Introduction

In this chapter, we focus on the role of the Sexual Assault Centre (SAC), for the provision of holistic care for adult men and women who have experienced sexual crime. These centres have a broad range of titles internationally, but strive to offer a similar model of responsive care for those who need to access services at a time of immense personal crisis. In the Republic of Ireland, they are called Sexual Assault Treatment Units (SATUs) whereas, in the UK, they are generally called Sexual Assault Referral Centres (SARCs). Regardless of the terminology used, it is clear that the ethos must be firmly patient-focused, providing medical and support services, in conjunction with a co-ordinated justice response.

In this chapter, we delineate the necessary components of care provision within SACs, being cognisant that many of these will be discussed in greater detail in other sections of this issue of Best Practice and Research Clinical Obstetrics and Gynaecology . It will also focus, therefore, on other aspects of a cohesive service, including infrastructural and funding considerations, guideline development, data collection, strategy implementation, and internal and external education. In view of our familiarity with the model of care available in the Republic of Ireland, much of the detail will pertain to these local services and recent developments. Nevertheless, this model of standardised, patient-focused care is based on best practice and would be eminently reproducible in other jurisdictions. Furthermore, we acknowledge the requirement for standardised and responsive services for children but, in the context of this chapter, we focus on care provision for men and women over the age of 14 years.

For the purposes of this chapter, the term SAC will be used throughout, even though it is accepted that a broad range of other descriptive terms (e.g. SATU, SARC) are also used.

History and evolution of sexual assault centres

Before the establishment of a defined service, the forensic medical examination of the complainant was conducted in the police station when an allegation of sexual crime was made. As expertise began to develop in relation to the medical examination, health professionals appreciated the inappropriateness of carrying out the examination in the general environs of a police building. Thus, the provision of an acceptable environment for forensic examination in police presence was the genesis of SACs first seen in the USA and then Australia in the 1970s.

The Sexual Assault Treatment Unit of the Rotunda Hospital in Dublin opened in 1985, and was thus the first SAC to provide service in Europe. St Mary’s Unit in Manchester, UK, was established the following year. These hospital-based units were composed of a combined interview and examination room for the purpose of the forensic medical examination, with police interview and aftercare delivered elsewhere.

Internationally, in countries where rape is recognised as a criminal act, services are available for the victim who reports the crime. The initial service has most often been led by a committed professional with a support team that has evolved with the developing expertise of the group such that the nominator of ‘centre of excellence’ would be applied. Further development of a national service has often been the result of recognition of local need for a service. Without a strategic approach to service development, other centres have developed, with expertise available locally but not always with all of the core elements of care provided.

In looking at the current services in a number of European countries, Australia and the USA, service provision is not lacking, but a deficiency can be seen in national, standardised services, such that every person has access to the multidisciplinary expertise of a SAC in all regions of a country. Norway and Ireland have such a national approach to the delivery of care for the adult victim of sexual crime, and new developments in England support the standardisation of SAC services nationally there.

Access to the services of an SAC in many countries is primarily through the police services. Thus, the person must report the crime before having access to the multidisciplinary health, forensic and support services available. Some evidence shows that where access to SAC services does not have the prerequisite of police involvement, that attendance rates are higher, potentially reducing the long-term sequelae of the incident.

The evolution of SAC care has seen the provision of psychological support and facility for police interview for the complainant at time of initial attendance, as well as the development of comprehensive psychological and sexual health aftercare. Taking social, demographic and geographic considerations into account, a nationally agreed level of service, so that all patients are assured of standard practice, is invaluable. Where all the services are delivered within the centre, the term ‘one stop shop’ has been used. In areas where SACs have been established, evidence shows improved access to forensic and medical examinations and to psychological support for complainants of rape, together with higher levels of user satisfaction with the services provided. Notwithstanding this, it has been acknowledged that ‘SARCs are not the whole answer, but taken together with improvements to the investigation and prosecution of sexual violence cases, and greater investment in the voluntary sector, their development offers a real opportunity to deliver justice to victims’.

Within the Irish context, an emphasis has been placed on development and standardisation of high-quality accessible care. This care is described in detail in a readily available and comprehensive inter-agency document, which aims to ensure that a patient receives similarly responsive and holistic forensic, medical, on-site psychological and follow-up care regardless of which of the six regional SATUs they attend. The core agreed model of care in Ireland also includes a multidisciplinary team, close links with the forensic science service and police service (An Garda Siochana). Defined funding streams are provided by Departments of Health and Justice. Similarly, in the UK context, SACs have been defined as a ‘one stop location where victims of sexual assault can receive medical care and counselling while at the same time having the opportunity to assist the police investigation into alleged offences, including the facilities for a high standard of forensic examination.’ In keeping with this, the Home Office has defined an SAC as ‘a dedicated facility to provide immediate and ongoing victim care within the context of a partnership arrangement between police, health and the voluntary sector’; this document also emphasises that an SAC does not just refer to a building, but embraces a concept of integrated, specialist, clinical interventions and a range of assessment and support services through defined care pathways. At present, however, the main difference between the UK and the Republic of Ireland is that, although far more SACs have been established in the UK, services are generally less standardised, with a greater disparity in equity and access in some geographic areas than in others.

