Assault characteristics and posttraumatic stress disorder in rape victims Bownes IT, O’Gorman EC, Sayers A. Assault characteristics and posttraumatic stress disorder in rape victims. Acta Psychiatr Scand 1991: 83: 27-30. A diagnosis of posttraumatic stress disorder (PTSD) encompasses several of the symptoms associated with the response to rape. The object of this study was to determine the incidence of PTSD among 51 rape victims and to compare the groups with and without PTSD with respect to the characteristics of the assaults. The results showed that 70% of the victims had PTSD and further suggested that PTSD was likely to be a long-term problem for these women. The results supported the view that psychological treatment approaches to rape victims should take into account the posttraumatic nature of the response. The incidence of rapes by strangers, of physical force being used, of weapons being displayed and of injuries being sustained by the victim were all higher in the group of women who had PTSD. These are all features that can be readily identified in the initial assessment of the rape victim and may help to identify the victims at risk of developing long-term psychological sequelae after rape. Appropriate therapeutic action taken early may influence the prognosis for a significant I proportion of rape victims.
The physical, cognitive and behavioural responses that typically follow rape are consistent with DSM-I11 criteria for posttraumatic stress disorder (PTSD) (1). Symptoms related to rape include: intrusive, unpleasant imagery; nightmares ; exaggerated startle responses ; disturbances in sleep patterns; guilt; impairment in concentration and memory; and fear or avoidance of rape-related situations. The course of these responses and their pattern of decline has been shown to vary across individuals (2). General symptom elevation including levels of depression tends to subside by the fourth month after rape (3,4) but both follow-up and retrospective studies of rape victims have shown that a proportion of victims remain symptomatic for years after the assault (5-7). Anxiety tends to be a more persistent post-rape reaction than depression (3, 8). The longitudinal data collected by Kilpatrick et al. (2) suggests that there is little added improvement in symptoms present 3 months after rape, and it has been further suggested that anxiety reactions resulting from rape may become chronic in nature (9). Numerous variables have been investigated in an effort to identify those that influence recovery from rape trauma. Many studies have reported an association between the response to rape and characteristics of the victim, including her level of pre-rape functioning. Atkeson et al. (3) found that demographic variables of age, psychiatric treatment history,
1. T. Bownes’, E. C. O‘Gorman’**, A. Sayers’
’
Department of Mental Health, Queen’s University of Belfast, Windsor House, Belfast City Hospital, Belfast, Northern Ireland, United Kingdom
Key words: posttraumatic stress disorder; rape; assault Ian T. Bownes, Department of Mental Health, Queen’s University of Belfast, Belfast, Northern Ireland, UK Accepted for publication August 12, 1990
physical health problems and socioeconomic status predicted duration of depressive symptoms. Cohen & Roth (10) found that individual differences in severity of symptoms were related to prior history of sexual assault. Miller et al. (1 1) found that disruption of social functioning after rape was associated with individual psychopathology prior to rape. However, continuing symptoms of fear and anxiety have also been found in rape victims who had no previous history of mental or emotional disturbance (8). Clearly, women do not have to have pre-existing psychopathology for the rape trauma to have a major impact on their lives. Studies reporting the relationship between specific aspects of the rape experience and immediate or long-term psychological trauma are conflicting. Cohen & Roth (10) reported that the level of force used during the attack was positively related to anxiety and intrusions. Ellis et al. (12) found that the victims of brutal rapes by strangers were significantly more fearful than the victims of less brutal acquaintance rapes. Becker et al. (13) found that use of a weapon by the assailant was related to depressive symptoms. However, Frank et al. (14) found no significant relationship between these assault variables and post-assault measures of depression, anxiety or fear. Cluss et al. (15) reported that greater threat was associated with higher self-esteem and Orlando & Koss (16) found that higher levels of force were associated with better sexual satisfaction after rape. 21
Bownes et al.
Atkeson et al. (3) found that the level of trauma in the rape situation did not predict continued depressive symptoms. However, different measures of victim outcome have been used in these studies and most them have sought a relationship between assault characteristics and single variables in the victims’ response patterns. It could be that the characteristics of the rape attack have differential effects on the various aspects of the victim’s emotional and behavioural response and on their interrelationships. Thus, a focus on single variables may make it difficult to obtain consistent associations between assault characteristics and victim trauma. The diagnostic criteria for PTSD are that the victim must have experienced an event outside the range of normal human experience and have symptoms lasting for longer than 1 month in each of the following categories : intrusive re-experiencing of the trauma; persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness ; and persistent autonomic signs of anxiety. Hence a diagnosis of PTSD encompasses a number of the individual variables that have been studied in the response to rape. The objective of this study was to determine the incidence of PTSD among a group of rape victims and to compare the groups with and without PTSD with respect to the characteristics of the assaults.
