Bethel C. #MeToo: the perfect storm needed to change attitudes toward sexual harassment and violence. Harvard Public Health Review. Fall 2018;16.

We need to be less afraid to ask people about their experiences of abuse.

Claire Bethel, independent consultant, former Deputy Director, Children and Young People’s Mental Health and Well-Being, Department of Health

The #MeToo and #TimesUp campaigns have led to calls for a radical change in attitudes to harassment, sexual violence, and abuse. These campaigns have not been uncontroversial—claims that we risk applying today’s standards to yesterday’s behavior have evoked huge antipathy.

That sexual harassment is engrained in our social ethos is exposed in surveys of school-aged children, with over one third of girls in mixed-sex schools personally experiencing sexual harassment at school.[1.National Education Unit and UK Feminista 2017, ‘It’s just everywhere’: a study of sexism in schools and how we tackle it. http://ukfeminista.org.uk/wp-content/uploads/2017/12/Report-Its-just-everywhere.pdf] Emerging technologies have enabled new forms of harassment, such as increasingly common and damaging online abuse[2.Hamilton-Giachritsis C, Hanson E, Whittle H, Beech A. ‘Everyone deserves to be happy and safe’: a mixed methods study exploring how online and offline child sexual abuse impact young people and how professionals respond to it. NSPCC, University of Bath, University of Birmingham, National Crime Agency. November 2017. https://www.nspcc.org.uk/globalassets/documents/research-reports/impact-online-offline-child-sexual-abuse.pdf] and ‘up-skirting’ – with calls for the latter to be made a criminal offence.[3. https://www.independent.co.uk/news/uk/crime/upskirt-photos-law-illegal-criminal-offence-needed-campaigners-statistics-10-girls-children-police-a8218491.html] Sexual violence and abuse are wide-ranging – from sexual abuse and exploitation to rape and modern-day slavery for sexual purposes. Despite the impact on all, sexual violence remains a gendered crime, with more girls and women affected, reflecting misogynistic and patriarchal attitudes inherited from ages past. Recent outcry over the proposal by the Parole Board to release from prison a serial ‘black cab’ rapist led to a judicial review, which overturned the decision,[4.https://www.judiciary.gov.uk/wp-content/uploads/2018/03/dsd-nbv-v-parole-board-and-ors-summary.pdf] raising the complex question of what can be done to protect the public from proven perpetrators who may re-offend.

 

How Widespread Is Sexual Violence?

Sexual violence may be described as a hidden epidemic, with low rates of prosecution and conviction, and considerable stigma associated with disclosure. Official statistics estimate that 20% of women and 4% of men in England and Wales have experienced sexual assault since the age of 16 — 3.1% of women and 0.8% of men in the past year.[5.Sexual Offences in England and Wales – Year ending March 2017. Office for National Statistics. https://tinyurl.com/y834hhwa] Approximately 1.3 million children in England will experience child sexual abuse by the age of 18.[6.Office of the Children’s Commissioner, Protecting children from harm: a critical assessment of child sexual abuse in the family network in England and priorities for action. Summary: November 2015. https://www.childrenscommissioner.gov.uk/wp-content/uploads/2017/06/Protecting-children-from-harm-executive-summary_0.pdf] Around 5 in 6 victims do not report their experiences to the police[7.Sexual Offences in England and Wales, op cit.]; there has, nevertheless, been a significant increase in police-recorded sexual offences, reflecting improved recording and a greater willingness to come forward.[8.Overview of violent crime and sexual offences. Office for National Statistics.]

