Making Change Meaningful for Prisoner-Survivors of Sexual Assault

Aims.
What can be done to improve the lives of male prisoners who have been subjected to sexual assaults? How can they be helped to overcome this trauma and reduce their risks of revictimization and reoffending? How can they be enabled to rebuild lives that transcend the stigmas of victimization, criminalization and imprisonment while overcoming the damaged relationships these engender? This project is seeking to generate research that can elaborate the nature of the changes being witnessed among men undertaking the pioneering OUT Spoken talking therapy programme in 15 North West UK prisons.

Objectives
The project will:
1. Conduct in-depth interviews with up to 50 male survivors of sexual assaults in prisons, at three time points over an 18 month period, and help them explain how they are seeking to overcome trauma and change.
2. Conduct semi-structured interviews with up to 20 prison staff to capture their perceptions of the impact of OUT Spoken, in order to capture the extent to which the delivery of trauma-informed practice is supported by staff in the prisons where the intervention is hosted.
3. Undertake comparative case analysis, utilising the interview data collated at two time points and the returns of responses to anxiety, depression and trauma inventories survivors give in therapy.
4. Produce bespoke recommendations on responses to male survivors of sexual assault addressed to the Victims Commissioner for England and Wales Advisory Group, SAAS (Sexual Assault Support Services) Partnership Board (NHS England, Ministry of Justice & Home Office), VAWG (violence Against Women and Girls) Working Group (cross-Government) and North West Prisons Group (NHS England/HMPPS).

Context and rationale
While women and girls are more likely to be victims of sexual assault than men and boys, there are many men who are survivors of sexual assault. Around 80% of male survivors do not seek support for the abuse they experienced or report these experiences to the police (ONS, 2021). 4% of men in the UK experience sexual assault by the age of 16, amounting to 155,000 male victims of sexual assault in the year ending March 2020 (ONS, 2021). It also suggests that at least 3.5% of adult men are victims of child sex abuse (ONS, 2020). One recent meta-review of mental health problems among prison populations shows that higher rates of trauma among prisoners compared to the general population can be explained in terms of the latter’s greater experiences of sexual abuse (Liu et al, 2021). Though small scale, a recent Canadian study reported that 46% of male prisoners had been subjected to non-consensual sex as children and 42% had been sexually assaulted as adults (MacKie et al, 2021).
Clues as to why men who have been sexually assaulted are over-represented in the prison population can be found in the high prevalence rates of sexual assault victimization among populations at risk of criminalization, including: care-leavers (Fox, 2016), young men involved in gang and drug-related offending; and paramilitaries (Bringedal Houge, 2014; Montgomery-Devlin, 2020). Sexual abuse is sometimes used to exploit or groom vulnerable young men to undertake risky activities in illicit economies, such as delivering drugs or exacting physical retribution on the behalf of others (Montgomery-Devlin, 2020). Though dated, the last British study of sexual assault rates in prisons, found that around 4% of those serving custodial sentences had been sexually assaulted within custody, and that in some establishments victimization rates were as high as 21% - with almost 90% of victims reporting multiple incidents (Banbury, 2004). Subsequent research has shown that institutional factors, like trading in illicit substances, staff shortages, cell-sharing, and overcrowding – all problems that are pervasive in the UK’s prison estate – compound the risk of being sexually violated, especially for LGBTQ+ prisoners and those ‘vulnerable’ to abuse, whether because of the crimes they have they have committed or their previous careers (Howard League, 2014; Sondhi et al, 2018).Remand prisoners, new arrivals and younger prisoners are also at heightened risk of sexually violation in the course of what are often brutal prisoner-on-prisoner drug searches (Wilkinsin and Flemming, 2021). Inevitably, the stigma of sexual assault and the paucity of specialist and dedicated support services for men who have been sexual assaulted in prisons and in community settings enables some perpetrators to reoffend with impunity, facilitating the repeat victimization of those unable to speak out (Mackie et al, 2005).

