Sexual safety in mental health services in Australia and New Zealand

Purpose

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has developed this Position Statement to address and advocate for the prevention of sexual harm and protection of all people admitted (tangata whaiora, consumers, patients, service users) to acute inpatient mental health and drug and alcohol services ^[b]. The same principles can be applied to rehabilitation, and forensic mental health facilities in addition to other settings that psychiatrists are involved in where incidents of sexual harm can arise.

This Position Statement does not address the sexual safety of staff. For more information on safety of psychiatrists, please see the Gender Equity Action Plan and Position Statement 48: Safety and wellbeing of psychiatrists and those in psychiatry training. 

Please note that this is a RANZCP position, not a policy, and will be kept to high-level principles.

Key messages

• The RANZCP supports the definition of sexual safety as being: ‘Being and feeling safe from any unwanted behaviour of a sexual nature, including sexual harassment and sexual assault, sexual language and observing sexualised behaviour’^[1]
• Protecting physical and psychological safety of all people attending mental health services is of critical importance. Clinicians, health services and health systems have a duty of care to manage all consumers safely, in a setting that promotes safety and recovery.^[2]
• If a sexual harm incident occurs or is reported, all parties involved must be supported and treated with the assumption of belief.^[3]
• The RANZCP recognises that particular populations may be more likely or vulnerable to be subject to sexual harm incidents. Women, children and adolescents, older people, LGBTIQ+ (irawhiti takatāpui) consumers/tangata whaiora, and those with a disability are all considered to be vulnerable groups. 
• There are reports of high rates of sexual assault and harassment being perpetrated against women^[2] in mental health inpatient units, with the alleged perpetrator being either another consumer or a staff member.
• Research indicates that mixed gender inpatient wards can have the impact of female consumers feeling unsafe.^{[4, 5, 6]}
• Providing female-only beds and wards can help to protect sexual and psychological safety, and bodily integrity.^[5] 

Background

Sexual safety is about the prevention of sexual harm and protection of consumers/tangata whaiora in acute inpatient mental health and drug and alcohol services. ‘Feelings of sexual safety are individualised and each person will have different situations that may cause them to feel greater or lesser safety from sexual harm.’[3] Incidents of sexual harm include, but are not limited to, incidents of rape, sexual assault and harassment including physical and verbal harassment, voyeurism, exhibitionism, and intimidation.[6, 7] Sexual assault refers to non-consensual physical sexual contact. Sexual harassment refers to any inappropriate or unwanted sexual contact including comments. These incidents not only breach human rights, but have the impact of re-traumatising individuals with potentially long-lasting deleterious consequences for their physical and mental wellbeing, and create a further barrier to their seeking mental healthcare. All people should feel safe when seeking healthcare, whether for mental or physical conditions.

Sexual harm in mental health services, specifically acute inpatient units, has been an issue for many years and at times receives attention in the media and from academics and advocates.^[7-17] Findings of reports and surveys consistently demonstrate that sexual harm in acute mental health inpatient facilities is an issue in both Australia and New Zealand.[7, 18] In acute inpatient health services, including mental health services, it is standard that all sexual activity is prohibited.[7, 19] This is distinguished from long term residential services. In acute inpatient mental health wards there are further concerns about capacity and consent.[7, 8, 19] 

Reporting and management of sexual harm incidents varies, and therefore there is low availability of clear data demonstrating true prevalence of incidents or trends over time.[7] Data is often considered sensitive and not available to access outside of secure facilities, such is the case in Queensland, or only the raw number of specific incidents is recorded rather than in respect to per capita figures. Likewise, investment in research on improving this aspect of delivery of healthcare has been limited.

A rights-based approach

Any sexual harm incidents in any setting are not acceptable. In mental health treatment settings, mental health services must abide by Mental Health Acts and their duty of care to ensure those accessing services are safe from sexual violence and assault. 

Breaches of sexual safety represent not only a breach of human rights, but indicate a compromise of the principles of equity, in relation to improving gender equity as well as the obligations for Māori under Te Tiriti o Waitangi[3].

Vulnerability and safety in acute inpatient mental health services

The RANZCP acknowledges that there are population groups who may be additionally vulnerable for various reasons. The majority of sexual harm incidents in acute mental health settings are breaches of the sexual safety of women by men.[7, 20] In the general population of Australia, 23% of women have been sexually assaulted, and in New Zealand, 24% of women have been sexually assaulted.[21, 22] Data relating to the prevalence of sexual safety breaches in acute care facilities is, as noted above, difficult to obtain due to privacy and sensitivity practices or due to records of incidents not being compared to patient numbers as a whole. These findings demonstrate prevalence, basis for feelings of fear, need for protection, and need for trauma-informed practice.

