Prevalence in the adult population

Although sexual assault is widespread and represents a major public health concern in the UK, given the wide range of mental and physical health problems associated with it, it remains largely underreported (Macdowall Reference Kilpatrick, Veronen, Best and Figley2013). The Crime Survey for England and Wales (CSEW; Office for National Statistics 2020) noted that 154 113 sexual offences against individuals aged 16–59 years were recorded by the police in England and Wales in the year ending March 2020, showing little change from the previous year (154 213). According to the CSEW (Office for National Statistics 2020), estimates for the year ending March 2020 showed that 2.2% of individuals aged 16 to 59 years had experienced sexual assault. The year ending March 2020 was the first year since 2012 with no increase in the number of sexual assaults, and the offence of rape was also seen to fall marginally from 55 771 to 55 130 offences for the same time period.

Prevalence of child sexual abuse among children and young people

The National Crime Survey (Office for National Statistics 2016), which reports on UK population survey data rather than crimes officially reported to police, highlighted some important characteristics of child sexual abuse. It estimated that such abuse had been experienced by 11% of girls and 3% of boys. Furthermore, of these, 27 and 3% respectively were later sexually assaulted as adults. Between 12 and 14% of people who identify as lesbian, gay, bisexual and trans (transgender, transsexual) (LGBT+) reported having experienced child sexual abuse. The abuse began quite early, with 27% of respondents having been abused by 6 years of age and 53% by age 9. In the year ending March 2019 (Office for National Statistics 2020), the police recorded 73 260 sexual offences against children, and around one-quarter (27%) of these were rape offences. Most children do not disclose abuse at the time it occurs but may disclose in later years, if at all. It is important to note that the definition of child sexual abuse within this survey applied only to incidents involving penetration, and these figures are therefore likely an underestimate of the scale of the problem.

Suicide: definitions and statistics

Most practitioners report feelings of anxiety when working with individuals who report suicidal ideation and/or intent and, from our own clinical experience, it is not uncommon for some practitioners to either overreact or underreact to the disclosure of suicidal thoughts by patients. It is therefore important to differentiate terminologies used in routine clinical practice, as different behaviours related to risk to self are likely to result in different management pathways. Box 1 offers definitions of the most commonly used terms.

Suicide statistics for the adult population

Suicide is the 14th leading cause of death worldwide, responsible for 1.5% of all mortality (O'Connor 2014) and it is the leading cause of death among young and middle-aged men in the UK (Office for National Statistics Reference Nock, Borges and Bromet2015). Suicide is therefore a major public health concern, with the World Health Organization (2014, p. 3) stating that every 40 s a person dies by suicide somewhere in the world, with many more attempting suicide. As regards UK statistics, 6507 people died by suicide in 2018, compared with 5821 in 2017, representing the first increase in deaths since 2013 (Office for National Statistics 2019). The latest report on suicides registered in 2018 in the UK by the Office for National Statistics (2019) reported a male suicide rate of 17.2 deaths per 100 000, representing an increase from the rate in 2017, but the female suicide rate of 5.4 deaths per 100 000 has remained consistent with the rates over the past decade (Office for National Statistics 2019). In 2018, Scotland was reported to have the highest suicide rate in Great Britain with 16.1 deaths per 100 000 persons (784 deaths), followed by Wales with a rate of 12.8 per 100 000 (349 deaths) and England the lowest with 10.3 deaths per 100 000 (5021 deaths) (Office for National Statistics 2019).

Among men, those aged 45–49 years presented the highest suicide rate, at 27.1 per 100 000 males and among women, those also aged 45–49 years had the highest rate, at 9.2 deaths per 100 000 females (Office for National Statistics 2019). Of note, death rates among the under 25s have generally increased in recent years, particularly 10- to 24-year-old females, where the rate has reached its highest level with 3.3 deaths per 100 000 females in 2018 (Office for National Statistics 2019). There has been a slight change in the male age groups that are more likely to die by suicide in the UK in recent decades: from 1991 until 2011, the highest age-specific male suicide rates were among men aged 30–44 years, whereas since 2013, men aged 45–59 years have had the highest rates, with 21.8 deaths per 100 000 population in 2017 (Office for National Statistics Reference O'Connor, O'Connnor, Platt and Gordon2018). This change in trend is thought to be linked to middle-aged men being more likely affected in recent years by economic adversity, alcoholism and social isolation (Samaritans 2018). The most common method of suicide for both men and women is by hanging, suffocation or strangulation, which account for 59.7% of all suicides among men and 42.1% among women (Office for National Statistics Reference O'Connor, O'Connnor, Platt and Gordon2018). The second most common method of suicide is poisoning, accounting for 18.2% of all suicides among men and 38.3% among women (Office for National Statistics 2018). Figure 1 illustrates UK suicide rates by gender in 2017.

