Introduction

As a truly universal human custom, dying is one of those rare things. We all do it sooner or later, however inexpertly. All societies mark it, some heavily, some lightly. Whole religions have been invented to militate against its all too evident, shocking finality. It happens more secretly in Western societies than most, but although it happens in every community we do not talk about it as we talk about politics, sex, religion and the economy. Many cultures, not all of them ancient, are on cosier terms with death than us.

Death and dying patients are an inevitable part of emergency medicine practice. Facing a surviving family, or counselling a dying patient, may for some symbolize failure in the battle against disease. In emergency medicine practice, one does not have the benefit of a long-standing doctor–patient relationship. The support and mutual understanding that are the cornerstones of family practice are missing, and so rapport has to be forged in the heat of the moment. Families need space and time to come to grips with death, but time and space are a precious commodity in the emergency department (ED). Access block and overcrowding should not preclude sensitive, empathetic grief management.

The cold, clean and sterile surroundings of a hospital morgue, or the shambles of a recently deserted resuscitation room, stand in stark contrast to the comfort, soft furnishings and music of the funeral parlour. To follow the heat and adrenaline rush of a difficult resuscitation with the grace and emotional energy required to care for a family, the members of which have now become patients, requires considerable effort. The survivors, however, deserve our care and compassion as much as did the recently deceased.

Similarly, management of the patient brought to the ED in extremis, even when death is anticipated, can be a complex and challenging task, as families, baling out through exhaustion, fear or ignorance, call an ambulance in the few hours prior to death, often in the middle of the night.

Most multicultural societies have no single distinct death ritual, nor a standard way of expressing loss and grief, as in monocultures. This, combined with the fact that most ED deaths are unexpected, places a significant responsibility on emergency physicians to initiate grief management and refer for continuing care.

Quality management of grief states can prevent significant morbidity, as unresolved grief can lead to later problems with physical and mental health.

The death process

Death does not occur at a finite moment. Cardiac death, cerebral death, brainstem death and cellular death form a continuum over minutes or hours. The legal definition of death varies between regions. The diagnosis of brain death can be made accurately and positively by appropriately qualified and experienced people using relatively simple bedside tests.¹ It is imperative, however, that any reversible condition producing depression of the brain must first be excluded. The time of death is the time when brain death is established, not the time when life support is ceased. Persons considered dead may continue to breathe for a considerable length of time, and faint cardiac action that cannot be detected in major vessels, or by auscultation, can continue to provide sufficient oxygen for vital organs to survive for some hours. So it is important that relatives are not informed of death until all breathing and cardiac activity have ceased. A second opinion and cardiac monitor can help verify this.

Dying persons

The dying and their families face numerous psychological issues as death draws nigh. Sometimes it can be difficult to counteract the tendency to focus on the physical and tactical needs of care, rather than the emotional, spiritual and cultural dimensions of human experience. A large family may need significant space, which can interfere with the routine work of the ED so a private room should be available. Dying persons can have a deep-seated fear of abandonment, accepting further treatment for the sake of the family or doctor, knowing that it will be of little personal benefit. Open communication and congruent goals for care should be forged early, and links with family doctor, caring specialist teams or hospice care should be established so that everyone feels safe and secure, with the proposed regimen, pending ward admission. Then all can pay special attention to physical comfort, symptom management, privacy and the confidentiality of the patient and family. Extensive references are immediately available on the internet, for staff and family.²

Palliative care workers experienced in bereavement care are concerned at the lack of support available particularly after hours in major healthcare institutions, where sudden death, traumatic death and death in unfamiliar and isolated circumstances make more likely the risk of complicated grief for those left behind.

The advent of sophisticated paramedic care has created a new class of patient, too ill to resuscitate with lethal illness. High (apnoeic) quadriplegia and catastrophic trauma patients can present conscious and in extremis. Early decisions to resuscitate can bring profound distress later and be hard to reverse.

In such cases life-sustaining treatment may legitimately be forgone if it is:

In the few minutes after arrival with inadequate information, it is easier to resuscitate first and answer questions afterwards.

