Rape Stereotypes, Younger Age, and Social Support Are Associated with Concerns About Help-Seeking at a Sexual Assault Center

Abstract

Sexual assault can lead to long-term health problems, yet many victims do not seek help from sexual assault centers. This cross-sectional observational study examined factors distinguishing help-seekers from non-help-seekers and identified factors related to concerns about help-seeking in non-help-seekers. A sample of 669 recent sexual assault victims (97.5% women; mean age 26) was recruited from sexual assault centers and social media; 251 had attended a sexual assault center and 418 had not. Multiple logistic regression was used to identify factors differentiating help-seekers and non-help-seekers. Logistic regressions identified factors associated with help-seeking, and ordinal logistic regressions examined factors related to 3 types of concerns among non-help-seekers: concerns about the incident, about the health service, and about potential negative consequences. Victims of assaults consistent with the rape stereotype (completed penetration, unknown perpetrator) were more likely to seek help. Among non-help-seekers, concerns about seeking help at a SAC were prevalent (34%-65%), while few felt they had no need (11.5%). Physical violence (OR = 0.33, 95% CI = 0.20-0.52) and higher age (OR = 0.97, 95% CI = 0.95-1.00) were linked to fewer incident-related concerns; penetration (OR = 1.73, 95% CI = 1.10-2.72) and highaer age (OR = 0.97, 95% CI = 0.94-0.99) to fewer service-related concerns; and physical violence (OR = 1.85, 95% CI = 1.18-2.90), penetration (OR = 1.95, 95% CI = 1.26-3.02), and social support (OR = 1.82, 95% CI = 0.68-0.99) to fewer concerns about negative consequences. Public information efforts highlighting the benefits of post-assault healthcare, especially for younger victims and those experiencing less stereotypical assaults, may encourage help-seeking. Support from family and friends may play an important role in victims’ decisions about seeking help.

Background

Sexual assault (SA) is highly prevalent in our society and carries a high risk of long-term mental and physical health problems. ¹ Several countries have established specialized healthcare services for SA victims to meet their immediate and/or intermediate health needs. These services are referred to by different names across countries; in Norway, they are known as Sexual Assault Centers (SACs). The 23 SACs in Norway each serve a defined geographic catchment area and are organized within specialist health services and regulated by the Directorate of Health’s Guideline for Quality and Competence in Sexual Assault Centers. They provide comprehensive care, including medical examination and treatment (eg, management of injuries, sexual health care, and testing and treatment for sexually transmitted infections), forensic examination for evidence collection, and psychosocial support. The Norwegian SAC model was based on the San Diego victim-centered approach, in which the aim of the psychosocial care and follow up is to improve the victim’s adjustment following SA. ² With the victim’s consent, the SAC can also facilitate contact with the police and a supportive attorney. All services are free of charge.

However, most SA victims do not turn to a SAC for help^3,4 or seek healthcare at all. ⁵ Little is known about the concerns SA victims may have if they consider seeking help at a SAC. Gaining insight into these concerns is crucial for enhancing access to healthcare services for victims of SA. The aim of this study was to reveal factors discriminating between SAC seekers and non SAC seekers and factors associated with participants’ concerns about seeking help.

In the early aftermath of sexual assault, most victims experience a high level of distress^6,7 and victims are at high risk for long-term physical and mental health problems.^8,9 Additionally, SA victims may sustain physical injuries during the assault, they may be at risk for sexually transmitted diseases and unwanted pregnancy, or they may need a forensic examination to secure evidence for a potential later police report. While not all victims require help at a Sexual Assault Center, those who do often evaluate the services favorably, although negative experiences and degrading treatment have also been reported. ¹⁰ Early health services for SA victims can potentially reduce long-term health problems. Reducing barriers and increasing the use of these services could represent an important gain in terms of health and well-being.

Previous research in this area has followed 2 main lines of investigation: Identifying discriminating factors between SA victims who do and do not seek medical or psychological help and exploring barriers against help-seeking in victims who do not seek help. Ethnic or sexual minority status, young age, a close relationship to the perpetrator, drug- or alcohol-facilitated SA, previous victimization experiences, and social isolation have been associated with a lower likelihood of help-seeking,^11-16 while stranger rape, physical injuries during the assault, institutional trust, and social support seems to increase the tendency to seek help.^4,17-19

Underuse of health services following sexual assault may have many causes, including the affordability, availability, and acceptability of services.^4,14 Previous literature has highlighted acceptability issues as particularly important for help-seeking after SA. Acceptability issues involve feelings, beliefs, or concerns about the incident or the available services that prevent victims from seeking help.^20,21 Holland and Cortina ²² additionally identified concerns or fears about potential negative consequences of help-seeking, for example that it would harm themselves, their social network or the perpetrator, as an important aspect of acceptability in victims. Thus, previous literature points to 3 important aspects of acceptability concerns, namely concerns about the incident itself, concerns about the health service, and concerns about potential consequences of seeking help.

