you anything that she is not
comfortable with. Examples of appropriate interview questions:
a. Tell me what happened. Please tell me everything you remember about what
happened. Describe to me what happened in the best way that you can. I know
these are hard questions, but in order for me to understand the care you will need, I
need to ask you more details about this. I will go as fast as I can.
b. Please explain any involvement of your body (e.g. mouth, vagina, anus, and
breast).
c. Can you tell about what happened here (PCMO points to wound)?
d. Are there any parts of the incident that you have difficulty remembering?
e. Is there anything that I did not ask you that you would like to tell me?
f. Can you describe what you were thinking or feeling during the incident?

4. The patient may omit or avoid describing details that are particularly painful.
However, it is important for the PCMO to understand what happened in order to
guide the exam and care to be provided. Reassure the patient that the information is
for this purpose and will be kept confidential, and that you believe her account of the
incident. Take a break during the exam if necessary.

5. After the Volunteer relates the incident to the PCMO, the PCMO may question to
clarify information in a careful manner so as not to imply blame or lead to answers.
An example of a good way to clarify information:

I did not quite understand what you said about your mouth and ejaculation. Can you
tell me that again?

6. Do not ask questions that begin with why as they imply blame. Typical questions
that should be avoided:
a. What were you doing there?
b. Why did you go there?
c. Remember in PST when we discussed that letting a man into your home gave him
permission to have sex with you? Im sure he was confused with your
signals.
d. Were you wearing something that could have led the man on?

7. Asking about alcohol is sensitive and it is important not to imply blame. Tell the Volunteer
that the history of alcohol consumption is important especially when providing prophylactic
medications that may react adversely with alcohol. If the Volunteer shows signs of being
uncomfortable with the response to this question, reassure her that alcohol consumption will not
be used to accuse or blame her for the assault. Appropriate questions to ask:
a. When was the last time you had an alcoholic drink as this might affect the drugs or
treatment that I may offer you?

8. Take sufficient time to gather the information needed to focus the clinical exam.

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9. Except to help clarify information, avoid asking questions repeatedly or asking the
Volunteer to repeat her story unnecessarily.

10. Avoid distractions or interruptions during the history and exam.

11. Write precisely in the Volunteers own words including the history of events, threats
made against her and name(s) of assailant(s). Use qualifying statements such as:
Volunteer states or Volunteer reports Document what the Volunteer says
exactly in quotation marks. Do not sanitize or remove remarks such as slang,
offensive, or derogatory statements.

12. Review health record and confirm on-going health concerns, medications, vaccine
status, urological issues, and current STIs.

13. Evaluate for possible pregnancy by asking for details of current contraceptive use
(consistently and correctly), last menstrual period, last date of consensual sex and
contraceptive used at that time.

D. Perform and Document the Sexual Assault Clinical Exam (Attachments D:


Female, E: Male, and F: Strangulation)

1. Prepare equipment and supplies before the Volunteer enters the exam room.

2. Use the Sexual Assault Clinical Exam For (Attachment D: Female or E: Male) to
document the history and examination.

3. Explain everything you will do in advance and as you do it.

4. Listen carefully to any concerns voiced by the Volunteer.

5. Check regularly throughout the exam about the patients level of anxiety.

6. Engage in dialog during the exam.

7. Consider talking to her about her work or family because in some cases this kind of
distraction may help sexual assault survivors cope with distress of the post-assault
examination.

8. Utilize the Strangulation Documentation Form (Attachment F) if appropriate.

9. Help to minimize PTSD reactions during the examination. (Sharkansky (2011).

Despite providers best efforts, sometimes posttraumatic stress symptoms occur during
an exam. If this happens, dont panic. Use grounding techniques with the patient:
Speak in a calm, matter of fact voice and avoid any sudden movem ents

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Reassure the Volunteer that she is in a safe environment, and although she is
having a reaction, she will be okay.
Explain that you are examining her asking permission to continue the
examination.
If the Volunteer requests, stop the examination.
Ask the patient (or remind her) where she is.
Offer the patient a drink of water, an extra gown (to cover up), or a warm or cold
washcloth for her face.
If possible, go with her into a different room to provide a change of environment.

E. Document the Exam

Follow Instructions Form for Clinical Examination Form (Attachment G)

6. CLINICAL STANDING ORDER SET AND MEDICAL TREATMENT PLAN


The Clinical Standing Order Set and Medical Treatment plan (Attachment H) includes
standing orders for examinations, laboratory, and medications to manage sexual assault. The
Clinical Standing Order Set form reflects the requirements in this Technical Guideline. It
must be used for every sexual assault patient seeking clinical care from the PCMO and
completed as appropriate per the Volunteers clinical needs. The Clinical Standing Order
Form must be placed in the separate sexual assault medical file attached to the medical
record.

