How helpful to recovery and healing are support and psychological interventions after exposure to sexual violence and abuse?

Key messages

• We found evidence that psychological or social (collectively known as ‘psychosocial’) interventions may reduce symptoms of post-traumatic stress disorder (PTSD) and depression in survivors of rape, sexual assault and abuse experienced during adulthood.

• Our review suggests that interventions did not worsen symptoms or lead to unwanted effects. However, as large numbers of participants dropped out of treatments or did not complete studies’ assessments, these findings are unclear. More recent studies were better at reporting information about participant safety, and reasons why survivors did not complete treatments or health and wellbeing assessments after the interventions.

• As the studies brought diverse groups of participants together, future research is needed to improve understanding about which interventions are most suited to particular groups of survivors, including those with long-term or complex trauma, as well as men and gender minorities. 'Emerging' interventions, which have potential to expand treatment choices for survivors, also warrant more evaluation.

What is 'sexual violence and abuse'?

‘Sexual violence and abuse’ means any sexual activity or act that happened without consent. It includes rape, sexual assault, sexual abuse and sexual harassment. It causes emotional and physical health problems that can be long-lasting. The effects are often made worse by fear, shame, feelings of self-blame and the negative responses of others.

How is sexual violence and abuse treated?

Survivors have a range of physical, sexual health and forensic care needs in the aftermath of rape, sexual assault or abuse. Psychosocial interventions may be offered in response to these needs at different stages in survivors’ recovery journeys. Some interventions aim to assist survivors by carefully re-exposing them to aspects of the original trauma to ‘process’ what happened (e.g. Trauma-focused Cognitive Behavioural Therapy (CBT)). Other treatments focus less on the traumatic memories, instead helping survivors cope with life after abuse (e.g. different forms of counselling; education about mental health; and support for a range of needs).

What did we want to find out?

We wanted to know whether psychosocial interventions help to relieve the mental health impact experienced by survivors as a result of rape, sexual assault or sexual abuse in adulthood. We also wanted to know if some types of interventions were more helpful than others.

What did we do?

We searched for studies comparing the effects of psychosocial interventions for individuals who had been subjected to rape, sexual assault or sexual abuse from the age of 18 years, with a control group (a group of participants who did not receive the intervention but instead were given their usual care, were placed on a waiting-list for treatment, or received very minimal assistance, such as leaflets). We looked for differences between groups on trauma and depression symptoms after receiving the intervention; dropout from interventions (non-completion); and any unwanted effects related to the intervention or research.

About the studies and their participants

We found 36 studies that placed consenting adult participants by chance into an intervention or a control group. Participants were invited from a range of settings: community; universities; places where people seek help for their mental health, sexual trauma (e.g. specialist sexual assault centres and emergency departments) or for problems that occur alongside the experience of sexual violence (e.g. primary care clinics); and via media requests. The studies included 3992 survivors; only 27 were men. Sixty per cent of participants were Black or from a minority ethnic or cultural background. The average age was 36 years, and nearly all had symptoms of PTSD.

Most studies were done in the USA (26); there were two from South Africa; two from the Democratic Republic of the Congo; and single studies from Australia, Canada, the Netherlands, Spain, Sweden and the UK. Five studies did not disclose a funding source; those that did reported public funding.

Over half the interventions were CBT-based. Support was mostly delivered one-to-one by trained mental health professionals and varied between 1 and 20 sessions.

What did we find?

Survivors who participate in a psychosocial intervention may experience a large reduction in PTSD and depression symptoms soon after the intervention is completed. Non-completion was not more common among survivors who experienced interventions compared to control groups, but this was based on a small number of studies. Psychosocial interventions may not increase the risk of unwanted effects. Only seven studies reported 21 unwanted effects, suggesting most researchers may not have actively monitored the negative impacts of interventions or participation in the studies.

What are the limitations of the evidence?

We have little confidence in the results because of concerns about the level of variation across the studies (e.g. types of survivor experiences, wide range of interventions and study sizes). It is possible that the allocation of survivors to one group or another may not have been entirely random. Furthermore, survivors who did not complete interventions or study assessments may have differed in important ways from survivors who did (e.g. had better/worse health problems).

How up-to-date is the evidence?

The evidence is up-to-date to January 2022.

Authors' conclusions: 

Our review suggests that survivors of rape, sexual violence and sexual abuse during adulthood may experience a large reduction in post-treatment PTSD symptoms and depressive symptoms after experiencing a psychosocial intervention, relative to comparison groups. Psychosocial interventions do not seem to increase dropout from treatment or adverse events/effects compared to controls. However, the number of dropouts and study attrition were generally high, potentially missing harms of exposure to interventions and/or research participation. Also, the differential effects of specific intervention types needs further investigation.