Breaking bad news

Most ED deaths are unanticipated, and informing families can be a harrowing experience. If the opportunity presents, it is essential that the family be well briefed during resuscitation and, where practicable, be involved in the process. A member of the family can be invited into the resuscitation room, where the senior emergency physician present should discuss the procedures under way and provide encouragement to touch, speak to and kiss the patient. This is not only reassuring, but the presence of numerous competent staff with an array of sophisticated equipment reassures family members that the healthcare team has not let them down, and this can prevent many doubts and questions later. If the outcome is hopeless this can be discussed with the family members, perhaps asking their permission before abandoning resuscitation. Even if they do not wish to accept such responsibility they will remember these moments for the rest of their lives. Having participated in the resuscitation and in the decision to stop can be helpful, even when the request has been declined.

The interview with the family of the recently deceased can be more difficult than the resuscitation. Handled with sensitivity, however, it can be a positive start to successful grieving and recovery.

Viewing the body

Relatives and their invited friends should be encouraged to view the body. By seeing the body, by feeling and touching, the grieving process, separation and rebuilding can start. People should be encouraged to speak to, touch, kiss, stroke, caress, even to argue, negotiate and cajole in private for as long as they wish. Without this time, weeks or months later, delusions can persist that the person might not have died, and conspiracy theories can emerge. The presence of a bereavement or viewing room can make this process much easier as, particularly with children, visiting can go on for several hours. A hospital morgue may be used, some have a purpose-built facility and appropriate staff support. Relatives should be informed of the necessity for police presence if the matter has been referred to the coroner.

Legal issues

By law, in all Australian states a body belongs to the Crown until a death certificate is issued. This is issued by the Registrar General after satisfactory details are supplied by a medical practitioner on the medical certificate as to the reasons for death. This is a legal document and is the source of information for the preparation of national mortality statistics. The quality of these statistics and subsequent public-health interventions depend largely on the ability of doctors to present accurate information.

Euthanasia

Euthanasia (active medical killing of terminally ill patients) is currently illegal in all states of Australia and New Zealand but is under active debate in Western society.³

For the proponents of euthanasia, patients are presumed to have endured pain and suffering, which, out of respect for autonomy and compassion, they should be able to relieve by choosing euthanasia.

For opponents of euthanasia this is seen as a potent reason for enhancing access to, and quality of, palliative-hospice care and mental health services. For many, the ‘slippery slope’, at the end of this is loss of the sanctity of life, a broadening of the criteria for euthanasia, and a gradual change in the values of society and the ethos of medicine frighteningly beckon. The debate highlights the difficulty of clinical decision-making in complex circumstances, which, in themselves, have been neglected in the euthanasia debate with its medical, social, legal and ethical arenas; the law and ethics cannot operate separately from clinical care.

The neutralists emphasize the lack of research into how and where people die and the inadequacies of training programmes for the care of the dying, which lead to calls for euthanasia and draw attention to the complexities and vicissitudes of the communications between patients and doctors.

Finally, clinical educators need to develop programmes that both explore the wider social issues of death and dying and ensure that the circumstances of this inevitable event are compassionate and humane.

Death certificates

Cases where a death must be referred to the coroner are usually detailed on the inside of the death certificate book. Any death suspected to be not entirely from natural causes requires reporting. The coroner’s office will assist.

Unless the emergency physician is thoroughly familiar with the patient and the medical history, and saw the patient prior to death, the opinion as to whether a death certificate should be issued should be left to the family practitioner, specialist or hospital unit normally caring for the patient. Where the cause of death is unclear, or no doctor has sufficient information to fill out a death certificate, an autopsy is required. Although this may cause distress to some families (and particular ethnic groups), any bona fide cultural concern can be referred to the coroner, where such matters are usually dealt with sensitively. Under the requirements of the Evidence Act, a body must be under the jurisdiction of the police from as soon as practicable after death until the coroner states that it is no longer required for legal purposes. Thus, any interference with the body is illegal, unless it is with the assent of the police officer in charge. The coroner’s office should be notified as soon as practicable after death, so a police officer, if required, can attend.

Organ donation

Although parenchymal organs are generally taken from beating-heart donors, the recently dead can be corneal or occasionally renal donors. Organ donation should be mentioned unless there are clinical contraindications, such as hepatitis B, HIV or malignancy. Relatives can ask later why donation was not suggested, and some really appreciate the opportunity to contribute to the welfare of others. A routine check of the driver’s licence or at the donor registry can help clarify the issue. All Australian states have access to professional transplant coordinators to facilitate the process once permission has been obtained.