A. Prevention of Pregnancy
Pregnancy occurs as a result of rape in about five percent of female victims. Treatment to
prevent pregnancy should be offered to victims and prescribed only after a pregnancy test has
been performed to rule out prior pregnancy. Following are the recommended doses of oral
contraceptive pills to be taken within 72 hours of the incident. A follow-up pregnancy test
must be performed 10 to 14 days after emergency contraception given or after the incident if
emergency contraception is declined.

Protocol for emergency contraception


(Should be taken within 72 hours after unprotected intercourse, but may be effective for up
to 5 days; obtain a negative pregnancy test first.)

Plan B One Step 2 tablets containing levonorgestrel 0.75mg at once


OR
An alternative oral contraceptive that is used for emergency contraception. Refer to
package inserts on particular oral contraceptive for appropriate dosing.
AND PROVIDE
Tigan 200mg suppositories or oral (to be used 3-4 times a day for nausea, if required).

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B. Prevention of Sexually-Transmitted Infections


These post exposure prophylaxis protocols are based on the CDCs Sexually Transmitted
Diseases Treatment Guidelines, 2015. It is important to assess the Volunteers alcohol
intake within the last 72 hours before prescribing metronidazole or tinidizole to prevent
untoward affects from this alcohol-drug combination. PCMOs are responsible for
knowing drug-resistant strains of sexually-transmitted infections in their own
country and should consult with OHS regarding any changes to the treatment
guidelines provided below.

1. Chlamydia, Gonorrhea, and Trichomonas

Treatment for the prevention of chlamydia, gonorrhea, and trichomonas is indicated.


Recommended regimen to prevent gonorrhea, chlamydia, and trichomonas

Ceftriaxone 250 mg (diluted in Lidocaine 1%) IM in a single dose


AND
Azithromycin 1 gm orally in a single dose
OR
Doxycycline 100 mg orally 2 times a day for 7 days
AND
Metronidazole 2gm orally in a single dose

Note For Penicillin Allergic Volunteers: Treatment for the prevention of chlamydia,
gonorrhea, and trichomonas.

(For Gonorrhea)
Azithromycin 2 gm orally in a single dose
AND
(For Chlamydia)
If Azithromycin is not used in gonorrhea treatment, then 1 gm orally in a single dose
OR
Doxycycline 100 mg orally 2 times a day for 7 days
AND
(For Trichomonas)
Metronidazole 2gm orally in a single dose

2. Prevention of Hepatitis B
Rape victims who are non-immune to hepatitis B should receive prophylaxis against
hepatitis B. Unless the Volunteer has received a complete hepatitis B vaccine series or is
immune due to prior hepatitis B infection (serologically confirmed, see below),
vaccination should be provided. Hepatitis B Immune Globulin 0.06 ml/kg IM (HBIG,
human) can be given if available and offers additional protection.

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A HbsAb must be drawn on all rape cases to confirm Hepatitis B immunity.

If Volunteer is not immune give:


1) HBIG (0.06 ml/kg) IM x 1 dose; should be given as soon as possible after
exposure and within 24 hours if possible.
2) HB vaccine 1 ml (20 ug) IM at a separate site as soon as possible, but
within 7 days of exposure, with the second and third doses given 1 month
and 6 months, respectively, after the first.

Hepatitis B vaccine 1.0ml IM (deltoid) at months 0, 1, 6 post-exposure. Vaccination


should be given within 24 hours post-exposure if possible;
AND if available,
Hepatitis B Immune Globulin (HBIG, human) 0.06 ml/kg IM. Give in two separate
injections if volume of injection greater than 2.5 ml. Vaccination should be given as soon
as possible post-exposure.

3. Hepatitis C
Hepatitis C infection can be transmitted by sexual exposures, therefore test for Hepatitis C
antibody at 6 months after the exposure. Notify OMS of all positive results.

4. HIV
The risk of acquiring HIV infection as a result of rape depends on the likelihood of the
assailant having HIV, the sexual acts performed, and other factors (associated trauma,
presence of other STDs, etc.) According to the CDC, HIV sero-conversion has
occurred in persons whose only known risk factor was sexual assault or sexual abuse,
but the frequency of this occurrence is probably low. In consensual sex, the risk for
HIV transmission from vaginal intercourse is 0.1%0.2% and for receptive rectal
intercourse, 0.5%3%. The risk for HIV transmission from oral sex is substantially
lower. Specific circumstances of an assault (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 an STD or genital lesions in the assailant or survivor also might increase the risk for
HIV. Refer to TG 712, HIV Prevention and Treatment for further guidance.

