Forensic observations and recommendations on sexual and gender based violence in Kenya

Abstract

Sexual and Gender Based Violence (SGBV) in Kenya is highly complex requiring a multi-sectoral approach for comprehensive management. This complexity is worsened by the acceptance of Sexual Violence within a patriarchal society, harmful traditional and cultural practices, breakdown of law and order especially during electoral periods, all heightened by abject poverty.

There are numerous programs on interventions costing millions in local and foreign currency, however grave gaps still exist at key levels across all sectors even after years of continued intervention.

The overall lack of specialist forensic knowledge required to strengthen key service provision contributes to the rise of many parallel and poor quality approaches. The challenges that victims face in accessing justice are tremendous while suspects' rights to a fair trial requires serious evaluation. The value of specialist forensic service provision in achieving Sustainable Development Goal number 16 in Kenya or in a developing country context cannot be underestimated.

Acronyms

ACEs

Adverse Childhood Experiences

CSA

Child Sexual Abuse

CCM

Coordinated Care Model

CCTV

Closed Circuit Television

CoC

Chain of Custody

DCS

Directorate of Children Services

DoJ

Department of Justice

DFPS

Division of Forensic and Pathology Services

DV

Domestic Violence

GBV

Gender Based Violence

GVRC

Gender Violence Recovery Center

GBVRC

Gender Based Violence Recovery Center

HIV

Human Immunodeficiency Virus

IPV

Intimate Partner Violence

IOSC

Isange One Stop Center

KDHS

Kenya Domestic Household Survey

KES

Kenya Shillings

KNH

Kenyatta National Hospital

MAAMC

Multi-Agency Assault Management Center

MoE

Ministry of Education

MoH

Ministry of Health

MoI

Ministry of Interior and Coordination of National Government

MoICT

Ministry of Information, Communication and Technology

MSF

Medecins San Frontieres

NGEC

National Gender Equality Commission

NAI

Non-Accidental Injury(s)

NPS

National Police Service

NWH

Nairobi Women's Hospital

OAG

Office of the Attorney General

ODPP

Office of the Director of Public Prosecutions

P3

Kenya Police Medical Report Form

PRC

Post Rape Care Form

PTSD

Post Traumatic Stress Disorder

RHMSU

Reproductive and Maternal Health Services Unit

SAGA

Semi Autonomous Government Agency

SGBV

Sexual and Gender Based Violence

SRGBV

School Related Gender Based Violence

STD

Sexually Transmitted Diseases

STI

Sexually Transmitted Infections

SV

Sexual Violence

SDG

Sustainable Development Goal

SOA

Sexual Offences Act 2006

TNA

Training Needs Assessment

TOT

Training of Trainers

UDHR

Universal Declaration of Human Rights

UHC

Universal Health Coverage

UN

United Nations

USD

United States Dollar

WHO

World Health Organization

Author's note

This report and the recommendations/proposal herein are an initiative of forensic practitioners’ stationed within the Division of Forensic and Pathology Services of the Ministry of Health and the National Police Service. It has been prepared for consideration by both state (inter-ministerial/state multi-sectoral) and non-state actors. The aim of this report is to shed light on the challenges and processes required to integrate the current mandatory multi-agency services and to tackle the menace of Sexual and Gender Based Violence for vulnerable groups.

The Kenyan law clearly defines the terms “assault” and “sexual assault”. In keeping with internationally recognized terminology, the authors agree to, and recognize, the use of the terms ‘assault’ in this report to refer to inflicted physical injuries while ‘sexual assault’ refers to all forms of sexual offences. In a bid to maintain contextual clarity in the Kenyan setting, the term Sexual and Gender Based Violence (SGBV) will be used throughout this report as it encompasses Child Sexual Abuse (CSA), Intimate Partner Violence (IPV) and Sexual Violence (SV). This report acknowledges that Child Neglect and Maltreatment and Non-Accidental injuries in childhood falls under child abuse requiring competencies in forensic medicine for proper management.

This report acknowledges that investigation of SGBV cases involves the living victims who continue to experience the long term negative consequences in the quest for justice and the journey to recovery. SGBV may also result in the transmission of Sexually Transmitted Infection(s), deaths due to abortion complications following sexual violence related pregnancies, and can be fatal as a result of injuries or as a consequence of homicide related deaths [1]. A large proportion of the burden of disease from SGBV is related to mental health problems manifesting as psychosomatic disorders, substance abuse amongst others.

It is critical to note that both sets of victims (living and deceased) and suspects of SGBV are equally important in relation to forensic considerations and may be considered as ‘moving crime scenes’ [2]. For this reason therefore victim management without suspect management may result in a compromised investigation. Recognizing the fact that victims and suspects of sexual and physical violence are crime scenes underscores the urgency with which these cases need to be dealt with. Handling these cases in a timely and professional manner not only facilitates medical treatment, but also allows for comprehensive forensic evidence gathering. To further clarify, processing half the crime scene namely only the victim, amounts to a basic violation of the rights of the suspect, who also has a right to be examined to ensure their right to a fair trial as provided in the Constitution of Kenya [3]. As a result of the quality of care required by both victims and suspects, this report does not endorse task shifting in the specialist practice of forensic medicine.

This report is written on the basis of the understanding of fundamental forensic and medical principles and the identification of major systemic gaps across the public sector that currently hinder the prevention and effective response to these cases countrywide. In addition, it should be noted that concerns addressed within this report may have been identified by other sectors and/or actors. The responsibility for opinions, observations, findings and recommendations in this report and for any errors of fact or interpretation rests solely with the authors.

Definition of terms

Assault refers to the direct or indirect application of force to the body of, or to the clothing or equipment worn by a person(s). Application of force includes the application of heat, light, electric current or any other form of energy, as well as the application of matter in solid, liquid or gaseous form(s) [4].

Defilement refers to an act which causes penetration of a child's genital organs according to the Sexual Offences Act under the Kenyan Law [5].

Expert Witness is a person whose level of specialized knowledge or skill in a particular field qualifies them to present their opinion about the facts of a case during legal proceedings [[6], [7]].

Forensic Medicine is branch of medicine where principles and the knowledge of medicine including laboratory examinations are applied to legal matters in both criminal and civil proceedings. There are various forensic disciplines within the practice of Forensic Medicine.

Forensic medical/science disciplines include and encompass

• ⁃Clinical Forensic Medicine: Custodial Medicine, Traffic Medicine, Child Abuse and Neglect, Domestic Violence, Sexual Violence
• ⁃Forensic Human Identification: Forensic Odontology, Forensic Anthropology
• ⁃Forensic Sciences: Forensic Biology, Forensic Genetics, Forensic Toxicology
• ⁃Forensic Pathology
• ⁃Forensic Photography
• ⁃Forensic Psychiatry
• ⁃Forensic Radiology
• ⁃Forensic Entomology
• ⁃Forensic Osteology
• ⁃Fingerprint Analysis
• ⁃Ballistics among other disciplines.

Genital Organs according to the Kenyan Law is defined as includes the whole or part of male or female genital organs including the anus [8].

Locard's Exchange Principle is a forensic principle that states every contact leaves a trace [9].

Medical Evidence is a form of expert evidence presented by medical professionals who are allowed to give their expert medical opinions (medical notes, photographs), which are admissible in court.

Multi-Agency Assault Management Center (MAAMC) refers to a proposed coordinated care model that addresses assault cases of Intimate Partner Violence (IPV), Non-Accidental Injuries (NAI) in childhood, Child Sexual Abuse (CSA), Sexual Violence (SV) or Sexual and Gender Based Violence (SGBV).

Non-Accidental Injuries in children refers to injuries sustained as the result of a deliberate action by another person [10].

Penetration means the partial or complete insertion of the genital organs

of a person into the genital organs of another person [11]. Applies to both child and adult sexual abuse.

Rape: A person commits the offence termed rape if:

• a)he or she intentionally and unlawfully commits an act which causes

• penetration with his or her genital organs;

• b)the other person does not consent to the penetration; or
• c)the consent is obtained by force or by means of threats or intimidation
• d)of any kind according to the Sexual Offences Act [12].

Sexual and Gender Based Violence is an umbrella term for harmful acts perpetrated against a person's will that includes acts that inflict physical, sexual or mental harm or suffering, threats of such acts, coercion, and other deprivations of liberty whether in public or in private [13].

