Sample characteristics and congruence

Seventy-five adolescents were followed up (53% retention). Study end assessments took place at a median (IQR) of 459 (430–488) days, or 15.3 (14.3–16.3) months post assault.

The cohort was 95% female (71 female, 3 male and 1 transgender young woman), 44% white, and had a mean age of 15.6 years at assault. The majority (92%) had attended the Havens as police referrals. Two thirds (68%) lived in the two most deprived IMD area quintiles [25]. One in six (18%) and two in five (39%) had a history of being in foster care or of previous social services involvement, respectively, prior to or at the time of the assault. One in three (33%) had a history of running away. One in six had a statement of special educational needs (17%) and 38% had extra help at school, with 14% of those in school attending a special school or unit. Twelve percent (12%) were neither in education, or employed at study entry. A third (34%) disclosed previous sexual abuse or assault. In a sizeable proportion, the index assault involved strangers (40%), multiple assailants (23%), violence (weapons or physical violence in 60%), or substance use around the time (30%). Ninety-three percent (93%) of assaults were reported rape.

Nineteen qualitative interviews (17 female, 1 male and 1 transgender young woman) were conducted at a median (range) of 43 (6–70) days following the study end assessment.

Table 1 shows the largely congruent characteristics of the cohort at recruitment and study end, for all participants. A smaller proportion of adolescents completing the study had social services involvement prior to the assault (39% vs. 52%, p = 0.002), and there were differences in IMD area distribution (p = 0.034).

Medium-term health outcomes and service access

Tables 2 and 3 show medium-term health outcomes for all participants following sexual assault, including longitudinal change in mental health symptom levels and substance use (Table 2), and changes in self-harm, physical symptoms and health service use (Table 3). Female-only data can be found in Supplementary Material. The proportion of young people reporting anxiety, PTS or depressive symptom levels above threshold (suggesting disorder) decreased significantly over time. However, 13–15 months post assault, 60%, 72% and 54%, respectively, remained at risk for an anxiety disorder, PTSD or depression. In-depth interview participants gave vivid descriptions of their states of mind, describing feelings of worthlessness, withdrawal, stress, anger and anhedonia. Some were unable to leave their homes. Normal functioning was impaired, sleep was disturbed, and panic attacks were common:

“[…] I’d literally become violent with rage and anger, […] and I remember kicking someone in their head, […] and I wasn’t a violent person, it’s just the minute someone said the word rape […]”

“I was just really down, really, really down, […] at the time I didn’t have nothing that I enjoyed, there was nothing.”

“… my anxiety was really bad […] Your heart beats fast […], and you get really sweaty and stuff, you know. It’s like you just can’t talk, you know, you can’t physically move, it’s like you’re frozen.”

Table 2 Longitudinal changes in mental health symptoms and substance useTable 3 Changes in self-harm, physical symptoms and health service use following sexual assault

Baseline levels of smoking, alcohol use and ever drug use (the latter measured cumulatively) were high at recruitment and higher at study end (36% vs 46%, 62% vs 80%, and 42% vs 61%, respectively), although only the alcohol use increase was significant. Levels of binge-drinking did not change overall (25% vs. 26%), but there were changes in individuals’ behaviour, with 12% stopping and 14% starting anew. The qualitative research confirmed the use of recreational drugs and alcohol to distract from unwanted feeling or thoughts or to help with sleep problems.

“I was smoking like two [£]20 bags worth of weed to get so high […] I didn’t know any other way to filter out the feelings, so I was just smoking, smoking, smoking […]”

“Drink, that’s another thing that helps me sleep, that’s the main reason that I do it half the time, just to sleep, […]”

Self-harm was common in the 12 months preceding sexual assault and reported more frequently afterwards (38% vs. 51%). A quarter of participants (25%) started self-harming after the assault. Twenty-six percent (26%) had also self-harmed previously, with evidence from the qualitative data suggesting that its practice was resumed as a means of coping.

“I used to cut. […] I don’t want to do it again, I really don’t but it’s, you know, depression when it comes, it’s the only thing I can turn to.”

Physical symptoms were common in the 12 months preceding sexual assault and reported more frequently afterwards with a near doubling in experience of poor sleep (47% vs. 87%) and a three-fold increase in change in appetite (27% vs. 75%). Qualitative data highlighted the substantial impact of the assault on sleep problems and their pervasive influence on other outcomes. Nightmares, insomnia and lack of a sleep routine were attributed to anxiety, panic attacks and flashbacks, and were exacerbated by more general worries over school, exams, foster placements and the police investigation. Sleep deprivation and disturbance in turn were held responsible for heightened anxiety and panic attacks, migraines, poor concentration, mood swings and irritability and, indirectly, for disinclination to attend school and work and inability to sustain friendships.

“Like today when I woke up I said I couldn’t go to college, […] I didn’t want to get up, I feel so depressed, and I’m just like I can’t go on […] I don’t want to talk to no-one, I just want to be by myself […]”

Two thirds of participants had visited a health service for a physical health problem in the 12 months prior to the assault, compared to four fifths between assault and study end (65% vs 82%). Similarly, nearly half accessed mental health help in the 12 months prior, and four fifths between the assault and study end (47% vs. 80%). Changes were seen in the number of participants accessing support from a mental health professional (29% vs. 60%), a counsellor (27% vs. 42%) or the voluntary sector or alternative therapies (3% vs. 18%).

