Adult sexual assault

Sexual violence is broadly defined as any sexual act (or attempted act) perpetrated against someone’s will.³ It includes rape and physical forms of sexual assault, as well as a range of more subtle behaviours such as sexual coercion, forced consumption of pornography, non-consensual condom removal (‘stealthing’) and unauthorised sharing of intimate images online.³

Sexual violence is prevalent in Australia. National surveys have demonstrated one in every five women and one in every 20 men have experienced sexual violence since the age of 15.¹ Rates of sexual violence perpetrated against non-binary and transgender people have also been reported as high.⁶ It is important to remember these estimates provide some idea of prevalence but are unlikely to represent the true scope of the problem. Sexual violence is underreported and many behaviours are not included in national surveys.^7–10 Thus, it can be reasonably assumed the true prevalence of sexual violence is much higher.

Sexual violence is consistently associated with poor mental and physical health outcomes for victims/survivors.³ These impacts can occur in the short, medium or long term following an assault. In the immediate aftermath, there can be obvious physical injuries or trauma to the genital or anal area,¹¹ which may require treatment (although for many types of sexual violence there may be no outward signs of injury at all). In the medium term, victims/survivors may find they have contracted an STI¹² or experience an unwanted pregnancy.³ Longer-term impacts can include post-traumatic stress disorder (PTSD), depression and anxiety, alcohol and substance misuse, eating disorders, gynaecological problems, suicidality and self-harm.^3,13,14 Long-lasting mental health problems are particularly common, with sexual violence often going unrecognised as an underlying cause.

Given the strong associations between sexual violence and poor health, victim/survivors tend to access health services, including general practice, more frequently than those who have not experienced sexual violence.^15,16 Australian studies have found almost half of women attending general practices had experienced at least one incident of sexual violence during their adult lives.^17,18 Attendance at general practices presents a critical opportunity for GPs to identify and respond to sexual violence in their patient populations.¹⁶ It is important to note many victims/survivors are reluctant to disclose what has happened to them.^1,4 The reasons can be complex and varied, but may include shame and embarrassment,¹⁹ self-blame⁸ or unwillingness to accept that what they experienced was a form of sexual violence.⁸ These barriers may be particularly pronounced when the perpetrator is an intimate partner^19,20 or when the sexual violence is more ‘subtle’. On the other hand, research suggests many victims/survivors may feel comfortable disclosing experiences of violence to their GP^4,16,21,22 if they receive a competent, non-judgemental and trauma-focused response.^21–23

The role of general practice

GPs can play a vital role in responding to adult sexual violence in the short, medium or long term. As there is often silence on the issue, GPs need to be proactive and maintain a high level of awareness that a history of sexual violence can be part of a patient’s past experiences.

GPs need to be:

• prepared for a disclosure and create an environment in which patients feel safe and able to be heard
• mindful when ordering or conducting medical procedures such as cervical screening tests, which may potentially trigger distress, and work with patients to reduce this distress
• mindful that people who have been sexually assaulted may be fearful and anxious when booking or attending an appointment.

Environment

It is important the individual GP and the entire practice team create a trauma-sensitive atmosphere and environment. Given the prevalence of sexual violence among the general practice patient population, it is highly likely multiple patients with a history of sexual violence will attend a clinic on any given day. It is essential every patient is provided with a warm and welcoming response from all the staff, beginning at the front desk; there is an option for patients to speak quietly and confidentially with reception staff; and a private space is available for patients who may need to use it. Posters outlining a short grounding exercise that patients can do unobtrusively in the waiting room may also help give the impression that the clinic has a trauma-informed focus.

Referrals

Patients who have experienced sexual violence may feel particularly anxious when referrals need to be made for specific medical and mental health issues. The GP can allay this anxiety in several ways. This might include:

• ensuring practitioners joining the patient’s care team are trained to be trauma-sensitive and understand the dynamics of sexual violence
• providing warm referrals to specialist care providers
• for some patients, the GP explaining their history directly to other specialist practitioners to avoid the patient having to repeat their story – this should only be done with the patient’s consent
• seeing the GP after attending the referral service to check their needs are being met.²⁴

Identification

Identification is straightforward if a victim/survivor presents at the practice because of sexual violence. In most cases a patient will likely present with vague, unexplained mental or physical health complaints. In these situations, identifying a patient’s sexual violence history can be challenging. It is not necessary for the GP to identify every patient in their practice who has experienced sexual violence; however, the GP does need to be aware of the possibility that sexual violence may underlie some common presentations.

GPs should be mindful of particular groups who appear to be at increased risk of sexual violence, including women with disabilities, women working in the sex industry, women experiencing other types of intimate partner abuse/violence (IPAV), women who are homeless, LGBTIQA+ people and people who have previously experienced sexual abuse.^2,20

Table 14.1 shows some possible presentations of sexual violence in the general practice setting.

