Sexual assault reporting amongst users of online sexual health services

Abstract

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.

Keywords

Sexual assault disclosure clinical STI care e-medicine sexual health

Introduction

Sexual assault (SA) is a physical and psychological violation in the form of a sexual act, inflicted on someone without their consent. Sexual violence has devastating consequences on well-being and quality of life: 39% survivors sustain physical injuries from rape/assault by penetration, 10% attempt suicide, 3% become pregnant and 3% are transmitted an STI.¹ A large proportion (63%) experience mental health and emotional problems eg psychological distress, post-traumatic stress disorder (PTSD), depressive disorders, sexual dysfunction, sexual risk behaviour, self-harming behaviours, problems with drug or alcohol abuse and over half go onto experience relationship or trust difficulties. For many, these issues are pervasive and chronic if untreated.^1–6

In England and Wales, it is estimated that 20% of women and 4% of men over 16 years have experienced some type of SA.¹ The US reported a lifetime experience of rape or other sexual violence in 19.3% and 43.9% of women and 1.7% and 23.4% of men respectively.^7,8 Gay/bisexual men appear more at risk compared to heterosexual men with sexual violence experienced by up to 54%.⁴,⁵,⁹ 12% of transgender people experience sexual violence before adulthood.¹⁰

In London, eleven women and girls are raped or sexually assaulted in each of London’s 32 boroughs every week.¹¹ Approximately 5 in 6 victims (83%) don’t report their experience to the police.¹ Under-reporting applies to all gender identity groups, and sexual orientations.¹² Nevertheless the number of sexual and rape offences increased in London by 80% and 140% respectively, between 2011 and 2019.¹³

Due to the consequences of SA many victims attend sexual health clinics (SHC) for confidential specialist care e.g. STI screening, genital/anal injuries, emergency contraception, HIV/Hepatitis B post exposure prevention (PEP), unplanned pregnancy, sexual dysfunction, and support to manage the sequelae of self-harming or sexual risk-taking behaviour. Thus, it is not surprising SA rates are high (21.4%) amongst London SHC attendees (28.2% female and 11.3% males).¹⁴

Online sexual health services (e-services) are increasing in availability and acceptability and can offer advantages over traditional SHC settings. Convenience, immediacy of access, privacy, anonymity, avoidance of parking/transport or childcare costs, and appeal to users feeling isolated or stigmatized are all factors that contribute to their popularity.^15–20

There is minimal literature on SA reporting by e-service users. However we are observing a shifting environment to online disclosures of sexual violence, influenced by the #metoo movement, where survivors voice disclosures through social media after periods of silence/being silenced and when systems or people have failed to validate or support them.²¹

Sexual Health London (SHL) is a free online STI testing service developed by the London Sexual Health Transformation Programme. Launched in 2018, it is commissioned by 29/33 participating London local authorities and to date has received almost half a million kit orders. The service is available to London residents of participating boroughs. Service users can request their kit by post or collection from a local SHC and can be tested for chlamydia, gonorrhoea, syphilis, HIV and Hepatitis B/C. The service was developed to screen asymptomatic patients and allow SHCs to focus resources on symptomatic, high risk patients or those with complex presentations. To order a kit, service users must complete a sexual health consultation online (e-triage) which includes the question Have you been a victim of a recent sexual assault? Adults who select “yes” to this question are shown online support pages and informed they will receive a “call back” from an SHL senior health adviser, the same/next working day to provide support. The discussion offers urgent clinical advice (e.g., sign-posting to provision of emergency contraception or post-exposure prophylaxis for HIV), psychological support and encourages referrals to police or sexual assault referral centre (SARC) where timelines permit for collecting forensic evidence.

We aim to report the rate of recent SA disclosure amongst users of our online STI screening service and identify the outcomes of their call back discussions.

Methods

Retrospective data regarding demographics and service outcomes were collected from adults that requested a kit between 1.1.20 and 18.2.20 and reported they were a victim of a recent sexual assault.

