Preventing sexual harm on mental health wards

01 February 2021

We are joined by Dr Amar Shah and Rachel Luby to discuss the statistics, safety and stigma surrounding sexual harm. A report published by the Care Quality Commission found there were 1,120 instances of sexual harm on mental health wards.

In response to the CQC report, The National Collaborating Centre for Mental Health (NCCMH), commissioned by NHS England, created guidance to improve sexual safety in inpatient settings. Dr Amar and Rachel will be letting us know what the next steps are. Find out more information about the NCCMH's Sexual Safety Collaborative.


Ella: Hello and welcome to the Royal College of Psychiatrists podcast with me Ella Marchant. In our conversation today, we will be discussing sexual harm on mental health wards and the work the College is doing to ensure patients, staff, and visitors, on in-patient wards feel safe. Naturally, there will be references to sexual incidents which may upset some listeners. A report published by the Care Quality Commission in 2018 found they were 1,120 instances of sexual harm involving both staff and patients. There were 29 alleged rapes and many other instances including exposure, nakedness, and verbal abuse using sexual language.

In response to the CQC report, the National Collaborating Centre for Mental Health, commissioned by NHS England have recently published guidance to improve sexual safety in in-patient settings and ensure that everyone, patients, staff, and visitors are safe from all types of sexual harm. Today, we're speaking to Dr Amar Shah, National Lead for the Mental Health Safety Improvement Program, and Rachel Luby, a mental health nurse whose Let's Talk About Sex initiative is already transforming care. We started with Dr Amar explaining what exactly is sexual harm.

Dr Amar: Sexual harm is when you feel uncomfortable, frightened, or intimidated in a sexual way by anybody in the health care environment. We recognize that this can come from a range of different types of activities so that it includes sexual harassment, sexual assault, or other types of sexual incidents too, such as witnessing something which makes them feel uncomfortable or sexually unsafe. There's quite a range of different potential activities or observations that can lead to someone feeling unsafe from sexual harm. Ultimately, it's about us making sure that everyone can feel safe, and being free from feeling uncomfortable, frightened, or intimidated in a sexual way by somebody that's in or near the vicinity in the health care setting. That's what we mean by being safe from sexual harm.

Ella: Amar could you tell us a little bit more about the statistics surrounding sexual harm on mental health wards which can shed some light on the scale of the problem?

Dr Amar: The statistics about sexual harm give us one sense of how prevalent this type of harm might be. When we look at the numbers of reported incidence, that's when people complete a DATIX form or something similar, it shows that about 3% of all of the incidence in mental health settings are related to sexual harm. We think that's probably an underrepresentation of how often people do feel unsafe or when they feel uncomfortable, frightened, or intimidated in a sexual way because lots of these incidences are probably going unreported at the moment. That's part of the reason why we're taking a quality improvement approach which encourages people to be more aware of when these particular experiences may be occurring and find simpler ways for us to understand how often they are actually occurring in our settings.

Ella: Today, we're talking about the sexual standards which have been created by the NCCMH. Rachel, how have these standards been created?

Rachel: Hi, and thank you for having me. I can tell you certainly about how I was involved in the creation of the standards and that was as part of the quality focus group. I actually joined that not as a mental health practitioner but actually as a woman and a user of mental health services, and someone that has experience being a survivor of sexual violence. What we did, we met in-person quite regularly and we discussed the proposals as they were being written up via email. As one would hope, the group was really diverse and it represented all of the protected characteristics.

As the project went on and I spoke a little bit about Let's Talk About Sex and the work that we was doing in East London Foundation Trust, I actually became part of the expert reference group as well. This was a group made up of experts in the field who already have some knowledge and some experience around sexual violence, and also trauma. That's something that I'm really passionate about in terms of ensuring that the services that we work in and that we may access are inclusive of everyone, including those with trauma histories. I think that if we include someone with a trauma history or a history of sexual violence then we tend to include everybody.

Ella: Absolutely. Rachel, you're a frontline member of staff, how do you want these standards to be applied in an in-patient setting?

Rachel: What's really important is that these standards are one way of us all going toward a trauma-informed approach. I know certainly, in the case of female in-patients, up to 50% are already survivors of sexual harm. It's about routine inquiry of all patients when they're admitted to hospital, and also when they're in the community about what their experiences are with trauma but also what safety means to them. It's about looking at an environment with I guess a critical eye and seeing what we can do to prioritize safety, promote trust and peer support, and empower people but also give a voice and choice.

Something that we have done in East London Foundation Trust is having leaflets so that when a person is admitted we already start that conversation about trauma, and about harm, and giving people voice. Whether that's whether to be admitted to-- In East London Foundation Trust, all our wards are single-gender but for other trusts, it will be about whether the person has a preference on single-sex or mixed-gender wards. If they do need to be restrained, how we can best do that. I think that that's about recognizing that traditionally and currently, our environments are places where people can be re-traumatized.

