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Examination of “The RAPE VICTIM” To be presented AOGD annual Conference on 25th October 2014 Dr. Sharda Jain Lifecare Centre


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Examination of “The RAPE VICTIM” To be presented AOGD annual Conference on 25th October 2014 Dr. Sharda Jain Lifecare Centre

  1. 1. Examination of “The RAPE VICTIM” Dr. Sharda Jain Director :- To be presented AOGD annual Conference on 25th october 2014
  3. 3. Our Promise W Teach every Doctor Exam. Of Rape VICTIM Rape Free India !! Looks a Dream
  4. 4. Black Day Dec. 2012 Shook conscience of Every Indian 16th NIRBHAYA
  5. 5. Total Failure of Mother India to protect Honor & Dignity of W
  6. 6. India's Biggest Shame
  7. 7. M WHY r Becoming BEAST HORRIBLE Weapon to torment W
  9. 9. Centre’s Stage
  10. 10. We all Realised !!
  11. 11. Rape W First Shatter Beyond your & mine imaginations
  12. 12. Rape Need to be STOPPED Second
  13. 13. Third Societies Views on Rape Victims Need to change
  14. 14. Fourth Rapist Should Not Go Scot Free
  15. 15. Time BOUND Fifth
  16. 16. Victims Need to Speak Up SPEAK - Up Sixth
  17. 17. Culture of Lousy Medical Exam. Of Rape Victim has to change !! Seventh
  18. 18. Total Apathy & Collective NEGLECT of Rape Survivor’s Exam. Can’t be IGNORED any further
  19. 19. Eighth Every Lady Doctor Has to Get Trained in Rape Victim Exam & Care
  20. 20. WHY ?
  21. 21. & Can Happen to anyone Rape is Increasing You , Me Our Daughter, Sister, Friend & Even Mother !!)
  22. 22. 2001 N.C.W. Marked Deficiency Noted In medical exam / Evidence Collection / std. care & No Rape crisis cell & centres
  23. 23. Manual, Film & Kit 2004 IMA, MOWCD, UNICEF Ignored by Medical Fraternity till 2011
  24. 24. 2011 DELHI HIGH COURT Land Mark judgment • Directing uniform examination protocol • Use a standard kit • Uniform Protocol of treatment • Uniform Training Module based on IMA FILM MANUAL THE MAKING OF NEW INDIA
  25. 25. 2013 RAPE Law amendment Thanks to Justice Verma Committee Gave us Much Hope
  26. 26. DELHI HIGH COURT - JUDGMENT justice sh. D Murgeshan and justice sh.V.K. Jain 2013 Directed Delhi government to issue all hospitals including those in Private sector Examination, FIRST AID & EMERGENCY TREATMENT to RAPE Victims - Free of Cost. Dept of Health and Family welfare NCT of Delhi has directed nursing homes and private hospital not to refuse emergency treatment to rape Victims / give care Failing which - face punishment.
  27. 27. PUNISHMENT FOR NON COMPLIANCE for we doctors – Exam/ Care/ Evidence collection Whoever, being in charge of a hospital , public or private , whether run by the central Government, local bodies or any other person, contravenes the provisions of sections 357c of the code of criminal procedure , 1973(2 of 1974), shall be punished with imprisonment for a term which may extend to one year or with fine (166B – IPC)
  28. 28. Lets Know the LAW New Definition Of RAPE (According to 2013 amendment) •Penetration of penis, to any extent, into the vagina, mouth, urethra or anus of a women or makes her to do so with him or any other person; or •Insert, to any extent, any object or a part of the body, not being the penis, into the vagina, the urethra or anus of a women or makes her to do so with him or any other person;
  29. 29. Lets Know the LAW Cond. New Definition Of RAPE (According to 2013 amendment) •Manipulation of any part of the body of a women so as to cause penetration into the vagina, urethra, anus or any part of body of such women or makes her to do so with him or any other person Or •Applies his mouth to the vagina, anus urethra of a women or makes her to do so with him or any other person, under the circumstances falling under any of the following seven descriptions:
  30. 30. Lets Know the LAW Cond. New Definition Of RAPE (According to 2013 amendment) FIRST – Against her will SECONDLY – without her consent THIRDLY – with her consent, when her consent has been obtained by putting her or any person in women she is interested in fear of death or of hurt. FOURTH – with her consent, when the man knows that he is not her husband and that her consent is given because she believes that he is another man to whom she is or believes herself to be lawfully married.
