Mary's Sexual Assault Referral Research Articles

Identifying the prevalence of genital injuries amongst patients attending Saint Mary's sexual assault referral centre following an allegation of digital penetration

This study aimed to (1) add to the limited evidence base regarding genital injury associated with digital vaginal penetration and (2) identify predisposing or protective factors to the identification of a genital injury. Data collection was performed retrospectively on the paper case files of 120 female adult (>18 years) patients alleging digital vaginal penetration with no penile vaginal penetration that had an acute FME at Saint Mary's Sexual Assault Referral Centre (SARC) Manchester. Descriptive statistics were used to investigate differences in the demographics of those reporting digital penetration, with and without injuries. Overall, 18% had genital injuries noted at the time of the FME. Posterior fourchette was the most common location of genital injury and abrasion was the most common injury type. It is worth further noting that all 22 patients where an injury was noted were of white ethnicity, only 12 patients in the sample were not white so caution is needed in interpretating this finding of a non-significant difference. Future research should consider injury and ethnicity more specifically. The findings from this study add to the existing evidence base and should prove useful to expert witnesses when called upon to interpret examination findings of sexual assault complainants as they relate to an allegation of digital penetration.

Use of SARC services by victims of sexual violence: Auditing the ethnicity of Saint Mary's Sexual Assault Referral Centre's clients

IntroductionSaint Mary's Sexual Assault Referral Centre (SARC) in Manchester provides services to adults and children who have suffered sexual assault. The ethnic composition of those who attended the centre was audited in 2001 and 2003 to measure how well it serves different ethnic groups. This paper provides an updated audit using 2019 data. MethodologyCensus data for Greater Manchester, and data from the Crime Survey of England and Wales (CSEW) showing rates of sexual assault for different ethnic groups, were used to predict the ethnic composition of sexual assault victims in Greater Manchester. These predicted figures were then compared with the ethnic composition of Saint Mary's SARC 2019 client base to measure how well the SARC is serving different groups. This comparison was repeated using data from the 2001 SARC client base to explore change over time. ResultsThe analysis shows that South Asians and Chinese individuals are underrepresented in the SARC client base, and that this issue has become more pronounced over time. Every other group is overrepresented. ConclusionThe underrepresentation of South Asian and Chinese clients at Saint Mary's SARC is concerning. Making the service more accessible to those from these ethnic groups should be a priority for the centre.

Identifying the prevalence of genito-anal injuries amongst clients attending St Mary's Sexual Assault Referral Centre following an allegation of anal penetration

BackgroundThere is a lack of clarity around the prevalence of anal injuries sustained following anal penetration. The aim of this study was to identify the prevalence of injury amongst clients attending Saint Mary's Sexual Assault Referral Centre (SARC), Manchester, UK following anal penetration and identify predisposing or protective factors such as age, sex and pubertal status. This should facilitate an evidence-based approach to providing evidence statements in court for allegations of anal penetration. MethodThis was an observational retrospective study analysing the forensic medical examination (FME) case notes of 239 clients between January 2015 and December 2016. Subjects were excluded if the nature of alleged assault was unclear. Data was extracted from the FME case notes on to a data collection proforma and statistical analysis undertaken. ResultsOf the 239 subject, 156 [65.3%] were female and 83 [34.7%] male. Subjects were predominantly post-pubertal, 185 [79.4%]. The alleged assaults were categorised in to penile anal, digital anal and object anal; penile anal assault was the most common type, 177 [75.97%]. No association was found between type of assault and presence of anal injury.Anal injuries did not occur more frequently in one sex than another [21.15% female, 21.69% male]. Logistic regression indicated pre-pubertal children were less likely to have injury [(odds ratio = 0.34, 95% CI (0.078, 0.70), p = 0.016)], although this was not significant when adjusted for time since assault. Most pre-pubertal children presented more than 72 h after alleged assault, [68.2% female, 73.1% male] The presence of anal injury was significantly associated with time since assault across all subjects, with those examined after 72 h less likely to have injury [p = 0.0016].A greater proportion of single suspect assaults [22.8%] resulted in anal injury than multiple suspect assaults [13.9%]. Whilst there was alcohol consumption in most alleged assaults against post-pubertal subjects [56.1% female, 50.9% male], there was no statistically significant data to associate alcohol consumption with anal injury. And, the same was true of drug consumption. Among post-pubertal females 96.21% of assaults involved threats or violence, comparable with 71.70% amongst post-pubertal males. The data did not suggest threats and violence increase the rate of anal injury. ConclusionThe study identifies a statistically significant relationship between time since assault and prevalence of anal injury. Further, a relationship between pubertal status and prevalence of anal injury was found. The low prevalence of anal injury amongst pre-pubertal children suggests that absence of injury at the time of examination, following allegation of anal assault, is a common finding. Importantly, whilst not demonstrating statistical significance, it should be noted that the majority of assaults reported in the study did not result in anal injury. The study provides contemporary evidence in the field of forensic medicine which can be used in court proceedings in allegations of anal assault.

