Sexual violence has been declared a serious public health problem by the World Health Organisation (Krug et al, 2002) and is estimated to affect 1 in 4 women and 1 in 20 men in England and Wales (Office for National Statistics, 2019). There is growing research highlighting an association between the experience of sexual violence and the development of mental health problems such as PTSD and substance misuse (Rees et al, 2015). It is imperative that the services used by survivors can effectively address their mental health and substance misuse problems in the critical days, weeks and months following their assault.
Sexual assault services are designed to provide this crucial care through collecting forensic evidence and conducting health checks. Sexual assault services take on various names and models across the world but are known as Sexual Assault Referral Centres (SARCs) in England and Wales. Research suggests that 40% of SARC service users are already known to mental health services (Brooker et al, 2015). However, SARCs often do not perform mental health and substance misuse assessments, and lack clear referral pathways into mental health and drug and alcohol services.
A recent systematic review (Stefanidou et al, 2020) aimed to examine the current evidence regarding mental health and substance misuse provision in sexual assault services internationally. The authors aimed to address three questions:
- What are the approaches to prevention, identification and treatment of mental health and substance misuse problems in different sexual assault service models?
- What models of treatment, service delivery and organisation in sexual assault services are effective regarding service users’ mental health and substance misuse outcomes?
- What are stakeholders’ views and policy recommendations about how sexual assault services should prevent, identify and treat mental health and substance misuse problems for people following a sexual assault?
A search was undertaken for literature published between 1975 – August 2018 from PsycINFO, MEDLINE, IBSS and CINAHL, followed by a web-based search up to December 2018.
Studies of sexual assault services were included if the service:
- offered specialist support within a single service to adults and/or children who had experienced sexual assault and
- supplied healthcare provision and the collection of forensic evidence and legal statements.
Both peer-reviewed and grey literature in the English language were eligible for inclusion. Other inclusion criteria on publication type, participants, intervention, comparison and outcomes were tailored to each of the (above) three research questions.
Included studies were quality assessed using the Mixed Methods Appraisal Tool (MMAT) which grades quality on a scale of 0-5. A score of 0 indicated low quality and 5 indicated high quality.
Findings were compared and synthesised in a narrative synthesis.
In total, 107 full text papers were included in the review. The quality assessment of these papers yielded a median MMAT score of 3 for the evaluation studies, indicating a moderate quality. Studies of policy documents had a median MMAT score of five, indicating high quality.
Question 1: Approaches to mental health and substance misuse
78 publications provided information on how sexual assault services identify and treat mental health and substance misuse problems.
Identification: 32 papers gave information on how 29 sexual assault services identified mental health and substance misuse problems among service users. The different approaches were:
- Unstructured or unspecified assessments (n=14), e.g. using professional judgement, casual observation and others
- Structured assessment not using validated measures (n=10)
- Structured assessment using validated standardised measures (n=5)
In-house support: 57 papers described how 48 sexual assault services provided in-house support for mental health and substance misuse problems. Types of in-house support provided included:
- Counselling as part of the follow up care (n=32)
- Unspecified type of emotional support (n=7)
- Psychological interventions as part of follow up care (n=5)
- Immediate emotional support only at first contact (n=2)
- No provision of emotional support (n=2)
Referral: 39 papers described 38 sexual assault service arrangements for referring service users on to mental health and substance misuse services:
- 32 reported signposting information and making referrals
- 6 reported referrals with an active follow-up to determine if the service user had accessed these services and to check ongoing mental health and substance misuse needs.
Question 2: Evaluation of interventions
6 papers reported findings from 5 studies evaluating the effectiveness of interventions for mental health or substance misuse within a sexual assault service.
- 5 papers reported 4 trials of video interventions of varying length and format:
- 2 papers found positive effects for the intervention on risk of marijuana abuse and anxiety respectively
- 3 papers found no significant differences between any groups on any of the outcomes, although one did report positive effects of the intervention on PTSD and depression among those with a prior history of assault.
- 1 paper evaluated a Cognitive Processing Therapy and found no significant differences between groups on any outcomes.
Question 3: Stakeholder views
34 papers described 32 studies reporting on stakeholders’ views on how sexual assault services should identify and respond to mental health and substance misuse problems:
- 18 studies reported recommendations specifically about assessment/management of mental health and substance misuse problems
- 25 studies reported more general recommendations regarding service organisation and delivery
- Other recommendations included the importance of 24/7 access, multi-lingual services, flexible appointments and accessibility to minority groups.
