When Granny is the Wolf: Understanding and Approaching College-aged Female Victims of Acquaintance Rape

| August 26, 2009 | 0 Comments

by Charlene Lam and Brenda Roman, MD

Ms. Lam is a fifth-year MD/MPH student and Dr. Roman is Professor and Director of Medical Student Education of Psychiatry at Boonshoft School of Medicine, Wright State University, Dayton, Ohio.

Psychiatry (Edgemont) 2009;6(8):18–26

Editor’s Note: All cases presented in the series “Psychotherapy Rounds” are composites constructed to illustrate teaching and learning points and are not meant to represent actual persons in treatment.

ABSTRACT

College is generally felt to be an exciting time in the lives of young people; however, some college-aged students find themselves in difficult situations. For young women especially, acquaintance rape in the college years is a risk. While men can also be victims of sexual assault, it is far more common for women to be victimized. This article reviews the literature of acquaintance rape, including situational risk factors, perpetrator characteristics, and victim characteristics, as well as strategies to prevent revictimization, utilizing a female victim as the composite case.

Key Words

rape, acquaintance rape, mental health consequences of rape, college mental health, treatment of acquaintance rape

INTRODUCTION

Within the past few decades, the issues surrounding rape have been elucidated, and rape is clearly identified as a major societal menace. However, myths about rape are still entrenched in our society and continue to be perpetuated through media and traditional gender roles.

Rape is defined as sexual behaviors involving some type of penetration due to force or the threat of force; a lack of consent; or inability to give consent due to age, intoxication, or mental status.[1] Rape can be divided into two major categories: “stranger” and “acquaintance.” Stranger rape occurs between two individuals who did not know each other before the incident. Acquaintance rape occurs between two individuals who knew each other in some capacity before the incident. Date rape, a subset of acquaintance rape, is defined as rape that occurs between two individuals who are romantically involved.[2] One of the most prominent and often detrimental misunderstandings about rape is that it occurs in dark alleys by psychopathic strangers. In reality, most rape is committed in homes by men women know and trust, also known as acquaintance rape.

While rape can occur at all ages, adolescents and young adult women are four times more likely to be victims of this violent crime than any other age group.[2] Young adult women in college are especially vulnerable to acquaintance rape. The landmark study of Koss, Gidycz, and Wisniewksi[3] revealed that approximately 54 percent of college women report some form of sexual assault.[3] Sexual assault is an inclusive term used to describe the full range of forced sexual acts, ranging from forced touching or kissing to verbally coerced intercourse to physically forced vaginal, oral, and anal penetration.[4]

More recent studies in 2000 by the National Institute of Justice and Bureau of Justice Statistics reported 1 in 5 women are raped while in college.[5] The beginning of the collegiate years is often a critical time, as freshmen women are notably susceptible to being sexually assaulted. Humphrey and White[6] observed that 34 percent of women in their first year of college experience sexual assault and 6.4 percent experience completed rape. By comparison, during their fourth year, 24 percent of women experience sexual assault and 3.9 percent experience completed rape.[6] Although it is estimated that approximately 700,000 women are sexually assaulted each year,[1] a minority of victims actually report the crime.[6] Koss[3] found that less than half of the victims tell anyone about the sexual assault, let alone the authorities.

The unique setting of college and the psychological development occurring during those years prove to be particularly conducive to rape. Adams-Curtis and Forbes explain the factors involved in acquaintance rape during college as, “The college experience juxtaposes the powerful motives of sex and aggression in a population that is still forming a stable identity within an environment that includes strong peer pressures for sexual activity, the ritualistic abuse of alcohol, a culture that objectifies women, and a culture that frequently views sexual intercourse as an act of masculine conquest.”[7]

In the following composite case, we examine the complex factors involved in the evaluation and treatment of female victims of acquaintance rape in a college setting. While men can also be victims of sexual assault, it is far more common for women to be victimized, and this paper focuses on the female victim. This paper highlights 1) the complex causes behind acquaintance rape, 2) the trauma and emotional impacts of acquaintance rape, 3) the short- and long-term health impacts of acquaintance rape, and 4) effective strategies for therapeutic sessions.

