Prevalence and risk of sexual violence victimization among mental health service users: a systematic review and meta-analyses

PURPOSE

People with mental disorders are more likely to experience sexual violence than the general population, but little is known about the prevalence of sexual violence in people who use psychiatric services. This paper aims to estimate the prevalence and odds of sexual violence victimisation within mental health services by gender and mental health setting (i.e. inpatient, outpatient and mixed settings).

METHODS

This study is a systematic review and meta-analysis (PROSPERO registration number: CRD4201810019). Three databases (Medline, Embase, PsychINFO) were searched and citation tracking, and reference screening of included studies was conducted. Studies were included if the prevalence and/or risk of sexual violence in psychiatric service users were reported or calculable across the past year or adult lifetime. The methodological quality of included studies was assessed. A random effects meta-analyses was conducted to estimate odds ratios and pooled prevalence estimates of sexual violence in different mental health settings.

RESULTS

Twenty-six studies were included encompassing 197,194 participants. The meta-analyses revealed high pooled prevalence estimates and increased odds of sexual violence victimisation in male and female psychiatric service users compared to non-psychiatric service users.

CONCLUSIONS

Mental health practitioners should be trained to respond effectively to disclosures of sexual violence, particularly from these vulnerable groups. Future sexual violence interventions should consider mental health as a treatment outcome.

Silenced Survivors: A Systematic Review of the Barriers to Reporting, Investigating, Prosecuting, and Sentencing of Adult Female Rape and Sexual Assault

Sexual victimization of adult women remains an underreported crime. This systematic review identified and synthesized the barriers to reporting, investigating, prosecuting, and sentencing cases of sexual assault and rape against adult women in Western countries. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a comprehensive search was conducted on August 3, 2023, across databases including PsycINFO, MEDLINE, Cochrane Library, Scopus, ProQuest Central, Web of Science, MedNar, and ProQuest Dissertations & Theses. Studies meeting the inclusion criteria provided relevant information on the decision not to formally disclose, investigate, prosecute, or convict incidents of sexual assault and rape of adult women. We included 28 studies and identified 70 barriers in total. Identified barriers were most prevalent to reporting, followed by investigating, prosecuting, and, lastly, sentencing. Key themes in the barriers included lack of trust in the criminal justice system, internal reactions, rape myths and societal norms, and perpetrator characteristics. The identified barriers emphasize an urgent need for reform of the criminal justice system's response to sexual assault and rape. Prioritizing victim-survivors' needs, enhancing transparency of the criminal justice system, and addressing attrition rates are crucial. Future studies need to engage with diverse population to address all victim-survivors' needs and provide further insights into the challenges across all stages of the criminal justice system to enhance the outcome of rape and sexual assault cases.

"I Cannot Tell Anyone:" There are Many Reasons

Purpose: The purpose of this study was to investigate variables associated with difficulty disclosing past trauma. Across several prevalence studies, 26% of adults never disclosed childhood abuse until adulthood when they were asked in a research survey or interview question. In this Institutional Review Board approved study, group differences were examined (ability and inability to disclose a traumatic event) as well as predictors for difficulty disclosing past trauma. Method: A non-clinical population (N = 693) was examined to determine prevalence rates and group differences between participants unable to tell someone about a past traumatic event (10%) compared to those who could disclose past traumatic events (90%). Variables included pathological dissociative processing, internalized shame, coping strategies (task, emotion, avoidance), and cumulative trauma exposure. Logistic regression analyses were conducted to determine predicting variables for disclosure difficulties. Findings: The group that had difficulty disclosing a past traumatic event had more cumulative trauma, pathological dissociative processing, emotion-oriented coping, and shame. In the first logistic regression analyses, interpersonal traumatic events were predictors for the inability to disclose a traumatic event (classified 90% of group membership). In the second logistic regression, shame and cumulative traumatic exposure were predicting factors (classified 90% of group membership). Conclusion: Difficulty speaking about a traumatic event was associated with interpersonal adult and childhood traumatic events, more internalized shame, and cumulative trauma exposure. It is recommended that clinicians working with patients with substantial traumatic exposure address shame, pathological dissociative processing, and emotion-oriented coping strategies if they detect trauma disclosure difficulties.

