Advocating for and supporting a radical reorientation of health care for sexual assault survivors
Research and advocacy conducted over the last 20 years have highlighted the deficiencies of health services for survivors of sexual assault globally, and in some countries there have been initiatives to improve care. Sexual Assault Nurse Examination (SANE) program models in Canada and best practice models from the US, Australia and some parts of Europe are directed towards the provision of holistic care - as does South African policy - but globally these remain exceptions. In general, services follow a predominantly medico-legal model with little focus on the psychosocial needs of survivors and great emphasis on medico-legal evidence collection.
There is a need for a radical reorientation of health care for survivors of sexual assault towards meeting their psychological, social and physical health needs in services staffed by appropriately trained providers. The SVRI has a key role to play in advocating for this global shift in how health services respond to survivors of sexual violence, both immediately after sexual assault and in the longer term, where high quality health services can exercise a critical role in reducing all sexual violence health related harms.
With funding from the Ford Foundation, the SVRI in partnership with our regional colleagues supported processes within 7 African countries: Rwanda, Zimbabwe, Zambia, Uganda, Malawi, Kenya and Nigeria to develop health sector responses to rape survivors, both immediately after rape and in the longer term, and to promote an appropriate and effective interface between the health, police and justice sectors. This project also helped us to support ad hoc requests for assistance in the region including requests from Ethiopia, Senegal, and Liberia.
Project Conceptual Framework
The project was built on four components: partnership, policy, research and training. Acknowledging the need for sustainable change to be driven at a country level, the project initially promoted the development of working partnerships between policy makers, service providers and trainers and women’s advocates within countries. Policy in the health sector is seen as essential for providing a road map for change and through this project we have promoted the development of appropriate national policy. Research has an important role in highlighting problems, developing arguments for the need for change and evidence based policy. We therefore encouraged the conduct and utilisation of research in this process. High quality services need to be provided by trained staff and so SVRI promoted the development of new models of training. The seven countries each had different starting points and there were differences in what was achievable within the life of the project.
This project aimed to shift the orientation and perceptions of the role of post rape care from a predominant focus on the collection of medico-legal evidence to the provision of holistic care to the meet the short, medium and long term mental and physical health needs of survivors.
The key project objectives were to:
- undertake activities and promote research to raise awareness with medico-legal forensic sexual assault educators, policy makers, service providers and women’s advocates of the disjuncture between services provided and survivors needs
- disseminate examples of good practice in policy and training related to sexual assault care
- promote the adaptation and replication of good practice in training and policy for sexual assault care internationally with a developing country focus.
Regional Training Activities
African Regional Training Programme for the Care and Support of Sexual Assault Survivors, 2 – 3 February 2009, Pretoria, South Africa
"The course and training has opened various doors for improvement [both] on a short time and long term basis …" (Course participant, February 2009)
"I am very honoured to be part of the course, I was enlightened on many issues and hope to apply all or many to my institution". (Course participant, February 2009)
Through the SVRI networks and partnerships, multidisciplinary teams from 7 African countries, namely: Kenya, Malawi, Rwanda, Uganda, Zimbabwe, Zambia and Nigeria were drawn to participate in the project. The first training programme was held from 2-13 February 2009 in Pretoria, South Africa.
The training programme was based on the South African national curriculum “Caring for survivors of sexual assault and rape: A training programme for health care providers in South Africa” and adapted for different disciplines, geographical and socio-cultural settings. The launch of the first training programme provided a number of valuable lessons for future trainings, and participants reported prioritizing the reframing and strengthening of services for rape survivors in their own countries. The project brief and training report are available online.
Rwanda like many other countries worldwide is facing the rampant problem of Sexual and Gender Based Violence. Sexual abuse occurs frequently within marriage, with a third of women report being raped by their husband (UNIFEM 2008). The issue of violence against women is high on the agenda of the Rwandan government. The Ministry of Health and others public institutions concerned with SGBV prevention and management have set forth strategies to respond to SGBV in Rwanda. The national health policy in general and the reproductive health policy in particular are committed to address SGBV. Specifically, the ministerial order n° 20/13 of 31/3/2006 provides guidelines for medical care of sexual violence against women. However there are still challenges; the health care providers still lack appropriate knowledge, competencies, skills and essential tools to effectively address SGBV (Draft Training Report 2010). In response, the Rwandan Ministry of Health developed a training resource for health care providers.
