Parameters of this review

A detailed national comparison of all of the protocols that exist to direct individual service responses to sexual assault is beyond the scope of this paper. Instead, we focus on the leading mechanisms used by individual states and territories to define the broad working relationships that currently exist between major hospitals, specialist sexual assault services, women's specific health agencies and community and regional health services, police services, and other victim support services whose business it is to respond to sexual assault.
Most of the protocols attempt to balance the victim's needs for counselling and advocacy support, with the requirements of forensic and/or medical care, and for victims to be informed about their options for accessing a legal response. This paper leans towards exploring how health care in particular is accommodated within the existing protocols.

This approach takes account of:

• the likelihood of health care responses being subjected to review as awareness of the often long-term health consequences of sexual assault increases;
• a shift in social policy away from specialist, gender-based service delivery to mainstream health and community based responses. This will challenge the achievements of feminist inspired approaches that have sought to position service delivery in the context of understanding sexual violence and its responses as highly gendered;
• how most protocols tend to prioritise the health needs of recent victims. This paper details the historical development of protocols and the emphasis given to implementing appropriate crisis care responses. Models both here and overseas are now seeking to look "beyond crisis care" in terms of delivering quality health services to survivors of sexual violence.

Most protocols aim to co-ordinate service responses that allow victims to have prompt access to counsellors, doctors, and to police should they decide to make a report following a sexual assault. However, the manner in which services are delivered within each state or territory in response to sexual assault "crisis calls" at an inter-agency level varies widely. ¹

The protocols examined in this Issues Paper were selected for the attention they give to health care issues and the extent to which their coverage is intended to be state- or territory wide. How adaptable the protocols might be across communities within individual states and territories was also explored. In particular, to gauge how flexible and adaptable individual protocols might be for accommodating the localised needs, resources, cultural specificities and geographical distances that smaller or more isolated service areas often manage (Neame and Heenan 2004).
This examination is also focused on protocols developed to meet the needs of adult victim/survivors of both recent and past sexual assault. In some instances protocols extend to services that provide care to children who are sexually assaulted. In those instances the descriptions will include reference to how the protocols might also be activated to respond to reports or notifications of child sexual assault. However protocols guiding service provision specifically for children are not included here.

In undertaking the background research for this paper, it was assumed that the protocols would be formalised, documented, easily accessible and, to a certain extent, standardised across jurisdictions or regions. While this was the case in the main, particularly for protocols encompassing the delivery of forensic services, it is also true that for some jurisdictions and regions the protocols are under-developed or are still in draft or preliminary stages. In these cases, the status of the protocols was unclear. Some had only partially been formalised, or the content was little-known, poorly understood or ignored within or across agencies and organisations. The documentation provided therefore ranged from ratified codes of practice, to partnership agreements, to a series of committee meeting minutes or even verbal discussions between agencies. Surprisingly, protocols are not always available to parties external to the partner organisations, and in a couple of instances were not able to be located by the organisations themselves. Not only does this variation reflect the level of status afforded to some of the protocols but has implications for the extent to which the protocols can be subjected to external review and evaluation.

"Surprisingly, protocols are not always available to parties external to the partner organisations, and in a couple of instances were not able to be located by the organisations themselves."

Finally, while the focus of this paper is on protocols that respond to victims of sexual assault, consideration must be given to the particular context of family and domestic violence (FDV). While the specific issue of male partner rape has often been the subject of neglect by researchers (Heenan 2004), more recent studies have been able to attest to the prevalence with which women experience sexual assault at the hands of their violent partners (Coker et al. 1998; Hegarty and Bush 2002). Specialist services in both the domestic violence and rape crisis fields have only recently themselves started to negotiate closer working relationships, in recognition of the extent to which sexual violence features amongst the range of violent behaviours experienced by women (Heenan 2004). Consequently some of the protocols reviewed here consider how the protocols relate to both sexual assault and FDV sectors.

What is a protocol?

The term "protocol" is used here in its widest sense to mean a formal agreement between different parties. It might refer to guidelines, policies and procedures, or codes of practice that involve co-ordination of services, Memoranda of Understanding, Strategic Plans, Standards of Practice, Partnership Agreements, and other shared agreements that formalise relationships across services. It is often used in a generic sense to refer to the documentation that often accompanies forensic investigation kits for sexual offences.

The variety of documentation illustrates the wide range of collaborative relationships that exist across agencies, institutions, and jurisdictions. Some protocols are "in-house" - that is, they apply to services provided within an institution such as a hospital or a government health service area, and may refer to the relationships between professionals such as nurses, doctors, counsellors or social workers. Others may describe the relationship between parties - for instance, where a peak body that represents the interests of sexual assault services across the state might have entered into a state-based agreement with a government department, or where a regional health care provider has established a particular working relationship with their local police service that can better serve the needs of the community in that particular location. Other "inter-agency" approaches guide the interaction between individual service providers. In regional and remote areas this can often mean an agreement between two individuals who may be the sole workers in an agency. Some protocols refer only to business-hours practice, some to after-hours, and some to 24-hour responses.

The delimitation of services under these protocols also varies. Some protocols relate to the provision of support through either medical or legal processes, and some combine both medical and legal. Others cover a broad spectrum of services from advocacy and support at reporting and forensic examination, through to longer-term health-care follow-up, and social reintegration. Protocols also delimit coordinated services to victim/survivors in various forms. These include rights advocacy (such as the right to be believed, or to make a report), support through processes (such as forensic processes or criminal injuries compensation claims), "case management" (coordinating responses by health and legal services), support to social networks (providing information and counselling to non-offending family and friends), and/or services to the community or to agency personnel in the form of training, debriefing opportunities (for other professionals working with victim/survivors), process clarification, obligation and responsibility clarification, enumeration and delineation.

The general rubric of "sexual assault protocols" covers three main types of response:

• Acute or crisis response - responding to recent sexual assault where the collection of forensic evidence is of primary concern;
• Service coordination response - where the coordination of (largely acute or crisis) counselling and advocacy support, medical care, police involvement (where appropriate) and maximising appropriate and non-aggravating service provision to victim/survivors is the primary concern of the protocol; and
• Historical response - where adults (including adolescents) report historical childhood sexual assault, or where an adult (or adolescent) reports sexual assault beyond the time in which a forensic examination is considered viable.

Elements of health sector protocols

In theory, there are a range of health care and medical responses available to victim/ survivors of sexual assault. This section provides an overview of the specific categories of responses identified above. They are: acute care, forensic examinations and follow-up medical care, and longer-term health responses. It is important to note, however, that while the same terminology might be used within the various protocols, the application or scope of the response might vary quite widely in practice.

Acute or crisis medical care

Acute or crisis responses are understood here to include sexual assault that has occurred within a prescribed timeframe, usually where the collection of forensic evidence is viable. The variation in timeframes nominated in the protocols looked at in this paper is between 48 to 96 hours. Regardless of whether there are physical injuries, most sexual assault services would suggest that, "[s]exual assault should be seen as a legitimate emergency case and given highest priority after those with life threatening illness, even where there is no evidence of severe physical injury" (Lincoln no date).

Dr Maureen Phillips, the Coordinator of the Medical/Forensic Services at Perth SARC also spoke of responding to the acute care needs of victims in ways that prioritised their emotional wellbeing:

"In the acute setting of recent sexual assault, a balance must be reached between access to Emergency Department facilities and the need for privacy, an emotionally supportive environment and adequate time. Severe physical injury is uncommon following sexual assault and the medical concerns of the majority of people will be adequately managed without the requirement for hospital treatment. In a minority of cases, some of which will not be immediately apparent, hospital treatment is essential. Recent sexual assault should be seen as a legitimate emergency and given high priority irrespective of physical injury, but the setting in which the patient is seen should be specific to their individual requirements. At SARC in Perth, we have the option of referring to any Emergency Dept or directly to the SARC facilities dependent on the patients needs as determined by medical or nursing triage."

