Dr. Maeve Eogan:

I thank the Chairman and the committee for inviting me to speak today. I am a consultant obstetrician and gynaecologist at the Rotunda Hospital but have been invited before this committee in my capacity as medical director of the hospital's sexual assault treatment unit, SATU, as well as the national sexual assault treatment unit. As we know, sexual violence occurs in all cultures and countries, with a range of epidemiological studies recording a far higher prevalence than previously thought. There is no "typical victim"; there is no "typical scenario". In the Irish context, as summarised in the Sexual Abuse and Violence in Ireland, SAVI, report, of which there has been much discussion in recent weeks, more than four in ten or 42% of women have reported some form of sexual abuse or assault in their lifetime. The most serious form of abuse, penetrative abuse, was experienced by 10% of women.

We know that disclosure of sexual violence enables the patient to get access to the medical and psychological care that they need, as well as facilitating commencement of a judicial investigation if the person chooses to engage with the criminal justice system. Both national and international data, however, highlight that for a broad range of reasons including self-blame, shame, fear of judgment and lack of information, many people who experience sexual violence never tell anyone about it. Almost half of those who disclosed a history of sexual abuse or assault in the SAVI survey, for example, had never previously disclosed it to anyone. Notwithstanding that, if someone is going to disclose sexual violence, it is very important to facilitate them to do so as soon as possible after the incident. Doing so enables appropriate provision of care, as well as the collection of relevant forensic evidence, including DNA evidence. It is hoped that provision of early responsive care may reduce the short-term and long-term physical and psychological effects of sexual violence.

To respond to this need, this country has six sexual assault treatment units, SATUs, to provide care to men and women over the age of 14 years who disclose sexual violence. These are located in Dublin, Cork, Waterford, Mullingar, Galway and Letterkenny and they aim to provide responsive care 24 hours a day, seven days a week. In addition there is a service in Limerick which provides out-of-hours care only. Each SATU is staffed by clinical nurse and midwife specialists and doctors trained in sexual assault forensic examination. Since 2009, we have collated national data for key service activities within the SATU. In 2016 more than 700 men and women attended SATU services.

SATU staff work collaboratively with allied agencies, including An Garda Síochána, Forensic Science Ireland, Rape Crisis Centres and Rape Crisis Network Ireland, paediatric forensic medical services and the Office of the Director of Public Prosecutions who together form the sexual assault response services. This group has developed national guidelines and aims to provide responsive patient care as espoused by our mission, vision and working philosophy.

As with my presentation to the Citizens' Assembly earlier in 2017, I am not presenting anonymised cases to assist deliberation and discussion. While any cases we discuss would be anonymous to us, a survivor of sexual violence may recognise themselves in the scenario and in that context they may feel re-victimised. For this reason I offer a fact-based overview and I will address questions.

When a patient discloses a recent incident of sexual violence and wishes to receive care in this regard, they have three options, which are explained to the patient in detail, and informed consent is obtained. Option number one allows access to prompt and thorough investigation of the incident and is most frequently chosen. This involves the patient reporting the incident to An Garda Síochána, who brings them to a SATU. The patient receives comprehensive medical care, including preventative treatment for infectious diseases and emergency contraception, psychological and forensic care from the allied rape crisis centre. Injuries are documented and treated and appropriate intimate and non-intimate samples are taken.

If the person chooses not to engage with An Garda Síochána and not to report the incident, he or she can attend the SATU to avail of a health check. In that context the person can still receive medical care, including emergency contraception and infectious disease prophylaxis. He or she can also receive psychological care, but without reporting the incident to An Garda Síochána. If the person chooses this option and subsequently changes their mind, the opportunity to take time-sensitive forensic samples may have passed, which could compromise potential prosecution. Because of Children First guidelines this option is only available to those persons over the age of 18. Because the opportunity to take forensic samples may be lost when a person chooses to not report, in 2016 we introduced the option of storage of evidence. Again, this is for patients over 18 years of age who are undecided whether or not to report to An Garda Síochána. They receive a health check and medical in the SATU, forensic samples are taken and stored within the SATU for a period of up to one year. With this option patients will also receive emergency contraception.