Clients who self-refer to a Sexual Assault Referral Centre (SARC): a preliminary exploration of client and case characteristics

ABSTRACT The Saint Mary's Sexual Assault Referral Centre (SARC) provides an integrated forensic medical and psychological support service, including support through the criminal justice process. The aims of this preliminary exploratory study were to establish the demographic characteristics of clients who self-refer to Saint Mary's SARC (i.e. those who have not been referred by the police), and to explore the nature of alleged assault and alleged perpetrator characteristics across cases. One-hundred and twenty-eight case notes of adult clients (64 police referrals and 64 self-referrals) from a 12-month period were selected for preliminary review and analyses. Results revealed that age, gender and relationship status were similar across both groups. Significant associations emerged, with the majority of self-referred clients being in either full-time employment or full-time education, with no reported additional needs (e.g. physical disability, learning disability). Self-referred clients also reported less information about the nature of the alleged assault and the alleged perpetrator, when compared to police-referred clients. Collectively, these preliminary findings suggest that self-referred clients present with a different case profile and potentially different service needs than those referred by the police. Further research is warranted with larger sample sizes from a wider range of SARCs.

Repeat attenders are disproportionately vulnerable: An exploration of revictimisation at Saint Mary's Sexual Assault Referral Centre

BackgroundBeing a victim of sexual assault is linked to many psychological and physical health problems. Experiencing one episode of assault is a risk factor for revictimisation. Saint Mary's Sexual Assault Referral Centre (SARC) provides aftercare for clients in Greater Manchester and Cheshire who have suffered sexual assault and rape, with physical, psychological and sexual health services. AimsThis work's primary aim was to establish the prevalence of re-attendance of adults for a forensic medical examination to Saint Mary's SARC. The secondary aim was to identify the characteristics and vulnerabilities of clients who re-attended Saint Mary's SARC during a twelve-month period. MethodsRetrospective analysis of 42 sets of forensic medical notes for repeat attenders in 2017 was performed. A control sample of 42 single attenders from 2017 was randomly selected for comparison. ResultsA total of 740 adult clients attended Saint Mary's for a forensic medical examination in 2017, 5.7% of whom had previously attended. Amongst these clients, significantly higher numbers experienced unemployment (p < 0.001), recent mental health complaints (p < 0.001), previous self-harm (p < 0.001), and previous suicide attempts (p = 0.001). There was a significantly larger number of repeat attenders who scored below the threshold that indicates likelihood of having a learning disability (p = 0.008). All clients who disclosed a history of alcohol abuse were repeat attenders. Repeat attenders were more likely to receive safeguarding than single attenders (p < 0.001). ConclusionsPrevalence of repeat attenders at Saint Mary's SARC is lower than reported in many other studies. However consistent with the wider literature, this demographic showed higher level of vulnerability, and higher likelihood of receiving safeguarding. SARC staff and services should be prepared to attend to the additional needs of this group. Powered.

‘I thought he was going to kill me’: Analysis of 204 case files of adults reporting non-fatal strangulation as part of a sexual assault over a 3 year period

