Table 5.8 Summary of reported physical health conditions for victims of sexual assault
Symptom
Gastrointestinal symptoms (including nausea, stomach-ache, colitis, indigestion, lack of appetite)
Pain (including pelvic, back, joint, muscle ache, headache)
Cardiopulmonary symptoms (palpitations, shortness of breath)
Neurologic symptoms (fainting, dizziness, blurred vision)
Sexual/reproductive symptoms (pre-menstrual symptoms, menstrual irregularities, pain during intercourse)
(Adapted with permission from Chandler, Ciccone, & Raphael, 2006; Clum, Nishith, & Resick, 2001; Golding, 1994)
5.3.2.2 Impact on mental health
As with other forms of interpersonal violence, rape has been associated with PTSD, depression, sleep disturbances, anxiety and fear, substance misuse and social adjustment problems (Clum et al., 2001; Tjaden & Thoennes, 2000). As with IPV victims, co-morbidity is a frequent occurrence (Kilpatrick & Acierno, 2003). Rape victims may also be more prone to suffering from PTSD than other victims of traumatic events (Kilpatrick, Amstadter, Resnick, & Ruggiero, 2007). The prevalence of PTSD amongst rape victims can vary from sample to sample although approximately one third of all rape victims demonstrate post-traumatic symptomology. Kilpatrick and Acierno found that 32% of their sample had lifetime PTSD and 12.4% had a current (past six months) diagnosis of PTSD.
Certain victim-related factors have also been demonstrated to increase the likelihood that rape victims will develop PTSD post-assault, such as suffering from a prior history of depression and prior alcohol misuse (Acierno, Resnick, Kilpatrick, Saunders, & Best, 1999). In addition, self-blame and maladaptive beliefs have also been linked with poorer health outcomes, in particular, characterological blame (blame attributed to the character of the victim) (Sigurvinsdottir & Ullman, 2015). Similarly, negative social reactions from others have been strongly related to greater PTSD severity. In particular, receiving negative or stigmatising responses have been most strongly related to PTSD severity (Ullman & Peter-Hagene, 2014). However, some factors can function to be protective against PTSD severity, with the education level of the victim, older age of the victim, and disclosing the assault in more detail associated with less PTSD severity (Ullman & Filipas, 2001a).
5.3.2.3 Acknowledged and unacknowledged rape victims
There is considerable controversy in examining whether victims who do not label their victimisation as rape can be/or are as traumatised by this experience as victims who do label their experience as rape (Conoscenti & McNally, 2006). Estimates suggest that of women who have been victims of rape, 42–73% do not label their victimisation as rape (Littleton, Rhatigan, & Axsom, 2007). Conoscenti and McNally (2006) found that acknowledged and unacknowledged rape victims did not differ in their levels of PTSD but acknowledged rape victims did report more intense health complaints than unacknowledged victims. Similarly, Cleere and Lynn (2013) found no differences in reported psychological distress between acknowledged and unacknowledged rape victims. However, Littleton and Henderson (2009) found that acknowledged rape victims reported more PTSD symptomology than unacknowledged victims, but that acknowledgement of the assault did not predict PTSD symptomology. Similarly, using path analysis, Harned (2004) showed that the distress that victims suffer stems from the assault itself, rather than the labelling of the experience. These findings tentatively suggest that acknowledgement status may not predict the impact of victimisation but the research in this area is still developing.
5.3.2.4 Characteristics of the assault
Most assault characteristics have not been found to be related to PTSD symptomology (e.g. victim-offender relationship); however, the victim’s perceived life threat and level of physical violence during the assault have been associated with more severe post-traumatic symptoms (Brown, Testa, & Messman-Moore, 2009; Ullman, Filipas, Townsend, & Starzynski, 2007). Increased levels of PTSD symptomology have also been found in multiply victimised women compared to single incident victims (Wilson, Calhoun, & Bernat, 1999). More recent research has focussed upon potential differences between forcible rape (where force, injury or threat of either is involved), incapacitated rape (involves voluntary intoxication of drugs/alcohol by the victim) and drug-assisted rape (involves deliberate intoxication of the victim using drugs/alcohol by the perpetrator) (Zinzow, Resnick, McCauley et al., 2010). These findings have demonstrated that victims of forcible rape have the highest risk for PTSD and major depressive episode when compared with non-victims. Furthermore, when compared with incapacitated rape and drug-assisted rape, forcible rape victims were at a higher risk of PTSD than incapacitated rape victims, and secondly were at a higher risk of a major depressive episode than both incapacitated rape and drug-assisted rape victims (Zinzow, Resnick, McCauley et al., 2010; Zinzow, Resnick, Amstadter et al., 2010). Similarly, Peter-Hagene and Ullman (2015) used cluster analysis based on assault characteristics to develop three types of rape characterised as (1) highest violence, (2) alcohol-related and (3) moderate-severity assaults. When comparing PTSD symptomology between these three groups, the victims in the highest violence group reported the highest level of PTSD severity when they were assessed at the beginning of the study. However, the difference between this group and the alcohol-related group did diminish when they were assessed a year later. Furthermore, the highest violence group and alcohol-related assaults reported the highest levels of PTSD symptoms when compared with the moderate-severity assault victims. Such findings suggest that the type of assault that a victim suffers will affect their mental health outcomes and, as such, this needs to be acknowledged by practitioners who may assess and treat such victims.