From the perspective of a victim/survivor there is also the possibility that pregnancy and sexually transmitted infections (STIs) may represent issues requiring acute or crisis responses. Emergency contraception, if it is to be administered, must be provided within appropriate timelines to have the best chance of being effective. While pregnancy is not an issue for male, or pre-pubescent or postmenopausal female victim/survivors, the potential for STIs must be considered across all age categories. However some studies have revealed how these issues are sometimes overlooked when treating a sexual assault victim. In the United States, research showed that for 160 cases of sexual assault [presenting at] emergency department visits, none had received "the full regimen of [recommended] antibiotics for sexually transmitted infections (STIs). [Only] 21 per cent of those eligible received emergency contraception" (Rovi and Shimoni 2002). Protocols can certainly assist in standardising the various health checks that should and must take place following a sexual assault. While most Australian protocols include healthcare check-lists, the question of whether pregnancy and STI concerns are always addressed, particularly beyond crisis care when the presence of STIs is more likely to become apparent in the weeks and months following the assault, still remains (Olle 2004).

Forensic examinations

Sexual assault is a crime. In order to successfully prosecute criminal activity under an adversarial system of criminal justice it is necessary to prove the guilt of the accused beyond reasonable doubt. Central to an accused's defence in most sexual assault cases is whether the prosecution can prove that the woman-complainant was not consenting to the activity in question. It is here that the collection of evidence, usually from the victim's body, can be critical for establishing an absence of consent or "free agreement".²

Ideally, forensic medical examinations are undertaken by trained medical personnel who have a sound understanding of the specific issues impacting on sexual assault victims. They are experienced in following the standard medico-legal procedures and in ensuring that the associated formal documentation that accompanies these procedures can be legally defended should they be required to give evidence in court on behalf of the prosecution.

Forensic examinations in and of themselves have no direct therapeutic purpose. Establishing processes for obtaining informed consent from the victim have therefore been at the core of developing protocols that might help victims to understand what is involved, to ensure they are aware of the nature of any agreement they may give, and to advise them of other health needs that may need to be addressed that fall beyond the scope of the forensic examination.

While restrictions limit the window of time through which useable forensic samples can be taken following an assault, in most states and territories it is possible for the samples to be collected and stored in a secure location while the victim/survivor decides whether to take legal action (see accompanying Table). The only exception here is Victoria. Having control over decision-making around whether to go ahead and report to police, and being able to make this decision outside the time of the immediate crisis, is said to be an important part of victims' regaining a sense of control over their lives particularly given the sense of powerlessness they experience during and immediately following the actual assault itself. (Scott, Walker and Gilmore 1995; Olle, D'Arcy and Gridley 2004).

Longer-term health issues

"Traumatic events call into question basic human relationships. They breach the attachments of family, friendship, love, and community. They shatter the construction of the self that is formed and sustained in relation to others. They undermine the belief systems that give meaning to human experience. They violate the victim's faith in a natural or divine order and cast the victim into a state of existential crisis" (Judith Herman 1992: 51).

Up to this point, discussion has focused on relatively short-term health responses and requirements of forensic medical care; however, there is a burgeoning body of research that now testifies to the longer-term health consequences of sexual violence. According to Jean Edwards' (1996: 1) understanding, the role of "specialised medical care as an integral part of the therapeutic management of sexual assault is a relatively recent concept". In the absence of this new social and policy landscape, women, and especially adult survivors, had largely been bearing the health effects of childhood sexual assault or historical sexual assault with no formal recognition of the extent to which their experiences were likely to substantially effect their health and wellbeing.

The health consequences generated by the trauma of sexual violence has the potential to endure well beyond the acute phase. These include both the physical, mental and emotional health of individuals as well as the social and economic health of entire communities. Physical health impacts documented by the World Health Organisation range from homicide through to increased vulnerability to disease (WHO 1997, v8).³

In terms of mental health outcomes, post-traumatic stress responses are particularly common (Scott et al. 1995: 53-71). Rates of traumatic and post-traumatic stress disorder and depression are greatly increased amongst women who have experienced violence as children, especially sexual abuse, and among women who have experienced violence including sexual violence in adult life (Finkelhor 1984; Brown and Adler 1991; American Medical Association on Scientific Affairs 1992; Bifulco, Saunders and Hamberger 1993 cited in WHO 1997, v8; Mullen et al. 1996). A wide range of post-traumatic stress responses carry the risk for many victim/survivors that the experience of surviving sexual assault will become embedded in normalised responses and manifest as significant and enduring mental health issues (WHO 1997, v4; D'Arcy 1999; Astbury 2001).⁴

Health responses to sexual assault cannot necessarily be equated to medical responses in this context. Where a health response might include some medical aspects, a medical response has the potential to be counter-productive to health outcomes, as discussed below.

Historical development of health sector protocols

It is now beyond dispute that sexual violence can have devastating effects on the lives of women and children. However, historically, sexual violence has been treated as a relatively rare event, hardly warranting of any serious attention by policy makers, much less by health practitioners and health services. Women in particular were thought to experience only minimal harm from rape especially in cases where she knew the offender or was already sexually active.

Research undertaken in more recent times has challenged these misconceptions with findings clearly demonstrating that sexual assault has profoundly negative effects on victims' physical, psychological and sexual health and, when left unaddressed, on the wider public health of communities (WHO 1997; Astbury 2001).⁵

It is only in very recent times in Australia, however, that sexual assault has been situated as an issue demanding a health response (Orr 1997). It was not until the early 1980s that the relationship between the health sector, specialist sexual assault services and legal services in Australia was first formalised (Carmody 1992; Orr 1997; Laing and Bobic 2002).

Largely, this was in response to victims describing their contact with police and the medical profession as highly distressing, and disproportionately focused on the requirements of investigations and the collection of forensic evidence, than on their emotional and physical well-being of victims. Research further attested to the discriminatory attitudes held by members of the "helping professions" that coincided with widely held beliefs about deserving and undeserving victims.

Dr Jean Edwards, Medical Officer at the Royal North Shore Hospital Sexual Assault Service in Sydney, chronicles the pejorative attitudes that prevailed in forensic medical teaching texts as late as 1979 in Australia. Edwards cites comments from classic texts that made claims such as:

• "It will be found that in many cases where a charge of rape is made that the woman was really a consenting party, and that the charge was made in fear of a discovery of her lapse" (Smith and Fiddes 1955: 288);
• "No difficulty is experienced in singling out the chaste from the wanton" (Simpson 1975: 194);
• "Many allegations of rape are false, possibly as many as 11 out of 12. Such allegations may be from spite, jealousy, in order to precipitate marriage, etc." (Gee 1979: 91);
• [in examining an accused] "If possible, take a history of the circumstances of the intercourse. The man's story may accord better with the facts than the girl's" (Gee: 94) (cited in Edwards 1996: 1-2).

Accordingly, forensic examiners and generalist health professionals responding to disclosures of sexual assault often delivered an inappropriate response, if indeed a response could be accessed at all (Carmody 1992: 14). Edwards notes that in New South Wales at least, no specialised training in sexual assault forensic assessments was available to doctors until 1988 (1995: 217). This meant that, for many victim/survivors, the services and processes intended to address the harms of sexual assault were often likely to have re-traumatised and silenced them. As research undertaken by Hardgrave, and then Bush, found during the 1970s: "Interventions [had] the potential to continue the victimisation of the woman or child who had been sexually assaulted" (Scott, Walker and Gilmore 1995: 27).

