Services for victim/survivors of sexual assault
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- Background to service provision: The prevalence of sexual violence, and barriers to reporting and disclosure
- Adverse outcomes of sexual assault experienced by victim/survivors
- Interventions to reduce psychological distress and their effectiveness
- Specialist sexual assault services in Australia: The existing research
- General health service providers working with victim/survivors of sexual assault: Some recommendations
Adverse outcomes of sexual assault experienced by victim/survivors
Immediate effects of sexual violence for the victim/survivor
Immediate effects include shock, fear and feelings of helplessness. Illusions regarding personal safety and being invulnerable in the world are shattered, and levels of psychological distress are very high in the first few weeks after the sexual assault but abate over the longer term (Koss et al., 1994). Victims can experience a range of physical injuries and damage to the urethra, vagina and anus and are at increased risk of contracting sexually transmissible infections including HIV/AIDS. Fears of contracting HIV and/or becoming pregnant as a result of sexual assault are pervasive (Holmes, Resnick, Kilpatrick, & Best, 1996; Resnick, Acierno, & Kilpatrick, 1997).
Long-term effects of sexual violence on the victim/survivor
Sexual violence, whether this occurs in childhood or adult life, is associated with a plethora of poor, long-term, physical health outcomes. These physical health problems include sexual and reproductive health problems, pain syndromes, eating disorders (especially bulimia nervosa), and gastro intestinal problems (Krakow et al., 2002; Leserman, Li, Drossman, & Hu, 1998).
Mental health problems such as major depression, generalised anxiety, panic, phobias, symptoms of traumatic stress and suicidal thoughts and actions are common. These can co-occur with reduced self-esteem and a damaged sense of gender identity.
Relationships can also suffer depending on how well or badly those closest to the victim such as a partner, family or friends are able to understand the impact of the sexual assault and how they respond to its disclosure (Coker et al., 2002; Fleming, Mullen, Sibthorpe, & Bammer, 1999; Koss, 1993; McMahon, Goodwin, & Stringer, 2000; Resnick et al., 1997). Being better informed about the psychological effects of sexual violence would greatly assist family and friends of survivors to feel more confident in providing support and understanding.
Women who have been sexually victimised as children face increased risks of subsequent rape and domestic violence in adult life and experience even higher rates of adverse health outcomes (Fleming et al., 1999).
'Post-traumatic stress disorder'
Of all the traumatic stressors researched so far including natural disasters such as earthquakes, hurricanes and tsunamis, it is the 'man made' trauma of sexual violence that most strongly predicts the subsequent development of post-traumatic stress disorder (PTSD) (Bruce et al., 2001; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Women who have experienced sexual violence constitute the single largest group of people suffering from PTSD (Calhoun & Resnick, 1993). Rape victims are six times more likely to develop PTSD at some point in their lives than non victimised women (Kessler et al., 1995; Kilpatrick, Edmunds, & Seymour, 1992). Women's risk of developing PTSD following exposure to trauma has been found to be approximately two-fold higher than men's. Women's PTSD also tends to last longer. This parallels the gender difference found for depression, with which PTSD frequently co-occurs (Breslau et al. 1998).
Feminist researchers have criticised the use of the psychiatric diagnosis of PTSD as the main way of understanding and responding to the psychological distress and the meaning of sexual violence for women. Both Edna Foa and her colleagues (Foa, Cashman, Jaycox, & Perry, 1997) and Judith Herman (1992) have argued that the assumptions and the symptoms that define the diagnosis of PTSD do not accurately reflect the range of traumatic experiences and traumatic effects experienced by survivors of sexual violence and whose PTSD is of a more complex type than that experienced by survivors of discrete traumatic events.
Like all psychiatric diagnoses, PTSD relies on the individualising and pathologising language of 'psychiatric symptoms' and represents the victim of sexual violence as the bearer of a psychiatric disorder. By focusing on the victim/survivors as a person with a mental illness needing treatment, attention is deflected from the social causation of rape and the generalised oppression of women. Moreover, the concentration on a set of decontextualised and medicalised set of problematic symptoms inherent in the diagnosis of PTSD also shifts attention from survivors' psychological concerns including the impact of sexual violence on their sense of themselves, their lives, their relationships, their sense of safety in the world and their overall health and wellbeing.
Sexually victimised women who develop PTSD are significantly more likely than those who do not, to have to contend with a number of other co-occurring or co-morbid psychological difficulties that may persist for many years (Kessler et al., 1995). Survivors who develop PTSD can be impacted by this both during the day when they experience intrusive thoughts and distressing recollections of the violence, and at night when nightmares and other sleep disturbances may be the norm rather than the exception (Choquet, Darves-Bornoz, Ledoux, Manfredi, & Hassler, 1997; Krakow et al., 2000; Krakow et al., 2002; Roberts, 1996). A number of the women interviewed in Lievore's (2005) study commented on being unable to sleep, not sleeping properly and having nightmares.
Nightmares are listed within the symptom cluster describing 're-experiencing symptoms' and difficulty getting to sleep and staying asleep are listed within the symptom cluster describing 'arousal symptoms'. One US study found that survivors with PTSD recalled having more than five nightmares per week on average (Krakow et al., 2002). Sleep problems affect the daytime functioning of those who experience them and impair functioning at work, diminish quality of life and are associated with a higher risk of accidents and increased health care costs (Roth, 2005). Prescribed medications for sleep problems include anxiolytics and hypnotics but over-the-counter medications, alcohol or other drugs are often used to self-treat (Roth, 2005).
Health providers have a unique opportunity to identify a history of sexual violence, diagnose psychological disorders and provide accurate and meaningful responses to survivors' sleep and other violence related health problems. Research to date suggests that few take this opportunity. A study of more than 3000 women attending general practitioners in Victoria found that only 9% of women who had experienced sexual abuse had ever disclosed this to their general practitioner, primarily because the practitioner had never asked about a history of victimisation (Mazza, Dennerstein, & Ryan, 1996). Yet recent Australian research (Vos et al., 2006) demonstrates that intimate partner violence including sexual violence is the single largest risk factor for ill health (primarily poor mental health) for Victorian women aged between 15 and 45 years.
A victim/survivor's negative experiences regarding the assault with those closest to them (family members, friends), and with the criminal justice sytem and health service providers (including counsellors) can contribute to what has been termed 'secondary victimisation'. Such victimisation is likely to exacerbate existing psychological distress (as outlined above) and delay recovery from the initial trauma (Campbell & Raja, 1999).
Secondary victimisation by service providers is a major preventible form of harm to the survivor and its elimination should be a priority for all professionals working with victim/survivors of sexual violence. Both the initial sexual assault and secondary traumatisation can initiate or reinforce harmful health behaviours including smoking, heavy alcohol and illicit drug use and reliance on prescribed and non prescribed medication. These behaviours are independently associated with poor mental and physical health (Resnick et al., 1997).
Patterns of utilisation of different forms of health care reveal some interesting variations. Overall, sexually victimised women have increased rates of utilisation of medical services compared with non-victimised women. However, they have lower rates of using mental health, services for victims and preventive health care (Jewkes, Sen, & Garcia-Moreno, 2002; Koss, Koss, & Woodruff, 1991; Springs & Friedrich, 1992).