FIG 1 UK suicide by gender in 2017 (data from Simms et al (2019); infographic created for the Samaritans and reproduced here with the permission of Jenni Munro, Samaritans Training Events Coordinator on behalf of the Samaritans research team).

Risk and protective factors for suicide in the adult population are discussed below (in the section ‘Identifying and assessing risk and protective factors’).

Suicide and risk of self-harm in children and young people

Rates of suicide in England and Wales have increased among adolescents by approximately 7.9% each year between 2010 and 2017 (Bould Reference Bould, Mars and Moran2019). There were gender differences, with suicide increasing at a higher rate for females between 2013 and 2017 (13.2% per year). This is a worrying trend. Moreover, Gayle (Reference Fortune and Hawton2019) reports an 11.8% increase in deaths by suicide among young people aged 10–24 in the UK. However, it can also occur in much younger children (<11 years old, i.e. prepubertal). It is estimated that in 2016 approximately 10 000 deaths by suicide worldwide were of children aged 10 or younger (World Health Organization 2016). The lower relative rate of suicide for prepubertal children means that there is less research available for this age group. Research for adolescents is less easily applied to younger children, owing to developmental differences between the two age groups.

Adults

Experiencing sexual violence is one of the most significant risk factors for suicide. Suicidal ideation and self-harm are common in people who have been sexually assaulted, with studies dating back to 35 years ago stating that up to 44% report suicidal ideation and 19% reporting self-harm (e.g. Kilpatrick Reference Joiner1985). These figures are unlikely to have changed significantly in recent years. Furthermore, a study conducted by Petrak et al (Reference O'Connor, Gaynes, Burda, Williams and Whitlock1997) in a busy central London genito-urinary medicine clinic found that 16% of women referred to a psychology service after experiencing sexual assault had made a suicide attempt (all by overdose) post-assault and that 9% had taken the overdose within 24 h of the assault having occurred. In the same study, 41% of women had attempted suicide prior to the recent sexual assault. As regards London's SARC statistics, an audit carried out in 2008 (Heke Reference Hanson, Kilpatrick, Falsetti, Freedy and Hobfoll2009) on risk identification among adults attending the service found that 14% had attempted suicide and 14% had self-harmed. However, it is unclear whether the suicide attempts and the self-harm occurred before or after the sexual assault. We believe that this figure is likely to be consistent across other SARCs in the UK. Moreover, a report by NHS England (Reference Macdowall, Gibson and Tanton2013) states that there is an increased risk of suicide for abused children when they reach their mid-twenties and more recent figures from the Office for National Statistics (Reference O'Connor, O'Connnor, Platt and Gordon2018) suggest that nearly two-thirds of complainants of rape and sexual assault (63%) suffered mental or emotional problems as a result of the assault and one in ten attempted suicide.

