25 October 2017

Identifying and responding to adult sexual violence

Clinical Mental Health Women

It is estimated that one in five Australian women has experienced some form of sexual violence in her adult lifetime.1 In most cases, the perpetrator is male, typically a known person such as a family member, friend, or intimate partner.

Although we commonly think of sexual violence in the context of rape, the term encompasses a range of sexual behaviours perpetrated against someone’s will; For example, unwanted kissing or touching, controlling or attempting to control a person’s reproductive choices, or using coercion or threats to obtain sexual acts. It also includes behaviours that do not necessarily involve physical contact, such as forcing someone to watch pornography, “flashing” or public masturbation.2

We know that there are strong associations between sexual violence victimisation and women’s poor physical and mental health.3 In particular, women who have experienced sexual violence often suffer from post-traumatic stress disorder (PTSD),4 anxiety and depression,5 sleep disturbances and difficulty with pelvic examinations,6 all of which can last for many years after the initial incident.

A recent study suggests that it is not just rape or completed sexual assault that is associated with poor mental health; other, more subtle, types of sexual violence, such as coercion, also have serious negative effects on women’s mental well-being7 and should be considered as underlying reasons for otherwise-unexplained symptoms of mental-health distress.

Despite the detrimental impact of sexual violence, many women do not access specialist services.8 Often they do not recognise that what they have experienced is sexual violence, particularly if the perpetrator was a husband or partner,9  and do not feel comfortable accessing support from a “sexual assault” service.

They may also feel a sense of shame or stigma about identifying as a victim of sexual violence, or they may blame themselves for the assault. They may also be reluctant to disclose to family or friends. Given these issues, the World Health Organisation has highlighted the role of primary care in responding to and supporting women who have experienced sexual violence.10

General practitioners, in particular, are well-placed to respond, since they see women regularly for a range of issues. They are also likely to see a large number of women who have histories of sexual violence. A recent study conducted in general practice found that around 45% of women in clinic waiting rooms had experienced at least one form of sexual violence since age 15. These women were significantly more likely to experience current anxiety and depressive symptoms than women who had never experienced sexual violence.7

Data from the Australian Bureau of Statistics also suggest that around 8% of women first told their GP about an incident of sexual violence, and a third went to the GP for help or advice.9

Although GPs may also see women in the immediate crisis period following an incident of rape or completed sexual assault, this article primarily focuses on what GPs can do to support women beyond the provision of emergency contraception, STI screening or forensic examination.

There are already clear guidelines through the RACGP white book about responding to women in the critical 72-hour period following an incident of rape or sexual assault.11 It is imperative that women are offered and encouraged to access the local specialised sexual assault services, not only to access specific medical care but to assist with a forensic history and examination.

Less information is available for GPs on how to respond to the longer-term consequences of adult sexual violence, and how to navigate the complexities of disclosure, referral, and ongoing support.

Asking about sexual violence

There are many reasons that women with sexual violence histories might present to general practice. The most common presentations, however, are likely to be related to mental-health issues. Otherwise-unexplained PTSD, anxiety or depression, self-harm or suicidal ideation, alcohol or substance misuse or eating disorder should alert the GP to the possibility of a sexual violence history.11

The World Health Organisation recommends asking women about sexual violence if they present with a condition that could be related,10 yet sometimes GPs seek to address women’s mental health without enquiring about violence.12

Once the GP has explored other possible explanations for the issue, if the woman is presenting alone, and if a disclosure has not been forthcoming, gently saying, “sometimes experiences that happened a long time ago can affect how you feel now. For example, I often see patients who have had an unwanted sexual experience in the past, who feel stressed, anxious or down. It is really common to feel this way. Do you think that might be the case for you?” may help to start a conversation about past experiences of sexual violence.

It is worthwhile to initially use terminology such as “unwanted sexual experiences” or “sexual things that you didn’t agree to” rather than “rape” or “sexual assault”. Some women may not like or relate to these terms or may not perceive their experiences as being a form of violence.

