Abstract
Despite the increase in sexual violence (SV) amongst young people, the use of formal services is poor. Effective coverage of health services is related to a satisfactory and quality care for the people who need a specific intervention. The aim of this study is to identify the factors that influence effective coverage of SV services from the perspective of young people and professionals in Spain. A qualitative study was conducted using an inductive thematic analysis approach based on 38 semistructured interviews with young people and professionals working in SV resource services and/or youth services in Spain, from September 2020 to October 2021. A content analysis was carried out. Both the professionals and young people referred to the fact that effective coverage is limited by the factors related to SV normalization and stigma, the lack of training of professionals, and the lack of human and economic resources. Furthermore, the young interviewees perceive sexual education as more biological and not focused on SV, as well as excessive bureaucracy, medicalization of processes, and the lack of trust in resources. However, the professionals mentioned the excessive specialization of psychological recovery accompaniment programmes and the lack of specialization of judicial institutions. To conclude, both the young people and professionals identified factors that reduce effective coverage of the services related to the social construction of the problem, training, and availability of resources. The young people also perceive other factors related to care and services, while the professionals place more emphasis on factors related to the user population.
1. Introduction
Sexual violence (SV) is any forced or coerced act or attempt to physically perform a sexual act without express consent, such as rape [1]. Furthermore, SV also considers other forms of abuse that do not entail physical contact, such as unwanted sexual comments or insinuations and actions to commercialize or use a person’s sexuality by means of coercion (psychological, extortion, threats) that offer occur in a digital setting [1]. It can happen anywhere and regardless of the relationship with the victim [1].
SV is a highly prevalent public health problem throughout the whole world [2]. In Spain, 13.7% of women declare to have suffered SV throughout their lives, whether in a relationship or not. In particular, young people between 16 and 24 years of age have suffered sexual violence to a greater extent throughout their lives than women 25 or over, both in relationships (12.4% vs. 8.9%) or not (11% vs. 6%) [3]. Recently published studies show a higher prevalence of SV in the last 12 months in women (10.5%) than men (6.8%) [4].
The most used resource by young adults when faced with an SV situation is informal support from friends and family [5, 6]. Support from formal resources is limited by some barriers that influence young people, such as trying to solve problems themselves, the lack of knowledge on resources, seeing professionals as strangers, trivialization of acts of SV in relationships, among others [7]. Furthermore, a lack of trust towards formal resources, as well as stigma in SV situations influence the victim’s behaviour to ask for help [6, 8, 9]. Currently, the majority of studies are focused on young people’s perspective [7, 10–15]. Only some research also includes the perspective of professionals working in SV services [16, 17].
Effective coverage of healthcare services refers to their capacity to offer a satisfactory and quality care [18–23]. The effectiveness of service coverage is influenced by factors, such as infrastructure, availability of adequate human resources, and physical and economic accessibility. On the other hand, attitudes, perceptions, values, and beliefs influence the acceptance of the resource and the predisposition to use it. For coverage to continue over time, the service must be perceived as useful and adapted to the target population.
A high frequency of SV, in particular amongst the young population, the scarce use of formal services among people exposed to SV, as well as the key role that these services have for people to recover their well-being [6], make it necessary to delve into the factors that influence access and use of formal care services for SV. The aim of this study is to identify the factors that influence the effective coverage of SV services from the perspective of professionals and young people.
2. Material and Methods
2.1. Study Design
Qualitative study using an inductive thematic analysis approach with 38 semistructured interviews conducted in Spain between September 2020 and October 2021. The study was carried out following a thematic analysis approach due to its potential to identify themes related to effective coverage and compare perceptions between young people and professionals. “SRQR” [24] and “COREQ” [25] have been used (see Tables 1 and 2 in the Supplementary Material).