History and evolution of sexual assault centres

Before the establishment of a defined service, the forensic medical examination of the complainant was conducted in the police station when an allegation of sexual crime was made. As expertise began to develop in relation to the medical examination, health professionals appreciated the inappropriateness of carrying out the examination in the general environs of a police building. Thus, the provision of an acceptable environment for forensic examination in police presence was the genesis of SACs first seen in the USA and then Australia in the 1970s.

The Sexual Assault Treatment Unit of the Rotunda Hospital in Dublin opened in 1985, and was thus the first SAC to provide service in Europe. St Mary’s Unit in Manchester, UK, was established the following year. These hospital-based units were composed of a combined interview and examination room for the purpose of the forensic medical examination, with police interview and aftercare delivered elsewhere.

Internationally, in countries where rape is recognised as a criminal act, services are available for the victim who reports the crime. The initial service has most often been led by a committed professional with a support team that has evolved with the developing expertise of the group such that the nominator of ‘centre of excellence’ would be applied. Further development of a national service has often been the result of recognition of local need for a service. Without a strategic approach to service development, other centres have developed, with expertise available locally but not always with all of the core elements of care provided.

In looking at the current services in a number of European countries, Australia and the USA, service provision is not lacking, but a deficiency can be seen in national, standardised services, such that every person has access to the multidisciplinary expertise of a SAC in all regions of a country. Norway and Ireland have such a national approach to the delivery of care for the adult victim of sexual crime, and new developments in England support the standardisation of SAC services nationally there.

Access to the services of an SAC in many countries is primarily through the police services. Thus, the person must report the crime before having access to the multidisciplinary health, forensic and support services available. Some evidence shows that where access to SAC services does not have the prerequisite of police involvement, that attendance rates are higher, potentially reducing the long-term sequelae of the incident.

The evolution of SAC care has seen the provision of psychological support and facility for police interview for the complainant at time of initial attendance, as well as the development of comprehensive psychological and sexual health aftercare. Taking social, demographic and geographic considerations into account, a nationally agreed level of service, so that all patients are assured of standard practice, is invaluable. Where all the services are delivered within the centre, the term ‘one stop shop’ has been used. In areas where SACs have been established, evidence shows improved access to forensic and medical examinations and to psychological support for complainants of rape, together with higher levels of user satisfaction with the services provided. Notwithstanding this, it has been acknowledged that ‘SARCs are not the whole answer, but taken together with improvements to the investigation and prosecution of sexual violence cases, and greater investment in the voluntary sector, their development offers a real opportunity to deliver justice to victims’.

Within the Irish context, an emphasis has been placed on development and standardisation of high-quality accessible care. This care is described in detail in a readily available and comprehensive inter-agency document, which aims to ensure that a patient receives similarly responsive and holistic forensic, medical, on-site psychological and follow-up care regardless of which of the six regional SATUs they attend. The core agreed model of care in Ireland also includes a multidisciplinary team, close links with the forensic science service and police service (An Garda Siochana). Defined funding streams are provided by Departments of Health and Justice. Similarly, in the UK context, SACs have been defined as a ‘one stop location where victims of sexual assault can receive medical care and counselling while at the same time having the opportunity to assist the police investigation into alleged offences, including the facilities for a high standard of forensic examination.’ In keeping with this, the Home Office has defined an SAC as ‘a dedicated facility to provide immediate and ongoing victim care within the context of a partnership arrangement between police, health and the voluntary sector’; this document also emphasises that an SAC does not just refer to a building, but embraces a concept of integrated, specialist, clinical interventions and a range of assessment and support services through defined care pathways. At present, however, the main difference between the UK and the Republic of Ireland is that, although far more SACs have been established in the UK, services are generally less standardised, with a greater disparity in equity and access in some geographic areas than in others.

