27 - Rape and Sexual Assault
Editors: Shader, Richard I.
Title: Manual of Psychiatric Therapeutics, 3rd Edition
Copyright 2003 Lippincott Williams & Wilkins
> Table of Contents > 27 - Rape and Sexual Assault
27
Rape and Sexual Assault
Janet E. Osterman
Jane E. Barbiasz
Richard I. Shader
Rape is an act of sexual violence perpetrated by one person against another. Rape should not be delimited to the common stereotype of a male stranger attacking a woman. Rape may occur in diverse situations and across the life span; children and the elderly are not spared. In the United States, where rape has an estimated prevalence of 9% to 13% for women and 0.7% to 5% for men, strangers account for only 22% of rapes. Boyfriends or domestic partners commit 19% of rapes, and another 38% are perpetrated by other family members.
Whether the event consists of the attack of an unknown male against a woman, the sexual subjugation of a woman by invading troops in a war zone, the molestation of a child by a pedophile or parent, the unwilling use of a weaker inmate by a stronger inmate in a prison setting, or the exploitation of a person subdued by alcohol or sedatives during a date, the central themes of rape are exploitation, domination, intimidation, humiliation, and force.
From a legal perspective, rape is defined as sexual intercourse perpetrated against the victim's will and consent or as sexual intercourse with a person who is unable to give consent due to age or mental impairment. Sexual assault is the term used for other forms of nonconsensual sexual activity, such as forced fellatio or forced anal penetration. Recently, date or acquaintance rape appears to have become more common; its true prevalence may be obscured or complicated by the use of amnesic drugs, such as the benzodiazepine flunitrazepam (Rohypnol) and the -aminobutyric acid agonist -hydroxybutyrate, which leave the victim without memory of the rape. How frequently these agents are used is unknown because their detection is obscured by rapid hepatic clearance and the lack of standard testing for -hydroxybutyrate.
Completed rape and sexual assault are common traumatic experiences. The National Comorbidity Survey found that 9.2% of women and 0.7% of men have been raped. The National Women's Study estimated that 12.7% or over 12 million adult women in the United States have experienced a completed rape and that an additional 14.3% or 13.5 million women have been sexually assaulted. For perspective, selected statistics from the National Victim Center for 1992 are listed in Table 27.1.
College student surveys found that 20% of women and 4% of men experienced forced sexual activity from a date or acquaintance. The 1994 Bureau of Justice's National Crime Victimization survey reported that 5% of adolescent rape victims were males.
According to the United States Department of Justice, a quarter of a million children are victims of sexual abuse each year. However, it is widely acknowledged that child rape and sexual assault are underreported and thus do not come to the attention of child protection services or other agencies. Child victims of rape or sexual assault often live with, are related to, or know the perpetrator. Up to 16% of American women are the victims of rape, attempted rape, or molestation before the age of 18. Limited data are available on the incidence of rape and childhood sexual abuse perpetrated against boys despite the recent media attention to victimization of boys by trusted members of the community.
I. Psychologic Sequelae of Rape and Sexual Assault
A. Consequences of Adult Rape and Sexual Assault
The psychologic sequelae of rape have been described in the literature since 1974 with the initial description of the rape trauma syndrome by Burgess and Holmstrom. The rape trauma syndrome is a two-phase reaction with an acute and a reorganization stage. The acute phase is characterized by disorganization, denial, and shock; the reorganization phase includes
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nightmares, fear, and avoidance behaviors. The symptoms of the reorganization phase are now subsumed under the diagnosis posttraumatic stress disorder (PTSD); the acute phase is most similar to the new Diagnostic and Statistical Manual of Mental Disorders, 4th edition, (DSM-IV) diagnosis of acute stress disorder.
TABLE 27.1. SELECTED STATISTICS FOR RAPE | ||
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PTSD, a clinical syndrome that may follow a traumatic event, such as rape and sexual assault, causes significant distress and morbidity. PTSD is characterized by the following three symptom clusters: reexperiencing of the traumatic event, avoidance of reminders of the traumatic event and emotional numbing, and hyperarousal symptoms. For example, a rape victim may experience intrusive thoughts of the rape, may suffer from nightmares of threat or rape, or may experience flashbacks of all or some portions of the rape experience. Avoidance of reminders of the rape are common, and these may include avoidance of the site of the rape or similar places, avoidance of sexual relations, or avoidance of people who are similar to the perpetrator. Rape victims may experience emotional numbing, such as a sense of being unable to have loving feelings, feeling detached from others, or having decreased interest. Difficulty falling asleep, being easily startled, irritability, and hypervigilance are common hyperarousal symptoms. Table 14.10 provides the formal diagnostic criteria for PTSD.
Since the 1980 inclusion of PTSD in the diagnostic nomenclature in DSM, 3rd edition, the psychologic sequelae of rape and the incidence of rape-related and sexual assault-related PTSD have been frequently studied. The National Comorbidity Survey found that 49.5% of women and 65% of men who had been raped suffered PTSD. In the National Women's Study, 12.4% of the 12 million American women rape victims and 6.7% of the 13.5 million sexual assault victims developed chronic PTSD. Foa et al. reported that 90% to 95% of female rape victims suffered symptoms of PTSD in the first 2 weeks after a rape, with nearly 50% continuing to suffer from PTSD 3 months later. In other studies, Foa found that, of the 52.4% of women suffering PTSD 2 months after being raped, 47.1% continued to suffer PTSD at 9 months. Thus, PTSD after rape may not be self-remitting but can become chronic and debilitating.
