Disease outbreaks put the health of us all at risk; however, some people continue to be at higher risk than others. The COVID-19 pandemic is a global disaster that has severely disrupted the lives of populations all over the world, and women and girls are disproportionally affected in times of conflict and crisis (Spangaro et al, 2013). Disasters exacerbate pre-existing gender inequalities and power hierarchies. With this, increased incidences of sexual violence may worsen as prolonged quarantine, social isolation and economic stressors increase tension inside and outside the home. Women and girls have been, and at times continue to be, isolated from the people and resources that can help support them, and they will have few (if any) opportunities to distance themselves from their abusers.
This article presents the challenges that people experiencing sexual violence face during the COVID-19 pandemic and suggests ways to improve practice in this period.
What is sexual violence?
Sexual violence is a term that covers various serious violent crimes—it means that someone forces or manipulates another person into unwanted sexual activity without their consent. It is important to note that in some cases of sexual violence an individual may not be aware that they are experiencing coercive/manipulative behaviour from another individual, so identifying and managing issues of consent can be exceptionally difficult.
Box 1 lists some of the criminal actions and behaviours that are recognised as sexual violence and abuse (Ministry of Justice, 2020). These crimes have devastating effects on an individual's immediate and long-term health and psychological wellbeing.
Sexual violence is not discriminatory of age, sex, religion, race, social status or class—all of society can be at risk of experiencing this; however, it remains a gender-based crime with women and girls being at greatest risk. The World Health Organization (WHO, 2017) estimates that globally 1 in 3 women have experienced either physical and/or sexual intimate partner violence or non-partner sexual violence in their lifetime. One-quarter of women in the UK aged 18-24 years have reported experiencing sexual abuse in childhood (Radford et al, 2011), with 1 in 5 women having been subjected to some form of sexual violence since the age of 16 years (Office for National Statistics (ONS), 2018).
Male sexual violence reporting is increasing within England and Wales, with current statistics (of reported rape, no other forms of sexual violence included) estimated to be around 12 000 (ONS, 2018); this compares with 1135 in 2005 (Hammond et al, 2016).
Research suggests that lesbian, gay, bisexual, transgender and queer (LGBTQ) individuals are at increased risk of sexual violence compared with their heterosexual, cisgender counterparts (Messinger and Koon-Magnin, 2019). Alongside this, the transgender community has seen a 53% rise of violent crime, including sexual assault and rape (Young, 2016). According to one study, 1 in 8 LGBTQ women experienced serious sexual assaulted or rape within the workplace. These statistics were even higher for black and minority ethnic (BAME) women, and disabled men and women, with 45% reporting sexual assault and 1 in 4 reporting serious sexual assault or rape (Trades Union Congress, 2019). Additionally, LGBTQ+ members of BAME communities seem to be particularly vulnerable to sexual violence, used as a form of ‘honour’-based violence to reassert control over them (Harvey et al, 2014).
The statistics presented above are difficult to confirm because the main survey exploring this information in the UK does not ask questions surrounding ethnicity. In addition, the anticipation that online sexual violence will increase is not unrealistic because people have more time to utilise private web resources through periods of lockdown.
Sexual coercion—or the act of putting pressure on someone physically, psychologically, financially or otherwise to manipulate or force them into engaging in sexual activity (Sathyanarayana Rao et al, 2013)—is of great concern while people are spending more time at home online. It is especially difficult to monitor and regulate online the issues of legal age and consent.
It is clear that statistics on sexual violence are difficult to determine and verify, although increased recording of these statistics is becoming more common across all the UK nations by both support agencies (public sector and charities/voluntary organisations) and the wider UK governments (ONS, 2018; Northern Ireland Statistics and Research Agency, 2019; Scottish Government, 2019). This has begun to give greater insight into the monumental scale of all types sexual violence today. That said, it is impossible to accurately measure the prevalence of sexual violence in the UK.
There are many challenges to understanding the prevalence of sexual violence, including:
Therefore, it is important to recognise that up to a staggering 5 in 6 survivors may decide not to disclose their experience (Brooker and Durmaz, 2015; ONS, 2018). However, previous research has suggested that survivors will disclose their experiences to at least one person at some point, and that more than often this will be a friend or family member (Dunn et al, 1999; Fisher et al, 2003; Ahrens et al, 2007; Ullman, 2010; Ullman and Peter-Hagene, 2014).
During periods of lockdown, and as these are eased, it is important to remember that individuals at risk will not have had access to the social support that can so often provide essential psychological care as readily as they would have normally. Sexual violence is a substantial and severe cause of psychological trauma, the consequences of which can include:
It is crucial not to overlook the importance of this social support for individuals and to recognise that without it survivors may be struggling psychologically.
Sexual violence in the context of COVID-19
Increased gender-based violence is a hidden ramification of the COVID-19 pandemic. As communities around the world face unprecedented uncertainty and follow their governments' guidance to stay at home or reduce contact with friends and family, women and girls are placed at heightened risk of domestic violence, intimate partner violence, child abuse, and other forms of sexual and gender-based violence.