Sexual assault

• a)
  penetrates the genital organs of another person with

  • (i)
    any part of the body of another or that person; or
  • (ii)
    an object manipulated by another or that person except where such penetration is carried out for proper and professional hygienic or medical purposes;
• b)manipulates any part of his or her body or the body of another person so as to cause penetration of the genital organ into or by any part of the other person's body according to the Sexual Offences Act [14].

Sexual Offences Act of 2006 is an Act of Parliament to make provision about sexual offences, their definition, prevention and the protection of all persons from harm from unlawful sexual acts [15].

Survivor refers to a person who lives through physical and or sexual violence, and will be used interchangeably with the term ‘victim’ or ‘patient’ in this report.

Suspect refers to an alleged assailant or perpetrator and will be used interchangeably in this report.

Victim refers to a living injured or deceased individual and the term victim will be used interchangeably or in addition to the term ‘survivor’ or ‘patient’ where relevant.

Methodology

This is not a scientific article neither does the article test any hypothesis. This is an experience based descriptive article, which provides an assessment of the management of Sexual and Gender Based Violence and includes Child Abuse. The content within this report is derived from the authors' experiences having worked within the Kenyan context interacting with numerous stakeholders both State and Non-State including victims, suspects and their families. The aim of this report is to highlight grave challenges and propose recommendations based on the authors’ observations.

1. Introduction

Sexual and Gender Based Violence (SGBV) is a violation of human rights resulting in immediate and long term negative effects on the physical, psychological and the social aspects of victims, their loved ones and society as a whole [[16], [17]].

Various parties are involved in the management of SGBV including: victims of the crime, suspects of the crime, those who investigate the crime, those who examine and treat the victim – two way medical management (a dual obligation process involving medical examination/treatment (that addresses the life threatening conditions, treatment of injuries, provision of sexually transmitted infection prophylactic medication and emergency contraception) and the forensic medical examination/investigation (examination, interpretation, documentation of injuries and evidence gathering including forensic specimen collection), those who receive, analyze and provide results of analysis of the evidence, all of whom may then be required to testify in court as witnesses or as expert witnesses, those who prosecute the crime, and those who protect victims from further harm [18].

The provision of quality care and access to justice of SGBV victims and suspects has its roots in forensic medicine and its related forensic disciplines. Training in forensic medicine is carried out at post-graduate level and is the medical specialization that plays a key role in the appropriate approach and response to the proper handling of SGBV cases [19].

In 2015, under the umbrella of the United Nations, countries adopted the 2030 Agenda for Sustainable Development and its 17 Sustainable Development Goals (SDG) [20]. While there is no stand-alone goal on science in the SDG's, there is not a single SDG in the new agenda that will not require inputs from science. The SDGs recognize the need to mobilize science at multiple levels and across disciplines to gather or create the necessary knowledge and thus lay the foundations for practices, innovations and technologies needed to address global challenges today and in the future [21].

From a forensic perspective, SDGs 3,4,5,16 and 17 [22] are interconnected by the challenges posed by SGBV and their respective target recommendations. These target recommendations provide an avenue towards the proper management of SGBV through the role of science in forensic medicine and its related disciplines to promote access to justice.

Forensic medical services that support the management of SGBV cases are interdependent with those of other divisions within the health sector such as Reproductive and Mental Health. The aforementioned interdependency extends beyond the health sector to other sectors such as the Directorate of Criminal Investigation, Department of Children Services, Witness Protection Agency, Office of the Director of Public Prosecutions amongst others. Therefore, forensic services are interlinked not only at procedural but also at policy level thus necessitating efficient interactions for practical solutions in addressing challenges in SGBV.

2. Contextual analysis

2.1. School related Gender Based Violence (SRGBV)

In 1991, 71 schoolgirls were raped and 19 killed at St. Kizito School in Meru, Kenya. The Deputy Principal was quoted telling the former President Moi that “the boys never meant any harm against the girls. They just wanted to rape” [23]. Twenty seven years later the case of sexual violence at Moi Girls School Nairobi [24] in June 2018, brings to the fore the magnitude of sexual and physical violence suffered by vulnerable population groups. The overwhelming disproportionate majority of the victims of SGBV are women and girls, and approximately 45% of women aged between 15 and 49 years have experienced sexual and/or physical violence in Kenya as stated by GVRC [25]. According to the Kenya Domestic Household Survey (KDHS) 2014, 38% of women aged 15–49 reported physical violence and 14% reported having experienced sexual violence [26]. In 2017,784 cases of rape, 3487 cases of defilement, 287 cases of incest, 107 cases of sodomy and 245 cases of indecent assault were reported [27].

During the Kenya Certificate of Primary Education examination of 2018, it is quoted that over 100 pupils sat these examinations while pregnant in Kilifi County [28]. It is not afar off that this aforementioned incident reflects abject poverty resulting in child prostitution to cater for basic necessities and the pregnant pupils are actual victims of societal failure [[29], [30]]. SRGBV has serious consequences for children's physical and mental health and well-being. SRGBV has been shown to adversely impact learning, school attendance, and completion of all learners and has wider negative impacts on families and communities [31].

2.2. Current response mechanisms in assault and sexual offence management cases

Following an alleged sexual violence, physical violence or child abuse case, the victims will report the issue in the following manner:

• i.Victims report to the police stations, and are then referred to medical facilities for examination where a medical report or in the case of sexual violence a manual form called a Post Rape Care Form (PRC) [32] may be available for documentation in triplicate.

The medical report and or PRC generated at the medical facility is then required back at the police station for the initiation of investigations through the issuance of the Kenya Police Medical Report Form (P3) [33]. This (P3) form acts as an exhibit, evidence that an injury was sustained.

OR

Victims report at a medical facility, receive medical treatment and High Vaginal Swab collection, and are then referred to the Police station to report the matter and be issued with a (P3) form.

• ii.Once issued with the (P3) form, the victims will have to visit a government designated medical facility for re-examination and completion of the P3 form, which may be a different facility altogether.

• The re-examination of the victim and completion of the (P3) can take day(s) to weeks as the victims move from one location/institution to another, and may have to wait for a specific day during the week when the medical practitioners are available to provide this service. This may/may not result in a re-examination (second examination), and may or may not be completed by copying the content from within the medical report/PRC form at the first point of examination (initial medical facility).

• iii.Once a P3 form is completed, the form is then returned to the police station by the Police officer as the P3 acts as an exhibit or evidence in a sexual offence or physical assault allegation. However, it is not uncommon for the victim(s) as well as interested parties to handle this forensic evidence.
• iv.Forensic specimens collected at the initial or subsequent medical facility, may or may not be collected by the police officer investigating the case for submission to the Government Chemist laboratory, Forensic Biology Unit. In the majority of cases there are limitations in the transference of forensic specimens from the point of collection to the laboratory for evidence analysis.
• v.Suspects may or may not be examined or undergo any reference sample collection at the Police Surgery in Nairobi, or at a public medical facility/institution. In addition, anecdotal reports from various stakeholders indicate that biological reference samples are rarely collected from victims.
• vi.All information is then placed in the police file pending court submission and prosecution.

2.3. Office of the Police Surgeon in Nairobi

As of May 2018, anecdotal reports from the Police Surgery in Nairobi convey that an average of 8 defilement cases, and at least 15 cases of Intimate Partner Violence (IPV) were registered daily. Further, an average of 4 mental status examinations were carried out on murder suspects weekly, many having allegedly fatally injured their spouses. These statistics represent a minute fraction of the much larger number of unreported and unpursued cases. The exact number of cases is difficult to establish since there is a lack of a coordinated prevention and response mechanism within the public sector that is required to support a fully optimal centralized data output system that would inform policies that will enable the comprehensive management of SGBV and Child Abuse. Currently, the majority of records on these cases are still preserved in manual format and are therefore at risk of damage and loss over time.Their future usefulness whose benefits cannot be compared to those that are automated [34].

SGBV may become fatal through homicide related deaths. WHO states that 38% of women victims of homicide die at the hands of their intimate partners. Deaths in addition occur from injuries, sequelae of sexually transmitted disease or deaths due to SGBV related induced abortions [35] A worrying emerging trend is the frequent reports of SGBV cases that are associated with electoral cycles, the homeless, and among persons with disabilities as well as mentally challenged persons. A further observation is conflict-related spillage of sexual violence following the influx of refugees into Kenya. The continued acts of SGBV perpetrated on this vulnerable group by perpetrators from the same context (country of origin) is a highly disturbing observation made by police surgeons. Survivors testimonials include the use of Sexual Violence as a weapon of war.

