omissions and shortcomings in the performance of the first forensic medical examination that are incompatible with the requirements of strict due diligence since: (i) they did not allow Brisa to be accompanied by a trusted person during the medical examination; (ii) there is no evidence that the girl or her mother was provided with information about the content of said examination or what the medical practice would be; (iii) it was not proven that the people who were present at the examination were professionals specially trained in caring for victims who were children or adolescents or that they were specialized in gynecology with training for this type of examination in cases of sexual violence; (iv) the presence of an excessive number of health personnel was confirmed; (v) Brisa's wish for the students to leave the exam room was not respected; (vi) physical force was used to perform the examination; (vii) her expressions of discomfort and pain were not respected; (viii) there is no evidence of Brisa's consent to carry out each of the forensic review procedures, and (ix) no record of the examination was made.207 113. Regarding the above, the Court reiterates the paramount importance of the doctor being trained to care for a girl victim of sexual violence and ensuring her a safe, adequate environment that is not intimidating, hostile or insensitive. Along these lines, the Court considers that the presence of a multiplicity of people during the gynecological examination of a girl who is a victim of sexual violence is contrary to the standards on the matter, since the girl is naked, exposing her genitals to a group of people who were not supposed to be present in a procedure of this nature, which implies an arbitrary intrusion into their private life and intimacy. The Court reiterates that this type of examination must be carried out on a single occasion, by a doctor trained in the matter and with the presence of only those people strictly necessary (supra para. 107). The Court understands that this especially serious act, in violation of due diligence, exposed Brisa to re-victimization. Bolivia should have adopted the necessary protection measures so that its institutions acted under the principle of the girl’s best interests, and prevented proceedings, which in themselves could bring with them elements of re-actualizing the trauma, from constituting an act of institutional violence. Based on all of the above, the Court understands that, during the forensic examination, the medical assessment was not carried out in a manner appropriate for the treatment of a girl victim of sexual violence, reviving her trauma 208 instead of protecting her and providing containment mechanisms that would make her feel safe, understood and listened to during the procedure to avoid her re-victimization. Furthermore, for this Court, the use of force and ignoring signs of the victim's pain and discomfort209 constituted an act of institutional violence of a sexual nature. countries, the preparation of a document signed by the adolescent is required as an expression of her agreement with it. Cf. Expert opinion of Miguel Cillero Bruñol during the public hearing, supra. 207 The Court agrees with the statement by the expert Mesa Peluffo during the public hearing of this case in the sense that before starting the forensic medical examination, it must be explained to the alleged victim why and how the examination is carried out, in a detailed manner and explain each step before undertaking it. “[Th]ey have to be told why you need to see their genitals and “I'm going to do it this way”, that is, “now you're going to have to open your legs, now I'm going to insert a speculum so I can see the vagina” and show her that it is a speculum, “see, I'm going to put this in, it's small, but then I'm going to enlarge it so I can see better.” “[T]his is the type of advance notice that should be given.” And “obviously” if the victim expresses some discomfort or pain or starts crying, you have to stop immediately, give them space, it is necessary to ask them if they want to go out for a moment. Cf. Expert opinion of Sylvia Mesa Peluffo during the public hearing of this case. 208 The expert Mesa Peluffo maintained that “[i]n regard to the psychological impact of revictimization by the State, as Judith Herman says, trauma is the affliction of those who have no power. In trauma the victim is helpless in the face of an overwhelming force. Traumatic events, such as rape, destroy the normal protective systems that give people a sense of control, connection and meaning, resulting in what we call post-traumatic stress disorder. The person, upon finding themselves in this helpless situation, presents a combination of feelings of anxiety and danger, maintains a permanent state of alert, has intrusive memories and nightmares related to the trauma, avoids any stimulus that reminds them of the traumatic events, may experience feelings of guilt, fear and anger, has difficulties relating to other people and their life trajectory is altered. The impact of revictimization on victims of sexual violence, especially girls and adolescents, is often devastating. Girls and adolescents deserve special protection in judicial processes, since the actions of justice officers can increase the trauma they have suffered as a result of violence. Therefore, it is essential to have special protocols for investigation and action, as well as to avoid actions that may lead to revictimization." Cf. Expert opinion of Sylvia Mesa Peluffo, supra. 209 According to expert Mesa Peluffo, the “medical examination carried out in the presence of several male students, who laughed at her when she said that she did not want them to be present and even forcibly opened her legs, may have been experienced by Brisa as a new rape, as it reactivated intrusive memories of the trauma.” Cf. Expert opinion of Sylvia Mesa Peluffo, supra. 37