CASE PRESENTATION

(This is a composite case example and is not based on a real patient.) Lauren, a 19-year-old woman in her sophomore year of college, reluctantly arrived at her University’s psychiatry office. Her parents, who reside in a different part of the country, had called the student affairs office with concerns about their daughter’s appearance and behavior while home over summer break. Despite her parents’ voicing their concerns, she insisted that everything was all right. She explained that her lower academic grades had been the result of both more difficult classes in her spring semester and adjusting to college life. Within a month of returning to college for her sophomore year, she tearfully called home to inform her parents that she was having difficulty with her classes and reluctantly agreed to seek help.

Upon gathering collateral history from her parents, the psychiatrist learned that Lauren had been a high achiever throughout high school. She was on the Dean’s list fall semester of her freshman year in college and was planning to major in Art History. She also joined a sorority the spring of her freshman year. Overall, from what they had known, she was very happy, doing well, and was looking forward to her sophomore year. They were shocked to see her over summer break when they noticed she had gained 15 pounds and seemed very quiet. Instead of spending time with childhood friends from her hometown, Lauren opted for clerical work at the business where she had worked during high school. As the weeks went by, she did seem to be happier and more like her usual self, so her parents were more hopeful that when she returned to college she would get back to her college routine and do well. But after receiving the distressing phone call from Lauren, they were very concerned about her well being.

KEY/PRACTICE POINT: Recognize the Complex Causes of Acquaintance Rape

The causes of sexual assault are complex. Berkowitz[8] proposes an integrative model to explain the factors involved in sexual assault and acquaintance rape. In the integrative model, the perpetrator’s and victim’s socialization, beliefs, and attitudes toward sexuality, in addition to their personality characteristics, combined with situational risk factors and the perpetrator’s misperception of the victim’s consent, all lead to an increased likelihood of sexual assault.[8]

Victim characteristics. There are a limited number of studies that report any defining characteristics of sexual assault victims. It has been suggested that such negative findings are the result of a research artifact caused by fear of retraumatizing these women by interviewing them at length, or a desire to avoid the appearance of blaming the victim.[7] From the available research in which victim characteristics have been identified, certain variables have been found to increase a woman’s chance of sexual assault. These include 1) previous victimization (including childhood abuse), 2) previous responses to coercion, and 3) prior dating history.

A cycle of victimization. Several studies have shown a strong correlation between current victimization and previous victimization.[6,9–11] Young adults who have been raped or have experienced attempted rape before the age 18 are 2 to 4.4 times as likely to experience sexual assault either in their first year of college or sometime during college.[6,11] A history of childhood sexual abuse also has been associated with increased risk of victimization.[6,10][ College and noncollege women who have been previous victims of rape or attempted rape tend to increase their consumption of alcohol, increase their number of consensual sexual partners, and to develop a decreased ability to resist unwanted advances compared to their counterparts who have not been victims of rape or attempted rape.[12,13][ These characteristics are independent risk factors for another sexual assault and demonstrate how previous victimization may lead to a cycle of continued victimization due to increased alcohol consumption, more sexual partners, and difficulty resisting unwanted advances. The mechanism underlying the development of this behavior pattern is likely related to lowered self esteem secondary to the sexual trauma, which predisposes the woman to further victimization.

Responses to coercion. Victims may differ from nonvictims in their responses to coercion. Previous victims may have difficulty recognizing dangerous situations and also use ineffective forms of resistance.[9,14] This may explain why previously victimized women are at higher risk for subsequent victimization.[7] Victims have more difficulty identifying circumstances when acquaintance rapes are likely to occur during common activities at familiar places.

Alcohol consumption. The increased use of alcohol common among victims of sexual abuse can impair judgment and limit effective responses to dangerous situations.

Number of sexual partners. Another variable that may increase a woman’s risk is her dating and sexual behavior.[7,10,15] There is a positive linear relationship between the number of sexual partners a woman has had and her risk of sexual assault. This may, however, be related to chance, in that the more partners a woman has, the higher odds that she can be exposed a potential perpetrator.[10]

Perpetrator characteristics. One of the most difficult aspects of developing strategies to avoid acquaintance rape is recognizing that a potential perpetrator is difficult to identify in advance. Acquaintance rape can occur regardless of a perpetrator’s education, socioeconomic status, drug addiction history, mental health history, or nonsexual assault criminal record. Koss et al[3] found that approximately 25 percent of college-aged men have used coercion during sexual contact. Rape is often ambiguously defined in the mind of the perpetrator and not necessarily premeditated. Perpetrators are often not charged or convicted in ambiguous cases of acquaintance rape, especially when victims do not seek medical care and there are no witnesses.

