Chapter 40- Rape and Sexual Assault

Thayel Notes

References to rape appear in literature from each era of civilization. It was not until the early 1970's that researchers attempted to describe the victim and rapist in terms that could lead to intervention.

Rape- crime involving lack of consent, force or threat of force, and sexual penetration.

Sexual Assault- forcible sexual acts performed without the victim's consent.

The use of force is important in identifying rape or sexual assault.

These are crimes of violence in which sex becomes the means of expressing violence. (Just as guns are the means of expressing the violence of murder).

Rape Trauma Syndrome- the life-threatening nature of the crime, helplessness, loss of control, and experiencing of self as an object of rage. This is an example of Post-Traumatic Syndrome.

This classification can be made when the following four conditions are met:

1. Existence of stressors.

2. Reexperience of the trauma.

3. Reduced involvement with the external world.

4. Two additional symptoms such as sleep disturbances and memory impairments.

Regaining internal equilibrium and the ability to reorganize life into a meaningful and productive whole becomes the goal of intervention.

Blitz Rape- Victim does not know the rapist and is not aware of her vulnerability.

Confidence Rape- Some interaction between the assailant and victim before the rape occurs.

Assessory-to-sex- sexual acts with a person who is unable to consent to sex. Example: a mentally retarded woman who is seduced by the promise of material goods in exchange for sexual activity.

Stress-related situation- events arising after initial consent to sex is given. Example: a woman may agree to a sexual experience with a man who later becomes violent and physically abusive.

Date Rape- similar to the stress-sex situation in that consent to be with the man has been given, but consent to sexual activity has not.

In each of these situations, sexual acts are rapists' means for acting out their distorted perceptions.

Myths and stereotypical views of rape define how a victim sees herself in relation to society, how society views the victim and the rapist, and the difficulty or ease with which a victim receives support from society.

Example: a prevalent myth is that rape is motivated by sexual desire and that the woman who is raped must have "asked for it".

Rape is not motivated by sexual desire but the desire to do violence. Blaming the victim only adds to the violent assault on her self-integrity.

If the victim is a person who society believes would not "ask for it", such as a child or an elderly woman, the rapist is viewed as very sick.

A young woman who is raped but not beaten is frequently viewed with little sympathy.

Rape continues to be one of the most frequently underreported crimes.

The multidimensional nature of societal attitudes toward rape has been demonstrated by two studies in which victim blames, offender characteristics, situational characteristics, and societal blame emerged as factors in the development of these attitudes.

Women tend to place greater blame on society for rape and sexual assault.

It is a sexual deviation wherein the offender's pathology becomes the etiology of the victims' trauma.

Rapists perform sexual acts in the service of nonsexual needs.

Power Rapist- wants to place a woman in a helpless, controlled situation where she cannot resist or refuse him. This situation provides the rapist with a reassuring sense of strength, mastery, security, and control, all of which compensate for his underlying feelings of inadequacy.

Anger Rapist- uses sexual assault to express and discharge feelings of intense anger, frustration, and contempt. The sexual assault is an impulsive act of aggression to retaliate against a world for perceived wrongs.

Sadistic Rapist- finds pleasure in premeditated and ritualistic acts of violence, usually involving bondage and torture.

Date Rapist- known to the victim, who has given consent to be with him, but not to sexual activity. Frequently is not reported.

Treatment has gained support, because criminal prosecution does not completely prevent the offender from posing a continued threat to society.

Four basic approaches have been used: Behavioral techniques, social skills training, psychodynamic techniques, and organic approaches.

Four components are:

1. Reduction in deviant arousal using aversive conditioning techniques.

2. Sex education, assertiveness training, and competency training.

3. Confrontation that causes offenders to empathize with victims, to label deviant behavior as inappropriate, and to apologize to victims.

4. An appropriate adult sexual outlet.

Anger rape is the most frequent type of rape; however, power rapist make up a larger population of incarcerated offenders.

Rape Crisis- internal and external disequilibrium experienced by the victim of rape or sexual assault.

The process of adaptation known as rape trauma syndrome involves becoming free from fear, redefining feelings of vulnerability and helplessness, and regaining control and equilibrium in life. Clustering of symptoms in response to the trauma of rape occurs during an acute phase.

Disorganization phase- includes the rape victim's immediate expressed or controlled reactions, her physical reactions, and her emotional reactions to a life-threatening situation. Prominent feelings are fright, anxiety, anger, and disbelief.

Second guessing often occurs and can be a source of guilt and in some instances can lead to severe depression.

Self-blame identifies changes she can make in the environment to increase feelings of control and mastery.

Controlled Reaction- rape victim appears outwardly calm and composed but has no less internal suffering and fear, just a different way of handing herself in the acute phase.

Physical reactions during the acute phase vary according to the injury incurred.

Emotional reactions to rape and sexual assault are primarily fear, anger, humiliation, and self-blame.

The length of the acute phase may vary from a few days to a few weeks.

Reorganization- adjustment and adaptation during the months following the rape or sexual assault.

Sexually assaulted women have definite long-term psychological problems, increased depression, substance abuse, anxiety disorders, and suicide in sexual assault victims.

The period of reorganization involves regaining equilibrium. This period of reorganization closely resembles the grief process.

Issues important to the rape victim during the reorganization process include the following:

1. Regaining a feeling of physical well being and safety.

2. Working through fears and phobias.

3. Coming to terms with losses, such as loss of self-esteem and loss of trust.

4. Assimilating the event into the person's sense of self.

Women who at the time of the attack face chronic life stressors, lack social support, suffer poor self esteem, or have been victims before are more likely to experience unresolved sexual trauma.

