Clinical practice. Care of the adult patient after sexual assault

Demographics and Care-Seeking Behaviors of Sexual Violence Survivors in South Kivu Province, Democratic Republic of Congo

Objectives: One of the most striking features of the ongoing conflict in the Democratic Republic of Congo (DRC) is the use of sexual violence. In spite of the brutality of these crimes, the experiences of women affected by sexual violence in Eastern DRC remain poorly characterized. This analysis aimed to (1) provide detailed demographics of sexual violence survivors presenting to Panzi Hospital; (2) examine how demographic factors might impact patterns of sexual violence; and (3) describe care-seeking behavior among sexual violence survivors.

Methods: The demographics and care-seeking behavior of sexual violence survivors in South Kivu Province were described from a retrospective registry-based study of sexual violence survivors presenting to Panzi Hospital (2004-2008).

Results: A total of 4311 records were reviewed. The mean age of survivors was 35 years. Most women (53%) were married, self-identified with the Bashi tribe (65%), and reported agriculture as their livelihood (74%). The mean time delay between sexual assault and seeking care was 10.4 months. Five reasons were identified to help explain the lengthy delays to seeking care: waiting for physical symptoms to develop or worsen before seeking medical attention, lack of means to access medical care, concerns that family would find out about the sexual assault, stigma surrounding sexual violence, and being abducted into sexual slavery for prolonged periods of time.

Conclusions: Many sexual assault survivors have very delayed presentations to medical attention. Promoting timely access of medical care may best be facilitated by reducing stigma and by educating women about the benefits of early medical care, even in the absence of injuries or symptoms.

(Disaster Med Public Health Preparedness. 2012;6:393-401)

A randomized controlled trial of trauma-focused cognitive behavioral therapy for sexually exploited, war-affected Congolese girls

OBJECTIVE

To assess the efficacy of trauma-focused cognitive behavioral therapy (TF-CBT) delivered by nonclinical facilitators in reducing posttraumatic stress, depression, and anxiety and conduct problems and increasing prosocial behavior in a group of war-affected, sexually exploited girls in a single-blind, parallel-design, randomized,+ controlled trial.

METHOD

Fifty-two 12- to 17-year-old, war-affected girls exposed to rape and inappropriate sexual touch in the Democratic Republic of Congo were screened for trauma, depression and anxiety, conduct problems, and prosocial behavior. They were then randomized to a 15 session, group-based, culturally modified TF-CBT (n = 24) group or a wait-list control group (n = 28). Primary analysis, by intention-to-treat, involving all randomly assigned participants occurred at pre- and postintervention and at 3-month follow-up (intervention group only).

RESULTS

Compared to the wait list control, the TF-CBT group experienced significantly greater reductions in trauma symptoms (F(1,49) = 52.708, p<0·001, χ(p)2 = 0.518). In addition, the TF-CBT group showed a highly significant improvement in symptoms of depression and anxiety, conduct problems, and prosocial behavior. At 3-months follow-up the effect size (Cohen's d) for the TF-CBT group was 2.04 (trauma symptoms), 2.45 (depression and anxiety), 0.95 (conduct problems), and-1.57 (prosocial behavior).

CONCLUSIONS

A group-based, culturally modified, TF-CBT intervention delivered by nonclinically trained Congolese facilitators resulted in a large, statistically significant reduction in posttraumatic stress symptoms and psychosocial difficulties among war-affected girls exposed to rape or sexual violence. Clinical trial registration information-An RCT of TF-CBT with sexually-exploited, war-affected girls in the DRC; http://clinicaltrials.gov/; NCT01483261.

Forensic medical examination of adolescent and adult victims of sexual violence

The acute care and examination of a victim of sexual violence must be carried out by a competent forensic examiner in a setting appropriate for crisis intervention, forensic evidence collection, and medical follow up. The aim of forensic evidence and biological material collection is to document an alleged physical or sexual contact between individuals and to corroborate the victim's and the assailant's history. This is why the forensic examiner is expected to be objective and in possession of specialised technical and scientific skills. These skills are addressed and recommendations are made on how to carry out a forensic examination. This includes medical and assault history, top-to-toe examination, biological material collection, and documenting injuries while obtaining the chain of custody. Yet, consensus on time limitations for forensic evidence collection is lacking. Available forensic evidence has been shown to benefit prosecution. To meet the legal system's needs, an interpretation of the findings in a written legal report is mandatory.

Sexual assault injuries and increased risk of HIV transmission

Sexual assault and HIV are coexisting public health problems. Sexual assault may increase HIV transmission risk through diverse mechanisms, such as infliction of anal, oral, and genital injuries by penile, digital, or object penetration, extragenital trauma, concurrent sexually transmitted infections, condom use, and whether the perpetrator was circumcised.