"In the End You Keep Silent": Help-Seeking Behavior Upon Sexual Victimization in Older Adults

Sexual violence is considered a prominent mental health problem. Exposure to sexual victimization during lifetime has been linked to mental health problems in old age. Research in adult victims has shown that they experience many barriers for disclosure and seeking professional help upon sexual victimization. However, information on help-seeking behavior in older victims of sexual violence is non-existent. With this study we aim for a better understanding of help-seeking behavior upon sexual violence in older adults. We used a mixed methods approach with an explanatory sequential design. Data were collected through structured face-to-face interviews with a random sample of 227 sexual violence victims of 70 years and older living in Belgium. Quantitative data were triangulated with qualitative data from 15 in-depth interviews with older victims. We found that up to 60% of older sexual violence victims never disclosed their experiences and 94% never sought professional help. Help-seeking is a complex process comprising several phases, which are affected by strong feelings of shame and self-blame, ageist premises and taboos about sexuality. In the end, most victims choose to cope on their own. Occasional disclosure only happens decades after the sexual violence took place. Older victims do not spontaneously disclose to healthcare workers but expect professionals to initiate the conversation. In conclusion, few older victims disclose or seek professional help upon sexual victimization. Healthcare professionals working with older adults need capacity building through training, screening tools, and care procedures to initiate conversation on sexual violence, and to detect signs, prevent, mitigate and respond to sexual victimization in older adults.

Online Social Reactions to Disclosure of Sexual Victimization via #MeToo and Symptoms of Post-Traumatic Stress Disorder

Sexual victimization is a major public health concern with significant consequences for survivors, their families, and society at large. Studies examining in-person disclosure of sexual victimization suggest that the way others respond to disclosure has a significant impact on survivors' well-being. With the advent of social media, more survivors are choosing to disclose their experience online. Research is needed to understand how social reactions to online disclosure of sexual victimization impact survivors. Accordingly, the current study examined the association between online social reactions to the disclosure of sexual victimization and symptoms of post-traumatic stress disorder (PTSD) symptoms in a sample of 195 individuals who disclosed their experience online via the hashtag #MeToo. Symptoms of PTSD were positively associated with the level of assault severity reported by the survivor, as well as receipt of online social reactions to disclosure via #MeToo that made fun, insulted, or said something to hurt the survivor. Online social reactions to disclosure via #MeToo that involved turning away from the survivor or providing unsupportive acknowledgment of the experience were unrelated with PTSD symptoms. PTSD symptoms were also not associated with the receipt of positive online social reactions to disclosure via #MeToo. Like research addressing in-person social reactions to disclosure of sexual victimization, some forms of online negative social reactions to disclosure of sexual victimization via #MeToo appear to be associated with worse psychological outcomes among survivors. Thus, online disclosure of sexual victimization and its impact needs to be attended to in clinical and research settings.

Clinical Neuropsychological Profile and Quality of Life in Women Who Have Suffered Gender-Based Violence

Background

This research characterizes the clinical and neuropsychological profiles and the quality of life in a group of Ecuadorian women who suffered physical violence, psychological violence, or sexual violence, exploring their relationships with sociodemographic factors.

Methods

A battery of tests were used to explore the clinical and neuropsychological functions and quality of life in 120 participants who were selected from a population affected by violence.

Results

Sixty percent of the participants showed clinical anxiety, 26.7% clinical depression, 40% post-traumatic stress disorder symptoms, 15% moderate personality disorder, and 51.7% a low quality-of-life index. Their Z-scores in the neuropsychological domains evaluated were verbal memory (Rey Auditory Verbal Learning Test = -1.35), working memory (Digits = -1.67), attention (D2 = -1.24), processing speed (Coding = -1.33; Trail Making Test A = 1.81), and executive function (Trail Making Test B = -1.15; Stroop = -0.20; verbal-semantic fluency test = 0.05; verbal fluency test = -1.23).

Conclusions

The majority of women who suffered gender-based violence presented clinical levels of anxiety, depression, and post-traumatic symptoms. The cognitive functions with lower scores (Z < -1.5) were working memory and processing speed, mediated by education factor.

Perceptions of Sexual Violence Terms Used in Statutes Throughout the United States

The terminology used to describe sexually violent offenses vary, and how these labels are interpreted by the public remains unclear. This study explores the terms for the primary-legally most severe-offense of sexual violence in legal statutes across the United States and investigates how different terms evoke different perceptions about crime severity. Results indicate that nine different terms are used to identify the primary offense of sexual violence in state statutes, with significant differences in perceived severity for these terms. The findings have implications for the public's (mis)understanding of sexual violence and the treatment of survivors and perpetrators.

