Healthcare professionals - supporting adults who present having experienced rape or sexual assault: clinical pathway

8. Health and Psychosocial Needs Assessment

8.1 Healthcare Assessment and Aftercare

This section sets out the processes for undertaking an assessment of the person’s healthcare needs, wellbeing and ongoing aftercare. Assessment for STI testing including consideration of Blood-Borne Virus (BBV) prophylaxis and pregnancy risk should be undertaken and managed in line with current guidelines and HIS Quality Indicator 5. It is important to note that should the person wish to have a FME, this should be done as soon as reasonably possible in order to preserve as much forensic evidence as possible. For details and guidance on the FME, refer to section 9.

Key points

• Supporting the healthcare needs of individuals is essential
• Health Boards must ensure that healthcare is made available to all who have experienced rape or sexual assault irrespective of whether the individual chooses to report to the police and/or undergo a FME
• A person centred, trauma-informed approach should take account of specific individual cultural and healthcare needs.
• The most appropriate method of contraception should be offered and provided as soon as possible. Refer to Faculty of Sexual and Reproductive Health (FSRH) for current guidance for Emergency Contraception (EC)^[58]
• Assessment of the possibility of existing pregnancy should be undertaken when indicated
• When the risk of Human Immunodeficiency Virus (HIV) infection is assessed as sufficient to recommend prescribing Post Exposure Prophylaxis following Sexual Exposure (PEPSE), starter packs should be commenced as soon as possible and within 72 hours of an assault. See British Association of Sexual Health and HIV (BASHH) HIV PEPSE guidance^[59] for current guidelines
• Hepatitis B vaccine is highly effective at preventing infection if given shortly after exposure and should be offered to all who may be at risk - see BASHH or local sexual health guidelines for current guidance on prescribing
• Human Papilloma Virus (HPV) vaccination should be offered to those who do not have a complete vaccination history in line with current national guidance^[60]
• Offer Sexually Transmitted Infection (STI) screening after appropriate incubation periods to allow exclusion of STIs associated with the incident. See BASHH guidance for management of STIs
• Due to increasing antibiotic resistance, STIs should be treated only after a positive test result. Prophylactic antibiotics should be considered in some circumstances when an individual is at increased risk e.g. multiple assailants and requiring an IUD as EC

Healthcare for victims of all sexes and gender identities must meet both immediate and ongoing health needs in a clinically appropriate sequence including:

• Treating physical injuries that have resulted from the assault
• Safety assessment
• Emergency contraception (where indicated)
• Testing and arranging treatment for sexually transmitted infections, post exposure prophylaxis against blood borne viruses and bacterial STIs
• Psychosocial assessment and support

The findings and observations from the assessments detailed below will be recorded in the immediate after care/medical examination follow up section of the digitised National Form within Cellma.

8.1.1 Assessment of Need for Emergency Contraception (EC)

Rape or sexual assault may place some individuals of reproductive age at risk of unwanted pregnancy. The healthcare professional should assess the need for, offer and provide EC.

The FSRH Clinical Guidelines on EC (2017)^[61] recommends that all individuals requiring EC after sexual assault should be offered all methods of EC including a Copper Intrauterine Device (Cu-IUD) if within the appropriate timeframe as it is the most effective method of EC. Following sexual assault, antibiotic cover for STI should be considered if an individual opts for Cu-IUD insertion.

The option of a FME should be discussed with the individual, with consideration of the timeframe for collection of forensic samples. If an individual accepts the offer of a FME, it should be explained that Cu-IUD insertion should be deferred until after a forensic examination has taken place in order to maximise potential for capture of assailant DNA. Some individuals may choose to prioritise pregnancy risk reduction and Cu-IUD insertion above a FME if there is to be a delay in arranging the examination. Clinicians should ensure that they provide adequate information to allow an individual to make an informed choice in this regard, dependent on their own priorities; it is important that their decision is respected.

If an individual opts to have a Cu-IUD inserted for EC after a forensic examination, their EC provider should arrange for Cu-IUD insertion to be carried out without delay after forensic examination has taken place. Oral EC should be offered in the interim in case the Cu-IUD cannot be inserted or the individual later changes their mind about Cu-IUD insertion.

Individuals who decline Cu-IUD insertion for EC after a rape or sexual assault should be offered oral EC as soon as possible, if within the appropriate timeframe.

Healthcare professionals should ensure that they provide adequate information to allow a person to make an informed choice in this regard, dependent on their own priorities; it is important that their decision is respected.

