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Objective Several schemes have been reported to improve treatment of rape and to encourage reporting. The development of a comprehensive forensic and follow up service for complainants of sexual assault is described, and activities of the first year are reviewed.
Design Retrospective review of case records of complainants examined in The Haven.
Setting Department of Sexual Health in a London teaching hospital.
Sample All case records, 676 complainants, from the first year of cases seen in The Haven.
Methods Description of setting up a service in partnership between the National Health Service and the Metropolitan Police, called The Haven. Analysis of a standardised proforma used for case records.
Results Mean age of complainants is 26 years (range 11–66); 6% were male. Assailant was categorised as a stranger in 52% of cases; attack involved physical violence in 50% of cases; 24% of victims had genital injuries; 39% had other physical injuries. Immediate care given at time of forensic examination included 30% of women receiving emergency contraception and 5% of clients receiving post-exposure prophylaxis against HIV. Fifty-five percent of clients returned for a sexual health screen and/or counselling. Thirty-one percent received screening for sexually transmitted infections and 12% were diagnosed with one or more infections.
Conclusions Requirements following sexual assault include forensic examination, first aid, postcoital contraception, prevention and management of sexually transmitted infections and psychosocial support. Provision of these services within a sexual health setting is feasible.
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King's College Hospital is in southeast London. Indices of deprivation in the local area of Lambeth, Southwark and Lewisham are high, as are levels of bacterial sexually transmitted infections, HIV infection and teenage pregnancy. The incidence of sexual assault is also very high, with approximately 850 cases each year being reported to the police from the area to be served. Initially, this comprised the three boroughs listed above with a further five, more peripheral ones. In addition, as there were frequently problems with availability of forensically trained doctors elsewhere in London, we agreed to see people alleging sexual assault from other areas when necessary and feasible.
Initially, the service was to be restricted to adults, with children being seen jointly with a paediatrician once further training had been provided. It became clear, however, that a significant number of adolescents were being sexually assaulted, and that their immediate needs were similar to those of adults. Following discussion with local community paediatricians, we therefore arranged that we would see young people aged 12–15, but that child protection teams would be involved and subsequently the adolescents would be referred to their local community paediatrician.
Additional staff were required so that a 24 hour a day cover could be provided. Staff working in sexual health have most of the necessary skills, and so we determined to integrate the new forensic service with existing services. We felt that it would also be much easier to support and manage those working at night if they also worked full- or part-time during the day, whether in the forensic or in the sexual health service.
Before The Haven opened the daytime forensic service was largely provided by a clinical research fellow/senior house officer rotation, and this post now forms a major part of daytime provision for The Haven. The postholder is based within the department for one year, during which time she takes part in the on-call rota for gynaecology and was not, therefore, available for night forensic work. Subsequently, she works in obstetrics and gynaecology for a year, while being available for court appearances. To this post was added a full-time staff doctor and eight clinical assistant posts of one to two sessions each; these doctors were appointed to work a one in nine on-call rota. The posts were advertised as forensic gynaecologists, with doctors appointed having experience in gynaecology, genitourinary medicine, family planning or general practice.
Additional posts were created to manage the day to day running of the service. These were a manager, a health adviser, an F grade practice development nurse and an administrator. At night, support is provided by crisis workers. Such posts have been in place at the St Mary's Centre, Manchester, for some years, where they provide counselling and support. At King's their role has been altered slightly so that they provide support to both the complainant and the examination, including assisting the doctor and decontaminating the suite after the examination. This shift of emphasis has enabled a clearer demarcation between healthcare and police involvement, with police chaperones no longer present during the forensic examination. Crisis workers were recruited from existing clinic nurses (three) and health advisers (three) as well as by advertising (four).
Home office guidelines state that female victims should be offered the opportunity of seeing a female doctor11. As 97% of those seen were expected to be female, we therefore advertised for and appointed female staff to provide the service.
Initial training for both doctors and crisis workers consisted of a weekend course on sexual offences examination, followed by a two-day course on preparation for court and a further two-day course on forensic examination of children. Crisis worker training was supplemented by a workshop with the police on handling evidence. New staff were also usually able to observe one or more examinations before being on-call. All training is provided free of charge to those working in the service. Regular update meetings for both crisis workers and doctors were arranged.
