Sexual health
Vol. 14 No 4 | Summer 2012
Feature
Sexual assault: a gynaecologist’s perspective
Prof Mike O’Connor AM
MD, DCH, DDU, FRCOG, FRANZCOG, MHL, FACLM, MForensMed


This article is 10 years old and may no longer reflect current clinical practice.

‘Rape is a culturally fostered means of suppressing women. Legally we say we deplore it, but mythically we romanticize and perpetuate it, and privately we excuse and overlook it.’1
Victoria Billings

Sexual assault is forced sexual violence against an unwilling victim. More than 90 per cent of victims are female. Women not in a relationship, women with intellectual disabilities (up to 90 per cent2) and Indigenous women are more at risk. Childhood survivors of incest are also more vulnerable to adult sexual assault. Worldwide, 13 per cent of women and three per cent of men report a lifetime experience of sexual assault. In Australia, one study3 in 1995, indicated that a female had a 1:4 chance of being sexually assaulted before the age of 18 years. In 2002, another study of more than Australian 6000 women demonstrated a 12 per cent rate of lifetime sexual violence by an intimate partner. Nearly half of those women were pregnant at the time of the assault.

One in five women in Australia will experience sexual assault at some time in their life and one in ten women who are sexually assaulted will be assaulted by their current or past intimate partner. While age is no barrier to experiencing sexual assault, women aged 15–24 years are most at risk. Women who live in rural areas, are Aboriginal or Torres Strait Islander, are experiencing domestic violence, have an alcohol or other drug addiction, suffer from a mental illness, have an intellectual disability or work as a sex worker, experience higher rates of sexual violence than the general community.4

Forensic aspects of sexual assault

Whether conviction of assailants assists victims in their recovery is uncertain. However, deterrents to criminal behaviour are important and require that proven perpetrators of sexual assault are punished. Few victims report these crimes and fewer still see their assailants convicted. Careful documentation and examination of victims’ injuries is necessary to achieve convictions. Many alleged assailants are found not guilty because of arguments by counsel that the defendant could not be placed at the scene of the crime at the time of the alleged offence. Ageing the victim’s injuries can be crucial for this argument to succeed or fail. Bruising or a contusion, for example, changes with time: it may be just a red mark in the first two days and then changes to blue to purple on days two to five. Thereafter bruising may be green and then yellow by days seven to ten. Contusions represent extravasation of blood into the surrounding tissues. This extravasation will follow the path of least resistance and thus may not be located at the site of the original injury. So when describing such injuries using the Sexual Assault Identification Kit, remember to describe the size, shape, site and assessment of the age of an injury. Because injuries change over time, a re-examination in three to ten days is useful.

Key points

  • Sexual assault is primarily a crime of violence and is not motivated by sexual gratification.
  • Over ten per cent of women report a lifetime experience of sexual assault.
  • Few victims report the crime to police and few assailants (five per cent) are ever convicted.
  • Vexatious claims of sexual assault are uncommon.
  • Medico-legal considerations often inhibit medical practitioners from becoming involved in victim management.
  • The absence of physical signs of assault does not disprove allegations: at least 50 per cent of victims have no detectible injury andonly one per cent have major genital injuries: most injuries are bruises or abrasions.
  • Most patients when asked about prior sexual assaults take no offence: few (ten per cent) have ever been asked before. Less than fiveper cent seek professional help.
  • Most victims report a fear of dying during the attack.
  • The sequelae of sexual assault include anxiety, depression, nightmares, ritualistic behaviour, phobias, sexual dysfunction, substanceabuse, marital disturbance and impaired work performance.
  • Experienced counselling is an important component of the healing process.• Victims may obtain closure in some cases by conviction of an assailant.
  • Forensic examinations must include careful examination of all relevant parts of the anatomy and care with obtaining, documentingand preserving specimens.
  • Gynaecologists need to treat all allegations seriously and manage victims with understanding and respect. An important strategy isto encourage victims to re-establish control over their personal lives.
  • Government Sexual Assault Services2 have expertise in sensitive and professional management of sexual assault victims, includingliaison with police and the justice system.
  • As of 1 October 2010, the NSW Rape Crisis Centre has provided clinical services for the new National Online and 1800Counselling Service. The 24/7 service responds to anyone in Australia who has experienced sexual assault, domestic or familyviolence: 1800 RESPECT (1800 424017).
  • RANZCOG has taken a leading role in educating Australian medical practitioners through its publication Medical Responses to Adults Who Have Experienced Sexual Assault: an Interactive Educational Module for Doctors, available via the Climate site.

