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. Author manuscript; available in PMC: 2022 Jan 1.
Published in final edited form as: J Forensic Nurs. 2021 Apr-Jun;17(2):84–92. doi: 10.1097/JFN.0000000000000321

Barriers to Accessing Mental Health Care after A Sexual Assault Medical Forensic Exam

Amanda K Gilmore 1,2,*, Ruschelle M Leone 1,2, Christine K Hahn 3, Dan Oesterle 1,2, Tatiana M Davidson 4
PMCID: PMC8387315  NIHMSID: NIHMS1665749  PMID: 33756526

Abstract

Background:

Research indicates low rates of accessing mental health care following sexual assault; however, barriers associated with accessing care are not well understood

Design:

Participants (N = 37) were recruited from a local hospital following a sexual assault medical forensic examination (SAMFE). Hierarchical linear regressions models examined the effects of age, racial identity, student status, insurance status, relationship to perpetrator, time since assault, problematic drinking, and posttraumatic stress symptoms on (1) barriers to accessing care and (2) likelihood to seeking mental health treatment.

Results:

Lack of insurance was associated with more barriers to accessing mental health care and higher likelihood of seeking post-SAMFE care at no charge. Posttraumatic stress symptoms were associated with more barriers to accessing care (p = .038). Identifying as a student (p = .026) and engaging in problematic drinking (p = .047) were associated with a lower likelihood of seeking post-SAMFE care, whereas increased symptoms of posttraumatic stress were associated with a greater likelihood of seeking post-SAMFE care (p = .007).

Conclusions:

Providing post-SAMFE care, irrespective of insurance, may be a needed first step in addressing the mental health needs of individuals with recent sexual assault. Secondary prevention programs targeted towards alcohol misuse may also be warranted.

Keywords: sexual assault, recent trauma, emergency department, mental health, health disparities, posttraumatic stress disorder

Sexual assault is a common experience in the United States (U.S.), with 18.3% of women and 1.4% men experiencing rape, the most severe form of sexual assault, in their lifetimes (Black et al., 2011). Sexual assault can result in significant mental health problems including, but not limited to, posttraumatic stress disorder (PTSD), depressive disorder, substance use disorders, and suicidal behavior (Dworkin et al., 2017). The majority of individuals who receive a sexual assault medical forensic exam (SAMFE) after a recent sexual assault do not receive mental health services to address any needs after the assault (Ackerman et al., 2006; Darnell et al., 2006; Gilmore et al., 2018). This is likely due to the significant barriers experienced by individuals who have experienced recent sexual assault.

There are numerous potential reasons people do not seek, or delay seeking, mental health services following sexual assault. In the general population, people report various instrumental and attitudinal barriers to seeking mental health services (Andrade et al., 2014; Clement et al., 2012; Mojtabai et al., 2012; Salaheddin, 2016). Commonly cited instrumental barriers include lack of knowledge about the availability of services, financial limitations, time constraints, and other concerns related to convenience access to services (Andrade et al., 2014; Clement et al., 2012; Mojtabai et al., 2012; Salaheddin, 2016). Frequently reported attitudinal barriers to seeking mental health services are negative beliefs about mental health treatment (e.g., not believing treatment would be effective), self-reliance (e.g., wanting to solve the problem on one’s own), or not believing the problem is severe enough to warrant services (Gulliver et al., 2010; Mojtabai et al., 2011; Salaheddin, 2016). Attitudinal barriers associated with less mental health service seeking include stigma-related beliefs such as embarrassment, concern about privacy related to mental health, and fear that providers would react negatively during mental health disclosure (Clement et al., 2012). Similarly, individuals who receive a SAMFE are not exempt from these commonly reported instrumental and attitudinal barriers to seeking post-SAMFE mental health services.