  31. 31. Lets Know the LAW Cond. New Definition Of RAPE (According to 2013 amendment) FIFTHLY – with her consent when, at the time of giving such consent, by reason of unsoundness of mind or intoxication or the administration by hem personally or through another of any stupefying or unwholesome substance, she is unable to understand the nature and consequences of that to which she gives consent. SIXTHLY – with or without her consent, when she is under eighteen years of age SEVENTHLY – when she is unable to commutate consent 2.INJURIES ON VICTIMS BODY HAS NO RELEVANCE
  32. 32. 3 Most Important Things Needed •Trained Doctor & her team • Special safe kit for examination • Std. Protocol of Collection & Treatment to prevent STD/ Pregnancy is crucial
  33. 33. What You Can do Before Reaching Hospital ? As soon as one comes across a victim Of Sexual assault, the first step is to ensure SAFETY • Take her to safe and secure place call the POLICE if danger from the assailant is still there. • Call a CLOSE FRIEND or RELATIVE-someone who will offer unconditional support.
  34. 34. INSTRUCTIONS TO THE VICTIM What You Can Do Before Reaching Hospital ? • One must take care not to clean up before taking them to hospital. The victim should not bath, go to the bathroom, comb hair, change clothes or brush teeth before undergoing a medical examination. • This will help to preserve all the evidence.
  35. 35. Principle of Emergency Care The doctor’s job at the emergency room is not to determine if the rape has happened or not. Rape is a legal term – a crime – and whether this crime has been committed or not will be decided by the Honorable court.
  36. 36. APPEA L SURVIVOR of Sexual Assault to be used & not the VICTIM of Sexual Assault so as to eliminate the stigma associated with word Victim.
  37. 37. Principle of Emergency Care of Rape Survivor Exam. & care • The attitude of the medical staff should be compassionate and not judgmental • Life threatening emergency, if present needs urgent attention
  38. 38. POLICE REQUISITION /FIR is not mandatory for seeking medical care and treatment of the victim. Guidelines for Medical Examination As per new law 2013
  39. 39. The GOALS of Medical Examinations • MEDICAL ASSESSMENT , documentation & TREATMENT of injuries and PREVENTION of pregnancy & STD • Collection of FORENSIC evidences • PSYCHOLOGICAL support
  40. 40. CAUTION If the ATTENDING DOCTOR FAILS TO COLLECT EVIDENCES PROPERLY, he / she may face the charges of DESTROYING THE EVIDENCES which is PUNISHABLE in India panel code
  41. 41. WHO should do the examination ? New law 2013 Medical examination of a female victim shall be conducted by a FEMALE REGISTERED MEDICAL PRACTITIONER, in absence there of , in presence of a female registered medical practitioner If the child age less then 12 years Pediatrician should perform the general examination and PSYCHOLOGIST should be called for PSYCHOLOGICAL support of the survivor
  42. 42. Place of Examination RMP employed in a HOSPITAL RUN BY GOVT. or a LOCAL AUTHORITY and , in the absence of such a practitioner by any other RMP within in the radius 16 Km From The Place where the offence has been committed on the Request Of A Police Officer not below the rank of a sub inspector
  43. 43. INFORMED CONSENT CONSENT IS ESSENTIAL AND NOBODY CAN FORCE A VICTIM TO UNDERGO A MEDICAL EXAMINATION WITHOUT HER CONSENT , NOT EVEN THE COURT . •IT RECOGNISES HER RIGHT TO CONSENT FOR PARTIAL EXAMINATION - she may also decide to undergo partial physical examination and / or genital examination and allow the collection of bodily evidence., •It is purely her wish whether to file a police complaint and initiate criminal proceedings against the accused.