8.1.2 Oral Emergency Contraception (EC)

People who choose and are eligible for oral EC after a rape or sexual assault should be offered it as soon as possible. There are two hormonal preparations licensed for use in the UK. Consult local guidance or FSRH guidance on EC Clinical Guidelines on Emergency Contraception (2017)^[62].

Follow up arrangements for pregnancy testing and provision of ongoing contraception should also be discussed.

Those clinicians who choose to opt out of providing particular procedures because of their personal beliefs and values must make sure that arrangements are made without delay for another suitably qualified colleague to advise, treat or refer the person.

Useful Resources

GMC (2013) Personal Beliefs and Medical Practice^[63]

Nursing and Midwifery Council (2018) The Code – Professional standards of practice and behaviour for nurses, midwives and nursing associates^[64]

FSRH (2017) Guidance for those undertaking or recertifying FSRH qualifications whose personal beliefs conflict with the provision of abortion or any method of contraception^[65]

8.1.3 Assessment of Pregnancy Risk and Pregnancy Diagnosis

It may become apparent that current pregnancy as a result of a rape or sexual assault is a possibility. Testing for this should be undertaken with consent either as a baseline or for diagnosis. This should include consideration of a repeat pregnancy test at an appropriate interval if required.

Both practical and emotional support for the person should be offered. There should be pathways in place to access services which support a person’s choice, both for continuing with any pregnancy and options relating to termination, where appropriate.

In cases where the person is pregnant at the time of the rape or sexual assault, it is important that they are seen at the appropriate antenatal service following the examination for any follow up care. This support should be organised by the nurse coordinator or equivalent - see Appendix B for further information on the nurse coordinator role.

8.1.4 Testing for, Prevention Against, and Management of Sexually Transmitted Infection

Rates of STI following a rape or sexual assault vary depending on the population studied, risk factors for STIs and the sensitivity of the test used for identifying the STI. STIs are identifiable at varying periods of time post-exposure depending on the incubation period of the infection.

It is important that there are appropriate care pathways with testing timeframes and defined protocols for management of any STIs. BASHH produce guidance on prevention, screening and management of STIs. Sexual Offence Examiners should consult the most up to date publications at: www.bashh.org/guidelines.

8.1.4.1 Testing for Sexually Transmitted Infections

Due to incubation periods samples for bacterial STIs should be undertaken with consideration of appropriate incubation periods (BASHH guidelines). Any screening samples for bacterial STIs (Chlamydia, Gonorrhoea and Trichomonas) taken at the time of a forensic examination should be taken after forensic samples.

In circumstances where a positive screening sample may be of forensic significance (where a minimal chance that the person could have acquired infection from anyone other than the assailant can be evidenced, usually in child cases or people without any previous sexual activity), baseline samples maybe taken at the time of examination and again 14 days’ post incident and forwarded with an accompanying chain of evidence form. This is dependent on local facilities and is only possible where the service infrastructure allows for the testing of STI and management of results as STI screening tests are performed in NHS laboratories rather than by the Scottish Police Authority (SPA).

Any follow up samples should be coordinated by the Nurse Coordinator or equivalent.

Consider further advice from local genitourinary medicine, sexual and reproductive health clinician, microbiologist (NHS Education for Scotland 2017).

Testing for some STIs (HIV, syphilis and hepatitis) is by blood testing. In recently disclosed incidents a serum save sample should be offered at the time of the FME and stored. Arrangements should be made to screen for BBV infections after appropriate incubation periods.

If any of the above mentioned blood tests are positive at follow up following incubation periods, the serum save sample can be tested to assess whether the infection may pre-date the incident. A negative serum save sample may indicate an association between the disclosed assault and the suspect as the source of infection.

Some individuals may opt to have opportunistic baseline BBV screening rather than a serum save whilst awaiting subsequent testing to exclude the possibility of infection related to the incident.

It is important to understand that the identification of an STI in the immediate period after sexual assault is seldom useful in court. Any request from the Crown Office & Procurator Fiscal Service (COPFS) for medical notes/STI screening should be explored and a court order provided. Further information on the sharing of personal sensitive information for court proceedings can be found in the communication released^[66] by the CMO in 2016.

8.1.4.2 HIV Post Exposure Prophylaxis (PEPSE)

In cases of sexual assault, risk assessment for HIV transmission is required. Guidance on this is available in: UK Guideline for the use of HIV Post-Exposure Prophylaxis Following Sexual Exposure (BASSH 2021)^[67] and in local NHS Health Board protocols.

When the risk is assessed to be sufficient to recommend prescribing of PEPSE, starter packs should be commenced as soon as possible and within 72 hours of an assault.

