Sexual assault units: Double trauma of sexual assaults
Doubly traumatised: that’s what happens to families when they learn a child of theirs has been sexually assaulted.
There’s the trauma from the horror of the abuse, and there’s the trauma of trying to find proper care for their child.
“No one knows what to do until they are in it,” said Eve Farrelly of Cari, a voluntary child therapy organisation.
“The parent finds out what happened to their child. They are in a world of trying to deal with child sexual abuse. They are just catapulted into a world of shock and fear and anger and rage.
“Then they have to negotiate an unknown terrain — the ad hoc services no one knows about and trying to gain access to them. It adds immensely to the trauma.”
Ms Farrelly said: “Families who find this horror on their doorstep can feel very isolated, but they also have an awful lot of questions and worries. Who do they speak to, if they are not linked in with people who have that information and approach?”
She said accessing treatment as soon as possible is crucial to recovery: “This should be the beginning of the healing process, with the forensic examination. It should be beginning the healing journey. It should not be adding trauma.”
As it stands, there is only one dedicated sexual assault treatment unit for children in the country, compared to six adult units.
The Child and Adolescent Sexual Assault Treatment Services (CASATS) is based in Galway, the brainchild of local paediatricians and nurses. “Dr Joanne Nelson led the way,” said Mary Flaherty, chief executive of Cari. “She’s a remarkable woman, a trailblazer. She came down from the North, saw the service for children here compared to there and began it in an informal way.”
The HSE began funding it in 2011 and attendances by children grew from 53 in that year to 78 the following year, dropping to 61 in 2013 and 64 in 2014, before increasing to 73 in 2015.
It takes children of all ages under the age of 16. The service is supposed to cater for the west and mid-west region.
In its annual report for 2015, CASATS said it provided a detailed medical and forensic examination service in a “child-friendly environment” and that “every effort is taken to ensure the child’s comfort”.
The various examinations can be stopped at any time if the child is distressed and, in most cases, the child can be reassured, it said.
“Feedback suggests children and adolescents often find forensic examinations therapeutic.”
It said that, since 2014, Cari has provided a 24-hour crisis support worker to the service and said they were a “tremendous asset”.
Ms Farrelly is co-ordinator of Cari’s Child Accompaniment Support Service and praised the work of the CASATS.
The CASATS report is contained within the National SATU Annual Key Service Activity Report 2015. It shows that 30% of the children attending it are from Galway.
“That figure for Galway speaks volumes,” said Ms Farrelly. “It shows that when a service is available people will use it. It’s not that child sexual assault is a particular problem in Galway. The necessity of the service is equally present in other parts of the country.”
The CASATS figures show that children from nine other counties attend the 24-hour facility.
“We have children travelling from Donegal to Galway,” said Ms Farrelly. “It can be a five-hour car journey. Then you have two hours at the unit and five hours back home.
“Remember that the children are typically five or six years old.”
The CASATS report reveals just how young the children can be: Three are aged one; six aged two; seven aged three, and 11 aged four (the highest number for any age). The average age is around seven.
“The kids going to [CASATS] are the lucky ones,” said Ms Farrelly. “They are linked in safely and appropriately into a caring, supportive, informative, non-judgmental place. All their needs are there and it sets them on the correct road: the road to healing.”
But she added: “Where are the kids not captured in CASATS?”
Only children above the age of 14 are treated in the adult sexual assault treatment units, but, apart from a new programme that has just started in the Rotunda, Cari does not provide an accompaniment service for those aged 14 and 15 in the units (Dublin Rape Crisis Centre accompanies those aged over 16, while rape crisis centres outside Dublin accompany those aged over 14).
Ms Farrelly said there was no handle on where children under the age of 14 were going, and how many did so. These children were taken by their parents to casualty wards or their GPs for help.
“It’s an ad hoc service,” said Ms Farrelly. “It keeps us in a dark place regarding statistics. We have no way of knowing what is going on.”
She said: “I think for families, that is unacceptable. Their child is not having the same service as adults, a service they need. The adult service is so much better. I don’t know why.”
Ms Flaherty said: “We are playing catch-up all the time. We know children have different therapeutic services to adults, the same is the case with forensic services.”
Both Ms Farrelly and Ms Flaherty welcome plans to set up a dedicated 24-hour service in the new national children’s hospital.
In a statement, the Children’s Hospital Group told the Irish Examiner that a forensic medical examination service will be set up in the Dublin hospital when it opens in 2021.
It said the specialist facility will take patients from the “eastern region”.
It said it will be led by general paediatricians and advanced nurse practitioners and nursing staff.
The statement said that an advanced nurse practitioner was appointed by the end of last year and that she was expected to commence her role early this year.
“The CHG is working with the HSE to develop this service through the annual service planning process.”