We conclude that a range of behavioural and CBT-based interventions may improve the mental health of survivors of rape, sexual assault and sexual abuse in the short term. Therefore, the needs and preferences of individuals must be considered in selecting suitable approaches to therapy and support. The primary outcome in this review focused on the post-treatment period and the question about whether benefits are sustained over time persists. However, attaining such evidence from studies that lack an active comparison may be impractical and even unethical. Thus, we suggest that studies undertake head-to-head comparisons of different intervention types; in particular, of novel, emerging therapies, with one-year plus follow-up periods. Additionally, researchers should focus on the therapeutic benefits and costs for subpopulations such as male survivors and those living with complex PTSD.

Read the full abstract...

Exposure to rape, sexual assault and sexual abuse has lifelong impacts for mental health and well-being. Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and Eye Movement Desensitisation and Reprocessing (EMDR) are among the most common interventions offered to survivors to alleviate post-traumatic stress disorder (PTSD) and other psychological impacts. Beyond such trauma-focused cognitive and behavioural approaches, there is a range of low-intensity interventions along with new and emerging non-exposure based approaches (trauma-sensitive yoga, Reconsolidation of Traumatic Memories and Lifespan Integration). This review presents a timely assessment of international evidence on any type of psychosocial intervention offered to individuals who experienced rape, sexual assault or sexual abuse as adults.


To assess the effects of psychosocial interventions on mental health and well-being for survivors of rape, sexual assault or sexual abuse experienced during adulthood.

Search strategy: 

In January 2022, we searched CENTRAL, MEDLINE, Embase, 12 other databases and three trials registers. We also checked reference lists of included studies, contacted authors and experts, and ran forward citation searches.

Selection criteria: 

Any study that allocated individuals or clusters of individuals by a random or quasi-random method to a psychosocial intervention that promoted recovery and healing following exposure to rape, sexual assault or sexual abuse in those aged 18 years and above compared with no or minimal intervention, usual care, wait-list, pharmacological only or active comparison(s). We classified psychosocial interventions according to Cochrane Common Mental Disorders Group’s psychological therapies list.

Data collection and analysis: 

We used the standard methodological procedures expected by Cochrane.

Main results: 

We included 36 studies (1991 to 2021) with 3992 participants randomly assigned to 60 experimental groups (3014; 76%) and 23 inactive comparator conditions (978, 24%).

The experimental groups consisted of: 32 Cognitive Behavioural Therapy (CBT); 10 behavioural interventions; three integrative therapies; three humanist; five other psychologically oriented interventions; and seven other psychosocial interventions. Delivery involved 1 to 20 (median 11) sessions of traditional face-to-face (41) or other individual formats (four); groups (nine); or involved computer-only interaction (six). Most studies were conducted in the USA (n = 26); two were from South Africa; two from the Democratic Republic of the Congo; with single studies from Australia, Canada, the Netherlands, Spain, Sweden and the UK. Five studies did not disclose a funding source, and all disclosed sources were public funding.

Participants were invited from a range of settings: from the community, through the media, from universities and in places where people might seek help for their mental health (e.g. war veterans), in the aftermath of sexual trauma (sexual assault centres and emergency departments) or for problems that accompany the experience of sexual violence (e.g. sexual health/primary care clinics). Participants randomised were 99% women (3965 participants) with just 27 men. Half were Black, African or African-American (1889 participants); 40% White/Caucasian (1530 participants); and 10% represented a range of other ethnic backgrounds (396 participants). The weighted mean age was 35.9 years (standard deviation (SD) 9.6). Eighty-two per cent had experienced rape or sexual assault in adulthood (3260/3992). Twenty-two studies (61%) required fulfilling a measured PTSD diagnostic threshold for inclusion; however, 94% of participants (2239/2370) were reported as having clinically relevant PTSD symptoms at entry.

The comparison of psychosocial interventions with inactive controls detected that there may be a beneficial effect at post-treatment favouring psychosocial interventions in reducing PTSD (standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.22 to -0.44; 16 studies, 1130 participants; low-certainty evidence; large effect size based on Cohen’s D); and depression (SMD -0.82, 95% CI -1.17 to -0.48; 12 studies, 901 participants; low-certainty evidence; large effect size). Psychosocial interventions, however, may not increase the risk of dropout from treatment compared to controls, with a risk ratio of 0.85 (95% CI 0.51 to 1.44; 5 studies, 242 participants; low-certainty evidence). Seven of the 23 studies (with 801 participants) comparing a psychosocial intervention to an inactive control reported on adverse events, with 21 events indicated. Psychosocial interventions may not increase the risk of adverse events compared to controls, with a risk ratio of 1.92 (95% CI 0.30 to 12.41; 6 studies; 622 participants; very low-certainty evidence).

We conducted an assessment of risk of bias using the RoB 2 tool on a total of 49 reported results. A high risk of bias affected 43% of PTSD results; 59% for depression symptoms; 40% for treatment dropout; and one-third for adverse events. The greatest sources of bias were problems with randomisation and missing outcome data. Heterogeneity was also high, ranging from I2 = 30% (adverse events) to I2 = 87% (PTSD).