Acute stress disorder, a recent addition to the diagnostic nomenclature, is characterized by dissociative reexperiencing, avoidance, and hyperarousal symptoms. Symptoms must begin between 2 days and 4 weeks after the index traumatic event. Dissociative experiences frequently
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predominate; they may include derealization, depersonalization, being in a daze, numbing, and amnesia. Some preliminary studies suggest that the presence of acute stress disorder is predictive for the development of PTSD; many studies show that peritraumatic dissociation is a risk factor for PTSD.Anxiety and depression are also common consequences of rape. Seventy-seven percent of rape victims reported significant fears in the year after a rape. One author reported that 41% of women suffered from depression 15 to 30 months after rape. Others have reported that the likelihood in women rape victims of suffering depression was related to the number of rapes, increasing from 46% after a single rape to 80% after two or more rapes. However, some studies report that the depressive response in the first year after the rape is no different than the frequency observed in control subjects.
Dissociative reactions, such as dissociative amnesia and depersonalization, may be both an acute and chronic consequence of rape.
Suicidal ideation has been estimated to occur in up to 50% of rape victims with reports of 3% in the first month, a figure that increases over time. A large random population survey found that 19% of rape victims reported a suicide attempt and that 44% reported suicidal ideation.
B. Consequences of Childhood Rape and Sexual Assault
Childhood rape and sexual assault frequently result in psychologic consequences both in childhood and in adulthood. PTSD in children is often characterized by repetitive play reenacting the trauma; thus, in the case of rape or sexual assault, children show repetitive sexual play behaviors. Recurrent dreams may be frightening, but without recognizable content. These behaviors must be differentiated from normal childhood sexual curiosity and other causes of nightmares or night terrors. Children who are subjected to sexual abuse may also exhibit somatic complaints, anxiety, and depression.
Adults with histories of childhood sexual abuse may meet the diagnostic criteria for PTSD, depressive disorders, borderline personality disorder, somatization disorder, and dissociative disorders. Childhood sexual abuse is one of the most common causes of adult PTSD, which afflicts 10% of the population. A survey of adult women found that 64% of those who had been raped as a child and 33% of those who were molested suffered from PTSD. Childhood sexual abuse is presumed by many to be a risk factor for the development of dissociative identity disorder (see Chapter 4). One study reported that 68% of a sample of 100 dissociative identity disorder patients suffered incest. In addition, childhood sexual assault is a significant risk factor for adult sexual victimization, with one study showing that 50% of adult rape victims reported childhood histories of sexual abuse.
A new concept, disorders of extreme stress (DES) or complex PTSD, has been proposed by van der Kolk, Herman, and others to define a posttraumatic clinical syndrome characterized by problems in self-regulation of affect and impulses; disordered interpersonal functioning; somatization; and alterations in attention or consciousness, perceptions of the perpetrator, self-perceptions, and meaning systems. These symptoms are currently described as associated features of PTSD in DSM-IV. Findings from the field trials for the DSM-IV found that adult survivors of childhood sexual abuse were about four times more likely to suffer from disorders of extreme stress. Adults who suffered both childhood sexual and physical abuse were about 14 times more likely to suffer from this symptom complex.
II. Emergency Treatment of Rape Victims
Rape is a psychologic crisis for the victim. The victim's family and friends may also suffer a psychologic crisis. Rape victims may present to the emergency room for treatment of physical or psychologic injuries, or they may be brought by the police for a forensic examination. In cases with severe or life-threatening injuries, the urgency of the patient's medical status will preclude early mental health interventions. However, for most rape victims, the need for medical
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treatment and forensic examination affords the emergency mental health clinician an opportunity to assess the patient's psychologic status, to provide early mental health interventions, and to address any family needs for clinical intervention. The mental health clinician is often part of a rape treatment team that addresses the physical, psychologic, and forensic needs of the patient, and he or she must be knowledgeable about all aspects of the emergency treatment of rape.
A. Psychologic Interventions
Recognizing that rape or sexual assault victims will likely be psychologically overwhelmed on arrival to the emergency department and that they will need interventions to diminish their distress is essential. Ideally, the patient will be immediately triaged to a private, quiet, supportive area within the emergency department. Family members or friends, with the patient's consent, should be contacted to provide additional support for the patient. If the patient is unwilling to contact family or friends, the clinician should explore the reasons with the patient because rape frequently induces issues of shame that may prevent the patient from making use of family and community support. Acknowledgment of this nearly universal response and a discussion of patients' needs for support may help patients include family or friends in their treatment. In addition, a sensitive exploration may help to determine if a family member or partner was the perpetrator. Upon the arrival of family or friends to the emergency department, the mental health clinician must assess their ability to provide support and must supply the interventions necessary to maximize their ability to give support.
A patient's initial presentation in the emergency department or to emergency personnel in the field almost always reflects persisting survival mode functioning. Survival mode functioning, as described by Chemtob, is characterized by specialized cognitive-affective mechanisms organized as flight, fight, and freeze behaviors. High levels of anxiety and avoidance are seen with persisting flight responses, patients with anger reflect persisting fight responses, whereas persisting freeze responses appear clinically as dissociation. The highly anxious ( flight ) or angry ( fight ) patient typically receives mental health interventions in the emergency department, whereas patients with dissociative or numbing ( freeze ) reactions present as quiet and withdrawn and they may not elicit a similar level of emergency mental health intervention. Despite this presentation, patients with dissociative reactions are at high risk for developing PTSD and they need specialized interventions.
Persistence of survival mode functioning after rape may complicate both the forensic evaluation and the medical treatment. Helping the patient move from a survival mode response to psychologic safety will also promote cooperation and a willingness to consent to the medical and forensic examinations. Although the physical examination and the collection of evidence are essential in the treatment of a rape victim, the physical contact and the vaginal, rectal, or oral examinations may act as triggers that stimulate further survival mode functioning and behaviors. Addressing the patient's psychologic needs for safety before proceeding to these examinations is essential unless severe or life-threatening injuries require immediate treatment.
