Adult specialist services for victim-survivors of sexual violence and abuse: a systematic map of evidence

Abstract

EXECUTIVE SUMMARY Background Around one in five women and one in twenty-five men are estimated to have experienced sexual violence or abuse since the age of 16. When combined with rates of child sexual abuse this figure is even higher. Sexual violence is detrimental to an individual’s physical health, emotional wellbeing and relationships, and incurs huge social and economic costs. Appropriate support and care for victim-survivors can help to protect against these negative consequences. Around 90% of sexual offences are committed by someone known to the victim and for a variety of reasons, cases often remain unreported to the police. Many victim-survivors mistrust statutory services to respond to their needs. While underreporting is still common, the number of police records of sexual violence crimes has increased considerably over the last few years. There has also been an increase in demand for specialist support services. In part, these patterns are thought to be linked to improved police recording procedures and a growing awareness of sexual violence and abuse through high-profile cases and related social media campaigns. This surge in demand, and especially the need for support for non-recent sexual abuse, coincides with severe budget cuts, and where commissioning of support services has been devolved to local commissioning bodies. Commissioners require evidence-based guidance on which services they should be commissioning in order to best serve victim-survivors. Overall aims To provide a systematic map of available evidence on any specialist adult services for victim-survivors of sexual violence and abuse. We included: • studies of people’s views about services in the UK • evaluations of interventions (using controlled and before-and-after designs, and cost-effectiveness studies) from OECD countries, • systematic reviews containing these kinds of studies The map will signal where there are gaps in the evidence base and where there is potential for an in-depth review of evidence to guide decisions about services for victim-survivors. Review question What is known about the effectiveness and appropriateness (availability, acceptability and accessibility) of specialist adult services for people who have experienced sexual violence and abuse? Method We conducted searches of electronic databases; website searches; reference list harvesting and contacted topic experts to identify potentially relevant items. We applied exclusion criteria to screen all items on title and abstract alone, and then retrieved reports and screened the full-text of all records included at title and abstract stage. All studies included at full-text screening were coded to describe their main characteristics – for example, the study’s purpose (people’s views of services, evaluation to improve services, or reviewing other studies), its geographic setting, who had provided data, and which type of sexual violence and/or service was being explored. We held a stakeholder event to consult on the initial findings from the map with victim-survivor advocates, service providers and practitioners and policy representatives. Suggestions from this event informed further analysis and the structure for presenting the narrative about the studies identified. In addition to the narrative contained in this report, EPPI-Mapper software was used to produce online interactive maps to visually display the findings and allow users to see the detail of included studies. Stakeholder influence on the map The stakeholders’ feedback informed the later iterations of the coding tool – for example, the age categories and additional population and service characteristics that we captured. Discussions at the stakeholder event also helped us to distinguish between population subgroups when categorising the studies, and influenced the descriptive terms that we used to describe these sets. Stakeholders also highlighted forthcoming and recently published studies. Four were added to the review to be screened on full text, one of which was included in our map. Summary of findings Studies included in the map In total we included 163 studies in our systematic map: 36 views studies, 106 evaluation studies, and 21 systematic reviews. Studies of people’s views about services in the UK (n=36) Of the 36 UK views studies, 26 focused on targeted services for victim-survivors of sexual violence and 10 focused on adaptations that general services, such as maternity or health services, could make to meet victim-survivors’ needs. The studies which focused on targeted services (n=26) were further categorised into four groups: targeted services for a specific population subgroup (n=9); services for victim-survivors who have additional forms of disadvantage (n=8); services for any type of victim-survivor of sexual violence (n=5); and how victim-survivors needs are met by services across a broad range of provision (n=4). Specific victim-survivor population subgroup Studies in this group (n=9) focussed on services for: people who had experienced so-called ‘honour’ based violence (n=1); child sexual exploitation (n=1); childhood sexual abuse (n=1); ritual abuse (n=1); forced marriage (n=1); male rape (n=1); and female black and minority ethnic (BME) victim-survivors (n=3). Victim-survivors with additional disadvantage Eight studies (n=8) focused on populations with co-existing vulnerabilities or disadvantage, including: mental health and substance misuse problems; learning or physical disabilities; and women seeking asylum. Any victim-survivor Five studies (n=5) concentrated on specific types of services or roles that support all victim-survivors of sexual violence. These were mostly