The problem of sexual violence
Sexual violence (SV) is defined as any sexual act or attempted sexual act that takes place without consent.1 Globally, one in three women across their lifetime are subjected to physical or SV by an intimate partner or SV from a non-partner.2 In England and Wales, crime survey data indicate that over half a million people experience SV each year and the number who disclose to the police or seek support is increasing annually. SV can affect health, relationships, confidence, work and family life over the life course. In 2010, the costs of SV were estimated to be £8.46 billion, with each rape costing £96,000.3 It is likely that these costs have risen considerably since then. A recent study using administrative data from Rape Crisis (RC) centres in one English county4 estimated that the lifetime cost of adult sexual abuse in that county alone was £248,431 per victim (£32,599 of which were the costs to specialist voluntary services). By comparison, the estimated lifetime cost of child sexual abuse (CSA) was £472,048 per victim (£32,316 of which were the costs to specialist voluntary services).
Role of the voluntary sector in supporting victim-survivors of sexual violence
In most parts of England, grassroots voluntary organisations have developed services in response to local needs. Although services vary from area to area, they often include crisis and longer-term counselling/therapy; telephone helplines; face-to-face advice; advocacy; play therapy for children; practical support in accessing other services; support groups and social and holistic activities. Most organisations offer specialist services to victim-survivors living in the local area. Some provide for specific groups, such as children/women/men-only services. More than 90% of victim-survivors who report SV are female, although male victim-survivors are often more heavily represented amongst those who have experienced childhood sexual abuse. Some services are grounded in feminist approaches to SV, while others take a more neutral political/philosophical approach. Most victim-survivors self-refer, while others are referred to voluntary sector specialist (VSS) SV services by a general practitioner (GP)/health/social care professional.5 An increasing number of individuals are referred by police or Sexual Assault Referral Centres (SARCs), which provide forensic examination and crisis support in the aftermath of SV and abuse. As of January 2018, there were known to be at least 207 VSS organisations in England providing support to victim-survivors,6 with 162 affiliated to one or more of the three umbrella organisations: The Survivors’ Trust; RC; and the more recently formed Male Survivors Partnership.
Voluntary sector specialist services sit alongside other local services for victim-survivors, for example, Independent Sexual Violence Advisers (ISVAs) who can provide crisis support, information, advice, advocacy and support through a criminal justice process. ISVAs can be linked into and based within SARCs,5 as well as being employed by and located in VSS organisations. Victim-survivors may also need NHS sexual health, drug/alcohol services or specialist mental health services. Given the potential long-term consequences of SV, other agencies/sectors may also be providing support, for example, housing or education.
National policy and the commissioning of voluntary sector specialist services for victim-survivors
In the last 12 years, there has been increasing national recognition in England that VSS services are essential in providing crisis and longer-term support to victim-survivors, enabling them to recover and thrive in the longer term. The Stern report in 20103 and several cross-government action plans on ending violence against women and girls,7,8 most recently in 2021,9 have highlighted the need for specialist support and therapy for victim-survivors to be provided in the voluntary sector. National commissioning guidance in 2013 highlighted the need for good linkages between all services for victim-survivors,10 and SARC specifications in 2015 required SARCs to have clear pathways into, and working relationships with, relevant third-sector services.11 The 2018 NHS national strategy statement highlights that many victim-survivors need lifelong care and calls for services to be more integrated so that individuals can access them seamlessly across agencies and sectors.12 Most recently, in March 2022, The Home Office refreshed their 2016 National Statement of Expectations,13 setting out how local commissioners should work together to commission effective, collaborative violence against women and girls services that ensure a whole system approach. This was underpinned by an accompanying ‘toolkit’ to help commissioners practically bring this vision to fruition.14