The emergency five-step approach to the emotionally traumatized person as described by Osterman and Chemtob is (a) to restore psychologic safety, (b) to provide information, (c) to correct erroneous attributions (often called misattributions ), (d) to restore and support effective coping, and (e) to ensure social support. Table 27.2 summarizes the steps in emergency care of the rape or sexual assault victim.
Psychologic safety must be restored by helping patients recognize that the rape is over and that they are now safe in the hospital. For patients who present with dissociation, providing grounding strategies, such as having them touch the examination table or other medical equipment (e.g., a stethoscope), is often necessary. Once the patient reports a sense of safety and knowledge
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that the danger has passed, providing information will allow the patient to begin to develop a cognitive map for understanding what has happened.
TABLE 27.2. EMERGENCY INTERVENTIONS FOR THE MEDICALLY STABLE RAPE VICTIM | ||||
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Rape victims and sexually assaulted patients require specialized information concerning their current medical status. They also typically have concerns and fears about future health problems, including sexually transmitted diseases (STDs) and pregnancy. It is common for victims of rape to have concerns about human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome. The patient may also have questions about the legal implications of this crime and may need information about the legal system and police involvement. She or he may have fears of reporting the crime or may need information or assistance about how to report the crime. The clinician should discuss the patient's concerns, acknowledging that the patient may not wish to press charges at this point but that the medical care providers will collect the evidence in the event she or he wishes to pursue charges at a later time.
Patient's concerns and needs for information provide an opportunity for a sensitive discussion of both the need for medical and forensic examinations and how these examinations will be conducted. The clinician must acknowledge the patient's fears about being touched and about having a vaginal or rectal examination. The mental health clinician should discuss that the examination might trigger a flashback or intrusive memory of the actual rape or sexual assault and should assure the patient that psychologic support will be given. The patient should be asked if she or he wishes to have a family member or friend present and should be informed about which members of the rape treatment team will be present during the examination. Informing the patient that he or she might have a reexperience of the trauma that is induced by the examination will prevent the patient from feeling as if she or he is going crazy, when or if a flashback occurs. Assuring the patient that a family member or friend may be present and that the mental health clinician will assist in managing any reexperiencing symptoms will help the patient cope with the examinations.
Victims of rape and sexual assault typically have erroneous beliefs or misattributions and frequently blame themselves (e.g., I should not have been out alone, I should not have worn a skirt that was this short ). Helping patients recognize the catastrophic nature of such beliefs, correcting any cognitive errors, and exploring their experience more realistically should decrease their anxiety, guilt, and anger.
The clinician should work to restore and support effective coping and to ensure social support. Psychoeducation for the patient and his or her family and friends about normative responses to trauma and common
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symptoms after rape can help restore the patient's sense of psychologic competence and can allay fears, for the family and friends and the patient, that he or she is crazy or has lost control. Families and friends should be assisted in developing strategies to provide necessary social support, and they must understand that their support is an essential component of the patient's ability to cope and recover. The mental health clinician should discuss potential problems with arousal, irritability, sleep, memory and recall, intrusive thoughts, nightmares, avoidance, and numbing. Validation of typical trauma responses by family and friends may decrease patients' shame or fears and allow them to accept support.
The impact of rape on intimacy and the potential for subsequent sexual touching to trigger a survival response should be discussed with the patient's sexual partner. This may help the partner understand that these responses are common after rape and that they are not a reflection on him or her, which may prevent the partner from responding to this perceived rejection with an angry statement that further increases the patient's transition to fight, flight, or dissociation. Patients should be encouraged to be active participants in their medical and mental health care and to help the clinician in assessing their coping skills and access to community resources.
A referral for crisis intervention should be made before the patient is discharged from the emergency service. When possible, patients should speak with the clinician they will see, and a firm appointment time should be set to maximize the likelihood of keeping the appointment. In addition, patients should be informed that they should return to the emergency service or the crisis center if they are having difficulties managing feelings, physical symptoms, or adjustment following the rape. In addition to the support from family and friends, referrals to appropriate community agencies, self-help groups, and outpatient mental health treatment are needed for ongoing social support. Some states provide financial support for mental health treatment following rape, and the patient should be informed about how to obtain such services.
B. Medical and Forensic Examinations
Many emergency services have initiated the use of the Sexual Assault Nurse Examiner (SANE) program that was developed in 1976 through a collaboration of nurses, physicians, hospital administrators, district attorneys, local police, and rape crisis advocates. A standardized approach, such as the SANE program, is necessary because medical care providers frequently do not have education and training in forensic issues, and thus they may be reluctant to testify in court. The SANE program aims to strengthen victims by advocating for them and by providing the necessary evidence in the event that a victim wishes to pursue criminal charges. That medical care providers are knowledgeable and skilled in meeting the medical and mental health needs of the patient and in evidence collection and handling is essential.
The primary goals of the SANE program are to assist the patient in returning to his or her pretrauma level of health, to involve him or her in medical decision making, and to collect forensic evidence that will withstand judicial scrutiny. The SANE program includes treatment for STDs, pregnancy prevention, and psychologic counseling. The SANE clinician is able to provide witness testimony for victims who elect to report the case and to involve the judicial system. Clinicians must be trained in the specific protocols of the SANE program for their state, because variations exist in legal standards among states.
If the SANE program is not used, the rape treatment team should be trained in the proper collection of evidence, as required by their state laws, and they should be familiar with the standard rape kit. Despite variations across jurisdictions, some protocols are standard across settings, and these are discussed. Although mental health clinicians may not perform the medical and forensic examination, they must be familiar with the procedures to assist fearful patients and to provide correct information.