2.4. Impact on mental health

Adverse Childhood Experiences (ACEs) are experiences suffered by children exposed to violence, survivors of physical, sexual and emotional abuse, observers of criminal activity in the home, substance abuse by parents or living in a dysfunctional domestic setting resulting in mental health problems and psychosomatic disorders characterized by numerous hospitalizations [36]. Up to 30% of child victims/survivors of sexual abuse are at a higher risk of becoming perpetrators of the same behavior [[37], [38]]. Another disconcerting observation at The Office of the Police Surgeon in Nairobi is the increased frequency of male child suspects.

2.5. Lack of well-managed forensic evidence

Fairness in justice for victims and suspects of SGBV and interested parties primarily (at a minimum) requires integrity of forensic evidence and the integrity of the chain of its custody which is intrinsic to evidence-based convictions. A major contributory factor in improper management of forensic evidence is the lack of Chain of Custody (CoC) of evidence mechanisms [39] including an inadequate PRC form and an outdated P3 form [40]. The consistent lack of well-managed forensic evidence [41] in accordance with international forensic best practices (forensic medical examination of injuries, their interpretation, documentation in medical notes and in the form of forensic photographs as well as the proper management of forensic evidence including its collection, labeling, preservation, storage and analysis) remains one of the major causative factors in the significantly low number of convictions. This in turn, leads to the inability to rein in repeat offences which remains core to the prevention (track, monitor, possibly publicize) of SGBV.

2.6. Legislative framework

Kenya has a comprehensive bulk of laws both domestic and international including policies and administrative measures set in place to guide the administration of justice in SGBV [42]. In a bid to support preventative action, the Sex Offenders Registry [43] is currently a manual registry retained within court custody that consists of convicted sex offenders. In 2008 subsidiary legislation made to the Sexual Offences Act of 2006 [44] made provisions for the Dangerous Offenders DNA Data Bank that is yet to be implemented. Currently, underway is the drafting of the Sexual Offences Policy initiated in October 2018 by the Office of the Attorney General (OAG) and the Department of Justice (DoJ) to guide the implementation of the Sexual Offences Act (SOA) of 2006.However, enactments specific to forensic best practice within police, medical and laboratory science agencies are yet to be established as part of the ongoing mechanism. It is yet to be seen as to whether the SOA of 2006 and or the Election Offences Act 37 of 2016 [45] will be reviewed to include specific amendments on sexual violence (including other human rights violations) related to electoral offences during state and civilian population interaction.

2.7. The dynamic between non-state agencies and the state

The support of non-state agencies in conducting awareness campaigns has consistently and admirably pursued the narrative to end SGBV in the Kenyan setting. There are numerous notable initiatives that have been supported by non state actors supporting state and non-state programs at facilities such as Kenyatta National Hospital (SGBV Clinic), Mama Lucy Kibaki Hospital, Makadara Health Center, Medecins Sans Frontieres clinics, Nairobi Women's Hospital (GVRC) to assist victims of SGBV among others.

These clinics work through a victim-centered approach and provide access to medical services, specimen collection (usually only high vaginal swabs) and psychological support services all of which may either be free, subsidized or paid up to assist victims. Specimens may be collected at these centers by medical personnel of different cadres who may or may not have received any previous sensitization on the skills required to conduct a forensic medical examination, and are unaware of the interlinked complexities between the ethical, legal and criminal dynamics of these cases.

SGBV in the Kenyan setting is driven by various narratives such as a ‘women’ problem or a ‘gender’ problem, a ‘human rights violation’ problem, a ‘reproductive health’ problem more recently an ‘unfair to the boy child’ problem. Though, these may be valid perceptions the access to justice component in SGBV is hardly understood as a significant ‘forensic’ problem that results from poor governance cutting across police forensics, medical forensics, laboratory science forensics [46] as well as in the higher education sector in Kenya. While non-state agencies programs assist to contribute to the response of SGBV, the lack of understanding and knowledge that solving a forensic problem will require a forensic led approach still remains, a fundamental drawback.

While the measurability of the impact of both state and non-state sector may include various indicators such as unwanted pregnancies prevented or sexually transmitted infections prevented, trainings held, participants’ sensitized/trained, the overall impact in terms of forensic management and access to justice for victims of SGBV from the sectors still remains unknown.

The handling of the non-state and state sector in managing SGBV is tilted in the favor of the non-state sector which has greater access to financial resources and personnel addressing various aspects of the problem. This is against the lean human resources of the state with even fewer specialists who have limited or no access to funding requirements. In addition, insufficient technical knowledge that cuts across various segments of the state and non-state sectors aggravates the lack of quality strategic interventions and strong coordination mechanisms that would contribute to a step-wise approach in addressing systemic overhaul. ‘If you define the problem correctly, you almost have the solution’ - Steve Jobs.

2.8. Development of guidelines and capacity building

The Reproductive and Maternal Health Services Unit (RHMSU) and development partners at the MoH developed the National Guidelines for the Management of Sexual Violence [47] and the National Standard Operating Procedures for the Management of Sexual Violence Against Children [48]. A training curriculum for the same was created that consists of a 5-day training program being carried out in various counties. The training covers: Gender Norms, Medical Management, Forensic Management, Monitoring and Evaluation, Sexual Offences and the Law, Rape in Humanitarian Crises. While this is a commendable initiative, much more than a 5-day training program will be required to impart the requisite competencies to the various cadres of medical personnel interested in and mandated to manage SGBV cases. According to Wells.D.,’Forensic medicine has a great deal to offer the investigation and prosecution of these offences …. and assists in the rebuilding of health, policing, judicial and social services, for the best interests of victims and their communities’ [49]. It is therefore critical to note that an investment for capacity-building in forensic medicine (post graduate) is required for medical practitioners and other health care professionals with cost estimates ranging from between USD 20,000 to USD 60,000.

Furthermore, a clear human resource capacity building strategy for the medical and the specialist forensic management of these cases is still lacking. This is compounded by an overall lack of awareness that supports an expectation that specialist forensic examination can be conducted at a primary level of care. In addition, a collaborative multi-disciplinary approach involving the national investigative, psychological, social, medical, forensic and legal instruments does not yet exist together holistically as a first point of access to the victim.

2.9. Cost of the problem

The economic burden of SGBV in Kenya is approximately KES 46 billion (USD 455 Million) per year which translates to 1.1% of the Kenya's Gross Domestic Product. At the national level, annual out-of-pocket medical-related expenses (money which a survivor or their family paid out of their own financial resources) were estimated at a staggering KES 10 billion (USD 99 Million). The productivity losses from serious injuries were estimated at about KES 25 billion (USD 24.7 Million) and from minor injuries at KES 8 billion (USD 79 Million). The study on the economic burden on survivors of SGBV found that productivity loss from premature mortality amounted to KES 5,840,664 (USD 57,868). Productivity loss per survivor from injuries was stated as amounting to KES 223,476 (USD 2214). Incarceration of a perpetrator negatively impacts families costing them at a minimum KES 80,000(USD 793) [[50], [51]] in a country where half the population lives on under USD 1.90 per day [52].

2.10. Corrupt practices

Corruption is a gross menace in all nations, resulting in the slow destruction of all sectors of governance and society [53]. Where the fight for justice and rehabilitation is concerned in Kenya, frequent allegations of corrupt acts across all sectors makes headlines in our setting. The main challenges facing service delivery in developing countries includes absenteeism, corruption, informal payments and mismanagement [54]. These series of behaviors, attitudes and acts are so entrenched that victims and suspects have succumbed to extortion practices to facilitate mandatory free services, without which, they face barriers in accessing justice. It is not uncommon for victims to stop pursuing cases and or drop charges due to the difficulties faced [[55], [56]].

3. Stakeholder mandates and challenges

3.1. Nation wide (state) sector/level

3.1.1. Core Mandate

• ➢To maintain overall ownership, regulation, coordination and responsibility for the prevention and response to assault management at all levels of government [57].
• ➢
  To contribute to the achievement of the Sustainable Development Goals

  • a)
    SDG 3 Good health and Well Being
  • b)
    SDG 4 Quality Education
  • c)
    SDG 5 Gender Equality
  • d)
    SDG 16 Peace, Justice and Strong Institutions'
  • e)
    SDG 17 Partnerships for Goals

3.1.2. Challenges

• I.The existence of fragmented mandatory multi-agency service provision required for the mechanisms of reporting, investigating, medical examination/treatment and forensic medical examination/investigation including evidence gathering and forensic specimen collection and analysis, prosecution and access to justice for victims/survivors [58].