It is also important to enquire about sexual violence when a woman discloses physical or psychological abuse in an intimate relationship. Often women will not voluntarily disclose sexual violence in a relationship, even when they have disclosed other types of abuse.13 Consequently, sexual violence perpetrated by partners is often overlooked. This is a problem since sexual violence in a relationship can be an ongoing issue, and is a risk factor for serious injury or homicide.14

When violence in a relationship is disclosed or suspected, GPs need to ask whether any sexual encounters have happened in the relationship that the woman did not want, or whether she has ever had sex with her partner because she felt afraid or unsafe.

Similarly, GPs need to be mindful that women who experience unwanted pregnancies or request forms of contraception that are undetectable to a partner may be experiencing reproductive coercion and need support around this issue. Questioning how the woman feels about the pregnancy/contraception, and how her partner has responded to it, may illicit a disclosure of reproductive coercion.

Often women will not voluntarily disclose sexual violence in a relationship to their GP

Responding to disclosure

Once a woman has disclosed an experience of sexual violence, it is important to make her feel heard and validated. Many women are afraid they will not be believed, and worry that they will be blamed for the assault. It is critical that the GP emphasise the woman is not to blame, and that sexual violence of any type is unacceptable.

Engaging in active listening without pressuring the woman to disclose more than she feels comfortable with is a good way to establish trust. Often all women need is for someone to acknowledge that the sexual violence happened and that the GP is there to support them.

Following disclosure, the focus needs to be on what the woman would like help with and what she feels would be useful to her recovery. Women who have experienced sexual violence often say they value the support of health professionals who enquire about their needs, rather than telling them what to do.15

For instance, some women value the opportunity to talk about the assault and be listened to non-judgementally, while others benefit more from practical strategies to help them move forward and heal. Women’s emotional responses to sexual violence can vary – some will feel angry and others sad or distressed. There is no “right” or “wrong” way to feel.

Medication can certainly be considered as an option if the woman is agreeable to this. It can be helpful to stabilise her mental health so that she can work on the underlying trauma more effectively.

While referral to specialist sexual violence services such as centres against sexual assault (CASAs) is vitally important, women tell us that there is more that health practitioners could do. CASAs typically have long waiting lists, and women may need support in the interim.

GPs can help by offering ongoing appointments to talk through issues, helping women to identify priorities for safety and wellbeing, and workshopping ways to strengthen women’s social support networks. They can also refer women on to psychologists or other private counsellors (preferably ones with training in responding to sexual violence).

It is important to remember, however, that referrals without follow-up can be perceived by women as the GP “washing their hands” of the issue or being uncomfortable addressing it. Checking up on how the woman is going once she has taken up a referral demonstrates ongoing care and is likely to be appreciated by the patient. Women often tell us that they like to feel that there is a team of people (including the GP) looking after them and working together to help them on a pathway to safety and healing.

In the case of sexual violence perpetrated by an intimate partner – particularly if physical or psychological abuse is also disclosed – the GP should ensure that the woman is safe to go home. Having a general safety discussion with the woman (including making a safety plan) is recommended, as well as referral to specialist domestic violence services.

The World Health Organisation has a useful mnemonic that summarises the recommendations for responding to disclosures of domestic and sexual violence:16

LISTEN: Listen to the woman closely, with empathy, and without judging.

INQUIRE: Ask about needs and concerns. Assess and respond to her various needs and concerns—emotional, physical, social and practical (e.g. childcare)

VALIDATE: Show her that you understand and believe her. Assure her that she is not to blame.

ENHANCE SAFETY: Discuss a plan to protect herself from further harm if violence occurs again.

SUPPORT: Support her by helping her connect to information, services and social support.

Sometimes women will disclose highly distressing events to the GP. The GP needs to control their own responses to these events.

Women appreciate empathy but may find that an excessively emotional response from their health professional reinforces their feelings that this is something they cannot recover from. It also leaves them feeling that the GP cannot help. As a woman from one of our research projects put it, the GP needs to be “caring, but professional”.

It can be useful for a GP to debrief with colleagues when such difficult situations arise. Self-care is essential when responding to patients who have experienced any violence, so as to avoid vicarious trauma.