BackgroundThere is growing awareness internationally around the prevalence and dangerousness of non-fatal strangulation (NFS). The aim of this study was to: (i) identify the prevalence of NFS in patients presenting to the Saint Mary's Sexual Assault Referral Centre (SARC), Manchester, UK for an acute forensic medical examination (FME) after a report of rape or sexual assault, (ii) explore the characteristics of patients reporting NFS compared to those who did not and (iii) explore the prevalence of various symptoms and signs associated with NFS. MethodData from case files of all patients attending in a three year period, January 1, 2017 to December 31, 2019, were analysed. There was not any age or gender related exclusion criteria. In the NFS cases the Saint Mary's SARC NFS pro-forma used as part of the contemporaneous medical notes was also reviewed. ResultsA total of 2196 adults (≥18 years old) attended Saint Mary's SARC for an acute FME during the three year study period. This comprised 1994 (90.7%) non-NFS cases and 204 (9.28%) NFS cases. The prevalence of NFS was 18.9% where the alleged perpetrator was a partner or ex-partner. For NFS cases, 96.6% (n = 197) of the patients were female and the alleged perpetrator was male in 98% (n = 200) of the NFS cases. 40% of the NFS cases had been strangled in their own homes and in 33% of cases children lived in that home. In 27% (n = 55) of the NFS cases the patient said that the alleged perpetrator had also strangled them on a previous occasion. 46.6% had an injury to the neck or above attributable to the NFS. 15.7% (n = 32) of the NFS cases reported loss of consciousness, 8.8% (n = 18) were incontinent of urine and 2% (n = 4) incontinent of faeces as a result of the NFS. Over a third of the patients (36.6%) thought that they were going to die during the NFS. ConclusionThe study shows that NFS in sexual assault is a gendered crime, with most victims female and most assailants male. NFS is prevalent and this prevalence increases where the alleged perpetrator is a partner or ex-partner. Many are assaulted in their own homes, homes frequently shared with children. Visible NFS injuries are not the norm yet fear of death is not uncommon. Over 1 in 6 (15.7%) reported loss of consciousness suggesting that they were victims of a near lethal assault. That 27% had previously been a victim of NFS by the same alleged perpetrator indicates that there are considerable numbers potentially living in fear and at risk. Awareness of the risk of NFS, and an enhanced response to it, is required by those looking after victims and all those in the criminal justice system.

Descriptive analysis of the context of child sexual abuse reportedly perpetrated by female suspects: Insights from Saint Mary’s Sexual Assault Referral Centre

BackgroundDetermining the prevalence and characteristics of female-perpetrated child sexual abuse (CSA) is fraught with difficultly. There is a historical lack of empirical research and a discrepancy between the number of cases that reach the attention of the authorities and its suspected prevalence in society. It is also noted that for a myriad of reasons many CSA reports do not progress through the criminal justice process so many remain as allegations rather than proven or disproven crimes. ObjectivesThe study set out to answer the research questions: ‘What are the characteristics and context of CSA reportedly perpetrated by females, and what are the similarities and differences in the context of alleged CSA committed by male and female suspects?’ Participants and settingThis study presents data from all service users aged 0–17 years (n = 986) that attended Saint Mary's Sexual Assault Referral Centre (SARC) for a forensic medical examination over a three-year period. MethodsData collection was performed retrospectively from the paper case files recorded at the time of attendance. Due to the small number of female suspects, analysis was restricted to frequency calculations. ResultsResults show females were reportedly involved in the alleged abuse of less than 4% of the children attending SARC. Females appeared more likely to be associated with the alleged abuse of younger children and abuse occurring within the child's home. ConclusionsThis study's most arresting feature is that despite the large number of CSA cases examined, it was rare to have a female suspect. This study demonstrates how much is still unknown about female-perpetrated CSA.

Sex workers reporting rape: Understanding their vulnerabilities to improve their care. The characteristics of sex workers who attend Saint Marys Sexual Assault Referral Centre

In the UK it is estimated that there are at least 70,000 sex workers, however, relatively little is known about who these people are. The Crime Survey for England and Wales estimated that 1 in 5 women have experienced sexual violence.(Flatley, 2018) 1 However, there is little known about sex workers who access sexual assault referral centres services. This study aims to create a picture of the needs and demographics of sex workers who attend Saint Mary's Sexual Assault Referral Centre and to help focus future research into this unique demographic. Between June 2017 and May 2019 there were 20 people who were reported to be sex workers that attended Saint Mary's SARC for a forensic medical examination. Their case notes were retrospectively analysed and compared to a control data set of similar size from the same time period. Notable findings include 19 of the 20 sex workers were female, 13 were described as white British, and 19 were described as being single. The sex worker population had higher rates of: mental health difficulties; children no longer under their care and substance abuse issues compared to the control group. The Saint Marys Centre reported reduced engagement from the sex worker cohort within the forensic medical examination process and were reported as having higher levels of non-disclosure of personal information. This study has shown the high level of vulnerability of sex workers who attend Saint Mary's Sexual Assault Referral Centre and their unique concerns when attending the centre.