• ➢Already traumatized victims may be further re-traumatized in subsequent examinations as they are forced to seek services in several institutions' over several days whose work is related but is done in isolation of other service providers
• ➢Numerous different forms of documentation are filled by different examiners (with differing levels of knowledge and skills/competencies) are required at the different points of care, causing dilution of information, amplifying the increase of errors, and causing loss of evidence.
• ➢
  Lack of proper data management mechanisms to ensure centralization of all data related to SGBV cases.

  • II.
    Lack of an appropriate independent/semi-autonomous national forensic structure which leads to a lack of coordination, operationalization, synergism and oversight required for the different arms of forensic service provision (Forensic Police Services, Forensic Medical Services, Forensic Laboratory Science Services).
  • III.
    Currently, there exists an inadequate/weak regulatory mechanism to ensure that multi-agency stakeholder institutions are regularly monitored and held accountable for their actions or lack of appropriate actions in the management of SGBV cases.
  • IV.
    A lack of a critical mass of trained human resources across all sectors with specialized knowledge and skills/competencies required for efficient quality service delivery in the management of these cases countrywide.
  • V.
    Capacity building efforts across all sectors lack a cohesive approach resulting in a lack of standardization of services offered which in turn results in erratic quality of care.
  • VI.
    Lack of civic education on duties of citizens to each other as members of a community for an appropriate crime scene response at community level.

3.2. Community/administrative level

3.2.1. Core Mandate

• ➢Protection of vulnerable groups from discrimination and harm.
• ➢Reporting of crimes/human rights violations to the relevant authorities for immediate action.

3.2.2. Challenges

• I.Poor understanding/lack of basic awareness of crime scene response, with evidence being lost at this point by tampering either with the victim, suspect, or the scene. (Bathing, discarding/burning clothes, concealing, murdering the victim)

3.3. Medical sector/level

3.3.1. Core Mandate

• ➢To simultaneously ensure medical intervention and a forensic medical examination (examination, interpretation, documentation of injuries and evidence gathering including forensic specimen collection), provide treatment as well as necessary referrals for the victim/survivor.

3.3.2. Challenges

• I.The behaviors, attitudes and biases of the first responders at medical levels that plays a role in underreporting [[59], [60]].
• II.Lack of awareness within the medical fraternity that the response to a case of SGBV has both a medical and forensic medical component which are equally important. Currently, focus is more on the medical examination/treatment and less on the comprehensive forensic medical examination/investigation which contributes to obstruction of justice in these cases.
• III.Inadequately trained medical personnel of all cadres with little or no understanding of fundamental forensic principles [61], resulting in inability to navigate through the forensic medical examination/investigation (examination, interpretation, documentation of injuries and evidence gathering including forensic specimen collection)
• IV.Workload requirements are too high, resulting in rushed examinations, numerous short cuts and errors. It should be noted that a thorough forensic medical examination for a single patient requires sufficient time.
• V.Multi-tasking due to inadequate support resulting in medical practitioners conducting administrative and various operational duties which leads to lack of consistency in handling these cases.
• VI.Inadequate support for medical practitioners who are compelled to work without nurses, records officers, protective gear and equipment which contravenes current legal provisions [62]. This contributes to the contamination of forensic evidence rendering it misleading and may result in a wrong judicial outcome [[63], [64]].
• VII.Lack of supervisory mechanisms to assess for burn-out/vicarious trauma/chronic fatigue which is a threat to the mental health and well being of medical and other service providers.
• VIII.Lack of understanding that engaging in a medical examination of a forensic case may result in court attendance to provide an expert witness testimony that requires an up-to-date understanding of relevant forensic medical knowledge.

3.4. Police sector/level [65]

3.4.1. Core Mandate

• ➢The primary state recipient of the knowledge that a crime has occurred
• ➢The police are the investigators of the case and maintain the guardianship of the chain of custody of evidence

3.4.2. Challenges

• I.The behaviors, attitudes and biases of the first responders at police levels that play a role in underreporting [[66], [67]].
• II.Little or absent training in fundamental aspects of forensic principles including crime scene management resulting in loss of crucial evidence at the scene, from the victim and from suspects. The basic foundation of Locard's principle [68], remains largely unknown and its application by police officers who may not be trained but may have to respond to these cases.
• III.Lack of a Chain of Custody form that provides chronological documentation of the movement (from one party to another) of evidentiary material from the time evidence is gathered to its presentation as an exhibit in court.
• IV.Currently, deployment processes result in high staff turnover causing a handful of trained personnel (learnt on the job) to undergo transfer from one station to another taking their skills and institutional memory with them. These gaps are filled in by inexperienced officers who require training.
• V.In Kenya the only Police Surgery located in Nairobi offers medico-legal consultation. However the infrastructure needs to be strengthened to ensure privacy and confidentiality for proper consultation and forensic medical examinations. The three physicians examine close to 100 cases daily including victims and suspects of SGBV at the same time and in the same location, which not only causes re-traumatization to the victims but damages the integrity of evidentiary material through contamination.
• VI.The public's negative social perception of police officers and police stations creates barriers to reporting and willingness to cooperate with investigators. This is further complicated by reports in the public domain of SGBV cases within police custody.

3.5. Judiciary sector/level [69].

Core Mandate:

• ➢To handle disputes in a just manner with a view to protecting the rights and liberties of all.

3.6. Prosecution sector/level [70].

Core Mandate:

• ➢To provide efficient, effective, fair and just prosecution (end-user of forensic evidence gathered) for all including victims and suspects.

3.7. Challenges of both judiciary and prosecution

• I.Judicial and prosecutorial officers lack the basic minimum required understanding of terms and dynamics surrounding Sexual and Gender Based Violence including age assessment methodologies resulting in the inability of the courts to verify court attendee testimony as expert witnesses leading to misinformation [71] and a misguided court causing unfair judicial outcomes.
• II.Currently, all cadres of medical personnel, regardless of their qualifications and experience, are considered expert witnesses in the specialized field of forensic medicine that requires extensive training at post-graduate level. This is a grave gap.
• III.Expert witnesses require sufficient time to consult, prepare and peer review a report for a case with accurate conclusions. Currently, expert witnesses are compelled to operate without any preparation or prior knowledge of the cases they present, thereby, contributing to the misinformation to courts which is in contravention of the individual's (victim's/suspect's) right to a fair trial.
• IV.Harassment of expert witnesses in the courts is as a result of the small number of expert witnesses compounded by communication breakdowns and an inefficient overall system of expert witness handling.

3.8. Non-State actors

(Non - Governmental Organizations, International Organizations, Civil Society Organizations, Community/Faith Based Organizations, private institutions, amongst others).

3.8.1. Mandate

• ➢To support government action in prevention and response to SGBV [72].

3.8.2. Challenges

• I.These actors, though with noble intentions of supporting the government actions in prevention and response to SGBV, are limited in their capacity to address some aspects of SGBV and thus end up working in a band - aid approach.
• II.A majority of these actors do not fully comprehend the criminal nature of these offenses and that forensic procedures in line with best practices are critical in evidence-based outcomes [[73], [74]].
• III.Some of these actors are private institutions that have not yet understood that provision of forensic services will require integrity of the chain of custody of evidence whose function is that of the police.
• IV.Lack of knowledge required for the provision of devices and gadgets to the population without appropriate government forensic (police, medical, laboratory science) and legal consultation.
• V.The blanket use of terminologies such as ‘Gender Based Violence Specialist’ and ‘Health Care Providers (HCP)’ in SGBV in the Kenyan context allows for the promotion of forensic mismanagement of these cases. The authors have observed numerous state and non-state personnel running technical forensic, medical, psychological, scientific programs and or policy mechanisms beyond the scope of their expertise and understanding. In addition, various platforms on SGBV feature these ‘specialists’ whose role in the proper management of SGBV cases remains unclear.
• VI.Currently, some of these actors exhibit increasing autonomy in the functions and operations that ought to be regulated by the government. These functions mainly center around capacity building and include:
• ➢
  Capacity building of medical practitioners, police and other state actors presenting the following concerns:

  • a.
    “Trainings” conducted by different non-state actors using different curriculae not subject to any forensic vetting process by the relevant forensic offices within the national government.
  • b.
    Capacity building by trainers whose qualifications are unknown to the forensic medical specialists within the State and especially when it concerns contact with victims at the forensic medical examination/investigation and evidence gathering and forensic specimen collection phase.
  • c.
    Freedom of selection of target regions including ‘hot spot areas’ that have not been subjected to forensic assessments prior to capacity building interventions resulting in challenges such as lack of contextualized forensic medical capacity building initiatives.
  • d.
    Evaluations (such as forensic and judicial) on the measurable impact of capacity building initiatives is currently unknown.
  • e.
    Absent capacity building on ethical considerations, human rights, and examination of suspects (this is for all trainings state and non state).