Bereavement counselling

Most hospitals have qualified practitioners to support the recently bereaved. Referral should be arranged prior to departure if counsellors have not already made contact. Ministers of religion are trained in grief counselling and are usually available after hours. People can feel unprepared to ask for them, and it is not necessary for the deceased to have had any religious affiliation to make use of such counsellors. The family doctor is also a useful resource and should always be informed promptly of the death of a practice patient. Social workers are expert in grief counselling, and many funeral companies now provide counselling services.

Subsequent issues

An ED protocol

Recommended actions for medical and nursing staff in dealing with grieving relatives:

Williams et al. have proposed integrating a bereavement management plan to deal sensitively with death in a busy ED.⁴ Their evaluation has shown that with educated staff, it is neither overly burdensome, nor confronting, it provides a human side of our role as healers in the face of death.

Professional issues

One of the important aspects of looking after survivors is caring for the carers, who are often overlooked. Those involved in caring for others who have experienced trauma need support and the opportunity to vent thoughts and feelings. Many authorities, including the National Association for Loss and Grief (NALAG), consider it imperative that formal diffusing and debriefing should be provided to any worker involved either at the scene of trauma or with surviving victims, or with family members of victims. The mental health of professionals is an important consideration, and due recognition should be given to this aspect so as to offset possible burnout. ED managers need to give attention to thresholds for adding debriefing to standing orders, as mandated in some hospitals. Junior and rotating staff may be less resistant than professional practitioners of emergency medicine. There is, however, a distinct propensity for those who spend their lives among misery to become cynical and full of black humour. The cultural norms of emergency medicine can become so integrated into personal values that the physician does not even recognize their presence. We should regularly assess our own emotional fatigue, and if there is a significant divergence between our personal values and career activities, we may be motivated to seek support from a trusted source.

Introduction

Rape, and all its variations and sub-entities, is an act of violence in which a sexual act is part of the assault. Sexual pleasure, in the way the general community would perceive this pleasure, is not the objective of the rapist. The intention is to subjugate, humiliate or control the victim, and the sexual act is the means by which this is achieved.¹

The failure to understand this fundamental distinction has allowed a host of misconceptions and myths to arise that not only tend to exonerate the perpetrator but transfer blame to the victim. Over 90% of the victims of adult sexual assault are women and 98% of the offenders are men. Therefore, for the purposes of this review, the victim is referred to as if female and the offender as if male.

Definitions

As the word ‘rape’ is surrounded by legal and emotional issues, the term ‘sexual assault’ is preferable. Sexual assault is a physical assault of a sexual nature directed towards another person without their consent. The assault may range from unwanted touching to sexual penetration without consent.

Sexual assault is a crime, with a legal definition, which may vary between states and territories. Each part of this definition has accumulated further legal interpretation and case law. Sexual assault has a number of elements. It is an act of a sexual nature, which is carried out against the will of the victim. The victim does not give consent, is intimidated to consent or is legally incapable of giving consent because of youth or incapacity. It includes attempts to force the victim into sexual activity and also includes rape, attempted rape, aggravated sexual assault (assault with a weapon or infliction of injury), indecent assault (oral or anal intercourse), penetration by objects and forced sexual activity that did not result in penetration. Penetration is not an essential element to sexual assault. Indeed, in many sexual assaults, the assailant is unable to initiate or complete sexual intercourse.²

The absence of physical resistance by the victim is not regarded as consent. Consent by intimidation or coercive conduct without physical threat is also a criminal act. Consent requires free agreement and a person may be incapable of consenting because of the influence of drugs or alcohol.

Sexual assault by a carer upon a child is termed sexual abuse. This is sexual activity in which consent is not an issue and involves the child in sexual activity that is either beyond the child’s understanding or contrary to accepted community standards. There are legal definitions regarding age, generally in the order of 15–17 years depending on the jurisdiction. Sexual violence involving a disabled person may also be either abuse or assault depending on the nature of the act or the circumstances of the victim.

Epidemiology

In the year 2003, Annual Recorded Crime Statistics³ indicate 18 237 reports of sexual assault to police in Australia. This represents an increase in reports to police from 12 186 in 1993 and indicates a sexual assault victimization prevalence rate for Australia of 91.7 victims per 100 000 persons. The National Crime and Safety Survey (NCSS) 2002 indicates a prevalence rate for females at 0.4% (33 000 victims) and for males 0.1% (4800 victims).⁴

The reported incidence of sexual assault thus reflects only a fraction of the actual frequency of the crime, although reporting rates are increasing. Victims hesitate to report because of humiliation, fear of retribution, fear they will not be believed, self-blame and lack of understanding of the criminal justice system. Victims are more likely to report sexual assault to police if the perpetrator was a stranger or the victim was physically injured.