Characteristics enhancing the possibility of a man committing sexual assault include socialization to traditional gender roles, belief in rape myths, personality variables, and involvement with all-male groups.

Traditional gender roles. Men are often socialized to believe in traditional gender roles, which encourage them to be aggressive, forceful, and dominant.[16,17] Berkowitz[8] observes that sexual identity is one of the most important tasks for young adult development, and that fulfilling sex role prescriptions is a vital task for college-aged men. While establishing their sexual identity, college-aged men may feel the need to be hyperaggressive or dominant in relationships as part of their psychological development, making them particularly at risk to act in a coercive, aggressive manner with female acquaintances. The belief in traditional gender roles contributes to the danger of sexual assault in college settings.

Rape myths. A rape myth is defined as any prejudiced, stereotyped, or false belief about rape, rape victims, and rapists.[18] Some examples of rape myths are “all women want to be raped” or “no means yes.” Acceptance of rape myths encourages and reinforces forceful male behavior. Several studies demonstrate that men who accept rape myths, condone violence toward women, and show hostility toward women are more likely to accept rape, blame rape victims, and affirm statements that say they would sexually assault women if no one found out.[16,17]

Personality characteristics. Certain personality characteristics and childhood experiences may also predispose men to sexual aggression. Rapaport and Burkhart19 found that immaturity, irresponsibility, the lack of social conscience, and values legitimizing aggression toward women are associated with sexual coercion in men. Other traits include hypermasculinity, need for power/dominance, impulsivity, and manipulativeness.[20] Another study showed that men with early initial sexual experiences, both forced and voluntary, were more likely to be sexually aggressive.[10] While in women, childhood abuse predisposes them to revictimization, in men, childhood abuse predisposes men to become perpetrators of sexual assault.

All-male groups. Participation in all-male groups, such as fraternities or athletic teams, can also encourage sexual assault. First, men may feel peer pressure to assert their masculinity. Within the group, sexual experiences are often touted to impress other members and gain acceptance. These pressures may result in sexual experiences a man later regrets.[8] Second, these all-male environments tend to reinforce rape-supportive attitudes, traditional gender roles, and encourage alcohol use to decrease women’s sexual reluctance.[8] In a college setting, where socialization with peers is an important part of life, the impact of peer pressure and consequent internalization of the group psyche is especially important.

Situational risk factors. Existing relationship. Studies show that 90 percent of college rapes are acquaintance rapes.[21,22] The most common situation for acquaintance rape, especially in college settings, is after social events and parties where alcohol is abundant. Situations predisposing victims to acquaintance rape include an existing relationship between the victim and perpetrator where there is a power differential with the man in more control. Muehlenhard and Linton[16] observed that most incidents of sexual assault occurred after the man and woman had known each other for at least a year.[16]

Especially in situations of acquaintance or date rape, there may have been previous positive feelings between the victim and perpetrator. Alcohol serves as a mediator, allowing the victim to misinterpret the intentions of the perpetrator. Although sexual coercion occasionally takes place with the use of a firearm, far more common at the university setting is the use of persuasion and persistence by the perpetrator. The situation becomes confusing to the impaired woman as she fears that an abrupt refusal may end her developing relationship with the potential perpetrator. The victim’s internal negotiation of her positive feelings versus a lack of readiness to engage in a physical relationship may provide enough time for the perpetrator to perceive inaction as affirmation to proceed.

These factors illustrate the problematic nature of acquaintance rape. These risk factors are often elements of daily college or workplace life and are difficult to avoid.[7] Additionally, in college, there are more opportunities for male and female acquaintances to be alone without chaperones than ever before in their lives.

Control over victim. Studies have found that rape occurs more often in situations where the perpetrator feels an increased control over the victim. Perpetrators justify the unwanted sexual contact with circumstantial factors. Muehlenhard et al[23] notes that perpetrators believe sexual assault is more acceptable in the perpertrator’s apartment, if he paid for the date, or if the woman asked the perpertrator out.[23]

Alcohol and date-rape drugs. While drugs such as flunitrazepam (Rohypnol), GHB (gamma hydroxybutyrate), ketamine, ecstasy (MDMA), and methamphetamine are all associated with acquaintance rape, alcohol is the most common substance. First, alcohol can decrease the victim’s ability to resist sexual advances by impairing the victim’s judgment and physical ability to resist. Abbey et al[24] describe a negative linear relationship between the amount of alcohol consumed and the level of ability to resist rape. Alcohol also distorts risk perception in victims. Situations that the victim might normally avoid when sober, such as returning to a dormitory room with a man, may seem acceptable when she is intoxicated, or it may be that she is unable to get home alone.

