SOUAIBY N, SMITH J, NAJA L, MICHAEL S.Â Clinical care for sexual assault survivors: the use of a Â multimedia training tool.Â Med Emergency, MJEM 2015; 23:3-9.
Key words: Multimedia training tool, sexual and gender based violence, sexual assault survivors, training of trainers
- Authorsâ€™ affiliation
- Article history / info
- Conflict of interest statement
Faculty of Medicine, Saint Joseph University, USJ, Beirut, Lebanon
Souaiby N, MD, MPH, MHM1, Smith J, MPH2, Naja L, MBA3 , Michael S, MPH3
1. Faculty of Medicine, Saint Joseph University, USJ, Beirut, Lebanon
2. ICAP, Columbia University Mailman School of Public Health, New York, USA
3. ABAAD-Resource Center for Gender Equality, Beirut, Lebanon
Received: Apr. 1, 2015
Revised: Apr. 22, 2015
Accepted: May 13, 2015
Introduction: Sexual assault rises as a global public health in conflict-affected populations where chaos prevails and gender based violence becomes as a strategy of war. The health effects of sexual violence include unwanted pregnancy, unsafe abortion, sexually transmitted infections (STIs), physical and psychological trauma, and social stigma. Training health care providers (HCPs) has been prioritized by humanitarian actors globally to improve the quality clinical care to survivors of sexual violence. However, few studies have evaluated the effectiveness of training interventions in refugee and post-conflict settings. Methods: A four to five days â€œtraining of trainersâ€ (ToT) was provided to relevant community health workers, nurses, midwives, doctors and other relevant field workers working in conflict-affected environments in Jordan, Turkey, Syria and Lebanon using the â€œClinical care for sexual assault survivors (CCSAS) multimedia training toolâ€ developed by International Rescue Committee (IRC).
Results: Overall, six ToTs took place; they included general practitioners, obstetrician/gynecologists, pediatricians, psychologist, forensic physicians, nurses, social workers, midwifes, and program officers. In Jordan, 50 participants (two groups of 25) have completed the training; the group improved by 142% on average at post-test in knowledge and attitudes to care for survivors (25% on average of correct answers at pretest, 60.5% on average at posttest). A second ToT in Jordan included 22 participants who have improved by 57.6% on average (50.3% vs. 79.3%). The third ToT in Turkey included 13 participants who have improved by 47% on average (38.5% vs. 56%). A forth ToT took place in Lebanon where 19 participants have improved by 62.5% on average (56% vs. 91%). The fifth ToT in Syria, included 18 participants who have improved by 46.2% on average (52% vs. 76%). And the sixth ToT took place in Turkey where nine participants have improved by 82.6% on average (46% on vs. 84%).
Discussion: All participants have successfully completed the training and showed improvement at the posttests. However, key challenges and limitations identified included logistics at the preparation and recruitment stages, language barrier and differences in cultural or religious views. Key barriers to quality care identified included poor or lack of access to services, lack of trained staff, lack of privacy and confidentiality and lack of essential resources and treatment including emergency contraception and HIV post-exposure prophylaxis (PEP) as well as unclear referral mechanism. Action plans were developed by participants to address these barriers and follow-up to evaluate progress was planned.
Conclusion: The CCSAS multimedia training tool showed an initial positive impact and has demonstrated effectiveness in promoting compassion and competence among trained HCPs and improving quality of clinical care for sexual assault survivors in such humanitarian settings. On-going technical and psychosocial support, long-term behavior change interventions, supply chain management, monitoring and evaluation, and interventions to raise awareness and identify survivors of sexual assault are needed in addition to the training to ensure quality clinical care is delivered to sexual assault survivors.
Sexual assault is a global public health and human rightsÂ challenge, and a particular threat to refugee and conflict-affectedÂ populations [1-3]. In fact, in such setting, where chaos prevail,Â gender based violence (GBV) emerges as a war strategy andÂ weapon [4-5]. The health effects of sexual violence have beenÂ well documented and include unwanted pregnancy, unsafeÂ abortion, sexually transmitted infections (STIs) including humanÂ immunodeficiency virus (HIV), physical injury, psychologicalÂ trauma, and social stigma . Timely access to quality clinicalÂ care, delivered by competent and compassionate health careÂ providers in a confidential care delivery setting, is essential toÂ begin a survivorâ€™s physical and emotional healing and reducethe risk of adverse consequences in the long-term.
