Rape and sexual assault

Rape and sexual assault are common. The Crime Survey for England and Wales estimated that 2.3% of adults (3.3% women and 1.2% men) aged 16 years and over were victims of sexual assault (including attempts) in the year ending March 2022. This equates to an estimated 1.1 million adults (798,000 women and 275,000 men). Approximately 16.6% of adults aged 16 years and over (7.9 million) had experienced sexual assault (including attempts) since the age of 16 years; 1.9 million were a victim of rape (7.7% women and 0.2% men).¹

The majority of victims know their assailant. Domestic violence is strongly linked to sexual assault and rape. Of the 85% of violent crimes against women which are domestic, 5% are rape and 11% are sexual.²

NB. At the time of updating this article (August 2023), the British Association for Sexual Health and HIV were updating their Sexual Assault Guidelines.

Legal definitions³

Rape: is defined as the penetration of the vagina, anus or mouth by a penis, without consent. Both men and women can be raped.

Assault by penetration: is the penetration of the vagina or anus with an object or body part, without consent.

Sexual assault: rape or assault by penetration including attempts are 'serious'; indecent exposure or unwanted touching are 'less serious'.

Sexual assault and rape can happen to anyone, although women are at greater risk than men. People who are already in a position of lesser power are those at greatest risk:⁴

• Survivors of childhood or adolescent sexual or physical abuse.

• Adolescents

• Young women: 16- to 24-year-old women are four times more likely to be sexually assaulted than any other age group.

• People with disabilities.

• People with substance abuse problems.

• Homeless people.

• Sex workers.

• Prisoners and women in detention centres.

• People in institutions, including the military.

• People in areas of military conflict.

Immediate care

The majority of victims never report their assault to police. However, many seek medical advice although they may not disclose the reason for their presentation: they may present with non-genital injuries and women may present requesting emergency contraception.

Particularly with young people, you need to remember to ask "Could you have said no?". Considering this possibility may make us feel uncomfortable, putting us outside of our comfort zone, especially if they then say "No".

You will have seen women in your surgeries who have recently been the victims of rape. This may be more likely if you work in a rural area. However, people who have been victims of a sexual assault don't necessarily go to the police or A&E, for a multitude of reasons.

Sexual Assault Referral Centre (SARC)

If the person does wish to report it to the police, they should be encouraged to do so promptly in order to obtain the best forensic evidence. They will be seen by specially trained police and then trained professionals at a Sexual Assault Referral Centre (SARC).

The services and support of the staff at a SARC are available to a victim whether or not they have reported the assault to police.

Being seen at a SARC will allow collection of evidence in an environment that avoids DNA contamination and victims can choose to be dealt with anonymously.

Subsequent evidence may be used in any legal case but does not oblige the victim to report their experience to the police, if they have not already done so. Click all sexual assault referral centres in England and Wales or go to The Survivors Trust.⁵ for details of your nearest SARC in England or Wales.

Pragmatic treatment

For those people who do not wish, at least initially, to report the assault to the police or attend a SARC, you need to be able to give them the best pragmatic treatment. You should not attempt a detailed forensic examination unless you have the specialist skills to do so and can provide the appropriate environment.⁶

The most important thing to do when someone tells you they have been the victim of a sexual assault is to listen to them. Believe them. The vast majority of allegations of sexual assault are true. Don't judge them. Be sensitive and offer to help.

Sexual assault is a profoundly disempowering experience and it is crucial to help people start the process of recovery by giving them back control over what is happening to them, including allowing them to decline any examination or onward referral. However, it is also important to try to find out exactly what happened:

• Where did it happen?

• When did it happen?

• Who did it?

The most fragile forensic evidence, which is lost within 24 hours of an assault, is that in the mouth. This can be collected in an early-evidence kit and should be considered even if the victim doesn't wish initially to involve the police, as they may change their mind later on.

A mouth rinse, plus a urine sample for drugs and alcohol which may have facilitated the assault, are available from police and can then be stored without any immediate decision needing to be made regarding either referral to a SARC or reporting of the incident.

Short-term effects

There are many risks following an assault:

The risk of pregnancy and any need for emergency contraception should be assessed and managed appropriately.

The risk of a sexually transmitted infection (STI), most commonly chlamydia and gonorrhoea but also the risk of hepatitis B and HIV, need to be considered (see below).

Most people experience profound emotional reactions in the weeks following a sexual assault. Approximately 50% recover from psychological effects at 12 weeks but for many the symptoms persist for many years:

• Depression: there is a significant risk of completed and attempted suicide in victims or rape.

• Post-traumatic stress disorder (PTSD): this is more likely following rape than any other crime. Early intervention is often indicated for distress, although randomised control trials (RCTs) indicate that psychological debriefing may actually harm rather than benefit the individual.⁷

Sexually transmitted infection risk and PEPSE

The levels of risk are often difficult to quantify. However, if in any doubt, prophylaxis against STIs should be provided. It is especially difficult when it comes to the risk of acquiring HIV.

PEPSE (post-exposure prophylaxis following sexual exposure), or nPEP - the US term for non-occupational PEP, is now a widely accepted strategy to reduce HIV transmission, although there has been some controversy that it may encourage risky sexual behaviour.

The British Association for Sexual Health and HIV (BASHH) published updated guidance for the use of post-exposure HIV prophylaxis in 2021.⁸

See also the articles on Sexually Transmitted Infections, Human Immunodeficiency Virus (HIV), HIV Counselling and HIV Post-exposure Prophylaxis for further information.

Long-term effects⁴

Disclosing previous sexual sexual abuse is a process that may take decades but patients are more likely to reveal a history of sexual assault if asked directly. Previous sexual abuse may be associated with pelvic pain, other chronic pain syndromes, fibromyalgia and chronic headaches; in one study, 46% of women attending a pelvic pain clinic had a history of abuse.

PTSD is the most common psychological long-term consequence of sexual assault and is more likely if:

• There was a perceived threat to life.

• Violent force was used.

• Reaction to disclosure was negative.

• The victim was from an ethnic minority.

• There had been previous abuse: survivors of childhood and adolescent abuse who are then sexually assaulted as adults are at the greatest risk of long-term sequelae.

• Previous mental health problems have been experienced, including depression and alcohol dependence.

Women with a history of childhood sexual abuse are more likely to develop cervical cancer, taking account of confounders, but less likely to access regular cervical screening.⁹ Professionals providing cervical training may require specific training in how to provide the best care for survivors of childhood or adult sexual assault.¹⁰

Learning points

• The importance of giving back control to someone who has been sexually assaulted: "While others saw me as unable to think for myself, the staff encouraged me to make my own informed decisions. Trusting in myself was crucial in restoring my sense of self worth".

• Those who have been sexually abused in the past find it very difficult to disclose their abuse history. There may be parallels to the abuse situation with any gynaecological examination.