Secondly, several studies have noted that men’s perception of women and their sexuality changes after the use of alcohol by both the victim and perpetrator.[25] From the perpetrator’s perspective, if a woman consumes alcohol, she becomes more interested in sex, more sexually disinhibited, and exhibits greater sexual initiative.[4,7] These perspectives may encourage men to pressure their counterparts to drink. In a survey of both incarcerated rapists and college students, Muehlenhard and Linton16 found that if a woman is intoxicated, she is considered by both groups as more responsible for the rape.[16] This enhanced perception of self responsibility has long-lasting psychological implications for the victim.

From the victim’s perspective, the desire to simply be accepted can contribute to her drinking behavior. When this is combined with naiveté about the effects of alcohol on her body and her judgment, a young woman may unintentionally find herself in a precarious situation. Parks et al[26] demonstrate that women who are “new” drinkers in college (women who abstained in high school) were at greater risk for victimization.

Alcohol functions as a double-edged sword. It can justify the perpetrator’s actions while placing the blame on the intoxicated victim. Just as alcohol impairs the victim, alcohol consumption also impairs the perpetrator, but in different ways. It tends to lower inhibition and increase sexual misperception resulting in heightened sexual aggression.[16,25] The state of intoxication may be used as an excuse to reduce his own level of responsibility.[27] He may explain that his judgment was too impaired to notice subtle signs of rejection or his impairment resulted in misinterpretation of platonic conversation as sexual attraction.

Misperception of platonic interest. Male misperception of a woman’s platonic interest as sexual is often implicated as a risk factor for sexual coercion. In most situations of misperception, the outcome does not exceed a bruised ego and social embarrassment. However, Farris et al[25] has identified a subgroup of individuals in which sexual misperception may be a part of other individual and situational variables that lead to sexual coercion.[25] In a review of sexual coercion and misperception of sexual intent, the authors concluded that some men are likely to perceive a woman as displaying more sexual intent than the woman herself believes she is displaying.[25] If the man perceives the woman to be sexually interested, he is more comfortable using force to obtain sex. Using this misperception as an explanation, perpetrators shift the blame on the victim such as “she led me on.” Situational factors, such as provocative clothing styles, use of alcohol, and a woman’s attractiveness, all contribute to sexual misperception. Furthermore, a subgroup of men who are more aggressive in general tend to perceive more sexual interest than less aggressive men.[25]

CASE PRESENTATION (continued)

At the first meeting, Lauren was very quiet, only answering direct questions and avoiding eye contact. She initially denied any stressful event, but midway through the session, she broke down and started crying uncontrollably, stating, “It’s all my fault!”

Psychiatrist: What do you mean by “it is all my fault?”
Patient: I went to a party last spring and got really drunk. A boy in one of my classes said that I could sleep in his dorm room. I trusted him. He had always been so considerate to me during class, and we had talked during lunch on occasion, so I really felt it would be okay. I just didn’t feel good enough to make it back to my dorm room all the way across campus by myself, so I went with him. Shortly after we got to his room, he began kissing me. I told him no, and when he started unbuttoning my jeans, I tried to push his hands away. He was showering me with compliments and said it would all be okay, but I said no again. He wouldn’t stop. But he was so drunk that maybe he didn’t noticed that I said no. I should have pushed him away harder. I should have never gotten drunk. What was I thinking when I let him take me home? I was so stupid!
Psychiatrist: How have you done since that night?
Patient: All I think about is what he did to me. I can’t concentrate on anything without seeing his face pop into my mind. I don’t sleep very well, and if I do fall asleep, I wake up with nightmares. Sometimes I drink just to fall asleep.
Psychiatrist: And you have not told anyone about what happened to you?
Patient: No, I am afraid that other people are going to call me a slut, especially my boyfriend who goes to college several hours from here. I just don’t trust anyone anymore.
Psychiatrist: But you did nothing wrong. Why do you feel that it is your fault?
Patient: I got drunk, and then I used very poor judgment by going back to his dorm room. If my parents find out, they will be so mad. They told me over and over that I shouldn’t drink alcohol. They don’t drink at all. If I hadn’t started drinking when I joined the sorority, then none of this would have ever happened.