Training health care providers (HCPs) has been prioritized byÂ humanitarian actors globally as a key component in improvingÂ the delivery of quality clinical care to survivors of sexual violenceÂ and there has been increasing demand to build an evidence baseÂ around training tools and methods effective in humanitarianÂ settings . Evaluations of training programs to date haveÂ demonstrated effects on the quality of clinical care delivery andÂ health and psychosocial outcomes for survivors in well-resourcedÂ medical settings [8-10]. However, few studies have evaluatedÂ the effectiveness of training interventions in refugee and post-conflictÂ settings.
MATERIALS AND METHODS
In order to meet the urgent need to increase the knowledge andÂ awareness on how to properly and efficiently care for sexualÂ assault survivors, a four to five days â€œtraining of trainersâ€ (ToT)Â was provided to relevant community health workers, nurses,Â midwives, doctors and other relevant field workers working inÂ conflict-affected environments where displaced populations areÂ facing such humanitarian crisis. Trainings took place in Amman,Â Antakya, Derek and Beirut.
The adopted training method was the â€œClinical care for sexualÂ assault survivors (CCSAS) multimedia training toolâ€ developedÂ by International Rescue Committee (IRC) as a unified trainingÂ tool aiming to improve clinical care for and general treatmentÂ of sexual assault survivors by providing medical instruction andÂ encouraging competent, compassionate, and confidential careÂ for sexual assault survivors in low-resource settings. The trainingÂ was intended to improve the quality of clinical care for sexualÂ assault survivors in diverse humanitarian settings.
As per the recruitment of HCPs and other relevant trainees, theÂ process included opening a general call for application entailingÂ a detailed syllabus for the training course; whereby individualsÂ expressed their interest in attending and submitted their resumeÂ to ensure that their qualifications are in-line with the pre-setÂ selection criteria for the training. The best qualified applicantsÂ were selected by the organizers -UNICEF and ABAAD in the caseÂ of Lebanon, IRC for the rest- to take part in the training.
Beside the introduction to the training and explaining the learningÂ objective; the training included five major sections:
Section 1: What every clinical worker needs to know
This section is intended to highlight the worldwide problem ofsexual assault, how cultural beliefs affect sexual assault survivorsÂ and survivorsâ€™ universal rights.
Section 2: Responsibilities of non-medical staff
This section is intended to describe the consequences of sexualÂ assault and how one can help a survivor start to heal.
Section 3: Direct Patient Care
This section contains directions on direct patient care includingÂ the following subsections:
– Receiving the patient and preliminary assessment
– Obtaining informed consent and taking the history
– Performing a physical exam
– Treatment and disease prevention
– Caring for male survivors
– Caring for young survivors
Section 4: Team Preparation
This section is intended to provide guidance on how to assessÂ the clinicâ€™s resources, organize the staff and materials neededÂ to care for survivors and map out referral network.
Section 5: Forensic Examination
This section is intended to provide relevant skills to be able toÂ conduct a compassionate, competent, and confidential forensicÂ examination, to obtain forensic specimens that can be used asÂ evidence and to properly document and store collected evidenceÂ to ensure permissibility in court.
Trainings were co-facilitated by clinical and GBV specialistsÂ experienced in working with sexual assault survivors using theÂ multimedia training tool in a standardized way according to theÂ methodology presented in a facilitatorâ€™s guide. This guide â€“ whichÂ can be downloaded online for free â€“ allowed for the training toÂ be unified whether in the content, timelines, ideas for exercisesÂ and workshop animation, etc, it also allowed for the trainingÂ to be reproducible, and for trainees to have same skills andÂ standard forms to use (such as drug treatment protocols, medicalÂ history and exam forms, and systematic clinical pathway of careÂ delivery (Figure 1). As such, the training was facilitated usingÂ multiple methods to engage participants and reinforce messagesÂ (Figures 2 to 5). It is also worth noting that the training wasÂ delivered with professional translation from English to Arabic andÂ Arabic to English and all training materials were distributed toÂ participants in both English and Arabic. As such, the followingÂ tools were adopted during the training:
Videos reenactment of interactions between health workersÂ and survivors of sexual assault was used to model best practiceÂ of competent, compassionate, confidential care. DocumentaryÂ style interviews with clinical care experts from around the worldÂ offered first hand perspectives on working with sexual assaultÂ survivors. Videos generated active discussion among participantsÂ about how to best care and interact with survivors.
