The importance of routine enquiry about a possible history of sexual abuse or sexual violence

Thanks to Dr Ingrassia for her recent editorial on the Independent Inquiry into Child Sexual Abuse in the UK, particular her focus on the role of mental health services.¹ She cites the mental health trust's collaboration project commenced in 2006 but omitted to mention that since 2008 it has been a policy requirement that all those on the care programme approach are routinely assessed about their possible history of sexual abuse or sexual violence – so-called ‘routine enquiry’. However, training figures for routine enquiry obtained from National Health Service (NHS) mental health trusts indicate that in 2015 (and again in 2017) routine enquiry is becoming less likely in clinical practice and we argued that the policy needed re-invigoration.²

Sexual assault referral centres (SARCs) provide a one-stop health shop for those that report a sexual assault. The NHS England specification for the SARC service³ implies that a thorough mental health assessment should take place in a SARC not least because decisions should be made about the best mental health service to access if required: if risk is a concern the crisis team; if the client is known to mental health services maybe the community mental health team or child and adolescent mental health services; or possibly an Improving Access to Psychological Therapies service if trauma is not complex.

In our experience such pathways are seldom formally negotiated, in the main, mental health services rebuff many SARC referrals. This often leaves specialist voluntary sector counselling services overwhelmed as they take on not just individuals with ‘acute’ cases (those recently sexually assaulted) but those with historic abuse too. The new national strategy for sexual abuse and assault services proposes that integrated commissioning is required involving NHS England, Clinical Commissioning Groups, Police and Crime Commissioners, local authorities, the Ministry of Justice and the Home office with the creation locally of a new Sexual Assault and Abuse Services Partnership Board.⁴

The articulation of formal pathways for those experiencing trauma following a sexual assault is clearly an important task for these new commissioning boards. In a recent audit of a SARC service we found the following.⁵ In a sample of 105 people who consented to undertake a full assessment: 76% of the sample had seen a health professional for their mental health in the preceding 12 months with half being treated by their general practitioner but an important subgroup of people (31%) were being seen by a mental health professional most often a psychiatrist; nearly one-fifth of the sample (19%) had been previously admitted to a psychiatric unit where, on average, they had been admitted three times in total. The remainder of the sample without any previous history of mental health treatment was now, following the sexual assault, at risk of developing a mental health problem.

To conclude, as Dr Ingrassia stated, ‘the responsibility rests with the sensitive and well-informed clinician's ability to see past the presenting problem’ – maybe a willingness to assess in this manner is a prerequisite to better pathways between SARCs and mental health services in the future.