Baseline blood and urine testing, including HIV testing, should be undertaken before PEPSE is prescribed. Treatment should continue for 28 days if the baseline HIV test is negative. Prescribing clinicians should check for interactions with prescribed or over the counter preparations on www.druginteractions.org. Appropriate follow up should be in place as recommended in the most recent BASHH/BHIVA guidelines.

8.1.4.3 Hepatitis A

At the time of publication, given the prevalence of this virus amongst men who have sex with men, consider the risk of Hepatitis A under these circumstances.

Hepatitis A vaccine can be given up to 14 days after exposure provided the exposure was within the infectious period of the source case during the prodromal illness or first week of jaundice (unlikely to be known in cases of sexual assault).

Immunoglobulin is also an option if given in an appropriate timeframe when there is a history of jaundice in the contact source (unlikely to be known in a sexual assault setting).

Immunoglobulin given within a few days and up to two weeks offers protection after contact with an infectious source. It may reduce symptoms if given within up to four weeks of contact.

See: 2017 Interim update of the 2015 BASHH National Guidelines for the Management of the Viral Hepatitis (BASHH 2017)^[68].

8.1.4.4 Hepatitis B

Hepatitis B testing is recommended for all people who present after rape or sexual assault (BASHH 2017).

Where there is a known risk of Hepatitis B transmission, refer to local protocols and clinical pathways (Public Health England: June 2017)^[69].

8.1.4.5 Hepatitis C

There is some evidence in high risk situations (known HCV positive source) that early treatment may be effective if there has been parenteral exposure and this should be discussed with local specialist genitourinary medicine or infectious diseases clinicians. There is currently no vaccine.

8.1.4.6 Human Papilloma Virus (HPV)

There is a Scottish vaccination programme in place for young women and for men who have sex with men up to the age of 45.

Vaccination should be considered for eligible people who have not commenced the vaccination schedule or with an incomplete vaccination history and arrangements should be made with local vaccination services.

Opportunistic cervical cytology may be considered if cervical screening is overdue at the time of a FME. Women may be less likely to engage in cervical screening following sexual violence and it may be helpful to provide information on local services.

8.1.4.7 Bacterial Sexually Transmitted Infections

In the interests of antibiotic stewardship offer testing for STIs after the appropriate incubation period and treat only if present.

Sampling methods are fairly non–invasive with the option of self-taken swabs and therefore tolerance of examinations need not be a deciding factor.

Consideration should be given to providing prophylactic treatment against bacterial STIs (Chlamydia, Gonorrhoea and Trichomonas), using a pragmatic approach based on the individual clinical picture and circumstances, for example if someone is likely to default from clinical follow up. The antibiotics provided should be informed by local resistance patterns. The default position of screening and treating only as required is preferable.

Local protocols will depend on local prevalence of infection and patterns of antibiotic resistance. See: British Association of Sexual Health and HIV (BASHH) (2012) UK National Guidelines on the Management of Adult and Adolescent Complainants of Sexual Assault (BASHH 2012)^[70]

Testing and prophylaxis for bacterial STIs and blood borne viruses after disclosure of rape or sexual assault

Immediate needs - disclosure within 14 days of assault

• Baseline HIV and hepatitis tests or save serum sample
• Commence HIV PEPSE if appropriate (within 72 hours)
• Commence hepatitis B vaccination (and hepatitis B immunoglobulin if assailant likely or known to be surface antigen carrier)
• Determine need for HPV vaccination
• Arrange appropriate testing, completion of PEPSE treatment and vaccination schedules
• Consider option for prophylaxis against bacterial STIs if IUD as emergency contraception or high risk of no future engagement with services

Disclosure after 14 days

• Offer screening for bacterial STIs
• Adapt the follow-up schedule accordingly:
  • HIV serology – testing at 4 weeks after risk will identify majority of HIV positive
  • Hepatitis B serology
  • Hepatitis B vaccination (if less than 2 weeks since sexual assault/rape)
  • Hepatitis C serology (minimum of 4 weeks post incident)
  • Syphilis serology (minimum of 4 weeks post incident)
  • Arrange appropriate testing, completion of vaccination schedules and any treatment of existing STIs identified

Presentation over 3 months

• Offer tests for bacterial STIs
• Offer syphilis, hepatitis B and C and HIV serology
• Determine need for completion of vaccination schedules depending on personal and clinical circumstances of any ongoing risks of exposure.