The majority of adults experience significant PTSD symptoms in the months following sexual assault (Steenkamp et al., 2012), yet only one-third of those who received a SAMFE sought recommended follow-up mental health services (Ackerman et al., 2006; Darnell et al., 2015; Gilmore et al., 2018). In addition to cultural norms that contribute to the aforementioned instrumental and attitudinal barriers to seeking general mental health services, individuals who have experienced sexual assault also experience stigma-related barriers that likely stem from norms and attitudes related to sexual violence (e.g., rape myths; [Edwards et al., 2011; Kennedy & Prock, 2018]). Barriers to receiving mental health services reported among urban and rural women recruited through rape crisis centers included cost, lack of access to services, being unaware of available services, concern about lack of sensitivity from providers, confidentiality concerns, shame, and self-blame (Logan et al., 2005). Similarly, male sexual assault survivors have reported instrumental barriers (e.g., issues with cost, insurance, scheduling) and stigma-related attitudinal barriers (e.g., being seen as weak) to receiving services related to sexual assault (Donne et al., 2018; Walsh et al., 2010). Concern related to how providers will treat survivors, such as fear they will be blamed for the assault or not believed, are also frequently endorsed barriers to seeking support services following sexual assault (Donne et al., 2018; Logan et al., 2005; Walsh et al., 2010).

The unique barriers experienced by individuals who have recently experienced a sexual assault are important to further explore given the long-term mental health symptoms experienced by this population. Research specifically examining barriers to receiving mental health services among women who have received a SAMFE is limited. Understanding barriers among this population is essential to informing methods to promote continued access to health care; a limitation of existing research is that the many studies have been qualitative in nature (Donne et al., 2018; Logan et al., 2005).

Predictors of Barriers to Mental Health Services

Characteristics of the sexual assault including perpetrator type may be an important factor related to barriers to care. For instance, despite widely held rape myths, perpetrators of sexual assault are often someone known to the survivor (Kilpatrick et al., 2007). Confidentiality concerns, shame, and social support concerns may exacerbate barriers to care when the perpetrator of the assault was an acquaintance/partner/known assailant. People who experience a sexual assault from an intimate partner were less likely to report receiving follow-up mental health services after receiving a SAMFE (Gilmore et al., 2018).

Post-assault mental health symptoms may also impact service utilization. Specifically, individuals with severe mental health symptoms may be more likely to access health care due to a higher immediate need. Previous research has found that people with more depressive symptoms are associated with higher likelihood of accessing care (Price et al., 2014). However, less is known about the association between acute stress and PTSD symptoms and barriers to accessing care. Further, there are specific demographic factors including gender, race/ethnicity, and age that are associated with accessing care more generally (Mackenzie et al., 2006; Roberts et al., 2011). More research is needed to understand the demographic factors associated with barriers to accessing mental health care following a sexual assault.

Current Study

In this study, we examined correlates of barriers to accessing care after a SAMFE, and examined factors associated with the likelihood of seeking care after a SAFME. Specifically, we examined demographic factors (age, sexual orientation, racial/ethnic identity, insurance status, student status), sexual assault factors (length of time since the assault, and relationship to the perpetrator of the assault), and mental health symptoms (problematic drinking, PTSD symptoms) with the goal of informing SANEs and advocacy centres of the potential risk factors that could be addressed at the hospital. Given the robust literature on the association between demographic factors and accessing care (Adams et al. 2014; Gearing et al., 2014; Gonzalez et al., 2011; Walker et al., 2015), we examined whether sexual assault factors and mental health symptoms are also associated with barriers to accessing care and the likelihood of seeking care. If unique factors are identified that are associated with more barriers to accessing care or lower the likelihood of accessing care, it may be possible to identify these individuals during the SAMFE to facilitate a “warm handoff “to follow-up care providers.

Methods

Participants

Participants were recruited to participate in this study to help improve health care during and after a SAMFE. Participants were eligible if they had experienced sexual assault and received a SAMFE at a local emergency department. A total of 194 individuals were invited to participate in the study of which 37 (19.07%) consented. This recruitment rate is consistent with other research conducted among samples of emergency department patients (13–22% recruitment rates; [Holeva & Tarrier, 2001; Molnar et al., 2007]). As displayed in Table 1, most participants identified as White, female, and were single. Approximately two-thirds of the participants were not in college and did not have insurance.

Table 1.