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For the medically stable patient who is able to consent to and to cooperate with evidence collection and whose rape or sexual assault occurred within the past 3 to 5 days, the nurse or physician can begin the medical and forensic examinations. The accepted time interval between the rape or sexual assault and evidence collection is determined by the state's legal standards. If these time standards are exceeded, only the medical examination is performed.
The patient's history must be obtained by a member of the rape treatment team. When a native language problem is present, a hospital interpreter is required because using a family member or friend both is inappropriate and is in violation of state evidence collection rules. The history will become part of the patient's legal statement if she or he wishes to seek legal recourse, and it must include the patient's account of the rape or sexual assault. The location of the assault, the number of assailants, and, if possible, the identity of the assailant(s) must be obtained. The clinician must document the patient's account of the rape, including what orifices were penetrated and with what and whether the rape or assault involved force, threats, or weapons. In addition, the patient's general medical information, including medical illnesses; past or present psychiatric disorders; allergies; and current pregnancy status and date of last menstrual period, if applicable, should be obtained and documented. A family history of psychiatric disorders is important, because this may be predictive of mental health sequelae following rape. Describing the examination and ascertaining if the patient understands the examination procedures are important.
When the patient arrives immediately after the rape or sexual assault, all of his or her clothing is collected; however, only the undergarments are collected if the patient's clothing was changed before admission. Some patients wish to change their clothing immediately upon admission to the emergency room. This request should be accommodated while ensuring the proper collection of evidence. It is recommended that the patient undress over a paper covering to maximize the collection of evidence. Ideally, only the patient should touch his or her clothing to prevent the contamination of the evidence, but medical personnel wearing gloves can provide assistance.
The physical and forensic examinations. These examinations include a general medical evaluation with attention to signs of physical trauma and the collection of legal evidence. The medical and forensic examinations may trigger reexperiencing symptoms in some patients. Speaking in a supportive manner to the patient and holding her or his hand throughout may help the patient recognize that she or he is not still back there, alone and helpless. Such interventions may assist patients in recognizing that they are now safe, are in the hospital, and are undergoing a physical examination.
Overwhelming trauma, such as rape, may result in amnesia for important aspects of the trauma, and therefore the patient may not be able to identify accurately which orifices were penetrated. A complete medical and forensic examination must include oral, anal, and vaginal examinations for trauma and sperm and seminal fluid collection. Evidence is obtained from fingernail scrapings; swabs of areas containing blood, saliva, or seminal fluid; and hair and fibers from the victim's body or clothing. The pubic area is combed for the collection of loose hair, and specimens of the patient's head and pubic hair are obtained for forensic comparison.
Laboratory analyses. Laboratory evidence includes blood for DNA screening and a saliva sample to determine the patient's secretor status. A urine specimen for a drug analysis is obtained, especially if the patient is suspected to have been drugged by the assailant. Ascertaining the patient's current hepatitis B status is common, whereas collection of cultures for STDs are obtained only when they are clinically relevant or are required by institutional protocols.
Prophylaxis for STDs. Prophylactic medical treatment of STDs varies with the treatment center's protocol. Most programs will administer prophylactic antibiotics for chlamydia, gonorrhea, trichomonas, and syphilis. When the victim does not know his or her hepatitis B status, the first dose of the vaccine is recommended, and the patient is given instructions regarding follow-up doses in 1 month and 6 months.
Prophylactic emergency treatment for HIV infection is currently being implemented in most settings. These protocols are likely to change and to undergo refinement as more is learned about this disease. Rape characteristics that are considered high risk for HIV exposure are stranger rape, multiple assailants, and vaginal or anal penetration with tearing. When a patient consents to prophylactic medications, she or he must know that strict adherence to the medication regime is crucial. Because the prophylactic protocols may change over time based on our current knowledge, consultation by the rape treatment team with their infectious diseases expert is essential.
Prophylaxis for pregnancy. Because estimates of risk of pregnancy resulting from rape range from 1% to 10%, female patients of childbearing age may be offered medications for prophylaxis. However, determining the patient's pregnancy status before administering pregnancy prophylaxis is essential. The patient should be informed that this treatment is 75% effective and that, if she does not menstruate within 21 days, she should have a repeat pregnancy test.
Psychologic reassessment and interventions. Once these examinations are completed, the mental health clinician should reassess the patient's status and should provide interventions for any psychologic symptoms that might have developed during the examination. After the examination, the mental health clinician should assess the patient for the reactivation of anxiety, anger, or dissociation and should provide interventions to ensure psychologic safety. The patient's coping status and his or her plans for follow-up treatments for both medical and mental health should be reviewed.
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III. Acute Mental Health Treatment
Few studies of acute treatment of psychologic distress after rape are available to guide interventions for victims of recent rapes. Many rape crisis centers provide acute interventions based on the debriefing models of Mitchell and Bray, which were developed for disaster interventions. However, the efficacy of such interventions for rape victims has not been established. In the authors' clinical experience, rape-focused groups in which patients are asked to provide details of the rape incident and their responses are not indicated as an initial intervention. Experience suggests that this approach tends to be overwhelming to patients and that it provides multiple triggers for the reexperiencing of the assault when no skills have evolved as yet to manage the sequelae of this. In addition, patients may come to redefine their rape experience as even more traumatizing when they learn of other, more frightening outcomes. The authors recommend an individual treatment that incorporates psychoeducation about the effects of trauma and rape, provides psychologic support, and assists the patient with processing the rape.
Some researchers have suggested that a brief prevention program consisting of exposure, relaxation training, and cognitive restructuring prevents the development of PTSD. However, subsequent work by these same authors found that this approach held no advantage over supportive counseling or routine assessment.
