Survivor-centred approach and referral

1The guiding principles

The survivor-centred approach puts the rights, needs and choices of the person at the centre of every decision. It rests on four principles:

• Safety: the physical and emotional safety of the survivor, her family and staff comes first. The risk of reprisals is assessed before every action.
• Confidentiality: information is shared only with the person's informed consent and only what is necessary. No names in reports, emails or meetings.
• Respect: the survivor decides. She is given all the information, her choices are respected, even those we do not share, and she is not judged.
• Non-discrimination: every person receives the same treatment, regardless of age, disability, status, ethnicity, sexual orientation or the type of violence experienced.

Confidentiality has limits: imminent risk to life, a child at risk, mandatory reporting obligations under the law. They must be explained from the outset, before the person discloses. For children, the principle of the child's best interests also applies.

2Receiving a disclosure without being a specialist

A driver, an enumerator or a distribution officer may receive a disclosure. The IASC GBV Pocket Guide gives them a simple course of action, based on psychological first aid: look, listen, link.

• Find a place where the person feels safe, ask whether she wants someone with her.
• Listen calmly, believe what she says, do not ask about the details of the assault, do not try to find out who the perpetrator is.
• Say simple things: "It is not your fault", "You did the right thing by telling me".
• Give accurate information about the available services (health, psychosocial, safety, legal), their cost, location, opening hours, and what will happen.
• Let the person choose; if she asks, make the link with the service.

What not to do: question her, take detailed notes, take photos, confront the perpetrator, inform the family or leaders without her consent, promise what you cannot deliver. Where there is no GBV actor, the Pocket Guide still asks you to support the person and give her information about the other services available.

3Clinical management of rape

Rape is a medical emergency. According to the WHO, UNFPA and UNHCR guidelines (2020), the survivor must be informed that she can receive free and confidential care, even without filing a complaint:

• HIV post-exposure prophylaxis (PEP): as early as possible, at the latest within 72 hours, for 28 days.
• Emergency contraception: up to 120 hours (5 days), by pill or copper intrauterine device; the earlier, the more effective.
• Presumptive treatment of sexually transmitted infections, hepatitis B and tetanus vaccination depending on vaccination status.
• Wound care, first-line psychological support, referral to mental health services.
• Forensic examination and evidence collection only with consent and if the person is considering legal action; provision of a medical certificate.

Beyond 72 or 120 hours, the survivor is still cared for: testing, STI treatment, pregnancy test, mental health care, counselling on legal pregnancy options. The Minimum Initial Service Package (MISP) for sexual and reproductive health makes this care a priority from the very first days.

4GBV case management

GBV case management is structured support, provided by a trained and supervised social worker, who coordinates services around the survivor. The Inter-Agency Guidelines (2017) describe six steps:

• Introduction and engagement: welcome, presentation of the service, limits of confidentiality, informed consent.
• Assessment of needs and safety.
• Case action plan developed with the survivor, including a safety plan.
• Implementation: direct services and accompanied referrals.
• Follow-up of the situation and of the quality of services received.
• Case closure when goals are met or at the survivor's request.

Quality benchmarks: a caseworker follows 15 to 20 active cases at most (a commonly used reference), receives regular supervision and staff care. Paper files are kept under lock and key, electronic files are password-protected, with codes instead of names.

5Building, testing and updating a referral pathway

A referral pathway is the tool that enables any humanitarian worker to refer a survivor to a service that is real, safe and available. In many evaluations, it exists on paper but fails in practice: phone numbers that do not answer, facilities that have closed, PEP kits out of stock, free-of-charge services not applied. Its design is the responsibility of the GBV sub-cluster, but each organisation is accountable for it in its own area of intervention. The Inter-Agency Minimum Standards standard on referral systems sets out the requirements.

Step 1: choose the services to include

Only services that meet verified minimum criteria are listed: staff trained in the survivor-centred approach, confidentiality (private space, secure files), free of charge, actual opening hours and, for health, availability of clinical management of rape with PEP kits and emergency contraception. A service that does not meet these criteria is listed separately, with caveats, or excluded pending an upgrade.

Step 2: establish entry points and time frames

Step 3: produce the material

The pathway fits on one double-sided page, in the local language and in French or English, with a simple diagram (entry point, health, case management, psychosocial, safety, legal) and, for each service: name, location, days and hours, job title of the focal point (not a person's name, which changes), phone number, languages spoken, accessibility, free of charge. It also includes the key messages of the GBV Pocket Guide and the rule: do not question, do not record details, inform and let her choose. For community use, a version without sensitive numbers is prepared, in the form of a pocket card for staff.

Step 4: test the pathway

Every month, or after any major change, the sub-cluster or the organisation checks each service:

• calling the number at different times, including evenings and weekends;
• checking the stock of PEP kits and emergency contraception with the facility's pharmacist;
• talking to the focal point to confirm opening hours and free-of-charge status;
• analysing the referrals made the previous month: how many were completed, time between referral and service, survivor feedback collected by caseworkers.

