Trends in victim, incident and care characteristics of a Dutch sexual assault center

. Background characteristics such as age and mental disability have hardly changed between 2013 and 2020. The proportion of known perpetrators remains high with approximately 80% in both cohorts, and the proportion of perpetrators who met victims on the Internet remains unchanged with approximately 6% in both cohorts. To improve our understanding of the influence of societal changes on help-seeking behavior, the monitoring of victim, incident and care characteristics remains crucial in the future.


Introduction
Forcing someone to perform or undergo sexual acts or undergo manual, oral, vaginal or anal sex against their will is considered sexual violence. 1Sexual violence is a global problem that one in three women have faced at some point in their lives. 2In the Netherlands, approximately 22% of women and 6% of men have experienced sexual violence. 1Especially young, vulnerable women, people with mental disabilities and people who have experienced violence in the past are at risk of becoming victims of sexual violence. 3,4In addition to the acute consequences of sexual violence such as sexually transmitted diseases (STD), injuries and unwanted pregnancies, victims experience many long-term health problems.These may be both physical ones, such as cardiovascular disease and medically unexplained symptoms (MUS), and psychological problems, such as posttraumatic stress disorder (PTSD), anxiety and depression. 5Besides, almost half the female and one in four male victims fall victim to sexual violence again, called revictimization. 3,4Professional help is known to prevent these negative consequences in the long term. 6Reporting to the police and social support after disclosing are also helpful for the recovery process. 7evertheless, the majority of victims does not seek help; they are in shock, confused, ashamed, feel guilty, are afraid that they will not be believed or even fear they will blamed themselves. 8Besides, in most cases the perpetrator is someone familiar to them, which often makes disclosure a challenging process. 9,10Providing multidisciplinary care like medical, forensic and police services in one place is strongly recommended to improve care for victims of sexual violence. 6,11Therefore, the Center for Sexual Violence Gelderland-Zuid en -Midden (CSG-GZM) was launched in the Netherlands in October 2012.Much has changed since then.Nowadays almost everyone in the Netherlands over the age of ten owns a smartphone and uses apps such as Facebook, Instagram, Twitter and Tinder.In 2014 people used to be ashamed of online dating and now meeting online is the second most common way to find a partner. 12At the same time, however, 70% of female Tinder users have experienced some kind of offensive behavior towards them. 13Furthermore, the sexual abuse of young boys in the Catholic Church and the sexual abuse of both sexes in sports and scouting clubs has been openly discussed in the media, and the #Metoo movement started in 2017, quickly expanded worldwide and influenced the disclosing process enormously.All these events have provided a platform for victims to share their stories. 7These changes also raise questions.Do a greater number of victims, especially male victims, find their way to the assault center and is the number of perpetrators who met victims on the Internet increasing?Our research question, therefore, is: are there differences in victim, incident and care characteristics between victims of sexual violence who attended the sexual assault center in the 2013-2016 cohort and the 2017-2020 cohort?

Setting
This study was performed at the CSG-GZM, which is a collaborative network involving the Emergency Department of the Radboud University Medical Center (ED), the public prosecution service for the East-Netherlands District, the municipal health service and the Primary Health Care Center. 3This center is one of the first centers for sexual violence in the Netherlands and provides interprofessional care for victims of acute sexual violence.Acute sexual violence is defined as sexual violence that happened less than eight days ago, an eight-day limit that is maintained because traces of evidence can be preserved within this period.Acute care takes place at the ED, where an ED physician and nurse provide urgent medical care while undertaking to preserve traces of evidence.Victims are informed about legal procedures.If they consider reporting, a police officer is called in for an informative consultation.If victims still consider reporting after they have been informed, a forensic physician is called in to perform a forensic medical examination (FME).In addition, medical care includes testing and preventive treatment for STDs, pregnancy counseling and injury treatment.The day after acute care took place, a case manager contacts the victim to initiate psychosocial follow-up care, which includes psychoeducation and watchful waiting as well as screening for PTSD at one month after the incident.

Study design and study population
This study includes victims of acute sexual violence who attended the sexual assault center between January 2013 and January 2020.In order to explore changes between early years and recent ones, we divided the data into a cohort from January 2013 till January 2016 and a cohort from January 2017 till January 2020.

Data collection
Data was collected from the victims' medical files and police reports.After permission to view the police data had been granted by the public prosecution service for the East-Netherlands District, the police established whether a victim had filed a report.Anonymity was preserved throughout all our handling of data from the victims' files.

