Exploring the similarities and differences amongst service users with and without learning disabilities attending Saint Marys Sexual Assault Referral Centre.

BACKGROUND: People with learning disabilities are over-represented amongst Sexual Assault Referral Centre service users. This work aims to explore the similarities and differences between service users with and without learning disabilities. METHOD: Medical notes of 52 service users likely to have a learning disability were compared with 52 service users not likely to have a learning disability (according to the Learning Disability Screening Questionnaire); all of whom attended Saint Marys SARC for a forensic medical examination during a 12-month period. RESULTS: Significant associations were found between the likelihood of learning disability and relationship to perpetrator; location of assault; alcohol use; time taken to present to SARC; domestic violence; self-harm; suicide attempts and mental health service involvement. CONCLUSIONS: People with learning disabilities in the sexually assaulted population are more likely to present with intersecting vulnerabilities emphasising the need for timely, accessible and appropriate patient-centred care for this group.

The disproportionately high prevalence of learning disabilities amongst adults attending Saint Marys Sexual Assault Referral Centre.

BACKGROUND: There is a dearth of reliable data on sexual assault prevalence amongst people with learning disabilities. This work aims to identify the prevalence of learning disabilities amongst adult clients attending Saint Marys Sexual Assault Referral Centre and ascertain the similarities/differences amongst clients with learning disabilities as compared to clients without. METHOD: A short validated Learning Disability Screening Questionnaire was completed by adult clients attending Saint Marys for a forensic medical examination during a twelve-month period. RESULTS: Amongst 679 clients who attended for an FME and completed the LDSQ, 8.2% were likely to have a learning disability and the presence of self-reported: mental health issues (X2  = 11.24, p = .001), self-harm (X2  = 5.63, p = .017) and substance misuse (X2  = 13.15906, p = .001). CONCLUSIONS: Consistent with the broader literature, people with learning disability were over-represented in the sexually assaulted population emphasizing the importance of timely, accessible and appropriate patient-centred care for this vulnerable group.

A systematic review of research into black and ethnic minority patients' views on self-management of type 2 diabetes.

CONTEXT: Eliciting patients' views of type 2 diabetes self-management provides insights on how policy and services might better support the needs of this population. OBJECTIVE: To synthesize black and ethnic minority patients' views on the barriers and facilitators influencing the self-management of type 2 diabetes. SEARCH STRATEGY: A systematic search of international literature published in nine electronic databases was undertaken in 2008. Search strategies used both MeSH and free-text terms. Two relevant journals were also hand searched. INCLUSION CRITERIA: Any primary empirical study published in the English language since 1986 that reported black and ethnic minority patients' views on type 2 diabetes self-management. DATA EXTRACTION AND SYNTHESIS: Data were extracted and study quality was formally assessed. Data were analysed using thematic synthesis. MAIN RESULTS: Fifty-seven studies were included, of qualitative (n = 54), mixed-method (n = 2) or quantitative (n = 1) design. Studies were from North America (n = 41), Europe (n = 14) and Australia (n = 2), including 1735 participants in total. Three analytical themes emerged: 'Importance of identity'; 'Being understood by others' and 'Making sense of condition', all linked conceptually under the overarching theme 'Sense of self'. The quality of the studies varied. DISCUSSION AND CONCLUSIONS: The findings provide insight into what black and minority ethnic people regard as the barriers to, and facilitators of self-management, as opposed to what health professionals, policy makers and trial researchers may have assumed. Recognition of the views of people with diabetes is essential for the design and delivery of patient-centred care and policies.

Apps and Adolescents: A Systematic Review of Adolescents' Use of Mobile Phone and Tablet Apps That Support Personal Management of Their Chronic or Long-Term Physical Conditions.