Concerns About the Incident

In the acute phase, minimizing the incident or its consequences may prevent the victim from acknowledging the incident as a rape or an assault, particularly in SAs that deviate from the ‘rape stereotype’ (violent and forced penetration by a stranger with a resistant victim).^18,23,24 Such concerns (eg, doubt that the incident was serious enough or would be considered an assault by the health service personnel) may deter individuals from seeking SA-specific health services, and has been associated with less help-seeking in SA victims.^13,18,22 For example, in a community sample, failure to acknowledge the incident as rape was a significant predictor of help-seeking behavior among women who experienced drug- or alcohol-facilitated rape. ¹³ Similarly, minimizing the sexual assault either by normalizing it (eg, ‘It happens to girls all the time’), or by comparing it to more severe forms of assault—hindered help-seeking among college students who had experienced sexual assault. ²²

Concerns About the Health Service

When considering seeking help, victims may worry about how they will be treated at the SAC, and if seeking help at a SAC will be beneficial to them. Previous research has demonstrated that victims have concerns about provider compassion or stigmatization,^25-27 that seeking help could harm them or be distressful, ³ and that lack of trust is associated with less help-seeking.^4,18

Concerns About Potential Consequences

Finally, even though the individual acknowledges the incident as an assault and is willing to seek help, concerns may remain about potential negative consequences of help-seeking. For example, the victim may worry that others could come to know about it, fear of retaliation, mandatory reporting/having to talk to the police, or otherwise losing control of the situation.^22,25,28 Sexual assault sometimes co-occurs with intimate partner violence, and victims may fear that seeking help could lead to an escalation of violence if the perpetrator becomes aware of it. ²⁹ In small communities, a lack of confidentiality and fear of stigma and gossip may further deter women from seeking help. ³⁰

Although several studies have investigated the concerns SA victims may have about seeking health services, we know less about the factors associated with these concerns. ⁴ For example it remains unclear whether help-seeking concerns vary by age, assault characteristics, or social support. Such information could be important for designing health services and for targeting information to particular subgroups of SA victims. Additionally, many previous studies have relied on particular types of samples such as college students or the military, have been conducted in the US, and as most prior studies took place many years after the assault, participants may struggle to accurately remember the concerns they experienced at the time.

The aim of the current study was to achieve insight into factors associated with help-seeking at a SAC and factors associated with concerns about such help-seeking among recent SA victims in the Norwegian context. Our objectives were: (1) To replicate and extend previous findings on discriminating factors between sexual assault victims who did and did not seek help at a SAC, in the context of a country characterized by high gender equality and institutional trust, (2) to assess concerns about help-seeking and to identify factors associated with these concerns in SA victims who did not seek help. These objectives were investigated in a sample of 669 recent SA victims who had, and had not, sought help at a SAC. Based on previous literature cited above we included the following potential predictors: Sociodemographic factors (ethnic minority status, age, poor financial situation), assault characteristics (assault severity and injuries, relationship to the perpetrator, victim intoxication), previous victimization, perceived social support, and institutional trust. We hypothesized that individuals with less stereotypical assault experiences would be less likely to seek help and have more concerns about help-seeking than others, and that lower institutional trust would be associated with greater concerns about the service and concerns about potential consequences.

Methods

Participants and Procedure

This study derives data from the first wave of the TRUST study, which is an ongoing, longitudinal observational study of mental health and recovery in recent Norwegian victims of SA. We recruited participants through 20 of the 23 Norwegian SACs and through social media. Inclusion criteria included being at least 16 years of age, understand Norwegian or English, and having experienced SA in the past 12 months. Recruitment to the study started in January 2023. The social media campaign was launched during October-November 2023 and repeated August-September 2024. SAC personnel informed patients, if they found it suitable in the acute clinical setting, about the study by showing an information video and/or handing out a leaflet. The social media campaign included a collaboration with social media influencers, relevant organizations, and a targeted campaign on Facebook and Instagram. The Instagram / Facebook poster had the following text: ‘Have you experienced sexual assault in the past year? By participating in the TRUST study you can help others who have similar experiences’.

Both recruitment strategies directed potential participants to the study web page with information about the study and a direct portal to the consent form. Potential participants entered their contact information on the study web page, which was transferred encrypted to the University of Oslo Server for sensitive data. Individuals willing to participate were asked to consent through a secure identity confirmation system ‘BANK ID’. Participants could choose between web questionnaires or telephone interviews. Interviews were conducted by members of the TRUST research team (healthcare personnel with experience in research interviews and 1 master of science in psychology). Upon completion of the questionnaire/interview, data was transferred encrypted (without local storage) to the University of Oslo Server for sensitive data (TSD).