Location of sexual assault centres

Victims of sexual crime need to be able to access appropriate care promptly; however, this care should be provided by professionals who are doing this work sufficiently often to maintain competency and skill. For this reason, it would generally be recommended that services would be regionalised. Minimum standards for Ireland recommend that ‘any victim of rape or sexual assault in Ireland is within a maximum of 3 hour drive of a unit,’ although another report recommended that an SAC be ideally established within 80 km of any given location. A report of a UK Department of Health Working group on recommendations for service delivery recommended a model in which a regional SARC, where most examinations would be undertaken) would be assisted by a few Local Sexual Assault Referral Centres for those complainants unable to travel to the RSARC. This report anticipated that such arrangements would ensure that the maximum travelling time for a complainant would be 120 min. In the European context, albeit looking at care for women only, it has been recommended that a minimum level of service provision would be one SAC per 400,000 women to enable ease of reporting of recent assaults and to ensure high-quality forensic and medical services.

The designation of a precise location of a SAC in any country is controversial; although these units need to be relatively local to ensure ease of access, they need be accessed sufficiently often in order to be sustainable and to enable staff to retain and increase all relevant professional competencies. Service provision for rural and remote areas is, therefore, inherently difficult. It is important that police services and other agencies in these areas have close links with regional centres to ensure prompt access to care within the SACs. Furthermore, it is important that SACs are not developed as stand-alone projects, but brought into the mainstream and linked to other services through strong partnership across police, health, local authority and independent sector organisations. In the UK, the Government response to the Stern Report acknowledged that a ‘one size fits all model’ may not be suitable for all local areas, and what matters is that victims receive the comprehensive support they need when they need it, so that that they can take positive steps to recovery. For example, an area may wish to have a small centre of expertise with a high number of follow-up sites because of its geography. Yet again, this report recognises the importance of involving all relevant partners, including voluntary and community sectors, to ensure appropriate referral and follow-up mechanisms.

In providing services in more remote areas of a country, the issue of sustainability of service with low numbers of attendances is suggested to be a limiting factor in development or maintenance of expertise. With more open access to such a service and developing the professionalism of the service providers beyond the core requirements of an SAC, such a service can build capacity and be a valuable, sustainable clinical service within a community.

Necessary infrastructure

Sexual Assault Centres must provide a ring-fenced, forensically clean environment for examination to avoid contamination of evidence. Changing and showering facilities should be provided for individuals to access after examination. This facility needs to be available and appropriately staffed 24 hours a day, 7 days a week, to ensure that it can be accessed promptly when required.

The centre must also have an area for provision of follow-up care, so that the forensically clean environment is only used for acute cases. Furthermore, individuals can find it difficult to return to the clinic room they attended immediately after the acute event when they come for a return visit, as it may cause them to recall some of the negative feelings they experienced at that time of immense personal crisis.

A sufficiently private area for the psychological support worker and crisis worker, with waiting areas for family and members of the police service, must also be considered when developing an SAC. Office space for administrative, nursing and medical staff should also be included, as well access to a meeting room for team or family meetings, peer review meetings and teaching sessions. A secure storage facility for patient records, and forensic samples if a delayed reporting option exists, is also imperative.

Access to a secure information technology system and skills enables development and implementation of an electronic database. Anonymised patient records can be completed for each attendance. This allows for collection of a minimum dataset of demographic and other statistics which facilitates data collection and production of key service activity reports. These reports allow for identification of emerging trends between different SACs and over time. This information may be useful for educational strategies and risk reduction, and also for service planning and funding applications. Performance targets such as time (and any delays) between attendance and examination can also be monitored.

Funding considerations

Funding for SAC services should be defined at national level, to allow development and implementation of an integrated strategic plan for service delivery. It is imperative that this care is available free of charge to anyone who wishes to access it. As these services involve close integration and co-ordination of patients’ health and medicolegal needs, funding may have to come through health and justice routes. The set-up and running costs of SACs may, however, be offset against the likely savings to the wider health economy and the long-term costs to the economy as a whole. Effective service provision may produce cost savings by reducing multiple assessments and waiting times for individuals who use non-integrated services, and reducing the number of people later referred for specialist services (e.g. mental and sexual health). In addition to this, addressing patient needs early through provision of care within an SAC delivers better health, well-being and quality of life to patients. Long-term productivity savings have been identified when the immediate aftermath of sexual assault is managed effectively and comprehensively.

Guideline development

As previously mentioned, development of SACs, ideally in line with a national strategic vision for sexual assault services, also facilitates development and implementation of core agreed models of care. Formal development of inter-agency guidelines and care-pathways facilitates provision of consistent, high-quality care. Preparation of these guidelines needs to include input from SAC staff, rape crisis personnel, the police service and forensic science services, enabling production and dissemination of an accessible, multi-agency document to ensure a responsive, evidence-based and comprehensive response to victims of sexual violence.

The experience in the Republic of Ireland has highlighted that the inter-agency links that were established to develop these practice guidelines have ensured an ongoing commitment to an integrated partnership approach to care. On a strategic level, the representatives of the various agencies also contribute to SAC steering groups and management committees, which promote ongoing excellence of service development and delivery of high-quality care.