Introduction

Sexual assault is under-reported and there is significant attrition of reported cases through the justice system.1–3 The patient’s willingness to participate in the forensic process can potentially influence case progression and outcomes.1 2 4 5 There is also some evidence that when the forensic examination is provided in a multidisciplinary sexual assault service, by forensically trained doctors and nurses working with counsellors or advocates, it can be ‘therapeutic’ rather than retraumatising.2 6 7

There is very little research on the understanding and experience of the medical forensic examination from the perspective of victim survivors who present for care following a recent sexual assault.8–10

Clinical context for this study

The government health system in New South Wales (NSW), Australia, provides 24-hour sexual assault services in every local health district (LHD) to support timely access to medical forensic care and psychosocial support to sexual assault victims. These services are, most often, located in the emergency department of a hospital. These services are a best practice ‘wrap around service’ combining psychosocial care, provided by a trained counsellor, with medical care provided by a forensically trained doctor or nurse. The immediate forensic service is provided to facilitate the likelihood of retrieving DNA evidence and documenting injuries. Regardless of whether patients have reported the sexual assault to police or not, a forensic examination is offered to all patients who attend a sexual assault service within the forensic time frame (depending on the nature of the assault, this could be 12, 24 or 48 hours or up to 5 or 7 days). A standardised protocol, the NSW Medical Forensic Examination Record (MFER), and a standardised Sexual Assault Investigation Kit (SAIK) for forensic sample collection are used throughout NSW and supported with training. Medical care encompasses assessment of sexually transmitted infections risk, prophylaxis and follow-up testing, provision of emergency contraception and injury management. Serious injuries are triaged and managed by the emergency department medical team. Psychosocial care is provided as a brief therapeutic intervention approach including psychoeducation on managing immediate impacts, safety assessment and information, and resource provision with the facilitation of ongoing counselling and/or other supports. The patient is able to opt for medical and/or counselling care, without a forensic service, or they can choose to have a forensic service provided by the forensically trained doctor or nurse. If the patient chooses a forensic service, there is the option of releasing the MFER and SAIK samples immediately to police for processing, or they can choose temporary hospital storage for 3 months (providing they are 16 years or older), during which time the patient can decide if they want to report to police and release the MFER and SAIK samples. If they do not release the samples to the police within 3 months, then the samples are usually destroyed. The MFER is retained within the sexual assault service as part of the confidential medical record. The Northern Sydney Local Health District covers an area of 900 square kilometres with a population of over 985 000 residents. Approximately 110 adolescent and adult patients per year present within 7 days of a sexual assault for acute care within the Northern Sydney Local Health District.

The potential benefit of a medical/forensic examination to case progression

The forensic examination itself is not for medical purposes and is often performed when there is no medical need for an examination. As discussed in the Issues Paper The Role of Forensic Medical Evidence in the Prosecution of Adult Sexual Assault from the Australian Centre for the Study of Sexual Assault, 2013, despite improved technologies and expectations of forensic evidence, national and international research presents a mixed picture of the association of forensic medical evidence and legal outcomes in sexual offence matters.2 There is a high attrition of sexual assault cases progressing through the criminal justice system11 but there is an understanding that forensic evidence, or the patient’s willingness to participate in the forensic process, can influence case progression.12

The history taken by the medical forensic examiner can be used as part of the police investigation. When a victim survivor is seen by a medical forensic examiner, the history taken is to assess medical and psychosocial needs as well as to direct the forensic examination; it is not intended to be a detailed record of events. However, it is often used to corroborate the report given by the patient to the police. The veracity of that report is improved by early presentation to a forensic service. In a 2018 American study, Alderden et al found ‘that prosecutors felt undergoing a forensic medical examination in itself supported victims’ credibility’.13 However, while retrieving DNA evidence can help identify a suspect or indicate sexual contact, prosecutors acknowledged that the DNA evidence is of little value when the case involves a defence of consent.13 The value of injury documentation has been demonstrated in research showing a significant association of injuries with filing of charges and conviction.14 An Australian study found the noting of injuries in witness statements can influence police perceptions of victim survivors and decision-making related to initial police investigations.15

However, most sexual assault presentations do not include physical injuries.16 A review of the literature by Du Mont and White in 20074 suggested that the forensic evidence itself had little impact on final legal outcomes but can influence other aspects of a legal case. Having a forensic examination can influence progression of the police investigation and the perception of the victim as a ‘real victim’ by the jury.12 There is Australian literature that discusses the influence of a medical forensic examination on the legal case from ‘police investigation, the decision to prosecute, the selection of charges that will be prosecuted, the decision to accept a plea, proceeding to trial, and the outcome at trial’.2

A stereotypical or archetypal expectation that the ‘real rape victim’ will present with injuries17 and undergo a forensic examination can influence the progression of the legal case.2 18 Some authors have suggested that, with the increase in popularity of television shows such as ‘Crime Scene Investigations’ that portray the infallibility of forensic techniques, jurors now expect forensic evidence to be presented. This has become known as the ‘CSI effect’.19 The fact that police and prosecutors believe that jurors expect and rely on forensic evidence creates an environment where it can influence case progression.2 17 18 The understanding and expectation of the benefit of the forensic examination process for the patient themselves presenting to a sexual assault service are not well studied.