DNA evidence is increasingly used to identify perpetrators of sexual assault. A single strand of hair may be sufficient to identify the assailant. Samples of semen, blood, saliva or skin can be taken and must be kept in dry containers. DNA samples degrade quickly: evidence left on or in the victim’s body degrades quickly over two to ten days, especially in moist areas, so sampling must be undertaken soon after the assault. It is important to establish a ‘chain of evidence’ to avoid claims of tampering with samples. Samples included in the kits should be signed and placed in sealed containers and held in lockable refrigerators or safes. Specimens may be released into the custody of police for transfer to government analytical laboratories only with consent by the victim.

Legal aspects of sexual assault

Legislation on sexual assault has the potential to set standards of acceptable behaviour and change community attitudes to unacceptable behaviour. The issue of what constitutes consent to sexual intercourse is still a contentious one and defence counsels often argue that consent was given. In NSW, the old crime of rape was amended in 1981 to divide the crime of sexual assault into the following categories:

  • Sexual assault inflicting grievous bodily harm. Penalty: up to 20 years in prison.
  • Sexual assault inflicting actual bodily harm or using a weapon. Penalty: up to 12 years in prison.
  • Sexual intercourse without consent. Penalty: up to ten years in prison.
  • Indecent assault. Penalty: up to six years in prison.

This division of the old statutory crime of rape encouraged guilty pleas to lesser degrees of sexual assault. Australian and New Zealand legislation that is relevant to specific states and territories includes the following:

  • NSW Crimes Act 1900, especially Section 61I;
  • Crimes Amendment (Consent-Sexual Assault Offences) Act2007;
  • Vic. Crimes Act 1958 especially Section 38;
  • Victorian Crimes Amendment (Rape) Act 2007;
  • Qld Criminal Code Act 1899, especially Chapters 22, 30and 32;
  • WA Criminal Code, especially Section 326;
  • Tas. Criminal Code Act 1924, especially Section 185;
  • NT Criminal Code of the Northern Territory, especially Section192;
  • ACT Crimes Act 1900, especially Section 92;
  • Commonwealth Crimes Act 1914 Part IIIA; and
  • New Zealand Crimes Act 1961.

In New Zealand, there is debate as to whether a European model of inquisitorial fact finding might be more suitable than the current English style of adversarial justice, particularly for historic offences. New Zealand is also exploring the opportunities for ‘restorative justice’ whereby victims can have a voice to explain to a convicted offender what harm he has caused and the means by which those harms can be alleviated. It also allows a victim to understand what happened, why it happened and why it happened to them.6 In Australia, similar systems are in place by way of Victim Impact Statements. These can be used for assessment of financial compensation.7

Medical aspects

Victims are concerned about the twin problems of pregnancy and contracting a sexually transmitted infection (STI) from the assault. Government sexual assault services manage these problems. In NSW there are 52 HELP centres. Pregnancy is rare.8 One Australian audit found that less than one per cent of victims conceived as a result of sexual assault. In the USA the rate of pregnancy following sexual assault is estimated as five per cent. Victims are offered emergency post-coital contraception with either ethinyl oestradiol (100µg) with levonorgestrel (0.5mg) (Yuzpe) or high-dose levonorgestrel (0.75mg) (Postinor), given within 72 hours of intercourse and repeated 12 hours later. These methods are effective in approximately 75 per cent of cases, but pregnancy tests should be offered several weeks later to exclude failures. STIs can include chlamydia, trichomonas, gonorrhoea (risk 6–12 per cent9), herpes simplex, syphilis (risk 0–3 per cent9), hepatitis B and C and HIV. Prophylaxis against HIV is controversial, but offered. Testing for these STIs, including follow up serological testing six weeks to three months later, is good practice.