Initially, we had intended to provide out of hours examinations within an existing small suite in the Accident and Emergency Department. Following discussions with the police, however, it was felt that a single dedicated unit would be preferable. This was developed within the Department of Sexual Health at King's College Hospital from a large examination room with integral shower room together with two adjacent rooms, one to become a waiting room/police interview room and the other for office use. To improve security and provide a sense of privacy, the unit was separated from the rest of the clinic by doors at each end of its corridor, with keypad access.
The name ‘The Haven’ was chosen by the police, with the potential aim of having several units with this name to serve different geographical areas across London.
DNA detection techniques are now extremely sensitive, making the risks of cross-contamination via staff or premises increasingly high and potentially jeopardising evidence. The Forensic Science Service provided advice on minimising the risks. Cleanable materials were used for all surfaces likely to come into contact with victims (e.g. chair seats). Staff wear fresh surgical ‘scrubs’ for each examination, and shower between examinations. Following an examination, the room is cleaned with fluid proven to be effective in removing DNA, and the absence of contaminating DNA has since been demonstrated by regular environmental checks carried out by the Forensic Science Service.
The object of forensic examination is to provide evidence that may be used in a court of law. Stringent procedures must therefore apply to the conduct and documentation of these examinations, as well as to the management of self-referred cases of sexual assault that may be reported to the police later. As the defence may use evidence of sexually transmitted infection to discredit a previously sexually active complainant, it is important to separate the forensic examination from sexual healthcare. The doctor and the crisis worker who carry out the initial examination are therefore never involved in the follow up of the victim, and forensic notes are kept separately from other clinic notes. The forensic examination is recorded on a proforma that is retained in The Haven, with the doctor taking a copy for the purpose of preparing a statement if necessary. A summary of the findings and management is placed in the routine clinic notes to guide staff seeing the complainant for follow up. After the examination, the police officer is given contact details of the doctor and crisis worker concerned, and a brief summary of the findings. Subsequently, a detailed statement is prepared upon request by the police.
Collaborative working between the police and an acute NHS trust illustrated inevitable differences in culture and work practices. Overcoming these required the development of detailed operational policies for each area as well as regular and lengthy multidisciplinary meetings between both groups. Many topics had to be considered in detail. Arrangements were needed for initial telephone contacts from police, or from the complainant in cases of self-referrals, to protect staff privacy. Arrangements for out-of-hours appointments needed to be negotiated between The Haven staff and the police depending on acuity, other bookings, distances involved and staff transport and security. The police required designated parking spaces and separate access to The Haven.
Previously, police officers assisted in examinations; this was clearly not their area of expertise and so the crisis workers took on this responsibility after negotiation about assignment of roles including who is responsible for collecting individual forensic samples. For example, the police now collect, label and bag up clothing, whereas crisis workers are generally responsible for organising the collection, labelling and bagging of urine samples and mouth swabs. Previously, the police provided forensic examination kits; subsequently, The Haven obtained them in bulk. Evidence obtained from those who have self-referred has to be stored by The Haven if permission has not been given to release samples to the police; this required the acquisition of a locked refrigerator and freezer as well as facilities for drying clothing to prevent contamination of forensic evidence by secondary growth. Other work streams included the development of standard proformas for collecting evidence in adults and in children; how the service was to be evaluated including a user perspective; and leaflets and other publicity including management of the extensive media interest.
As many complainants of sexual assault have other injuries, close links have been established between The Haven and local Accident and Emergency departments, with examinations carried out there if essential. If an examination under anaesthesia is necessary, the forensic examination is carried out in theatre. Drug-assisted rape is an increasing concern, and carries risks of respiratory problems. Resuscitation equipment including a defibrillator are therefore available in The Haven, as is first aid equipment, and packs of hormonal postcoital contraception, antibiotics, post-exposure prophylaxis for HIV and hepatitis, analgesics and tetanus toxoid.
