Sexual assault centers: Attendance rates, and differences between early and late presenting cases

Introduction

Sexual assaults (SA) are a risk to health 1–3, affecting far more victims than previously imagined. European lifetime prevalences of SA in females from late adolescence are estimated at 6–16% (lowest estimate excluding partner perpetrators; highest including attempted penetration, rape and forced intercourse) with annual incidences between 1 and 2% 4–7. SA are still under-reported to health services and police 3–10. Self-referral sexual assault service centers (SACs) have been established in several countries. In the Nordic countries most SACs are free of charge, organized within emergency or gynecology wards and offer medical care, psychological support and standardized forensic examination prior to the victims’ decision to involve police. Because of the short- and long-term health risks associated with SA, most SACs aim to publicize their existence and encourage attendance. A second aim is to provide adequate documentation for legal purposes.

The few SAC-based studies where attendance rates can be estimated disclose a considerable variation from 17 to 49/100,000 inhabitants (all ages and both genders) (Table I) 11–14. This variability probably reflects that only selected groups of victims are seen at SACs, even at those with the highest attendance rates. Most assaults are perpetrated by partners or other known persons, strangers being responsible for only 10–25% 4–7. However, among cases seen at SACs, assaults by strangers account for 40–70% of cases (12, 13), (15, 16). In addition, many SACs report mean or median ages of victims as being ≥25 years 11–15, (17), whilst in population surveys the age group 16–24 years is most at risk (4, 6), (18, 19).

This skewed sampling may partly be due to time limitations prevalent at SACs. As a major aim of SACs has been to provide forensic medical examination (FME), several SACs restrict their service to cases attending in time for trace evidence collection, and these cases command most attention in SAC-based studies. There is a paucity of studies on victims who present later, at some time after the assault.

We present a two-year series of cases seen at an urban, self-referral SAC serving a defined catchment area and admitting late-presenting victims. The main aims of the study were to describe attendance rates, to estimate the quantitative gap between cases seen and those actually occurring, as well as to explore differences between early and late presented cases, and services requested in those groups.

Material and methods

The study was based on retrospectively collected data from cases seen in 1996 and 1999 at the Sexual Assault referral Center in Oslo, Norway, and from corresponding police files. The study was approved by the National Data Inspectorate, the Regional Research Ethics Committee and the Committee for Secrecy and Research (for the judiciary system).

This SAC serves the entire Oslo population of about 500,000, and is integrated within the city's main outpatient emergency ward. Established in 1986, and originally intended for acute cases of sexual assault, the SAC no longer adheres to strict time limitations. All victims are offered a 3–4-month follow-up and are referred to other services if appropriate.

The years 1996 and 1999 were chosen because the first author was already familiar with the majority of cases through practical work at the SAC during these two years. Using cases from several years back was necessary to ensure that all cases were legally complete.

The annual number of cases was approximately 150 during the first 11 years up to 1997 and stabilized at 205±15 after 1998. Consequently, the years embraced by this study were considered representative.

Data regarding medical, forensic, and counseling casework were gathered from standardized SAC files. Variables with respect to assaults were based on victims’ descriptions and categorized as follows:

As this SAC served a defined population, attendance rates could be calculated, both for the total population and the female population most at risk (i.e. a more accurate means of comparing, eliminating bias due to differences in age and gender profiles within populations). Population data were obtained from Statistics Norway (see http://www.ssb.no). Cases registered with the police were traced through national police registers. Initially the identities of victims were cross-checked against the national population register. Several victims were found to have died, with cause of death not given. The year of death was noted.

Results

A total of 354 (146 + 208) cases were seen in 1996 and 1999, respectively, resulting in attendance rates of 30 and 41/100,000 (Table I); female attendance rates being 90 and 122/100,000. The mean age of victims was 27.5 years (range 13–85; 80% 16–34 years). Six percent of victims were male. The 21 males were more often than females exposed to multiple and stranger perpetrators, and four subjects were mentally handicapped.

Excluding vague cases, 0.07% of the female population 24–55 years consulted the SAC in 1999, while according to an open survey in this population, 1% had suffered rape, 2% rape or forced sex and/or attempted rape in 2002 (7). Assuming these comparable, the proportion between those seen and those actually victimized was estimated between 3.5 and 7%. Attendance rates for victims 14–23 years were 0.31%, and the population incidence is unavailable for this group.

