Sexual Violence: What to Consider First

Chapter 18
Sexual Violence: What to Consider First


Catherine White


Sexual Assault Referral Centre, St Mary’s Manchester, UK






OVERVIEW



  • Sexual assault is common but hard for victims to disclose
  • Physical and psychological consequences can be severe and long-lasting
  • Offering choices can help victims regain control lost through the assault
  • Immediate considerations include safety and medical, forensic and psychological needs




Disclosure of sexual assault


Victims of sexual violence may present in a number of ways (Box 18.1), some obvious but others easily overlooked. Remember it may be incredibly difficult for victims to talk about what has happened to them.






Box 18.1 Some ways a sexual assault or rape victim might present



  • Direct disclosure of assault (acute or historic).
  • Request for emergency contraception.
  • Sexually transmitted infection (STI) screening.
  • HIV post-exposure prophylaxis.
  • Unwanted pregnancy.
  • Victim of physical violence, including domestic violence.
  • Depression, anxiety, psychosis, chronic pelvic pain, dyspareunia, drug and alcohol misuse, self-harm and suicide.




Sexual violence and abuse can cause severe, long-lasting harm to individuals in a range of ways: health, social and economic. It can worsen inequalities, which mostly affect women, the vulnerable and the disadvantaged, and is often linked to domestic violence – see Box 18.2.






Box 18.2 Statistics re sexual violence



  • 1 in 4 women have been abused during their lifetime.
  • 1 in 5 girls and 1 in 10 boys experience some form of childhood sexual abuse.
  • 1 in 40 adult women and 1 in 200 adult men (aged 16–59) were sexually assaulted in 2010–11 in the UK.
  • 3.1 million women have been sexually assaulted since the age of 16.
  • 40–50% of women experiencing physically abusive domestic violence are also raped.
  • 70% of female mental health inpatients have experienced physical or sexual abuse.
  • Just under 50% of female mental health service users have been subjected to sexual abuse.
  • Around 50% of female mental health service users have been subjected to physical abuse in childhood, notwithstanding adult abuse, which they may also experience.
  • 23% of women and 3% of men experience sexual assault as an adult.




Offering choices and options


Sexual violence is about control. During the assault, the victim has no control over what happens to them. An important element of aiding recovery is to offer back control as soon as possible.


Your task is to:



  • Assess what a person might need.
  • Explain this to them in a way that they can understand.
  • Offer them choices.

You will need to have an idea of what is entailed (Table 18.1), the timescales involved and who your relevant local service providers are (e.g. a local sexual assault referral centre, SARC).


Table 18.1 Things to consider when someone discloses rape.















Immediate safety

  • Are they safe?
  • Are there any children or other dependents to consider?
  • Are any safeguarding referrals required?
  • Are you safe?
Medical needs

  • Injuries, assessment and treatment
  • Emergency contraception
  • HIV post-exposure prophylaxis following sexual exposure (PEPSE)
  • Hepatitis B PEPSE
  • Screening for sexually transmitted infections
  • Pregnancy testing
Forensic needs

  • Preservation of evidence
  • Documentation of injuries, including photography where necessary
  • Documentation of allegations
  • All to a standard so that evidence is admissible in court
Psychological needs

  • Of the complainant (including risk of self-harm, suicide)
  • Of other witnesses
  • Of yourself and other members of staff

Consent and confidentiality


From the outset, before information is divulged, the clinician must make the limitations of confidentiality very clear to the patient.


If the case proceeds along the criminal justice route then it is highly likely that there will be a request for the medical notes to be disclosed to the courts.


Equally, the patient must be aware that should information be divulged which suggests that children or vulnerable adults are at risk then it will be necessary to share this information.


When does a patient’s disclosure put a doctor under a duty to report to someone else, such as social services or the police?


Whether victims want to report the abuse to police or social services or not, the doctor must weigh their wishes against the doctor’s duty to protect them and also any possible threat to others posed by the alleged offender.


In the UK, you would always report to police, social care and safeguarding teams:



  • Child victims who are not Gillick-competent.
  • Adult victims with a permanent loss of capacity.

If unsure, you can consult a variety of sources, including senior colleagues, safeguarding teams, local child protection guidelines, medical defence organisation and so on. The UK Faculty of Forensic and Legal Medicine (FFLM) has produced guidelines for clinicians dealing with a patient who may have been assaulted and seems not to have full capacity (Faculty of Forensic and Legal Medicine, 2011).


Remember that gaining consent from any patient is always important (Box 18.3). This is especially relevant with the sexual assault victim, who has had power and control taken from them during the assault.






Box 18.3 Remember the key elements of consent


For consent to be valid, it must be given voluntarily by an appropriately informed person (the patient, or where relevant someone with parental responsibility for a patient under the age of 18) who has the capacity to consent to the intervention in question.


Acquiescence where the person does not know what the intervention entails is not ‘consent’.





Capacity and the Mental Capacity Act


The definition of, assessment of and responsibilities in relation to capacity (also known as mental capacity) in England and Wales are laid out in the Mental Capacity Act (MCA) 2005.


The MCA applies to all adults aged 16 and over. It defines ‘capacity’ as the ability to make a decision (see Box 18.4). It relates to the process of making a decision and not to the outcome of the decision. It is not limited to medical decisions but can apply to any decision-making process.






Box 18.4 The key issues of capacity



  • All adults are presumed to have capacity unless there is evidence to the contrary.
  • Capacity is task specific. A person may be capable of deciding one issue but not another.
  • Capacity is also time specific. A person’s capacity may alter with time.




The MCA defines lack of capacity thus: if, at the time the decision needs to be made, a patient is unable to make the decision because of an ‘impairment of, or a disturbance in the functioning of, the mind or brain’, they are deemed incapable.


The term ‘capacity’ was previously used interchangeably with the term ‘competence’. Since the MCA 2005, ‘capacity’ is the preferred term.


The MCA lays out five statutory principles



  • A person must be assumed to have capacity unless it is established otherwise.
  • A person is not to be treated as unable to make a decision unless all practicable steps to help him or her to do so have failed. (Note that this includes communicating in an appropriate way; the clinician may need to arrange for interpreters or signers to be present or use visual aids.)
  • A person is not to be treated as unable to make a decision merely because he or she makes an unwise decision.
  • An action or a decision taken under this Act for or on behalf of a person who lacks capacity must be taken in his or her best interests.
  • Before the action or decision is taken, consider whether its purpose can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action.

Health care professionals are warned that a person cannot be judged to lack capacity simply because of age, appearance or behaviour.


Assessment of capacity


In order to assess someone’s capacity to make a valid treatment decision, consider two criteria:



  1. Do they have an impairment of mind or brain (temporary or permanent)?
  2. Does the impairment mean that the person is unable to make the decision in question, at the time at which it needs to be made (see Box 18.5)?

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Dec 9, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Sexual Violence: What to Consider First

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