4. Recommendations [75].

RECOMMENDATION NO	SECTOR RESONSIBLE	OBJECTIVES	ACTION	DELIVERABLE
Recommendation 1	National/County Government
Recommendation 1.1	Mapping of the current national and county (only public sector) infrastructure of SBGV prevention, response and protective mechanisms	To identify the current available resources in the public sector so as to assess the gaps and then seek to address them	To set up an inter-ministerial taskforce comprising of all relevant ministries, state departments', Council of Governors and set terms of reference for its work	A report on national/county (only public sector) resources available for tackling the SGBV menace
Recommendation 1.2	Reorganization and Redistribution of available state resources (staff/infrastructure/equipment/vehicles)	The development of Multi- Agency Assault Management Centers one per county (These are specialized multi-agency centers,24 h/day 7 days/week with trained staff from various state sectors deployed and operating here)	Review the report on the available resources in section 1.1 to develop a strategy on resource mobilization for identified deficits Seek to identify what resources fit best where and how to place them	A resource mobilization strategy for the implementation plan of the development of MAAMC centers countrywide
Recommendation 1.3	To harmonize all forensic documentation for SGBV/Child Abuse/Assault cases	To reduce victim fatigue and re-traumatization, dilution of information and loss of evidence	To engage stakeholders for the adoption of a reviewed and updated Government of Kenya Medical Examination Report Form (P3) To engage stakeholders for the review of a draft Chain of Custody Form To further engage stakeholders on the adoption of a reviewed and updated post mortem form	An updated Government of Kenya Forensic Medical Examination Report Form (P3) A Gazetted Chain of Custody Form An updated Government of Kenya Police Post- Mortem Form (P23A)
Recommendation 1.4	The creation of an independent/semi-autonomous National Forensic Institute	To ensure the coordination of forensic service provision and promotion of forensic best practices and standards (e.g. national approved sexual assault evidence collection kits, forensic evidence packaging amongst others) To ensure that legislation on forensic service provision is cohesive and does not further fragment services.	An agreement between key state stakeholders for the set up of a mechanism to restructure forensic service provision To seek a budgetary allocation to develop legislation for coordinated provision of forensic services under the guidance of the Office of the Attorney General	An independent/semi-autonomous National forensics Institute established and operationalised A draft legislation on the coordinated provision of the wide range of forensic services for necessary executive, parliamentary and presidential assent.
Recommendation 1.5	To create a centralized regulatory, monitoring and evaluation mechanism for SGBV	To ensure that a strong, efficient and functioning regulatory and monitoring mechanism for SGBV is in place.	To review current efforts at regulation and monitoring and identify opportunities to strengthen regulatory, monitoring and evaluation efforts by way of an assessment report.	A regulation, monitoring and evaluation template An assessment report on regulation, monitoring and evaluation in SGBV
Recommendation 1.6	Standardization of all training programs in SGBV related matters. (content/syllabi/materials/staff) for all sectors (state and non-state) Verification and Authorization of all capacity building programs across all sectors (state and non-state) Training forensic specialists at internationally recognized universities/institutions'	To harmonize all training efforts across all sectors (state and non-state) to ensure accountability in capacity building and quality service provision Ensure that all capacity building program(s) current and future on the management of SGBV cases are verified and authorized by respective state forensic services offices (including but not limited to police, medical, laboratory science) To build a critical mass of forensic specialists according to internationally accepted standards of forensic best practice.	Request for all information on capacity building programs from all sectors (state and non-state) To where necessary draft legislation, policies, make amendments' so as to make it a requirement that all program heads of capacity building programs submit program details for verification and authorization by respective state forensic services offices (including but not limited to police, medical, laboratory) Request all relevant ministries housing a forensic component to prioritize and create a budgetary allocation for the post graduate training of forensic specialists	A centralized database of all information on capacity building efforts countrywide A national register of all verified and authorized capacity building programs in SGBV (state and non-state) that is reviewed and regularly updated. A critical mass of qualified forensic specialists Quality management of victims/survivors and suspects National Training of Trainers (TOTs) programs established and conducted by the forensic specialists on best practices in the provision of forensic services
Recommendation 2	Community Level Recommendation	Objectives	Action	Deliverable
Recommendation 2.1	Civic education must go hand in hand with reform initiatives across all sectors.	To build awareness and change the perception on community crime scene response To ensure the development of mandatory responses to SGBV in all institutions'	Conduct a review of all current information on SGBV that is within the public domain using a multi-disciplinary approach To engage the public via media campaigns' All institutions' (state and non –state) should ensure that there are policies (clear, well communicated with internal accountability mechanisms) to safe guard individuals and respond to SGBV	A well informed society
Recommendation 3	Medical Level Recommendations	Objectives	Action	Deliverable
Recommendation 3.1	To ensure there exists a human resource strategy for forensic medical staff and practice	To identify suitable cadres of personnel to carry out forensic medical services with clearly defined scope of practice	To engage the Ministry of Health and county health sectors to map out human resources working on forensic medical cases	A forensic medical human resource strategy A gazetted list of medical personnel working in forensic medical programs countrywide
Recommendation 3.2	Capacity building of forensic medical staff	To build a qualified medical workforce that is aware of fundamental forensic medical principles and can apply them to cases for a fair judicial outcome	To conduct a Training Needs Assessment (TNA) and come up with a TNA report Implementation of the recommendations of the Training Needs Assessment report	A competent forensic medical workforce that contributes positively to the criminal justice system
Recommendation 3.3	Development of standard operating procedures in the forensic medical methods and principles of SGBV and Non – Accidental Injuries in Childhood	To ensure that quality forensic medical services are provided at all institutions carrying out forensic medical services. To ensure that victims/survivors/suspects' receive a thorough forensic medical examination including expert witness testimony	The Clinical Forensic Medicine Unit is mandated to initiate a mechanism to create standard operating procedures and algorithms	A standard operating procedure for forensic medical methods and principles applicable to SGBV and Non – Accidental Injuries in Childhood
Recommendation 3.4	Provide sufficient support staff (medical and non-medical)	To ensure that forensic medical and non-medical staff are supported to function optimally	Engage relevant ministries where these medical and non-medical staff are housed for re-deployment to the Multi-Agency Assault Management Centers	Timely, equitable, efficient and effective quality service provision through well-functioning Multi-Agency Assault Management Centers
Recommendation 3.5	Regular supervision for maintenance of mental and physical well-being of staff	To ensure a regular mechanism on debriefing of forensic medical and non-medical staff in the MAAMCs and within criminal justice system	Engage relevant state and non-state actors for mandatory psychosocial support mechanism(s)	A mentally healthy workforce dealing with SGBV
Recommendation 4	Police Level Recommendations	Objectives	Action	Deliverable
Recommendation 4.1	The creation of a special unit for investigation of sex crimes for the optimal management of these cases; Sex Crimes Unit.	To ensure the formation of an SGBV unit to investigate SGBV crimes. To equip the investigating officers to adequately handle victims/survivors/suspects and evidentiary material.	To request the National Police Service to form a Sex Crimes Unit utilizing existing trained personnel. To create a Terms of Reference for this unit Including matters to do with deployment (e.g.do not transfer staff outside of the scope of work).	A robust and driven investigative unit with a strategic and operational mandate in crimes of SGBV. A team that has acquired the attitudes and skills to address SGBV cases that desires to be retained in this line of investigative work.
Recommendation 4.2	To ensure that the investigation component of provision of services for victims of SGBV attended to by the police investigators at the Multi -Agency Assault Management Centers according to international best practice.	To bring the police investigators and the beneficiaries of the service in close proximity to other service providers in a safe, friendly and ethical environment.	Through the Sex Crimes Unit and the local county structures deploy investigating officers whose mandate is solely SGBV investigation.	A dedicated and well supported network of SGBV investigators. Well developed mechanism to maintain integrity of evidentiary material.
Recommendation 4.3	Capacity building for police investigators deployed within the Sex Crimes Unit.	To adequately train police investigators within the Sex Crimes Unit responsible for SGBV case investigation.	To engage the appropriate (Internal and external police related and non-police related) consultants well versed with the police sectors response to SGBV. The aim of this is to create: ➢A modern, practical and contextualized curriculum for training ➢A training strategy ➢A deployment strategy	A modern, practical and contextualized curriculum on SGBV investigation. A knowledgeable and well informed Sex Crimes Unit with the ability to apply their attitudes/skills/competencies to the management of SGBV.
Recommendation 4.4	A capacity building mechanism that involves a basic sensitization on SGBV for all police within the National Police Service.	To ensure a police force that appreciates the high level crime of SGBV and the need for proper investigations.	To review the current curriculum and make proposed amendments on content, training hours within the context of overall training.	An up-to date overall training curriculum for the National Police Service that respects the rights of victims and suspects in accordance with the Constitution of Kenya and other adopted international laws that Kenya is signatory to.
Recommendation 5	Judicial/Prosecutor Level Recommendations	Objectives	Action	Deliverable
Recommendation 5.1	Capacity building of Judicial and prosecutorial officers	To build the capacity of judicial and prosecutorial officers within the criminal justice system to better understand the terms and dynamics of SGBV crimes.	Current trainings of these officers should be updated to include key topics in forensic medicine with sufficient time provided for each.	Officers better able to navigate through medico – legal expert witness testimony and contribute to fair judicial outcomes.
Recommendation 5.2	Recognition of the need for the management of forensic medical expert witnesses in terms of their gazettement, involvement in pre-trial preparation and facilitation to and from the courts.	To ensure support for the gazettement of forensic medical expert witnesses to provide services and subsequent testimony in court within a standardized system. To ensure that all expert witnesses are allocated sufficient time for peer review, report formulation including interpretation of results and consultation with relevant stakeholders before testimony. Facilitation of Expert witnesses in the criminal justice system.	The ODPP/Department of Justice as primary stakeholders should champion a multi-stakeholder initiative on the development of Guidelines for the Management of Expert Witnesses.	Gazetted Forensic Medical Expert Witnesses A Guideline on the Management of Expert Witnesses
Recommendation 6	Institutions - Education Recommendations	Objectives	Action	Deliverable
Recommendation 6.1	To ensure the establishment and operation of an independent complaints' reporting mechanism for learning and teaching staff.	To enable unhindered and timely reporting by any individual to the office of the ombudsman.	To deploy an ombudsman and set terms of reference for the post (with an intention to grow this into a unit for operational coverage).	An Ombudsman Unit developed at the Ministry of Education.
Recommendation 6.2	To ensure that response mechanisms to SGBV are clearly understood at orientation/induction into learning institutions	To holistically orient learning and teaching staff into educational institutions	To engage the relevant stakeholders to ensure that standard operating procedures are regularly reviewed and updated.	A regularly reviewed and updated standard operating procedure addressing response to SGBV A well oriented individual who is knowledgeable on the response required for effective management in case of SGBV
Recommendation 6.3	To ensure that the school infrastructure promotes the safety of learning and teaching staff at all times.	To ensure adherence, harmonization, review and updating of school safety standards.	To set up a school safety technical working group and set up a terms of reference for it. (Including examine Architectural/infrastructure design vs. school Population).	The development of a safety data sheet/template (regularly reviewed and updated). All schools provide regular safety data reports.
Recommendation 6.4	To deter sexual predators from school going children.	To utilize forensic science to identify the perpetrators involved in Child Sexual Assault of school going children.	Through the MoI, MoH and DCS launch immediate official investigations to locate, identify, arrest and prosecute all those involved in the crime.	Located, identified and prosecuted sex offenders. New era of deterrence of SRGBV in Kenya. A platform for psychotherapy and rehabilitation for all minors involved (victims and/or suspects).
Recommendation 7	Institutions – Correctional Facilities Recommendations	Objectives	Action	Deliverable
Recommendation 7.1	To ensure protection of all persons detained in custody including those in need of protection, those awaiting trial outcomes, those convicted of crimes and or those in need of rehabilitation: ➢Police custody ➢Prison facilities ➢Borstal/Juvenile correctional institutions.	To review current legislation for persons in custody to address prevention, response and protection of detained persons from SGBV and torture. To ensure CCTV surveillance systems in all facilities as a deterrent strategy (reducing risk for SGBV and other crimes).	Draft legislation on the elimination of sexual and assault offences in custody. To ensure security mapping of all correctional facilities for the purpose of CCTV installation guided by principles to reduce/eliminate the risk of SGBV and other crimes.	A custodial/prison sexual and Non Sexual Assault Elimination Act Well mapped installation of CCTV surveillance in all correctional facilities reducing risk of SGBV and other crimes.
Recommendation 7.2	To improve the infrastructure of correctional facilities by adhering to the Mandela Rules (United Nations Standard Minimum Rules for the treatment of prisoners) which are necessary for rehabilitation.	To reduce overcrowding in correctional facilities for the purpose of reducing SGBV related crimes.	To upgrade the infrastructure of current facilities. To increase the number of facilities	Upgraded current correctional facilities. A higher number of correctional facilities.
Recommendation 7.3	To establish the status on custodial medicine (a branch of forensic medicine).	To conduct an assessment on custodial medicine.	To engage relevant stakeholders to establish a mechanism with Terms of Reference for a joint assessment on custodial medicine in Kenya.	A joint assessment report encompassing all aspects of custodial medicine with recommendations for implementation.
Recommendation 8	Ethics and Anti-Corruption Commission Recommendation	Objectives	Action	Deliverable
	To promote integrity through preventative measures.	To reduce avenues that create opportunities for corruption in the management of SGBV.	Conduct an assessment on opportunities for corruption in the current response to SGBV in Kenya.	An assessment report on the opportunities for corruption with recommendations for implementation.