A fake survivor is never used to test a service: verification is done transparently with the facilities.

Step 5: disseminate and train

All staff in contact with the population receive the pathway and a two-hour session on the GBV Pocket Guide: distribution staff, enumerators, WASH promoters, drivers, guards, staff of non-specialised health centres. The minimum target set by many sub-clusters is that 100% of field staff of member organisations have received the updated pathway. The date of the update appears at the top of the document; a version more than three months old is considered out of date.

An untested referral pathway is more dangerous than useful: a survivor referred to a facility that is closed or out of kits loses time she does not have, and often loses trust in the whole system.

6Informed consent in practice, including for children

Informed consent is not a signature: it is a process through which the person understands what is being offered, the benefits, the risks, the limits of confidentiality and her right to refuse or change her mind, and then freely expresses her decision. It is obtained for each distinct action: opening a case file, referral to a specific service, sharing information with that service, recording non-identifying data in the GBVIMS.

The elements to explain, in order

1. Who you are, your role and what the service can and cannot do.
2. That everything she says remains confidential, with exceptions: imminent danger to her life or someone else's, a child at risk, a legal reporting obligation if one exists. These exceptions are explained before she says anything.
3. The options available and what each one involves in practice (for example: "at the health centre, a midwife will see you alone; she will offer you an HIV treatment to take for 28 days").
4. That she can refuse part or all of it, and that refusing changes nothing in the humanitarian assistance she receives.
5. That she can withdraw her consent at any time.

Understanding is checked by asking the person to rephrase, not with a simple "have you understood?". For people who cannot read, consent is given orally and recorded by the caseworker on the form.

Children: benchmarks from the Caring for Child Survivors guidelines (IRC and UNICEF, 2012)

The parent or caregiver is not appropriate if they are the alleged perpetrator, are complicit, exert pressure contrary to the child's interests (for example for marriage to the perpetrator) or are absent. The decision is always documented and validated by the supervisor. Coordination with child protection is systematic; where specialised actors exist, case management for a child survivor is entrusted to a caseworker trained in the 2012 guidelines, in line with the agreement between the GBV and child protection Areas of Responsibility.

Mandatory reporting

When the law requires reporting (for example of violence against minors), the caseworker: (1) explains it before the interview; (2) assesses with her supervisor the risks that reporting creates for the survivor (reprisals, treatment by the police, forced marriage to the perpetrator); (3) informs the survivor of what will be passed on, to whom and when; (4) passes on the minimum information necessary; (5) accompanies the survivor through what follows. The GBV AoR position is to prioritise the survivor's safety and choice while respecting the legal framework; organisations clarify their internal policy and include it in the SOPs.

Consent to recording in the GBVIMS is separate from consent to services: a survivor can accept care and refuse to have data shared, even anonymously. Her refusal is respected and the incident is not included in the shared statistics.

7Clinical management of rape: protocol and organisation of the service

The GBV programme manager is not a clinician, but must know the protocol in order to refer correctly, advocate for supplies and check quality. The references are the WHO, UNFPA and UNHCR guide on clinical management of rape and intimate partner violence survivors (2020), the Inter-Agency Field Manual on Reproductive Health in Humanitarian Settings (IAWG, 2018) and the Minimum Initial Service Package (MISP), whose objective 2 is to prevent sexual violence and respond to the needs of survivors.

The care package by time frame

Organisation of the service

• 24-hour availability in at least one facility per area, with free transport available at night.
• Staff: at least two health workers trained in clinical management of rape per facility (to cover absences), the option of being seen by a woman, a trained female interpreter if needed.
• Location: a private room, away from through traffic, with a discreet route that does not signal the reason for the visit (no "GBV door").
• Supplies: the Inter-Agency Reproductive Health Kits include a Kit 3 dedicated to post-rape treatment; UNFPA provides them in emergencies through the health cluster. Monthly stock monitoring is part of testing the referral pathway.
• Completely free of charge, without a police report or identity document. Where local practice requires a police report, this is a priority advocacy issue for the sub-cluster with the ministry of health.
• Documentation: medical file kept under lock and key, medical certificate given to the survivor, who decides how to use it.

Quality indicators to monitor

• Proportion of eligible rape survivors (less than 72 hours) who received PEP; target: 100% of eligible survivors who accept it.
• Proportion of rape survivors arriving within 72 hours: a low rate signals information or access barriers.
• Proportion of health facilities in the area with kits and trained staff.
• Completion rate of the 28-day PEP course, known through follow-up.

The key community message is not "report violence" but "after a rape, go to the health centre as quickly as possible: care is free, confidential and effective if given early".

8Case management: tools, risk levels, supervision and psychosocial support

The Interagency Gender-Based Violence Case Management Guidelines (2017) describe six steps, presented in the previous section. This section details the practical tools and organisational benchmarks that distinguish a serious service from simple listening.

