Clinical pathways to support adults who experienced sexual assault: consultation

2. Understanding and responding to the needs of people who have experienced rape and sexual assault

This section:

• Focuses on the societal and cultural context of gender based violence, abuse and sexual violence;
• Outlines the need for services that respond appropriately to the needs of People who have experienced rape, sexual assault or child sexual abuse.

2.1 Gender Based Violence and Domestic Abuse

Sexual violence affects the population of Scotland; it perpetuates inequality and prevents the achievement of potential, not only those who directly experience it or those that fear it, but also their families, and communities (Scottish Government 2016).

The term Gender Based Violence is used to describe violence, predominantly against women and girls, in the context of gender inequality. Gender based violence encompasses:

• Domestic abuse
• Rape and sexual assault
• Childhood sexual abuse
• Commercial sexual exploitation
• Sexual harassment and stalking
• Harmful traditions and practices

The roots of gender based violence are deeply embedded within societal and cultural attitudes towards women and in notions of how men and women should behave, particularly in relation to sexual matters (Health Scotland 2018).

These attitudes can have significant impact on people who have been raped and can deter them from seeking help due to fear of judgment. Fear of judgement is particularly common among people with pre-existing vulnerabilities or criminal convictions for example sex workers, substance users or those living with domestic abuse. This results in significant under reporting (see section 3.3)

Sexual violence within relationships should always be considered within the wider context of domestic abuse. Those most at risk of domestic violence are those with co-vulnerabilities and perpetrators can be adept at targeting these individuals (see section 3.2). An assessment of ongoing risk should be undertaken with any individual of intimate partner violence and child protection issues (NHS Education Scotland 2017).

2.2 Responsive Services

Evidence demonstrates that a timely, person-centred service following sexual assault can positively influence a person’s long term health, wellbeing, and recovery. Such a service also helps ensure continued engagement in any criminal justice process, as well as the collection of high quality evidence to support the criminal justice process.

The dual benefits of a dedicated service for the health and wellbeing of the person and the collection of evidence to support the delivery of justice are quite considerable. Emotional, practical, and clinical support; Wellbeing of the patient; and forensic evidence collection are key factors with rape and sexual assault investigations – as well as being central to health outcomes and maintaining the confidence of the complainant throughout the judicial process
(Lovett et al 2004; European Parliament 2013; Angiolini 2015)

For the individual, the long-term effects of sexual violence can have both immediate and longer term impacts on physical and mental health and wellbeing as well as on coping strategies which may bring their own health impacts. Effects can vary and can include depression, anxiety, post-traumatic stress disorder, psychosis, alcohol and drug misuse, self-harm and suicide, and obesity. Such outcomes have a higher prevalence reported amongst young people. Sexual violence may also affect personal economic ability and can worsen the impact of inequalities in women, the vulnerable and the disadvantaged, and is often linked to domestic violence (Department of Health 2012, Conaglen and Gallimore 2014). It also can have an impact on those close to them, including individuals dependent on them such as children and others.

2.3 Trauma Informed Services

2.3.1 Trauma Informed Practice

A trauma informed examination takes into account the impact that sexual violence may have on a person and seeks to ensure that their experience of trauma is not repeated or triggered in the examination. It offers them a very different relational experience from the assault or rape, one which may help to start the healing process rather than hinder it.

Principles of trauma informed practice:

• Realise the prevalence of trauma
• Recognise the impact of trauma
• Respond using trauma informed principles, both personally and as an organisation
• Resist re-traumatisation through offering choice and collaboration, power and control, safety and trust.

2.3.2 Understanding the impact of trauma

The human response to threat – fight, flight and freeze – is designed to ensure survival. In the context of sexual assault most individuals will exhibit the freeze response. If the freeze function is unsuccessful, the body will move to a ‘flop’ state, changing from predominantly sympathetic to parasympathetic activation. This will result in reduced muscle tension and reduced cortical functioning in order to ‘lessen the impact’. Individuals who exhibit this will be submissive and make little or no outward protest to what is happening to them. Complete emotional and physical detachment while experiencing the assault (dissociation) can enable a person to endure horrifying experiences beyond their control, however may lead to long term issues affecting their physical and mental wellbeing.

Useful resources

Dr Caroline Bruce, Clinical Psychologist and Dr Julie Cumming, Sexual Offences Examiner: Trauma Informed Practice in the Forensic Setting: A conversation

NHS Education Scotland (2017) Transforming Psychological Trauma: A knowledge and skills Framework for the Scottish Workforce

NHS Health Scotland (2018) Gender Based Violence

NHS Lanarkshire: Trauma and the Brain: Understanding Abuse Survivors Responses

NHS Education Scotland (2018) Opening Doors: Trauma Informed Practice for the Workforce https://vimeo.com/274703693