Case studies conveyed issues for discussion and opportunities toÂ assess comprehension. Text cards provided detailed technicalÂ information about best practices and standards of care.
Group exercises allowed participants to role play active listeningÂ skills, responding to common emotional reactions of survivors,Â talking with suicide survivors, obtaining informed consent, andÂ documenting care on a medical history and exam form withÂ pictograms.
Summaries allowed each participant to summarize a part ofÂ the training giving them the opportunity to address the groupÂ as a trainer which was challenging for some of them but very
A â€œCCSAS ToTâ€ was conducted with the International MedicalÂ Corps (IMC) and the Ministry of Health (MoH) in Amman, Jordan,Â in November 2011. A total of 50 participants, divided in 2 groupsÂ of 25 (A and B) attended the training. They represented IMC andÂ MoH Jordan. IMC and MoH clinic staff attending the trainingÂ included general practitioners, obstetrician and gynecologists,Â pediatricians, psychologist, forensic physicians, nurses, socialÂ workers, midwifes, and program officers.
Groups A and B each has successfully completed the training;Â they improved by 142% on average at posttest in knowledge andÂ attitudes to care for survivors (25% on average of correct answersÂ at pretest, 60.5% on average at posttest). This could be explainedÂ by the very low knowledge at the pretest, and that the trainingÂ information and skills were mainly attained.
Another ToT was conducted in this same year in Jordan. A total ofÂ 22 participants attended the training representing IMC, IRC Jordan,Â IRC Iraq, and the United Nations Population Fund (UNFPA). IMCÂ clinic staff attending the training included general practitioners,Â obstetricians and gynecologists, pediatricians, psychiatrists,Â nurses, pharmacists, case managers, and program officers. IMCÂ management also attended the first day of training. Seven menÂ and fifteen women attended. Participants successfully completedÂ this training and improved by 57.6% on average at posttest inÂ knowledge and attitudes to care for survivors (50.3% on averageÂ of correct answers at pretest, 79.3% on average at posttest).
Another CCSAS ToT was conducted with the International RescueÂ Committee in Antakya, Turkey in October 2014. A group ofÂ 13 participants each successfully completed the training. IRC,Â MDM and Syrian American Medical Society trainees attendedÂ the training workshop. The group improved by 47% on averageÂ at posttest in knowledge and attitudes to care for survivors (38.5%Â on average of correct answers at pretest, 56% on average atÂ posttest).
In 2014, another ToT took place in Lebanon where 19 participantsÂ have successfully completed the training they includedÂ general physicians, obstetricians and gynecologists, midwives,Â psychologists, and other public health administrative positions.Â They improved by 62.5% on average at posttest in knowledge andÂ attitudes to care for survivors (56% on average of correct answersÂ at pretest, 91% on average at posttest).
In April 2015, the CCSAS ToT was conducted in Derek, Syria. AÂ group of 18 participants successfully completed the training.Â Participants included obstetricians and gynecologists, midwives,Â social workers and psycho-social officer. The group improved byÂ 46.2% on average at posttest, in knowledge and attitude towardsÂ survivors (52% on average of correct answers at pretest, 76% onÂ average at posttest).
Another training was conducted in May 2015, in Antakya,Â Turkey. The ToT performed entailed a group of nine participantsÂ successfully completed the training. They were all physiciansÂ (including surgeon, dentist, gynecologist, two family physiciansÂ and two emergency physicians) except one social worker.
T he group improved by 82.6% on average at posttest, inÂ knowledge and attitude towards survivors (46% on average ofÂ correct answers at pretest, 84% on average at posttest). This wasÂ the best result in terms of knowledge, amongst all groups thatÂ were trained in the last four years in Jordan, Lebanon, Turkey
Table 1 presents a summary of results of pretests and posttestsÂ conducted (aslo highlighted in graph 1) and shows the level ofÂ improvement in the trainees (as shown in graph 2). As suchÂ it reflects the effectiveness of the training itself as the higherÂ percentages of improvement were observed among the lowestÂ knowledge at pretest.
