Authors: Holly Betterly, MD, et al.
Abstract: Sexual assault in the inpatient psychiatric setting is a significant problem with serious, lasting consequences. It is important for psychiatric providers to appreciate the nature and magnitude of this problem to be able to provide an appropriate response when faced with these challenging scenarios, as well as to advocate for the implementation of preventive measures.
This review of existing literature describes the epidemiology of sexual assaults in these settings, and explores the characteristics of both victims and perpetrators, with a particular focus on factors relevant to the inpatient psychiatric patient population.
Literature does not identify a way to reliably predict which patients are most likely to engage in sexually inappropriate behaviors on an inpatient psychiatric unit. But the medical, ethical, and legal challenges that such cases present are defined, followed by a review of current management and prevention strategies, and suggested future directions for research.
As is the case with sexual assault in the community, the prevalence of sexual assault in the inpatient psychiatric setting is likely underreported because of a wide range of challenges faced by both patients and staff, say the authors.
Patients may hesitate to report because of stigma, guilt, powerlessness, mistrust, concerns of being met with disbelief or retaliation, or fear of the perpetrator. Staff may hesitate out of concerns about legal implications, reliability of allegations, a culture of silence, or disbelief that such an incident could occur.
Sexual assault in the inpatient psychiatric setting presents a host of questions for providers, ranging from medical challenges (e.g., sexually transmitted infection and unintended pregnancy) to ethical challenges (e.g., how to approach an apparently delusional report of sexual assault), to legal challenges (e.g., civil liability and criminal litigation that arise from inpatient sexual behaviors).
This review aims to highlight the magnitude of the problem, illustrate the potential consequences, and outline future directions towards prevention and management strategies.
“As the field of Psychiatry continues to evolve from its paternalistic roots to person-centered care, the subject of patient sexuality remains in the dark,” say the authors. “Discussions with patients about healthy sexuality are not routine in Psychiatry. Many psychiatrists have not been trained, or are not competent in taking a sexual history or evaluating a patient’s sexual health. As a result, discussions with patients about sexual needs do not occur.”
Importance: Adults with a history of serious mental illness are at an increased risk of experiencing sexual violence, with rates two to eight times higher than in the general population. Given this increased risk, as well as the lasting consequences, sexual violence represents an area of serious concern for those who provide care to people with psychiatric disorders. Research indicates that 40% of community mental health outpatients have experienced sexual assault at some point during their adulthood, and between 5% to 45% of mental health inpatients have experienced sexual violence during an inpatient admission.
Availability: Published in General Hospital Psychiatry