During this time, rape crisis services, many of them voluntary, laboured under the failure of police and hospital staff to recognise the importance of providing victims with access to immediate crisis counselling and support. Rape crisis counsellors were often not contacted until the victim had already undergone the forensic examination or until after they had commenced making their statement to police. In other instances, workers were not contacted at all and victims were kept unaware of the existence of services, or of their right to decide against making a formal report to police (Orr 1997: 58-59).

The determination of the women's movement to advocate for systems change in the treatment of sexual assault led to greater public attention being given to the plight of rape victims (Carmody 1992; Orr 1997). Around the same time, empirical research began to expose the "science" of rape trauma. In 1974, Ann Wolbert Burgess and Lynda Holmstrom published their landmark research documenting their contact with more than140 sexual assault victims as they worked to establish a model of crisis intervention through a nurse referral program at the Boston City Hospital (1974a, 1974b). Through establishing the Victim Counseling Program, Burgess and Holmstrom concentrated on developing a counselling approach that could reduce the potential for long-term physical and psychological effects of rape, while allowing the effects of rape to be more comprehensively understood and monitored. It was in this context that they coined the term "rape trauma syndrome" as a way of explaining how, for many women, the aftermath of rape was psychologically, emotionally and often physically debilitating (Burgess and Holmstrom 1974b).⁶ Their research ultimately provided the scientific foundation for establishing service approaches that prioritised more immediate and appropriate crisis intervention, that put victims' physical and emotional wellbeing first.

During the 1980s, rape crisis services, many of them voluntary, laboured under the failure of police and hospital staff to recognise the importance of providing victims with access to immediate crisis counselling and support.

Judith Herman's work (1992) in recognising the degree of psychological trauma experienced by survivors of sexual assault precipitated moves to formally recognise the kind of "syndrome" of which Burgess and Holmstrom first spoke (1974a, 1974b). Post-traumatic stress disorder (PTSD) is now listed in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), published by the American Psychiatric Association (2000). This manual covers all mental health disorders for both adults and children and is the standard reference guide for psychiatrists in the United States and many other countries. While there is disagreement about the nature, accuracy and limitations of a clinical diagnosis such as PTSD in the context of understanding the impact of sexual assault, the formal recognition by the medical profession of a syndrome arising from trauma (where sexual assault is specifically nominated as a traumatic experience) was significant in locating the impact of sexual assault squarely within a health discourse.

As Herman (1992: 118-122) notes in her celebrated book, Trauma and Recovery:

"The lack of an accurate and comprehensive diagnostic concept has serious consequences for treatment, because the connection between the patient's present symptoms and the traumatic experience is frequently lost . . . Practically any name that gives recognition to the syndrome is better than no name at all." (See also MacKinnon on the importance of naming the effects of rape, cited in Graycar and Morgan 1990: 273). Sexual assault medical officer Dr Jean Edwards also pointed to the "substantial body of knowledge which recognises that dealing effectively with trauma as close as possible to its occurrence, and following up in the immediate period following the trauma is effective in helping to avoid the development of complex or prolonged PTSD symptoms" (1996 un-numbered pages: final page). The recognition that early intervention could mitigate the harms of sexual assault therefore became foundational to the manner in which feminist service frameworks for sexual assault evolved.⁷

In Australia, rape reform advocates applied the principles of crisis intervention theory in calling for service models that could allow 24-hour crisis care and support to be provided to recent victims. Handbooks and kits subsequently developed to guide service provision in the context of rape crisis work emphasised the importance of counsellors being equipped to co-ordinate the services of forensic examiners and police, while ensuring that as far as possible victims would be treated with sensitivity and respect, and would be able to make informed decisions about their legal, medical and counselling options (Gilmore and Evans 1980; Hewitt and Scott 1983).

By the early 1980s, state and territory governments, mostly through their respective health portfolios, had agreed to at least partially fund a number of specialist services for responding to sexual assault and family and domestic violence (Carmody 1992). Many of these developed from what had been self-run or volunteer groups that had previously existed without any formal government support (Orr 1997; Hunt 1998). Through the establishment of these specialist agencies, with their commitment to being informed by the neglected voices and experiences of victims themselves, grew a sound knowledge-base around what constituted good practice responses to sexual assault.

The recognition that early intervention could mitigate the harms of sexual assault therefore became foundational to the manner in which feminist service frameworks for sexual assault evolved.

In 1990, the Centre Against Sexual Assault (CASA House) in Melbourne first published Breaking the Silence: A Guide to Supporting Adult Victim/Survivors of Sexual Assault, clearly promoting a model of service that enshrined a victims right's-based approach (Scott, Walker and Gilmore 1995). Similar to Burgess and Holmstrom (1974a, 1974b), the authors sought to formulate an approach to service delivery that would, first and foremost, be grounded in practice and therefore remain accountable to women victims, both individually and collectively (Scott, Walker and Gilmore 1995: vii). It acknowledged the diverse needs of women making disclosures of both recent and past assaults, offered a framework for providing effective support to victims seeking crisis care or follow-up counselling support, and synthesised information that situated the treatment of rape within an historical, social, and political context. The Manual also resourced workers with very practical information about supporting women to access their medical and legal rights (Scott, Walker and Gilmore 1995: pp. 75 and 85).

This kind of methodical approach to outlining "the practice" of delivering good quality and consistent service responses was formalised in 1998 after the National Association of Services Against Sexual Violence (NASASV), with input from representatives from eighty services throughout Australia, published the National Standards of Practice Manual For Services Against Sexual Violence (Dean, Hardiman and Draper 1998). The Manual consolidated what constituted a professional and consistent service response to women, children and men who experienced sexual violence. Principles of access and equity, and a commitment to advocating a victim's rights approach, broadly defined the conceptual framework through which standards of excellence in direct service provision for sexual assault were to be measured. Most services against sexual assault now reference their practice against these national standards. These will be discussed in more detail in the next section of this paper.

While there are no guarantees that governments will continue to support specialist services as the primary point of intervention in response to both recent and past sexual assault, there undoubtedly now exists a public policy position that takes sexual violence, and violence against women and children in their homes, seriously. Most states and territories have policy documents or strategies that specifically point to violence against women as a key policy area for women's health, women's safety and for crime prevention. We now have the capacity to better estimate the size and scope of sexual violence through surveys that measure incidence and prevalence in local, national and global contexts (ABS 1996; Lievore 2003; Mouzos and Makkai 2004).

Much work has also been done to reform laws with a view to increasing the reporting rate of sexual assault and other crimes of sexual violence including violence perpetrated against women in their own homes by their partners or other family members. The rationale being that increased reporting will result in higher rates of convictions for sexual violence, that can act to prevent perpetrators from re-offending or to deter others from offending in the first place (Easteal 1992; VLRC 2003). For services, however, meeting the emotional support and health care needs of victims, especially in the immediate aftermath of an assault, has been a critical focus, regardless of the advent of police involvement.

Over the past two decades in Australia, the development of protocols guiding the inter-agency efforts of health (including forensic), counselling support and police services have attempted to cut across these kinds of competing interests. However, much of the focus has been contained to the period immediately following the initial presentation. Few of the protocols, at this stage, speak directly to the issue of managing longer-term health care needs of victim/survivors.