BACKGROUND: The prevalence of physical chronic or long-term conditions in adolescents aged 10-24 years is rising. Mobile phone and tablet mobile technologies featuring software program apps are widely used by these adolescents and their healthy peers for social networking or gaming. Apps are also used in health care to support personal condition management and they have considerable potential in this context. There is a growing body of literature on app use in health contexts, thereby making a systematic review of their effectiveness very timely. OBJECTIVE: To systematically review the literature on the effectiveness of mobile apps designed to support adolescents' management of their physical chronic or long-term conditions. METHODS: We conducted a review of the English-language literature published since 2003 in five relevant bibliographical databases using key search terms. Two independent reviewers screened titles and abstracts using data extraction and quality assessment tools. RESULTS: The search returned 1120 hits. Of the 19 eligible full-text papers, four met our review criteria, reporting one pilot randomized controlled trial and three pretest/post-test studies. Samples ranged from 4 to 18 participants, with a combined sample of 46 participants. The apps reported were targeted at type 1 diabetes, asthma, and cancer. Two papers provided data for calculating effect size. Heterogeneity in terms of study design, reported outcomes, follow-up times, participants' ages, and health conditions prevented meta-analyses. There was variation in whether adolescents received guidance in using the app or were solely responsible for navigating the app. Three studies reported some level of patient involvement in app design, development, and/or evaluation. Health professional involvement in the modelling stages of apps was reported in all studies, although it was not always clear whether specific clinical (as opposed to academic) expertise in working with adolescents was represented. The dearth of studies and the small overall sample size emphasizes the need for future studies of the development, evaluation, use, and effectiveness of mobile apps to support adolescents' personal management of their conditions. CONCLUSIONS: A key finding of the review is the paucity of evidence-based apps that exist, in contrast to the thousands of apps available on the app market that are not evidence-based or user or professional informed. Although we aimed to assess the effectiveness of apps, the dearth of studies meeting our criteria meant that we were unable to be conclusive in this regard. Based on the available evidence, apps may be considered feasible health interventions, but more studies involving larger sample sizes, and with patient and health professional input at all stages, are needed to determine apps' acceptability and effectiveness. This review provides valuable findings and paves the way for future rigorous development and evaluation of health apps for adolescents with chronic or long-term conditions.

British-Pakistani women's perspectives of diabetes self-management: the role of identity.

AIMS AND OBJECTIVES: To explore the effects of type 2 diabetes on British-Pakistani women's identity and its relationship with self-management. BACKGROUND: Type 2 diabetes is more prevalent and has worse outcomes among some ethnic minority groups. This may be due to poorer self-management and an inadequate match of health services to patient needs. The influence that type 2 diabetes has on British-Pakistani women's identity and subsequent self-management has received limited attention. DESIGN: An explorative qualitative study. METHODS: Face-to-face semi-structured English and Urdu language interviews were conducted with a purposively selected heterogeneous sample of 15 British-Pakistani women with type 2 diabetes. Transcripts were analysed thematically. RESULTS: Four themes emerged: Perceived change in self emphasised how British-Pakistani women underwent a conscious adaptation of identity following diagnosis; Familiarity with ill health reflected women's adjustment to their changed identity over time; Diagnosis improves social support enabled women to accept changes within themselves and Supporting family is a barrier to self-management demonstrated how family roles were an aspect of women's identities that was resilient to change. The over-arching theme Role re-alignment enables successful self-management encapsulated how self-management was a continuous process where achievements needed to be sustained. Inter-generational differences were also noted: first generation women talked about challenges associated with ageing and co-morbidities; second generation women talked about familial and work roles competing with self-management. CONCLUSIONS: The complex nature of British-Pakistani women's self-identification requires consideration when planning and delivering healthcare. RELEVANCE TO CLINICAL PRACTICE: Culturally competent practice should recognise how generational status influences self-identity and diabetes self-management in ethnically diverse women. Health professionals should remain mindful of effective self-management occurring alongside, and being influenced by, other aspects of life.

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.

Otolaryngology contribution to the care of patients following non-fatal strangulation in the settings of alleged sexual assault.