Recommended HIV Post Exposure Prophylaxis:


Truvada (Tenofovir 300mg + Emtricitabine 200mg) 1 tablet orally QD for 28 days,
AND
Isentress (Raltegravir 400mg) 1 tablet orally BID for 28 days

Truvada carries a Black Box Warning indicating risk of hepatotoxicity and exacerbation of
Hepatitis B therefore it is imperative that HbsAg is drawn prior to prescribing Truvada.

C. Drug Facilitated Sexual Assault (DFSA)


The PCMO is not authorized to collect specimens (hair, urine, or blood) to ascertain if a
drug facilitated sexual assault occurred. The reasons for this are:
Lack of sophistication and/or validity of local laboratories
Any illegal substances found in the specimen could be used against the Volunteer
in the local court system
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There is a high likelihood that DFSA drugs metabolize quickly and are not found
in the specimen.
There is no chain of custody for the specimen; therefore, the specimen is not
admissible.

7. DISCHARGE INSTRUCTIONS
A Volunteer who has been a victim of sexual assault will need follow- up clinical care and
emotional support. The following documents should be provided to the Volunteer to educate,
reinforce, and promote compliance with post exposure prophylaxis care and follow- up.

A. Sexual Assault Discharge Information & Instructions for Volunteers Form

The Sexual Assault Discharge Information & Instructions for Volunteers Form
(Attachment I) should be used for follow-up care and instructions to inform Volunteers of
the treatment they have received and follow up clinical requirements.

B. 127-C Forms at Close of Service

Upon Close of Service, all Volunteers who have been treated or are currently undergoing
treatment for sexual assault must receive 127-Cs for counseling and any outstanding follow-
up clinical care and testing.

The PCMO should issue a 127-C for any outstanding sexually-transmitted infection testing or
pregnancy per instructions in this guideline and as appropriate.
For psychological support and counseling, the 127-C must be for a PhD psychologist or
psychiatrist with these instructions:
Provide three initial counseling sessions to provide support and evaluate for further
counseling needs. Call the Post Service Unit for additional sessions at 202-692-1540
opt.7.

C. SUMMARY CHRONOLOGICAL NOTE


The summary note (example in Attachment J) is a chronologic note in SOAP
documentation format to recap the clinical examination, the PCMOs assessment and the
plan for the Volunteers continued care. The summary note should be put in the separate
sexual assault medical file attached to the medical record.

8. PCMO REGISTERED NURSE PRIVILEGES MEDICAL AND SAFE EXAM


Registered Nurse PCMOs who undergone training on Technical Guideline 540 at Medical
Overseas Staff Training (MOST) and who have been granted gynecological exam privileges
through the Volunteer Support Credentialing Committee as outlined in TG 605, may be
granted, at the discretion of the Chief Clinical Programs, standing order TG 540. If
granted TG 540 privileges, the RN PCMO may perform the medical exam to determine
medical care needs of the victim and perform the SAFE exam as outlined in in TG 542.

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9. COMMUNITY BACK-UP PROVIDER COVERAGE INFORMATION REGARDING
SEXUAL ASSAULT MANAGEMENT

Community back-up providers must be provided information on how to manage a sexual


assault when providing clinical coverage to a post when the PCMO is not available for
coverage. A step-by-step guide to response is outlined in Attachment L, A Step-by-Step
Guide to a Sexual Assault Report by a Volunteer to the Medical Duty Phone. This
information can also be found in TG 185 Back up Healthcare Providers.

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Faugno, Diana (MSN, RN, CPN, SANE-A, SANE-P, FAAFS, DF-IAFN. Director, End Violence
Against Women International. http://www.evawintl.org/about.aspx

Guidelines for Responding to Rape and Sexual Assault. (2013). Office of Safety & Security,
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Giardin, B.W., Faugno, D.K., Spencer, M.J. & Giardino, A.P. (2003). Sexual Assault:
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Office on Violence Against Women. (2004, September) A National Protocol for Sexual Assault
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Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., Hugelshofer, D. S., Shaw-Hegwer, J., et
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Rape, Abuse, and Incest National network (RAINN). (2009). Statistics. http://www.rainn.org/

Sharkansky, E. (2011). Sexual trauma: Information for womens medical providers. National
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Sirchie. (n.d.). VEC#100 Exam and Consent forms and Sexual Assault Forensic Evidence
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Washington DC Sexual Assault Nurse Examiners (SANE) Protocols. 2011.

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Weathers, F. W., Litz, B. T., Herman, D., Huska, J., & Keane, T. (1994). The PTSD checklist
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