This is a plain English summary of an original research article
Teenagers who have been sexually assaulted are at risk of mental health conditions and poor school performance, research found. The increased risk lasted for more than a year.
Adolescents are at higher risk of sexual assault than any other age group. This is also the time when mental health problems often start, and when young people take key exams and make decisions about university. However, little is known about the lasting impact of assault on teenagers’ mental health and education.
The study found that most teenagers who reported sexual assault had symptoms of post-traumatic stress disorder, anxiety or depression within 6 weeks of the assault. After 1 year, teenagers’ risk had reduced but was still high; more than half had symptoms of at least 1 of these conditions.
Among teenagers who reported sexual assault, poor school attendance became more likely over the following year. Poor attendance was twice as likely at 1 year than 6 weeks after the assault. The teenagers said that this was because of mental health problems and difficulty sleeping. Poor school attendance led to worse performance at school, which in turn increased anxiety and sleep problems.
The researchers say that schools need more help in supporting pupils who have reported sexual assault. They say that schools need training, and support to implement guidance.
What’s the issue?
Sexual violence is common in young people; 1 in 6 of those aged 11 to 17 said they have experienced sexual abuse. Social disadvantage (for instance, living in a deprived area) increases the risk, as does having learning disabilities or other vulnerabilities, such as previous mental health issues and living in care.
Most previous research into the effects of sexual assault has looked at adults. Traumatic events could have different effects during the teenage years, when the brain is still developing.
Teenagers who have been sexually assaulted are known to be more likely than their peers to develop mental health problems shortly after an assault, including post-traumatic stress disorder, anxiety and depression. They are more likely to have poor performance at school, have early or multiple sexual partners, and to have relationship problems with friends, families or partners. But studies have only looked at outcomes in the short term.
The World Health Organization has called for research into the long-term needs of children and adolescents who have reported sexual violence. This research team previously followed-up young people 5 months after an assault, and found a high proportion of mental health disorders. This risk was greatest in teenagers who had previous mental health problems, and those who had used social services before the assault.
In the current study, the researchers looked at the impact of an assault on adolescents’ physical and mental health and education over 14 to 16 months. They hope this information will inform support services on how to promote recovery, improve mental health and achieve better educational outcomes.
The study was carried out in the 3 NHS sexual assault referral clinics serving Greater London (the Havens). It included 75 adolescents (aged 13 to 17 years) who had reported a sexual assault within the past 6 weeks. Most (95%) were female and just less than half (44%) were White. Most (68%) came from deprived areas.
At the start of the study participants answered questions about their physical and mental health, use of health services, and education. They answered the same questionnaires just over a year later (14 to 16 months). 19 of the young people also had a face-to-face interview at the end of the study.
- Mental health problems affected many young people. Although some improved during the study, most of the group were still affected by the study end. After 1 year, 72% teenagers had post-traumatic stress symptoms (down from 90% at the start); 54% had depressive symptoms (down from 89%) and 60% had anxiety symptoms (down from 76%). Almost half (47%) of the teenagers received mental health support in the year before the assault; this increased to 80% in the year after.
- Physical symptoms, such as headaches and stomach pain, were more frequent in the year after a sexual assault than in the year before. Poor sleep became almost twice as likely, reported by 47% teenagers before the assault and 87% afterwards. Appetite changes almost tripled after the assault (rising from 27% to 75%). Many (65%) teenagers had accessed healthcare services for physical symptoms in the year before the assault; this increased to 82% in the year after.
- Self-harm was common in the year before the assault (38% teenagers), and even more likely afterwards (51%). 1 in 4 (25%) started self-harming after the assault (not all of those who had self-harmed before the assault continued to self-harm afterwards).
- Education was disrupted: long absences from school (over 30 days) more than doubled (from 22% to 47%) during the study period.
Teenagers’ social and personal circumstances had a greater impact on their recovery than the type of assault. Social services involvement before the assault (such as having experience of foster care) and previous mental health needs were linked to poorer mental health and school attendance a year after the assault.