Outcomes of the call back were collected by manual review of the e-records. Data was collated and anonymised before analysis using a password protected Excel database. The study was approved by Chelsea and Westminster Hospital NHS Trust as a service evaluation. Local research ethics committee approval was not sought: The tool www.hra-decisiontools.org.uk classed the study as research but confirmed it did not require ethics committee approval.

Results

Between 01/01/2020 and 18/02/2020, there were 47662 kit orders by 45841 unique adult (>18yrs) users. 0.5% (242/45841) users triggered at least one call back for a SA during the study period. Eight of these users triggered two call backs but these all related to the same SA.

Gender, age, ethnic group and sexuality of the 242 users triggering a call back are shown in Table 1. The median and mean age was 26 years, range 18-55yrs. The majority of users were female (54.0%), heterosexual (72%), of white ethnicity (44.4%) and 80.4% had attended a SHC before. Lambeth (10.0%), Wandsworth (7.2%), Southwark (6.8%) and Tower Hamlets (6.4%) were the residing boroughs for most users reporting a SA.

Table 1.

Demographics, call back discussion and outcomes of SA survivors.

Gender	N	%	Sexuality	N	%
Male	114	45.6%	Heterosexual men	75	30.0%
Female	135	54.0%	Heterosexual women	105	42.0%
Trans/non binary	1	0.4%	MSM	30	12.0%
Total	250		WSW	2	0.8%
			Bisexual men	9	3.6%
			Bisexual women	28	11.2%
Ethnicity			Undetermined	1	0.4%
African	28	11.2%	Total	250
Asian	24	9.6%
Caribbean	23	9.2%	Ever visited SHC
Other	64	25.6%	Never	49	19.6%
White	111	44.4%	Within the last year	108	43.2%
	250		More than 1 yr ago	93	37.2%
				250
Discussion about reporting during the call back			Time between SA and kit order
			< 1 wk	12	13.8%
Already reported to police	11	12.6%	< 1 m	30	34.5%
Already seen by SARC	2	2.3%	< 3 m	44	50.6%
Already reported/seen by police and SARC^a	3	3.4%	< 6 m	49	56.3%
Declined to report	34	39.1%	< 1 yr	57	65.5%
Not provided/documented	37	42.5%	> 1-5 yrs	62	71.3%
Total	87		> 5 yrs	68	78.2%
			Not provided/documented	19	21.8%
Interventions by SHL team			Total	87
Police referral	0	0.0%
SARC referral	1	1.1%	Other SA information
Referred to SHC for	8	9.2%	Didn’t want to talk about it	22	25.3%
Emergency/general contraception	3		SA whilst intoxicated/spiked	13	14.9%
Health adviser support	1		Stealthing type assault	4	4.6%
STI testing / treatment	1		No additional information provided	42	48.3%
Not Documented	3		Total	87
No onward referrals	78	90.0%

^aSexual assault referral centre.

SHL’s policy obligates a minimum of three contact attempts for each user triggering a call back, via a range of contact media. Successful contact took place in 79.3% (192/242) call backs: a SA was confirmed in 87/242 (36%) users, 101/242 (41.7%) denied a SA and stated they had made an error on the triage (77/101(76.2%) were male, 24/101 female), 2/242 had their account locked for fraudulent use and in 2/242 (20.7%) users the communication exchange became too limited to confirm a SA. 50/242 users failed to respond to three contact attempts. After the call back the team made one referral to a SARC and eight referrals to a SHC.

Where information was provided about timeframes (68/87), the SA occurred within the previous week in 17.6% (12/68), within one month in 44.1% (30/68) and within three months in 64.7% (44/68) cases (range 1d to 14yrs). The perpetrator(s), where information was provided (40/87), were: casual acquaintance/partner 22.5% (9/40), stranger 27.5% (11/40), work colleague 15% (6/40), known partner 27.5% (11/40), and other 7.5% (3/40).

