Midwives work in many settings– Rachel Murray, Clinical Nurse- Midwife manager and Forensic Midwife Examiner for sexual offences, Bristol, shares information around sexual offences and why midwives should be aware of referral pathways. NB: trigger warning. The article contains some graphic detail.
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Understanding Sexual offences and referral pathways for midwives
Trigger warning: the article contains graphic detail around sexual offences. Please seek support if you are affected by reading this information.
Violence against women and girls (VAWG) is an umbrella term used to describe a range of abuse types experienced by women and girls, more so than men and boys. These include domestic abuse and homicide, child sexual and other abuse, female genital mutilation (FGM), forced marriage, honour-based violence and harassment in both the workplace and in public life.
Midwives are highly attuned to domestic violence as it relates to pregnancy, but less so about sexual assault (SA) which covers an array of actions from rape to sexual touching and may be perpetrated by an intimate partner or a stranger. It is an uncomfortable subject to think about, let alone raise and discuss with our clients, however, it is an issue that should be on all of our professional radars.
The Sexual Offences Act (2003) has three parts. Part 1, explained below, covers the non-consensual offences of rape, assault by penetration and causing a person to engage in sexual activity without consent and covers England, Wales and in part Northern Ireland. Part 2, not addressed within this article contains measures for protecting the public from sexual harm and Part 3 contains general provisions relating to the act.
Under Section 1, of part 1, it is an offence for a person (A) to intentionally penetrate the vagina, anus or mouth of another person (B) with his penis, without their consent (rape). Whether a belief in consent is reasonable is to be determined by having ‘regard for’ or considering all the circumstances including any steps the alleged perpetrator has taken to ascertain whether the alleged victim consents. This and any offence under section 5 of the act (which references rape of a child under the age of 13 which will not be addressed in this article), are the only offences that can be committed by a male, because they relate to penile penetration.
Under section 2, of part 1, assault by penetration occurs where a person (A) intentionally penetrates the vagina or anus of another person (B) without their consent and does not reasonably believe that they consented. The penetration may be with a part of the perpetrators body, eg a finger, or anything else eg a bottle or other item where the penetration is sexual in nature (as defined by the act and excludes intimate searches and medical procedures). Whether a belief in consent is applicable here is also subject to having regard for all the circumstances.
Under section 3, of part 1, sexual assault is the offence when person (A) intentionally sexually touches another person (B) without that person’s consent and where there is no reasonable belief that they consent. The meaning of ‘touching’ is defined in section 79(8) and refers to touching with any part of the body; with anything else; through anything and touching amounting to penetration. Under section 78, the phrase ‘sexual’ as it applies to the offence of sexual assault has two limbs: a) covers any activity that the reasonable person would always consider by its nature, to be sexual eg sexual intercourse and oral sex b) covers activity that by its nature, the reasonable person may or may not consider to be sexual depending on the circumstances, intentions or both of the person carrying out the act eg digital penetration of the vagina may or may not be sexual. It may not be sexual in nature if carried out as part of a medical examination (but equally could be sexual when carried out under the guise of a medical examination if the intent of the person carrying out the act is sexual). Therefore, the reasonable person would need to consider the nature of the activity, the circumstances in which it was carried out and the purpose of any of the participants to determine whether or not the act is sexual. If from looking at the the nature of the activity, it would not appear to the reasonable person that the activity might be sexual, the activity does not meet the standard necessary to consider it sexual assault, even if an individual achieves sexual gratification from the activity. Consequently, sexual assault covers a wide variety of behaviours.
Under section 4, of part 1, causing a person to engage in sexual activity without consent, an offence is committed if a person (A) intentionally causes another person (B) to engage in sexual activity, without their consent and without a reasonable belief of consent. The activity involved may include penetration of the victim’s vagina or anus; penetration of their mouth with a penis; penetration of the vagina or anus with a part of the perpetrators body or by anything else used by them.
Cautious estimates from the Sexual Offences in England and Wales Overview; year ending March 2022, which aggregates data from the Crime Survey of England and Wales (CSEW), police recorded crime from the Home Office and data from services available to victims of sexual offences and therefore providing the best measure of victimisation, identify that 2.3% of adults were victims of sexual assault. A further breakdown of statistics within this figure found that 3.3% of victims were women comparative to 1.2% of men. This equates to an estimated 1.1 million adults, 798,000 of which were women and 275,000 men. These statistics demonstrate that women are on average 3 times more likely to be assaulted than men.
Data and analysis from Census 2021 found that approximately 16.6% adults aged 16 and over (7.9 million) had experienced sexual assault or attempted sexual assault since the age of 16. 1.9 million were a victim of rape, 7.7% of which were women and 0.2% men.
For the year ending March 2023, the most up to date information contained within CSEW identified that police only reported and recorded sexual offences totalled 193,096 incidents in the 16-59 years age group. Data is only collected within this age reference range and due to an inbuilt error in data generation, only 8 months of data was gathered, consequently, 4 months of data is missing which represents a significant number of reports that went unrecorded. Offences reported included rape, assault and sexual touching. This was consistent with findings from previous years.
Reporting of offences is rising year on year but shockingly, fewer than one in six victims of rape or other forms of SA are reported, consequently the true nature and statistics of sexual violence are significantly higher. If 1 person in every 6 represents the 193,096 recorded incidents referred to above, this leaves an extrapolated 965,480 unreported offences that have occurred over the 8 months of data collection (5 x 193,096), the majority of which have occurred to women. This would still be a cautious estimate of the total number of sexual offences across England and Wales annually.
