Training Programme on Multisectoral Sexual Assault Interventions for Women

1. Training Programme on MultisectoralSexual Assault Interventions for Women

2. Module I: Introduction

3. Purpose To provide participants with the knowledge and tools to deliver multisectoralsexual assault interventions for women training

4. Learning objectives To define sexual violence, its prevalence, causes and consequences To challenge the myths and stereotypes underpinning sexual violence To examine the factors that inhibit women disclosing and reporting To establish what is best practice for services in responding to victims of sexual violence To identify the policies that should be in place to enable best practice To examine the benefits and implementation of the COSAI Benchmarking and Evaluation Tool

5. Learning outcomes An understanding of sexual violence, prevalence, causes and impacts An awareness of myths and stereotypes underpinning sexual violence An understanding of the factors that inhibit women disclosing and reporting and what helps women feel supported and safe A commitment to best practice in the provision of front line sexual violence services A commitment to promote and implement the COSAI Benchmarking and Evaluation Tool An understanding of intersectoral and collaborative working to support and enable best practice

6. Who’s here today?

7. Ground rules • Do not interrupt while others are speaking • Everyone should listen to what others are saying as well as speak • Maintain confidentiality of what is shared. • Show respect for others, and others’ experiences • Do not speak aggressively or make personal attacks • Do not express views or use language that is racist, sexist, homophobic or which discriminates in terms of disability, age or class • Do not judge other trainees • Be open to learning new ideas Time out clause: Due to the nature of the issues covered in this training, some participants may feel distressed or upset by the exercises and may need to take a break from the session. Please feel free to do so.

8. Module II: Defining sexual violence

9. WHO definition of sexual violence “Any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic a person’s sexuality, using coercion, threats of harm or physical force, by any person regardless of relationship to the victim, in any setting, including but not limited to home and work”. (WHO 2002)

10. Identifying forms of sexual violence against women Exercise – group discussion >

11. Forms of sexual violence (WHO) Penetration by a penis of the vagina, anus or mouth Rape within marriage or dating relationships Rape by strangers Systematic rape during armed conflict Unwanted sexual advances or sexual harassment, including demanding sex in return for favours Sexual abuse of mentally or physically disabled people Sexual abuse of children Forced marriage or cohabitation, including the marriage of children Denial of the right to use contraception or to adopt other measures to protect against sexually transmitted diseases Forced abortion Violent acts against the sexual integrity of women, including female genital mutilation and obligatory inspections for virginity Forced prostitution and trafficking This is not a definitive list

12. The extent of sexual violence Exercise - quiz >

13. Over 400,000 women and 80,000 men in England and Wales are estimated to have suffered a completed or attempted sexual assault in the past year Sexual violence in England Perpetrators of sexual assaults experienced by women since the age of 16 • Almost 20% of women and 3% of men had suffered a sexual assault since the age of 16 • One in ten adult victims of serious sexual assault report the incident to the police • Young women aged 16-19 years are at greatest risk of sexual assault (7.9%)

14. Module III: Causes of sexual violence

15. The causes of sexual violence Exercise: why do some people think that sexual violence against women happens? >

16. Power and control Because he thought he could get away with it To teach her a lesson ‘She’s my girlfriend / wife, I can do what I like’ He likes to control women Oppression of women through group behaviour (from shouting at women in the street to gang rape and murder) Ineffective use of law Lack of sanctions / law (in both civil society and in war situations) Social conditioning Macho expectations of what it is to be a ‘real’ man Society allows men to think women are sexually available He has no respect for women / thinks all women are slags / tarts (misogyny) Society endorses sexual violence through pornography, sexualisation of women Excuses men might make Alcohol or drug dependency Stress/poverty/oppression He can’t control himself Mental illness Testosterone Sexual frustration He misread the signals She came to my house, she must have wanted sex Women say ‘no’ when they mean ‘yes’ Reasons why a women might blame herself She led him on She was making him jealous She was drunk She was wearing provocative clothing She shouldn’t have been walking home alone in the dark All violence against women is unacceptable and is a crime