Material and methods
The population studied had all been referred to and examiced by a consultant psychiatrist (E.C.O’G.) for medico-legal assessment between January 1983 and December 1988. Each individual had been the victim of a rape (i.e., vaginal penetration without her consent) that had been reported to the police, and was seeking compensation under the Criminal Injuries (Northern Ireland) Order. Fifty-one referrals were studied. The interval between the incident and psychiatric examination varied. The mean time elapsed was 9 months and the range was 6 months - 3 years. The case notes for each referral were studied by the research team members. These included a full psychiatric history and examination of mental state, a detailed list of all symptoms reported since the assault, their time of onset and duration, any treatment received and, where appropriate, medical and surgical reports. Details of the rape were obtained from the victim and from police reports, forensic medical officers’ reports and statements. A comprehensive check-list including the characteristic symptoms of PTSD as defined in DSM-I11 was completed for each referral. The data collected were subjected to computer analysis and statistical tests. Fisher’s 28
exact probability test was used to compare the groups with and without PTSD. The mean age of the sample at the time of the rape was 21.8 years (range 16-47); 84% were single, 78% employed or students, 8 % had a family history of psychiatric illness in a first-degree relative, 12% received psychiatric treatment prior to the rape from their general practitioner only and 12% had previously consulted a psychiatrist. In the year preceding the rape, 39% had no experience of traumatic life events and 25:h had experienced 1,24% 2, 10% 3 and 2% 4. None of the sample had a previous history of sexual assault. Results
Of the 51 rape victims studied, 70% had PTSD as defined by DSM-I11 criteria. The frequency of the characteristic symptoms for the 2 groups is shown in Table 1. In every case the onset of the symptoms was less than 6 months after the trauma, and the duration of each symptom was longer than 1 month. Differences in the incidences of the symptoms between the 2 groups were statistically significant, except for the incidence of recurrent dreams and symptoms of emotional detachment and constricted affect. There was no significant statistical difference between the 2 groups with respect to age, marital status, employment status, number of recent life events, past history of psychiatric illness or family history of psychiatric illness. In addition, no significant statistical difference was found between the 2 groups regarding the type of psychiatric treatment received up to the time of the interview, time taken off work and decision to change job. More of the rapes in the PTSD group were carried out by strangers (72% vs 27%, P < 0.01). More of Table 1. Symptoms characteristic of PTSD
Recurrent intrusive recollections Recurrent dreams As if phenomenon Decline in interest Emotional detatchment Constricted affect Hyperalertness Insomnia Memory or concentration impairment Phobic avoidance Time elapsed since assault (months) Mean SD Range
Overall
PTSD
non-PTSD
(n=51)
(n=36
(n=15)
P
47 (92%) 45 (88%) 29 (57%) 47 (92%) 42 (82%) 47 (92%) 31 161%) 39 (76%)
36 (100%) 34 (94%) 27 (74%) 36 (100%) 32 (87%) 35 (97%) 27 (74%) 34 (94%)
11 (73%) 11 (73%) 2 (13%) 11 (73%) 10 (67%) 12 (80%) 4 (28%) 5 (33%)
0.005 NS 0.005 0.005 NS NS 0.005 0.001
33 165%) 33 (65%)
30 (83%) 31 (86%)
3 (20%) 2 (13%)
0.001 0.001
8.8 2.4 6-36
9.2 3.2 6-36
8.3 2.4 6-12
NS
PTSD after rape
the rapes in the non-PTSD group took place in an indoor setting (25 % vs 53 %, P = 0.05). The majority of attacks (61 %)were reported to have lasted longer than 30 min; the PTSD and non-PTSD groups did not differ in this respect. Verbal threats alone were used to gain victim compliance in only 14% of incidents among the PTSD group vs 47% of incidents among the non-PTSD group (P< 0.02). The majority of victims in both groups were subjected to some form of physical aggression, the most common form being physical restraint involving non-brutal violence, including holding, pushing, slapping and hair-pulling. Brutal aggression including punching, kicking or choking of the victim took place in 24% of rapes in the PTSD group vs 6% in the non-PTSD group (P = 0.06). None of the attacks in the nonPTSD group had involved a weapon vx 22% of rapes in the PTSD group ( P < 0.05). The majority (60%) of victims in the non-PTSD group escaped without significant injury vs 28% in the PTSD group (P < 0.05). Thirty percent of the PTSD group had severe injuries, including genital lacerations, black eyes, loss of teeth and severe bruising, vs 7% in the non-PTSD group (P = 0.06). Similar percentages of victims in both groups were subjected to additional acts of sexual abuse and forced to participate in reciprocation of sexual activity. The overall incidence of forcible fellatio was 22%, of anal intercourse 8 % and of repeated intercourse 24%. Discussion