Reliably estimating the damaging health effects and enormous economic costs of sexual assault and domestic and family violence on the lives of individual victim/ survivors, and on the broader community, have been relatively recent endeavours (Lee 2001; Laing and Bobic 2002; Krug et al. 2002; Access Economics 2004). However, landmark population-based research undertaken by the Victorian Health Promotion Foundation during 2004 unambiguously placed the impact of intimate partner violence as the leading risk factor to women's health (VicHealth 2004).⁸ In fact, the study found intimate partner violence (including sexual violence) "is responsible for more ill-health and premature death in Victorian women under the age of 45 than any other well-known risk factors, including high blood pressure, obesity and smoking" (VicHealth 2004: 8). The specific health outcomes that contributed to the "disease burden" of intimate partner violence on women included: problems with depression and anxiety, suicide, drug use and risky levels of smoking and alcohol consumption. Clearly this study has implications for how we, as researchers, as service providers, as policy officers, as governments, come to (re)view the points at which we can most effectively intervene, prevent, educate and raise awareness about violence against women.

In the following two sections, we will examine how inter-agency protocols currently harness the co-ordination of health, counselling and legal services in response to sexual assault.

Protocols and perspectives

This section explores some of the specific protocols that guide the medical response to sexual assault across the various states and territories in Australia. In the main, these protocols represent the formal working agreements developed between medical and health professionals, sexual assault services and police in coordinating appropriate responses to victim/survivors of recent sexual assault.

While the role of medical practitioners has traditionally been confined to forensic examinations that give emphasis to the collection of "physical" evidence that might assist with any court proceedings that follow from a police investigation,⁹ the specific mechanisms that drive the provision of forensic services vary across individual states and territories. For example, forensic examinations may be undertaken by doctors employed by sexual assault services, by police or more directly by the state government, they may be in general practice, or work in local health centres or hospitals; they may provide acute care in response to the immediate aftermath of a sexual assault only, or provide follow- up care throughout the months following the assault.

This section maps the details of individual protocols and specifically outlines: the parties to the protocol; when the document was first introduced; the circumstances under which the protocol should be activated (whether for adult and/or child victims, for recent and/or past assaults); any requirements for training by services who are the subject of the protocols; and the nature of the forensic or medical care provided.

In the main, these protocols represent the formal working agreements developed between medical and health professionals, sexual assault services and police in coordinating appropriate responses to victim/survivors of recent sexual assault.

The level of detail provided here tends to correspond with how well information about the history, development or establishment of protocols had, at the time of writing this paper, been archived or recorded. In some instances, anecdotal information was sought directly from services providers to supplement information about the protocols. In other contexts, ACSSA was able to obtain reports, publications, or rationale papers that helped to explain how the protocols came to life. Common to almost all states or territories, however, was how little was known about the operation of the various protocols. While some service providers emphasised the organic nature of the documents, or the extent to which the protocols tended to remain "dynamic", few of the existing protocols had been subjected to more formal evaluation.

Greater attention is then given to the development of protocols in both Melbourne (Victoria) and Townsville (Queensland) largely because they are both well documented, but also because they represent, respectively, one of the earliest and one of the most recently developed protocols in this area.

While this paper focuses primarily on health responses to sexual assault, the role of police and the legal system is often particularised in the protocols given the potential impact that forensic evidence might have on the success or otherwise of criminal prosecutions.¹⁰ Research has continued to show how the presence of injuries or other forensic evidence can impact significantly on jury decision-making or in supporting victim-complainants' accounts in court (Bargen and Fishwick 1995; Heenan and McKelvie 1996; Clarke 2002). To this end, many of the protocols attempt to balance the counselling, health care and support needs of victims with the requirements of police investigations.

However, for the purposes of this paper, only limited attention will be given to the police role or the legal aspects of individual protocols; the intention of this work is to scope, nationally, the range of current medical and health care responses being provided to victims of sexual assault. The focus on health responses also acknowledges the vast numbers of victims who ultimately decide against reporting to police, but who are nonetheless faced with imperatives around their medical and longer-term health needs. The immediate concerns that often follow a recent assault, such as the risk of pregnancy and sexually transmitted infection, possible injuries, and the levels of shock and distress, are a priority for many victims regardless of whether or not they opt to pursue a legal response.

The next section outlines some of the key influences on the development of interagency protocols: health policy, and in particular women's health policy, guides the provision and operation of major health care service responses to victims of sexual assault; police services, in their role as gate-keepers to the criminal justice system, are also important players in the development of guidelines or protocols directing responses to sexual assault; and, importantly, the experiences and perspectives of victim/survivors, often related through service providers, have not only informed the development of coordinated service response models but provided a measure against which practice can, and ought, be critically assessed. The development of the national standards of practice has also set an important benchmark for the delivery of consistent, professional, and high quality service responses to victims of sexual violence. These will briefly be considered in turn before outlining the details of individual protocols in the next section.

The influence of health policy

Health policy development for women in Australia is mainly referenced against the principles of the National Women's Health Policy (NWHP), established in 1985, which was said to have "signalled the beginning of joint State and Federal program funding initiatives" (Dean, Hardiman and Draper 1998). The goal of the NWHP was: "to improve the health and wellbeing of all women in Australia, with a focus on those most at risk, and to encourage the health system to be more responsive to the needs of women". As one of its seven priority health issues, the policy nominates violence against women specifically:

"Violence against women - a need for preventative strategies was identified which addresses the conditions underlying women's vulnerability to physical and sexual violence. Support services (including economic support) for survivors and their children and community education programs were highlighted as important requirements in this area." (Commonwealth Department of Community Services and Health 1989)

State health departments reference the NWHP as an important guide for the development of local policy. For example, New South Wales Health (2002: 4, 14- 15) draws on this priority area in its Women's Health Outcomes Framework, nominating violence as one of five priority areas in the social determinants of women's health outcomes. The equivalent in Queensland states its "Women's Health Policy was developed to complement the National Women's Health Policy" while taking into account, "the state's decentralised population, geographical isolation and related difficulties of health access" (Queensland Health 1993: 5). In Victoria, the Women's Health and Wellbeing Strategy notes that the NWHP "implementation was instrumental in building on the established service system in Victoria" (DHS 2002: 7). Ultimately, it is state government health policy that provides the basic framework through which health service providers, including sexual assault services, are able to structure their approach to service delivery.

The influence of police

Although not a focus of this review, police remain one of the principal points of entry for victims who seek a criminal justice response, and therefore feature significantly in terms of the design and application of some of the inter-agency protocols reviewed here.

Increasingly throughout the 1980s, police operations and practices came under scrutiny in response to suggestions that police attitudes towards rape victims could largely explain the continued low levels of reporting (Freckelton 1988; Nixon 1992). High levels of disbelief, insensitive questioning and a failure to ensure victims received appropriate medical care and counselling support gave rise to immediate calls for specialised training and education for police members (Orr 1997). In Victoria, it prompted the adoption of a Police Code of Practice For Sexual Assault Cases, the first of its kind in Australia to co-ordinate a timely, sensitive and effective response from police, counsellors and forensic medical officers to victims of recent assaults that aimed to increase the confidence of sexual assault victims and the public in the police management of sexual assault cases (Heenan and Ross 1995).

Despite some important changes being instituted by police forces across Australia, the recent report of the Western Australian Ombudsman, An Investigation into the Police Response to Assault in the Family Home (2003), suggested that the different levels of awareness and personal prejudice carried by individual officers in handling reports of violence against women, continued to result in women receiving less than adequate responses. Examples included in the report referred to occasions of active bias by police against a woman reporting assault (2003: 10), apparent dismissal or minimisation of another report (2003: 14), and in another case it was suggested police employed an air of tedium when dealing with a victim (2003: 14).

A worker at a Women's Refuge (2003: 14) confirmed how inconsistent approaches left workers feeling less than confident in knowing how victims would be treated:

"It depends on who you've got . . . some of the guys are excellent and do their job beautifully, and you couldn't fault them. But there are others who think it's a pain in the side, it's a nuisance, it's a disturbance, let's get rid of it and move on . . . So it depends on who you're working with . . . Some of them follow the letter of the law and others don't."

