Friday, September 05, 2014

40% of Women with Severe Mental Illness Are Victims of Rape or Attempted Rape

This statistic is sad, but it's not at all surprising. I would wager that number is low. But when you add childhood physical abuse and neglect, and those with narcissistic mothers or primary caretakers, we're edging up to 100%. Interestingly, 60% of the women with SMI were given a schizophrenia diagnosis.

This article is open access, and I have included the discussion and conclusion sections below.

40% of women with severe mental illness are victims of rape or attempted rape 

September 4, 2014

Women with severe mental illness are up to five times more likely than the general population to be victims of sexual assault and two to three times more likely to suffer domestic violence, reveals new research led by UCL and King's College London funded by the Medical Research Council and the Big Lottery.

The study, published in Psychological Medicine, found that 40% of women surveyed with severe mental illness had suffered rape or attempted rape in adulthood, of whom 53% had attempted suicide as a result. In the general population, 7% of women had been victims of rape or attempted rape, of whom 3% had attempted suicide. 12% of men with severe mental illness had been seriously sexually assaulted, compared with 0.5% of the general population.

The findings are based on a survey of 303 randomly-recruited psychiatric outpatients who had been in contact with community services for a year or more, 60% of whom had a diagnosis of schizophrenia. They were interviewed using the British Crime Survey questionnaire for domestic and sexual violence, and their responses were compared to those from 22,606 respondents to the 2011/12 national crime survey. The results were adjusted for a wide range of socio-economic factors including age, ethnicity and marital status.

"The number of rape victims among women with severe mental illness is staggering," says lead author Dr Hind Khalifeh of UCL's Division of Psychiatry. "At the time of the survey, 10% had experienced sexual assault in the past year, showing that the problems continue throughout adulthood. Considering the high rate of suicide attempts among rape victims in this group, clinicians assessing people after a suicide attempt should consider asking them if they have been sexually assaulted. Currently this is not done and so patients may miss opportunities to receive specialist support."

Men and women with mental illness were also found to be more likely to be victims of domestic violence than the general population. Domestic violence includes emotional, physical and sexual abuse.* 69% of women and 49% of men with severe mental illness reported adulthood domestic violence.

Domestic violence from family members (other than partners) made up 63% of total domestic violence cases against psychiatric patients compared with 35% of the general population. "Most domestic violence prevention policies for adults focus on partner violence, but this study shows that interventions for psychiatric patients also need to target family violence," says Dr Khalifeh.

The study shows a strong association between mental illness and sexual and domestic violence, but the direction of causality is not certain. In some cases, experiences of violence may have contributed to the onset of mental illness. However, violence experienced in the past year would have been after diagnosis of severe mental illness since all participating patients had been under the care of mental health services for at least a year.

The results were adjusted for drug and alcohol use in the past year, but this did not significantly affect the outcomes and causality is hard to determine. Drug and alcohol use may increase the risk of being a victim, but equally victims of violence may turn to drugs or alcohol as a way of coping.

Senior author Louise Howard, Professor in Women's Mental Health at King's College London, says: "This study highlights that patients with severe mental illness are at substantially increased risk of being a victim of domestic and sexual violence. Despite the public's concern about violence being perpetrated by patients with severe mental illness, the reality for patients is that they are at increased risk of being victims of some of the most damaging types of violence."

Article adapted by Medical News Today from original press release.

H. Khalifeh, P. Moran, R. Borschmann, K. Dean, C. Hart, J. Hogg, D. Osborn, S. Johnson, and L. M. Howard. (2014, Sept 4). Domestic and sexual violence against patients with severe mental illness. Psychological Medicine; Open access publication.

*Definitions of domestic and sexual violence are given below:

Domestic violence: Emotional, physical or sexual abuse (as defined below) perpetrated by partner (boyfriend or girlfriend; husband, wife or civil partner) or family member other than partner (parents, children, siblings or any other relatives) 

Emotional abuse: perpetrator did any of the following: (a) Prevented them from having fair share of money (b) Stopped them from seeing friends or relatives (c) Repeatedly belittled them so they felt worthless (d) Threatened to hurt them or someone close to them (e) Threatened them with a weapon or threatened to kill them 

Physical violence: perpetrator did any of the following (a) Pushed them, held them down or slapped them (b) Kicked, bit or hit them, or threw something at them (c) Choked or tried to strangle them (d) Used some other kind of force against them 

Sexual violence: perpetrator did any of the following in a way that caused fear, alarm or distress: (a) Indecently exposed themselves to them (b) Touched them sexually when they did not want it (e.g. groping, touching of breasts or bottom, unwanted kissing) ( (c) Forced them to have sexual intercourse, or to take part in some other sexual act, when they made it clear that they did not agree or when they were not capable of consent (Serious Sexual Assault). 