In both Australia and New Zealand, it is common for hospitals and psychiatry inpatient units to admit consumers into mixed gender wards.[2,21 23, 24] There are risks of sexual harm in mixed gender wards; there are reports of high rates of sexual assault and harassment being perpetrated against women, with the alleged perpetrator being usually either staff or another consumer.[2, 21] Perpetrators are overwhelmingly identified as being men who were also inpatient consumers.[7] In mixed-gender wards reports of sexual assault are 6 times higher than in single gender settings.[25] Many women report feelings of anxiety when placed in mixed gender wards.[21] Despite this, the issue is often overlooked and inpatient units continue to be designed to admit male and female consumers together.[2]

People with a mental illness are vulnerable to being subject to sexual harm due to possible symptoms of their illness, or history of trauma.[10, 26] Particular mental health conditions may have symptoms such as sexual disinhibition, impulsivity, and engaging in risky behaviours, which can increase vulnerability.[3, 7] People who experience childhood sexual abuse, and disproportionately this occurs to girls, are more likely to experience sexual abuse in adulthood, and are also more likely to require admission to mental health services.[5, 14] 

In assessing vulnerability, consideration of intersectional risk factors should take place. Aboriginal and Torres Strait Islander communities, Māori, LGBTIQ+/irawhiti takatāpui communities, and people who are culturally and linguistically diverse, are more likely to have previous experiences of trauma.[7, 27] People with a disability, in particular women with disabilities, experience sexual abuse at disproportionately high rates.[7]

Aboriginal and Torres Strait Islander women experience rates of sexual violence at a rate of up to 5 times higher than non-indigenous women, and that up to 90% of violence against Aboriginal and Torres Strait Islander women is not reported.[28] Female tāngata whaiora reported experience high levels of sexual violence, or fearing the same.[29] Intergenerational trauma due to the effects of colonialism and historical oppressive governmental policies exacerbates the issues in reporting and vulnerability highlighted above. Culturally safe trauma informed care arrangements should be provided to mitigate these risks.

The needs of trans and gender diverse (TGD) consumers must be considered where gender segregation occurs to ensure that care provision is gender sensitive.[7, 20] For more information, please see the RANZCP’s Position Statement 83: Recognising and addressing the mental health needs of the LGBTIQ+ population and Position Statement 103: Recognising and addressing the mental health needs of people experiencing Gender Dysphoria / Gender Incongruence.

Across the age spectrum

Sexual safety approaches must consider people across the age spectrum, including children and adolescents, adults, and older adults.[5, 20] Limited data exists on rates of sexual harm incidents by age. A New Zealand study found that older adults are more often placed in mixed-gender hospital wards than other age groups.[21, 24] People with dementia are vulnerable to sexual harm due to the nature of their condition.[30]

Potential perpetrators

The limited available data, such as reports to the Mental Health Complaints Commissioner in Victoria, found alleged perpetrators were most often other consumers with fewer reports for staff and visitors.[5, 8] However, this data is likely to reflect both the inevitable underreporting of sexual harm incidents and then further likelihood of underreporting of incidents that involve staff.[31] This is due to the power mbalance and vulnerability experienced by those admitted to mental health inpatient wards, which is exacerbated for particularly vulnerable groups such as women, people with disabilities, members of the LGBTIQ+/irawhiti takatāpui community and Aboriginal and Torres Strait Islander people and Māori.[7]

Risk factors for consumers perpetuating harm include male gender, and may also include presentations of aggression, intimidatory or violent behaviours, psychotic symptoms including delusions and auditory hallucinations that may incite sexual harm.[7, 20, 23] 

Staff on mental health inpatient units may not be aware of consumers’ forensic histories, including that of sexual harm.[21] Knowledge of prior sexual trauma is key in assisting with the detection and addressing of potential victimisation in acute care facilities.[6] It is also important to consider the potential of specific consumers to potentially perpetrate sexual harm when unwell. This may be uncharacteristic for that person and directly attributable to mental health symptoms. However, many victims report that trauma was exacerbated by staff and governance responses to breaches of sexual safety being tolerated or dismissed due to the mitigation of the perpetrator’s illness (where the breach is perpetrated by another inpatient consumer). [7]

Ensuring consideration of an individual’s risk and developing and implementing a safety plan to minimise the risk of a breach to someone else’s safety is an important part of clinical management of a consumer on an inpatient unit.[20] Risk assessments for potential perpetrators should address the identified primary risk factors including gender, heightened aggressive tendencies, sexual disinhibition and dependency needs.[7]

Roles and responsibilities

Psychiatrists: Leadership

Psychiatrists have a clear leadership role within the clinical governance of mental health inpatient wards and ensuring duty of care to all those admitted. This includes the prevention of sexual harm within health services. Risk assessment and management within inpatient mental health facilities is complex and relies on understanding and acknowledging the various factors that make a consumer vulnerable to, or more likely to perpetrate, sexual harm.