When police members in remote areas are known to be less than sympathetic to victims, the impact on communities is profound. It is, nonetheless, encouraging that the same document also reports specific examples of appropriate responses to family violence, particularly by individual Domestic Violence Liaison Officers in the Western Australian Police Service (WAPS). Some of those stationed in remote regions also dealt sensitively and appropriately with issues around diversity and distance as part of their regular policing duties, rather than see them as barriers to "good police practice" (2003: 38). At the conclusion of her report, the Western Australian Ombudsman's strong recommendation is for the police response to be "uniformly regulated via a Minimum Standards Protocol approach" (2003: 47).

While it is still the case that police members maintain significant control over the steps that are taken following a report of sexual assault, in general terms, there appear to have been significant improvements in the police handling of sexual assault (VLRC 2003). This is particularly the case for those sections of police that have developed a specialised role in responding to reports of sexual offences. Nonetheless, there are studies that continue to attest to problems with the detectives in charge of investigating sexual offences.

According to Jan Jordan's (2004) study of police decision-making in New Zealand, investigating police are sometimes basing their charging decisions on inappropriate judgements about the victim's credibility before having conducted a thorough investigation of the allegations. These kinds of attitudes and practices were also evident amongst the discussions recently held with Victorian detectives (VLRC 2004), a number of whom suggested disproportionately high numbers of false reports amongst those claiming to be the victims of recent assaults. The extent to which these kinds of attitudes work to undermine and subvert both the spirit and the intention of existing health care protocols, however, remains unclear.

The influence of victim/survivor perspectives

The urgent call to governments by women's services to provide for an adequate response to sexual assault was principally mobilised through the testimonies of victims who repeatedly described insensitive and inappropriate treatment at the hands of police and forensic examiners. Liz Orr (1997) and Moira Carmody (1992)¹¹ have each traced the history of feminist service development and the successes of the women's movement in securing both resources and commitments from State governments for fundamental change to the traditional medico-legal response to sexual violence. The emphasis became one of services (including police) providing respectful care and support, informing victims about their legal and medical options, while naming the assault unambiguously as a crime (Carmody 1992; Edwards 1995; Orr 1997; Cook, David and Grant 1999).

The challenge has been to develop and maintain protocols with key agencies that observe these principles, whilst allowing victims to maintain control over decision-making processes with respect to their counselling, legal and health care options.

As previously discussed, in building on victim/survivor's testimonies about what constituted effective intervention, feminist services worked to develop models that were essentially "rights based". The challenge has been to develop and maintain protocols with key agencies that observe these principles, whilst allowing victims to maintain control over decision-making processes with respect to their counselling, legal and health care options.

Influence of national standards of practice

The production of the National Standards of Practice Manual for Services Against Sexual Violence in 1998 (hereafter referred to as the "National Standards"), developed in consultation with over 80 services throughout the country, was a milestone in "represent[ing] the first Australian effort to document the nature of the professional response to which women, children and men are entitled following sexual violence" (Dean, Hardiman and Draper 1998: i). While the Manual is primarily geared to establishing "good practice" amongst service providers who work directly with women in counselling contexts, its purpose is to provide services, both specialist and generalist, with the tools to work sensitively with victims of sexual assault in any context.

Specifically, the Manual nominates standards of practice that cover issues such as: access and equity, direct service to individual adults and children and to groups, community education and professional training, planning and evaluation; the need for services to remain transparent and accountable; and the obligation of agencies to work towards structural reform or social change in the wider community's treatment and awareness of sexual violence. Further, the Manual refers to the need for formal protocols between sexual assault services and police, and separately, between medical, including forensic, services.

States and Territories: Interagency sexual assault protocols

Interagency sexual assault protocols

This section provides an overview of some of the protocols that guide state and territory health care and service responses to victims of sexual assault. It is by no means a definitive record of all of the documents, agreements or inter-agency guidelines that may exist between services around the country. However, it does offer some useful guidance for distinguishing the various formal approaches that have been designed and introduced to govern medical and health care responses in various contexts. Under-represented in this overview is an appreciation of the less formal agreements that exist, and the variety of other relationships that have been established between community services and health care providers with more marginalised groups and communities, but that remain unrecorded or unpublished.

The following table of interagency sexual assault protocols is supplemented with commentaries provided by services to ACSSA as part of its review of rural and regional responses to sexual assault (See Briefing Paper 3, Responding to sexual assault in rural communities, by Neame and Heenan 2004). A sample of services in both large regional settings and in smaller remote or isolated regions of Australia were asked to reflect on the particular challenges they faced in terms of being able to offer victim/survivors the services set out in interagency protocols designed for state wide application (Neame and Heenan 2004). The author of this review spoke further with workers in other service contexts to gain a wider appreciation of how different state and territory protocols worked in practice.

The table is divided according to the formal protocols that currently operate in individual states and territories, and are designed to identify areas of common ground. The documentation gives attention to whether specific reference is made to both sexual assault and family and domestic violence, the extent to which the protocols differ for disclosures in relation to recent or past assaults, and the influence that access and equity issues, such as cultural and ability-based barriers including language and the use of interpreters, may have had on the content of protocols. These issues are highlighted in more detail in the commentary following the relevant table sections, rather than in the tables themselves.

The table itself specifies: the name of the protocol or document; year of introduction and whether any subsequent evaluation or review; the agencies who are party to the protocol; characteristics of victim/survivors for whom the protocol guides service (such as age, gender); training nominated for workers, or for implementation or induction, cross-agency awareness, or community education purposes; and specific approach governing the delivery and approach to forensic/ acute care following recent sexual assault.

The level of detail presented in the final column has been included to highlight the variation in how forensic evidence or samples are collected and maintained. These are important differences given that they tend to circumscribe the options available to victims of recent sexual assaults, especially with regard to making a police report. For example, in Victoria, a forensic examination will only be undertaken where the victim has indicated her willingness to make a formal statement to police. In South Australia, a forensic examination will be offered and the samples properly collected and stored, for up to six months while the victim/survivor decides whether to go ahead with a police report. In some remote areas, forensic samples cannot be maintained at all unless there is lockable refrigeration on site. To this end, we detail the scope of the general practice in each state and territory.

Discusssion

In sections one and two of this paper, we explored the historical development of protocols in Australia and outlined the details of inter-agency protocols as they currently exist. This final section is in two major parts.

First, we examine some of the common themes that have arisen out of this snapshot view of health sector protocols and ask how the protocols remain relevant to the work of health, support, and legal agencies, and what might be done to improve their effectiveness?

In the second part we analyse recent Australian and international research that examines the profound impact of sexual assault on the individual lives of (mostly) women, on families, and on communities and the significance of these studies in considering any future re-design of inter-agency protocols that respond to victims' longe- term health care needs.

Effectiveness of protocols

The agency perspective

While some of the protocols, at least in principle, begin to address the concerns of victim advocates as well as take into account the issues raised by research over the past three decades, there are a number of limitations, at an agency level, that effect their implementation. A significant finding of this paper is the variation in understanding, within any particular sector, of the applicability of protocols. Three major city-based services suggested that their protocols tended to direct the service-response provided by agencies outside of major city areas and were not in fact, for varying reasons, applied directly within their own services.