92.6% (224/242) kits were dispatched, and of these 73.7% (165/224) kits were returned and tested during the study period. Seventeen infections were identified amongst fifteen users (10 chlamydia, 3 gonorrhoea, 3 syphilis, 1 hepatitis B) giving an STI prevalence of 9.1% (15/165). One user had become pregnant following her assault.

Discussion

To our knowledge this is the first descriptive observational study looking at SA disclosures amongst users of e-services. National figures estimate 3.1% of 16–59 year old women (510,000) and 0.8% of men (138,000) living in England and Wales, have been assaulted in the previous twelve months.¹ In our study we identified a lower reporting rate (0.5%) of SA, although the timeframes for the SA differs (recent vs <12 m). SHL doesn’t offer screening to users with symptoms, instead directing them to SHC. Survivors may preferentially attend a SHC/SARC/police to address the multiple and urgent care needs (aside from STI screening) that arise from an SA. SHL also highlights to survivors during their triage the benefits of attending a SARC/police so users may disengage from the online service before placing a kit order. Some users may choose to test but not disclose their assault online. Given these factors our observed rate may be an underestimation of the true rate.

By initiating a telephonic discussion to survivors of a recent assault, to offer urgent clinical support, a high number of users responded to our contact attempts (79.3%), but only 45.3% confirmed a SA and over half (52.6%) denied a SA, claiming they made a triage error. Of those confirming history of a SA, a third of the SAs were not recent (>3 m) and over a quarter (25.3%) didn’t want to enter into a discussion about the incident. The kit return rate (73.7%) was slightly lower compared with SHL’s general users (79.6%) and the observed 6.1% prevalence of chlamydia is lower than the national chlamydia screening prevalence rate (10.1%).²²

In keeping with other literature, 16% of those who confirmed a SA (14/87) had already reported to the police, although if we exclude those where information wasn’t provided (n = 37) the reporting rate is higher (28%).¹⁴ For those who hadn’t reported, no user could be encouraged to do so, and 86.2% of users either did not (or chose not to) provide the timing of the SA or confirmed it had taken place more than a week previously, meaning they would likely have missed the window for forensic evidence collection. Petrak who surveyed SHC attendees about historical SA identified police reporting rates of 21% (12.5% men and 24.1% women) with varied reasons for non-reporting: 58.6% wish to forget, 32.8% fear of not being believed, 27.6% fear of other’s reaction, 24% knowing the assailant, and 24.1% fear going to court.¹⁴ Ceelen also reported a similarly low reporting rate of 20% with shame, guilt and lack of evidence as some of the reasons behind their decision.²³ Many of these reasons may be shared by the non-reporting survivors in our study.

There are several arguments for routine questioning about SA in sexual health services. SHC attendees have high rates of historic SA.¹⁴ Disclosure of traumatic events is typically associated with positive outcomes and survivors can experience intensification of psychological sequelae if they don’t receive adequate care after an assault.^24,25 SA survivors are receptive to being asked about sexual violence but are often not asked about it by healthcare professionals and are more likely to disclose when asked directly than to volunteer this information (82.5% vs 24.6%).²⁶ So unless we ask about SA, victims don’t get the support they need.

Aside from the advantages over SHCs, mentioned above, online services offer features that can facilitate disclosures of sexual violence.³ These include: a sense of anonymity, control in being able to test the response of a service and disengage at any time, stigma - not being exposed to potentially judgmental staff, convenient and timely access, a service accessible from the safety and privacy of their own home and crude translation tools can be used for non-English speaking users without needing family or friends to interpret.³ Hence online services are well placed to be screening service users about sexual violence and offering telephonic or remote support for those needing it. Furthermore, several remote or technology based options have shown value in supporting SA survivors - an online SA hotline model has shown good user satisfaction rates and utility for survivors who hadn’t sought help or had unresolved issues from accessing support elsewhere;²⁷ testing a mHealth app model to address SA needs was found to be useful and user friendly;³ Munro-Kramer’s work supports the concept of tech delivered alternative interventions for survivors – the important tenets being an empathic and one stop shop approach, enabling survivor agency and control and complete confidentiality.²⁸ Littleton provided online interventions (including therapist facilitated cognitive behavioural therapy) for rape related PTSD which led to reduced PTSD, depressive and anxiety symptoms.²⁹