Leadership is also about advocacy and where there are insurmountable barriers to providing safe care, as with any serious risk, the onus is to ensure this is reported and escalated. A psychiatrist also provides leadership in ensuring a ward milieu where there is trauma informed, gender sensitive and victim centred response when incidents are reported. Finally, leadership is required in ensuring the appropriate care and consideration be provided to those perpetrators who have uncharacteristically acted during an acute and severe episode of mental illness, given this is also a potential lapse on duty of care to that individual as well as the victim by the service.

Services: Provision of policy, procedure, and training

It is a core responsibility of health services to provide a safe environment for consumers.[32] Services must have a sexual safety policy and procedure to enable staff to enact consistent, best practice sexual harm prevention and response.[7-9, 13, 15, 23] Such documents provide staff with a course of action, avenues for support, and clear, documented accountabilities.[16] Similarly, staff require training to ensure that are aware of the risks and their responsibilities in managing them, and to ensure that safe, trauma-informed, and gender-sensitive practice is provided.[7, 8, 9, 13-15, 23, 32-35]

Governments: Monitoring

There are now a number of jurisdictional based and international guidelines for reducing risk.[3, 8, 20, 26, 36] However, it is unclear how widely best practice is implemented. Ensuring adherence to local policy and guidelines as well as best practice are essential to ensuring the provision of safe and quality care. 

It is a core responsibility of health services to provide a safe environment for consumers, and it is the role of those monitoring the quality of health services to ensure this responsibility in being met.[32] The RANZCP highlights that a national accreditation standard for facilities regarding the sexual safety of consumers could require facilities to publicly report de-identified quantitative data on incidents annually, and enabling national data collection.

Data collection 

Data collection and monitoring are required for reports of and responses to sexual harm incidents in acute inpatient mental health services.[12, 23] The research highlights that recording and reporting practices for allegations and responses to incidents of sexual harm on mental health inpatient units vary and do not suffice.[12,13] All incidents should be consistently reported and recorded nationally for data collection purposes, and de-identified data should be publicly reported.[12, 23] Systems of governance are needed to ensure that all incidents receive a safe and adequate response.[8]

A national policy or strategy would support a consistent, coordinated national response and method of data collection and reporting to help understand prevalence and inform improved future prevention and response.[2, 7, 23] Such a policy should including funding for research on effective methods of preventing incidents of sexual harm in acute inpatient mental health services to assist in improving procedures.[11]

Prevention

Design of acute inpatient mental health services

Environment design impacts consumer safety and care.[20, 37, 38] It is an important quality and safety standard to provide a safe environment for consumer care, considering the design of the treatment environment.[39, 40] Consideration must be given to the design of the new units to improve sexual safety for consumers.[20, 41] 

Secure, women-only areas (including bedrooms, bathrooms, and common areas) should be available to improve safe care for women, and for mixed gender areas, additional measures must be undertaken to ensure these are safe for all people.[2, 20, 23, 32, 41] Additional measures have included swipe card access to bedrooms, and the provision of personal alarms either to carry or located in rooms.[3, 7, 8, 32, 41] The gender of staff must be considered in single-gender units, with organisational policies and procedures in place for consumer access requests to a mental health clinicians of their preferred gender.[23, 39]

Visibility of consumers by staff to enable appropriate supervision is also a design consideration.[,7, 20, 23, 32, 42] Adequate staffing levels, availability of staff supervision also plays a role.[8, 10, 23, 32]

The RANZCP highlights the high priority of design considerations for ensuring sexual safety for all new mental health inpatient units, comparable to the requirements to minimise self-harm and suicide risks, where for instance it is a requirement that there be the consideration of removal of any potential ligature points within a ward.[10, 32, 39, 40] The implementation of a national accreditation standard for health services that is specifically for ensuring sexual safety of consumers would enable regulatory oversight. Design considerations should be developed also to ensure older units can be retro-fitted to meet contemporary standards of safety and quality around sexual safety. 

Women-only areas do not remove all risk of sexual harm.[20] Women may still experience risks to their safety in women-only areas, as same-sex inpatient consumers, staff or visitors may perpetrate offences, or due to security lapses.[23] Fear can limit women’s use of mixed-gender common areas, and sexual harm can occur in common areas.[14, 23]

Sexual risk assessments

People with a mental illness are vulnerable to sexual harm due to a number of factors including possible symptoms of their illness, prescribed medication, history of trauma.[8, 24, 36] For this reason, a consumer’s sexual safety is one of a range of risks that must be assessed and addressed in the same way as any other risk.[7, 8, 23, 26, 33] Such an assessment would address risk to self and others in addition to risk from others, and take into account considerations raised in the section ‘Vulnerability and safety in acute inpatient mental health services’.[10, 33] The development of a safety plan in response to such as assessment is as important as the assessment itself.[20] Clinicians must find a balance of protecting the sexual safety of consumers while not imposing a sense of risk aversion and paternalism.