The case file tools

Risk levels and follow-up frequency (practice benchmarks)

Caseload and supervision

• Commonly used benchmark: 15 to 20 active cases per full-time caseworker; beyond that, quality and safety decline. A high-volume team plans for recruitment or a waiting list managed through risk assessment, never simple accumulation.
• A case management supervisor generally oversees 4 to 6 caseworkers; she conducts weekly individual supervision (at least one hour), a monthly review of a sample of case files and one observed session per quarter.
• Profile: caseworkers are preferably recruited locally, speak the survivors' language, are women when working with women and girls, and receive at least ten days of initial training (2017 guidelines, caring for child survivors, psychological first aid, data security).

Mental health and psychosocial support

The IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (2007) organise interventions in a four-level pyramid: basic services and security; community and family supports; focused, non-specialised supports; specialised services. For survivors:

• psychological first aid is the standard for any initial contact;
• safe space activities and support groups belong to the second and third levels;
• validated brief psychological interventions, such as WHO's Problem Management Plus (PM+), can be delivered by trained and supervised non-specialist staff;
• severe conditions (major depression, suicide risk, psychosis) are referred to specialised services, drawing on the mhGAP Humanitarian Intervention Guide (WHO and UNHCR, 2015).

The caseworker is not a psychotherapist. Her role is to assess, provide first-line support, coordinate and refer; she does not conduct "trauma therapy" without specific training and supervision.

9Full example: Amina's journey, from disclosure to case closure

Fictional situation. Kerewa displacement site, 23,000 people. An NGO provides case management in a women and girls' safe space; the site's health centre has PEP kits and a trained midwife; a referral hospital is 18 km away. Amina (fictional first name), 26, mother of two children, lives with her husband and her mother-in-law.

Timeline

What the example teaches

• The decisive link was the non-specialist CCCM staff member, trained in the GBV Pocket Guide and holding an updated referral pathway: PEP started at 15 hours.
• Every decision (forensic examination, complaint, shelter) was made by Amina, after full information. The caseworker never contacted the husband.
• The safety plan did not prevent the discovery of the tablets: it was revised immediately. A safety plan is a living document.
• In the GBVIMS, the incident is recorded as rape, with consent to share non-identifying data; the physical assault on day 10 is recorded as a separate incident (physical assault, intimate partner perpetrator), because it is a new event.

Case file data for the monthly report (aggregated)

Only the following appear in the shared statistics: one rape incident, presentation within 72 hours, PEP received, referral to health and psychosocial services; one incident of physical assault by an intimate partner. No first name, no block, no precise date.

10Common mistakes, contextual variations, interview questions and references

Common mistakes

What donors, evaluators and auditors look at

• Validated SOPs, a dated and tested referral pathway, and proof of training of non-specialist staff.
• Clinical quality indicators (PEP within 72 hours) and case management indicators (caseload per caseworker, frequency of supervision, satisfaction).
• Data protection measures: coded forms, storage, information-sharing protocol. An auditor must never be able to consult a named case file; verification that activities took place relies on coded registers, supervision reports and interviews with staff.
• Budgeting for staff care and supervision, required in particular by the Minimum Standards (standard on staff care and support).

Variations by context

• Sudden-onset emergency: priority given to clinical management and psychological first aid; case management started with a core of experienced staff and simplified procedures.
• Protracted crisis: gradual integration into public services (health centres, social services), training of government staff, transition plan.
• Urban settings: dispersed services, transport costs, helplines; check the administrative requirements of public hospitals.
• Remote management and insecurity: the IRC Guidelines for Mobile and Remote GBV Service Delivery (2018) set conditions (prior assessment of phone safety, agreed codes, numbers not registered in the survivor's name, no sensitive written messages).
• Local partners with low capacity: start with information and referral, support progression to case management through six to twelve months of mentoring, share clinical supervision and fund supervisor positions.

Interview questions

Key references

• Gender-Based Violence Information Management System Steering Committee and Interagency GBV Case Management Working Group, Interagency Gender-Based Violence Case Management Guidelines (2017).
• IRC and UNICEF, Caring for Child Survivors of Sexual Abuse: Guidelines for Health and Psychosocial Service Providers in Humanitarian Settings (2012).
• WHO, UNFPA and UNHCR, Clinical Management of Rape and Intimate Partner Violence Survivors (2020).
• IAWG, Inter-Agency Field Manual on Reproductive Health in Humanitarian Settings (2018), chapter on the MISP.
• IASC and GBV AoR, GBV Pocket Guide and its mobile application.
• IASC, Guidelines on Mental Health and Psychosocial Support in Emergency Settings (2007).
• WHO and UNHCR, mhGAP Humanitarian Intervention Guide (2015); WHO, Problem Management Plus (PM+) (2016).
• IRC, Guidelines for Mobile and Remote Gender-Based Violence Service Delivery (2018).
• WHO, War Trauma Foundation and World Vision International, Psychological First Aid: Guide for Field Workers (2011).