Presentation

Given the high prevalence, it follows that any clinician having regular contact with patients will frequently encounter victims of sexual violence. Given the reluctance of most victims to disclose their abuse, the chances of the doctor discovering this important aspect in the medical history will be heavily dependent on an awareness of the scale of the problem, its potential sequelae, a natural curiosity and utilization of superior communication skills. The extent to which a patient may reveal details of abuse/violence will depend on issues particular to them, the setting and the degree of confidence they have in the clinician to respond appropriately with the information. Creating an environment conducive to disclosure and a workforce that can then cope is key.

Presentations may be acute or historical. There may be a direct disclosure or the victim may present with issues secondary to the assault, such as unintended pregnancy, dyspareunia, anxiety and depression, without volunteering that they have been assaulted. The potential long‐term health consequences are considerable as illustrated in Fig. 67.1.

Where a patient has either made a disclosure or the clinician has a high degree of suspicion that it has happened, a number of issues must be considered.

• What needs the patient may have (Table 67.1):
  
  
  
  • Medical
    
  • Forensic
    
  • Psychological
    
  • Social/practical
    
  • Safeguarding.
  
  
• What legal/statutory duties the clinician may have, such as:
  
  
  
  • Safeguarding referrals
    
  • Female genital mutilation reporting.
  
  
• What are the options for the patient and what are their ideas, concerns and expectations?
  
• What resources are available to assist (the patient and the clinician) and how might they be accessed?

Management of a victim who presents acutely

Sexual violence is about control. During an assault a victim has no control over what happens to them. An important element of aiding recovery is to offer back control as soon as possible. This is best done by going at their pace, offering them information and outlining their options, and avoiding a paternalistic approach. Where possible the patient should be offered a choice of gender regarding healthcare workers. In all cases a chaperone should be used.

Capacity and consent

As with every patient encounter, the clinician has a duty to consider whether the patient has the capacity to make decisions. Whilst sexual violence can happen to anyone, there is a high preponderance of victims who are particularly vulnerable, by way of risk factors such as learning disabilities, mental health problems, and alcohol and substance misuse. Many may have a history of prior abuse, such as child abuse or domestic violence. For this reason extra care must be taken considering mental capacity.

The definition and assessment of, and responsibilities in relation to, capacity (also known as mental capacity) in England and Wales are laid out in the Mental Capacity Act 2005, which applies to all adults aged 16+. The Mental Capacity Act 2005 defines capacity as the ability to make a decision. It relates to the process of making a decision and not to the outcome of the decision. It is not limited to medical decisions, but can apply to any decision‐making process (e.g. financial or social choices).

Capacity is task‐specific: a person may be capable of deciding one issue but not another. Capacity is also time‐specific: a person’s capacity may alter with time. The Mental Capacity Act 2005 defines the lack of capacity as follows: if, at the time the decision needs to be made, patients are unable to make the decision because of an ‘impairment of, or a disturbance in the functioning of, the mind or brain’, they are deemed incapable. The term ‘capacity’ was previously used interchangeably with the term ‘competence’. Since the Mental Capacity Act 2005, ‘capacity’ is the preferred term.

The Mental Capacity Act 2005 lays out five statutory principles.

1. A person must be assumed to have capacity unless it is established that he lacks capacity.
   
2. A person is not to be treated as unable to make a decision unless all practicable steps to help him or her to do so have been taken without success. (This includes communicating in an appropriate way. In forensic practice the clinician may need to arrange for interpreters or signers to be present or use visual aids.)
   
3. A person is not to be treated as unable to make a decision merely because he makes an unwise decision.
   
4. An act done, or a decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests.
   
5. Before the act is done, or the decision is made, regard must be had as to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action.

Healthcare professionals are warned that a person cannot be judged to lack capacity simply because of age, appearance or behaviour.

History

The level of detail required in the history‐taking will be dependent on the circumstances. For example, if the patient presents to a primary care clinician and there is a local SARC that the patient consents to be referred on to, then the history‐taking can be limited to cover the immediate urgent needs (see Table 67.1). In broad terms, the history‐taking should cover both the forensic and medical elements of the assessment (Table 67.2).

All clinicians should be mindful of the forensic aspects of the encounter and be aware that their notes are likely to form part of the evidence in any subsequent criminal justice process. Consequently, they should consider the following.

• Record keeping should be accurate, clear and contemporaneous.
  
• Consider what questions to ask and why. How might any information gained be relevant to the task at hand?
  
• Use open‐ended rather than closed questions as much as possible and record responses verbatim.
  
• Go at the pace of the patient.
  
• Use language that the patient can understand.
  
• Explore the patient’s ideas, concerns and expectations.
  
• Be non‐judgemental in both attitude towards the patient and records made.
  
• Keep objective findings distinct from subjective opinion.
  
• There will be forensic as well as therapeutic aspects.

The history‐taking will need to be modified depending on the circumstances of each case. For example, where child sexual exploitation is a possibility, the history should cover associated risk factors such as missing from home, school truancy, power imbalance in the relationship (see Spotting the Signs: A national proforma for identifying risk of child sexual exploitation in sexual health settings [3]).

Examination

As with the history‐taking, the examination will have forensic as well as medical/therapeutic elements, and often there is an overlap (Table 67.3). Prior to commencing the examination, carry out the following.

• Explain to the patient what you wish to do, why you wish to do it and that you will explain any findings at the end.
  
• Recheck that you have consent to continue (remembering that consent is an ongoing process).
  
• Reassure the patient that they can halt the examination at any time.
  
• Ensure that a chaperone is present.
  
• Ensure privacy with no unnecessary people present and no interruptions.
  
• Go at the pace of the patient; explain the process as you proceed using language they can understand.

The examination should be holistic, top to toe, starting with a general body examination before proceeding to an anogenital examination. Use a proforma as an aide memoire if possible. Document findings in the written notes as well as using body diagrams where necessary. Record negative as well as positive examination findings. If any aspect of the examination is not done, record this carefully as well as the reasons why. Objective findings should be clearly separated from subjective opinion.