Despite the plethora of national guidance, evidence suggests that national policies have not necessarily resulted in local improvements, with VSS services being under extreme funding pressures,15 particularly in a ‘post-pandemic’ climate. One study found a 31% cut in English local authority (LA) funding to domestic and SV services between November 2010 and December 2011.16 Evidence submitted to the 2018 All-Party Parliamentary Group inquiry into the funding and commissioning of SV services found that organisations were struggling with unprecedented demand. This linked to increased awareness of SV due to national and global sensitising campaigns such as #MeToo and Everyone’s Invited, in parallel with greater recognition of non-recent childhood sexual abuse through, for example, the Independent Inquiry.17 The Inquiry found that funding of specialist SV services has not kept pace with need, and this has created inconsistencies and gaps in service provision across England and Wales. VSS services have been particularly hard hit by public sector funding cuts and devolution of certain commissioning arrangements.18 Funding pressures have been exacerbated by coronavirus 2019 (COVID-19), where increases in demand and the level of support existent victim-survivors require have intensified.19 The Rape Crisis report Holding it Together20 found that across 39-member organisations, 1.1 million sessions of specialist support were delivered between 2020 and 2021, constituting a 41% increase from 2019 to 2020. While unprecedented financial investment [largely from the Ministry of Justice (MoJ) and Police and Crime Commissioners (PCCs)] has been directed into VSS services to manage this need, as of April 2021, over 10,000 victim-survivors remained on RC waiting lists – some of which spanned 2 years. Perhaps more than ever, COVID-19 has underscored the need for long-term funding for the specialist voluntary sector, in order for services to upscale in a way that can meet demand. In May 2022, the government released its Victim Funding Strategy,21 aimed at simplifying and aligning funding for victim services across government, introducing national commissioning standards and consistent outcomes across services. Within the strategy, a commitment to multiyear funding is made and it is anticipated that the upcoming Victim’s Bill will include a statutory responsibility for local authorities, PCCs and Integrated Care Boards to collaborate when commissioning domestic, sexual and other forms of serious violence service. How these aspirations will translate into practice is yet to be established.
The position in England contrasts with that in Scotland, where a strong national focus on preventing and responding to SV has already led to new standards for health care;22 a workforce knowledge and skills framework for trauma-informed care;23 and a national taskforce work-plan focusing on improving the design and delivery of services, strengthening care pathways, improving quality and developing the workforce.24 A national mapping exercise of advocacy services for victims of violence against women and girls across Scotland has also been undertaken, which identifies gaps in services for rural areas; women who are trafficked or in sex work; children/young people; black and minority ethnic groups; and asylum seekers.25 Work is well underway to improve the governance, financial management and sustainability of VSS services for victim-survivors in Scotland.26
In England, the funding and commissioning of services has become increasingly complex, as a result of changes to the structure and funding of health27 and criminal justice. Funding for VSS services comes from charitable trusts plus local and national statutory sources, via health, local authorities and criminal justice organisations. This creates a complex network of responsibilities at a local level, requiring a high degree of collaboration between commissioners.18 The complex and changing nature of commissioning, and by default local services, creates challenges for providers in ensuring there are integrated, multidisciplinary care pathways available.28 It also compounds VSS service difficulties in establishing and maintaining relationships, particularly with public sector providers, not least because there is a prevailing attitude that VSS services are ‘amateur’ and small scale.28
Future planned changes for the sector potentially include further devolution of the MoJ Rape and Sexual Abuse Support Fund (RASASF) to PCCs and/or mayors – following the piloting of devolution in several areas of England – although this is unlikely to happen before March 2023. Ambiguities also exist around how Clinical Commissioning Groups’ (CCGs) transition into integrated care systems (ICSs) will impact local relationships and funding arrangements. In response to the complexity, commissioning appears to have become quite fragmented.18 In some areas, new and untested local models of collaborative commissioning are emerging, such as contracting with a lead provider for a network of local services, which may include VSS providers.18 One consequence is that the previous model of a mixed economy of provision for victims, that included smaller organisations who are adept at meeting the needs of specific groups at the local level, has become untenable under the drive towards a free market model.29 In other areas, VSS providers are taking the initiative and collaborating between themselves, moving to common standards and seeking to join up services locally via partnerships and consortia.30 They are also working with statutory providers, particularly SARCs, to deliver crisis counselling and other responses.31 Commissioners, in turn, are looking for evidence to support these new approaches;10,11,18,32 however, little is known about their effectiveness and how they might impact on services for victim-survivors.