The World Health Organization (WHO) recommends that GPs ask about sexual violence when assessing conditions that may be caused or complicated by such violence, such as those noted above.⁵ If the patient is presenting alone, the GP can gently say:

This may help reduce some of the stigma associated with being a ‘victim’ of sexual violence and help the patient feel more comfortable disclosing their experience. Initially refer to ‘unwanted sexual experiences’ rather than ‘sexual violence’ or ‘rape’ given that many people do not relate to these more confronting terms.

Disclosure

A patient may disclose sexual violence immediately, or years after the event. Disclosure may be unexpected or made in response to gentle questioning in the context of the assessment of other health problems. GPs need to be prepared in advance for a disclosure. If a GP is planning to ask about violence, a longer appointment may be required. They need to be aware of local protocols, legal obligations and reporting requirements, useful resources and referrals. It is important to consider issues of confidentiality and to ask about violence when the person is alone and to be aware that a patient may not be ready to disclose when asked.

The WHO clinical handbook on healthcare for women subjected to IPAV or sexual violence²⁵ recommends that women should be provided with immediate first-line support on disclosure through the LIVES (Listen, Inquire, Validate, Enhance safety, Support) approach (refer to Box 14.1). Although it was developed for women, the same principles apply to patients of any gender who disclose sexual violence.

When responding to a disclosure, it is vital that you ensure the patient is central and in control of any decisions about further care. People who have experienced sexual violence often say they value the support of health professionals who inquire about their needs, rather than telling them what to do.²⁶

Response

Most sexual violence-related health concerns can be readily managed in general practice.

Managing immediate health concerns

These include concerns related to a disclosure of recent sexual violence, particularly in the case of rape or sexual assault. Table 14.2 outlines aspects of medical care. Some of the options available after recent sexual violence are time limited, but other options can be provided at any time a patient discloses they have been sexually assaulted.

Patients may at times present with vague memories of an assault, for example, if the assault was drug or alcohol facilitated. Others may have no memory of an assault, but have been in situations that raise real concerns that they have been assaulted. In general, it is prudent to provide the same care as you would for a patient who has a clearer memory of the assault.

The RACGP has detailed information about managing immediate medical concerns.

Table 14.2. Considerations for healthcare following recent sexual violence

STI, sexually transmitted infection

Managing medium- and long-term health impacts

GPs are ideally placed as a consistent care provider to address a range of physical and mental health concerns caused by sexual violence. Some patients recover with minimal support from the GP. But for others, even though many years may have passed since an experience of sexual violence, ongoing issues continue to cause a significant impact on their quality of life. It is not possible to accurately predict which patient will experience prolonged distress, although compounding risk factors such as a history of childhood sexual abuse, concurrent IPAV, or alcohol or substance misuse may make recovery more challenging.^26–28 GPs need to be aware that individual responses and impacts of sexual violence are variable²⁹ and may change with time. It is important to ask the patient about their current concerns and needs and work with them to determine how they would like to address these. Scheduling regular appointments to review progress²⁴ can help to identify when the patient may need a change in the care plan.

Mental health impacts of sexual violence predominate in the medium and long term, although some patients will also experience ongoing physical impacts such as chronic pelvic pain and other conditions as noted in Table 14.1. The range of mental health concerns includes depression, PTSD, generalised anxiety disorder, substance abuse and panic disorder.^3,14 These can impact interpersonal relationships and their view of the world.²⁹ Many of these issues can be helped by trauma-informed counselling, although talk-based therapies are not useful for all patients³⁰ (mindfulness or trauma-informed yoga can be suggested as an alternative). There is limited evidence to suggest that trauma-based cognitive behavioural therapy can assist in the management of PTSD symptoms³¹ for patients who are not currently experiencing violence.

Antidepressant medication (if appropriate) can be considered if the patient is receptive. This can help stabilise their mood so they can more effectively work on the underlying trauma.

Suicidal ideation and self-harm are common experiences of people with sexual violence histories^28,32 and are of particular concern. A risk assessment can help identify patients who need more support and management to improve safety. This should be repeated at each review as changes may occur during the recovery process.

Women experiencing IPAV or reproductive coercion

GPs should be alert to the possibility of sexual violence when a woman discloses other types of IPAV.^19,33 Sexual violence against women in the context of intimate relationships is very common. Women may not voluntarily disclose that sexual violence is happening in their relationship, even after disclosing physical or psychological abuse.¹⁹ GPs should sensitively inquire about whether a woman has felt pressured, forced or blackmailed into unwanted sex if she mentions physical or psychological violence or indicators of coercive control. Women who have experienced intimate partner sexual violence may feel an acute sense of betrayal and damage to their self-esteem, which differs from women assaulted by a stranger.³⁴

Similarly, sexual violence may be a mechanism through which a partner seeks to control a woman’s reproductive choices.^35,36 Questioning how a woman feels about a pregnancy/contraception, and how her partner has responded to it, may elicit a disclosure of reproductive coercion.²⁴ Safety should always be reviewed when IPAV, including reproductive coercion, are identified and at any follow-up appointments. Refer to Chapter 3: First-line response to intimate partner abuse and violence: Safety and risk assessment.