Demographic Information and Descriptive Statistics

N % Treatment Barriers M (SD)
Total Sample 37 53.03 (18.64)
Race/Ethnicity1
 African American 4 10.8% 69.00 (33.53)
 Asian/Pacific Islander 1 2.7% 48.00
 White 32 86.5% 51.19 (16.05)
 Hispanic/Latinx 2 5.4% 39.5 (7.78)
Gender
 Female 35 94.6% 53.17 (19.00)
 Male 2 5.4% 50.50 (14.85)
Marital Status2
 Single (never married) 21 56.8% 53.05 (22.22)
 Married 4 10.8% 43.75 (9.91)
 Divorced 2 5.4% 63.00 (5.66)
 In a serious relationship 7 18.9% 56.88 (18.64)
 Dating 7 18.9% 58.71 (14.91)
Student Status
 Not current a student 25 67.6% 54.88 (20.92)
 Currently a student 12 32.4% 49.17 (12.60)
Insurance Status
 Insurance 25 67.6% 48.44 (14.52)
 No Insurance 12 32.4% 62.58 (23.02)
Time Since Sexual Assault Occurred
 Less than 1 week 1 2.7% 40.00
 2–4 weeks 1 2.7% 35.00
 1–3 months 8 21.6% 57.86 (30.19)
 3–6 months 7 18.9% 52.29 (19.47)
 6–12 months 10 27% 54.50 (13.38)
 12–24 months 7 18.9% 48.43 (19.35)
Relationship with Perpetrator3
 Strangers 18 48.8% 49.94 (12.36)
 Casual Acquaintance 20 54.1% 55.15 (22.86)
 Partner 1 2.7% 60.00
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Note: percentages do not add up to 100 due to missing data

1

Participants identified both race and ethnicity, and therefore, add up to over 100%

2

Participants were able to identify more than one relationship status (e.g., could have been divorced and dating)

3

two participants identified the perpetrator as both a stranger and a causal acquaintance resulting.

Measures

Demographics and Sexual Assault Characteristics.

Participants completed a survey about their demographic factors and sexual assault characteristics. This survey included questions regarding age, self-identified sexual orientation, racial identity, ethnic identity, insurance status, student status, length of time since the assault, and relationship to the perpetrator of the assault (i.e., stranger, casual acquaintance, partner; [Gilmore et al., 2019]). For the purpose of analyses, racial/ethnicity was coded as a dichotomous variable (i.e., non-Latinx White, n = 30, non-White, n = 7 [Latinx/White = 2; African American = 4; Asian/Pacific Islander = 1]).

Problematic Drinking was assessed with the AUDIT-C (Bush et al., 1998), a three-item measure that reliably assesses hazardous and harmful patterns of alcohol consumption. The AUDIT-C is scored on a 0–12 scale, with higher scores reflecting greater problematic drinking. A score greater than or equal to 4 for men, and greater than or equal to 3 for women, indicates hazardous drinking or active alcohol use problems (Bush et al., 1998).

PTSD symptoms were measured with the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5), a 20-item measure used to assess for PTSD symptoms (Blevins et al., 2015). Participants indicated how much they have been bothered by each PTSD symptom over the past month on a 1 (not at all) to 5 (extremely) scale. Scores were summed, with higher scores indicating greater PTSD symptom severity. A score greater than or equal to 33 has been shown to detect PTSD (Blevins et al., 2015; Wortmann et al., 2016).

Barriers to Accessing Care was assessed with the Barriers to Access to Care Evaluation Version 3 (Clement et al., 2012), a 30-item measure used to assess stigma and non-stigma related barriers to accessing mental health care. Participants were asked to indicate how much, on a 0 (not at all) to 3 (a lot) scale, each barrier stopped, delayed, or encouraged them from getting professional mental health care following a sexual assault. High scores indicate more barriers.

Likelihood of Seeking Care was measured by asking participants on a 10-point Likert-type scale how likely they would be to contact a local mental health professional if offered no charge care as part of a grant or advocacy center. High scores indicate a greater likelihood of seeking care.

Procedure

All procedures were approved by the institution’s Institutional Review Board. Participants were recruited to either complete a survey online or to complete a survey combined with an interview (Gilmore et al., 2019). Therefore, participants either completed the survey online or on a computer in an office. Participants recruited to complete the survey online completed the consent process online; however, participants recruited to complete the survey combined with an interview completed the consent process via videoconferencing or in person. No differences were reported in the barriers to accessing care (t (35) = −1.55, p = .526) or likelihood of seeking care (t (34) = −.49, p = .465) between participants completing the survey online (Mbarriers = 61.78, SDbarriers = 21.92; Mtreatment likelihood = 5.63, SDtreatment likelihood = 3.2) or in person (Mbarriers = 51.73, SDbarriers = 15.69; Mtreatment likelihood = 4.90, SDtreatment likelihood = 2.96); therefore, online and in person participants were merged for data analysis.