Another risk factor depends on where the woman is in her life cycle.

The nurse may suspect unresolved sexual trauma when the following conditions are present:

1. Persistent phobic symptoms.

2. Retreat from sexual themes and lowered self-esteem.

3. Minor event triggers the symptoms of the trauma.

4. Anniversary date of the sexual assault brings on symptoms.

5. Totally avoids contact with members of the opposite sex.

6. Relationships with family and friends shift in negative ways.

A community intervention program can help the victim recover from rape traumas. This program brings together medical, legal, police, and judicial systems toward the common goal of helping her resolve the crisis.

Aims of community intervention include the following:

1. Police are knowledgeable and concerned about the crime.

2. Medical treatment is administered with care, and good evidence is collected.

3. The DA's office works closely with the police, medical and forensic department to ensure apprehension and conviction.

4. The public is educated and assured of the effectiveness of responses from the various systems.

When these aims have been met, victims are more willing to report the assault and more likely to work through the events surrounding the attack successfully.

Assessing a victim of rape or sexual assault begins t the initial encounter.

Assessing the victim's physical status is necessary to determine the extent of external and internal injuries and to begin planning appropriate medical interventions.

Appearance and the condition of her body must not be altered.

Physical evidence is essential to the apprehension and prosecution of the assailant.

When assessing the victim's emotional state, the nurse first attends to her primary concerns.

Emotional assessment also includes determining the victim's perception of the event, her coping behaviors, and her situational and social supports.

Of particular importance in assessment is the role of self-blame, especially the distinction between maladaptive and adaptive uses of self-blame.

Behavioral self-blame- adaptive, control oriented responses. The victim can believe that she can avoid similar experiences in the future and thereby have a sense of regaining control and decreased helplessness.

Characterological self-blame- maladaptive and associated with depression and helplessness.

Behavioral self-blame can serve 3 needs: perceived control over one's life, to preserve belief in a just world, and to find meaning for negative life experiences. When self-blame is helpful to the victim, it may be inaccurately viewed by others.

Awareness that expression of negative affect and behavioral self-blame may be helpful can assist the nurse in carrying out the nursing process.

1. Physical needs:

Risk for infection

Risk for trauma

Altered nutrition: less than body requirements

Pain, acute

Sleep pattern disturbance

Sexual dysfunction

2. Emotional needs:

Anxiety

Rape-trauma syndrome

Spiritual distress

Impaired social interaction

Powerlessness

Fear

Body image disturbance

Ineffective individual coping

Ineffective family coping

Altered family process

Altered growth and development

Impaired verbal communication

Knowledge deficit

Planning during the first hours after an assault should include the following:

1. Medical attention to the victim.

2. Notification of significant people in the victim’s life.

3. Plans for the victim to leave the medical facility.

4. Plans for the victim's immediate safety.

5. Plans for follow-up contact with a crisis counselor during the interim period.

During the interim period, the first few days after an assault, plans must be made to recontact the victim, refer her to a victim support center, or continue supportive counseling. Long-term plans should include providing support at certain times of stress, such as police investigations, court proceedings, and the anniversary of the attack.

The primary goal of nursing intervention is establishing a therapeutic alliance with the victim.

It is not unusual for the woman to feel dirty, guilty or in other ways unacceptable.

Because the victim may misinterpret any questions or comments not directly related to her immediate situation as blaming or rejecting, the nurse should delay probing questions until the therapeutic alliance is established.

After establishing rapport with the victim, the nurse should begin to prepare her for the events she will encounter in the emergency room and during interactions with hospital, police and other personnel.

This information provides the victim with a needed sense of control and boundaries.

In this immediate rape crisis, the nurse determines the victim's emotional needs.

Once physical needs have been addressed, the victim can use the therapeutic relationship to begin her necessary ventilation about the assault. She should be encouraged to talk about the event and about her feelings. This helps the woman regain a sense of control.

During the immediate contact with the victim, the nurse explores the woman's concerns for her own physical safety.

The rape victim likely will express concern for her family and friends. Helping family and friends explore their feelings, particularly feelings of anger, can free them from the intensity of these feelings and enable them to be more sensitive to and supportive of the victim. Significant others may engage in a "conspiracy of silence". This silent approach only intensifies the victim's feelings of guilt, shame, and unworthiness of love.

Refer the victim to a counseling center or decide to continue working with her through the telephone. Note several phone numbers where the woman may be reached. She may choose to stay with family or friends. Never call at work unless arranged in advance.

The victim should be instructed about the medical follow-up she will need during the interim phase.

She always should receive written instructions for medication and doctors' appointments, reinforced with verbal instructions.

The victim should feel she can recontact the nurse in the days following the assault to ask questions, talk, and share feelings.

During reorganization, the nurse intervenes by counseling on the telephone or through face-to-face contact or by monitoring the woman's coping and adaptive behaviors. Anticipatory guidance is extremely helpful during the weeks and months following the attack.

Often, apprehension and court proceedings occur after the woman has begun reorganizing her life. She may have moved past the acute phase of rape trauma syndrome and may have begun to adapt and live her life once again.

Nurses must face their own fears about rape, their anger, and their feelings of helplessness. Understanding and acknowledging these feelings allows nurses to attend to the feelings of victims.

Few women are prepared for rape or sexual assault. Each woman brings to the experience a unique array of personal coping skills, personality characteristics, history with stress, and social networks. The nurse must evaluate each encounter with the victim to monitor the progress of coping and the effectiveness of intervention.

Individual therapy with a clinical nurse specialist, psychologist, psychiatrist, or social worker may be the referral of choice.

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