10 documents of government and expert guidelines were included. Government guidance lacked specification on how mental health should be assessed and how needs regarding drug or alcohol use should be addressed.
This study is the first to systematically review the evidence relating to the approaches sexual assault services take when addressing mental health and substance misuse needs globally. It represents a thorough and necessary assessment of the available literature.
The findings demonstrated a lack of structure in how sexual assault services identify mental health and substance use needs, primarily exercising more subjective methods like clinical judgement. Supportive counselling was provided more than structured psychological interventions, with sparse evidence regarding the efficacy of treatment models for mental health and substance misuse outcomes.
Key stakeholder views included the importance of accessibility, flexibility, appropriate support and staff training and continuity of care. There was little evidence on the views of service users, but where included, they underlined the importance of long-term support and multi-agency communication.
Strengths and limitations
Firstly, non-English language papers were excluded, and policy guidance papers were restricted to England, which could have resulted in the omission of relevant papers, and somewhat limits the relevance of the review on an international level. However, in terms of assessing the evidence across time, the authors astutely chose 1975 as the lower restriction date since this when the pioneering SANE (Sexual Assault Nurse Examiner) model was introduced in America, with the SARC model being introduced just over a decade later in the UK. Ultimately the search strategy is robust and comprehensive.
Many studies did not have a focus on mental health and therefore approaches to mental health provision could only be described in broad categories. This could cause significant variations in care to be concealed. Additionally, some older studies may not be reflective of current practice or stakeholder perspectives.
The MMAT quality assessment tool was used due to its utility across a variety of designs and methodologies. However, the authors comment that some papers received high MMAT scores, despite clear flaws such as a lack of published protocol or a lack of clearly specified primary outcomes.
Finally, as with any systematic review, the quality of the evidence base must be considered. Several studies had methodological limitations, high attrition rates or lacked service user input. The reviewers also found almost no information about how substance misuse needs should be assessed in sexual assault services.
The authors describe 2 key questions arising from the review that could be explored through RCTs or naturalistic comparisons:
- Does structured screening of mental health and substance misuse in sexual assault services increase the uptake of mental health and substance use support, and improve outcomes?
- Which psychological therapies should be provided by sexual assault services or by external services, and what are the referral criteria?
This review further highlights how few studies explore the views of survivors first-hand. It is of paramount importance that survivors’ experiences and views of SARC service provision are collected and considered. This includes underrepresented (BAME, LGBT and learning disability) groups.
Policy and practice
The review exposes inconsistencies in how sexual assault services identify service users with mental health and substance misuse problems. However, even if these problems are identified, these services are ill-equipped to provide effective psychological therapies. The authors advise prioritising structured screening, and the use of reliable measures.
UK policy guidance lacked specificity on how SARCs should address the mental health and substance use needs of service users. Additionally, the provision of mental health and substance misuse services were shown to vary by location, resulting in a postcode lottery. More refined evidence-based guidance is needed for service planners and commissioners to address this.
Overall a consensus was identified from stakeholders that SARCs should be universal in affording kindness, compassion and respect to service users. In a world where many service users are routinely retraumatised by the systems that are supposed to help them, SARCs could be at the forefront of empowering survivors and promoting recovery with the right reform.
Statement of interests
Stefanidou, T., Hughes, E., Kester, K., Edmondson, A., Majeed-Ariss, R., Smith, C., Ariss, S., Brooker, C., Gilchrist, G., Kendal, S., Lucock, M., Maxted, F., Perot, C., Shallcross, R., Trevillion, K. and Lloyd-Evans, B., 2020. The identification and treatment of mental health and substance misuse problems in sexual assault services: A systematic review. PLOS ONE, 15(4), p.e0231260. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0231260
Krug E, Dahlberg L, Mercy J, Zwi A, Lozano R, eds. 2002. World report on violence and health. World Health Organisation, Geneva. [online] Available at: https://apps.who.int/iris/bitstream/handle/10665/42495/9241545615_eng.pdf.
Rees S, Silove D, Chey T, Ivancic L, Steel Z, Creamer M, et al. Lifetime Prevalence of Gender-Based Violence in Women and the Relationship With Mental Disorders and Psychosocial Function. JAMA. 2011; 306(5):513–21.
Brooker C, Durmaz E. Mental health, sexual violence and the work of Sexual Assault Referral centres (SARCs) in England. J Forensic Leg Med. 2015; 31:47–51