The extent to which the inter-agency protocols were known about and/or adequately applied across health, sexual assault service-providers and legal agencies was certainly uneven according to staff at several sexual assault support services. In general, senior staff across most of the key organisations appeared to have some knowledge and understanding of the protocols they operated under (and were signatories to), although there were occasions when individuals were clearly unsure of the status or existence of claimed to have no knowledge at all. On other occasions, sexual assault workers suggested that agencies that were unclear about the status of interagency protocols, sometimes gave deference to the manuals and procedures that more broadly governed the service response of the organisation. For example, hospital emergency department workers might refer to "in-house" hospital procedures, while police might direct attention to their operating procedures manuals as over-riding the status of any other type of document.

Another factor impacting on the effectiveness of protocols is the extent to which collaboration between agencies has genuinely been achieved. Integrated health service delivery models, like those found in Sydney, Perth, Hobart and Adelaide, have been most effective in streamlining the extent to which victim/survivors will be obliged to repeat the details of their abuse. These integrated health models offer forensic and counselling services on the same premises, either attached to, or close by hospitals where emergency departments can provide medical treatment for serious injury. Pregnancy and STI testing and the provision of prevention and amelioration measures such as emergency contraception counselling services, follow-up medical care, and short-term counselling for acute or recent sexual assault, are all provided in an environment of relative security and comfort.

Another advantage of such an integrated model is the opportunity for increasing specialisation and professional development in sexual assault service provision afforded to medical personnel. The Melbourne metropolitan CASA model meets this concern to a certain extent. Hospital services are located close-by where all medical and follow-up medical health care can be accommodated. Counselling is provided in a discrete non-medicalised environment, similar to the Sydney, Perth, Hobart and Adelaide services. Brisbane, Townsville and Gold Coast services in Queensland also provide similar services.

However, a high degree of collaboration amongst colleagues from different disciplines (for example nurses, doctors and counsellors within services) is a prerequisite for the effective implementation of this integrated kind of model. Genuine efforts to work collaboratively is not always possible. For example, emergency department personnel at some of the hospitals considered do not share this type of close collegial relationship.

Furthermore, the advantages of the integrated model are not available outside major metropolitan centres, and protocols designed with this model in mind may not always be appropriate to regional and remote services. For example, the requirement in Victoria to provide medical and forensic services within two hours of a report being made, for instance, is no simple matter when the only means of access to services for the victim is via plane or boat.

As a worker from one sexual assault service noted:

"Access to forensic examinations is difficult. A victim might travel a couple of hours to a police station, from which they may be taken to another to be interviewed by CIB (again a couple of hours drive), and from there might have to be driven another couple of hours to be examined by a Doctor, back to the station for a second time, then back home."¹⁶

Many island communities all around Australia have no specialised on-site services for responding to sexual assault. Even where there are a number of services that might separately be able to provide a health care response to sexual assault, in more isolated regions, they may not have established the mechanisms through which they can better co-ordinate their responses. This is of course also true in some major city areas, although not for the same reasons. Even where protocols are able to be applied, and can be adapted to localised situations, there is often an issue of accountability. Few of the inter-agency protocols had been subject to evaluation or included formal mechanisms for monitoring compliance.

It must also be acknowledged, however, that the existing inter-agency protocols may be fundamentally inconsistent with the kind of approach that might be more culturally appropriate to meet the needs of particular communities. At least two Indigenous communities, according to the workers in these regions, have begun to consolidate their own programs for dealing with violence against women. These programs bear philosophical similarities to the major city protocols but operate in distinctively community-based ways with specific reference to the skills of community elders rather than be accountable to the government departments.

Flexibility is also important in those regions where forensically-trained medical staff must substitute for doctors where none are available, or where doctoring is variable due to high turnover rates. While the allocation of sufficient resources to training and recruitment could conceivably address the shortfall of trained specialists, the need to more permanently place specialists outside of the major cities areas is well recognised. Interest in the training of nurses to provide forensic services is increasing in Australia. Recommendation 7(a) of the report by the Department of Health and Human Services (DHHS) in Tasmania, titled Justice Matters, is "considering adopting or adapting the American model of Sexual Assault Nurse Examiners (SANE) in sexual assault cases" (Davies 2002: 10).

A recent report from the United Kingdom, Forensic Nursing: An Option for Improving Responses to Reported Rape and Sexual Assault, concludes that "forensic nursing can provide a cost-effective option to: address delays in the provision of forensic examinations; increase the availability of female forensic examiners; and also has the potential to enhance professional standards" (Regan et al. 2004:1). Nurses have previously been able to access specialist forensic training in Australia. For example, the doctors employed by the rape and sexual assault service in South Australia, Yarrow Place, currently deliver training in forensics where some of the participants in the course have been nurses (some from remote areas). The difference with SANE training is that it is a program developed specifically for professional nurses.¹⁷ SANE nursing certainly provides one option for addressing some of the issues arising with the paucity of forensic expertise in regional areas.

In discussing the effectiveness of the inter-agency protocols, a majority of workers were nonetheless enthusiastic or hopeful about the protocols improving the working relationships across agency groups. This is perhaps best demonstrated by the continued goodwill between parties to existing protocols, and their willingness to continue developing practices according to perceived needs of victim/survivors and of the system. Nonetheless, it is important for agencies to have access to "evidence-based" understandings of how the protocols are working in practice if the inter-agency protocols are to remain relevant to the needs of individual victims.

The victim/survivor perspective

How successful the individual protocols may have been for ameliorating the difficulties originally identified by victim survivors has not been comprehensively assessed. Some information can be gleaned from surveys (Heenan and Ross 1995; D'Arcy 1999), or through listening to the testimonies of victims about their contact with services following disclosure (see for instance, Keally and Killey 1996; Kripps 1996).

Nonetheless, it is important for agencies to have access to "evidence-based" understandings of how the protocols are working in practice if the inter-agency protocols are to remain relevant to the needs of individual victims.

The Victorian evaluation of the Police Code of Practice was certainly helpful for being able to identify problems of non-compliance early, and ensuring that the Code did not lose momentum in shaping more workable relationships across the key agencies involved (Heenan and Ross 1995). It also meant that the principles of prioritising the victims needs (medical, emotional and legal) were further endorsed. Other protocols, such as the Queensland Guidelines, have built in the requirement and the resources for ongoing monitoring. There is the potential in this context for greater attention to be given to how relevant and effective the guidelines continue to prove, and to monitor any changes in practice, service use, and victim satisfaction.

Sexual assault and health: International research and policy directions

The health effects of sexual violence have only recently emerged as an area of concern in public policy terms. It is now clear that violence against women is a primary indicator of women's health outcomes across the life-span. Here we look briefly at international and Australian research into what is fast becoming a compelling evidence base that reliably links women's ill-health with the incidence and prevalence of domestic violence and sexual assault. We consider at the implications of this overview for ongoing development and practice of agency responses to sexual assault in the health sector, and for specific sexual assault protocol development and implementation.

Public/community health and sexual violence

The effects of sexual assault and other forms of violence take a significant toll on the health of entire communities. In Australia this was reliably illustrated in the recently-published report by the Victorian Health Promotion Foundation (hereafter VicHealth) titled "The health costs of violence: Measuring the burden of disease caused by intimate partner violence" (VicHealth 2004). The report confirms what women survivors have been telling us for decades, that sexual and physical violence has an enduring impact on their health.

Indeed, the study found that: "Intimate partner violence is responsible for more ill-health and premature death in Victorian women under the age of 45 than any other of the well-known risk factors, including high blood pressure, obesity and smoking" (VicHealth 2004: 8).

Internationally, the World Health Organisation (WHO) has held a series of conferences looking at public health over the past three decades and now recognises the impacts of violence against women as one of the most significant health issues facing world communities. Research considered by World Health Organisation and the Global Forum for Health Research have identified the health burden of sexual assault and violence against women as greater than the combined effects of malaria and traffic accidents (WHO 1997, vol. 4).

