PART C – Other systems A detailed medical, obstetric and gynaecological history should be taken, including questions on sexual activity, menstruation and contraception. Physical signs after sexual violations and rape depend very much on the interval between the assault and the examination. Immediately after the rape of a woman, semen may be detected. She may have injuries all over her body. There may be bruises and bite marks, on the lips, neck, shoulders, buttocks and breasts. The vulva, vagina, anus and the urethra should be carefully examined and special attention should be paid to the perineum. There may be external signs of perineal tears, with laceration of the margin of the vaginal introitus or anus. Where injuries are gross, fistulae between vagina and the rectum may be seen. The presence and condition of a hymen should be noted. (Knight, 1991b). After electrical torture and/or blows in the genital region, haematuria may be found, due to injuries to the urethra and bladder (Lunde & Ortmann, 1992). Most acute symptoms disappear over time, and it may not be possible to differentiate scars of the perineum from scars after childbirth or scars following a sexually transmitted disease. Later, women may present themselves with complaints of vaginal bleeding, decreased sexual desire, genital irritation, pain during intercourse and urinary tract infections 31 (Campbell, 2002). Sexual torture may leave traces in the musculo-skeletal system, structural injuries, functional disturbances and dysfunctioning of the pelvic joints in women. They often have lumbar pain, and complain of pains in the genitalia, menstrual disturbances and sexual problems (Arcel, 2002). Damage to the genitals is most severe in girls under 15 years of age, and in girls and women who have previously been subjected to female genital mutilation. These girls and women are also at higher risk of contracting sexually transmitted diseases (STDs) or Human Immuno-deficiency Virus (HIV). Health care workers should always consider sexually transmitted diseases after rape. Soldiers, even during peacetime, have STD infection rates two to five times higher than those of civilian populations. The chance of infection is therefore considerable for women who have been raped by soldiers (Machel, 2000). Consequences of pregnancy and delivery, as well as of an unsafe abortion, must be considered. The most frequent complications are incomplete abortion, sepsis, haemorrhage and intra-abdominal injury, such as puncturing or tearing of the uterus (WHO, 1998). (See § 185, §§ 215-228 and § 232 in the Istanbul Protocol.)