2.2. Sample Strategy and Participants
The selection criteria for the young people were (1) age (18–21 years and 22–24 years); (2) sex; (3) level of studies (university or not); (4) place of origin (migrant and national); (5) geographical distribution according to region. In order to select the professionals, the following characteristics of the resources, where they worked, were considered: (1) type of resource management (public administration or associations); (2) scope of action (approach to SV and youth services); (3) geographical distribution according to region. The regions included in the study were the Region of Valencia, Balearic Islands, Catalonia, the Region of Madrid, the Basque Country, and the Region of Navarre.
After an initial online search, the researchers contacted potential participants who were informed about the objectives of the study. The participation rate was 100%. The criteria to finalize information collection was discourse saturation. Finally, 23 young people and 15 professionals were interviewed. The characteristics of the participants are reflected in Tables 1 and 2.
2.3. Data Collection
Two themed scripts were drafted and adapted to each profile (See Table 3 in the Supplementary Material), which were tested and adapted in the first phases of the field work. The interviews were semistructured, and the script was open in order to maintain the conversational logic. In the interviews with the young people, the sex of the participants was taken into account so that the interviewer was of the same sex. 26 interviews were conducted by telephone and 12 by video call. The interviews were conducted individually (interviewer and participant) in Spanish and lasted between 50–70 minutes. They were digitally recorded with audio and transcribed verbatim. No interviews needed to be repeated.
2.4. Ethical Considerations
Participation in the study was voluntary. Confidentiality and anonymity rights were guaranteed at all times. All participants previously received documentation about the study and signed an informed consent form. The project was approved by the Ethical Committee of the University of Alicante (UA-2020-07-07).
2.5. Data Analysis
An inductive thematic analysis was conducted [26] with the software Atlas.ti (version 8). The analysis process took place in two phases.
In the first phase, an external team conducted a preanalysis of the interview content. Under consensus, they elaborated a coding tree based on the objectives of the project and the information and experience obtained in the development of the field work. A double coding of the interviews was carried out, and the information was triangulated between two analysts. This content was divided into two blocks: (1) response of the agents to SV; and (2) assessment of the response by the interviewees (see Table 4 in the Supplementary Material).
In the second phase, the interviews were carefully read in order to understand the context and become familiar with data. Furthermore, new information was added to the codes of the second block related to the difficulties perceived in the responses. This was debated and agreed upon by the authors. This set of data, called perceived difficulties in the responses, was coded for content and similarity. Following an inductive approach, codes with similar ideas were grouped together and classified into potential themes called categories. The final categories were redefined, discussed, and negotiated among all authors to obtain the main topics of all the content.
This process involved constant two-way movements between the preliminary codes, categories, and topics up to the influence of the theoretical framework related to effective coverage [18–23] and other theoretical models [27].
3. Results
Based on the analysis, the following emerge as factors that reduce the effective coverage of services: (i) the social context; (ii) the characteristics of the people affected; and (iii) the characteristics of the services and professionals. The corresponding categories and codes are summarized in Table 3.
4. Factors on the Social Context That Influence Effective Coverage
4.1. Scarce Awareness on Sexual Violence
Both groups of interviewees consider that some young people are not aware of the types of SV that exist. They find it difficult to identify situations of sexual harassment or certain sexual assaults as SV. This makes it difficult to get both formal and informal help.
“Because it’s what I’ve seen, so, my colleagues usually do it (...) and the girl gets annoyed and I say it and it’s obvious. (...) I mean tell me who likes it (...) to be catcalled or someone they don’t know is saying things (...)” (HOM-02).
“When they’re identified with the emotion or the act, they do understand that they didn’t want it [have a non-consensual sexual relationship] (...) They find it difficult to realize they didn’t want to (...) they haven’t found a name for what’s happened to them” (AVG-31).
The difficulty in identifying it is associated with normalizing SV behaviours integrated in affective-sexual relationships, in groups of friends, or in society.
“There are some difficulties (...) with harassment and certain touching, which is related to another (...) and when they’re in your surroundings (...) there’s still the pressure from the group (...)” (AVG-38).
“...Affective-sexual relationships of a more stable relationship. Then there’s the barrier of trying to normalize (...) [non-consensual sexual assault or relationship] this couldn’t have happened” (HOM-04).