Evidence base for the value of voluntary sector specialist services for victim-survivors
There is very little empirical evidence about the scope, range and effectiveness of VSS provision, or what victim-survivors value and want from services. There is no systematic review evidence and the few previous studies that exist are small scale and local, typically with ˂ 20 staff and/or victim-survivor respondents. The exceptions are a national survey with 395 adult victim-survivors of CSA33 and evidence from nearly 7000 victim-survivors submitted to the Independent Inquiry into Child Sexual Abuse.34,35 Victim-survivors typically want timely, locally available services, a choice of therapy and long-term support from agencies taking a joined-up approach.34 They want to feel listened to, believed and respected,33,35 and the independence of VSS services from statutory provision is seen as a key benefit.36 Counselling and psychotherapy are often cited as the most helpful services, but as noted, waiting lists are often long and therapy may be time-limited.33 There has also been some trend towards MoJ and PCC funding prioritising ISVA over counselling provision.20
Many victim-survivors need and use VSS services over the life course.33 One study found that VSS services were the most commonly used services by victim-survivors, after GP, mental health and NHS counselling and were more highly rated than statutory provision – by a margin of 41% for counselling and 12% for psychotherapy.33 Over 70% of victim-survivors who had used both types of service rated VSS as good compared with ˂ 20% for statutory services. In another study, Scottish Rape Crisis centres were seen as trusted places of safety, offering confidential, non-judgemental responses, empowering victim-survivors and providing long-term support.37 Gekoski et al.35 found that victim-survivors of childhood sexual abuse rated VSS provision most highly out of all forms of support received. Similarly, ISVAs report that victim-survivors have greater trust in and preference for VSS services compared with statutory provision,36,38 want flexible services which respond quickly and which are delivered in ways which empower and offer control.38 NHS services have been criticised for being inflexible and time-limited, with victim-survivors often being referred to generic, rather than specialist, support.18 Indeed, victim-survivors can and do experience secondary trauma in response to the ways in which staff within statutory services (inappropriately) interact with them.34
Four small studies on VSS services highlighted the impacts of under-resourcing, resulting in gaps in provision whereby victim-survivors were required to travel considerable distances, sometimes in excess of 100 miles, to access support,18 as well as geographical variation in the level and types of provision offered.37 Groups underserved included older victim-survivors39 and male victim-survivors of rape.40,41 There is evidence that not all VSS services identify and engage with under-represented populations in a consistent way and this may affect the quality of support received.40 For example, as noted, many VSS providers are orientated to a feminist-empowerment approach that emphasises structural gender inequalities and inherent power differentials between men and women. These may not neatly translate to accommodate the SV committed by women against other women, for example. It is therefore important that commissioners recognise the different political and philosophical rationales – that are often combined – which underpin services (including survivor empowerment, trauma-informed and intersectional approaches), as this can affect the quality and nature of provision for different population groups.
Referral routes between organisations have been noted as complex with staff not always signposting victim-survivors to other agencies,36 and SARC and VSS staff reporting problems referring to mental health services specifically.20,42 VSS staff report that referrals from other agencies are inconsistent and their knowledge about VSS services is variable.36 As noted, most VSS providers offer counselling and/or therapy which systematic review evidence shows can reduce post-traumatic stress, depression and anxiety.43 The specialist nature of VSS therapy compared well with NHS therapy in one study,36 while another found that access to psychological care had improved in the past 10 years.44 In a more recent study, victim-survivors who had accessed RC centres in England and Wales experienced greater feelings of empowerment and an ability to exercise control, a decrease in the frequency of ‘flashbacks’ and less frequent panic attacks.45
There is no literature on the effectiveness of different approaches to commissioning services for victim-survivors. Anecdotal evidence and research from the sector suggests significant problems exist, including: over-reliance on short-term funding; poor understanding amongst commissioners of what VSS services do leading to service cuts; lack of engagement by the health sector; confusion between services for domestic violence and SV; and confusion about which agencies are responsible for funding what services.18 There are concerns that as VSS services increasingly rely on funding from large governmental, public sector or charitable organisations (e.g. the RASASF), they have less autonomy to determine the way they care for and support victim-survivors, as they focus on meeting funders’ priorities and outcomes.46 There is also a paucity of evidence about the needs and experiences of staff working in VSS services, who can do so in a voluntary capacity, as highlighted in a recent study which found inconsistencies between the staff support systems and regulatory frameworks underpinning public sector and VSS services.47
Theoretical background and contribution to theory
The academic literature on the voluntary sector suggests that it has distinctive practices, relationships and an ethos of service provision, including being non-judgemental, nurturing users and developing positive relational skills.48 Voluntary sector organisations also have potentially unique attributes as organisations, compared with both statutory and private sector services. For example, involving users in governance, being driven by a social mission, having a closeness to and expertise in communities or particular groups.49 Many voluntary organisations involve current and former service users as volunteers or subsequently paid staff, and have relatively flat hierarchies which blur the distinction between staff, volunteers and service users.50,51 Reducing power differentials in this way between service providers and users can help build the personal capacity of service users, particularly those from vulnerable or excluded groups.50,52 These positive attributes of the voluntary sector along with a mistrust of state agencies among victim-survivors, and reluctance and/or difficulties in accessing statutory provision, partly explains the dominance of the voluntary sector as an alternative source of support. It seems likely that VSS providers are in a good position to offer services which impact positively on outcomes for users, occupying a specialist ‘niche’ within the wider ecosystem of services for victim-survivors and offering an alternative approach to statutory sector provision.