The first two sections of the training generated active discussionÂ about common myths: men cannot control sexual urges, aÂ woman may be to blame for sexual assault because of the wayÂ she dressed, and if a husband forces his wife to have sex it is notÂ sexual assault . Participants discussed challenges faced inÂ protecting survivorsâ€™ rights to privacy and confidentiality. TheyÂ also discussed the fact that when women in this region areÂ arrested, they are automatically labeled as sexually assaultedÂ which can cause harm to them once free .
New and active discussions were also generated about theÂ need to have programs responding to violence against menÂ in detention centers and camps. Trainees said that they areÂ receiving more and more case of sexual violence against boysÂ and this is due to the lack of programs reserved to them. UsuallyÂ programs targeted mainly girls .
Another critical issue concerning the reporting of rape cases toÂ authorities was discussed: By law, reporting is mandatory withoutÂ the consent of the survivor which doesnâ€™t adhere to ethics.
In some regions where nongovernmental armed forces controlÂ the ground, the â€œnon-official authoritiesâ€ request and oblige careÂ workers to share their findings. This can harm the principles ofÂ confidentiality.
In section 3, participants appreciated resources of WHOÂ international drug treatment protocols, medical history and examÂ forms, and systematic clinical pathway of care delivery. TheyÂ also commented on learning mental health needs of survivorsÂ and communication techniques: active listening skills for historyÂ taking and conducting the exam. They acquired new techniquesÂ to approach psychosocial cases since Psychosocial support is notÂ always accepted by the community.
Real and concrete cases related to collective rape and itsÂ devastative consequences were discussed: pregnancy out ofÂ rape, prohibition of abortion in the absence of any alternativeÂ to help women.
In section 4 all participants show interest to apply this trainingÂ in their different settings. This section guided them throughÂ adapting the lessons learned in the training to their local contextÂ by conducting a situation analysis and developing an action planÂ for the improvement of services for sexual assault survivors.
Participants were coached to map the future eventual trainingsÂ to be conducted with their referral networks; to conduct a trainingÂ checklist of resources needed (logistics, recruitment, agenda,Â objectives, etc.). They also discussed action plans to addressÂ gaps and barriers in the management of future cases and sharedÂ their assessments with the trainer to identify common challengesÂ and responses.
In section 5 covering the legal aspects and the importance ofÂ forensic evidence, basic principles were developed. TraineesÂ showed interest and were convinced that forensic evidencesÂ could be helpful to the international community when liabilitiesÂ are searched.
Furthermore, in the evaluation of the training, when asked to listÂ the topics that were not discussed during the training, but thatÂ were relevant to their work, participants wanted to learn moreÂ about SGBV in the context of Syrian crisis and which protocolsÂ are applicable in Syria. Moreover, they showed interest in buildingÂ a network from different actors in SGBV field inside Syria, allÂ of which to be linked to a central focal point. In fact, a call-inÂ hotline was provided in order to maintain communication with
relevant trainees and doctors in order to provide medical adviceÂ for sexual assaults cases which highlights the positive impact ofÂ the training and the high confidence in trainers. Also, with theÂ consent of trainees, feedback on training and improvement ofÂ trainees were discussed via social media (skype, whatsApp, etc.)Â with relevant management.
As for â€œthe ability to apply new acquired skills into their workâ€,Â most felt â€˜more confidentâ€ about handling SGBV cases asÂ discussed in the training, while others were â€œless confidentâ€Â because of lack of resources (absence of funding, inappropriateÂ settings, etc.) to develop such programs.
As for having â€œconcrete plans to apply their new acquired skillsâ€,Â suggestions included performing training and capacity buildingÂ for hospital staff, doctors, Non Governmental OrganizationÂ (NGO) staff and other relevant stakeholders. Also, they suggestedÂ providing training in Primary Healthcare Centers (PHC) andÂ building networks to link relevant stakeholders for futureÂ collaboration, in addition to providing private setting to ensureÂ privacy of the survivor. But most importantly, throughout thisÂ workshop, trainees became more aware of the importance ofÂ mental health counselling to victims especially at an early stageÂ because of its inferring consequences (nightmares, sleep quality,Â distress, quality of life impairment, etc.) [10;14].