IV. Treatments for Posttraumatic Stress Disorder After Rape
According to recently published treatment guidelines for PTSD, both exposure-based therapies and pharmacotherapy are efficacious for the treatment of PTSD. Cognitive-behavior therapy (CBT) receives the highest endorsement. The more recently developed eye movement desensitization and reprocessing
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(EMDR) approach is also identified as an option. Recommended medications are selective serotonin reuptake inhibitors, venlafaxine, and nefazodone. Group therapy and psychodynamic psychotherapy, although both are widely used to treat PTSD, have not been systematically or adequately studied. All therapies for PTSD aim to reduce the patient's anxieties and fears, to assist the patient with mastering and integrating the memories of the traumatic event, and to return the patient to psychologic health. The development of a good working relationship and therapeutic alliance is essential to effective treatment. Involvement of selected family members or partners either in family or couples therapy or in periodic involvement in the patient's individual therapy may be beneficial to both the patient and the family.
A. Cognitive-Behavior Therapeutic Approaches
Early behavior theories conceptualized PTSD as a conditioned fear response and adapted treatments known to be effective for other anxiety disorders. Imaginal exposure or flooding was introduced in the early 1980s for the treatment of male veterans suffering from PTSD. According to behavior theory, exposure to the feared memories as seen in imaginal exposure relieves symptoms through habituation or extinction; the patient becomes less fearful of reminders of the trauma. Another variant, anxiety management training, was also adapted for the treatment of PTSD. This approach assists in overcoming fears through the development of anxiety management skills. Stress inoculation therapy (SIT), was formulated specifically for rape victims. SIT provides education and coping skills, including relaxation skills, breathing control, role playing, cognitive restructuring, thought stopping, and guided self-dialogue. Studies of SIT in the treatment of rape have demonstrated significant reductions in PTSD symptoms.
Emotional processing theory attributes any fear reduction to the correction of stimulus stimulus and stimulus response associations and erroneous attributions. In exposure therapy, the patient's fear is activated while corrective material that is incompatible with the fear structure is presented. The patient learns that being reminded of the rape while in a safe setting is not dangerous and that he or she can discriminate between remembering and being there. The patient learns that anxiety and fear can be reduced and that having anxiety or other PTSD symptoms does not result in a loss of control.
CBT for PTSD after rape, as developed by Foa et al., uses imaginal (prolonged) exposure (PE) in a safe therapeutic setting. The patient is instructed to go back to the time of the rape, to relive the rape in his or her imagination, and, with eyes closed, to describe the rape as if it were presently occurring. The session may be taped, and the patient is given homework to repeat the exposure between sessions. The goal is to diminish the patient's distress rapidly through repeated exposure until the patient is able to recall the rape without becoming symptomatic.
A limited number of studies comparing PE and SIT have found that both are effective for treating PTSD after rape. Patients treated with PE continue to improve after treatment, yet SIT-treated patients show no additional gains. Studies of combined PE SIT, SIT, and PE find that all three treatments produce significant improvement in both PTSD and depressive symptoms, although anxiety and overall social adjustment are most helped by PE.
Cognitive processing therapy was developed by Resick and Schnicke for the treatment of rape victims with PTSD. Cognitive processing therapy combines exposure therapy, anxiety management training, and cognitive restructuring. Patients are asked to describe the rape in writing and to read the account as the means of exposure. The cognitive component addresses faulty thinking patterns and focuses on the following five core themes for rape victims: safety, trust, power, esteem, and intimacy. In one recent study comparing cognitive processing therapy, PE, and a waiting list control group, cognitive processing therapy and PE were found to be equally effective in decreasing symptoms of PTSD.
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B. Eye Movement Desensitization and Reprocessing
Eye movement desensitization and reprocessing (EMDR) is a treatment program developed by Shapiro for the treatment of PTSD. EMDR is indicated only when no likelihood of legal testimony exists as testimony following EMDR may not be admissable in some jurisdictions. EMDR includes exposure to memories and images of a traumatic event, an assessment of the psychologic distress and self-beliefs relating to these images or memories ( negative cognition ), identification of a competing cognitive appraisal ( positive cognition ), and examination of the physiologic reactions to the recalled memory or images ( body scan ). Exposure to the traumatic image, body sensations, and negative cognition during rapid lateral eye movements is thought to assist the patient with processing the traumatic event and with modifying both cognitive and emotional responses. Progress toward these goals is measured by a decreased level of distress and an increased acceptance of the positive cognition. Some evidence supports the efficacy of EMDR in the treatment of PTSD.
C. Psychodynamic Psychotherapy
This therapy conceptualizes PTSD as a failure of integration of the traumatic experience into the patient's overall meaning structure that results in the continued intrusions of thoughts and subsequent avoidance. The aims of psychodynamic treatment are to assist patients in reframing of their cognitive appraisal of the experience to reduce fears and feelings of helplessness and to facilitate and support emotional processing. This is expected to promote integration of the trauma into enduring schemas about self and others. To date, no well-designed studies of either group or individual psychodynamic psychotherapies have been reported for the treatment of PTSD or rape.