PHOTO 5.3 As with other forms of interpersonal violence, rape has been associated with PTSD, depression, sleep disturbances, anxiety and fear, substance misuse, and social adjustment problems.
Source: © Darrin Henry/Getty Images
5.3.2.5 Male victims of rape
Men are more often viewed as the perpetrator of sexual crime than the victim (Mezey & King, 2000). However, a change in rape legislation in 1994 in England and Wales broadened the definition of a rape to encompass men as victims of rape. The Sexual Offences Act 2003 therefore defines rape as a crime that both men and women can be a victim of but that only men can perpetrate (as penetration is defined as penetration by a penis). Du Mont, Macdonald, White, & Turner (2013) found that a third of their sample of male rape victims sustained physical injuries, whereas, Weiss (2010) found that 9% of male rape victims reported sustaining physical injury from the assault.
Psychological effects of victimisation are similar to those of female victims with reports of depression, PTSD, mood disturbances and suicide attempts (Coxell & King, 2010). Male victims also report issues with sexuality and masculinity such that victims felt a perceived loss of masculinity in being subjected to the rape (Walker, Archer, & Davies, 2005). Davies & Rutland (2007) suggest that many male rape victims are distrustful of seeking help because of the reactions that they may encounter, foreseeing homophobic attitudes (even when the victim is not homosexual) and stereotypical views of the masculine gender role. The perception of men and their physical strength often means that a male rape victim may choose not to disclose their assault to anyone, increasing their sense of isolation (Willis, 2009).
5.3.2.6 Recovery and involvement in the criminal justice system
Victims of rape do recover from the negative effects of the rape. However, rates of recovery from victimisation may be slower for sexual assault victims compared to nonsexual assault victims (Gilboa-Schechtman & Foa, 2004). There may also be differences in the processes of seeking help for the effects of victimisation. Amstadter et al. (2010) found that help-seeking amongst rape victims was associated with PTSD symptoms, but not depression or substance misuse. Interventions have been shown to be effective in treating much of the symptomology associated with rape victimisation, such as depression and PTSD. Vickerman and Margolin (2009) suggest that cognitive behavioural progra
mmes have demonstrated effectiveness in improving symptomology along with some support for cognitive processing therapy, prolonged exposure therapy, and stress inoculation training.
Rape victims may frequently choose to not disclose their victimisation to anyone else or may delay their reporting until a certain period of time after the attack. Disclosure patterns have been found to differentiate between victims of rape in terms of mental and physical health outcomes. Ahrens, Stansell, & Jennings (2010) found four distinct disclosure patterns: (1) victims who never told anyone about the attack (non-disclosure); (2) victims who delayed the disclosure of the attack (labelled slow starters); (3) victims who immediately disclosed but stopped disclosing following this point (labelled crisis disclosures); and (4) victims who continued to engage in disclosing (labelled ongoing disclosers). This study found that victims who did not disclose their attack reported higher levels of depression and post-traumatic stress when compared with other disclosure groups; however, no differences were found in relation to physical health.
Reporting a rape to the police can be a challenging experience for rape victims and is a step that many do not choose to complete (HMCPSI/HMIC, 2007). Known as “secondary victimisation” (Campbell et al., 1999), a significant number of rape victims have reported the police to be an unhelpful source of support (Ullman & Filipas, 2001b). Kaukinen & DeMaris (2009) found that police reporting seemed to exacerbate the impact of sexual assault, increasing the levels of depression reported. Other studies have linked increased PTSD symptomology with negative social reactions, which may be received from formal help sources such as the police (e.g. Filipas & Ullman, 2001). However, these relationships must be interpreted cautiously because certain types of rape are more likely to be reported to the police (Du Mont, Miller, & Myhr, 2003). It may be that these types of rapes are associated with more significant long-term effects (Kaukinen & DeMaris, 2009).
