Caring for victims of sexual violence

Approximately one in four people will experience sexual violence in their lifetime. As such, a GP may well be in a position whereby a patient discloses such an experience during a consultation. The appropriate GP response involves consideration of health needs as well as legal/forensic issues and safeguarding concerns. Many GPs might reasonably consider that to be a challenging consultation, especially if arising in the midst of a typical busy session. This article provides succinct practical advice to GPs who need to respond effectively to adult patients who disclose sexual violence. The appropriate GP response to cases of child sexual abuse differs significantly from that of adult patients, and is not addressed here. 

Clinical scenario

Rachel, a 21-year-old university student, attends her GP. She begins the consultation by asking for tests for sexually transmitted infection. The GP takes a brief history, asking about symptoms, recent exposures and barrier contraception. During the consultation Rachel becomes tearful and visibly anxious. The GP recognises Rachel’s distress and responds to her: “I can see that you are upset; is there anything else that you would like to tell me?” Rachel discloses that she has been raped and that she does not know what to do.

First response

The long-term psychological recovery from sexual violence is strongly influenced by the response of the first people to whom a disclosure is made. Care should be exercised to ensure a non-judgemental approach. Many survivors of sexual violence highlight loss of control as a major distressing feature of their experience. For that reason, it is considered helpful to empower patients by explaining the options available to them while reminding them that, while you will provide information and advice, they are the final decision-makers in respect of their care. 

Where the patient might best be cared for

• The patient, acting on the advice of the GP, will decide upon their preferred choice of care. The GP must be able to inform the patient of the available options, including:
• Immediate emergency department (ED) referral
• Forensic clinical examination at a sexual assault treatment unit (SATU) along with reporting the incident to An Garda Siochana
• Health check at a SATU
• Forensic clinical examination at a SATU without immediate reporting to An Garda Siochana (but including collection and storage of forensic samples for potential use at a later date)
• GP care (ie. addressing health/forensic/safeguarding needs).

Emergency department referral

In contrast to widely accepted myths, the vast majority of patients who experience sexual violence will not sustain major physical injury. However, the GP should first consider the medical stability of the patient, as one would after any  trauma. A minority of patients will require immediate care at an emergency department. 

Addressing life-threatening medical needs should take priority over forensic evidence collection. Should you be required to refer a patient to the ED for urgent medical care, however, you should still ask the patient whether or not they wish to have a forensic clinical examination, with or without the involvement of An Garda Siochana, because it is possible for SATU staff to travel to the ED and to conduct an examination there. 

Care at a SATU

If the GP is to be able to inform the patient about decision-making in regard to attending SATU, then the GP must understand what happens at a SATU. Adult patients can choose between the three options listed above (forensic clincial examination along with reporting to An Garda Siochana; health check; and forensic clinical examination without immediate reporting to An Garda Siochana). Most commonly, patients choose forensic clinical examination along with reporting to An Garda Siochana. In that case, the patient is provided with an appointment to attend the SATU, usually within three hours of contacting the unit/on-call examiner. 

A member of An Garda Siochana attends so that chain of custody provisions can be accounted for in the collection of forensic evidence. On arrival at the SATU the patient is greeted by a psychological support volunteer from a local rape crisis centre and provided with as much time as they wish to discuss their experience. Thereafter, they meet with the forensic medical examiner (FME), usually a doctor (including many GPs) or clinical nurse/midwife specialist. 

Informed consent is obtained for each part of the assessment and a person-centred approach ensures that the patient is the central decision-maker. This means that they may consent to or refuse any individual component of the assessment. If the patient chooses to proceed, the FME takes a full medical history, including past medical and surgical histories, gynaecological and sexual histories, psychiatric history, medications and allergies. The FME takes a brief history of the reported incident of sexual violence in order to guide best possible care of the patient. However, a high level of sensitivity should be exercised to avoid adding to the patient’s distress. 

History-taking is followed by a ‘top-to-toe’ clinical examination, whereby the FME diagnoses and documents any bodily injuries. Selected forensic samples are taken, depending on the history provided by the patient, and might include head hair, fingernail clippings, skin swabs or saliva. An anogenital examination is carried out in a sensitive manner to avoid distress. Patients often report this part of the examination to be reassuring because it assists them with dispelling their concerns around their sexual and reproductive health. Forensic samples (eg. swabs and hair) are also obtained from the anogenital area.