The Nature of Child Sexual Abuse among Boys and Girls Attending Saint Mary's Sexual Assault Referral Centre in Greater Manchester

This study set out to answer the research question: ‘What are the similarities and differences in the nature of abuse, patterns of disclosure and characteristics of the perpetrator between boys and girls attending a sexual assault referral centre (SARC) for a forensic medical examination?' Retrospective data collection was undertaken from paper case files of 986 service users (142 boys, 844 girls) who attended Saint Mary's SARC for a forensic medical examination (April 2012–March 2015). Demographic data as well as information on the context of the abuse were coded into a standardised digital format. Cross‐tabulation and Pearson's chi‐squared tests were performed to compare the abuse experienced and how abuse was disclosed by children of different genders and ages. Older children accounted for 20 per cent of the boys and 56 per cent of the girls. A higher proportion of girls attended the SARC after a single abusive episode; the abuse of boys was more frequently reported by a parental figure; and boys' abuse was reported later. Younger children were more likely to be abused in the family environment. Younger girls were more likely to experience abuse by a single perpetrator, whereas all boys reported multiple perpetrators. These findings suggest that the relationship between child sexual abuse (CSA) and gender is a complicated and nuanced one.‘What are the similarities and differences in the nature of abuse, patterns of disclosure and characteristics of the perpetrator between boys and girls attending a sexual assault referral centre (SARC) for a forensic medical examination?'Key Practitioner Messages Some gender differences in CSA may be due to professionals' perceptions. It is important to remain mindful that boys may present differently to girls. Care should be taken when interpreting these results. The majority of CSA is not disclosed nor identified. Where it is, few children receive a forensic medical examination. Practitioners need to be alert to this to safeguard children adequately. Future research can pursue how identified differences affect boys and girls, thereby enabling better support or protection for children.

The experiences of sexually assaulted people attending Saint Mary's Sexual Assault Referral Centre for a forensic medical examination

This study explores the experiences of people who have attended Saint Mary's Sexual Assault Referral Centre (SARC) for a forensic medical examination (FME). Within the United Kingdom, SARCs support complainants following a sexual assault, delivering specialised care and gathering medico-legal evidence for court proceedings. To date, there has been limited research evaluating SARCs responses towards complainants. 863 Feedback and Evaluation forms, from a three-year period, completed by clients who had accessed Saint Mary's SARC's forensic medical examination service were evaluated. Descriptive statistical analysis found a large majority of clients were ‘very satisfied’ with the crisis worker, forensic physician and police. Content analysis of the free text responses found more nuanced experiences, which impacted clients overall experience within the SARC. These comments were split into two themes, ‘Compliments’ and ‘Suggestions for improvement’. There were 404 comments focusing on compliments of the service and the staff. Compliments included messages of thanks, with praise for professionalism of the staff and importance of the service. Clients noted in particular that the FME service was delivered in challenging circumstances i.e. the immediate aftermath of a sexual assault. There were 34 comments which made suggestions for improvements. These suggestions focused on pragmatic and logistic issues.

The high prevalence of pre-existing mental health complaints in clients attending Saint Mary's Sexual Assault Referral Centre: Implications for initial management and engagement with the Independent Sexual Violence Advisor service at the centre

BackgroundThe Saint Mary's Sexual Assault Referral Centre has a unique service delivery model whereby it provides an integrated physical and psychological support services to clients, women men and children, living in Greater Manchester. The service is available to those who have reported rape or sexual assault, whether this is recent or historic. Clients living in surrounding areas of Cheshire are provided with forensic and medical services at Saint Mary's Centre, with follow-up care provided locally, as appropriate. AimsThe primary objective was to identify the prevalence of self-reported pre-existing mental health complaints amongst adult clients who attended Saint Mary's Centre for a forensic medical examination. The secondary objective was to consider levels of engagement with the Centre's Independent Sexual Violence Advisor service by comparing clients who reported a mental health complaint to clients who did not. MethodOne-hundred and eighty sets of client's notes from 2016 were retrospectively analysed. Client inclusion criteria were that they were (a) over the age of 18 years when attending the Centre, (b) had attended for a forensic medical examination. Results69% of clients analysed reported a pre-existing mental health complaint. The time taken for clients to present to Saint Mary's Centre following a reported assault tended to be later for the clients with self-reported mental health problems than those without. However, there was no difference in the long-term engagement with the Centre's Independent Sexual Violence Advisor service at the Centre between the two groups. ConclusionPrevalence of self-reported pre-existing mental health complaints is extremely high in clients presenting at Saint Mary's Centre as compared to national and regional prevalence rates for mental health complaints in the general population. The vulnerability of this client group should be considered when they attend a SARC and support provided should be appropriate and accessible to their needs. Staff should have adequate training and supervision to be able to respond in this way.