The results of this study indicate that PTSD is a frequent sequela of rape. The mean time between the assault and interview was nearly 9 months so that, in every case, the victims were interviewed after initial symptom elevation would have been expected to subside. Previous studies have shown that psychological symptoms present after this interval show little resolution with time (6, 8). Thus the results would suggest that PTSD is likely to be a long-term problem for a significant proportion of rape victims. However, as in all studies of rape victims, sampling bias is inherent in these results. All the victims studied were litigants. Characteristics both of the assault and of the victim have been shown to influence reporting of rape, and contact with the criminal justice system has been shown to be related to victim outcome (2, 10, 15, 17). In particular, contact with the police and legal system has been associated with increased fear and anxiety (2, 17). Thus our findings may not be typical of all rape attacks in some respects. For example, the incidence of rapes by strangers, of victim injuries and of use of significant physical force may be proportionately higher since these aspects of the attack are associated with
increased reporting, and the high prevalence and duration of symptoms of fear and anxiety may be due, in part, to contact with the legal system. Moreover, the interval between attack and psychiatric examination may have led to problems of memory reconstruction (although corroborative evidence from police statements and medical officers’ reports was available, it did not always cover all the aspects of the assaults investigated). However, we believe that useful conclusions can be drawn on the basis of the differences between the 2 groups studied. Differences were found between the group of rape victims who had PTSD and the group who did not with respect to certain characteristics of the assault. The incidences of rapes by strangers, of physical force being used, of weapons being present and of injuries sustained by the victim were all higher in the group of women found to have PTSD. This suggests that an association may exist between these assault characteristics and the generation of PTSD, although clearly there is a need for more research, including longitudinal studies, to clarify these findings. Elucidation of the relationship between assault characteristics and long-term psychological trauma in the victim would be of immense practical value as it would enable rapid identification of at-risk victims. Thus appropriate therapeutic action could be taken early and this could be of importance for the prognosis in a significant proportion of rape victims. Traditionally, the psychological sequelae encountered in rape victims have been perceived as a response to a life-threatening experience (18, 19). This study supports the view that the aetiology of the psychological trauma of rape is more complicated. Rape differs from many other events associated with PTSD in that a human being acting intentionally is the source of the trauma (21). The psychological characteristics of rapists have been shown to be related to the nature of the assaults they instigate, including such characteristics as degree of acquaintance with the victim, the level of aggression displayed and the extent to which the intention of the assault is to inflict physical injury on the victim (22-24). During the rape attack, rapist and victim are involved in a psychodynamically complex interaction. The psychological characteristics of the rapist play a major part in determining the nature of this interaction, including his interpretation of and reaction to the victim’s behaviour during the attack. For some rapists, the need to humiliate and injure through aggression is the prime motive for the attack and physical abuse of the victim may continue after she has shown her willingness to comply with his demands. In other rapists the need to achieve sexual dominance is the most important aspect of the attack, and aggression diminishes in response to compliance on the part of the victim. In some rapists 29
Bownes et al.