Disclosure of Sexual Victimization: Effects of Invalidation and Shame on Re-Disclosure

Research on disclosure of sexual victimization has consistently demonstrated that the act of disclosure and the disclosure recipient have a synergistic effect in facilitating either positive or negative post-assault outcomes. While negative judgments such as victim blame have been argued to serve a silencing function, experimental investigations of this claim are lacking. The current study investigated whether invalidating feedback in response to self-disclosure of a personally distressing event produced feelings of shame, and whether shame influenced subsequent decisions around re-disclosure. Feedback type (validating, invalidating, no feedback) was manipulated in a sample of 142 college students. Results partially supported the hypothesis that shame resulted from invalidation, however shame was better predicted by individual perceptions of invalidation than the experimental manipulation. Although few participants opted to make changes to the content of their narrative for re-disclosure, those who did had higher levels of state shame. Results suggest that shame may be the affective mechanism by which invalidating judgments silence victims of sexual violence. The present study also supports the distinction previously made between Restore and Protect motivations in managing this shame. This study provides experimental support for the notion that an aversion to being shamed, communicated via an individual's perception of emotional invalidation, features in judgments of re-disclosure. Perceptions of invalidation, however, vary individually. Professionals working with victims of sexual violence should be mindful of the importance of shame attenuation in facilitating and encouraging disclosure.

The stronger and the weaker sex - gender differences in the perception of individuals who experienced physical and sexual violence in childhood. A scoping review

BACKGROUND

Violence against children is an issue of serious concern. Stigma impacts coping with childhood trauma. A central aspect regarding disclosing trauma and seeking help is the social perception of the victim and survivor's gender.

OBJECTIVE

This review aims to synthesize qualitative and quantitative research about the impact of the victim and survivor gender on the societal perceptions of individuals who have experienced sexual and/or physical violence in childhood.

PARTICIPANTS AND SETTING

This review considered both society's and victims and survivors' perspectives on gender-linked perceptions concerning individuals with childhood trauma.

METHODS

The initial search was conducted in November 2021 and involved the databases Web of Science, PubMed, and PsychInfo. All studies, published in English or German, that reported study design, sample characteristics, and gender-linked perceptions of individuals with a history of sexual and/or physical violence in childhood were included.

RESULTS

A total of 10,373 studies were identified, of which 20 studies were eligible for review. Six studies reported no significant victim gender effect. However, when significant victim gender effects were present, males were characterized with considerably more stigmatizing attributes regarding the blame category while females were exposed to considerably more stigmatizing attributes regarding the harm category.

CONCLUSIONS

Females and males experience stigmatization reflecting typical stereotypes of femininity and masculinity. Thus, females are perceived as more vulnerable, more burdened, and with a higher need for security than males. Males are seen as more blameworthy and less trustworthy than females due to their presumed capability to physically resist or escape abuse.

"Sometimes It Seems Easier to Push It Away": A Study Into the Barriers to Help-Seeking for Victims of Sexual Violence

Experiencing sexual violence may have serious long-term consequences for victims. Seeking help may decrease the chances of developing long-term physical and psychosocial problems. Still not every victim seeks help, and especially with victimization of sexual violence, there may be several reasons as to why. The barriers to help-seeking are diverse and may depend on several contextual factors. This study, as part of a larger research project, aimed to determine the barriers that victims of sexual violence experience in their decision to seek help in a non-college setting. This mixed-methods study included an online survey (N = 133) and open-ended survey (N = 207) amongst victims of 18 years and older. The online survey data were analyzed using chi-square tests for independence and t-tests; the open-ended survey data were analyzed using a descriptive approach. The online survey data showed that minimization of the incident was higher for non-help-seekers, whilst distrust toward support providers and issues with the accessibility of help were higher for help-seekers. No further significant associations were found between the decision to seek help and the barriers to help-seeking. From the open-ended survey data, three categories of barriers were distinguished: (a) individual barriers, such as feelings of shame, (b) interpersonal barriers, such as the fear of negative social reactions and (c) sociocultural barriers, such as societal stereotypes regarding sexual violence. The findings suggest that victims experience various, but primarily individual, barriers to help-seeking and that these barriers do not strongly differ between help-seekers and non-help-seekers. This study highlights the importance of addressing barriers to help-seeking on an organizational and societal level to encourage help-seeking.