Finally, trainees wished to seek further support andÂ communication from IRC and other international andÂ local NGOs in order to be able to efficiently apply acquiredÂ knowledge.
DISCUSSION AND RECOMMENDATIONS
Overall, the recruitment of trainees was good. They were all veryÂ motivated and followed the whole training without complaintsÂ and expressed what a great experience it was for them. In fact,Â it was beneficial to have participation from groups that wereÂ diverse in specialty, background, age and gender. Active andÂ open discussion was generated and participants learned fromÂ one anotherâ€™s clinical and counseling expertise as well as oneÂ anotherâ€™s beliefs and values.
There was a sense of cooperation and commitment fromÂ all candidates. They were friendly, with a good team spirit.Â Participants were also very helpful and had valuable interventionsÂ during the sessions.
However, based on initial findings from the evaluation andÂ training, key challenges were identified. They included limitationsÂ on the different levels, starting from the organization phase of theÂ training, where choice of location and other logistics includingÂ transportation of trainees or trainer were encountered especiallyÂ in Derek, and during the implementation phase of the trainingÂ where language was a key barrier in the first ToT provided. InÂ fact, although training provided by a highly experienced andÂ competent GBV expert, and although a professional translatorÂ was present at the training, the language remained a barrier inÂ the active discussion however this was taking into considerationÂ in other ToTs where trainings were the trainer was bilingual withÂ Arabic as a native language. Moreover, the need for an Arabic toolÂ has pushed efforts from IRC, The United Nations Childrenâ€™s FundÂ (UNICEF) and ABAAD to translate the facilitatorâ€™s guide. A firstÂ draft is developed but is not yet published as some terminologiesÂ need to be adapted to the context taking into consideration someÂ words sensitivity.
Also, it is worth noting that cultural or religious differences wereÂ observed while conducting the trainings in different countriesÂ and sometimes within the same country (for e.g. North eastÂ Derek vs. Damascus). This was reflected in the expressing beliefsÂ and point of views pertaining to virginity, the use of sensitiveÂ photos in the training, etc.
Moreover, challenges faced at the stage of spreading this acquiredÂ knowledge in conflict-affected areas where it is mostly neededÂ but where the implication of authorities and political party isÂ absent because of ongoing conflict and instable political contextÂ where armed forces prevail.
Key barriers to quality care identified included poor or lackÂ of access to services, lack of trained staff, lack of privacy andÂ confidentiality and lack of essential resources and treatmentÂ including emergency contraception and HIV post-exposureÂ prophylaxis (PEP) as well as unclear referral mechanism. Action
plans were developed by participants to address these barriersÂ and follow-up to evaluate progress was planned.
It is also worth noting that a one-to-one evaluation was performedÂ by the trainer. Results were not included as to preserve the privacyÂ and confidentiality of the evaluation, however general main keyÂ points and findings were reflects in the overall recommendationsÂ provided hereafter:
– Providing a refresher training (of two to three days) in a four-sixÂ months period from the date of the first training, followed by anÂ assessment and coaching that aims to support the trainees inÂ translating the knowledge gained from the training into feasibleÂ actions. This process will predominantly focus on developing aÂ clear action plan for the process of receiving and caring for theÂ survivor, using a participatory approach. This was partially startedÂ with the group and can be pursued by trainees themselves.
– Disseminating the CCSAS multimedia training tool amongÂ humanitarian actors on a wide scale to improve the quality ofÂ care for sexual assault survivors through improved knowledge,Â confidence, and attitudes among HCPs and improved facilityÂ preparedness.
– Promoting community awareness of CCSAS services available,Â throughout poster display and patient information materials, etc.
– Performing screening for sexual assault cases taking place InÂ order to better asses the magnitude of the problem especiallyÂ that literature and studies on SGBV in the Middle east are scarce.
– Referring survivors directly to a designated private consultationÂ room with privacy sign or locked or guarded door to ensure.
– Maintaining survivorsâ€™ medical records with a code and storeÂ in a separate locked cabinet.
– Conducting on-going refresher trainings in CCSAS among allÂ relevant staff.
– Disseminating job aides such as drug treatment protocols andÂ clinical care pathways as well as medical history and exam formsÂ with pictograms to guide care.