SA survivors are predominantly female, yet we observed similar rates of SA regardless of gender.¹,¹⁴ Many of the users who claimed they reported a SA in error were men. There have been three design iterations of the SA triage question since service launch, to reduce ambiguity, but a high error, rate has persisted. The question appears early in the triage and not nestled amongst questions which commonly generate a yes response. During a recent safeguarding evaluation of 16–17 year old service users we did not observe this level of misinterpretation. We suspect some of the adults citing an error as well as many who declined discussion or referral, may have been a victim of a SA and were willing to disclose this to obtain the right kit or appropriate range of tests but did not wish to or were not ready to discuss it further. Some survivors may have already disclosed or received satisfactory support and don’t want to revisit the experience and others have moved on without needing any support, but there may be survivors that need support who were not open to a discussion or were potentially open to discussion but did not find the way in which our e-service offered it, acceptable or convenient. Disclosure and seeking help following sexual violence is a complex area, with multifaceted barriers. Many believe it was their own fault, others are fearful of consequences, therapist induced harm and secondary victimisation.²⁴,^30–34 Some have concerns about privacy or confidentiality and others adopt ways of coping such as avoidance based coping or minimising the experience.³,³³ Lack of availability or suitability of support services, stigma that can perpetuate self-blame and shame, lack of time, are also factors preventing getting the right help.²⁴,³³ Further research is warranted to identify alternative or better methods of facilitating disclosures online and also signposting and/or referral to support services for those that do disclose, perhaps involving focus groups and SA survivors.

There is minimal research on sexual violence amongst men and minority sexual orientation populations. Male SA is under reported and under recognised and only 17.6% seek professional support.⁶ Those who are perpetrated by friend or family, sustain physical injuries, are under 18 years of age, or receive threats or are confronted with a weapon are more likely to seek help.^6,35 Seeking help after an assault is particularly difficult for men.³⁵ Expectations from society, stigma and traditional gender roles and norms influence how men respond to victimisation from sexual violence.⁶,³⁶ Heterosexual men worry they may appear weak if they experience violence from a woman, or gay if assaulted by a man.³⁷ Men who have sex with men may be afraid of being outed, or of receiving homophobic responses from health-care professionals, or not being believed by police.⁹ In the US the most common attitudinal barrier to men seeking treatment is the desire to handle the problem on their own.^38,39 They may not seek help or report violence until their general wellbeing is significantly and negatively impacted and the “right fit” and establishing a trusting therapeutic relationship with the professional were identified as important to opening discussions of sexual violence experiences.⁶,⁴⁰

Our findings are limited by incomplete data detailing what support the service user had already accessed (e.g. SARC), what the user’s expectations were when reporting the violence on the e-triage (e.g. was it just for follow-up STI screening or were they actively seeking other types of support around the SA), and specific details about the type/nature of each assault. These details were either not consistently asked or documented by the SHL team, or not provided by the user on questioning.

SHL now plans to provide SA survivors the option of receiving a call back instead of the service directly contacting them, and using SMS to give each user control in terms of choosing a safe and convenient time for that conversation. The service now has established integration with the London SARCs to facilitate referrals for those needing follow up STI screening via SHL. Validation methods are being explored to reduce the error rate. Lastly, SHL staff training around SA, and use of a proforma, could ensure all needs are identified and addressed for those accepting SHL support, and help drive better documentation and data completion. We will audit these changes following implementation.