We divided sexual violence by perpetrator into sexual domestic violence (perpetrated by partner or family members) and sexual non-domestic violence (perpetrated by strangers or acquaintances). The control study sample was randomly divided into two groups with slightly different questions on the perpetrator of sexual violence - such that it was possible to estimate domestic sexual violence in the whole study sample, and non-domestic sexual violence in only half the sample. We were able to estimate these subtypes for the entire patient sample. 

Adverse impact of serious sexual assaults (SSA): SSA led to one or more of the following: 
(a) Physical injuries / illness: Minor bruising or black eye, scratches, severe bruising or bleeding from cuts, internal injuries or broken bones/ teeth, other physical injuries, contracting a disease, becoming pregnant 
(b) Psychological/social problems: Mental or emotional problems, such as difficulty sleeping/ nightmares; depression; low self-esteem; stopped trusting people / difficulty in other relationships; stopped going out 
(c) Suicide attempt
Source: UCL (University College London)

* * * * *

 Here is the discussion and conclusion from the article, which is certainly worth looking at.


This study compared the prevalence of domestic and sexual violence against patients with SMI under the on-going care of mental health services with a general population control group, and found a high prevalence and markedly excess odds of these experiences among patients with SMI. Among domestic violence victims, family violence was experienced by a greater proportion of SMI than control victims. Women with SMI were more likely to attempt suicide as a result of SSA than female victims without SMI, and more likely to disclose sexual violence to health professionals and the police.

The prevalence estimates for domestic and sexual violence among women with SMI are in line with previous studies (Goodman et al. 1997; Teplin et al. 2005; Hughes et al. 2012). To our knowledge, no past studies have compared domestic violence in psychiatric patients with a general population control sample (Oram et al. 2013). We found that people with diagnosed SMI in contact with psychiatric services had 2- to 4-fold elevated odds of all subtypes of domestic violence (emotional, physical and sexual) compared to the general population. These findings suggest that clinicians should routinely enquire not just about physical domestic violence, but also emotional and sexual abuse – especially given the increasing evidence that emotional abuse may have a greater health impact than physical violence (Yoshihama et al. 2009; Jewkes, 2010). The relationship between experiencing violence and SMI is likely to be bi-directional (Danielson et al. 1998; Chen et al. 2010; Jonas et al. 2014), but we report increased risk of recent violence occurring after illness onset. In this study, substance misuse appeared to account for a proportion of the excess violence risk, and may be a suitable target for intervention, although the direction of causality is unclear, since being a victim can lead to increased substance misuse as a coping mechanism (Coker et al. 2002).

We found that family violence comprised a greater proportion of overall domestic and sexual violence experiences among victims with SMI than general population victims (Krug, 2002). People with SMI are known to have elevated risks of childhood maltreatment, and abuse by family members, including parents, may extend into adulthood (Varese et al. 2012). Most domestic violence prevention policies among working-age adults have focused on partner violence, but our findings suggest that interventions among patients with SMI also need to target family violence.

We detected a 6- to 8-fold elevation in the odds of sexual assault among both men and women with SMI. This is lower than the 17-fold risk reported in a recent US study (Teplin et al. 2005), but we adjusted for a broader range of confounders, and included estimates for lifetime rather than just past-year sexual assaults (where prevalence is low and estimates are imprecise). Half of the women with SMI who experienced SSA reported attempting suicide as a result of these experiences. In patients with SMI, suicide attempts may be seen as a direct result of acute psychotic relapse (Fialko et al. 2006), with under-detection of trauma and related post-traumatic stress disorder as a trigger for suicidal behaviour.

The finding of substantially elevated risk of domestic and sexual violence victimization among patients with SMI mirrors the findings of a high prevalence of all types of victimization, including violent crime by strangers or acquaintances (Bengtsson-Tops & Ehliasson, 2012; Katsikidou et al. 2013), as well as non-violent crime such as thefts, burglaries and criminal damage (Teplin et al. 2005). Future research should explore shared and unique risk factors for these victimization experiences, in order to guide effective interventions. Patients with an abuse history may benefit from trauma-focused psychological therapy (Warshaw et al. 2013; WHO, 2013b). These interventions have an evidence base in non-psychiatric populations, mainly in antenatal or accident and emergency settings, but their effectiveness for patients with SMI has not been fully explored (Mueser et al. 2008).