Moreover, there have been moves in recent decades to position health with the language of human rights. In 1978 the International Conference on Primary Health Care, meeting in Alma-Ata made the following Declaration (in part):

"The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right" (Declaration of Alma-Ata International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978).¹⁸

The Ottawa Charter for Health Promotion in 1986 also recognised that public health policy is central to providing the conditions in which communities can build flexible and sustainable partnerships aimed at addressing health concerns. The Charter further notes that this requires "full and continuous access to information, learning opportunities for health, as well as funding support" (Ottawa Charter for Health Promotion 1986: Strengthen Community Action).

The collective findings of this research confirm that sexual violence is preventable and generates serious and ongoing consequences for the health and wellbeing of individual victim/survivors, has a calculable cost to the whole community both in financial terms and in terms of the health of communities, and requires a proactive, determined focus on the part of government and community in order to reduce and ultimately eliminate it. The role that health sector protocols can play in this context cannot be underestimated in terms of ensuring the health needs of victim/survivors are met, throughout their lives.

We know that we have the capacity to respond as a community to serious and preventable health problems. An example is the enduring cultural change brought about by a concerted and sustained effort to address the alarming trauma and damage caused by traffic accidents. It is no longer culturally acceptable to drive under the influence of alcohol and many publicly funded campaigns aimed at reducing injury and death from speeding, driving while fatigued, and dangerous driving, have reduced the incidence of traffic accidents dramatically since campaigning commenced in earnest in the 1970s.

Given what research now shows us about the health burden of sexual and other forms of violence, it is not unrealistic to expect that we would respond with the same dedicated efforts to reducing the causes or contributors to the trauma and damage that results from violence. Campaigns aimed at primary prevention will require major policy commitments from all levels of government. On the other hand, health sector protocols may assist by providing earlier points of intervention through which victims may access support and more readily link their health status with their experiences of violence.

In 1997 the World Health Organisation declared violence against women and girls a major health and human rights issue (WHO 1997, vol. 4). International policy directions in addressing the health needs of those who have experienced sexual violence are reflected in Australian federal and state health policies as discussed in section two. In theory at least, Australian policy responses to the health needs of victim/survivors of sexual violence align well with international policy directions. This is also true in the specific instance of health sector protocols as exemplified in the major sexual assault services around the country. It could be said that they represent models of good practice. There are, however, a range of factors that continue to influence the practical application of these umbrella policies and these are explored further below.

Limiting factors on health responses

Specialist sexual assault services, including women's health sector agencies, provide responses that address the core concerns of victim/survivor centred practice within a feminist framework. Individuals in other health services, as well as individual police members, are certainly striving to improve their practice in terms of responding appropriately to the needs of victim/survivors of sexual assault. Unfortunately, however, the overwhelming experience of women accessing health services for issues arising from sexual violence is that the health sector is generally ill-prepared and under-informed about the health issues victim/survivors face. Some services may in fact respond in ways that further compounds the effects of violence on victims by responses that are more informed by prejudice, than by understanding the social and situational contexts in which most sexual assault occurs.

Several Australian studies have documented some of the factors restricting or preventing appropriate responses by the health sector and other services, despite best practice policy and protocols. Surveys conducted as part of the Australian Longitudinal Study on Women's Health, known widely as Women's Health Australia, found that in response to questions about the effectiveness of help sought in instances of violence only "a relatively small proportion of the women were satisfied with the help they received when they asked for it" (Parker 2001:191). While the researchers are here referring to women's experiences of domestic violence broadly, they nonetheless surmise that "the ability of health and police services to respond appropriately to women who have experienced violence and abuse needs improvement". Parker goes on to note that there are possibilities for much improved outcomes for women experiencing violence with a "more proactive approach from health, social and police services" (2001: 191).

A major factor limiting the capacity of the health system to respond is the nonrecognition of sexual violence as a health issue, and the lack of sufficient training and skills development to address health professionals' awareness and capacity to respond appropriately. Research by Mazza, Dennerstein and Ryan (1996: 15) found that in a population of women¹⁹ attending their general practitioner, "importantly, about three-quarters of respondents [to the survey] had never been asked by their doctors about domestic violence or childhood physical abuse". In the case of both adult and child sexual assault, 53 per cent of survey respondents had not disclosed to their doctor because they "had never found it relevant to the consultation" and for 27 per cent their doctor had never asked (1996: 15). Overall, among the 15 general practices in Mazza's study sexual violence was grossly under-detected by doctors. As Mazza notes, not only are women not making the connection between their symptoms and sexual violence, neither are their doctors. She goes on to suggest that where the potential for abuse is overlooked in diagnosis, "treatment is likely to be inappropriate and potentially harmful" (Mazza et al. 1996: 17).

Others have commented on the paucity of medical professional recognition of the issue of sexual violence. Jenny Barry (1992: 48) observes that although "the community has been grappling with adult sexual assault for a long time . . . the medical profession has been notably silent in this area". In recognition of the harmful impacts of under-detection or misdiagnosis of the health effects of sexual violence, the Australian Health Minister's Advisory Council (AHMAC) undertook to address the lack of awareness and skills among medical professionals and commissioned the interactive educational module, Medical Responses to Adults Who Have Experienced Sexual Assault (Olle 2004). This module will be available to doctors across Australia in 2004.

The potential to redress this failure to identify and respond to sexual violence is perhaps one of the most heartening aspects of work in this field. According to the World Health Organisation (WHO 1997, vol. 9: 2):

"Studies show that with proper training and protocols, health care workers can become more sensitive to issues of violence against women. One example is the emergency department of the Medical College of Pennsylvania, Philadelphia, PA, United States. After introducing training and protocols on violence, the proportion of female trauma patients found to be battered increased fivefold, from 6 per cent to 30 per cent."

The impact of the lack of specialised knowledge and insight outside of sexual assault services is to limit the capacity of the whole health system to respond appropriately. On the other hand, it is hard to overstate the potential for vastly improved health outcomes across the spectrum both in terms of responding to individual victims and for the whole community.

A range of other factors also influence the practical delivery of appropriate health responses. Most notably these include where services are limited by: size or resource levels; geographic proximity to other (partner or specialist) service providers; adequate skills and training in relevant and appropriate service responses; and where the requisite will to respond appropriately does not prevail or cannot be monitored and adequately supervised.

A major factor limiting the capacity of the health system to respond is the non-recognition of sexual violence as a health issue, and the lack of sufficient training and skills development to address health professionals' awareness and capacity to respond appropriately.

Protocols are clearly one mechanism for reducing the extent to which individual factors can have a disproportionate influence on inter-agency responses. However, one significant and recurring theme to emerge in discussions with various workers was the extent to which the community profile of issues like sexual assault and intimate partner violence can sometimes be dependent on the attitudes and personalities of people living and working in the community itself (OSW 1998; Western Australian Ombudsman 2003; Neame and Heenan 2004). This factor may have the potential to drive efficient, appropriate and transformative service provision and greater recognition of the extent and effects of sexual violence on the community, or it may work to undermine effective responses. The particular values, insights and skills of workers can certainly influence the nature and approach to delivering services to victims of sexual assault and domestic violence in the local community.

Workers in some of the remote and very remote regions were careful to impress their awareness of the influence they themselves could have on a small and isolated community. One worker spoke of recently having left a position and speculated that it was time to move on because she felt it was possible that her personality and her style of response and interaction may, after some years in the area, have constricted community growth in directions she may not have recognised. The case study of the development of guidelines in Townsville, in Queensland, is further testament to the idea of progress being firmly linked to the commitment and energy of a small number of very determined people.