Once an incident of sexual assault has been reported to the police, one in four cases result in the perpetrator being charged.⁵ The conviction rate is low, with less than 50% of defendants found guilty.⁶

Overwhelmingly, the offender is known to the victim. Recorded Crime Statistics (2002)³ show that almost three in five female victims of sexual assault report that the offender was known to them. Assaults most commonly occur in the victim or perpetrator’s home. The assailant was most likely to be the victim’s boyfriend or date (34%), a friend (27%) or a previous partner (21%). The violation of trust that this represents also has a significant effect on the victim. Spousal rape is often more violent and repetitive than other rape and is less commonly reported, in part because of economic dependency.⁷ Persons with intellectual disability are at high risk with very few prosecutions. Data collected by survey of 4000 victims of sexual assault in Australia in 2000 revealed one in five victims identified as having a disability.⁸

The victim’s response to the assault is also important. NCSS 2002⁴ data confirm that four out of five women do not tell police about incidents. Most women look for the support of family, friends, neighbours and workmates. One in five women who suffer a sexual assault does not disclose to anyone, seeks no help and takes no action as a result of the assault.

Rape myths and barriers to care

Any review of the literature on sexual assault will uncover discussions regarding social attitudes and preconceptions, often called rape myths. In general, these myths reflect positions, values or feelings that are not based on fact. Many of the rape myths arise and are perpetuated by socialization processes that specify sex-role behaviours and attitudes towards women. Date rape is thought to be exceedingly under-reported because the victim believes to have contributed to the act because the victim participated in foreplay. Acceptance of these rape myths can convey that victims are responsible for the assault, altering the expectation of jurors, and making it harder to report and recover from sexual assault, reinforcing the victim’s guilt and shame. Indeed, the ABS study⁵ found that 12.5% of women did not report the assault to the police because of shame and embarrassment.

Emergency physicians and nurses need to be aware of these attitudes that the victim and they themselves may have when approaching the sexual assault victim. A non-judgemental, accepting stance by care providers is essential. The victim will have enough self-doubt without carers adding to that. It is not the health professional’s role to make a judgement as to whether the rape occurred; the courts will decide this. False allegations of rape are made, but given the perceived penalties associated with reporting a rape, such a person is likely to be disturbed and in need of help anyway.

Medical care for the victim

The objective for the attending doctor is firstly to provide for the medical needs of the victim and also, if required, to collect forensic evidence to assist in any police investigation. The history taken from the victim must be very specific and questions should be restricted to obtaining information for these purposes only. Questions should not lead into other aspects of the assault which are not relevant to the examining doctor’s involvement. It is important not to prolong the examination for the victim. Furthermore, undirected questioning risks bringing inconsistencies into the description of the assault that may hinder subsequent criminal proceedings.

In general terms, there are three matters that need attention when assessing the medical needs of the sexual assault victim. These are the risk of:

The literature typically describes about half the victims having some sort of physical injury,^9–13 although less than 5% of victims require admission to hospital for treatment. An analysis of over 1000 cases¹⁴ in the USA revealed that physical examination showed evidence of general body trauma in 64% of victims. Genital trauma was noted in 52%, while 20.4% had no injuries documented. An Australian study confirmed non-genital injuries in 46% of women and genital injury in only 22%.¹⁵ These findings indicate that many sexual assault victims may not have either general or genital trauma on examination, and this absence does not mean that an assault did not occur.

Studies of the genital injuries of victims using colposcopy¹⁶ have revealed that up to 87% of patients have some type of injury. More conventional examination of the premenopausal victim will reveal that only around a third have genital injuries documented, usually cervical erosions, abrasions, bruising and swelling. Generally, such injuries do not require specific treatment with up to one-third being asymptomatic. Nonetheless, they should be assessed and documented. Toluidine blue staining may also increase the detection rate of perineal lacerations in adult victims.¹⁰

If injuries are photographed, this is best done by a practitioner qualified in forensic photography. The victim may not give an accurate indication of the injuries such may be the emotional impact of the assault. Some victims are unable to recall even if penetration occurred.