5. Conclusion

There already exists a global understanding that tackling SRGBV will require a coordinated, multilevel and multifaceted approach. Effective solutions will need long-term and cost effective strategies for the prevention of SRGBV, combined with mechanisms that respond to and provide protection for those affected and that ensure accountability [76].

Therefore, it should be noted that the overall coordination and proper handling of SGBV (prevention, response and protection) should occur at the state level and is overarching, notwithstanding the setting in which it takes place. The approach towards this coordination must at the minimum be inter-ministerial/state multi-sectoral with identified champions to bring effective change to the management of SGBV in Kenya. An inter-ministerial/state multi-sectoral coordination mechanism must acknowledge the following: the investigation that is police investigation and medical investigation through forensics as a specialization plays a key role in solving SGBV crimes without which prosecutorial and judicial efforts will continue to be crippled.

The structural challenges that face the forensics field in the country have to be critically examined to ensure efficient interactions between forensic skill sets - police, medical, laboratory science - all of significance and required to ensure work is carried out synergistically within independent impartial investigative structures for reporting to support to the justice sector.

In addition, from a bird's eye view the structure of forensic medical service provision for SGBV cannot be delinked from clinical forensic medicine (SGBV survivor/child abuse victim), forensic death investigation (SGBV deceased) and custodial medicine (SGBV in custody – living and deceased victims and suspects including rehabilitation of convicted offenders).

Though the state and non-state focus for justice often times takes a victim/survivor centered approach, there must be a move towards objectivity by providing an avenue for proper suspect management. In this regard, all parties should take into account the fact that suspects, both minors and adults, are innocent until proven guilty and their fundamental human rights and freedoms - including the access to medical care (Including mental health care) and their right to a fair trial - must be respected [[77], [78]].

The design of a Multi-Agency Assault Management Center Model should ensure mechanisms are in place to ensure that suspect management, including examination, must be done away from victim examination to avoid re-traumatization of victims, contamination of victim/suspect specimens, and exposing or placing forensic medical examiners in difficult positions that may result in professional bias and contamination when required to examine a victim and a suspect in the same case and in the same location.

The role of non-state actors in maintaining the momentum on the SGBV narrative and support in Kenya cannot be underscored. In the strategic handling of the state and non-state actor relationship, the public sector should endeavor to provide a well-structured and regulated environment for all actors, enabling state and non-state actors to function efficiently. To provide the aforementioned environment by the public sector for the proper management of an SGBV victim/suspect, the consolidation of a multi-agency (multi-ministerial/state multi-sectoral) collaboration and operational response is required rather than one that seeks to promote only a medical care response setting that may be networked but is still fragmented.