Prior to completing any study procedures, potential participants either viewed an information statement about the study procedures or completed informed consent processes based on whether they completed the survey online or as part of an interview. Upon completion, participants were thanked and compensated ($25 if completing the survey online and $50 if completing the survey and interview).

Analysis.

To examine barriers associated with accessing health care after a SAMFE, we used a hierarchal linear regression to determine if age, racial/ethnic identity, student status, insurance status, relationship to perpetrator, time since assault, problematic drinking, and PTSD symptoms were associated with: (1) barriers to accessing care1; and (2) likelihood of seeking care. Variables were entered in the order of theoretical importance. This allowed for examination of how latter variables added to the prediction of the model after the effects of the effects of the initial independent variables had been considered. Age, racial identity, student status, insurance status was entered into Step 1 of each model. Additionally, relationship to perpetrator, time since assault, problematic drinking, and PTSD symptoms were entered into Step 2.

Results

Descriptive Analyses.

The length of time since the sexual assault varied among participants (Mdays = 34.59; SDdays = 24.50). Most assaults were perpetrated by a causal acquaintance (54.1%; n = 20), followed by a stranger (48.8%; n = 18) and partner (2.7%; n = 1), respectively. Participants reported clinically significant levels of posttraumatic stress, with the average score being well above the recommended clinical cut-off of 33 (PCL-5: M = 55.35; SD = 22.10; Blevins et al., 2015; Wortmann et al., 2016). Most participants were at risk of alcohol-related problems, with the average score for men and women being above the hazardous drinking cut off score of 3 and 4, respectively (AUDIT-C: M = 5.97; SD = 3.01). In terms of barriers to accessing care, participants reported more non-stigma related barriers (M = 32.46, SD = 10.91) compared to stigma-related barriers (M = 20.57, SD = 8.96; t (36) = −10.13, p < .001). Treatment related barriers by demographic variables can be found in Table 1.

Correlations for pertinent variables are in Table 2. Time since assault was correlated with likelihood of seeking care suggesting that fewer days since the sexual assault was associated with greater likelihood to seek care. Participants who had insurance (insurance status) reported less barriers to care than individuals without insurance. Additionally, greater PTSD symptoms were associated with more barriers to care, but a greater likelihood of seeking post-SAMFE care (likelihood of seeking care).

Table 2.

Descriptive Statistics and Intercorrelations.

M (SD) 2. 3. 4. 5. 6. 7. 8. 9. 10.
1. Age 28.65 (8.38) −.30 −.48** .10 .01 −.01 .04 .09 −.06 −.30
2. Racial/Ethnic Identity -- .11 −.40* .11 .03 −.27 −.10 .12 −.12
3. Student Status -- −.14 .09 .01 −.11 −.02 −.15 −.25
4. Insurance Status -- .01 .11 −.12 −.42* −.36* −.22
5. Relationship to Perpetrator -- .13 −.34* .04 .15 −.10
6. Time Since Assault -- −.06 −.25 −.02 −.35*
7. Alcohol Misuse 5.97 (3.01) .22 .13 −.01
8. PTSD Symptoms 55.35 (22.10) .47** .49**
9. Barriers to Treatment 53.03 (18.64) .13
10. Likelihood of Accessing Care 5.31 (3.06)
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Note:

*

p < .05

**

p < .001

Barriers to Accessing Care.

In the model examining barriers to accessing care, Step 1 was not significant F(4, 29) = 1.75, p = .165, R2. = .20. Therefore, factors entered into the model did not predict barriers to accessing care well. Nonetheless, insurance was significantly associated with barriers to accessing care, such that individuals without insurance reported more barriers (see Table 3). Step 2 did not account for any additional variance in the model F(8, 25) = 1.77, p = .131, ΔR2. = .17. Results revealed a significant effect of PTSD symptoms, such that individuals who reported more symptoms endorsed greater barriers to accessing care (see Table 3). In sum, the model that included all of the variables of interest (Step 2) revealed that PTSD symptoms were the only factor associated with barriers to accessing care.

Table 3.