Further reasons for keeping the trauma of sexual assault private are self-evident in studies of masculinities in prisons (Sim, 1994; Kupers, 2001: Jewkes, 2002; Maguire, 2020) and were once well documented in the few classic studies of male survivors, all of which emphasize the role of institutionalized homophobia and stigma (Etherington, 1995, King et al, 1992; West et al, 1992). But these 20th century studies are of decreasing utility in a world where there have been uneven shifts in public attitudes regarding same-sex attraction and the internet is used both to mobilise support for survivors and by perpetrators who circulate child sexual abuse and rape and sexual offences material online, amplifying the harms perpetrated against survivors indeterminately. It is perhaps also pertinent to note that in a criminal justice context where only 1.2% of complainants in rape cases see the perpetrator convicted (Home Affairs Committee, 2022), men with histories of disadvantage and criminal involvement have few reasons to feel confident that reporting to the police will deliver justice. Many have, ultimately, to contend with the long-term impacts of sexual assault – poor mental health, anger, self-loathing, physical injury, sexual dysfunction, difficulties with building close relationships, fear and terror – alone. Survivors of sexual violence are vulnerable to a range of mental health problems, including both ‘common’ but nonetheless distressing mental health difficulties such as anxiety, depression, and Post-Traumatic Stress Disorder (PTSD), as well as severe and enduring problems that are highly prevalent in prison settings, such as psychosis and personality disorders (Varese et al, 2012; Potter et al, 2018). Recent findings of the James Lind Alliance Priority Setting Partnership on Sexual Violence (2020) underline the many gaps in provision to redress the mental health and wellbeing needs of male survivors. In the absence of an evidence base demonstrating what can be done to positively support male survivors of sexual assault, this situation is unlikely to improve radically and remains particularly acute for men serving long prison sentences, especially those who have committed serious criminal offences and whose prospects for rehabilitation and reintegration post-release are severely constricted.

Team and Project Management
Prof David Gadd is an expert in the study of gender-based violence and narrative interview methods, as well as ESRC Impact finalist 2022. He will lead the project, manage the team, sourcing and providing training where necessary; be responsible for data management, security and archiving; conduct 20% of the fieldwork.
Prof Filippo Varese is an NIHR Advanced Fellow and Clinical Senior Lecturer at the University of Manchester, and Director of the Complex Trauma and Resilience Research Unit at Greater Manchester Mental Health NHS Foundation Trust. At no cost to the faculty, he will lead the analysis of anxiety, depression and trauma inventories and their fit with case study data; lead the project's response to any adverse incidents; provide clinical supervision to the fieldwork team should it be required.
Dr Emily Turner is an experienced prison researcher and the co-ordinator of Learning Criminology Inside, UoM’s Learning Together course. She will conduct 20% of the fieldwork and data analysis; lead the development of all outputs directed at prisoners and prison staff; deputise for Gadd when he is on annual leave.

Ms Jess Glynn is a researcher who will undertake the project fieldwork and preliminary analysis.

Method

A sample of up to 50 prisoners who have attended some or all of the OUT Spoken programme will be interviewed at three times points over an 18 month period. The sample will include a mix of survivors of child sexual abuse and adult victimisation in community settings, as well as men assaulted in prisons - though these are not mutually exclusive groups. We will ensure representation from LGBTQ+ and minority ethnic populations consistent with their profiles in the prison population. 20 staff interviews will also be conducted. Interviews will be conducted primarily using Microsoft Teams - following substantive investment in six iPads already secured from the University of Manchester. Participants will undertake Free Association Narrative Interviews. [Month 2 -16]

To capture the complexities unearthed by the interviews, the first stage of the data analysis will involve the construction of case studies that summarise the lives of participants, including contradictions and tensions in the stories told. These case studies, which will be drafted after the first interviews, will then be updated so they include content from the second interviews alongside an analysis of the responses to mental health questionnaires routinely administered as part of therapy: the GAD-7 (Spitzer et al, 2006), the PHQ-9 (Kroenke et al, 2001) and the PCL-5 (Weathers et al, 2018) – widely used measures to assess the severity of symptoms of anxiety, depression and post-traumatic stress, respectively. Up to 21 discrete entries, gathered over the 20–32-week intervention, will be available for GAD7 and PHQ9 measures, plus a further 7 for PCL-5. In this way, the study will ensure subtle shifts in well-being and style of narration are captured as well as actual life events are captured for analysis. [Months 3-19]

We will then undertake a comparative case analysis to identify how prisoner-survivors invest in change and what better futures for them might look like. The questionnaire data will be entered into a REDCAP database centrally managed by the UoM research team. Baseline and end-of-treatment scores will be analysed to first check whether the change brought about by the intervention is reliable (using the Leeds Reliable Change index comparing pre-post treatment scores at the individual participant level) and statistically significant (paired t-test or non-parametric equivalent tests), and whether the gains are clinically significant (by applying widely used cut offs for the above measures).

We will also collect and examine data pertaining to OUT Spoken intervention recruitment (e.g. referrals and uptake of the intervention) and engagement/retention (number of session attended, number of drop-outs etc.) to evaluate the potential acceptability of the intervention to varied user groups. Prisoners’ accounts will be compared to the prison staff accounts of how they perceive the programme to be working.

Planned Outputs
A 10-page key findings report will make recommendations tailored to policymaking and standard setting bodies, including the Victims Commissioner’s Advisory Group, the Sexual Assault and Abuse Services Partnership Board, the Violence Against Women and Girls Working Group and the Northwest Prisons Group.

Learning materials and workshops that help students, in the university and in criminal justice settings, understand prisoners' experiences of sexual assault will be developed and road-tested.