– Accompanying CCSAS training with on-going technical supportÂ to ensure knowledge and confidence in direct patient care forÂ sexual assault survivors is sustained; long-term behavior changeÂ interventions to address identified gaps in HCP sensitizationÂ and negative attitudes related to sexual assault; supply chainÂ management to ensure health facilities are equipped withÂ necessary supplies to provide services; monitoring and evaluationÂ to ensure quality of care is sustained; and interventions to raiseÂ awareness and identify survivors of sexual assault for improvedÂ access to CCSAS.
– Coordinating with the United Nations Population Fund and otherÂ international parties to obtain PEP kits where needed.
– Using adjusted dosages of registered contraceptives for theÂ purpose of emergency contraception .
– Disseminate referral protocols for services within IMC andÂ external referrals to MoH and other advanced medical,Â counseling, forensic, and legal services.
– Enhancing CCSAS training pertaining to psychosocial careÂ and support for survivors; clinical treatment protocols; validatedÂ monitoring and evaluation tools; awareness raising materials; andÂ tools for identifying survivors of sexual assault.
The CCSAS multimedia training tool showed an initial positiveÂ impact and has demonstrated effectiveness in promotingÂ compassion and competence among trained HCPs andÂ improving quality of clinical care for sexual assault survivors inÂ such humanitarian settings . The evaluation revealed limitationsÂ in the capacity of HCPs and quality of care for sexual assaultÂ survivors in low-resource settings. Aspects of the training thatÂ were more effective included respecting survivorsâ€™ universalÂ rights, obtaining informed consent, conducting a medicalÂ history, performing a physical exam, while training componentsÂ focusing on beliefs about sexual assault, treatment and diseaseÂ prevention, care for child survivors, and care for male survivorsÂ need to be improved. However, It was also of utmost importance
to unify the â€œCCSAS languageâ€ as to having a standard PEP andÂ emergency contraception protocols to follow and to for traineesÂ to develop relevant skills and know-how, in addition to acquiringÂ the necessary resources including PEP kits and emergencyÂ contraception which are often lacking in resource limited andÂ conflict affected settings.
Finally, on-going technical support, long-term behavior changeÂ interventions, supply chain management, monitoring andÂ evaluation, and interventions to raise awareness and identifyÂ survivors of sexual assault are needed in addition to the trainingÂ to ensure quality clinical care is delivered to sexual assaultÂ survivors. More follow up and refresher workshops need toÂ be performed. However, it is to be taking into considerationÂ that various countries have different sets of laws, policies andÂ procedures and/or lack of ones in the case of conflict areas.Â Local, national and internationals efforts need to combine theirÂ resources and support to ensure optimal corrective actions andÂ follow up.
Authorâ€™s note 1. Krug E, Dahlberg L, Mercy J, Zwi A, Lozano R. World report on violence and health. Geneva (SUI): World Health Organization; 2002. 2. Ward J, Vann B. Gender-based Violence in Refugee Settings. Lancet 2002; s13-4. 3. Johnson K, Scott J, Rughita B, Kisielewski M, Asher J, Ong R, et al. Association of sexual violence and human rights violations with physical and mental health in territories of the eastern democratic republic of Congo. JAMA 2010; 304:553-62. 4. Marsh M, Purdin S, Navani A. Addressing sexual violence in humanitarian emergencies. Global Public Health 2006; 1:133-46. 5. Sexual and gender-based violence against refugees, returnees and internally displaced persons. United Nations High Commissioner for Refugees; 2003 May. 6. Ellsberg M, Jansen HA, Heise L, Watts CH, Garcia-Moreno C. Intimate Partner Violence and Womenâ€™s Physical and mental health in the WHO multi-country study on womenâ€™s health and domestic violence: An observational study. Lancet 2008; 371:1165-72. 7. Action against sexual and gender based violence: An updated strategy. United Nations High Commissioner for Refugees; 2011 June. 8. Martin S, Young S, Billings D, Bross C. Health care-based interventions for women who have experienced sexual violence. A review of the literature. Trauma Violence Abuse 2007; 8:3-18. 9. Kim JC, Askew I, Muvhango L, Dwane N, Abramsky T, Jan S, et al. Comprehensive care and HIV prophylaxis after sexual assault in rural South Africa: the Refentse intervention study. BMJ 2009; 338:b515. 10. Campbell R, Patterson D, Lichty LF. The effectiveness of sexual assault nurse examiner (SANE) programs: a review of psychological, medical, legal, and community outcomes. Trauma Violence Abuse 2005; 6:313-29. 11. Davies M, Gilston J, Rogers P. Examining the relationship between male rape myth acceptance, female rape myth acceptance, victim blame, homophobia, gender roles, and ambivalent sexism. J Interpers Violence 2012; 27:2807-23. 12. Koss MP. Blame, shame, and community: Justice responses to violence against women. Am Psychol 2000; 55:1332-43. 13. Carpenter C. Recognizing gender-based violence against civilian men and boys in conflict situations security dialogue 2006; 37:83-103. 14. Krakow B, Melendrez D, Johnston L, Warner TD, Clark JO, Pacheco M, et al. Sleep-disordered breathing, psychiatric distress, and quality of life impairment in sexual assault survivors. J Nerv Ment Dis 2002; 190:442-52. 15. Lee C, Krause S, Matthews J, Quick D, Chynoweth S. Emergency contraception in conflict-affected settings. The Reproductive Health Response in Conflict Consortium; 2004.
