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.
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.
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 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.
Table 14.1. Possible presentations of sexual violence in general practice
- Fear or anger
- Concern about relationships
- Disclosure of physical or psychological abuse
- Shame or embarrassment
- Substance abuse
- Sexual dysfunction
- Self-harm or suicidal ideation
- Lack of energy
- Unintended pregnancy
- Disrupted menstrual cycle
- Gastrointestinal problems
- •Severe sleep disturbances
- Urinary, genital and pelvic pain
- Other chronic pain (eg headaches)
- Eating disorders, anxiety or depression
- A sense of being dirty or contaminated
- Difficulty with cervical screening
- Sexually transmitted infections
- Concerns about sexuality (for male victims/survivors)
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:
‘Sometimes things that happened in the past can affect how you feel now. For example, I often see patients who have had an unwanted sexual experience in the past, who feel stressed, anxious or down. It is really common to feel this way. Do you think that might be the case for you?’
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.
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.
Box 14.1. The WHO LIVES approach25
- Listen closely, with empathy, and without judgement.
- Inquire about needs and concerns.
- Validate and show you understand and believe the patient. Assure them they are not to blame.
- Enhance safety. Discuss a plan to protect from further harm.
- Support with referrals if needed and follow-up.
Refer to Chapter 2 for more detail about LIVES.
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
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
- Assess and treat serious injuries, including inquiry about and assessment for strangulation
- Assess and manage common post-assault injuries
- On disclosure of recent assault
- For long-term concerns about physical damage, any time after disclosure
- Assess need for emergency contraception and offer as required
- Options available:
- Copper intrauterine contraceptive device: most effective form of emergency contraception; must be inserted up to 120 hours post unprotected sexual intercourse
- Ulipristal acetate 30 mg: most effective oral emergency contraception; effective up to 120 hours post unprotected sexual intercourse
- Levonorgestrel 1.5 mg: marketed for use within 72 hours but some efficacy up to 96 hours post unprotected sexual intercourse
- For further information on emergency contraception refer to Royal College of Obstetricians and Gynaecologists emergency contraception guideline
- Note: Trans men may also require emergency contraception
- Pregnancy test three weeks post assault
- If pregnant from an assault, provide usual pregnancy option information and consider collection of evidence from the pregnancy: seek permission to speak to detective investigating the case
- Assess and manage the risk of sexually transmissible infection
- Ensure local referral information is available for advice and referral for post-exposure prophylaxis against STIs. Contact the local sexual health clinic, specialist sexual assault service or infectious disease specialist
- Baseline testing on presentation
- Follow-up testing at two, six and 12 weeks post assault
- HIV post-exposure prophylaxis to start within 72 hours of assault
- Hepatitis B post-exposure prophylaxis requires hepatitis B immunoglobulin to be started within 72 hours of assault (but may be given up to 14 days post-exposure) and a course of hepatitis B immunisation to be started within 14 days post-assault
- Assess and manage suicide risk and other mental health concerns
- Assess risk and develop safety plan
- Offer resources including 24-hour numbers
- Refer when further assistance is required
- Repeat on each review
- Plan for support for times of increased stress (eg giving evidence in court)
- Provide legal options and refer for forensic medical examination for collection of forensic evidence if patient requesting police investigation
- Ensure local referral information is available
Advise re: preserving forensic evidence if the conduct of the forensic medical examination will be delayed − if possible no shower, take clothes to forensic medical examination in separate bags
- Note: many victims/survivors will have already showered prior to a forensic medical examination and should still be offered this option despite having showered
- Wear gloves while conducting any examination
- Some sexual assault services provide evidence storage and time to decide on legal action
- Document consultation carefully as GP may be required to provide a report and/or give evidence in court
- Forensic medical examination: within 72 hours, or up to seven days (and rarely to 10 days) post-assault depending on the jurisdiction and sexual assault service
- Patient can seek legal action at any time post-assault whether or not forensic medical examination is conducted
- Assess for safety and consider legal obligations
- Conduct risk assessment when intimate partner violence is identified, including safety of children
- Provide information and refer as required
- Conduct safety assessment following sexual assault
- Complete any mandatory requirements (eg child abuse reporting)
- Develop and confirm plan for care with patient
- Provide written information
- Develop plan for care with patient and follow-up depending on time frame of disclosure and issues to be addressed
- Add follow-up to recall
- Provide written information and resources
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 histories28,32 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.