In February 2010, the Ministry of Health in partnership with the SVRI and the Population Council, organized a training of national trainers to familiarise them with the manual and equip them with necessary skills and tools to train district trainers who, in turn, will train health care providers countrywide. The SVRI Ford Project Coordinator, was invited as a co-facilitator on this training. The training was held at Rwamagana District from February 22nd to March 5th, 2010. Thirty five participants took part in this training and at the end of the training presented district plans for the roll out of this training and for strengthening responses to sexual and gender based violence in their districts more generally. Key recommendations made as a result of these presentations are to:
Establish one stop centres at district hospitals if not available at a provincial level;
- Vaccinate all health care providers against hepatitis B and C;
- Ensure protocols for SGBV victim care and support and perpetrator management are available in all health services;
- Increase partnership & collaboration with all stakeholders in fighting against SGBV,
- Ensure the availability of essential medicine;
- Develop guidelines for the clinical management of SGBV;
- Increase sensitization and community awareness through local leaders and other parties that work with communities daily basis; and
- Accelerate the GBV clinical management training.
The SVRI will continue to liaise closely with our partners in Rwanda and provide support as required with regards the roll out and implementation of these plans.
Zimbabwe is home to high levels of sexual violence. Surveys report between 25% (Macro International 2007) to 37% of women report having been sexually assaulted at some point in her life (Watts, Kwaramba, Nalovu, Keogh, 1998). Although, child sexual abuse is reportedly very high; few children present to services in time to qualify for Post Exposure Prophylaxis (Garura, 2009). Violence against women and children is set against a backdrop of high levels of political uncertainty, economic decline, impunity for gendered violence, and is firmly rooted in gender inequality. In recognition of the need to address violence against women in Zimbabwe, Parirenyatwa Hospital, a government run hospital based in Harare, opened a rape crisis centre in March 2009. In preparation for the opening, staff contacted the SVRI for assistance with training of staff and supporting the development of a national response to rape, through research, curriculum development and training.
To support these efforts, the SVRI facilitated a site visit to South Africa of staff, a team of representatives from both the government and staff of the Adult Rape Clinic (ARC) as well as facilitated their attendance at the SVRI multi-sectoral regional training in February 2009. To ensure the consolidation of skills gained through the February training, the Zimbabwe team prioritised the need for a country specific training event. In preparation for the training, a site visit to Zimbabwe was undertaken from 28 – 29 May 2009. The purpose of the visit was to facilitate the development of a training plan, programme and a detailed understanding of the overall process and nature of the training.
A ten day training workshop on the management of sexual violence was then conducted from 20-31 July 2009 (MHCW & SVRI 2010). The Zimbabwe training programme drew content from both the Zimbabwe and South African national curricula. The training programme was co-facilitated by the Medical Research Council, South Africa, and the AIDS & TB Directorate, Ministry of Health, Zimbabwe.
Zimbabwe training report: African regional training Programme for care and support of sexual assault survivors. Management of sexual violence workshop. Ministry of Health and Child Welfare Zimbabwe, 20 - 31 July 2009.
The SVRI believes strongly in working in partnership, both to extend our reach and to enhance, rather than duplicate efforts to strengthen sexual assault services in the region. The following organisations were key partners in this project:
- Ford Foundation
- Medical Research Council of South Africa
- Population Council
- Carnegie Gender Intervention (Nigeria)
- IntraHealth International Inc. (Rwanda)
- ICAP / Rwanda – Columbia University
- Zimbabwe Ministry of Health
- Rwanda Ministry of Health
- Nigeria Federal Ministry of Health
- University of Jos (Teaching Hospital & Law Faculty)
- US President’s Emergency Plan For AIDS Relief
Online Resources and Links
- Improving healthcare access for survivors of sexual assault, Nursing@Georgetown, the online Women’s Health Nurse Practitioner program from the Georgetown University School of Nursing & Health Studies, November 2019.
- Strengthening health systems to respond to women subjected to intimate partner violence or sexual violence: A manual for health managers, WHO clinical and policy guidelines, 2017.
- Responding to children and adolescents who have been sexually abused, WHO clinical guidelines, 2017.
- Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. World Health Organization. 2013.
- National guidelines on management of sexual violence in Kenya. Ministry of Public Health & Sanitation & Ministry of Medical Services, 2nd Edition, 2009.
- The uses and impacts of medico-legal evidence in sexual assault cases: A global review. Du Mont, J. & White, D., Sexual Violence Research Initiative, World Health Organisation, 2007.
- Research summary: The uses and impacts of medico-legal evidence in sexual assault cases - A global review. Du Mont J. & White D, Sexual Violence Research Initiative, 2007.
- Primary level mental health care for common mental disorder in resource poor settings: Models and practice. A literature review. Lazarus, R and Freeman, M. 2009.
- Africa Regional Sexual and Gender-based Violence Network, Population Council.
- Workshop report on medico-legal responses to sexual violence. Strengthening the medico-legal response to sexual violence through multi-disciplinary collaboration among organizations and partners in Eastern, Central and Southern Africa. Nairobi, Kenya. LVCT, SVRI, 2-6 June 2008.
- Workshop: Medico-legal convening in response to sexual violence, Safari Park Hotel, Nairobi, Kenya, 2 – 5 June 2008.
- SVRI Medico-legal page