Although we tend to shy away from acknowledging that restraint can happen, we need to acknowledge, one, that it does. Two, that it can and does cause harm for everyone involved. Three, actually, there are ways that we can make it better. It's asking someone, "If we have to hold you, how can we do that in a way that is most sensitive?" Whether that's about having a beanbag, or if a person has a preference for female staff or male staff. Or whether it's in prime whether it's a prime restraint. It's about staff that are prepared to have those conversations around both sexual health and sexual safety.

It's about recognizing that we need to move from a place where diagnosis might overshadow somebody's distress or discomfort. Just having that awareness that we don't have all the answers but there are external services that do exist and often more than willing to come into our service and support us or somewhere where we can signposts our patients to. It's also about having policies and procedures. Traditionally, if there has been an incident around sexual violence the response is inconsistent because there isn't something that we are able to follow, in terms of both the practical response but also the emotional response.

Ella: You mentioned there that 50% of women admitted to inpatient settings, like mental health wards, have experienced sexual harm and assault. How important is it for staff who are on the wards to know someone's history before they're admitted?

Rachel: I actually think that's a really important question because actually, I don't think it's important at all. The reason I say that is although routine inquiry is vital, not every person is going to be willing or able to disclose. Something I've spoken about is my personal experience with sexual violence. I actually didn't tell a single mental health professional for over 12 years. Rather than putting the onus on the patient to make that disclosure, it's actually about coming from the approach where we assume everyone may have had experience of one, trauma but two, sexual trauma.

I think just being aware that those statistics can be really helpful. We're not just looking at our patients. The staff that we work with, visitors that come into contact with the service, and of course, first and foremost, our patients, they are all likely to have some kind of trauma history and they are certainly a lot more likely to have a sexual trauma history. Instead of a person having to make that disclosure, we just assume and we look at what we can do to create environments that are inclusive of someone that may or may not have been a survivor or a victim of sexual violence.

Ella: Thank you so much for explaining that. I understand completely now that what you're saying is, rather than having a patient disclose or have to disclose, it's more that staff members are prepared and trained.

Rachel: Yes, training is really important. Certainly, the work that I've done, and also just the literature around this subject, it's staff aware that sexual safety and sexual health is part of their role and they also recognize it as being very important. That much fewer staff are actually having or able to have those conversations and that is where training comes in. It's training about looking at how can we be more confident to have those conversations and how can we just improve knowledge of the subject because that's often something that can put people off is if there is a question, what if I don't know the answer? That's what a lot of people said, and I'm really pleased that in the standard, there is a recommendation for co-produced training around just increase in knowledge.

Ella: Absolutely. Amar, what do you feel are the consequences of not educating people about sex on the wards? I do think that we as a society would like to pretend that mental health patients and service users are not sexual people.

Dr Amar: This is really important. Rachel has done some fantastic work on this topic already. One of the things about trying to raise the profile of sexual safety and being free from sexual harm is about recognizing individual sexuality and sexual needs. Part of what we want to encourage people to do is to have more conversations because the more that we can really start understanding each individual person's history and experience, how they want to be related to and talked to, and referred to how they express their own needs, sexual and non-sexual, and how we can support that when they come into a mental health setting, the better we'll be able to work together collaboratively and ensure that people are able to be themselves.

It's when people start to feel like their needs aren't being met, that they're not being heard, that people will resort to behaviors that are ultimately unhelpful for themselves and those around them. We really want to encourage through the sexual standards and through the improvement collaborative that teams of staff and service users together start to have conversations about what we expect from each other. One of those is to find ways for us to understand better the sexual health of our service users and how to improve people's sexual health but also their sexual needs and their desires and how they can make sure that they meet those needs in a way that's safe for themselves and those around them.

Ella: Rachel, what do you think are the societal restrictions that we have on mental health patients and service users not being sexual people? Why do you think that's happened?

Rachel: A lot of this comes probably just through that stereotypical view of a person with mental illness. As mental health professionals, we come back or we reflect the society so those same views that people may have, in terms of a person with mental illness, doesn't have the capacity to choose a partner or to engage in healthy sexual behavior, relationships, or the view that someone with mental illness is more likely to engage in risky sex behavior. The reality is that our patients are more likely to engage in risky sex or the sex trade, they are more likely to have multiple partners, they are more likely to have unprotected sex, unplanned pregnancy, or be victims of sexual violence or domestic violence. 

That shows that one, they are capable of having sex but it also shows that they aren't receiving support from services in terms of access to sexual health services in terms of knowledge about sex and healthy relationships. It's about our first professionals, one, to recognize and respond to our own biases around the idea that people do not engage in sexual activity and two, actually, look at what we can do to overcome those biases. We need to abandon the idea that our patients do not have sex and we need to embrace those conversations with them and recognize that they have a right to healthy and loving relationships just as you or I do.