  44. 44. Many Hospitals make these cases MLC & Inform the police • In that case police comes in to actions • But no body can examine her without her consent if she is under the age of 12 years or a mentally subnormal person, the written consent of the parents
  45. 45. Medical Examination • ABSOLUTE PRIVACY • Medical Exam.-should be treat as an EMERGENCY • EMERGENCY MEDICAL CARE is a priority over collection of evidence THE ATTITUDE towards patients should be Nonjudgmental , Empathetic and Reassuring
  48. 48. The statement of the victim in her words must be written down as much as possible “WORD FOR WORD”. The amount of violence used, the position of the assailant, and the mode of attack should be elicited. It is necessary to inquire if vaginal, oral, or rectal contact occurred. Her statement should be noted with reference to:- •Pain •Haemorrhage •Sensation as to penetration and emission and •The appearance of discharge •If she cried for help, or was too terrified to do so, or she fainted Enquiry should be made of the events after the all eged assault, e. g, if she has changed her clothing, bathed or passed urine. Any delay in making complain to the authorities should have a proper explanation. A record should be made of the statement of others who accompany her. The degree of agreement of the various statements is important.
  49. 49. Collection of OUTER Clothes & INNER clothes of Survival of Sexual Assault separately Separately on big piece of paper wrap & seal fresh set of clothes provided
  50. 50. The Principal Features of the Examination are:- 1. Mouth, breast , genital and rectum are examined closely. Injury markers on body are described and documentation clearly. Drawings should be used to described injuries. 2. Debris from any is collection in a separate envelop, labeled and sealed 3. Loose debris from finger nails and scrapings collection in envelops sealed and marked.
  51. 51. Guidelines for Injuries As per new law 2013 • SIGN OF STRUGGLE on Clothes & Body are IRRELEVANT according to New Law • Injuries are seen in only one third cases. • Common sites of extra genital trauma are mouth, throat, wrists, arms, breast and thighs. It is essential to do a careful recording of the findings if there presents.
  52. 52. The women usually scratches the assailant during the struggle and this may result in injury to her nail which should be recorded. The debris under nail should be removed and examined for the presence of tags of epithelium, blood, fibers, etc, of the assailant Nails Scrapping
  53. 53. The Principal Features of the Examination are:- 4. Any suspected stain on body collected by putting distil water rolling the swab stick over it and the stick placed in an envelop. 5. A paper placed under the buttocks of the patient, comb the patient’s public hair, collect loose hair in the same paper and seal it 6. Patient’s Public hair, which appear matted, to be cut and sealed in another envelop.
  54. 54. The Principal Features of the Examination are:- 7. VULVA examined for signs of injury and the finding noted down. 8. SPECULUM EXAMINATION AFTER EXPLAINING THE PROCEDURE – swab collection from slides two are handed over to the accompanying police constable and rest two sent to the forensic lab. The swab is put separately in the tube. 9. FLUID AND MUCUS FROM CERVIX collection & slide prepared. The swab is placed in a tube sealed. Another swab collection from cervix and streaked on chocolate agar plate and the swab discarded.
  55. 55. The Principal Features of the Examination are:- • 10. washing the vagina by saline from a preloaded syringe, stirred by speculum, fluid drawn, put on the slide & examined under microscope for spermatoa • Rectal examination is performed if suspected – proctoscopy performed by surgeon using smallest size proctoscope , any injury noted, swab collected and put in a tube • Examination of oral cavity : swabs taken from sides of molar teeth slide prepared and swab kept in the tubes.
  56. 56. Two finger admissibility Test • On a women victim shall not be performed (As per Guidelines for Medical Examination As per new law 2013 & WHO guidelines. and • Recording of “victim is habituated to sexual inter course or not” shall not form a part of report at all.
  57. 57. Menstruation is not a bar for Examination “MENSTRUATION IS NOT BAR TO ILLEGAL SEXUAL INTERCOURSE”.
  58. 58. Body fluids samples collection and radiological examination 1. BLOOD : for ABO grouping and Rh typing HIV, Hepatitis , Syphilis 2. URINE : For alcohol intoxication and pregnancy test. 3. X RAY : wrist, pelvis, shoulder and knee for confirmation of age. 4. Sample for GONORRHEA is already taken on chocolate agar plate No specimen should be left alone at any time . All specimens are placed in yellow bag which is kept in locked refrigerator till the time samples are handed over to police constable who would take them to forensic science laboratory
  59. 59. Motility of Sperm – Prepare a hanging drop Preparation Motile sperms can visualized up to four – five hours The smears are fixed with drop of alcohol
  60. 60. Collection of Evidence • Even if the victim is NOT SURE, whether she wants to report the attack, it is still important to collect and preserve evidence so it can be accessed at a later date, if necessary. • Evidence if not collect within 48 to 72 hours of the incident is often unrecoverable or invalid.