Online Disclosure of Sexual Victimization: A Systematic Review

We map the available scientific literature on how and why victims of sexual violence use digital platforms in the aftermath of victimization. Twenty-four empirical studies on sexual victimization and online disclosure were identified by systematically searching Web of Science and PsycINFO, checking reference lists, and consulting authors about relevant publications. The literature on online disclosure of sexual victimization does not yield a coherent picture. International literature pays limited attention to the various components of online disclosure like the characteristics of victims who disclosure online and the characteristics of the disclosure messages. Most studies focused on motivations for and reactions to online disclosure. Victims of sexual violence disclose sexual victimization online to seek support for clarification and validation, unburdening, documenting, seeking justice, informing others, or commercial goals (individual-oriented disclosure) and to provide support, educate, and as a form of activism (other-oriented disclosure). Responses to online disclosure are predominantly positive. Negative responses are rare. This review provides a comprehensive overview of multidisciplinary empirical information and displays knowledge gaps in victimological research. Future research should use robust quantitative and/or qualitative designs with substantial sample sizes, comparing victims who do disclose their sexual victimization online to victims who do not and comparing disclosure on different online platforms to increase generalizability. Potential for online support is identified, in which online disclosure can serve as a relatively safe alternative to off-line disclosure. This offers points of intervention for assistance and victim support in facilitating the use of the internet for support for victims of sexual violence.

"It's Hard to Show Empathy in a Text": Developing a Web-based Sexual Assault Hotline in a College Setting

To increase access to counseling and advocacy services and respond to changes in communication preferences, many victim service programs are expanding their traditional telephone hotlines and adding web chat or text hotlines. However, there is little research available about these web and text-based hotlines. We examined program data collected in the first year of operation of a web-based crisis hotline for sexual assault survivors at a large Midwestern university in the United States as part of a larger evaluation project. We examined how often the web-based chat hotline was used and explored patterns of use by time of day and month, comparing to records from the phone hotline operated by the same campus-based victim service program. We also conducted interviews and two group discussions with volunteers and staff about their experiences with providing crisis intervention in a web-chat medium. Findings suggest that the web-based crisis hotline is being used frequently, nearly as often as the telephone hotline and doubling the total number of crisis contacts the organization had in the year prior to adding the web-based chat hotline. Staff and volunteers identified a number of advantages of a web-based hotline, including increased privacy and accessibility for survivors. Difficulty identifying and conveying emotions in the web-chat context was one of the primary challenges described by staff and volunteers. Operating the web-hotline, therefore, requires additional training for volunteers and staff on how to translate crisis intervention skills into a text-based medium. Suggestions for how to communicate effectively in text-based crisis intervention are discussed, along with other considerations for designing a web or text hotline.

Perception of Gender Equality Matters: Targets' Responses to Workplace Sexual Harassment in Chinese Metropolises

Workplace sexual harassment (WSH) has been recognized in the literature as a serious problem for the past 40 years. Since 2017, the global #MeToo movement has fostered local awareness of WSH and inspired researchers in China to pay increasing attention. Guided by the gender empowerment theory, this study investigated the relationships between women's responses as targets of WSH (e.g., choosing avoidance or confrontation) and both their perceptions of gender equality and their knowledge of the relevant national laws. We used data from a recent large-scale online survey conducted on the topic of sexual harassment among Chinese women in four metropolitan cities in 2018 and selected 862 women who had experienced WSH during the previous 12 months as the study sample. The results revealed that 545 of the respondents chose to show resistance when faced with WSH, while 287 identified their boss as their harasser. In addition, respondents' perceptions of gender equality and their knowledge of national laws on anti-domestic violence were shown to have positive effects on their responses as targets of WSH. Moreover, monthly income, household registration, and type of WSH were found to be associated with targets' responses in a statistically significant way, whereas their marital status, educational background, and age were not. Furthermore, the study found that the boss as harasser weakened the relationship between women's perception of gender equality and their active response to WSH incidents. With this study, we advance our understanding of the important role that perceptions of gender equality play in women's responses as targets of WSH, and we discuss implications for prevention and intervention efforts that encourage targets to actively respond. We advocate promoting education on gender equality, fostering awareness of the laws and regulations relevant to WSH, and cultivating an organizational culture and environment that is hostile toward WSH.

Trauma and psychosis: a qualitative study exploring the perspectives of people with psychosis on the influence of traumatic experiences on psychotic symptoms and quality of life

BACKGROUND

Despite experiencing high rates of trauma and trauma-related conditions, people with psychosis are seldomly asked about possible traumatic events. While there are some barriers to discussing trauma in clinical services, research has shown that disclosure is not only possible but also beneficial to both psychotic and traumatic symptoms. The current study is the first to evaluate service users' perception of the influence of trauma on the development and maintenance of their psychotic symptoms, as well as their views on how their life and mental health have been affected by traumatic events and their disclosure (or lack of).

METHODS

Eleven participants with experiences of psychosis and trauma took part in semi-structured interviews.