Summary of Hierarchical Regression for Barriers to Mental Health Treatment and Likelihood of Accessing Post-SAMFE Care

Barriers to Mental Health Treatment
b SE β t 95% CI p
Step 1
Age −.28 .46 −.12 −.61 −1.22, .66 .545
Racial/Ethnic Identity −1.28 9.36 −.03 −.14 −20.42, 17.85 .892
Student Status −8.83 7.97 −.22 −1.11 −25.12, 7.47 .277
Insurance Status −16.71 7.24 −.41 −2.31 −31.51–1.91 .028
Step 2
Age −.35 .45 −.16 −.80 −1.27, .56 .434
Racial/Ethnic Identity 2.38 10.03 .05 .24 −18.27, 23.04 .814
Student Status −9.56 7.84 −.23 −1.22 −25.71, 6.59 .234
Insurance Status −7.86 8.21 −.19 −.96 −24.78, 9.06 .348
Relationship to Perpetrator 6.15 6.10 .18 1.01 −6.41, 18.70 .323
Time Since Assault 1.40 2.56 .09 .55 −3.88, 6.68 .590
Problematic Drinking .22 1.17 .03 .18 −2.20, 2.63 .855
PTSD Symptoms .36 .17 .43 2.19 .02, .70 .038
Likelihood of Seeking Post-SAMFE Care
b SE β t 95% CI p
Step 1
Age −.07 .07 −.20 −1.00 −.21, .07 .326
Racial/Ethnic Identity −2.53 1.43 −.32 −1.77 −5.46, .40 .088
Student Status −2.40 1.22 −.38 −1.97 −4.90, .09 .059
Insurance Status −2.29 1.11 −.36 −2.07 −4.56, −.02 .048
Step 2
Age −.08 .06 −.23 −1.34 −.20, .04 .193
Racial/Ethnic Identity −2.37 1.34 −.30 −1.76 −5.13, .40 .090
Student Status −2.48 1.05 −.39 −2.36 −4.64, −.31 .026
Insurance Status −1.00 1.10 −.16 −.91 −3.26, 1.27 .372
Relationship to Perpetrator −.52 .82 −.09 −.63 −2.20, 1.17 .533
Time Since Assault −.50 .34 −.21 −1.45 −1.20, .21 .160
Problematic Drinking −.33 .16 −.33 −2.09 −.65, −.01 .047
PTSD Symptoms .07 .02 .49 2.95 .02, .11 .007
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Note: Bolded effects are significant at p < .05.

Likelihood to Seek No Charge Post-SAMFE Care.

In the model examining likelihood to seek no charge care, the first model was not significant F(4,29) = 2.11, p = .105, R2 = .23. Therefore, the factors entered into the model did not predict likelihood of seeking post-SAMFE care well. Findings demonstrated that insurance status was negatively associated with likelihood of seeking care, such that individuals without insurance reported a higher likelihood to seek no charge post-SAMFE care (see Table 3). Step 2 of the model was significant F(8, 25) = 53.543, p = .007, ΔR2. = .31. Findings demonstrated that students were less likely to seek post-SAMFE care (see Table 3). Additionally, individuals who reported more problematic drinking were less likely to seek care, whereas individuals who reported greater PTSD symptoms were more likely to seek care. In sum, the model that included all of the variables of interest (Step 2) was significant, while the model that only included demographic variables was not. The model that included all of the variables of interest revealed that students and individuals who engaged in problematic drinking were less likely to seek care and participants with greater PTSD symptoms were more likely to seek care.

Discussion

The current study adds to the limited research on barriers to accessing mental health care and the likelihood of seeking such care among individuals who received a SAMFE. Findings from the current study suggest that only PTSD symptom severity was associated with more barriers to accessing mental health treatment after controlling for demographic factors. That is, individuals with more severe PTSD symptoms experienced more barriers. However, when looking at self-reported rated likelihood of seeking some form of care (including mental health or advocacy), student status, problematic drinking, and PTSD symptom severity were associated with likelihood of seeking post-SAMFE care. Specifically, identifying as a student and more problematic drinking were associated with lower likelihood of seeking post-SAMFE care, whereas more severe PTSD symptoms were associated with a higher likelihood of seeking post-SAMFE care when offered as free services. Therefore, although more severe PTSD symptoms were associated with more barriers to care, it may not be an impeding factor for seeking care, whereas problematic drinking and student status may be risk factors for not seeking post-SAMFE care.