These statistics are something that should concern all midwives and constitute a significant public health issue. As a gender biased form of violence, encompassing women in their childbearing years, it is invariable that all midwives will have either victims or survivors of SA on their caseloads. This potential number of victims of sexual assault raises the question of what the midwife’s role is both in asking if our clients are experiencing sexual assault or have done historically and if faced with a disclosure what steps they should take next.
Domestic violence is a common occurrence during pregnancy and as a result, midwives are adept at asking direct questions to ascertain the safety of women under their care. Through our training and experience, we understand that domestic violence encompasses a variety of types of abuse including sexual abuse. We need to become equally comfortable at asking direct questions about experiences of sexual assault and abuse in order to provide the best support and outcomes for mother and baby and know where to refer to for dedicated care.
Across the country are a number of Sexual Assault Referral Centres (SARC’s) that accept self-referrals from individuals who do not wish at that time to disclose an assault to the police, as well as referrals from health, social care and other agencies. The police also refer cases to a SARC when an assault is disclosed to them. SARCS are jointly commissioned and funded by regional police forces and the NHS or police forces and private companies that provide SARC services. A SARC provides dedicated, trauma informed care to complainants of sexual assault. For acute sexual assaults, they offer a forensic medical examination (FME) which comprises of a forensically focused interview utilising a biopsychosocial approach to gather information that covers a clients physical, mental, sexual, gynaecological and reproductive health care and needs as well as information about their personal circumstances such as home life, work life, leisure activities and offers acute follow up care to include assessments of risk of pregnancy (if not already pregnant), risk of contracting hepatitis B, HIV and other sexually transmitted diseases, acute mental health and safeguarding risks and prescribing of medication as required or the making of onwards referrals as needed.
The examination also includes a forensic medical examination, in which bodily and genital injuries if present are assessed, photographed, accurately described, measured and body mapped and forensic samples taken. Not all victims of acute assaults wish to have a full forensic examination, but a referral is still appropriate and accepted in order that individuals can access appropriate follow up care. For some, it may be the first time they’ve disclosed an assault or talked at length to anyone about it. Telling their story and having someone trained to hear and acknowledge it can be extremely validating. For non-acute cases, referrals are still accepted, again in order that appropriate follow up care can be provided.
When forensic samples are taken, they are either handed to the police for processing if the referral came from them or samples are stored on site for up to two years and two months, after which samples must be destroyed in line with the requirements of the Human Tissues Act (2004). At any point within the two years and two months, a person who has self-referred to the SARC can report an assault to the police and provide consent for their forensic samples and clinical records of their forensic examination to be provided to the police.
Midwives are ideally placed to not only refer into a SARC but to also provide care within them as a Forensic Midwife Examiner for sexual offences. Forensic midwifery isn’t a role traditionally considered that of the midwife, however, it is an extremely interesting, niche and highly specialist way of working, with a unique and dynamic intersection of clinical, forensic, advocacy skills and legal knowledge and awareness. Midwives work to their usual NMC guidelines and additionally comply with a wide variety of other relevant guidance such as Faculty of Forensic and Legal Medicine (FFLM), British Association for Sexual Health and HIV (BASHH), Faculty of Sexual and Reproductive Healthcare (FSHR) guidelines, within the constraints of the Human Tissues Act (2004) and with an awareness of the Police and Criminal Evidence Act (PACE, 1984) and others.
So often, due to competing demands and service constraints, midwives undertaking ‘traditional’ midwifery roles are unable to practice in a truly holistic manner as they would wish to do. In forensic midwifery, the opposite is true. During an FME the entire focus is on that one client throughout. The ability to provide uninterrupted, high-level care at an exceptionally difficult time in a client’s life is extremely rewarding. It sounds counterintuitive that a client could leave a SARC laughing or joking, but it happens more often than not and when they do, we as forensic practitioners specialising in sexual assault, understand that their healing journey has begun.
References:
British Association for Sexual Health and HIV (BASHH) (2023). Various guidelines. http://www.bashhguidelines.org [Accessed 18/12/23].
Census 2021. The Office of National Statistics (ONS) (2021). http://www.ons.gov.uk [Accessed 18/12/23].
Crime Survey of England and Wales (CSEW): Year ending June 2023.The Office of National Statistics. http://www.ons.gov.uk [Accessed 18/12/23].
Faculty of Sexual and Reproductive Healthcare (FSHR) (2023). Various guidelines. http://www.FSRH.org [Accessed 18/12/23].
Human Tissue Act (2004). http://www.legislation.gov.uk [Accessed 19/12/23].
Police and Criminal Evidence Act (PACE) (1984). http://www.legislation.gov.uk [Accessed 19/12/23].
Sexual Offences in England and Wales Overview: year ending March 2022. http://www.ons.gov.uk [Accessed 18/12/23].
The Faculty of Forensic and Legal Medicine (FFLM). Guidelines – FFLM (2023). https://www.FFLM.ac.uk [Accessed 18/12/23].
The Nursing and Midwifery Council (NMC). The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates (2023). www.NMC.org.uk [Accessed 18/12/23].
The Sexual Offences Act (2003). http://www.legislation.gov.uk [Accessed 19/12/23].
Rachel Murray,
Clinical Nurse- Midwife manager and Forensic Midwife Examiner for sexual offences, Bristol
January 2024