Where voluntary organisations work closely in partnership with the public sector, the relationship has been theorised as a collaborative one, suggesting there is scope for synergy between statutory and voluntary services.53 However, the commissioning and performance management arrangements expected by statutory funders could undermine the distinctive characteristics of the voluntary sector, imposing expectations derived from business models of operation which dissociate voluntary organisations from their social foundations.49 Other commentators recognise that commissioners have a difficult and conflicted role in shaping and managing networks of care.54
For this study, the underpinning theory is Billis and Glennerster’s theory that the voluntary sector has a comparative advantage in the provision of human services compared with the statutory and private sectors.50 This will help us to understand and explain the prominence and distinctiveness of the voluntary sector in providing support to victim-survivors of SV and identify the unique and prominent features that enable them to respond more sensitively to needs. The unique features that the theory identifies include: a flatter organisational structure with less distance and distinction between senior or decision-making staff and those on the front line; closeness to communities; and being mission-led and driven by core values and purpose (for our study, to support victim-survivors of SV). The theory also identifies that the users of voluntary sector services often suffer personal/social disadvantage, stigma and isolation, which make it difficult for them to access statutory services. This is particularly relevant to victim-survivors of SV and abuse. Such states of personal and social disadvantage can also lead to economic disadvantage or financial hardship, so that private support may not be an accessible option. The theory leads us to postulate that it is in their interactions with victim-survivors that the unique and distinctive features of VSS services become important. In accessing VSS services, we expect that victim-survivors are more likely to be met by staff with the required motivation, sensitivity and knowledge to support them, as there is less of a gap between those delivering and those accessing services. Thus, the study seeks to understand: the nature of the distinctive features of voluntary organisations providing support to victim-survivors; the relationship between the distinctive features and the particular support needs of victim-survivors; and how these shape interactions with victim-survivors.
Although the main theoretical underpinning of this study relates to the role of the voluntary sector, the research also draws on the theory of trauma-informed approaches to care, which has been developing over the past 10 years.55,56 This approach now underpins service delivery in a number of countries, including Scotland,22,57 although national policy in England has been slow to adopt the approach.58 A trauma-informed approach is based on six principles of safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice and choice; cultural, historical and gender issues. These principles align well with the values, ethos and culture of the voluntary sector in general. The research therefore theorises that what victim-survivors want from and value about VSS provision is likely to be in line with trauma-informed approaches to care.
Rationale for the study
Given the evolving nature of national policies on SV, the complex nature of the commissioning and funding arrangements which support the local implementation of policy, and the absence of any good-quality evidence, the first step must be to describe and analyse the patterns of VSS provision across England, and identify what needs are being met and for which groups of victim-survivors. This includes looking for explanations for variations in these patterns and the forces that have shaped local provision. In the absence of high-quality evidence about victim-survivors’ experiences of VSS services, the research places victim-survivors’ views and experiences at its centre. We analysed the degree to which provision meets victim-survivors’ expressed needs, looking for gaps and overlaps in service; underserved subgroups in the population; the use of service rationing; the use of recognised service quality standards; and the extent to which VSS services are a coherent part of an area’s service offering to victim-survivors, with VSS providers also supporting victim-survivors to access other services.
