Sexual assault

Introduction

Sexual assault is defined as an act of a sexual nature carried out against a person’s will. Following sexual assault, a patient presenting should first be evaluated for acute traumatic physical injuries and drug or alcohol exposure. The victim should be offered prophylaxis for sexually transmitted infections (STIs) and pregnancy as appropriate. If the clinician is required to collect forensic evidence to assist in any police investigation, consent must be obtained for recording the victim’s account of the assault, the findings on physical examination and the collection of forensic material. Follow-up medical care and psychological support should be arranged prior to safe discharge.

Definitions

Every jurisdiction has its own legislation and definitions used to describe all types of sexual offences with a lack of consent being the crucial issue. Sexual assault is an act of a sexual nature where the victim does not give consent and includes attempts to force the victim into sexual activity. Types of sexual assault include rape (sexual penetration), sexual assault (intentional touching of a sexual nature) and attempted or threatened rape or sexual assault (assault with intent to commit a sexual offence). Penetration is not an essential element to sexual assault.

The absence of physical resistance by the victim is not regarded as consent. Consent means free agreement of a persons’ free will. Consent is not given when a person is physically forced or intimidated or if he or she is incapable of giving consent due to being asleep or so affected by drugs or alcohol that free agreement is not possible.

Sexual assault by a carer upon a child or dependent person (such as a disabled person) is termed sexual abuse. In this case consent is not at issue as it involves the child in sexual activity that is either beyond the child’s understanding or contrary to accepted community standards. Legal definitions regarding age vary depending on the jurisdiction.

Epidemiology

It is estimated that 0.4% of Australians aged 18 years and over experience sexual assault. Crime statistics are limited; it is estimated, for example, in the Australian Bureau of Statistics Personal Safety Survey 2005, that only 19% of women who were sexually assaulted reported the incident to police. Victims hesitate to report because of humiliation, fear of retribution, fear that they will not be believed, self-blame and lack of understanding of the criminal justice system.

Males experience sexual assault less frequently; for females, it is estimated that less than a quarter were assaulted by a stranger. Stranger assaults are more common among males.

Sexual assault is more common in vulnerable populations. Individuals in psychiatric facilities may be targeted and their reports may not be believed, as may occur with intellectually or physically disabled persons with diminished ability to detect or escape from such danger. Homeless women with serious mental illness have a very high lifetime risk for this violent victimization. Young adult male prisoners are also at risk.

Barriers to care

The ABS study found that once an incident of sexual assault has been reported to the police, one in four cases results in the perpetrator being charged, but the conviction rate is low, with less than 50% of defendants found guilty. The study showed that 12.5% of women also did not report the assault to the police because of shame and embarrassment. Emergency physicians and nurses must be aware of these attitudes that the victim and they themselves may have when approaching the sexual assault victim. A non-judgmental, accepting stance by care providers is essential. It is not the health professional’s role to make a judgement as to whether a criminal offence occurred; the courts will decide this. False allegations of rape are made, but such a person is likely to be in need of help in any event.

The role of the doctor in attending to victims of sexual assault who have consented to forensic examination and evidence collection is not the usual model of a therapeutic relationship. There is a dual obligation, as it is recognized that the physician has both a therapeutic role and a duty to the court to provide completely objective expertise in collecting evidence and interpreting the findings on examination to a court of law, where the impartiality of experts is key to their duty.