Although the TRUST study is ongoing, recruitment to the first wave is completed. Altogether, 669 individuals participated in the first wave of the study, of whom 251 (37.5%) had attended a SAC and 418 (62.5%) had not. The majority of participants were women 97.5% (n = 652), with a mean age of 26 years (range: 16-72). Our intention was to recruit participants who had experienced a SA within the last year. Nevertheless, SA victims for whom more than a year had passed, and who wanted to participate in the study, were not rejected. The time that had passed since the SA varied between participants: 0 to <6 months: 40% (n = 262), 6 months to 1 year: 29% (n = 191), more than a year: 31% (n = 204).

Consent to participate: All participants signed an informed consent, and the study was approved by the Regional Committee for Medical and Health Research, South-East, Norway (REK398925/2022) in accordance with Norwegian law. Potential adverse reactions to participation were assessed, and those who needed support were offered consultation(s) at an independent stress and trauma clinic. The data file was deidentified and data storage is approved by ‘SIKT’ in Norway. More information about the study procedures and ethical considerations have been published elsewhere. ³¹

Measures

Dependent Variables

Participants were asked if they had attended a SAC related to the recent sexual assault (yes/no). Participants who had not attended a SAC were presented a list of 9 potential concerns about seeking help at a SAC and asked to tick off each reason that was relevant for their decision. These 9 items represented 3 categories of concerns: (1) Concerns about the incident (Unsure if it was a SA, Thought it was not serious enough, Unsure if the SAC would think it was serious enough); (2) Concerns about the SAC service (Didn’t think health personnel could help me, Thought it was too late, Thought it would be unpleasant); (3) Concerns about the consequences (Afraid to lose control of the situation, Afraid others should get to know about it, Afraid I had to talk to/report to the police). For each of these categories of concerns, a count variable was constructed reflecting the number of ‘yes’ answers within each category (0-1-2-3).

Three additional items relevant for help-seeking at a SAC were not included in the outcome variable: ‘Practical problems’ (eg, ‘too far, didn’t have the time’, ‘Had no need’, and ‘None of these concerns were relevant for my decision’.

Independent Variables

Sociodemographic variables included age and ethnic minority status. Ethnic minority status was measured as either non-(country) origin and/or self-perceived minority status (such as belonging to an indigenuous group). Education level indicated whether or not the participant had completed 13 years of education. A dichotomous variable of self-perceived financial situation was constructed indicating whether or not the participants perceived their financial situation to be worse than most people.

Assault characteristics included Penetration during the assault (yes/no), Injuries and/or physical violence during the assault (yes/no), Victim intoxication during the assault (yes/no), and Relationship to the perpetrator (from a list of potential perpetrators, we dichotomized responses into Romantic partner/Family/Friend/Colleague/Fellow Student vs Stranger/Person recently met).

Previous sexual victimization included child sexual abuse and/or previous adult sexual assault. Child sexual abuse was measured by the following item from the Child and Adolescent Trauma Screen: ‘Did someone do sexual things with you, or made you do sexual things with them, when you could not say no, were forced or pressured?’. ³² Previous adult sexual assault was measured by the following item: ‘After age 18: Have you previously experienced one or more sexual assault(s)?’

Current Perceived Social Support was measured by Duke-UNC Functional Social Support Questionnaire (FSSQ). ³³ The scale comprises 7 items: Having people around you that care about what happens to you; receiving love and care from close ones; having someone to talk to about work/school/study problems; having trusted people you can talk to about personal or family problems; being included in social activities with others; getting useful advice about important things in life; and being cared for when sick. Respondents were asked to evaluate each item on a 5-point scale: ‘Much less than I would like’ (1), ‘Less than I would like’ (2); ‘Somewhat, but would like more’ (3); ‘Almost as much as I would like’ (4); and ‘As much as I would like’ (5). The FSSQ has been shown to be valid and reliable ³³ Cronbach’s alpha in the present study was .91. A mean score was calculated for the 625 participants (93.4%) who had answered 4 or more of the 7 items on the scale.

Institutional trust was measured by 3 items from the European Social Survey (https://www.europeansocialsurvey.org/methodology/methodology-overview): (1) ‘How much do you personally trust the police?’; (2) ‘How much do you personally trust the legal system?’; (3) ‘How much do you personally trust the health system?’. All items are scored on a scale from 0 (no trust at all) to 10 (complete trust). Cronbach’s alpha was .80. A mean score was calculated to reflect ‘Institutional trust’ for the 625 participants (93.4%) who had answered at least 2 items on the scale.