This study has highlighted a low number of users reporting a recent SA online and of those that do, a significant number later cite the disclosure as an error, do not wish to discuss their experience, and/or are not eligible or open to onward referral. Using e-triage to screen for SA followed by service-initiated telephonic support to everyone disclosing a SA does not appear to be acceptable or useful to all users. Further exploration is needed to assess what type of user prefers managing SA needs online, and what types of care they are open to in order to deliver a more tailored service that is acceptable and offers utility. Since the study was undertaken, the COVID 19 pandemic has changed many sexual health delivery models, decreasing access to face-to-face services and increasing reliance on online services. This work is therefore urgently needed, so we can better understand how to make non face-to-face services as acceptable and effective as possible for all survivors of SA and avoid adversely impacting this vulnerable group even further.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Sara Day

References

Office for National Statistics. Sexual offences in England and Wales: year ending March 2017. Analyses on sexual offences from the year ending March 2017 Crime Survey for England and Wales and crimes recorded by police. UK: Office for National Statistics.

Dworkin

Menon

Bystrynski

, et al. Sexual assault victimization and psychopathology: a review and meta-analysis. Clin Psychol Rev 2017; 56: 65–81.

Gilmore

Davidson

Leone

, et al. Usability testing of a mobile health intervention to address acute care needs after sexual assault. Int J Environ Res Public Health 2019; 16: 3088.

Nasrullah

Oraka

Chavez

, et al. Non-volitional sex and HIV-related sexual risk behaviors among men who have sex with men in the United States. AIDS (London, England) 2015; 29: 1673.

Bullock

Beckson

Male victims of sexual assault: phenomenology, psychology, physiology. J Am Acad Psychiatry Law 2011; 39: 197–205.

Donne

DeLuca

Pleskach

, et al. Barriers to and facilitators of Help-Seeking behavior among men who experience sexual violence. Am J Mens Health 2018; 12: 189–201.

Breiding

Smith

Basile

, et al. Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization – national intimate partner and sexual violence survey, United States. MMWR Morb Mortal Wkly Rep 2011; 63: 1–18.

Elliott

Mok

Briere

Adult sexual assault: prevalence, symptomatology, and sex differences in the general population. J Trauma Stress 2004; 17: 203–211.

National Coalition of Anti-Violence Programs. Hate violence against the LGBTQ communities in the US in 2009. https://avp.org/wp-content/uploads/2017/04/2011_NCAVP_HV_Reports.pdf (accessed 2 July 2020).

10.

Grant

Mottet

Tanis

, et al. Injustice at every turn: a report of the national transgender discrimination survey. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.

11.

Greater London Authority. A safer city for women and girls. The London tackling violence against women and girls strategy. March 2018. https://www.london.gov.uk/sites/default/files/vawg_strategy_2018-21.pdf (accessed 21 September 2020).

12.

Department of Justice – Office of Justice Programs. Nearly 3.4 million violent crimes went unreported to police from 2006 to 2010. Press release. 2012 https://www.prnewswire.com/news-releases/nearly-34-million-violent-crimes-per-year-went-unreported-to-police-from-2006-to-2010-165576036.html

13.

London Metropolitan Police: sexual offences on the rise, www.london.gov.uk/press-releases/assembly/sexual-offences-on-the-rise-in-london.https://www.met.police.uk/sd/stats-and-data/met/crime-data-dashboard/ (2019, accessed 21 September 2020).

14.

Petrak

Skinner

Claydon

EJ.

The prevalence of sexual assault in a genitourinary medicine clinic: service implications. Genitourin Med 1995; 71: 98–102.

15.

Fitzgerald

Wooler

Petrovic

, et al. Barriers to engagement in acute and post-acute sexual assault response services: a practice-based scoping review. Int J Emerg Ment Heal Hum Resil 2017; 19: 1522–4821.

16.

Kersaudy-Rahib

Lydié

Leroy

, et al. Chlamyweb study II: a randomised controlled trial (RCT) of an online offer of home-based Chlamydia trachomatis sampling in France. Sex Transm Infect 2017 May; 93: 188–195.

17.

De Visser

O’Neill

Identifying and understanding barriers to sexually transmissible infection testing among young people. Sex Health 2013; 10: 553–558.

18.

Salway Hottes

Farrell

Bondyra

, et al. Internet-based HIV and sexually transmitted infection testing in British Columbia, Canada: opinions and expectations of prospective clients. J Med Internet Res 2012; 14: e41.