KEY POINT: Recognize the Trauma Experienced and Emotional Impact of Acquaintance Rape

Guilt and shame. In Lauren’s case, the level of what is traditionally considered extreme physical trauma or violent force was low. In fact, the perpetrator relied on the art of persuasion and purposeful oblivion to Lauren’s body language and her impairment. Perhaps he himself was too impaired to notice it. This results in a unique element of trauma to the victim: self blame.
Generally, acquaintance rape victims are more likely to be held responsible for the rape than stranger rape victims.[28] Victims who are not physically harmed are doubted by both themselves and by bystanders about the authenticity of the rape. The more physical force or trauma that is involved, the less the victim is held responsible or blamed.[29] On the other hand, when the victim appears unscathed or does not report the crime until months after the incident, the victim’s credibility is questioned.[4] Additionally, victims who were under the influence of alcohol are more likely to be seen as responsible for the event. These three factors (low physical force, skepticism from bystanders, and alcohol) all contribute to the self blame. Amplifying the emotional trauma is the fact that bystanders often judge victims negatively for their choices of clothing, dating behavior, and personality.

Betrayal and anger. Knowing the perpetrator prior to the sexual assault can be especially problematic.[16] Dichotomous or ambivalent feelings toward the perpetrator can be extremely confusing to the victim and prevent any clear understanding of the situation. The victim is forced to confront and question her basic sense of security and trust. She may feel betrayed by both her own trusted senses and someone she considered to be her friend. These feelings are difficult to resolve, and since the victim often remains silent and does not report being raped, she receives no support. The betrayal she has experienced can evolve into chronic negative feelings such as anger.

Previously, the victim may have had positive feelings toward the perpetrator, which can intensify the victim’s feelings of guilt. She may erroneously believe that somehow she “brought it on herself” by acting too friendly. Having to negotiate these feelings can be particularly difficult for a young woman who is still in the process of forming her own identity. Another aspect that differs in acquaintance rape as compared to stranger rape, especially in college, is that the victim can continually and unexpectedly see her perpetrator. This can be particularly disturbing and impede recovery. Realizing the negative consequences of the assault on her own life while assuming that the perpetrator’s life is unchanged can produce resentment and anger.

Lack of support. In college, students lack the strong support network they were accustomed to at home. Acquaintance rape evokes a deep sense of betrayal and forces one to confront one’s own judgment, making it more difficult to confide in family or anyone else after the event. Therefore, while the traumatic and emotional impacts of acquaintance rape differ from those of stranger rape, these impacts are very serious, causing the victim to blame herself for the rape and question her basic sense of judgment and trust.

PRACTICE POINT: Internalized Feelings of Guilt, Shame, Betrayal and Anger are Barriers to Recovery

Following acquaintance rape, the victim is often unable to seek help because she blames herself for the incident, is ashamed of the event, and fears judgment from others. Acquaintance rape victims are unlikely to report their perpetrator to the police or tell anyone at all.[6] The psychiatrist must be empathic to the victim’s experience and validate her feelings. While telling the victim that she is not responsible may seem obvious, the victim may still believe in her internal “badness.” Thus, helping the patient overcome her self blame can be very challenging. Exploring her sense of self esteem prior to the rape is important; unfortunately, in cases of prior childhood abuse, the victim’s self esteem is already damaged. If the young woman had been fairly self assured previously, it may be more possible to draw on her past feelings of relatively positive self esteem to aid in recovery.
A cognitive-behavioral approach, challenging automatic assumptions, can be important in the recovery phase, as illustrated next.

CASE PRESENTATION (continued)

On the next visit, Lauren was visibly distraught, as she had seen her perpetrator earlier in the dining hall. He was sitting with his male group of friends and they started laughing as she walked in. She was certain that they were pointing and laughing at her. She thought she even heard the word “slut” come from the table.

Initially, after the rape, her perpetrator tried to contact her and suggested that they hang out. She, however, made every attempt to avoid him, and had hoped that he would not return to the same college. Seeing him again shattered her hopes that he might be so ashamed of what he had done that he would flee the college.