D. Psychopharmacology
Only a limited number of pharmacologic studies of rape victims having PTSD have been published, and no studies of combined cognitive-behavioral approaches and pharmacotherapy are seen in the literature. Early pharmacologic drug trials for PTSD focusing on the use of monoamine oxidase inhibitors or tricyclic antidepressants yielded mixed results. More recent studies have used the selective serotonin reuptake inhibitors because of their greater tolerability and improved safety margins, and a few have shown benefit (e.g., citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline). One anecdotal study of sertraline (mean dose, 150 mg per day) in rape victims reported that four of five women with chronic PTSD had a greater than 30% reduction in PTSD symptoms after a 12-week trial. In another 12-week open trial in 17 patients (2 had been raped as adults and 7 had been sexually abused as children [the remainder were victims of nonsexual assault]) of paroxetine (mean dose, 42.5 mg per day), some improvement was noted for intrusive thoughts, avoidance behaviors, and hyperarousal, as well as in associated symptoms of anxiety, depression, and dissociation. Studies of both sertraline and fluoxetine in mixed community populations, including sexual assault victims and victims of childhood sexual abuse, found efficacy for the arousal and avoidance and/or numbing symptom clusters but reported no change for the reexperiencing symptoms. Several other medications, including nefazodone, valproate, carbamazepine, lithium, propranolol, trazodone, venlafaxine, mirtazapine, clonidine, alprazolam, and clonazepam, have been investigated in open-label, small-sample studies of chronic PTSD, although none of these has been specifically studied in a population of rape victims. Except for the two benzodiazepines, all these agents have shown improvement in at least one aspect of PTSD. Given the degree of comorbid substance abuse in patients with PTSD, any use of benzodiazepines beyond a brief exposure could become problematic. In addition, some of the subjective sleep disturbance experienced by sexual assault victims may be the result of sleep-related movement or breathing disorders, and benzodiazepine use is not likely to be optimal for these causes of disturbed sleep.
Limited and preliminary studies suggest that both -adrenergic receptor antagonists (e.g., propranolol) and 2-adrenergic receptor agonists (e.g., clonidine) may have some beneficial effects, particularly with the arousal
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and reexperiencing symptoms of PTSD. Based on the observations of Raskind et al., the editor of this text (R.I.S.) has observed in uncontrolled clinical use that the 1-adrenergic receptor antagonist prazosin (1 to 3 mg per day) reduces hyperarousal and related nightmares, flashbacks, anxiety, and dissociative behaviors in a few women with childhood sexual abuse histories and current adult PTSD.
Unfortunately, no double-blind studies have been conducted of drug treatments in the immediate aftermath of trauma. For patients with persisting anxiety who are not responsive to acute psychologic interventions, judicious and temporary use of a benzodiazepine may calm the patient sufficiently to allow his or her engagement in psychologic interventions.
V. Special Populations
A. Children
Children who have been raped are rarely brought to medical attention, unless they have suffered injuries requiring medical treatment. The care of children who have been raped, sexually assaulted, or sexually abused includes the same treatment as that discussed for adult rape victims but it must also include additional knowledge of pediatric growth and psychosocial development.
Emergency interventions for the child rape victim are complicated because the adult who brings the child for treatment is sometimes the perpetrator or she or he may have complex issues regarding her or his relationship to the perpetrator. The perpetrator may in fact be a person respected by the family, as has been seen in the publicized cases of the rape of children by clergy, coaches, teachers, and other trusted members of the community. Pedophiles typically groom their victims, and they may devote much time and energy to developing a trusting relationship with the family, child, and community to increase access to a child or children.
When child sexual abuse or rape is suspected, it is essential that a clinician speak to the child without the accompanying adult(s) being present. Interviewing the child alone may provide an opportunity for the child to identify the perpetrator and may allow medical care providers to assure the child that appropriate protective steps will be taken. Furthermore, the presence of an accompanying adult may be distracting to the child, and it may limit the adult's ability to act as a witness in legal proceedings.
Mandatory reporting to child protection services may be required if the rape or assault was perpetrated by a person responsible for the child's care or one who is in a position of authority or who has a significant relationship with the child (e.g., relative or someone living in the home) or if parental neglect is suspected. Child protection and police notification requirements vary across jurisdictions. Clinicians must be aware of the reporting regulations for their state.
Recognizing that the parent(s) or guardian(s) of this child typically present with posttraumatic responses, exhibiting anger, anxiety, or dissociation as previously described, is important. Support and psychoeducation as outlined in the five-step approach are indicated to maximize the parents' or guardians' functioning and ability to help care for their traumatized child. Common themes include a sense of failure as a parent, a sense of betrayal if the perpetrator was a trusted individual, and fears about the effects of the rape or sexual assault on the physical and emotional well-being of the child. The parent or guardian may be able to provide information about the suspected perpetrator, and he or she can give information about how he or she learned of the abuse, rape, or sexual assault.
The pediatric physical and forensic examinations follow many of the protocols of the adult examination, including collection of evidence and screening and prevention of STDs, HIV, and pregnancy, but they must provide additional psychologic support. When possible, the child should be examined in a pediatric area or a quiet area of the hospital with toys or coloring materials available. The interview is critical for obtaining evidence about the rape, assault, or abuse, and it should take place as soon as possible to
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avoid suspicion that the statements were influenced by others. The clinician must be sensitive to the child's readiness and ability to talk, his or her emotional and physical needs, and the time of the last suspected incident. If the last incident of abuse or rape occurred within 72 hours, the physical and forensic examinations must be carried out.
The initial task of the interviewer is to provide a safe and trusting environment and to explain to the child the purpose of the interview. Beginning with neutral questions about school, friends, and favorite activities and then moving to inquiries about what happened is best. The child should tell of his or her experience, and he or she may use anatomical dolls or drawings; however, the use of anatomical dolls is controversial, and the admissibility of information generated by using anatomical dolls varies from state to state. Dolls and drawings are useful to help define the child's language for body parts and to give details of what happened. All drawings should be labeled, dated, and signed by the child and entered into the medical record.
Consent laws vary across states, with some allowing only a parent or guardian to authorize the examination, unless the parent or guardian is the suspected offender. Other states allow police, social services, or the court to authorize the examination, and, in some states adolescents are able to consent for themselves. In addition, the child must agree (i.e., give consent) to the examination.
