He was later forced to perform a sex act on a man, in front of the trafficker and some other men. He struggled to recount both of these incidents, describing his fear and the force he felt under to do as the men told him. He has described suicidal feelings, difficulty in sleeping, nightmares and depression. Physical symptoms from rape There may be no physical signs or symptoms after male or female rape, whether from Sexually Transmitted Infections (STIs) or physical injury. A person who has suffered multiple rape, even over a period of many years, may have no signs or symptoms. Sexual health screenings should be conducted in order to treat any STIs as early as possible, but a negative outcome does not undermine a person’s claim that they have been raped any more than a lack of physical signs of other injury. Chronic lower abdominal pain is a common symptom in women who have suffered rape and sexual abuse. Ultrasound scanning (which is often used to investigate this pain) often fails to identify any physical cause. However, investigation is essential: a possible cause of lower abdominal pain is pelvic inflammatory disease as a result of sexually transmitted infections. Victims of trafficking should have access to prompt testing for sexually transmitted infections so they can be identified and treated. This includes the detection of blood-borne viruses such as HIV and Hepatitis B and C. Genito-urinary symptoms are also common due to the physical trauma of rape and/or sexually transmitted infections. Also, some women respond to the defilement they feel from rape by engaging in excessive washing and scrubbing of the vagina. This can disrupt normal vaginal flora and may cause thrush or bacterial vaginosis. The mechanical trauma of rape (i.e. force used in the pelvis) may result in a ligamentous or other tissue injury that causes long term pain even in the absence of medically identifiable pathology. Anal rape is common in trafficking cases but is often not disclosed by victims, or is disclosed with great difficulty and at a late stage, due to feelings of intense shame experienced. Men and women who have suffered anal rape may have pain and/or bleeding from their anus, or constipation arising from rape injuries. These symptoms can last a long time, especially if they are left untreated. 3.1.2 Clinical Investigation of Lesions Physical injuries can be medically evaluated to determine the degree of their consistency with ill-treatment. The ap- pearance, size, shape and location of a lesion often yields information about its likely cause. The Istanbul Protocol provides important standards which are recognized in international law for the evaluation of physical injuries and there are other useful existing medical guidelines and literature which help clinicians to evaluate the likelihood of physical injuries being caused through assault27. However the Istanbul Protocol advises that “ultimately, it is the overall evaluation of all lesions and not the consistency of each lesion with a particular form of torture that is important in assessing the torture story”. 28 HBF clinicians often observe and document trafficking cases in which a person has a long history of beatings to the body but does not have any scars which can be directly attributed to those beatings. Blows which do not penetrate the skin commonly leave only temporary bruising which heals without leaving a scar. Again, the Istanbul Protocol cautions that “… To the extent that physical evidence of torture exists, it provides important confirmatory evidence that a person has been tortured. However, the absence of such physical evidence should not be construed to suggest that torture did not occur, since such acts of violence against persons frequently leave no marks or permanent scars.” 29 Where there are multiple scars, their distribution may conform to the type of injury inflicted, e.g. scars on the wrists from tying, on the back or shoulders from beating, “defence” injuries on the forearms, palms or scars over the shins from being kicked.30 The pattern of scars can assist in providing evidence that ill-treatment has occurred. However, an absence of scarring should not be interpreted as meaning that ill-treatment did not occur. Many forms of ill-treatment (such as kicks, slaps, Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, „Acute lesions are often characteristic of torture, because they show a pattern of inflicted injury that differs from non-inflicted injuries, for example, their shape, repetition, distribution on the body.”; “[…] abrasions may show a pattern that reflects the contours of the instrument or surface that inflicted the injury”; Ibid., para. 196: “[r]egular patterns of small incisional scars could be due to traditional healers. … [but] [a]n asymmetrical pattern and different sizes of scars are probably significant in the diagnosis of torture” 59