She again blamed herself for the rape, insisting that had she not been drinking, he would not have been able to rape her, as she could have “fought him off.”

Psychiatrist: You told him “no.” Without consent, he proceeded to force himself onto you. That is rape.
Patient: I know that intellectually, but I made a stupid mistake in going back to his room. I would not have done that had I been sober.
Psychiatrist: I hear you. Yes, you made a mistake in judgment, but in no way does that make you responsible for him raping you.
Patient: Well, my parents would blame me if they knew. They have always told me that alcohol leads to horrible things—and they were right! I don’t even know how to face them! They will be so disappointed.
Psychiatrist: You have told me that there are many views that you do not share with your parents, and it sounds like your feelings about alcohol and the people who choose to drink are different from your parents.
Patient: Yes, my parents are ultra-conservative, and I think about a lot of things in a more open- minded manner than them. So I don’t believe that my drinking that night was all wrong—I do think drinking is just part of college life—but my parents will blame me. I just know they will.
Psychiatrist: At this time, I am most interested in how you view what happened to you. You are assuming responsibility for the rape, despite the fact that you said “no” and he proceeded without your consent. That is not your fault, regardless of your state of mind. He forced intercourse with you, without your consent.
Patient: I am beginning to see your point—that this really wasn’t my fault—but I still feel like a horrible person.
Psychiatrist: That is understandable—you have a lot of complex feelings to work through.

KEY POINT: Revictimization Can Occur

The victim of acquaintance rape may continually and unexpectedly see her perpetrator on campus or in the community. This can be particularly disturbing and impede recovery. The continued contact offers the opportunity for repeated unwanted sexual contact, perhaps through manipulation and guilt. In a sample of college students who have been sexually assaulted, 23 percent stated that they had sexual intercourse with their assailants at least one subsequent time.

Women who experienced completed rape were more likely to continue sexual activity with their perpetrators compared to those women who successfully blocked their perpetrators.[30] Victims may feel that repeated sexual contact or beginning a relationship with the perpetrator alters the initial incident into a mutual decision. Continued sexual contact with the assailant may also indicate the victim’s desire to regain control of her sex life and eliminate those images of the sexual assault. It further demonstrates the increased risk of repeated victimization.

Acquaintance rape victims not only are at risk for recurrent contact with their initial perpetrator, but they must also recognize potential new assailants. Victims may develop difficulties with risk recognition, which impairs their ability to remove themselves from threatening situations. Soller-Baillo et al9 describe risk recognition as particularly relevant in acquaintance/date rape situations, where the relationship between victim and perpetrator is critical in providing a context for appropriately assessing and responding to threat cues.

PRACTICE POINT: Prevent Revictimization

Difficulty in defending against unwanted sexual contact plays a role in the cycle of sexual victimization. Therefore, one important aspect of therapy is preventing revictimization. Therapeutic sessions should include educating victims about how to identify sexually aggressive men and dangerous situations and helping them become more emotionally sensitive to threat cues.[9] Especially challenging, in cases of acquaintance rape, is the fact that the situations to avoid are daily parts of life. Adams-Curtis and Forbes[7] describe the sexual coercion in aquaintance rape as appearing to be the consequence of normal sexual negotiations and expectations gone seriously awry. “The factors influencing the progression from normal sexual negotiations to coercive sexuality are often commonplace elements of college life.”[7]

The conundrum is how to realistically advise victims. Victims must learn to distinguish who may have ulterior motives and what kinds of circumstances are threatening. With the strong sense of invulnerability and orientation toward enjoying life inherent in young adult attitudes, getting any student to accurately recognize dangerous situations can be difficult. For victims, there may be a strong desire to return to “how things were” before the incident. They may strive to continue with their lives as previously, thereby, putting them at the risk again. It is important to help victims of acquaintance rape to develop the ability to balance their sense of heightened vulnerability without living in seclusion.

Emphasis also needs to be placed on the risks of heavy drinking during social situations. This should be done carefully since the victim may already have deep feelings of self blame surrounding alcohol use and its contributions to the rape.

CASE PRESENTATION (continued)

On a subsequent visit, Lauren further disclosed that ever since the rape, she was terrified of becoming pregnant. She had no idea if her perpetrator had used a condom, so despite already having been on oral contraceptives, Lauren went to the pharmacy and obtained Plan B, an over-the-counter contraceptive hormone pill that prevents pregnancy up to three days following unprotected sex. She also went to the student health clinic to get tested for sexually transmitted diseases, including human immunodeficiency virus. Although all results were negative, she still feared long-term repercussions. She insisted that her boyfriend use condoms despite her use of oral contraceptives.