Social outcomes

Table 4 shows social outcomes following assault for all participants. Female-only data can be found in Supplementary Material. Fourteen percent (14%) of participants had experienced re-victimisation by study end and the proportion ever in foster care had nearly doubled (18% vs. 32%). Persistent absence from school doubled (22% vs. 47%) over the course of the study. Rates of being NEET were high throughout but reduced from 28 to 15%. Three of 22 participants aged < 16 years at study end were not in school (14%). Overall, those disengaged from education and employment rose from 31 to 41%.

Table 4 Social outcomes following sexual assault

Qualitative data illuminated the mechanisms at work in the strong association between assault and persistent absence from school. Mental health issues impacted on attendance, concentration, and performance. Sleep problems led to difficulty getting up and out, and some were immobilised and house-bound by panic attacks and agoraphobia. Absence for court hearings and other appointments disrupted attendance and, where the assailant was a fellow pupil, the young person was disinclined to attend school alongside them or their peers (for fear of repercussions). Once at school or college, lethargy, lack of motivation and inability to concentrate, compounded by feelings of worthlessness and low self-esteem, hindered educational progress and attainment.

“For a while I just couldn’t do it [school], I couldn’t, I didn’t want to be around people, I just wanted to be alone. I even used to find it hard to get out of my bed, I just wanted to be in the dark, zoned out […]”

“[…] like usually when I go to court […] I can’t go to school the next day because I’ll be a bit upset and like I just can’t be bothered to see anyone […]”

The qualitative data also suggested a bidirectional relationship between mental health problems and disengagement from education. Anxiety and depression had a detrimental effect on academic performance which in turn led to further mental health and sleep problems resulting in a vicious spiral. Deterioration in conduct, including outbursts of anger and aggression, caused disciplinary issues, particularly where teachers were unaware of the assault. Participants reported a lack of understanding on the part of schools of how to support them post-assault and few allowances having been made for its effects on academic performance. Some were excluded, others dropped out permanently or temporarily, or repeated a year, and several were relocated to another school.

“ [...] so I didn’t go to school for a long time, then going back so then I was behind and I’m not coming in some days because I just feel like I just don’t want to see anyone and then into class I wouldn’t concentrate like it feels just all really long so my school was just like, your attendance is really bad, like you’re not going to get good [grades] [...] so it was a thing where it was best me just to drop out and just, yeah.”

Educational attainment was adversely affected with lasting consequences for career aspirations.

“I was looking at [xxxx] University for example to do medicine, you need five A*, I got two, I was predicted eight, so if that never happened, I could have gone to [xxxx].”

What quantitative data were unable to capture, and in-depth accounts illustrated vividly, was the impact of the assault on relationships with family members, partners and peers and their importance for outcomes. Initial disruptions to close relationships were common. Most participants described increased tension at home in the months following assault. Parents’ first reaction was often to be over-protective, curtailing their child’s freedom and causing them to feel untrusted and punished. Participants felt guilt at having upset their parents. Those in sexual relationships reported increased arguments and difficulties engaging in sexual activity. One participant whose boyfriend assaulted her grieved the loss of this relationship. Friendships deteriorated or ended due to a combination of social withdrawal and uncertainty about how to manage the relationship.

“[…] people would say rape jokes just to get a reaction out of me and that just made my temper even worse […]”

“… after it happened, they didn’t really know how to treat me. They didn’t know if I needed the support or if I just wanted to forget about it and because I never brought it up, they just never brought it up but they’d always kind of tread on eggshells.”

Longer-term outcomes however were often more positive. Relationships with some parents became closer following emotional disclosure; new, healthier friendships were forged; and relationships with teachers improved, especially if the young person changed schools and had a fresh start. In these instances, friends and family were seen as being important in providing beneficial support and reassurance.

“[…] there was a girl at school actually [...] she was the one who, like, helped me through, didn’t judge me, I think she was like the first person who made me laugh.[...] she didn’t ask too much questions like everyone else did, about what happened, [...] the only thing she asked me was, okay, do you want to go and do this?”

“[Mum and I] were having arguments about the fact that I wasn’t opening up to her. Because I have been known to bottle things up a lot, but yeah, after all of it came out [...] I wasn’t always in bed, like just being on my own. I was actually, like, playing with the dog and going out in the garden with her, [...] spending time with people for once.”

Associations with key outcomes

Tables 5, 6 shows associations with key medium-term outcomes including mental health symptoms above threshold and disengagement from education and employment, for females only. A sensitivity analysis was conducted to include all participants and the results were similar with no major differences.

Table 5 Crude and adjusted associations between socio-demographic and assault characteristics, vulnerability factors and service use, and adverse mental health outcomes among female participants onlyTable 6 Crude and adjusted associations between socio-demographic and assault characteristics, vulnerability factors and service use, and an adverse education/employment outcome among female participants only

Univariate regression analyses showed an association between enduring PTS symptoms and mixed ethnicity. Social services involvement prior to or at the time of assault predicted enduring anxiety and depressive symptoms at study end, including after adjusting for age, ethnicity and deprivation. Mental health disorder at first (4–5 month) follow-up predicted enduring PTS and depressive symptoms at study end after adjusting for the same factors.

Social services involvement prior to or at the time of assault, mental health help in the 12 months pre-assault and mental health disorder at first follow-up were also associated with disengagement from education and employment at study end, although only social care involvement remained significant after adjusting for age, ethnicity and deprivation. There was an association between being in foster care at study entry or end and an adverse education/employment outcome.

No associations were observed between assault characteristics and mental health or education/employment outcomes.