Measurements and definitions
This study focusses on the differences between victims in the 2013-2016 cohort and those in the 2017-2020 cohort.Background characteristics are: age, gender, ethnicity, living situation, presence of mental disability, presence of psychosocial care prior to the incident, use of psychotropic drugs, presence of prior sexual and domestic violence, type of sexual violence, number of perpetrators, relationship to the perpetrator, presence of Drug Facilitated Sexual Abuse (DFSA), FME, number of reports made to the police, referrer to the center, presence of contact with the case-manager and time between incident and arrival at the ED.These characteristics were also used to compare the two cohorts, except for ethnicity due to small numbers.Characteristics are further explained in Table 1.

Data analysis
Data was analyzed in SPSS version 25.Missing information of victims was coded as "missing values" and not included in the analysis.We used chi-square tests to compare variables between cohort 1 (2013-2016) and cohort 2 (2017-2020).P-values of <0.05 were considered significant.regarding the 2016-2019 data.Permission to collect data of reports by victims of sexual violence was obtained from the Public Prosecution Service of the East-Netherlands District of the police (September 2015-PaG/BIZ/48362 and July 2018-PaG/BJZ/52211).The database in SPSS was fully anonymized.The database was saved on a computer to which only the research team had access.The registry forms were stored in a secure data storage archive.

Results
Table 2 shows the characteristics of the study population.Between January 2017 and January 2020, a total of 270 victims of acute sexual violence attended the assault center.This is more than three times as many victims as between January 2013 and January 2016, when only 83 victims attended the assault center.The percentage of self-referrals increased significantly, from 10% in 2013-2016 to 30% in 2017-2020.We found a significant decrease in the use of psychotropic drugs among victims from 24% to 11% in recent years.Another significant finding was that the number of victims who received psychosocial follow-up care from the case manager increased from 64% in 2013-2016 to 79% in 2017-2020.Although not significant, there is an increasing number of 18-25-year-olds (23%-36%) who visit the CSG-GZM.The relationship of the victim to the perpetrator remained unchanged, with the perpetrator being known in 80% of the cases and meeting the victim on the Internet in 6% of the cases (Table 3).A police report was filed in 40% of all cases in both cohorts.No significant differences, finally, were found for gender, presence of mental disability, living situation, presence of prior violence, presence of psychosocial care prior to the incident, type of violence, number of perpetrators, presence of DFSA, FME and time between the incident and arrival at the ED.

Results
This study focuses on identifying changes in victim, incident and care characteristics since the assault center was set up.Immediately noticeable is the strongly increased number of victims who sought help, rising from 83 to 270 victims.This indicates that three times as many victims visit the center and receive the care they need.The number of selfreferrals also increased from 10% to 30%, meaning that more victims find their way to the center on their own.As the center, next to its website, created a Twitter account in 2011, a Facebook account in 2015 and an Instagram account in 2019, the center is also represented on social media, making it easier for victims to find.This may apply particularly to 18-25-year-olds.In addition, the use of psychotropic drugs decreased from 24% to 11%, while the percentage of victims who received professional psychosocial care remained the same, with approximately half the victims in both cohorts.This suggests that fewer psychotropic drugs are prescribed or that more victims without serious psychiatric disorders now also attend the center.It is known that only 11% of female victims and 4% of male victims in the general population report to the police. 1 In our study, approximately 60% of all victims in both cohorts participated in the FME, and approximately 40% of all victims in both cohorts reported to the police.Although the number of victims attending the center more than tripled, the percentage of victims who actually report to the police has not changed.This suggests that victims are not looking for legal help alone but particularly seek medical help as well as psychosocial care.The number of victims who are in touch with the case manager rising from 64% to 79% supports this hypothesis.Contrary to expectations, the number of minors, known to be a vulnerable group, has not increased despite the increased use of smartphones and social media.A possible explanation might be that parents now have the option of controlling their children's smartphone and app use, which prevents minors from getting involved in dangerous situations.Although the number of male victims increased, the percentage remained equally low, with 5% and 4%, respectively, of all victims in both cohorts.Finally, there has been no change in the victims' relationship to the perpetrator, which does not correspond with our expectation that the proportion of perpetrators meeting victims on the Internet would go up due to the increased use of social media and dating apps.