 

Recent Inquiries

Recent attention has focused on historic abuse of children, some committed by high-profile, previously revered celebrities; organisational abuse; and child sexual exploitation, leading to numerous inquiries. The Independent Inquiry into Child Sexual Abuse has launched 13 investigations into a range of institutions, including the army, BBC and local authorities, looking at failures to protect children from sexual abuse.[9. https://www.iicsa.org.uk/about-us] The recently-exposed phenomenon of systematic grooming and sexual exploitation of children by organised networks has led to inquiries in places as far apart as Derby, Oxford, Rotherham and Devon. An unintended consequence of this is the downplaying of the unarguably more prevalent familial sexual abuse[10.The Office of the Children’s Commissioner’s Inquiry into Child Sexual Abuse in the Family, Protecting children from harm: A critical assessment of child sexual abuse in the family network in England and priorities for action (2015). Final Report, p3.]; only approximately 1 in 8 cases come to the attention of statutory agencies[11.Ibid page 4], despite the damage inflicted as a result of abuse from caregivers, which may be lifelong and severe.[12.Fergusson D. M., McLeod G. F. & Horwood L. J. (2013). Childhood sexual abuse and adult developmental outcomes: Findings from a 30-year longitudinal study in New Zealand. Child abuse & neglect, 37(9), 664-674 https://psycho-trauma.nl/wp-content/uploads/2015/11/Fergusson-McLeod-Horwood-2003.-30-year-longitudinal-study-child-sexual-abuse-in-New-Zealand.pdf]

 

Why Is It Important?

The impact of sexual violence is significant. Victims experience consequences throughout the life course, frequently retraumatised through revictimization, as they experience different kinds of abuse as a consequence of their vulnerability[13.Classen C, Palesh O G, Aggarwai R, Sexual revictimization, a review of the empirical literature. Trauma, Violence and Abuse http://journals.sagepub.com/doi/pdf/10.1177/1524838005275087 (2005)]. There are obvious impacts on mental health, including depression and post-traumatic stress disorder.[14.H. Khalifeh, P. Moran,R. Borschmann, K. Dean et al, Domestic and sexual violence against patients with severe mental illness Psychological Medicine, Volume 45, Issue 4, pp 875-886, March 2015. https://www.cambridge.org/core/journals/psychological-medicine/article/domestic-and-sexual-violence-against-patients-with-severe-mental-illness/A7787F698B3B2FBAEA8172A34F3CF246] Others include physical sequelae, such as injury and sexually transmitted infections[15.Berelowitz, S. et al. “If only someone had listened.” The Office of the Children’s Commissioner’s Inquiry into Child Sexual Exploitation in Gangs and Groups Final Report. London: Office of the Children’s Commissioner. https://www.childrenscommissioner.gov.uk/wpcontent/uploads/2017/07/If_only_someone_had_listened.pdf Appendix 3 (2013)] The long-term economic effects are also significant; the estimated lifetime cost of rape—for the victim, statutory agencies and society—is estimated at $122,461 per victim.[16.Peterson C, DeGue S, Florence C, Colby N, Lokey MS. Lifetime economic burden of rape among US adults, American Journal of Preventive Medicine 2017: 691-701]

 

Developments in England

The thrust of public policy and services is on prevention, protection, disruption, penalties, and support for victims, with agencies encouraged to work collaboratively at strategic and operational levels through multi-agency fora. Successive governments and the London Mayor have published comprehensive strategies on Violence Against Women and Girls.[17.Ending violence against women and girls strategy 2016-2020, HM Government, https://tinyurl.com/gmyu68g][18.A safer city for women and girls: the London tackling violence against women and girls strategy 2018-2021, London Mayor, https://www.london.gov.uk/sites/default/files/vawg_strategy_2018-21.pdf. March 2018.]The importance of Adverse Childhood Experiences (ACEs)—including abuse—is increasingly recognized as a predictor of future life chances, including physical health.[19.Bellis M, Lowey H, Leckenby N, Hughes K, Harrison D. Adverse childhood experiences: retrospective study to determine their impact on adult health behaviours and health outcomes in a UK population. Journal of Public Health Volume 36 Issue 1 (March 2014) pp 81-91] The Parliamentary Science and Technology Select Committee is currently addressing the evidence linking adverse childhood experiences with long-term negative outcomes[20.https://www.parliament.uk/business/committees/committees-a-z/commons-select/science-and-technology-committee/news-parliament-2017/evidence-based-early-years-inquiry-launched-17-19/] to see what can be done to improve treatment of mental health conditions associated with these experiences.