Most non-genital injuries are found on the head, neck and face. One-third are on the extremities and 15% on the trunk. Again, the large majority of these injuries require either symptomatic or outpatient care (abrasions, lacerations and minor fractures). Less than 1% are serious enough to warrant admission. Very occasionally, rape may turn into murder. A study from Florida found that one in 1500 sexual assaults resulted in the death of the victim, with asphyxiation being the most common cause of death.¹⁷ While there has been no comparable Australian study, the Australian Institute of Criminology reports that there were 288 homicides committed in Australia in 2003 and a sexual assault was the precipitating factor in 9.¹⁸

The risk of sexually transmitted diseases following rape is 4–56%, with infection reflecting those organisms that are locally prevalent. One study showed that with baseline testing, 43% of victims had evidence of pre-existing infection.⁷ The finding of pre-existing infection is not admissible in court, under Australian law. Baseline screening¹⁹ for the following is worthwhile if follow-up can be arranged:

Poor follow-up rates are the norm and consideration of offering prophylactic antibiotics may be appropriate.

While the risk of acquiring an infection is difficult to define, women generally accept an offer of prophylaxis for infection (Table 21.2), although the effectiveness of

Table 21.2.1 Treatment options for the sexual assault victim

this approach has not yet been fully evaluated. Intramuscular ceftriaxone 250 mg together with 1 g azithromycin orally is the suggested antibiotic regimen for chlamydia and gonorrhoea.²⁰ Ceftriaxone can be mixed with lignocaine to reduce the pain of the injection.²¹

Given the low prevalence of syphilis in the general community, it may be reasonable not to give benzathine penicillin routinely but to have syphilis serology performed at 3 months, depending on the circumstances and whether follow-up can be assured.

Hepatitis B virus can be transmitted by sexual intercourse^22–24 but the risk of transmission is undefined. By comparison, the risk of infection following a percutaneous needlestick from an HBAg-positive individual to an HBAb-negative recipient is 5–43%.²⁵ Prophylaxis with hepatitis B vaccine 1 mL IMI is indicated. HBV vaccination and hepatitis B immune globulin (400 IU IMI) should be available where the assailant is either known to be HBV+ve or the woman is considered to be particularly at risk of infection. Hepatitis B vaccination without HBIG is highly effective in preventing HBV infection in sexual contacts of persons who have chronic HBV infection. Persons exposed to an assailant with acute HBV infection additionally require HBIG which prevents 75% of such infections.²⁶

It is likely that the victim will be concerned about HIV or will become concerned at a later date. The offer of HIV testing should be made accompanied by the usual full explanation, and written consent needs to be obtained if the test is done. A prospective study from the Royal London Hospital of 124 victims found one case of HIV seroconversion that could have been a result of a sexual assault.²⁷ Risk assessment includes the probability that the source is infected, the likelihood of transmission at that exposure, the interval before therapy, the efficacy of the drugs and adherence to therapy. The risk of transmission of HIV following percutaneous needlestick exposure from a known HIV-positive source is considered to be 0.4%. The risk for HIV transmission per episode of receptive penile anal exposure is 0.1–3%. The risk per episode of receptive vaginal exposure is 0.1–0.2%.²⁸ The risk following exposure to other body fluids is not known but should be lower.

Studies on healthcare workers are not applicable as they have had rapid access to HIV status of the contaminant and access to antiviral agents often within 1–2 hours. Note as many as 35% of healthcare workers do not finish the course due to side effects. However, the circumstances of the victim or the assault may necessitate the consideration of HIV prophylaxis, for example a male rape in a prison setting. Risk is highest for homosexually active men and people from endemic regions such as sub-Saharan Africa.²⁹ If post-exposure prophylaxis is advisable on the basis of high risk then a starter pack of antiretroviral post-exposure prophylaxis with a three-drug regimen should be started within 72 h,³⁰ ideally at 1–2 h. Tenofovir 300 mg and emtricitabine 200 mg once daily will be the more appropriate regimen for significant exposures in most cases. These should be dispensed with patient information provided. Urgent follow-up consultation with the local HIV specialist service can be sought.³¹ Tetanus prophylaxis must be considered as part of the management of any injuries in the normal way.