An example of a multi-agency service provision for the management of SGBV in the East African Community Region is the Isange One Stop Center (IOSC) Joint Program in Rwanda [79]. IOSC is a Multi-Sectoral and Interdisciplinary Program being implemented by the Ministry of Gender and Family Promotion, Ministry of Health, Rwanda National Police, the Ministry of Justice, under the coordination of the Ministry of Gender and Family Promotion. Evaluations of the Rwandan Government and ONE UN IOSC carried out in January 2013 [80] and in December 2016 [81] on the project for the national scale up of the above-mentioned center reveal crucial insights to ensure that the approach towards the actualization of Multi-Agency Assault Management Centers (MAAMCs) in Kenya is holistic and standardized in approach whilst acknowledging and taking into account specificities of the various counties.

The MAAMC model currently proposed within this report follows an integrated service model that can be considered for replication and contextualization as a foundational corrective measure in the provision of quality standardized services for victims while considering suspects. The key to success in the implementation of these centers lies squarely in inter-ministerial/state multi-sectoral coordination and a focused capacity building strategy (based on a clear human resource strategy) all efficiently linking both National and County governments.

Therefore, the first step at the current time is to understand that addressing SGBV challenges in the Kenyan context lies in the commitment to review current approaches within the policy environment, engage key state actors at the decision making level, and re-initiate a new conversation on interconnectedness.

ANNEX 1. THE SHAKO KALSI ILLUSTRATION DEPICTING FRAGMENTED SERVICE PROVISION

Notes

This diagram depicts the current fragmentation and imbalance (±) of services offered to victims across all sectors resulting in the lack of provision of quality standardized services across the board.This has resulted in lack of a centralized data output mechanism that is required for research to inform policies in SGBV.

This fragmentation of essential services to the victims results in: numerous movements (back and forth) of victims and the investigating officer, victim shaming, re-traumatization of victims, increased turnaround time, and wastage of financial resources. It provides a platform for corrupt practices enhancing barriers to justice and potential further re-victimization of the victim by society including perpetrators of the crime. The environment amplifies evidential loss across the board leading to causation of high acquittals further emboldening perpetrators.

Though, the illustration focuses on victim movement, the rights of the suspect to proper management is a challenge that needs to be addressed.

ANNEX 2. THE SHAKO KALSI PROPOSED MODEL OF A MULTI - AGENCY ASSAULT MANAGEMENT CENTRE FOR COUNTIES IN KENYA

Notes

The proposed model of the Multi-Agency Assault Management Center (MAAMC) follows after the model of devolved governance by creating access for the population to key primary and specialist services in one location that supports quality care, access to justice and the right to the highest attainable standard of health as per the constitution of Kenya 2010. Within this proposed integrated model of the MAAMC there is a flow of processes from section one all the way through to section seven. There are various key considerations for each of these sections.

The benefits of the multi-agency assault management center include:

• I.Improved local community awareness on appropriate response by bringing key services closer to the community (at county level).
• II.Easier reporting mechanism for victims including the use of a hotline for rapid response by experts.
• III.Promotes the easier available consultative communication between interested parties/facilities and the MAAMC personnel. An example is that the local police are able to receive appropriate advise by the police forensic investigators at the center (enhancing the synergistic approach by the police towards the management of cases).
• IV.All mandatory services are accessed at one location (end-to-end service provision for the victims) with access to experts/specialists as a first line of management for SGBV cases (all matters of consent taken into account).
• V.Clearly assigned human resource structure per center staffed with well-trained competent personnel with clear job descriptions and reporting structures that have the right attitudes and provide quality care.
• VI.Allows for provision of standardized services to effect workflows that allow for effective service delivery and reduced turnaround time for overall case management.
• VII.Provides the appropriate infrastructure and work environment for staff working here. Additionally it ensures that victim recovery and rehabilitation is carried out in the right environment including follow up of the victim.
• VIII.Provides a structured approach towards the whole process of evidence management from collection, dispatch to receipt of results of analysis
• IX.Proximity of staff promotes overall internal coordination including peer reviews and pre-trial preparations required to provide objective evidence based information to courts.
• X.Ease of communication between courts and experts due to greater on the ground linkages with the courts (a meaningful network)
• XI.Ensures a proper data management mechanism that provides a real time source of data.
• XII.Promotes the use of automation which assists in the reduction of opportunities for corrupt practices. In addition, will assist service delivery by the use of tracking mechanisms.
• XIII.Provides a designated system of expert witnesses that are supported to efficiently compile forensic reports and facilitated to present their testimony. This will in turn reduce adjournments and ultimately the turnaround time for cases in the courts.
• XIV.This model may facilitate better coordination at (policy and operational levels) between various key ministries and stakeholders to synergistically realize respective mandates.

In addition, there are specific approaches at the level of the national government required to support the effective implementation of at least one center in each of the 47 counties. To actualize this, proposed strategies are required to support appropriate interventions by key stakeholders including the: Office of the Attorney General and the Department of Justice, Ministry of Interior and Coordination of National Government, Ministry of Health, Ministry of Information, Communication and Technology, Office of the Director of Public Prosecution, Ministry of Public Service, Youth and Gender Affairs, Council of Governors, County Governments and the National Gender Equality Commission. The implementation of this model will promote better understanding of the problem, county specific dynamics and the overall management of SGBV in Kenya at this level. Thus, ensuring that there are meaningful interventions made to support state and non-state stakeholders’ aspirations in prevention, response and protection of victims of SGBV crimes.

It is anticipated that this model will support the reduction of the current fragmentation of key services and its overall negative impact.

ANNEX 3. : MAAMCs CONTRIBUTION TO THE SUSTAINABLE DEVELOPMENT GOALS

SDG	SDG STANDS FOR	SDG TARGETS	MAAMC CONTRIBUTION
3	Good Health and Well Being (Ensure healthy Lives and promote well-being for all at all ages)	3.5 - Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol	Gathers the evidentiary material for analysis enhancing the need for strengthened Forensic Toxicology capacity (Drug and substance use analysis). As a result to contribute to the collection of disaggregated data on Drug Facilitated Rape to provide information on the contribution of these drugs to SGBV
		3.7 - By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes	To contribute to and promote preventive measures and the appropriate response to SGBV at county and national levels of government
		3.8 - Achieve universal health coverage, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines	To contribute and facilitate the provision of needs of victims of SGBV by assisting them to access health package services (emergency services under basic and specialized essential health services) that are essentially accessible and available to all as per Universal Health Coverage aspirations. These include provision of STI prophylaxis and emergency contraception.
		3.C - Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries	To contribute to the development of a critical mass of a qualified forensic medical workforce, ensuring further appropriate capacity building and career progression for staff
4	Quality Education (Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all)	T8 - Build and upgrade education facilities that are child, disability and gender sensitive and provide safe, nonviolent, inclusive and effective learning environments for all	To contribute to response mechanisms in collaboration and cooperation with the educational facilities in counties and a proposed Office of the Ombudsman at Ministry of Education
5	Gender Equality (Achieve gender equality and empower all women and girls)	T1 - End all forms of discrimination against all women and girls everywhere T2 - Eliminate all forms of violence against all women and girls in the public and private spheres, including trafficking and sexual and other types of exploitation T3 - Eliminate all harmful practices, such as child, early and forced marriage and female genital mutilation	To systematically and consistently use forensic medical science to bring about confidence in evidence based convictions. This will serve as a deterrent to potential perpetrators by changing the perception of getting away with a SGBV crime in the Criminal Justice System. To act as source of relevant information for the public/community in regards to factors contributing to SGBV and child abuse
		T4 - Ensure women's full and effective participation and equal opportunities for leadership at all levels of decision making in political, economic and public life	To ensure equitable opportunities for women to be identified, recruited and deployed for work at the centers. To encourage and mentor women and girls to undertake a field of medicine that is of great value in terms of social justice to the society.
16	Peace, Justice and Strong Institutions (Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels)	T2 - End abuse, exploitation, trafficking and all forms of violence against and torture of children	A dedicated child protection network ensuring immediate response to distress following suspected child sexual assault/child abuse. To ensure a strong linkage with all non – MAAMC medical facilities to ensure mandatory reporting of suspected child abuse cases for referral and consultation Through the children's officers ensure the placement of children in safe and child friendly environments A child friendly examination environment equipped with relevant video conferencing facilities for use in court. Advocate and promote the publicization of child sex offenders for the purposes of child protection
		T3 - promote the rule of law at the national and international levels and ensure equal access to justice for all	Will enhance the public's confidence in the State's response to SGBV
		T5 - Substantially reduce corruption and bribery in all their forms T6 - Develop effective, accountable and transparent institutions at all levels	Will ensure the establishment of transparent and effective systems for work flow processes through automation
		T7 - Ensure responsive, inclusive, participatory and representative decision making at all levels	The positioning and presence of different stakeholders (multi-agency staff) in the center will ensure that holistic/comprehensive management of each victim/case is carried out including peer reviews and pre-trial preparations
		T10 - Ensure public access to information and protect fundamental freedoms, in accordance with national legislation and international agreements	Acts as a source of relevant information for the public to essential services as well as their rights and freedoms. Promotes transparency in interventions and programs including medical ethical management that is respect for autonomy, beneficence, nonmalficence and justice.
		T11 Strengthen relevant national institutions, including through international cooperation, for building capacity at all levels, in particular in developing countries, to prevent violence and combat terrorism and crime	Would strengthen the cooperation and improve the collaboration of the different agencies working together under a national body to oversee the technical support to county centers.
17	Partnerships for goals (Revitalize the global partnership for sustainable development)	Capacity Building Target T1 - Enhance international support for implementing effective and targeted capacity-building in developing countries to support national plans to implement all the sustainable development goals, including through North-South, South-South and triangular cooperation Multi – stakeholder partnerships T1 - Enhance the global partnership for sustainable development, complemented by multi-stakeholder partnerships that mobilize and share knowledge, expertise, technology and financial resources, to support the achievement of the sustainable development goals in all countries, in particular developing countries T2 - Encourage and promote effective public, public-private and civil society partnerships, building on the experience and resourcing strategies of partnerships	Liaison with well renowned education institutions for training of personnel from the different sectors who comprise the response team Linkage with relevant institutions' globally for capacity building and mentorship Human resource capacity building strategy will be employed for a relevant partnership mechanism
		Data, Monitoring and Accountability T1 - Enhance capacity-building support to developing countries, including for least developed countries, to increase significantly the availability of high-quality, timely and reliable data relevant in national contexts	Contributes to the collection of disaggregated data on SGBV