the need for total control over the victim is so strong that even slight or involuntary sounds or movements on her part may provoke an explosive escalation of violence. In other rapists, passive or unresponsive behaviour on the part of the victim may increase rage and aggression. A rapist may seek to involve the victim in his distorted perception of the situation by demanding that she respond to him in an erotic manner or may accuse her of inviting or even enjoying the attack. The psychological trauma of the interaction may be intensified for the victim by the display of inappropriate, unexpected or deviant reactions on the part of the rapist to her behaviour during the attack. This may make her rationalization and assimilation of the experience more difficult, and psychological symptoms may be generated in a more intense and ultimately more prolonged form. Thus, the psychological characteristics of the rapist may considerably impact both the psychodynamics of the assault and victim trauma. We believe that the importance of such characteristics of the assault as the presence of a weapon and the relationship of assailant to victim in the generation of the psychological sequelae of rape may lie in their reflection of the psychological characteristics of the rapist. Victims of rape are routinely acknowledged to need issue-oriented, supportive crisis counselling. More specialized treatment is often only deemed necessary where the victim has important underlying psychopathology such as a past or current history of psychiatric difficulties or has evinced other problems in addition to those seen as part of the rape trauma syndrome (27, 28). The results of this study support the view that treatment approaches to rape victims should take into account the posttraumatic nature of the response to rape. Furthermore, we feel that the results also indicate that the characteristics of the rape attack are relevant to long-term victim trauma. References 1. NOTMANMT, NADELSON CC. The rape victim: psychodynamic considerations. Am J Psychiatry 1976: 133: 408-413. 2. KILPATRICK DG, VERONENLJ, RESICKPA. The aftermath of rape: recent empirical findings. Am J Orthopsychiatry 1979: 49: 658-659. 3. ATKESONBM, CALHOUNKS, RESICKPA, ELLIS EM. Victims of rape: repeated assessment of depressive symptoms. J Consult Clin Psychol 1982: 50: 96-102. 4. RESICKPA, CALHOUNKS, ATKESONBM, ELLISEM. Social adjustment in victims of sexual assault. J Consult Clin Psycho1 1981: 49: 705-712. AM. The aftermath 5. MCCAHILLTW, MEYERLC, FISHMAN of rape. Lexington, MA: Heath and Company, 1979. DG, VERONEN LJ, BEST CL. Factors pre6. KILPATRICK dicting psychological distress among rape victims. In:
30
FIGLEYCR, ed. Trauma and its wake. New York: Brunner/Mazel, 1984. DG. Stress management for rape 7. VERONENLJ, KILPATRICK victims. In: MEICHENBAUM D, JAREMKO ME, ed. Stress reduction and prevention. New York: Plenum Press, 1983. 8. NADELSON CC, NOTMANMT, ZACKSONH, GORNICK J. A follow-up study of rape victims. Am J Psychiatry 1982: 139: 1266-1270. KS, ATKESONBM, RESICKPA. A longitudinal 9. CALHOUN examination of fear reactions in victims of rape. J Psychol 1982: 29: 655-661. 10. COHENLJ, ROTH S. The psychological aftermath of rape: long-term effects and individual differences in recovery. J Soc Clin Psychol 1987: 5 : 525-534. 11. MILLERWR, WILLIAMS M, BERNSTEIN MH. The effects of rape on marital and sexual adjustment. Am J Family Ther 1982: 10: 51-58. 12. ELLISEM, ATKESON BM, CALHOUN KS. An assessment of long-term reaction to rape. J Abnorm Psychol 1981: 90: 263-266. 13. BECKERJV. SKINNERLJ. ABEL GG et al. DeDressive symptoms as’sociated with sexual assault. J Sex M a r h Ther 1984: 10: 185-191. 14 F R A N KE, T U R N E R SM, STEWART B. Initial response to rape: the impact of factors within the rape situation. J Behav Assess 1980: 2: 39-53. J, FRANK LE, STEWART BD, WEST 15 CLUSSPA, BROUGHTON D. The rape victims: psychological correlates of participation in the legal process. Criminal Justice Behav 1983: 10: 342-357. 16. ORLANDO JA, Koss MP. The effect of sexual victimization on sexual satisfaction: a study of the negative-association hypothesis. J Abnorm Psychol 1983: 92: 104-106. 17. KILPATRICK DG, VERONENLJ, RESICKPA. Assessment of the aftermath of rape: changing patterns of fear. J Behav Assess 1979: 1: 133-148. S , SCHERLDS. Patterns of response among 18. SUTHERLAND victims of rape. Am J Orthopsychiatry 1970: 40: 503-511. 19. BURGESS AW, HOLSTROM LL. Rape trauma syndrome. Am J Psychiatry 1974: 131: 981-986. 20. Fox S S , SCHERLDJ. Crisis intervention with victims of rape. Soc Work 1972: 17: 37-42. HI, SADOCK BJ. Post-traumatic stress disorder. In: 21. KAPLAN Clinical psychiatry. Baltimore: Williams & Wilkins, 1988. LL. Rape, power 22. GROTHAN, BURGESSAW, HOLSTROM anger and sexuality. Am J Psychiatry 1980: 137: 806-810. RA, COHENML, SEGHORN TK. Development of 23. PRENTKY a rational taxonomy for the classification of rapists: the Massachusetts Treatment Centre System. Bull Am Acad Psychiatry Law 1985: 13: 39-70. 24. SEGHORNT, COHEN M. The psychology of the rape assailant. In: CERRANW, MCGARRYAL, PETTYC, ed. Modern legal medicine, psychiatry and forensic science. Philadelphia: FA Davis, 1980. AN, BURGESS AW. Rape: a sexual deviation. Am J 25. GROTH Orthopsychiatry 1977: 47: 401-406. RA, BURGESS AW, CARTER DL. Victim responses 26. PRENTKY by rapist type: an empirical and clinical analysis. J Interpers Violence 1986: 1: 73-98. 27. BURGESSAW, HOLSTROMLL. Recovery from rape and prior life stress. Res Nursing Health 1978: 1: 165-174. 28. FRANK E, TURNERSM, STEWART BD, JACOBM, WESTD. Past psychiatric symptoms and the response of sexual assault. Compr Psychiatry 1981: 22: 479-487.