Where a patient has decided to report to An Garda Siochana, a Garda will accept the forensic samples from the FME at the time of the examination and arrange their delivery to the national forensic science laboratory. If a patient has chosen to undergo forensic clinical examination at a SATU without immediate reporting to An Garda Siochana, then forensic samples are obtained but instead of being provided to a Garda, they are stored securely so that they may be used as evidence at a future date should the patient choose to report the incident. 

In all cases, after the examination, the FME provides medical care in accordance with the individual needs of the patient. Depending on indications, this might include emergency contraception, STI prophylaxis, minor wound-care, initiation of a schedule of hepatitis B vaccination and/or consideration of anti-hepatitis B immunoglobulin and/or HIV post-exposure prophylaxis. If a patient has chosen to only avail of a health check, then the forensic samples are not obtained and the entire focus of care is on addressing health needs such as those just listed. Patients who attend a SATU are routinely assessed for suicide risk prior to discharge. In some cases where health needs are identified that cannot be managed by the SATU staff, then onward referral may be organised (eg. a patient who is regarded as at risk of suicide may need psychiatric review via immediate referral to acute mental health services).

Before any patient leaves the SATU, they are provided with the unit’s contact details so that they can contact the service if they have any future care-related queries. Follow-up care is also discussed with the patient and they are normally offered the option of returning to the SATU for further STI screening and/or hepatitis vaccination as indicated. Some patients will decline a review appointment, choosing instead to attend their GP or a hospital GUM clinic. Patients are also provided with contact details for their local rape crisis centre for ongoing psychological support. 

Patients are asked if they would like their GP to be informed of their visit to the SATU. Some will decline, preferring anonymity. However, if the patient is agreeable, the FME will share a brief letter with the GP, or provide the patient with a letter to bring to their GP, outlining the medical care provided and recommendations for follow-up care (eg. repeat STI screening or further vaccination). Where a GP cannot provide appropriate follow-up care, perhaps because it lies outside of their individual scope of practice, then it is normally possible for the SATU to provide follow-up care for the patient. GPs should not hesitate to contact SATU, provided the patient provides consent to discuss their case, as SATU staff are keen to ensure best possible continuity of care for patients.

Care provided by GPs

Some patients may refuse onward referral and insist their GP provides care. In such circumstances, a GP cannot reasonably be expected to provide the same level of forensic and medical care as would be provided at a SATU. The GP has a duty to explain this to the patient, so as to ensure an informed decision-making process. 

Of course, some patients will choose to be cared for by their GP, with whom they will likely have an established positive doctor-patient relationship. What can the GP do in such a case? It is recommended that the GP attempt to address health and forensic needs in so far as they practically can within their scope of practice and available resources. The following points may be helpful:

• To reiterate previous advice; consider whether there is any immediate risk (eg. significant physical injury)
• Document the patient’s story accurately (you may be asked for a legal report in the future)
• Consider risk of HIV/hepatitis transmission (is the assailant known to be positive or from a high-risk group such as MSM, sub-Saharan African, intravenous drug abuser, etc.)
• Take a full medical history if the patient is not already well-known to you
• Examine the patient carefully and document all identified injuries accurately
• Consider pregnancy testing and emergency contraception options
• Consider a tetanus booster (if patient has wounds and no recent booster)
• Consider hepatitis B vaccination and prophylaxis against chlamydia and other STI
• Contact an infectious disease specialist and/or a SATU if there is a significant risk of HIV/hepatitis (HIV prophylaxis needs to be commenced within 72 hours, but is more effective if taken earlier; hepatitis B prophylaxis can be taken up to six weeks after exposure)
• Plan appropriate STI screening (either within general practice or at a GUM clinic)
• Consider patient’s safety; suicide risk, ongoing contact with assailant
• Consider safety of others; domestic violence, children in the home (social work referral may be appropriate/mandated). The welfare of the child is of paramount importance
• If the patient is under 18 years of age, Children First reporting procedures apply (ie. TUSLA referral)
• Provide contact details for local/national rape crisis support. If a patient chooses to go to a SATU for forensic clinical examination, then the chances of obtaining forensic evidence can be maximised if they are advised not to wash prior to their appointment (ie. not to bathe, shower, brush teeth, wipe anogenital area, dispose of sanitary wear, etc). 

Consultation with the GP section of the aforementioned national guideline document is recommended should you need to respond quickly to a disclosure of adult sexual violence: www.hse.ie/satu. Further detail is available there. Most SATUs have a doctor or nurse on-call at all times.