Among victims of sexual assault, a higher proportion of SMI than control victims reported their experiences to the police, but there is evidence that they are often disbelieved and discriminated against within the criminal justice system (Hester, 2013; Pettit et al. 2013). Only 43% of patients had disclosed their experiences to a healthcare professional, despite the fact that this patient population had received intensive support from psychiatric services for at least a year in order to be included in the study. Health professionals often fail to detect trauma histories in patients with SMI, or where they do detect it, they often fail to address it in patients’ management plans, (Howard et al. 2010; Nyame et al. 2013). This may lead to treatment resistance for the primary mental disorder (Mueser et al. 2002). There is therefore a need for interventions that improve detection of violence by healthcare professionals, and the provision of subsequent support. There is evidence from a pilot study that a complex intervention which includes reciprocal training of mental health and domestic violence sector professionals, and a care pathway with integrated advocacy services, can improve detection and outcomes of domestic violence among psychiatric patients (Trevillion et al. 2014). Our findings suggest the need to include screening and support for sexual assaults in such interventions. Effective interventions would require joint working with voluntary sector organization and the criminal justice system (Krug, 2002; WHO,

Strengths of this study include: the large randomly selected sample; reliable, validated measures of violence experiences; hypothesis-based analyses and careful adjustment for confounders. We adjusted for a broader range of confounders than most previous related studies (Hughes et al. 2012; Oram et al. 2013), including adjustment for demographics and individual/area deprivation. We also explored potential mediation by substance misuse. One limitation is the lack of data on violence perpetration among controls, so we could not adjust for the potential mediating effect of this factor.

Potential limitations include the cross-sectional nature of the study, which precludes firm conclusions about direction of causality. All patients had been under the care of mental health services for more than 1 year, so by definition past-year violence would have occurred after the onset of SMI (notwithstanding measurement error). Nonetheless the causal direction remains uncertain, since patients with SMI may have had historical victimization experiences, which may put them at risk of recent violence.

The response rate was somewhat low at 52%, but we researched a sensitive topic in a hard-to-reach population. Although domestic and sexual violence are sensitive topics for any group, they may be even more sensitive and complex for patients in secondary mental healthcare to discuss. This is because this particular group suffers from stigma related to violence risk (Link et al. 1999), and may worry about additional consequences of disclosure such as involuntary hospital admission (Pettit et al. 2013). We used a rigorous random sampling procedure rather than a convenience sample (unlike many previous related studies) (Hughes et al. 2012; Oram et al. 2013), and nonresponders had the same demographic profile (in terms of age and sex) as participants. We did not have additional details on the characteristics of nonresponders, so it is difficult to comment on the likely magnitude and direction of non-response bias.

It is worth noting that this study relates to patients with SMI in contact with secondary mental health services, so the findings may not generalize to those with similar mental disorders who do not require on-going psychiatric care. In national UK surveys, two thirds of patients with a diagnosis of a psychotic disorder were found to be in contact with mental health services (McManus et al. 2010). Those in contact with services may be at increased risk of victimization, due to a potential excess of risk factors such as social isolation, substance misuse or violence perpetration.

The crime survey definition of domestic violence does not have sufficient detail on context, severity and frequency to allow a distinction between recurrent, controlling severe abuse and incidents of violence reflecting relationship couple tension (Johnson, 2006). Reporting bias is possible, since patients and controls may have different thresholds for disclosing violence, although there is no evidence to suggest that people with SMI over-report these experiences (Goodman et al. 1999). Residual confounding is possible. This general population control sample may have included a small proportion of people with SMI (<3%) (Health and Social Care Information Centre, 2013) although the effect of this would have been to have biased the ORs closer to the null. We compared a London-based patient sample with a national control sample (to ensure adequate power), but violence prevalence did not differ by region of residence in the control group (ONS, 2013). The findings from the sensitivity analysis, which compared patients to London-based controls, were consistent with those comparing patients to national-based controls.


Men and women with SMI who are under the on-going care of psychiatric services are 2–8 times more likely to experience sexual and domestic violence than the general population, with a high relative burden of family violence. Women with SMI are more likely than women in the general population to suffer psychological ill health and attempt suicide following sexual assaults, but most do not disclose violence to healthcare professionals. Healthcare professionals need to work closely with the voluntary sector and criminal justice system in order to effectively address the high burden of violence in this population. Potentially effective support includes advocacy and trauma-focused psychological interventions (Mueser et al. 2008; Trevillion et al. 2014). Healthcare professionals need to consider victimization as a potential trigger for suicide attempts among patients. Future research should explore reasons for non-disclosure to healthcare professionals, and test the effectiveness of interventions to improve the detection of victimization and support offered by mental healthcare professionals.
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