The physical, cognitive and behavioural responses that typically follow rape are consistent with DSM-I11 criteria for posttraumatic stress disorder (PTSD) (1). Symptoms related to rape include: intrusive, unpleasant imagery; nightmares ; exaggerated startle responses ; disturbances in sleep patterns; guilt; impairment in concentration and memory; and fear or avoidance of rape-related situations. The course of these responses and their pattern of decline has been shown to vary across individuals (2). General symptom elevation including levels of depression tends to subside by the fourth month after rape (3,4) but both follow-up and retrospective studies of rape victims have shown that a proportion of victims remain symptomatic for years after the assault (5-7). Anxiety tends to be a more persistent post-rape reaction than depression (3, 8). The longitudinal data collected by Kilpatrick et al. (2) suggests that there is little added improvement in symptoms present 3 months after rape, and it has been further suggested that anxiety reactions resulting from rape may become chronic in nature (9). Numerous variables have been investigated in an effort to identify those that influence recovery from rape trauma. Many studies have reported an association between the response to rape and characteristics of the victim, including her level of pre-rape functioning. Atkeson et al. (3) found that demographic variables of age, psychiatric treatment history,
1. T. Bownes’, E. C. O‘Gorman’**, A. Sayers’
’
Department of Mental Health, Queen’s University of Belfast, Windsor House, Belfast City Hospital, Belfast, Northern Ireland, United Kingdom
Key words: posttraumatic stress disorder; rape; assault Ian T. Bownes, Department of Mental Health, Queen’s University of Belfast, Belfast, Northern Ireland, UK Accepted for publication August 12, 1990
physical health problems and socioeconomic status predicted duration of depressive symptoms. Cohen & Roth (10) found that individual differences in severity of symptoms were related to prior history of sexual assault. Miller et al. (1 1) found that disruption of social functioning after rape was associated with individual psychopathology prior to rape. However, continuing symptoms of fear and anxiety have also been found in rape victims who had no previous history of mental or emotional disturbance (8). Clearly, women do not have to have pre-existing psychopathology for the rape trauma to have a major impact on their lives. Studies reporting the relationship between specific aspects of the rape experience and immediate or long-term psychological trauma are conflicting. Cohen & Roth (10) reported that the level of force used during the attack was positively related to anxiety and intrusions. Ellis et al. (12) found that the victims of brutal rapes by strangers were significantly more fearful than the victims of less brutal acquaintance rapes. Becker et al. (13) found that use of a weapon by the assailant was related to depressive symptoms. However, Frank et al. (14) found no significant relationship between these assault variables and post-assault measures of depression, anxiety or fear. Cluss et al. (15) reported that greater threat was associated with higher self-esteem and Orlando & Koss (16) found that higher levels of force were associated with better sexual satisfaction after rape. 21
Bownes et al.
Atkeson et al. (3) found that the level of trauma in the rape situation did not predict continued depressive symptoms. However, different measures of victim outcome have been used in these studies and most them have sought a relationship between assault characteristics and single variables in the victims’ response patterns. It could be that the characteristics of the rape attack have differential effects on the various aspects of the victim’s emotional and behavioural response and on their interrelationships. Thus, a focus on single variables may make it difficult to obtain consistent associations between assault characteristics and victim trauma. The diagnostic criteria for PTSD are that the victim must have experienced an event outside the range of normal human experience and have symptoms lasting for longer than 1 month in each of the following categories : intrusive re-experiencing of the trauma; persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness ; and persistent autonomic signs of anxiety. Hence a diagnosis of PTSD encompasses a number of the individual variables that have been studied in the response to rape. The objective of this study was to determine the incidence of PTSD among a group of rape victims and to compare the groups with and without PTSD with respect to the characteristics of the assaults.