19.

Griffiths

Lindenmeyer

Powell

, et al. Why are health care interventions delivered over the internet? A systematic review of the published literature. J Med Internet Res 2006; 8: e10.

20.

Lorimer

McDaid

Young men’s views toward the barriers and facilitators of internet-based Chlamydia trachomatis screening: qualitative study. J Med Internet Res 2013; 15: e265.

21.

Alaggia

Wang

“I never told anyone until the #metoo movement”: what can we learn from sexual abuse and sexual assault disclosures made through social media? Child Abuse Negl 2020; 103: 104312.

22.

Health Protection Report. Sexually transmitted infections and screening for chlamydia in England, 2018 Volume 13 Number 19 7, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/806118/hpr1919_stis-ncsp_ann18.pdf (2019, accessed 21 September 2020).

23.

Ceelen

Dorn

van Huis

, et al. Characteristics and post-decision attitudes of non-reporting sexual violence victims. J Interpers Violence 2019; 34: 1961–1977.

24.

Carson

Babad

Brown

, et al. Why women are not talking about it: reasons for nondisclosure of sexual victimization and associated symptoms of posttraumatic stress disorder and depression. Violence Against Women 2020; 26: 271–295.

25.

Holland

Cortina

LM.

“It happens to girls all the time”: examining sexual assault survivors' reasons for not using campus supports. Am J Community Psychol 2017; 59: 50–64.

26.

Berry

Rutledge

CM.

Factors that influence women to disclose sexual assault history to health care providers. J Obstet Gynecol Neonatal Nurs 2016; 45: 553–564.

27.

Finn

Garner

Wilson

Volunteer and user evaluation of the national sexual assault online hotline. Eval Program Plann 2011; 34: 266–272.

28.

Munro-Kramer

Dulin

Gaither

What survivors want: understanding the needs of sexual assault survivors. J Am Coll Health 2017; 65: 297–305.

29.

Littleton

Grills

Kline

, et al. The from survivor to thriver program: RCT of an online therapist-facilitated program for rape-related PTSD. J Anxiety Disord 2016; 43: 41–51.

30.

Logan

Evans

Stevenson

, et al. Barriers to services for rural and urban survivors of rape. J Interpers Violence 2005; 20: 591–616.

31.

Walsh

Banyard

Moynihan

, et al. Disclosure and service use on a college campus after an unwanted sexual experience. J Trauma Dissociation 2010; 11: 134–151.

32.

Campbell

Raja

Secondary victimization of rape victims: insights from mental health professionals who treat survivors of violence. Violence Vict 1999; 14: 261–275.

33.

Abavi

Branston

Mason

, et al. An exploration of sexual assault survivors’ discourse online on help-seeking. Violence Vict 2020; 35: 126–140.

34.

Carretta

Burgess

DeMarco

To tell or not to tell. Violence Against Women 2016; 22: 1499–1518.

35.

Monk-Turner

Light

Male sexual assault and rape: who seeks counseling?

Sex Abuse 2010; 22: 255–265.

36.

Howard

Debnam

Wang

, et al. 10-year trends in physical dating violence victimization among U.S. adolescent males. Int Q Community Health Educ 2011; 32: 283–305.

37.

Sable

Danis

Mauzy

, et al. Barriers to reporting sexual assault for women and men: perspectives of college students. J Am Coll Health 2006; 55: 157–162.

38.

Andrade

Alonso

Mneimneh

, et al. Barriers to mental health treatment: results from the WHO world mental health surveys. Psychol Med 2014; 44: 1303–1317.

39.

Mojtabai

Olfson

Sampson

, et al. Barriers to mental health treatment: results from the national comorbidity survey replication. Psychol Med 2011; 41: 1751–1761.

40.

Turchik

McLean

Rafie

, et al. Perceived barriers to care and provider gender preferences among veteran men who have experienced military sexual trauma: a qualitative analysis. Psychol Serv 2013; 10: 213–222.