Male, non-binary or gender-diverse victims/survivors

Male, non-binary and gender-diverse people experience many similar emotional and psychological responses to women after sexual violence. The principles outlined above are equally appropriate for these patients.

In addition, a common issue for men who have been sexually assaulted is concern about their sexuality. Sexual acts they may have been forced to perform (or have performed on them) may challenge their perception of their sexuality. For example, getting an erection or ejaculating during the assault are physiological processes, but may be interpreted by the victim as an emotional response. GPs may need to take more time with male patients to ensure they understand the difference.

For non-binary and gender-diverse patients, sexual violence can be experienced in the context of discrimination or transphobia. Trans patients may be more likely to self-blame, fearing their gender presentation ‘caused’ the sexual violence. They may be particularly reluctant to disclose for fear of judgement or an insensitive response. Ensuring the practice and the GP’s response is supportive and welcoming to people of all genders is critical to being able to gain the trust of patients who are gender-diverse or non-binary. Refer to ‘LGBTIQA+’ chapter.

Boundaries and self-care

Responding to sexual violence can be challenging for the GP. Good self-care is essential, including ensuring there are opportunities to debrief with colleagues or supervisors. GPs should be alert to the possibility of vicarious trauma and take steps to manage this (refer to self-care chapter.) It is also important to acknowledge many GPs will themselves have a history of sexual violence or other traumas.

GPs should set clear boundaries with patients around their role. This helps to keep expectations realistic and avoid distress to the patient.

Sarah, age 25 years, is an occasional patient of your practice. She comes to see you because she has been having trouble sleeping and is feeling really low. She is not managing at work, and thinks she needs some time to ‘sort herself out’. You talk with her about her concerns and ask her how things have been at home. She tells you she split up with her partner three months ago and that she rented a room in a share house after this. She moved out of there recently and is now staying with a friend. On further discussion, she tells you that she moved out five weeks ago because one of her flatmates raped her.

You provide a supportive response to this disclosure and talk with Sarah about her concerns. She says she is most worried about her mental health because she had been having a hard time with the breakdown of her relationship before she was raped and is now feeling much worse.

You conduct a mental health assessment, and as part of this ask her whether she has had any thoughts of suicide and self-harm. She nods and starts to cry. You acknowledge her distress and let her know that people often feel this way after an assault. The thoughts are frightening but are very likely to settle with time and support.

Sarah agrees to have a suicide risk assessment. You determine that she is having passive suicidal thoughts, with no actual plans about how or when she would harm herself. You develop a safety plan with her and give her numbers she could call, including a 24-hour service should she need this. You normalise the reactions she is having and talk with her about treatment options.

Sarah says she is feeling much better having spoken to you and will get back into exercise again, as this always elevates her mood. You establish that she is safe with her friend and can stay there until she finds new accommodation. Her friend is supportive and is aware of how she has been feeling.

Sarah is not worried about pregnancy as she took the emergency pill and has done a pregnancy test since then. She is concerned about STIs and would like to come back for a check-up. She hasn’t thought about legal action in relation to the assault as yet.

You give her a work certificate and make an appointment for review and STI check.

You see Sarah again the following week. She says she has been up and down, but is sleeping better and is generally more like her normal self. She says that the suicidal thoughts have decreased significantly and that she talks with her friend when she is feeling low. Sarah says she is now able to go back to work.

You conduct the STI check-up and her first cervical screening test (CST). This is done with her consent and a careful explanation of each step in the process.

Her STI tests and CST are negative. At a follow-up appointment, Sarah tells you that she would like to talk to someone to help her decide about legal action. She agrees to a warm referral to the Sexual Assault Service and they make an appointment to see her.

You also make an appointment to see Sarah in two weeks. At this time, she tells you she is doing well, is feeling more positive and able to move on with her life. She attended her appointment at the Sexual Assault Service and decided that she would provide information to the police, but not go through with the legal process. The counsellors helped her to find an appropriate person to talk to about unresolved issues from her relationship breakdown and this counselling has really helped. She was offered counselling at the Sexual Assault Service to help with the reactions to the assault, but she feels that she is recovering well with the support of her family and friends.

You suggest that she make an appointment with you if she is having problems, otherwise you will see her when her 12-week post-assault blood test for STIs is due.

At the 12 weeks post-assault test appointment, Sarah says she is not feeling much better, but is managing to get to work each day and catch up with a small group of friends socially. She has constant feelings of self-blame and intrusive thoughts of the assault when she is not occupied with her work. She agrees to go back to the sexual assault service for some trauma-focused cognitive behavioural therapy.

The role of the GP in identifying, responding, and supporting patients who have experienced sexual violence is vitally important. GPs should feel confident that with some simple strategies and a patient and trauma-focused mindset, they can provide effective support in the short, medium and long term.

• Clinical management of patients presenting following a sexual assault
• Survivor video stories
• Care package for adults who have experienced sexual trauma
• Trans and gender-diverse health care (Equinox)
• Management of PTSD
• Survivor resource