This study was preregistered (https://osf.io/jxmcf/overview). The study followed the relevant EQUATOR guideline, the STROBE guideline for observational studies. ³⁴

Statistical Analyses

We used Pearson’s r to examine correlations between continuous variables.

Discriminating Factors Between Help-Seeker and Non-Help-Seeker

Logistic regressions was used to assess associations between independent variables and help-seeking (having sought help at a SAC or not).

Factors Associated with Help-Seeking Concerns

Ordinal logistic regressions were used to assess associations between independent variables and 3 categories of help-seeking concerns (Concerns about the incident, Concerns about the SAC service, and concerns about the consequences).

In all regressions, we first performed unadjusted analyses, secondly an adjusted model 1 including all independent variables apart from social support and institutional trust, and finally a fully adjusted model 2. The justification for entering social support and institutional trust only in model 2, was that these variables might have been influenced by the sexual assault. In all regressions, we used multiple imputation with 200 imputed datasets. Correlation analyses were performed in IBM SPSS statistics for Windows, version 29, regressions were performed in R with the R package mice for multiple imputation.

Sample size estimation was conducted for the study as a whole (https://osf.io/jxmcf/overview). The number of degrees of freedom available in the regression analyses was determinded based on the recommendations given by Harrell. ³⁵ First the limiting sample size for each type of regression is determined for each type of response variable (Table 4.1 page 73), then this number is divided by 15 as a ‘good average requirement’ (page 72). For the logistic regression, the degrees of freedom available were 16, and in the 3 ordinal regressions, degrees of freedom available were 25 to 26, hence our models were well within these restrictions.

Results

The majority of participants were women, had an ethnic majority status, and had completed at least 13 years of education (Table 1). The sample represented primarily severe SAs in that most participants reported completed penetration. About half had been so drunk or otherwise intoxicated that they were not able to consent or resist the assault. More than half reported a close relationship to the perpetrator, and the majority had experienced SA before the index incident.

Table 1.

Sociodemographics, Assault Characteristics, Victimization History, Support, and Institutional Trust in SAC attenders and non-attenders.

Characteristics	Total (n = 669)	SAC attenders (n = 247)	SAC non-attenders (n = 422)
	% (n)/Mean (SD)	% (n)/Mean (SD)	% (n)/Mean (SD)
Sociodemographics
Age	26.4 (8.1)	26.0 (8.0)	27.0 (8.2)
Gender: Female	97.5 (652)	99.2 (245)	96.4 (407)
National minority status	16.9 (113)	17.4 (43)	16.6 (70)
Education: Completed 13 years of education	83.7 (560)	85.0 (210)	82.9 (350)
Poor financial situation	40.0 (254)	36.4 (84)	42.1 (170)
Assault characteristics
Penetration	81.8 (547)	87.9 (217)	78.2 (330)
Physical violence	24.1 (161)	27.5 (68)	22.0 (93)
Close relationship to the perpetrator a	64.5 (430)	47.2 (116)	74.6 (314)
Victim intoxication	48.4 (324)	53.4 (132)	45.5 (192)
Victimization history
Previous CSA and/or previous SA	82.2 (486)	74.4 (160)	86.7 (326)
Support and trust
Perceived social support	3.5 (1.1)	3.5 (1.1)	3.5 (1.0)
Institutional trust	4.7 (2.5)	5.1 (2.5)	4.5 (2.5)

Note. Missing values: 0%-11.7%. CSA = child sexual abuse; SA = sexual assault.

^aRomantic partner/ex-partner/family member/friend/colleague/fellow student.

Correlations Between Scale Variables

Age was negatively correlated with perceived social support (−0.18) and with institutional trust (−0.17), and social support was positively correlated with institutional trust (0.31). All P-values < .001.

Factors Associated with Help-Seeking at a SAC

In unadjusted analyses, completed sexual penetration and victim intoxication during the assault were both positively and significantly associated with help-seeking at a SAC (Table 2). In contrast, having a close relationship to the perpetrator as well as previous sexual victimization were associated with decreased odds of help-seeking. In adjusted analyses, these factors remained significant. For example, victims who had experiences completed penetration were twice as likely, while victims with previous victimization were half as likely, to seek help at a SAC. Adjustment for other variables did not much affect the odds ratios for these factors. Female gender was associated with higher odds of help-seeking, but this should be interpreted with caution, as only 17 men participated in this study. Higher institutional trust was associated with help-seeking in unadjusted analyses, but did not reach significance in adjusted models.

Table 2.

Factors Associated with Help-seeking at a SAC, Logistic Regression with Multiple Imputation, Odds Ratios (OR) with 95% Confidence Intervals (CI).