The statement said that an outpatient child sexual abuse counselling and therapy service was available at Crumlin Children’s Hospital, Temple Street Hospital, and Tallaght Hospital (9pm-5pm, Monday to Friday).
It said this facility will move to two new paediatric out-patient department and urgent care centres at Connolly Hospital and Tallaght Hospital.
“These facilities are expected to open on a phased basis from 2018,” read the statement.
Ms Flaherty said that even when the new national children’s hospital service opens, there will still be many parts of the country not covered.
She said there had been talk of a service in Cork or Waterford, but did not know where that was at.
“We want child therapeutic services at least at the same level as adults,” she said.
“We are not fixed on a number of units, but there should be a reasonable geographic spread.
“We need an analysis of data, which we don’t have, and we need to look at best international practice.”
She added: “It should be an adequate level. We might not need six of them, but we certainly need more than one and a bit and the one planned. The needs are enormous.”
‘Units are here to help when crisis strikes’
“These are the type of services that no one wants to access,” explained Dr Maeve Eogan.
She is the medical director of National Sexual Assault Treatment Unit (SATU) Services and consultant obstetrician and gynaecologist at the Rotunda Hospital, where the Dublin SATU is located.
“It is important the units exist and are located around the country. It means that people from all over Ireland, over the age of 14, can access the same standard of care.”
SATUs are mainly used in crisis situations, in the wake of a sexual attack, and, in most cases, though not all, the victim is brought there by gardaí.
From a medical point of view, the units take forensic samples for possible garda prosecutions as well as emergency contraception and treatment for sexually transmitted infections, if necessary.
A development last year was that SATUs could securely store forensic samples, if a patient, at a later date, wanted to report the crime to gardaí.
Medical care is also provided for other physical injuries that might have been inflicted. Figures show that happens in over a third of all cases nationally and almost half of cases at some of the country’s six units.
SATUs provide an “integrated service”. In addition to medical care, psychological and emotional support is provided as well as linkage with the justice system through the gardaí.
“We provide emergency contraception, if necessary, treatment for STIs, and care, either physical or psychological trauma that the patient may be suffering, and we take care of forensic evidence that we can give to An Garda Síochána and assist in the detection of crime,” said Dr Eogan.
She compiled the SATU Annual Key Service Activity Report 2015, which includes reports from the six SATUs, information from which are analysed and detailed in today’s Irish Examiner.
Dr Eogan said the rape crisis centres provide an “essential service” in psychological and emotional support.
“Every attendee at a SATU is offered psychological service from the local rape crisis centre, who are absolutely wonderful, and are all volunteers,” she said.
Dr Eogan is happy with the level of service provided by the six SATUs.
“The current level of service is very good, it’s appropriate to what patients need,” she said, adding that patients may have to travel to their nearest unit.
“It can be difficult to travel from Drogheda to Dublin, but it is better to travel and receive the appropriate level of care, by trained and experienced staff, rather than receive care from someone who isn’t,” she said.
“We provide an integrated service, involving gardaí, GPs, psychological support, forensic examiners, and nursing staff.”
She said the standout problem in the whole area is the service available for children under the age of 14, apart from the sole dedicated facility in the state, located in Galway.
“If you are 23, and had sexual violence visited upon you, you would have access to services very quickly, regardless of where you lived,” she said.
“But, if you are a child, the parent or the garda may have to make up to nine phone calls, they may have to hunt up and down for someone to take care of their child in an acute sense.”
She said this isn’t because the medical professionals don’t want to help.
“There aren’t designated facilities. It often depends on the goodwill or grace and favour of a professional fitting a child in at the end of the clinic. They are trained to do it, but they are not facilitated infrastructurally. They do not have the required resources in terms of staff or support.”
She added: “Here and there, there are pockets of very good care, and an excellent service in Galway, but there are areas of the country, including Dublin, where people face a serious challenge.”
She said that late last year, a system was put in place whereby Cari, the voluntary therapeutic organisation for children, accompanies children aged 14 and 15 to the adult SATU in the Rotunda. Those aged 16 and over are accompanied by the Dublin Rape Crisis Centre.
She said the Cari accompaniment service was “still in its infancy” as it was only in its first few months.
She said the issue of facilities for children was not within her remit, as it falls outside the SATU services, but she said she supported her paediatric colleagues advocating for such services.
She said the work within SATUs is very difficult because of what they are facing.
“A key part is that we provide peer-to-peer and emotional support to each other so we don’t suffer vicarious trauma, in order to look after the team, so the team can look after the patients. None of us is immune to some of the stories you can hear.”
She said they often have to deal with situations where the patient doesn’t know what has happened.
“It’s very traumatic for patients,” she said. “We do have patients who wake up in a strange location, with a person they are not expecting, their clothes are in disarray, and they are uncertain what happened.”