Ongoing management

In the longer-term there are also things the GP can do to support women who have experienced sexual violence. Women often struggle to identify and navigate the myriad of services available, particularly in the mental health sector. The GP can help women decide which services might be suitable for their individual needs. They can also provide referrals once a service has been chosen, which can include the woman’s trauma history to avoid her having to repeat her story to another provider. Many women appreciate this kind of sensitive information sharing, providing it is done with their consent.

Once a trust relationship has been built up, some women will appreciate the opportunity to regularly check in with the GP to talk through issues. However, it can also be helpful to have backup options on hand for times when the GP may be away or unable to schedule an appointment. Ensuring that women know who they can call in a crisis situation (e.g. sexual assault crisis line, or lifeline) can make them feel more supported.

Conclusion

Sexual violence is prevalent in general practice. It is critical that GPs consider sexual violence as a possible explanation for mental health distress in their female patients. This article shows that there are many simple ways that GPs can help identify and respond to patients in addition to referring to specialist services. The GP has an important role to play in supporting women affected by sexual violence on a pathway to safety and healing.

Dr Laura Tarzia is Senior Research Fellow at the Department of General Practice, the University
of Melbourne

References:

1. Australian Bureau of Statistics. Personal safety survey2012. In: Australian Bureau of Statistics, (ed.). 2013.

2. World Health Organization. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence.  2013. Geneva, Switzerland: WHO.

3. Campbell R, Dworkin E and Cabral G. An ecological model of the impact of sexual assault on women’s mental health. Trauma, Violence & Abuse 2009; 10: 225-246.

4. Pico-Alfonso MA, Garcia-Linares MI, Celda-Navarro N, et al. The impact of physical, psychological, and sexual intimate male partner violence on women’s mental health: depressive symptoms, posttraumatic stress disorder, state anxiety, and suicide. Journal of Women’s Health 2006; 15: 599-611.

5. Chen L, Murad M, Paras M, et al. Sexual abuse and lifetime diagnosis of psychiatric disorders: systematic review and meta-analysis. Proceedings of the MAYO Clinic 2010; 85: 618-629.

6. Luce H, Schrager S and Gilchrist V. Sexual assault of women. American Family Physician 2010; 81: 489-495.

7. Tarzia L, Maxwell S, Valpied J, et al. Sexual violence associated with poor mental health in women attending Australian general practices. Australian & New Zealand Journal of Public Health 2017; in press.

8. Banyard VL, Ward S, Cohn ES, et al. Unwanted sexual contact on campus: a comparison of women’s and men’s experiences. Violence & Victims 2007; 22: 52-70.

9. Cox P. Violence against women in Australia: additional analysis of the Australian Bureau of Statistics’ personal safety survey 2012. Anrows horizons: 01/2015.  2015. Sydney, Australia: australia’s national research organisation for women’s safety limited (anrows).

10. World Health Organization. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines.  2013. Geneva, Switzerland: WHO.

11. Royal Australian College of General Practitioners. Abuse and violence: working with our patients in general pracice. 4th edition ed. Melbourne: Royal Australian College of General Practitioners, 2014.

12. Mertin P, Moyle S and Veremeenko K. Intimate partner violence and women’s presentations in general practice settings: barriers to disclosure and implications for therapeutic interventions. Clinical Psychologist 2015: 140. Report. Doi: 10.1111/cp.12039.

13. Wall L. Research report: the many facets of shame in intimate partner sexual violence.  2012. Melbourne: Australian Institute of Family Studies.

14. Campbell J and Soeken K. Forced sex and intimate partner violence: effects on women’s risk and women’s health. Violence Against Women 1999; 5: 1017-1035.

15. Hegarty K, Tarzia L, Rees S, et al. Women’s input to a trauma-informed systems model of care in health settings: the with study, http://anrows.org.au/womens-input-trauma-informed-systems-model-care-in-health-settings-the-study (2016, accessed 31 march 2017).

16. World Health Organization. Health care for women subjected to intimate partner violence or sexual violence: a clinical handbook.  2014. Geneva, Switzerland: World Health Organisation.

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