The World Health Organisation’s (WHO) definition of sexual violence (SV) in 2015 is: “any sexual act that is perpetrated against someone’s will” committed “by any person regardless of their relationship to the victim, in any setting”. It includes, but is not limited to, rape, attempted rape and sexual slavery, as well as unwanted touching, threatened SV and verbal sexual harassment [1].
SV is a major public health problem [2], with a lifetime prevalence in European women of 5,2% committed by a non-partner and 25,4% by the victims (ex-)partner [3]. The Sexpert study in Flanders found a prevalence of 22,3% and 10,7% in case of respectively girls and boys. For adult women and men the percentages of lifetime victimization were respectively 13,8% and 2,4% [4]. A multi-level analysis in 10 European countries showed lifetime sexual victimisation rates of 20,4% and 10,1% for respectively Belgian young women and men aged 16 to 27 years [5]. The prevalence of SV in case of Lesbian, Gay, Bisexual and Transgender people (LGBT’s) is 31,7% to 41,1% and in case of migrants 56,6%, making them groups at risk [6,7,8,9]. However it remains impossible to exactly compare prevalence studies, due to differences in study designs, selection and response bias. Nevertheless since only 1 out of 10 victims report SV, the prevalence is strongly underestimated [10,11,12].
SV has important physical, reproductive and psychological implications for victims [13]. Many patients develop symptoms of functional somatic syndromes, posttraumatic stress disorder (PTSD), depression, substance abuse and despair [13, 14], in the context of facing stigmatization, rape myths and stereotypes [15]. In order to provide the needed support, international guidelines state that caregivers should recognise these symptoms and explore the patient’s history of SV [16, 17].
Figure 1 illustrates the WHO’s recommended initial care after acute sexual assault [17]. Early presentation is crucial for the forensic examination, tests, proper treatment and referral within 72 h after the incident [11, 15]. Guidelines advice to conduct the forensic examination simultaneously with the physical examination, according to the anamnestic findings, at the victim’s pace and after receiving informed consent [15, 18, 19]. The required safety and privacy should be guaranteed [16, 20]. Depending on the victim’s wishes, a family member, relative or attendant should be able to offer support during the examination. The patient should never be fully undressed, while examinations and interviews should be reduced to a minimum where possible. Caregivers should give patients the opportunity to make an informed autonomous treatment choice and respect the choice made [15, 16]. Every victim also needs appropriate support from family, relatives and health professionals with regular follow-up during the first 1–3 months [17]. At follow-up consultations patients should be asked about treatment difficulties, their personal lives, their emotional wellbeing and their concerns [21].
According to the WHO, a holistic approach of health care focuses not only on the patient’s physical, emotional and social needs but also on their past, future and broader context, requiring a strong collaboration among different stakeholders [22].
By integrating the perspective, needs and preferences of patients, patient-centred care tries to focus on the wellbeing of the victim [17, 21]. After SV many victims have lost control and autonomy of their lives. In order to regain this control and autonomy, it is required to provide a safe environment and thorough information. To this end, caregivers should acquire appropriate knowledge, attitudes and practice in caring for victims of SV [21, 23].
Furthermore, the access to health care plays a central role in a patient-centred approach, which can be evaluated using 5 dimensions, i.e. accessibility, acceptability, availability, affordability and appropriateness [24].
As part of the broader context of the victim, it is desirable for caregivers to support the family and relatives as well [17, 21, 25]. Family and relatives can be affected in different ways. First, because SV to a loved one is a trauma for themselves, affecting their emotional wellbeing as well. Secondly they might be a victim or witness of SV themselves and need psychosocial support [25, 26].
The intended model for the foundation of a Sexual Assault Care Centre (SACC) in Belgium builds on existing Sexual Assault Referral Centre (SARC), Sexual Assault Nurse Examiner (SANE), Sexual Assault Treatment Unit (SATU) and Sexual Assault Referral Team (SART) models [9, 27,28,29,30]. In order to give holistic and patient-centred care, the model aims to provide acute and follow-up care at one place provided by one central health professional supported by a team of specialist professionals, as recommended by the WHO [15]. The SACC will be located nearby an emergency service on hospital grounds with a separate access and a guaranteed 24/7 accessibility.
During the first contact in the SACC, a forensic nurse or SANE will take care of the acute forensic, medical and psychosocial support of the victim. Other responsibilities of the forensic nurse are online and telephonic assistance, registration and raising awareness about SV.
After the acute support, the case manager is the single point of contact and is responsible for adequate follow-up, referral and the cooperation with different stakeholders in the care for SV victims.
A team of professionals consisting of a gynaecologist, an urologist, an infectious disease specialist, a paediatrician, a forensic physician and a psychiatrist will provide support to the forensic nurse and the case manager if needed.
During the first month post assault the case manager will contact the victim at least 4 times, starting at day 1 after discharge. Furthermore at least 2 appointments with the SACC’s psychologist will be arranged. A total of 12 to 20 free appointments with a qualified psychologist are provided depending on the patient’s wishes and psychosocial assessment. When indicated 1 appointment at the AIDS Referral Centre (ARC), gynaecologist, urologist or paediatrician will be scheduled. A schematic overview clarifies the initial care after acute sexual assault in the intended SACC (see Fig. 2).
In order to guarantee specialised care, every stakeholder attached to the SACC will receive a common training in the care for victims of SV, followed by a function-specific training for the forensic nurse, case manager and psychologist [31].
Having ratified the convention of Istanbul, the Belgian federal government intended to explore the feasibility of raising SACCs in the Belgian health and judiciary system [32, 33]. This project aimed to assess the care for victims of SV in Belgium anno 2016 and evaluate the transition to the eligible approach.
In the context of this project, this study focused on the evaluation of the health care for victims of SV in Belgian hospitals anno 2016 and more specifically on the role of caregivers in establishing a patient-centred care aiming to formulate recommendations for the intended model.