It should be noted that lockdown may have also provided a protective effect for some of those experiencing or who are at risk of sexual violence from someone they do not live with (eg a non-cohabiting partner, or travel restrictions in the case of FGM (female genital mutilation), sexual trafficking or forced marriage). As lockdown eases, these risks will again rise.
Past epidemics have demonstrated that violence against women can increase in scale because of the ensuing social and economic consequences (Onyango et al, 2019). Sexual violence is about power and control, and when the perpetrator experiences a lack of control or fears surrounding job security, finances and social life, this element of violence may intensify. Similarly, with fewer people on the streets during periods of lockdown, and as we move in and out of these phases, perpetrators may be considering how to target their victims. Around 90% of those who experience sexual violence have known their perpetrator (Brooks-Hay, 2019) and, as social gatherings become more frequent, the numbers of these crimes are expected to rise.
As the governments of the four UK nations restrict movement and ask people to stay at home, reports of domestic abuse and child abuse have increased. Some organisations are seeing a dramatic rise in calls to domestic abuse helplines. For example, the domestic abuse helpline charity Refuge (2020a) reported a 50% increase in calls to its helpline over the 2 months after the start of lockdown and a more than 300% increase in visits to its helpline website, and subsequently a 66% increase (Refuge, 2020b).
Although UK Rape Crisis organisations have not reported a dramatic rise in the number of calls since lockdown measures began up to the time of writing (October 2020), data from Rape Crisis Network Ireland (2020) showed a 98% rise from March to June 2020 of the number of contacts made by survivors seeking support.
For many, home is not a safe place. The increase in risk is not unique to the UK and is a reported risk among societies worldwide, including China, Italy, Cyprus and Spain (Bradbury-Jones and Isham, 2020; Roesch at al, 2020). Many adults and children may feel trapped ‘at home’ (some will not be in their own home) and unable to escape or seek refuge. There will also be a risk for some people calling helplines when the perpetrator may be able to hear or eavesdrop on the call, potentially escalating the violence.
All the UK governments have acknowledged that measures announced to tackle COVID-19 (stay at home) could cause anxiety and other mental health challenges for those who have experienced sexual violence and abuse, and worsen the suffering of those currently experiencing or feel at risk of sexual violence and abuse.
During periods of lockdown, not only is it harder for healthcare workers to screen for sexual violence and abuse due to reduced access to health services, the reassignment of staff and reduction in staff numbers due to social isolation/distancing rules, but also because referral pathways to care have been severely disrupted. The impact of this could be catastrophic. In relation to a global pandemic such as COVID-19, during which schools and workplaces have been closed and police and emergency service provision is often less resourced or targeted elsewhere, the severity of sexual violence cannot be ignored. As already mentioned, vulnerability in crisis can be exacerbated due to a lack of available support and a social network (John et al, 2020).
Currently, the UK national guidance of COVID-19 restrictions and measures are changing fast. At time of writing, the new national lockdown will inevitably increase exposure to abuse and limit access services, with survivors once again faced with difficulties in finding support.
Accessing services is also bounded by uncertainty, fear of infection, strained resources and anticipation of social distancing measures in health and social care settings, which may prevent people from seeking help and lessen the ability to build therapeutic relationships that might encourage disclosure. The professionals who would normally pick up signs of sexual violence or be in a position whereby someone might disclose an experience of sexual violence to them have either been restricted in going to their workplaces or patients' homes, or have restricted workloads and clinics (nurses, doctors, midwifes, allied health professionals and health visitors).
Once restrictions are relaxed, priorities of care may be focused on working remotely, and catching up with cancelled consultations, as opposed to having time to pick up social cues and discuss and probe around holistic needs. Video and telephone consultations have become more common in health care during lockdown and look set to become a part of everyday working for health professionals. Although this can prove beneficial to some (for example, decreased travel time and exposure to people), there are many challenges for staff and patients in disclosing sexual violence (eg limitations to recognising personal cues, perpetrators being in the house, worries about internet security).
It is essential that healthcare staff are aware of these risks, can recognise indicators of abuse, and offer tangible advice and support. This is not an area of care that should be overlooked. However, it is recognised that asking questions about such sensitive topics can come out of context of the patient's attendance.
Having an assessment tool that allows for ‘routine’ questions about sexual violence opens up the dialogue for all. When considering the statistics presented above, this approach is as essential as asking whether someone smokes or how many units of alcohol they drink a week.