Why this research is needed now
To date, there has been limited research into what victim-survivors want from and value about VSS services, how they link with other key services and how they are funded by councils, the police and health services. There is also a lack of evidence around the lifetime cost of SV and abuse, contributing to difficulties in the commissioning of specialist SV services. This research aims to benefit both victim-survivors of SV and the NHS. The number of victim-survivors of SV is increasing year on year. In 2017–8, 150,732 sexual offences were reported to police, a 24% increase on the previous year and the highest figure since records began.59 Just over one-third of offences are for rape.59 However, SV is under-reported, with the national crime survey estimating that 2% of adults, 646,000 people aged 16–59 years, experienced SV in England and Wales in 2017–8, while 4 million adults have experienced a sexual assault at some point since the age of 16 years.60 Added to this are unknown numbers of children and older people, not currently recorded. Increased reporting of non-recent sexual abuse is likely to continue, linked to inquiries exposing abuse within UK institutions, while public health needs assessments continue to predict future increases in demand,61,62 particularly as lockdown measures ease. As the trend towards greater reporting of SV continues, each year more people will be looking to VSS services for support. Increases in demand are likely to be compounded by statutory services restricting access to services such as mental health, which victim-survivors may have used previously.
The impacts of SV on victim-survivors’ health and well-being are well known. Rates of post-traumatic stress disorder are highest for SV compared with all other traumatic events.63 Depression, anxiety, suicide, self-harm, alcohol/drug abuse and sexually transmitted infection rates are all high38,64 and impacts on mortality have been found.65 Victim-survivors report adverse effects on relationships with partners, family and friends and on their confidence/ability to work66 and participate in social/community life. Some impacts can be passed on to the next generation.56 Therefore, the burden on individual victim-survivors, the NHS and wider society if these impacts go untreated, is likely to be excessive. Given current and projected rises in SV and the cost to victim-survivors and society if needs go unmet, the time is right for this report. We will produce timely and invaluable evidence for commissioners about the role and distinctiveness of VSS services for victim-survivors, providing examples of innovative practice, and making recommendations about how funding and commissioning arrangements can be improved in order to strengthen overall service provision for victim-survivors. The findings will therefore support the local implementation of current national policies on responding to SV and violence against women and girls.7,12
A note about terminology
To support with consistency in reporting findings across all work packages (WPs) of the study, certain terminology is used throughout this report. The authors have carefully considered how to use certain words and phrases and have consulted with the co-researcher team throughout the decision-making process. Accepting the limitations and varying interpretations, we have agreed the following terminology.
Victim-survivor
This term is used to describe the individual subjected to any form of SV and abuse, and, in this context, the individual service user/client of the VSS service. We acknowledge that opinions and preferences vary because not everyone who has experienced SV regard themselves as a victim and, similarly, not everyone regards themselves as having survived. The term victim-survivor is an attempt to encompass differing/both perspectives.
Voluntary sector specialist
The acronym ‘VSS’ is used to refer to SV ‘voluntary sector specialist’ services. The term is often inadequately defined. We refer to it to mean services located in the third sector that include smaller services as well as those with a national profile. The primary purpose of a VSS service is to support someone who is or has been affected by SV.14 It is important to highlight the specialist role, whereby staff have a dedicated knowledge (and training) around SV and abuse – understanding its political and social dimensions. Other language that is currently popular is specialist ‘by and for’ services which are: ‘specialist services that are led, designed and delivered by and for the users and communities they aim to serve (for example survivors from ethnic minority backgrounds, deaf and disabled victims and LGBT victims)’ (p. 9).13
Sexual violence
The term ‘sexual violence’ (abbreviated to SV) is used as an all-encompassing term following the World Health Organization definition, being inclusive of verbal as well as physical acts. However, different VSS services may use their own terminology to talk about acts and behaviours, and victim-survivors will have personal perceptions of what falls under this definition. Examples of SV may include (but not be limited to) non-consensual touching, stroking, messages, ‘jokes’ and name calling, penetration and photo-taking/sharing (and attempts at these acts). Under our definition of SV, we include SV and abuse – ‘abuse’ being the more commonly used term to refer to offences against children.