Abuse and violence - Working with our patients in general practice

 

Introduction

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Sexual assault is any behaviour of a sexual nature that makes a person feel intimidated, threatened or frightened. It is behaviour that is unwanted and uninvited where another person uses physical, emotional or psychological forms of coercion. It is committed more frequently than many people realise and can include any activity from sexual harassment through to life-threatening rape. The latter is defined as the physically forced or otherwise coerced penetration of the vulva or anus with a penis, other body part, or object, and may also include oral penetration.³

Every person 16 years and over has the right to choose about participating in sexual activity and must be afforded the opportunity to form free agreement (consent). Free agreement may be negated by many factors, including age, intellectual ability, use of force, threats or fraud, and the effects of drugs and/or alcohol. In some states, including NSW, it is specifically recognised that a person who is substantially intoxicated cannot consent to sex. Sexual assault is always violence – never a legitimate expression of a person’s sexuality, love or affection.

Sexual assault is a distressing experience and people who have been sexually assaulted report higher rates of adverse health outcomes.^232–234 It is important to make it clear that sexual assault is never the fault of the victim. Above all sexual assault takes away the person’s control over what happens to their body so an understanding of this and a non-judgemental approach is essential. Many survivors access specialist sexual assault counselling when they are ready to do so, and find this helpful. The provision of high quality forensic and medical care is critical to successful patient outcomes following a recent sexual assault. GPs not familiar with forensic care should consult an appropriate sexual assault centre (refer to Resources).

GPs may not see many acute sexual assault presentations and may more often be involved in follow-up or other health issues, such as patients asking for emergency contraception or STI checks. The most frequent presentation of sexual-assault-related health issues to GPs will be for physical and other health conditions that are the long-term impacts of child sexual abuse. Commonly, patients may also be experiencing sexual harassment and intimate partner sexual assault.

 

Prevalence

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In 2011, there were 17,238 reports of sexual assault in Australia or 76 reports per 100,000 people.²³¹ This is likely to be lower than the true prevalence, due to under-reporting.

The age patterns for reports of sexual assault victims in Australia are similar for both sexes, peaking in the 10–14 year age group and then declining, but with rates of assaults against females being consistently higher in all age groups than in males.²³¹

For females aged 10–14 years, the rate of sexual assault was 494 per 100,000 population, compared with 96 per 100,000 for males.³

The Australian Bureau of Statistics 2012 Personal Safety Survey¹⁰ showed that 17% of women (1,494,000) aged 18 years and over and 4% of men (336,000) aged 18 years and over have experienced at least one episode of sexual assault since the age of 15.

Relationship to perpetrator

Both men and women who had experienced sexual assault since the age of 15 were more likely to have been sexually assaulted by someone they knew, for example a friend or family member, than by a stranger. Specifically, in 2011, almost half of all victims were sexually assaulted by a ‘known other’ and 31% by a family member. Strangers accounted for only 15% of sexual assaults in 2011.²³¹

Using a broad and inclusive definition of sexual coercion, an Australian survey found that 2.8% of men and 10.3% of women reported sexual coercion under the age of 16 years.²¹⁴ Only 31.5% of men and 37.9% of women had ever talked to someone about the assault, with the majority talking solely to a friend.²¹⁴ A low 2.6% of men and 8.4% of women reported the incident to police. These data provide a small insight into how common sexual coercion is in our society, and how infrequently disclosure is made or legal action instigated.²¹⁴

People who have an increased risk of sexual assault

Certain groups of people appear to experience sexual assault more frequently and sexual assault can be part of intimate partner or family violence:

• Socio demographic risk
  • women²¹⁴
  • young people, aged 10–14 years²³¹
  • Aboriginal or Torres Strait Islander peoples.
• Associated health issue
  • alcohol users (either consumed by choice or via spiked drinks)²³⁵
  • illicit drug users (taken by choice or consumed via spiked drinks), including those injecting²³⁶
  • mental health issues
  • a disability (including learning difficulties).²³⁷
• Past history of abuse
  • previous experiences of sexual assault²³⁸
  • a history of childhood sexual assault (up to one in three women who were sexually assaulted as a child report sexual assault as an adult).²³⁹
• Living or working in circumstances such as:
  • poverty²³⁹
  • homelessness or threat of homelessness²⁴⁰
  • the sex industry²⁴¹
  • custody and incarceration²⁴²
  • travelling or being an international student
  • an area of war and civil crisis.²⁴³

The majority of victims who have been sexually assaulted do not report the incident to the police. They may fear that they will not be believed, or are reluctant to enter a system that they fear will treat them as being responsible for the assault. Reporting of sexual assault is also dependent on the person’s previous experience with authority figures. They may also not recognise the incident as an assault or may blame themselves – this may also be influenced by cultural issues.