Material and methods
The population studied had all been referred to and examiced by a consultant psychiatrist (E.C.O’G.) for medico-legal assessment between January 1983 and December 1988. Each individual had been the victim of a rape (i.e., vaginal penetration without her consent) that had been reported to the police, and was seeking compensation under the Criminal Injuries (Northern Ireland) Order. Fifty-one referrals were studied. The interval between the incident and psychiatric examination varied. The mean time elapsed was 9 months and the range was 6 months - 3 years. The case notes for each referral were studied by the research team members. These included a full psychiatric history and examination of mental state, a detailed list of all symptoms reported since the assault, their time of onset and duration, any treatment received and, where appropriate, medical and surgical reports. Details of the rape were obtained from the victim and from police reports, forensic medical officers’ reports and statements. A comprehensive check-list including the characteristic symptoms of PTSD as defined in DSM-I11 was completed for each referral. The data collected were subjected to computer analysis and statistical tests. Fisher’s 28
exact probability test was used to compare the groups with and without PTSD. The mean age of the sample at the time of the rape was 21.8 years (range 16-47); 84% were single, 78% employed or students, 8 % had a family history of psychiatric illness in a first-degree relative, 12% received psychiatric treatment prior to the rape from their general practitioner only and 12% had previously consulted a psychiatrist. In the year preceding the rape, 39% had no experience of traumatic life events and 25:h had experienced 1,24% 2, 10% 3 and 2% 4. None of the sample had a previous history of sexual assault. Results
Of the 51 rape victims studied, 70% had PTSD as defined by DSM-I11 criteria. The frequency of the characteristic symptoms for the 2 groups is shown in Table 1. In every case the onset of the symptoms was less than 6 months after the trauma, and the duration of each symptom was longer than 1 month. Differences in the incidences of the symptoms between the 2 groups were statistically significant, except for the incidence of recurrent dreams and symptoms of emotional detachment and constricted affect. There was no significant statistical difference between the 2 groups with respect to age, marital status, employment status, number of recent life events, past history of psychiatric illness or family history of psychiatric illness. In addition, no significant statistical difference was found between the 2 groups regarding the type of psychiatric treatment received up to the time of the interview, time taken off work and decision to change job. More of the rapes in the PTSD group were carried out by strangers (72% vs 27%, P < 0.01). More of Table 1. Symptoms characteristic of PTSD
Recurrent intrusive recollections Recurrent dreams As if phenomenon Decline in interest Emotional detatchment Constricted affect Hyperalertness Insomnia Memory or concentration impairment Phobic avoidance Time elapsed since assault (months) Mean SD Range
Overall
PTSD
non-PTSD
(n=51)
(n=36
(n=15)
P
47 (92%) 45 (88%) 29 (57%) 47 (92%) 42 (82%) 47 (92%) 31 161%) 39 (76%)
36 (100%) 34 (94%) 27 (74%) 36 (100%) 32 (87%) 35 (97%) 27 (74%) 34 (94%)
11 (73%) 11 (73%) 2 (13%) 11 (73%) 10 (67%) 12 (80%) 4 (28%) 5 (33%)
0.005 NS 0.005 0.005 NS NS 0.005 0.001
33 165%) 33 (65%)
30 (83%) 31 (86%)
3 (20%) 2 (13%)
0.001 0.001
8.8 2.4 6-36
9.2 3.2 6-36
8.3 2.4 6-12
NS
PTSD after rape
the rapes in the non-PTSD group took place in an indoor setting (25 % vs 53 %, P = 0.05). The majority of attacks (61 %)were reported to have lasted longer than 30 min; the PTSD and non-PTSD groups did not differ in this respect. Verbal threats alone were used to gain victim compliance in only 14% of incidents among the PTSD group vs 47% of incidents among the non-PTSD group (P< 0.02). The majority of victims in both groups were subjected to some form of physical aggression, the most common form being physical restraint involving non-brutal violence, including holding, pushing, slapping and hair-pulling. Brutal aggression including punching, kicking or choking of the victim took place in 24% of rapes in the PTSD group vs 6% in the non-PTSD group (P = 0.06). None of the attacks in the nonPTSD group had involved a weapon vx 22% of rapes in the PTSD group ( P < 0.05). The majority (60%) of victims in the non-PTSD group escaped without significant injury vs 28% in the PTSD group (P < 0.05). Thirty percent of the PTSD group had severe injuries, including genital lacerations, black eyes, loss of teeth and severe bruising, vs 7% in the non-PTSD group (P = 0.06). Similar percentages of victims in both groups were subjected to additional acts of sexual abuse and forced to participate in reciprocation of sexual activity. The overall incidence of forcible fellatio was 22%, of anal intercourse 8 % and of repeated intercourse 24%. Discussion