Independent variables	Unadjusted				Model 1				Model 2
	95% CI				95% CI				95% CI
	OR	Lower	Upper	P-value	OR	Lower	Upper	P-value	OR	Lower	Upper	P-value
Sociodemographics
Age	0.99	0.97	1.01	.331	0.99	0.97	1.01	.448	0.99	0.97	1.02	.497
Gender: Female	4.51	1.02	19.96	.047	5.16	1.07	24.89	.041	5.61	1.13	27.82	.035
Ethnic minority status	1.06	0.70	1.60	.797	1.16	0.74	1.82	.509	1.17	0.74	1.85	.491
Completed 13 years of education	0.86	0.56	1.32	.482	0.88	0.54	1.42	.600	0.89	0.54	1.45	.632
Poor financial situation	0.80	0.57	1.11	.180	1.02	0.70	1.47	.934	1.03	0.71	1.50	.873
Assault characteristics
Penetration	2.02	1.29	3.15	.002	2.08	1.28	3.38	.003	2.12	1.31	3.46	.002
Physical violence	1.34	0.94	1.93	.110	1.46	0.96	2.20	.074	1.47	0.97	2.22	.070
Close relationship to the perpetrator a	0.30	0.22	0.42	<.001	0.29	0.20	0.41	<.001	0.30	0.21	0.42	<.001
Victim intoxication	1.37	1.00	1.89	.048	1.52	1.07	2.16	.020	1.51	1.06	2.15	.023
Victimization history
Previous CSA and/or SA	0.46	0.30	0.71	<.001	0.47	0.30	0.75	.002	0.49	0.30	0.80	.005
Support and trust
Social support	1.03	0.89	1.21	.675	-	-	-	-	0.91	0.75	1.09	.301
Institutional trust	1.10	1.03	1.18	.004	-	-	-	-	1.08	1.00	1.17	.063

Note. SAC = sexual assault centers.

^aRomantic partner/ex-partner/family member/friend/colleague/fellow student.

Concerns About Help-Seeking at a SAC

Concerns about the incident, concerns about the SAC service, and concerns about the consequences, are displayed in Table 3. All types of concerns were frequently reported, particularly concerns about the severity of the assault, fear of having to talk to the police, and uncertainty about labeling what happened as a sexual assault, which were reported by half or more of the participants. Concerns about the incident was the most frequently reported type of concern.

Table 3.

Concerns About SAC Help-seeking in SAC Non-attenders (N = 418).

	Frequency		Frequency		Frequency
Concerns about the incident	% (n)	Concerns about the service	% (n)	Concerns about the consequences	% (n)
Type of concern		Type of concern		Type of concern
Unsure if it was a sexual assault	50.1 (211)	Health personnel could not help me	41.1 (172)	Afraid to lose control	40.7 (170)
Thought it was not serious enough	64.8 (271)	Thought it was too late	33.5 (140)	Afraid I had to talk to the police	52.6 (220)
Unsure if the SAC would think it was serious enough	43.3 (181)	Thought it would be unpleasant	45.9 (192)	Afraid others should get to know about it	40.7 (170)
Number of concerns		Number of concerns		Number of concerns
0	23.7 (99)	0	28.0 (117)	0	32.1 (134)
1	19.1 (80)	1	33.7 (141)	1	23.0 (96)
2	32.1 (134)	2	28.0 (117)	2	23.9 (100)
3	25.1 (105)	3	10.3 (43)	3	21.1 (88)

N = 418.

Few participants reported that they had no need for SAC services (11.5%, n = 48), or that the concerns listed were not relevant for their decision (3.6%, n = 15). Practical difficulties, such as travel distance, lack of transport, or lack of time, were reported as a concern by a minority of the participants (21.1%, n = 88).

Factors associated with the different types of concerns are displayed in Tables 4 to 6. In unadjusted analyses, almost all investigated factors were significantly associated with all 3 types of concerns. For example, both institutional trust and perceived social support were associated with less concerns of all 3 types. In adjusted analyses, however, only a few factors remained significantly associated with these concerns. Physical violence during the assault and older age were the only factors significantly associated with less concerns about the incident. Penetration and older age were significantly associated with less concerns about the service. Penetration, physical violence, and social support were all significantly associated with less concerns about the consequences of help-seeking.

Table 4.

Factors Associated with Number of Concerns about the Incident, Ordinal Logistic Regression with Multiple Imputation, Odds Ratios (OR), 95% Confidence, and P-values.