Therefore, the young people and professionals agree how the resistance that exists about talking about sexual relations and sexuality, outside the intimate or private setting, has a negative influence, making it difficult to access specialized services.
“I think because of the taboo and stigma that there still is around sexuality (...) there’s a lot of ignorance by families (...) many institutions and associations, it seems they’re scared to approach the topic” (SJ-42).
“So, to have a sexualized message there’s no problem, but when the time comes to tell our sexual problems, there’s an invisible barrier” (HOM-02).
Regarding the nonidentification with the stereotypes of victims, both believe that it makes it difficult to seek help. One professional highlighted that young girls/women do not feel represented by that image of an assaulted woman, as there is currently a social image that women should be autonomous, empowered, and be able to solve external difficulties. However, one young girl/woman related it to masculine stereotypes in the case of men who are victims of SV.
“...I don’t want to belong to that group of abused women [what young people say] (...) because that implicitly means I’m submissive, I have no personality, I follow (...) in young women even more, because they’re presumed to be stronger, they can deal with everything (...)” (AVG-39).
“I think it could possibly be more about ego, manhood, more than masculine character (...) that those things shouldn’t affect them [Access barriers for young men] (MUJ-12).
Finally, young men and women identified concealment-silence practices in male victims of SV and related this behaviour to the concept of masculinity and gender roles.
“(...) that social pressure of not being able to say anything because they’ll be belittled...” [In the context of a friend’s rape when he verbalized it after a long time and didn’t ask for help (formal or informal)] (MUJ-13).
Regarding the educational content in the system, the young people believe it is a barrier to understand SV. The biological approach to sexuality does not include individual, social, and ethical responsibility, leaving the affective part out, as well as consent, discriminatory attitudes, violent behaviours, etc.
“I haven’t had any sex education, just in 3rd year of high school, on how to wear a condom and that was it. I think all that [training in SV andgender-based violence] needs to be developed more if we want these problems to end (...)” (HOM-08).
4.2. Lack of Social Acceptance of Resources
The professional and young interviewees agree that rejection towards feminism and gender-based violence (GBV) creates animadversion towards the services and a defensive reaction that prevents them from accessing information on SV and prevention and awareness programmes.
“Many boys left quite resistant. Because they saw them as places of indoctrination, where feminazis come, etc... [in interventions to raise awareness on youth resources]” (SJ-36).
“In the end, they can take it badly because they think that all men are seen the same way, right? (...) that we’re attacking them all the time...” (MUJ-12).
The young people express a lack of trust towards institutions and resources limit accepting the resource and, therefore, initial access. This is highlighted in police and legal settings, especially with SV cases that have been on the media.
“Well the case of “La Manada” [case on the media of a rape that had a social reaction because of the legal measures], what happened, that was a joke. (...) Yeah, yeah, of course the State (...) so, unfortunately, I don’t trust it (...)” (HOM-18).
5. Factors That Influence Affected People (Victims, Aggressors, and Close Environment) and Make Effective Coverage Difficult
5.1. Different Social Situations
Both the professionals and young people believe age is a barrier to access formal resources. The professionals identify age with dependency and the need to have consent from a parent, while the young people relate it to the lack of maturity in awareness processes, acceptance, and decision-making.
“Let’s talk about parent consent, to be able to deal with young girls...” (AVG-39).
“ (...) the younger you are, the smaller you are, I think it’s more complicated...you don’t have the necessary resources (...) the less mature you are, well, it’s more difficult” (HOM-05).
Regarding a precarious socioeconomic situation, a young boy/man relates it directly to economic resources “because they can’t afford it (HOM-05),” while a professional links the socioeconomic level to the difficulty in obtaining information. Although the resources are accessible and free, if they do not know they exist, they cannot use them.
“There are difficulties (...) the digital gap (...) lack of economic resources so, they need to be on social networks, WhatsApp, Facebook and Instagram, even e-mail to be informed (...)” (SJ-41).