NOTE

Goal 16 is the center-piece of the SDGs approach to peace, justice and security and is a new thematic area within the global development agenda. The relationship between poverty, inequality, crime, security and access to justice is well understood. Exposure to crime and violence is more acute for those who experience high levels of inequality, poverty or poor access to services [82]. According to Tollulah Oni, the achievement of the SDG's will require political will and investment as well as policies that are informed by evidence noting that policies and strategies are more likely to succeed if they are based on science. These SDG goals are inter-linked goals and an inter-sectoral approach delivers benefits but it also requires trade-offs from scientists and policymakers [83].

ANNEX 4. ILLUSTRATION OF FORENSIC EXAMINATION AND DOCUMENTATION FLAWS

Disclaimer: This is a brief report illustrating the inefficiency of key aspects of forensic medical examinations. This illustration on documentation flaws is as a result of examination at the initial medical facility and the notable gaps highlighted here are as a result of a re-examination of the victim and assessment of the initial documentation by a clinical forensic medical specialist.

Warning: The photographs may be disturbing, however the authors’ opine that these cases (Annex 4 and Annex 5) represent the true reality.

Ethical considerations and consent for examination, photography and publication was given by the victims and relevant authorities.

CASE 1

Miss J. M, a 21 year old female victim of physical and sexual assault by an intimate partner. She was examined at a medical facility the same day and referred for the completion of the Kenya Police Medical Report Form (P3) three days later.

On General Examination:

She was found to be distressed and sobbing. She had bilateral peri-orbital edema and bruising (‘black eyes’).

Further examination revealed the following findings:

• I.Bruised abraded swelling on the right side of the forehead. Dressed multiple punctate/puncture injuries on the right side of the head. Single linear abrasion extending from the swelling on the forehead to the left of the forehead. See Fig. 1C
• II.Possible healing partial bite mark on the left shoulder blade, a possible healed bite mark at the right shoulder blade. Both at different stages of healing. Scrape abrasion on the 5th digit of right upper limb. See Fig 1A and 1B.
• III.Linear abrasion on the dorsum aspect of the right first digit of the right lower limb (Big toe)

Fig. 1A.

Left shoulder blade

Fig. 1B.

Right Shoulder blade4

Fig. 1C.

Right side of the forehead and right fronto-parietal region5

Fig. 1D.

Above: Survivor's medical notes from the Primary Health Centre6

NOTABLE GAPS IDENTIFIED IN THE INITIAL REPORT

Absent indication of the mental and emotional state of the survivor.

Possible Bite Marks described solely as Bruises, showcasing inadequate injury interpretation. Bite Marks should be swabbed for DNA sample analysis from saliva.

Absent photography or use of geometric references.

Linear Abrasion described as a ‘Cut’, which does not give indication of the possible mechanism of injury.

The genital examination findings fail to provide information about the anatomy and/or state of the genitalia.

Note: Consent for the above case was obtained to allow the usage of these cases in this report. An improvised scale (in a resource poor setting) was used as geometric reference of injuries photographed. Photos by Dr.K.Shako.

ANNEX 5. ILLUSTRATION OF FORENSIC EXAMINATION AND DOCUMENTATION FLAWS

CASE 2

Disclaimer: This is a brief report illustrating the inefficiency of key aspects of forensic medical examinations. This illustration on documentation flaws is as a result of examination at the initial medical facility and the notable gaps highlighted here are as a result of a re-examination of the victim and assessment of the initial documentation by a clinical forensic medical specialist.

Warning: The photographs may be disturbing, however the authors’ opine that these cases (Annex 4 and Annex 5) represent the true reality.

In August 2014, an 8 year old boy was carried into the examination room for examination and completion of the Kenya Police Medical Report Form (P3). The child was unable to walk or move, and unable to talk.

He was allegedly assaulted over an unknown period of time by his guardians (aunt).The mother was homeless, and left him with his father,who then abandoned him at his sister's house. She lived with her husband and their two children.

The couple appeared at the Children's Department, with their children and Ismael*, claiming that he had been an ill-mannered child and needed to be placed in an approved school or children's home.

Upon seeing the child, the social worker directed the couple to a police station to “report” the case. The social worker who suspected child abuse handed them a sealed note with directions to submit these to the Police. The note indicated that the police were to arrest the couple and charge them with child abuse.

At the Police Station, the couple was arrested. The child was escorted to a medical facility where he was examined, treated and discharged (without medication). These photographs were captured as part of the examination at a public medical facility. The examiner conducted the examination in a resource poor setting.

Fig. 2A.

7

Fig. 2B.

8

Injuries are different stages of healing. Multiple tramline bruises of varying lengths and in different directions.

Circular abrasions on the lower back.

Multiple healing scratch marks and linear abrasions scattered over the lower back.

Fig. 2C.

9

Tramline bruises, Pressure sores, Bilateral pedal edema, Distended abdomen, undernourished.

Fig. 2D.

10

Healing multiple circular patterned injuries on the both cheeks and left mastoid and left side of the neck-possible bite marks or burns.

Healing linear abrasions left side of the neck.

Fig. 2E.

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Note: Consent for the above case was obtained to allow the usage of these cases in this report. An improvised scale was used as geometric reference of injuries photographed. Photographs by Dr.K.Shako.

NOTABLE GAPS IDENTIFIED IN THE INITIAL REPORT

No referral to experts (pediatrician, forensic odontologist, nutritionist, psychotherapist).

No request for full skeletal x-ray to identify healing or current fractures.

Lack of coherence - grammatical errors making it difficult to understand the report, thereby casting doubt on the competency of the examiner for forensic examination.

Absent indication of injuries.

Incorrect diagnosis; not in keeping with accepted medical and forensic terminology.

Disclosure of P24 marker status (confidential information unless the court seeks for this information).

Funding

The writing of this report and the professional qualifications acquired by the authors did not receive any specific financial support from any agencies, public, commercial or not-for-profit sectors.

Conflicts of interest

Kizzie Shako is the only clinical forensic medical specialist in Kenya working at the Division as Head of the Clinical Forensic Medicine Unit and is seconded to the National Police Service as a Police Surgeon. She is the founder of an advocacy organization that raises awareness in matters touching on clinical forensic medicine. Myrna Kalsi is a forensic odontologist who works in the Division of Forensic and Pathology Services. They are both involved in the development of various national policies/guidelines/tools and capacity building initiatives.