The physical and forensic examination is similar to the adult examination, with some modifications. In prepubertal girls, a speculum examination is indicated only if vaginal injuries are present, and, if required, it may be done under general anesthesia. Specimens can be collected using a sterile cotton swab. STD testing is performed when the suspected offender is known to have an STD or is at high risk for an STD, when the child has signs and symptoms of an STD, or if the community has a high prevalence of STDs. Treatment for STDs is considered if the offender is known to have an STD, when the child at risk for STDs is not likely to come for follow-up visits, if the assault was a single episode by a stranger, or when multiple assailants were involved. The American Academy of Pediatrics recommends that adolescents should be offered prophylaxis for syphilis, gonorrhea, and chlamydia, as well as for pregnancy.
Disclosure of sexual abuse or assault by a child requires significant psychologic support. As in the adult patient, survival mode functioning may be present, and the child will need to move to a place of psychologic safety. The child may feel both relief and fear with the disclosure, as well as regarding the ensuing disruption of family or community that may follow depending on the role of the perpetrator. Shame, guilt, anger, confusion, fear, betrayal, isolation, sadness, and fear of abandonment are common emotions. As in the adult patient, the medical examination may induce flashbacks with which the child has few psychologic resources for coping. The mental health clinician's role is to support the child's coping, to provide protection, and to allow the child to discuss his or her fears and concerns.
The developmental phase of the child, which is not necessarily the same as his or her chronologic age, must be understood and should be incorporated into the treatment strategies. Children younger than 2 years of age typically react to trauma with clinging; crying; or aggressive behaviors, such as biting. The 2-year-old to 6-year-old child may reenact the trauma repeatedly, may develop separation anxiety, or may show regressive behaviors. Six-year-old to 10-year-old children often develop multiple somatic complaints, loss of appetite, and sleep disturbances, as well as regressed behaviors. The preteen to early teen may exhibit anger, mood swings, withdrawal from family and friends, somatic complaints, or denial or repetition of the trauma. Adolescents may become critical of parents and authority figures; may withdraw from others; may have sleep and appetite disturbance; or may turn to risk-taking behaviors, drugs, or alcohol. Children and adolescents may develop PTSD, depression, and suicidality after a rape or sexual assault. A national
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survey of adult women survivors of childhood rape identified a threat to life, physical injury, testifying about rape, and multiple rape types as predictors of PTSD after rape.
The family must be informed of the pattern of responses and of the need for early mental health treatment to assist their child with coping with the trauma of rape or sexual assault. Because the needs of families after disclosure of sexual abuse or assault are complex, all families, in addition to the child, must be referred for mental health assessment and treatment. Contacting the family a few days after the disclosure to offer support and additional resources and information is recommended.
Psychotherapeutic approaches to the traumatized child often combine CBT, psychodynamic, and family-based interventions; exposure is typically seen as a necessary component. Few controlled studies for the treatment of childhood PTSD and still fewer after rape or sexual assault have been conducted. In a study of 90 sexually abused children, CBT for the child and the child parent dyad reduced PTSD symptoms, depression, and externalizing behaviors in the children and increased parenting skills, as compared with community care. CBT limited to the parents improved parenting skills, but it did not improve symptoms in the child. Another study of 32 mother daughter pairs after sexual abuse of the daughter found that both CBT and supportive psychotherapy decreased the child's PTSD symptoms, as well as both internalizing and externalizing behaviors. The mothers in the CBT group showed decreases in self-blame and in expectations of negative impact on the child. EMDR has not been studied in children who have been raped or sexually assaulted; however, a controlled study of EMDR for the treatment of children with PTSD after natural disasters demonstrated significant improvement in PTSD symptoms, anxiety, and depression. No controlled studies of pharmacologic treatments of childhood PTSD have been conducted.
B. Disabled Persons
Few studies exist about rape of physically or mentally disabled persons, whether mentally retarded or psychotic persons. However, this population is an especially vulnerable group because the disabled person may be incapable of preventing rape or fearful of reporting a sexual assault, especially if the perpetrator is a caretaker. Mentally disabled persons have additional barriers in communicating about abuse because they may not be able to describe or articulate their experience. As is the case in the treatment of children, the patient may be accompanied by the perpetrator who will present the history of injuries or assault. Interviewing the disabled patient alone is essential to allow him or her to identify the perpetrator. In some states, the treatment team is mandated to report abuse of disabled persons if the perpetrator is a caretaker or family member.
The approach to the medical and forensic examination is modified to accommodate the patient's mental status and functional age. The cognitively impaired or psychotic patient may not comprehend the need for the medical or forensic examination and thus may require additional support and education from the mental health clinician. The rape treatment team must proceed only with the cooperation of the patient, and it should continue to assess the patient's understanding of the examination and should provide education as needed. Psychotherapy interventions for rape sequelae must take into account the patient's functional age and mental functioning.
C. The Elderly
The true incidence of rape in elderly women is unknown; however, in 1995, the United States Department of Justice estimated that rape occurred in only 4 of 10,000 women over age 65 years. It is likely that elderly women underreport rape because of shame and social fears. The elderly rape victim typically is a woman who lives alone and who is raped at home, although elderly women may also suffer rape from an acquaintance or caregiver. In addition to the psychologic distress that may result from rape at any age, rape
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in this age group may increase feelings of vulnerability for both the victim and her family regarding common life-span issues, such as independence versus dependence. The elderly rape victim and family may need assistance in determining if this patient could or should live independently.
D. Domestic Violence and Rape
Domestic violence includes not only physical violence but also partner rape. An estimated 33% to 46% of women who have been physically abused by a partner have also been raped or sexually assaulted by the partner. A community study found that nearly 24% of the rape cases were committed by husbands. A 1996 study of domestic violence in gay relationships reported that 39% of men have been raped by their partners.
Domestic violence continues to be underreported and underrecognized in emergency settings because of multiple barriers, including the failure to ask about domestic violence or partner rape, staff perceptions that they are too busy to address such complex social issues, staff frustrations that victims will return to the abusing partner, or concerns about invading family privacy. Women often do not report spousal or partner rape as unwanted or coerced sexual acts, and, in the context of marriage, such acts are rarely defined by women as rape. Women and men presenting with injuries or suspected domestic violence should also be asked about coerced sexual acts and partner rape. When the patient does not wish to acknowledge the domestic violence or to receive services, safety planning or information about shelters should be provided.