The potential benefits of a medical/forensic examination to the victim survivor

When a forensic examination is provided to a sexual assault victim survivor, in a specialised service that incorporates psychosocial, medical and forensic care, it can be of benefit to the patient beyond that of providing evidence for a legal case. A recent study of patients presenting to a sexual assault service in London explored the experiences of patients presenting to a specialised service6 and counters previous research that suggested that the forensic examination retraumatised victims.20 The newer model of care that encompasses counselling and properly trained and ‘trauma-informed’, specialised sexual assault forensic examiners appears to provide a supportive environment where patients can gain a ‘therapeutic’ benefit from the forensic examination.2 A recent paper, which included interviews with adolescents who had undergone a medical forensic examination, demonstrated that this trauma-informed approach, with emphasis on information sharing and supporting the autonomy of the young people, could provide a transformative experience for young people. The paper demonstrated it can help them integrate their psychological and physical sense of themselves. The forensic medical examination can facilitate the healing and recovery process.6

Older research identified ‘revictimization’ of sexual assault victims. Maier describes this: ‘Revictimization refers to the blame and stigmatizing responses to victims by police or others and the trauma that victims experience following the rape itself. More specifically, the term has been used to refer to the distress, alienation and blame that victims may experience after the assault at the hands of the criminal justice and medical systems’.21 22 A 2009 Canadian study of 19 women who had presented to a specialised sexual assault service found that while many of the women felt distressed by the examination, most also felt empowered.23 Most women presented primarily for medical or psychosocial care and some women indicated that they mistakenly thought that they had to undergo a forensic examination in order to receive medical care. The majority of the women in the study had a forensic examination in the hope that it would serve a justice purpose and make the perpetrator accountable. Victims often fear that disclosure may not be believed by others or authorities as sexual assault is mostly perpetrated without witnesses, and may be compounded by a pre-existing relationship with the perpetrator, grooming tactics, and/or facilitated by alcohol or drug use. There is a lack of literature exploring the role of anxiety about the forensic examination or the ‘rape kit’ as a deterrent for victims of sexual violence reporting or presenting for care. There is some evidence, from a literature review paper, that showing a video of the procedure to women who present to a sexual assault service reduced stress during the procedure.24 That review also suggested that women were more likely to present to a primarily medical service rather than a primarily forensic service. It also highlighted the importance of providing a dedicated medical forensic service rather than the models previously used which expected the gynaecology or emergency staff to see patients for sexual assault care, including forensic examination, while also managing an emergency care load.24

There may be a role for educating the general public, and/or targeting populations that are currently over-represented as victims in crime and safety surveys (eg, women, young people, gender and sexually diverse populations, Aboriginal and Torres Strait Islander women), about what is involved in a forensic examination and the medical and psychosocial services that are available. This could include information about the option of having a forensic examination and temporary hospital storage without release to police. Further research on the psychological and healthcare benefits from having a forensic service with temporary storage located within a health facility would help to justify the use of resources for providing this forensic service, which may not ever result in release of information or samples to police.

Sexual assault victim survivors are more likely to report to family or friends than to formal support services and the response of these allies can determine how the victim/survivor interacts with formal support services.25 As gender-based violence is so prevalent, it is important to understand what the general population, including potential future victim survivors and allies, understand about these services.

Research aims

This research aims to explore the experience of the patients who present acutely to a sexual assault service, especially their experience of the medical forensic examination. The research will also explore the general public’s understanding of the role of health services after sexual assault. Gaining an understanding of how the general population view the ‘rape kit’ and what they know about sexual assault services will help to inform how services can be made more visible and accessible. Additionally, by surveying a sample of victim survivors who did not present acutely to a sexual assault service, we aim to gain insights into barriers to attendance.

The overarching aim is to improve knowledge of available services to facilitate victims of sexual assault seeking timely care.

Methods and analysis

This protocol describes stage 2 of a larger research project, the Acute Sexual Assault Presentations (ASAP) study.

Stage 1, a file review of 2 years of patient files from 2018 to 2019, preceded stage 2. This data collection was completed in 2023 and has informed the design of stage 2. Stage 2 has four substudies: (1) a patient feedback questionnaire; (2) patient interviews; (3) a general population survey; and (4) a survey of victim survivors. See figure 1.