Trauma-informed practice

Trauma causes a wide array of mental and physical health conditions which can further exacerbate existing illnesses and slow or prevent recovery. People with mental illness can suffer adverse health outcomes and re-traumatisation due to sexual abuse in psychiatric facilities.[43] Studies have shown that mental health services are not consistently trauma-informed.[23] People with a mental illness often have a history of trauma, and therefore it is critical that care provision is trauma-informed.[23] Trauma-informed care takes past trauma into account. It is important to acknowledge that practices of seclusion and restraint can be experienced as traumatic and violent.[23] For more information, please see the RANZCP Position Statement 61: Minimising and, where possible, eliminating the use of seclusion and restraint in people with mental illness and Position Statement 100: Trauma-informed practice.

Response 

Safety is paramount. Key actions for a safe response include, but are not limited to:

• Take all allegations of sexual harm incidents seriously.[22, 31] All people reporting sexual harm incidents must be heard and provided with supports.[3] Support must also be provided to the alleged perpetrator.[3]
• For psychiatrists, take a leadership role in determining and providing therapeutic support. 
• Place the alleged victim in a safe environment which may require relocation of either, or both, the alleged victim or perpetrator.[31, 36] The safety of other people in the location must also be considered.[31, 36] 
• Manage the incident in a way that takes the preferences of the alleged victim into account.[31] 
• Keep records to ensure consumers who may have previously reported an incident perpetrated by another consumer is not re-admitted to the same area as the alleged perpetrator.[22]
• Provide the consumer with the appropriate information, referrals, and follow-up supports (including post-discharge) that are available to them, including mental health supports, forensic medical examinations, and police reports and investigations.[5, 6, 22, 30, 31] 

Recommendations

The RANZCP recommends that acute mental health inpatient services:

• Ensure policies and procedures are in place for consistent responses to reports of sexual harm incidents. 
• Train and support staff to enact policies and procedures appropriately and consistently.
• Design new units to include women-only areas.
• Adapt existing units with inpatient facilities to retro-fit and enable women-only facilities as well as additional measures to ensure safety within units.

The RANZCP recommends that governments:

• Implement a national accreditation standard for facilities regarding the sexual safety of consumers, requiring facilities to publicly report de-identified quantitative data on incidents annually, and enabling national data collection.
• Develop and implement a national policy or strategy regarding the sexual safety of consumers.
• Regular psychiatrist led auditing of implementation of policies and procedures. 

Additional resources

• Australasian Psychiatry. Why gender equity matters for psychiatry; 2021
• Australian Health Practitioner Regulation Agency (AHPRA) and the National Boards Joint Statement. No place for sexism, sexual harassment or violence in healthcare; 2021  
• Australia's National Research Organisation for Women's Safety (ANROWS). Safe for women? Preventing gender-based violence in mental health inpatient units; 2020
• Belet B., Demeulemeester E., Vaiva G. Sexual violence within mental health units: The forgotten fight?; 2021
• Hughes, E., Lucock, M., and Brooker, C. Sexual violence and mental health services: a call to action. Cambridge University Press; 2019.
• Maylea, C. The capacity to consent to sex in mental health inpatient units; 2019
• Mental Health Complaints Commissioner (VIC): The right to be safe: Ensuring sexual safety in acute mental health inpatient units. Sexual safety project report; 2021
• National Ethics Advisory Committee (NZ): Mixed gender hospital accommodation; 2021
• National Health Service Care Quality Commission (UK): Sexual safety on mental health wards; 2018
• New South Wales (NSW) Health: Sexual Safety - Responsibilities and Minimum Requirements for Mental Health Services; 2021
• RANZCP Professional Practice Guideline 20: Information sharing with families/whānau/carers
• Royal College of Nursing: Sexual safety in mental health; 2021
• Royal College of Psychiatrists (UK) Podcast: Preventing sexual harm on mental health wards
• Royal College of Psychiatrists (UK) National Collaborating Centre for Mental Health (UK) Sexual Safety Collaborative. Standards and guidance to improve sexual safety on mental health and learning disabilities inpatient pathways; 2020 
• Royal College of Psychiatrists (UK): Sexual safety assessment tool. 
• Victorian Government. Women and mental health services; 2022
• Victorian Chief Psychiatrist. Promoting sexual safety; 2022
• Watson, J., Maylea, C., Roberts, R., Hill, N., & McCallum, S. Preventing gender-based violence in mental health inpatient units. Sydney, NSW: ANROWS; 2020.
• Western Australia (WA) Chief Psychiatrist’s Guidelines for the Sexual Safety of Consumers of Mental Health Services in WA; 2020

Notes

References

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