RESULTS

Consistently with previous literature, our participants reported high rates of interpersonal trauma, but had rarely had the opportunity to discuss any of these events. Using thematic analysis, we identified three major themes that have important implications for healthcare: factors that facilitate or hinder talking about trauma; consequences of talking or not; and relationship between trauma and psychosis. Participants generally benefited from talking about trauma and concerningly often associated the prolonged lack of opportunities to discuss traumatic events with negative feelings towards the self and with a deterioration of their mental health. Participants also recognised direct links between past traumas and the content and characteristics of their psychotic experiences.

CONCLUSIONS

Our findings highlight the importance, as perceived by service users, of discussing trauma and looking at psychosis through a "trauma lens". These results stress the need to systematically assess trauma history and traumatic symptoms in psychosis and might potentially help to overcome clinicians' worries about discussing trauma with service users. Our findings underscore the need to change current practice and implement trauma-informed approaches to understand clients' difficulties and provide support.

Sexual Victimization Disclosure: A Cluster Analysis Approach to Understanding Victimization Experiences in Disclosers and Non-Disclosers

Research has used cluster analysis to identify clusters, or groups, of sexual victimization survivors who share similar assault experiences. However, researchers have not investigated whether disclosure status is a key component of the survivors' experience. The current study identified two clusters among 174 disclosing and non-disclosing sexual victimization survivors. Cluster One (n = 74) included an incapacitated assault by a lesser-known perpetrator and disclosure of the event. Cluster Two (n = 100) included a verbally instigated assault by a well-known perpetrator and nondisclosure of the event. Follow up independent t-tests revealed that women in Cluster One had significantly higher depression and posttraumatic stress disorder (PTSD) symptoms than women in Cluster Two. Results support prior research identifying clusters of victimization based on assault characteristics and suggest that disclosure status is a key variable in the recovery process. Specific implications for clinicians, policy makers, and the community are discussed.

Why Do Women Talk About It? Reasons for Disclosure of Sexual Victimization and Associated Symptomology

Many sexual victimization survivors disclose their experience; however, there is limited research investigating why women disclose this experience and how reasons relate to psychopathology. The current online study aims to further understand the experiences of 142 female survivors (aged 18-29 years) by identifying their reason for disclosure and investigating how reasons relate to self-reported depression and post-traumatic stress disorder (PTSD) symptomology. Qualitative analyses identified two reasons: intentional and elicited disclosures. Hierarchical linear regressions revealed that elicited disclosures were associated with higher PTSD symptomology than intentional disclosures above and beyond relevant covariates, suggesting that disclosure reason is an important factor in the recovery process.

Sexual assault reporting amongst users of online sexual health services

Sexual assault (SA) survivors often attend sexual health clinics (SHC) for care relating to their assault. Reported rates of SA amongst SHC attendees can be high. Online sexual health services are becoming increasingly popular. Sexual Health London (SHL) is a large online sexual transmitted infection (STI) screening service. Between 1.1.20– 8.2.20, 0.5% (242/45841) (54% female, 45.6% male) of adults disclosed a recent SA when ordering an online STI testing kit. 79% (192/242) users engaged in a call back discussion initiated by the SHL team: 45% (87/192) users confirmed a SA had occurred and 53% (101/242) users denied an assault (particularly men) stating they had reported this in error. 18% (16/87) users had already reported their SA to the police/sexual assault centre, and one user accepted an onward referral. This study found a low reporting rate of SA amongst SHL users, but despite a high response rate to call backs, >50% cited they reported in error, 25% (22/87) didn’t want to discuss their SA and few accepted onward referrals. Using e-triage to screen for SA followed by service-initiated telephonic support to everyone who discloses, may not be acceptable or offer utility to all. Further evaluation of ways to engage these individuals is required.

Reasons for and Experiences of Sexual Assault Nondisclosure in a Diverse Community Sample

PURPOSE

After a sexual assault (SA), victims often disclose their SA to an informal support provider (SP) to receive social support; however, many survivors do not disclose or wait months or years to tell anyone. While research exists on disclosure, social reactions of informal SPs to disclosure, and how those reactions affect the victim both positively and negatively, little research exists on reasons for and impact of adult SA survivors' nondisclosure to informal social network members.

METHOD

This qualitative interview study examined 42 ethnically diverse women who had disclosed SA to an informal SP (e.g., friend, family, significant other). For this study, nondisclosure of SA mentioned by survivors was examined.

RESULTS

Various reasons for not telling people in their lives and/or delaying doing so were uncovered including fear of negative social reactions, lack of perceived available support and fear of burdening others, family and social norms expectations, and anticipated problematic gendered responses by both men (e.g., violence) and women (e.g., overwhelmed) SPs.

CONCLUSIONS

Implications for future SA disclosure research and supporting survivors in their choice to selectively/not disclose are discussed.