Figure 1

Acute sexual assault presentations study overview.

Patient feedback questionnaire

Analysis of 4 years of patient feedback questionnaires routinely completed by patients (aged 14 years and over) who have presented to the sexual assault service and received a medical forensic response after a recent sexual assault. This is a 24-question, English, paper questionnaire (online supplemental material) including simple tick box options, Likert scales (using sad to smiley faces for ‘poor’, ‘average’, ‘good’, ‘great’) and free-text options. The questionnaire was adapted from the client feedback form developed by Saint Mary’s Sexual Assault Referral Centre in Manchester, UK. The multidisciplinary team, with survey experience, were involved in adapting the questionnaire to our client population. We received informal feedback from existing patients. Considering the research gap regarding the patient experience of the examination itself, we added questions specifically on this to address our research questions. This simple paper-based questionnaire was originally approved by the Human Research Ethics Committee (HREC) as a Quality Improvement Activity commencing in March 2020 and subsequently became standard practice. Patients are offered this questionnaire and an information sheet at the end of their presentation when they are waiting for their discharge papers. If they choose to complete the questionnaire, they seal it in to an envelope that is collected and given to the PI and the deidentified data are entered in to an Excel spreadsheet. Access to and reporting for research purposes of this data were approved by the HREC as part of the ASAP study stage 2 application. A descriptive analysis will be performed to explore the experience of patients attending the sexual assault service. This includes their experience presenting to the emergency department, interactions with police, perceptions of the counselling support and medical care they received, experience of the medical forensic examination and ways the service can be improved.

Semistructured interviews with patients

Patients answering the Patient Feedback Questionnaire can answer a question to opt in to being contacted for involvement in future research. Survey responses and patient files will be reviewed to select interview subjects. Suitable patients will be purposively selected to gain insight into a range of experiences. Patients will be invited to participate in interviews based on characteristics of the sexual assault such as relationship with perpetrator, alcohol and drug facilitation, sleep status of the victim survivor, police involvement, type of examination (including speculum use), injury presence and level of distress at the time of examination. This is to allow for a wide range of patient, assault and examination experiences. Interview number will be dependent on saturation of new data; estimated 12–20 participants. They will be contacted by the lead author by email or text message, depending on their preferred method, given information about the interview and invited to participate in a 20–30 min semistructured interview. The interview will be conducted either by Microsoft Teams (Microsoft Corporation, Washington, USA) or in person, depending on the participant’s preference. A semistructured interview guide has been developed by the lead author (MS) with advice from one of the team (JMS) who has extensive experience in qualitative methods. We have drawn on existing literature and clinical experience to develop the interview guide with the aim of addressing our research questions. The lead author (MS) will conduct the interviews with guidance during the process from JMS. MS is an experienced medical forensic examiner so will be able to bring her experience and knowledge to the interviews to gain an understanding of the responses and circumstances the participants might discuss. MS will also be able to bring her experience to guide the interview to be trauma informed and patient focused. The ethics-approved Introductory Script and Semi-structured Interview Guide will be used. The focus of the interview is the care they received after the assault to explore the experience of the response from the sexual assault service. Consent can be written or verbal at the time of recording the interview (if being conducted via Microsoft Teams). Follow-up psychological support will be made available to all participants.

The audio-visual recorded interviews will be transcribed verbatim by transcription software (embedded in Microsoft Teams). The recorded interview will be checked for transcription accuracy, video then deleted, and deidentified. Two of the researchers will conduct a reflexive thematic analysis following the phases outlined by Braun and Clarke.26–30 Qualitative data analysis software (NVivo) will be used for data management. We will explore the participants’ access to the service and expectations and experience of the service, focusing on what was helpful, what they found difficult and what could be improved. These interviews are to commence in 2025.

General population survey

An online REDCap survey has been developed by the team and distribution commenced in late 2024 to the general population (aged 14 years and over), focusing on the residents of the LHD, to explore their understanding of the available medical forensic response after recent sexual assault. We have developed the survey questions by focusing on the role of sexual assault services, guided by policy and practice. The questions are designed to ascertain what the general public know about the existence of, and the role of, the service. We have tested the survey questions to try to ensure they will address the research questions. This will include the population’s understanding of the existence of a specialised sexual assault service, how to access care, expectations of confidentiality and police reporting, expectations of services provided including the medical/forensic examination, counselling, medical care and follow-up. Those who identify as having experienced sexual assault will be diverted to the survey for survivors (substudy 4).