Support services
Each of the four UK governments has its own support agencies in their sexual violence support pages. Box 2 lists a selection of agencies that people who have experienced sexual violence can contact online and by telephone, and which also provide further resources.
| Scotland | |
|---|---|
| 24-hour Domestic Abuse and Forced Marriage Helpline | 0800 027 1234 |
| Rape Crisis Scotland | https://www.rapecrisisscotland.org.uk |
| List of support agencies for female survivors | https://www.mygov.scot/rape-assault/support-for-female-victims |
| List of support agencies for male survivors | https://www.mygov.scot/rape-assault/support-for-male-victims |
| Northern Ireland | |
| List of support agencies for survivors of sexual violence | https://www.nidirect.gov.uk/articles/support-services-victims |
| Nexus NI | https://nexusni.org |
| Domestic and Sexual Abuse Helpline | 0808 802 1414 |
| England and Wales | |
| The Survivors Trust | www.thesurvivorstrust.org |
| Rape Crisis helpline and Live Chat Helpline | www.rapecrisis.org.uk |
| Victim Support | www.victimsupport.org.uk |
| Welsh Woman's Aid | https://www.welshwomensaid.org.uk |
| Samaritans | https://www.samaritans.org |
| Safeline | https://www.safeline.org.uk |
| Forced Marriage Unit | 0207 008 0151 |
| Home Office guides | |
| Three steps to escaping violence against women and girls. A guide for black and minority ethnic (BME) women and children | https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/97923/english-3-steps.pdf |
| Female genital mutilation | https://www.gov.uk/government/collections/female-genital-mutilation |
As health professionals, safeguarding should always be considered and assessed throughout a consultation. Not all episodes of sexual violence may trigger a safeguarding referral. However, should this be a concern, the safeguarding adults and children service within the health professional's organisation will provide invaluable advice and guidance.
Sexual health services will offer practical support surrounding infection testing and emergency contraception, and signposting for support services including Sexual Assault Referral Centres (SARCs). SARCs offer immediate specialist medical, forensic, practical and emotional support for anyone who has been raped or sexually assaulted, regardless of whether the survivor chooses to report the offence to the police. The centres have specially trained staff who will help people make informed decisions about what they want to do next. It is essential that healthcare staff know where their local SARC is and have the contact details readily available (to find a local centre, go to https://tinyurl.com/nhsuk-sarc and enter the postcode or town). Every step of your support/management should be discussed with the survivor.
Not all service users will be willing to disclose their experience or discuss their risk of sexual violence, and having non-face-to-face resources is essential for signposting and providing support at arm's length. Box 3 lists some of the resources that can be provided to signpost survivors.
Having these resources will also allow the survivor to know your service is a supportive environment for them to access help and advice should they decide to disclose face to face with a practitioner.
The Social Care Institute for Excellence (2020) suggests in relation to interpersonal violence that a ‘twin-track’ approach is paramount and includes:
Furthermore, for a length of time many providers will be working remotely, so it is important that engaging with people who have experienced sexual violence and sharing information continues regularly and in creative ways, safely and securely.
Recommendations
In the current climate it is important to consider how healthcare services can adapt to encourage disclosure and support people experiencing sexual violence. Although the NHS is under extreme pressure, with COVID-19 challenging the capacity of services, there are steps that should be considered to help reduce the risk and effects of sexual violence.
Each of the four UK governments needs to identify and resource services that encourage disclosure and support victims of sexual violence. These services need to be accessible to people in a time when different parts of the country are under different lockdown measures, ranging from social distancing to advice to stay at home, where possible. Many third sector organisations have had their funding cut dramatically over the past 10 years, and are having to work in new ways that will be challenging and costly. The UK governments must look at how these services can be best supported to provide the provision that is so desperately needed.
Health professionals should consider how practice might use telemedicine effectively to encourage disclosure, offer support and provide treatment to people who experience sexual violence, yet acknowledge that, in cases where the individual is living with their abuser, this can be challenging, and staff need to be aware of not increasing the risk of abuse.
There are already some apps being utilised, such as Hestia's Bright Sky (https://www.hestia.org/brightsky)—which provides information and support to anyone in an abusive relationship. More research into the effectiveness of telemedicine for delivering care to people experiencing sexual violence is necessary to enable services to move forward in times such as this. Individual practitioners need to be supported and guided on the available evidence and services for people experiencing sexual violence.
Supporting survivors of sexual violence can be emotionally challenging for health professionals, and they may have anxieties with regard to a wide range of issues, including:
It is essential that healthcare staff are supported when dealing with this topic—accessing support from colleagues and seeking supervision where necessary is essential.
Organisations' safeguarding adults and children's teams can provide help and guidance to healthcare staff supporting survivors of sexual violence, both pre- and post-disclosure.
It may not be only professional support that those engaging with survivors of sexual violence will need during and after supporting them. Meeting the needs of these individuals can trigger personal feeling towards this topic and you may not wish to disclose your own past experience(s) within your work environment. Should this be the case, consider accessing your own GP service for advice and guidance on where you can seek support. You can also contact Rape Crisis which provides counselling for those recently and historically affected by sexual violence. Other areas of confidential support could be your workplace occupational health department, NHS talking therapies self-referral and private psychological support agencies.
It is important that we learn from the past and strive to create a more supportive environment for people who are disclosing experiences of sexual violence. In particular when the world is in crisis, many services are put on hold, and survivors' voices continue to be silenced.