Her relationship with her boyfriend was tumultuous since the incident. Before college, she had originally planned to remain a virgin; however, when saying goodbye to her boyfriend before moving away to college, “I ended up acting on my sexual impulses.” Although she admitted that she felt pressured by her boyfriend, she felt that the decision to become sexually active was mutual. Following the rape, however, she had no desire to be sexually active with her boyfriend, and was only sexually active with him after having several drinks because “…it was easier that way.” Every time she was sexually active with her boyfriend, she experienced flashbacks of the rape. Her boyfriend was perplexed by her behavior. She never told him about the sexual assault, due to fear that he would end the relationship. She was relieved that he was in college in another state because that minimized their time together. She also revealed that she was reluctant to tell her parents about the rape because she thought they would inevitably question all of her sexual activities.

KEY POINT: Acquaintance Rape May Have Short- and Long-term Health Impacts

The above portion of the case highlights multiple health-related issues that the psychiatrist may need to address with the acquaintance rape victim. Depending on when the patient presents for treatment, there may be different health concerns. The immediate health concerns that should be addressed include the possibility of pregnancy and sexually transmitted diseases. In the longer term, women with a history of acquaintance rape develop more health problems and affective disorders.29
Affective and anxiety disorders. Rape victims are predisposed to depression, anxiety, posttraumatic stress disorder (PTSD), and attempted suicide. Sexual assault victims who develop PTSD can have symptoms persisting for at least one year after assault.

Sexual dysfunction. Sexual dysfunction is also a problem that can persist.31 Several studies conclude that after rape, the frequency of sexual contact decreases.[31] Sexual stimuli are perceived as anxiety provoking and evoke intrusive memories.

Satisfaction and pleasure in sexual activities are reduced in victims for at least one year. Victims develop sexual problems that include response inhibition, such as fear, dysfunction of arousal, and lack of desire. Sexual dysfunction may not be an immediate concern of the victim. However, it is important for the psychiatrist to inquire about sexual dysfunction. Victims may be ashamed to talk about it; however, failure to address sexual dysfunction prevents recovery. Sexual dysfunction can be best treated by enabling the victim to engage in pleasurable, consensual sexual activities. It helps the victim overcome negative feelings associated with sexuality. Becker et al[32] indicates that sexual dysfunction, specifically dealing with desire, should be treated by focusing on the cognitive aspects of the negative perception of sexual stimuli.[32] Furthermore, addressing feelings of anger, shame, and guilt by cognitive interventions may help the patient overcome these feelings, prevent sexual dysfunction, and minimize longer term psychiatric impairment.

Pregnancy and sexually transmitted diseases. The possibility of pregnancy should always be addressed. Victims may not have the resources to address pregnancy alone, and so may require help to appropriately navigate the available resources, depending on the time of presentation after the rape. A positive pregnancy test creates another set of major issues for the victim, including the struggle to pursue an abortion or carry the pregnancy to term. Religious beliefs, moral beliefs, and family of origin issues will certainly become the focus of future therapy sessions as the issue of an unexpected pregnancy is discussed.

Other medical problems. When compared to nonvictims, rape victims complain of more physical problems and perceive themselves as less healthy. Humphrey and White[6] observed that victims will likely seek medical attention for somatic complaints related to their sexual assault.[6] Therefore, it is important to assess the possibility of sexual assault as the underlying cause of multiple psychosomatic complaints.[6]

CONCLUSION

Acquaintance rape is not a novel concept and yet the incidence of sexual assault has not significantly changed in the last 50 years.[7] Rape myths continue to circulate, in effect encouraging and justifying the crime and silencing the victims. Although fictional, Lauren’s case reflects the reality of acquaintance rape. In rape, regardless of the situation and whether the perpetrator was a stranger or acquaintance, trauma and its consequent emotional and health impacts are present. In situations of date/acquaintance rape, victims may have to deal with additional issues of betrayal, self blame, guilt, continued contact with perpetrator, and the intense desire for secrecy. These are challenging barriers to recovery. Attention to health- and mood- related disorders, in addition to education to prevent revictimization, are central aspects of therapy sessions.

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