A combination of purposive sampling and convenience voluntary response sampling will be used to reach the general population within the LHD. We will disseminate information about the survey with a survey link through multiple avenues including local community networks and social media community groups. This will include government and non-government service organisations, universities, community social media groups, multicultural community networks, Aboriginal and Torres Strait Islander services and gender and sexuality diverse community networks. We will aim for at least 200 responses, which will provide a minimum level of precision of ±7% on estimates of proportions. An information page at the start of the REDCap survey will explain the research project, the content of the survey, crisis support numbers and how the data will be used prior to asking participants if they agree and allowing them to continue to the eligibility criteria and to complete the survey if eligible. A descriptive analysis of the survey data will be performed to explore the knowledge and understanding in the population sampled.

Survey of victim survivors

Victim survivors of sexual assault (aged 14 years and over), currently living in NSW, will be eligible for the survey. For the survey, we are using a definition of sexual assault as used by the NSW Ministry of Health in their information for victim survivors.31 This eligibility question will ask if they have been ‘sexually assaulted (forced, coerced or tricked into a sexual act or exposed to a sexual situation you didn’t consent to)’. Knowing that most victim survivors of sexual assault do not present to services for formal support, we anticipate that a high proportion of victim survivors in our sample will not have presented to a sexual assault service. We will collect responses from those who did access a sexual assault service after their most recent assault and those who did not. The survey aims to assess the understanding of specialised sexual assault services available and the facilitators and barriers to accessing those services. The survey question development was informed by existing literature and clinical experience regarding the facilitators and barriers. The questions were piloted and adapted by the research team, including the clinical director of a survivor support group, and survivor peer support groups. Pilot responses were used for checking the data collection tools would generate data that would address our research questions. A combination of purposive sampling and convenience voluntary response sampling and snowball sampling will be used to reach survivors of sexual assault. This online survey distribution commenced in 2024 concurrently with the general population survey so that victim survivors can be diverted if they commence the general population survey. Distribution is primarily be via Full Stop Australia, a 24-hour support service, and The Survivor Hub, a peer support organisation. A message is posted on these services’ social media groups (including Instagram and Facebook) and websites and distributed by peers to their networks via private communication networks, for example, closed social media groups and email distribution lists. We aim for 100 responses which will provide a minimum level of precision of ±10% on estimates of proportions responses. An information page at the start of the REDCap survey explains the research project, the content of the survey, crisis support numbers and how the data will be used prior to asking participants if they agree and allowing them to continue to the eligibility criteria and to complete the survey if eligible. A descriptive analysis of the survey data will be performed to gain an understanding of the awareness and expectations of specialised sexual assault services and the facilitators and barriers to attending including lack of knowledge, misperceptions about what was available, access difficulties, concern about police involvement or lack of confidentiality, concern about having a forensic examination, nature of the sexual assault for example, known perpetrator, injuries present and alcohol use. A multivariable analysis for associations using logistic regression will explore the factors that are associated with not presenting to a sexual assault service, for example, demographics, known/unknown perpetrator, demographic details, alcohol use and presence of injuries.

Patient and public involvement

The Clinical Director of a survivor support organisation, Full Stop Australia, is part of the research team and has contributed to all aspects of the study design and will be involved in analysis, reporting and dissemination of results.

A survivor peer support group (The Survivor Hub), survivor support organisation (Full Stop Australia) and a support group for gender diverse people (The Gender Centre) were involved in the design of the survey for victim survivors.

The Survivor Hub and Full Stop Australia are involved in distribution of the survey for victim survivors and dissemination of results.

Patients participating in the semistructured interviews will be invited to an online meeting, where participants can remain anonymous, using Microsoft Teams as a way of disseminating the research findings to the participants prior to reporting the results more widely. They will also be provided with information and access to psychological support following this meeting

Ethics and dissemination

This project has received approval from the Northern Sydney Local Health District Human Research Ethics Committee (2022/ETH01766).

The ethical complexities of victim survivors as research subjects and clinicians as researchers have been carefully considered as part of the ethics approval process. Support processes are in place for participants and researchers, including access to 24-hour crisis support lines. The development of the research has included input from external stakeholders including a survivor peer group and a survivor support group.

Data from the research are securely stored on a NSW Health share-drive and findings will be used for reporting purposes within the Northern Sydney Local Health District. Findings will be used for feedback to stakeholders (including police, the emergency department and sexual assault service staff, and sexual violence support and advocacy groups), as a resource to inform policy and in publications in peer-reviewed journals and conference proceedings. At the time of publication of findings in peer-reviewed journals, mainstream media will be engaged to reach a wider audience.

Outcomes from the interviews will be presented to the research participants who participated in the semistructured interviews. They will be invited to participate anonymously in an online meeting using Microsoft Teams as a way of disseminating the research findings to the participants.

This research forms part of Dr Stewart’s PhD being undertaken at the University of Sydney and will be used for academic purposes in presentations and publications.