BACKGROUND: Non-fatal strangulation as a consequence of a sexual assault attack or domestic violence represents serious bodily harm. Otolaryngologists have an important role in documenting physical findings and managing airway symptoms. This study aimed to describe our otolaryngology department's experience managing patients referred from the sexual assault referral centre who suffered non-fatal strangulation. METHOD: A retrospective analysis of patients suffering non-fatal strangulation referred to the Manchester University Hospitals NHS Foundation Trust Otolaryngology Department from Saint Mary's Sexual Assault Referral Centre in Manchester between 1 January 2017 and 31 December 2019 was carried out. RESULTS: A total of 86 patients were referred from Saint Mary's Sexual Assault Referral Centre. Of these patients, 56 were given telephone advice and the remaining 30 were seen by the on-call otolaryngology team. In addition, 20 out of 30 (66.6 per cent) patients underwent fibre-optic nasal endoscopy. Common presenting symptoms were neck pain (81.4 per cent), dyspnoea (80.2 per cent) and dizziness (72.1 per cent). Five patients had identifiable laryngeal injury on endoscopy. CONCLUSION: Meticulous documentation is recommended when managing patients who suffer non-fatal strangulation because medical records may be used as evidence in criminal investigations.

The impact of COVID19 pandemic and government enforced lockdowns on levels of attendance and context of sexual assaults reported at Saint Marys Sexual Assault Referral Centre.

Globally, government enforced lockdowns were one measure introduced to reduce the transmission of COVID-19. The impact of these social movement restrictions on victims of sexual assault and their access of sexual assault services needed clarity. This study aimed to understand the impact of COVID-19 pandemic lockdowns on: Sexual Assault Referral Centres (SARC) attendance; characteristics of clients; characteristics of alleged perpetrators and nature of sexual assaults. Routinely collected data from the Saint Mary's SARC in the North West of England over two financial years, April 2019-March 2020 (pre-COVID-19) and April 2020-March 2021 (during COVID-19), were analysed. Compared to the pre COVID-19 year, monthly SARC attendance for children and adults decreased during national lockdowns and increased as restrictions lifted. Ethnicity of clients was significantly different during COVID-19 with more South Asian adults and more bi-racial children attending. Attendance of adults aged over 57 years also significantly increased during COVID-19. A significant increase in adults meeting alleged perpetrators online and a significant decrease in alleged perpetrators being a sex worker client were also identified. Finally, a significant increase in not-recorded data for health characteristics of adult and child clients was noted. While this study has illuminated some changes in the vulnerability profile of clients attending SARC during COVID-19 and its associated lockdowns, it has also highlighted shortcomings in changes to usual care introduced in the challenging and changing context of a global pandemic. These findings in parallel usefully recommend areas in need of service improvement.

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

INTRODUCTION: Saint 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. METHODOLOGY: Census 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. RESULTS: The 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. CONCLUSION: The 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.

Top 10 priorities for Sexual Violence and Abuse Research: indings of the James Lind Alliance Sexual Violence Priority Setting Partnership.

OBJECTIVES: To establish a James Lind Alliance (JLA) Priority Setting Partnership (PSP) to identify research priorities relevant to the health and social care needs of adults with lived experience of recent and/or historical sexual violence/abuse. PARTICIPANTS: Adults (aged 18+ years) with lived experience of sexual violence/abuse (ie, 'survivors') were consulted for this PSP, alongside healthcare and social care professionals who support survivors across the public, voluntary, community, independent practice and social enterprise sectors. METHODS: In line with standard JLA PSP methodology, participants completed an initial online survey to propose research questions relevant to the health and social care needs of survivors. Research questions unanswered by current evidence were identified, and a second online survey was deployed to identify respondents' priorities from this list. Questions prioritised through the second survey were presented at a consensus meeting with key stakeholders to agree the top 10 research priorities using a modified nominal group technique approach. RESULTS: 223 participants (54% survivors) provided 484 suggested questions. Seventy-five unique questions unanswered by research were identified and subsequently ranked by 343 participants (60% survivors). A consensus meeting with 31 stakeholders (42% survivors) examined the top-ranking priorities from the second survey and agreed the top 10 research priorities. These included research into forms of support and recovery outcomes valued by survivors, how to best support people of colour/black, Asian and minority ethnic and lesbian, gay, bisexual, transgender, and queer (LGBTQ+) survivors, improving access to high-quality psychological therapies, reducing public misconceptions/stigma, the impact of involvement in the criminal justice system on well-being, and how physical and mental health services can become more 'trauma informed'. CONCLUSIONS: These research priorities identify crucial gaps in the existing evidence to better support adult survivors of sexual violence and abuse. Researchers and funders should prioritise further work in these priority areas identified by survivors and the professionals who support them.

