Sexual violence within mental health units: The forgotten fight?

Sexual violence is significantly associated with the development of numerous psychiatric disorders, including posttraumatic stress disorder (PTSD), depression, anxiety disorders and substance use disorders. Self-harm and suicide are also common outcomes of sexual abuses. The relationship between sexual violence and mental health goes both ways: psychiatric disorders are also risk factors for sexual assault. People with severe mental illness have significantly higher odds of sexual victimization than people without mental illness.

There is growing evidence that sexual incidents occurring during hospitalization in psychiatry are not uncommon. In a 2005 American study, 8% of psychiatric inpatients reported being forced into sexual contact by another patient, and 3% reported sexual coercion by a staff member (Frueh et al., 2005). In the United Kingdom, an analysis of reports of incidents from 54 mental health trusts, published by the Care Quality Commission in 2018, revealed 273 sexual assaults and 29 alleged rapes between April and June 2017 (Hughes et al., 2019). In France, 24 rapes and 143 sexual assaults were reported in mental health units between 2015 and 2018 (Direction Générale de l’Offre de Soins, 2020). With half of rapes and a third of sexual assaults reported in the healthcare environment, psychiatry was, by far, the sector most affected by sexual violence (Direction Générale de l’Offre de Soins, 2020).

However, these figures are probably underestimated. A French report published in 2011 (Lalande and Lepine, 2011), and two recent editorials addressing sexual violence in the United Kingdom (Hughes et al., 2019) and the United States (Barnett, 2020), pointed out that sexual incidents were particularly difficult to quantify and may be under-reported by mental health staff. This lack of report was mostly due to (1) victims often abstaining from reporting sexual assault to their caregivers (Hughes et al., 2019; Lalande and Lepine, 2011); (2) caregivers questioning the victim’s statement because of his or her mental condition (Barnett, 2020; Lalande and Lepine, 2011), or because the alleged aggressor was a member of the staff (Barnett, 2020); and (3) the fear of legal action against the unit (Barnett, 2020; Hughes et al., 2019; Lalande and Lepine, 2011). Importantly, in all those countries, there has been concern about the quality of care the victims received: in many cases, the answer to disclosure or discovery of a sexual assault was considered as inappropriate, with heterogeneous medical and psychological care (Barnett, 2020; Lalande and Lepine, 2011), along with delayed or inexistent legal proceedings (Barnett, 2020; Hughes et al., 2019; Lalande and Lepine, 2011). The lack of training of mental health professionals and the absence of detailed clinical guidelines were the main causes of inadequate care (Barnett, 2020; Hughes et al., 2019; Lalande and Lepine, 2011).

Improving the quality of care for patients who are victims of sexual violence within mental health units is an emergency. We offer several recommendations to address the aforementioned issues. First, reliable clinical guidelines should be provided to every mental health units, describing the course of action to be followed after revelation of a sexual assault or rape. Creating a safe environment should always be the first step, in order to insure the patient’s physical and psychological safety. Only after safety is confirmed should the following measures be offered to the victim: urgent psychological assessment, urgent medical examination and urgent screening and/or prophylaxis for sexually transmitted infections should be proposed to the patient to assess the immediate impact of sexual violence and to prevent both its short and long-term consequences. The refusal of one examination should neither questioned the veracity of the assault, nor prevent the realization of the others. As early as possible, the victim should be provided with information on the legal proceedings following an assault, and be offered to be accompanied to the police department. A detailed report must be filled and sent to the administration of the institution for every incident.

Second, there is an urgent need to train mental health caregivers. The response given by mental health professionals after discovery of a sexual assault has a direct impact on victim’s psychiatric prognosis and their adherence to care. Questioning the plausibility of sexual violence or delivering inadequate care can result in a loss of trust in mental health professionals, leading to discontinuation of treatment with dramatic mental health outcomes. Trauma-related disorders are indeed associated with high psychiatric comorbidities and high mortality. Moreover, a significant number of victims will never mention those assaults, and therefore, will never access appropriate treatment. Offering a safe place to the victims during hospitalization might be the only occasion to refer them to specialized care and to help them improve their condition. In this regard, it is imperative to institute specific training to every professional working in mental health units.

Finally, early detection strategies need to be implemented to detect sexual assaults within psychiatric settings and offer care to abused patients unable to communicate because of their mental condition, or because of their fear or shame. Although most countries are still lacking such tools, some like Australia already developed guidelines and trauma-specific staff training to prevent sexual incidents or, if needed, to appropriately respond to sexual incidents within psychiatric services. Similar strategies should be developed in every country to ensure the sexual safety of all mental health service users.

The first step is probably to engage a dialogue within psychiatric facilities. The breakthrough of the #Metoo movement in 2017 allowed freedom of speech for victims of sexual violence from various areas of the society (politics, sport, culture, etc.) and led to unprecedented debates about how to prevent and respond to sexual violence. It seems, however, that this liberation of speech did not reach psychiatric institutions yet. Even though mental health service users constitute a group at high risk of sexual victimization, and despite worrying figures, the subject of sexual violence within mental health units is still taboo in many countries. We cannot let it become an Omertà. While psychiatric inpatients and mental health professionals keep struggling with sexual violence, they need better tools to confront it. It is time to speak up about sexual violence within our mental health units. And it is more than time to act upon it.