She said that not every victim of sexual violence has a physical injury and that there are no conclusive tests that can say if vaginal penetration has happened or not.
“Some find it hard, they are not sure what to recover from,” said Dr Eogan.
“If you can remember, at least you can work through those moments and try to gain closure in the weeks, months, and years ahead. If you can’t remember, the healing can be difficult.”
She said that, frequently, patients’ inability to remember what happened is associated with alcohol intake.
“Alcohol is probably the biggest date rape drug in the country,” she said.
“Just because there may be an association with alcohol, that does not mean alcohol caused it. But alcohol makes you vulnerable.”
She admitted that raising the issue of alcohol is a sensitive matter.
“Because of fears we had of implying patients were some way culpable, for up to 10 years of our service we were less likely to comment on the association of alcohol and patients who attend. We were concerned that by highlighting that link you are in some way implying culpability. That’s not the message.”
She said victims can sometimes blame themselves.
“Of all crimes, sexual crime seems to bring so much blame, so much shame, so much fear of judgment,” Dr Eogan said.
“No person in this world deserves to be raped or a victim of sexual crime. It’s really important to try and debunk self-blame of victims of sexual violence.
“It’s the perpetrators of sexual violence that should be held to account.”
Why a few minutes’ talking is crucial in helping victims lift the self-blame
Reassuring people who have just been sexually assaulted that it’s “not their fault” is often part of what rape crisis volunteers have to do, said Mary Crilly, director of the Cork Sexual Violence Centre.
The centre provides an accompaniment service at the sexual assault treatment unit in the South Infirmary Hospital, in situations where the person would like their assistance.
“We have to be introduced, they [the staff] see if the person wants to talk to us,” said Ms Crilly.
“Our volunteer could be there 10-15 minutes max. The person has to undergo medical examinations and the last thing they want is a long conversation and loads of questions.
“But we tell them, ‘We are here for you’. They will know where to go to. They don’t have to start looking around for us.”
She said that initial contact can make a huge difference: “If we can come over to them and reassure them it is not their fault, that’s great.
“Whether it’s a 14-year-old girl or women aged 70, what goes through all of them is, it was their fault — they knew the guy, they said something or did something.
“If you can get through to them in those few minutes that it is not their fault, that’s important.”
She said society allows victims of sexual assault to take the blame. “We reassure them that’s not the case.”
Ms Crilly said there are situations, often involving a teenager or young woman where the parents are present at the SATU.
“There could be a family member, say of a young person. Maybe the young person doesn’t want to talk. The parents are in shock. This is their worst nightmare, this happening to their own daughter or son. They don’t know where to go.
“For parents, there is so much shock and hurt and even anger. They might be blaming their daughter for the situation. There are a lot of mixed emotions.”
She said: “They might want to go back to normal, but what has happened to them is not normal. They need help.”
She said that many follow up offers of help with the centre, but that it can take time.
“It could have happened last February and they are only coming in to us now.”
She said that, in her experience, around 80% of victims know their attacker and said that only one in four victims go to a SATU.
Ms Crilly noted a figure from the SATU Annual Key Service Activity Report 2015, which recorded a higher than average percentage of patients in the Cork SATU reporting drinking more than four units of alcohol in the 12 hours before the attack.
Alcohol is an issue as it makes people “more vulnerable”, she said.
“Girls are out for the night and don’t think it will happen to them, that it happens to other people. They might also expect [a possible attacker] would be someone they don’t know, but it could be the guy around the table who is controlling and manipulative.”
She stressed that pointing out that alcohol can make you vulnerable should not be conflated with apportioning blame on a girl because of her drinking.
“The attitude is, if a girl’s drunk, she’s responsible, but if a boy’s drunk, he’s not. The attitude is it’s their own fault.”
She said three out of four victims won’t report to SATU, in many cases because they had been drinking. “The attitude that it’s the girl’s own fault gives a minority of men the unconscious green light,” said Ms Crilly. “They think that girls in such situations are fair game.”
She said the majority of men were appalled by this attitude, but that a minority were doing it and continued to do it. “If a young man has been drinking and is assaulted on Patrick’s St at 2am, the attitude is, there should be more gardaí on the street, but if a young girl is raped after drinking at the same time, people think differently.
“It’s one big injustice. If you are a victim of sexual violence it’s your own fault, but with other forms of violence, that’s not the case.”
She said the work of SATUs is “vital” and that the Cork unit is “very good and very professional”.
She said there is a “huge gap” in terms of services for children under 14.
“There were discussions in Cork about this years ago,” she said, “but it seems to have disappeared.”
Cliona Saidléar of Rape Crisis Network Ireland agreed that the services for children were “lagging behind adult services”.