17. Module IV: Why women find it difficult to report sexual violence

18. Why many women do not disclose or report sexual violence Exercise small group discussion > See appendix/handout 4 >

19. Module V: The impact of sexual violence

20. The impact of sexual violence Wider community Family and friends Woman

21. Impact of sexual violence on women who have experienced sexual violence Physical injuries may not be present: • Less than half of sexual assault victims have any physical injury • Less than a quarter have anogenital injury (injuries relating to the anus and genitals) It is helpful to categorise the physical health consequences of sexual assault in three ways: acute, medium term and long term

22. Acute injury may include: • Bruises - fingergrip pattern on arms and inner thighs • Abrasions and scratches • Lacerations (tear of skin caused by blunt trauma) • Incisions (wound caused by sharp edge or blade) • Bites, burns, fractures • Bleeding from the vagina (either from acute injury or menstrual), anus or an acute wound

23. Medium term consequences include: • Unintended pregnancy - consider termination of pregnancy if lawful • Care in continuing pregnancy • Sexually transmitted infection including HIV/AIDS, hepatitis B as well as chlamydia, gonococcus, trichomonas vaginalis and syphilis

24. Longer term consequences include: • Problems in pregnancy - recurrent miscarriage, premature rupture of membranes • Sexual difficulties - painful intercourse, spasm of vaginal entrance muscles, disorders of desire, arousal and orgasm, aversion to sex • Infertility • HIV • Pelvic Inflammatory Disease • Chronic pelvic pain • Irritable Bowel Syndrome • Asthma, • Heart attack • Eating disorders • Self harm

25. Mental health consequences • Acute trauma reactions • Few hours to a few days • May be delayed for days or even weeks Symptoms include: • Anxiety, panic, confusion • Numbness • Shock • Memory gaps • Impaired ability to think/function • Distorted perception of time • Depression • Guilt, shame • Dissociation • Amnesia

26. Longer term mental health consequences include: The consequences are often severe and persistent enough to have a significant impact on the person's day-to-day life including breakdown of relationships, work-related problemsand substance use related problems. • Anxiety – panic, disorientation • Depression • Isolation • Post-traumatic stress disorder • Nightmares and flashbacks • Sleep problems • Self-harm • Suicidal behaviour

27. The impacts of sexual violence: case study Case study exercise - Sarah Discuss in small groups: What might Sarah’s immediate concerns be? What injuries might she have? What forensic samples should be taken? What are the issues to be addressed in the short and medium term? What are possible long term consequences for Sarah? See appendices/handouts 5 and 6 >

28. The wider impacts of sexual violence Exercise What are the wider impacts of sexual violence on families and friends, communities and society as a whole? See appendices/handouts 5 and 6 >

29. Module VI: Models of intervention for sexual assault

30. Services for victims of sexual assault Forensic services - Gather forensic DNA evidence, document injuries Medical services - Treat injuries, provide emergency contraception, prophylaxis and follow-up STI screening Psychosocial services - Counselling, support, guidance and referral to other organisations/social services Police and legal services - Enforce the law (e.g. by identifying perpetrators), protect victims’ rights and ensure their safety and referral to appropriate services

31. Service coordination • Movement in USA in 1970s towards coordinated care • Professionals from different fields providing co-ordinated services in a single location • Create a common understanding about the multidimensional context of care

32. Sexual Assault Referral Centre (SARC) pathway – United Kingdom

33. Case study: SafePlace Merseyside Sefton StHelens Liverpool Knowsley Wirral SafePlace Merseyside

34. Case study: SafePlace Merseyside • City-centre SARC serving a population of approximately 1.3 million residents plus students, tourists etc. (95% clients female) • A coordinated model of sexual assault service provision. Provides forensic and medical services; immediate support and care and access to longer term psychosocial services, advocacy and support via the Independent Sexual Violence Advisors (ISVAs) • Accessible 24 hours a day, 7 days a week, all year round • All services are free • All service providers work with coordinated protocols, practices and reporting processes that have been agreed upon by all agencies e.g. confidential information sharing, client flow and referrals, ethical and safety standards