In interviews, some teenagers said they were unable to leave their homes, or described feeling worthless, angry and stressed. One said: “I’d literally become violent with rage and anger, …and I remember kicking someone in their head, … I wasn’t a violent person, it’s just the minute someone said the word rape.” Another said: “I was just really down, really, really down, …at the time I didn’t have nothing that I enjoyed.”
Many teenagers said that tension increased at home after the assault. They felt they were not trusted by parents, or felt guilty for upsetting them. Those in sexual relationships had difficulties engaging in sexual activity afterwards. Their social withdrawal damaged friendships. Teenagers used recreational drugs and alcohol to distract themselves from unwanted thoughts, and self-harm as a means of coping.
Teenagers were concerned about the disruption to their education. Mental health conditions (such as anxiety and depression) and sleep problems caused them to miss school and made schoolwork difficult. Teenagers described a vicious circle: mental health conditions led to school absences, that caused stress and made mental health problems worse. Teens were reluctant to attend school if the person who assaulted them was a fellow pupil. They felt that schools did not know how to support them.
Why is this important?
Sexual assault led to worse performance at school, an increase in mental health problems, and social exclusion. Many teenagers in the study lived in disadvantaged areas, had previously received help for mental health and/or from social services, and needed extra support at school. 1 in 7 (14%) experienced a second assault by the end of the study, and the proportion who had been in foster care nearly doubled (from 18% to 32%).
The mental and physical health symptoms reported in this study were higher than in the general population. Young people who had been involved with social services, or who had mental health problems before the assault had worse mental health problems and worse school attendance afterwards. Sexual assault can therefore increase health inequalities in this already vulnerable group.
Where the attacker was a fellow pupil, teenagers were reluctant to attend school. Schools may be unable to exclude pupils while an investigation is under way. As a result, schools are often more likely to remove the young person who has been assaulted.
The researchers say schools need to:
- keep a young person safe at school without isolating them
- disclose sexual assault to social care or parents in a way that gives the young person a feeling of control over their confidentiality
- manage the behaviour of someone traumatised by an assault.
Schools need better support to achieve these aims and to handle sexual assault, the researchers say.
The Government provides guidelines to help schools manage reports of sexual assault. These have recently been updated (September 2022). The research team says that so far, the guidelines have made little difference to the problems faced by young people at their clinics. They suggest that schools need more training and support to implement the guidelines. Teenagers need support from different professionals to address their educational and emotional needs, and their risk of repeat assault.
Charities such as the National Society for the Prevention of Cruelty to Children and Barnardo’s can provide short-term help. Young people with ongoing mental health problems need the support of the NHS Child and Adolescent Mental Health Services. This service is currently stretched, and unable to meet demand. For young people in London, NHS England has provided additional funds for sexual assault hubs. These bring together medical, emotional and advocacy support for children and young people who have experienced sexual abuse, but they are still evolving in some areas.
Most teenagers in this study (92%) had been referred to the Havens service by the police. Larger studies, in wider geographical areas and among young people who have not reported or are not receiving support from specialist clinics, would be helpful. Many assaults, particularly those on adolescent boys, go unreported. The researchers say increased awareness could reduce stigma and help young people come forward if they have been assaulted.
You may be interested to read
This Alert is based on: Clarke V, and others. Medium‑term health and social outcomes in adolescents
following sexual assault: a prospective mixed‑methods cohort study. Social Psychiatry and Psychiatric Epidemiology 2021; doi: 10.1007/s00127-021-02127-4.
The research paper by the same team that looked at the shorter-term impact of sexual assault in these participants: Khadr S, and others. Mental and sexual health outcomes following sexual assault in adolescents: a prospective cohort study. Lancet Child and Adolescent Health 2018;2:9.
The charity Rape Crisis England & Wales provides help and support for people who have been sexually assaulted.
Funding: This project was funded by the NIHR Policy Research Programme.
Conflicts of Interest: The study authors declare no conflicts of interest.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.