She said the Galway Child and Adolescent Sexual Assault Treatment Service was the initiative of local doctors and nurses but that it should be part of a national delivery of services, one replicated in other parts of the country.
She said SATUs provide an “immediate response” and a “crisis intervention” after an assault has just happened.
She said because SATUs are inter-agency facilities, “every need” is provided: Counsellors, support workers, rape crisis centre volunteers, forensic nurses, doctors, and gardaí.
Ms Saidlear said the accompaniment services that rape crisis centres provide at SATUs are “a critical part” of the required response to survivors straight after an assault. “That support has to be respectful,” she said. “Survivors can feel pressured, so they need to feel they were listened to and got what they needed.”
Young female student attacked by someone she knows in her home after 9pm
It tends to take place in the home.
In most cases, it happens between 9pm and 9am.
You are female and you are in your 20s.
In many cases you are a student.
Drink is often taken.
And, in most cases, you know the person.
That is the picture, in broad brushstrokes, of those attending the country’s six sexual assault treatment units (SATU).
That includes those who know they have been violated and those who are not sure, or simply don’t know.
The six units are located in Dublin, Cork, Waterford, Mullingar, Galway, and Letterkenny.
The busiest units are Dublin (Rotunda), Mullingar, and Cork.
In addition, there is a specialist unit for children, the Child and Adolescent Sexual Assault Treatment Service (CASATS), based in Galway — the only one in the country.
The figures compiled by National SATU Services provide a rare insight into the features of sexual violence — as captured by SATUs, which, experts point out, only see a fraction of all cases.
The figures are contained in the 130-page SATU Annual Key Service Activity Report 2015.
This brings together the individual detailed reports of the six units.
This is what it shows.
The numbers attending the adult SATUs rose from 628 in 2014 to 685 in 2015. Including CASATS, they rose from 692 to 758 (up 10%).
The figures for the individual units were: Cork, 100 (103 in 2014); Donegal, 45 (40), Galway SATU, 64 (48); Galway CASATS, 73 (64); Midland, 102 (85); Rotunda, 317 (286) and Waterford, 57 (66).
In almost two-thirds of cases nationally, the attacker is known to the victim.
But the relationship varies. Acquaintances account for almost 40% of all attackers, some of them only recently known to the victim.
Intimate partners, either current or former, make up 8%, and friends a further 11% of cases.
Strangers account for 28% of attackers nationally. Though a minority, they are the single biggest category. In some units (Waterford, Cork), they account for around 40% of cases.
For children, the situation is different: Only in 2% of cases is the person a stranger. In six out of ten cases, it’s a family member — in all cases, bar one, a male.
The figures also show that, in a third of cases, a child assailant was involved.
In four out of ten cases, the attack took place either in the victim’s home or that of the assailant. In some units (midlands, Galway), this increased to around half of all attacks.
Almost three in ten attacks happened in other indoor locations, though the types of places are not specified.
In some 7% of cases, they occurred in a car or taxi, though this figure was as high as 12% in the Galway SATU.
Some 5% of attacks occurred in a field or a park, though this was as high as 14% in Waterford.
Other outdoor areas account for 20% of cases.
In more than nine out of ten cases nationally, the patients at SATUs are female. The age range goes from 14 to 86.
In CASATS, the age range is from one to 16. The greatest single number of victims are aged 4 (11 of the 73) and almost 40% of the children are aged four or under.
Taking in all units, the average age is 25. In total, 157 (21%) of the 758 victims are under the age of 16.
In terms of occupation of the victim, some 43% are students (as high as 58% in Galway), 27% are employed, and 30% are unemployed.
In 83% of cases nationally, there in one attacker. In 9% of incidents, there are multiple assailants. The figure for multiple assailants is the highest in the CASATS (18%), followed by Cork and Galway (11%).
Alcohol features strongly in this area. Nationally, 44% of patients said they drank more than four units in the 12 hours before the attack. This figure rose to 69% in Cork and 58% in Donegal.
The average consumption was eight units (about four pints).
In a further 11% of cases, the patients said they had consumed drugs (illegal or prescribed), a figure ranging from 7% in Cork to 18% in Galway.
Another 11% of patients said they were concerned that they had been drugged in order to be sexually assaulted, a figure rising to 23% in Waterford.
More than a third said they had suffered physical trauma, rising to 47% in Waterford and 46% in the Midlands.
In almost two out of ten cases, patients were unsure if a sexual assault had occurred, reaching a high of 27% in Cork.
The figures show that 9pm-9am is the busiest time for SATUs, reflecting when the bulk of attendances happen.
Sundays and Mondays are the busiest days in most units, while August, October and December are the busiest months.
How to get help
South Infirmary/Victoria University Hospital
Letterkenny University Hospital
Hazelwood House, Parkmore Rd, Ballybrit
Midland Regional Hospital
University Hospital Waterford