The effectiveness of sexual assault referral centres with regard to mental health and substance use: a national mixed-methods study - the MiMoS Study.

Background: Sexual assault referral centres have been established to provide an integrated service that includes forensic examination, health interventions and emotional support. However, it is unclear how the mental health and substance use needs are being addressed. Aim: To identify what works for whom under what circumstances for people with mental health or substance use issues who attend sexual assault referral centres. Setting and sample: Staff and adult survivors in English sexual assault referral centres and partner agency staff. Design: A mixed-method multistage study using realist methodology comprising five work packages. This consisted of a systematic review and realist synthesis (work package 1); a national audit of sexual assault referral centres (work package 2); a cross-sectional prevalence study of mental health and drug and alcohol needs (work package 3); case studies in six sexual assault referral centre settings (work package 4), partner agencies and survivors; and secondary data analysis of outcomes of therapy for sexual assault survivors (work package 5). Findings: There is a paucity of evidence identified in the review to support specific ways of addressing mental health and substance use. There is limited mental health expertise in sexual assault referral centres and limited use of screening tools based on the audit. In the prevalence study, participants (n = 78) reported high levels of psychological distress one to six weeks after sexual assault referral centre attendance (94% of people had symptoms of post-traumatic stress disorder). From work package 4 qualitative analysis, survivors identified how trauma-informed care potentially reduced risk of re-traumatisation. Sexual assault referral centre staff found having someone with mental health expertise in the team helpful not only in helping plan onward referrals but also in supporting staff. Both sexual assault referral centre staff and survivors highlighted challenges in onward referral, particularly to NHS mental health care, including gaps in provision and long waiting times. Work package 5 analysis demonstrated that people with recorded sexual assault had higher levels of baseline psychological distress and received more therapy but their average change scores at end point were similar to those without sexual trauma. Limitations: The study was adversely affected by the pandemic. The data were collected during successive lockdowns when services were not operating as usual, as well as the overlay of anxiety and isolation due to the pandemic. Conclusions: People who attend sexual assault centres have significant mental health and substance use needs. However, sexual assault referral centres vary in how they address these issues. Access to follow-up support from mental health services needs to be improved (especially for those deemed to have 'complex' needs) and there is some indication that co-located psychological therapies provision improves the survivor experience. Routine data analysis demonstrated that those with sexual assault can benefit from therapy but require more intensity than those without sexual assault. Future work: Further research is needed to evaluate the effectiveness and cost-effectiveness of providing co-located psychological therapy in the sexual assault referral centres, as well as evaluating the long-term needs and outcomes of people who attend these centres. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (16/117/03) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 21. Trial registration: This trial is registered as PROSPERO 2018 CRD42018119706 and ISRCTN 18208347.

We undertook several studies including: Searching and examining published research (review). A survey that asked sexual assault referral centres how mental health and substance use are addressed. Questionnaires: survivors who had recently attended a sexual assault referral centre completed questionnaires on mental health, alcohol and drugs, and quality of life. Interviews with staff at sexual assault referral centres and survivors of assualts. Routine data: we analysed anonymous data from mental health services to compare how those with sexual assault benefit from psychological therapy. We combined the findings from all the aspects of the study to conclude that most people who attend sexual assault referral centres have significant mental health needs; however, the response to these needs is variable within sexual assault referral centres. Survivors report that the sexual assault referral centres offer a caring and supportive service, but many also reported difficulties in accessing the right support afterwards. Where there was co-located psychological therapy, there were benefits for both survivors and the wider team. We also showed that, despite high needs, people surviving sexual assault can benefit from therapies but may need more therapy than those who have not experienced sexual assault.