located in the statutory sector. Two addressed specialist provision in the criminal justice sector, and three addressed Sexual Assault Referral Centres (SARC), of which one was a comparison between SARCs and voluntary sector services. Victim-survivor needs in relation to broad provision of services Four studies (n=4) explored views on how any needs were met (or otherwise) by broader provision of services. Two of these were needs assessments across regional areas, one looked at ways to best deliver group work, and one explored the potential of co-production in Violence Against Women services in Wales. Adaptations (n=10) The remaining studies (n=10) addressed how general services, such as maternity, general healthcare, mental healthcare and the police could meet the needs of victim-survivors of sexual violence by way of adaptations. Evaluations of interventions to support victim-survivors of sexual violence (n=106) Evaluation studies were mainly US-based (n=62). Across all OECD countries, most evaluations aimed to assess a therapy for improving mental health outcomes (n=84). Other interventions included education for professionals (n=8) or victim-survivors (n=4), services such advocacy or police services (n=9) and secondary prevention of HIV among victim-survivors (n=1). Most evaluations reported quantitative findings about outcomes or impact (n=86), eight studies were qualitative evaluations of processes only, and 12 studies were evaluations of both outcomes and processes. All UK outcomes evaluations assessed types of therapies (n=4). We found eight UK-based process evaluations of: a national advocacy service in Scotland (two evaluations); a Rape Crisis Centre in Tyneside; training for mental health practitioners to improve practice around abuse histories; a pilot project to support victim-survivors of historic child sex exploitation in Leeds; a specialist sexual assault police investigation unit; and specialist services for female victim-survivors of childhood sexual abuse (two evaluations). Systematic reviews (n=21) The systematic reviews focused on four distinct population types of victim-survivors of sexual violence including those who had experienced: female genital mutilation (FGM) (n=8), sexual violence including rape and sexual assault (n=6), sexual abuse as a child (n=5) and human trafficking (n=2). Most reviews (n=16) examined the effectiveness of interventions. The types of interventions reviewed were predominantly mental health and psychological interventions to reduce post-traumatic stress disorder (PTSD) and improve psychosocial wellbeing (n=11). The other five intervention reviews addressed early intervention; non-surgical responses to FGM; the role of the forensic examiner; educational interventions to increase awareness of sex trafficking among healthcare professionals; and interventions to reduce HIV and sexually transmitted infections. Three reviews explored views and experiences of service-users and two explored the views of professionals about skills and attitudes. Included studies were conducted in different countries with the majority in the US, while only 15 out of 309 studies were conducted in the UK. Gaps in the evidence We identified no effectiveness or cost-effectiveness studies of UK specialist services for victim-survivors of sexual violence. UK views studies focussing on a range of perspectives and populations were included in the map. However, only one study looked at male victim-survivors. This study sought professionals’ views only, so we did not locate any studies which addressed male victim-survivors’ views. Stakeholder group Stakeholders described research conducted in the US as being of limited relevance to their own practice. Information on cost-effectiveness and cost-saving was highly sought after by stakeholders, although it was understood to be scarce. Service providers wanted to know the best way to spend their money, and indicated they would value a review examining which therapies, counselling or service referrals are most effective, in which contexts, and also the benefits of specialist service provision in the voluntary sector over those provided by a generic health provider. Stakeholders expressed their interest in evidence relating to pathways and referral, relationships between commissioners and providers, the effects of cuts to services, access to services, access to mental health services, suicide risk, and service waiting lists and “turn-away” rates. Outcome measurements relating to empowerment and feeling in control, relationships, and ability to work and study were all seen as important ways of assessing victim-survivors’ recovery. Implications and conclusion We identified a lack of evidence on the effectiveness (and cost-effectiveness) of UK statutory and voluntary specialist services for victim-survivors of sexual violence. However, a lack of evidence should not be interpreted to mean that these services are not effective. We identified eight process evaluations and a range of UK views studies which give insight into the views and experiences of victim-survivors and the professionals that support them. Some studies focus on services that serve all types of victim-survivor of sexual violence, whereas others focus on different subgroups of victim-survivor populations (BME women, people subjected to sex trafficking ‘honour’-based violence and forced marriage) and victim-survivors who have additional vulnerabilities or disadvantage (women with mental health or substance misuse problems, women who are disabled, women seeking asylum). These sets of UK studies warrant quality appraisal and in-depth synthesis or syntheses which could provide a nuanced understanding of UK victim-survivors’ service needs across a range and population subgroups and types of sexual violence