 

The role of GPs

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GPs need to maintain a high level of awareness that a history of sexual assault can be part of a patient’s history. The GP’s role includes identification and response to acute assault as needed and management of long-term consequences of sexual assault.

The most prevalent forms of sexual violence are child sexual abuse, sexual harassment and intimate partner sexual assault. Gender attitudes towards women are thought to underlie both intimate partner abuse and sexual violence³ (refer to Chapter 2 ).

 

Identification

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Types of presentations in general practice

A patient may disclose a sexual assault immediately, or years after the event.

GPs working in casualties and within sexual assault services will be seeing patients presenting immediately or very soon after the sexual assault. They will be trained to provide forensic assessment and to arrange follow-up.

Other presentations to general practice following a recent sexual assault may be for emergency contraception or STI checks. The patient may report that her behaviour was atypical – ‘not like me’. If patients present for these reasons, it is important to consider asking gently whether this was consensual sex. Later presentations may be for mental health and other health problems.

Sexual assault is extremely damaging to the victim’s sense of safety and self-esteem. It can result in a range of physical, mental and emotional disturbances.

Medical consequences of sexual assault can include:

• immediate effects
  • physical injuries
  • unintended pregnancy, terminations and STIs
  • psychological affects
• long-term effects
  • recovering from sexual assault can take many years. There are many ways of dealing with the experience. Some of the more common presentations are listed in Table 11.

 

Any post-assault reactions such as those outlined are important to note – nearly one-third of victims will develop rape-related PTSD. Victims are also three times more likely to experience a major depressive disorder compared to those who have not been sexually assaulted.²⁴⁵

 

Disclosure of sexual assault

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Disclosure of sexual assault will rarely be direct and most likely will be couched in vague stories, clues or terms. The disclosure may take the GP by surprise. However, there are a number of strategies that can be used in dealing with a disclosure. Taking victim concerns into account helps to set the scene for the consultation.

In 2013, the WHO released clinical and policy guidelines for GPs responding to intimate partner abuse and sexual violence.³

The guidelines recommend that GPs ask women about sexual violence as part of assessing conditions that may be caused or complicated by such violence. These include mental health symptoms, alcohol and other substance use, chronic pain or chronic digestive or reproductive symptoms.

Before asking about violence you need to ensure that it is safe to do so — for example that the abusive partner is not present — and that you have systems in place that promote safety and a referral network. GPs should provide immediate first-line support to women and men who disclose violence, including:

• being non-judgemental and supportive, and validating what the woman/man is saying
• providing practical care and support that responds to her/his concerns, but does not intrude
• asking about their history of violence, listening carefully, but not pressuring the patient to talk
• helping them access information about resources, including legal and other services that the patient might think helpful
• assisting the patient to increase safety for themselves
• providing or mobilising social support.

Survivors’ concerns can revolve around issues of confidentiality (especially relatives and friends finding out), issues of blame, shame and medical issues – for example, pregnancy and STIs. The issue of confidentiality can present ethical dilemmas. The GP cannot maintain confidentiality when the safety of the patient, especially a child, is at risk. GPs are mandated to report child sexual abuse (refer to Chapter 6 ). Discussion with a colleague, sexual assault service and/or medical defence organisation may help clarify any dilemmas the GP may have in making such a report.

 

Management

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Management will vary depending on when the assault occurred. It is important to listen to the patient, believe their story, and be non-judgemental and supportive. Management includes:

• being aware of treatment options
• allowing the patient to accept or decline treatment options using shared decision making
• being aware of local resources – for example, sexual assault counsellors, group support
• contraception, STIs and what needs to be offered now
• forensic examination if a recent assault – this needs to be performed by an appropriately trained doctor or nurse as soon as possible after the assault, preferably within 72 hours²⁴⁶
• follow-up – patients may need to return for follow-up at 2, 6, and 12 weeks following STI checks
• continuing your involvement as the patient’s GP.

Any investigations performed depend on the nature of the assault and prevalence of the STI in the geographic area. Screening recommendations following a recent sexual assault, suggested prophylaxis, and a review program are outlined in Tables 12–14.

Information is also available from the National Management Guidelines for Sexually Transmissible Infections.

Also check with your local health department or centre for disease control, as there are some variations in treatments in different parts of Australia.

Source: Mein JK, Palmer CM, et al. Management of acute adult sexual assault.  Med J Aust 2003; 178(5):226-230© Copyright 2003 The Medical Journal of Australia - adapted with permission. The MJA accepts no responsibility for any error in the adaptation. 