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

BACKGROUND: There 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. METHOD: This 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. RESULTS: Of 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. CONCLUSION: The 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.

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

BACKGROUND: Being 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. AIMS: This 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. METHODS: Retrospective 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. RESULTS: A 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). CONCLUSIONS: Prevalence 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.

BACKGROUND: There 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. METHOD: Data 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. RESULTS: A 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. CONCLUSION: The 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.

BACKGROUND: Determining 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. OBJECTIVES: The 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 SETTING: This 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. METHODS: Data 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. RESULTS: Results 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. CONCLUSIONS: This 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.

Minimising trauma in staff at a sexual assault referral centre: What and who is needed?

INTRODUCTION: This study investigates staff's perspectives on the characteristics required to work in a sexual assault referral centre and the support and training they believe sexual assault referral centres should provide to minimise the negative impacts of the work and provide a supportive working environment. METHODS: Semi- structured interviews were conducted with 12 staff, and a focus group was held with a further four staff of a sexual assault referral centre. The data were examined using thematic analysis. RESULTS: Findings indicated that to work in a in sexual assault referral centre staff need to be understanding, empathetic, non-judgemental, supportive, flexible and resilient as well as having coping skills. The support structures and processes staff reported as being essential to creating a supportive working environment and reducing vicarious trauma were: supervision; training; peer support and shadowing. CONCLUSIONS: Working in a SARC is stressful and emotionally difficult work. This study provides valuable insights about the individual and environmental factors SARC staff believe are required to have a happy and healthy workforce delivering a gold standard of care to victim-survivors of sexual violence.

The identification and treatment of mental health and substance misuse problems in sexual assault services: A systematic review.

BACKGROUND: Specialist sexual assault services, which collect forensic evidence and offer holistic healthcare to people following sexual assault, have been established internationally. In England, these services are called sexual assault referral centres (SARCs). Mental health and substance misuse problems are common among SARC attendees, but little is known about how SARCs should address these needs. This review aims to seek and synthesise evidence regarding approaches to identification and support for mental health and substance misuse problems in SARCs and corresponding services internationally; empirical evidence regarding effective service models; and stakeholders' views and policy recommendations about optimal SARC practice. METHODS: A systematic review was undertaken. PsycINFO, MEDLINE, IBSS and CINAHL were searched from 1975 to August 2018. A web-based search up to December 2018 was also conducted to identify government and expert guidelines on SARCs. Quality assessment and narrative synthesis were conducted. RESULTS: We included 107 papers. We found that identification based on clinical judgement, supportive counselling and referral to other services without active follow-up were the most common approaches. Evaluations of interventions for post-rape psychopathology in attendees of sexual assault services provided mixed evidence of moderate quality. Very little evidence was found regarding interventions or support for substance misuse. Stakeholders emphasised the importance of accessibility, flexibility, continuity of care, in-house psychological support, staff trained in mental health as well as specialist support for LGBT groups and people with learning difficulties. Guidelines suggested that SARCs should assess for mental health and substance misuse and provide in-house emotional support, but the extent and nature of support were not clarified. Both stakeholders and guidelines recommended close partnership between sexual assault services and local counselling services. CONCLUSIONS: This review suggests that there is big variation in the mental health and substance misuse provision both across and within different sexual assault service models. We found no robust evidence about how sexual assault services can achieve good mental health and substance misuse outcomes for service users. Clearer guidance for service planners and commissioners, informed by robust evidence about optimal service organisations and pathways, is required. PROSPERO registration number: CRD42018119706.

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.

BACKGROUND: The 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. AIMS: The 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. METHOD: One-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. RESULTS: 69% 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. CONCLUSION: Prevalence 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.

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.