Comparison with other literature
Societal changes and increased numbers of victims seeking help are seen in other countries as well.After a serious case of child abuse (the Tønder-case) in Denmark, which was widely published in the newspapers and spurred intense public debate, the number of cases at the Institute of Forensic Medicine in southern Denmark showed a rise of 22%.The investigators concluded that there was greater attention for similar incidents among both the general population and professionals. 14In 2020, a Canadian study on disclosing sexual violence on social media after the #metoo movement concluded that social media has become a new option for disclosing sexual violence.It also revealed that, until the #metoo movement started, a large number of victims did not know that what had happened to them was actually sexual violence. 15The #metoo movement has caused victims to feel acknowledged and heard.Victims are also more aware now that sexual violence is a criminal offense and that help is available for them.In the general population, in addition, there is more knowledge of victims' reactions to it, such as freezing, being paralyzed by fear, being immobile and being unable to oppose. 16A research from 2020 states that social media activism in response to sexism promotes an enactment of women's social identity, thereby mobilizing them to further action. 17urthermore, the phenomenon of using social media to connect with others who have had similar experiences has been studied for other circumstances like life-limiting or life-threatening conditions as well. 18ocial media platforms can be useful adjuncts to the mental care of adolescents and young adults. 19Social media technologies offer exciting new means for engaging and communicating with adolecents and young adults as it already succesfully has been used to provide appropriate interventions and education. 20In 2019, a proposal for a new law on involuntary sex was submitted to the Dutch House of Representatives, a law that will also criminalize involuntary sex without the use of force.In response, the majority of the Dutch population (88%) agreed that it should be considered rape if there is no mutual consent. 21Despite these societal changes, disclosure is still a difficult process for a lot of victims.This is especially true for men.In the general population, 19% of men have experienced sexually transgressive behavior towards them, and 6% of men have been victims of unwanted manual, oral or anal sex. 1 One in three male victims never talk about the abuse.Only one in five male victims eventually seek help, whereas women seek help twice as often. 1,22Feelings of shame and guilt are common in all victims of sexual violence but they are even more prevalent in boys who are brought up to believe that only girls can be victims of sexual violence and that men are supposed to be dominant and aggressive predators. 10,22Genital responses such as erection and ejaculation, which occur in 20% of male victims, cause even more confusion, shame and guilt. 22Eventually only one in ten female and one in sixteen male victims of sexual violence report to the police. 1 There are several reasons that may prevent victims from reporting. 9In more than 75% of all cases, first of all, the perpetrator is someone they know, so victims might want to spare the perpetrator by not reporting the crime.Another common reason not to report is that victims want to move on and forget about the incident because they do not want to get entangled in a legal mess and reexperience the incident over and over again.Some victims even wonder if they can actually file a report because they feel responsible for what happened and do not know that what happened to them is sexual violence.Victims may be scared of the perpetrator, finally, because threats have been made or the perpetrator knows the victim's address.

Strengths and limitations
As a database with data of all cases of sexual violence has been maintained from the start, our study provides robust and reliable information with no gaps in the data, which makes it possible to compare data from the early years with more recent years. 3The CSG-GZM, furthermore, is the first Dutch assault center that shows validated reporting rates.In most other studies, reporting rates are assessed by asking victims about their consideration to report, not by registered and verified police reporting data.As the CSG-GZM was one of the first assault centers in the Netherlands, it has information available from the period before certain developments in society, such as the #metoo movement, emerged.In addition, this study took into account various aspects of human differences such as age, gender, ethnicity and mental disability.A limitation of our study is that our population consisted of victims who attended an assault center, a study population that is already more inclined to seek help, which makes our findings not applicable to the general population.Finally, the number of male non-Western victims of sexual violence remains low in both cohorts, making it difficult to conduct an analysis.It has been reported in the literature that male and non-Western victims are less likely to seek professional help. 7The possible connection between social media and the massive increase in self-referrals has not been statistically examined in this research.

Practice and research implications
One of our main findings is the strongly increased number of victims who seek help, particularly through self-referrals.Victims find their way to the center more easily.Social media is an easy and accessible way to reach victims, which could be used more often by various professional institutions.We should focus more on male victims and how to reach them, by using games and comics, for example or leaving flyers at sports clubs.Publicity campaigns or the media should pay more attention to the fact that perpetrators are known to their victims in most cases, that men can become victims of sexual violence too and that certain responses such as freezing or genital response may also occur also unwanted.Sex education in schools might be a good way to introduce this information at a young age, including the meaning of transgressive behavior.We also have to increase awareness of the variety of professional help that is available after sexual violence as victims often do not know where to go.We believe that further elaboration and investigation of victims' experiences, wishes and needs will be very useful.Such additional information will help to provide more targeted and tailored care and to reach more victims.It is also imperative to keep collecting data at the assault center to keep track of societal changes and changes in victims' help-seeking behavior.

Table 1
Centre for Sexual Violence Gelderland-Zuid en -Midden.A centre for victims of sexual violence, specifically for victims living in the southern and central part of the Dutch province of Gelderland.Definitions of characteristics.The CMO Radboudumc was consulted for this study and gave approval on March 19, 2015 (file number 2012-1218) regarding the 2013-2016 data and on January 15, 2019 (file number 2018-4661) (Suspicion of) sexual activity (assault or rape) where consent is absent or invalid due to the effect of drugs (including alcohol) Forensic medical examination (FME)Examination conducted by a forensic physician to collect traces of evidence of the crime.An FME is not performed ie victims are determined not to report to the police.A. Hiddink-Til et al.2.6.Ethical aspects

Table 3
Relationship to the perpetrator in percentages.