A risk assessment for HIV is carried out at the time of forensic examination. Factors taken into account include risks related to the assault, such as a history of trauma, defloration, anal intercourse or multiple assailants, or risks related to the assailant(s), such as information about injecting drug use, homo- or bisexuality or coming from a high prevalence area for HIV. Most clients are reassured that their risk of acquisition of HIV is extremely low, but post-exposure prophylaxis is offered when the risk appears significant; this consists of a starter pack containing a three-day supply of the anti-retrovirals. Combivir and nelfinavir, together with anti-emetics, anti-diarrhoeals and written information. Clients are reassessed after two days.
Treatment for bacterial sexually transmitted infections such gonorrhoea and Chlamydia is only instituted at the time of forensic examination if the client has obvious symptoms. Complainants who are unable or unwilling to be screened for sexually transmitted infections, or to return for follow up are offered prophylaxis against Chlamydia and gonorrhoea. Screening for sexually transmitted infections, further medical care and psychological support are arranged at a follow up visit, generally at The Haven but elsewhere if more convenient for the client. This visit is scheduled for 6–10 days after the assault to allow for incubation periods of sexually transmitted infections. A separate visit also enables separation of medical and forensic notes and care, thereby avoiding the finding of a sexually transmitted infection being used to disparage a previously sexually active client in court.
When someone presents for examination following sexual assault, a supportive environment is essential, but formal counselling is inappropriate. Most complainants are in shock or denial; those referred by the police will have already had to undergo the potentially traumatic experience of explaining what happened, whereas self-referrers who may wish to inform the police should for legal reasons not be counselled until after they have given a statement.
At The Haven all crisis workers are trained to provide immediate psychosocial support. At follow up the needs of clients are assessed and counselling offered by the health adviser. Clients with needs that cannot be provided within the service are referred on, either locally or in their district of residence. A good relationship with other agencies, such as Victim Support, is essential to this process being successful. Some clients will only wish to access counselling months or years later, and so written information about potential later sources of help is also provided.
Rape often brings up issues from the past, such as shame, guilt or past incidents, where complainants have had similar experiences of loss of control, and these commonly surface during counselling sessions. The counselling provided is short term and aims at establishing trust and empowering clients; if long term input is required further referrals are made for psychotherapy.
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The Haven saw 676 complainants of sexual assault between its launch on 8 May 2000 to 31 May 2001. Of these 534 (79%) were referred by the police for forensic examinations, 142 clients (21%) were self-referrals, of whom 15 (2%) referred themselves but accepted police involvement subsequently. Seventy-two cases (11%) came from outside the boroughs served.
The mean age of complainants was 26 years (age range 11–66); 110 (16%) were aged between 11 and 15 years, and 39 (6%) were male.
Details of the assailant were recorded in 673 cases. Four hundred and five complainants (60%) alleged attacks involving a sole male assailant. Of the attacks by multiple assailants, 33 involved two men, 17 involved three men, 6 involved four men, 4 involved five men, 4 involved six men and 1 involved seven men. The relationship of the complainant and the assailant is illustrated in Table 1. The stranger 1 category describes an assailant who is completely unknown to the complainant. A stranger 2 assailant is categorised as someone whom the complainant meets but cannot trace as regards name and address.
Table 1. Relationship between complainant and alleged assailant. Values are given as n (%).
|Relationship||Number of complainants (n= 676)|
|Stranger 1*||218 (32)|
|Stranger 2**||134 (20)|
|Current partner||36 (5)|
|Family member||8 (1)|
|Not known||19 (3)|
Complainants reported using illegal drugs in the three days before the assault in 75 (11%) of cases and using two or more units of alcohol in 202 (30%) of cases.
Physical violence was reported in 341 (50%) of attacks; 76 (11%) assailants used a weapon. Genital injuries were documented in the forensic notes of 163 (24%) of complainants and 262 (39%) had injuries documented elsewhere on their bodies. The type of assault alleged varied (Table 2).