It is clear from this summary of care options that regardless of which option the patient chooses in terms of reporting the incident, she will be offered emergency contraception, which is successful in preventing pregnancy in the majority of patients if provided within the appropriate timeframe. I have included a table in my written statement that highlights the efficacy of the available contraceptives with up to 99% of pregnancies being prevented when emergency contraception is given in a timely fashion.

All patients who attend SATUs are then offered a series of follow-up appointments, to provide ongoing support and to undertake sexually transmitted diseases, STI, screening, pregnancy testing and to meet any other needs as required. All of the women will have been offered emergency contraception and it is thus rare that we confirm a pregnancy at a follow-up visit, however up to one third of our patients do not attend for these reviews. The follow-up data, including on pregnancy, on some who attend SATU services is incomplete.

While pregnancy after rape is infrequently encountered in those who attend SATU services, the extrapolated rape-related pregnancy rate is 5%. This estimate results from a three year survey of over 4,000 women regarding the prevalence and incidence of rape and related physical and mental health outcomes. This study was published more than 20 years ago, but in broad terms the figure is consistent with recent data from Rape Crisis Network Ireland, which was presented at the Citizens' Assembly, and also consistent with data that Ms Noeline Blackwell will present today.

An individual’s pregnancy risk will, of course, be influenced by the time in the menstrual cycle at which the incident occurred as well as other variables. While it is reassuring that few pregnancies occur in the population who attend SATU services for care, women do become pregnant after sexual violence either because they did not disclose the incident and thus did not receive emergency contraception or because they received emergency contraception and it failed. Studies have identified that women who become pregnant after sexual violence may only present after the first trimester of pregnancy, during the second trimester. This limits options in terms of decision making with regard to continuing the pregnancy.

In 2015, 5% of women attending an Irish Rape Crisis Centre reported that they became pregnant as a result of rape. The majority went on to give birth and parent but other outcomes included miscarriage, stillbirth, adoption and fostering and termination of pregnancy. As the committee is aware, termination of pregnancy for a woman who is pregnant as a result of rape is currently only available in this country if there is a substantial risk to her life, including risk of suicide, which can only be averted by termination of pregnancy. Under-disclosure of sexual violence, however, is common so it is very likely that women who have become pregnant as a result of sexual violence in the State are represented in the population who travel for termination of pregnancy in another jurisdiction or in the population who access Mifepristone or Misoprostal online.

It must also be emphasised that it would not be appropriate to mandate that these women would be obliged to report the details and circumstances of this incident to An Garda Síochána or other regulatory third party if termination became available in this jurisdiction, prior to being approved for termination of pregnancy.

Finally, it is vital to remember that even in the context of intimate examination by trained personnel, there is no physical finding that conclusively demonstrates that unwanted sexual contact has occurred. Published and peer reviewed literature - of which there is much - shows that the presence and pattern of injuries sustained during a sexual assault can show considerable variation ranging from a complete absence of injuries, which is most frequently seen, to fatal injuries, which thankfully is very rare. There is a considerable evidence base confirming that genital injury is not an inevitable consequence of sexual assault and that lack of genital injury does not imply consent by the victim and does not imply lack of penetration by the assailant. Furthermore, the belief that absence of the hymen confirms that there has been penetration of the vagina is incorrect. Equally false is the suggestion that a normal or intact hymen means that penetration has not occurred. In support of this, for example, one paper reviewed examination findings in a group of pregnant adolescents and identified that despite definitive evidence of sexual contact having occurred - all these adolescents were pregnant - only 2 of 36 adolescents had genital changes that were diagnostic of penetrating trauma. From the physical perspective, therefore, there is no conclusive test that women who are pregnant after rape could or should be subjected to.

In summary, holistic, patient-focused services for women who have experienced sexual crime mean that pregnancy as a result of rape is infrequently encountered by those of us who work in SATU services. Therefore, in addition to the other health, forensic and societal benefits of reporting sexual crime, in terms of pregnancy prevention it is imperative that people are encouraged and enabled to disclose acutely in order that they can receive appropriate care including emergency contraception, which works very well.

With regard to access to termination of pregnancy on the grounds that the pregnancy was conceived through sexual violence, it is important to acknowledge that very many women do not wish to report that rape has occurred, and should not be mandated to do so. Furthermore, even if disclosure does occur I must reiterate the absence and inappropriateness of any single conclusive test which could be used to either confirm or refute the disclosure.