The current study findings suggest that insurance can be an important demographic factor when attempting to ensure those in need are able to access care. Prior to considering mental health symptoms, individuals without insurance reported more barriers (both stigma and non-stigma related barriers) to accessing mental health care than those with insurance. This finding is intuitive, in that there are significant barriers to accessing care for those without insurance. However, it is important to note that the barriers assessed included a variety of barriers, including stigma-related barriers and not just logistical barriers. Further, individuals surprisingly reported more non-stigma related barriers than stigma-related barriers.

It is possible that individuals without insurance have not only logistical barriers to overcome to access mental health treatment, they may also have a compounding level of stigma related to not having insurance on top of the general stigma associated with accessing mental health care and experiencing sexual assault. Nonetheless, the barrier of not having insurance is not one that should be overlooked. In the U.S., the 1994 Violence Against Women Act allowed for provision of SAMFE without cost to individuals who experienced sexual assault (Boba & Lilley, 2009), however, there has not been a similar service for mental health care after the SAMFE. Individuals must pay for services or they are able to apply for victim’s assistance through the state in which the assault occurred which requires the means to pay up front mental health costs.

Interestingly, individuals were more likely to access free care if they had more severe PTSD symptoms. This suggests that individuals may actually be accessing care if it is needed when the barrier of cost is lifted, despite other significant barriers. Due to the high rates of dropout for PTSD-related treatments (Hoge et al., 2017), it may be useful to assess for and address any treatment-related barriers that may exist for individuals when they call to schedule an appointment. This may help ensure that individuals who are in most need of care are actually able to access care.

Problematic drinking emerged as a potential barrier to seeking post-SAMFE care in the current study. Future research should further explore why this association might exist. One possible explanation is that individuals who engage in alcohol misuse may experience more stigma-related barriers to accessing mental health care. However, the findings from the current study do not support that explanation. It is possible that there are specific stigma-related concerns specifically regarding problematic drinking that were not assessed in the current study that may be contributing to this association. Future research should explore specific stigma related to problematic drinking after a sexual assault to determine if there are any behavioral or cognitive mechanisms that can be targeted to increase post-SAMFE care.

Strengths and Limitations

The results from this study advance our knowledge of understanding perceived barriers to accessing mental health services post-sexual assault. As noted, findings from the current study regarding the increased level of both instrumental and attitudinal barriers among those without insurance, are a key strength of this study. Specifically, future efforts can ensure that individuals without insurance are provided assistance, possibly even cost-free care, to offset the burdensome cost associated with upfront costs of receiving assault-related mental health care, prior to obtaining victim compensation reimbursement. Another strength of the present study includes findings identifying individuals with lower-severity of PTSD symptoms and greater severity of problematic drinking, as both being less likely to access post-SAMFE care. Further, this study assessed individuals who received a SAMFE and did not restrict time since SAMFE.

Whereas the present study contributes to the literature in several ways, some limitations must be noted. First, it is important to note that this study only examined barriers to accessing mental health care among individuals receiving a SAMFE. Although this research provides critical insight into barriers to accessing care post-assault – future research is warranted. Specifically, it is estimated that the majority of individuals experiencing an assault do not receive a SAMFE, yet likely experience the same mental health consequences as individuals receiving an exam. Therefore, future research might assess additional barriers to receiving a SAMFE along with other post-assault mental health services, among individuals not presenting for a SAMFE. It also must be noted that this sample was somewhat homogenous in nature. The majority of participants in this study were women who identified as White. Further, the sample size was small and accessed from one hospital; therefore, it may not generalize to other populations. Given that, it is possible that individuals of different racial/ethnic backgrounds might experience differences in barriers to treatment; future research could further examine racial/ethnic identity. Similarly, future research assessing logistical and attitudinal barriers faced by men experiencing a sexual assault is also warranted. This study was also limited in that sexual orientation was not examined as a correlate of receiving mental health treatment post-assault. Future research could be targeted towards sexual and gender minorities, specifically, as individuals within this community face the highest rates of sexual victimization (McCauley et al., 2018), and possibly face different perceived barriers to post-assault treatment. The current study assessed current mental health symptoms, and did not prospectively examine the differences in barriers based on mental health symptoms prior to the SA and after the SA. Finally, the present study revealed that identifying as a student and having higher rates of alcohol misuse, was significantly associated with lack of receiving follow-up mental health treatment, post-assault. Although informative, these results are limited as they are not able to be contextualized. Given the high prevalence of experiencing sexual assault, particularly among college women – with the majority of assaults including use of alcohol by the victim – warrants further examination. Future research should aim to explore the intersection between problematic drinking, possible co-morbidity (e.g., PTSD symptoms, depression), identifying as a student, and accessing treatment post-assault, to better contextualize and inform sexual assault prevention programming. Finally, although a response rate of 19% is consistent with previous research (Holeva, 2001; Molnar, 2007), it is important to recognize that factors associated with barriers and likelihood to seek services after a sexual assault may be different among non-responders, who may be more resistant to help-seeking. It is also important to note that actual receipt of care was not assessed in the current study and future research should examine medical records to determine if there are factors associated with receipt of care.