Independent variables	Unadjusted				Model 1				Model 2
	95% CI				95% CI				95% CI
	OR	Lower	Upper	P-value	OR	Lower	Upper	P-value	OR	Lower	Upper	P-value
Sociodemographics
Age	0.12	0.07	0.23	<.001	0.98	0.95	1.00	.050	0.97	0.95	1.00	.028
Gender: Female	0.63	0.26	1.54	.307	1.69	0.63	4.51	.293	1.69	0.63	4.52	.297
Ethnic minority status	0.30	0.23	0.38	<.001	0.74	0.47	1.18	.206	0.71	0.44	1.14	.153
Completed 13 years of education	0.31	0.25	0.40	<.001	1.20	0.73	1.98	.463	1.14	0.69	1.89	.614
Poor financial situation	0.30	0.23	0.39	<.001	1.12	0.77	1.62	.558	1.05	0.72	1.54	.795
Assault characteristics
Penetration	0.34	0.23	0.50	<.001	1.36	0.88	2.09	.163	1.35	0.88	2.08	.173
Physical violence	0.23	0.17	0.29	<.001	0.33	0.21	0.53	<.001	0.33	0.20	0.52	<.001
Close relationship to the perpetrator a	0.35	0.24	0.51	<.001	1.25	0.83	1.88	.288	1.23	0.81	1.86	.327
Victim intoxication	0.38	0.29	0.50	<.001	1.27	0.88	1.82	.194	1.27	0.89	1.83	.192
Victimization history
Previous CSA and/or SA	0.23	0.14	0.37	<.001	0.69	0.40	1.19	.183	0.61	0.35	1.08	.088
Support and trust
Social support	0.33	0.18	0.61	<.001	-	-	-	-	0.96	0.79	1.16	.671
Institutional trust	0.28	0.19	0.42	<.001	-	-	-	-	0.94	0.87	1.02	.146

Note. CSA = child sexual abuse, SA = sexual assault.

^aRomantic partner/ex-partner/family member/friend/colleague/fellow student.

Table 6.

Factors Associated with Number of Concerns about the Consequences, Ordinal Logistic Regression with Multiple Imputation, Odds Ratios (OR), 95% Confidence, and P-values.

Independent variables	Unadjusted				Model 1				Model 2
	95% CI				95% CI				95% CI
	OR	Lower	Upper	P-value	OR	Lower	Upper	P-value	OR	Lower	Upper	P-value
Sociodemographics
Age	0.47	0.26	0.84	.010	0.99	0.97	1.01	.301	0.98	0.96	1.01	.172
Gender: Female	0.67	0.26	1.74	.414	1.35	0.52	3.53	.538	1.31	0.50	3.43	.583
Ethnic minority status	0.45	0.36	0.56	<.001	0.84	0.53	1.35	.473	0.80	0.50	1.28	.352
Completed 13 years of education	0.47	0.38	0.59	<.001	0.95	0.59	1.53	.829	0.90	0.55	1.45	.654
Poor financial situation	0.47	0.36	0.60	<.001	1.00	0.70	1.45	.980	0.94	0.65	1.37	.750
Assault characteristics
Penetration	0.79	0.55	1.15	.226	1.89	1.23	2.91	.004	1.95	1.26	3.02	.003
Physical violence	0.53	0.43	0.66	<.001	1.89	1.21	2.96	.005	1.85	1.18	2.90	.007
Close relationship to the perpetrator a	0.47	0.33	0.68	<.001	0.92	0.61	1.38	.686	0.94	0.62	1.40	.748
Victim intoxication	0.49	0.38	0.64	<.001	1.18	0.82	1.69	.365	1.18	0.82	1.70	.364
Victimization history
Previous CSA and/or SA	0.57	0.35	0.94	.028	1.19	0.69	2.06	.540	1.06	0.60	1.87	.853
Support and trust
Social support	0.26	0.14	0.48	<.001	-	-	-	-	0.82	0.68	0.99	.043
Institutional trust	0.40	0.27	0.58	<.001	-	-	-	-	0.99	0.92	1.08	.877

Note. CSA = child sexual abuse, SA = sexual assault.

^aRomantic partner/ex-partner/family member/friend/colleague/fellow student.

Table 5.

Factors Associated with Number of Concerns about the Service, Ordinal Logistic Regression with Multiple Imputation, Odds Ratios (OR), 95% Confidence, and P-values.