On the other hand, only the professionals identify intellectual disability as a factor that limits communication with victims, alongside the lack of adaptation by the legal system to the characteristics of this group and the absence of an inclusive perspective.
“In cases of sexual assault (...) a disabled woman, that’s something else...if she reports it but doesn’t tell it in the way the legal system needs to read it, well there’s a big added difficulty when reporting it (...)” (AVG-39).
Only the young people identify being a migrant as an access barrier to resources due to being scared of going to the police or not having a residency permit.
“If for whatever reason you’re an undocumented migrant and you don’t have any documents, it’s much more difficult. (…)” (MUJ-23).
5.2. Social Stigma
The young people and professionals express that certain feelings, such as fear, shame, and blame are factors that make effective coverage difficult as they prevent young people from asking for help.
“It’s mainly shame and pressure and fear that someone will find out they’re there or that the aggressor will know. Or they’re embarrassed that someone will know what’s happened to them” (MUJ-06).
“There are people that aren’t even able to go past that barrier because they’re scared (...) they admit they weren’t able to ring the bell the first time and they left…” (AVG-44).
Furthermore, both groups of interviewees related said feelings towards their close environment judging the victim. This makes it difficult for young people to access resources as they do not feel supported.
“Well maybe the stigma a bit...At the end of the day it’s a resource that, as it conditions your image in society, especially if you’re young...” (MUJ-10).
“They get a message of brutal rejection, from blaming, to not believing them...and then there are times when that, furthermore, if the aggressor is from the family environment, it’s generated as a...as a fight (...) the same in circles of friends...” (AVG-32).
Regarding the prejudices about professionals of resources, both groups of participants identify this factor as a difficulty for young people to attend. Several young people identify these prejudices specifically in police settings as they are the door to accessing other services in many cases.
“They don’t try to empathize much with women. So, they’ll think they’re doing it, that they’re lying, they’re doing it to be the victim or get something out of it, a revenge. (…) [In context of policemen] (MUJ-12).
6. Factors Related to Services and Professionals That Influence Effective Coverage
6.1. Training of Professionals
Both groups of interviewees perceive the lack of training in gender perspective, sexuality, and SV as a limiting factor. The professionals agree that training is insufficient to carry out quality interventions, while the young participants highlight the lack of training in services that are the doorway to SV resources. On the other hand, only the professionals have identified a lack of training when working with young people. This makes adapting the interventions difficult (Table 4).
6.2. Improvable Institutional Care
The young people and professionals agree on the deficient psychological therapy due to the high demand. Furthermore, they both coincide on the hostility, length, uncertainty, lack of adaptation, and efficacy of legal processes. This is an obstacle regarding the continuous use of resources. This is in addition to the lack of specialization of institutions, especially in the legal scope, as SV is treated like any criminal offence when it occurs outside intimate partner violence.
“For gender-based violence in a relationship, there are specialized lawyers, there are specialized courts. (...) However, for sexual violence there isn’t. (...) so, it’s a comparative grievance and it isn’t yet given the dimension it has...” (AVG-34).
Despite promoting SV specialization of legal resources, the professional participants consider that an excessive focus on SV can sometimes be counterproductive, as it does not address the consequences that violence has on other aspects of women’s lives (work, family, friendships, etc.). In addition, group interventions or interventions with their environment are omitted (Table 4).
The young people have identified excessive institutional procedures, referral between services, and having to go successive times as limitations to effective coverage. This is related to other factors that only the young people have identified, such as the delay in psychosocial attention or medicalization of the processes (Table 4).
