Where do those experiencing sexual violence seek help and is routine enquiry acceptable within a sexual healthcare setting? Findings from a population-based survey Original research

Sexual violence (SV) has substantial physical, psychological, social and economic impacts. Certain groups, including women, racially and sexually minoritised communities, and disabled people, are at higher risk. Despite increased public awareness (for example, the #MeToo movement), SV remains stigmatised and underdisclosed to healthcare services, with most victims not seeking medical care. Healthcare settings can provide immediate medical care, STI testing, pregnancy prevention, safeguarding and referral to specialist services (such as sexual assault referral centres, SARCs), yet public awareness of SARCs is low. This study aimed to understand where people would seek support after SV, evaluate perceptions of sexual and reproductive health services (SRHS) as a setting for support, and assess the acceptability of routine enquiry about SV within SRHS.

Prior research shows low rates of healthcare utilisation after SV (for example, approximately one-fifth of US adult women seek medical care post-assault). Disclosure to healthcare providers can be acceptable and beneficial when responses are validating and supportive, but optimal strategies to facilitate disclosure, including routine enquiry, remain unclear and evidence is limited and often focused on women. Barriers to help-seeking include stigma, myths around 'real rape' and 'legitimate victims', and mistrust in the police and justice system, particularly among minoritised groups. Specialist third-sector organisations (for example, Rape Crisis) provide advocacy and long-term support, with many users being adult survivors of childhood sexual abuse. Help-seeking preferences likely vary by SV type, life stage and individual characteristics, suggesting a tailored rather than 'one-size-fits-all' approach is needed. Awareness of SARCs is low despite their role in forensic and medical care. Disability is associated with higher SV prevalence and may shape help-seeking preferences (for example, preference for primary care due to established relationships).

Design: Cross-sectional, online population-based survey in England, UK, following the Consensus-Based Checklist for Reporting of Survey Studies (CROSS). Development: Items were informed by literature review, interviews with individuals who had experienced SV, and input from an expert advisory group (patient advocates, researchers, healthcare staff). A statistician advised during the design phase. Face validity testing involved 10 advisors/researchers to assess clarity, length (<15 minutes), and completeness. Pilot: 7-day online pilot (6–12 January 2022) with 300 participants; interim analysis informed minor wording/order changes. Pilot data were included in the final analysis. Sampling and recruitment: The survey was distributed via Dynata’s online panel (~600,000 UK residents). Quotas ensured diversity: age (≥5% aged 18–24; ≤10% aged ≥55) and ethnicity (≤85% white British; ≥1% black), reflecting national census distributions. Eligibility: Adults aged ≥18 years residing in England. Data collection: 19–31 January 2022; minimum target n≥2000. Format: Mobile-/tablet-/desktop-compatible; participation rewarded via e-rewards. Ethics and consent: HRA approval granted (27 July 2021; RG_19-102 SA01). Anonymised data; online informed consent; support contacts provided. Confidentiality: No direct contact between researchers and respondents. Survey content: Three sections with optional responses: (1) demographics; (2) knowledge of services and preferred support locations after SV; (3) history of SV (including 'not sure' with follow-up reasons) and opinions on what supports safety in SRHS following unwanted sexual activity. Routine enquiry: Assessed support for being routinely asked about 'sexual activity that was not agreed to' in SRHS, contingent on four prerequisites: safety, confidentiality, staff training, and option to decline. Non-support reasons captured via multiple-choice and free-text. Outcomes: Primary—first-choice and top three choices for support after SV; acceptability of routine enquiry in SRHS (in-person and via telephone). Secondary—awareness/use of SRHS; experiences disclosing SV in SRHS, primary care, SARC, and ED via 5-point Likert scales (felt believed; felt blamed; glad disclosed; felt safe/supported). Analysis: Descriptive statistics summarised demographics, prevalence, and preferences. Group comparisons used chi-square tests for nominal variables and Mann–Whitney U for ordinal variables. Paired comparisons of disclosure experiences across settings used Wilcoxon signed-rank tests (restricted to respondents with experiences in both settings). SPSS v28 used; two-sided p<0.05 considered significant. Handling missing/ambiguous responses: 'Not sure' and 'prefer not to say' excluded from specific analyses unless noted. For SV history, 'not sure' responses were combined with 'yes' based on provided reasons indicating likely SV occurrence.