The results of this study indicate that PTSD is a frequent sequela of rape. The mean time between the assault and interview was nearly 9 months so that, in every case, the victims were interviewed after initial symptom elevation would have been expected to subside. Previous studies have shown that psychological symptoms present after this interval show little resolution with time (6, 8). Thus the results would suggest that PTSD is likely to be a long-term problem for a significant proportion of rape victims. However, as in all studies of rape victims, sampling bias is inherent in these results. All the victims studied were litigants. Characteristics both of the assault and of the victim have been shown to influence reporting of rape, and contact with the criminal justice system has been shown to be related to victim outcome (2, 10, 15, 17). In particular, contact with the police and legal system has been associated with increased fear and anxiety (2, 17). Thus our findings may not be typical of all rape attacks in some respects. For example, the incidence of rapes by strangers, of victim injuries and of use of significant physical force may be proportionately higher since these aspects of the attack are associated with
increased reporting, and the high prevalence and duration of symptoms of fear and anxiety may be due, in part, to contact with the legal system. Moreover, the interval between attack and psychiatric examination may have led to problems of memory reconstruction (although corroborative evidence from police statements and medical officers’ reports was available, it did not always cover all the aspects of the assaults investigated). However, we believe that useful conclusions can be drawn on the basis of the differences between the 2 groups studied. Differences were found between the group of rape victims who had PTSD and the group who did not with respect to certain characteristics of the assault. The incidences of rapes by strangers, of physical force being used, of weapons being present and of injuries sustained by the victim were all higher in the group of women found to have PTSD. This suggests that an association may exist between these assault characteristics and the generation of PTSD, although clearly there is a need for more research, including longitudinal studies, to clarify these findings. Elucidation of the relationship between assault characteristics and long-term psychological trauma in the victim would be of immense practical value as it would enable rapid identification of at-risk victims. Thus appropriate therapeutic action could be taken early and this could be of importance for the prognosis in a significant proportion of rape victims. Traditionally, the psychological sequelae encountered in rape victims have been perceived as a response to a life-threatening experience (18, 19). This study supports the view that the aetiology of the psychological trauma of rape is more complicated. Rape differs from many other events associated with PTSD in that a human being acting intentionally is the source of the trauma (21). The psychological characteristics of rapists have been shown to be related to the nature of the assaults they instigate, including such characteristics as degree of acquaintance with the victim, the level of aggression displayed and the extent to which the intention of the assault is to inflict physical injury on the victim (22-24). During the rape attack, rapist and victim are involved in a psychodynamically complex interaction. The psychological characteristics of the rapist play a major part in determining the nature of this interaction, including his interpretation of and reaction to the victim’s behaviour during the attack. For some rapists, the need to humiliate and injure through aggression is the prime motive for the attack and physical abuse of the victim may continue after she has shown her willingness to comply with his demands. In other rapists the need to achieve sexual dominance is the most important aspect of the attack, and aggression diminishes in response to compliance on the part of the victim. In some rapists 29
Bownes et al.
the need for total control over the victim is so strong that even slight or involuntary sounds or movements on her part may provoke an explosive escalation of violence. In other rapists, passive or unresponsive behaviour on the part of the victim may increase rage and aggression. A rapist may seek to involve the victim in his distorted perception of the situation by demanding that she respond to him in an erotic manner or may accuse her of inviting or even enjoying the attack. The psychological trauma of the interaction may be intensified for the victim by the display of inappropriate, unexpected or deviant reactions on the part of the rapist to her behaviour during the attack. This may make her rationalization and assimilation of the experience more