E. Male Rape
Both adult and child male victims of rape and sexual assault, including forced anal intercourse, forced fellatio, and forced ejaculation, are underidentified and are poorly served by the current systems of care. No estimates are available of the numbers of male rapes in the community. In prison populations, the estimate is that 0.5% to 3% of inmates are raped. Studies estimate that 6% to 10% of people being treated in rape crisis centers are male, although the fact that male victims rarely seek treatment is frequently noted. Barriers include social beliefs that a man should be able to defend himself; the victim's fears that his sexual orientation will be questioned; the male ethic that men are self-reliant; and significant shame, guilt, and humiliation.
The emergency treatment of male victims of rape may be complicated by injuries, because men are more likely to have suffered greater physical harm, to have had multiple assaults and assailants, to be held longer in captivity, to be attacked by strangers, and to have had weapons displayed or used. Themes common to men that may need to be addressed in emergency interventions include issues surrounding masculinity and perceptions that the victim is weak, fears raised by him about his own sexual identity or orientation, or worries that others will now question his sexual orientation. Several studies noted that a common clinical presentation in male rape victims is that of anger and hostility, although the other survival responses of anxiety and dissociation may also present.
Long-term themes have been reported to include sexual dysfunction and sexual identity or orientation confusion that is most pronounced if the victim was forced to ejaculate. Male victims of anal penetration may not be aware that penile pressure on the prostate may cause involuntary erections and even orgasms. The victim who does not understand the physiologic nature of this response may feel shame and confusion about his response. Currently, no treatment outcome studies of male rape victims are available; however, the PTSD literature may be used as a guide while bearing in mind themes and misattributions common to male victims. Further study is essential to increase the knowledge of male rape, its consequences, and treatments.
F. Date and Acquaintance Rape
This applies when the perpetrator is someone known to or someone who is dating the rape victim. Victims of date rape rarely report the rape to the authorities, and they frequently attribute the rape to their own poor judgment.
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Estimates from college samples range from 13% for date and acquaintance rape to 68% for coerced sexual activity by a date or acquaintance. Use of drugs and alcohol by the victim or the perpetrator is highly correlated with coerced sexual activity. As was previously noted, unwitting victims may be given a date rape drug, such as flunitrazepam or -hydroxybutyrate, leaving them without any memory of being raped.
G. Gang Rape or Rape by Multiple Perpetrators
This is estimated to occur in up to 2% of college samples and 26% of police samples. Gang rapes, because they involve multiple assailants and sexual assaults, lead to prolonged assault duration and thus to an increased risk of injury, STDs, and PTSD. A community police sample found that the victims and offenders were more likely to be younger, that more attacks occurred at night and outdoors, and that victims offered less resistance when compared with single offender rapes.
H. Cultural Considerations
The meaning of rape and the patient's response will be highly determined by the patient's cultural group and religious beliefs. The mental health clinician must understand the role of culture in treating rape victims, as failure to understand the cultural meaning of rape will impair the patient's progress. In many cultures, rape is considered to bring shame upon the woman and her family; she will be mistreated, blamed, or excluded from social events (e.g., socially outcast) or considered unworthy of marriage. When the clinician is not aware of the patient's culture and the cultural beliefs, attempting to correct these misattributions with the family or patient may result in more distress for the patient and may further preclude access to treatment.
I. Refugees
The world is estimated to have over 23 million refugees, with most displaced due to war, ethnic cleansing, religious conflicts, or political persecution. Since the time of antiquity, rape has been a sanctioned activity of the conqueror. Organized rape and torture were prominent in conflicts such as in Bosnia and Kosovo. Thus, refugees from war-torn areas of the world may be suffering not only from the trauma of war, displacement from their home, and the loss of friends and family, but they may have also suffered rape at the hands of the enemy. Whereas the community rapist may act to demean the victim, the rapist in war or political conflicts may also be asserting the right of the victor to rape and pillage, signifying their dominance and the powerlessness of the vanquished. Treatment approaches must attend to the multiple trauma experiences, issues of acculturation, and cross-cultural considerations.
J. Perpetrators
Rapists are a heterogeneous group. For most rapists, issues of control and aggression predominate. In the United States, the estimate is that 15% of forcible rapes are perpetrated by males under the age of 18; many of these individuals have a personal history of trauma or neglect and a history of committing other antisocial acts. One study found that 42% had suffered physical abuse, 39% were sexually abused, 26% suffered childhood neglect, and 63% were witness to severe domestic violence. Most rapists have aggressive and antisocial traits, and they show little empathy for their victims. Others may be socially inhibited and shy. Both groups may have underlying feelings of inadequacy with a desire to degrade, humiliate, or injure their victims. Estimates of the frequency of paraphilia among rapists vary widely, beginning with conservative estimates of 5%. Paraphilic rapists compose a subgroup of rapists who obtain sexual pleasure through the domination of an unwilling victim.
VI. Useful Contacts
Two useful contacts are the National Sexual Violence Resource Center, which can be reached by telephone at 877-739-3895; by fax at 717-909-0714; and by e-mail at http://www.resourcesnsvrc.org, and the National Health Resource Center on Domestic Violence, which can be reached by telephone at 888-792-2873, by fax at 415-252-8991, and by website at http://endabuse.org/programs/display.php3?DocID=41.
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ACKNOWLEDGMENT
The authors are indebted to Drs. Carol C. Nadelson, Malkah T. Notman, and Johanna Perlmutter for their earlier version of this chapter, which appeared in the second edition of this text.
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