Finally, long-term health care is not specifically addressed in many of the protocols reviewed here. This is hardly surprising given that so much of the early policy focus was on fundamentally improving the response that victims of recent assaults encountered at the point of crisis care. However, the contemporary climate also inhibits a longer term focus. Sexual assault services are typically funded to provide short-to-medium term counselling. Hospitals, in this context, are therefore responding to mostly acute and shorter-term medical issues. Non-government services such as Women's Health Centres do provide a greater degree of longer-term support to women survivors through group programs and individual counselling, community development and public advocacy. However, this generally falls far short of assessing the kinds of life-span health outcomes that are increasingly being linked to women's long term experiences of intimate partner and family violence. This will require vastly new ways of responding to the issues.

The cost of sexual violence and health responses

In terms of cost to the community, research conducted by the World Health Organisation (WHO 1997, vol. 8) around sexual assault indicates that:

"The costs to society of violence against women are tremendous, in terms of health care alone. A proportion of these costs are for treating serious physical injury. A substantial amount is also spent on psychological problems including managing anxieties and symptoms which happier, more confident, women may be able to tolerate, ignore or shrug off."

They also cite costs in terms of systemic responses such as investigation and legal costs across the spectrum, rehabilitative programs for perpetrators, medical and social service costs (including child protection services), and costs associated with reduced productivity and employment.

The particular values, insights and skills of workers can certainly influence the nature and approach to delivering services to victims of sexual assault and domestic violence in the local community.

The research that informs the reports written by Lesley Laing and Natasha Bobic (2002), Christina Lee (2001), and Vichealth (2004), also points to the false economy in under-funding specialist services to victim/survivors of sexual violence especially given that these services are also the prime motivators in community education, and in driving discourse about appropriate support responses and prevention. In their literature review of studies into the costs of FDV, Laing and Bobic (2002: 26) note:

"Several of the studies addressed the question of the proportion of costs of domestic violence borne by different parties. The Tasmanian and Northern Territory studies found that governments bear the largest proportion of direct costs and that women bear the largest proportion of indirect costs. This, however, may be a consequence of the similar methodologies applied in these two studies. The approach of the Brisbane City Council study (Henderson 2000a) is interesting in this respect, in that the point is made that the direct costs of services provided by government are in fact indirect costs to the business sector, incurred through taxation. The Tasmanian and Northern Territory studies make a similar point - that is, that the whole community incurs high costs due to domestic violence - by denoting the share of costs paid by governments as 'community/government'."

In any event it is clear that there are significant costs to all sectors of the community as a result of sexual and other forms of violence. Whoever bears the ultimate cost, the imposition of the costs is largely preventable. However prevention relies on the dedication of adequate resources and a commitment in policy terms to ensuring the stability and permanence of services working on prevention, without undermining the capacity of organisations to provide direct service to women, children and men who have already experienced sexual violence.

Against the Odds (OSW 1998), reports that in the instance of family and domestic violence, "it needs to be acknowledged that existing domestic violence services are typically stretched to their limits, and that demand for assistance far exceeds the present service-capacity of most agencies and organisations" (1998: 94). Kate Baxter further addresses the issue of resourcing in her paper on rural services, titled Starting from Scratch (in Breckenridge and Carmody 1992: 177-179). To this extent, studies confirm that a growing awareness of the prevalence, seriousness and persistence of violence against women, along with the health and economic costs to both individuals and the community, is almost directly correlating with an ever-diminishing pool of resources. A consistent response from across the sector of sexual assault services is that resourcing is inadequate to the task of meeting the growing demand for direct service - that is, one to one counselling and advocacy, and the demands of community education.²⁰

Concluding remarks

Health sector and interagency protocols aimed at providing consistent, professional and appropriate responses to sexual assault are relatively new features of the Australian health policy and practice landscape. In the afterglow of highly successful feminist lobbying throughout the 1980s, aimed at improving systems responses to women who were victims of sexual offences, services were keenly committed to establishing working agreements across agencies that would allow for victim's emotional, medical and legal support needs to be consistently met.

Lessons from overseas studies helped to shape the direction in which services in Australia would develop. In the late 1970s Ann Burgess and Lynda Holmstrom (1974a, 1974b) exposed the science of "rape trauma" that identified how immediate crisis intervention was more effective at dealing with the damaging effects of sexual violence. "Good practice" was seen to lie in agencies being committed to prioritising the emotional support and health care needs of victims regardless of whether s/he opted for police or legal intervention. National standards were formulated for workers in both specialist sexual assault services and other more generic health services that would consolidate a consistent service response to victims that was grounded first and foremost in practice, and where the rights of victims to determine any "next steps" were both supported and respected.

The mechanisms developed over the past two decades to guide inter-agency responses to sexual assault have attempted to coordinate service responses that manage what have historically been competing interests among, on the one hand, police and forensic doctors eager to maximise the potential for successful prosecutions and, on the other, counsellors advocating on behalf of victims to ensure their counselling and support needs are properly met. The influence of state and federal health policy in providing a backdrop against which protocols could be shaped was undeniably significant during the mid 1980s, alongside successful lobbying for improvements to police practices and calls for standardising good practice, nationally, across service agencies.

This ACSSA Issues paper has provided a snap-shot view for services to look across state and territory borders to assess the kinds of protocols that currently exist to guide inter-agency responses to the health care needs of victims. The table was designed to illustrate graphically the particular mechanisms that operate in each jurisdiction, and included: the parties to the protocol, the point at which the protocol was first introduced, the circumstances under which each protocol is activated, requirements for training by services and individuals who are signatories to the protocol, and the nature of forensic or medical care provided.

In the relatively short life of the existing protocols in Australia, the emphasis has remained squarely on the need for early intervention to mitigate the potentially long-term harm caused to victims of sexual assault who are left unsupported or disbelieved. This is now reflected in the vast majority of protocols with forensic and emergency medical responses clearly positioned as central within each document.

However, maintaining acute or crisis care responses as the optimum focus for responding to the health care needs of victims has resulted in less attention being given to the potential for longer-term or life-span health effects of sexual violence for individuals. Where specialist sexual assault services generally maintain services for victim/survivors regardless of the time elapsed since the assault, protocols within the mainstream health sector do not explicitly acknowledge the need for responses over time or over life-spans. For victim/survivors for whom no initial acute response was possible or desirable, or for those for whom no response was historically available, the health sector is only now beginning to recognise the possibility of providing responses in the longer term.

The approach taken by Yarrow Place, the rape and sexual assault service in South Australia, is a case in point. The service is designed to ensure that women's forensic and longer-term health care needs can adequately be met on site, regardless of when the assault occurred. Hence, women victims, who may months or even years after the assault endeavour to seek medical support, especially in terms of gynecological care, can continue to access the service at Yarrow Place and be assured of seeing a doctor who is both sensitive and aware of the effects of sexual violence.

Overall, this paper has demonstrated the importance of states and territories finding ways of evaluating their existing protocols that can allow for information-sharing across borders about how to progress or re-develop approaches to service-delivery in the light of new developments in the field. Moreover, following the emergence of research that reveals the compelling association between the health impacts of sexual assault and other forms of intimate and familial violence, greater attention must now be given to developing training for general practitioners and other workers within the health care system to raise their awareness and capacities in being able to identify and respond to health issues that can emerge as a result of being exposed to experiences of violence. It is here that the greatest scope lies for further developing health sector protocols that can better guide responses to both recent and past disclosures of sexual assault, in a bid to improve on the health outcomes for the vast majority of victim/survivors.

The way is open to build on the important lessons learned in the development of systemic acute responses and to more fully integrate the whole of life experience of individuals who experience sexual and physical violence. The health and wellbeing of victims, and the community at large, depends on it.

References

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