difficult, and psychological symptoms may be generated in a more intense and ultimately more prolonged form. Thus, the psychological characteristics of the rapist may considerably impact both the psychodynamics of the assault and victim trauma. We believe that the importance of such characteristics of the assault as the presence of a weapon and the relationship of assailant to victim in the generation of the psychological sequelae of rape may lie in their reflection of the psychological characteristics of the rapist. Victims of rape are routinely acknowledged to need issue-oriented, supportive crisis counselling. More specialized treatment is often only deemed necessary where the victim has important underlying psychopathology such as a past or current history of psychiatric difficulties or has evinced other problems in addition to those seen as part of the rape trauma syndrome (27, 28). The results of this study support the view that treatment approaches to rape victims should take into account the posttraumatic nature of the response to rape. Furthermore, we feel that the results also indicate that the characteristics of the rape attack are relevant to long-term victim trauma. References 1. NOTMANMT, NADELSON CC. The rape victim: psychodynamic considerations. Am J Psychiatry 1976: 133: 408-413. 2. KILPATRICK DG, VERONENLJ, RESICKPA. The aftermath of rape: recent empirical findings. Am J Orthopsychiatry 1979: 49: 658-659. 3. ATKESONBM, CALHOUNKS, RESICKPA, ELLIS EM. Victims of rape: repeated assessment of depressive symptoms. J Consult Clin Psychol 1982: 50: 96-102. 4. RESICKPA, CALHOUNKS, ATKESONBM, ELLISEM. Social adjustment in victims of sexual assault. J Consult Clin Psycho1 1981: 49: 705-712. AM. The aftermath 5. MCCAHILLTW, MEYERLC, FISHMAN of rape. Lexington, MA: Heath and Company, 1979. DG, VERONEN LJ, BEST CL. Factors pre6. KILPATRICK dicting psychological distress among rape victims. In:
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FIGLEYCR, ed. Trauma and its wake. New York: Brunner/Mazel, 1984. DG. Stress management for rape 7. VERONENLJ, KILPATRICK victims. In: MEICHENBAUM D, JAREMKO ME, ed. Stress reduction and prevention. New York: Plenum Press, 1983. 8. NADELSON CC, NOTMANMT, ZACKSONH, GORNICK J. A follow-up study of rape victims. Am J Psychiatry 1982: 139: 1266-1270. KS, ATKESONBM, RESICKPA. A longitudinal 9. CALHOUN examination of fear reactions in victims of rape. J Psychol 1982: 29: 655-661. 10. COHENLJ, ROTH S. The psychological aftermath of rape: long-term effects and individual differences in recovery. J Soc Clin Psychol 1987: 5 : 525-534. 11. MILLERWR, WILLIAMS M, BERNSTEIN MH. The effects of rape on marital and sexual adjustment. Am J Family Ther 1982: 10: 51-58. 12. ELLISEM, ATKESON BM, CALHOUN KS. An assessment of long-term reaction to rape. J Abnorm Psychol 1981: 90: 263-266. 13. BECKERJV. SKINNERLJ. ABEL GG et al. DeDressive symptoms as’sociated with sexual assault. J Sex M a r h Ther 1984: 10: 185-191. 14 F R A N KE, T U R N E R SM, STEWART B. Initial response to rape: the impact of factors within the rape situation. J Behav Assess 1980: 2: 39-53. J, FRANK LE, STEWART BD, WEST 15 CLUSSPA, BROUGHTON D. The rape victims: psychological correlates of participation in the legal process. Criminal Justice Behav 1983: 10: 342-357. 16. ORLANDO JA, Koss MP. The effect of sexual victimization on sexual satisfaction: a study of the negative-association hypothesis. J Abnorm Psychol 1983: 92: 104-106. 17. KILPATRICK DG, VERONENLJ, RESICKPA. Assessment of the aftermath of rape: changing patterns of fear. J Behav Assess 1979: 1: 133-148. S , SCHERLDS. Patterns of response among 18. SUTHERLAND victims of rape. Am J Orthopsychiatry 1970: 40: 503-511. 19. BURGESS AW, HOLSTROM LL. Rape trauma syndrome. Am J Psychiatry 1974: 131: 981-986. 20. Fox S S , SCHERLDJ. Crisis intervention with victims of rape. Soc Work 1972: 17: 37-42. HI, SADOCK BJ. Post-traumatic stress disorder. In: 21. KAPLAN Clinical psychiatry. Baltimore: Williams & Wilkins, 1988. LL. Rape, power 22. GROTHAN, BURGESSAW, HOLSTROM anger and sexuality. Am J Psychiatry 1980: 137: 806-810. RA, COHENML, SEGHORN TK. Development of 23. PRENTKY a rational taxonomy for the classification of rapists: the Massachusetts Treatment Centre System. Bull Am Acad Psychiatry Law 1985: 13: 39-70. 24. SEGHORNT, COHEN M. The psychology of the rape assailant. In: CERRANW, MCGARRYAL, PETTYC, ed. Modern legal medicine, psychiatry and forensic science. Philadelphia: FA Davis, 1980. AN, BURGESS AW. Rape: a sexual deviation. Am J 25. GROTH Orthopsychiatry 1977: 47: 401-406. RA, BURGESS AW, CARTER DL. Victim responses 26. PRENTKY by rapist type: an empirical and clinical analysis. J Interpers Violence 1986: 1: 73-98. 27. BURGESSAW, HOLSTROMLL. Recovery from rape and prior life stress. Res Nursing Health 1978: 1: 165-174. 28. FRANK E, TURNERSM, STEWART BD, JACOBM, WESTD. Past psychiatric symptoms and the response of sexual assault. Compr Psychiatry 1981: 22: 479-487.