Sample: 2007 respondents; majority white ethnicity (85.5%), female (62.3%), heterosexual (87.0%); 14.2% disabled; 72.4% in an intimate relationship. Prevalence of SV: Of 1960 respondents answering SV history, 27.1% (n=532) reported SV; an additional 4.5% (n=89) were 'not sure'. For analyses, 'not sure' combined with 'yes' yielded 31.7% (621/1960). Among those reporting SV, 37.0% (210/567) experienced SV in childhood. SV prevalence was higher among younger respondents (p<0.001), females (p<0.001), sexually minoritised respondents (p<0.001), and disabled respondents (p<0.001). Preferred places for support after SV: Overall, police were the most frequent first choice (n=520; 25.9%). Police inclusion in top three: 62.1% (n=1246). Rape Crisis in top three: 47.1% (n=946). SARCs were sixth overall: included in top three by 31.2% (n=626); first choice for 5.1% (n=102). Respondents with SV history were less likely to choose police as first choice than those without SV history (17.2% vs 29.9%, p<0.001). In the SV-history group, first-choice rankings: Rape Crisis/similar charity 24.0% (n=149), primary care 20.8% (n=129), police 17.2% (n=107), SRHS 8.5% (n=53). SV-history respondents were more likely to choose SRHS (8.5% vs 5.2%, p=0.004) or to tell no one (5.8% vs 3.2%, p=0.007). Sociodemographic associations with first choice: Police as first choice less likely among younger (p<0.001), non-white (p=0.034), and disabled (p=0.015) respondents; in multivariable analysis, younger age (p<0.001) and SV history (p<0.001) remained independent predictors of lower police selection, while non-white ethnicity (p=0.105) and disability (p=0.103) were not significant. SRHS first choice was more common in males (p=0.019), non-white respondents (p=0.002), and younger respondents (p<0.001). SARC first choice was more common in younger respondents (p=0.001). Primary care as first choice was more common among disabled respondents (p<0.001). Awareness and use of SRHS: 84.9% (n=1703) had heard of SRHS; 44.7% (n=898) had attended. Awareness that SRHS offer SV support: 51.3% (n=1030). Experiences disclosing SV in healthcare settings (among those with such experiences): In SRHS (n≈180–183): felt believed—77.6% scored 4–5; felt safe/supported—71.7% scored 4–5; felt blamed—61.0% scored 4–5 (note reversed scale); glad disclosed—73.6% scored 4–5. Paired comparisons with primary care, SARC, and ED showed no significant differences across settings. Routine enquiry about SV in SRHS: Support when attending SRHS was high (84.4%; n=1693). Non-support reasons included preference to let patients decide (n=156), potential to upset patients (n=102), perceived irrelevance to SRHS (n=30), and time constraints (n=23). Support for routine enquiry was higher among respondents with SV history (87.3% vs 83.6%, p=0.037), younger respondents (p<0.001), those with non-heterosexual orientation (p<0.001), and those in intimate relationships (p=0.045). Support during telephone consultations was lower but still majority (71.8%; n=1441), with 14.0% unsure.

The study demonstrates that while many people indicate they would seek support after SV, preferred sources vary markedly by prior SV experience and sociodemographic characteristics. Overall, police were a common first choice; however, younger people and those with prior SV were less likely to prefer police, instead favouring Rape Crisis or primary care, which may reflect trust, perceived needs, or previous experiences. Disabled respondents were more likely to prefer primary care, possibly due to established therapeutic relationships and holistic support. Awareness of SRHS was high but only half knew SRHS provide SV support; SARCs ranked relatively low, highlighting potential gaps in public awareness and alignment with survivor priorities. Experiences of disclosure across healthcare settings were broadly similar, underscoring the potential for multiple healthcare entry points to provide supportive care. High acceptability of routine enquiry within SRHS—especially among younger, sexually minoritised, and SV-experienced respondents—suggests that, with appropriate safeguards (safety, confidentiality, trained staff, and option to decline), routine enquiry could increase disclosure and facilitate timely support. The findings support a tailored, trauma-informed approach that considers age, gender, ethnicity, disability, sexual orientation, and SV history, rather than a one-size-fits-all model.

SV was reported by 27.1% of respondents (31.7% including 'not sure'), indicating substantial lifetime prevalence. Although many respondents would seek police support, younger individuals and those with SV histories were less likely to do so, preferring Rape Crisis or primary care. Public awareness of SRHS as a source of SV support is modest, and SARCs may lack visibility. Routine enquiry about SV is highly acceptable in SRHS, especially among those most affected, though acceptability declines with age and is lower for telephone consultations. The study supports introducing routine enquiry in SRHS contingent on staff training, safety and confidentiality processes, and clear referral pathways, and emphasizes the need for tailored, trauma-informed services that address diverse needs and trust concerns across sociodemographic groups. Future research should optimise implementation of routine enquiry, improve public awareness of SARCs, investigate reasons some respondents felt blamed after disclosure, and explore the specific needs and preferences of disabled survivors and other minoritised groups.

Key limitations include: self-selected online sample requiring device access, likely skewing towards higher socioeconomic groups; overrepresentation of females relative to census; use of 'prefer not to say' and 'not sure' categories, with some necessary grouping (for example, 'not sure' about SV combined with 'yes'), potentially introducing misclassification; lack of detail on type/severity or timing of disability; hypothetical nature of many help-seeking responses for those without SV experience; potential misinterpretation of one Likert item (felt blamed) due to reversed scale direction; and exclusion of some cases from specific analyses where responses were missing/ambiguous.