Implications for Clinical Forensic Nursing Practice

While the current manuscript does not suggest that sexual assault nurse examiners (SANEs) should expand their scope of practice to include mental health care, it may provide insights to the referrals that are provided to individuals who have experienced recent sexual assault who are receiving a SAMFE. First, there are significant barriers for individuals who receive a SAMFE to access follow-up care. Second, there may be specific risk factors regarding access of follow-up care that SANEs may be able to pay attention to and provide extra support in terms of getting follow-up care for that individual. Specifically, in the current study, engaging in problematic drinking was associated with a lower likelihood of seeking care even after controlling for demographic and assault characteristics and providing care free of charge.

In order to facilitate mental health treatment, SANEs and forensic nurses might consider developing networks with mental health treatment communities. It may be possible for SANEs and forensic nurses to assist with connecting individuals receiving a SAMFE to a mental health care provider if they have developed networks with mental health treatment communities. This may be particularly important among individuals who engage in problematic drinking given that the current study found that those who engage in heavy episodic drinking are less likely to seek post-SAMFE care. One option would be for SANEs and forensic nurses to provide individuals with screeners for mental health problems (e.g., with a paper and pencil or electronic assessment of alcohol misuse like the AUDIT) and assist those in need with a “warm handoff” referral where they call a potential mental health provider together in the exam room to schedule an intake appointment. “Warm handoff” referrals may be particularly useful to individuals who experience barriers to accessing care and among those who are less likely to seek care themselves, especially at the acute period after a recent sexual assault. To extend the prospective success of this approach, nurse examiners may consider using a brief motivational interviewing (Miller & Rollnick, 2013) approach to discussing ambivalence towards problematic drinking-related treatment post-assault. Given these findings, positioning forensic nurses to establish a positive therapeutic alliance with patients may decrease some treatment-related barriers post-assault, and increase motivation to engage in continued treatment.

Since participants reported greater non-stigma related barriers compared to stigma-related barriers to care, SANEs and forensic nurses should be prepared to direct patients to resources that may decrease logistical barriers to care. SANEs and forensic nurses should be aware that people who lack insurance likely have greater barriers accessing post-assault care. A strong connection between SANEs and forensic nurses with social workers in the hospital and victim advocates, may assist connecting patients with lack of insurance to treatment options that decrease logistical barriers to care. In addition, SANEs and forensic nurses are in a unique position to explain the importance of post-assault care to patients.

Conclusions

This is one of the first investigations testing predictors of perceived barriers to seeking mental health services and likelihood of seeking care following sexual assault among people who received a sexual assault medical forensic exam. Research over the past several decades has consistently indicated that this population does not access mental health services, despite high reported need of services and existence of available evidence-based mental health treatment (Ackerman, 2006; Darnell, 2015; Gilmore, 2018; Steenkamp, 2012). Therefore, we extended this work to examine predictors of barriers to accessing care as well as likelihood of accessing free post-SAMFE care.

Acknowledgments

This project was supported by the South Carolina Telehealth Alliance. Manuscript preparation was partially supported by a grant from the National Institute on Drug Abuse (K23DA042935 to the first author) and the South Carolina Clinical & Translation Research (SCTR) Institute, with an academic home at the Medical University of South Carolina NIH—NCATS Grant Number UL1 TR001450.

Footnotes

1

Separate models for the outcomes of stigma and non-stigma related barriers (Clement et al., 2012) were initially conducted. Models yielded a similar pattern of effects, and thus the full scale that included both stigma and non-stigma related barriers was used.

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