Table 2. Types of intercourse reported by complainants referred by the police. Values are given as n (%).
|Type of intercourse reported||Number of complainants (n= 521)|
|Vaginal intercourse alone||264 (50)|
|Anal intercourse alone||23 (4)|
|Oral intercourse alone||16 (3)|
|Vaginal intercourse and oral intercourse||50 (10)|
|Vaginal intercourse and anal intercourse||24 (5)|
|Vaginal intercourse, anal intercourse and oral intercourse||17 (3)|
|Anal intercourse and oral intercourse||8 (2)|
|Not known/not recorded||64 (12)|
Prophylactic antibiotics were prescribed for 47 (7%) complainants and 203 (30%) received postcoital contraception. Thirty-four (5%) received a three-day starter pack of post-exposure prophylaxis against HIV (PEP), but 20 (59%) of these did not return for repeat prescriptions and thereby complete the recommended month's of therapy.
Eighty-two (12%) complainants declined follow up at The Haven and subsequently 224 (33%) did not attend their follow up appointment. A screen for sexually transmitted infections was carried out in 211 (31%) complainants of whom 25 (12%) were diagnosed with one or more infections (Table 3). A health advisor saw 222 (60%) of those attending the follow up clinic for psychosocial support and counselling.
Table 3. Sexually transmissible infections in the 211 complainants of rape screened. Values are given as n (%).
|Sexually transmissible infection||Number of patients (n= 211)|
|C. trachomatis||12 (6)|
|T. vaginalis||6 (3)|
|N. gonorrhoeae||4 (2)|
|Positive syphilis serology||1 (0.5)|
|Genital warts||1 (0.5)|
|Hepatitis B markers||1 (0.5)|
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The Haven is the first centre in the United Kingdom to offer a comprehensive forensic and follow up service to complainants of sexual assault in a sexual health setting. The centre benefits from being sited in an acute hospital but having close police links, as there is a single point of contact for examinations as well as easy access to emergency treatment in the Accident and Emergency Department and links with local paediatricians, psychiatrists and gynaecologists. The Haven's group structure also supports health professionals in this difficult area and establishes a forum for continued education, peer discussion, audit and research. The structure also enables collaborative working with the Forensic Science Service and the local police chaperones.
In the year 2000/2001, a total of 8593 allegations of rape were made to the police in England and Wales, representing an average rise of 9% each year for the previous decade12. During this same period the percentage of rape cases heard in court resulting in a conviction fell markedly, with the rate of conviction for rape, after trial, decreasing from 1 in 3 cases reported (33%) in 1977 to 1 in 13 (7.5%) in 199913. With improvements in documentation, collection of high quality forensic evidence, increased reporting rates and the support offered through The Haven, it is hoped that this trend can be reversed.
Some findings mirror those found previously: Most victims are female and only a minority have genital injuries but other injuries are commonly seen. Previous studies have found that most of those assaulted know their assailants14,15, but differentiating acquaintances from recently met—but untraceable—strangers (the stranger 2 category) highlighted that 352 (52%) of those attending The Haven had been assaulted by complete or relative strangers. About a third of the victims reported that they used alcohol and around one-quarter reported using illegal drugs. The prevalence of sexually transmitted infections was relatively low, however, many of the young females at highest risk opted for prophylactic antibiotics rather than screening.
The Haven initially offered examination to victims aged 12 and over but there was a clear need to extend this service to acute presentations of sexual assault for younger children. Following planning meetings and joint training with community paediatricians, joint examination for those under 12 became available in February 2001. One difficulty is space; The Haven is already under pressure at busy times and the ideal would be to have a designated child-friendly waiting room and examination room.
Not only is accurate documentation vital in forensic examinations for strong prosecutions, but information gathered at these examinations is also valuable for research. The Haven provides approaching 9% of the total number of rape examinations in England and Wales and as such, documents patterns of these sexual assaults7. A comprehensive database has therefore been developed for the use of both The Haven and the Metropolitan Police.
In its first year The Haven saw 72 cases (11%) from outside the area it serves, and was unable to accommodate some additional cases. Following detailed evaluation including favourable reviews by Her Majesty's Inspectorate of Constabulary13 and the Metropolitan Police Authority, the Metropolitan Police now plans to develop more Havens to serve the remainder of London, thereby enabling equivalent care to be widely offered. We hope that as the service offered to complainants of sexual assault improves, victims will feel more able to report the crime to the police, and that with improvements in evidence collection and documentation, increased reporting rates and the support offered through services such as The Haven, convictions for rape will also maximise.