Useful resources British Association of Sexual Health and HIV (2012) UK National Guidelines on the Management of Adult and Adolescent Complainants of Sexual Assault British Association of Sexual Health and HIV (2015) United Kingdom National Guideline on the Management of the Viral Hepatitides A, B and C^[71] British Association of Sexual Health and HIV (2015) UK Guideline for the use of HIV Post-Exposure Prophylaxis Following Sexual Exposure^[72] British Association of Sexual Health and HIV (2017) 2017 Interim update of the 2015 BASHH National Guidelines for the Management of the Viral Hepatitides^[73] Faculty of Sexual and Reproductive Health (2017) Clinical Guidance: Emergency Contraception^[74] Faculty of Forensic and Legal Medicine (2016) Guidance on paternity testing^[75]

Public Health England (June 2017) The Green Book Hepatitis B: chapter 18^[76]

8.2 Psychosocial Risk Assessment

8.2.1 Assessment

It is important to ascertain the immediate and future safety of people who have experienced rape or sexual assault.

This should include:

• Mental health and psychological needs
• Risk of suicide and use of harmful coping strategies (refer to the Applied Suicide Intervention Skills Training (ASIST)^[77] for more information)
• Any previous self-harm or recent suicidal ideation
• Safety and ongoing risk particularly in people who at that time are at risk. This should include stalking. Their home may be a crime scene and/or the perpetrator may know where the person lives and they may feel at ongoing risk as a result
• Domestic abuse, including coercive control
• Alcohol and drug history
• Child protection issues (for further details on this, please see national guidance)^[78]
• Consideration of the safety and wellbeing for those who are cared for by the person who has experienced rape or sexual assault

In cases associated with domestic abuse, a Risk Identification Checklist (RIC) should be used. The third sector organisation Safe Lives has developed the Safe Lives DASH risk checklist which should be completed and appropriate information sharing and referral undertaken. Guidance and further information can be found on the Safe Lives^[79] website.

The Domestic Abuse, Stalking and Honour Based Violence (DASH) assessment forms part of the clinical record and is not part of the forensic documentation.

Where there is police involvement, they will use a Domestic Abuse Questionnaire (DAQ). Where issues of risk are identified, this should be shared appropriately between agencies, according to local protocol, to avoid duplication and aid management.

Alternative safe accommodation may need to be sourced with assistance from investigating police officers, violence against women services (e.g. Women’s Aid) or local authority social work or homeless services.

Legislation, as outlined in the Adult Support and Protection (Scotland) Act 2007, may require sharing information in particular circumstances with social work. The Act defines 'adults at risk' as those (aged 16 years or over) who:

• Are unable to safeguard their own wellbeing, property, rights or other interests
• Are at risk of harm; and
• Because they are affected by disability, mental disorder, illness or physical or mental infirmity, are more vulnerable to being harmed than adults who are not so affected

An adult is at risk of harm if:

• Another person's conduct is causing (or is likely to cause) the adult to be harmed
• The adult is engaging (or is likely to engage) in conduct which causes (or is likely to cause) self-harm

It is important to consider if child protection is an issue. If the person affected by sexual violence is the main carer of children and their psychological wellbeing is affected, they may require additional support. Check current support resources in place. Where there are concerns and a lack of current support systems, discuss additional support options with social work to allow for child protection procedures to be followed^[80].

8.2.2 Support and Psychological Care

Contact by a Nurse Co-ordinator in the days following the FME offers the opportunity to discuss with the person any aftercare needs and identify any new health or social care needs or concerns. If support mechanisms are in place to monitor whether normal coping mechanisms fail to resume, then timely referral to further support services or counselling can take place. See section 10.1 for more details on the Rape Crisis Advocacy Project.

People should have information about how to get back in touch with services if they wish to re-engage or require more support and should be given information about what their follow-on care may entail.

Anxiety and depression after a rape or sexual assault can appear early and are common. The majority of people recover whilst a minority will go on to develop Post-Traumatic Stress Disorder (PTSD).

Further information on follow up care and ongoing support can be found in section 10.

Individuals should have control in determining their own needs and arrangements for follow up care and support should be made. The person should be discharged to a safe environment, ideally accompanied by a family member, guardian, friend or support person. Consent to contact the person to remind them of future appointments and arrangements should be confirmed and the preferred method documented prior to discharge. If not already in contact, consent for contact from a Nurse Coordinator and Rape Crisis Advocacy Worker should be obtained. Information about support services should also be provided in an appropriate format. Support should be provided in order to ensure that referrals are carried out as well as providing additional information for people who may face barriers in accessing these services.

Useful Resources

The Safe Lives Dash Risk Identification Checklist^[81]

General Medical Council (2018)

Rape Crisis Scotland (2019) Supporting LGBTI survivors of sexual violence^[82]

Scottish Government (2016) Scotland's National Action Plan to Prevent and Eradicate FGM^[83]

Equality and Human Rights Commission (2019) Protected Characteristics^[84]