Independent variables	Unadjusted				Model 1				Model 2
	95% CI				95% CI				95% CI
	OR	Lower	Upper	P-value	OR	Lower	Upper	P-value	OR	Lower	Upper	P-value
Sociodemographics
Age	0.24	0.13	0.45	<.001	0.97	0.95	1.00	.021	0.97	0.94	0.99	.011
Gender: Female	0.34	0.13	0.84	.020	0.64	0.24	1.68	.362	0.66	0.25	1.73	.395
Ethnic minority status	0.37	0.30	0.47	<.001	0.75	0.47	1.20	.225	0.72	0.45	1.16	.179
Completed 13 years of education	0.38	0.30	0.48	<.001	0.76	0.46	1.24	.269	0.72	0.44	1.20	.208
Poor financial situation	0.38	0.29	0.49	<.001	0.98	0.67	1.42	.907	0.95	0.65	1.39	.801
Assault characteristics
Penetration	0.57	0.39	0.85	.006	1.68	1.07	2.63	.024	1.73	1.10	2.72	.017
Physical violence	0.39	0.31	0.49	<.001	1.06	0.67	1.67	.797	1.06	0.67	1.67	.802
Close relationship to the perpetrator a	0.46	0.32	0.67	<.001	1.22	0.81	1.84	.340	1.25	0.83	1.88	.287
Victim intoxication	0.45	0.35	0.59	<.001	1.35	0.94	1.94	.099	1.35	0.94	1.94	.100
Victimization history
Previous CSA and/or SA	0.46	0.29	0.75	.002	1.30	0.75	2.24	.348	1.23	0.69	2.17	.482
Support and trust
Social support	0.30	0.16	0.56	<.001	-	-	-	-	0.85	0.70	1.03	.100
Institutional trust	0.40	0.27	0.60	<.001	-	-	-	-	1.02	0.94	1.11	.605

Note. CSA = child sexual abuse, SA = sexual assault.

^aRomantic partner/ex-partner/family member/friend/colleague/fellow student.

Discussion

The primary contribution of this paper was the identification of factors related to help-seeking and concerns about help-seeking at a SAC in a large sample of recent SA victims.

Very few participants reported that they had no need for SAC services. Nevertheless, the majority did not seek such services. This decision may have been influenced by concerns about the incident, the health service, and the potential consequences. These results call for targeted interventions aimed at reducing barriers against help-seeking in certain groups of SA victims.

The discriminating factors between help-seeker and non-help-seekers in this sample were characteristics of the assault, relationship to the perpetrator, and the victim’s previous experience with sexual assault or child sexual abuse. Victims of assaults in line with the ‘rape stereotype’ were more likely to seek help at a SAC. This is in line with previous findings showing that assaults by a known perpetrator and previous victimization are related to less formal help-seeking,^12,13,19 while forcible rapes including penetration, violence, or injuries are associated with more help-seeking.^19,36,37 Individuals with a prior history of sexual assault or sexual abuse may be less likely to seek acute care, potentially due to heightened feelings of shame or increased concern about negative social reactions. ¹³

Victim intoxication was associated with higher odds of help-seeking in our study. This may be surprising because alcohol-related assaults may be considered to deviate somewhat from the ‘rape stereotype’, and has been associated with more blaming social reactions. ¹⁹ Previous research has shown conflicting results regarding the role of victim intoxication during the SA.^13,19 It is possible that blaming of alcohol-related assaults vary between cultures, or may have changed over time, as the current study investigated recent assaults. In contrast to some previous studies on help-seeking^11,38 lower education and minority status were not significantly related to help-seeking at a SAC.

Only a small minority (about 12%) of our participants reported that they had no need for SAC services, which is in stark contrast to a study from Honduras, were the most common reason for not seeking care was a sense that it was not needed. ²⁸ Although our participants recognized a need for help, they expressed numerous concerns about seeking it. The majority was uncertain whether the incident was sufficiently severe, or whether they should label it as an assault, even though 82% of our sample had experienced involuntary penetration. Such ‘minimization’ may be understood as a way to cope with otherwise overwhelming emotions, but can also be an important obstacle to get needed healthcare.^18,24,39 Concerns about the health service at the SAC and the potential negative consequences of seeking help were also highly frequent among our participants, in accordance with previous studies.^3,4,15,22

This study extends existing research on help-seeking concerns by examining the factors associated with these concerns. Our results indicated that physical violence during the assault, as well as higher age, were related to less concerns about the severity of the incident, while completed penetration and higher age were associated with less concerns about the service, and both penetration and physical violence, as well as social support, were significantly associated with less concerns about the consequences. These results need to be replicated in other samples and contexts, but they highlight the potential for tailoring information about SAC services to specific groups of SA victims.