35. The client’s journey - referral Client experiences sexual assault Reports incident to the police Contacts SARC directly (self-referral) Contact via other agency (e.g. Social services; Emergency Department) Officers attend and take brief first account Police Sexual Offences Liaison Officer (SOLO)accompanies client to SARC Sexual Assault Referral Centre (SARC)

36. The client’s journey – Once at the SARC Police SOLO discusses first account with FME Client is met by Crisis Worker (CW) who provides specialist support and acts as the client’s advocate Client enters the pre-exam room. Forensic Medical Examiner (FME) is introduced and explains the forensic process The FME asks medical questions and obtains written consent from the client for the medical/forensic examination Client enters the examination suite, either alone or with support as required. Examination takes place Client leaves examination suite with option of shower. Onward referral, PEPSE*, emergency contraception and hepatitis vaccinations are discussed by CW and FME. CW makes safeguarding referrals where necessary. *Post-exposure prophylaxis for HIV

37. The client’s journey – Beyond the examination Client is contacted by Independent Sexual Violence Advisor (ISVA) and offered follow-up care and support, which can include supporting the client through the criminal justice process Client is contacted to attend Genitourinary Medicine (GUM) clinic for sexual health screening

38. Case study: SafePlace Merseyside Pre-exam room Hallway

39. Case study: SafePlace Merseyside Examination suite

40. Case study: SafePlace Merseyside Post-exam room

41. Independent Sexual Violence Advisors (ISVAs) • Victim-focused advocates for victims of sexual assault • Conduct risk assessment for client, including self-harm, Post-Traumatic Stress Disorder (PTSD), depression, anxiety, low self-esteem, need for a refuge or safe house, childcare, social services • Information used to develop a bespoke client care plan • ISVAs also provide • Information about the criminal justice system • Support and advocacy through the criminal justice process • Help with health issues, emotional support and attending relevant appointments • Referral to other services or agencies • Client’s relationship with ISVA may continue for weeks or months after an assault (often up to 18 months)

42. Sexual Assault Services (SAS) - Australia

43. SAS – Australia cont • 24/7 crisis response providing support and information on a victim’s choices • SAS coordinates and facilitates the implementation of the person’s chosen action, drawing on strong links with the police and prosecutors • Crisis intervention and forensic examination carried out at partner hospital • Emphasis on longer-term continuity of care and advocacy

44. Centres of Excellence (CoE), Scandinavia

45. CoE – Scandinavia cont • Specialise in emergency response; emergency medical treatment and care, forensic examination and crisis counselling • Trained nurses support victim during police questioning and ensure legal procedures are followed • Staff have extensive expertise and Centres have an additional research function • Research to increase understanding of the consequences of rape and sexual assault, as well as to improve prevention measures

46. Agencies involved in supporting women who have experienced sexual violence Case study exercise > See appendix/handouts 7>

47. Case study: Mary’s story One afternoon Mary was home getting ready to go pick up the children from school when her husband, David, came back unexpectedly. He came into the kitchen, smiled and told his wife he wanted to have sex. Mary refused because she had to go, but David threw her down on the floor and raped her. Afterwards, Mary felt traumatised and betrayed and wondered if she should have seen it coming. In the early days of their relationship, when they met at university, David had seemed so charming. After a few months, Mary was in love with him. Only once, before they got engaged, had he threatened to slap her. When she started crying, he softened and said that he was sorry, he loved her and did not want to lose her. Not long after that, they got married, despite the fact that Mary’s mother thought that her outgoing daughter had become quiet and withdrawn. After Mary and David got married, all her friends gradually disappeared.

48. Case study: questions for discussion • Which agencies might provide the help Mary needs? • What would Mary’s pathway to seek help look like in your local area/country? • Can you identify any gaps or barriers for Mary accessing support? • What can be improved to assist Mary in getting the help she needs? Case study adapted from New Philanthropy Capital: A Hard Knock on Life

49. Module VII: The COSAI Benchmarking & Evaluation Tool

50. Principles and uses of benchmarking techniques and tools Discussion >