 

Challenges

Challenges in tackling sexual violence include fiscal constraints due to austerity, with local governments set to lose the majority of central government grants.[21.https://www.nao.org.uk/wp-content/uploads/2016/11/Overview-Local-government.pdf] Central government funding to the Voluntary and Community Sector tends to be short-term, such as the Tampon Tax, which allocates £15m a year generated by taxation on sanitary products to support disadvantaged women, including those affected by abuse.[22. Department for Culture, Media and Sports, https://tinyurl.com/yba47cjs] This causes major issues regarding the sustainability and capacity of the sector that remains vital in providing support to victims of sexual assault, and many charities in the sector are struggling for survival.[23.See https://www.independent.co.uk/news/uk/home-news/harvey-weinstein-rape-sexual-assault-allegations-rape-crisis-survivorsuk-a8080456.html] It is difficult for practitioners to deliver evidence-based interventions which promote recovery in a complex and rapidly-changing commissioning system with multiple providers, limited funding and escalating demand fuelled by increased publicity, including the #MeToo movement.[24.Ibid]

 

Policy Implications

Developments in recent years include investment in a Sexual Assault Referral Centre in every police force area in England; the appointment of Independent Sexual Violence Advisers to improve outcomes for victims in the immediate aftermath of rape; and a pilot of the first Child House for child victims of sexual abuse and exploitation, modelled on the US Child Advocacy Centers[25. A safer city for women and girls: the London tackling violence against women and girls strategy 2018-2021, London Mayor, op cit, page 82.]. The English Government introduced routine inquiry in 2003 so that all women are asked about their experiences of violence and abuse in mental health assessments.[26.http://webarchive.nationalarchives.gov.uk/20120503230231/] A major report in 2015 on children’s mental health[27.‘Future in Mind: Promoting, protecting and improving our children and young people’s mental health and wellbeing’. Department of Health, NHS England (March 2015)] recommended that sensitive inquiry is extended to young people in line with approved clinical guidelines.[28.National Institute for Health and Care Excellence (2014). NICE public health guidance 50.https://www.nice.org.uk/guidance/ph50/chapter/1-Recommendations#recommendation-5-create-an-environment-for-disclosing-domestic-violence-and-abuse]] And yet, while there is recognition of the relevance of history of abuse to the patient, there is little evidence of mental health professionals covering child sexual abuse during assessments.[29.Hepworth I, McGowan L. Do mental health professionals enquire about child sexual abuse during routine mental health assessment in acute mental health settings? A substantive literature review. Journal of Psychiatric Mental Health Nursing, 2013 Aug:20(6): 473-83. https://www.ncbi.nlm.nih.gov/pubmed/22702227] Furthermore, only 22% of abused mental health service users were found to receive abuse-focused therapy.[30.Agar K, Read J. What happens when people disclose sexual or physical abuse to staff at a community mental health centre? International Journal of Mental Health Nursing. https://doi.org/10.1046/j.1440-0979.2002.00230.x]

Sexual harassment and violence are everybody’s business, starting with prevention through education to change attitudes from infancy to promote prosocial behavior, tackle misogynistic attitudes and encourage children to report abuse as espoused by the NSPCC in their ‘Let’s Talk Pants’ campaign.[31.NSPCC https://www.nspcc.org.uk/preventing-abuse/keeping-children-safe/underwear-rule/] Practitioners working in health and social care services need to be trauma-informed in their approach—more aware of the impact of sexual violence and abuse on an individual’s health and wellbeing. Training and leadership are needed to overcome reluctance to ask about abuse, and services delivering evidence-based interventions should be available to follow disclosure.[32.NatCen, Guidance for Trust managers, Implementing and sustaining routine enquiry about violence and abuse in mental health services. Responding effectively to violence and abuse (REVA project) Briefing 2. October 2015. http://natcen.ac.uk/media/1057975/REVA_Brief-2_Guidance-for-Trust-managers_FINAL_071015.pdf]Routine inquiry provides the opportunity to disclose that many victims have sought for years—a vital first step on the road to recovery.

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