RANZCOG’s role in education and management

In 2005, a RANZCOG multidisciplinary working party produced a 150-page training handbook entitled: Medical Responses to Adults Who Have Experienced Sexual Assault. It was designed to be incorporated into both GP and specialist training programs to prepare doctors to care for patients who have been sexually assaulted. It contains:

  • a comprehensive look at the range of health outcomes experienced by adults who have been sexually assaulted;
  • scenarios though which doctors can become familiar with signs alerting them to the possibility that their patient has experienced sexual assault;
  • self-learning tasks that provide the opportunity to explore a range of responses to the disclosure of sexual assault; and
  • a section on self-care for doctors and a list of contacts for referrals to sexual assault services, plus a list of further resources and additional reading in specialist areas.

Concluding remarks

Few gynaecologists feel comfortable managing women who are sexual assault victims. In the acute phase of post-traumatic stress it is usual for women to be poor historians and are understandably highly distressed. Medical practitioners often fear giving evidence in court, but prior workshop training in court procedures is useful. The high percentage of women affected by sexual assault means that they will often present to gynaecologists with a range of functional gynaecological symptoms as part of their chronic post-traumatic stress disorder. Gynaecologists need to be aware of the possible underlying reasons if they are to avoid embarking on a range of unnecessary and unhelpful investigations. Few women resent questions being asked about possible sexual violence. Their illogical shame and guilt prevent them from volunteering that information. Competent management of such patients can be a rewarding and vital element in a woman’s recovery from sexual assault.

Case report: sexual assault as the hidden agenda

‘Jillian’ was a career Navy sailor employed as a driver. The sailors who were her frequent passengers would often make jokes about her driving skills. In 1986, Jillian was sexually assaulted by a Navy officer. He told her that should she notify the Navy police he would make sure that her annual personal appraisals were so bad that she would never be promoted. The assault was never reported. Two years later Jillian began presenting to her gynaecologist with a series of physical complaints: dyspareunia, dysmenorrhoea, menorrhagia as well as loss of libido and relationship difficulties. All of these were treated seriously and investigated: STI checks, pelvic ultrasound, and laparoscopy. All these investigations proved negative. The gynaecologist was aware of the sexual assault, but never offered counselling. Jillian left the Navy and became a Commonwealth public servant. A year later she committed suicide. The gynaecologist was left wondering if he could have managed the situation better.

References

  1. Victoria Billings “Sex: We Need Another Revolution” The Womans-book Fawcett 1974.
  2. S Salthouse and C Frohmader. ‘Double the Odds: Domestic Violence and Women with Disabilities’ (Paper presented at Home Truths Conference, Melbourne, 15–17 September 2004).
  3. Tomison AM. (1995), Update on Child Sexual Abuse, National Child Protection Clearinghouse, Issues Paper no. 5, Summer, Australian Institute of Family Studies, Melbourne.
  4. ABS (1996).Women’s Safety Australia. Australian Bureau of Statistics: Canberra.
  5. http://www.health.nsw.gov.au/policies/pd/2005/pdf/PD2005_607.pdf viewed 11 Oct 2012.
  6. http://www.justice.govt.nz/policy/supporting-victims/sexual-violence/improvements.
  7. http://www.health.nsw.gov.au/policies/pd/2005/pdf/PD2005_607.pdf viewed 11 Oct 2012.
  8. ACOG Committee on Healthcare for Underserved Women. Sexual Assault. August 2011 http://www.acog.org/Resources_And_ Publications/Committee_Opinions/Committee_on_Health_Care_for_ Underserved_Women/Sexual_Assault .
  9. http://cid.oxfordjournals.org/content/12/Supplement_6/S682.short .

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