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 (University College London) 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."
*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