Improving service responses for people with learning disabilities who have been sexually assaulted: An audit of forensic services

Accessible summary When people report being sexually assaulted they can be examined by a specially trained doctor to see how the assault might have affected them. They may also ask for help from a counsellor or other specially trained support workers. These staff might belong to a sexual assault referral centre (SARC). This study reports findings from work that staff from St Mary's SARC in Manchester did so that they could improve the services they offer to people with learning disabilities who have been sexually assaulted. A staff survey showed that staff thought they might not always recognise if a person had learning disabilities or another learning difficulty like dyslexia. We wonder if knowing the difference is as important as knowing how to support people well. Looking at patient notes showed that patients with learning disabilities received less follow‐up care than patients without learning disabilities. This study describes the first step that the SARC team took to improve their service. Improvements have been made based on these first findings, including some of those recommended by staff in their surveys. These will be reported in another paper to see if they have made a difference to people with learning disabilities. AbstractBackgroundPeople with learning disabilities are more likely to experience sexual abuse and less likely to access support than the general population, this is due to a range of variables at the individual, societal and service‐delivery level. This study presents a service evaluation of St Mary's Sexual Assault Referral Centre, Manchester to explore its ability to provide meaningful support to people with learning disabilities and to identify ways to improve its responses.Materials and MethodsThe service evaluation had two components: (i) A staff survey to elicit self‐perception of the knowledge and skills required to meaningfully support people with learning disabilities who attended the centre following an allegation of rape or sexual assault (ii) An audit of patient notes to compare service delivered to patients with a learning disability to those without.ResultsForty‐two members of staff (over 75% response rate) completed the survey which found a lack of differentiation between learning disabilities and other types of neurodiversity. The majority of responders reported having enough knowledge about learning disabilities to do their job and feeling confident in their abilities. Nonetheless, all the staff reported that they would like more learning disability training. An audit of the patients’ notes found people with learning disabilities accessed fewer follow‐up care services than people without learning disabilities.ConclusionsThe results identify areas for staff training to improve meaningful support for people with learning disabilities alongside a note of caution against a focus on labelling. By introducing more accessible support a diverse group of people can benefit.

Female genital injuries resulting from consensual and non-consensual vaginal intercourse

Objectives The purpose of this study was to compare the incidence of genital injury following penile–vaginal penetration with and without consent. Design This study compared observations of genital injuries from two cohorts. Setting Participants were drawn from St. Mary's Sexual Assault Referral Centre and a general practice surgery in Manchester, and a general practice surgery in Buckinghamshire. Participants Two cohorts were recruited: a retrospective cohort of 500 complainants referred to a specialist Sexual Assault Referral Centre (the Cases) and 68 women recruited at the time of their routine cervical smear test who had recently had sexual intercourse (the Comparison group). Main outcome measures Presence of genital injuries. Results 22.8% ( n = 00, 95% CI 19.2–26.7) of adult complainants of penile–vaginal rape by a single assailant sustained an injury to the genitalia that was visible within 48 h of the incident. This was approximately three times more than the 5.9% ( n = 68, 95% CI 1.6–14.4) of women who sustained a genital injury during consensual sex. This was a statistically significant difference ( a < 0.05, p = 0.0007). Factors such as hormonal status, position during intercourse, criminal justice outcome, relationship to assailant, and the locations, sizes and types of injuries were also considered but the only factor associated with injury was the relationship with the complainant, with an increased risk of injury if the assailant was known to the complainant ( p = 0.019). Conclusions Most complainants of rape ( n = 500, 77%, 95% CI 73–81%) will not sustain any genital injury, although women are three times more likely to sustain a genital injury from an assault than consensual intercourse.

Further Aspects of Male-on-Male Rape and Sexual Assault in Greater Manchester

The purpose of this paper is to describe pertinent non-medical circumstances around male-on-male sexual assault, and supplements the earlier article in this journal regarding forensic medical aspects of this population. As services (medical, policing and judicial) see more males they will need to adapt themselves to their needs as well as those of their female clients. St. Mary's Sexual Assault Referral Centre (Greater Manchester, UK) opened in October 1986. Up to May 2003 it had seen 376 male (370 individual clients) and 7,789 female cases (7,403 clients). Of these, significantly fewer males reported to the police than females, although this difference has disappeared in recent years. There were also significant differences between the sexes regarding relationship, number of assailants, and assault location. There were no statistically significant differences between the sexes for age of the client, and presence in the assault of weapons or additional violence.