The risk of pregnancy following a single unprotected coitus has proven difficult to define. However, a large prospective study from North America rated the risk of pregnancy from rape as 5%.³²

The progestagen levonorgestrel is used alone for emergency contraception in a dose of 1.5 mg. If this single dose is given within 72 h the proportion of pregnancies prevented was 85% in the WHO multicentre study.³³ The earlier it is given, the more effective it is.

The literature demonstrates that there is poor compliance with follow-up instructions. Arrangements for follow-up testing for pregnancy, sexually transmitted diseases, HIV and hepatitis B vaccination should be supplied as written instructions as victims may subsequently remember little of their interview.

The forensic examination

The forensic examination is carried out at the request of the police for the purpose of obtaining evidence of the rape or assault that could be used in a prosecution. Specific consent should be sought before this examination is undertaken, as therapeutic benefit is not intended. Police services produce kits that give a comprehensive guide to the examinations required for the various aspects of the prosecution. These kits also contain a comprehensive range of swabs, slides and specimen containers for the collection of this evidence. It is important for the examining doctor to be very familiar with the contents of these kits and have an organized approach to collection of all specimens. This familiarization must occur beforehand and should not be left until the time of the examination. Careful documentation of all general and genital injuries is valuable and may be aided by use of a body map. Description of wounds needs to be accurate, comprehensive and use descriptive definitions provided with the police kit to maximize communication across disciplines involved. Grey-Eurom and Seaberg³⁴ found that evidence of genital and non-genital trauma was significantly associated with successful prosecution.

It is important to recognize that the victim may not be able to make an immediate decision as to whether to proceed to making a formal statement to the police. However, there are time constraints on the collection of forensic evidence. A solution may be to collect the evidence and have the police store it. The victim can then make an unhurried decision over the next few days as to whether the victim wishes to proceed. The forensic examination should also be guided by the history. For example, if anal intercourse has not occurred, there is no point in putting the victim through a rectal examination.

It is always the victim’s prerogative as to whether the examination is to occur and whether all parts of the examination are to be performed. The legal concept of ‘the chain of evidence’ must be followed in the handling of forensic specimens. The chain of evidence does not require a police officer to be present during the examination, but the specimens should be handed to the police after the examination is concluded.

The objectives of the forensic examination are quite specific. They are to collect evidence regarding:

Psychological impact of a sexual assault

The predominant psychological reaction of the sexual assault victim is a devastating and profound sense of loss.⁴¹ There are two major causes of this. First, throughout the assault the victim may well be in grave fear for her own survival. It is common knowledge that rapists sometimes murder their victims and the use of actual or threatened violence possibly supported by a weapon is an almost universal feature of rape. Second, the victim suffers a gross invasion of bodily boundaries in a manner that removes her control over that which she holds most personal to her.

As a result, sexual assault survivors are more likely to develop post-traumatic stress disorder than victims of any other crime.⁴²

Following a sexual assault, the victim can show a wide range of emotional responses, but these can generally be characterized into one of two broad types: expressed or controlled. In the expressed style, the victim’s fear and anxiety may be shown by crying and obvious distress. In the controlled style, the victim will be outwardly calm, even appearing detached or nonchalant. It is important for caregivers to recognize these emotional styles exist and not to make value judgements about victims’ credibility on the basis of their emotional presentation.

After this comes a reorganization phase in which the victim attempts to assimilate the event and recover her lifestyle. Continuing counselling can assist the victim during this phase by providing an opportunity for ventilation of feelings, providing reassurance and support of adaptive behaviour and education.

Up to 95% of victims may meet the criteria of post-traumatic stress disorder following the rape,⁴³ and as many as 16.5% of victims still show stress-related symptoms 17 years after the attack.⁴⁴ Survivors report a variety of emotional changes in the longer term following the assault, including fear, anxiety and depression. Many report sexual dysfunction and disruption of relationships,⁴¹ a finding that has also been noted in male victims.⁴⁵ On the other hand, appropriate interventions and support can lead to better outcomes, including changes that could be viewed as positive. One cohort of survivors saw themselves as stronger, more careful, more self-reliant, independent or thoughtful.⁴⁶

Even though emergency physicians play a brief role in the care of the victim, they can also have an important impact on psychological recovery. It has been found that the greater the support the doctor provides to the victim, the better the outcome,⁴⁷ and that the victims consider the manner in which the medical examination is performed as more important than other factors such as the gender of the doctor. However, the same study found doctors to be the least supportive in comparison to other health professionals, families, friends and social service agencies.

Sexual assault in special circumstances

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