The author would like to acknowledge the support ofÂ ABAAD as well as IRC and UNICEF as partners in theaccomplishment of these ToTs.Â The author also declares no conflict of interest with partiesÂ who have funded these ToTs.
1. Krug E, Dahlberg L, Mercy J, Zwi A, Lozano R. World report on violence and health. Geneva (SUI): World Health Organization; 2002.
2. Ward J, Vann B. Gender-based Violence in Refugee Settings. Lancet 2002; s13-4.
3. Johnson K, Scott J, Rughita B, Kisielewski M, Asher J, Ong R, et al. Association of sexual violence and human rights violations with physical and mental health in territories of the eastern democratic republic of Congo. JAMA 2010; 304:553-62.
4. Marsh M, Purdin S, Navani A. Addressing sexual violence in humanitarian emergencies. Global Public Health 2006; 1:133-46.
5. Sexual and gender-based violence against refugees, returnees and internally displaced persons. United Nations High Commissioner for Refugees; 2003 May.
6. Ellsberg M, Jansen HA, Heise L, Watts CH, Garcia-Moreno C. Intimate Partner Violence and Womenâ€™s Physical and mental health in the WHO multi-country study on womenâ€™s health and domestic violence: An observational study. Lancet 2008; 371:1165-72.
7. Action against sexual and gender based violence: An updated strategy. United Nations High Commissioner for Refugees; 2011 June.
8. Martin S, Young S, Billings D, Bross C. Health care-based interventions for women who have experienced sexual violence. A review of the literature. Trauma Violence Abuse 2007; 8:3-18.
9. Kim JC, Askew I, Muvhango L, Dwane N, Abramsky T, Jan S, et al. Comprehensive care and HIV prophylaxis after sexual assault in rural South Africa: the Refentse intervention study. BMJ 2009; 338:b515.
10. Campbell R, Patterson D, Lichty LF. The effectiveness of sexual assault nurse examiner (SANE) programs: a review of psychological, medical, legal, and community outcomes. Trauma Violence Abuse 2005; 6:313-29.
11. Davies M, Gilston J, Rogers P. Examining the relationship between male rape myth acceptance, female rape myth acceptance, victim blame, homophobia, gender roles, and ambivalent sexism. J Interpers Violence 2012; 27:2807-23.
12. Koss MP. Blame, shame, and community: Justice responses to violence against women. Am Psychol 2000; 55:1332-43.
13. Carpenter C. Recognizing gender-based violence against civilian men and boys in conflict situations security dialogue 2006; 37:83-103.
14. Krakow B, Melendrez D, Johnston L, Warner TD, Clark JO, Pacheco M, et al. Sleep-disordered breathing, psychiatric distress, and quality of life impairment in sexual assault survivors. J Nerv Ment Dis 2002; 190:442-52.
15. Lee C, Krause S, Matthews J, Quick D, Chynoweth S. Emergency contraception in conflict-affected settings. The Reproductive Health Response in Conflict Consortium; 2004.