A total of 180 (50.7%) were registered with the police. In total, 238 FME and 283 medical examinations were carried out; 300 victims received counseling. Twelve victims refrained from further treatment after receiving brief information regarding available services.

Almost half of the victims had vulnerability factors or disabilities, with prior sexual violation being the most frequent (Table II). Drug/alcohol addicts had more often experienced prior abuse and included all but one of the prostitutes. Among the 349 victims, 19 (5.4%) were deceased by 2005 (mean 3 years after SAC consultation, range 0–7 years). Eight among the subsequently dead had an addiction problem, two were diagnosed with fatal somatic disease, and one with psychosis. Two were more than 80 years old; excepting these, the average age at SAC visit was 29 years (range 20–59).

Sexual assault types are shown in Table II. Most victims had experienced non-consensual penile penetration. Multiple perpetrators were reported by 18%; all unknown or peripherally known to the victim. A total of 50% of assailants were strangers, 9% a current or former partner. Those unable to inform on assailants were either suffering from mental disability (9 cases) or amnesia. Only 48 cases fitted the ‘rape stereotype’.

Discussion

The center has expanded within its existing capacity, and a need for differentiated services for later attendees has become evident.

The attendance rates show that 0.9–1.2/1,000 of the female population aged 14–55 years visited the Oslo SAC annually, with one in five arriving later than one week post-assault. These rates are fairly high when compared to other studies (Table I), also when specified for early arriving or police-registered cases. Despite these rates there may be a wide gap between cases seen and those actually occurring. Regarding females 24–55 years, cases seen at SAC are estimated to represent 4–7% of all likely assaults. Younger victims show higher attendance rates. Still, the gap for these may be as wide since they are more at risk (4, 6), (18, 19). In Reykjavik, Iceland the SAC has reported considerably higher attendance rates for those 16–20 years of age (12). Studies addressing help-seeking behavior report that 10–36% of victims of sexual/domestic violence seek medical aid (4, 6), (9, 10, 20), but few have specified intervals post-assault or type of institution consulted. Given the difficulties in achieving accurate comparison, the estimated gap does not seem disproportionate.

We assume that cases not seen at the Oslo SAC in many aspects resemble our late cohort as young age, exploitation by partners or acquaintances, being subjected to pressure/verbal coercion, are also prominent in population surveys. Additionally, certain groups facing stronger taboos or particular risk are likely to be under-represented at SAC. These include males (21), homosexuals (22, 23), non-Western ethnicities (20% of Oslo's population were of non-Western origin in 1996/1999), the physically or mentally handicapped (24), persons with severe mental illness (25) and addicts (26).

Consequently, any SAC series tends to represent a narrow and skewed selection of actually occurring assaults. By including the late presentations the skew may be reduced.

Studies on help-seeking behavior provide additional information for understanding the pattern of self-selection for attending a SAC. Reasons stated for attending include physical injuries (4, 9, 10), fear of infection/pregnancy or need for further referral (9, 10, 27) and social expectations and expectations of help (27). Victims of assaults by strangers (9, 10, 28) and those reporting to the police are more likely to accept and receive medical aid (10).

Reasons given for not seeking help include embarrassment, a desire to forget, fear of not being believed, wanting secrecy, fear of physical examination and not perceiving any need (9, 27, 29). Known assailant and current use of recreational/addictive substances are associated with not seeking care (10). In Oslo, despite advertising the SAC, we found that many victims were unaware of its existence, were uncertain whether their particular case belonged to the target group or were not aware of the possibility to obtain help without police involvement (30).

In short, five issues seem important for attendance: Obvious medical or forensic reasons, awareness of SAC services, social support, rape stereotypes and trauma sustained. Stereotypes may prevent victims from identifying the assault as such (6, 26), 30–32. Actually, 40–57% of women subjected to assaults meeting the legal definition of rape, do not define the act as rape. If perpetrated by a partner, the proportion is 70% (6, 33). Traumatic situations like SA elicit changes in cognitive function, such as confusion, disturbed processing of information, indecisiveness, post-assault avoidance reactions (embarrassment, avoiding reminders, suppression of memories), as well as guilt and shame. Such reactions prevent victims from disclosing the assault, and must be overcome if victims are to seek assistance. Myths of rape, blaming the victim, contribute to reluctance.