6.3. Service Infrastructure
Both groups of participants share that resources are focused on GBV and middle-aged women. This factor is identified as a barrier as it excludes other groups affected by SV. The professionals identified several reasons for this: unadjusted schedules, minors not being able to go to centres without a guardian, and spaces and interventions not adequately adjusted to young people. Regarding the latter, both groups identified the lack of focusing on young people. The professional interviewees believe this is related to the information disseminated by the media, as the use of social networks is limited; while for the young people, the message is aimed at adults and they do not feel identified with it. Both the professionals and young people coincide with the fact that information on bureaucratic procedures and resources is limited and, what does exist, is not adequately adapted to young people. Finally, they agree that the lack of both human and economic resources make it difficult for them to function properly. This is reflected in the quality of the response by the youngsters (Table 4).
“I’d put one, well for each neighbourhood, or every 2, to be honest, whether for planning (...)” (MUJ-23).
“(...) many times, the lack of resources, staff, means you can’t do everything, you know? (...)” (SJ-43).
One youth service professional identified that the lack of protocols makes detection, referral, and correct care difficult for these young people. However, the young people give importance to the presence of nearby resources and they perceive inequality in their territorial distribution (Table 4).
“For any tool to work, for...more effectiveness, it needs to be nearby...You create a 016 [GBV telephone number in Spain] you’re addressing a specific population [...] a number like 016 [national], it’s really general, state-wide...and it can be seen as something really...formal, institutional...” [access barriers] (HOM-03).
7. Discussion
In terms of the results of this study, both the professionals and young people coincide that some factors related to the sociocultural context limit effective coverage. They highlight the confusion surrounding the concept of SV, as well as its normalization. Furthermore, both groups identify factors related to the victims and close relatives. Discourses are similar regarding factors such as low socioeconomic level, feelings of blame, shame, and the reaction by those close to them. The professionals agree that age is a barrier as victims formally depend on their parents to use the services and, for the young people, it is related to maturity. There are also differences in the discourses on factors related to the characteristics of the services, including training of professionals and the explanation given by them and the young people on the lack of reaching young people. There are other factors that only the professionals have identified: lack of specialization in legal resources or the lack or protocols adapted to young people. However, the young people have identified other factors such as a lack of training in SV and GBV in education, lack of trust in institutions, or excessive bureaucracy.
Regarding the sociocultural context, normalizing this violence makes many young people unaware of having suffered it, as sexuality has been limited to the private sphere or they do not identify with the stereotypes of victims [7, 28, 29]. This is aggravated when there is alcohol consumption, as it increases the feeling of blame, exempting the aggressors from responsibility [13]. Tools that encourage proactive responses by witnesses could help victims identify SV [30].
Regarding the factors related to those affected, both groups of interviewees agree that a precarious socioeconomic situation makes accessing and using formal services difficult [10, 13, 20]. This occurs despite the fact that accessing resources in Spain is universal. The professionals argue that there are economic difficulties to access information on the Internet, while the young people discuss economic difficulties as using transport or the lack of time due to precarious work situations. As observed, the material resources of each individual have an impact on inequalities in health and well-being [31] and have a noticeable influence on accessing services [20]. Likewise, the emotions experienced related to the negative reaction by family and friends, alongside the belief that professionals will not believe the victim, prevent young people from using formal services [7, 12, 13, 16, 28]. These emotions are so strong that even professionals who are victims of SV, with knowledge of formal resources, have been noticeably conditioned to seek help [28].
Regarding the characteristics of the resources, both groups identify that a greater provision in economic and human resources would help improve effective coverage [28, 32, 33]. Furthermore, the adequacy of services for the target population is an important factor for them to adhere to resources [22]. In order to do so, services should be adapted to the needs of young people or vulnerable groups in legal processes and in the dynamics of care in resources, as well as providing understandable and accessible information [7, 12, 13, 16, 32–34].
Regarding the barriers identified only by the professionals, intellectual disability negatively influences communication and the lack of adaptation of care as it is assumed that they do not have the capacity/credibility to face a legal process and they are treated as “asexual” and infantilized people [16, 32, 33].