^{Source: Mein JK, Palmer CM, et al. Management of acute adult sexual assault.  Med J Aust 2003; 178(5):226-230© Copyright 2003 The Medical Journal of Australia - adapted with permission. The MJA accepts no responsibility for any error in the adaptation.} 

^{Source: Mein JK, Palmer CM, et al. Management of acute adult sexual assault.  Med J Aust 2003; 178(5):226-230© Copyright 2003 The Medical Journal of Australia - adapted with permission. The MJA accepts no responsibility for any error in the adaptation.} 

 

Male sexual assault

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Apart from the specific gynecological and reproductive health issues for women, men experience many similar emotional and psychological impacts of sexual assault. The principles outlined above are equally appropriate for men.

A common issue for men who have been sexually assaulted is concern about their sexuality. Sexual acts that 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. It is good to take the time with your patient to ensure that they understand the difference.

Male sexual assault may involve more force and violence, and physical injuries may be more severe. Societal and other values may prevent men from disclosing sexual assault; again the strategies discussed earlier can be applied – for example, involvement of police and sexual assault teams.

The decision whether to report an assault to the police is ultimately the victim’s. They may want to access help in making their decision through rape crisis and sexual assault centres. A nationwide list can be found at Forensic and Medical Sexual Assault Clinicians Australia (refer to Resources). The most important exception to this rule is mandatory reporting for children, in which case GPs are mandated to report child sexual abuse (refer to Chapters 6 and 13 ).

There may be other circumstances where a GP may consider reporting. In cases where the person has an intellectual disability or dementia you may involve the legal guardian, provided they are not the abuser. This may also be a consideration where an ongoing risk is present for the victim. In these circumstances, discussion with a medical defence association and colleagues may be of use before deciding whether to disclose to the police.

 

Conclusion

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Sexual assault requires a multidimensional team of providers to assist survivors on a pathway of healing and recovery. A GP who is trained in gender-sensitive sexual assault care and examination should be available at all times of the day or night at a district level.

Clinical care of survivors of sexual assault,³ in addition to first line support – listening, practical care and support, offering comfort – includes using shared decision making by:

• offering emergency contraception – levonorgestrel within 72 hours or IUD within 5 days
• considering offering HIV post-exposure prophylaxis within 3 days for sexual exposure – get advice from an on-call immunologist about the level of risk as soon as possible
• exploring legal and other community services referral
• documentation
• encouraging support within the victim’s community.

Watchful waiting in the first 3 months, using regular follow-up and offers of ongoing support, allows the GP to identify the women who become incapacitated during this time by post-rape symptoms. In this case psychological therapies specific to women who have been traumatised may be helpful. GPs should also treat any mental health issues in accordance with best evidence guidelines for depression, alcohol or drug use problems. For women after 3 months, GPs need to assess for a diagnosis of PTSD.

Case study: Sarah

Sarah, 26 years of age, presents to the GP with worries about ‘the possibility of vaginal infection’. On careful history taking the story begins to take shape. Sarah worked part time in a club while studying. She reveals that she had gone home with one of the local patrons for a cup of coffee and he had sexually assaulted her. She has been unable to tell anyone since it happened 2 weeks ago.

Diagnosis

Sarah has been sexually assaulted and now has concerns about pregnancy and STI. She appears to have continued to function for the last 2 weeks and wishes to address her feelings and seek help now.

Management

You need to acknowledge that Sarah has been sexually assaulted and then help her deal with the consequences. Is she pregnant? Does she have an STI? All these issues need to be addressed in this and subsequent consultations.

Emotionally, Sarah needs to talk about what has happened to her so that she can perhaps understand and be aware of how this may be affecting her. You should explore the options with Sarah of reporting the incident to the police, being referred to a sexual assault service for counselling, and considering if she could share this with a member of her family or with a friend. Sarah is also given the option of seeing the GP once a week for 4–5 sessions to begin to work through these issues. Consider using a mental health plan and using a mental health referral to someone with appropriate training in this area if this is needed.

Outcome

Sarah is not pregnant nor has she contracted any STIs. She opted to see you for four sessions and was able to discuss this with her family who were very supportive. She may need further help. Other victims may feel more comfortable talking with a counsellor or attending a sexual assault centre.

 

Resources

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Please refer to Appendix 7 for resources nationally and in your area.

 

Further information

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Adult sexual assault – this article discusses forensic care for those who have experienced adult sexual abuse.

Better Access Initiative – the MBS item relating to GP Mental Health Care Plans may be useful for survivors wanting to initiate ongoing mental healthcare.

RACGP information relating to GP Mental Health Care Plans.

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