Ella: That leads us nicely onto the cultural taboos surrounding sex. Dr Amar.

Dr Amar: I think part of this is really about trying to move from just seeing someone's mental health needs when they are admitted to a mental health setting and starting to see the whole person. We've made a lot of strides across the mental health sector to really think about people's physical health over the last few years. I think the next step really is to think about people's sexual health too and see it as part of really understanding the whole person and all of their health needs and their lifestyle needs and their recovery needs.

For me, it's not necessarily about a culture or stereotypes, it's more to do with just starting to recognize the relevance of seeing the whole person when someone comes into a mental health setting and not just their mental disorder, which obviously, we're here to provide support for people with mental health difficulties and we've got expertise in that but actually, to be able to really do that well, we need to understand the whole person, all that they bring from their history and experiences and all of their assets, and really think about how to best support people in their recovery and future life, which involves often lots of things that are unrelated to their mental health needs.

For me, this is another really important step for us in mental health service provision to really start to pay attention to sexual harm, first of all, to make sure our inpatient units are free from harm but then start to move even beyond harm reduction to think about sexual health and sexuality and making sure we're working with people to support them with their needs around sexuality and sexual health.

Ella: We've touched a little bit on the improvement collaborative, could you tell us a little bit more about the improvement collaborative and what it does?

Dr Amar: Yes, for me, it's really exciting because in England we've only just begun to start applying improvement as a systematic method to help us work through some really complex safety issues. We've just completed the first of these improvement collaboratives across England on the topic of restrictive practice in mental health and known disability settings which as we know has been a really contentious and difficult topic for us to solve. We've tried training and policy and all sorts of top-down ways to reduce the use of restrictive practice but actually, through applying quality improvement and working directly with teams of service users and staff in in-patient settings, we've been able to help people really understand what would work in their setting, try out new creative ideas that could really make a difference and we've seen some fantastic results from that. 

It's been a really great step to now apply the same approach of quality improvement to the topic of sexual harm and improving sexual safety in our units. We are working with over 50 different units from a whole range of settings across England, both mental health and learning disability settings, with all ages to really help teams of staff and service users think about how they would adopt the standards that have just been published but more importantly, for them to think about how can they start the conversation in their units?

How can they really start to create together clear expectations of what the environment should be providing in terms of being safe from sexual harm and trying out some new ideas that they may not have tried before, such as thinking about how would we co-produce training in trauma-informed care or how can we make sure people have the right kind of information they need on this topic? How can we make it more transparent so we can see when people feel unsafe or when they feel intimidated or frightened based on sexualized activity in the ward?

For me, this is a great opportunity for us to really understand from the ground up what would make a difference in a whole range of different settings so that we can learn our way through what is a really complex topic, and that's the beauty of quality improvement, that it really supports our staff who are at the point of care, and our service users to really own the process of change and think what would make a difference for them in their setting, and to apply a systematic method to test out new ideas and see which ones work.

Ella: Perfect. Thank you so much. Rachel, if people could take one thing away from today's conversation, what would you like them to take away?

Rachel: If people could take one thing away from today's conversation, I would say that it's that this is the time for change and you can be part of that change, and this is a really amazing opportunity not only for us to improve the ward environment from the perspective of harm but actually to also promote recovery. We know that having a healthy and loving relationship is one of the biggest protective factors against relapse for a person with serious and enduring mental illness. Actually, if we are able to recognize that those biases around our own moral values, religious beliefs or age or gender or upbringing, confront them, and become willing and ready to talk about sexual health and sexual safety, then we can actually improve the quality and the experience of care that we give.

Ella: Dr Amar, the same question to you?

Dr Amar: Two things come to mind. One is to really urge people to make sure we're co-producing our work in this area, so making sure we're involving people with lived experience right from the outset in helping us think about how to start this conversation and start developing ideas. The second suggestion I have for people is just to open up safe spaces for us to have the conversation together. What we found from our 50 odd teams that are working on this topic is that a lot of their first year of work has involved really finding ways to come together and talk about the topic, listen to each other, and then that will really open up a conversation that's headed to often been not listened to or heard before about what really contributes to creating safe spaces on our in-patient wards.

Ella: Thank you so much to Dr Amar and Rachel for speaking on the podcast and sharing these important stories and the ways in which we are taking positive steps to prevent sexual harm on mental health wards. If you would like more information on this topic, please go to our website and select Improving Care from the top of the screen, then National Collaborating Centre for Mental Health, and then select Sexual Safety Collaborative.


Read more to receive further information regarding a career in psychiatry