When and how to safely ask young people about sexual harm

The prevalence of sexual harm in Aotearoa is undeniably alarming. Accurate data are hard to access, but the statistics we do have from the latest New Zealand Crime and Victims Survey are horrifying: 24 per cent of adults have experienced sexual harm at some point in their lives, with females being at three times greater risk than males. Most victims are in the 15 to 24-year-old age group.

The survey also tells us that very few victims ever discuss their experience with anyone – approximately 6 per cent report to the police, with slightly more talking to a trusted support person or family member.

Some choose to talk to a health provider. When they do, this appears to be a positive thing – creating a more trusting therapeutic relationship between provider and patient, building greater clinician understanding of the patient and their health context, and enabling management of some of the sequelae of trauma.

In view of that, should we be routinely asking young people about sexual harm? If so, who should we ask, how should we ask, and how should we respond if we get a positive answer?

Having this knowledge helps me understand my patient’s journey, and to explore some of the factors that might be contributing to their health and wellbeing

This is a difficult question to answer as it’s definitely not a one-size-fits-all approach. In general, I think routinely asking (as opposed to only asking if you have a suspected case) is a good thing, providing the following criteria are met:

• it is safe to ask – we should only ask someone when they are on their own (ie, no support person, parent, friend, partner or verbal child accompanying them)
• you know how to ask
• you have time to ask in a sensitive, empathetic manner, and you have time to listen to the response
• you know how to respond – there is no point asking about sexual harm if you don’t know what to do when a young person tells you this has happened to them.

It’s also important to be clear in your own head why you are asking. For me, having this knowledge helps me understand my patient’s journey, and to explore some of the factors that might be contributing to their health and wellbeing. Sometimes, it’s a “penny drop” moment, perhaps shedding some light on why my standard approach to managing their symptoms hasn’t worked. It also enables me to offer some specialised help and support, if needed, which may reduce the impact their trauma will have in the future.

However, I do take a cautious and thoughtful approach and choose my timing carefully – talking about historical experiences of trauma, especially when asked out of the blue, can be triggering, and there is the potential to do more harm than good.

If done well, routine enquiry, compared with case-based enquiry (ie, asking just when you have concerns), can also:

• normalise the subject matter and actively demonstrate to young people that this is a health issue, something we care about, and something we can help them with if they’d like
• demonstrate to patients that if this happens in the future, we are a safe place to come and disclose
• avoid patients feeling stereotyped as we are asking everyone, not just people who we think might be “victims”.

Current advice is that we should ask all female patients aged 16 and over, when it is appropriate to do so. The evidence for routinely asking all males isn’t as strong, but this doesn’t mean we shouldn’t ask, and I certainly do if I am supporting someone struggling with any mood issue, substance misuse or other mental health issue that could be related to pre-existing trauma.

We know young people are particularly at risk, so trying to incorporate questions around sexual harm into your HEEADSSS framework is a good idea.

Other groups that are especially vulnerable include:

• Māori and Pacific young people
• young people from the LGBTQIA+ communities
• people living with disabilities
• young people who are in environments where there is lot of alcohol or drug use (eg, students in tertiary institutions).

It is often easiest to ask about sexual harm when you are having a consultation where that topic “fits in” intuitively. This might be when you are doing a new patient appointment and gathering a lot of other information about the young person’s life, or when you are having a sexual health or contraception consultation.

However, routine enquiry can and should happen at any time that feels right; you just need to clearly signpost that you are going to ask so your patient has time to piece together and consider their response.

I preface any routine enquiry with an obvious statement about confidentiality. In my experience, if you don’t do this, almost no young person is going to disclose anything to you, let alone their history of sexual harm. The words I use are along the lines of:

“Everything we talk about today is confidential – that means your information will stay between you and me, and it isn’t shared with your parents or anybody else. I will also document it in your medical record so it’s there the next time I meet with you. The only time I might need to share your information with anyone else is if I am worried for your, or someone else’s, safety. If that happens, I will let you know before I speak with anyone else.”

In terms of signposting, I do this in a variety of ways, depending on the situation and the person I am with. I choose words such as:

“I’m going to ask you a few questions now that are very personal/sensitive and may feel hard to answer. I ask all my patients these questions. You don’t have to answer them, but if you do, it might help me understand what is going on and figure out how best to support you.”

A simple statement like this not only gives your patient time to formulate their response but also reassures them that you ask everyone, you haven’t singled them out, and that you are asking because you want to help them, not just because you want to know about their life.

With this age group, I don’t then launch straight into questions about sexual harm or past trauma as that can be very confronting, but I do start asking about sex and sexual experiences as they more naturally lead into the harder questions. When it comes to asking specifically about sexual harm, I use variations of the following questions, again depending on the age and stage of the person:

• Has anyone ever had sexual contact with you that you didn’t want to happen?
• Has anyone ever had sexual contact with you when you weren’t able to consent or say yes? For example, that might include if you were drunk, asleep or unwell.
• Has anyone ever taken or shared photos or video of you in a sexual situation without your consent, or made you watch pornography when you didn’t want to?

The reason for the specific questions (which can feel clunky until you are used to saying them) is that many young people won’t have framed what happened to them as “sexual harm” or “sexual assault”. Unless you specifically talk about sharing of images or someone having sex with them when they were drunk, they won’t necessarily bring it up, even though it has been a source of great distress for them.

It goes without saying that whatever your young patient discloses to you, it is your role to be supportive, non-judgemental and affirming. I usually express sympathy for what they have been through and thank them for sharing the information with me – it takes a lot of trust!

Your specific response will then depend on:

• what happened to them and when – you might need more information from them before engaging the right supports
• what they want to do – it is very important that victims or survivors are empowered to make choices about who is involved in the process and at what stage (eg, some may want to speak to the police, while others will be adamant they don’t want to – both responses are fine)
• what your health pathway tells you to do as this will vary slightly from region to region.

I try to encourage all young people who have experienced sexual harm to engage with a specialist agency. For medical care, advice and support, as well as forensic examinations if desired, Sexual Abuse Assessment and Treatment Services (SAATS) around the country are available 24/7. For crisis support or to access counselling, the agencies vary depending on where you are. These agencies are experienced in this field and can provide the wrap-around that often isn’t possible within the limitations of general practice.

For a list of local providers and supports, visit: medsac.org.nz/saats-help

Cathy Stephenson is a specialist GP at Mauri Ora, Student Health and Counselling, Victoria University of Wellington