Our results indicate that particular attention should be given to young SA victims, as they had more concerns about how to understand the incident. This is contrary to a recent review study that revealed that older respondents were more hesitant to accept an incident as an assault when it did not fit the stereotypical representation of rape. ⁴⁰ It is possible that attitudes are changing in the young. Holland et al ³⁹ have argued that ‘what is seen as severe’ relates to the social and institutional discourse around sexual assault. An Australian study described how victim-blaming and misogyny normalized sexual violence and discouraged help-seeking. ⁴¹ Changes in attitudes toward SA may occur for example as a result of the postfactual development, the rise of the right-wing movement and the reliance on social media for information.^42-44 Our participants entered the study because they (at that point in time) labeled the incident as a SA but still expressed much concern about the ‘severity’ of the incident at the time when they considered seeking help. Interventions are needed to help sexual assault victims, especially younger individuals, better understand what constitutes sexual assault, enabling earlier recognition and timely access to health care. Additionally, it is important to emphasize that SAC services can be beneficial even in the absence of physical injuries or forensic evidence. School-based educational programs and regular public information campaigns may be effective strategies for improving public literacy about sexual assault.

Younger age was also associated with more, and completed penetration with less, concerns about the health service at the SAC. This finding suggests a need for targeted information that can explain the potential benefits of healthcare after SA to young people, and and reassure those who are uncertain about how to understand the incident that they are welcome to seek help. Additionally, providing a consultation service at the SAC could assist individuals who are unsure about the nature of the incident or the availability of services beyond the acute phase.

Our results indicate that SA victims of less stereotypical assaults (such as not completed penetration, no physical violence, or a known perpetrator) have more of all kinds of concerns that can represent barriers to help-seeking. This finding is in accordance with several previous studies documenting that non-stereotypical assaults are less easily recognized as an assault and associated with less help-seeking.^4,18

Finally, as perceived social support was negatively associated with concerns about seeking help at a SAC, our results indicate that family and friends may play an important role in decisions about help-seeking. Social support has been linked to help-seeking also in previous research, ⁴ but in this study it was specifically related to potential consequences, such as fear about losing control, of having to talk to the police, and that others should get to know about it. One possible interpretation is that individuals with strong social ties may feel less threatened by potential negative reactions or social exclusion following SA, or that support from family or friends may have directly motivated them to seek help. Further research is necessary to understand the specific role of social support in the context of help-seeking.

Diversity

This study was conducted in Norway which is characterized by high ranking on gender equality and institutional trust,^45,46 and by an accessible public health system in which SAC services are provided free of charge. Nevertheless, the help-seeking concerns observed were highly similar to those documented in other countries, as outlined above, which might suggest that rape stereotypes are not substantially shaped by formal gender equality. Because only a small number of participants were male and few identified as gender or ethnic minorities, the extent to which these findings generalize to men and minority groups is unclear.

Limitations

This study was cross-sectional and relied on self-report, with the inherent risk of bias or forgetting. Selection bias is likely, and the sample cannot be considered representative of all SA victims. Unmeasured variables may have affected our results. The small number of male participants limits the ability to identify potential gender differences. Similarly, analyses of ethnic subgroups were not feasible because of the small number of participants in each group. As we only had data on concerns in participants who did not seek help at a SAC, we could not compare concerns in those who sought help and those who did not. Further, we did not have information about the relative importance of the various concerns, nor on potential concerns about seeking other health services than SACs. Participants memory for their potential concerns may have been more reliable in victims with more resent assaults. Perceived social support and institutional trust may have been affected by the sexual assault. Despite these limitations, this study had several strengths included recruitment relatively shortly after SA and a sufficient sample size with very little missing data.

Future research is needed to clarify how perceived risks, benefits, and concerns differ between SA victims who seek help and those who do not, and to examine whether victims feel their concerns were justified after seeking help. It is also important to document patient experiences at the SAC and the actual benefit of the healthcare provided at the SACs, as these may differ across cultures and contexts, and to assess the impact of awareness interventions or campaigns targeting the general public, victims of sexual assault, and their families and friends. Future qualitative research could enhance understanding of the multifaceted nature of victim experiences.

While not all sexual assault victims may benefit from seeking help, it is clear that many victims recognize a need for support yet do not pursue it. Health professionals working with SA victims should be aware of the concerns they may have about help-seeking, and be careful not to confirm negative expectations, for example by belittling the incident or not ensuring confidentiality. Public awareness campaigns, such as suggested by Walsh et al ¹³ could potentially increase people’s knowledge about health services and sexual assault. A consultation service could potentially help victims who experience doubt or ambivalence about seeking help, and it is essential that the SACs have sufficient resources to ensure adequate awareness of the services they provide.

Conclusion

SA victims who experienced assaults in line with the ‘rape stereotype’ were more likely to seek help at a SAC. Among victims who did not seek help at a SAC, concerns about the incident, the service, and the potential consequences of seeking help were all highly prevalent. Notably, participants did not agree that they refrained from seeking help because they did not need it. Younger victims were particularly concerned about the incident and about the service, and individuals with less stereotypical assault experiences had more concerns than others. Social support can be important for help seeking, particularly when it comes to reducing a fear for negative consequences of seeking help.