To arrive early at a SAC, victims must quickly recognize the assault and seek assistance, or confide with someone who is able to act on their behalf. Most early presenting victims were escorted to the SAC, suggesting that confiding is important for early help-seeking. About two-thirds of victims inform someone, mainly friends and relatives (4, 6, 8) – half at an early stage. The preponderance of unknown perpetrators in early cases corresponds with previous research; victims of strangers are more likely to seek help 8–10, (28). In suspected and unclear cases victims may seek clarification. Victims with an addiction problem are probably under-represented, but tend to arrive early if at all.

Our results confirm the association between FME/medical examination and police reporting (10), but do not clarify if use of these services are interdependent.

The frequency and severity of injuries corresponded to other Western studies 12–15, (34). Injuries sustained may facilitate attendance as they correspond to the stereotype of force or constitute proof, even if medical treatment is seldom required.

Of early presenting victims 85–90% accepted counseling and baseline tests for STD/pregnancy. A substantial proportion of these victims were referred elsewhere and most hospitalizations derived from this cohort. This suggests that fear of infection/pregnancy and need for referral are important reasons for early attendance. However, only 55% of those medically examined returned for follow-up and final sexually transmitted diseases testing. Actually, most SACs achieve a 30–60% compliance with follow-up (15, 35, 36). Non-compliance may be a symptom of avoidance, common following psychological trauma, and alliance-building and active outreach are important counteracting strategies (30, 36).

Among the late presentations there was a preponderance of young age, penetrative assaults, acquainted assailants, and verbal coercion. Several factors may contribute to this pattern, including unawareness of the SAC or of the possibility to seek socio-medical help only. Victims may initially think they will cope or consider their physical/mental injuries too trivial for professional intervention. Non-consensual penile penetration has a significant traumatic effect (1) and the preponderance of penetrative assault amongst late presenters may indicate serious trauma and persisting need for help. Non-stereotypic assaults are difficult to define, delaying exposure. Adolescents are more influenced by rape ‘myths’ (32), and more often suffer non-stereotypical and alcohol/drug-associated assault (18, 32). Alcohol/drugs are viewed elsewhere as obstacles to expose the assault (10). This study could only confirm a strong association between assaults and inebriants.

Help-seeking seemed the dominating motive for late consultation as only one-third had involved the police. According to Oslo police statistics, half of all reporting rape consult a physician, and a quarter report later than a month post-assault (37). A police routine of referring all complainants of sexual assault to SAC, irrespective of post-assault interval, might increase the numbers assisted and provide more medicolegal documentation.

In order to increase attendance rates extensive public information is mandatory (30). Victims and those in whom they confide need to know where to turn and what services may be obtained at a SAC, where the primary aim is to provide help, irrespective of police involvement. Similar information should be directed toward professionals encountering victims in schools, health- and social agencies, or within the police services. Information strategies should aim at reaching those particularly at risk, as well as those with extra barriers against attendance. It should be emphasized that SAC deals with a variety of SA, not only rape. Furthermore, facts to contradict stereotypes, as well as information about trauma reactions, should be conveyed.

This study comprised all consecutive victims from a self-referral SAC covering a defined population, where the prevalence/incidence of SA has been studied previously and thus gives a broadly informative overview. The few victims included twice are unlikely to introduce substantial bias in a series like this. However, the retrospective study design and data collected from victims under varying degrees of stress, create variations in the detail recorded and makes it more difficult to assess vulnerability. A prospective design could provide more complete case information, but the problem of victims unable/unwilling to disclose details would persist.

The establishment of SACs is a measure likely to improve attendance after sexual assault. An agreement upon presentation of defined attendance rates would enable inter-center comparisons. Strengthening services for victims of sexual assault is justified, considering the ensuing health risks reported to a largely young victim population, many of whom come from highly vulnerable groups with a considerable psychiatric morbidity and mortality within the next years after sexual assault. The services should accept late presenters, and public and professional knowledge must be improved on this and other aspects of sexual assault.