Campbell, Wasco, Ahrens, Sefl, & Barnes (2001) found that contact with the legal system was considered hurtful by half of the victims in their sample; however, a third did consider this contact to be healing. Victims whose cases were not prosecuted were more likely to consider this contact with the legal system to be hurtful.
5.4 SUMMARY
Both male and female victims of childhood maltreatment and adulthood IPV and rape have been shown to suffer significant physical and psychological effects as result of their victimisation. These effects may manifest themselves differently in male and female victims. This may be particular true in IPV, where males have been shown to exhibit a narrower range of effects from victimisation compared to females who may suffer from externalising and/or internalising disorders.
Recovery from these effects is possible with engagement in effective interventions, including treatments that combine both cognitive and behavioural approaches, for example, cognitive processing therapy for adult victims diagnosed with PTSD.
It is important to acknowledge that many individuals do not show these negative long-term consequences, but research methodology has meant that the focus until recently was on more negative outcomes.
There has been a growing interest in children and adults who show “resilience”, coming from the recognition that many individuals lead successful lives following maltreating experiences.
It is important to investigate the pathways by which different outcomes occur in order to establish interventions and prevention programmes to reduce suffering and the impact on individuals in childhood and adulthood, as well as on their families, the community and society.
ESSAY/DISCUSSION QUESTIONS
Critically evaluate the evidence that children who have been abused or neglected are at increased risk of negative long-term outcomes in both childhood and adulthood.
Discuss the methodological difficulties associated with the measurement of child abuse and neglect, both in terms of rates of occurrence and outcomes.
Discuss the impact of IPV victimisation, focussing upon physical and mental health effects.
Critically evaluate the factors that affect reported levels of mental health issues in rape victims.
ANNOTATED READING LIST
Li, F. & Godinet, M. T. (2014). The impact of repeated maltreatment on behavioural trajectories from early childhood to early adolescence. Children and Youth Services Review, 36, 22–29. This paper reports on a large cohort study and demonstrates that those children who experience repeated abuse and neglect begin to show more behavioural difficulties with each subsequent victimisation and as time passes.
Dixon, L., Hamilton-Giachritsis, C. E., & Browne, K. D. (2009). Patterns of risk and protective factors in the intergenerational cycle of maltreatment. Journal of Family Violence, 24, 111–122. This journal article presents empirical data on parents who continue the intergenerational cycle of maltreatment compared to those who break the cycle or begin to maltreat their own children in the absence of a history of abuse.
Mersky, J. P., & Topitzes, J. (2010). Comparing adult outcomes of maltreated and non-maltreated children: A prospective longitudinal investigation. Children and Youth Services Review, 32, 1086–1096. This paper reports a prospective study on long-term outcomes for maltreated children, including associations with negative outcomes but also reviews factors predictive of resilience.
Ellsberg, M., Jansen, H., Heise, L., Watts, C. H., & Garcia-Moreno, C. (2008). Intimate partner violence and women’s physical and mental health in the WHO multi-country study on women’s health and domestic violence: An observational study. The Lancet, 371, 1165–1172. This paper is a large study, sampling from 10 countries, examining the impact of IPV victimisation on both physical and mental health.
Randle, A. A., & Graham, C. A. (2011). A review of the evidence on the effects of intimate partner violence on men. Psychology of Men & Masculinity, 12, 97–111. This is a good review of the often neglected topic of the impact of intimate partner violence on men. The paper is also useful in identifying where this research needs to be developed in the future.
Amstadter, A. B., Zinzow, H. M., McCauley, J. L., Strachan, M., Ruggiero, K. J., Resnick, H. S., & Kilpatrick, D. G. (2010). Prevalence and correlates of service utilisation and help-seeking in a national college sample of female rape victims. Journal of Anxiety Disorders, 24, 900–902. This paper examines the help-seeking of victims of rape, identifying the sources of help that were accessed as well as examining how this related to mental health.
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Abramsky, T., Watts, C. H., Garcia-Moreno, C., Devries, K., Kiss, L., Ellsberg, M., Jansen, H. A. F. M., & Heise, L. (2011). What factors are associated with recent intimate partner violence? Findings from the WHO multi-country study on women’s health and domestic violence. BMC Public Health, 11, 109.
Acierno, R., Resnick, H., Kilpatrick, D. G., Saunders, B., & Best, C. L. (1999). Risk factors for rape, physical assault and posttraumatic stress disorder in women: Examination of differential multivariate relationships. Journal of Anxiety Disorders, 13, 541–563.
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