Abuse and violence - Working with our patients in general practice


The White Book
Chapter 9.  Sexual assault
☰ Table of contents


Key messages

  • Sexual assault is very common, with one in five women and one in twenty men having experienced an assault in their adult lives231
  • Many victims do not report sexual assault; therefore the effects, both physical and psychological, may go untreated231
  • Particular groups are at greater risk of sexual assault, including young people, those with a disability, and those who have previously experienced abuse231
 

Recommendations

  • Offer first-line support to women and men who are survivors of sexual assault by any perpetrator3Practice point
  • Consider and ask about post trauma responses by assessing for mental health problems – acute stress, PTSD depression, alcohol and drug use problems, suicidality or self-harm and offering appropriate support and treatment3 Practice point
  • Offer emergency contraception if within 72 hours of assault and offer all women sexually transmitted infection investigation, prophylaxis and treatment as appropriate3 Practice point


Introduction


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


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


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


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.
Table 11. Common presentations of sexual assault
  • Fear
  • Self-blame/self-harm
  • Guilt
  • Anger
  • Concern about relationships
  • Shame
  • Flashbacks
  • Substance abuse
  • Sexual dysfunction
  • Suicide or suicidal ideation
  • Lack of energy
  • Disrupted menstrual cycle
  • Exhaustion
  • Gastrointestinal problems
  • Severe sleep disturbances
  • Urinary, genital and pelvic pain
  • Joint stiffness
  • Other chronic pain states
  • Eating disorders, anxiety or depression
  • Ambivalence regarding legal prosecution
  • A sense of being damaged or contaminated

 

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


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


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.

Table 12. Baseline screening recommendations to be considered for STIs

Infection

Test

Site (take according to history)

HIV

HIV antibody

Blood

Hepatitis B

Hepatitis B surface antigen (HbsAg), core antibody

Blood

Syphilis

Rapid plasma regain (RPR) + treponema pallidumTreponema pallidum EIA (TPEIA)

Blood

Chlamydia

Polymerase chain reaction

Endocervical swab, first void urine or high vaginal swab

Gonorrhoea

Polymerase chain reaction or microscopy, culture and sensitivity (MC&S)

Endocervical swab, first void urine, rectal swab* or throat swab*

Trichomonas

Microscopy, culture and sensitivity (MC&S)
PCR may be available in some jurisdictions

High vaginal swab

* MC&S only as PCR is not validated for these sites


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. 

Table 13. Suggested prophylaxis to be considered for STIs

STI

Treatment

Chlamydia

Azithromycin (1g orally)

Hepatitis B

Hepatitis B vaccine (1mL intramuscularly [IM])

Gonorrhoea
(only if considered high risk)

Ceftriaxone (250 mg IM)
OR
Where local gonococcal sensitivities permit:
Ciprofloxacin (500 mg orally)
OR
Amoxycillin (3g orally) and probenecid (1g orally)

Syphilis (if high risk)

Benzathine penicillin (1.8g IM)

HIV (if high risk)

Telephone local infectious diseases or sexual health physician urgently; initial dose must be given within 72 hours, sooner is better

Other STIs

Consult local infectious diseases or sexual health physician


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. 

Table 14. Review program

2–3 days
Assess injury healing if relevant

2 weeks
Test results, pregnancy testing, healing, coping
Follow-up testing: HIV chlamydia, gonorrhoea, trichomonas (depending on local prevalence and practice)

3 months
Follow-up serological tests for HIV, hepatitis B virus, syphilis

6 months (if hepatitis C was considered a risk)
Follow-up serological test for hepatitis C virus if a test was performed initially
Examine and swab, as appropriate, all sites that as a result of the assault are at risk of infection


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


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


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


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

 

Further information


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.

  1. World Health Organization. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: WHO, 2013. 
  2. Australian Bureau of Statistics. Personal Safety. Canberra: ABS, 2012. 
  3. De Visser RO, Smith AMA, Rissel CE, et al. Experiences of sexual coercion among a representation sample of adults. Aust N Z J Public Health 2003;27:198–203. 
  4. Australian Institute of Criminology. Australian Crimes: Facts and figures. Canberra: Australian Institute of Criminology, 2013. 
  5. Jozkowski KN, Sanders SA. Health and sexual outcomes of women who have experienced forced or coercive sex. Women Health 2012;52:101–18. 
  6. Miller TR, Cohen MA, Wiersema B. Victim costs and consequences: A new look – National Institute of Justice Research Report. Maryland: US Department of Justice, Office of Justice Programs, 1996.
  7. Samuels JE, Thacker SB. Full Report of the Prevalence, Incidence, and Consequences of Violence Against Women. Findings From the National Violence Against Women Survey: National Institute of Justice, US Department of Justice. Centers for Disease Control and Prevention, 2000. 
  8. Hurley M, Parker H, Wells DL. The epidemiology of drug facilitated sexual assault. J Clin Forensic Med 2006;13:181–5. 
  9. Tucker JS, Wenzel SL, Straus JB, Ryan GW, Golinelli D. Experiencing interpersonal violence: perspectives of sexually active, substance-using women living in shelters and low-income housing. Violence Against Women 2005;11:1319–40. 
  10. Murray S, Powell A. Sexual assault and adults with a disability. Enabling recognition, disclosure and a just response. Melbourne: Australian Centre for the Study of Sexual Assault, 2008. 
  11. VanZile-Tamsen C, Testa M, Livingston JA. The impact of sexual assault history and relationship context on appraisal of and responses to acquaintance sexual assault risk. J Interpers Violence 2005;20:813–32. 
  12. Loh C, Gidycz CA. A prospective analysis of the relationship between childhood sexual victimization and perpetration of dating violence and sexual assault in adulthood. J Interpers Violence 2006;21:732–49. 
  13. Morrison Z. Homelessness and sexual assault. Melbourne: Australian Centre for the Study of Sexual Assault, 2009. 
  14. Quadara A. Sex workers and sexual assault in Australia. Melbourne: Australian Centre for the Study of Sexual Assault, 2008. 
  15. Tarczon C, Quadara A. The nature and extent of sexual assault and abuse in Australia. Melbourne: Australia Centre for the Study of Sexual Assault, 2012. 
  16. Amowitz LL, Reis C, Lyons KH, et al. Prevalence of war-related sexual violence and other human rights abuses among internally displaced persons in Sierra Leone. JAMA 2002;287:513–21. 
  17. Burgess AW, Holmstrom LL. Rape trauma syndrome. Am J Psychiatry 1974;131:981–6. 
  18. Green AH. Child sexual abuse: immediate and long-term effects and intervention. J Am Acad Child Adolesc Psychiatry 1993;32:890–902. 
  19. World Health Organization. Guidelines for medico-legal care of sexual violence survivors. Geneva: WHO, 2003.