  61. 61. SPECIAL TESTS , if Required • COLPOSCOPY for Examination microtrauma • TOLUDINE BLUE : Stains microtrauma area & better visualized. It is than washed with water • WOODS LAMP EXAMINATION may help identify semen, which will fluoresce ,. The flurescent area should br swabbed with cotton tipped applicator moistened with sterile water. • BITE MARK CASTING can be done by unwaxed dental floss
  62. 62. Optional in Virgins & Children
  63. 63. Rape is a Rape !!
  64. 64. Hard to disprove
  65. 65. Treatment AIM • Pregnancy prevention • Sexually Transmitted Disease Prevention • Emotional Support
  66. 66. Prophylactic treatment for all patients • Injection tetanus toxoid 0.5 mL SC • EMERGENCY CONTRACEPTION offered Tab Levonorgestrel 75 microgram with in 72 hours & to be repeated after 12 hours or Tab Mala N 2 tab stat follwed by 2 tab after 12 hours UPT : to be repeated at 1,2 weeks MTP : if need be
  67. 67. Sexually transmitted diseases Incubation period of common infections • Gonorrhea 3-4 days • Trichomonas 1-4 weeks • Chlamydia 7-14 days • Warts several months • Herpes 2-14 days • Herpes vaginosis 2-14 days • Syphilis 3 months
  68. 68. Universal STD Prophylaxis Metrogyl 2gm orally - single dose Azithromycin 1g - orally single dose Oral Cefixime 400 mg orally single dose
  69. 69. Prophylactic treatment for all patients 1) For GONORRHEA Oral azithromycin 1 gm orally single dose Oral Cefixime 400 mg orally single dose 2) For CHLAMYDIA Oral azythromycin 1 gm single dose Or Oral DOXYCYCLINE 100 mg twice daily for 7 days
  70. 70. Prophylactic treatment for all patients 3) For HIV (Initiate within 4hr for maximum benefits), the basic regiman includes: Oral Zidovudine 300 mg twice daily for 4 weeks plus oral Lamivudine 150 mg twice daily for 4 weeks
  71. 71. HIV If the transmission risk for HIV is perceived to be high (bleeding the assailant was at high of having HIV): example regima to be given which includes: • Basic regimen plus • Indinavir 800mg thrice daily for 4 weeks or Nelfinavir 750 mg thrice daily for 4 weeks
  72. 72. Optional • Hepatitis B vaccination
  73. 73. Emotional Support Sexual assault victim need unconditional emotional support as they may be struggling with emotions of Anger, Fear, Guilt, Shame and anxiety
  74. 74. Emotional Support The Victim May Suffer From • Sleep disturbances • Lack of appetite • Depression and nightmare • Physical pain
  75. 75. Counseling Most victims find counseling helpful in the process of recovering and moving on with their life. The care a patients initially receives - influences her recovery from the trauma suffered due to rape Follow up is must
  77. 77. SAFE (Sexual assault Evidence collection) Kit Help Collect different Evidences Contents: Mannual to guide doctos – 21 pager document to guide the doctor protocol book containing forms Form 1 : consent Form 2 : medical history Form 3 : sexual assault history Form 4 : forensic examination
  78. 78. SAFE (Sexual assault Evidence collection) Kit Help Collect different Evidences Form 5: General exam & age estimation Form 6 : Discharge slip All forms have 2 copies 4 envelopes containing envelops – 11 Envelops (2A to 2K): body samples 8 envelopes (3A to 3H) : genital and anal samples Step – wise arrangement of all envelops to prevent omissions
  79. 79. FILM On Medical Examination of Rape Victim Prepared by MOWCD/ IMA Youtube
  80. 80. 2013 RAPE Law amendment at one year No doubt picture will be different 5 yrs hence No Monitoring Mechanism onground No Attempt to Prevent Failure of Prosecution No Accountability No women Safety Review of
  81. 81. Please Remember Girls can not stop rape just by changing their own behavior violent people never stop unless they are Punished Please join hands with Delhi Gynaecologists forum’s campaign to do great medical examination & care
  82. 82. Girls must learn self defense self defense self defense
  83. 83. Thank You