Children and young people

Khadr et al (Reference Jacobs2018) conducted a prospective cohort study of a clinical population of adolescents (age 13–17) accessing the Havens (London's SARC). The study looked at characteristics of the adolescents in terms of demographics and mental health presentation. Shortly after reporting child sexual abuse, 90% of the participants were at risk (as measured by screening questionnaires) of developing post-traumatic stress disorder (PTSD), 88% were at risk of depression and 71% were at risk of anxiety disorder. This risk decreased over time for depression but less so for PTSD and anxiety disorders. At 4–5 months post-assault, 80% had at least one psychiatric disorder. Interestingly, these were linked to pre-existing vulnerability factors rather than characteristics of the offence, in contrast to the understanding of mental health outcomes following sexual offences (e.g. Chen Reference Callaghan, Waldock, Callaghan and Waldock2010) that cites the offence as the precipitant of mental health difficulties. In the 12 months before the reported incident, 41% of the sample self-harmed. Of course, the child sexual abuse might have been ongoing before the reported incident and so the self-harm may be in this context. Additionally, 72% were the most socially deprived, as classified by the index of multiple deprivation for England (cited in Khadr Reference Khadr, Clarke and Wellings2018). The least deprived in the sample were at higher risk for developing PTSD and anxiety disorders, and 8% of females became victims of a further sexual assault (Khadr Reference Jacobs2018), for reasons thought to relate to their vulnerability. When previous mental health support was controlled for, previous Social Services involvement was significant in terms of later mental health outcomes, whereas previous self-harm and previous child sexual abuse were not.

A study by Tomasula et al (2012) on the link between child sexual abuse and suicide in adolescents in the USA found that males who had experienced child sexual abuse were 10 times more likely to attempt suicide than males who had not. In turn, female victims of child sexual abuse were five times more likely to attempt suicide than non-victims. Victims of child sexual abuse were also more likely to carry out medically serious self-harm and more medically serious suicide attempts than non-victims. This was more apparent for males than females. Although the authors acknowledge that the method of data collection may have led to underestimating the scale of the problem, the results are alarming in terms of the consequences for SARCs of keeping young people safe from suicide and self-harm. Given the evidence on the link between sexual assault/child sexual abuse and the increased risk of self-harm and suicide, it is crucial that SARCs and other services consider how to assess, understand and manage risk.

When to assess risk in a SARC and what to ask

Risk is dynamic, changing over time, and should be assessed at every contact (Box 2). When assessing risk, it is important to balance the seriousness of the possible outcomes with the probability that they will occur, based on specific risk factors. This means that, however confident and competent a practitioner might be in the assessment of risk, there can never be an absolute guarantee. When assessing suicidal ideation, questions should be directed towards determining the presence or absence of: suicidal ideation, the persistence of the ideation, the likelihood of it being acted on and risk to others. Furthermore, it is important to assess level of hopelessness; whether the patient has thoughts about a specific, available method of suicide; whether they have ever acted on such thoughts in the past; whether they are able to dismiss the thoughts; ability to reassure you of their safety, for example until the next appointment; circumstances likely to make things worse; willingness to ask for help if crisis occurs. It is important also to be mindful that some patients who are experiencing suicidal ideation deliberately deny having such thoughts. Other factors to be aware of include the use of drugs and/or alcohol and a marked change in psychiatric symptomatology, such as psychomotor retardation. In individuals presenting with psychomotor retardation, the risk of suicide may increase as their condition improves because of the reduction in inhibition. It is also important to consider the developmental stage of the patient and any risk factors specific or relevant to that age group.

Contrary to some myths around suicide, there is no evidence to suggest that enquiring about suicidal thoughts and/or suicidal plans increases risk of suicidal ideation or self-harm. In fact, there is some evidence that it is beneficial for those at higher risk (Dazzi Reference Chen, Murad and Paras2014).

Box 3 lists questions to be considered when conducting a risk assessment with a patient.

Should risk assessment tools be used?

Although the risk assessment guidance provided in this article may seem familiar to many practitioners, it is nonetheless important to include it. Despite the existence of a number of risk assessment scales for suicide, none to date provides enough robust evidence to justify their routine use in clinical settings (Bolton Reference Bolton, Gunnell and Turecki2015; Chan Reference Burnam, Stein and Golding2016; Quinlivan Reference O'Connor and Kirtley2017). It is therefore not surprising that NICE stresses the importance of conducting a risk assessment but does not support the use of specific risk assessment tools (NICE Reference Kõlves and De Leo2011).

A psychosocial assessment that is carried out in a compassionate manner is key to establishing a positive rapport between a clinician and a patient in distress. It is also important to ask about suicide in a direct but sensitive manner.

When carrying out a risk assessment, it is important to identify protective factors that might reduce the risk of suicide. Some patients who present with protective factors still attempt and carry out suicide, but protective factors often contribute to increased resilience when faced with stress and/or adversity.