It is interesting to outline the factors only identified by the young people. On the one hand, they highlight those related to a lack of awareness, such as concealing SV experiences (in male victims) due to gender stereotypes of hegemonic masculinity [11, 29, 35] and a lack of SV and GBV training. The young people identify education in sexuality as insufficient. Including aspects in the training that eradicate existing myths on affective-sexual relationships [36] could have a positive impact on interpersonal relationships, given the association of these myths with a higher justification of SV, as well as a lower predisposition to help in an observed SV situation [37].
On the other hand, the young people identify the lack of trust in institutions as a barrier [11, 28, 32]. Anticipating a negative experience towards services causes revictimization, a traumatic experience in the help-seeking process. This encourages the victim or people who know their experience because they are media cases, to not to seek help in the event of a future aggression [38, 39]. Such revictimization due to bureaucratization has been identified by GBV professionals rather than victims in other studies [28, 32].
The young people and professionals have identified different factors and there are discrepancies in some identified by both of them. For the professionals, age implies bureaucratic and economic dependence, while for the young people they prioritize a lack of maturity as a barrier to seek help [7, 40]. On the other hand, the lack of training of professionals in SV-GBV has been identified by both groups [16, 28, 32, 33]. However, the young people emphasize the lack of training in health and police services, leading to retraumatizing experiences and slowing down using the network of formal services. Finally, for the professionals, the lack of reaching young people is due to not using the appropriate means, on the other hand, for the young people, they consider the message to not be adapted. Therefore, reinforcing the use of technology with appropriate messages is important for the help-seeking process of young people [17].
7.1. Limitations and Strengths
One of the main limitations of this study is that participants, as in other studies [7, 28, 34], frequently refer to situations of severe SV, limiting the factors found in this study to such situations. More research is needed on the associated factors of effective coverage in other, less severe, types of SV. Furthermore, the intentional sampling used could lead to a selection bias due to the fact that the participants are more understanding towards SV and that the majority of nonuniversity students are migrants. The results may not be generalizable, but they may be applicable to some contexts with which we have compared our results. In order to improve this transferability, a detailed description of the sample and study participants was drafted. The credibility of the study was ensured with double coding and triangulation of the information, guaranteeing greater reliability with the critical review of the results. In terms of guaranteeing reliability, verbatim citations were used, as well as the inductive approach of analysis and a detailed description of the methodological process [41].
8. Conclusions
Both the interviewed young people and professionals have identified a considerable number of factors that reduce the effective coverage of related services. The young people perceive more factors related to the social context, care, and services, while the professionals recognize factors related to the user population. A greater alignment in their perceptions is required to improve service coverage. Future research should take into account the perspective of both young people and professionals in order to observe whether there is an alignment or discordance in opinions. Delving into this aspect would be advisable to create strategies that are in line with the reality of young people, thus improving effective coverage.
Data Availability
The data used to support the findings of this study are included within the article.
Additional Points
What Is Known About This Topic? (i) When young adults require help in the face of sexual violence (SV), they opt for informal support from friends and family. (ii) The stigma towards SV situations, the trivialization of the SV acts, the lack of knowledge on resources, and attempting to solve problems themselves are some facts that influence the search for help in formal resources. What Does This Document Offer? (i) Some opinions between both groups of interviewees are aligned, however, some differences are also observed. (ii) Effective coverage is undermined by a lack of training in sexuality that does not take into account the gender perspective and the psychosocial aspect of sexual relations among young people. This normalizes SV misconceptions that limit access to related health and social services. (iii) Trusting institutions and training professionals is crucial to ensure young people use frontline services (police, health services) and once there, guarantee they receive an effective response to their needs.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
Acknowledgments
The CIBER of Epidemiology and Public Health (CIBERESP) with the project “Sexual Violence Associated Factors and Perceptions among Youth: A Mixed Method Approach” (Ref. ESP20PI02).
Supplementary Materials
Checklist of reports for the qualitative study. (i) Table 1: standards for Reporting Qualitative Research (SRQR). (ii) Table 2: consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist (COREQ). Complementary information to the methodology. (iii) Table 3: final structure of the interview scripts. (iv) Table 4: coding tree. (Supplementary Materials)